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Paranoid personality disorder

Paranoid personality disorder (PPD) is a mental disorder characterized by paranoia, and a pervasive, long-standing suspiciousness and generalized mistrust of others. People with this personality disorder may be hypersensitive, easily insulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers and they often think they are in danger and look for signs and threats of that danger, potentially not appreciating other interpretations or evidence. They tend to be guarded and suspicious and have quite constricted emotional lives. Their reduced capacity for meaningful emotional involvement and the general pattern of isolated withdrawal often lend a quality of schizoid isolation to their life experience. People with PPD may have a tendency to bear grudges, suspiciousness, tendency to interpret others' actions as hostile, persistent tendency to self-reference, or a tenacious sense of personal right. Patients with this disorder can also have significant comorbidity with other personality disorders, such as schizotypal, schizoid, narcissistic, avoidant, and borderline. Causes A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist. A large long-term Norwegian twin study found paranoid personality disorder to be modestly heritable and to share a portion of its genetic and environmental risk factors with the other cluster A personality disorders, schizoid and schizotypal. Psychosocial theories implicate projection of negative internal feelings and parental modeling. Cognitive theorists believe the disorder to be a result of an underlying belief that other people are unfriendly in combination with a lack of self-awareness. Diagnosis ICD-10 The World Health Organization's ICD-10 lists paranoid personality disorder under. It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria. It is also pointed out that for different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and other obligations. PPD is characterized by at least three of the following symptoms: excessive sensitivity to setbacks and rebuffs; tendency to bear grudges persistently (i.e. refusal to forgive insults and injuries or slights); suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous; a combative and tenacious sense of self-righteousness out of keeping with the actual situation; recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner; tendency to experience excessive self-aggrandizing, manifest in a persistent self-referential attitude; preoccupation with unsubstantiated "conspiratorial" explanations of events both immediate to the patient and in the world at large. Includes: expansive paranoid, fanatic, querulant and sensitive paranoid personality disorder. Excludes: delusional disorder and schizophrenia. DSM-5 The American Psychiatric Association's DSM-5 has similar criteria for paranoid personality disorder. They require in general the presence of lasting distrust and suspicion of others, interpreting their motives as malevolent, from an early adult age, occurring in a range of situations. Four of seven specific issues must be present, which include different types of suspicions or doubt (such as of being exploited, or that remarks have a subtle threatening meaning), in some cases regarding others in general or specifically friends or partners, and in some cases referring to a response of holding grudges or reacting angrily. PPD is characterized by a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts. To qualify for a diagnosis, the patient must meet at least four out of the following criteria: Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them. Reads hidden demeaning or threatening meanings into benign remarks or events. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). Perceives attacks on their character or reputation that are not apparent to others and is quick to react angrily or to counterattack. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. The DSM-5 lists paranoid personality disorder essentially unchanged from the DSM-IV-TR version and lists associated features that describe it in a more quotidian way. These features include suspiciousness, intimacy avoidance, hostility and unusual beliefs/experiences. Other Various researchers and clinicians may propose varieties and subsets or dimensions of personality related to the official diagnoses. Psychologist Theodore Millon has proposed five subtypes of paranoid personality: Differential diagnosis The paranoid may be at greater than average risk of experiencing major depressive disorder, agoraphobia, social anxiety disorder, obsessive-compulsive disorder and substance-related disorders. Criteria for other personality disorder diagnoses are commonly also met, such as: schizoid, schizotypal, narcissistic, avoidant, borderline and negativistic personality disorder. Treatment Partly as a result of tendencies to mistrust others, there have been few studies conducted over the treatment of paranoid personality disorder. Currently, there are no medicines FDA approved in treating PPD, but antidepressants, antipsychotics, and mood stabilizers may be prescribed under wrong assumptions to treat some of the symptoms. Another form of treatment of PPD is psychoanalysis, normally used in cases where both PPD and BPD are present. However, no published studies directly state the effectiveness of this form of treatment on specifically PPD, as opposed to its effects on BPD. CBT (Cognitive Behavioral Therapy) has also been suggested as a possible treatment to paranoid personality disorder, but while case studies have shown improvement in the symptoms of the disorder, no systematic/widespread data has been collected to support this. Treatments for PPD can be challenging, as individuals with PPD are reluctant in finding help and have difficulty trusting others. Epidemiology PPD occurs in about 0.5–4.4% of the general population. It is seen in 2–10% of psychiatric outpatients. In clinical samples men have higher rates, whereas epidemiologically there is a reported higher rate of women. History Paranoid personality disorder is listed in DSM-V and was included in all previous versions of the DSM. One of the earliest descriptions of the paranoid personality comes from the French psychiatrist Valentin Magnan who described a "fragile personality" that showed idiosyncratic thinking, hypochondriasis, undue sensitivity, referential thinking, and suspiciousness. Closely related to this description is Emil Kraepelin's description from 1905 of a pseudo-querulous personality who is "always on the alert to find grievance, but without delusions", vain, self-absorbed, sensitive, irritable, litigious, obstinate, and living at strife with the world. In 1921, he renamed the condition paranoid personality and described these people as distrustful, feeling unjustly treated and feeling subjected to hostility, interference and oppression. He also observed a contradiction in these personalities: on the one hand, they stubbornly hold on to their unusual ideas, on the other hand, they often accept every piece of gossip as the truth. Kraepelin also noted that paranoid personalities were often present in people who later developed paranoid psychosis. Subsequent writers also considered traits like suspiciousness and hostility to predispose people to developing delusional illnesses, particularly "late paraphrenias" of old age. Following Kraepelin, Eugen Bleuler described "contentious psychopathy" or "paranoid constitution" as displaying the characteristic triad of suspiciousness, grandiosity, and feelings of persecution. He also emphasized that these people's false assumptions do not attain the form of real delusion. Ernst Kretschmer emphasized the sensitive inner core of the paranoia-prone personality: they feel shy and inadequate but at the same time they have an attitude of entitlement. They attribute their failures to the machinations of others but secretly to their own inadequacy. They experience constant tension between feelings of self-importance and experiencing the environment as unappreciative and humiliating. Karl Jaspers, a German phenomenologist, described "self-insecure" personalities who resemble the paranoid personality. According to Jaspers, such people experience inner humiliation, brought about by outside experiences and their interpretations of them. They have an urge to get external confirmation to their self-deprecation and that makes them see insults in the behavior of other people. They suffer from every slight because they seek the real reason for them in themselves. This kind of insecurity leads to overcompensation: compulsive formality, strict social observances, and exaggerated displays of assurance. In 1950, Kurt Schneider described the "fanatic psychopaths" and divided them into two categories: the combative type that is very insistent about his false notions and actively quarrelsome, and the eccentric type that is passive, secretive, vulnerable to esoteric sects, but nonetheless suspicious about others. The descriptions of Leonhard and Sheperd from the sixties describe paranoid people as overvaluing their abilities and attributing their failure to the ill-will of others; they also mention that their interpersonal relations are disturbed and they are in constant conflict with others. In 1975, Polatin described the paranoid personality as rigid, suspicious, watchful, self-centered and selfish, inwardly hypersensitive, but emotionally undemonstrative. However, when there is a difference of opinion, the underlying mistrust, authoritarianism, and rage burst through. In the 1980s, paranoid personality disorder received little attention, and when it did receive it, the focus was on its potential relationship to paranoid schizophrenia. The most significant contribution of this decade comes from Theodore Millon who divided the features of paranoid personality disorder to four categories: 1) Behavioral characteristics of vigilance, abrasive irritability, and counterattack 2) Complaints indicating oversensitivity, social isolation, and mistrust 3) The dynamics of denying personal insecurities, attributing these to others, and self-inflation through grandiose fantasies 4) Coping style of detesting dependence and hostile distancing of oneself from others Controversy Due to repeated concerns of the validity of PPD and poor empirical evidence, it has been suggested that PPD be removed from the DSM. This is believed to contribute to low research output on PPD. See also References External links National Personality Disorder website for England Articles about Personality Disorders in Web4health web site Cluster A personality disorders Paranoia

Pitt–Hopkins syndrome

Pitt–Hopkins syndrome (PTHS) is a rare genetic disorder characterized by developmental delay, moderate to severe intellectual disability, distinctive facial features, and possible intermittent hyperventilation followed by apnea. Epilepsy (recurrent seizures)often occurs in Pitt-Hopkins. It is part of the clinical spectrum of Rett-like syndromes. Pitt-hopkins syndrome is clinically similar to Angelman syndrome, Rett-syndrome, Mowat Wilson syndrome, and ATR-X syndrome. As more is learned about Pitt–Hopkins, the developmental spectrum of the disorder is widening, and can also include difficulties with anxiety, autism, ADHD, and sensory disorders. It is associated with an abnormality within chromosome 18 which causes insufficient expression of the TCF4 gene. Those with PTHS have reported high rates of self-injury and aggressive behaviors usually related to autism and their sensory disorders. PTHS has traditionally been associated with severe cognitive impairment, however true intelligence is difficult to measure given motor and speech difficulties. Thanks to augmentative communication and more progressive therapies, many individuals can achieve much more than initially thought. It has become clearer that there is a wider range of cognitive abilities in Pitt–Hopkins than reported in much of the scientific literature. No cure is known for Pitt-Hopkins syndrome, but it is possible to treat associated symptoms. Researchers have developed cell and rodent models to test therapies for Pitt–Hopkins. PTHS is estimated to occur in 1:11,000 to 1:41,000 people. Signs and symptoms PTHS can be seen as early as childhood. The earliest signs in infants is the lower face and the high nasal root. The facial features are characteristic and include: Broad nasal bridge with bulbous tip Wide mouth Cupid's bow philtrum Prominent ears Thin eyebrows Flat feet, overriding toes, and fetal pads are also common. Short stature and scoliosis occur frequently. Other features of Pitt-Hopkins syndrome may include constipation and other gastrointestinal problems, an unusually small head (microcephaly), nearsightedness (myopia), eyes that do not look in the same direction (strabismus), short stature, and minor brain abnormalities Adults who have PTHS may have trouble with their speech. Craniofacial features, which are important when diagnosing PTHS, become more visible as the person gets older. Children with Pitt-Hopkins syndrome typically have a happy, excitable demeanor with frequent smiling, laughter, and hand-flapping movements. However, they can also experience anxiety and behavioral problems. Gastrointestinal Gastrointestinal difficulties are common in individuals with Pitt-Hopkins and can include constipation, reflux, and burping. Severe constipation often occurs over the entire lifespan. Breathing issues may cause air swallowing and associated pain. Low muscle tone can cause feeding issues at an early age. Neurological Epilepsy is not uncommon in Pitt-Hopkins and is reported in 37%-50% of cases. The onset of seizures can occur in infants or throughout adulthood. A variety of seizures can occur. Electroencephalographic (EEG) patterns can be typical or atypical, depending on the individual. Magnetic resonance imaging (MRI) reveals that deviations in the brain may occur in individuals with Pitt-Hopkins. These can include a small corpus callosum, wide ventricles, and deviations in the posterior fossa. Many individuals with Pitt Hopkins can also have typical brain structures. Musculoskeletal. Minor hand and foot anomalies such as slender or small hands and feet, broad fingertips, clinodactyly, tapered fingers, transverse palmar crease, flat feet with hindfoot valgus deformity, overriding toes, and short metatarsals have been reported. Absent flexion creases of the thumbs may occur with thumb ankylosis. In one individual an absent thumb tendon was found during surgery [Authors, personal observation]. Genetics The genetic cause of this disorder was described in 2007. This disorder is due to a haploinsufficiency of the transcription factor 4 (TCF4) gene which is located on the long arm of chromosome 18 (18q21.2) The mutational spectrum appears to be 40% point mutations, 30% small deletions/insertions and 30% deletions. All appear to be de novo mutations. The risk in siblings is low, but higher than the general population due to parental germline mosaicism. A Pitt–Hopkins-like phenotype has been assigned to autosomal recessive mutations of the contactin associated protein like 2 (CNTNAP2) gene on the long arm of chromosome 7 (7q33-q36) and the neurexin 1 alpha (NRXN1) gene on the short arm of chromosome 2 (2p16.3). Malformations in the CNS can be seen in about 60 to 70% of patients on MRI scans. Pitt–Hopkins patients with a TCF4 deletion can lack the syndrome's characteristic facial features. Diagnosis There is not a certain diagnostic criteria, but there are a few symptoms that support a diagnosis of PTHS. Some examples are: facial dysmorphism, early onset global developmental delay, moderate to severe intellectual disability, breathing abnormalities, and a lack of other major congenital abnormalities. Zollino and colleagues defined diagnostic criteria based on characteristic features found in 75% of cases genetically confirmed for PTHS, termed cardinal features. If a person shows 9 cardinal features, they are classified as having PTHS. It is possible that a phenotype resembling PTHS can occur without the mutation in the TCF4 gene. Mutations in the TCF4 gene do not always result in stereotypical Pitt-Hopkins syndrome. Half of the individuals with PTHS are reported to have seizures, starting from childhood to the late teens. Around 50% of those affected show abnormalities on brain imaging. These include a hypoplastic corpus callosum with a missing rostrum and posterior part of the splenium, with bulbous caudate nuclei bulging towards the frontal horns. Electroencephalograms show an excess of slow components. According to the clinical diagnosis. PTHS is in the same group as Pervasive Developmental Disorders. When a patient is suspected of having PTHS, genetic tests looking at the TCF4 gene are typically done. Some argue for a genetic test to occur first, followed by a clinical assessment. Differential diagnosis PTHS is symptomatically similar to Angelman syndrome, Rett syndrome and Mowat–Wilson syndrome. Angelman syndrome most closely resembles PTHS. Both have absent speech and a "happy" disposition. Of the differentials, Rett syndrome is the least close to PTHS. This syndrome is seen as a progressive encephalopathy. Both Angelman syndrome and Rett syndrome lack the distinctive facial features of PTHS. Mowat–Wilson syndrome is seen in early infancy and is characterized by distinctive facial abnormalities. Treatment There is no specific treatment for this condition. It is based on symptomatology. Since there is a lack of treatment, people with PTHS use behavioral and training approaches. Comorbidities may also be treated. Care from a medical team including neurologists, ophthalmologists, pulmonologists, and gastroenterologists may be utilized. Recommendations for developmental delay and intellectual disability in the U.S. (may differ depending on country): Early intervention program from newborn to age 3 will allow access to different therapies (occupational, physical, speech, and feeding). Developmental preschool through public school systems from ages 3 to 5. The child will need an evaluation before getting into the program, to see what kind of therapy is needed. From the ages 5–21 the child's school may create an IEP (based on the child's functions and needs). Children are encouraged to stay in school until at least the age of 21. History The condition was first described in 1978, by D. Pitt and I. Hopkins (The Children's Cottages Training Centre, Kew and Royal Children's Hospital, Melbourne, Australia) in two unrelated patients. References External links Transcription factor deficiencies Syndromes affecting the eye Disorders causing seizures Syndromic autism Rare diseases Syndromes with ADHD

Personal development

Personal development or self-improvement consists of activities that develop a person's capabilities and potential, enhance quality of life, and facilitate the realization of dreams and aspirations. Personal development may take place over the course of an individual's entire lifespan and is not limited to one stage of a person's life. It can include official and informal actions for developing others in roles such as teacher, guide, counselor, manager, coach, or mentor, and it is not restricted to self-help. When personal development takes place in the context of institutions, it refers to the methods, programs, tools, techniques, and assessment systems offered to support positive adult development at the individual level in organizations. Overview Among other things, personal development may include the following activities: Social entrepreneurship or civic engagement Participating in festivals, conferences, or conventions Improving self-awareness Improving self-knowledge Improving skills and/or learning new ones Building or renewing identity/self-esteem Developing strengths or talents Improving a career Identifying or improving potential Building employability or (alternatively) human capital Enhancing lifestyle and/or the quality of life and time management calculating the return on time invested. Improving health Improving wealth or social status Fulfilling aspirations Initiating a life enterprise Defining and executing personal development plans (PDPs) Improving social relations or emotional intelligence Spiritual identity development and recognition A distinction can be made between personal development and personal growth. Although similar, both concepts portray different ideas. Personal development specifies the focus of the "what" that is evolving, while personal growth entails a much more holistic view of broader concepts including morals and values being developed. Personal development can also include developing other people's skills and personalities.This can happen through roles such as those of a teacher or mentor, either through a personal competency (such as the alleged skill of certain managers in developing the potential of employees) or through a professional service (such as providing training, assessment, or coaching). Beyond improving oneself and developing others, "personal development" labels a field of practice and research: As a field of practice, personal development includes personal-development methods, learning programs, assessment systems, tools, and techniques. As a field of research, personal-development topics appear in psychology journals, education research, management journals and books, and human-development economics. Any sort of development—whether economic, political, biological, organizational or personal—requires a framework if one wishes to know whether a change has actually occurred. In the case of personal development, an individual often functions as the primary judge of improvement or of regression, but the validation of objective improvement requires assessment using standard criteria. Personal-development frameworks may include: Goals or benchmarks that define the end-points Strategies or plans for reaching goals Measurement and assessment of progress, levels or stages that define milestones along a development path A feedback system to provide information on changes As an industry Personal development as an industry has several business-relationship formats of operating. The main ways are business-to-consumer and business-to-business. However, there have been two new ways emerge: consumer-to-business and consumer-to-consumer. The personal development market had a global market size of 38.28 billion dollars in 2019. Business-to-consumer market A wide array of personal development products are available to individuals. Examples include self-help books; education technology, neuroenhancement, and experiential learning (instructor-led training, motivational speeches, seminars, social or spiritual retreats). Domains Higher education, cognitive training Personal finance Weight loss, physical fitness, nutrition, and beauty enhancement Large-group awareness training Sensory deprivation Time-management Yoga Martial arts Initiation ceremonies Meditation Asceticism General methods of personal development also include: Life coaching or counseling Recommendation systems Nootropics, such as caffeinated drinks Brain computer interface Virtual assistant Business-to-business market Some consulting firms such as DDI and FranklinCovey specialize in personal development, but generalist firms operating in the fields of human resources, recruitment and organizational strategy—such as Hewitt, Watson Wyatt Worldwide, Hay Group, McKinsey, Boston Consulting Group, and Korn/Ferry—have entered what they perceive as a growing market, not to mention smaller firms and self-employed professionals who provide consulting, training and coaching. Origins Major religions—such as the age-old Abrahamic and Indian religions—as well as 20th-century New Age philosophies have variously used practices such as prayer, music, dance, singing, chanting, poetry, writing, sports and martial arts. Michel Foucault describes in Care of the Self the techniques of epimelia used in ancient Greece and Rome, which included dieting, exercise, sexual abstinence, contemplation, prayer, and confession—some of which also became practices within different branches of Christianity. Wushu and tai chi utilize traditional Chinese techniques, including breathing and qi exercises, meditation, martial arts, as well as practices linked to traditional Chinese medicine, such as dieting, massage, and acupuncture. Two individual ancient philosophical traditions: those of Aristotle (Western tradition) and Confucius (Eastern tradition) stand out and contribute to the worldwide view of "personal development" in the 21st century. Elsewhere anonymous or named founders of schools of self-development appear endemic—note the traditions of the Indian sub-continent in this regard. South Asian traditions Some ancient Indians aspired to "beingness, wisdom and happiness". Paul Oliver suggests that the popularity of Indian traditions for a personal developer may lie in their relative lack of prescriptive doctrine. Islamic personal development Khurram Murad describes that personal development in Islam is to work towards eternal life in Jannuh. There are many avenues in the journey to paradise, such as devoted practicing of the laws of the Quran and Sunnah, such as optimized service towards the self and others. Sincere worship of Allah is the foundation for self-discovery and self-development. Allah has provided ways to help those striving towards eternal life, including staying away from things of the world. These worldly things can distract those away from the path to paradise. It does not mean worldly success is inherently disruptive but can become so when spiritual beliefs do not align with the Sunnah. In the end, paradise will bring satisfaction to those working on their personal development because of the pleasure that comes from Allah. Aristotle and the Western tradition The Greek philosopher Aristotle (384 BCE322 BCE) wrote Nicomachean Ethics, in which he defined personal development as a category of phronesis or practical wisdom, where the practice of virtues (arête) leads to eudaimonia, commonly translated as "happiness" but more accurately understood as "human flourishing" or "living well". Aristotle continues to influence the Western concept of personal development , particularly in the economics of human development and in positive psychology. Confucius and the East Asian tradition In Chinese tradition, Confucius (around 551 BCE479 BCE) founded an ongoing philosophy. His ideas continue to influence family values, education and personnel management in China and East Asia. In his Great Learning Confucius wrote: Contexts Psychology Psychology became linked to personal development in the early 20th century starting with the research efforts of Alfred Adler (1870–1937) and Carl Jung (1875–1961). Adler refused to limit psychology to analysis alone. He made the important point that aspirations focus on looking forward and do not limit themselves to unconscious drives or to childhood experiences. He also originated the concepts of lifestyle (1929—he defined "lifestyle" as an individual's characteristic approach to life, in facing problems) and of self-image, as a concept that influenced management under the heading of work-life balance, also known as the equilibrium between a person's career and personal life. Carl Gustav Jung made contributions to personal development with his concept of individuation, which he saw as the drive of the individual to achieve the wholeness and balance of the Self. Daniel Levinson (1920–1994) developed Jung's early concept of "life stages" and included a sociological perspective. Levinson proposed that personal development comes under the influence—throughout life—of aspirations, which he called "the Dream": Research on success in reaching goals, as undertaken by Albert Bandura (1925–2021), suggested that self-efficacy best explains why people with the same level of knowledge and skills get very different results. Having self-efficacy leads to an increased likelihood of success. According to Bandura self-confidence functions as a powerful predictor of success because: It causes you to expect to succeed It allows you take risks and set challenging goals It helps you keep trying if at first you do not succeed It helps you control emotions and fears when life may throw more difficult things your way In 1998 Martin Seligman won election to a one-year term as President of the American Psychological Association and proposed a new focus: on healthy individuals rather than on pathology (he created the "positive psychology" current) Carl Rogers proposed a theory about humanistic psychology called Self Concept. This concept consisted of two ideas of the self. The first idea is the ideal self which describes the person we want to be. The second one is the real self which is the objective view of one self and who we really are. Rogers emphasized that healthy development is when the real self and the ideal self are accurate. Incongruence is what Rogers described to be when the real self and the ideal self are not accurate in their viewings. The ideal self is not lowered in order to compensate for the real self, but the real self is lifted by the ideal self in order to achieve healthy development. It is important to note that real lasting personal development is only achieved through meaningful and lasting accomplishments. Viktor Frankl emphasized this by stating "Genuine and lasting well-being is the result of a “life well-lived”. In an article written by Ugur, H., Constantinescu, P.M., & Stevens, M.J. (2015) they described that society has taught us to create positive illusions that give the appearance of positive development but are only effective in the short term. Additionally, they give two examples of personal development. The first is hedonic well-being which is the pursuit of pleasurable experiences that lead to increased personal happiness. The second is eudaimonic well-being which is living life by making choices that are congruent with authentic being. Social psychology Social psychology heavily emphasizes and focuses on human behavior and how individuals interact with others in society. Infants develop socially by creating trusting and dependent relationships with others—namely parental figures. They learn how to act and treat other people based on the example of parental figures and other adults they interact with often. Toddlers further develop social skills. Additionally, they begin to gain a desire for autonomy and grow more and more independent as they grow older. The balance of social involvement and autonomy varies per person, but normally autonomous behavior increases with age. Some studies suggest that selfishness begins to diminish, and prosocial behaviors increase, between the ages of six years old to twelve years old. Additionally, the years of adulthood are times of development—self-actualization, relational and occupational development, loss, and coping skills development, etc.—affected by those around us: parents, co-workers, romantic partners, and children. Social psychology draws from many other psychological theories and principles yet views them through a lens of social interaction. Psychodynamic psychology The psychodynamic view of personal development varies from other perspectives. Namely, that the development of our traits, personalities, and thinking patterns are predominantly subconscious. Psychodynamic theory suggests these subconscious changes—which emerge as external actions—are formed from suppressed sexual and aggressive urges and other internalized conflicts. Sigmund Freud and other notable psychodynamic theorists postulate that these repressed cognitions form during childhood and adolescence. Conscious development would then be "digging up" these repressed memories and feelings. Once repressed memories and emotions are discovered, an individual can sift through them and receive healthy closure. Much, if not all, of conscious development occurs with the aid of a trained psychodynamic therapist. Cognitive-behavioral psychology Cognitive-behavioral views on personal development follow traditional patterns of personal development: behavior modification, cognitive reframing, and successive approximation being some of the more notable techniques. An individual is seen as in control of their actions and their thoughts, though self-mastery is required. With behavior modification, individuals will develop personal skills and traits by altering their behavior independent of their emotions. For example, a person may feel intense anger but would still behave in a positive manner. They are able to suppress their emotions and act in a more socially acceptable way. The accumulation of these efforts would change the person into a more patient individual. Cognitive reframing plays an instrumental role in personal development. Cognitive-behavioral psychologists believe that how we view events is more important than the event itself. Thus, if one can view negative events in beneficial ways, they can progress and develop with fewer setbacks. Successive approximation—or shaping—most closely aligns with personal development. Successive approximation is when one desires a final result but takes incremental steps to achieve the result. Normally, each successful step towards the final goal is rewarded until the goal is achieved. Personal development, if it is to be long-lasting, is achieved incrementally. Educational psychology Educational psychology focuses on the human learning experience: learning and teaching methods, aptitude testing, and so on. Educational psychology seeks to further personal development by increasing one's ability to learn, retain information, and apply knowledge to real-world experiences. If one is able to increase efficacious learning, they are better equipped for personal development. Early education Education offers children the opportunity to begin personal development at a young age. The curriculum taught at school must be carefully planned and managed in order to successfully promote personal development. Providing an environment for children that allows for quality social relationships to be made and clearly communicated objectives and aims is key to their development. If early education fails to meet these qualifications, it can greatly stunt development in children, hindering their success in education as well as society. They can fall behind in development compared to peers of the same age group. Higher education During the 1960s a large increase in the number of students on American campuses led to research on the personal development needs of undergraduate students. Arthur Chickering defined seven vectors of personal development for young adults during their undergraduate years: Developing competence Managing emotions Achieving autonomy and interdependence Developing mature interpersonal relationships Establishing personal identity Developing purpose Developing integrity In the UK, personal development took a central place in university policy in 1997 when the Dearing Report declared that universities should go beyond academic teaching to provide students with personal development. In 2001 a Quality Assessment Agency for UK universities produced guidelines for universities to enhance personal development as: a structured and supported process undertaken by an individual to reflect upon their own learning, performance and/or achievement and to plan for their personal, educational and career development; objectives related explicitly to student development; to improve the capacity of students to understand what and how they are learning, and to review, plan and take responsibility for their own learning In the 1990s, business schools began to set up specific personal-development programs for leadership and career orientation and in 1998 the European Foundation for Management Development set up the EQUIS accreditation system which specified that personal development must form part of the learning process through internships, working on team projects and going abroad for work or exchange programs. The first personal development certification required for business school graduation originated in 2002 as a partnership between Metizo, a personal-development consulting firm, and the Euromed Management School in Marseilles: students must not only complete assignments but also demonstrate self-awareness and achievement of personal-development competencies. As an academic department, personal development as a specific discipline is often associated with business schools. As an area of research, personal development draws on links to other academic disciplines: Education for questions of learning and assessment Psychology for motivation and personality Sociology for identity and social networks Economics for human capital and economic value Philosophy for ethics and self-reflection Developmental activities Personal Development can include gaining self-awareness of the course of one's lifespan. It includes multiple definitions but is different from self knowledge. Self-awareness is more in depth and explores the conscious and unconscious aspects of ourselves. We are able to gain self-awareness through socializing and communicating according to the social behaviorism view. Self-awareness can also be a positive intrapersonal experience where one is able to reflect during a moment of action or past actions. Becoming more self aware can help us to increase our emotional intelligence, leadership skills, and performance. The workplace Abraham Maslow (1908–1970), proposed a hierarchy of needs with self actualization at the top, defined as "the desire to become more and more what one is, to become everything that one is capable of becoming". In other words, self actualization is the ambition to become a better version of oneself, to become everything one is capable of being. Since Maslow himself believed that only a small minority of people self-actualize—he estimated one percent—his hierarchy of needs had the consequence that organizations came to regard self-actualization or personal development as occurring at the top of the organizational pyramid, while openness and job security in the workplace would fulfill the needs of the mass of employees. As organizations and labor markets became more global, responsibility for development shifted from the company to the individual. In 1999 management thinker Peter Drucker wrote in the Harvard Business Review: Management professors Sumantra Ghoshal of the London Business School and Christopher Bartlett of the Harvard Business School wrote in 1997 that companies must manage people individually and establish a new work contract. On the one hand, the company must allegedly recognize that personal development creates economic value: "market performance flows not from the omnipotent wisdom of top managers but from the initiative, creativity and skills of all employees". On the other hand, employees should recognize that their work includes personal development and "embrace the invigorating force of continuous learning and personal development". The 1997 publication of Ghoshal's and Bartlett's Individualized Corporation corresponded to a change in career development from a system of predefined paths defined by companies, to a strategy defined by the individual and matched to the needs of organizations in an open landscape of possibilities. Another contribution to the study of career development came with the recognition that women's careers show specific personal needs and different development paths from men. The 2007 study of women's careers by Sylvia Ann Hewlett Off-Ramps and On-Ramps had a major impact on the way companies view careers. Further work on the career as a personal development process came from study by Herminia Ibarra in her Working Identity on the relationship with career change and identity change, indicating that priorities of work and lifestyle continually develop through life. Personal development programs in companies fall into two categories: the provision of employee benefits and the fostering of development strategies. Employee surveys may help organizations find out personal-development needs, preferences and problems, and they use the results to design benefits programs. Typical programs in this category include: Work-life balance Time management Stress management Health programs Counseling As an investment, personal development programs have the goal of increasing human capital or improving productivity, innovation or quality. Proponents actually see such programs not as a cost but as an investment with results linked to an organization's strategic development goals. Employees gain access to these investment-oriented programs by selection according to the value and future potential of the employee, usually defined in a talent management architecture including populations such as new hires, perceived high-potential employees, perceived key employees, sales staff, research staff and perceived future leaders. Organizations may also offer other (non-investment-oriented) programs to many or even all employees. Personal development also forms an element in management tools such as personal development planning, assessing one's level of ability using a competency grid, or getting feedback from a 360 questionnaire filled in by colleagues at different levels in the organization. A common criticism surrounding personal development programs is that they are often treated as an arbitrary performance management tool to pay lip service to, but ultimately ignored. As such, many companies have decided to replace personal development programs with SMART Personal Development Objectives, which are regularly reviewed and updated. Personal Development Objectives help employees achieve career goals and improve overall performance. Criticism Scholars have targeted self-help claims as misleading and incorrect. In 2005, Steve Salerno portrayed the American self-help movement—he uses the acronym "SHAM": the "Self-Help and Actualization Movement"—not only as ineffective in achieving its goals but also as socially harmful, and that self-help customers keep investing more money in these services regardless of their effectiveness. Others similarly point out that with self-help books "supply increases the demand ... The more people read them, the more they think they need them ... more like an addiction than an alliance". Self-help writers have been described as working "in the area of the ideological, the imagined, the narrativized. ... although a veneer of scientism permeates the[ir] work, there is also an underlying armature of moralizing". See also Coaching End-of-history illusion Holland Codes Human Potential Movement Know thyself Life planning Life skills Micropsychoanalysis Self-discovery Training and development True Will References

Emotional and behavioral disorders

Emotional and behavioral disorders (EBD; also known as behavioral and emotional disorders) refer to a disability classification used in educational settings that allows educational institutions to provide special education and related services to students who have displayed poor social and/or academic progress. The classification is often given to students after conducting a Functional Behavior Analysis. These students need individualized behavior supports such as a Behavior Intervention Plan, to receive a free and appropriate public education. Students with EBD may be eligible for an Individualized Education Plan (IEP) and/or accommodations in the classroom through a 504 Plan. History Early history Before any studies were done on the subject, mental illnesses were often thought to be a form of demonic possession or witchcraft. Since much was unknown, there was little to no distinction between the different types of mental illness and developmental disorders that we refer to today. Most often, they were dealt with by performing an exorcism on the person exhibiting signs of any mental illness. In the early to mid-1800s, asylums were introduced to America and Europe. There, patients were treated cruelly and often referred to as lunatics by doctors in the professional fields. The main focus of asylums were to shun people with mental illnesses from the public. In 1963, the Community Mental Health Centers Construction Act (Public Law 88–164), was passed by Congress and signed by John F. Kennedy, which provided federal funding to community mental health centers. This legislation changed the way that mental health services were handled and also led to the closure of many large asylums. Many laws soon followed assisting more and more people with EBDs. 1978 came with the passing of Public Law 94- 142 which required free and public education to all disabled children including those with EBDs. An extension of PL 94–142, PL 99-457, was put into act which would provide services to all disabled children from the ages of 3-5 by the 1990–91 school year. PL 94-142 has since been renamed to the Individuals with Disabilities Education Act (IDEA). Use and development of the term Various terms have been used to describe irregular emotional and behavioral disorders. Many of the terms such as mental illness and psychopathology were used to describe adults with such conditions. Mental illness was a label for most people with any type of disorder and it was common for people with emotional and behavioral disorders to be labeled with a mental illness. However, those terms were avoided when describing children as it seemed too stigmatizing. In the late 1900s the term "behaviorally disordered" appeared. Some professionals in the field of special education accepted the term while others felt it ignored emotional issues. In order to make a more uniformed terminology, the National Mental Health and Special Education Coalition, which consists of over thirty professional and advocacy groups, coined the term "emotional and behavioral disorders" in 1988. Criteria According to the Individuals with Disabilities Education Act an EBD classification is required if one or more of the following characteristics is excessively observed in a student over a significant amount of time: Learning challenges that cannot be explained by intellectual, sensory, or health factors. Trouble keeping up or building satisfactory relationships with peers and teachers. Inappropriate behavior (against self or others) or emotions (shares the need to harm others or self, low self-worth) in normal conditions. An overall attitude of unhappiness or depression. A tendency to develop physical symptoms or fears related with individual or school issues. The term "EBD" includes students diagnosed with schizophrenia. However, it does not have any significant bearing on students who are socially maladjusted unless they also meet the above criteria. Criticisms Providing or failing to provide an EBD classification to a student may be controversial, as the IDEA does not clarify which children would be considered "socially maladjusted". Students with a psychiatric diagnosis of conduct disorder are not guaranteed to receive additional educational services under an EBD classification. Students with an EBD classification who meet the diagnostic criteria for various disruptive behavior disorders, including attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD) do not have an automatic eligibility to receive an IEP or 504 Plan. Students considered "socially maladjusted", but ineligible for an EBD classification (i.e., students diagnosed with conduct disorder), often receive better educational services in special education classrooms or alternative schools with high structure, clear rules, and consistent consequences. Student characteristics Students with EBD are a diverse population with a wide range of intellectual and academic abilities. Males, African-Americans, and economically disadvantaged students are over-represented in the EBD population, and students with EBD are more likely to live in single-parent homes, foster homes, or other non-traditional living situations. These students also tend to have low rates of positive social interactions with peers in educational contexts. Students with EBD are often categorized as "internalizers" (e.g., have poor self-esteem, or are diagnosed with an anxiety disorder or mood disorder) or "externalizers" (e.g., disrupt classroom instruction, or are diagnosed with disruptive behavior disorders such as oppositional defiant disorder and conduct disorder). Male students may be over-represented in the EBD population because they appear to be more likely to exhibit disruptive externalizing behavior that interferes with classroom instruction. Females may be more likely to exhibit internalizing behavior that does not interfere with classroom instruction, though to what extent this perception is due to social expectations of differences in male and female behavior is unclear. In any case, it is important to note that both internalizing and externalizing behaviour can and do occur in either sex; Students with EBD are also at an increased risk for learning disabilities, school dropout, substance abuse, and juvenile delinquency. Internalizing and externalizing behavior A person with EBD with "internalizing" behavior may have poor self-esteem, have depression, experience loss of interest in social, academic, and other life activities, and may exhibit non-suicidal self-injury or substance abuse. Students with internalizing behavior may also have a diagnosis of separation anxiety or another anxiety disorder, post-traumatic stress disorder (PTSD), specific or social phobia, obsessive–compulsive disorder (OCD), panic disorder, and/or an eating disorder. Teachers are more likely to write referrals for students that are overly disruptive. Screening tools used to detect students with high levels of "internalizing" behavior are not sensitive and are rarely used in practice. Students with EBD with "externalizing" behavior may be aggressive, non-compliant, extroverted, or disruptive. Students with EBD that show externalizing behavior are often diagnosed with attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder,autism spectrum disorder and/or bipolar disorder; however, this population can also include typically developing children that have learned to exhibit externalizing behavior for various reasons (e.g., escape from academic demands or access to attention). These students often have difficulty inhibiting emotional responses resulting from anger, frustration, and disappointment. Students who "externalize" exhibit behaviors such as insulting, provoking, threatening, bullying, cursing, and fighting, along with other forms of aggression. Male students with EBD exhibit externalizing behavior more often than their female counterparts. Children and adolescents with ADD or ADHD may display different types of externalizing behavior and should be either medicated or going through behavioral treatment for their diagnosis. Adolescents with severe ADHD would likely benefit most from both medication and behavioral treatment. Younger children should go through behavioral treatment before being treated with medication. Another recommended form of treatment for children and adolescents diagnosed with ADHD would be counseling from a mental health professional. Treatment options will improve performance of children and adolescents on emotion recognition tasks, specifically response time as there is no difficulty recognizing human emotions. The degree of required treatments vary depending on the degree of ADD or ADHD the individual has. Treatment for these types of behaviors should include the parents as it is evident that their parenting skills impact on how their child deals with their symptoms, especially when at a younger age. Parents going through a parenting skills training program were reported a decrease in internalizing and externalizing behavior in their children post-training program. The program included learning how to give positive attention, increase good behavior with small frequent rewards and specific praise as well as learning how to decrease attention when the child behaved poorly. Effect in cognition In recent years, many researchers have been interested in exploring the relationship between emotional disorders and cognition. Evidence has revealed that there is a relationship between the two. Strauman (1989) investigated how emotional disorders shape a person's cognitive structure, that is, the mental processes people utilize to make sense of the world around them. He recruited three groups of individuals: those with social phobias, those with depression, and controls with no emotional disorder diagnosis. He wanted to determine whether these groups had a cognitive structure showing an actual/ideal (AI) discrepancy (referring to an individual not believing that they have achieved their personal desires) or actual/own/other (AOO) discrepancy (referring to an individual's actions not living up to what their significant other believes that they need to be). He found that depressed individuals had the highest AI discrepancy and social phobics had the greatest AOO discrepancy, while the controls were lower or in between the two for both discrepancies. Specific cognitive processes (e.g., attention) may be different in those with emotional disorders. MacLeod, Mathews, and Tata (1986) tested the reaction times of 32 participants, some of whom were diagnosed with Generalized Anxiety disorder, when presented with threatening words. They found that when threatening words were presented, people with greater anxiety tended to have increased selective attention, meaning that they reacted quicker to a stimulus in an area where a threatening word was just presented (32-59ms faster). When in the control group, subjects reacted slower when there was a threatening word proceeding the stimulus (16-32ms slower). Emotional disorders can also alter the way people regulate their emotions. Joormann and Gotlib (2010) conducted a study with depressed, or previously depressed, individuals to test this. They found that, when compared to individuals who have never had a depressive episode, previously and currently depressed individuals tended to use maladaptive emotion regulation strategies (such as rumination or brooding) more. They also found that when depressed individuals displayed cognitive inhibition (slowing of response to a variable that had been previously ignored) when asked to describe a negative word (ignored variable was a positive word), they were less likely to ruminate or brood. When they displayed cognitive inhibition when asked to describe a positive word (ignored variable was a negative word), they were more likely to reflect. Services in the United States There are many types of services available to EBD students, referenced below. One service is one-on-one support (or an aide) who assists in everyday activities and academics. Another service is foundations offer behavior services as well as counseling support. Some services include classrooms that are dedicated to educational foundations and work on building the student up possessively. States also offer dedicated schools with multiple resources that help students with EBD excel and transition (back) into local schools. Texas The state of Texas has the Texas Behavior Support Initiative (TBSI) authorized by Senate Bill 1196 and Texas Administrative Code §89.1053. With its design to provide knowledge for the use of constructive behavior interventions and to aid students, including students with disabilities. TBSI meets the legislative requirements for the use of restraint and time-out, along with providing the baseline work for behavior strategies and prevention throughout each environment. New York The state of New York has the Foundations Behavioral Health that has been approved out of state educations and residential provider with the New York State Education Dept. Foundations offer Academic and Behavioral Health Services to students between the ages of 14 and 21. This program allows students educational experience to have strategic interventions to aid their social and behavioral functioning. Some of the program's highlights include Functional Behavioral Assessment (FBA), Behavioral Intervention Plan (BIP) & Community Based Instruction (CBI). California The state of California has Spectrum Center classrooms in Los Angeles and the San Francisco area which are providing Emotional Disabilities and Behavioral Services. They provide academic classrooms for students who are actively working to improve grade-level standards and working toward getting their high school diploma. The main practice is the use of Positive Behavior Interventions and Supports (PBIS). PBIS instructional practices help students determine their skill level and progress, restore their skills through direct instruction, knowing the standards on their grade level and small group counseling. Michigan The state of Michigan has a Behavioral Education Center (BEC) in Bangor. Its purpose is to aid local schools directs with students between the ages of 5 and 26 years old with EBD's. Along with having students use appropriate behaviors and skills to successfully return to their local school setting. Classroom programs, consultation, coaching, and professional development services are available within the school districts. Florida The state of Florida has Students with Emotional/Behavioral Disabilities Network (SEDNET). SEDNET projects across the state aid the local school districts to work with those at-risk of EBD's. “Dealing with adverse behavior in the educational environment,” it serves students who poorly function at home, school, or community due to drugs and substance abuse or mental health issues. SEDNET 2A Services: Family Services Planning Team (FSPT)- agencies, school officials and SEDNET meet with parents to assist and aid the child's poor performance at school and home. Positive Behavior Support providing technical assistance to promote positive behavior. Classroom Observation/Teacher Consultation- working with EBD children using successful strategies and tips in a classroom environment. References External links Behaviour Management (EBD) Review Group: Published reviews School and classroom behaviour Disability by type Mental disorders diagnosed in childhood Emotional issues

Aboulomania

Aboulomania is a mental disorder in which the patient displays pathological indecisiveness. The term was created in 1883 by the neurologist William Alexander Hammond, who defined it as: ‘a form of insanity characterised by an inertness, torpor, or paralysis of the will’. It is typically associated with anxiety, stress, depression, and mental anguish, severely affecting one's ability to function socially. In extreme cases, difficulties arising from the disorder can lead to suicide. Although many people are indecisive at times, it is rarely to the extent of obsession. The part of the brain that is tied to making rational choices, the prefrontal cortex, can hold several pieces of information at any given time. This may quickly overwhelm somebody when trying to make decisions, regardless of the importance of that decision. They may come up with reasons that their decisions will turn out badly, causing them to over-analyze every situation critically in a classic case of paralysis by analysis. Lack of information, valuation difficulty, and outcome uncertainty can become an obsession for those with aboulomania. Although it is a recognised and diagnosable mental disorder, aboulomania is not recognised by the Diagnostic and Statistical Manual of Mental disorders (DSM-5). Symptoms Aboulomania is characterised by great indecision and an inability to, or difficulty in, making any kind of choice in a person's daily life. This significantly affects functioning, specifically the ability to function socially, making it difficult to maintain family and personal relationships. There is a significant overlap between the symptoms of aboulomania and obsessive compulsive disorder (OCD). With pathological doubt and significant impairment in decision-making being prevalent across both conditions. Many OCD patients can be considered to have a form of pathological indecision, which is also displayed in aboulomania patients. Some aboulomania symptoms are: Lack of self confidence Avoiding spending time alone High levels of uncertainty and anxiety Anticipatory anxiety regarding decisions, usually leading to mental blocks Avoiding personal responsibility, e.g making decisions Decision-making process takes a long time Decision-making process is extremely difficult Difficulty functioning independently or making decisions without support from others Over-analysis of situations Dysfunctional post-decision behaviour, e.g worry, re-assessing of decisions Obsessing over inability to make decisions Some level of indecision exists within normal psychopathology, and it has been found that having extensive choice is demotivating to consumers in supermarkets, who prefer limited-choice contexts. However, this indecision is rarely to the extent of obsession. According to the DSM-IV definition, when symptoms become clinically significant, and associated with distress and impairment to the functioning of the individual, they can be considered part of a mental disorder. When the symptoms are relating to indecision this disorder may be aboulomania. It has also been found that indecision is a common characteristic in mental disorders like depression, and is associated with OCD tendencies, conditions both associated with aboulomania. Risk factors The underlying causes of aboulomania have not been empirically proven. The factors contributing towards the development of aboulomania are likely a combination of both environmental factors, taking place during development, and biological factors. Biological factors The pre-frontal cortex of the brain, the cortex responsible for decision-making and making conscious decisions, may be directly involved in the condition. It has been found that human patients with damage to their pre-frontal cortex exhibit poor decision-making. It is speculated that individuals suffering from aboulomania have an irregularly functioning pre-frontal cortex, and so develop and obsession with over-analysis and outcome uncertainty regarding decisions. Environmental factors Some researchers believe that parenting styles can lead to the development of aboulomania, especially among individuals susceptible to the disorder due to biological factors. Parenting styles that are overprotective or authoritarian, as well as over-involvement or intrusive behaviours from the primary caregiver, can encourage dependence in the child. Parents will be seen to reward loyalty and reject or punish the child's attempts to gain independence. This creates significant doubts and uncertainty in the individual regarding their ability to function independently of others. Parental over-involvement may arise from the caregiver's own dependency needs, which are fulfilled by the child's dependence. Individuals with aboulomania have often been socially humiliated by others in their developmental years. Bullying among children is broadly associated with adverse mental health outcomes, such as developing depression and anxiety, conditions both closely associated with aboulomania. Aboulomania development may also be triggered by the shame, insecurities and lack of self-trust which arise from the bullying. The child develops suspicions that they are incapable of living autonomously, which are then reinforced by the parenting style and behaviours of their primary caregiver. In response to these feelings, they portray a helplessness that elicits caregiving behaviour by others in their lives. Diagnosis and treatment For the diagnosis of aboulomania, a mental professional must initially eliminate physical illness or neurological damage as an explanation for the patient's symptoms. To do this, the medical professional must perform physical examinations and a complete medical history. Then the patient can be referred to a psychiatrist who assesses the prevalence of aboulomania using a clinical interview relating to their symptoms. There are currently no laboratory tests to diagnose aboulomania specifically. But, there are assessment tools available to psychiatrists to aid in the evaluation of aboulomania: The Minnesota Multiphasic Personality Inventory (MMPI) The Millon Clinical Multiaxal Inventory - Fourth Edition (MCMI-IV) The Rorschach Psychodiagnostic Test The Thematic Apperception Test (TAT) Psychotherapy is the preferred method for treating aboulomania, to reduce the adverse effects of patients’ symptoms, which may be similar to those of people suffering from OCD, anxiety or depression. Therapy can be used to help the patient become more independent, one method for this may be assertiveness training to help develop self-confidence. Medication can also be used to treat patients with aboulomania if it is comorbid with other mental disorders, such as depression or anxiety. Criticisms The majority of credible sources used are not specific to aboulomania but have been related to a specific aspect of the mental disorder. For example, the book ‘Preventing Bullying Through Science, Policy, and Practice’ which was connected to the impacts of childhood upbringing on the later development of aboulomania. References Aboulomania: Understanding the Struggles of Indecisiveness Mania

Executive dysfunction

In psychology and neuroscience, executive dysfunction, or executive function deficit, is a disruption to the efficacy of the executive functions, which is a group of cognitive processes that regulate, control, and manage other cognitive processes. Executive dysfunction can refer to both neurocognitive deficits and behavioural symptoms. It is implicated in numerous psychopathologies and mental disorders, as well as short-term and long-term changes in non-clinical executive control. Executive dysfunction is the mechanism underlying ADHD paralysis, and in a broader context, it can encompass other cognitive difficulties like planning, organizing, initiating tasks and regulating emotions. It is a core characteristic of ADHD and can elucidate numerous other recognized symptoms. Overview Executive functioning is a theoretical construct representing a domain of cognitive processes that regulate, control, and manage other cognitive processes. Executive functioning is not a unitary concept; it is a broad description of the set of processes involved in certain areas of cognitive and behavioural control. Executive processes are integral to higher brain function, particularly in the areas of goal formation, planning, goal-directed action, self-monitoring, attention, response inhibition, and coordination of complex cognition and motor control for effective performance. Deficits of the executive functions are observed in all populations to varying degrees, but severe executive dysfunction can have devastating effects on cognition and behaviour in both individual and social contexts on a day-to-day basis. Executive dysfunction does occur to a minor degree in all individuals on both short-term and long-term scales. In non-clinical populations, the activation of executive processes appears to inhibit further activation of the same processes, suggesting a mechanism for normal fluctuations in executive control. Decline in executive functioning is also associated with both normal and clinical aging. The decline of memory processes as people age appears to affect executive functions, which also points to the general role of memory in executive functioning. Executive dysfunction appears to consistently involve disruptions in task-oriented behavior, which requires executive control in the inhibition of habitual responses and goal activation. Such executive control is responsible for adjusting behaviour to reconcile environmental changes with goals for effective behaviour. Impairments in set shifting ability are a notable feature of executive dysfunction; set shifting is the cognitive ability to dynamically change focus between points of fixation based on changing goals and environmental stimuli. This offers a parsimonious explanation for the common occurrence of impulsive, hyperactive, disorganized, and aggressive behaviour in clinical patients with executive dysfunction. A 2011 study confirms there is a lack of self-control, greater impulsivity, and greater disorganization with executive dysfunction, leading to greater amounts of aggressive behavior. Executive dysfunction, particularly in working memory capacity, may also lead to varying degrees of emotional dysregulation, which can manifest as chronic depression, anxiety, or hyperemotionality. Russell Barkley proposed a hybrid model of the role of behavioural disinhibition in the presentation of ADHD, which has served as the basis for much research of both ADHD and broader implications of the executive system. Other common and distinctive symptoms of executive dysfunction include utilization behaviour, which is compulsive manipulation/use of nearby objects due simply to their presence and accessibility (rather than a functional reason); and imitation behaviour, a tendency to rely on imitation as a primary means of social interaction. Research also suggests that executive set shifting is a co-mediator with episodic memory of feeling-of-knowing (FOK) accuracy, such that executive dysfunction may reduce FOK accuracy. There is some evidence suggesting that executive dysfunction may produce beneficial effects as well as maladaptive ones. Abraham et al. demonstrate that creative thinking in schizophrenia is mediated by executive dysfunction, and they establish a firm etiology for creativity in psychoticism, pinpointing a cognitive preference for broader top-down associative thinking versus goal-oriented thinking, which closely resembles aspects of ADHD. It is postulated that elements of psychosis are present in both ADHD and schizophrenia/schizotypy due to dopamine overlap. Cause The cause of executive dysfunction is heterogeneous, as many neurocognitive processes are involved in the executive system and each may be compromised by a range of genetic and environmental factors. Learning and development of long-term memory play a role in the severity of executive dysfunction through dynamic interaction with neurological characteristics. Studies in cognitive neuroscience suggest that executive functions are widely distributed throughout the brain, though a few areas have been isolated as primary contributors. Executive dysfunction is studied extensively in clinical neuropsychology as well, allowing correlations to be drawn between such dysexecutive symptoms and their neurological correlates. A 2015 study confirmed that executive dysfunction has a positive correlation with neurodevelopmental disorders such as autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD). Executive processes are closely integrated with memory retrieval capabilities for overall cognitive control; in particular, goal/task-information is stored in both short-term and long-term memory, and effective performance requires effective storage and retrieval of this information. Executive dysfunction characterizes many of the symptoms observed in numerous clinical populations. In the case of acquired brain injury and neurodegenerative diseases there is a clear neurological etiology producing dysexecutive symptoms. Conversely, syndromes and disorders are defined and diagnosed based on their symptomatology rather than etiology. Thus, while Parkinson's disease, a neurodegenerative condition, causes executive dysfunction, a disorder such as attention-deficit/hyperactivity disorder is a classification given to a set of subjectively-determined symptoms implicating executive dysfunction – models from the 1990s and 2000s indicate that such clinical symptoms are caused by executive dysfunction. Neurophysiology Executive functioning is not a unitary concept. Many studies have been conducted in an attempt to pinpoint the exact regions of the brain that lead to executive dysfunction, producing a vast amount of often conflicting information indicating wide and inconsistent distribution of such functions. A common assumption is that disrupted executive control processes are associated with pathology in prefrontal brain regions. This is supported to some extent by the primary literature, which shows both pre-frontal activation and communication between the pre-frontal cortex and other areas associated with executive functions such as the basal ganglia and cerebellum. In most cases of executive dysfunction, deficits are attributed to either frontal lobe damage or dysfunction, or to disruption in fronto-subcortical connectivity. Neuroimaging with PET and fMRI has confirmed the relationship between executive function and functional frontal pathology. Neuroimaging studies have also suggested that some constituent functions are not discretely localized in prefrontal regions. Functional imaging studies using different tests of executive function have implicated the dorsolateral prefrontal cortex to be the primary site of cortical activation during these tasks. In addition, PET studies of patients with Parkinson's disease have suggested that tests of executive function are associated with abnormal function in the globus pallidus and appear to be the genuine result of basal ganglia damage. With substantial cognitive load, fMRI signals indicate a common network of frontal, parietal and occipital cortices, thalamus, and the cerebellum. This observation suggests that executive function is mediated by dynamic and flexible networks that are characterized using functional integration and effective connectivity analyses. The complete circuit underlying executive function includes both a direct and an indirect circuit. The neural circuit responsible for executive functioning is, in fact, located primarily in the frontal lobe. This main circuit originates in the dorsolateral prefrontal cortex/orbitofrontal cortex and then projects through the striatum and thalamus to return to the prefrontal cortex. Not surprisingly, plaques and tangles in the frontal cortex can cause disruption in functions as well as damage to the connections between prefrontal cortex and the hippocampus. Another important point is in the finding that structural MRI images link the severity of white matter lesions to deficits in cognition. The emerging view suggests that cognitive processes materialize from networks that span multiple cortical sites with closely collaborative and over-lapping functions. A challenge for future research will be to map the multiple brain regions that might combine with each other in a vast number of ways, depending on the task requirements. Genetics Certain genes have been identified with a clear correlation to executive dysfunction and related psychopathologies. According to Friedman et al. (2008), the heritability of executive functions is among the highest of any psychological trait. The dopamine receptor D4 gene (DRD4) with 7'-repeating polymorphism (7R) has been repeatedly shown to correlate strongly with impulsive response style on psychological tests of executive dysfunction, particularly in clinical ADHD. The catechol-o-methyl transferase gene (COMT) codes for an enzyme that degrades catecholamine neurotransmitters (DA and NE), and its Val158Met polymorphism is linked with the modulation of task-oriented cognition and behavior (including set shifting) and the experience of reward, which are major aspects of executive functioning. COMT is also linked to methylphenidate (stimulant medication) response in children with ADHD. Both the DRD4/7R and COMT/Val158Met polymorphisms are also correlated with executive dysfunction in schizophrenia and schizotypal behaviour. Evolutionary perspective The prefrontal lobe controls two related executive functioning domains. The first is mediation of abilities involved in planning, problem solving, and understanding information, as well as engaging in working memory processes and controlled attention. In this sense, the prefrontal lobe is involved with dealing with basic, everyday situations, especially those involving metacognitive functions. The second domain involves the ability to fulfill biological needs through the coordination of cognition and emotions which are both associated with the frontal and prefrontal areas. From an evolutionary perspective, it has been hypothesized that the executive system may have evolved to serve several adaptive purposes. The prefrontal lobe in humans has been associated both with metacognitive executive functions and emotional executive functions. Theory and evidence suggest that the frontal lobes in other primates also mediate and regulate emotion, but do not demonstrate the metacognitive abilities that are demonstrated in humans. This uniqueness of the executive system to humans implies that there was also something unique about the environment of ancestral humans, which gave rise to the need for executive functions as adaptations to that environment. Some examples of possible adaptive problems that would have been solved by the evolution of an executive system are: social exchange, imitation and observational learning, enhanced pedagogical understanding, tool construction and use, and effective communication. In a similar vein, some have argued that the unique metacognitive capabilities demonstrated by humans have arisen out of the development of a sophisticated language (symbolization) systems and culture. Moreover, in a developmental context, it has been proposed that each executive function capability originated as a form of public behaviour directed at the external environment, but then became self-directed, and then finally, became private to the individual, over the course of the development of self-regulation. These shifts in function illustrate the evolutionarily salient strategy of maximizing longer-term social consequences over near-term ones, through the development of an internal control of behaviour. Testing and measurement There are several measures that can be employed to assess the executive functioning capabilities of an individual. Although a trained non-professional working outside of an institutionalized setting can legally and competently perform many of these measures, a trained professional administering the test in a standardized setting will yield the most accurate results. Clock drawing test The Clock drawing test (CDT) is a brief cognitive task that can be used by physicians who suspect neurological dysfunction based on history and physical examination. It is relatively easy to train non-professional staff to administer a CDT. Therefore, this is a test that can easily be administered in educational and geriatric settings and can be utilized as a precursory measure to indicate the likelihood of further/future deficits. Also, generational, educational and cultural differences are not perceived as impacting the utility of the CDT. The procedure of the CDT begins with the instruction to the participant to draw a clock reading a specific time (generally 11:10). After the task is complete, the test administrator draws a clock with the hands set at the same specific time. Then the patient is asked to copy the image. Errors in clock drawing are classified according to the following categories: omissions, perseverations, rotations, misplacements, distortions, substitutions and additions. Memory, concentration, initiation, energy, mental clarity and indecision are all measures that are scored during this activity. Those with deficits in executive functioning will often make errors on the first clock but not the second. In other words, they will be unable to generate their own example, but will show proficiency in the copying task. Stroop task The cognitive mechanism involved in the Stroop task is referred to as directed attention. The Stroop task requires the participant to engage in and allows assessment of processes such as attention management, speed and accuracy of reading words and colours and of inhibition of competing stimuli. The stimulus is a colour word that is printed in a different colour than what the written word reads. For example, the word "red" is written in a blue font. One must verbally classify the colour that the word is displayed/printed in, while ignoring the information provided by the written word. In the aforementioned example, this would require the participant to say "blue" when presented with the stimulus. Although the majority of people will show some slowing when given incompatible text versus font colour, this is more severe in individuals with deficits in inhibition. The Stroop task takes advantage of the fact that most humans are so proficient at reading colour words that it is extremely difficult to ignore this information, and instead acknowledge, recognize and say the colour the word is printed in. The Stroop task is an assessment of attentional vitality and flexibility. More modern variations of the Stroop task tend to be more difficult and often try to limit the sensitivity of the test. Trail-making test Another prominent test of executive dysfunction is known as the Trail-making test. This test is composed of two main parts (Part A & Part B). Part B differs from Part A specifically in that it assesses more complex factors of motor control and perception. Part B of the Trail-making test consists of multiple circles containing letters (A-L) and numbers (1-12). The participant's objective for this test is to connect the circles in order, alternating between number and letter (e.g. 1-A-2-B) from start to finish. The participant is required not to lift their pencil from the page. The task is also timed as a means of assessing speed of processing. Set-switching tasks in Part B have low motor and perceptual selection demands, and therefore provide a clearer index of executive function. Throughout this task, some of the executive function skills that are being measured include impulsivity, visual attention and motor speed. Wisconsin card sorting test The Wisconsin Card Sorting Test (WCST) is used to determine an individual's competence in abstract reasoning, and the ability to change problem-solving strategies when needed. These abilities are primarily determined by the frontal lobes and basal ganglia, which are crucial components of executive functioning; making the WCST a good measure for this purpose. The WCST utilizes a deck of 128 cards that contains four stimulus cards. The figures on the cards differ with respect to color, quantity, and shape. The participants are then given a pile of additional cards and are asked to match each one to one of the previous cards. Typically, children between ages 9 and 11 are able to show the cognitive flexibility that is needed for this test. In clinical populations The executive system's broad range of functions relies on, and is instrumental in, a broad range of neurocognitive processes. Clinical presentation of severe executive dysfunction that is unrelated to a specific disease or disorder is classified as a dysexecutive syndrome, and often appears following damage to the frontal lobes of the cerebral cortex. As a result, executive dysfunction is implicated etiologically and/or co-morbidly in many psychiatric illnesses, which often show the same symptoms as the dysexecutive syndrome. It has been assessed and researched extensively in relation to cognitive developmental disorders, psychotic disorders, affective disorders, and conduct disorders, as well as neurodegenerative diseases and acquired brain injury (ABI). Environmental dependency syndrome is a dysexecutive syndrome marked by significant behavioural dependence on environmental cues and is marked by excessive imitation and utilization behaviour. It has been observed in patients with a variety of etiologies including ABI, exposure to phendimetrazine tartrate, stroke, and various frontal lobe lesions. Schizophrenia Schizophrenia is commonly described as a mental disorder in which a person becomes detached from reality because of disruptions in the pattern of thinking and perception. Although the etiology is not completely understood, it is closely related to dopaminergic activity and is strongly associated with both neurocognitive and genetic elements of executive dysfunction. Individuals with schizophrenia may demonstrate amnesia for portions of their episodic memory. Observed damage to explicit, consciously accessed memory is generally attributed to the fragmented thoughts that characterize the disorder. These fragmented thoughts are suggested to produce a similarly fragmented organization in memory during encoding and storage, making retrieval more difficult. However, implicit memory is generally preserved in patients with schizophrenia. Patients with schizophrenia demonstrate spared performance on measures of visual and verbal attention and concentration, as well as on immediate digit span recall, suggesting that observed deficits cannot be attributed to deficits in attention or short-term memory. However, impaired performance was measured on psychometric measures assumed to assess higher order executive function. Working memory and multi-tasking impairments typically characterize the disorder. Persons with schizophrenia also tend to demonstrate deficits in response inhibition and cognitive flexibility. Patients often demonstrate noticeable deficits in the central executive component of working memory as conceptualized by Baddeley and Hitch. However, performance on tasks associated with the phonological loop and visuospatial sketchpad are typically less affected. More specifically, patients with schizophrenia show impairment to the central executive component of working memory, specific to tasks in which the visuospatial system is required for central executive control. The phonological system appears to be more generally spared overall. Attention deficit hyperactivity disorder A triad of core symptoms – inattention, hyperactivity, and impulsivity – characterize attention deficit hyperactivity disorder (ADHD). Individuals with ADHD often experience problems with organization, discipline, and setting priorities, and these difficulties often persist from childhood through adulthood. In both children and adults with ADHD, an underlying executive dysfunction involving the prefrontal regions and other interconnected subcortical structures has been found. As a result, people with ADHD commonly perform more poorly than matched controls on interference control, mental flexibility and verbal fluency. Also, a more central impairment in self-regulation is noted in cases of ADHD. However, some research has suggested the possibility that the severity of executive dysfunction in individuals with ADHD declines with age as they learn to compensate for the aforementioned deficits. Thus, a decrease in executive dysfunction in adults with ADHD as compared to children with ADHD is thought reflective of compensatory strategies employed on behalf of the adults (e.g. using schedules to organize tasks) rather than neurological differences. Although ADHD has typically been conceptualized in a categorical diagnostic paradigm, it has also been proposed that this disorder should be considered within a more dimensional behavioural model that links executive functions to observed deficits. Proponents argue that classic conceptions of ADHD falsely localize the problem at perception (input) rather than focusing on the inner processes involved in producing appropriate behaviour (output). Moreover, others have theorized that the appropriate development of inhibition (something that is seen to be lacking in individuals with ADHD) is essential for the normal performance of other neuropsychological abilities such as working memory, and emotional self-regulation. Thus, within this model, deficits in inhibition are conceptualized to be developmental and the result of atypically operating executive systems. Both ADHD and obesity are complicated disorders and each produces a large impact on an individual's social well-being. This being both a physical and psychological disorder has reinforced that obese individuals with ADHD need more treatment time (with associated costs), and are at a higher risk of developing physical and emotional complications. The cognitive ability to develop a comprehensive self-construct and the ability to demonstrate capable emotion regulation is a core deficit observed in people with ADHD and is linked to deficits in executive function. Overall, low executive functioning seen in individuals with ADHD has been correlated with tendencies to overeat, as well as with emotional eating. This particular interest in the relationship between ADHD and obesity is rarely clinically assessed and may deserve more attention in future research. Autism spectrum disorder Autism is diagnosed based on the presence of markedly abnormal or impaired development in social interaction and communication and a markedly restricted or repetitive repertoire of stereotypic movements, activities, and/or interests. It is a disorder that is defined according to behaviour as no specific biological markers are known. Due to the variability in severity and impairment in functioning exhibited by autistic people, the disorder is typically conceptualized as existing along a continuum (or spectrum) of severity. Autistic individuals commonly show impairment in three main areas of executive functioning: Fluency. Fluency refers to the ability to generate novel ideas and responses. Although adult populations are largely underrepresented in this area of research, findings have suggested that autistic children generate fewer novel words and ideas and produce less complex responses than matched controls. Planning. Planning refers to a complex, dynamic process, wherein a sequence of planned actions must be developed, monitored, re-evaluated and updated. Autistic persons demonstrate impairment on tasks requiring planning abilities relative to typically functioning controls, with this impairment maintained over time. As might be suspected, in the case of autism comorbid with learning disability, an additive deficit is observed in many cases. Flexibility. Poor mental flexibility, as demonstrated in autistic individuals, is characterized by perseverative, stereotyped behaviour, and deficits in both the regulation and modulation of motor acts. Some research has suggested that autistic individuals experience a sort of 'stuck-in-set' perseveration that is specific to the disorder, rather than a more global perseveration tendency. These deficits have been exhibited in cross-cultural samples and have been shown to persist over time. Autistic individuals have also been shown to react slower as well as perform slower in tasks that require mental flexibility when compared to their neurotypical peers. Although there has been some debate, inhibition is generally no longer considered to be an executive function deficit in autistic people. Autistic individuals have demonstrated differential performance on various tests of inhibition, with results being taken to indicate a general difficulty in the inhibition of a habitual response. However, performance on the Stroop task, for example, has been unimpaired relative to matched controls. An alternative explanation has suggested that executive function tests that demonstrate a clear rationale are passed by autistic individuals. In this light, it is the design of the measures of inhibition that have been implicated in the observation of impaired performance rather than inhibition being a core deficit. In general, autistic individuals show relatively spared performance on tasks that do not require mentalization. These include: use of desire and emotion words, sequencing behavioural pictures, and the recognition of basic facial emotional expressions. In contrast, autistic individuals typically demonstrated impaired performance on tasks that do require mentalizing. These include: false beliefs, use of belief and idea words, sequencing mentalistic pictures, and recognizing complex emotions such as scheming. Bipolar disorder Bipolar disorder is a mood disorder that is characterized by both highs (mania) and lows (depression) in mood. These changes in mood sometimes alternate rapidly (changes within days or weeks) and sometimes not so rapidly (within weeks or months). A 2006 study provided strong evidence of cognitive impairments in individuals with bipolar disorder, particularly in executive function and verbal learning. Moreover, these cognitive deficits appear to be consistent cross-culturally, indicating that these impairments are characteristic of the disorder and not attributable to differences in cultural values, norms, or practice. Functional neuroimaging studies have implicated abnormalities in the dorsolateral prefrontal cortex and the anterior cingulate cortex as being volumetrically different in individuals with bipolar disorder. Individuals affected by bipolar disorder exhibit deficits in strategic thinking, inhibitory control, working memory, attention, and initiation that are independent of affective state. In contrast to the more generalized cognitive impairment demonstrated in persons with schizophrenia, for example, deficits in bipolar disorder are typically less severe and more restricted. It has been suggested that a "stable dys-regulation of prefrontal function or the subcortical-frontal circuitry [of the brain] may underlie the cognitive disturbances of bipolar disorder". Executive dysfunction in bipolar disorder is suggested to be associated particularly with the manic state, and is largely accounted for in terms of the formal thought disorder that is a feature of mania. It is important to note, however, that patients with bipolar disorder with a history of psychosis demonstrated greater impairment on measures of executive functioning and spatial working memory compared with bipolar patients without a history of psychosis suggesting that psychotic symptoms are correlated with executive dysfunction. Parkinson's disease Parkinson's disease (PD) primarily involves damage to subcortical brain structures and is usually associated with movement difficulties, in addition to problems with memory and thought processes. Persons affected by PD often demonstrate difficulties in working memory, a component of executive functioning. Cognitive deficits found in early PD process appear to involve primarily the fronto-executive functions. Moreover, studies of the role of dopamine in the cognition of PD patients have suggested that PD patients with inadequate dopamine supplementation are more impaired in their performance on measures of executive functioning. This suggests that dopamine may contribute to executive control processes. Increased distractibility, problems in set formation and maintaining and shifting attentional sets, deficits in executive functions such as self-directed planning, problems solving, and working memory have been reported in PD patients. In terms of working memory specifically, persons with PD show deficits in the areas of: a) spatial working memory; b) central executive aspects of working memory; c) loss of episodic memories; d) locating events in time. Spatial working memory PD patients often demonstrate difficulty in updating changes in spatial information and often become disoriented. They do not keep track of spatial contextual information in the same way that a typical person would do almost automatically. Similarly, they often have trouble remembering the locations of objects that they have recently seen, and thus also have trouble with encoding this information into long-term memory. Central executive aspects PD is often characterized by a difficulty in regulating and controlling one's stream of thought, and how memories are utilized in guiding future behaviour. Also, persons affected by PD often demonstrate perseverative behaviours such as continuing to pursue a goal after it is completed, or an inability to adopt a new strategy that may be more appropriate in achieving a goal. However, some research from 2007 suggests that PD patients may actually be less persistent in pursuing goals than typical persons and may abandon tasks sooner when they encounter problems of a higher level of difficulty. Loss of episodic memories The loss of episodic memories in PD patients typically demonstrates a temporal gradient wherein older memories are generally more preserved than newer memories. Also, while forgetting event content is less compromised in Parkinson's than in Alzheimer's, the opposite is true for event data memories. Locating events in time PD patients often demonstrate deficits in their ability to sequence information, or date events. Part of the problems is hypothesized to be due to a more fundamental difficulty in coordinating or planning retrieval strategies, rather than failure at the level of encoding or storing information in memory. This deficit is also likely to be due to an underlying difficulty in properly retrieving script information. PD patients often exhibit signs of irrelevant intrusions, incorrect ordering of events, and omission of minor components in their script retrieval, leading to disorganized and inappropriate application of script information. Treatment Medication Methylphenidate- and amphetamine-based medications are first-line treatments for ADHD. On average, these stimulants are more effective at treating core ADHD symptoms including executive dysfunction than psychosocial treatment alone. Their efficacy treating ADHD is among the highest of any psychotropic medication treating any psychiatric condition. Treatment with methylphenidate or other ADHD medications reduces core ADHD symptoms equally well with or without psychosocial treatment. However, psychosocial treatment may confer other benefits. Psychosocial treatment Since 1997, there has been experimental and clinical practice of psychosocial treatment for adults with executive dysfunction, and particularly attention-deficit/hyperactivity disorder (ADHD). Psychosocial treatment addresses the many facets of executive difficulties, and as the name suggests, covers academic, occupational and social deficits. Psychosocial treatment facilitates marked improvements in major symptoms of executive dysfunction such as time management, organization and self-esteem. One kind of psychosocial treatment has been found to be particularly helpful, Behavioral Parent Training (BPT). Behavioral Parent Training (BPT) helps parents learn, through the help of a trained mental health professional, how to help their child behave better. This outlines proper use of reward and punishment with the child, mostly using methods of positive and negative reinforcement rather than punishment. For example, taking away a positive reinforcement such as praise, as opposed to adding a punishment. Psychosocial treatments are effective for adults with attention-deficit/hyperactivity disorder (ADHD) as well. One study shows that there are a number of useful psychosocial interventions that help adults with ADHD live better lives too. These included mindfulness training, cognitive based behavioral therapy, as well as education to help the participants recognize problem behaviors in their lives. Cognitive-behavioral therapy and group rehabilitation Cognitive-behavioural therapy (CBT) is a frequently suggested treatment for executive dysfunction, but has shown limited effectiveness. However, a study of CBT in a group rehabilitation setting showed a significant increase in positive treatment outcome compared with individual therapy. Patients' self-reported symptoms on 16 different ADHD/executive-related items were reduced following the treatment period. Treatment for patients with acquired brain injury The use of auditory stimuli has been examined in the treatment of dysexecutive syndrome. The presentation of auditory stimuli causes an interruption in current activity, which appears to aid in preventing "goal neglect" by increasing the patients' ability to monitor time and focus on goals. Given such stimuli, subjects no longer performed below their age group average IQ. Patients with acquired brain injury have also been exposed to goal management training (GMT). GMT skills are associated with paper-and-pencil tasks that are suitable for patients having difficulty setting goals. From these studies there has been support for the effectiveness of GMT and the treatment of executive dysfunction due to ABI. Developmental context An understanding of how executive dysfunction shapes development has implications how we conceptualize executive functions and their role in shaping the individual. Disorders affecting children such as ADHD, along with oppositional defiant disorder, conduct disorder, high functioning autism, and Tourette's syndrome have all been suggested to involve executive functioning deficits. The main focus of research in 2000s had been on working memory, planning, set shifting, inhibition, and fluency. This research suggests that differences exist between typically functioning, matched controls, and clinical groups, on measures of executive functioning. Some research has suggested a link between a child's abilities to gain information about the world around them and having the ability to override emotions in order to behave appropriately. One study required children to perform a task from a series of psychological tests, with their performance used as a measure of executive function. The tests included assessments of: executive functions (self-regulation, monitoring, attention, flexibility in thinking), language, sensorimotor, visuospatial, and learning, in addition to social perception. The findings suggested that the development of theory of mind in younger children is linked to executive control abilities with development impaired in individuals who exhibit signs of executive dysfunction. It has been made known that young children with behavioral problems show poor verbal ability and executive functions. The exact distinction between parenting style and the importance of family structure on child development is still somewhat unclear. However, in infancy and early childhood, parenting is among the most critical external influences on child reactivity. In Mahoney's study of maternal communication, results indicated that the way mothers interacted with their children accounted for almost 25% of variability in children's rate of development. Every child is unique, making parenting an emotional challenge that should be most closely related to the child's level of emotional self-regulation (persistence, frustration and compliance). A promising approach that was being investigated in 2006 amid intellectually disabled children and their parents is responsive teaching. Responsive teaching is an early intervention curriculum designed to address the cognitive, language, and social needs of young children with developmental problems. Based on the principle of "active learning", responsive teaching is a method that is was being applauded in 1980s as adaptable for individual caregivers, children and their combined needs The effect of parenting styles on the development of children is an important area of research that seems to be forever ongoing and altering. There is no doubt that there is a prominent link between parental interaction and child development but the best child-rearing technique continues to vary amongst experts. Comorbidity Flexibility problems are more likely to be related to anxiety, and metacognition problems are more likely to be related to depression. Socio-cultural implications Education In the classroom environment, children with executive dysfunction typically demonstrate skill deficits that can be categorized into two broad domains: a) self-regulatory skills; and b) goal-oriented skills. The table below is an adaptation of McDougall's summary and provides an overview of specific executive function deficits that are commonly observed in a classroom environment. It also offers examples of how these deficits are likely to manifest in behaviour. Self-regulatory skills Goal-oriented skills Teachers play a crucial role in the implementation of strategies aimed at improving academic success and classroom functioning in individuals with executive dysfunction. In a classroom environment, the goal of intervention should ultimately be to apply external control, as needed (e.g. adapt the environment to suit the child, provide adult support) in an attempt to modify problem behaviours or supplement skill deficits. Ultimately, executive function difficulties should not be attributed to negative personality traits or characteristics (e.g. laziness, lack of motivation, apathy, and stubbornness) as these attributions are neither useful nor accurate. Several factors should be considered in the development of intervention strategies. These include, but are not limited to: developmental level of the child, comorbid disabilities, environmental changes, motivating factors, and coaching strategies. It is also recommended that strategies should take a proactive approach in managing behaviour or skill deficits (when possible), rather than adopt a reactive approach. For example, an awareness of where a student may have difficulty throughout the course of the day can aid the teacher in planning to avoid these situations or in planning to accommodate the needs of the student. People with executive dysfunction have a slower cognitive processing speed and thus often take longer to complete tasks than people who demonstrate typical executive function capabilities. This can be frustrating for the individual and can serve to impede academic progress. Disorders affecting children such as ADHD, along with oppositional defiant disorder, conduct disorder, high functioning autism and Tourette's syndrome have all been suggested to involve executive functioning deficits. The main focus of research in the 2000s had been on working memory, planning, set shifting, inhibition, and fluency. This research suggests that differences exist between typically functioning, matched controls and clinical groups, on measures of executive functioning. Moreover, some people with ADHD report experiencing frequent feelings of drowsiness. This can hinder their attention for lectures, readings, and completing assignments. Individuals with this disorder have also been found to require more stimuli for information processing in reading and writing. Slow processing may manifest in behavior as signaling a lack of motivation on behalf of the learner. However, slow processing is reflective of an impairment of the ability to coordinate and integrate multiple skills and information sources. The main concern with individuals with autism regarding learning is in the imitation of skills. This can be a barrier in many aspects such as learning about others intentions, mental states, speech, language, and general social skills. Individuals with autism tend to be dependent on the routines that they have already mastered, and have difficulty with initiating new non-routine tasks. Although an estimated 25–40% of people with autism also have a learning disability, many will demonstrate an impressive rote memory and memory for factual knowledge. As such, repetition is the primary and most successful method for instruction when teaching people with autism. Being attentive and focused for people with Tourette's syndrome is a difficult process. People affected by this disorder tend to be easily distracted and act very impulsively. That is why it is very important to have a quiet setting with few distractions for the ultimate learning environment. Focusing is particularly difficult for those who are affected by Tourette's syndrome comorbid with other disorders such as ADHD or obsessive-compulsive disorder, it makes focusing very difficult. Also, these individuals can be found to repeat words or phrases consistently either immediately after they are learned or after a delayed period of time. Criminal behaviour Prefrontal dysfunction has been found as a marker for persistent, criminal behavior. The prefrontal cortex is involved with mental functions including; affective range of emotions, forethought, and self-control. Moreover, there is a scarcity of mental control displayed by individuals with a dysfunction in this area over their behavior, reduced flexibility and self-control and their difficulty to conceive behavioral consequences, which may conclude in unstable (or criminal) behavior. In a 2008 study conducted by Barbosa & Monteiro, it was discovered that the recurrent criminals that were considered in this study had executive dysfunction. In view of the fact that abnormalities in executive function can limit how people respond to rehabilitation and re-socialization programs these findings of the recurrent criminals are justified. Statistically significant relations have been discerned between anti-social behavior and executive function deficits. These findings relate to the emotional instability that is connected with executive function as a detrimental symptom that can also be linked towards criminal behavior. Conversely, it is unclear as to the specificity of anti-social behavior to executive function deficits as opposed to other generalized neuropsychological deficits. The uncontrollable deficiency of executive function has an increased expectancy for aggressive behavior that can result in a criminal deed. Orbitofrontal injury also hinders the ability to be risk avoidant, make social judgments, and may cause reflexive aggression. A common retort to these findings is that the higher incidence of cerebral lesions among the criminal population may be due to the peril associated with a life of crime. Along with this reasoning, it would be assumed that some other personality trait is responsible for the disregard of social acceptability and reduction in social aptitude. Furthermore, some think the dysfunction cannot be entirely to blame. There are interacting environmental factors that also have an influence on the likelihood of criminal action. This theory proposes that individuals with this deficit are less able to control impulses or foresee the consequences of actions that seem attractive at the time (see above) and are also typically provoked by environmental factors. One must recognize that the frustrations of life, combined with a limited ability to control life events, can easily cause aggression and/or other criminal activities. See also Autonoetic consciousness References Self Neuropsychology Neuropsychological assessment Cognitive science Motor control

Millon Clinical Multiaxial Inventory

The Millon Clinical Multiaxial Inventory – Fourth Edition (MCMI-IV) is the most recent edition of the Millon Clinical Multiaxial Inventory. The MCMI is a psychological assessment tool intended to provide information on personality traits and psychopathology, including specific mental disorders outlined in the DSM-5. It is intended for adults (18 and over) with at least a 5th grade reading level who are currently seeking mental health services. The MCMI was developed and standardized specifically on clinical populations (i.e. patients in clinical settings or people with existing mental health problems), and the authors are very specific that it should not be used with the general population or adolescents. However, there is evidence base that shows that it may still retain validity on non-clinical populations, and so psychologists will sometimes administer the test to members of the general population, with caution. The concepts involved in the questions and their presentation make it unsuitable for those with below average intelligence or reading ability. The MCMI-IV is based on Theodore Millon's evolutionary theory and is organized according to a multiaxial format. Updates to each version of the MCMI coincide with revisions to the DSM. The fourth edition is composed of 195 true-false questions that take approximately 25–30 minutes to complete. It was created by Theodore Millon, Seth Grossman, and Carrie Millon. The test is modeled on four categories of scales: 15 Personality Pattern Scales 10 Clinical Syndrome Scales 5 Validity Scales: 3 Modifying Indices; 2 Random Response Indicators 45 Grossman Personality Facet Scales (based on Seth Grossman's theories of personality and psychopathology) Theory The Millon Clinical Multiaxial Inventories are based on Theodore Millon's evolutionary theory. Millon's theory is one of many theories of personality. Briefly the theory is divided into three core components which Millon cited as representing the most basic motivations. These core components are which each manifest in distinct polarities (in parentheses): Existence (Pleasure – Pain) Adaptation (Passive – Active) Reproduction (Self – Other) Furthermore, this theory presents personality as manifesting in three functional and structural domains, which are further divided into subdomains: Behavioral Phenomenological Intrapsychic Biophysical Finally, the Millon Evolutionary Theory outlines 15 personalities, each with a normal and abnormal presentation. The MCMI-IV is one of several measures in a body of personality assessments developed by Millon and associates based on his theory of personality. History MCMI In 1969, Theodore Millon wrote a book called Modern Psychopathology, after which he received many letters from students stating that his ideas were helpful in writing their dissertations. This was the event that prompted him to undertake test construction of the MCMI himself. The original version of the MCMI was published in 1977 and corresponds with the DSM-III. It contained 11 personality scales and 9 clinical syndrome scales. MCMI-II With the publication of the DSM-III-R, a new version of the MCMI (MCMI-II) was published in 1987 to reflect the changes made to the revised DSM. The MCMI-II contained 13 personality scales and 9 clinical syndrome scales. The antisocial-aggressive scale was separated into two separate scales, and the masochistic (self-defeating) scale was added. Additionally, 3 modifying indices added and a 3-point item-weighting system introduced. MCMI-III The MCMI-III was published in 1994 and reflected revisions made in the DSM-IV. This version eliminated specific personality scales and added scales for depressive and PTSD bringing the total number of scales to 14 personality scales, 10 clinical syndrome scales, and 5 correction scales. The previous 3-point item-weighting scale was modified to a 2-point scale. Additional content was added to include child abuse, anorexia and bulimia. The Grossman Facet scales are also new to this version. The MCMI-III is composed of 175 true-false questions that reportedly take 25–30 minutes to complete. MCMI-IV The MCMI-IV was published in 2015. This version contains 195 true-false items and takes approximately 25–30 minutes to complete. The MCMI-IV consists of 5 validity scales, 15 personality scales and 10 clinical syndrome scales. Changes from the MCMI-III include a complete normative update, both new and updated test items, changes to remain aligned to the DSM-5, the inclusion of ICD-10 code types, an updated set of Grossman Facet Scales, the addition of critical responses, and the addition of the Turbulent Personality Scale. Format The MCMI-IV contains a total of 30 scales broken down into 25 clinical scales and 5 validity scales. The 25 clinical scales are divided into 15 personality and 10 clinical syndrome scales (the clinical syndrome scales are further divided into 7 Clinical Syndromes and 3 Severe Clinical Syndromes). The personality scales are further divided into 12 Clinical Personality Patterns and 3 Severe Personality Pathology scales. Personality scales The personality scales are associated with personality patterns identified in Millon's evolutionary theory and the DSM-5 personality disorders. There are two main categories of personality scales: Clinical Personality Pattern Scales and Severe Personality Pathology Scales. Each of the personality scales contain 3 Grossman Facet Scales for a total of 45 Grossman Facet Scales. When interpreting the personality scales, the authors recommend that qualified professionals interpret the Severe Personality Pathology scales before the Clinical Personality Pattern scales as the pattern of responding indicated by the Severe Personality Pathology scale scores may also affect the scores on the Clinical Personality Pattern scales (i.e. if an individual scores high on the Severe Personality Pathology scale P (Paranoid), this may also explain the pattern of scores on the Clinical Personality Pattern scales). Grossman Facet Scales The Grossman Facet Scales were added to improve the overall clinical utility and specificity of the test, and attempt to influence future iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The hope was the DSM would adopt the prototypical feature identification method used in the MCMI to differentiate between personality disorders. There are three facet scales within each of the Clinical Personality Patterns and Severe Personality Pathology scales. Each facet scale is thought to help identify the key descriptive components of each personality scale, making it easier to evaluate slight differences in symptom presentations between people with elevated scores on the same personality scale. For instance, two profiles with an elevated score on the Borderline scale may have differences in their Temperamentally Labile facet scale scores. This would mean, for clinical treatment or assessment planning, you could have a better understanding of how quickly and spontaneously a person's mood may change, compared to others with elevated Borderline scale scores. There are also some noteworthy limitations of the Grossman facet scales. The MCMI personality scales share some of the same test items, leading to strong intercorrelations between different personality scales. Additionally, each facet consists of less than 10 items and the items are often similar to ones in other facets of the same personality scale. Thus, it is unclear how much a facet measures a unique component of a personality scale. Furthermore, statistical analysis has found some items within the facet scales may not be consistently measuring the same component as other items on that scale, with some item alpha coefficients as low as .51. For these reasons it is recommended to use supplemental information, in addition to that provided by the facet scales, to inform any assessment or treatment decisions. Summary table of personality scales Clinical syndrome scales 10 Clinical Syndrome Scales correspond with clinical disorders of the DSM-5. Similar to the personality scales, the 10 clinical syndrome scales are broken down into 7 clinical syndrome scales (A-R) and 3 severe clinical syndrome scales (SS-PP). When interpreting the clinical scales, the authors recommend that qualified professionals interpret the Severe Clinical Syndrome scales before the Clinical Syndrome scales as the pattern of responding indicated by the Severe Clinical Syndrome scale scores may also affect the scores on the Clinical Syndrome scales (e.g. if an individual scores high on the Severe P scale Clinical Syndrome scale score (e.g. Thought Disorder), this may also explain the pattern of scores on the other Clinical Syndrome scales). Summary table of clinical syndrome scales Validity scales of MCMI Modifying indices The modifying indices consist of 3 scales: the Disclosure Scale (X), the Desirability Scale (Y) and the Debasement Scale (Z). These scales are used to provide information about a patient's response style, including whether they presented themselves in a positive light (elevated Desirability scale) or negative light (elevated Debasement scale). The Disclosure scale measures whether the person was open in the assessment, or if they were unwilling to share details about his/her history. Random response indicators These two scales assist in detecting random responding. In general, the Validity Scale (V) contains a number of improbable items which may indicate questionable results if endorsed. The Inconsistency Scale (W) detects differences in responses to pairs of items that should be endorsed similarly. The more inconsistent responding on pairs of items, the more confident the examiner can be that the person is responding randomly, as opposed to carefully considering their response to items. Validity The MCMI-IV was updated in 2015, with revised items and a new normative sample of 1,547 clinical patients. The process of updating the MCMI-IV was an iterative process from item generation, through item tryout, to standardization and the selection of final items to be included in the full scale. Test construction underwent three stages of validation, more commonly known as the tripartite model of test construction (theoretical-substantive validity, internal-structural validity, and external-criterion validity). As development was an iterative process, each step was reanalyzed each time items were added or eliminated. Theoretical-substantive validity The first stage was a deductive approach and involved developing a large pool of items. 245 new items were generated by the authors in accordance with relevant personality research, reference materials, and the current diagnostic criteria. These items were then administered to 449 clinical and non-clinical participants. The number of items was reduced based on a rational approach according to the degree to which they fit Millon's evolutionary theory. Items were also eliminated based on simplicity, grammar, content, and scale relevance. Internal-structural validity Once the initial item pool was reduced after piloting, the second validation stage assessed how well items interrelated, and the psychometric properties of the test were determined. 106 items were retained and administered along with the 175 MCMI-III items. The ability of the MCMI items to give reliable indications of the domains of interest were examined using internal consistency and test-retest reliability. Internal consistency is the extent to which the items on a scale generally measure the same thing. Cronbach's alpha values (an estimate of internal consistency) median (average) values were 0.84 for the personality pattern scales, 0.83 for the clinical syndrome scales, and 0.80 for the Grossman Facet Scales. Test-retest reliability is an estimate of the stability of the responses in the same person over a brief period of time. Examining test-retest reliability requires administering the items from the MCMI-IV at two different time periods. The median testing interval between administrations was 13 days. The higher the correlation between scores at two time points, more stable the measure is. Based on 129 participants, the test-retest reliability of the MCMI-IV personality and clinical syndrome scales ranged from 0.73 (Delusional) to 0.93 (Histrionic) with a most values above 0.80. These statistics indicate that the measure is highly stable over a short period of time; however, no long-term data are available. After examining the psychometrics of these "tryout" items, 50 items were replaced, resulting in 284 items that were administered to the standardization sample of 1,547 clinical patients. External-criterion validity The final validation stage included examining convergent and discriminative validity of the test, which is assessed by correlating the test with similar/dissimilar instruments. Most correlations between the MCMI-IV Personality Pattern scales and the MMPI-2-RF (another widely used and validated measure of personality psychopathology) Restructured Clinical scales were low to moderate. Some, but not all, of the MCMI-IV Clinical Syndrome scales were correlated moderately to highly with the MMPI-2-RF Restructured Clinical and Specific Problem scales. The authors describe these relationships as "support for the measurement of similar constructs" across measures and that the validity correlations are consistent with the "argument that the two assessments are best used complimentarily to elucidate personality and clinical symptomatology in the therapeutic context". Scoring system Patients' raw scores are converted to Base Rate (BR) scores to allow comparison between the personality indices. Converting scores to a common metric is typical in psychological testing so test users can compare the scores across different indices. However, most psychological tests use a standard score metric, such as a T-score; the BR metric is unique to the Millon instruments. Although the Millon instruments emphasize personality functioning as a spectrum from healthy to disordered, the developers found it important to develop various clinically relevant thresholds or anchors for scores. BR scores are indexed on a scale of 0 – 115, with 0 representing a raw score of 0, a score of 60 representing the median of a clinical distribution, 75 serving as the cut score for presence of disorder, 85 serving as the cut score for prominence of disorder, and 115 corresponding to the maximum raw score. BR scores falling in the 60-74 range represent normal functioning, 75-84 correspond to abnormal personality patterns but average functioning, and BR scores above 85 are considered clinically significant (i.e., representing a diagnosis and functional impairment). Conversion from raw scores to BR scores is relatively complex, and its derivation is based largely on the characteristics of a sample of 235 psychiatric patients, from which developers obtained MCMI profiles and clinician ratings of the examinees’ level of functioning and diagnosis. The median raw score for each scale within this sample was assigned a BR score of 60, and BR scores of 75 and 85 were assigned to raw score values that corresponded to the base rates of presence and prominence within the sample, respectively, of the condition represented by each scale. Intermediate values were interpolated between the anchor scores. In addition, “corrections” to the BR scores are made to adjust for each examinee's response style as reflected by scores on the Modifying Indices. For example, if a Modifying Index score suggests that an examinee was not sufficiently candid (e.g., employed a socially desirable response style), BR scores are adjusted upward to reflect greater severity than the raw scores would suggest. Accordingly, the test is not appropriate for nonclinical populations or those without psychopathological concerns, as BR scores may adjust and indicate pathology in a case of normal functioning. Because computation of BR scores is conducted via computer (or mail-in) scoring, the complex modifying process is not transparent to test users. Although this scaling is referred to as Base Rate scores, their values are anchored to base rates of psychiatric conditions in their developmental sample, and may not reflect the base rates of pathology specific to the population from which a given examinee is drawn. Further, because they are derived from a psychiatric sample, they cannot be applied meaningfully to nonpsychiatric samples, for which no norms are available and for which Modifying Indices adjustments have not been developed. Interpretation Administration and interpretation of results should only be completed by a professional with the proper qualifications. The test creators advise that test users have completed a recognized graduate training program in psychology, supervised training and experience with personality scales, and possess an understanding of Millon's underlying theory. Computer-based test interpretation reports are also available for the results of the MCMI-IV. As with all computer-based test interpretations, the authors caution that these interpretations should be considered a "professional-to-professional consultation" and integrated with other sources of information. The interpretation of the results from the MCMI-IV is a complex process that requires integrating scores from all of the scales with other available information such as history and interview. Test results may be considered invalid based on a number of different response patterns on the modifying indices. Disclosure is the only score in the MCMI-IV in which the raw scores are interpreted and in which a particularly low score is clinically relevant. A raw score above 114 or below 7 is considered not to be an accurate representation of the patient's personality style as they either over-or under-disclosed and may indicate questionable results. Desirability or Debasement base rate scores of 75 or greater indicate that the examiner should proceed with caution. Personality and Clinical Syndrome base rate scores of 75–84 are taken to indicate the presence of a personality trait or clinical syndrome (for the Clinical Syndromes scales). Scores of 85 or above indicate the persistence of a personality trait or clinical syndrome. Invalidity is a measure of random responding, ability to understand item content, appropriate attention to item content, and as an additional measure of response style. The scale is very sensitive to random responding. Scores on this scale determine whether the test protocol is valid or invalid. Similar measurement tools The MCMI is one of several self-report measurement tools designed to provide information about psychological functioning and personality psychopathology. Similar tests include the Minnesota Multiphasic Personality Inventory and the Personality Assessment Inventory. See also Clinical psychology Personality test Psychological testing References External links Millon Clinical Multiaxial Inventory-III, at Pearson Education, Inc. Personality tests

Apophenia

Apophenia is the tendency to perceive meaningful connections between unrelated things. The term (German: from the Greek verb ἀποφαίνειν (apophaínein)) was coined by psychiatrist Klaus Conrad in his 1958 publication on the beginning stages of schizophrenia. He defined it as "unmotivated seeing of connections [accompanied by] a specific feeling of abnormal meaningfulness". He described the early stages of delusional thought as self-referential over-interpretations of actual sensory perceptions, as opposed to hallucinations. Apophenia has also come to describe a human propensity to unreasonably seek definite patterns in random information, such as can occur in gambling. Introduction Apophenia can be considered a commonplace effect of brain function. Taken to an extreme, however, it can be a symptom of psychiatric dysfunction, for example, as a symptom in schizophrenia, where a patient sees hostile patterns (for example, a conspiracy to persecute them) in ordinary actions. Apophenia is also typical of conspiracy theories, where coincidences may be woven together into an apparent plot. Examples Pareidolia Pareidolia is a type of apophenia involving the perception of images or sounds in random stimuli. A common example is the perception of a face within an inanimate object—the headlights and grill of an automobile may appear to be "grinning". People around the world see the "Man in the Moon". People sometimes see the face of a religious figure in a piece of toast or in the grain of a piece of wood. There is strong evidence that psychedelic drugs tend to induce or enhance pareidolia. Pareidolia usually occurs as a result of the fusiform face area—which is the part of the human brain responsible for seeing faces—mistakenly interpreting an object, shape or configuration with some kind of perceived "face-like" features as being a face. Gambling Gamblers may imagine that they see patterns in the numbers that appear in lotteries, card games, or roulette wheels, where no such patterns exist. A common example of this is the gambler's fallacy. Statistics In statistics, apophenia is an example of a type I error – the false identification of patterns in data. It may be compared to a so-called false positive in other test situations. Finance The problem of apophenia in finance has been addressed in academic articles. More specifically, within the world of finance itself, the examples most prone to apophenia are trading, structuring, sales, and compensation. Related terms In contrast to an epiphany, an apophany (i.e., an instance of apophenia) does not provide insight into the nature of reality nor its interconnectedness, but is a "process of repetitively and monotonously experiencing abnormal meanings in the entire surrounding experiential field". Such meanings are entirely self-referential, solipsistic, and paranoid—"being observed, spoken about, the object of eavesdropping, followed by strangers". Thus the English term "apophenia" has a somewhat different meaning from that which Conrad defined when he coined the term "Apophänie". Synchronicity Synchronicity can be considered synonymous with correlation, without any statement about the veracity of various causal inferences. Patternicity In 2008, Michael Shermer coined the word patternicity, defining it as "the tendency to find meaningful patterns in meaningless noise". Agenticity In The Believing Brain (2011), Shermer wrote that humans have "the tendency to infuse patterns with meaning, intention, and agency", which he called agenticity. Clustering illusion A clustering illusion is a type of cognitive bias in which a person sees a pattern in a random sequence of numbers or events. Many theories have been disproved as a result of this bias being highlighted. One case, during the early 2000s, involved the occurrence of breast cancer among employees of ABC Studios in Queensland. A study found that the incidence of breast cancer at the studios was six times the rate in the rest of Queensland. An examination found no correlation between the heightened incidence and any factors related to the site, or any genetic or lifestyle factors of the employees. Causes Although there is no confirmed reason as to why apophenia occurs, there are some respected theories. Models of pattern recognition Pattern recognition is a cognitive process that involves retrieving information either from long-term, short-term, or working memory and matching it with information from stimuli. There are three different ways in which this may happen and go wrong, resulting in apophenia. Template matching The stimulus is compared to templates, which are abstracted or partial representations of previously seen stimuli. These templates are stored in long-term memory as a result of past learning or educational experiences. For example, D, d, D, d, D and d are all recognized as the same letter. Template-matching detection processes, when applied to more complex data sets (such as, for example, a painting or clusters of data) can result in the wrong template being matched. A false positive detection will result in apophenia. Prototype matching This is similar to template matching, except for the fact that prototypes are complete representations of a stimulus. The prototype need not be something that has been previously seen—for example it might be an average or amalgam of previous stimuli. Crucially, an exact match is not needed. An example of prototype matching would be to look at an animal such as a tiger and instead of recognizing that it has features that match the definition of a tiger (template matching), recognizing that it's similar to a particular mental image one has of a tiger (prototype matching). This type of pattern recognition can result in apophenia based on the fact that since the brain is not looking for exact matches, it can pick up some characteristics of a match and assume it fits. This is more common with pareidolia than data collection. Feature analysis The stimulus is first broken down into its features and then processed. This model of pattern recognition says that the processing goes through four stages: detection, pattern dissection, feature comparison in memory, and recognition. Evolution One of the explanations put forth by evolutionary psychologists for apophenia is that it is not a flaw in the cognition of human brains but rather something that has come about through years of need. The study of this topic is referred to as error management theory. One of the most accredited studies in this field is Skinner's box. This experiment involved taking a hungry pigeon, placing it in a box and releasing food pellets at random times. The pigeon received a food pellet while performing some action; and so, rather than attributing the arrival of the pellet to randomness, the pigeon repeats that action, and continues to do so until another pellet falls. As the pigeon increases the number of times it performs the action, it gains the impression that it also increased the times it was "rewarded" with a pellet, although the release in fact remained entirely random. See also Alignments of random points Anthropomorphism Barnum effect Causality Clustering illusion Confirmation bias False equivalence Ideas and delusions of reference Ideomotor phenomenon Magical thinking Schizotypal personality disorder Synesthesia Texas sharpshooter fallacy Post hoc ergo propter hoc References Further reading External links Cognitive biases Randomness

Schizoid personality disorder

Schizoid personality disorder (, often abbreviated as SzPD or ScPD) is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment, and apathy. Affected individuals may be unable to form intimate attachments to others and simultaneously possess a rich and elaborate but exclusively internal fantasy world. Other associated features include stilted speech, a lack of deriving enjoyment from most activities, feeling as though one is an "observer" rather than a participant in life, an inability to tolerate emotional expectations of others, apparent indifference when praised or criticized, all forms of asexuality, and idiosyncratic moral or political beliefs. Symptoms typically start in late childhood or adolescence. The cause of SzPD is uncertain, but there is some evidence of links and shared genetic risk between SzPD, other cluster A personality disorders, and schizophrenia. Thus, SzPD is considered to be a "schizophrenia-like personality disorder". It is diagnosed by clinical observation, and it can be very difficult to distinguish SzPD from other mental disorders or conditions (such as autism spectrum disorder, with which it may sometimes overlap). The effectiveness of psychotherapeutic and pharmacological treatments for the disorder has yet to be empirically and systematically investigated. This is largely because people with SzPD rarely seek treatment for their condition. Originally, low doses of atypical antipsychotics were used to treat some symptoms of SzPD, but their use is no longer recommended. The substituted amphetamine bupropion may be used to treat associated anhedonia. However, it is not general practice to treat SzPD with medications, other than for the short-term treatment of acute co-occurring disorders (e.g. depression). Talk therapies such as cognitive behavioral therapy (CBT) may not be effective, because people with SzPD may have a hard time forming a good working relationship with a therapist. SzPD is a poorly studied disorder, and there is little clinical data on SzPD because it is rarely encountered in clinical settings. Studies have generally reported a prevalence of less than 1%. It is more commonly diagnosed in males than in females. SzPD is linked to negative outcomes, including a significantly compromised quality of life, reduced overall functioning even after 15 years, and one of the lowest levels of "life success" of all personality disorders (measured as "status, wealth and successful relationships"). Bullying is particularly common towards schizoid individuals. Suicide may be a running mental theme for schizoid individuals, though they are not likely to attempt it. Some symptoms of SzPD (e.g. solitary lifestyle, emotional detachment, loneliness, and impaired communication), however, have been stated as general risk factors for serious suicidal behavior. History The term schizoid was coined in 1908 by Eugen Bleuler to describe a human tendency to direct attention toward one's inner life and away from the external world. Bleuler labeled the exaggeration of this tendency the "schizoid personality". He described these personalities as "comfortably dull and at the same time sensitive, people who in a narrow manner pursue vague purposes". In 1910, August Hoch introduced a very similar concept called the "shut-in" personality. Characteristics of it were reticence, reclusiveness, shyness and a preference for living in fantasy worlds, among others. In 1925, Russian psychiatrist Grunya Sukhareva described a "schizoid psychopathy" in a group of children, resembling today's SzPD and ASD. About a decade later Pyotr Gannushkin also included Schizoids and Dreamers in his detailed typology of personality types. The descriptive tradition began in 1925 with the description of observable schizoid behaviors by Ernst Kretschmer. He organized those into three groups of characteristics: Unsociability, quietness, reservedness, seriousness and eccentricity. Timidity, shyness with feelings, sensitivity, nervousness, excitability, fondness of nature and books. Pliability, kindliness, honesty, indifference, silence and cold emotional attitudes. These characteristics were the precursors of the DSM-III division of the schizoid character into three distinct personality disorders: schizotypal, avoidant and schizoid. Kretschmer himself, however, did not conceive of separating these behaviors to the point of radical isolation but considered them to be simultaneously present as varying potentials in schizoid individuals. For Kretschmer, the majority of schizoid people are not either oversensitive or cold, but they are oversensitive and cold "at the same time" in quite different relative proportions, with a tendency to move along these dimensions from one behavior to the other. The second path, that of dynamic psychiatry, began in 1924 with observations by Eugen Bleuler, who observed that the schizoid person and schizoid pathology were not things to be set apart. Ronald Fairbairn's seminal work on the schizoid personality, from which most of what is known today about schizoid phenomena is derived, was presented in 1940. Here, Fairbairn delineated four central schizoid themes: The need to regulate interpersonal distance as a central focus of concern. The ability to mobilize self-preservative defenses and self-reliance. A pervasive tension between the anxiety-laden need for attachment and the defensive need for distance that manifests in observable behavior as indifference. An overvaluation of the inner world at the expense of the outer world. Following Fairbairn's derivation of SzPD from a combination of derealization, depersonalization, splitting, the oral stage of making all subjects into partial objects, and intellectualization; the dynamic psychiatry tradition has continued to produce rich explorations on the schizoid character, most notably from writers Nannarello (1953), Laing (1965), Winnicott (1965), Guntrip (1969), Khan (1974), Akhtar (1987), Seinfeld (1991), Manfield (1992) and Klein (1995). The DSM-I had the diagnosis of schizoid personality, which was defined by avoidance of close relationships, inability to express aggressive feelings, and autistic thinking (thinking which is preoccupied with one's inner experience). The DSM-II later updated the definition to include daydreaming, detachment from reality, and sensitivity. It was incorporated into the DSM-III as schizoid personality disorder to describe difficulties forming meaningful social relationships and a persistent pattern of disconnection and apathy. The diagnosis of SzPD made it to the DSM-IV and DSM-V. Epidemiology It remains unclear how prevalent the disorder is. It may be present in anywhere from 0.5% to 7% of the population and possibly 14% of the homeless population. Gender differences in this disorder are also unclear. Some research has suggested that this disorder may occur more frequently in men than women. SzPD is uncommon in clinical settings (about 2.2%) and occurs more commonly in males. It is rare compared with other personality disorders. Philip Manfield suggests that the "schizoid condition", which roughly includes the DSM schizoid, avoidant and schizotypal personality disorders, is represented by "as many as forty percent of all personality disorders." Manfield adds: "This huge discrepancy [from the ten percent reported by therapists for the condition] is probably largely because someone with a schizoid disorder is less likely to seek treatment than someone with other axis-II disorders." A 2008 study assessing personality and mood disorder prevalence among homeless people at New York City drop-in centers reported an SzPD rate of 65% among this sample. The study did not assess homeless people who did not show up at drop-in centers, and the rates of most other personality and mood disorders within the drop-in centers were lower than that of SzPD. The authors noted the limitations of the study, including the higher male-to-female ratio in the sample and the absence of subjects outside the support system or receiving other support (e.g., shelters) as well as the absence of subjects in geographical settings outside New York City, a large city often considered a magnet for disenfranchised people. A University of Colorado Colorado Springs study comparing personality disorders and Myers–Briggs Type Indicator types found that the disorder had a significant correlation with the Introverted (I) and Thinking (T) preferences. Etiology Environmental Perfectionist and hypercritical parenting or cold, neglectful, and distant parenting contribute to the onset of SzPD. For a person with SzPD, their parents likely were intolerant of their emotional experiences. They may have been forced to repress and compartmentalize their emotions, possibly resulting in the onset of difficulties expressing and processing emotional experiences. These difficulties lead to the child feeling rejected and developing the belief that the only safe environment is one where they are alone and inexpressive. People with SzPD may also have internalized the belief that their emotions are dangerous to themselves and others due to the negative responses received from others. In their status of isolation and emotional bluntness they can be self-sufficient and safe. Childhood trauma can also contribute to feelings of emptiness in adulthood. Alcoholism in parents is associated with a heightened risk of developing SzPD. Genetic Sula Wolff, who did extensive research and clinical work with children and teenagers with schizoid symptoms, stated that "schizoid personality has a constitutional, probably genetic, basis." Research on heritability and this disorder is lacking. Twin studies with SzPD traits (e.g., low sociability and low warmth) suggest that these traits are inherited. Besides this indirect evidence, the direct heritability estimates of SzPD range from 50% to 59%. Earlier, less methodologically rigorous research had found the heritability rate to be 29%. The pathophysiology of SzPD remains unclear. Genetic relationships with people who have schizophrenia spectrum disorders increase the risk of developing schizoid personality disorder. People with SzPD can have a history of schizotypy before developing the disorder. SzPD symptoms can be premorbid to schizophrenia. Neurological Prenatal malnutrition, premature birth, and low birth weight are all thought to play a role in the development of SzPD. SzPD is associated with reduced serotonergic and dopaminergic pathways in areas such as the frontal lobe, amygdala, and striatum. Traumatic brain injuries to the frontal lobe may also contribute to the onset of SzPD as that area of the brain controls areas such as emotion and socialization. Deficits in the right hemisphere of the brain may also be associated with SzPD. Lower levels of low-density lipoprotein cholesterol may be correlated with the presence of schizoid traits in women. Excess indices in the left hemisphere may also be related to SzPD. Prognosis Traits of schizoid personality disorder appear in childhood and adolescence. Children with this disorder usually have poor relationships with others, social anxiety, internal fantasies, strange behavior, and hyperactivity. These behaviors can result in teasing and bullying at the hands of others. It is common for people with SzPD to have had major depressive disorder in childhood. SzPD is associated with lower levels of achievement, a compromised quality of life, and a worse outcome of treatment. Treatment for this disorder is under-studied and poorly understood. There is no widely accepted and approved psychotherapy or medication for this disorder. It is one of the most poorly researched psychiatric disorders. Professionals may misunderstand the disorder and the client, potentially reinforcing a feeling of failure and negatively impacting their willingness to continue to commit to treatment. Clinicians tend to worry that they are incapable of properly treating the patient. It is rare for someone with this disorder to voluntarily seek treatment without a comorbid disorder or pressure from family or friends. In treatment, people with SzPD are usually disinterested and often minimize symptoms. Patients with SzPD may fear losing their independence through therapy. Many schizoid individuals will avoid making the efforts required to establish a proper relationship with the therapist. It can be difficult for them to open up or discuss their emotions in therapy. Although people with this disorder can still improve, it is unlikely they will ever experience significant joy through social interaction. Signs and symptoms Social isolation SzPD is associated with a dismissive-avoidant attachment style. People with this disorder will rarely maintain close relationships and often exclusively choose to participate in solitary activities. People with schizoid personality disorder typically have no close friends or confidants, except for a close relative on occasions. They usually prefer hobbies and activities that do not require interaction with others. People with SzPD may be averse to social situations due to difficulties deriving pleasure from physical or emotional sensations, rather than social anhedonia. One potential motivation for avoiding social situations is that they feel that it intrudes on their freedom. Relationships can feel suffocating for people with SzPD, and they may think of them as opportunities for entrapment. Patients with this disorder are often independent and turn to themselves as sources of validation. They tend to be the happiest when in relationships in which their partner places few emotional or intimate demands on them and does not expect phatic or social niceties. It is not necessarily people they want to avoid, but negative or positive emotional expectations, emotional intimacy, and self-disclosure. Patients with SzPD can feel as if close emotional bonds are dangerous to themselves and others. They may have feelings of inadequacy or shame. Some people with SzPD may experience a deep desire to connect with others, yet will be terrified by the dangers inherent in doing so. Avoidance of social situations may be a method of avoiding being hurt or rejected. Individuals with SzPD can form relationships with others based on intellectual, physical, familial, occupational, or recreational activities, as long as there is no need for emotional intimacy. Donald Winnicott explains this is because schizoid individuals "prefer to make relationships on their own terms and not in terms of the impulses of other people." Failing to attain that, they prefer isolation. In general, friendship for schizoid individuals is usually limited to one other person, who is often also schizoid, forming what has been called a union of two eccentrics; "within it – the ecstatic cult of personality, outside it – everything is sharply rejected and despised". Their unique lifestyle can lead to social rejection and people with SzPD are at a higher risk of facing bullying or homelessness. This social rejection can reinforce their asocial behavior. Sexuality People with this disorder usually have little to no interest in sexual or romantic relationships. They rarely date or marry. Sex often causes individuals with SzPD to feel that their personal space is being violated, and they commonly feel that masturbation or sexual abstinence is preferable to the emotional closeness they must tolerate when having sex. Significantly broadening this picture are notable exceptions of SzPD individuals who engage in occasional or even frequent sexual activities with others. Individuals with SzPD have long been noted to have an increased rate of unconventional sexual tendencies, though if present, these are rarely acted upon. Schizoid people are often labeled asexual or present with "a lack of sexual identity". Kernberg states that this apparent lack of sexuality does not represent a lack of sexual definition but rather a combination of several strong fixations to cope with the same conflicts. People with SzPD are often able to pursue any fantasies with content on the Internet while remaining completely unengaged with the outside world. Emotions Sensory or emotional experiences typically provide little enjoyment for people with SzPD. They rarely display strong emotions or react to anything. People with SzPD can have difficulty expressing themselves and seem to be directionless or passive. Individuals with SzPD can also experience anhedonia. They can also have difficulty understanding others' emotions and social cues. It can be hard for people with SzPD to assess the impact of their actions in social situations. People with this condition are often indifferent towards criticism or praise and can appear distant, aloof, or uncaring to others. They may avoid others and expressing themselves as a method of keeping others distant and preventing themselves from being hurt. Remaining alone and expressionless can feel safe and comfortable for people with SzPD. Expressing themselves can make them feel shame or discomfort. People with SzPD may feel inadequate and can be sensitive, although they have difficulty expressing it. Alexithymia, or difficulties understanding one's own emotions, is common amongst people with SzPD. This leads to them isolating themselves to avoid the discomfort and stimulation that emotional experiences offer. According to Guntrip, Klein, and others, people with SzPD may possess a hidden sense of superiority and lack dependence on other people's opinions. This is very different from the grandiosity seen in narcissistic personality disorder, which is described as "burdened with envy" and with a desire to destroy or put down others. Additionally, schizoid individuals do not go out of their way to achieve social validation. Unlike narcissists, schizoid people will often keep their creations private to avoid unwelcome attention or the feeling that their ideas and thoughts are being appropriated by the public. When forced to rely on others, a person with SzPD may feel panic or terror. Feelings of unreality Patients with SzPD often feel unreal, empty, and separate from their own emotions. They tend to perceive themselves as fundamentally different from others and can believe that they are fundamentally unlikeable. Other people often seem strange and incomprehensible to a person with SzPD. Reality can feel unenjoyable and uninteresting to people with SzPD. They have difficulty finding motivation and lack ambition. Patients with SzPD often feel as if they are "going through the motions" or that "life passes them by." Many describe feeling as if they are observing life from a distance. Aaron Beck and his colleagues report that people with SzPD seem comfortable with their aloof lifestyle and consider themselves observers, rather than participants in the world around them. But they also mention that many of their schizoid patients recognize themselves as socially deviant (or even defective) when confronted with the different lives of ordinary people – especially when they read books or see movies focusing on relationships. Even when schizoid individuals may not long for closeness, they can become weary of being "on the outside, looking in". These feelings may lead to depression, depersonalization, or derealization. If they do, schizoid people often experience feeling "like a robot" or "going through life in a dream". People with SzPD may try to avoid all physical activity in order to become nobody and disconnect from reality. This can lead to the patient spending a large quantity of time sleeping and ignoring bodily functions such as hygiene. Internal fantasy Although this disorder does not affect the patient's capacity to understand reality, they may engage in excessive daydreaming and introspection. Their daydreams can grow to consume most of their lives. Real life can become secondary to their fantasy, and they can have complex lives and relationships which exist entirely inside of their internal fantasy. These daydreams may constitute a defense mechanism to protect the patient from the outside world and its difficulties. Common themes in their internal fantasies are omnipotence and grandiosity. The related schizotypal personality disorder and schizophrenia are reported to have ties to creative thinking, and it is speculated that the internal fantasy aspect of SzPD may also be reflective of this thinking. Alternatively, there has been an especially large contribution of people with schizoid symptoms to science and theoretical areas of knowledge, including mathematics, physics, economics, etc. At the same time, people with SzPD are helpless at many practical activities because of their symptoms. Suicide and self-harm Symptoms of SzPD such as isolation and the blunted affect put people with schizoid personality disorder at a higher risk of suicide and non-suicidal self-harm. This may be because their reduced capacities for emotion prevent them from properly dealing with strife. Their solitary nature may contribute by preventing them from finding relief in relationships. Demonstrative suicides or suicide blackmail, as seen in cluster B personality disorders such as borderline, histrionic, or antisocial, are extremely rare among schizoid individuals. As in other clinical mental health settings, among suicidal inpatients, individuals with SzPD are not as well represented as some other groups. A 2011 study on suicidal inpatients at a Moscow hospital found that schizoid individuals were the least common patients, while those with cluster B personality disorders were the most common. Low weight A study that looked at the body mass index (BMI) of a sample of both male adolescents diagnosed with SzPD and those diagnosed with Asperger syndrome found that the BMI of all patients was significantly below normal. Clinical records indicated abnormal eating behavior by some patients. Some patients would only eat when alone and refused to eat out. Restrictive diets and fears of disease were also found. It was suggested that the anhedonia of SzPD may also affect eating, leading schizoid individuals to not enjoy it. Alternatively, it was suggested that schizoid individuals may not feel hunger as strongly as others or not respond to it, a certain withdrawal "from themselves". Substance abuse Very little data exists for rates of substance use disorder among people with SzPD, but existing studies suggest they are less likely to have substance abuse problems than the general population. One study found that significantly fewer boys with SzPD had alcohol problems than a control group of non-schizoid people. Another study evaluating personality disorder profiles in substance abusers found that substance abusers who showed schizoid symptoms were more likely to abuse one substance rather than many, in contrast to other personality disorders such as borderline, antisocial, or histrionic, which were more likely to abuse many. American psychotherapist Sharon Ekleberry states that the impoverished social connections experienced by people with SzPD limit their exposure to the drug culture and that they have limited inclination to learn how to do illegal drugs. Describing them as "highly resistant to influence", she additionally states that even if they could access illegal drugs, they would be disinclined to use them in public or social settings, and because they would be more likely to use alcohol or cannabis alone than for social disinhibition, they would not be particularly vulnerable to negative consequences in early use. People with SzPD are at a lower risk of substance abuse issues than people with other personality disorders. They may form relationships with their substances as a substitute for human contact or to cope with emotional issues. People with SzPD may desire psychedelic drugs more than other kinds. Secret schizoids Many schizoid individuals display an engaging, interactive personality, contradicting the observable characteristic emphasized by the DSM-5 and ICD-10 definitions of the schizoid personality. Guntrip (using ideas of Klein, Fairbairn, and Winnicott) classifies these individuals as "secret schizoids", who behave with socially available, interested, engaged, and involved interaction yet remain emotionally withdrawn and sequestered within the safety of the internal world. Klein distinguishes between a "classic" SzPD and a "secret" SzPD, which occur "just as often" as each other. Klein cautions one should not misidentify the schizoid person as a result of the patient's defensive, compensatory interaction with the external world. He suggests one ask the person what their subjective experience is, to detect the presence of the schizoid refusal of emotional intimacy and preference for objective fact. A 2013 study looking at personality disorders and Internet use found that being online more hours per day predicted signs of SzPD. Additionally, SzPD correlated with lower phone call use and fewer Facebook friends. Descriptions of the schizoid personality as "hidden" behind an outward appearance of emotional engagement have been recognized since 1940, with Fairbairn's description of "schizoid exhibitionism", in which the schizoid individual can express a great deal of feeling and make what appear to be impressive social contacts yet, in reality, gives nothing and loses nothing. Because they are "playing a part", their personality is not involved. According to Fairbairn, the person disowns the part they are playing, and the schizoid individual seeks to preserve their personality intact and immune from compromise. The schizoid person's false persona is based on what those around them define as normal or good behavior, as a form of compliance. Further references to the secret schizoid come from Masud Khan, Jeffrey Seinfeld, and Philip Manfield. These scholars described secret schizoids as people who enjoy public speaking engagements but experience great difficulty during the breaks when audience members would attempt to engage them emotionally. These references expose the problems in relying on outer observable behavior for assessing the presence of personality disorders in certain individuals. Comorbid disorders Agoraphobia Avoidant personality disorder Antisocial personality disorder Borderline personality disorder Post-traumatic stress disorder Major depressive disorder Generalized anxiety disorder Panic disorder Paranoid personality disorder Social anxiety disorder Schizotypal personality disorder Obsessive–compulsive disorder Autism Spectrum Disorder Several studies have reported an overlap or comorbidity with autism spectrum disorder and Asperger syndrome. Asperger syndrome had traditionally been called "schizoid disorder of childhood", and Eugen Bleuler coined both the terms "autism" and "schizoid" to describe withdrawal to an internal fantasy, against which any influence from outside becomes an intolerable disturbance. In a 2012 study of a sample of 54 young adults with Asperger syndrome, it was found that 26% of them also met the criteria for SzPD, the highest comorbidity out of any personality disorder in the sample (the other comorbidities were 19% for obsessive–compulsive personality disorder, 13% for avoidant personality disorder and one female with schizotypal personality disorder). Additionally, twice as many men with Asperger syndrome met the criteria for SzPD than women. While 41% of the whole sample were unemployed with no occupation, this rose to 62% for the Asperger's and SzPD comorbid group. Tantam suggested that Asperger syndrome may confer an increased risk of developing SzPD. A 2019 study found that 54% of a group of males aged 11 to 25 with Asperger syndrome showed significant SzPD traits, with 6% meeting full diagnostic criteria for SzPD, compared to 0% of a control group. In the 2012 study, it was noted that the DSM may complicate diagnosis by requiring the exclusion of a pervasive developmental disorder (PDD) before establishing a diagnosis of SzPD. The study found that social interaction impairments, stereotyped behaviors, and specific interests were more severe in the individuals with Asperger syndrome also fulfilling SzPD criteria, against the notion that social interaction skills are unimpaired in SzPD. The authors believe that a substantial subgroup of people with autism spectrum disorder or PDD have clear "schizoid traits" and correspond largely to the "loners" in Lorna Wing's classification The autism spectrum (Lancet 1997), described by Sula Wolff. The authors of the 2019 study hypothesized that it is extremely likely that historic cohorts of adults diagnosed with SzPD either also had childhood-onset autistic syndromes or were misdiagnosed. They stressed that further research to clarify overlap and distinctions between these two syndromes was strongly warranted, especially given that high-functioning autism spectrum disorders are now recognized in around 1% of the population. Treatment Medication There are no effective medications for schizoid personality disorder. However, certain medications may reduce the symptoms of SzPD and treat co-occurring mental disorders. Since the symptoms of SzPD mirror the negative symptoms of schizophrenia, antipsychotics have been suggested as a potentially effective medication for SzPD. Originally, low doses of atypical antipsychotics like risperidone or olanzapine were used to alleviate social deficits and blunted affect. However, a 2012 review concluded that atypical antipsychotics were ineffective for treating personality disorders. Antidepressants, SSRIs, anxiolitics, bupropion, modafinil, benzodiazepines, and biofeedback may also be effective treatments. Psychotherapy Treatment for this disorder uses a combination of cognitive-behavioral therapy and psychodynamic psychotherapy. These techniques can be used to help patients identify their defense mechanisms and change them. Therapists attempt to establish healthy relationships with their clients, helping to combat their internalized belief that relationships are harmful and unhelpful. Relationships with a therapist can seem terrifying and intrusive to a person with SzPD. They may feel as if they need to alter or hide their feelings to meet the therapist's demands or expectations. To combat this, therapists try to gradually increase their patient's emotional expression. Expressing too much too early can lead to their ending therapy. Treatment must be person centered, with clients feeling understood and well regarded. This can allow them to connect with and understand their emotions. When people with SzPD do not have their feelings validated, this will confirm their belief that expressing themselves is dangerous. Therapists attempt to avoid intruding on their patients' lives or restricting their freedoms, so as to prevent them from feeling as if therapy is intolerable. Because of this, therapy is usually less structured than treatment programs for other disorders. Patients may benefit from long-term treatment lasting several years. Inpatient care may be effective for treating SzPD and other Cluster A disorders. Controversy The original concept of the schizoid character developed by Ernst Kretschmer in the 1920s comprised a mix of avoidant, schizotypal, and schizoid traits. It was not until 1980 and the work of Theodore Millon that led to splitting this concept into three personality disorders (now schizoid, schizotypal, and avoidant). This caused debate about whether this was accurate or if these traits were different expressions of a single personality disorder. It has also been argued due to the poor consistency and efficiency of diagnosis due to overlapping traits that SzPD should be removed altogether from the DSM. A 2012 article suggested that two different disorders may better represent SzPD: one affect-constricted disorder (belonging to schizotypal PD) and a seclusive disorder (belonging to avoidant PD). They called for the replacement of the SzPD category from future editions of the DSM with a dimensional model which would allow for the description of schizoid traits on an individual basis. Some critics such as Nancy McWilliams of Rutgers University and Panagiotis Parpottas of European University Cyprus argue that the definition of SzPD is flawed due to cultural bias and that it does not constitute a mental disorder but simply an avoidant attachment style requiring a more distant emotional proximity. If that is true, then many of the more problematic reactions these individuals show in social situations may be partly accounted for by the judgments commonly imposed on people with this style. Similarly, John Oldham, using a dimensional approach, thinks that most people with schizoid character features do not have a full-blown personality disorder. Impairment is mandatory for any behavior to be diagnosed as a personality disorder. Diagnosis Guntrip criteria Ralph Klein, Clinical Director of the Masterson Institute, delineates the following nine characteristics of the schizoid personality as described by Harry Guntrip: Introversion Withdrawnness Narcissism Self-sufficiency A sense of superiority Loss of affect Loneliness Depersonalization Regression The description of Guntrip's nine characteristics should clarify some differences between the traditional DSM portrait of SzPD and the traditional informed object relations view. All nine characteristics are consistent. Most, if not all, must be present to diagnose a schizoid disorder. Millon's subtypes Theodore Millon restricted the term "schizoid" to those personalities who lack the capacity to form social relationships. He characterizes their way of thinking as being vague and void of thoughts and as sometimes having a "defective perceptual scanning". Because they often do not perceive cues that trigger affective responses, they experience fewer emotional reactions. For Millon, SzPD is distinguished from other personality disorders in that it is "the personality disorder that lacks a personality." He criticizes that this may be due to the current diagnostic criteria: They describe SzPD only by an absence of certain traits, which results in a "deficit syndrome" or "vacuum". Instead of delineating the presence of something, they mention solely what is lacking. Therefore, it is hard to describe and research such a concept. He identified four subtypes of SzPD. Any schizoid individual may exhibit none or one of the following: Akhtar's profile American psychoanalyst Salman Akhtar provided a comprehensive phenomenological profile of SzPD in which classic and contemporary descriptive views are synthesized with psychoanalytic observations. This profile is summarized in the table reproduced below that lists clinical features that involve six areas of psychosocial functioning and are organized by "overt" and "covert" manifestations. "Overt" and "covert" are intended to denote seemingly contradictory aspects that may both simultaneously be present in an individual. These designations do not necessarily imply their conscious or unconscious existence. The covert characteristics are by definition difficult to discern and not immediately apparent. Additionally, the lack of data on the frequency of many of the features makes their relative diagnostic weight difficult to distinguish at this time. However, Akhtar states that his profile has several advantages over the DSM in terms of maintaining historical continuity of the use of the word schizoid, valuing depth and complexity over descriptive oversimplification and helping provide a more meaningful differential diagnosis of SzPD from other personality disorders. Differential diagnosis See also Alexithymia Asociality Cognitive disengagement syndrome Counterphobic attitude Dissociation (psychology) Hermit Hikikomori Recluse Schizothymia Schizotypy Social disorder Social isolation Schizoid avoidant behavior Schizotypal personality disorder References External links David Kishik, "Self Study: Notes on the Schizoid Condition" The Biological foundations of the Schizoid Process NY Times article "Like a Fish Needs a Bicycle: For Some People, Intimacy Is Toxic" Psychology Today (2017): The Disappearance of the Schizoid Personality Cluster A personality disorders Schizophrenia Personality disorders

Wernicke encephalopathy

Wernicke encephalopathy (WE), also Wernicke's encephalopathy, or wet brain is the presence of neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves, in particular thiamine (vitamin B1). The condition is part of a larger group of thiamine deficiency disorders that includes beriberi, in all its forms, and alcoholic Korsakoff syndrome. When it occurs simultaneously with alcoholic Korsakoff syndrome it is known as Wernicke–Korsakoff syndrome. Classically, Wernicke encephalopathy is characterised by a triad of symptoms: ophthalmoplegia, ataxia, and confusion. Around 10% of patients exhibit all three features, and other symptoms may also be present. While it is commonly regarded as a condition particular to malnourished people with alcohol misuse, it can be caused by a variety of diseases. It is treated with thiamine supplementation, which can lead to improvement of the symptoms and often complete resolution, particularly in those where alcohol misuse is not the underlying cause. Often other nutrients also need to be replaced, depending on the cause. Medical literature notes how managing the condition in a timely fashion can avoid worsening symptoms. Wernicke encephalopathy may be present in the general population with a prevalence of around 2%, and is considered underdiagnosed; probably, many cases are in patients who do not have commonly-associated symptoms. Signs and symptoms The classic triad of symptoms found in Wernicke encephalopathy is: ophthalmoplegia (later expanded to other eye movement disorders, most commonly affecting the lateral rectus muscle. Lateral nystagmus is most commonly seen although lateral rectus palsy, usually bilateral, may be seen). ataxia (later expanded to imbalance or any cerebellar signs) confusion (later expanded to other mental changes. Has 82% incidence in diagnosis cases) Other symptoms found in patients with this condition include: pupillary changes, retinal hemorrhage, papilledema, impaired vision and hearing, vision loss hearing loss, fatigability, apathy, irritability, drowsiness, psycho and/or motor slowing dysphagia, blush, sleep apnea, epilepsy and stupor lactic acidosis memory impairment, amnesia, depression, psychosis hypothermia, polyneuropathy, hyperhidrosis. Although hypothermia is usually diagnosed with a body temperature of 35 °C (95 °F), or less, incipient cooling caused by deregulation in the central nervous system (CNS) needs to be monitored because it can promote the development of an infection. The patient may report feeling cold, followed by mild chills, cold skin, moderate pallor, tachycardia, hypertension, tremor or piloerection. External warming techniques are advised to prevent hypothermia. Among the frequently altered functions are the cardio circulatory. There may be tachycardia, dyspnea, chest pain, orthostatic hypotension, changes in heart rate and blood pressure. The lack of thiamine sometimes affects other major energy consumers, the myocardium, and also patients may have developed cardiomegaly. Heart failure with lactic acidosis syndrome has been observed. Cardiac abnormalities are an aspect of the WE, which was not included in the traditional approach, and are not classified as a separate disease. Infections have been pointed out as one of the most frequent triggers of death in WE. Furthermore, infections are usually present in pediatric cases. In the last stage other symptoms may occur: hyperthermia, increased muscle tone, spastic paralysis, choreic dyskinesias and coma. Because of the frequent involvement of heart, eyes and peripheral nervous system, several authors prefer to call it Wernicke disease rather than simply encephalopathy. Early symptoms are nonspecific, and it has been stated that WE may present nonspecific findings. In Wernicke Korsakoff's syndrome some single symptoms are present in about one-third. Location of the lesion Depending on the location of the brain lesion different symptoms are more frequent: Brainstem tegmentum. - Ocular: pupillary changes. Extraocular muscle palsy; gaze palsy: nystagmus. Hypothalamus. Medulla: dorsal nuc. of vagus. - Autonomic dysfunction: temperature; cardiocirculatory; respiratory. Medulla: vestibular region. Cerebellum. - Ataxia. Dorsomedial nuc. of thalamus. Mammillary bodies. - Amnestic syndrome for recent memory. Mamillary lesion are characteristic-small petechial hemorrhages are found. Diffuse cerebral dysfunction.- Altered cognition: global confusional state. Brainstem: periaqueductal gray.- Reduction of consciousness Hypothalamic lesions may also affect the immune system, which is known in people who consume excessive amounts of alcohol, causing dysplasias and infections. Korsakoff syndrome Korsakoff syndrome, characterised by memory impairment, confabulation, confusion and personality changes, has a strong and recognised link with WE. A very high percentage of patients with Wernicke–Korsakoff syndrome also have peripheral neuropathy, and many people who consume excess alcohol have this neuropathy without other neurologic signs or symptoms. Korsakoff's occurs much more frequently in WE due to chronic alcoholism. It is uncommon among those who do not consume excessive amounts of alcohol. Up to 80% of WE patients who misuse alcohol develop Korsakoff's syndrome. In Korsakoff's, is usually observed atrophy of the thalamus and the mammillary bodies, and frontal lobe involvement. In a study, half of Wernicke–Korsakoff cases had good recovery from the amnesic state, which may take from 2 months to 10 years. Risk factors Wernicke encephalopathy has classically been thought of as a disease solely of people who drink excessive amounts of alcohol, but it is also found in the chronically undernourished, and in recent years had been discovered post bariatric surgery. Without being exhaustive, the documented causes of Wernicke encephalopathy have included: pancreatitis, liver dysfunction, chronic diarrhea, celiac disease, Crohn's disease, uremia, thyrotoxicosis vomiting, hyperemesis gravidarum, malabsorption, gastrointestinal surgery or diseases incomplete parenteral nutrition, starvation/fasting chemotherapy, renal dialysis, diuretic therapy, stem cell/marrow transplantation cancer, AIDS, Creutzfeldt–Jakob disease, febrile infections this disease may even occur in some people with normal, or even high blood thiamine levels, or people with deficiencies in intracellular transport of this vitamin. Selected genetic mutations, including presence of the X-linked transketolase-like 1 gene, SLC19A2 thiamine transporter protein mutations, and the aldehyde dehydrogenase-2 gene, which may predispose to alcohol use disorder. The APOE epsilon-4 allele, involved in Alzheimer's disease, may increase the chance of developing neurological symptoms. Pathophysiology Thiamine deficiency and errors of thiamine metabolism are believed to be the primary cause of Wernicke encephalopathy. Thiamine, also called B1, helps to break down glucose. Specifically, it acts as an essential coenzyme to the TCA cycle and the pentose phosphate shunt. Thiamine is first metabolised to its more active form, thiamine diphosphate (TDP), before it is used. The body only has 2–3 weeks of thiamine reserves, which are readily exhausted without intake, or if depletion occurs rapidly, such as in chronic inflammatory states or in diabetes. Thiamine is involved in: Metabolism of carbohydrates, releasing energy. Production of neurotransmitters including glutamic acid and GABA. Lipid metabolism, necessary for myelin production. Amino acid modification. Probably linked to the production of taurine, of great cardiac importance. Neuropathology The primary neurological-related injury caused by thiamine deficiency in WE is three-fold: oxidative damage, mitochondrial injury leading to apoptosis, and directly stimulating a pro-apoptotic pathway. Thiamine deficiency affects both neurons and astrocytes, glial cells of the brain. Thiamine deficiency alters the glutamate uptake of astrocytes, through changes in the expression of astrocytic glutamate transporters EAAT1 and EAAT2, leading to excitotoxicity. Other changes include those to the GABA transporter subtype GAT-3, GFAP, glutamine synthetase, and the Aquaporin 4 channel. Focal lactic acidosis also causes secondary oedema, oxidative stress, inflammation and white matter damage. Pathological anatomy Despite its name, WE is not related to Wernicke's area, a region of the brain associated with speech and language interpretation. Brain lesions in WE are usually credited to focal lactic acidosis. An absence of thiamine can lead to too much pyruvate within the cells since it is not available to help convert pyruvate through the TCA cycle. An increase in pyruvate causes an increase in lactate concentration leading to focal lactic acidosis. Lesions can be reversed in most cases with immediate supplementation of thiamine. Lesions are usually symmetrical in the periventricular region, diencephalon, the midbrain, hypothalamus, and cerebellar vermis. Brainstem lesions may include cranial nerve III, IV, VI and VIII nuclei, the medial thalamic nuclei, and the dorsal nucleus of the vagus nerve. Oedema may be found in the regions surrounding the third ventricle, and fourth ventricle, also appearing petechiae and small hemorrhages. Chronic cases can present the atrophy of the mammillary bodies. In 1949, the idea that WE lesions are a result of a disruption to the blood-brain barrier was introduced. Large proteins passing into the brain can put neurological tissue at risk of toxic effects. The blood-brain barrier junctions are typically found to have WE lesions located at that region of the brain. An altered blood–brain barrier may cause a perturbed response to certain drugs and foods. Diagnosis Diagnosis of Wernicke encephalopathy or disease is made clinically. Caine et al. in 1997 established criteria that Wernicke encephalopathy can be diagnosed in any patient with just two or more of the main symptoms noted above. The sensitivity of the diagnosis by the classic triad was 23% but increased to 85% taking two or more of the four classic features. These criteria are challenged because all the cases he studied were people who drank excessive amounts of alcohol. Some consider it sufficient to suspect the presence of the disease with only one of the principal symptoms. Some British hospital protocols suspect WE with any one of these symptoms: confusion, decreased consciousness level (or unconsciousness, stupor or coma), memory loss, ataxia or unsteadiness, ophthalmoplegia or nystagmus, and unexplained hypotension with hypothermia. The presence of only one sign should be sufficient for treatment. The sensitivity of magnetic resonance imaging (MR) was 53% and the specificity was 93%. The reversible cytotoxic edema was considered the most characteristic lesion of WE. The location of the lesions were more frequently atypical among people who drank appropriate amounts of alcohol, while typical contrast enhancement in the thalamus and the mammillary bodies was observed frequently associated with alcohol misuse. These abnormalities may include: Dorsomedial thalami, periaqueductal gray matter, mamillary bodies, tectal plate and brainstem nuclei are commonly affected. Involvement is always bilateral and symmetric. Value of DWI in the diagnosis of WE is minimal. Axial FLAIR MRI images represent the best diagnostic MRI sequence. Contrast material may highlight involvement of the mamillary bodies. There appears to be very little value for CT scans. Thiamine can be measured using an erythrocyte transketolase activity assay, or by activation by measurement of in vitro thiamine diphosphate levels. Normal thiamine levels do not necessarily rule out the presence of WE, as this may be a patient with difficulties in intracellular transport. Prevention There are hospital protocols for prevention, supplementing with thiamine in the presence of: history of alcohol misuse or related seizures, requirement for IV glucose, signs of malnutrition, poor diet, recent diarrhea or vomiting, peripheral neuropathy, intercurrent illness, delirium tremens or treatment for DTs, and others. Some experts advise parenteral thiamine should be given to all at-risk patients in the emergency department. In the clinical diagnosis should be remembered that early symptoms are nonspecific, and it has been stated that WE may present nonspecific findings. There is consensus to provide water-soluble vitamins and minerals after gastric operations. In some countries certain foods have been supplemented with thiamine, and have reduced WE cases. Improvement is difficult to quantify because they applied several different actions. Avoiding or moderating alcohol consumption and having adequate nutrition reduces one of the main risk factors in developing Wernicke–Korsakoff syndrome.. Treatment Most symptoms will improve quickly if deficiencies are treated early. Memory disorder may be permanent. In patients suspected of WE, thiamine treatment should be started immediately. Blood should be immediately taken to test for thiamine, other vitamins and minerals levels. Following this an immediate intravenous or intramuscular dose of thiamine should be administered two or three times daily. Thiamine administration is usually continued until clinical improvement ceases. Considering the diversity of possible causes and several surprising symptomatologic presentations, and because there is low assumed risk of toxicity of thiamine, because the therapeutic response is often dramatic from the first day, some qualified authors indicate parenteral thiamine if WE is suspected, both as a resource for diagnosis and treatment. The diagnosis is highly supported by the response to parenteral thiamine, but is not sufficient to be excluded by the lack of it. Parenteral thiamine administration is associated with a very small risk of anaphylaxis. People who consume excessive amounts of alcohol may have poor dietary intakes of several vitamins, and impaired thiamine absorption, metabolism, and storage; they may thus require higher doses. If glucose is given, such as in people with an alcohol use disorder who are also hypoglycaemic, thiamine must be given concurrently. If this is not done, the glucose will rapidly consume the remaining thiamine reserves, exacerbating this condition. The observation of edema in MR, and also the finding of inflation and macrophages in necropsied tissues, has led to successful administration of antiinflammatories. Other nutritional abnormalities should also be looked for, as they may be exacerbating the disease. In particular, magnesium, a cofactor of transketolase which may induce or aggravate the disease. Other supplements may also be needed, including: cobalamin, ascorbic acid, folic acid, nicotinamide, zinc, phosphorus (dicalcium phosphate) and in some cases taurine, especially suitable when there cardiocirculatory impairment. Patient-guided nutrition is suggested. In patients with Wernicke–Korsakoff syndrome, even higher doses of parenteral thiamine are recommended. Concurrent toxic effects of alcohol should also be considered. Epidemiology There are no conclusive statistical studies, all figures are based on partial studies. Wernicke's lesions were observed in 0.8 to 2.8% of the general population autopsies, and 12.5% of people with an alcohol use disorder. This figure increases to 35% of such individuals if including cerebellar damage due to lack of thiamine. Most autopsy cases were from people with an alcohol use disorder. Autopsy series were performed in hospitals on the material available which is unlikely to be representative of the entire population. Considering the slight affectations, previous to the generation of observable lesions at necropsy, the percentage should be higher. There is evidence to indicate that Wernicke encephalopathy is underdiagnosed. For example, in one 1986 study, 80% of cases were diagnosed postmortem. Is estimated that only 5–14% of patients with WE are diagnosed in life. In a series of autopsy studies held in Recife, Brazil, it was found that only 7 out of 36 had consumed excessive amounts of alcohol, and only a small minority had malnutrition. In a reviewed of 53 published case reports from 2001 to 2011, the relationship with alcohol was also about 20% (10 out of 53 cases). WE related to alcohol misuse is more common in males and is more common in females when not related to alcohol misuse. In alcohol-related cases, WE patients average the age of 40, and non-alcohol-related cases typically occur in younger people. History WE was first identified in 1881 by the German neurologist Carl Wernicke, although the link with thiamine was not identified until the 1930s. Carl Wernicke discovered the sensory center of speech. Wernicke figured out that Broca's area was not the only center of speech, it was also able to distinguish motor aphasia from sensory aphasia. He also pointed to the possibility of conduction aphasia since he came to understand the arrangement of the brain's extrinsic and intrinsic connections. He demonstrated that the sensory information reached its corresponding area in the cerebral cortex through projection fibers. From there, this information, following the association system, would be distributed to different regions of the cortex, integrating sensory processing. He reported three patients with WE, including two men (aged 33 and 36) who were alcoholics and one woman (aged 20) who ingested sulfuric acid, leading to pyloric stenosis. All three had ocular motor abnormalities and he performed an autopsy on each, providing a clinical-pathological correlation. A similar presentation of this disease was described by the Russian psychiatrist Sergei Korsakoff in a series of articles published 1887–1891; where the chronic version of WE was described as Korsakoff's Syndrome, involving symptoms of amnesia. References External links Alcohol and health Malnutrition Central nervous system disorders Vitamin deficiencies Thiamine Medical triads

Confusion

In medicine, confusion is the quality or state of being bewildered or unclear. The term "acute mental confusion" is often used interchangeably with delirium in the International Statistical Classification of Diseases and Related Health Problems and the Medical Subject Headings publications to describe the pathology. These refer to the loss of orientation, or the ability to place oneself correctly in the world by time, location and personal identity. Mental confusion is sometimes accompanied by disordered consciousness (the loss of linear thinking) and memory loss (the inability to correctly recall previous events or learn new material). Etymology The word confusion derives from the Latin word, confundo, which means "confuse, mix, blend, pour together, disorder, embroil." Causes Confusion may result from drug side effects or from a relatively sudden brain dysfunction. Acute confusion is often called delirium (or "acute confusional state"), although delirium often includes a much broader array of disorders than simple confusion. These disorders include the inability to focus attention; various impairments in awareness, and temporal or spatial dis-orientation. Mental confusion can result from chronic organic brain pathologies, such as dementia, as well. Other Acute stress reaction Alcoholism Anemia Anticholinergic toxicity Anxiety Brain damage Brain tumor Concussion Dehydration Encephalopathy Epileptic seizure Depression Fatigue Fever Brain injury Heat stroke Hypoglycemia Hypothermia Hypothyroidism Jet lag Kidney failure Kidney infection (pyelonephritis) Lactic acidosis Lassa fever Lewy body dementia Listeria Lyme disease Meningitis Postpartum depression & Postpartum psychosis Psychotic Disorder Reye's syndrome Rocky Mountain spotted fever (RMSF) Schizophrenia Sick building syndrome Sleep apnea Stroke Yellow fever STDs & STIs Streptococcal Infections Toxicity Toxic shock syndrome Transient ischemic attack (TIA, Mini-Stroke) Vitamin B12 deficiency Acute Porphyria West Nile virus Differential diagnosis The most common causes of drug induced acute confusion are dopaminergic drugs (used for the treatment of Parkinson's disease), diuretics, tricyclic, tetracyclic antidepressants and benzodiazepines or alcohol. The elderly, and especially those with pre-existing dementia, are most at risk for drug induced acute confusional states. New research is finding a link between vitamin D deficiency and cognitive impairment (which includes "foggy brain"). See also Cognitive distortion References External links National Library of Medicine - National Institutes of Health Cognitive dissonance Emotions Neurology Symptoms and signs of mental disorders Failure Mental states Cognitive neuroscience Error Anxiety de:Verworrenheit

Factitious disorder imposed on another

Factitious disorder imposed on another (FDIA), also known as fabricated or induced illness by carers (FII) and first named as Munchausen syndrome by proxy (MSbP) after Munchausen syndrome, is a mental health disorder in which a caregiver creates the appearance of health problems in another person, typically their child, and sometimes (rarely) when an adult simulates an illness in another adult partner. This might include altering test samples or injuring a child. The caregiver or partner then presents the person as being sick or injured. Permanent injury or death of the victim can occur as a result of the disorder. The behaviour might be motivated by the caregiver or partner seeking sympathy or attention. The cause of FDIA is unknown. The primary motive may be to gain attention and manipulate physicians. Risk factors for FDIA include pregnancy related complications and a mother who was abused as a child or has factitious disorder imposed on self. Diagnosis of a child's caregiver is supported when removing the child from the caregiver results in improvement of symptoms or video surveillance without the knowledge of the caregiver finds concerns. The victims of those affected by the disorder are considered to have been subjected to a form of physical abuse and medical neglect. Management of FDIA in the affected 'caregiver' may require putting the child in foster care. It is not known how effective therapy is for FDIA; it is assumed it may work for those who admit they have a problem. The prevalence of FDIA is unknown, but it appears to be relatively rare. More than 90% of cases involve a person's mother. The prognosis for the caregiver is poor. However, there is a burgeoning literature on possible courses of therapy. The condition was first named as "Munchausen syndrome by proxy" in 1977 by British pediatrician Roy Meadow. Some aspects of FDIA may represent criminal behavior. Signs and symptoms In factitious disorder imposed on another, a caregiver or partner makes a dependent or other person appear mentally or physically ill in order to gain attention. To perpetuate the medical relationship, the caregiver or partner systematically misrepresents symptoms, fabricates signs, manipulates laboratory tests, or even purposely harms the dependent (e.g. by poisoning, suffocation, infection, physical injury). The caregiver is not performing this behavior for obvious external reward, such as money. Most present about three medical problems in some combination of the 103 different reported symptoms. The most-frequently reported problems are apnea (26.8% of cases), anorexia or feeding problems (24.6% of cases), diarrhea (20%), seizures (17.5%), cyanosis (blue skin) (11.7%), behavior (10.4%), asthma (9.5%), allergy (9.3%), and fevers (8.6%). Other symptoms include failure to thrive, vomiting, bleeding, rash, and infections. Many of these symptoms are easy to fake because they are subjective. A parent reporting that their child had a fever in the past 24 hours is making a claim that is impossible to prove or disprove. The number and variety of presented symptoms contribute to the difficulty in reaching a proper diagnosis. Aside from the motive (most commonly attributed to be a gain in attention or sympathy), another feature that differentiates FDIA from "typical" physical child abuse is the degree of premeditation involved. Whereas most physical abuse entails lashing out at a child in response to some behavior (e.g., crying, bedwetting, spilling food), assaults on the FDIA victim tend to be unprovoked and planned. Also unique to this form of abuse is the role that health care providers play by actively, albeit unintentionally, enabling the abuse. By reacting to the concerns and demands of perpetrators, medical professionals are manipulated into a partnership of child maltreatment. Challenging cases that defy simple medical explanations may prompt health care providers to pursue unusual or rare diagnoses, thus allocating even more time to the child and the abuser. Even without prompting, medical professionals may be easily seduced into prescribing diagnostic tests and therapies that may be painful, costly, or potentially injurious to the child. If the health practitioner resists ordering further tests, drugs, procedures, surgeries, or specialists, the FDIA abuser makes the medical system appear negligent for refusing to help a sick child and their selfless parent. Like those with Munchausen syndrome, FDIA perpetrators are known to switch medical providers frequently until they find one that is willing to meet their level of need; this practice is known as "doctor shopping" or "hospital hopping". The perpetrator continues the abuse because maintaining the child in the role of patient satisfies the abuser's needs. The cure for the victim is to separate the child completely from the abuser. When parental visits are allowed, sometimes there is a disastrous outcome for the child. Even when the child is removed, the perpetrator may then abuse another child: a sibling or other child in the family. Factitious disorder imposed on another can have many long-term emotional effects on a child. Depending on their experience of medical interventions, some children may learn that they are most likely to receive the positive parental attention they crave when they are playing the sick role in front of health care providers. Several case reports describe Munchausen syndrome patients suspected of themselves having been FDIA victims. Seeking personal gratification through illness can thus become a lifelong and multi-generational disorder in some cases. In stark contrast, other reports suggest survivors of FDIA develop an avoidance of medical treatment with post-traumatic responses to it. The adult caregiver who has abused the child often seems comfortable and not upset over the child's hospitalization. While the child is hospitalized, medical professionals must monitor the caregiver's visits to prevent an attempt to worsen the child's condition. In addition, in many jurisdictions, medical professionals have a duty to report such abuse to legal authorities. Diagnosis Use of the term "Munchausen syndrome by proxy" is controversial. In the World Health Organization's International Statistical Classification of Diseases, 10th Revision (ICD-10), the official diagnosis is factitious disorder (301.51 in ICD-9, F68.12 in ICD-10). Within the United States, factitious disorder imposed on another (FDIA or FDIoA) was officially recognized as a disorder in 2013, while in the United Kingdom, it is known as fabricated or induced illness by carers (FII). In DSM-5, the diagnostic manual published by the American Psychiatric Association in 2013, this disorder is listed under 300.19 Factitious disorder. This, in turn, encompasses two types: Factitious Disorder Imposed on Self Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy); the diagnosis is assigned to the perpetrator; the person affected may be assigned an abuse diagnosis (e.g. child abuse). Both types include an optional specifier to identify if the observed behavior was a single episode or part of recurrent episodes. Warning signs Warning signs of the disorder include: A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling, and unexplained. Physical or laboratory findings that are highly unusual, discrepant with patient's presentation or history, or physically or clinically impossible. A parent who appears medically knowledgeable, fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients' problems. A highly attentive parent who is reluctant to leave their child's side and who themselves seem to require constant attention. A parent who appears unusually calm in the face of serious difficulties in their child's medical course while being highly supportive and encouraging of the physician, or one who is angry, devalues staff, and demands further intervention, more procedures, second opinions, and transfers to more sophisticated facilities. The suspected parent may work in the health-care field themselves or profess an interest in a health-related job. The signs and symptoms of a child's illness may lessen or simply vanish in the parent's absence (hospitalization and careful monitoring may be necessary to establish this causal relationship). A family history of similar or unexplained illness or death in a sibling. A parent with symptoms similar to their child's own medical problems or an illness history that itself is puzzling and unusual. A suspected emotionally distant relationship between parents; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with a serious illness. A parent who reports dramatic, negative events, such as house fires, burglaries, or car accidents, that affect them and their family while their child is undergoing treatment. A parent who seems to have an insatiable need for adulation or who makes self-serving efforts for public acknowledgment of their abilities. A child who inexplicably deteriorates whenever discharge is planned. A child that looks for cueing from a parent in order to feign illness when medical personnel are present. A child that is overly articulate regarding medical terminology and their own disease process for their age. A child that presents to the Emergency Department with a history of repeat illness, injury, or hospitalization. Epidemiology FDIA is rare. Incidence rate estimates range from 1 to 28 per million children, although some assume that it may be much more common. One study in Italy found that 4 out of more than 700 children admitted to the hospital met the criteria (0.53%). In this study, stringent diagnostic criteria were used, which required at least one test outcome or event that could not possibly have occurred without deliberate intervention by the FDIA person. In one study, the average age of the affected individual at the time of diagnosis was four years old. Slightly over 50% were aged 24 months or younger, and 75% were under six years old. The average duration from onset of symptoms to diagnosis was 22 months. By the time of diagnosis, six percent of the affected persons were dead, mostly from apnea (a common result of smothering) or starvation, and seven percent had long-term or permanent injury. About half of the affected had siblings; 25% of the known siblings were dead, and 61% of siblings had symptoms similar to the affected or that were otherwise suspicious. The mother was the perpetrator in 76.5% of the cases, the father in 6.7%. Studies have showed that over 90% of FDIA cases, the abuser is the mother or another female guardian or caregiver. A psychodynamic model of this kind of maternal abuse exists. Fathers and other male caregivers have been the perpetrators in seven percent of the cases studied. When they are not actively involved in the abuse, the fathers or male guardians of FDIA victims are often described as being distant, emotionally disengaged, and powerless. These men play a passive role in FDIA by being frequently absent from the home and rarely visiting the hospitalized child. Usually, they vehemently deny the possibility of abuse, even in the face of overwhelming evidence or their child's pleas for help. Prognosis Studies have shown a mortality rate of between six and ten percent, making it perhaps the most lethal form of abuse. Society and culture Terminology The term "Munchausen syndrome by proxy", in the United States, has never officially been included as a distinct mental disorder by the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fifth edition. Although the DSM-III (1980) and DSM-III-R (1987) included Munchausen syndrome, they did not include MSbP. DSM-IV (1994) and DSM-IV-TR (2000) added MSbP as a proposal only, and although it was finally recognized as a disorder in DSM-5 (2013), each of the last three editions of the DSM designated the disorder by a different name. FDIA has been given different names in different places and at different times. What follows is a partial list of alternative names that have been either used or proposed (with approximate dates): Factitious Disorder Imposed on Another (current) (U.S., 2013) American Psychiatric Association, DSM-5 Factitious Disorder by Proxy (FDP, FDbP) (proposed) (U.S., 2000) American Psychiatric Association, DSM-IV-TR Fictitious Disorder by Proxy (FDP, FDbP) (proposed) (U.S., 1994) American Psychiatric Association, DSM-IV Fabricated or Induced Illness by Carers (FII) (U.K., 2002) The Royal College of Pediatrics and Child Health Factitious Illness by Proxy (1996) World Health Organization Pediatric Condition Falsification (PCF) (proposed) (U.S., 2002) American Professional Society on the Abuse of Children proposed this term to diagnose the victim (child); the perpetrator (caregiver) would be diagnosed "factitious disorder by proxy"; MSbP would be retained as the name applied to the 'disorder' that contains these two elements, a diagnosis in the child and a diagnosis in the caretaker. Induced Illness (Munchausen Syndrome by Proxy) (Ireland, 1999–2002) Department of Health and Children Munchausen Syndrome by Proxy (2002) Professor Roy Meadow. Meadow's Syndrome (1984–1987) named after Roy Meadow. This label, however, had already been in use since 1957 to describe a completely unrelated and rare form of cardiomyopathy. Polle Syndrome (1977–1984) coined by Burman and Stevens, from the then-common belief that Baron Münchhausen's second wife gave birth to a daughter named Polle during their marriage. The baron declared that the baby was not his, and the child died from "seizures" at the age of 10 months. The name fell out of favor after 1984, when it was discovered that Polle was not the baby's name, but rather was the name of her mother's hometown. While it initially included only the infliction of harmful medical care, the term has subsequently been extended to include cases in which the only harm arose from medical neglect, noncompliance, or even educational interference. The term is derived from Munchausen syndrome, a psychiatric factitious disorder wherein those affected feign disease, illness, or psychological trauma to draw attention, sympathy, or reassurance to themselves. Munchausen syndrome by proxy perpetrators, by contrast, are willing to fulfill their need for positive attention by hurting their own child, thereby assuming the sick role onto their child, by proxy. These proxies then gain personal attention and support by taking on this fictitious "hero role" and receive positive attention from others, by appearing to care for and save their so-called sick child. They are named after Baron Munchausen, a literary character based on Hieronymus Karl Friedrich, Freiherr von Münchhausen (1720–1797), a German nobleman and well-known storyteller. In 1785, writer and con artist Rudolf Erich Raspe anonymously published a book in which a fictional version of "Baron Munchausen" tells fantastic and impossible stories about himself, establishing a popular literary archetype of a bombastic exaggerator. Initial description "Munchausen syndrome" was first described by British endocrinologist and haematologist Richard Asher in 1951 as when someone invents or exaggerates medical symptoms, sometimes engaging in self-harm, to gain attention or sympathy. The term "Munchausen syndrome by proxy" was first coined by John Money and June Faith Werlwas in a 1976 paper titled " in the parents of psychosocial dwarfs: Two cases" to describe the abuse-induced and neglect-induced symptoms of the syndrome of abuse dwarfism. That same year, Sneed and Bell wrote an article titled "The Dauphin of Munchausen: factitious passage of renal stones in a child". According to other sources, the term was created by the British pediatrician Roy Meadow in 1977. In 1977, Meadow – then professor of pediatrics at the University of Leeds, England – described the extraordinary behavior of two mothers. According to Meadow, one had poisoned her toddler with excessive quantities of salt. The other had introduced her own blood into her baby's urine sample. This second case occurred during a series of Outpatient visits to the Paediatric Clinic of Dr. Bill Arrowsmith at Doncaster Royal Infirmary. He referred to this behavior as Munchausen syndrome by proxy (MSbP). The medical community was initially skeptical of FDIA's existence, but it gradually gained acceptance as a recognized condition. Controversy During the 1990s and early 2000s, Roy Meadow was an expert witness in several murder cases involving MSbP/FII. Meadow was knighted for his work for child protection, though later, his reputation, and consequently the credibility of MSbP, became damaged when several convictions of child killing, in which he acted as an expert witness, were overturned. The mothers in those cases were wrongly convicted of murdering two or more of their children, and had already been imprisoned for up to six years. One case was that of Sally Clark. Clark was a lawyer wrongly convicted in 1999 of the murder of her two baby sons, largely on the basis of Meadow's evidence. As an expert witness for the prosecution, Meadow asserted that the odds of there being two unexplained infant deaths in one family were one in 73 million. That figure was crucial in sending Clark to jail but was hotly disputed by the Royal Statistical Society, who wrote to the Lord Chancellor to complain. It was subsequently shown that the true odds were much greater once other factors (e.g. genetic or environmental) were taken into consideration, meaning that there was a significantly higher likelihood of two deaths happening as a chance occurrence than Meadow had claimed during the trial. Those odds in fact range from a low of 1:8500 to as high as 1:200. It emerged later that there was clear evidence of a Staphylococcus aureus infection that had spread as far as the child's cerebrospinal fluid. Clark was released in January 2003 after three judges quashed her convictions in the Court of Appeal in London, but suffering from catastrophic trauma of the experience, she later died from alcohol poisoning. Meadow was involved as a prosecution witness in three other high-profile cases resulting in mothers being imprisoned and subsequently cleared of wrongdoing: Trupti Patel, Angela Cannings and Donna Anthony. In 2003, Lord Howe, the Opposition spokesman on health, accused Meadow of inventing a "theory without science" and refusing to produce any real evidence to prove that Munchausen syndrome by proxy actually exists. It is important to distinguish between the act of harming a child, which can be easily verified, and motive, which is much harder to verify and which FDIA tries to explain. For example, a caregiver may wish to harm a child out of malice and then attempt to conceal it as illness to avoid detection of abuse, rather than to draw attention and sympathy. The distinction is often crucial in criminal proceedings, in which the prosecutor must prove both the act and the mental element constituting a crime to establish guilt. In most legal jurisdictions, a doctor can give expert witness testimony as to whether a child was being harmed but cannot speculate regarding the motive of the caregiver. FII merely refers to the fact that illness is induced or fabricated and does not specifically limit the motives of such acts to a caregiver's need for attention and/or sympathy. Meadow was investigated by the British General Medical Council (GMC) over evidence he gave in the Sally Clark trial. In July 2005, the GMC declared Meadow guilty of "serious professional misconduct", and he was struck off the medical register for giving "erroneous" and "misleading" evidence. At appeal, High Court judge Mr. Justice Collins said of the severity of his punishment that "It is very difficult to think that the giving of honest, albeit mistaken evidence could - save in an exceptional case - properly lead to such a finding." Collins's judgment raises important points concerning the liability of expert witnesses – his view is that referral to the GMC by the losing side is an unacceptable threat and that only the Court should decide whether its witnesses are seriously deficient and refer them to their professional bodies. In addition to the controversy surrounding expert witnesses, an article appeared in the forensic literature that detailed legal cases involving controversy surrounding the murder suspect. The article provides a brief review of the research and criminal cases involving Munchausen syndrome by proxy in which psychopathic mothers and caregivers were the murderers. It also briefly describes the importance of gathering behavioral data, including observations of the parents who commit the criminal acts. The article references the 1997 work of Southall, Plunkett, Banks, Falkov, and Samuels, in which covert video recorders were used to monitor the hospital rooms of suspected FDIA victims. In 30 out of 39 cases, a parent was observed intentionally suffocating their child; in two they were seen attempting to poison a child; in another, the mother deliberately broke her three-month-old daughter's arm. Upon further investigation, those 39 patients, ages one month to 3 years old, had 41 siblings; 12 of those had died suddenly and unexpectedly. The use of covert video, while apparently extremely effective, raises controversy in some jurisdictions over privacy rights. Legal status In most legal jurisdictions, doctors are allowed to give evidence only in regard to whether the child is being harmed. They are not allowed to give evidence in regard to the motive. Australia and the UK have established the legal precedent that FDIA does not exist as a medico-legal entity. In a June 2004 appeal hearing, the Supreme Court of Queensland, Australia, stated: The Queensland Supreme Court further ruled that the determination of whether or not a defendant had caused intentional harm to a child was a matter for the jury to decide and not for the determination by expert witnesses: Principles of law and implications for legal processes that may be deduced from these findings are that: Any matters brought before a Court of Law should be determined by the facts, not by suppositions attached to a label describing a behavior, i.e., MSBP/FII/FDBP; MSBP/FII/FDBP is not a mental disorder (i.e., not defined as such in DSM IV), and the evidence of a psychiatrist should not therefore be admissible; MSBP/FII/FDBP has been stated to be a behavior describing a form of child abuse and not a medical diagnosis of either a parent or a child. A medical practitioner cannot therefore state that a person "suffers" from MSBP/FII/FDBP, and such evidence should also therefore be inadmissible. The evidence of a medical practitioner should be confined to what they observed and heard and what forensic information was found by recognized medical investigative procedures; A label used to describe a behavior is not helpful in determining guilt and is prejudicial. By applying an ambiguous label of MSBP/FII to a woman is implying guilt without factual supportive and corroborative evidence; The assertion that other people may behave in this way, i.e., fabricate and/or induce illness in children to gain attention for themselves (FII/MSBP/FDBY), contained within the label is not factual evidence that this individual has behaved in this way. Again therefore, the application of the label is prejudicial to fairness and a finding based on fact. The Queensland Judgment was adopted into English law in the High Court of Justice by Mr. Justice Ryder. In his final conclusions regarding Factitious Disorder, Ryder states that: In his book Playing Sick (2004), Marc Feldman notes that such findings have been in the minority among U.S. and even Australian courts. Pediatricians and other physicians have banded together to oppose limitations on child-abuse professionals whose work includes FII detection. The April 2007 issue of the journal Pediatrics specifically mentions Meadow as an individual who has been inappropriately maligned. In the context of child protection (a child being removed from the custody of a parent), the Australian state of New South Wales uses a "on the balance of probabilities" test, rather than a "beyond reasonable doubt" test. Therefore, in the case "The Secretary, Department of Family and Community Services and the Harper Children [2016] NSWChC 3", the expert testimony of Professor David Isaacs that a certain blood test result was "highly unlikely" to occur naturally or accidentally (without any speculation about motive), was sufficient to refuse the return of the affected child and his younger siblings to the mother. The children had initially been removed from the mother's custody after the blood test results became known. The fact that the affected child quickly improved both medically and behaviourly after being removed was also a factor. Notable cases Beverley Allitt, a British nurse who murdered four children and injured a further nine in 1991 at Grantham and Kesteven Hospital, Lincolnshire, was diagnosed with Munchausen syndrome by proxy. Wendi Michelle Scott is a Frederick, Maryland, mother who was charged with sickening her four-year-old daughter. The book Sickened, by Julie Gregory, details her life growing up with a mother who had Munchausen by proxy, who took her to various doctors, coached her to act sicker than she was and to exaggerate her symptoms, and who demanded increasingly invasive procedures to diagnose Gregory's enforced imaginary illnesses. Lisa Hayden-Johnson of Devon was jailed for three years and three months after subjecting her son to a total of 325 medical actions – including being forced to use a wheelchair and being fed through a tube in his stomach. She claimed her son had a long list of illnesses including diabetes, food allergies, cerebral palsy, and cystic fibrosis, describing him as "the most ill child in Britain" and receiving numerous cash donations and charity gifts, including two cruises. In the mid-1990s, Kathy Bush gained public sympathy for the plight of her daughter, Jennifer, who by the age of 8 had undergone 40 surgeries and spent over 640 days in hospitals for gastrointestinal disorders. The acclaim led to a visit with first lady Hillary Clinton, who championed Bush's plight as evidence of need for medical reform. However, in 1996, Kathy Bush was arrested and charged with child abuse and Medicaid fraud, accused of sabotaging Jennifer's medical equipment and drugs to agitate and prolong her illness. Jennifer was moved to foster care where she quickly regained her health. The prosecutors claimed Kathy was driven by Munchausen Syndrome by Proxy, and she was convicted to a five-year sentence in 1999. Kathy was released after serving three years in 2005, always maintaining her innocence, and having gotten back in contact with Jennifer via correspondence. In 2014, 26-year-old Lacey Spears was charged in Westchester County, New York, with second-degree depraved murder and first-degree manslaughter. She fed her son dangerous amounts of salt after she conducted research on the Internet about its effects. Her actions were allegedly motivated by the social media attention she gained on Facebook, Twitter, and blogs. She was convicted of second-degree murder on March 2, 2015, and sentenced to 20 years to life in prison. Dee Dee Blanchard was a Missouri mother who was murdered by her daughter and a boyfriend in 2015 after having claimed for years that her daughter, Gypsy Rose, was sick and disabled; to the point of shaving her head, making her use a wheelchair in public, and subjecting her to unnecessary medication and surgery. Gypsy possessed no outstanding illnesses. Feldman said it is the first case he is aware of in a quarter-century of research where the victim killed the abuser. Their story was shown on HBO's documentary film Mommy Dead and Dearest and is featured in the Hulu limited series The Act. Gypsy Rose pleaded guilty to second-degree murder and received a ten-year sentence until being released on parole in December 2023, her boyfriend was convicted of first-degree murder and is sentenced to life in prison without parole. Rapper Eminem has spoken about how his mother would frequently take him to hospitals to receive treatment for illnesses that he did not have. His song "Cleanin' Out My Closet" includes a lyric regarding the illness, "...going through public housing systems victim of Münchausen syndrome. My whole life I was made to believe I was sick, when I wasn't 'til I grew up now I blew up..." His mother's illness resulted in Eminem receiving custody of his younger brother, Nathan. In 2013, when Justina Pelletier was 14, her parents took her to the emergency room at Boston Children's Hospital where doctors diagnosed her problems as psychiatric, but when her parents rejected the diagnosis and attempted to have her released, the hospital filed a report with Massachusetts Department of Children and Families alleging medical child abuse. This resulted in her being housed for 18 months in the psychiatric hospital, with her parents having limited access, until a judge ordered her returned to her parents. In 2016 her parents sued Boston Children's for medical malpractice, alleging that their civil rights were violated. At the trial, Pelletier's treating neurologist stated that several of her doctors suspected factitious disorder by proxy, and wanted her parents to stop encouraging her to be sick. Her parents lost the lawsuit, with one juror stating that Pelletier's parents thought of psychiatry as "psychological baloney". Megan Bhari (1996/7-2018) and her mother had formed a charity, Believe in Magic, to help ill children based on the claim that Megan had a brain tumor. It is unclear to what extent FDIA, Factitious Disorder Imposed on Self, and malingering may have been present but an inquest after her death found no morphological abnormalities in her brain. Directed towards animals Medical literature describes a subset of FDIA caregivers, where the proxy is a pet rather than another person. These cases are labeled Munchhausen syndrome by proxy: pet (MSbP:P). In these cases, pet owners correspond to caregivers in traditional FDIA presentations involving human proxies. No extensive survey has yet been made of the extant literature, and there has been no speculation as to how closely FDIA:P tracks with human FDIA. See also Factitious disorder imposed on self List of Munchausen by proxy cases Folie à deux Hypochondria Iatrogenesis Munchausen by Internet Psychosomatic illness Run (2020 American film) Everything, Everything (novel) References Forensic psychology Factitious disorders Psychopathological syndromes Child abuse Wikipedia medicine articles ready to translate

Institutionalisation

In sociology, institutionalisation (or institutionalization) is the process of embedding some conception (for example a belief, norm, social role, particular value or mode of behavior) within an organization, social system, or society as a whole. The term may also be used to refer to committing a particular individual or group to an institution, such as a mental or welfare institution. The term may also be used in a political sense to apply to the creation or organization of governmental institutions or particular bodies responsible for overseeing or implementing policy, for example in welfare or development. During the period of the Industrial Revolution in Europe many countries went through a period of "institutionalization", which saw a large expansion and development of the role of government within society, particularly into areas seen previously as the private sphere. Institutionalization is also seen as an important part of the process of modernization in developing countries, involving again the expansion and improved organization of government structures. History During the period from 1850 to 1930 many types of institutions were created by public subscription, Parliament and local authorities to provide housing, healthcare, education, and financial support for individuals in need. At the upper end of the scale, public boarding schools such as Eton and Harrow were founded or greatly extended to meet the growing demand for the education of the children of those in colonial service overseas. These were seen as models of social improvement, and many inferior imitations followed for the lower social orders. Virtually every borough in the UK was required by legislation to make provision for paupers, homeless, released prisoners, convicted criminals, orphans, disabled war veterans, older people with no means of support, deaf and blind schools, schools and colonies for those with learning disabilities or mental health problems. Distinguishing features of such institutions were frequently, but not exclusively: communal dormitories communal kitchens and dining facilities rural, isolated locations restrictions on personal liberty and possessions uniforms oppressive, authoritarian regimes strict systems of rules and codes of conduct boards of visitors or trustees, usually drawn from the ranks of the upper middle classes, the so-called "great and good" hierarchical systems of management compulsory religious attendance involvement of inmates as unpaid or poorly rewarded labour in return for small privileges widespread abuse of human rights, dignity rigid separation of the sexes excessive reliance on medication and physical restraints Many of these organisations, whilst originally expressing idealistic aspirations and aims, became "total" institutions within a generation or two of their foundation, providing in some cases cradle-to-grave housing, occupation and social control. Founding charters usually proclaimed beneficial outcomes of "reform" (or rehabilitation) of character through moral and occupation education and discipline, but in practice inmates were often trapped in a system that provided no obvious route of escape or promotion. As late as the 1950s, in Britain, several hundred thousand people lived in Victorian asylums and "colonies". References See also Deinstitutionalisation Social institutions

Intensive outpatient program

An intensive outpatient program (IOP), also known as an intensive outpatient treatment (IOT) program, is a structured non-residential psychological treatment program which addresses mental health disorders and substance use disorders (SUDs) that do not require detoxification through a combination of group-based psychotherapy, individual psychotherapy, family counseling, educational groups, and strategies for encouraging motivation and engagement in treatment. IOP operates on a small scale and does not require the intensive residential or partial day services typically offered by the larger, more comprehensive treatment facilities. The typical IOP program offers group therapy and generally facilitates 9-19 hours a week of programming for mental health and addiction treatment. IOP allows the individual to be able to participate in their daily affairs, such as work, and then participate in treatment at an appropriate facility in the morning or at the end of the day. With an IOP, classes, sessions, meetings, and workshops are scheduled throughout the day, and individuals are expected to adhere to the strict structure of the program. Online IOP has been shown to be effective as well. The typical IOP program encourages active participation in 12-step programs in addition to IOP participation. IOP can be more effective than individual therapy for chemical dependency. IOP is also used by some HMOs as transitional treatment for patients just released from treatment in a psychiatric hospital or upon discharge from a residential treatment program. See also Partial hospitalization (PHP) References Treatment of mental disorders Addiction psychiatry

Hierarchical Taxonomy of Psychopathology

The Hierarchical Taxonomy Of Psychopathology (HiTOP) consortium was formed in 2015 as a grassroots effort to articulate a classification of mental health problems based on recent scientific findings on how the components of mental disorders fit together. The consortium is developing the HiTOP model, a classification system, or taxonomy, of mental disorders, or psychopathology, aiming to prioritize scientific results over convention and clinical opinion. The motives for proposing this classification were to aid clinical practice and mental health research. The consortium was organized by Drs. Roman Kotov, Robert Krueger, and David Watson. At inception it included 40 psychologists and psychiatrists, who had a record of scientific contributions to classification of psychopathology The HiTOP model aims to address limitations of traditional classification systems for mental illness, such as the DSM-5 and ICD-10, by organizing psychopathology according to evidence from research on observable patterns of mental health problems. When the HiTOP model is complete, it will form a detailed hierarchical classification system for mental illness starting from the most basic building blocks and proceeding to the highest level of generality: combining individual signs and symptoms into narrow components or traits, and then combining these symptom components and traits into (in order of increasing generality) syndromes, subfactors, spectra, and superspectra. Currently, several aspects of the model are provisional or incomplete. History of the quantitative classification movement through HiTOP Throughout the history of psychiatric classification, two approaches have been taken to deciding the content and boundaries of mental disorders that enter official diagnostic rubrics. A first one might be termed authoritative: experts and members of official bodies meet to determine classificatory rubrics through group discussions and associated political processes. This approach characterizes traditional classification systems, such as the DSM and the ICD. A second approach might be termed empirical. In this approach, data are gathered on psychopathological building blocks. These data are then analyzed to address specific research questions. For example, does a specific list of symptoms delineate a single psychopathological entity or multiple entities? This approach is sometimes characterized as more "bottom up" (i.e., starting with raw observations and inferring the presence of diagnostic concepts), compared with the more "top down" approach (i.e., starting with a general clinical concept and deducing the symptoms that might define it) of official classification systems. These approaches, although distinguishable, are not entirely separable. Some amount of empiricism and some amount of expert authority is inevitably present in both (i.e., authoritative classification approaches have relied on specific types of empiricism as part of their construction process, and an empirical approach begins with the expertise needed to assemble and assess specific psychopathological building blocks). Nevertheless, authoritative approaches tend to weigh putative expertise, disciplinary background, and tradition heavily. The consortium aims for an empirical rather than authoritative approach, but it has been argued that the HiTOP model is partly authoritative as it is grounded on a traditional but arbitrary statistical approach. The empirical movement has a long history, beginning with the work of Thomas Moore, Hans Eysenck, Richard Wittenborn, Maurice Lorr, and John Overall, who developed measures to assess signs and symptoms of psychiatric inpatients, and identified empirical dimensions of symptomatology through factor analysis of these instruments. Others have searched for natural categories using such techniques as cluster analysis. Similarly, research on patterns of emotional (also called affective) experience helped to identify dimensions of depression and anxiety symptoms. Factor analytic studies of child symptomatology found clusters of emotional and behavioral problems that remain in use in research and clinical assessment today. Finally, factor analyses of comorbidity among common adult disorders revealed higher-order dimensions of psychopathology that inspired a growing and diverse literature. The most recent large-scale effort in this movement toward empirically based classification emerged in the spring of 2015. Forty scholars working in the classification of psychopathology started a consortium (now over 160 members with 10 workgroups) devoted to articulating an empirically based classification system of mental illness. Their initial proposed model – the Hierarchical Taxonomy of Psychopathology – has been claimed to provide a marked departure from DSM and ICD. The HiTOP model is based on structural studies that span from age 2 to 90 and include samples from many non-Western societies. However, Western samples are over-represented in this literature and very little research has been done with people over age 60. The HiTOP model does not account for individual level developmental processes that may lead to various disorder outcomes. To update HiTOP as new structural and validation studies become available, the Consortium formed a Revisions Workgroup. This workgroup has designed a process for continuous evidence-based revision of the model. This process is intended to be nimble enough to keep pace with a rapidly growing literature on the structure of psychopathology, but not so fickle as to result in numerous changes without substantiated support. HiTOP structure Fundamental findings that shaped HiTOP Three fundamental findings shaped HiTOP. First, psychopathology is best characterized by dimensions rather than in discrete categories. Dimensions are defined as continua that reflect individual differences in a maladaptive characteristic across the entire population (e.g., social anxiety is a dimension that ranges from comfortable social interactions to distress in nearly all social situations). Dimensions reflect differences in degree (i.e., continua), rather than in kind (i.e., people are either in or outside of each category), as the evidence to date suggests that psychopathology exists on a continuum with normal-range functioning. These dimensions can be organized hierarchically from narrowest to broadest (see Figure). Specifically, dimensional description improves reliability and eliminates the need for “Other Specified” or “Unspecified” diagnoses, as every person has a standing on each dimension and thus is described. Nevertheless, some qualitative boundaries may exist in psychopathology. If categorical entities are identified and replicated, they would be added to HiTOP. Indeed, the term dimensional is not used in the name of the model, in recognition of openness to evidence on discrete entities. Second, HiTOP assumes that the natural organization of psychopathology can be discerned in co-occurrence of its features. Classification that follows co-occurrence ensures coherence of diagnostic entities, so that related signs and symptoms are assigned together to tightly knit dimensions, whereas unrelated features are placed on different dimensions. Moreover, such constructs capture information about common genetics, risk factors, biomarkers, and treatment response shared by co-occurring forms of psychopathology. Third, psychopathology can be organized hierarchically from narrow to broad dimensions. Numerous studies have found that specific psychopathology dimensions aggregate into more general factors. Patterns of comorbidity are represented by higher-order dimensions. Accordingly, comorbidity is measured and expressed in scores that researchers and clinicians can use. Organization of HiTOP model Consistent with these three fundamental findings, the HiTOP model consists of hierarchically organized dimensions identified in covariation of psychopathology features. Signs, symptoms, and maladaptive traits and behaviors are grouped into homogeneous components- constellations of closely related symptom manifestations; for example, fears of working, reading, eating, or drinking in front of others form performance anxiety cluster. Maladaptive traits are specific pathological personality characteristics, such as submissiveness. The leading conceptualization is that symptoms and maladaptive traits differ only in time frame. A symptom component reflects current functioning (e.g., past month), whereas the corresponding trait reflects functioning on the same dimension in general—that is, over many years. Closely related homogenous components are combined into dimensional syndromes (e.g., social anxiety). Syndromes are composites of related components/traits, such as a social anxiety syndrome that encompasses both performance anxiety and interaction anxiety. Of note, the term syndrome can be used to indicate a category (for instance, some medical diseases such as Lyme disease are probably best thought of as natural discrete problems that someone either wholly has or wholly does not have), but here we use it to indicate a dimension. Importantly, HiTOP syndromes do not necessarily map onto traditional, categorical disorders like those found in DSM and ICD. Studies often have used categorical disorders to define HiTOP dimensions, but these categorical disorders are used as proxies and are not part of HiTOP as such. Rather than re-arranging DSM and ICD disorders, HiTOP aims to create a system based on signs and symptoms described in these manuals (as well as additional symptoms) and reorganize them based on how studies have found them to occur in combination. Clusters of closely related syndromes form subfactors, such as the fear subfactor formed by strong links between social anxiety, agoraphobia, and specific phobias. Spectra are larger constellations of syndromes, such as an internalizing spectrum composed of syndromes from fear, distress, eating pathology, and sexual problems subfactors. Six spectra have been included in HiTOP so far: The thought disorder spectrum comprises maladaptive traits of peculiarity, unusual beliefs, unusual experiences, and fantasy proneness, as well as symptom dimensions of disorganization and reality distortion; also symptom dimensions of dissociation and mania are linked to this spectrum provisionally. The thought disorder spectrum includes some signs and symptoms of such disorders as schizophrenia and related disorders, mood disorders with psychosis, schizotypal personality disorder, and paranoid personality disorder, and provisionally dissociative disorders and bipolar disorders. The detachment spectrum comprises maladaptive traits of emotional detachment, anhedonia, social withdrawal, and romantic disinterest, as well as symptom dimensions of inexpressivity and avolition. The detachment spectrum includes some signs and symptoms of such disorders as schizoid personality disorder, avoidant personality disorder, schizotypal personality disorder, and schizophrenia and related disorders. The antagonistic externalizing spectrum comprises maladaptive traits of manipulativeness, deceitfulness, callousness, grandiosity, aggression, rudeness, domineering, and suspiciousness, as well as symptom dimensions characteristic of antisocial behavior, such as theft, fraud, destruction of property, and aggression. The antagonistic externalizing spectrum includes some signs and symptoms of such disorders as conduct disorder, antisocial personality disorder, intermittent explosive disorder, oppositional defiant disorder, histrionic personality disorder, paranoid personality disorder, narcissistic personality disorder, and provisionally borderline personality disorder. The disinhibited externalizing spectrum comprises maladaptive traits of impulsivity, irresponsibility, distractibility, disorganization, risk taking, (low) perfectionism, (low) workaholism, as well as symptom dimensions characteristic of antisocial behavior (listed above), substance use and abuse, inattention, and hyperactivity. The disinhibited externalizing spectrum includes some signs and symptoms of such disorders as alcohol use disorder, substance use disorders, ADHD, conduct disorder, antisocial personality disorder, intermittent explosive disorder, oppositional defiant disorder, and provisionally borderline personality disorder. The internalizing spectrum comprises maladaptive traits of emotional lability, anxiousness, separation insecurity, submissiveness, perseveration, and anhedonia, as well as symptom dimensions characteristic of distress, fear, eating problems, and sexual problems; also symptom dimensions of mania are linked to this spectrum provisionally. The internalizing spectrum includes some signs and symptoms of such disorders as major depressive disorder, dysthymia, generalized anxiety disorder, posttraumatic stress disorder, borderline personality disorder, agoraphobia, obsessive-compulsive disorder, panic disorder, social anxiety disorder, specific phobias, anorexia nervosa, binge eating disorder, bulimia nervosa, sexual problems such as arousal difficulties, low desire, orgasmic dysfunction, and sexual pain, and provisionally bipolar disorders. The somatoform spectrum comprises symptom dimensions of conversion, somatization, malaise, head pain, gastrointestinal symptoms, and cognitive symptoms. The somatoform spectrum includes some signs and symptoms of such disorders as illness anxiety and somatic symptom disorder. Superspectra are very broad dimensions comprising multiple spectra, such as a general factor of psychopathology (or p-factor) that represents the liability shared by all mental disorders and the externalizing superspectrum that captures the overlap between the disinhibited and antagonistic externalizing spectra. Recently, emotional dysfunction and psychosis superspectra have also been proposed, capturing the overlap between the internalizing and somatoform spectra, and between the thought disorder and detachment spectra, respectively. Limitations of traditional classification systems Arbitrary boundaries between psychopathology and normality Traditional systems consider all mental disorders to be categories (i.e., people are either in or outside of each category), whereas the evidence to date suggests that psychopathology exists on a continuum with normal-range functioning. In fact, not a single mental disorder has been established in the scientific literature as a discrete categorical entity. Consistent with this evidence, the HiTOP model defines psychopathology along continuous dimensions rather than in discrete categories. Importantly, HiTOP treats the discrete vs. continuous nature of psychopathology as a research question, and the consortium continues to investigate it. Heterogeneity within disorders Many existing diagnoses are quite heterogeneous in terms of observable symptoms. For instance, there are over 600,000 symptom presentations that satisfy diagnostic criteria for DSM-5 posttraumatic stress disorder. The HiTOP model is informed by evidence from research on observable patterns of mental health problems, grouping related symptoms together and assigning unrelated symptoms to different syndromes, thereby identifying unitary constructs and reducing diagnostic heterogeneity. One limitation of a taxonomy based on symptom correlations such as HiTOP is their inability to handle the multifinality and equifinality of developmental processes. Frequent disorder co-occurrence Co-occurrence among mental disorders, often referred to as comorbidity, is very common in the clinic and general population alike. Comorbidity complicates research design and clinical decision-making, as additional conditions can distort study results and affect treatment (i.e. researching the specific causes of a condition like major depressive disorder is complicated when many study participants will meet criteria for additional syndromes). In terms of classification, high comorbidity suggests that some conditions have been split unnecessarily into multiple diagnoses, indicating the need to redraw boundaries between disorders. Comorbidity also conveys important information about shared risk factors, pathological processes, and illness course. A hierarchical and dimensional classification system such as HiTOP aims to explain these patterns and make it explicitly available to researchers and clinicians. Unclear boundaries between disorders and diagnostic instability Traditional diagnoses generally show limited reliability, as can be expected when arbitrary groups are created out of naturally dimensional phenomena. For example, the DSM-5 Field Trials found that 40% of diagnoses did not meet even a relaxed cutoff for acceptable interrater reliability, indicating boundaries between disorders are unclear. Further, DSM diagnoses have shown low stability over time (i.e., people can fluctuate in diagnostic status even over short intervals with trivial changes in symptom severity). A quantitative classification such as HiTOP also helps to address the issue of instability, as indicated by the high test–retest reliability of dimensional psychopathology constructs. Validity evidence Validation of an empirical classification system like HiTOP is an ongoing process, but it already has produced a substantial body of evidence that can be summarized in the following five areas: Substantial twin and molecular evidence indicates that genetic associations among forms of psychopathology largely parallel HiTOP organization. Biobehavioral constructs of Research Domain Criteria link to HiTOP dimensions with appreciable specificity. Accumulating evidence suggests that environmental exposures, such as childhood maltreatment and discrimination, are better construed as risk factors for HiTOP dimensions rather than DSM disorders. Many treatments such as antipsychotics, serotonin reuptake inhibitors, and various psychotherapies are thought to act on HiTOP dimensions ranging from symptom components to superspectra. Emerging evidence suggests that HiTOP constructs show stronger associations with genetic and neurobiologic markers than DSM diagnoses. Research utility Theoretical models of the causes and consequences of psychiatric problems have traditionally been framed around diagnoses. New research highlights the importance of extending this focus to encompass dimensions that span many diagnoses, including both narrowly defined symptoms and traits (e.g., obsessions) and broader clusters of psychological conditions (e.g., internalizing spectrum). The hierarchical structure of HiTOP implies that any cause or outcome of mental illness could emerge because of its effects on broad higher order dimensions, the syndromes, or specific lower order dimensions. An association between a DSM diagnosis and some outcome could reflect one (or more) qualitatively distinct pathways. As an example, individual differences in HiTOP spectra and superspectra are more strongly linked than traditional syndromes to potent stressors that occur early in development like childhood maltreatment, peer victimization, racial discrimination. Although this approach of comparing pathways to and from dimensions at different levels of HiTOP has been the most common application, it is not the only one. HiTOP constructs are useful predictors of clinical outcomes, such as chronicity, impairment, and suicidality. Ample evidence indicates that dimensional phenotypes tend to be more informative than traditional diagnoses in prognostication. They also account for psychosocial impairment both concurrently and prospectively, explaining differences in impairment several times better than categorical diagnoses. Other outcomes, such as suicidality and future treatment-seeking, appear to follow the same pattern. Other researchers have evaluated the joint predictive power of sets of HiTOP dimensions above and beyond the corresponding DSM–5 diagnosis. This approach explicitly compares the explanatory potential of dimensional versus categorical approaches to psychopathology. Additional ways HiTOP can be useful in empirical research include its dimensions serving as outcomes of experimental manipulations both in the lab and in a randomized clinical trial, although such applications are understudied. HiTOP can be assessed directly with validated measures, avoiding the complications of extracting dimensions from DSM-based data using tools like factor analysis that require larger samples. Finally, modeling of symptom-level data enables investigators to simultaneously examine psychopathology at multiple levels of breadth in relation to the same criterion. The Measure Development Workgroup is currently constructing both questionnaire and interview tools to measure all HiTOP dimensions and provide crucial comprehensive data for testing and revising HiTOP. Clinical utility In the HiTOP framework, psychopathology of given patient is no longer described with a list of categorical diagnoses, but as a profile on dimensions with varying degrees of severity and including all levels from components and traits through spectra and superspectra. HiTOP explicitly acknowledges the clinical reality that no clear divisions are empirically supported between most mental disorders and normality or, oftentimes, even between neighboring disorders. In practice, clinical decisions are not simply whether to treat the patient or not (reflecting whether the disorder is present or not). Rather, a graded set of interventions varying in intensity is typically deployed in response to a corresponding level of clinical need. HiTOP profile is compatible with this approach, and multiple ranges can be specified on a given dimension to guide the choice of intervention. Currently there is no evidence that compares treatment outcomes using HiTOP model results to conventional approaches including the DSM. HiTOP’s adoption of a dimensional perspective does not necessarily preclude the use of categories in clinical practice. For example, it is common in medicine to superimpose data-driven categories (e.g., normal, mild, moderate, or severe) on dimensional measures, such as blood pressure, cholesterol, or weight. A similar approach can be used with HiTOP. Ranges of cut points can be based on a pragmatic assessment of relative costs and benefits. For instance, in primary care settings, a more liberal (i.e., inclusive or sensitive) threshold can be used for identifying patients requiring more detailed follow-up. Conversely, decisions about more intensive or risky treatments can use a more conservative (i.e., exclusive or specific) threshold. Research has begun to delineate such ranges for some measures, but much more is needed to cover the full spectrum. Most importantly, HiTOP explicitly acknowledges that ranges are pragmatic and not absolute, recognizing the need for flexibility in clinical decision-making. Categorical and dimensional systems can relay equivalent information as long as cut points are not reified, an approach that is explicit in the HiTOP model. Clinicians tend to use DSM diagnoses for billing much more than for case conceptualization or treatment decisions. Many clinicians report that formal diagnosis does not provide helpful guidance beyond cardinal symptoms (e.g. after recording the primary features of the disorder, clinicians may not refer back to the formal diagnosis for purposes of treatment planning or selection). A chief objective of HiTOP is to make diagnosis more useful for clinicians. Three types of evidence support this aspiration. First, HiTOP dimensions show substantially higher reliability than DSM diagnoses, meaning the dimensional profile is likely to be more consistent over time and more likely to be agreed upon across multiple clinicians. Second, growing evidence indicates that these dimensions are about twice as informative as diagnoses in answering such clinical questions as who is impaired by symptoms, who will need services, who will recover, and who will attempt suicide. Third, though it is debated, initial survey data from clinicians indicated that they see more utility in HiTOP dimensions than DSM diagnoses. Nevertheless, much is currently unknown about the clinical utility of HiTOP. The topic needs both further research and pragmatic guidance such as the development of HiTOP-based practice guidelines. In the HiTOP consortium, the Measure Development Workgroup is constructing a comprehensive new inventory expected to be ready for clinical use in 2022. Meanwhile, the Clinical Translation Workgroup has assembled a battery of existing normed and validate self-report measures that assesses most of the model and requires 40 minutes to complete. The battery is free, self-administered, and automatically scored. The Workgroup also developed manuals, trainings, and online resources to help clinicians with practical questions such as billing. The battery is used in a dozen psychology and psychiatry clinics that participate in the HiTOP Field Trials to test questions about clinical utility of the system. Personality and personality disorders Included within the HiTOP structure are personality disorders, as well as general personality traits. It is worth providing particular attention to the personality disorders and personality because the shift to a dimensional structure has been rather successful for the personality disorders, including even a formal recognition within Section III of DSM-5 (for emerging measures and models) and within the forthcoming ICD-11. Personality disorders have been included within every edition of the DSM as categorical syndromes, such as the borderline, narcissistic, schizotypal, and antisocial (or psychopathic). However, the validity of these diagnostic categories have long been questioned, including the concerns regarding arbitrary boundary with normal personality functioning, substantial overlap across the different syndromes, and considerable heterogeneity within each diagnostic category. The heterogeneity within each category and the overlap across categories hinder considerably the ability to identity a pathology that is specific to a particular syndrome and a unified, consistent treatment protocol. The Five Factor Model (FFM) is arguably the predominant dimensional model of general personality structure, consisting of the domains of neuroticism (or emotional instability), extraversion versus introversion, openness (or unconventionality), agreeableness versus antagonism, and conscientiousness (or constraint). The FFM has substantial construct validity, including multivariate behavior genetics with respect to its structure, cognitive neuroscience coordination, childhood antecedents, temporal stability across the life span, and cross-cultural validity, both through emic studies considering the structures indigenous to alternative languages and a large number of etic studies across major regions of the world, including North America, South America, Western Europe, Eastern Europe, Southern Europe, the Middle East, Africa, Oceania, South–Southeast Asia, and East Asia.  The FFM has also been shown to be useful in predicting a wide variety of important life outcomes, both positive and negative. There is also a considerable body of research to demonstrate that the DSM and ICD personality disorders are maladaptive variants of the domains (and facets) of the FFM. This empirical support includes researchers descriptions of each personality disorder in terms of the FFM, clinicians descriptions, and research relating measures of the FFM to alternative measures of the personality disorders. One can in fact use an FFM measure to assess for the presence of many of the personality disorders, such as borderline and antisocial, yielding indices that are equal in validity to the direct, traditional measures of these personality disorders. Finally, there is also a body of research to indicate that clinicians prefer dimensional trait models over the DSM categorical syndromes for patient description and treatment planning. Section III of DSM-5, for emerging measures and models, now includes a dimensional trait model, consisting of the five dimensional trait domains of negative affectivity, detachment, psychoticism, antagonism, and disinhibition, along with 25 underlying facets, which can be assessed with the Personality Inventory for DSM-5 (PID-5). Research with the PID-5 has indicated excellent coverage of the DSM-5 Section II (or DSM-IV) categorical syndromes. It should be acknowledged though that the DSM-5 Section III Alternative Model of Personality Disorder does still retain six of the DSM-IV categorical syndromes. A more extensive shift to a dimensional trait model is provided by the forthcoming ICD-11, which includes the five trait domains of negative affectivity, detachment, dissociality, disinhibition, and anankastia (along with a borderline pattern specifier). The ICD-11 trait model does not include a domain of psychoticism as the ICD has placed schizotypal traits within the spectrum of schizophrenia rather than within the personality disorders. The DSM-5 trait model does not include a domain of anankastia, but in the initial version of the trait model there was a domain of compulsivity that is closely aligned with anankastia. Both the DSM-5 Section III and ICD-11 dimensional trait models are aligned with the FFM. “These domains [of the DSM-5 dimensional trait model] can be understood as maladaptive variants of the domains of the five-factor model of personality”. As stated in DSM-5, “these five broad domains are maladaptive variants of the five domains of the extensively validated and replicated personality model known as the ‘Big Five,’ or the Five Factor Model of personality”. The five domains of ICD-11 are likewise aligned with the FFM: “Negative Affective with neuroticism, Detachment with low extraversion, Dissocial with low agreeableness, Disinhibited with low conscientiousness and Anankastic with high conscientiousness” References Classification of mental disorders

Psychosomatic medicine

Psychosomatic medicine is an interdisciplinary medical field exploring the relationships among social, psychological, behavioral factors on bodily processes and quality of life in humans and animals. The academic forebearer of the modern field of behavioral medicine and a part of the practice of consultation-liaison psychiatry, psychosomatic medicine integrates interdisciplinary evaluation and management involving diverse specialties including psychiatry, psychology, neurology, psychoanalysis, internal medicine, pediatrics, surgery, allergy, dermatology, and psychoneuroimmunology. Clinical situations where mental processes act as a major factor affecting medical outcomes are areas where psychosomatic medicine has competence. Psychosomatic disorders Some physical diseases are believed to have a mental component derived from stresses and strains of everyday living. This has been suggested, for example, of lower back pain and high blood pressure, which some researchers have suggested may be related to stresses in everyday life. The psychosomatic framework additionally sees mental and emotional states as capable of significantly influencing the course of any physical illness. Psychiatry traditionally distinguishes between psychosomatic disorders, disorders in which mental factors play a significant role in the development, expression, or resolution of a physical illness, and somatoform disorders, disorders in which mental factors are the sole cause of a physical illness. It is difficult to establish for certain whether an illness has a psychosomatic component. A psychosomatic component is often inferred when there are some aspects of the patient's presentation that are unaccounted for by biological factors, or some cases where there is no biological explanation at all. For instance, Helicobacter pylori causes 80% of peptic ulcers. However, most people living with Helicobacter pylori do not develop ulcers, and 20% of patients with ulcers have no H. pylori infection. Therefore, in these cases, psychological factors could still play some role. Similarly, in irritable bowel syndrome (IBS), there are abnormalities in the behavior of the gut. However, there are no actual structural changes in the gut, so stress and emotions might still play a role. The strongest perspective on psychosomatic disorders is that attempting to distinguish between purely physical and mixed psychosomatic disorders is obsolete as almost all physical illness have mental factors that determine their onset, presentation, maintenance, susceptibility to treatment, and resolution. According to this view, even the course of serious illnesses, such as cancer, can potentially be influenced by a person's thoughts, feelings and general state of mental health. Addressing such factors is the remit of the applied field of behavioral medicine. In modern society, psychosomatic aspects of illness are often attributed to stress making the remediation of stress one important factor in the development, treatment, and prevention of psychosomatic illness. Connotations of the term "psychosomatic illness" The term psychosomatic disease was most likely first used by Paul D. MacLean in his 1949 seminal paper ‘Psychosomatic disease and the “visceral brain”; recent developments bearing on the Papez theory of emotions.’ In the field of psychosomatic medicine, the phrase "psychosomatic illness" is used more narrowly than it is within the general population. For example, in lay language, the term often encompasses illnesses with no physical basis at all, and even illnesses that are faked (malingering). In contrast, in contemporary psychosomatic medicine, the term is normally restricted to those illnesses that do have a clear physical basis, but where it is believed that psychological and mental factors also play a role. Some researchers within the field believe that this overly broad interpretation of the term may have caused the discipline to fall into disrepute clinically. For this reason, among others, the field of behavioral medicine has taken over much of the remit of psychosomatic medicine in practice and there exist large areas of overlap in the scientific research. Criticism Studies have yielded mixed evidence regarding the impact of psychosomatic factors in illnesses. Early evidence suggested that patients with advanced-stage cancer may be able to survive longer if provided with psychotherapy to improve their social support and outlook. However, a major review published in 2007, which evaluated the evidence for these benefits, concluded that no studies meeting the minimum quality standards required in this field have demonstrated such a benefit. The review further argues that unsubstantiated claims that "positive outlook" or "fighting spirit" can help slow cancer may be harmful to the patients themselves if they come to believe that their poor progress results from "not having the right attitude". Treatment While in the U.S., psychosomatic medicine is considered a subspecialty of the fields of psychiatry and neurology, in Germany and other European countries it is considered a subspecialty of internal medicine. Thure von Uexküll and contemporary physicians following his thoughts regard the psychosomatic approach as a core attitude of medical doctors, thereby declaring it not as a subspecialty, but rather an integrated part of every specialty. Medical treatments and psychotherapy are used to treat illnesses believed to have a psychosomatic component. History In the medieval Islamic world the Persian psychologist-physicians Ahmed ibn Sahl al-Balkhi (d. 934) and Haly Abbas (d. 994) developed an early model of illness that emphasized the interaction of the mind and the body. He proposed that a patient's physiology and psychology can influence one another. Contrary to Hippocrates and Galen, Ahmed ibn Sahl al-Balkhi did not believe that mere regulation and modulation of the body tempers and medication would remedy mental disorders because words play a vital and necessary role in emotional regulation. To change such behaviors, he used techniques, such as belief altering, regular musing, rehearsals of experiences, and imagination. In the beginnings of the 20th century, there was a renewed interest in psychosomatic concepts. Psychoanalyst Franz Alexander had a deep interest in understanding the dynamic interrelation between mind and body. Sigmund Freud pursued a deep interest in psychosomatic illnesses following his correspondence with Georg Groddeck who was, at the time, researching the possibility of treating physical disorders through psychological processes. Hélène Michel-Wolfromm applied psychosomatic medicine to the field of gynecology and sexual problems experienced by women. In the 1970s, Thure von Uexküll and his colleagues in Germany and elsewhere proposed a biosemiotic theory (the umwelt concept) that was widely influential as a theoretical framework for conceptualizing mind-body relations. This model shows that life is a meaning or functional system. Farzad Goli further explains in Biosemiotic Medicine (2016), how signs in the form of matter (e.g., atoms, molecules, cells), energy (e.g., electrical signals in nervous system), symbols (e.g., words, images, machine codes), and reflections (e.g., mindful moments, metacognition) can be interpreted and translated into each other. Henri Laborit, one of the founders of modern neuropsychopharmacology, carried out experiments in the 1970s that showed that illness quickly occurred when there was inhibition of action in rats. Rats in exactly the same stressful situations but whom were not inhibited in their behavior (those who could flee or fight—even if fighting is completely ineffective) had no negative health consequences. He proposed that psychosomatic illnesses in humans largely have their source in the constraints that society puts on individuals in order to maintain hierarchical structures of dominance. The film My American Uncle, directed by Alain Resnais and influenced by Laborit, explores the relationship between self and society and the effects of the inhibition of action. In February 2005, the Boston Syndromic Surveillance System detected an increase in young men seeking medical treatment for stroke. Most of them did not actually experience a stroke, but the largest number presented a day after Tedy Bruschi, a local sports figure, was hospitalized for a stroke. Presumably they began misinterpreting their own harmless symptoms, a group phenomenon now known as Tedy Bruschi syndrome. Robert Adler is credited with coining the term Psychoneuroimmunology (PNI) to categorize a new field of study also known as mind-body medicine. The principles of mind-body medicine suggest that our mind and the emotional thoughts we produce have an incredible impact on our physiology, either positive or negative. PNI integrates the mental/psychological, nervous, and immune system, and these systems are further linked together by ligands, which are hormones, neurotransmitters and peptides. PNI studies how every single cell in our body is in constant communication—how they are literally having a conversation and are responsible for 98% of all data transferred between the body and the brain. Dr. Candace Pert, a professor and neuroscientist who discovered the opiate receptor, called this communication between our cells the ‘Molecules of Emotion' because they produce the feelings of bliss, hunger, anger, relaxation, or satiety. Dr. Pert maintains that our body is our subconscious mind, so what is going on in the subconscious mind is being played out by our body. See also , also known as "somatoform disorder" References External links Mind-Body Medicine: An Overview, US National Institutes of Health, Center for Complementary and Integrative Health NIH Academy of Psychosomatic Medicine Psychosomatics, journal of the Academy of Psychosomatic Medicine American Psychosomatic Society Psychosomatic Medicine, journal of the American Psychosomatic Society Medical specialties Mind–body interventions Stress (biological and psychological) Anxiety disorder treatment Immune system Somatic psychology

Psychiatrist

A psychiatrist is a physician who specializes in psychiatry. Psychiatrists are physicians who evaluate patients to determine whether their symptoms are the result of a physical illness, a combination of physical and mental ailments or strictly mental issues. Sometimes a psychiatrist works within a multi-disciplinary team, which may comprise clinical psychologists, social workers, occupational therapists, and nursing staff. Psychiatrists have broad training in a biopsychosocial approach to the assessment and management of mental illness. As part of the clinical assessment process, psychiatrists may employ a mental status examination; a physical examination; brain imaging such as a computerized tomography, magnetic resonance imaging, or positron emission tomography scan; and blood testing. Psychiatrists use pharmacologic, psychotherapeutic, and/or interventional approaches to treat mental disorders. Subspecialties The field of psychiatry has many subspecialties that require additional (fellowship) training, which, in the US, are certified by the American Board of Psychiatry and Neurology (ABPN) and require Maintenance of Certification Program to continue. These include the following: Clinical neurophysiology Forensic psychiatry Addiction psychiatry Child and adolescent psychiatry Geriatric psychiatry Palliative care Pain management Consultation-liaison psychiatry Sleep medicine Brain injury medicine Further, other specialties that exist include: Cross-cultural psychiatry Emergency psychiatry Learning disability Neurodevelopmental disorder Cognition diseases, as in various forms of dementia Biological psychiatry Community psychiatry Global mental health Military psychiatry Social psychiatry Sports psychiatry The United Council for Neurologic Subspecialties in the United States offers certification and fellowship program accreditation in the subspecialties of behavioral neurology and neuropsychiatry, which is open to both neurologists and psychiatrists. Some psychiatrists specialize in helping certain age groups. Pediatric psychiatry is the area of the profession working with children in addressing psychological problems. Psychiatrists specializing in geriatric psychiatry work with the elderly and are called geriatric psychiatrists or geropsychiatrists. Those who practice psychiatry in the workplace are called occupational psychiatrists in the United States and occupational psychology is the name used for the most similar discipline in the UK. Psychiatrists working in the courtroom and reporting to the judge and jury, in both criminal and civil court cases, are called forensic psychiatrists, who also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units. Other psychiatrists may also specialize in psychopharmacology, psychotherapy, psychiatric genetics, neuroimaging, dementia-related disorders such as Alzheimer's disease, attention deficit hyperactivity disorder, sleep medicine, pain medicine, palliative medicine, eating disorders, sexual disorders, women's health, global mental health, early psychosis intervention, mood disorders and anxiety disorders such as obsessive–compulsive disorder and post-traumatic stress disorder. Psychiatrists work in a wide variety of settings. Some are full-time medical researchers, many see patients in private medical practices, and consult liaison psychiatrists see patients in hospital settings where psychiatric and other medical conditions interact. Professional requirements While requirements to become a psychiatric physician differ from country to country, all require a medical degree. India In India, a Bachelor of Medicine, Bachelor of Surgery (MBBS) degree is the basic qualification needed to do psychiatry. After completing an MBBS (including an internship), they can attend various PG medical entrance exams and get a Doctor of Medicine (M.D.) in psychiatry, which is a 3-year course. Diploma course in psychiatry or DNB psychiatry can also be taken to become a psychiatrist. Netherlands In the Netherlands, one must complete medical school after which one is certified as a medical doctor. After a strict selection program, one can specialize for 4.5-years in psychiatry. During this specialization, the resident has to do a 6-month residency in the field of social psychiatry, a 12-month residency in a field of their own choice (which can be child psychiatry, forensic psychiatry, somatic medicine, or medical research). To become an adolescent psychiatrist, one has to do an extra specialization period of 2 more years. In short, this means that it takes at least 10.5 years of study to become a psychiatrist which can go up to 12.5 years if one becomes a children's and adolescent psychiatrist. Pakistan In Pakistan, one must complete basic medical education, an MBBS, then get registered with the Pakistan Medical and Dental Council (PMDC) as a general practitioner after a one-year mandatory internship, house job. After registration with PMDC, one has to take the FCPS-I exam. After that, they pursue four additional years of training in psychiatry at the College of Physicians and Surgeons Pakistan. Training includes rotations in general medicine, neurology, and clinical psychology for three months each, during the first two years. There is a mid-exam intermediate module and a final exam after four years. Hong Kong In the Hong Kong Special Administrative Region (HKSAR), psychiatrists are required to obtain a medical degree, followed by a minimum of six years of specialized training. Then, they must achieve fellowship at the Hong Kong College of Psychiatrists and attain the qualification of 'specialist in psychiatry' from the Medical Council. Certified psychiatrists are included in the registry. The fees charged by specialist psychiatrists vary. In private clinics, the cost of a consultation starts from HK$1,500. Compared to private clinics, the fees for specialist outpatient services of the Hospital Authority are lower, but the waiting time can be as long as two years. For Eligible Persons, the first consultation fee is HK$135, and each subsequent consultation fee is HK$80. Additionally, the cost for each type of medication is HK$15. United Kingdom and the Republic of Ireland In the United Kingdom, psychiatrists must hold a medical degree. Following this, the individual will work as a foundation house officer for two additional years in the UK, or one year as an intern in the Republic of Ireland to achieve registration as a basic medical practitioner. Training in psychiatry can then begin and it is taken in two parts: three years of basic specialist training culminating in the MRCPsych exam, followed by three years of higher specialist training referred to as "ST4-6" in the UK and "Senior Registrar Training" in the Republic of Ireland. Candidates with MRCPsych degree and complete basic training must reinterview for higher specialist training. At this stage, the development of special interests such as forensic or child/adolescent takes place. At the end of 3 years of higher specialist training, candidates are awarded a Certificate of Completion of (Specialist) Training (CC(S)T). At this stage, the psychiatrist can register as a specialist, and the qualification of CC(S)T is recognized in all EU/EEA states. As such, training in the UK and Ireland is considerably longer than in the US or Canada and frequently takes around 8–9 years following graduation from medical school. Those with a CC(S)T will be able to apply for consultant posts. Those with training from outside the EU/EEA should consult local/native medical boards to review their qualifications and eligibility for equivalence recognition (for example, those with a US residency and ABPN qualification). United States and Canada In the United States and Canada, one must first attain the degree of M.D. or Doctor of Osteopathic Medicine, followed by practice as a psychiatric resident for another four years (five years in Canada). This extended period involves comprehensive training in psychiatric diagnosis, psychopharmacology, medical care issues, and psychotherapies. All accredited psychiatry residencies in the United States require proficiency in cognitive behavioral, brief, psychodynamic, and supportive psychotherapies. Psychiatry residents are required to complete at least four post-graduate months of internal medicine or pediatrics, plus a minimum of two months of neurology during their first year of residency, referred to as an "internship". After completing their training, psychiatrists are eligible to take a specialty board examination to become board-certified. The total amount of time required to complete educational and training requirements in the field of psychiatry in the United States is twelve years after high school. Subspecialists in child and adolescent psychiatry are required to complete a two-year fellowship program, the first year of which can run concurrently with the fourth year of the general psychiatry residency program. This adds one to two years of training. The average compensation for psychiatrists in the U.S. in 2023 was $309,000. See also References Further reading Mental health occupations

Functional psychology

Functional psychology or functionalism refers to a psychological school of thought that was a direct outgrowth of Darwinian thinking which focuses attention on the utility and purpose of behavior that has been modified over years of human existence. Edward L. Thorndike, best known for his experiments with trial-and-error learning, came to be known as the leader of the loosely defined movement. This movement arose in the U.S. in the late 19th century in direct contrast to Edward Titchener's structuralism, which focused on the contents of consciousness rather than the motives and ideals of human behavior. Functionalism denies the principle of introspection, which tends to investigate the inner workings of human thinking rather than understanding the biological processes of the human consciousness. While functionalism eventually became its own formal school, it built on structuralism's concern for the anatomy of the mind and led to greater concern over the functions of the mind and later to the psychological approach of behaviorism. History Functionalism opposed the prevailing structuralism of psychology of the late 19th century. Edward Titchener, the main structuralist, gave psychology its first definition as a science of the study of mental experience, of consciousness, to be studied by trained introspection. At the start of the nineteenth century, there was a discrepancy between psychologists who were interested in the analysis of the structures of the mind and those who turned their attention to studying the function of mental processes. This resulted in a battle of structuralism versus functionalism. The main goal of Structuralism was to make attempts to study human consciousness within the confines of an actual living experience, but this could make studying the human mind impossible, functionalism is in stark contrast to that. Structural psychology was concerned with mental contents while functionalism is concerned with mental operations. It is argued that structural psychology emanated from philosophy and remained closely allied to it, while functionalism has a close ally in biology. William James is considered to be the founder of functional psychology. But he would not consider himself as a functionalist, nor did he truly like the way science divided itself into schools. John Dewey, George Herbert Mead, Harvey A. Carr, and especially James Rowland Angell were the main proponents of functionalism at the University of Chicago. Another group at Columbia, including notably James McKeen Cattell, Edward L. Thorndike, and Robert S. Woodworth, were also considered functionalists and shared some of the opinions of Chicago's professors. Egon Brunswik represents a more recent, but Continental, version. The functionalists retained an emphasis on conscious experience. Behaviourists also rejected the method of introspection but criticized functionalism because it was not based on controlled experiments and its theories provided little predictive ability. B.F. Skinner was a developer of behaviourism. He did not think that considering how the mind affects behaviour was worthwhile, for he considered behaviour simply as a learned response to an external stimulus. Yet, such behaviourist concepts tend to deny the human capacity for random, unpredictable, sentient decision-making, further blocking the functionalist concept that human behaviour is an active process driven by the individual. Perhaps, a combination of both the functionalist and behaviourist perspectives provides scientists with the most empirical value, but, even so, it remains philosophically (and physiologically) difficult to integrate the two concepts without raising further questions about human behaviour. For instance, consider the interrelationship between three elements: the human environment, the human autonomic nervous system (our fight or flight muscle responses), and the human somatic nervous system (our voluntary muscle control). The behaviourist perspective explains a mixture of both types of muscle behaviour, whereas the functionalist perspective resides mostly in the somatic nervous system. It can be argued that all behavioural origins begin within the nervous system, prompting all scientists of human behaviour to possess basic physiological understandings, something very well understood by the functionalist founder William James. The main problems with structuralism were the elements and their attributes, their modes of composition, structural characteristics, and the role of attention. Because of these problems, many psychologists began to shift their attention from mental states to mental processes. This change of thought was preceded by a change in the whole conception of what psychology is. Three parts ushered functional psychology into the modern-day psychology. Utilizing the Darwinian ideology, the mind was considered to perform a diverse biological function on its own and can evolve and adapt to varying circumstances. Secondly, the physiological functioning of the organism results in the development of the consciousness. Lastly, the promise of the impact of functional psychology to the improvement of education, mental hygiene and abnormal states. Notable people James Angell James Angell was a proponent of the struggle for the emergence of functional psychology. He argued that mental elements identified by the structuralist were temporary and only existed at the moment of sensory perception. During his American Psychological Association presidential address, Angell laid out three major ideas regarding functionalism. The first of his ideas being that functional psychology is focused on mental operations and their relationship with biology and these mental operations were a way of dealing with the conditions of the environment. Second, mental operations contribute to the relationship between an organism's needs and the environment in which it lives. Its mental functions aid in the survival of the organism in unfamiliar situations. Lastly, functionalism does not abide by the rules of dualism because it is the study of how mental functions relate to behavior. Mary Calkins Mary Calkins attempted to make strides in reconciling structural and functional psychology during her APA presidential address. It was a goal of Calkin's for her school of self-psychology to be a place where functionalism and structuralism could unite under common ground. John Dewey John Dewey, an American psychologist and philosopher, became the organizing principle behind the Chicago school of functional psychology in 1894. His first important contribution to the development of functional psychology was a paper criticizing "the reflex arc" concept in psychology. Herman Ebbinghaus Herman Ebbinghaus's study on memory was a monumental moment in psychology. He was influenced by the Fechner's work on perception and from the Elements of Psychophysics. He used himself as a subject when he set out to prove that some higher mental processes could be experimentally investigated. His experiment was hailed as an important contribution to psychology by Wundt. William James James was the first American psychologist and wrote the first general textbook regarding psychology. In this approach he reasoned that the mental act of consciousness must be an important biological function. He also noted that it was a psychologist's job to understand these functions so they can discover how the mental processes operate. This idea was an alternative approach to Structuralism, which was the first paradigm in psychology (Gordon, 1995). In opposition of Titchener's idea that the mind was simple, William James argued that the mind should be a dynamic concept. James's main contribution to functionalism was his theory of the subconscious. He said there were three ways of looking at the subconscious in which it may be related to the conscious. First, the subconscious is identical in nature with states of consciousness. Second, it's the same as conscious but impersonal. Lastly, he said that the subconscious is a simple brain state but with no mental counterpart. According to An Illustrated History of American Psychology, James was the most influential pioneer. In 1890, he argued that psychology should be a division of biology and adaptation should be an area of focus. His main theories that contributed to the development of functional psychology were his ideas about the role of consciousness, the effects of emotions, and the usefulness of instincts and habits Joseph Jastrow In 1901, Joseph Jastrow declared that functional psychology appeared to welcome the other areas of psychology that were neglected by structuralism. In 1905, a wave of acceptance was eminent as there had been a widespread acceptance of functionalism over the structural view of psychology. Edward Titchener Edward Titchener made arguments that structural psychology preceded functional psychology because mental structures need to be isolated and understood before their function be ascertained. Despite Titchener's enthusiasm towards functional psychology, he was weary and urged other psychologists to avoid the appeal of functional psychology and continue to embrace the rigorous introspective experimental psychology. James Ward James Ward was a pioneer of functional psychology in Britain. Once a minister, after experiencing a turmoil in his spiritual life, he turned to psychology but not without an attempt at physiology. He eventually settled for philosophy. He later made attempts at establishing psychological laboratory. Ward believed perception is not passive reception of sensation, but an active grasping of the environment. Ward's presence influenced the adoption of functionalist view in British psychology and later served as the turning point for the development of cognitive psychology. Wilhelm Wundt Later in his life, Dewey neglected to mention Wilhelm Wundt, a German philosopher and psychologist, as an influence towards his functional psychology. In fact, Dewey gave all credit to James. At the time it didn't seem worthwhile to bring up old theories from a German philosopher who only held a temporary spotlight and whose reputation went into a rather negative decline in America in the early twentieth century. Wundt's major contribution to functional psychology was when he made will into a structural concept. Though controversial, according to Titchener's definition of structuralism, Wundt was actually more of a structuralist than functionalist. Despite this claim, it is possibly one of the greatest ironies in the history of psychology that Wundt be deemed responsible for major contributions to functionalism due to his spark of several functionalist rebellions. Contemporary descendants Evolutionary psychology is based on the idea that knowledge concerning the function of the psychological phenomena affecting human evolution is necessary for a complete understanding of the human psyche. Even the project of studying the evolutionary functions of consciousness is now an active topic of study. Like evolutionary psychology, James's functionalism was inspired by Charles Darwin's theory of natural selection. Functionalism was the basis of development for several subtypes of psychology including child and developmental psychology, clinical psychology, psychometrics, and industrial/vocational psychology. Functionalism eventually dropped out of popular favor and was replaced by the next dominant paradigm, behaviourism. See also Functionalism (philosophy of mind) References External links "functionalism" – Encyclopædia Britannica Online Mary Calkins (1906) "A Reconciliation Between Structural And Functional Psychology" James R. Angell (1907) "The Province of Functional Psychology" James R. Angell (1906), Psychology: An Introductory Study of the Structure and Function of Human Consciousness Behaviorism History of psychology William James Psychological theories Consciousness

Institutional syndrome

In clinical and abnormal psychology, institutionalization or institutional syndrome refers to deficits or disabilities in social and life skills, which develop after a person has spent a long period living in mental hospitals, prisons or other remote institutions. In other words, individuals in institutions may be deprived (whether unintentionally or not) of independence and of responsibility, to the point that once they return to "outside life" they are often unable to manage many of its demands; it has also been argued that institutionalized individuals become psychologically more prone to mental health problems. The term institutionalization can also be used to describe the process of committing an individual to a mental hospital or prison, or to describe institutional syndrome; thus the phrase "X is institutionalized" may mean either that X has been placed in an institution or that X is suffering the psychological effects of having been in an institution for an extended period of time. Background In Europe and North America, the trend of putting the mentally ill into mental hospitals began as early as the 17th century, and hospitals often focused more on "restraining" or controlling inmates than on curing them, although hospital conditions improved somewhat with movements for human treatment, such as moral management. By the mid-20th century, overcrowding in institutions, the failure of institutional treatment to cure most mental illnesses, and the advent of drugs such as Thorazine prompted many hospitals to begin discharging patients in large numbers, in the beginning of the deinstitutionalization movement (the process of gradually moving people from inpatient care in mental hospitals, to outpatient care). Deinstitutionalization did not always result in better treatment, however, and in many ways it helped reveal some of the shortcomings of institutional care, as discharged patients were often unable to take care of themselves, and many ended up homeless or in jail. In other words, many of these patients had become "institutionalized" and were unable to adjust to independent living. One of the first studies to address the issue of institutionalization directly was British psychiatrist Russell Barton's 1959 book Institutional Neurosis, which claimed that many symptoms of mental illness (specifically, psychosis) were not physical brain defects as once thought, but were consequences of institutions' "stripping" (a term probably first used in this context by Erving Goffman) away the "psychological crutches" of their patients. Since the middle of the 20th century, the problem of institutionalization has been one of the motivating factors for the increasing popularity of deinstitutionalization and the growth of community mental health services, since some mental healthcare providers believe that institutional care may create as many problems as it solves. Romanian children who suffered from severe neglect at a young age were adopted by families. Research reveals that the post-institutional syndrome occurring in these children gave rise to symptoms of autistic behavior. Studies done on eight Romanian adoptees living in the Netherlands revealed that about one third of the children exhibited behavioral and communication problems resembling that of autism. Issues for discharged patients Individuals who suffer from institutional syndrome can face several kinds of difficulties upon returning to the community. The lack of independence and responsibility for patients within institutions, along with the 'depressing' and 'dehumanizing' environment, can make it difficult for patients to live and work independently. Furthermore, the experience of being in an institution may often have exacerbated individuals' illness: proponents of labeling theory claim that individuals who are socially "labeled" as mentally ill suffer stigmatization and alienation that lead to psychological damage and a lessening of self-esteem, and thus that being placed in a mental health institution can actually cause individuals to become more mentally ill. Notes References Psychopathological syndromes

Cognitive impairment

Cognitive impairment is an inclusive term to describe any characteristic that acts as a barrier to the cognition process or different areas of cognition. Cognition, also known as cognitive function, refers to the mental processes of how a person gains knowledge, uses existing knowledge, and understands things that are happening around them using their thoughts and senses. Cognitive impairment can be in different domains or aspects of a person's cognitive function including memory, attention span, planning, reasoning, decision-making, language (comprehension, writing, speech), executive functioning, and visuospatial functioning. The term cognitive impairment covers many different diseases and conditions and may also be symptom or manifestation of a different underlying condition. Examples include impairments in overall intelligence (as with intellectual disabilities), specific and restricted impairments in cognitive abilities (such as in learning disorders like dyslexia), neuropsychological impairments (such as in attention, working memory or executive function), or it may describe drug-induced impairment in cognition and memory (such as that seen with alcohol, glucocorticoids, and the benzodiazepines.). Cognitive impairments may be short-term, progressive (gets worse over time), or permanent. There are different approaches to assessing or diagnosing a cognitive impairment including neuropsychological testing using various different tests that consider the different domains of cognition. Examples of shorter assessment clinical tools include the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). There are many different syndromes and pathologies that cause cognitive impairment including dementia, mild neurocognitive disorder, and Alzheimer's disease. Cause Cognitive impairments may be caused by many different factors including environmental factors or injuries to the brain (e.g. traumatic brain injury), neurological illnesses, or mental disorders. While more common in elderly people, not all people who are elderly have cognitive impairments. Some known causes of cognitive impairments that are more common in younger people are: chromosomal abnormalities or genetic syndromes, exposure to teratogens while in utero (e.g., prenatal exposure to drugs), undernourishment, poisonings, autism, and child abuse. Stroke, dementia, depression, schizophrenia, substance abuse, brain tumours, malnutrition, brain injuries, hormonal disorders, and other chronic disorders may result in cognitive impairment with aging. Cognitive impairment may also be caused by a pathology in the brain. Examples include Alzheimer's disease, Parkinson's disease, HIV/AIDS-induced dementia, dementia with Lewy bodies, and Huntington’s disease. Short-term cognitive impairment can be caused by pharmaceutical drugs such as sedatives. Screening Screening for cognitive impairment in those over the age of 65 without symptoms is of unclear benefit versus harm as of 2020. In a large population-based cohort study included 579,710 66-year-old adults who were followed for a total of 3,870,293 person-years (average 6.68 ± 1.33 years per person), subjective cognitive decline was significantly associated with an increased risk of subsequent dementia. In addition to a series of cognitive tests, general practitioner physicians often also rely on clinical judgement for diagnosing cognitive impairment. Clinical judgement is ideal when paired with additional tests to that permit the medical professional to confirm the diagnosis or confirm the absence of a diagnosis. Clinical judgement in these cases may also help inform the choice in additional tests. Treatment Deciding on an appropriate treatment for people with cognitive decline takes clinical judgement based on the diagnosis (the specific cognitive problem), the person's symptoms, other patient factors including expectations and the person's own ideas, and previous approaches to helping the person. Other findings Although one would expect cognitive decline to have major effects on job performance, it seems that there is little to no correlation of health with job performance. With the exception of cognitive-dependent jobs such as air-traffic controller, professional athlete, or other elite jobs, age does not seem to impact one's job performance. This obviously conflicts with cognitive tests given, so the matter has been researched further. One possible reason for this conclusion is the rare need for a person to perform at their maximum. There is a difference between typical functioning, that is – the normal level of functioning for daily life, and maximal functioning, that is – what cognitive tests observe as our maximum level of functioning. As the maximum cognitive ability that we are able to achieve decreases, it may not actually affect our daily lives, which only require the normal level. Some studies have indicated that childhood hunger might have a protective effect on cognitive decline. One possible explanation is that the onset of age-related changes in the body can be delayed by calorie restriction. Another possible explanation is the selective survival effect, as the study participants who had a childhood with hunger tend to be the healthiest of their era. Prognosis When a person's level of cognition declines, it is often harder to live in an independent setting. Some people may have trouble taking care of themselves and the burden on the people caring for them can increase. Some people require supportive healthcare and, in some cases, institutionalization. Research The role of light therapy for treating people with cognitive impairment or dementia is not fully understood. See also PASS Theory of Intelligence Fluid and crystallized intelligence Dementia References Further reading Das, J.P. (2002). A better look at intelligence. Current Directions in Psychology, 11, 28–32. Goldstein, Gerald; Beers, Susan, eds (2004). Comprehensive Handbook of Psychological Assessment: Volume I: Intellectual and Neurological Assessment. Hoboken, NJ: John Wiley & Sons. Sattler, Jerome M. (2008). Assessment of Children: Cognitive Foundations. La Mesa (CA): Jerome M. Sattler, Publisher. External links Cognition Cognitive disorders Developmental disabilities Pediatrics

Psychopathy

Psychopathy, or psychopathic personality, is a personality construct characterized by impaired empathy and remorse, in combination with traits of boldness, disinhibition, and egocentrism. These traits are often masked by superficial charm and immunity to stress, which create an outward appearance of apparent normalcy. Hervey M. Cleckley, an American psychiatrist, influenced the initial diagnostic criteria for antisocial personality reaction/disturbance in the Diagnostic and Statistical Manual of Mental Disorders (DSM), as did American psychologist George E. Partridge. The DSM and International Classification of Diseases (ICD) subsequently introduced the diagnoses of antisocial personality disorder (ASPD) and dissocial personality disorder (DPD) respectively, stating that these diagnoses have been referred to (or include what is referred to) as psychopathy or sociopathy. The creation of ASPD and DPD was driven by the fact that many of the classic traits of psychopathy were impossible to measure objectively. Canadian psychologist Robert D. Hare later re-popularized the construct of psychopathy in criminology with his Psychopathy Checklist. Although no psychiatric or psychological organization has sanctioned a diagnosis titled "psychopathy", assessments of psychopathic characteristics are widely used in criminal justice settings in some nations and may have important consequences for individuals. The study of psychopathy is an active field of research. The term is also used by the general public, popular press, and in fictional portrayals. While the abbreviated term "psycho" is often employed in common usage in general media along with "crazy", "insane", and "mentally ill", there is a categorical difference between psychosis and psychopathy. History Etymology The word psychopathy is a joining of the Greek words psyche "soul" and pathos "suffering, feeling". The first documented use is from 1847 in Germany as psychopatisch, and the noun psychopath has been traced to 1885. In medicine, patho- has a more specific meaning of disease (Thus pathology has meant the study of disease since 1610, and psychopathology has meant the study of mental disorder in general since 1847. A sense of "a subject of pathology, morbid, excessive" is attested from 1845, including the phrase pathological liar from 1891 in the medical literature). The term psychopathy initially had a very general meaning referring to all sorts of mental disorders and social aberrations, popularised from 1891 in Germany by Koch's concept of "psychopathic inferiority". Some medical dictionaries still define psychopathy in both a narrow and broad sense, such as MedlinePlus from the U.S. National Library of Medicine. On the other hand, Stedman's Medical Dictionary defines "psychopath" only as a "former designation" for a person with an antisocial type of personality disorder. The term psychosis was also used in Germany from 1841, originally in a very general sense. The suffix -ωσις (-osis) meant in this case "abnormal condition". This term or its adjective psychotic would come to refer to the more severe mental disturbances and then specifically to mental states or disorders characterized by hallucinations, delusions or in some other sense markedly out of touch with reality. The slang term psycho has been traced to a shortening of the adjective psychopathic from 1936, and from 1942 as a shortening of the noun psychopath, but it is also used as shorthand for psychotic or crazed. The media usually uses the term psychopath to designate any criminal whose offenses are particularly abhorrent and unnatural, but that is not its original or general psychiatric meaning. Sociopathy The word element socio- has been commonly used in compound words since around 1880. The term sociopathy may have been first introduced in 1909 in Germany by biological psychiatrist Karl Birnbaum and in 1930 in the US by educational psychologist George E. Partridge, as an alternative to the concept of psychopathy. It was used to indicate that the defining feature is violation of social norms, or antisocial behavior, and may be social or biological in origin. The terms sociopathy and psychopathy were once used interchangeably in relation to antisocial personality disorder, though this usage is outdated in medicine and psychiatry. Psychopathy, however, is a highly popular construct in the psychology literature. Furthermore, the DSM-5 introduced the dimensional model of personality disorders in Section III, which includes a specifier for psychopathic traits. According to the DSM, psychopathy is not a standalone diagnosis, but the authors attempted to measure "psychopathic traits" via a specifier. In one study, the "Psychopathic Features Specifier" has been modeled on Factor 1 of the Psychopathic Personality Inventory, known as Fearless Dominance. To some, it is evidence of psychopathy not being a more extreme version of ASPD, but as an emergent compound trait that manifests when Antisocial Personality Disorder is present in combination with high levels of Fearless Dominance (or Boldness as it's known in the Triarchic Model). Analyses showed that this Section III ASPD greatly outperformed Section II ASPD in predicting scores on Hare’s (2003) Psychopathy Checklist-Revised. Section III ASPD including the 'Psychopathic Traits Specifier' can be seen on page 765 of the DSM-5 or Page 885 of the DSM-5-TR. The term is used in various ways in contemporary usage. Robert Hare stated in the popular science book Snakes in Suits that sociopathy and psychopathy are often used interchangeably, but in some cases the term sociopathy is preferred because it is less likely than is psychopathy to be confused with psychosis, whereas in other cases the two terms may be used with different meanings that reflect the user's views on its origins and determinants. Hare contended that the term sociopathy is preferred by those who see the causes as due to social factors and early environment, and the term psychopathy is preferred by those who believe that there are psychological, biological, and genetic factors involved in addition to environmental factors. Hare also provides his own definitions: he describes psychopathy as lacking a sense of empathy or morality, but sociopathy as only differing from the average person in the sense of right and wrong. Precursors Ancient writings that have been connected to psychopathic traits include Deuteronomy and a description of an unscrupulous man by the Greek philosopher Theophrastus around 300 BC. The concept of psychopathy has been indirectly connected to the early 19th century work of Pinel (1801; "mania without delirium") and Pritchard (1835; "moral insanity"), although historians have largely discredited the idea of a direct equivalence. Psychopathy originally described any illness of the mind, but found its application to a narrow subset of mental conditions when it was used toward the end of the 19th century by the German psychiatrist Julius Koch (1891) to describe various behavioral and moral dysfunction in the absence of an obvious mental illness or intellectual disability. He applied the term psychopathic inferiority to various chronic conditions and character disorders, and his work would influence the later conception of the personality disorder. The term psychopathic came to be used to describe a diverse range of dysfunctional or antisocial behavior and mental and sexual deviances, including at the time homosexuality. It was often used to imply an underlying "constitutional" or genetic origin. Disparate early descriptions likely set the stage for modern controversies about the definition of psychopathy. 20th century An influential figure in shaping modern American conceptualizations of psychopathy was American psychiatrist Hervey Cleckley. In his classic monograph, The Mask of Sanity (1941), Cleckley drew on a small series of vivid case studies of psychiatric patients at a Veterans Administration hospital in Georgia to provide a description for psychopathy. Cleckley used the metaphor of the "mask" to refer to the tendency of psychopaths to appear confident, personable, and well-adjusted compared to most psychiatric patients, while revealing underlying pathology through their actions over time. Cleckley formulated sixteen criteria for psychopathy. The Scottish psychiatrist David Henderson had also been influential in Europe from 1939 in narrowing the diagnosis. The diagnostic category of sociopathic personality in early editions of the Diagnostic and Statistical Manual (DSM) had some key similarities to Cleckley's ideas, though in 1980 when renamed Antisocial Personality Disorder some of the underlying personality assumptions were removed. In 1980, Canadian psychologist Robert D. Hare introduced an alternative measure, the "Psychopathy Checklist" (PCL) based largely on Cleckley's criteria, which was revised in 1991 (PCL-R), and is the most widely used measure of psychopathy. There are also several self-report tests, with the Psychopathic Personality Inventory (PPI) used more often among these in contemporary adult research. Famous individuals have sometimes been diagnosed, albeit at a distance, as psychopaths. As one example out of many possible from history, in a 1972 version of a secret report originally prepared for the Office of Strategic Services in 1943, and which may have been intended to be used as propaganda, non-medical psychoanalyst Walter C. Langer suggested Adolf Hitler was probably a psychopath. However, others have not drawn this conclusion; clinical forensic psychologist Glenn Walters argues that Hitler's actions do not warrant a diagnosis of psychopathy as, although he showed several characteristics of criminality, he was not always egocentric, callously disregarding of feelings or lacking impulse control, and there is no proof he could not learn from mistakes. Definition Concepts There are multiple conceptualizations of psychopathy, including Cleckleyan psychopathy (Hervey Cleckley's conception entailing bold, disinhibited behavior, and "feckless disregard") and criminal psychopathy (a meaner, more aggressive and disinhibited conception explicitly entailing persistent and sometimes serious criminal behavior). The latter conceptualization is typically used as the modern clinical concept and assessed by the Psychopathy Checklist. The label "psychopath" may have implications and stigma related to decisions about punishment severity for criminal acts, medical treatment, civil commitments, etc. Efforts have therefore been made to clarify the meaning of the term. It has been suggested that those who share the same emotional deficiencies and psychopathic features, but are properly socialized, should not be designated as 'psychopaths'. The triarchic model suggests that different conceptions of psychopathy emphasize three observable characteristics to various degrees. Analyses have been made with respect to the applicability of measurement tools such as the Psychopathy Checklist (PCL, PCL-R) and Psychopathic Personality Inventory (PPI) to this model. Boldness. Low fear including stress-tolerance, toleration of unfamiliarity and danger, and high self-confidence and social assertiveness. The PCL-R measures this relatively poorly and mainly through Facet 1 of Factor 1. Similar to PPI fearless dominance. May correspond to differences in the amygdala and other neurological systems associated with fear. Disinhibition. Poor impulse control including problems with planning and foresight, lacking affect and urge control, demand for immediate gratification, and poor behavioral restraints. Similar to PCL-R Factor 2 and PPI impulsive antisociality. May correspond to impairments in frontal lobe systems that are involved in such control. Meanness. Lacking empathy and close attachments with others, disdain of close attachments, use of cruelty to gain empowerment, exploitative tendencies, defiance of authority, and destructive excitement seeking. The PCL-R in general is related to this but in particular some elements in Factor 1. Similar to PPI, but also includes elements of subscales in impulsive antisociality. Psychopathy has been conceptualized as a hybrid condition marked by a paradoxical combination of superficial charm, poise, emotional resilience, and venturesomeness on the outside but deep-seated affective disturbances and impulse control deficits on the inside. From this perspective, psychopathy is at least in part characterized by psychologically adaptive traits. Furthermore, according to this view, psychopathy may be linked to at least some interpersonally successful outcomes, such as effective leadership, business accomplishments, and heroism. Measurement An early and influential analysis from Harris and colleagues indicated that a discrete category, or taxon, may underlie PCL-R psychopathy, allowing it to be measured and analyzed. However, this was only found for the behavioral Factor 2 items they identified, child problem behaviors; adult criminal behavior did not support the existence of a taxon. Marcus, John, and Edens more recently performed a series of statistical analyses on PPI scores and concluded that psychopathy may best be conceptualized as having a "dimensional latent structure" like depression. Marcus et al. repeated the study on a larger sample of prisoners, using the PCL-R and seeking to rule out other experimental or statistical issues that may have produced the previously different findings. They again found that the psychopathy measurements do not appear to be identifying a discrete type (a taxon). They suggest that while for legal or other practical purposes an arbitrary cut-off point on trait scores might be used, there is actually no clear scientific evidence for an objective point of difference by which to label some people "psychopaths"; in other words, a "psychopath" may be more accurately described as someone who is "relatively psychopathic". The PCL-R was developed for research, not clinical forensic diagnosis, and even for research purposes to improve understanding of the underlying issues, it is necessary to examine dimensions of personality in general rather than only a constellation of traits. The PCL-R test has been used to determine "true" or primary psychopaths (individuals that score a 30 or higher on the PCL-R test). Primary psychopaths are distinguished from secondary psychopaths, and contrast with those who are legitimately considered antisocial. Personality dimensions Studies have linked psychopathy to alternative dimensions such as antagonism (high), conscientiousness (low) and anxiousness (low). Psychopathy has also been linked to high psychoticism—a theorized dimension referring to tough, aggressive or hostile tendencies. Aspects of this that appear associated with psychopathy are lack of socialization and responsibility, impulsivity, sensation-seeking (in some cases), and aggression. Otto Kernberg, from a particular psychoanalytic perspective, believed psychopathy should be considered as part of a spectrum of pathological narcissism, that would range from narcissistic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end. Psychopathy, narcissism and Machiavellianism, three personality traits that are together referred to as the dark triad, share certain characteristics, such as a callous-manipulative interpersonal style. The dark tetrad refers to these traits with the addition of sadism. Several psychologists have asserted that subclinical psychopathy and Machiavellianism are more or less interchangeable. There is a subscale on the Psychopathic Personality Inventory (PPI) dubbed "Machiavellian Egocentricity". Delroy Paulhus has asserted that the difference that most miss is that while both are characterized by manipulativeness and unemotionality, psychopaths tend to be more reckless. One study asserted that "the ability to adapt, reappraise and reassess a situation may be key factors differentiating Machiavellianism from psychopathy, for example". Psychopathy and machiavellianism were also correlated similarly in responses to affective stimuli, and both are negatively correlated with recognition of facial emotions. Many have suggested merging the dark triad traits (especially Machiavellianism and psychopathy) into one construct, given empirical studies which show immense overlap. Criticism of current conceptions The current conceptions of psychopathy have been criticized for being poorly conceptualized, highly subjective, and encompassing a wide variety of underlying disorders. Dorothy Otnow Lewis has written: Half of the Hare Psychopathy Checklist consists of symptoms of mania, hypomania, and frontal-lobe dysfunction, which frequently results in underlying disorders being dismissed. Hare's conception of psychopathy has also been criticized for being reductionist, dismissive, tautological, and ignorant of context as well as the dynamic nature of human behavior. Some have called for rejection of the concept altogether, due to its vague, subjective and judgmental nature that makes it prone to misuse. A systematic review determined that the PCL is weakly predictive of criminal behavior, but not of lack of conscience, or treatment and rehabilitation outcomes. These findings contradict widespread beliefs amongst professionals in forensics. Psychopathic individuals do not show regret or remorse. This was thought to be due to an inability to generate this emotion in response to negative outcomes. However, in 2016, people with antisocial personality disorder and dissocial personality disorder were found to experience regret, but did not use the regret to guide their choice in behavior. There was no lack of regret but a problem to think through a range of potential actions and estimating the outcome values. In an experiment published in March 2007 at the University of Southern California neuroscientist Antonio R. Damasio and his colleagues showed that subjects with damage to the ventromedial prefrontal cortex lack the ability to empathically feel their way to moral answers, and that when confronted with moral dilemmas, these brain-damaged patients coldly came up with "end-justifies-the-means" answers, leading Damasio to conclude that the point was not that they reached immoral conclusions, but that when they were confronted by a difficult issue – in this case as whether to shoot down a passenger plane hijacked by terrorists before it hits a major city – these patients appear to reach decisions without the anguish that afflicts those with typically functioning brains. According to Adrian Raine, a clinical neuroscientist also at the University of Southern California, one of this study's implications is that society may have to rethink how it judges immoral people: "Psychopaths often feel no empathy or remorse. Without that awareness, people relying exclusively on reasoning seem to find it harder to sort their way through moral thickets. Does that mean they should be held to different standards of accountability?" Signs and symptoms Socially, psychopathy typically involves extensive callous and manipulative self-serving behaviors with no regard for others, and often is associated with repeated delinquency, crime and violence. Mentally, impairments in processes related to affect and cognition, particularly socially related mental processes, have also been found. Developmentally, symptoms of psychopathy have been identified in young children with conduct disorder, and suggests at least a partial constitutional factor that influences its development. Primary features Disagreement exists over which features should be considered as part of psychopathy, with researchers identifying around 40 traits supposedly indicative of the construct, though the following characteristics are almost universally considered central. Core traits Cooke and Michie (2001) proposed a three-factor model of the Psychopathy Checklist-Revised which has seen widespread application in other measures (e.g. Youth Psychopathic Traits Inventory, Antisocial Process Screening Device). Arrogant and deceitful interpersonal style: impression management or superficial charm, inflated and grandiose sense of self-worth, pathological lying/deceit, and manipulation for personal gain. Deficient affective experience: lack of remorse or guilt, shallow affect (coldness and unemotionality), callousness and lack of empathy, and failure to accept responsibility for own actions. Impulsive and irresponsible lifestyle: impulsivity, sensation-seeking and risk-taking, irresponsible and unreliable behavior, financially parasitic lifestyle and lack of realistic, long-term goals. Low anxiety and fearlessness Cleckley's (1941) original description of psychopathy included the absence of nervousness and neurotic disorders, and later theorists referred to psychopaths as fearless or thick-skinned. While it is often claimed that the PCL-R does not include low anxiety or fearlessness, such features do contribute to the scoring of the Facet 1 (interpersonal) items, mainly through self-assurance, unrealistic optimism, brazenness and imperturbability. Indeed, while self-report studies have been inconsistent using the two-factor model of the PCL-R, studies which separate Factor 1 into interpersonal and affective facets, more regularly show modest associations between Facet 1 and low anxiety, boldness and fearless dominance (especially items assessing glibness/charm and grandiosity). When both psychopathy and low anxiety/boldness are measured using interviews, both interpersonal and affective facets are both associated with fearlessness and lack of internalizing disorders. The importance of low anxiety/fearlessness to psychopathy has historically been underscored through behavioral and physiological studies showing diminished responses to threatening stimuli (interpersonal and affective facets both contributing). However, it is not known whether this is reflected in reduced experience of state fear or where it reflects impaired detection and response to threat-related stimuli. Moreover, such deficits in threat responding are known to be reduced or even abolished when attention is focused on the threatening stimuli. Offending Criminality In terms of simple correlations, the PCL-R manual states an average score of 22.1 has been found in North American prisoner samples, and that 20.5% scored 30 or higher. An analysis of prisoner samples from outside North America found a somewhat lower average value of 17.5. Studies have found that psychopathy scores correlated with repeated imprisonment, detention in higher security, disciplinary infractions, and substance misuse. Psychopathy, as measured with the PCL-R in institutional settings, shows in meta-analyses small to moderate effect sizes with institutional misbehavior, postrelease crime, or postrelease violent crime with similar effects for the three outcomes. Individual studies give similar results for adult offenders, forensic psychiatric samples, community samples, and youth. The PCL-R is poorer at predicting sexual re-offending. This small to moderate effect appears to be due largely to the scale items that assess impulsive behaviors and past criminal history, which are well-established but very general risk factors. The aspects of core personality often held to be distinctively psychopathic generally show little or no predictive link to crime by themselves. For example, Factor 1 of the PCL-R and Fearless dominance of the PPI-R have smaller or no relationship to crime, including violent crime. In contrast, Factor 2 and Impulsive antisociality of the PPI-R are associated more strongly with criminality. Factor 2 has a relationship of similar strength to that of the PCL-R as a whole. The antisocial facet of the PCL-R is still predictive of future violence after controlling for past criminal behavior which, together with results regarding the PPI-R which by design does not include past criminal behavior, suggests that impulsive behaviors is an independent risk factor. Thus, the concept of psychopathy may perform poorly when attempted to be used as a general theory of crime. Violence Studies have suggested a strong correlation between psychopathy scores and violence, and the PCL-R emphasizes features that are somewhat predictive of violent behavior. Researchers, however, have noted that psychopathy is dissociable from and not synonymous with violence. It has been suggested that psychopathy is associated with "instrumental aggression", also known as predatory, proactive, or "cold blooded" aggression, a form of aggression characterized by reduced emotion and conducted with a goal differing from but facilitated by the commission of harm. One conclusion in this regard was made by a 2002 study of homicide offenders, which reported that the homicides committed by homicidal offenders with psychopathy were almost always (93.3%) primarily instrumental, significantly more than the proportion (48.4%) of those committed by non-psychopathic homicidal offenders, with the instrumentality of the homicide also correlated with the total PCL-R score of the offender as well as their scores on the Factor 1 "interpersonal-affective" dimension. However, contrary to the equating of this to mean exclusively "in cold blood", more than a third of the homicides committed by psychopathic offenders involved some component of emotional reactivity as well. In any case, FBI profilers indicate that serious victim injury is generally an emotional offense, and some research supports this, at least with regard to sexual offending. One study has found more serious offending by non-psychopathic offenders on average than by offenders with psychopathy (e.g. more homicides versus more armed robbery and property offenses) and another that the Affective facet of the PCL-R predicted reduced offense seriousness. Studies on perpetrators of domestic violence find that abusers have high rates of psychopathy, with the prevalence estimated to be at around 15-30%. Furthermore, the commission of domestic violence is correlated with Factor 1 of the PCL-R, which describes the emotional deficits and the callous and exploitative interpersonal style found in psychopathy. The prevalence of psychopathy among domestic abusers indicate that the core characteristics of psychopathy, such as callousness, remorselessness, and a lack of close interpersonal bonds, predispose those with psychopathy to committing domestic abuse, and suggest that the domestic abuses committed by these individuals are callously perpetrated (i.e. instrumentally aggressive) rather than a case of emotional aggression and therefore may not be amenable to the types of psychosocial interventions commonly given to domestic abuse perpetrators. Some clinicians suggest that assessment of the construct of psychopathy does not necessarily add value to violence risk assessment. A large systematic review and meta-regression found that the PCL performed the poorest out of nine tools for predicting violence. In addition, studies conducted by the authors or translators of violence prediction measures, including the PCL, show on average more positive results than those conducted by more independent investigators. There are several other risk assessment instruments which can predict further crime with an accuracy similar to the PCL-R and some of these are considerably easier, quicker, and less expensive to administer. This may even be done automatically by a computer simply based on data such as age, gender, number of previous convictions and age of first conviction. Some of these assessments may also identify treatment change and goals, identify quick changes that may help short-term management, identify more specific kinds of violence that may be at risk, and may have established specific probabilities of offending for specific scores. Nonetheless, the PCL-R may continue to be popular for risk assessment because of its pioneering role and the large amount of research done using it. The Federal Bureau of Investigation reports that psychopathic behavior is consistent with traits common to some serial killers, including sensation seeking, a lack of remorse or guilt, impulsivity, the need for control, and predatory behavior. It has also been found that the homicide victims of psychopathic offenders were disproportionately female in comparison to the more equitable gender distribution of victims of non-psychopathic offenders. Sexual offending Psychopathy has been associated with commission of sexual crime, with some researchers arguing that it is correlated with a preference for violent sexual behavior. A 2011 study of conditional releases for Canadian male federal offenders found that psychopathy was related to more violent and non-violent offences but not more sexual offences. For child molesters, psychopathy was associated with more offences. A study on the relationship between psychopathy scores and types of aggression in a sample of sexual murderers, in which 84.2% of the sample had PCL-R scores above 20 and 47.4% above 30, found that 82.4% of those with scores above 30 had engaged in sadistic violence (defined as enjoyment indicated by self-report or evidence) compared to 52.6% of those with scores below 30, and total PCL-R and Factor 1 scores correlated significantly with sadistic violence. Despite this, it is reported that offenders with psychopathy (both sexual and non-sexual offenders) are about 2.5 times more likely to be granted conditional release compared to non-psychopathic offenders. Hildebrand and colleagues (2004) have uncovered an interaction between psychopathy and deviant sexual interests, wherein those high in psychopathy who also endorsed deviant sexual interests were more likely to recidivate sexually. A subsequent meta-analysis has consolidated such a result. In considering the issue of possible reunification of some sex offenders into homes with a non-offending parent and children, it has been advised that any sex offender with a significant criminal history should be assessed on the PCL-R, and if they score 18 or higher, then they should be excluded from any consideration of being placed in a home with children under any circumstances. There is, however, increasing concern that PCL scores are too inconsistent between different examiners, including in its use to evaluate sex offenders. Other offending The possibility of psychopathy has been associated with organized crime, economic crime and war crimes. Terrorists are sometimes considered psychopathic, and comparisons may be drawn with traits such as antisocial violence, a selfish world view that precludes the welfare of others, a lack of remorse or guilt, and blame externalization. However, John Horgan, author of The Psychology of Terrorism, argues that such comparisons could also then be drawn more widely: for example, to soldiers in wars. Coordinated terrorist activity requires organization, loyalty and ideological fanaticism often to the extreme of sacrificing oneself for an ideological cause. Traits such as a self-centered disposition, unreliability, poor behavioral controls, and unusual behaviors may disadvantage or preclude psychopathic individuals in conducting organized terrorism. It may be that a significant portion of people with psychopathy are socially successful and tend to express their antisocial behavior through more covert avenues such as social manipulation or white collar crime. Such individuals are sometimes referred to as "successful psychopaths", and may not necessarily always have extensive histories of traditional antisocial behavior as characteristic of traditional psychopathy. Childhood and adolescent precursors The PCL:YV is an adaptation of the PCL-R for individuals aged 13–18 years. It is, like the PCL-R, done by a trained rater based on an interview and an examination of criminal and other records. The "Antisocial Process Screening Device" (APSD) is also an adaptation of the PCL-R. It can be administered by parents or teachers for individuals aged 6–13 years. High psychopathy scores for both juveniles (as measured with these instruments) and adults (as measured with the PCL-R and other measurement tools) have similar associations with other variables, including similar ability in predicting violence and criminality. Juvenile psychopathy may also be associated with more negative emotionality such as anger, hostility, anxiety, and depression. Psychopathic traits in youth typically comprise three factors: callous/unemotional, narcissism, and impulsivity/irresponsibility. There is positive correlation between early negative life events of the ages 0–4 and the emotion-based aspects of psychopathy. There are moderate to high correlations between psychopathy rankings from late childhood to early adolescence. The correlations are considerably lower from early- or mid-adolescence to adulthood. In one study most of the similarities were on the Impulsive- and Antisocial-Behavior scales. Of those adolescents who scored in the top 5% highest psychopathy scores at age 13, less than one third (29%) were classified as psychopathic at age 24. Some recent studies have also found poorer ability at predicting long-term, adult offending. Conduct disorder Conduct disorder is diagnosed based on a prolonged pattern of antisocial behavior in childhood and/or adolescence, and may be seen as a precursor to ASPD. Some researchers have speculated that there are two subtypes of conduct disorder which mark dual developmental pathways to adult psychopathy. The DSM allows differentiating between childhood onset before age 10 and adolescent onset at age 10 and later. Childhood onset is argued to be more due to a personality disorder caused by neurological deficits interacting with an adverse environment. For many, but not all, childhood onset is associated with what is in Terrie Moffitt's developmental theory of crime referred to as "life-course- persistent" antisocial behavior as well as poorer health and economic status. Adolescent onset is argued to more typically be associated with short-term antisocial behavior. It has been suggested that the combination of early-onset conduct disorder and ADHD may be associated with life-course-persistent antisocial behaviors as well as psychopathy. There is evidence that this combination is more aggressive and antisocial than those with conduct disorder alone. However, it is not a particularly distinct group since the vast majority of young children with conduct disorder also have ADHD. Some evidence indicates that this group has deficits in behavioral inhibition, similar to that of adults with psychopathy. They may not be more likely than those with conduct disorder alone to have the interpersonal/affective features and the deficits in emotional processing characteristic of adults with psychopathy. Proponents of different types/dimensions of psychopathy have seen this type as possibly corresponding to adult secondary psychopathy and increased disinhibition in the triarchic model. The DSM-5 includes a specifier for those with conduct disorder who also display a callous, unemotional interpersonal style across multiple settings and relationships. The specifier is based on research which suggests that those with conduct disorder who also meet criteria for the specifier tend to have a more severe form of the disorder with an earlier onset as well as a different response to treatment. Proponents of different types/dimensions of psychopathy have seen this as possibly corresponding to adult primary psychopathy and increased boldness and/or meanness in the triarchic model. Mental traits Cognition Dysfunctions in the prefrontal cortex and amygdala regions of the brain have been associated with specific learning impairments in psychopathy. Damage to the ventromedial prefrontal cortex, which regulates the activity in the amygdala, leads to common characteristics in psychopathic individuals.Since the 1980s, scientists have linked traumatic brain injury, including damage to these regions, with violent and psychopathic behavior. Patients with damage in such areas resembled "psychopathic individuals" whose brains were incapable of acquiring social and moral knowledge; those who acquired damage as children may have trouble conceptualizing social or moral reasoning, while those with adult-acquired damage may be aware of proper social and moral conduct but be unable to behave appropriately. Dysfunctions in the amygdala and ventromedial prefrontal cortex may also impair stimulus-reinforced learning in psychopaths, whether punishment-based or reward-based. People scoring 25 or higher in the PCL-R, with an associated history of violent behavior, appear to have significantly reduced mean microstructural integrity in their uncinate fasciculus—white matter connecting the amygdala and orbitofrontal cortex. There is evidence from DT-MRI of breakdowns in the white matter connections between these two important areas. Although some studies have suggested inverse relationships between psychopathy and intelligence, including with regards to verbal IQ, Hare and Neumann state that a large literature demonstrates at most only a weak association between psychopathy and IQ, noting that the early pioneer Cleckley included good intelligence in his checklist due to selection bias (since many of his patients were "well educated and from middle-class or upper-class backgrounds") and that "there is no obvious theoretical reason why the disorder described by Cleckley or other clinicians should be related to intelligence; some psychopaths are bright, others less so". Studies also indicate that different aspects of the definition of psychopathy (e.g. interpersonal, affective (emotion), behavioral and lifestyle components) can show different links to intelligence, and the result can depend on the type of intelligence assessment (e.g. verbal, creative, practical, analytical). Emotion recognition and empathy A large body of research suggests that psychopathy is associated with atypical responses to distress cues from other people, more precisely an impaired emotional empathy in the recognition of, and response to, facial expressions, body gestures and vocal tones of fear, sadness, pain and happiness. This impaired recognition and reduced autonomic responsiveness might be partly accounted for by a decreased activation of the fusiform and extrastriate cortical regions. The underlying biological surfaces for processing expressions of happiness are functionally intact in psychopaths, although less responsive than those of controls. The neuroimaging literature is unclear as to whether deficits are specific to particular emotions such as fear. The overall pattern of results across studies indicates that people diagnosed with psychopathy demonstrate reduced MRI, fMRI, aMRI, PET, and SPECT activity in areas of the brain. Research has also shown that an approximate 18% smaller amygdala size contributes to a significantly lower emotional sensation in regards to fear, sadness, amongst other negative emotions, which may likely be the reason as to why psychopathic individuals have lower empathy. Some recent fMRI studies have reported that emotion perception deficits in psychopathy are pervasive across emotions (positives and negatives). Studies on children with psychopathic tendencies have also shown such associations. Meta-analyses have also found evidence of impairments in both vocal and facial emotional recognition for several emotions (i.e., not only fear and sadness) in both adults and children/adolescents. Moral judgment Psychopathy has been associated with amorality—an absence of, indifference towards, or disregard for moral beliefs. There are few firm data on patterns of moral judgment. Studies of developmental level (sophistication) of moral reasoning found all possible results—lower, higher or the same as non-psychopaths. Studies that compared judgments of personal moral transgressions versus judgments of breaking conventional rules or laws found that psychopaths rated them as equally severe, whereas non-psychopaths rated the rule-breaking as less severe. A study comparing judgments of whether personal or impersonal harm would be endorsed in order to achieve the rationally maximum (utilitarian) amount of welfare found no significant differences between subjects high and low in psychopathy. However, a further study using the same tests found that prisoners scoring high on the PCL were more likely to endorse impersonal harm or rule violations than non-psychopathic controls were. The psychopathic offenders who scored low in anxiety were also more willing to endorse personal harm on average. Assessing accidents, where one person harmed another unintentionally, psychopaths judged such actions to be more morally permissible. This result has been considered a reflection of psychopaths' failure to appreciate the emotional aspect of the victim's harmful experience. Cause Behavioral genetic studies have identified potential genetic and non-genetic contributors to psychopathy, including influences on brain function. Proponents of the triarchic model believe that psychopathy results from the interaction of genetic predispositions and an adverse environment. What is adverse may differ depending on the underlying predisposition: for example, it is hypothesized that persons having high boldness may respond poorly to punishment but may respond better to rewards and secure attachments. Genetic Genetically informed studies of the personality characteristics typical of individuals with psychopathy have found moderate genetic (as well as non-genetic) influences. On the PPI, fearless dominance and impulsive antisociality were similarly influenced by genetic factors and uncorrelated with each other. Genetic factors may generally influence the development of psychopathy while environmental factors affect the specific expression of the traits that predominate. A study on a large group of children found more than 60% heritability for "callous-unemotional traits" and that conduct disorder among children with these traits has a higher heritability than among children without these traits. Environment A study by Farrington of a sample of London males followed between age 8 and 48 included studying which factors scored 10 or more on the PCL:SV at age 48. The strongest factors included having a convicted parent, being physically neglected, low involvement of the father with the boy, low family income, and coming from a disrupted family. Other significant factors included poor supervision, abuse, harsh discipline, large family size, delinquent sibling, young mother, depressed mother, low social class, and poor housing. There has also been association between psychopathy and detrimental treatment by peers. However, it is difficult to determine the extent of an environmental influence on the development of psychopathy because of evidence of its strong heritability. Brain injury Researchers have linked head injuries with psychopathy and violence. Since the 1980s, scientists have associated traumatic brain injury, such as damage to the prefrontal cortex, including the orbitofrontal cortex, with psychopathic behavior and a deficient ability to make morally and socially acceptable decisions, a condition that has been termed "acquired sociopathy", or "pseudopsychopathy". Individuals with damage to the area of the prefrontal cortex known as the ventromedial prefrontal cortex show remarkable similarities to diagnosed psychopathic individuals, displaying reduced autonomic response to emotional stimuli, deficits in aversive conditioning, similar preferences in moral and economic decision making, and diminished empathy and social emotions like guilt or shame. These emotional and moral impairments may be especially severe when the brain injury occurs at a young age. Children with early damage in the prefrontal cortex may never fully develop social or moral reasoning and become "psychopathic individuals ... characterized by high levels of aggression and antisocial behavior performed without guilt or empathy for their victims". Additionally, damage to the amygdala may impair the ability of the prefrontal cortex to interpret feedback from the limbic system, which could result in uninhibited signals that manifest in violent and aggressive behavior. Childhood trauma Other theories Evolutionary explanations Psychopathy is associated with several adverse life outcomes as well as increased risk of disability and death due to factors such as violence, accidents, homicides, and suicides. This, in combination with the evidence for genetic influences, is evolutionarily puzzling and may suggest that there are compensating evolutionary advantages, and researchers within evolutionary psychology have proposed several evolutionary explanations. According to one hypothesis, some traits associated with psychopathy may be socially adaptive, and psychopathy may be a frequency-dependent, socially parasitic strategy, which may work as long as there is a large population of altruistic and trusting individuals, relative to the population of psychopathic individuals, to be exploited. It is also suggested that some traits associated with psychopathy such as early, promiscuous, adulterous, and coercive sexuality may increase reproductive success. Robert Hare has stated that many psychopathic males have a pattern of mating with and quickly abandoning women, and thereby have a high fertility rate, resulting in children that may inherit a predisposition to psychopathy. Criticism includes that it may be better to look at the contributing personality factors rather than treat psychopathy as a unitary concept due to poor testability. Furthermore, if psychopathy is caused by the combined effects of a very large number of adverse mutations then each mutation may have such a small effect that it escapes natural selection. The personality is thought to be influenced by a very large number of genes and may be disrupted by random mutations, and psychopathy may instead be a product of a high mutation load. Psychopathy has alternatively been suggested to be a spandrel, a byproduct, or side-effect, of the evolution of adaptive traits rather than an adaptation in itself. Mechanisms Psychological Some laboratory research demonstrates correlations between psychopathy and atypical responses to aversive stimuli, including weak conditioning to painful stimuli and poor learning of avoiding responses that cause punishment, as well as low reactivity in the autonomic nervous system as measured with skin conductance while waiting for a painful stimulus but not when the stimulus occurs. While it has been argued that the reward system functions normally, some studies have also found reduced reactivity to pleasurable stimuli. According to the response modulation hypothesis, psychopathic individuals have also had difficulty switching from an ongoing action despite environmental cues signaling a need to do so. This may explain the difficulty responding to punishment, although it is unclear if it can explain findings such as deficient conditioning. There may be methodological issues regarding the research. While establishing a range of idiosyncrasies on average in linguistic and affective processing under certain conditions, this research program has not confirmed a common pathology of psychopathy. Neurological Thanks to advancing MRI studies, experts are able to visualize specific brain differences and abnormalities of individuals with psychopathy in areas that control emotions, social interactions, ethics, morality, regret, impulsivity and conscience within the brain. Blair, a researcher who pioneered research into psychopathic tendencies stated, "With regard to psychopathy, we have clear indications regarding why the pathology gives rise to the emotional and behavioral disturbance and important insights into the neural systems implicated in this pathology". Dadds et al., remarks that despite a rapidly advancing neuroscience of empathy, little is known about the developmental underpinnings of the psychopathic disconnect between affective and cognitive empathy. A 2008 review by Weber et al. suggested that psychopathy is sometimes associated with brain abnormalities in prefrontal-temporo-limbic regions that are involved in emotional and learning processes, among others. Neuroimaging studies have found structural and functional differences between those scoring high and low on the PCL-R in a 2011 review by Skeem et al. stating that they are "most notably in the amygdala, hippocampus and parahippocampal gyri, anterior and posterior cingulate cortex, striatum, insula, and frontal and temporal cortex". The amygdala and frontal areas have been suggested as particularly important. People scoring 25 or higher in the PCL-R, with an associated history of violent behavior, appear on average to have significantly reduced microstructural integrity between the white matter connecting the amygdala and orbitofrontal cortex (such as the uncinate fasciculus). The evidence suggested that the degree of abnormality was significantly related to the degree of psychopathy and may explain the offending behaviors. Furthermore, changes in the amygdala have been associated with "callous-unemotional" traits in children. However, the amygdala has also been associated with positive emotions, and there have been inconsistent results in the studies in particular areas, which may be due to methodological issues. Others have cast doubt on the amygdala as important for psychopathy, with one meta-analysis suggesting that most studies on the amygdala and psychopathy find no effect and that studies finding a negative effect (that psychopaths display less amygdala activity) have lower statistical power. Some of these findings are consistent with other research and theories. For example, in a neuroimaging study of how individuals with psychopathy respond to emotional words, widespread differences in activation patterns have been shown across the temporal lobe when psychopathic criminals were compared to "normal" volunteers, which is consistent with views in clinical psychology. Additionally, the notion of psychopathy being characterized by low fear is consistent with findings of abnormalities in the amygdala, since deficits in aversive conditioning and instrumental learning are thought to result from amygdala dysfunction, potentially compounded by orbitofrontal cortex dysfunction, although the specific reasons are unknown. Considerable research has documented the presence of the two subtypes of primary and secondary psychopathy. Proponents of the primary-secondary psychopathy distinction and triarchic model argue that there are neurological differences between these subgroups of psychopathy which support their views. For instance, the boldness factor in the triarchic model is argued to be associated with reduced activity in the amygdala during fearful or aversive stimuli and reduced startle response, while the disinhibition factor is argued to be associated with impairment of frontal lobe tasks. There is evidence that boldness and disinhibition are genetically distinguishable. Biochemical High levels of testosterone combined with low levels of cortisol and/or serotonin have been theorized as contributing factors. Testosterone is "associated with approach-related behavior, reward sensitivity, and fear reduction", and injecting testosterone "shift[s] the balance from punishment to reward sensitivity", decreases fearfulness, and increases "responding to angry faces". Some studies have found that high testosterone levels are associated with antisocial and aggressive behaviors, yet other research suggests that testosterone alone does not cause aggression but increases dominance-seeking. It is unclear from studies if psychopathy correlates with high testosterone levels, but a few studies have found that disruption of serotonin neurotransmission disrupts cortisol reactivity to a stress-inducing speech task. Thus, dysregulation of serotonin in the brain may contribute to the low cortisol levels observed in psychopathy. Cortisol increases withdrawal behavior and sensitivity to punishment and aversive conditioning, which are abnormally low in individuals with psychopathy and may underlie their impaired aversion learning and disinhibited behavior. High testosterone levels combined with low serotonin levels are associated with "impulsive and highly negative reactions", and may increase violent aggression when an individual is provoked or becomes frustrated. Several animal studies note the role of serotonergic functioning in impulsive aggression and antisocial behavior. However, some studies on animal and human subjects have suggested that the emotional-interpersonal traits and predatory aggression of psychopathy, in contrast to impulsive and reactive aggression, is related to increased serotoninergic functioning. A study by Dolan and Anderson, regarding the relationship between serotonin and psychopathic traits in a sample of personality disordered offenders, found that serotonin functioning as measured by prolactin response, while inversely associated with impulsive and antisocial traits, were positively correlated with arrogant and deceitful traits, and, to a lesser extent, callous and remorseless traits. Bariş Yildirim theorizes that the 5-HTTLPR "long" allele, which is generally regarded as protective against internalizing disorders, may interact with other serotoninergic genes to create a hyper-regulation and dampening of affective processes that results in psychopathy's emotional impairments. Furthermore, the combination of the 5-HTTLPR long allele and high testosterone levels has been found to result in a reduced response to threat as measured by cortisol reactivity, which mirrors the fear deficits found in those with psychopathy. Studies have suggested other correlations. Psychopathy was associated in two studies with an increased ratio of HVA (a dopamine metabolite) to 5-HIAA (a serotonin metabolite). Studies have found that individuals with the traits meeting criteria for psychopathy show a greater dopamine response to potential "rewards" such as monetary promises or taking drugs such as amphetamines. This has been theoretically linked to increased impulsivity. A 2010 British study found that a large 2D:4D digit ratio, an indication of high prenatal estrogen exposure, was a "positive correlate of psychopathy in females, and a positive correlate of callous affect (psychopathy sub-scale) in males". Findings have also shown monoamine oxidase A to affect the predictive ability of the PCL-R. Monoamine oxidases (MAOs) are enzymes that are involved in the breakdown of neurotransmitters such as serotonin and dopamine and are, therefore, capable of influencing feelings, mood, and behavior in individuals. Findings suggest that further research is needed in this area. Diagnosis Tools Psychopathy Checklist Psychopathy is most commonly assessed with the Psychopathy Checklist, Revised (PCL-R), created by Robert D. Hare based on Cleckley's criteria from the 1940s, criminological concepts such as those of William and Joan McCord, and his own research on criminals and incarcerated offenders in Canada. The PCL-R is widely used and is referred to by some as the "gold standard" for assessing psychopathy. There are nonetheless numerous criticisms of the PCL-R as a theoretical tool and in real-world usage. Psychopathic Personality Inventory Unlike the PCL, the Psychopathic Personality Inventory (PPI) was developed to comprehensively index personality traits without explicitly referring to antisocial or criminal behaviors themselves. It is a self-report scale that was developed originally for non-clinical samples (e.g. university students) rather than prisoners, though may be used with the latter. It was revised in 2005 to become the PPI-R and now comprises 154 items organized into eight subscales. The item scores have been found to group into two overarching and largely separate factors (unlike the PCL-R factors), Fearless-Dominance and Impulsive Antisociality, plus a third factor, Coldheartedness, which is largely dependent on scores on the other two. Factor 1 is associated with social efficacy while Factor 2 is associated with maladaptive tendencies. A person may score at different levels on the different factors, but the overall score indicates the extent of psychopathic personality. Triarchic Psychopathy Measure The Triarchic Psychopathy Measure, otherwise known as the TriPM, is a 58-item, self-report assessment that measures psychopathy within the three traits identified in the triarchic model: boldness, meanness and disinhibition. Each trait is measured on separate subscales and added up resulting in a total psychopathy score. The TriPM includes various components of other measures for assessing psychopathy, including meanness and disinhibition patterns within the psychopathic personality. However, there are differing approaches in the measurement of the boldness construct. The boldness construct is used to highlighting the social and interpersonal implications of the psychopathic personality. DSM and ICD There are currently two widely established systems for classifying mental disorders—the International Classification of Diseases (ICD) produced by the World Health Organization (WHO) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) produced by the American Psychiatric Association (APA). Both list categories of disorders thought to be distinct types, and have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. The first edition of the DSM in 1952 had a section on sociopathic personality disturbances, then a general term that included such things as homosexuality and alcoholism as well as an "antisocial reaction" and "dyssocial reaction". The latter two eventually became antisocial personality disorder (ASPD) in the DSM and dissocial personality disorder in the ICD. Both manuals have stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy, although neither diagnostic manual has ever included a disorder officially titled as such. Other tools There are some traditional personality tests that contain subscales relating to psychopathy, though they assess relatively non-specific tendencies towards antisocial or criminal behavior. These include the Minnesota Multiphasic Personality Inventory (Psychopathic Deviate scale), California Psychological Inventory (Socialization scale), and Millon Clinical Multiaxial Inventory Antisocial Personality Disorder scale. There is also the Levenson Self-Report Psychopathy Scale (LSRP) and the Hare Self-Report Psychopathy Scale (HSRP), but in terms of self-report tests, the PPI/PPI-R has become more used than either of these in modern psychopathy research on adults. Comorbidity Studies suggest strong comorbidity between psychopathy and antisocial personality disorder. Among numerous studies, positive correlations have also been reported between psychopathy and histrionic, narcissistic, borderline, paranoid, and schizoid personality disorders, panic and obsessive–compulsive disorders, but not neurotic disorders in general, schizophrenia, or depression. Factor 1 and the boldness scale of psychopathy measurements are associated with narcissism and histrionic personality disorder. This is due to a psychopath's cognitive and affective egocentrism. However, while a narcissistic individual might view themselves as confident, they might seek out validation and attention from others to validate their self-worth, whereas a psychopathic individual usually lacks such ambitions. Attention deficit hyperactivity disorder (ADHD) is known to be highly comorbid with conduct disorder (a theorized precursor to ASPD), and may also co-occur with psychopathic tendencies. This may be explained in part by deficits in executive function. Anxiety disorders often co-occur with ASPD, and contrary to assumptions, psychopathy can sometimes be marked by anxiety; this appears to be related to items from Factor 2 but not Factor 1 of the PCL-R. Psychopathy is also associated with substance use disorders. Michael Fitzgerald suggested overlaps between (primary) psychopathy and Asperger syndrome in terms of fearlessness, planning of acts, empathy deficits, callous behaviour, and sometimes superficial charisma. Studies investigating similarities and differences between psychopathy and autism indicate that autism and psychopathy are not part of the same construct. Rather both conditions might co-occur in some individuals. Recent studies indicate that some individuals with an autism diagnosis also show callous and unemotional traits (a risk-factor for developing psychopathy), but are less strongly associated with conduct problems. Likewise, some people with Asperger syndrome have shown correlations with the "unemotional" factor and "behavioural dyscontrol" factor of psychopathy, but not the "interpersonal" factor. It has been suggested that psychopathy may be comorbid with several other conditions than these, but limited work on comorbidity has been carried out. This may be partly due to difficulties in using inpatient groups from certain institutions to assess comorbidity, owing to the likelihood of some bias in sample selection. Sex differences Research on psychopathy has largely been done on men and the PCL-R was developed using mainly male criminal samples, raising the question of how well the results apply to women. Men score higher than women on both the PCL-R and the PPI and on both of their main scales. The differences tend to be somewhat larger on the interpersonal-affective scale than on the antisocial scale. Most but not all studies have found broadly similar factor structure for men and women. Many associations with other personality traits are similar, although in one study the antisocial factor was more strongly related with impulsivity in men and more strongly related with openness to experience in women. It has been suggested that psychopathy in men manifest more as an antisocial pattern while in women it manifests more as a histrionic pattern. Studies on this have shown mixed results. PCL-R scores may be somewhat less predictive of violence and recidivism in women. On the other hand, psychopathy may have a stronger relationship with suicide and possibly internalizing symptoms in women. A suggestion is that psychopathy manifests more as externalizing behaviors in men and more as internalizing behaviors in women. Furthermore, one study has suggested substantial gender differences were found in the etiology of psychopathy. For girls, 75% of the variance in severe callous and unemotional traits was attributable to environmental factors and just 0% of the variance was attributable to genetic factors. In boys, the link was reversed. Studies have also found that women in prison score significantly lower on psychopathy than men, with one study reporting only 11 percent of violent females in prison met the psychopathy criteria in comparison to 31 percent of violent males. Other studies have also indicated that high psychopathic females are rare in forensic settings. Management Clinical Psychopathy has often been considered untreatable. Its unique characteristics makes it among the most refractory of personality disorders, a class of mental illnesses that are already traditionally considered difficult to treat. People with psychopathy are generally unmotivated to seek treatment for their condition, and can be uncooperative in therapy. Attempts to treat psychopathy with the current tools available to psychiatry have been disappointing. Harris and Rice's Handbook of Psychopathy says that there is currently little evidence for a cure or effective treatment for psychopathy; as yet, no pharmacological therapies are known to or have been trialed for alleviating the emotional, interpersonal and moral deficits of psychopathy, and patients with psychopathy who undergo psychotherapy might gain the skills to become more adept at the manipulation and deception of others and be more likely to commit crime. Some studies suggest that punishment and behavior modification techniques are ineffective at modifying the behavior of psychopathic individuals as they are insensitive to punishment or threat. These failures have led to a widely pessimistic view on its treatment prospects, a view that is exacerbated by the little research being done into psychopathy compared to the efforts committed to other mental illnesses, which makes it more difficult to gain the understanding of this condition that is necessary to develop effective therapies. Although the core character deficits of highly psychopathic individuals are likely to be highly incorrigible to the currently available treatment methods, the antisocial and criminal behavior associated with it may be more amenable to management, the management of which being the main aim of therapy programs in correctional settings. It has been suggested that the treatments that may be most likely to be effective at reducing overt antisocial and criminal behavior are those that focus on self-interest, emphasizing the tangible, material value of prosocial behavior, with interventions that develop skills to obtain what the patient wants out of life in prosocial rather than antisocial ways. To this end, various therapies have been tried with the aim of reducing the criminal activity of incarcerated offenders with psychopathy, with mixed success. As psychopathic individuals are insensitive to sanction, reward-based management, in which small privileges are granted in exchange for good behavior, has been suggested and used to manage their behavior in institutional settings. Psychiatric medications may also alleviate co-occurring conditions sometimes associated with psychopathy or with symptoms such as aggression or impulsivity, including antipsychotic, antidepressant or mood-stabilizing medications, although none have yet been approved by the FDA for this purpose. For example, a study found that the antipsychotic clozapine may be effective in reducing various behavioral dysfunctions in a sample of high-security hospital inpatients with antisocial personality disorder and psychopathic traits. However, research into the pharmacological treatment of psychopathy and the related condition antisocial personality disorder is minimal, with much of the knowledge in this area being extrapolations based on what is known about pharmacology in other mental disorders. Legal The PCL-R, the PCL:SV, and the PCL:YV are highly regarded and widely used in criminal justice settings, particularly in North America. They may be used for risk assessment and for assessing treatment potential and be used as part of the decisions regarding bail, sentence, which prison to use, parole, and regarding whether a youth should be tried as a juvenile or as an adult. There have been several criticisms against its use in legal settings. They include the general criticisms against the PCL-R, the availability of other risk assessment tools which may have advantages, and the excessive pessimism surrounding the prognosis and treatment possibilities of those who are diagnosed with psychopathy. The interrater reliability of the PCL-R can be high when used carefully in research but tend to be poor in applied settings. In particular Factor 1 items are somewhat subjective. In sexually violent predator cases the PCL-R scores given by prosecution experts were consistently higher than those given by defense experts in one study. The scoring may also be influenced by other differences between raters. In one study it was estimated that of the PCL-R variance, about 45% was due to true offender differences, 20% was due to which side the rater testified for, and 30% was due to other rater differences. To aid a criminal investigation, certain interrogation approaches may be used to exploit and leverage the personality traits of suspects thought to have psychopathy and make them more likely to divulge information. United Kingdom The PCL-R score cut-off for a label of psychopathy is 25 out of 40 in the United Kingdom, instead of 30 as it is in the United States. In the United Kingdom, "psychopathic disorder" was legally defined in the Mental Health Act (UK), under MHA1983, as "a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned". This term was intended to reflect the presence of a personality disorder in terms of conditions for detention under the Mental Health Act 1983. Amendments to MHA1983 within the Mental Health Act 2007 abolished the term "psychopathic disorder", with all conditions for detention (e.g. mental illness, personality disorder, etc.) encompassed by the generic term of "mental disorder". In England and Wales, the diagnosis of dissocial personality disorder is grounds for detention in secure psychiatric hospitals under the Mental Health Act if they have committed serious crimes, but since such individuals are disruptive to other patients and not responsive to usual treatment methods this alternative to traditional incarceration is often not used. United States "Sexual psychopath" laws Starting in the 1930s, before some modern concepts of psychopathy were developed, "sexual psychopath" laws, the term referring broadly to mental illness, were introduced by some states, and by the mid-1960s more than half of the states had such laws. Sexual offenses were considered to be caused by underlying mental illnesses, and it was thought that sex offenders should be treated, in agreement with the general rehabilitative trends at this time. Courts committed sex offenders to a mental health facility for community protection and treatment. Starting in 1970, many of these laws were modified or abolished in favor of more traditional responses such as imprisonment due to criticism of the "sexual psychopath" concept as lacking scientific evidence, the treatment being ineffective, and predictions of future offending being dubious. There were also a series of cases where persons treated and released committed new sexual offenses. Starting in the 1990s, several states have passed sexually dangerous person laws, including registration, housing restrictions, public notification, mandatory reporting by health care professionals, and civil commitment, which permits indefinite confinement after a sentence has been completed. Psychopathy measurements may be used in the confinement decision process. Prognosis The prognosis for psychopathy in forensic and clinical settings is quite poor, with some studies reporting that treatment may worsen the antisocial aspects of psychopathy as measured by recidivism rates, though it is noted that one of the frequently cited studies finding increased criminal recidivism after treatment, a 2011 retrospective study of a treatment program in the 1960s, had several serious methodological problems and likely would not be approved of today. However, some relatively rigorous quasi-experimental studies using more modern treatment methods have found improvements regarding reducing future violent and other criminal behavior, regardless of PCL-R scores, although none were randomized controlled trials. Various other studies have found improvements in risk factors for crime such as substance abuse. No study has yet examined whether the personality traits that form the core character disturbances of psychopathy could be changed by such treatments. Frequency A 2008 study using the PCL:SV found that 1.2% of a US sample scored 13 or more out of 24, indicating "potential psychopathy". The scores correlated significantly with violence, alcohol use, and lower intelligence. A 2009 British study by Coid et al., also using the PCL:SV, reported a community prevalence of 0.6% scoring 13 or more. However, if the scoring was adjusted to the recommended 18 or more, this would have left the prevalence closer to 0.1%. The scores correlated with younger age, male gender, suicide attempts, violence, imprisonment, homelessness, drug dependence, personality disorders (histrionic, borderline and antisocial), and panic and obsessive–compulsive disorders. Psychopathy has a much higher prevalence in the convicted and incarcerated population, where it is thought that an estimated 15–25% of prisoners qualify for the diagnosis. A study on a sample of inmates in the UK found that 7.7% of the inmates interviewed met the PCL-R cut-off of 30 for a diagnosis of psychopathy. A study on a sample of inmates in Iran using the PCL:SV found a prevalence of 23% scoring 18 or more. A study by Nathan Brooks from Bond University found that around one in five corporate bosses display clinically significant psychopathic traits - a proportion similar to that among prisoners. Society and culture In the workplace There is limited research on psychopathy in the general work populace, in part because the PCL-R includes antisocial behavior as a significant core factor (obtaining a PCL-R score above the threshold is unlikely without having significant scores on the antisocial-lifestyle factor) and does not include positive adjustment characteristics, and most researchers have studied psychopathy in incarcerated criminals, a relatively accessible population of research subjects. However, psychologists Fritzon and Board, in their study comparing the incidence of personality disorders in business executives against criminals detained in a mental hospital, found that the profiles of some senior business managers contained significant elements of personality disorders, including those referred to as the "emotional components", or interpersonal-affective traits, of psychopathy. Factors such as boldness, disinhibition, and meanness as defined in the triarchic model, in combination with other advantages such as a favorable upbringing and high intelligence, are thought to correlate with stress immunity and stability, and may contribute to this particular expression. Such individuals are sometimes referred to as "successful psychopaths" or "corporate psychopaths" and they may not always have extensive histories of traditional criminal or antisocial behavior characteristic of the traditional conceptualization of psychopathy. Robert Hare claims that the prevalence of psychopathic traits is higher in the business world than in the general population, reporting that while about 1% of the general population meet the clinical criteria for psychopathy, figures of around 3–4% have been cited for more senior positions in business. Hare considers newspaper tycoon Robert Maxwell to have been a strong candidate as a "corporate psychopath". Academics on this subject believe that although psychopathy is manifested in only a small percentage of workplace staff, it is more common at higher levels of corporate organizations, and its negative effects (for example, increased bullying, conflict, stress, staff turnover, absenteeism, reduction in productivity) often causes a ripple effect throughout an organization, setting the tone for an entire corporate culture. Employees with the disorder are self-serving opportunists, and may disadvantage their own organizations to further their own interests. They may be charming to staff above their level in the workplace hierarchy, aiding their ascent through the organization, but abusive to staff below their level, and can do enormous damage when they are positioned in senior management roles. Psychopathy as measured by the PCL-R is associated with lower performance appraisals among corporate professionals. The psychologist Oliver James identifies psychopathy as one of the dark triadic traits in the workplace, the others being narcissism and Machiavellianism, which, like psychopathy, can have negative consequences. According to a study from the University of Notre Dame published in the Journal of Business Ethics, psychopaths have a natural advantage in workplaces overrun by abusive supervision, and are more likely to thrive under abusive bosses, being more resistant to stress, including interpersonal abuse, and having less of a need for positive relationships than others. In fiction Characters with psychopathy or sociopathy are some of the most notorious characters in film and literature, but their characterizations may only vaguely or partly relate to the concept of psychopathy as it is defined in psychiatry, criminology, and research. The character may be identified as having psychopathy within the fictional work itself, by its creators, or from the opinions of audiences and critics, and may be based on undefined popular stereotypes of psychopathy. Characters with psychopathic traits have appeared in Greek and Roman mythology, Bible stories, and some of Shakespeare's works. Such characters are often portrayed in an exaggerated fashion and typically in the role of a villain or antihero, where the general characteristics and stereotypes associated with psychopathy are useful to facilitate conflict and danger. Because the definitions, criteria, and popular conceptions throughout its history have varied over the years and continue to change even now, many of the characters characterized as psychopathic in notable works at the time of publication may no longer fit the current definition and conception of psychopathy. There are several archetypal images of psychopathy in both lay and professional accounts which only partly overlap and can involve contradictory traits: the charming con artist, the deranged serial killer and mass murderer, the callous and scheming businessperson, and the chronic low-level offender and juvenile delinquent. The public concept reflects some combination of fear of a mythical bogeyman, the disgust and intrigue surrounding evil, and fascination and sometimes perhaps envy of people who might appear to go through life without attachments and unencumbered by guilt, anguish or insecurity. See also Collective narcissism Moral psychology Serial rapist Violence and autism References Bibliography Black, Will (2014) Psychopathic Cultures and Toxic Empires Frontline Noir, Edinburgh Blair, J. et al. (2005) The Psychopath – Emotion and the Brain. Malden, MA: Blackwell Publishing, Dutton, K. (2012) The Wisdom of Psychopaths (e-book) Häkkänen-Nyholm, H. & Nyholm, J-O. (2012). Psychopathy and Law: A Practitioners Guide. Chichester: John Wiley & Sons. Oakley, Barbara, Evil Genes: Why Rome Fell, Hitler Rose, Enron Failed, and My Sister Stole My Mother's Boyfriend. Prometheus Books, Amherst, NY, 2007, . Stone, Michael H., M.D. & Brucato, Gary, Ph.D., The New Evil: Understanding the Emergence of Modern Violent Crime (Amherst, N.Y.: Prometheus Books). . Thiessen, W Slip-ups and the dangerous mind: Seeing through and living beyond the psychopath (2012). Thimble, Michael H.F.R.C.P., F.R.C. Psych. Psychopathology of Frontal Lobe Syndromes. External links Handbook of Psychopathy, 2nd Edition (2018) on Google Books. The Mask of Sanity, 5th Edition, PDF of Hervey Cleckley's book, 1988 Without Conscience Official web site of Robert Hare Philpapers Psychopathy Understanding The Psychopath: Key Definitions & Research Psychopathy Is website The Paradox of Psychopathy Psychiatric Times, 2007 (nb: inconsistent access) Into the Mind of a Killer Nature, 2001 What Psychopaths Teach Us about How to Succeed Scientific American, October 2012 "When Your Child is a Psychopath" in The Atlantic 1840s neologisms Criminology Dark triad Forensic psychology Obsolete terms for mental disorders Behavioural sciences

Neurodevelopmental disorder

Neurodevelopmental disorders are a group of mental conditions affecting the development of the nervous system, which includes the brain and spinal cord. According to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) published in 2013, these conditions generally appear in early childhood, usually before children start school, and can persist into adulthood. The key characteristic of all these disorders is that they negatively impact a person's functioning in one or more domains of life (personal, social, academic, occupational) depending on the disorder and deficits it has caused. All of these disorders and their levels of impairment exist on a spectrum, and affected individuals can experience varying degrees of symptoms and deficits, despite having the same diagnosis. The DSM-5 classifies neurodevelopmental disorders into six overarching groups: intellectual, communication, autism, attention deficit hyperactivity, motor, and specific learning disorders. Often one disorder is accompanied by another. Classification Intellectual disability Intellectual disability, also known as general learning disability is a disorder that affects the ability to learn, retain, or process information; to think critically or abstractly, and to solve problems. Adaptive behaviour is limited, affecting daily living activities. Global developmental delay is categorized under intellectual disability and is diagnosed when several areas of intellectual functioning are affected. Communication disorders A communication disorder is any disorder that affects an individual's ability to comprehend, detect, or apply language and speech to engage in dialogue effectively with others. This also encompasses deficiencies in verbal and nonverbal communication styles. The delays and disorders can range from simple sound substitution to the inability to understand or use one's native language. Autism spectrum disorder Autism, also called autism spectrum disorder (ASD) or autism spectrum condition (ASC), is a neurodevelopmental disorder characterized by symptoms of deficient reciprocal social communication and the presence of restricted, repetitive, and inflexible patterns of behavior. While its severity and specific manifestations vary widely across the spectrum, autism generally affects a person's ability to understand and connect with others, as well as their adaptability to everyday situations. Like most developmental disorders, autism exists along a dimension of symptom severity, subjective distress, and functional impairment. A consequence of this dimensionality is substantial variability in the nature and extent of support a person with ASD requires. A formal diagnosis of ASD requires not merely the presence of ASD symptoms, but symptoms that cause significant impairment in multiple domains of functioning, in addition to being excessive or atypical enough to be developmentally and socioculturally inappropriate. Attention deficit hyperactivity disorder Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by executive dysfunction occasioning symptoms of inattention, hyperactivity, impulsivity and emotional dysregulation that are excessive and pervasive, impairing in multiple contexts, and developmentally-inappropriate. ADHD symptoms arise from executive dysfunction, and emotional dysregulation is often considered a core symptom. Difficulties in self-regulation such as time management, inhibition and sustained attention may cause poor professional performance, relationship difficulties and numerous health risks, collectively predisposing to a diminished quality of life and a direct average reduction in life expectancy of 13 years. ADHD is associated with other neurodevelopmental and mental disorders as well as non-psychiatric disorders, which can cause additional impairment. Motor disorders Motor disorders including developmental coordination disorder, stereotypic movement disorder, and tic disorders (such as Tourette's syndrome), and apraxia of speech. Specific learning disorders Deficits in any area of information processing can manifest in a variety of specific learning disabilities (SLD). It is possible for an individual to have more than one of these difficulties. This is referred to as comorbidity or co-occurrence of learning disabilities. In the UK, the term dual diagnosis is often used to refer to co-occurrence of learning difficulties. Currently being researched There are neurodevelopmental research projects examining potential new classifications of disorders including: Nonverbal learning disorder (NLD or NVLD), a neurodevelopmental disorder thought to be linked to white matter in the right hemisphere of the brain and generally considered to include (a) low visuospatial intelligence; (b) discrepancy between verbal and visuospatial intelligence; (c) visuoconstructive and fine-motor coordination skills; (d) visuospatial memory tasks; (e) reading better than mathematical achievement; and (f) socioemotional skills. While Nonverbal learning disorder is not categorized in the ICD or DSM as a discrete classification, "the majority of researchers and clinicians agree that the profile of NLD clearly exists (but see Spreen, 2011, for an exception), but they disagree on the need for a specific clinical category and on the criteria for its identification." Presentation Consequences The multitude of neurodevelopmental disorders span a wide range of associated symptoms and severity, resulting in different degrees of mental, emotional, physical, and economic consequences for individuals, and in turn families, social groups, and society. Causes The development of the nervous system is tightly regulated and timed; it is influenced by both genetic programs and the prenatal environment. Any significant deviation from the normal developmental trajectory early in life can result in missing or abnormal neuronal architecture or connectivity. Because of the temporal and spatial complexity of the developmental trajectory, there are many potential causes of neurodevelopmental disorders that may affect different areas of the nervous system at different times and ages. These range from social deprivation, genetic and metabolic diseases, immune disorders, infectious diseases, nutritional factors, physical trauma, and toxic and prenatal environmental factors. Some neurodevelopmental disorders, such as autism and other pervasive developmental disorders, are considered multifactorial syndromes which have many causes that converge to a more specific neurodevelopmental manifestation. Some deficits may be predicted from observed deviations in the maturation patterns of the infant gut microbiome. Social deprivation Deprivation from social and emotional care causes severe delays in brain and cognitive development. Studies with children growing up in Romanian orphanages during Nicolae Ceauşescu's regime reveal profound effects of social deprivation and language deprivation on the developing brain. These effects are time-dependent. The longer children stayed in negligent institutional care, the greater the consequences. By contrast, adoption at an early age mitigated some of the effects of earlier institutionalization. Genetic disorders A prominent example of a genetically determined neurodevelopmental disorder is trisomy 21, also known as Down syndrome. This disorder usually results from an extra chromosome 21, although in uncommon instances it is related to other chromosomal abnormalities such as translocation of the genetic material. It is characterized by short stature, epicanthal (eyelid) folds, abnormal fingerprints, and palm prints, heart defects, poor muscle tone (delay of neurological development), and intellectual disabilities (delay of intellectual development). Less commonly known genetically determined neurodevelopmental disorders include Fragile X syndrome. Fragile X syndrome was first described in 1943 by Martin and Bell, studying persons with family history of sex-linked "mental defects". Rett syndrome, another X-linked disorder, produces severe functional limitations. Williams syndrome is caused by small deletions of genetic material from chromosome 7. The most common recurrent copy number variation disorder is DiGeorge syndrome (22q11.2 deletion syndrome), followed by Prader-Willi syndrome and Angelman syndrome. Immune dysfunction Immune reactions during pregnancy, both maternal and of the developing child, may produce neurodevelopmental disorders. One typical immune reaction in infants and children is PANDAS, or Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection. Another disorder is Sydenham's chorea, which results in more abnormal movements of the body and fewer psychological sequellae. Both are immune reactions against brain tissue that follow infection by Streptococcus bacteria. Susceptibility to these immune diseases may be genetically determined, so sometimes several family members may have one or both of them following an epidemic of Strep infection. Infectious diseases Systemic infections can result in neurodevelopmental consequences, when they occur in infancy and childhood of humans, but would not be called a primary neurodevelopmental disorder. For example HIV Infections of the head and brain, like brain abscesses, meningitis or encephalitis have a high risk of causing neurodevelopmental problems and eventually a disorder. For example, measles can progress to subacute sclerosing panencephalitis. A number of infectious diseases can be transmitted congenitally (either before or at birth), and can cause serious neurodevelopmental problems, as for example the viruses HSV, CMV, rubella (congenital rubella syndrome), Zika virus, or bacteria like Treponema pallidum in congenital syphilis, which may progress to neurosyphilis if it remains untreated. Protozoa like Plasmodium or Toxoplasma which can cause congenital toxoplasmosis with multiple cysts in the brain and other organs, leading to a variety of neurological deficits. Some cases of schizophrenia may be related to congenital infections, though the majority are of unknown causes. Metabolic disorders Metabolic disorders in either the mother or the child can cause neurodevelopmental disorders. Two examples are diabetes mellitus (a multifactorial disorder) and phenylketonuria (an inborn error of metabolism). Many such inherited diseases may directly affect the child's metabolism and neural development but less commonly they can indirectly affect the child during gestation. (See also teratology). In a child, type 1 diabetes can produce neurodevelopmental damage by the effects of excess or insufficient glucose. The problems continue and may worsen throughout childhood if the diabetes is not well controlled. Type 2 diabetes may be preceded in its onset by impaired cognitive functioning. A non-diabetic fetus can also be subjected to glucose effects if its mother has undetected gestational diabetes. Maternal diabetes causes excessive birth size, making it harder for the infant to pass through the birth canal without injury or it can directly produce early neurodevelopmental deficits. Usually the neurodevelopmental symptoms will decrease in later childhood. Phenylketonuria, also known as PKU, can induce neurodevelopmental problems and children with PKU require a strict diet to prevent intellectual disability and other disorders. In the maternal form of PKU, excessive maternal phenylalanine can be absorbed by the fetus even if the fetus has not inherited the disease. This can produce intellectual disability and other disorders. Nutrition Nutrition disorders and nutritional deficits may cause neurodevelopmental disorders, such as spina bifida, and the rarely occurring anencephaly, both of which are neural tube defects with malformation and dysfunction of the nervous system and its supporting structures, leading to serious physical disability and emotional sequelae. The most common nutritional cause of neural tube defects is folic acid deficiency in the mother, a B vitamin usually found in fruits, vegetables, whole grains, and milk products. (Neural tube defects are also caused by medications and other environmental causes, many of which interfere with folate metabolism, thus they are considered to have multifactorial causes.) Another deficiency, iodine deficiency, produces a spectrum of neurodevelopmental disorders ranging from mild emotional disturbance to severe intellectual disability. (see also congenital iodine deficiency syndrome). Excesses in both maternal and infant diets may cause disorders as well, with foods or food supplements proving toxic in large amounts. For instance in 1973 K.L. Jones and D.W. Smith of the University of Washington Medical School in Seattle found a pattern of "craniofacial, limb, and cardiovascular defects associated with prenatal onset growth deficiency and developmental delay" in children of alcoholic mothers, now called fetal alcohol syndrome, It has significant symptom overlap with several other entirely unrelated neurodevelopmental disorders. Physical trauma Brain trauma in the developing human is a common cause (over 400,000 injuries per year in the US alone, without clear information as to how many produce developmental sequellae) of neurodevelopmental syndromes. It may be subdivided into two major categories, congenital injury (including injury resulting from otherwise uncomplicated premature birth) and injury occurring in infancy or childhood. Common causes of congenital injury are asphyxia (obstruction of the trachea), hypoxia (lack of oxygen to the brain), and the mechanical trauma of the birth process itself. Placenta Although it not clear yet as strong is the correlation between placenta and brain, a growing number of studies are linking placenta to fetal brain development. Diagnosis Neurodevelopmental disorders are diagnosed by evaluating the presence of characteristic symptoms or behaviors in a child, typically after a parent, guardian, teacher, or other responsible adult has raised concerns to a doctor. Neurodevelopmental disorders may also be confirmed by genetic testing. Traditionally, disease related genetic and genomic factors are detected by karyotype analysis, which detects clinically significant genetic abnormalities for 5% of children with a diagnosed disorder. , chromosomal microarray analysis (CMA) was proposed to replace karyotyping because of its ability to detect smaller chromosome abnormalities and copy-number variants, leading to greater diagnostic yield in about 20% of cases. The American College of Medical Genetics and Genomics and the American Academy of Pediatrics recommend CMA as standard of care in the US. Management See also Developmental disability Epigenetics Microcephaly Teratology TRPM3-related neurodevelopmental disorders References Further reading External links A Review of Neurodevelopmental Disorders – Medscape review Neurological disorders

Erethism

Erethism, also known as erethismus mercurialis, mad hatter disease, or mad hatter syndrome, is a neurological disorder which affects the whole central nervous system, as well as a symptom complex, derived from mercury poisoning. Erethism is characterized by behavioral changes such as irritability, low self-confidence, depression, apathy, shyness and timidity, and in some extreme cases with prolonged exposure to mercury vapors, by delirium, personality changes and memory loss. People with erethism often have difficulty with social interactions. Associated physical problems may include a decrease in physical strength, headaches, general pain, and tremors, as well as an irregular heartbeat. Mercury is an element that is found worldwide in soil, rocks, and water. People who get erethism are often exposed to mercury through their jobs. Some of the higher risk jobs that can lead to occupational exposure of workers to mercury are working in a chlor-alkali, thermometer, glassblowing, or fluorescent light bulb factory, and working in construction, dental clinics, or in gold and silver mines. In factories, workers are exposed to mercury primarily through the base products and processes involved in making the final end consumer product. In dental clinics it is primarily through their interaction and installation of dental amalgams to treat dental caries. In the case of mining, mercury is used in the process to purify and completely extract the precious metals. Some elemental and chemical forms of mercury (vapor, methylmercury, inorganic mercury) are more toxic than other forms. The human fetus and medically compromised people (for example, patients with lung or kidney problems) are the most susceptible to the toxic effects of mercury. Mercury poisoning can also occur outside of occupational exposures including in the home. Inhalation of mercury vapor may stem from cultural and religious rituals where mercury is sprinkled on the floor of a home or car, burned in a candle, or mixed with perfume. Due to widespread use and popular concern, the risk of toxicity from dental amalgam has been exhaustively investigated. It has conclusively been shown to be safe although in 2020 the FDA issued new guidance for at-risk populations who should avoid mercury amalgam. Historically, this was common among old England felt-hatmakers who had long-term exposure to vapors from the mercury they used to stabilize the wool in a process called felting, where hair was cut from a pelt of an animal such as a rabbit. The industrial workers were exposed to the mercury vapors, giving rise to the expression "mad as a hatter". Some believe that the character the Mad Hatter in Lewis Carroll's Alice in Wonderland is an example of someone with erethism, but the origin of this account is unclear. The character was almost certainly based on Theophilus Carter, an eccentric furniture dealer who was well known to Carroll. Signs and symptoms Acute mercury exposure has given rise to psychotic reactions such as delirium, hallucinations, and suicidal tendency. Occupational exposure has resulted in erethism, with irritability, excitability, excessive shyness, and insomnia as the principal features of a broad-ranging functional disturbance. With continuing exposure, a fine tremor develops, initially involving the hands and later spreading to the eyelids, lips, and tongue, causing violent muscular spasms in the most severe cases. The tremor is reflected in the handwriting which has a characteristic appearance. In milder cases, erethism and tremor regress slowly over a period of years following removal from exposure. Decreased nerve conduction velocity in mercury-exposed workers has been demonstrated. Long-term, low-level exposure has been found to be associated with less pronounced symptoms of erethism, characterized by fatigue, irritability, loss of memory, vivid dreams, and depression (WHO, 1976). Effects of chronic occupational exposure to mercury, such as that commonly experienced by affected hatters, include mental confusion, emotional disturbances, and muscular weakness. Severe neurological damage and kidney damage can also occur. Signs and symptoms can include red fingers, red toes, red cheeks, sweating, loss of hearing, bleeding from the ears and mouth, loss of appendages such as teeth, hair, and nails, lack of coordination, poor memory, shyness, insomnia, nervousness, tremors, and dizziness. A survey of exposed U.S. hatters revealed predominantly neurological symptomatology, including intention tremor. After chronic exposure to the mercury vapours, hatters tended to develop characteristic psychological traits, such as pathological shyness and marked irritability (see box). Such manifestations among hatters prompted several popular names for erethism, including "mad hatter disease", "mad hatter syndrome", "hatter's shakes" and "Danbury shakes". Biomarkers of exposure While hatters in the past were diagnosed with erethism through their symptoms, it was sometimes harder to prove that erethism was the result of mercury exposure, as seen in the case of the hatters of New Jersey below. Today, although erethism from the hat making industry is no longer an issue, it persists in other high-risk occupations. As a result, methods have been established to measure the mercury exposure of workers more accurately. They include the collection and testing of mercury levels in blood, hair, nails, and urine. Most of these biomarkers have a shorter half-life for mercury (e.g. in blood the half-life is usually only around 2–4 days), which makes some of them better for testing acute, high doses of mercury exposure. However, mercury in urine has a much longer half-life (measured in weeks to months), and unlike the other biomarkers is more representative of the total body burden of inorganic and elemental mercury. This makes it the ideal biomarker for measuring occupational exposure to mercury because it is suitable to measuring low, chronic exposure, and specifically exposure to inorganic and elemental mercury (i.e. mercury vapor), which are the two types most likely to be encountered in a higher risk occupation. History among hatters Especially in the 19th century, inorganic mercury in the form of mercuric nitrate was commonly used in the production of felt for hats. During a process called carroting, in which furs from small animals such as rabbits, hares or beavers were separated from their skins and matted together, an orange-colored solution containing mercuric nitrate was used as a smoothing agent. The resulting felt was then repeatedly shaped into large cones, shrunk in boiling water and dried. In treated felts, a slow reaction released volatile free mercury. Hatters (or milliners) who came into contact with vapours from the impregnated felt often worked in confined areas. Use of mercury in hatmaking is thought to have been adopted by the Huguenots in 17th-century France, at a time when the dangers of mercury exposure were already known. This process was initially kept a trade secret in France, where hatmaking rapidly became a hazardous occupation. At the end of the 17th century the Huguenots carried the secret to England, following the revocation of the Edict of Nantes. During the Victorian era the hatters' malaise became proverbial, as reflected in popular expressions like "mad as a hatter" (see below) and "the hatters' shakes". The first description of symptoms of mercury poisoning among hatters appears to have been made in St Petersburg, Russia, in 1829. In the United States, a thorough occupational description of mercury poisoning among New Jersey hatters was published locally by Addison Freeman in 1860. Adolph Kussmaul's definitive clinical description of mercury poisoning published in 1861 contained only passing references to hatmakers, including a case originally reported in 1845 of a 15-year-old Parisian girl, the severity of whose tremors following two years of carroting prompted opium treatment. In Britain, the toxicologist Alfred Swaine Taylor reported the disease in a hatmaker in 1864. In 1869, the French Academy of Medicine demonstrated the health hazards posed to hatmakers. Alternatives to mercury use in hatmaking became available by 1874. In the United States, a hydrochloride-based process was patented in 1888 to obviate the use of mercury, but was ignored. In 1898, legislation was passed in France to protect hatmakers from the risks of mercury exposure. By the turn of the 20th century, mercury poisoning among British hatters had become a rarity. In the United States, the mercury-based process continued to be adopted until as late as 1941, when it was abandoned mainly due to the wartime need for the heavy metal in the manufacture of detonators. Thus, for much of the 20th century mercury poisoning remained common in the U.S. hatmaking industries, including those located in Danbury, Connecticut (giving rise to the expression the "Danbury shakes"). Another 20th-century cohort of affected hatmakers has been studied in Tuscany, Italy. Hatters of New Jersey The experience of hatmakers in New Jersey is well documented and has been reviewed by Richard Wedeen. In 1860, at a time when the hatmaking industry in towns such as Newark, Orange and Bloomfield was growing rapidly, a physician from Orange called J. Addison Freeman published an article titled "Mercurial Disease Among Hatters" in the Transactions of the Medical Society of New Jersey. This groundbreaking paper provided a clinical account of the effects of chronic mercury poisoning among the workforce, coupled with an occupational description of the use of mercuric nitrate during carroting and inhalation of mercury vapour later in the process (during finishing, forming and sizing). Freeman concluded that "A proper regard for the health of this class of citizens demands that mercury should not be used so extensively in the manufacture of hats, and that if its use is essential, that the hat finishers' room should be large, with a high ceiling, and well ventilated." Freeman's call for prevention went unheeded. In 1878, an inspection of 25 firms around Newark conducted by Dr L. Dennis on behalf of the Essex County Medical Society revealed "mercurial disease" in 25% of 1,589 hatters. Dennis recognized that this prevalence figure was probably an underestimate, given the workers' fear of being fired if they admitted to being diseased. Although Dennis did recommend the use of fans in the workplace he attributed most of the hatters' health problems to excessive alcohol use (thus using the stigma of drunkenness in a mainly immigrant workforce to justify the unsanitary working conditions provided by employers). Some voluntary reductions in mercury exposure were implemented after Lawrence T. Fell, a former journeyman hatter from Orange who had become a successful manufacturer, was appointed Inspector of Factories in 1883. In the late nineteenth century, a pressing health issue among hatters was tuberculosis. This deadly communicable disease was rife in the extremely unhygienic wet and steamy enclosed spaces in which the hatters were expected to work (in its annual report for 1889, the New Jersey Bureau of Labor and Industries expressed incredulity at the conditions—see box). Two-thirds of the recorded deaths of hatters in Newark and Orange between 1873 and 1876 were caused by pulmonary disease, most often in men under 30 years of age, and elevated death rates from tuberculosis persisted into the twentieth century. Consequently, public health campaigns to prevent tuberculosis spreading from the hatters into the wider community tended to eclipse the issue of mercury poisoning. For instance, in 1886 J. W. Stickler, working on behalf of the New Jersey Board of Health, promoted prevention of tuberculosis among hatters, but deemed mercurialism "uncommon", despite having reported tremors in 15–50% of the workers he had surveyed. While hatters seemed to regard the shakes as an inevitable price to pay for their work rather than a readily preventable disease, their employers professed ignorance of the problem. In a 1901 survey of 11 employers of over a thousand hatters in Newark and Orange, the head of the Bureau of Statistics of New Jersey, William Stainsby, found a lack of awareness of any disease peculiar to hatters apart from tuberculosis and rheumatism (though one employer remarked that "work at the trade develops an inordinate craving for strong drink"). By 1934 the U.S. Public Health Service estimated that 80% of American felt makers had mercurial tremors. Nevertheless, trade union campaigns (led by the United States Hat Finishers Association, originally formed in 1854) never addressed the issue and, unlike in France, no relevant legislation was ever adopted in the United States. Instead, it seems to have been the need for mercury in the war effort that eventually brought to an end the use of mercuric nitrate in U.S. hatmaking; in a meeting convened by the U.S. Public Health Service in 1941, the manufacturers voluntarily agreed to adopt a readily available alternative process using hydrogen peroxide. "Mad as a hatter" Although the expression "mad as a hatter" was associated with the syndrome, the origin of the phrase is uncertain. Lewis Carroll's iconic Mad Hatter character in Alice's Adventures in Wonderland displays markedly eccentric behavior, which includes taking a bite out of a teacup. Carroll would have been familiar with the phenomenon of dementia among hatters, but the literary character is thought to be directly inspired by Theophilus Carter, an eccentric furniture dealer who did not show signs of mercury poisoning. The actor Johnny Depp has said of his portrayal of a carrot-orange haired Mad Hatter in Tim Burton's 2010 film, Alice in Wonderland that the character "was poisoned ... and it was coming out through his hair, through his fingernails and eyes". See also Danbury Hatters' case Minamata disease Notes References Sources Industrial hygiene Mercury poisoning Neurological disorders Occupational diseases Shyness

Abnormality (behavior)

Abnormality (or dysfunctional behavior or maladaptive behavior or deviant behavior) is a behavioral characteristic assigned to those with conditions that are regarded as dysfunctional. Behavior is considered to be abnormal when it is atypical or out of the ordinary, consists of undesirable behavior, and results in impairment in the individual's functioning. As applied to humans, abnormality may also encompass deviance, which refers to behavior that is considered to transgress social norms. The definition of abnormal behavior in humans is an often debated issue in abnormal psychology. Abnormal behavior should not be confused with unusual behavior. Behavior that is out of the ordinary is not necessarily indicative of a mental or psychological disorder. Abnormal behavior, on the other hand, while not a mental disorder in itself, is often an indicator of a possible mental and/or psychological disorder. A psychological disorder is defined as an "ongoing dysfunctional pattern of thought, emotion, and behavior that causes significant distress, and is considered deviant in that person's culture or society". Abnormal behavior, as it relates to psychological disorders, would be "ongoing" and a cause of "significant distress". A mental disorder describes a patient who has a medical condition whereby the medical practitioner makes a judgment that the patient is exhibiting abnormal behavior based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Thus, simply because a behavior is unusual it does not make it abnormal; it is only considered abnormal if it meets these criteria. The DSM-5 is used by both researchers and clinicians in diagnosing a potential mental disorder. The criteria needed to be met in the DSM-5 vary for each mental disorder. Unlike physical abnormalities in one's health where symptoms are objective, psychology health professionals cannot use objective symptoms when evaluating someone for abnormalities in behavior. Several conventional criteria There are five main criteria of abnormality. They are: Statistical Criterion Social Criterion Personal Discomfort (Distress) Maladaptive Behavior Deviation from Ideal Abnormal behaviors are "actions that are unexpected and often evaluated negatively because they differ from typical or usual behavior". The following criteria are subjective: Maladaptive and malfunctional behaviors: behaviors, which, due to circumstance, are not fully adapted to the environment. Instead, they become malfunctional and detrimental to the individual, or others. For example, a mouse continuing to attempt to escape when escape is obviously impossible. Behavior that violates the standards of society. When people do not follow the conventional social and moral rules of their society, the behavior is considered to be abnormal. Observer discomfort. If a person's behavior brings discomfort to those in observation, it is likely to be considered abnormal. The standard criteria in psychology and psychiatry is that of mental illness or mental disorder. Determination of abnormality in behavior is based upon medical diagnosis. Other criteria include: Statistical infrequency: statistically rare behaviors are called abnormal. Though not always the case, the presence of abnormal behavior in people is usually rare or statistically unusual. Any specific abnormal behavior may be unusual, but it is not uncommon for people to exhibit some form of prolonged abnormal behavior at some point in their lives. Deviation from social norms: behavior that is deviant from social norms is defined as the departure or deviation of an individual from society's unwritten rules (norms). For example, if one were to witness a person jumping around, nude, on the streets, the person would likely be perceived as abnormal to most people, as they have broken society's norms about wearing clothing. There are also a number of criteria for one to examine before reaching a judgment as to whether someone has deviated from society's norms: Culture: what may be seen as normal in one culture, may be seen as abnormal in another. Situation & context one is placed in: for example, going to the toilet is a normal human act, but going in the middle of a supermarket would be most likely seen as highly abnormal, i.e., defecating or urinating in public is illegal as a misdemeanor act of indecent public conduct. Age: a child at the age of three could get away with taking off clothing in public, but not a person at the age of twenty. Gender: a male responding with behavior normally reacted to as female, and vice versa, is often likely to be seen as abnormal or deviant from social norms. Historical context: standards of normal behavior change in some societies--sometimes very rapidly. Failure to function adequately: behavior that is abnormal. These criteria are necessary to label an abnormality as a disorder, if the individual is unable to cope with the demands of everyday life. Psychologists can disagree on the boundaries that define what is 'functioning' and what is 'adequately', however, as some behaviors that can cause 'failure to function' are not seen as bad. For example, firefighters risking their lives to save people in a blazing fire may be ‘failing to function’ in the fact that they are risking their lives, and in another context, their actions could be construed as pathological, but within the context of being a firefighter said risks are not at odds with adequate functioning. Deviation from ideal mental health: defines abnormality by determining if the behavior the individual is displaying is affecting their mental well-being. As with the failure to function definition, the boundaries that stipulate what 'ideal mental health' is are not clearly defined. A frequent problem with the definition is that all individuals at some point in their life deviate from ideal mental health, but it does not mean the behavior is abnormal. For example, someone who has lost a relative is distressed and deviates from "ideal mental health" for a time, but their distress is not defined as abnormal, as distress is an expected reaction. A common approach to defining abnormality is a multi-criteria approach, where all definitions of abnormality are used to determine whether an individual's behavior is abnormal. For example, psychologists would be prepared to define an individual's behavior as "abnormal" if the following criteria are met: The individual is engaging in behavior that is preventing them from functioning. The individual is engaging in behavior that breaks a social norm. The individual is engaging in behavior that is statistically infrequent. A good example of an abnormal behavior assessed by a multi-criteria approach is depression: it is commonly seen as a deviation from ideal mental stability, it often stops the individual from 'functioning' in normal life, and, although it is a relatively common mental disorder, it is still statistically infrequent. Most people do not experience significant major depressive disorder in their lifetime. Thus, depression and its associated behaviors would be considered abnormal. See also Anti-social behaviour Deviance Dysfunctional family Eccentricity (behavior) List of abnormal behaviors in animals Norm (social) Normalization (sociology) Psychopathy Social alienation Notes and references Problem behavior Deviance (sociology)

National Alliance on Mental Illness

The National Alliance on Mental Illness (NAMI) is a United States–based nonprofit organization originally founded as a grassroots group by family members of people diagnosed with mental illness. NAMI identifies its mission as "providing advocacy, education, support and public awareness so that all individuals and families affected by mental illness can build better lives" and its vision as "a world where all people affected by mental illness live healthy, fulfilling lives supported by a community that cares". NAMI offers classes and trainings for people living with mental illnesses, their families, community members, and professionals, including what is termed psychoeducation, or education about mental illness. NAMI holds regular events which combine fundraising for the organization and education, including Mental Illness Awareness Week and NAMIWalks. Headquartered in Arlington, Virginia, NAMI has around 1,000 state and local affiliates and is represented in all 50 U.S. states, Washington, D.C., and Puerto Rico. Funding comes from individual contributions, corporate sponsorships, events, and grants. NAMI publishes a magazine around twice a year called The Advocate. NAMI also runs a HelpLine five days a week. History NAMI was founded in Madison, Wisconsin, by Harriet Shetler and Beverly Young. The two women both had sons diagnosed with schizophrenia, and "were tired of being blamed for their sons' mental illness". Unhappy with the lack of services available and the treatment of those living with mental illness, the women sought out others with similar concerns. The first meeting held to address these issues in mental health led to the formation of the National Alliance for the Mentally Ill in 1979. In 1997, the legal name was changed to the acronym NAMI by a vote of the membership due to concerns that the name National Alliance for the Mentally Ill did not use person-first language. In 2005, the meaning of NAMI was changed to the backronym National Alliance on Mental Illness. Mission NAMI identifies its mission as to promote recovery by preserving and strengthening family relationships "affected by mental illness". NAMI's programs and services include education, support groups, informational publications, and presentations. Although originally focused primarily on family members, in more recent years NAMI has moved toward trying to include people diagnosed with mental illness as well (although activists have criticized these efforts). In addition, NAMI has a strong focus on discriminatory attitudes and behaviors about mental illness (what they term stigma); another identified goal is "to increase public and professional understanding", and "to improve the mental health system". Structure The National Alliance on Mental Illness is a 501(c)(3) nonprofit run by a board of directors who are elected by membership. NAMI National is the umbrella organization; state and local affiliates operate semi-independently, in an attempt to more accurately represent those in the surrounding communities. Since 2020, NAMI has been using a five-year strategic plan. The current chief executive officer is Daniel H. Gillison, Jr., who prior to NAMI led the American Psychiatric Association Foundation (APAF), the nonprofit arm of American Psychiatric Association. The national chief executive officer from 2014 to 2019 was Mary Giliberti, who resigned on April 24, 2019. Gilberti has a law degree from Yale University and clerked for Judge Phyllis A. Kravitch. Before coming to NAMI, Giliberti worked as a senior attorney at Bazelon Center for Mental Health Law for almost ten years and the Senate Health, Education, Labor, and Pensions Committee from 2008 to 2014. She worked for NAMI National during this time as the director of public policy and advocacy for federal and state issues. In 2017, she was "appointed by the Secretary of the U.S. Department of Health and Human Service (HHS) to serve as one of 14 non-federal members of HHS’ Interdepartmental Serious Mental Illness Coordinating Committee." National and state NAMI organizations function to provide Governance, Public Education, Political Advocacy, and management of NAMI's Educational Programs. At the local level, local NAMI chapters also provide assistance in obtaining mental health resources, scheduling and administration of NAMI's programs, and hosting local meetings and events for NAMI members. In February 2020, NAMI Sioux Falls merged with the South Dakota Office. The move was a result of a decision by the national NAMI office. Partnerships Celebrities NAMI has partnered with a number of celebrities and influencers, including: CEO Alliance for Mental Health Beginning in 2020, NAMI CEO Daniel Gillison, Jr. has assembled a coalition of leaders of national mental health organizations to "chart a new course" for the country's care system. The coalition includes representatives from the American Foundation for Suicide Prevention, American Psychiatric Association, American Psychological Association, Massachusetts Association of Mental Health, Meadows Mental Health Policy Institute, Mental Health America, National Association for Behavioral Healthcare, National Council for Mental Wellbeing, and Treatment Advocacy Center, among others. Community partners NAMI works with non-partisan VoteRiders to spread state-specific information on voter ID requirements. Additional partners include: Alpha Kappa Alpha Counter Logic Gaming Fox Sports HOSA-Future Health Professionals Instagram Jack and Jill of America The Jed Foundation Lokai Stanley Center for Psychiatric Research at Broad Institute Tumblr Women's Health Philosophy and positions NAMI generally endorses a medical model approach to mental illnesses, and previously was a major proponent of terming them "serious brain disorders" during the "decade of the brain". NAMI endorses the term anosognosia, or "that someone is unaware of their own mental health condition or that they can’t perceive their condition accurately". While NAMI previously referred to mental illnesses as "serious brain disorders", current advice on their "How we talk about NAMI" page recommends against this language. Advocacy NAMI advocates to improve the lives of people affected by mental health conditions. Their policy priorities include improving healthcare, crisis response, and stopping discrimination and harmful practices. Programs NAMI programs are generally in the area of support and education for individuals and families, often for no cost. The programs are set up through local NAMI Affiliate organizations, with different programs varying in their targeted audience. NAMI Family-to-Family The NAMI Family-to-Family Education Program is a free eight-week course targeted toward family and friends of individuals with mental illness, providing education from a medical model perspective of mental illness. Originally offered as a twelve-week program, but updated to a shorter model in 2020, the courses are taught by a NAMI-trained family member of a person diagnosed with a psychiatric disorder. Family-to-Family is taught in 44 states, and two provinces in Canada. The program was developed by clinical psychologist Joyce Burland. Facilitators are required to teach material from the curriculum without alteration. Purpose The Family-to-Family program provides general information about mental illness and how it is currently treated from a medical model perspective. The programs cover mental illnesses including schizophrenia, depression, bipolar disorder, etc., as well as the indications and side effects of medications. Family-to-Family takes a biologically-based approach to explaining mental illness and its treatments. According to the NAMI website, Family-to-Family program states its goals as teaching coping and advocacy skills, providing mutual support, how to "handle a crisis", "information on mental health conditions and how they affect the brain", and locating resources in the community Evidence Base The NAMI Family-to-Family program has initial research evidence; one randomized clinical trial showed gains in empowerment, increases in problem solving and reductions in participant anxiety scores following the class; these changes persisted at 6 month follow up. These studies confirm an earlier finding that Family-to-Family graduates describe a permanent transformation in the understanding and engagement with mental illness in themselves and their family. Because a randomized controlled trial is at risk of poor external validity by mechanism of self-selection, Dixon and colleges sought out to strengthen the evidence base by confirming the benefits attributed to Family-to-Family with a subset of individuals who declined participation during initial studies The NAMI Family-to-Family program was found to increase self efficacy in family members involved in caring for a family member with schizophrenia while reducing subjective burden and need for information. In light of recent research, Family-to-Family was added to the SAMHSA National Registry of Evidence-Based Programs and Practices (NREPP), although as of January 2018 this database and designation has been eliminated by SAMHSA. NAMI Peer-to-Peer The NAMI Peer-to-Peer is an eight-week educational program aimed at adults diagnosed with a mental illness. The NAMI Peer-to-Peer program describes the course as a holistic approach to recovery through lectures, discussions, interactive exercises, and teaching stress management techniques. The program provides information about biological explanations of mental illness, symptoms, and personal experiences. The program also includes information about interacting with healthcare providers as well as decision making and stress reducing skills. The Peer-to-Peer philosophy is advertised as being centered around certain values such as individuality, autonomy, and unconditional positive regard. The program is also available in Spanish Preliminary studies have suggested Peer-to-Peer provided many of its purported benefits (e.g. self-empowerment, disorder management, confidence). Peer interventions in general have been studied more extensively, having been found to increase social adjustment NAMI In Our Own Voice The NAMI In Our Own Voice (IOOV) program started as a mental health consumer education program for people living with schizophrenia in 1996, and was further developed to IOOV with grant funding from Eli Lily & Co. in 2002. The program was based on the idea that those successfully living with mental illness were experts in a sense, and sharing their stories would benefit those with similar struggles. The program approached this by relaying the idea that recovery is possible, attempting to build confidence and self-esteem. Because of the initial success of the program and positive reception, IOOV also took on the role of public advocacy. NAMI In Our Own Voice involves two trained speakers presenting personal experiences related to mental illness, in front of an audience. Unlike the majority of NAMI's programs, IOOV consists of a single presentation educating groups of individuals with the acknowledgement many are likely unfamiliar with mental illness. The program's aims include raising awareness regarding NAMI and mental illness in general, addressing stigma, and empowering those affected by mental illness. Other than those directly affected by mental illness, In Our Own Voice often educates groups of individuals like law enforcement, politicians, and students. In Our Own Voice has been shown to be superior at reducing self stigmatization of families when compared to clinician led education. Research into the effectiveness of the NAMI In Our Own Voice program has shown the program also can be of benefit to Graduate level therapists and adolescents. A 2016 study evaluating IOOV in California found significant reductions in desire for social distancing after attending an IOOV presentation, although no validated measures were used in the evaluation. NAMI Basics The NAMI Basics Program is a six-session course for parents or other primary caregivers of children and adolescents living with mental illness. NAMI Basics is conceptually similar to NAMI Family-to-Family in that it aims to educate families, but recognizes providing care for a child living with mental illness presents unique challenges in parenting, and that mental illness in children typically manifest differently than in adults. Because of the development of the brain and nervous system throughout childhood and adolescence, information regarding mental illness biology and its presentation is fundamentally different from with adults. The NAMI Basics program has a relatively short time course to accommodate parents' difficulty in attending because of their caregiver status. NAMI Connection The NAMI Connection Recovery Support Group Program is a weekly support group for adults living with mental illness. The program is for adults 18+ diagnosed with mental illness and groups are usually weekly for 90 minutes. The support groups are led by trained facilitators who identify as having experienced mental illness themselves. NAMI On Campus NAMI On Campus is an initiative for university students to start NAMI On Campus organizations within their respective universities. NAMI On Campus was started to address the mental health issues of college-aged students. Adolescence and early adulthood are periods where the onset of mental illness is common, with 75 percent of mental illnesses beginning by age 24. When asked what barriers, if any, prevented them from gaining support and treatment, surveys found stigma to be the number one barrier. Ending the Silence This 50-minute or one hour program is available for students, school staff, and family members. It involves two presenters: one who shares educational information and one who is a young adult living well in recovery who shares their personal story. This program has been shown to improve the mental health knowledge of middle- and high school students. In 2017, Former Second Lady of the United States Tipper Gore gave a $1 million donation to the Ending the Silence program. Funding NAMI receives funding from both private and public sources, including corporations, federal agencies, foundations and individuals. NAMI maintains that it is committed to avoiding conflicts of interest and does not endorse nor support any specific service or treatment. Records of NAMI's quarterly grants and contributions since 2009 are freely available on its website. In 2017, NAMI had a 16% increase in overall revenue. Corporate sponsors NAMI's current and recent corporate sponsors include: NAMIWalks The 2017 annual report noted "$11.3 million raised across the country by 68,000 participants." COVID-19 Mental Health Support Fund NAMI launched the COVID-19 Mental Health Support Fund in response to the COVID-19 pandemic. The fund received donations from its corporate partners as well as the Center for Disaster Philanthropy, Hearst Foundation, Johnson & Johnson, Kind, LivaNova, Starbucks and Thrive Global. NAMI also launched the Frontline Wellness program to support healthcare workers, funded by the American College of Emergency Physicians, Harvard T.H. Chan School of Public Health, and various corporations. Criticism The funding of NAMI by multiple pharmaceutical companies was reported by the investigative magazine Mother Jones in 1999, including that an Eli Lilly and Company executive was then "on loan" to NAMI working out of NAMI headquarters. During a 2009 investigation into the drug industry's influence on the practice of medicine, U.S. Senator Chuck Grassley (R-IA) sent letters to NAMI and about a dozen other influential disease and patient advocacy organizations asking about their ties to drug and device makers. The investigation confirmed pharmaceutical companies provided a majority of NAMI's funding, a finding which led to NAMI releasing documents listing donations over $5,000. Dr. Peter Breggin, a leader of the anti-psychiatry movement and opponent of COVID-19 lockdowns, refers to NAMI as an "AstroTurf lobbying organization" of the "psychopharmaceutical complex." See also Biological Psychiatry Cole Resource Center Psychiatric survivors movement Self-help groups for mental health Treatment Advocacy Center Moon Knight - episodes' end credits end with disclaimers relating to NAMI. References External links NAMI.org - Official NAMI website Mental health support groups 1979 establishments in the United States Health and disability rights organizations in the United States Mental health organizations based in Virginia Organizations established in 1979 501(c)(3) organizations

Rosenhan experiment

The Rosenhan experiment or Thud experiment was an experiment regarding the validity of psychiatric diagnosis. For the experiment, participants submitted themselves for evaluation at various psychiatric institutions and feigned hallucinations in order to be accepted, but acted normally from then onward. Each was diagnosed with a psychiatric disorder and given antipsychotic medication. The study was arranged by psychologist David Rosenhan, a Stanford University professor, and published by the journal Science in 1973 with the title On Being Sane In Insane Places. It is considered an important and influential criticism of psychiatric diagnosis, and broached the topic of wrongful involuntary commitment. The experiment is said to have "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible". Rosenhan claimed that he, along with eight other people (five men and three women), entered 12 hospitals in five states near the west coast of the US. Three of the participants were admitted for only a brief period of time, and in order to obtain sufficient documented experiences, they re-applied to additional institutions. Respondents defended psychiatry against the experiment's conclusions, saying that as psychiatric diagnosis relies largely on the patient's report of their experiences, faking their presence no more demonstrates problems with psychiatric diagnosis than lying about other medical symptoms. It has been alleged that at least part of the published results were distorted or falsified. Pseudopatient experiment While listening to a lecture by Ronald D. Laing, a psychiatrist associated with anti-psychiatry claims, Rosenhan conceived of the experiment as a way to test the reliability of psychiatric diagnoses. The study concluded "it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals" and also illustrated the dangers of dehumanization and suggestion in psychiatric institutions. It suggested that the use of community mental health facilities which concentrated on specific problems and behaviors rather than psychiatric terminology might be a solution, and recommended education to make psychiatric workers more aware of the social psychology of their facilities. Rosenhan himself and seven mentally healthy associates, termed "pseudopatients", attempted to gain admission to psychiatric hospitals by telephoning for an appointment and feigning auditory hallucinations. The hospital staff were not informed of the experiment. The pseudopatients included a psychology graduate student aged in his twenties, three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife. None had a history of mental illness. Pseudopatients used pseudonyms, and those who were mental health professionals were given false jobs in a different sector to avoid invoking any special treatment or scrutiny. Apart from giving false names and employment details, further biographical details were reported truthfully. During their initial psychiatric assessment, the pseudopatients claimed to be hearing voices of the same sex as the patient which were often unclear, but which seemed to pronounce the words "empty", "hollow", or "thud", and nothing else. These words were chosen as they vaguely suggest some sort of existential crisis and for the lack of any published literature referencing them as psychotic symptoms. No other psychiatric symptoms were claimed according to Rosenhan's publication, but medical records have indicated that, at least in the case of one pseudopatient, more were shared to the hospital such as not being able to sleep, feeling cold all over, being unable to work for six months, being sensitive to radio signals, having suicidal thoughts, etc. Grimacing and twitching were also observed by the doctor who examined one of the pseudopatients. If admitted, the pseudopatients were instructed to "act normally", reporting that they felt fine and no longer heard voices. Hospital records obtained after the experiment indicate that all pseudopatients were characterized as friendly and cooperative by staff. All were admitted, to 12 psychiatric hospitals across the United States, including underfunded public hospitals in rural areas, urban university-run hospitals with excellent reputations, and one expensive private hospital. Though presented with identical symptoms, seven were diagnosed with schizophrenia at public hospitals, and one with manic-depressive psychosis, a more optimistic diagnosis with better clinical outcomes, at the private hospital. Their stays ranged from 7 to 52 days, and the average was 19 days. All but one were discharged with a diagnosis of schizophrenia "in remission", which Rosenhan considered as evidence that mental illness is perceived as an irreversible condition creating a lifelong stigma rather than a curable illness. Despite openly and frequently taking extensive notes on the behavior of the staff and other patients, none of the pseudopatients were identified as impostors by the hospital staff, although many of the other psychiatric patients seemed to be able to correctly identify them as impostors. In the first three hospitalizations, 35 of the total of 118 patients expressed a suspicion that the pseudopatients were sane, with some suggesting that the patients were researchers or journalists investigating the hospital. Hospital notes indicated that staff interpreted much of the pseudopatients' behavior in terms of mental illness. For example, one nurse labeled the note-taking of one pseudopatient as "writing behavior" and considered it pathological. The patients' normal biographies were described in hospital records consistent with what was expected of schizophrenics by the then-dominant theories of its cause. The experiment required the pseudopatients to get out of the hospital on their own by getting the hospital to release them, though a lawyer was retained to be on call for emergencies when it became clear that the pseudopatients would not ever be voluntarily released on short notice. Once admitted and diagnosed, the pseudopatients were not able to obtain their release until they agreed with the psychiatrists that they were mentally ill and began taking antipsychotic medications, which they flushed down a toilet. No staff member reported that the pseudopatients were flushing their medication down the toilets. Rosenhan and the other pseudopatients reported an overwhelming sense of dehumanization, severe invasion of privacy, and boredom while hospitalized. Their possessions were searched randomly, and they were sometimes observed while using the toilet. They reported that though the staff seemed to be well-meaning, they generally objectified and dehumanized the patients, often discussing patients at length in their presence as though they were not there, and avoiding direct interaction with patients except as strictly necessary to perform official duties. Some attendants were prone to verbal and physical abuse of patients when other staff were not present. A group of patients waiting outside the cafeteria half an hour before lunchtime were said by a doctor to his students to be experiencing "oral-acquisitive" psychiatric symptoms. Contact with doctors averaged 6.8 minutes per day. Non-existent impostor experiment For this experiment, Rosenhan used a well-known research and teaching hospital, the staff of which had learned of the results of the initial study but claimed that similar errors could not be made at their institution. Rosenhan arranged with them that during a three-month period, one or more pseudopatients would attempt to gain admission and the staff would rate every incoming patient as to the likelihood they were an impostor. Of 193 patients, 41 were considered to be impostors and a further 42 were considered suspect. In reality, Rosenhan had sent no pseudopatients; all patients suspected as impostors by the hospital staff were ordinary patients. This resulted in a conclusion that "any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one". Impact Rosenhan published his findings in Science, in which he criticized the reliability of psychiatric diagnosis and the disempowering and demeaning nature of patient care experienced by the associates during the study. Additionally, he described his work in a variety of news appearances, including to the BBC: The experiment is said to have "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible". Criticisms Many respondents to the publication defended psychiatry, saying that as psychiatric diagnosis relies largely on the patient's report of their experiences, faking their presence no more demonstrates problems with psychiatric diagnosis than lying about other medical symptoms. In this vein, psychiatrist Robert Spitzer quoted Seymour S. Kety in a 1975 criticism of Rosenhan's study: If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition. Kety also said that psychiatrists should not necessarily be expected to assume that a patient is pretending to have mental illness, thus the study lacked realism. Instead of considering realistic problems in diagnosis, such as comorbidity or differential diagnosis between disorders with similar symptoms, Rosenhan dismissed the criticism as further examples of the "experimenter effect" or "expectation bias," and evidence for his interpretation that he had discovered genuine problems of diagnosis rather than being fooled by his method. Accusation of fraud In The Great Pretender, a 2019 book on Rosenhan, author Susannah Cahalan questions the veracity and validity of the Rosenhan experiment. Examining documents left by Rosenhan after his death, Cahalan finds apparent distortion in the Science article: inconsistent data, misleading descriptions, and inaccurate or fabricated quotations from psychiatric records. Moreover, despite an extensive search, she is only able to identify two of the eight pseudopatients: Rosenhan himself, and a graduate student whose testimony is allegedly inconsistent with Rosenhan's description in the article. Due to Rosenhan's seeming willingness to alter the truth in other ways regarding the experiment, Cahalan questions whether some or all of the six other pseudopatients might have been simply invented by Rosenhan. In February 2023, Andrew Scull of the University of California at San Diego published an article in the peer-reviewed journal History of Psychiatry in support of Cahalan's allegations. Related experiments In 1887 American investigative journalist Nellie Bly feigned symptoms of mental illness to gain admission to a lunatic asylum and report on the terrible conditions therein. The results were published as Ten Days in a Mad-House. In 1968 Maurice K. Temerlin split 25 psychiatrists into two groups and had them listen to an actor portraying a character of normal mental health. One group was told that the actor "was a very interesting man because he looked neurotic, but actually was quite psychotic" while the other was told nothing. Sixty percent of the former group diagnosed psychoses, most often schizophrenia, while none of the control group did so. In 1988, Loring and Powell gave 290 psychiatrists a transcript of a patient interview and told half of them that the patient was black and the other half white; they concluded of the results that "clinicians appear to ascribe violence, suspiciousness, and dangerousness to black clients even though the case studies are the same as the case studies for the white clients." In 2004, psychologist Lauren Slater claimed to have performed an experiment very similar to Rosenhan's for her book Opening Skinner's Box. Slater wrote that she had presented herself at 9 psychiatric emergency rooms with auditory hallucinations, resulting in being diagnosed "almost every time" with psychotic depression. However, when challenged to provide evidence of actually performing her experiment, she could not. The serious methodological and other concerns regarding Slater's work appeared as a series of responses to a journal report, in the same journal. In 2008, the BBC's science television series Horizon performed a similar experiment for two episodes entitled "How Mad Are You?". The experiment involved ten subjects, five with previously diagnosed mental health conditions, and five with no such diagnosis. They were observed by three experts in mental health diagnoses and their challenge was to identify the five with mental health problems solely from their behavior, without speaking to the subjects or learning anything of their histories. The experts correctly diagnosed two of the ten patients, misdiagnosed one patient, and incorrectly identified two healthy patients as having mental health problems. Unlike the other experiments listed here, however, the purpose of this journalistic exercise was not to criticize the diagnostic process, but to minimize the stigmatization of the mentally ill. It was intended to show that people with a previous diagnosis of a mental illness could live normal lives with their health problems not obvious to observers from their behavior. See also Psychiatric hospital § Undercover journalism References Notes Rosenhan DL. The contextual nature of psychiatric diagnosis. J Abnorm Psychol. 1975;84:462–74 External links On being sane in insane places. . Rosenhan experiment summary BBC Radio 4, "Mind Changers", Series 4 Episode 1: The Pseudo-Patient Study 1973 in science Academic scandals Anti-psychiatry Experimental psychology History of psychology Psychiatric false diagnosis Psychology experiments Social problems in medicine

Narcissistic personality disorder

Narcissistic personality disorder (NPD) is a personality disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive need for admiration, and a diminished ability to empathize with other people's feelings. Narcissistic personality disorder is one of the sub-types of the broader category known as personality disorders. It is often comorbid with other mental disorders and associated with significant functional impairment and psychosocial disability. Personality disorders are a class of mental disorders characterized by enduring and inflexible maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by any culture. These patterns develop by early adulthood, and are associated with significant distress or impairment. Criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). There is no standard treatment for NPD. Its high comorbidity with other mental disorders influences treatment choice and outcomes. Psychotherapeutic treatments generally fall into two categories: psychoanalytic/psychodynamic and cognitive behavioral therapy, with growing support for integration of both in therapy. However, there is an almost complete lack of studies determining the effectiveness of treatments. One's subjective experience of the mental disorder, as well as their agreement to and level of engagement with treatment, are highly dependent on their motivation to change. Signs and symptoms Despite outward signs of grandiosity, many people with NPD struggle with symptoms of intense shame, worthlessness, low self-compassion, and self-loathing. Their view of themselves is extremely malleable and dependent on others' opinions of them. They are also hypersensitive to criticism and possess an intense need for admiration. People with NPD gain self-worth and meaning through this admiration. Individuals with NPD are often motivated to achieve their goals, status, improvement, and perfectionism, and to ignore relationships or avoid situations due to fears of incompetence, failure, worthlessness, inferiority, shame, humiliation, and losing control. People with NPD will try to gain social status and approval in an attempt to avoid and combat these feelings, often by exaggerating their skills, accomplishments, and their degree of intimacy with people they consider high-status. Alongside this, they may have difficulty accepting help, vengeful fantasies, a sense of entitlement, and they may feign humility. They are more likely to try forms of plastic surgery due to a desire to gain attention and to be seen as beautiful. A sense of personal superiority may lead them to monopolize conversations, look down on others or to become impatient and disdainful when other persons talk about themselves. Drastic shifts in levels of self-esteem can result in a significantly decreased ability to regulate emotions. Patients with NPD have an impaired ability to recognize facial expressions or mimic emotions, as well as a lower capacity for emotional empathy and emotional intelligence. However they do not display a compromised capacity for cognitive empathy or an impaired theory of mind, which are the abilities to understand others' feelings and attribute mental states to oneself or others respectively. They may also have difficulty relating to others’ experiences and being emotionally vulnerable. People with NPD are less likely to engage in prosocial behavior. They can still act in selfless ways to improve others' perceptions of them, advance their social status, or if explicitly told to. Despite these characteristics, they are more likely to overestimate their capacity for empathy. It is common for people with NPD to have difficult relationships. Narcissists may disrespect others' boundaries or idealize and devalue them. They commonly keep people emotionally distant, and project, deny, or split. Narcissists respond with anger and hostility towards rejection, and can degrade, insult, or blame others who disagree with them. They generally lack self-awareness, and will have a difficult time understanding their own traits and narcissistic tendencies, either due to a belief that NPD characteristics do not apply to them, or due to a refusal to accept or endorse negative characteristics in an attempt to maintain a positive self image. Narcissists can have difficulty seeing multiple perspectives on issues and might engage in black and white thinking. Despite this, people with NPD will often feel as they are skilled at accurately assessing others' feelings. Problematic social media use Diagnosis The DSM-5 indicates that: "Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting, and cause significant functional impairment or subjective distress, do they constitute narcissistic personality disorder." Given the high-function sociability associated with narcissism, some people with NPD might not view such a diagnosis as a functional impairment to their lives. Although overconfidence tends to make people with NPD very ambitious, such a mindset does not necessarily lead to professional high achievement and success, because they refuse to take risks, in order to avoid failure or the appearance of failure. Moreover, the psychological inability to tolerate disagreement, contradiction, and criticism, makes it difficult for persons with NPD to work cooperatively or to maintain long-term relationships. DSM-5 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes NPD as possessing at least five of the following nine criteria. A grandiose sense of self-importance (exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love Believing that they are "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) Requiring excessive admiration A sense of entitlement (unreasonable expectations of especially favorable treatment or automatic compliance with their expectations) Being interpersonally exploitative (taking advantage of others to achieve their own ends) Lacking empathy (unwilling to recognize or identify with the feelings and needs of others) Often being envious of others or believing that others are envious of them Showing arrogant, haughty behaviors or attitudes Within the DSM-5, NPD is a cluster B personality disorder. Individuals with cluster B personality disorders often appear dramatic, emotional, or erratic. Narcissistic personality disorder is a mental disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive craving for admiration, and a diminished ability to empathize with others' feelings. A diagnosis of NPD, like other personality disorders, is made by a qualified healthcare professional in a clinical interview. In the narcissistic personality disorder, there is a fragile sense of self that becomes a view of oneself as exceptional. Narcissistic personality disorder usually develops either in youth or in early adulthood. True symptoms of NPD are pervasive, are apparent in varied social situations, and are rigidly consistent over time. Severe symptoms of NPD can significantly impair the person's mental capabilities to develop meaningful human relationships, such as friendship, kinship, and marriage. Generally, the symptoms of NPD also impair the person's psychological abilities to function socially, either at work or at school, or within important societal settings. The DSM-5 indicates that, in order to qualify as symptomatic of NPD, the person's manifested personality traits must substantially differ from social norms. ICD-11 and ICD-10 In the International Statistical Classification of Diseases and Related Health Problems, 11th Edition ICD-11 of the World Health Organization (WHO), all personality disorders are diagnosed under a single title called "personality disorder". The criteria for diagnosis are mainly concerned with assessing dysfunction, distress and maladaptive behavior. Once a diagnosis has been made, the clinician then can draw upon five trait domains to describe the particular causes of dysfunction, as these have major implications for potential treatments. NPD, as it currently conceptualised, would correspond more or less entirely to the ICD-11 trait of Dissociality, which includes self-centredness (grandiosity, attention-seeking, entitlement and egocentricity) and lack of empathy (callousness, ruthlessness, manipulativeness, interpersonal exploitativeness, and hostility). In the previous edition, the ICD-10, narcissistic personality disorder (NPD) is listed under the category of "other specific personality disorders", meaning the ICD-10 required that cases otherwise described as NPD in the DSM-5 would only need to meet a general set of diagnostic criteria. Differential diagnosis The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders. People with a fragile variant of NPD (see Subtypes) are prone to bouts of psychological depression, often to the degree that meets the clinical criteria for a co-occurring depressive disorder. NPD is associated with the occurrence of bipolar disorder and substance use disorders, especially cocaine use disorder. NPD may also be comorbid or differentiated with the occurrence of other mental disorders, including histrionic personality disorder, borderline personality disorder, antisocial personality disorder, or paranoid personality disorder. NPD should also be differentiated from mania and hypomania as these cases can also present with grandiosity, but present with different levels of functional impairment. It is common for children and adolescents to display personality traits that resemble NPD, but such occurrences are usually transient, and register below the clinical criteria for a formal diagnosis of NPD. Subtypes Although the DSM-5 diagnostic criteria for NPD has been viewed as homogeneous, there are a variety of subtypes used for classification of NPD. There is poor consensus on how many subtypes exist, but there is broad acceptance that there are at least two: grandiose or overt narcissism, and vulnerable or covert narcissism. However, none of the subtypes of NPD are recognized in the DSM-5 or in the ICD-11. Empirically verified subtypes Some research has indicated the existence of three subtypes of NPD, which can be distinguished by symptom criteria, comorbidity and other clinical criteria. These are as follows: Grandiose/Overt: the group exhibits grandiosity, entitlement, interpersonal exploitativeness and manipulation, pursuit of power and control, lack of empathy and remorse, and marked irritability and hostility. This group was noted for high levels of comorbid antisocial and paranoid personality disorders, substance abuse, externalizing, unemployment and greater likelihood of violence. Of note, Russ et al. observed that this group "do not appear to suffer from underlying feelings of inadequacy or to be prone to negative affect states other than anger", an observation corroborated by recent research which found this variant to show strong inverse associations with depressive, anxious-avoidant, and dependant/victimised features. Vulnerable/Covert: this variant is defined by feelings of shame, envy, resentment, and inferiority (which is occasionally "masked" by arrogance), entitlement, a belief that one is misunderstood or unappreciated, and excessive reactivity to slights or criticism. This variant is associated with elevated levels of neuroticism, psychological distress, depression, and anxiety. In fact, recent research suggests that vulnerable narcissism is mostly the product of dysfunctional levels of neuroticism. Vulnerable narcissism is sometimes comorbid with diagnoses of avoidant, borderline and dependent personality disorders. High-functioning/Exhibitionistic: A third subtype for classifying people with NPD, initially theorized by psychiatrist Glen Gabbard, is termed high functioning or exhibitionistic. This variant has been described as "high functioning narcissists [who] were grandiose, competitive, attention-seeking, and sexually provocative; they tended to show adaptive functioning and utilize their narcissistic traits to succeed." This group has been found to have relatively few psychological issues and high rates of obsessive-compulsive personality disorder, with excessive perfectionism posited as a potential cause for their impairment. Others Oblivious/Hypervigilant: Glen Gabbard described two subtypes of NPD in 1989, later referred to as equivalent to, the grandiose and vulnerable subtypes. The first was the "oblivious" subtype of narcissist, equivalent to the grandiose subtype. This group was described as being grandiose, arrogant and thick-skinned, while also exhibiting personality traits of helplessness and emotional emptiness, low self-esteem and shame. These were observed in people with NPD to be expressed as socially avoidant behavior in situations where self-presentation is difficult or impossible, leading to withdrawal from situations where social approval is not given. The second subtype Gabbard described was termed "hypervigilant", equivalent to the vulnerable subtype. People with this subtype of NPD were described as having easily hurt feelings, an oversensitive temperament, and persistent feelings of shame. Communal narcissism: A fourth type is the communal narcissist. Communal narcissism is a form of narcissism that occurs in group settings. It is characterized by an inflated sense of importance and a need for admiration from others. In relation to the grandiose narcissist, a communal narcissist is arrogant and self-motivating, and shares the sense of entitlement and grandiosity. However, the communal narcissist seeks power and admiration in the communal realm. They see themselves as altruistic, saintly, caring, helpful, and warm. Individuals who display communal narcissism often seek out positions of power and influence within their groups. Millon's subtypes In the study Disorders of Personality: DSM-IV-TM and Beyond (1996), Theodore Millon suggested five subtypes of NPD, although they did not identify specific treatments per subtype. Masterson's subtypes (exhibitionist and closet) In 1993, James F. Masterson proposed two subtypes for pathological narcissism, exhibitionist and closet. Both fail to adequately develop an age- and phase- appropriate self because of defects in the quality of psychological nurturing provided, usually by the mother. A person with exhibitionist narcissism is similar to NPD described in the DSM-IV and differs from closet narcissism in several ways. A person with closet narcissism is more likely to be described as having a deflated, inadequate self-perception and greater awareness of emptiness within. A person with exhibitionist narcissism would be described as having an inflated, grandiose self-perception with little or no conscious awareness of feelings of emptiness. Such a person would assume that their condition was normal and that others were just like them. A person with closet narcissism is described to seek constant approval from others and appears similar to those with borderline personality disorder in the need to please others. A person with exhibitionist narcissism seeks perfect admiration all the time from others. Malignant narcissism Malignant narcissism, a term first coined in Erich Fromm's 1964 book The Heart of Man: Its Genius for Good and Evil, is a syndrome consisting of a combination of NPD, antisocial personality disorder, and paranoid traits. A person with malignant narcissism was described as deriving higher levels of psychological gratification from accomplishments over time, suspected to worsen the disorder. Because a person with malignant narcissism becomes more involved in psychological gratification, it was suspected to be a risk factor for developing antisocial, paranoid, and schizoid personality disorders. The term malignant is added to the term narcissist to indicate that individuals with this disorder have a severe form of narcissistic disorder that is characterized also by features of paranoia, psychopathy (anti-social behaviors), aggression, and sadism. Historical demarcation of grandiose and vulnerable types Over the years, many clinicians and theorists have described two variants of NPD akin to the grandiose and vulnerable expressions of trait narcissism. Some examples include: Assessment and screening Narcissistic Personality Inventory Risk factors for NPD and grandiose/overt and vulnerable/covert subtypes are measured using the narcissistic personality inventory, an assessment tool originally developed in 1979, which has undergone multiple iterations with new versions in 1984, 2006 and 2014. It captures principally grandiose narcissism, but also seems to capture elements of vulnerability. A popular three-factor model has it that grandiose narcissism is assessed via the Leadership/Authority and Grandiose/Exhibitionism facets, while a combination of grandiose and vulnerable traits are indexed by the Entitlement/Exploitativeness facet. Pathological Narcissism Inventory The Pathological Narcissism Inventory (PNI) was designed to measure fluctuations in grandiose and vulnerable narcissistic states, similar to what is ostensibly observed by some clinicians (though empirical demonstration of this phenomenon is lacking). While having both "grandiosity" and vulnerability scales, empirically both seem to primarily capture vulnerable narcissism. The PNI scales show significant associations with parasuicidal behavior, suicide attempts, homicidal ideation, and several aspects of psychotherapy utilization. Five-Factor Narcissism Inventory In 2013, the Five-Factor Narcissism Inventory (FFNI) was defined as a comprehensive assay of grandiose and vulnerable expressions of trait narcissism. The scale measures 11 traits of grandiose narcissism and 4 traits of vulnerable narcissism, both of which correlate with clinical ratings of NPD (with grandiose features of arrogance, grandiose fantasies, manipulativeness, entitlement and exploitativeness showing stronger relations). Later analysis revealed that the FFNI actually measures three factors: Agentic Extraversion: an exaggerated sense of self-importance, grandiose fantasies, striving for greatness and acclaim, social dominance and authoritativeness, and exhibitionistic, charming interpersonal conduct. Self-Centred Antagonism: disdain for others, psychological entitlement, interpersonally exploitative and manipulative behaviour, lack of empathy, anger in response to criticism or rebuke, suspiciousness, and thrill-seeking. Narcissistic Neuroticism: shame-proneness, oversensitivity and negative emotionality to criticism and rebuke, and excessive need for admiration to maintain self-esteem. Grandiose narcissism is a combination of agency and antagonism, and vulnerability is a combination of antagonism and neuroticism. The three factors show differential associations with clinically important variables. Agentic traits are associated with high self-esteem, positive view others and the future, autonomous and authentic living, commitment to personal growth, sense of purpose in life and life satisfaction. Neurotic traits show precisely the opposite correlation with all of these variables, while antagonistic traits show more complex associations; they are associated with negative view of others (but necessarily of the self), a sense of alienation from their 'true self', disinterest in personal growth, negative relationships with others, and all forms of aggression. Millon Clinical Multiaxial Inventory The Millon Clinical Multiaxial Inventory (MCMI) is another diagnostic test developed by Theodore Millon. The MCMI includes a scale for narcissism. The NPI and MCMI have been found to be well correlated. Whereas the MCMI measures narcissistic personality disorder (NPD), the NPI measures narcissism as it occurs in the general population; the MCMI is a screening tool. In other words, the NPI measures "normal" narcissism; i.e., most people who score very high on the NPI do not have NPD. Indeed, the NPI does not capture any sort of narcissism taxon as would be expected if it measured NPD. A 2020 study found that females scored significantly higher on vulnerable narcissism than males, but no gender differences were found for grandiose narcissism. Causes The cause of narcissistic personality disorder (NPD) is unclear, although there is evidence for a strong biological or genetic underpinning. Research has found NPD has a strong heritable component. It is unclear if or how much a person's upbringing contributes to the development of NPD, although many speculative theories have been proposed. Evidence to support social factors in the development of NPD is limited. Some studies have found NPD correlates with permissive and overindulgent parenting in childhood, while others have found correlations with harsh discipline, neglect or abuse. Findings have been inconsistent, and scientists do not know if these correlations are causal, as these studies do not control for genetic confounding. This problem of genetic confounding is explained by psychologist Svenn Torgersen in a 2009 review: Twin studies allow scientists to assess the influence of genes and environment, in particular, how much of the variation in a trait is attributed to the "shared environment" (influences shared by twins, such as parents and upbringing) or the "unshared environment" (measurement error, noise, differing illnesses between twins, randomness in brain growth, and social or non-social experiences that only one twin experienced). According to a 2018 review, twin studies of NPD have found little or no influence from the shared environment, and a major contribution of genes and the non-shared environment: According to neurogeneticist Kevin Mitchell, a lack of influence from the shared environment indicates that the non-shared environmental influence may be largely non-social, perhaps reflecting innate processes such as randomness in brain growth. Neuroscientists have also studied the brains of people with NPD using structural imaging technology. A 2021 review concluded the most consistent finding among NPD patients is lowered gray matter volume in the medial prefrontal cortex. Studies of the occurrence of narcissistic personality disorder identified structural abnormalities in the brains of people with NPD, specifically, a lesser volume of gray matter in the left, anterior insular cortex. The results of a 2015 study associated the condition of NPD with a reduced volume of gray matter in the prefrontal cortex. The regions of the brain identified and studied – the insular cortex and the prefrontal cortex – are associated with the human emotions of empathy and compassion, and with the mental functions of cognition and emotional regulation. The neurological findings of the studies suggest that NPD may be related to a compromised capacity for emotional empathy and emotional regulation. Evolutionary models of NPD have also been proposed. According to psychologist Marco Del Giudice, cluster B traits including NPD, predict increased mating success and fertility. NPD could potentially be an adaptive evolutionary phenomena, though a risky one that can sometimes result in social rejection and failure to reproduce. Another proposal is that NPD may result from an excess of traits which are only adaptive in moderate amounts (leadership success increases with moderate degrees of narcissism, but declines at the high end of narcissism). Research on NPD is limited, because patients are hard to recruit for study. The cause of narcissistic personality disorder requires further research. Management Treatment for NPD is primarily psychotherapeutic; there is no clear evidence that psychopharmacological treatment is effective for NPD, although it can prove useful for treating comorbid disorders. Psychotherapeutic treatment falls into two general categories: psychoanalytic/psychodynamic and cognitive behavioral. Psychoanalytic therapies include schema therapy, transference focused psychotherapy, mentalization-based treatment and metacognitive psychotherapy. Cognitive behavioral therapies include cognitive behavioral therapy and dialectal behavior therapy. Formats also include group therapy and couples therapy. The specific choice of treatment varies based on individual presentations. Management of narcissistic personality disorder has not been well studied, however many treatments tailored to NPD exist. Therapy is complicated by the lack of treatment-seeking behavior in people with NPD, despite mental distress. Additionally, people with narcissistic personality disorders have decreased life satisfaction and lower qualities of life, irrespective of diagnosis. People with NPD often present with comorbid mental disorders, complicating diagnosis and treatment. NPD is rarely the primary reason for which people seek mental health treatment. When people with NPD enter treatment (psychologic or psychiatric), they often express seeking relief from a comorbid mental disorder, including major depressive disorder, a substance use disorder (drug addiction), or bipolar disorder. Prognosis , no treatment guidelines exist for NPD and no empirical studies have been conducted on specific NPD groups to determine efficacy for psychotherapies and pharmacology. Though there is no known single cure for NPD, there are some things one can do to lessen its symptoms. Medications such as antidepressants, which treat depression, are commonly prescribed by healthcare providers; mood stabilizers to reduce mood swings and antipsychotic drugs to reduce the prevalence of psychotic episodes. The presence of NPD in patients undergoing psychotherapy for the treatment of other mental disorders is associated with slower treatment progress and higher dropout rates. In this therapy, the goals often are examining traits and behaviors that negatively affect life, identifying ways these behaviors cause distress to the person and others, exploring early experiences that contributed to narcissistic defenses, developing new coping mechanisms to replace those defenses, helping the person see themselves and others in more realistic and nuanced ways, rather than wholly good or wholly bad, identifying and practicing more helpful patterns of behavior, developing interpersonal skills, and learning to consider the needs and feelings of others. Epidemiology , overall prevalence is estimated to range from 0.8% to 6.2%. In 2008 under the DSM-IV, lifetime prevalence of NPD was estimated to be 6.2%, with 7.7% for men and 4.8% for women, with a 2015 study confirming the gender difference. In clinical settings, prevalence estimates range from 1% to 15%. The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders. History The term "narcissism" comes from a first century (written in the year 8 AD) book by the Roman poet Ovid. Metamorphoses Book III is a myth about two main characters, Narcissus and Echo. Narcissus is a handsome young man who spurns the advances of many potential lovers. When Narcissus rejects the nymph Echo, named this way because she was cursed to only echo the sounds that others made, the gods punish him by making him fall in love with his own reflection in a pool of water. When Narcissus discovers that the object of his love cannot love him back, he slowly pines away and dies. The concept of excessive selfishness has been recognized throughout history. In ancient Greece, the concept was understood as hubris. It is only since the late 1800s that narcissism has been defined in psychological terms: Havelock Ellis (1898) was the first psychologist to use the term when he linked the myth to the condition in one of his patients. Sigmund Freud (1905–1953) used the terms "narcissistic libido" in his Three Essays on the Theory of Sexuality. Ernest Jones (1913/1951) was the first to construe extreme narcissism as a character flaw. Robert Waelder (1925) published the first case study of narcissism. His patient was a successful scientist with an attitude of superiority, an obsession with fostering self-respect, and a lack of normal feelings of guilt. The patient was aloof and independent from others and had an inability to empathize with others' situations, and was selfish sexually. Waelder's patient was also overly logical and analytical and valued abstract intellectual thought (thinking for thinking's sake) over the practical application of scientific knowledge. Narcissistic personality was first described by the psychoanalyst Robert Waelder in 1925. The term narcissistic personality disorder (NPD) was coined by Heinz Kohut in 1968. Waelder's initial study has been influential in the way narcissism and the clinical disorder Narcissistic personality disorder are defined today Freudianism and psychoanalysis Much early history of narcissism and NPD originates from psychoanalysis. Regarding the adult neurotic's sense of omnipotence, Sigmund Freud said that "this belief is a frank acknowledgement of a relic of the old megalomania of infancy"; and concluded that: "we can detect an element of megalomania in most other forms of paranoic disorder. We are justified in assuming that this megalomania is essentially of an infantile nature, and that, as development proceeds, it is sacrificed to social considerations." Narcissistic injury and narcissistic scar are terms used by Freud in the 1920s. Narcissistic wound and narcissistic blow are other, almost interchangeable, terms. When wounded in the ego, either by a real or a perceived criticism, a narcissistic person's displays of anger can be disproportionate to the nature of the criticism suffered; but typically, the actions and responses of the NPD person are deliberate and calculated. Despite occasional flare-ups of personal insecurity, the inflated self-concept of the NPD person is primarily stable. In The Psychology of Gambling (1957), Edmund Bergler considered megalomania to be a normal occurrence in the psychology of a child, a condition later reactivated in adult life, if the individual takes up gambling. In The Psychoanalytic Theory of Neurosis (1946), Otto Fenichel said that people who, in their later lives, respond with denial to their own narcissistic injury usually undergo a similar regression to the megalomania of childhood. Narcissistic supply Narcissistic supply was a concept introduced by Otto Fenichel in 1938, to describe a type of admiration, interpersonal support, or sustenance drawn by an individual from his or her environment and essential to their self-esteem. The term is typically used in a negative sense, describing a pathological or excessive need for attention or admiration that does not take into account the feelings, opinions, or preferences of other people. Narcissistic rage The term narcissistic rage was a concept introduced by Heinz Kohut in 1972. Narcissistic rage was theorised as a reaction to a perceived threat to a narcissist's self-esteem or self-worth. Narcissistic rage occurs on a continuum from aloofness, to expressions of mild irritation or annoyance, to serious outbursts, including violent attacks. Narcissistic rage reactions are not necessarily limited to narcissistic personality disorder. They may also be seen in catatonic, paranoid delusion, and depressive episodes. It was later suggested that narcissistic people have two layers of rage; the first layer of rage being directed constant anger towards someone else, with the second layer being self-deprecating. Object relations In the second half of the 20th century, in contrast to Freud's perspective of megalomania as an obstacle to psychoanalysis, in the US and UK Kleinian psychologists used the object relations theory to re-evaluate megalomania as a defence mechanism. This Kleinian therapeutic approach built upon Heinz Kohut's view of narcissistic megalomania as an aspect of normal mental development, by contrast with Otto Kernberg's consideration of such grandiosity as a pathological distortion of normal psychological development. To the extent that people are pathologically narcissistic, the person with NPD can be a self-absorbed individual who passes blame by psychological projection and is intolerant of contradictory views and opinions; is apathetic towards the emotional, mental, and psychological needs of other people; and is indifferent to the negative effects of their behaviors, whilst insisting that people should see them as an ideal person. The merging of the terms "inflated self-concept" and "actual self" is evident in later research on the grandiosity component of narcissistic personality disorder, along with incorporating the defence mechanisms of idealization and devaluation and of denial. Comparison to other personality disorders NPD shares properties with borderline personality disorder, including social stigma, unclear causes and prevalence rates. In a 2020 study, it was argued that NPD is following a similar historical trend to borderline personality disorder: "In the past three decades, enormous progress has been made to elucidate the psychopathology, longitudinal course, and effective treatment for BPD. NPD, which remains as similarly stigmatized and poorly understood as BPD once was, now carries the potential for a new wave of investigation and treatment development." However, NPD also shares some commonality with the now discredited "multiple personality disorder" (MPD) personality constellation in popular culture and clinical lore. MPD received a high level of mainstream media attention the 1980s, followed by a nearly complete removal from public discourse within the following two decades; this was in part due to thorough debunking many of its propositions and the evident societal harm created by its entry into the legal defence realm. Similar to MPD, NPD has been the subject of high levels of preoccupation in social and popular media forums, without a firm empirical basis despite over a century of description in clinical lore. The NPD label may be misused colloquially and clinically to disparage a target for the purpose of buttressing one's own self-esteem, or other motives that are detrimental for the person receiving the label. Finally, the rise in popular interest in NPD is not accompanied by hypothesized increases in narcissism among recent generations, despite widespread assumptions to the contrary. Controversy The extent of controversy about narcissism was on display when the committee on personality disorders for the 5th Edition (2013) of the Diagnostic and Statistical Manual of Mental Disorders recommended the removal of Narcissistic Personality from the manual. A contentious three-year debate unfolded in the clinical community with one of the sharpest critics being John Gunderson, who led the DSM personality disorders committee for the 4th edition of the manual. The American Psychiatric Association's (APA) formulation, description, and definition of narcissistic personality disorder, as published in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed., Text Revision (DSM-IV-TR, 2000), was criticised by clinicians as inadequately describing the range and complexity of the personality disorder that is NPD. That it is excessively focused upon "the narcissistic individual's external, symptomatic, or social interpersonal patterns – at the expense of ... internal complexity and individual suffering", which reduced the clinical utility of the NPD definition in the DSM-IV-TR. In revising the diagnostic criteria for personality disorders, the work group for the list of "Personality and Personality Disorders" proposed the elimination of narcissistic personality disorder (NPD) as a distinct entry in the DSM-5, and thus replaced a categorical approach to NPD with a dimensional approach, which is based upon the severity of the dysfunctional-personality-trait domains. Clinicians critical of the DSM-5 revision characterized the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist", which is of limited usefulness in clinical practice. Despite the reintroduction of the NPD entry, the APA's re-formulation, re-description, and re-definition of NPD, towards a dimensional view based upon personality traits, remains in the list of personality disorders of the DSM-5. A 2011 study concluded that narcissism should be conceived as personality dimensions pertinent to the full range of personality disorders, rather than as a distinct diagnostic category. In a 2012 literature review about NPD, the researchers concluded that narcissistic personality disorder "shows nosological inconsistency, and that its consideration as a trait domain needed further research would be strongly beneficial to the field." In a 2018 latent structure analysis, results suggested that the DSM-5 NPD criteria fail to distinguish some aspects of narcissism relevant to diagnosis of NPD and subclinical narcissism. In popular culture Suzanne Stone-Maretto, Nicole Kidman's character in the film To Die For (1995), wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she "was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder... had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder". Jay Gatsby, the eponymous character of F. Scott Fitzgerald's novel The Great Gatsby (1925), "an archetype of self-made American men seeking to join high society", has been described by English professor Giles Mitchell as a "pathological narcissist" for whom the "ego-ideal" has become "inflated and destructive" and whose "grandiose lies, poor sense of reality, sense of entitlement, and exploitive treatment of others" conspire toward his own demise. See also Messiah complex Superiority complex References Further reading Dark triad Psychoanalytic terminology Wikipedia medicine articles ready to translate Wikipedia neurology articles ready to translate

Schizotypy

In psychology, schizotypy is a theoretical concept that posits a continuum of personality characteristics and experiences, ranging from normal dissociative, imaginative states to extreme states of mind related to psychosis, especially schizophrenia. The continuum of personality proposed in schizotypy is in contrast to a categorical view of psychosis, wherein psychosis is considered a particular (usually pathological) state of mind, which the person either has or does not have. Development of the concept The categorical view of psychosis is most associated with Emil Kraepelin, who created criteria for the medical diagnosis and classification of different forms of psychotic illness. Particularly, he made the distinction between dementia praecox (now called schizophrenia), manic depressive insanity and non-psychotic states. Modern diagnostic systems used in psychiatry (such as the DSM) maintain this categorical view. In contrast, psychiatrist Eugen Bleuler did not believe there was a clear separation between sanity and madness, believing instead that psychosis was simply an extreme expression of thoughts and behaviours that could be present to varying degrees throughout the population. The concept of psychosis as a spectrum was further developed by psychologists such as Hans Eysenck and Gordon Claridge, who sought to understand unusual variations in thought and behaviour in terms of personality theory. Eysenck conceptualised cognitive and behavioral variations as all together forming a single personality trait, psychoticism. Meehl et al. 1964 first coined the term 'schizotypy,' and through examination of unusual experiences in the general population and clustering of symptoms in individuals diagnosed with schizophrenia. The work of Claridge suggested that this personality trait was more complex than had been previously thought and could be broken down into four factors. Unusual experiences: The disposition to have unusual perceptual and other cognitive experiences, such as hallucinations, magical or superstitious belief and interpretation of events (see also delusions). This factor is also often referred to as "positive schizotypy" and "cognitive-perceptual" schizotypy Cognitive disorganization: A tendency for thoughts to become derailed, disorganised or tangential (see also formal thought disorder). This factor is also often referred to as "disorganized schizotypy" Introverted anhedonia: A tendency to introverted, emotionally flat and asocial behaviour, associated with a deficiency in the ability to feel pleasure from social and physical stimulation. This factor is also often referred to as "negative schizotypy" and "schizoidia" Impulsive nonconformity: The disposition to unstable mood and behaviour particularly with regard to rules and social conventions. The relationship between schizotypy, mental health and mental illness Although aiming to reflect some of the features present in diagnosable mental illness, schizotypy does not necessarily imply that someone who is more schizotypal than someone else is more ill. For example, certain aspects of schizotypy may be beneficial. Both the unusual experiences and cognitive disorganisation aspects have been linked to creativity and artistic achievement. Jackson proposed the concept of 'benign schizotypy' in relation to certain classes of religious experience, which he suggested might be regarded as a form of problem-solving and therefore of adaptive value. The link between positive schizotypy and certain facets of creativity is consistent with the notion of a "healthy schizotypy", which may account for the persistence of schizophrenia-related genes in the population despite their many dysfunctional aspects. The extent of schizotypy can be measured using certain diagnostic tests, such as the O-LIFE. However, the exact nature of the relationship between schizotypy and diagnosable psychotic illness is still controversial. One of the key concerns that researchers have had is that questionnaire-based measures of schizotypy, when analysed using factor analysis, do not suggest that schizotypy is a unified, homogeneous concept. The three main approaches have been labelled as 'quasi-dimensional', 'dimensional' and 'fully dimensional'. Each approach is sometimes used to imply that schizotypy reflects a cognitive or biological vulnerability to psychosis, although this may remain dormant and never express itself, unless triggered by appropriate environmental events or conditions (such as certain doses of drugs or high levels of stress). Quasi-dimensional approach The quasi-dimensional model may be traced back to Bleuler (the inventor of the term 'schizophrenia'), who commented on two types of continuity between normality and psychosis: that between the schizophrenic and his or her relatives, and that between the patient's premorbid and post-morbid personalities (i.e. their personality before and after the onset of overt psychosis). On the first score he commented: 'If one observes the relatives of our patients, one often finds in them peculiarities which are qualitatively identical with those of the patients themselves, so that the disease appears to be only a quantitative increase of the anomalies seen in the parents and siblings.' On the second point, Bleuler discusses in a number of places whether peculiarities displayed by the patient before admission to hospital should be regarded as premonitory symptoms of the disease or merely indications of a predisposition to develop it. Despite these observations of continuity Bleuler himself remained an advocate of the disease model of schizophrenia. To this end he invoked a concept of latent schizophrenia, writing: 'In [the latent] form, we can see in nuce [in a nutshell] all the symptoms and all the combinations of symptoms which are present in the manifest types of the disease.' Later advocates of the quasi-dimensional view of schizotypy are Rado and Meehl, according to both of whom schizotypal symptoms merely represent less explicitly expressed manifestations of the underlying disease process which is schizophrenia. Rado proposed the term 'schizotype' to describe the person whose genetic make-up gave him or her a lifelong predisposition to schizophrenia. The quasi-dimensional model is so called because the only dimension it postulates is that of gradations of severity or explicitness in relation to the symptoms of a disease process: namely schizophrenia. Dimensional approach The dimensional approach, influenced by personality theory, argues that full blown psychotic illness is just the most extreme end of the schizotypy spectrum and there is a natural continuum between people with low and high levels of schizotypy. This model is most closely associated with the work of Hans Eysenck, who regarded the person exhibiting the full-blown manifestations of psychosis as simply someone occupying the extreme upper end of his 'psychoticism' dimension. Support for the dimensional model comes from the fact that high-scorers on measures of schizotypy may meet, or partially fulfill, the diagnostic criteria for schizophrenia spectrum disorders, such as schizophrenia, schizoaffective disorder, schizoid personality disorder and schizotypal personality disorder. Similarly, when analyzed, schizotypy traits often break down into similar groups as do symptoms from schizophrenia (although they are typically present in much less intense forms). Fully dimensional approach Claridge calls the latest version of his model 'the fully dimensional approach'. However, it might also be characterised as the hybrid or composite approach, as it incorporates elements of both the disease model and the dimensional one. On this latest Claridge model, schizotypy is regarded as a dimension of personality, normally distributed throughout the population, as in the Eysenck model. However, schizophrenia itself is regarded as a breakdown process, quite distinct from the continuously distributed trait of schizotypy, and forming a second, graded continuum, ranging from schizotypal personality disorder to full-blown schizophrenic psychosis. The model is characterised as fully dimensional because, not only is the personality trait of schizotypy continuously graded, but the independent continuum of the breakdown processes is also graded rather than categorical. The fully dimensional approach argues that full blown psychosis is not just high schizotypy, but must involve other factors that make it qualitatively different and pathological. Relationship to other personality traits and sociodemographics Many research studies have examined the relationship between schizotypy and various standard models of personality, such as the five factor model. Research has linked the unusual experiences factor to high neuroticism and openness to experience. Unusual experience in combination with positive affectivity also appears to predict religiosity/spirituality. One study found that a moderate level of unusual experiences predicted increased religiosity, but a high level of unusual experiences predicted lower religiosity, and that impulsive non-conformity was associated with lower religiosity, as well as lower values of tradition and conformity. The introvertive anhedonia factor has been linked to high neuroticism and low extraversion. The cognitive disorganisation factor as well as the impulsive non-conformity factor have been linked to low conscientiousness. It has been argued that these findings provide evidence for a fully dimensional model of schizotypy and that there is a continuum between normal personality and schizotypy. Relationships between schizotypy and the Temperament and Character Inventory have also been examined. Self-transcendence, a trait associated with openness to "spiritual" ideas and experiences, has moderate positive associations with schizotypy, particularly with unusual experiences. Cloninger described the specific combination of high self-transcendence, low cooperativeness, and low self-directedness as a "schizotypal personality style" and research has found that this specific combination of traits is associated with a "high risk" of schizotypy. Low cooperativeness and self-directedness combined with high self-transcendence may result in openness to odd or unusual ideas and behaviours associated with distorted perceptions of reality. On the other hand, high levels of cooperativeness and self-directedness may protect against the schizotypal tendencies associated with high self-transcendence. One study examined the relationship between the dimensional MBTI scales, and found that schizotypy was associated with a tendency toward introversion, intuition (as opposed to sensing), thinking (as opposed to feeling), and prospecting (as opposed to judging), which can be represented by the "INTP" personality type in the MBTI model. Intuition is conceptually similar to the Big Five "openness to experience" trait which is thought to be increased in schizotypy, thinking represents the tendency to prefer objectivity and evidence in making decisions and forming beliefs and is conceptually similar to the lower level "intellect" factor of openness in the Big Five, and prospecting is conceptually similar to low conscientiousness in the Big Five. Schizotypy shows positive associations with traits that are associated with fast life history strategies, including increased sociosexuality (characterized by increased effort for short term sexual relationships, lower effort for long term sexual relationships, increased total amount of sexual partners, and lower sexual disgust) and impulsivity. Personality disorders Schizotypy shows positive associations with overall psychopathy, however when considering the primary and secondary factors of psychopathy, schizotypy is associated with lower primary psychopathy (also called fearless dominance) and higher secondary psychopathy (also called self-centered impulsivity, or disinhibition). Narcissism is negatively associated with schizotypy, (though persons high in schizotypy may experience grandiose delusions along with idionomia, a sense of deviance and enlightenment, which may be mistaken for narcissism), and borderline personality traits are positively associated with schizotypy as well hypomanic personality traits. Schizotypy also shows positive relationships with schizoid, paranoid, and avoidant personality traits, and a negative relationship with obsessive-compulsive personality traits (particularly with disorganized schizotypy). In contrast to obsessive-compulsive personality disorder, obsessive-compulsive disorder shows a positive relationship with schizotypy. Cognitive function There is evidence that schizotypy correlates with differentially enhanced and impaired aspects of cognitive function. These findings include schizotypy being positively associated with enhanced global processing over local processing, lower latent inhibition, attention & memory deficits, enhanced creativity & imagination, and enhanced associative thinking. Autism Correlational studies of schizotypy and autistic traits tend to find positive correlations, most strongly with negative schizotypy, to a lesser extent disorganized schizotypy, and weak, absent, or negative correlations with positive schizotypy. Diagnosed schizophrenia and autism spectrum disorder (ASD) also overlap statistically. However, several researchers have suggested that positive correlations between schizotypy and autism are not necessarily evidence of overlap, but rather are due to a lack of specificity of measurements for autistic and schizotypal traits, and the confounding variable of social difficulties and social-cognitive dysfunction which occur in both autism and schizotypy. Researchers have suggested that high comorbidity between diagnosed ASD and schizophrenia are highly unreliable and misleading due to a severe inadequacy of the DSM and diagnostic interviews for differential diagnosis. Studies which show apparent overlap between the causes of autism and the causes of schizotypy also have significant methodological issues. Multiple evolutionary theories of schizotypy place schizotypy and autistic traits at opposite poles of a continuum, with relation to traits such as theory of mind, life history and mating strategies, "mentalistic" or creative cognition and "mechanistic" cognition, and predictive processing. In agreement with this, schizotypy (particularly positive, impulsive, and disorganized schizotypy) shows a negative association with autistic traits when controlling for social difficulty, which has been well replicated across different countries, scales, methods, and independent research teams, and a diametric autism-schizotypy continuum factor emerges through factor analysis. Notably, some studies find a direct negative association with positive schizotypy and autistic traits even when social difficulty is not controlled for. Some researchers have interpreted these findings as indicating that autistic and schizotypal traits are both overlapping and diametrical in different aspects, with autistic social difficulties and negative schizotypal symptoms being a shared dimension, and positive, disorganized, and impulsive schizotypy as a dimension that is diametrically opposed to autism. Possible biological bases of schizotypy Cognitive imbalances and tradeoffs Predictive processing Andersen (2022) put forth a model of schizotypy based on the predictive processing framework, where lower importance is attributed to sensory prediction errors for updating beliefs in individuals with high schizotypy. Essentially, this means that schizotypy is a cognitive-perceptual specialization for processing chaotic and noisy data, where patterns and relationships exist but can only be detected if minor inconsistencies are ignored (i.e., focusing on the 'big picture'). Andersen suggests that a tradeoff exists in predictive processing, where giving higher weight to prediction errors prevents the detection of false patterns (i.e. apophenia) at the cost of being unable to detect higher level patterns, and giving lower weight to prediction errors allows for the detection of higher level patterns at the cost of occasionally detecting patterns that don't exist, as in delusions and hallucinations that occur in schizotypy. This model explains features of schizotypy and previous models of schizotypy, such as the hyper-mentalizing model originally proposed by Abu-Akel (1999), hyper-associative cognition, the hyper-imagination model by Crespi (2016), antagonomia (acting in ways directly opposing societal values) and idiosyncratic worldviews, attentional differences such as latent inhibition, hyper-openness, increased exploratory behavior, and enhanced cognitive abilities in insight problem solving, creativity, and global processing. Hormone abnormalities Oxytocin & testosterone There is some evidence to suggest that abnormalities in the regulation of oxytocin & testosterone are related to schizotypy. Crespi (2015) provides evidence that schizophrenia and related disorders may involve increased or dysregulated oxytocin, and relatively decreased testosterone, leading to "hyper-developed" social cognition, although Crespi's model of schizotypy has been criticized. Evidence for oxytocin's role in schizotypy includes genes associated with higher oxytocin levels being associated with higher levels of positive schizotypy, blood oxytocin levels positively associated with schizotypy in females, ratio of genes associated with low testosterone and high oxytocin positively associated with schizotypy and negatively with autistic traits, oxytocin levels being associated with higher social anxiety, and oxytocin being associated with global processing, divergent thinking, and creativity, which are also strongly associated with schizotypy. Anhedonia Anhedonia, or a reduced ability to experience pleasure, is a feature of full-blown schizophrenia that was commented on by both Kraepelin and Bleuler. However, they regarded it as just one among a number of features that tended to characterise the ‘deterioration’, as they saw it, of the schizophrenic's emotional life. In other words, it was an effect, rather than a cause, of the disease process. Rado reversed this way of thinking, and ascribed anhedonia a causal role. He considered that the crucial neural deficit in the schizotype was an ‘integrative pleasure deficiency’, i.e. an innate deficiency in the ability to experience pleasure. Meehl took on this view, and attempted to relate this deficiency to abnormality in the dopamine system in the brain, which is implicated in the human reward system. Questionnaire research on schizotypy in normal subjects is ambiguous with regard to the causal role, if any, of anhedonia. Nettle and McCreery and Claridge found that high schizotypes as measured by factor 1 (above) scored lower than controls on the introverted anhedonia factor, as if they were particularly enjoying life. Various writers, including Kelley and Coursey and L.J. and J.P. Chapman suggest that anhedonia, if present as a pre-existent trait in a person, may act as a potentiating factor, whereas a high capacity for hedonic enjoyment might act as a protecting one. Weakness of inhibitory mechanisms Negative priming Negative priming is "the ability of a preceding stimulus to inhibit the response to a subsequent stimulus." Individuals diagnosed with schizophrenia or schizotypy exhibit “reduced or abolished NP [negative priming], especially in the presence of positive symptomatology, acute psychosis, high severity of symptoms, and/or lack of medication.” SAWCI The phenomenon of semantic activation without conscious identification (SAWCI) is said to be displayed when a person shows a priming effect from the processing of consciously undetectable words. For example, a person who has just been shown the word ‘giraffe’, but at a speed at which he or she was not able consciously to report what it was, may nevertheless identify more quickly than usual another animal word on the next trial. Evans found that high schizotypes showed a greater priming effect than controls in such a situation. She argued that this could be accounted for by a relative weakness of inhibitory mechanisms in the semantic networks of high schizotypes. Attention, working memory, and executive functions Schizotypy symptoms have been related to deficits in executive functions, which entails the psychological processes that supersede habitual inclinations with novel responses and behaviors to fulfill important goals. In particular, when schizotypy is elevated, the ability to filter out task-irrelevant stimuli may be impaired. That is, participants who score highly on schizotypy tend to fail to ignore a previously preexposed, non-reinforced stimulus as compared to a non-preexposed, novel and potentially important event. Enhanced performance on verbal fluency has been associated with high levels of positive schizotypy, i.e. increased reports of hallucination-like experiences, delusional ideation, and perceptual aberrations. However, decreased performance was associated with negative schizotypy, such as anhedonia. Many studies have also shown that individuals who exhibit schizotypy features demonstrate deficits in attention and working memory. Abnormalities of arousal Claridge suggested that one consequence of a weakness of inhibitory mechanisms in high schizotypes and schizophrenics might be a relative failure of homeostasis in the central nervous system. It was proposed that this could lead to both lability of arousal and dissociation of arousal in different parts of the nervous system. Dissociation of different arousal systems Claridge and co-workers have found various types of abnormal co-variation between different psychophysiological variables in schizotypes, including between measures of cortical and autonomic arousal. McCreery and Claridge found evidence of a relative activation of the right cerebral hemisphere as compared with the left in high schizotypes attempting to induce a hallucinatory episode in the laboratory. This suggested a relative dissociation of arousal between the two hemispheres in such people as compared with controls. Hyperarousal A failure of homeostasis in the central nervous system could lead to episodes of hyper-arousal. Oswald has pointed out that extreme stress and hyper-arousal can lead to sleep as a provoked reaction. McCreery has suggested that this could account for the phenomenological similarities between Stage 1 sleep and psychosis, which include hallucinations, delusions, and flattened or inappropriate affect (emotions). On this model, high schizotypes and schizophrenics are people who are liable to what Oswald calls 'micro-sleeps', or intrusions of Stage 1 sleep phenomena into waking consciousness, on account of their tendency to high arousal. In support of this view McCreery points to the high correlation that has been found to exist between scores on the Chapmans' Perceptual Aberration scale, which measures proneness to perceptual anomalies such as hallucinations, and the Chapmans' Hypomania scale, which measures a tendency to episodes of heightened arousal. This correlation is found despite the fact that there is no overlap of item content between the two scales. In the clinical field there is also the paradoxical finding of Stevens and Darbyshire, that schizophrenic patients exhibiting the symptom of catatonia can be aroused from their apparent stupor by the administration of sedative rather than stimulant drugs. They wrote: 'The psychic state in catatonic schizophrenia can be described as one of great excitement (i.e., hyperalertness)[...] The inhibition of activity apparently does not alter the inner seething excitement.' It is argued that such a view would be consistent with the model that suggests schizophrenics and high schizotypes are people with a tendency to hyper-arousal. Aberrant salience hypothesis Kapur (2003) proposed that a hyperdopaminergic state, at a "brain" level of description, leads to an aberrant assignment of salience to the elements of one's experience, at a "mind" level. Dopamine mediates the conversion of the neural representation of an external stimulus from a neutral bit of information into an attractive or aversive entity, i.e. a salient event. Symptoms of schizophrenia and schizotypy may arise out of ‘the aberrant assignment of salience to external objects and internal representations’; and antipsychotic medications may reduce positive symptoms by attenuating aberrant motivational salience, via blockade of the Dopamine D2 receptors (Kapur, 2003). There is no evidence however on a link between attentional irregularities and enhanced stimulus salience in schizotypy. See also References Further reading Claridge, G. (1997) Schizotypy: Implications for Illness and Health. Oxford University Press. Schizophrenia Psychosis Psychological concepts

Dissociative fugue

Dissociative fugue, formerly called a fugue state or psychogenic fugue, is a rare psychiatric phenomenon characterized by reversible amnesia for one's identity in conjunction with unexpected wandering or travel. This is sometimes accompanied by the establishment of a new identity and the inability to recall personal information prior to the presentation of symptoms. Dissociative fugue is a mental and behavioral disorder that is classified variously as a dissociative disorder, a conversion disorder, and a somatic symptom disorder. It is a facet of dissociative amnesia, according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). After recovery from a fugue state, previous memories usually return intact, and further treatment is unnecessary. An episode of fugue is not characterized as attributable to a psychiatric disorder if it can be related to the ingestion of psychotropic substances, to physical trauma, to a general medical condition, or to dissociative identity disorder, delirium, or dementia. Fugues are precipitated by a series of long-term traumatic episodes. It is most commonly associated with childhood victims of sexual abuse who learn to dissociate memory of the abuse (dissociative amnesia). Signs and symptoms Symptoms of a dissociative fugue include mild confusion and once the fugue ends, possible depression, grief, shame, and discomfort. People have also experienced post-fugue anger. Another symptom of the fugue state can consist of loss of one's identity. Diagnosis Before dissociative fugue can be diagnosed, either dissociative amnesia or dissociative identity disorder must be diagnosed. The only difference between dissociative amnesia, dissociative identity disorder and dissociative fugue is that the person affected by the latter travels or wanders. This traveling or wandering is typically associated with the amnesia-induced identity or the person's physical surroundings. Sometimes dissociative fugue cannot be diagnosed until the patient returns to their pre-fugue identity and is distressed to find themselves in unfamiliar circumstances, sometimes with awareness of "lost time". The diagnosis is usually made retroactively when a doctor reviews the history and collects information that documents the circumstances before the patient left home, the travel itself, and the establishment of an alternative life. Functional amnesia can also be situation-specific, varying from all forms and variations of trauma or generally violent experiences, with the person experiencing severe memory loss for a particular trauma. Committing homicide, experiencing or committing a violent crime such as rape or torture, experiencing combat violence, attempting suicide, and being in automobile accidents and natural disasters have all induced cases of situation-specific amnesia. In these unusual cases, care must be exercised in interpreting cases of psychogenic amnesia when there are compelling motives to feign memory deficits for legal or financial reasons. However, although some fraction of psychogenic amnesia cases can be explained in this fashion, it is generally acknowledged that true cases are not uncommon. Both global and situationally specific amnesia are often distinguished from the organic amnesic syndrome, in that the capacity to store new memories and experiences remains intact. Given the very delicate and oftentimes dramatic nature of memory loss in such cases, there usually is a concerted effort to help the person recover their identity and history. This will sometimes allow the subject to recover spontaneously, when particular cues are encountered. Definition The cause of the fugue state is related to dissociative amnesia (code 300.12 of the DSM-IV codes), which has several other subtypes: selective amnesia, generalized amnesia, continuous amnesia, and systematized amnesia, in addition to the subtype "dissociative fugue". Unlike retrograde amnesia (which is popularly referred to simply as "amnesia", the state where someone forgets events before brain damage), dissociative amnesia is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, DSM-IV codes 291.1 & 292.83) or a neurological or other general medical condition (e.g., amnestic disorder due to a head trauma, DSM-IV Code 294.0). It is a complex neuropsychological process. As the person experiencing a dissociative fugue may have recently experienced the reappearance of an event or person representing an earlier trauma, the emergence of an armoring or defensive personality seems to be for some, a logical defense strategy in the situation. Therefore, the terminology "fugue state" may carry a slight linguistic distinction from "dissociative fugue", the former implying a greater degree of "motion". For the purposes of this article, then, a "fugue state" occurs while one is "acting out" a "dissociative fugue". The DSM-IV defines "dissociative fugue" as: sudden, unexpected travel away from home or one's customary place of work, with inability to recall one's past confusion about personal identity, or the assumption of a new identity significant distress or impairment The Merck Manual defines "dissociative fugue" as: One or more episodes of amnesia in which the inability to recall some or all of one's past and either the loss of one's identity or the formation of a new identity occur with sudden, unexpected, purposeful travel away from home. In support of this definition, the Merck Manual further defines dissociative amnesia as: An inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by normal forgetfulness. Prognosis The DSM-IV-TR states that the fugue may have a duration from days to months, and recovery is usually rapid. However, some cases may be refractory. An individual usually has only one episode. Cases Shirley Ardell Mason (1923–1998), also known as "Sybil", would disappear and then reappear with no recollection of what happened during the time span. She recalled "being here and then not here" and having no identity of herself. It was claimed by her psychiatrist, Cornelia Wilbur, that she also had dissociative identity disorder. Wilbur's diagnosis of DID was disputed by Wilbur's contemporary Herbert Spiegel. Jody Roberts, a reporter for the Tacoma News Tribune, disappeared in 1985, only to be found 12 years later in Sitka, Alaska, living under the name of "Jane Dee Williams". While there were some initial suspicions that she had been faking amnesia, some experts have come to believe that she genuinely experienced a protracted fugue state. David Fitzpatrick, who had dissociative fugue disorder, was profiled in the UK on Five's television series Extraordinary People. He entered a fugue state on December 4, 2005, and was working on regaining his entire life's memories at the time of his appearance in his episode of the documentary series. Hannah Upp, a teacher originally from Salem, Oregon, was given a diagnosis of dissociative fugue after she had disappeared from her New York home in August 2008 and was rescued from the New York Harbor 20 days later. News coverage at the time focused on her refusal to speak to detectives right after she was found and the fact that she was seen checking her email at Apple Stores while she was missing. This coverage has since led to criticism of the often "condemning and discrediting" attitude toward dissociative conditions. On September 3, 2013, she went into another fugue, disappearing from her new job as a teacher's assistant at Crossway Community Montessori in Kensington, Maryland. She was found unharmed two days later on September 5, 2013, in Wheaton, Maryland. On September 14, 2017, she went missing again, having last been seen near Sapphire Beach in her home in St. Thomas right before the arrival of Hurricane Maria that month. Her mother and a group of friends searched for her in the Virgin Islands and surrounding areas; , she remains missing. Jeff Ingram appeared in Denver in 2006 with no memory of his name or where he was from. After his appearance on national television, to appeal for help identifying himself, his fiancée called Denver police identifying him. The episode was diagnosed as dissociative fugue. As of December 2012, Ingram had experienced three incidents of amnesia: in 1994, 2006, and 2007. Doug Bruce "came to" on a subway train claiming to have no memory of his name or where he was from, nor any identification documents. Bruneri-Canella case (alleged reappearance of a man who had gone missing in World War I) Agatha Christie (possibly) Lizzie Borden, who may have murdered her father and stepmother under fugue state Fictional cases Paris, Texas, a film by Wim Wenders where the protagonist (Harry Dean Stanton) portrays and must cope with the disorder The Fisher King, a film by Terry Gilliam where the protagonist (Robin Williams) portrays the disorder in order to cope with losing his wife in a homicide he witnessed Lost Highway, a film by David Lynch that explores the disorder Nurse Betty, a film by Neil LaBute where the protagonist (Renée Zellweger) portrays the disorder in order to cope with losing her husband to a homicide she witnessed K-Pax, a film by Iain Softley where the protagonist (Kevin Spacey) is suspected of having some form of the disorder brought on from losing his family in a homicide The Next Doctor, an episode of Doctor Who in which the Doctor (David Tennant) encounters Jackson Lake (David Morrissey), a character who portrays the disorder, believing himself to be the Doctor. Franklyn, a film written and directed by Gerald McMorrow where two of the supporting protagonists (Ryan Phillippe) and (Sam Riley) show traits of the disorder in order to cope with PTSD from Combat stress reaction and family Bereavement Man Down, a film by Dito Montiel where the protagonist (Shia LaBeouf) shows traits of the disorder in order to cope with PTSD from Combat stress reaction and Bereavement The Naked Sun novel by Isaac Asimov about a murder committed under fugue state In Breaking Bad, the protagonist Walter White fakes a fugue state in Season 2 episode 3 "Bit by a Dead Bee", as an alibi to the murder of Tuco Salamanca. See also Depersonalization disorder (DSM-IV dissociative disorders 300.6) Dromomania, a similar historical diagnosis involving a strong desire to wander or travel Structured Clinical Interview for DSM-IV References External links "Dissociative Fugue" from the Merck & Co. website. Dissociative disorders Memory disorders Symptoms and signs of mental disorders Types of travel

State hospital

A state hospital is a hospital funded and operated by the government of a state. In some countries, such as South Africa, the term is synonymous with public hospital. In other countries, like the United States, general public hospitals are operated by local governments. Due in part to the efforts of Dorothea Dix, the term "state hospital" generally refers to a public psychiatric hospital operated by a state government for persons committed to compulsory psychiatric care after being found not guilty of serious violent crimes on the basis of insanity. In the United Kingdom, the term may refer to one particular psychiatric hospital known as the State Hospital. References Types of hospitals Psychiatric hospitals Hospitals

Internal Family Systems Model

The Internal Family Systems Model (IFS) is an integrative approach to individual psychotherapy developed by Richard C. Schwartz in the 1980s. It combines systems thinking with the view that the mind is made up of relatively discrete subpersonalities, each with its own unique viewpoint and qualities. IFS uses systems psychology, particularly as developed for family therapy, to understand how these collections of subpersonalities are organized. Parts IFS posits that the mind is made up of multiple parts, and underlying them is a person's core or true Self. Like members of a family, a person's inner parts can take on extreme roles or subpersonalities. Each part has its own perspective, interests, memories, and viewpoint. A core tenet of IFS is that every part has a positive intent, even if its actions are counterproductive or cause dysfunction. There is no need to fight with, coerce, or eliminate parts; the IFS method promotes internal connection and harmony to bring the mind back into balance. IFS therapy aims to heal wounded parts and restore mental balance. The first step is to access the core Self and then, from there, understand the different parts in order to heal them. In the IFS model, there are three general types of parts: Exiles represent psychological trauma, often from childhood, and they carry the pain and fear. Exiles may become isolated from the other parts and polarize the system. Managers and Firefighters try to protect a person's consciousness by preventing the Exiles' pain from coming to awareness. Managers take on a preemptive, protective role. They influence the way a person interacts with the external world, protecting the person from harm and preventing painful or traumatic experiences from flooding the person's conscious awareness. Firefighters emerge when Exiles break out and demand attention. They work to divert attention away from the Exile's hurt and shame, which leads to impulsive and/or inappropriate behaviors like overeating, drug use, and/or violence. They can also distract a person from pain by excessively focusing attention on more subtle activities such as overworking or overmedicating. The internal system IFS focuses on the relationships between parts and the core Self. The goal of therapy is to create a cooperative and trusting relationship between the Self and each part. There are three primary types of relationships between parts: protection, polarization, and alliance. Protection is provided by Managers and Firefighters. They intend to spare Exiles from harm and protect the individual from the Exile's pain. Polarization occurs between two parts that battle each other to determine how a person feels or behaves in a certain situation. Each part believes that it must act as it does in order to counter the extreme behavior of the other part. IFS has a method for working with polarized parts. Alliance is formed between two different parts if they're working together to accomplish the same goal. IFS method IFS practitioners report a well-defined therapeutic method for individual therapy based on the following principles. In this description, the term "protector" refers to either a manager or firefighter. Parts in extreme roles carry "burdens", which are painful emotions or negative beliefs that they have taken on as a result of past harmful experiences, often in childhood. These burdens are not intrinsic to the part and therefore they can be released or "unburdened" through IFS therapy, allowing the part to assume its natural healthy role. The Self is the agent of psychological healing. Therapists help their clients to access and remain in Self, providing guidance along the way. Protectors usually can't let go of their protective roles and transform until the Exiles they are protecting have been unburdened. There is no attempt to work with Exiles until the client has obtained permission from the Protectors who are protecting it. This allegedly makes the method relatively safe, even in working with traumatized parts. The Self is the natural leader of the internal system. However, because of past harmful incidents or relationships, Protectors have stepped in and taken over for the Self. One Protector after another is activated and takes the lead, causing dysfunctional behavior. Protectors are also frequently in conflict with each other, resulting in internal chaos or stagnation. The aim is for the Protectors to trust the Self and allow it to lead the system, creating internal harmony under its guidance. The first step is to help the client access the Self. Next, the Self gets to know the Protector(s), its positive intent, and develops a trusting relationship with it. Then, with the Protector's permission, the client accesses the Exile(s) to uncover the childhood incident or relationship which is the source of the burden(s) it carries. The Exile is retrieved from the past situation and guided to release its burdens. Finally, the Protector can then let go of its protective role and assume a healthy one. Critiques Therapists Sharon A. Deacon and Jonathan C. Davis suggested that working with one's parts may "be emotional and anxiety-provoking for clients", and that IFS may not work well with delusional, paranoid, or schizophrenic clients who may not be grounded in reality and therefore misuse the idea of "parts". See also Dissociation (psychology) Ego-state therapy Family therapy Inner Relationship Focusing Family Constellations Intrapersonal communication Inner Team Inside Out (2015 film) References Further reading Books Peer-reviewed articles External links Psychological models Psychotherapeutical theories Conceptions of self Intrapersonal communication

Clinical formulation

A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more categorical approach of psychiatric diagnosis. In clinical practice, formulations are used to communicate a hypothesis and provide framework for developing the most suitable treatment approach. It is most commonly used by clinical psychologists and is deemed to be a core component of that profession. Mental health nurses, social workers, and some psychiatrists may also use formulations. Types of formulation Different psychological schools or models utilize clinical formulations, including cognitive behavioral therapy (CBT) and related therapies: systemic therapy, psychodynamic therapy, and applied behavior analysis. The structure and content of a clinical formulation is determined by the psychological model. Most systems of formulation contain the following broad categories of information: symptoms and problems; precipitating stressors or events; predisposing life events or stressors; and an explanatory mechanism that links the preceding categories together and offers a description of the precipitants and maintaining influences of the person's problems. Behavioral case formulations used in applied behavior analysis and behavior therapy are built on a rank list of problem behaviors, from which a functional analysis is conducted, sometimes based on relational frame theory. Such functional analysis is also used in third-generation behavior therapy or clinical behavior analysis such as acceptance and commitment therapy and functional analytic psychotherapy. Functional analysis looks at setting events (ecological variables, history effects, and motivating operations), antecedents, behavior chains, the problem behavior, and the consequences, short- and long-term, for the behavior. A model of formulation that is more specific to CBT is described by Jacqueline Persons. This has seven components: problem list, core beliefs, precipitants and activating situations, origins, working hypothesis, treatment plan, and predicted obstacles to treatment. A psychodynamic formulation would consist of a summarizing statement, a description of nondynamic factors, description of core psychodynamics using a specific model (such as ego psychology, object relations or self psychology), and a prognostic assessment which identifies the potential areas of resistance in therapy. One school of psychotherapy which relies heavily on the formulation is cognitive analytic therapy (CAT). CAT is a fixed-term therapy, typically of around 16 sessions. At around session four, a formal written reformulation letter is offered to the patient which forms the basis for the rest of the treatment. This is usually followed by a diagrammatic reformulation to amplify and reinforce the letter. Many psychologists use an integrative psychotherapy approach to formulation. This is to take advantage of the benefits of resources from each model the psychologist is trained in, according to the patient's needs. Critical evaluation of formulations The quality of specific clinical formulations, and the quality of the general theoretical models used in those formulations, can be evaluated with criteria such as: Clarity and parsimony: Is the model understandable and internally consistent, and are key concepts discrete, specific, and non-redundant? Precision and testability: Does the model produce testable hypotheses, with operationally defined and measurable concepts? Empirical adequacy: Are the posited mechanisms within the model empirically validated? Comprehensiveness and generalizability: Is the model holistic enough to apply across a range of clinical phenomena? Utility and applied value: Does it facilitate shared meaning-making between clinician and client, and are interventions based on the model shown to be effective? Formulations can vary in temporal scope from case-based to episode-based or moment-based, and formulations may evolve during the course of treatment. Therefore, ongoing monitoring, testing, and assessment during treatment are necessary: monitoring can take the form of session-by-session progress reviews using quantitative measures, and formulations can be modified if an intervention is not as effective as hoped. History Psychologist George Kelly, who developed personal construct theory in the 1950s, noted his complaint against traditional diagnosis in his book The Psychology of Personal Constructs (1955): "Much of the reform proposed by the psychology of personal constructs is directed towards the tendency for psychologists to impose preemptive constructions upon human behaviour. Diagnosis is all too frequently an attempt to cram a whole live struggling client into a nosological category." In place of nosological categories, Kelly used the word "formulation" and mentioned two types of formulation: a first stage of structuralization, in which the clinician tentatively organizes clinical case information "in terms of dimensions rather than in terms of disease entities" while focusing on "the more important ways in which the client can change, and not merely ways in which the psychologist can distinguish him from other persons", and a second stage of construction, in which the clinician seeks a kind of negotiated integration of the clinician's organization of the case information with the client's personal meanings. Psychologists Hans Eysenck, Monte B. Shapiro, Vic Meyer, and Ira Turkat were also among the early developers of systematic individualized alternatives to diagnosis. Meyer has been credited with providing perhaps the first training course of behaviour therapy based on a case formulation model, at the Middlesex Hospital Medical School in London in 1970. Meyer's original choice of words for clinical formulation were "behavioural formulation" or "problem formulation". See also Clinical decision support system Clinical guideline Clinical pathway Common factors theory Problem structuring methods SOAP note Therapeutic assessment Treatment decision support (tools for clients) References Further reading Medical terminology Psychiatric assessment Psychotherapy

Psychological resilience

Psychological resilience is the ability to cope mentally and emotionally with a crisis, or to return to pre-crisis status quickly. The term was popularized in the 1970s and 1980s by psychologist Emmy Werner as she conducted a forty-year-long study of a cohort of Hawaiian children who came from low socioeconomic status backgrounds. Numerous factors influence a person's level of resilience. Internal factors include personal characteristics such as self-esteem, self-regulation, and a positive outlook on life. External factors include social support systems, including relationships with family, friends, and community, as well as access to resources and opportunities. People can leverage psychological interventions and other strategies to enhance their resilience and better cope with adversity. These include cognitive-behavioral techniques, mindfulness practices, building psychosocial factors, fostering positive emotions, and promoting self-compassion. Overview A resilient person uses "mental processes and behaviors in promoting personal assets and protecting self from the potential negative effects of stressors". Psychological resilience is an adaptation in a person's psychological traits and experiences that allows them to regain or remain in a healthy mental state during crises/chaos without long-term negative consequences. It is difficult to measure and test this psychological construct because resilience can be interpreted in a variety of ways. Most psychological paradigms (biomedical, cognitive-behavioral, sociocultural, etc.) have their own perspective of what resilience looks like, where it comes from, and how it can be developed. There are numerous definitions of psychological resilience, most of which center around two concepts: adversity and positive adaptation. Positive emotions, social support, and hardiness can influence a person to become more resilient. A psychologically resilient person can resist adverse mental conditions that are often associated with unfavorable life circumstances. This differs from psychological recovery which is associated with returning to those mental conditions that preceded a traumatic experience or personal loss. Research on psychological resilience has shown that it plays a crucial role in promoting mental health and well-being. Resilient people are better equipped to navigate life's challenges, maintain positive emotions, and recover from setbacks. They demonstrate higher levels of self-efficacy, optimism, and problem-solving skills, which contribute to their ability to adapt and thrive in adverse situations. Resilience is a "positive adaptation" after a stressful or adverse situation. When a person is "bombarded by daily stress, it disrupts their internal and external sense of balance, presenting challenges as well as opportunities." The routine stressors of daily life can have positive impacts which promote resilience. Some psychologists believe that it is not stress itself that promotes resilience but rather the person's perception of their stress and of their level of control. The presence of stress allows people to practice resilience. It is unknown what the correct level of stress is for each person. Some people can handle more stress than others. Stress is experienced in a person's life course at times of difficult life transitions, involving developmental and social change; traumatic life events, including grief and loss; and environmental pressures, encompassing poverty and community violence. Resilience is the integrated adaptation of physical, mental, and spiritual aspects to circumstances, and a coherent sense of self that is able to maintain normative developmental tasks that occur at various stages of life. The Children's Institute of the University of Rochester explains that "resilience research is focused on studying those who engage in life with hope and humor despite devastating losses". Resilience is not only about overcoming a deeply stressful situation, but also coming out of such a situation with "competent functioning". Resiliency allows a person to rebound from adversity as a strengthened and more resourceful person. Some characteristics associated with psychological resilience include: an easy temperament, good self-esteem, planning skills, and a supportive environment inside and outside of the family. When an event is appraised as comprehensible (predictable), manageable (controllable), and somehow meaningful (explainable) a resilient response is more likely. Process Psychological resilience is commonly understood as a process. It can also be characterized as a tool a person develops over time, or as a personal trait of the person ("resiliency"). Most research shows resilience as the result of people being able to interact with their environments and participate in processes that either promote well-being or protect them against the overwhelming influence of relative risk. This research supports the model in which psychological resilience is seen as a process rather than a trait—something to develop or pursue, rather than a static endowment or endpoint. When people are faced with an adverse condition, there are three ways in which they may approach the situation. respond with anger or aggression become overwhelmed and shut down feel the emotion about the situation and appropriately handle the emotion Resilience is promoted through the third approach, which is employed by individuals who adapt and change their current patterns to cope with disruptive states, thereby enhancing their well-being. In contrast, the first and second approaches lead individuals to adopt a victim mentality, blaming others and rejecting coping methods even after a crisis has passed. These individuals tend to react instinctively rather than respond thoughtfully, clinging to negative emotions such as fear, anger, anxiety, distress, helplessness, and hopelessness. Such emotions decrease problem-solving abilities and weaken resilience, making it harder to recover. Resilient people, on the other hand, actively cope, bounce back, and find solutions. Their resilience is further supported by protective environments, including good families, schools, communities, and social policies, which provide cumulative protective factors that bolster their ability to withstand and recover from exposure to risk factors. Resilience can be viewed as a developmental process (the process of developing resilience), or as indicated by a response process. In the latter approach, the effects of an event or stressor on a situationally relevant indicator variable are studied, distinguishing immediate responses, dynamic responses, and recovery patterns. In response to a stressor, more-resilient people show some (but less than less-resilient people) increase in stress. The speed with which this stress response returns to pre-stressor levels is also indicative of a person's resilience. Biological models From a scientific standpoint, resilience’s contested definition is multifaceted in relation to genetics, revealing a complex link between biological mechanisms and resilience "Resilience, conceptualized as a positive bio-psychological adaptation, has proven to be a useful theoretical context for understanding variables for predicting long-term health and well-being". Three notable bases for resilience—self-confidence, self-esteem and self-concept—each have roots in a different nervous system—respectively, the somatic nervous system, the autonomic nervous system, and the central nervous system. Research indicates that, like trauma, resilience is influenced by epigenetic modifications. Increased DNA methylation of the growth factor GDNF in certain brain regions promotes stress resilience, as do molecular adaptations of the blood–brain barrier. The two neurotransmitters primarily responsible for stress buffering within the brain are dopamine and endogenous opioids, as evidenced by research showing that dopamine and opioid antagonists increased stress response in both humans and animals. Primary and secondary rewards reduce negative reactivity of stress in the brain in both humans and animals. The relationship between social support and stress resilience is thought to be mediated by the oxytocin system's impact on the hypothalamic-pituitary-adrenal axis. Alongside such neurotransmitters, stress-induced alterations in brain structures, such as the prefrontal cortex (PFC) and hippocampus have been linked to mental health issues like depression and anxiety. The increased activation of the medial prefrontal cortex and glutamatergic circuits has emerged as a potential factor in enhancing resilience as “environmental enrichment… increases the complexity of… pyramidal neurons in hippocampus and PFC, suggesting… a shared feature of resilience under these two distinct condition[s]." History The first research on resilience was published in 1973. The study used epidemiology—the study of disease prevalence—to uncover the risks and the protective factors that now help define resilience. A year later, the same group of researchers created tools to look at systems that support development of resilience. Emmy Werner was one of the early scientists to use the term resilience. She studied a cohort of children from Kauai, Hawaii. Kauai was quite poor and many of the children in the study grew up with alcoholic or mentally ill parents. Many of the parents were also out of work. Werner noted that of the children who grew up in these detrimental situations, two-thirds exhibited destructive behaviors in their later-teen years, such as chronic unemployment, substance abuse, and out-of-wedlock births (in girls). However, one-third of these youngsters did not exhibit destructive behaviors. Werner called the latter group resilient. Thus, resilient children and their families were those who, by definition, demonstrated traits that allowed them to be more successful than non-resilient children and families. Resilience also emerged as a major theoretical and research topic in the 1980s in studies of children with mothers diagnosed with schizophrenia. A 1989 study showed that children with a schizophrenic parent may not obtain an appropriate level of comforting caregiving—compared to children with healthy parents—and that such situations often had a detrimental impact on children's development. On the other hand, some children of ill parents thrived and were competent in academic achievement, which led researchers to make efforts to understand such responses to adversity. Since the onset of the research on resilience, researchers have been devoted to discovering protective factors that explain people's adaptation to adverse conditions, such as maltreatment, catastrophic life events, or urban poverty. Researchers endeavor to uncover how some factors (e.g. connection to family) may contribute to positive outcomes. Trait resilience Temperamental and constitutional disposition is a major factor in resilience. It is one of the necessary precursors of resilience along with warmth in family cohesion and accessibility of prosocial support systems. There are three kinds of temperamental systems that play part in resilience: the appetitive system, defensive system, and attentional system. Trait resilience is negatively correlated with the personality traits of neuroticism and negative emotionality, which represent tendencies to see and react to the world as threatening, problematic, and distressing, and to view oneself as vulnerable. Trait resilience is positively correlated with the personality traits of openness and positive emotionality, that represent tendencies to engage with and confront the world with confidence self-directedness. Resilience traits are personal characteristics that express how people approach and react to events that they experience as negative. Trait resilience is generally considered via two methods: direct assessment of traits through resilience measures and proxy assessments of resilience in which existing cognate psychological constructs are used to explain resilient outcomes. Typically, trait resilience measures explore how individuals tend to react to and cope with adverse events. Proxy assessments of resilience, sometimes referred to as the buffering approach, view resilience as the antithesis of risk, focusing on how psychological processes interrelate with negative events to mitigate their effects. Possibly an individual perseverance trait, conceptually related to persistence and resilience, could also be measured behaviorally by means of arduous, difficult, or otherwise unpleasant tasks. Developing and sustaining resilience There are several theories or models that attempt to describe subcomponents, prerequisites, predictors, or correlates of resilience. Fletcher and Sarkar found five factors that develop and sustain a person's resilience: the ability to make realistic plans and being capable of taking the steps necessary to follow through with them confidence in one's strengths and abilities communication and problem-solving skills the ability to manage strong impulses and feelings having good self-esteem Among older adults, Kamalpour et al. found that the important factors are external connections, grit, independence, self-care, self-acceptance, altruism, hardship experience, health status, and positive perspective on life. Another study examined thirteen high-achieving professionals who seek challenging situations that require resilience, all of whom had experienced challenges in the workplace and negative life events over the course of their careers but who had also been recognized for their great achievements in their respective fields. Participants were interviewed about everyday life in the workplace as well as their experiences with resilience and thriving. The study found six main predictors of resilience: positive and proactive personality, experience and learning, sense of control, flexibility and adaptability, balance and perspective, and perceived social support. High achievers were also found to engage in many activities unrelated to their work such as engaging in hobbies, exercising, and organizing meetups with friends and loved ones. The American Psychological Association, in its popular psychology-oriented Psychology topics publication, suggests the following tactics people can use to build resilience: Prioritize relationships. Join a social group. Take care of your body. Practice mindfulness. Avoid negative coping outlets (like alcohol use). Help others. Be proactive; search for solutions. Make progress toward your goals. Look for opportunities for self-discovery. Keep things in perspective. Accept change. Maintain a hopeful outlook. Learn from your past. The idea that one can build one's resilience implies that resilience is a developable characteristic, and so is perhaps at odds with the theory that resilience is a process. Positive emotions The relationship between positive emotions and resilience has been extensively studied. People who maintain positive emotions while they face adversity are more flexibile in their thinking and problem solving. Positive emotions also help people recover from stressful experiences. People who maintain positive emotions are better-defended from the physiological effects of negative emotions, and are better-equipped to cope adaptively, to build enduring social resources, and to enhance their well-being. The ability to consciously monitor the factors that influence one's mood is correlated with a positive emotional state. This is not to say that positive emotions are merely a by-product of resilience, but rather that feeling positive emotions during stressful experiences may have adaptive benefits in the coping process. Resilient people who have a propensity for coping strategies that concretely elicit positive emotions—such as benefit-finding and cognitive reappraisal, humor, optimism, and goal-directed problem-focused coping—may strengthen their resistance to stress by allocating more access to these positive emotional resources. Social support from caring adults encouraged resilience among participants by providing them with access to conventional activities. Positive emotions have physiological consequences. For example, humor leads to improvements in immune system functioning and increases in levels of salivary immunoglobulin A, a vital system antibody, which serves as the body's first line of defense in respiratory illnesses. Other health outcomes include faster injury recovery rate and lower readmission rates to hospitals for the elderly, and reductions in the length of hospital stay. One study has found early indications that older adults who have increased levels of psychological resilience have decreased odds of death or inability to walk after recovering from hip fracture surgery. In another study, trait-resilient individuals experiencing positive emotions more quickly rebounded from cardiovascular activation that was initially generated by negative emotional arousal. Social support Social support is an important factor in the development of resilience. While many competing definitions of social support exist, they tend to concern one's degree of access to, and use of, strong ties to other people who are similar to oneself. Social support requires solidarity and trust, intimate communication, and mutual obligation both within and outside the family. Military studies have found that resilience is also dependent on group support: unit cohesion and morale is the best predictor of combat resiliency within a unit or organization. Resilience is highly correlated with peer support and group cohesion. Units with high cohesion tend to experience a lower rate of psychological breakdowns than units with low cohesion and morale. High cohesion and morale enhance adaptive stress reactions. War veterans who had more social support were less likely to develop post-traumatic stress disorder. Cognitive behavioral therapy A number of self-help approaches to resilience-building have been developed, drawing mainly on cognitive behavioral therapy (CBT) and rational emotive behavior therapy (REBT). For example, a group cognitive-behavioral intervention, called the Penn Resiliency Program (PRP), fosters aspects of resilience. A meta-analysis of 17 PRP studies showed that the intervention significantly reduces depressive symptoms over time. In CBT, building resilience is a matter of mindfully changing behaviors and thought patterns. The first step is to change the nature of self-talk—the internal monologue people have that reinforces beliefs about their self-efficacy and self-value. To build resilience, a person needs to replace negative self-talk, such as "I can't do this" and "I can't handle this", with positive self-talk. This helps to reduce psychological stress when a person faces a difficult challenge. The second step is to prepare for challenges, crises, and emergencies. Businesses prepare by creating emergency response plans, business continuity plans, and contingency plans. Similarly, an individual can create a financial cushion to help with economic stressors, maintain supportive social networks, and develop emergency response plans. Language learning and communication Language learning and communication help develop resilience in people who travel, study abroad, work internationally, or in those who find themselves as refugees in countries where their home language is not spoken. Research conducted by the British Council found a strong relationship between language and resilience in refugees. Providing adequate English-learning programs and support for Syrian refugees builds resilience not only in the individual, but also in the host community. Language builds resilience in five ways: home language and literacy development Development of home language and literacy helps create the foundation for a shared identity. By maintaining the home language, even when displaced, a person not only learns better in school, but enhances their ability to learn other languages. This improves resilience by providing a shared culture and sense of identity that allows refugees to maintain close relationships to others who share their identity and sets them up to possibly return one day. access to education, training, and employment This allows refugees to establish themselves in their host country and provides more ease when attempting to access information, apply to work or school, or obtain professional documentation. Securing access to education or employment is largely dependent on language competency, and both education and employment provide security and success that enhance resilience and confidence. learning together and social cohesion Learning together encourages resilience through social cohesion and networks. When refugees engage in language-learning activities with host communities, engagement and communication increases. Both refugee and host community are more likely to celebrate diversity, share their stories, build relationships, engage in the community, and provide each other with support. This creates a sense of belonging with the host communities alongside the sense of belonging established with other members of the refugee community through home language. addressing the effects of trauma on learning Additionally, language programs and language learning can help address the effects of trauma by providing a means to discuss and understand. Refugees are more capable of expressing their trauma, including the effects of loss, when they can effectively communicate with their host community. Especially in schools, language learning establishes safe spaces through storytelling, which further reinforces comfort with a new language, and can in turn lead to increased resilience. building inclusivity This is more focused on providing resources. By providing institutions or schools with more language-based learning and cultural material, the host community can learn how to better address the needs of the refugee community. This feeds back into the increased resilience of refugees by creating a sense of belonging and community. Another study shows the impacts of storytelling in building resilience. It aligns with many of the five factors identified by the study completed by the British Council, as it emphasizes the importance of sharing traumatic experiences through language. It showed that those who were exposed to more stories, from family or friends, had a more holistic view of life's struggles, and were thus more resilient, especially when surrounded by foreign languages or attempting to learn a new language. Development programs The Head Start program promotes resilience, as does the Big Brothers Big Sisters Programme, Centered Coaching & Consulting,, the Abecedarian Early Intervention Project, and social programs for youth with emotional or behavioral difficulties. The Positive Behavior Supports and Intervention program is a trauma-informed, resilience-based program for elementary age students. It has four components: positive reinforcements such as encouraging feedback; understanding that behavior is a response to unmet needs or a survival response; promoting belonging, mastery, and independence; and creating an environment to support the student through sensory tools, mental health breaks, and play. Tuesday's Children, a family service organization, works to build psychological resilience through programs such as Mentoring and Project Common Bond, an eight-day peace-building and leadership initiative for people aged 15–20, from around the world, who have been directly impacted by terrorism. Military organizations test personnel for the ability to function under stressful circumstances by deliberately subjecting them to stress during training. Those students who do not exhibit the necessary resilience can be screened out of the training. Those who remain can be given stress inoculation training. The process is repeated as personnel apply for increasingly demanding positions, such as special forces. Other factors Another protective factor involves external social support, which helps moderate the negative effects of environmental hazards or stressful situations and guides vulnerable individuals toward optimistic paths. One study distinguished three contexts for protective factors: Personal Attributes: Traits such as an outgoing personality, perceptiveness, and a positive self-concept. Family Environment: Close and supportive relationships with at least one family member or an emotionally stable parent. Community Support: Support and guidance from peers and community members. A study of the elderly in Zurich, Switzerland, illuminated the role humor plays to help people remain happy in the face of age-related adversity. Research has also been conducted into individual differences in resilience. Self-esteem, ego-control, and ego-resiliency are related to behavioral adaptation. Maltreated children who feel good about themselves may process risk situations differently by and, thereby, avoiding negative internalized self-perceptions. Ego-control is "the threshold or operating characteristics of an individual with regard to the expression or containment" of their impulses, feelings, and desires. Ego-resilience refers to the "dynamic capacity, to modify his or her model level of ego-control, in either direction, as a function of the demand characteristics of the environmental context" Demographic information (e.g., gender) and resources (e.g., social support) also predict resilience. After disaster women tend to show less resilience than men, and people who were less involved in affinity groups and organisations also showed less resilience. Certain aspects of religions, spirituality, or mindfulness could promote or hinder certain psychological virtues that increase resilience. However, the "there has not yet been much direct empirical research looking specifically at the association of religion and ordinary strengths and virtues". In a review of the literature on the relationship between religiosity/spirituality and PTSD, about half of the studies showed a positive relationship and half showed a negative relationship between measures of religiosity/spirituality and resilience. The United States Army was criticized for promoting spirituality in its Comprehensive Soldier Fitness program as a way to prevent PTSD, due to the lack of conclusive supporting data. Forgiveness plays a role in resilience among patients with chronic pain (but not in the severity of the pain). Resilience is also enhanced in people who develop effective coping skills for stress. Coping skills help people reduce stress levels, so they remain functional. Coping skills include using meditation, exercise, socialization, and self-care practices to maintain a healthy level of stress. Bibliotherapy, positive tracking of events, and enhancing psychosocial protective factors with positive psychological resources are other methods for resilience building. Increasing a person's arsenal of coping skills builds resilience. A study of 230 adults, diagnosed with depression and anxiety, showed that emotional regulation contributed to resilience in patients. The emotional regulation strategies focused on planning, positively reappraising events, and reducing rumination. Patients with improved resilience experienced better treatment outcomes than patients with non-resilience focused treatment plans. This suggests psychotherapeutic interventions may better handle mental disorders by focusing on psychological resilience. Other factors associated with resilience include the capacity to make realistic plans, self-confidence and a positive self image, communications skills, and the capacity to manage strong feelings and impulses. Children Adverse childhood experiences (ACEs) are events that occur in a child's life that could lead to maladaptive symptoms such as tension, low mood, repetitive and recurring thoughts, and . Maltreated children who experience some risk factors (e.g., single parenting, limited maternal education, or family unemployment), show lower ego-resilience and intelligence than children who were not maltreated. Maltreated children are also more likely to withdraw and demonstrate behavior problems. Ego-resiliency and positive self-esteem predict competent adaptation in maltreated children. Psychological resilience which helps overcome adverse events does not solely explain why some children experience post-traumatic growth and some do not. Resilience is the product of a number of developmental processes over time that allow children to experience small exposures to adversity or age appropriate challenges and develop skills to handle those challenges. This gives children a sense of pride and self-worth. Two "protective factors"—characteristics of children or situations that help children in the context of risk—are good cognitive functioning (like cognitive self-regulation and IQ) and positive relationships (especially with competent adults, like parents). Children who have protective factors in their lives tend to do better in some risky contexts. However, children do better when not exposed to high levels of risk or adversity. There are a few protective factors of young children that are consistent over differences in culture and stressors (poverty, war, divorce of parents, natural disasters, etc.): capable parenting other close relationships intelligence self-control motivation to succeed self-confidence and self-efficacy faith, hope, belief life has meaning effective schools effective communities effective cultural practices Ann Masten calls these protective factors "ordinary magic"—the ordinary human adaptive systems that are shaped by biological and cultural evolution. In her book, Ordinary Magic: Resilience in Development, she discusses the "immigrant paradox", the phenomenon that first-generation immigrant youth are more resilient than their children. Researchers hypothesize that "there may be culturally based resiliency that is lost with succeeding generations as they become distanced from their culture of origin." Another hypothesis is that those who choose to immigrate are more likely to be more resilient. Neurocognitive resilience Trauma is defined as an emotional response to distressing event, and PTSD is a mental disorder the develops after a person has experienced a dangerous event, for instance car accident or environmental disaster. The findings of a study conducted on a sample of 226 individuals who had experienced trauma indicate a positive association between resilience and enhanced nonverbal memory, as well as a measure of emotional learning. The findings of the study indicate that individuals who exhibited resilience demonstrated a lower incidence of depressed and post-traumatic stress disorder (PTSD) symptoms. Conversely, those who lacked resilience exhibited a higher likelihood of experiencing unemployment and having a history of suicide attempts. The research additionally revealed that the experience of severe childhood abuse or exposure to trauma was correlated with a lack of resilience. The results indicate that resilience could potentially serve as a substitute measure for emotional learning, a process that is frequently impaired in stress-related mental disorders. This finding has the potential to enhance our comprehension of resilience. Young adults Sports provide benefits such as social support or a boost in self confidence. The findings of a study investigating the correlation between resilience and symptom resolution in adolescents and young adults who have experienced sport-related concussions (SRC) indicate that individuals with lower initial resilience ratings tend to exhibit a higher number and severity of post-concussion symptoms (PCSS), elevated levels of anxiety and depression, and a delayed recovery process from SRC. Additionally, the research revealed that those who initially scored lower on resilience assessments were less inclined to describe a sense of returning to their pre-injury state and experienced more pronounced exacerbation of symptoms resulting from both physical and cognitive exertion, even after resuming sports or physical activity. This finding illustrates the significant impact that resilience can have on the process of physical and mental recovery. Role of the family Family environments that are caring and stable, hold high expectations for children's behavior, and encourage participation by children in the life of the family are environments that more successfully foster resilience in children. Most resilient children have a strong relationship with at least one adult (not always a parent), and this relationship helps to diminish risk associated with family discord. Parental resilience—the ability of parents to deliver competent high-quality parenting, despite the presence of risk factors—plays an important role in children's resilience. Understanding the characteristics of quality parenting is critical to the idea of parental resilience. However, resilience research has focused on the well-being of children, with limited academic attention paid to factors that may contribute to the resilience of parents. Even if divorce produces stress, the availability of social support from family and community can reduce this stress and yield positive outcomes. A family that emphasizes the value of assigned chores, caring for brothers or sisters, and the contribution of part-time work in supporting the family helps to foster resilience. Some practices that poor parents utilize help to promote resilience in families. These include frequent displays of warmth, affection, and emotional support; reasonable expectations for children combined with straightforward, not overly harsh discipline; family routines and celebrations; and the maintenance of common values regarding money and leisure. According to sociologist Christopher B. Doob, "Poor children growing up in resilient families have received significant support for doing well as they enter the social world—starting in daycare programs and then in schooling." The Besht model of natural resilience-building through parenting, in an ideal family with positive access and support from family and friends, has four key markers: realistic upbringing effective risk communications positivity and restructuring of demanding situations building self efficacy and hardiness In this model, self-efficacy is the belief in one's ability to organize and execute the courses of action required to achieve goals and hardiness is a composite of interrelated attitudes of commitment, control, and challenge. Role of school Resilient children in classroom environments work and play well, hold high expectations, and demonstrate locus of control, self-esteem, self-efficacy, and autonomy. These things work together to prevent the debilitating behaviors that are associated with learned helplessness. Research on Mexican–American high school students found that a sense of belonging to school was the only significant predictor of academic resilience, though a sense of belonging to family, a peer group, and a culture higher academic resilience. "Although cultural loyalty overall was not a significant predictor of resilience, certain cultural influences nonetheless contribute to resilient outcomes, like familism and cultural pride and awareness." The results "indicate a negative relationship between cultural pride and the ethnic homogeneity of a school." The researchers hypothesize that "ethnicity becomes a salient and important characteristic in more ethnically diverse settings". A strong connection with one's cultural identity is an important protective factor against stress and is indicative of increased resilience. While classroom resources have been created to promote resilience in students, the most effective ways to ensure resilience in children is by protecting their natural adaptive systems from breaking down or being hijacked. At home, resilience can be promoted through a positive home environment and emphasizing cultural practices and values. In school, this can be done by ensuring that each student develops and maintains a sense of belonging to the school through positive relationships with classroom peers and a caring teacher. A sense of belonging—whether it be in a culture, family, or another group—predicts resiliency against any given stressor. Role of the community Communities play a role in fostering resilience. The clearest sign of a cohesive and supportive community is the presence of social organizations that provide healthy human development. Services are unlikely to be used unless there is good communication about them. Children who are repeatedly relocated do not benefit from these resources, as their opportunities for resilience-building community participation are disrupted with every relocation. Outcomes in adulthood Patients who show resilience to adverse events in childhood may have worse outcomes later in life. A study in the American Journal of Psychiatry interviewed 1420 participants with a Child and Adolescent Psychiatric Assessment up to 8 times as children. Of those 1,266 were interviewed as adults, and this group had higher risks for anxiety, depression and problems with work or education. This was accompanied by worse physical health outcomes. The study authors posit that the goal of public health should be to reduce childhood trauma, and not promote resilience. Specific situations Divorce Cultivating resilience may be beneficial to all parties involved in divorce. The level of resilience a child will experience after their parents have split is dependent on both internal and external variables. Some of these variables include their psychological and physical state and the level of support they receive from their schools, friends, and family friends. Children differ by age, gender, and temperament in their capacity to cope with divorce. About 20–25% of children "demonstrate severe emotional and behavioral problems" when going through a divorce, compared to 10% of children exhibiting similar problems in married families. Despite this, approximately 75–80% of these children will "develop into well-adjusted adults with no lasting psychological or behavioral problems". This goes to show that most children have the resilience needed to endure their parents' divorce. The effects of the divorce extend past the separation of the parents. Residual conflict between parents, financial problems, and the re-partnering or remarriage of parents can cause stress. Studies have shown conflicting results about the effect of post-divorce conflict on a child's healthy adjustment. Divorce may reduce children's financial means and associated lifestyle. For example, economizing may mean a child cannot continue to participate in extracurricular activities such as sports and music lessons, which can be detrimental to their social lives. A parent's repartnering or remarrying can add conflict and anger to a child's home environment. One reason re-partnering causes additional stress is because of the lack of clarity in roles and relationships; the child may not know how to react and behave with this new quasi-parent figure in their life. Bringing in a new partner/spouse may be most stressful when done shortly after the divorce. Divorce is not a single event, but encompasses multiple changes and challenges. Internal factors promote resiliency in the child, as do external factors in the environment. Certain programs such as the 14-week Children's Support Group and the Children of Divorce Intervention Program may help a child cope with the changes that occur from a divorce. Bullying Beyond preventing bullying, it is also important to consider interventions based on emotional intelligence when bullying occurs. Emotional intelligence may foster resilience in victims. When a person faces stress and adversity, especially of a repetitive nature, their ability to adapt is an important factor in whether they have a more positive or negative outcome. One study examining adolescents who illustrated resilience to bullying found higher behavioral resilience in girls and higher emotional resilience in boys. The study's authors suggested the targeting of psychosocial skills as a form of intervention. Emotional intelligence promotes resilience to stress and the ability to manage stress and other negative emotions can restrain a victim from going on to perpetuate aggression. Emotion regulation is an important factor in resilience. Emotional perception significantly facilitates lower negative emotionality during stress, while emotional understanding facilitates resilience and correlates with positive affect. Natural disasters Resilience after a natural disaster can be gauged on an individual level (each person in the community), a community level (everyone collectively in the affected locality), and on a physical level (the locality's environment and infrastructure). UNESCAP-funded research on how communities show resiliency in the wake of natural disasters found that communities were more physically resilient if community members banded together and made resiliency a collective effort. Social support, especially the ability to pool resources, is key to resilience. Communities that pooled social, natural, and economic resources were more resilient and could overcome disasters more quickly than communities that took a more individualistic approach. The World Economic Forum met in 2014 to discuss resiliency after natural disasters. They concluded that countries that are more economically sound, and whose members can diversify their livelihoods, show higher levels of resiliency. this had not been studied in depth, but the ideas discussed in this forum appeared fairly consistent with existing research. Individual resilience in the wake of natural disasters can be predicted by the level of emotion the person experienced and was able to process during and following the disaster. Those who employ emotional styles of coping were able to grow from their experiences and to help others. In these instances, experiencing emotions was adaptive. Those who did not engage with their emotions and who employed avoidant and suppressive coping styles had poorer mental health outcomes following disaster. Death of a family member little research had been done on the topic of family resilience in the wake of the death of a family member. Clinical attention to bereavement has focused on the individual mourning process rather than on the family unit as a whole. Resiliency in this context is the "ability to maintain a stable equilibrium" that is conducive to balance, harmony, and recovery. Families manage familial distortions caused by the death of the family member by reorganizing relationships and changing patterns of functioning to adapt to their new situation. People who exhibiting resilience in the wake of trauma can successfully traverse the bereavement process without long-term negative consequences. One of the healthiest behaviors displayed by resilient families in the wake of a death is honest and open communication. This facilitates an understanding of the crisis. Sharing the experience of the death can promote immediate and long-term adaptation. Empathy is a crucial component in familial resilience because it allows mourners to understand other positions, tolerate conflict, and grapple with differences that may arise. Another crucial component to resilience is the maintenance of a routine that binds the family together through regular contact and order. The continuation of education and a connection with peers and teachers at school is an important support for children struggling with the death of a family member. Professional settings Resilience has been examined in the context of failure and setbacks in workplace settings. Psychological resilience is one of the core constructs of positive organizational behavior and has captured scholars' and practitioners' attention. Research has highlighted certain personality traits, personal resources (e.g., self-efficacy, work-life balance, social competencies), personal attitudes (e.g., sense of purpose, job commitment), positive emotions, and work resources (e.g., social support, positive organizational context) as potential facilitators of workplace resilience. Attention has also been directed to the role of resilience in innovative contexts. Due to high degrees of uncertainty and complexity in the innovation process, failure and setbacks happen frequently in this context. These can harm affected individuals' motivation and willingness to take risks, so their resilience is essential for them to productively engage in future innovative activities. A resilience construct specifically aligned to the peculiarities of the innovation context was needed to diagnose and develop innovators' resilience: Innovator Resilience Potential (IRP). Based on Bandura's social cognitive theory, IRP has six components: self-efficacy, outcome expectancy, optimism, hope, self-esteem, and risk propensity. It reflects a process perspective on resilience: IRP can be interpreted either as an antecedent of how a setback affects an innovator, or as an outcome of the process that is influenced by the setback situation. A measurement scale of IRP was developed and validated in 2018. Cultural differences There is controversy about the indicators of good psychological and social development when resilience is studied across different cultures and contexts. The American Psychological Association's Task Force on Resilience and Strength in Black Children and Adolescents, for example, notes that there may be special skills that these young people and families have that help them cope, including the ability to resist racial prejudice. Researchers of indigenous health have shown the impact of culture, history, community values, and geographical settings on resilience in indigenous communities. People who cope may also show "hidden resilience" when they do not conform with society's expectations for how someone is supposed to behave (for example, in some contexts aggression may aid resilience, or less emotional engagement may be protective in situations of abuse). Resilience in individualist and collectivist communities Individualist cultures, such as those of the U.S., Austria, Spain, and Canada, emphasize personal goals, initiatives, and achievements. Independence, self-reliance, and individual rights are highly valued by members of individualistic cultures. The ideal person in individualist societies is assertive, strong, and innovative. People in this culture tend to describe themselves in terms of their unique traits—"I am analytical and curious". Economic, political, and social policies reflect the culture's interest in individualism. Collectivist cultures, such as those of Japan, Sweden, Turkey, and Guatemala, emphasize family and group work goals. The rules of these societies promote unity, brotherhood, and selflessness. Families and communities practice cohesion and cooperation. The ideal person in collectivist societies is trustworthy, honest, sensitive, and generous—emphasizing intrapersonal skills. Collectivists tend to describe themselves in terms of their roles—"I am a good husband and a loyal friend". In a study on the consequences of disaster on a culture's individualism, researchers operationalized these cultures by identifying indicative phrases in a society's literature. Words that showed the theme of individualism include, "able, achieve, differ, own, personal, prefer, and special." Words that indicated collectivism include, "belong, duty, give, harmony, obey, share, together." Differences in response to natural disasters Natural disasters threaten to destroy communities, displace families, degrade cultural integrity, and diminish an individual's level of functioning. Comparing individualist community reactions to collectivist community responses after natural disasters illustrates their differences and respective strengths as tools of resilience. Some suggest that because disasters strengthen the need to rely on other people and social structures, they reduce individual agency and the sense of autonomy, and so regions with heightened exposure to disaster should cultivate collectivism. However, interviews with and experiments on disaster survivors indicate that disaster-induced anxiety and stress decrease one's focus on social-contextual information—a key component of collectivism. So disasters may increase individualism. In a study into the association between socio-ecological indicators and cultural-level change in individualism, for each socio-ecological indicator, frequency of disasters was associated with greater (rather than less) individualism. Supplementary analyses indicated that the frequency of disasters was more strongly correlated with individualism-related shifts than was the magnitude of disasters or the frequency of disasters qualified by the number of deaths. Baby-naming is one indicator of change. Urbanization was linked to preference for uniqueness in baby-naming practices at a one-year lag, secularism was linked to individualist shifts in interpersonal structure at both lags, and disaster prevalence was linked to more unique naming practices at both lags. Secularism and disaster prevalence contributed to shifts in naming practices. Disaster recovery research focuses on psychology and social systems but does not adequately address interpersonal networking or relationship formation and maintenance. One disaster response theory holds that people who use existing communication networks fare better during and after disasters. Moreover, they can play important roles in disaster recovery by organizing and helping others use communication networks and by coordinating with institutions. Building strong, self-reliant communities whose members know each other, know each other's needs, and are aware of existing communication networks, is a possible source of resilience in disasters. Individualist societies promote individual responsibility for self-sufficiency; collectivist culture defines self-sufficiency within an interdependent communal context. Even where individualism is salient, a group thrives when its members choose social over personal goals and seek to maintain harmony, and where they value collectivist over individualist behavior. The concept of resilience in language While not all languages have a direct translation for the English word "resilience", nearly every culture has a word that relates to a similar concept, suggesting a common understanding of what resilience is. Even if a word does not directly translate to "resilience" in English, it relays a meaning similar enough to the concept and is used as such within the language. If a specific word for resilience does not exist in a language, speakers of that language typically assign a similar word that insinuates resilience based on context. Many languages use words that translate to "elasticity" or "bounce", which are used in context to capture the meaning of resilience. For example, one of the main words for "resilience" in Chinese literally translates to "rebound", one of the main words for "resilience" in Greek translates to "bounce" (another translates to "cheerfulness"), and one of the main words for "resilience" in Russian translates to "elasticity," just as it does in German. However, this is not the case for all languages. For example, if a Spanish speaker wanted to say "resilience", their main two options translate to "resistance" and "defense against adversity". Many languages have words that translate better to "tenacity" or "grit" better than they do to "resilience". While these languages may not have a word that exactly translates to "resilience", English speakers often use the words tenacity or grit when referring to resilience. Arabic has a word solely for resilience, but also two other common expressions to relay the concept, which directly translate to "capacity on deflation" or "reactivity of the body", but are better translated as "impact strength" and "resilience of the body" respectively. A few languages, such as Finnish, have words that express resilience in a way that cannot be translated back to English. In Finnish, the word and concept "" has been recently studied by a designated Sisu Scale, which is composed of both beneficial and harmful sides of . , measured by the Sisu Scale, has correlations with English langugage equivalents, but the harmful side of does not seem to have any corresponding concept in English-language-based scales. Sometimes has been translated to "grit" in English; blends the concepts of resilience, tenacity, determination, perseverance, and courage into one word that has become a facet of Finnish culture. Measurement Direct measurement Resilience is measured by evaluating personal qualities that reflect people's approach and response to negative experiences. Trait resilience is typically assessed using two methods: direct evaluation of traits through resilience measures, and proxy assessment of resilience, in which related psychological constructs are used to explain resilient outcomes. There are more than 30 resilience measures that assess over 50 different variables related to resilience, but there is no universally accepted "gold standard" for measuring resilience. Five of the established self-report measures of psychological resilience are: Ego Resiliency Scale measures a person's ability to exercise control over their impulses or inhibition in response to environmental demands, with the aim of maintaining or enhancing their ego equilibrium. Hardiness Scale encompasses three main dimensions: (1) commitment (a conviction that life has purpose), (2) control (confidence in one's ability to navigate life), and (3) challenge (aptitude for and pleasure in adapting to change) Psychological Resilience Scale assesses a "resilience core" characterized by five traits (purposeful life, perseverance, self-reliance, equanimity, and existential aloneness) that reflect an individual's physical and mental resilience throughout their lifespan Connor-Davidson Resilience Scale developed in a clinical treatment setting that conceptualized resilience as arising from four factors: Brief Resilience Scale assesses resilience as the capacity to bounce back from unfavorable circumstances The Resilience Systems Scales was produced to investigate and measure the underlying structure of the 115 items from these five most-commonly cited trait resilience scales in the literature. Three strong latent factors account for most of the variance accounted for by the five most popular resilience scales, and replicated ecological systems theory: Engineering resilience The capability of a system to quickly and effortlessly restore itself to a stable equilibrium state after a disruption, as measured by its speed and ease of recovery. Ecological resilience The capacity of a system to endure or resist disruptions while preserving a steady state and adapting to necessary changes in its functioning. Adaptive capacity The ability to continuously adjust functions and processes in order to be ready to adapt to any disruption. 'Proxy' measurement Resilience literature identifies five main trait domains that serve as stress-buffers and can be used as proxies to describe resilience outcomes: personality A resilient personality includes positive expressions of the five-factor personality traits such as high emotional stability, extraversion, conscientiousness, openness, and agreeableness. cognitive abilities and executive functions Resilience is identified through effective use of executive functions and processing of experiential demands, or through an overarching cognitive mapping system that integrates information from current situations, prior experience, and goal-driven processes. affective systems, which include emotional regulation systems Emotion regulation systems are based on the broaden-and-build theory, in which there is . eudaimonic well-being resilience emerges from natural well-being processes (e.g. autonomy, purpose in life, environmental mastery) and underlying genetic and neural substrates and acts as a protective resilient factor across life-span transitions. health systems This also reflects the broaden-and-build theory, where there is a reciprocal relationship between trait resilience and positive health functioning through the promotion of feeling capable to deal with adverse health situations. Mixed model A mixed model of resilience can be derived from direct and proxy measures of resilience. A search for latent factors among 61 direct and proxy resilience assessments, suggested four main factors: recovery Resilience scales that focus on recovery, such as engineering resilience, align with reports of stability in emotional and health systems. The most fitting theoretical framework for this is the broaden-and-build theory of positive emotions. This theory highlights how positive emotions can foster resilient health systems and enable individuals to recover from setbacks. sustainability Resilience scales that reflect "sustainability," such as engineering resilience, align with conscientiousness, lower levels of dysexecutive functioning, and five dimensions of eudaimonic well-being. Theoretically, resilience is the effective use of executive functions and processing of experiential demands (also known as resilient functioning), where an overarching cognitive mapping system integrates information from current situations, prior experience, and goal-driven processes (known as the cognitive model of resilience). adaptability resilience Resilience scales that assess adaptability, such as adaptive capacity, are associated with higher levels of extraversion (such as being enthusiastic, talkative, assertive, and gregarious) and openness-to-experience (such as being intellectually curious, creative, and imaginative). These personality factors are often reported to form a higher-order factor known as "beta" or "plasticity", which reflects a drive for growth, agency, and reduced inhibition by preferring new and diverse experiences while reducing fixed patterns of behavior. These findings suggest that adaptability can be seen as a complement to growth, agency, and reduced inhibition. social cohesion Several resilience measures converge to suggest an underlying social cohesion factor, in which social support, care, and cohesion among family and friends (as featured in various scales within the literature) form a single latent factor. These findings point to the possibility of adopting a "mixed model" of resilience in which direct assessments of resilience could be employed alongside cognate psychological measures to improve the evaluation of resilience. Criticism As with other psychological phenomena, there is controversy about how resilience should be defined. Its definition affects research focuses; differing or imprecise definitions lead to inconsistent research. Research on resilience has become more heterogeneous in its outcomes and measures, convincing some researchers to abandon the term altogether due to it being attributed to all outcomes of research where results were more positive than expected. There is also disagreement among researchers as to whether psychological resilience is a character trait or state of being. Psychological resilience has also been referred to . However, it is generally agreed upon that resilience is a buildable resource. There is also evidence that resilience can indicate a capacity . Adolescents who have a high level of adaptation (i.e. resilience) tend to struggle with dealing with other psychological problems later on in life. This is due to an overload of their stress response systems. There is evidence that the higher one's resilience is, the lower one's vulnerability. Brad Evans and Julian Reid criticize resilience discourse and its rising popularity in their book, Resilient Life. The authors assert that can put the onus of disaster response on individuals rather than publicly coordinated efforts. Tied to the emergence of neoliberalism, climate change, third-world development, and other discourses, Evans and Reid argue that promoting resilience draws attention away from governmental responsibility and towards self-responsibility and healthy psychological effects such as post-traumatic growth. See also References Further reading External links National Resilience Resource Center Research on resilience at Dalhousie University Motivation Psychological adjustment Psychological resilience Self-sustainability

Self-care

Self-care has been defined as the process of establishing behaviors to ensure holistic well-being of oneself, to promote health, and actively manage illness when it occurs. Individuals engage in some form of self-care daily with food choices, exercise, sleep, and hygiene. Self-care is not only a solo activity, as the community—a group that supports the person performing self-care—overall plays a role in access to, implementation of, and success of self-care activities. Routine self-care is important when someone is not experiencing any symptoms of illness, but self-care becomes essential when illness occurs. General benefits of routine self-care include prevention of illness, improved mental health, and comparatively better quality of life. Self-care practices vary from individual to individual. Self-care is seen as a partial solution to the global rise in health care costs that is placed on governments worldwide. A lack of self-care in terms of personal health, hygiene and living conditions is referred to as self-neglect. Caregivers or personal care assistants may be needed. There is a growing body of knowledge related to these home care workers. Self-care and self-management, as described by Lorig and Holman, are closely related concepts. In their spearheading paper, they defined three self-management tasks: medical management, role management, and emotional management; and six self-management skills: problem solving, decision making, resource utilization, the formation of a patient–provider partnership, action planning, and self-tailoring. History While the concept of self care has received increased attention in recent years, it has ancient origins. Socrates has been credited with founding the self-care movement in ancient Greece, and care are of oneself and loved ones has been shown to exist since human beings appeared on earth. Self-care has also been connected to the Black feminist movement through civil rights activist and poet Audre Lorde. Self-care was used to preserve black feminist's identities, energize their activism, and preserve their minds during the civil rights movement. Self-care remains a primary form of personal and community healthcare worldwide; self-care practices vary greatly around the world. Self-care and illness Chronic illness (a health condition that is persistent and long lasting, often impacts one's whole life, e.g., heart failure, diabetes, high blood pressure) requires behaviors that control the illness, decrease symptoms, and improve survival such as medication adherence and symptom monitoring. An acute illness like an infection (e.g., COVID) requires the same types of self-care behaviors required of people with a chronic illness, but the medication adherence and symptom monitoring behaviors associated with an acute illness are typically short lived. Routine health maintenance self-care behaviors that individuals engage in (e.g., adequate sleep) are still required of those dealing with acute or chronic illness. For the majority of people with a chronic illness, time spent having that illness managed by a health professional is vastly outweighed by time spent in self-care. It has been estimated that most people with a chronic illness spend only about 0.001% or 10 hours per year of their time with a healthcare provider. In people with chronic illness, self-care is associated with fewer symptoms, fewer hospitalizations, better quality of life, and longer survival compared to individuals in whom self-care is poor. Self-care can be physically and mentally difficult for those with chronic illness, as their illness is persistent and treated in a vastly different manner from an acute illness. Factors influencing self-care There are numerous factors that affect self-care. These factors can be grouped as personal factors (e.g., person, problem, and environment), external factors, and processes. Personal factors: Lack of motivation: when one doesn’t have enough energy. This can be caused by stress, anxiety, or other mental health illnesses. Cultural beliefs: this includes traditional gender roles, family relationships, collectivism. This can also affect self care behaviors. Self-efficacy or confidence: one’s confidence can positively or negatively affect their mental state. Functional and cognitive abilities: by not being perfect humans, one tends to focus on their weakness. Support from others: such as from family or friends can be crucial to have a healthy and positive mindset to do self-care. Access to care: depending on the self-care some require specific resources or objects in order to carry out. External factors: Living situation: can greatly affect an individual’s self-care. Surrounding environment: must be safe and promote self-care for all residents. Proximity of health care facilities: are important to have at a close radius from one’s household. As well as office/clinic opening hours and affordability must be taken into consideration. Processes: Experiences Knowledge Skill Values Self-care practices are shaped by what are seen as the proper lifestyle choices of local communities. Social determinants of health play an important role in self-care practices. Internal personal factors such as motivation, emotions, and cognitive abilities also influence self-care maintenance behaviors. Motivation is often the driving force behind performing self-care maintenance behaviors. Goal setting is a practice associated with motivated self care. A person with depression is more likely to have a poor dietary intake low in fruits and vegetables, reduced physical activity, and poor medication adherence. An individual with impaired cognitive or functional abilities (e.g., memory impairment) also has a diminished capacity to perform self-care maintenance behaviors such as medication adherence which relies on memory to maintain a schedule. Self-care is influenced by an individual's attitude and belief in his or her self-efficacy or confidence in performing tasks and overcoming barriers. Cultural beliefs and values may also influence self-care. Cultures that promote a hard-working lifestyle may view self-care in contradictory ways Personal values have been shown to have an effect on self-care in Type 2 Diabetes Mellitus. Social support systems can influence how an individual performs self-care maintenance. Social support systems include family, friends, and other community or religious support groups. These support systems provide opportunities for self-care discussions and decisions. Shared care can reduce stress on individuals with chronic illness. There are numerous self-care requisites applicable to all individuals of all ages for the maintenance of health and well-being. The balance between solitude or rest, and activities such as social interactions is a key tenet of self-care practices. The prevention and avoidance of human hazards and participation in social groups are also requisites. The autonomous performance of self-care behaviors is thought to aid elderly patients. Perceived autonomy, self-efficacy and adequate illness representation are additional elements of self-care, which are said to aid people with chronic conditions. Measurement of self-care behaviors A variety of self-report instruments have been developed to allow clinicians and researchers to measure the level of self-care in different situations for both patients and their caregivers: These instruments are freely available in numerous languages. Many of these instruments have a caregiver version available to encourage dyadic research. Self-Care Heart Failure Index Self-Care of Hypertension Inventory Self-Care of Diabetes Inventory Self-Care of Coronary Heart Disease Inventory Self-Care of Chronic Illness Inventory Self-care of Chronic Obstructive Pulmonary Disease Middle-range theory of self-care of chronic illness According to the middle-range theory of chronic illness, these behaviors are captured in the concepts of self-care maintenance, self-care monitoring, and self-care management. Self-care maintenance refers to those behaviors used to maintain physical and emotional stability. Self-care monitoring is the process of observing oneself for changes in signs and symptoms. Self-care management is the response to signs and symptoms when they occur. The recognition and evaluation of symptoms is a key aspect of self-care. Below these concepts are discussed both as general concepts and as specific self-care behaviors are (e.g., exercise). Self-care maintenance Self-care maintenance refers to those behaviors performed to improve well-being, preserve health, or to maintain physical and emotional stability. Self-care maintenance behaviours include illness prevention and maintaining proper hygiene. Specific illness prevention measures include tobacco avoidance, regular exercise, and a healthy diet. Taking medication as prescribed by a healthcare provider and receiving vaccinations are also important specific self-care behaviors. Vaccinations provide immunity for the body to actively prevent an infectious disease. Tobacco use is the largest preventable cause of death and disease in the US. Overall health and quality of life have been found to improve, and the risk of disease and premature death are reduced due to the decrease in tobacco intake. The benefits of regular physical activity include weight control; reduced risk of chronic disease; strengthened bones and muscles; improved mental health; improved ability to participate in daily activities; and decreased mortality. The Centre for Disease Control and Prevention (CDC) recommends two hours and thirty minutes of moderate activity each week, including brisk walking, swimming, or bike riding. Another aspect of self-care maintenance is a healthy diet consisting of a wide variety of fresh fruits and vegetables, lean meats, and other proteins. Processed foods including fats, sugars, and sodium are to be avoided, under the practice of self-care. Hygiene is another important part of self-care maintenance. Hygienic behaviors include adequate sleep, regular oral care, and hand washing. Getting seven to eight hours of sleep each night can protect physical and mental health. Sleep deficiency increases the risk of heart disease, kidney disease, high blood pressure, diabetes, excess weight, and risk-taking behaviour. Tooth brushing and personal hygiene can prevent oral infections. Health-related self-care topics include; General fitness training and physical exercise Healthy diet, meals, diet foods and fasting Smoking cessation and avoiding excessive alcohol use Personal hygiene Life extension Pain management Stress management Self-help and personal development Self-care portals and the use of health apps Objective Measures of Specific Self-Care Maintenance Behaviors: Interventions to improve maintenance behaviors Self-care is considered to be a continuous learning process. Knowledge is essential but not sufficient to improve self-care. Multifaceted interventions that tailor education to the individual are more effective than patient education alone. "Teach-back" is used to gauge how much information is retained after patient teaching. Teach-back occurs when patients are asked to repeat information that was given to them. The educator checks for gaps in the patient's understanding, reinforces messages, and creates a collaborative conversation with the patient. It is important for individuals with a chronic illness to comprehend and recall information received about their condition. Teach-back education can both educate patients and assess learning. For example, a provider can initiate teach-back is by asking, "I want to make sure that I explained everything clearly. If you were talking to your neighbor, what would you tell her/him we talked about today". This phrase protects the patient's self-esteem while placing responsibility for understanding on both the provider and patient. One study performed showed that patients with heart failure who received teach-back education had a 12% lower readmission rate compared to patients who did not receive teach-back. Although the teach-back method is effective in the short-term, there is little evidence to support its long-term effect. Long-term knowledge retention is crucial for self-care, so further research is needed on this approach. Habits are automatic responses to commonly encountered situations such as handwashing after restroom use. A habit is formed when environmental cues result in a behavior with minimal conscious deliberation. Behavioral economics is a subset of the study of economics that examines how cognitive, social, and emotional factors play in role in an individual's economic decisions. Behavioral economics is now influencing the design of healthcare interventions aimed at improving self-care maintenance. Behavioral economics takes into account the complexity and irrationality of human behavior. Motivational interviewing is a way to engage critical thinking in relation to self-care needs. Motivational interviewing uses an interviewing style that focuses on the individual's goals in any context. Motivational interviewing is based on three psychological theories: cognitive dissonance, self-perception, and the transtheoretical model of change. Motivational interviewing is intended to enhance intrinsic motivation for change. Health coaching is a method of promoting motivation to initiate and maintain behavioral change. The health coach facilitates behavioral change by emphasizing personal goals, life experiences, and values. Monitoring Self-care monitoring is the process of surveillance that involves measurement and perception of bodily changes, or "body listening". It can be helpful to understand the concept of bodymind when monitoring self-care. Effective self-care monitoring also requires the ability to label and interpret changes in the body as normal or abnormal. Recognizing bodily signs and symptoms, understanding disease progression, and their respective treatments allow competency in knowing when to seek further medical help. Self-care monitoring consists of both the perception and measurement of symptoms. Symptom perception is the process of monitoring one's body for signs of changing health. This includes body awareness or body listening, and the recognition of symptoms relevant to health. Changes in health status or body function can be monitored with various tools and technologies. The range and complexity of medical devices used in both hospital and home care settings are increasing. Certain devices are specific to a common need of a disease process such as glucose monitors for tracking blood sugar levels in diabetic patients. Other devices can provide a more general set of information, such as a weight scale, blood pressure cuff, pulse oximeter, etc. Less technological tools include organizers, charts, and diagrams to trend or keep track of progress such as the number of calories, mood, vital sign measurements, etc. Barriers to monitoring The ability to engage in self-care monitoring impacts disease progression. Barriers to monitoring can go unrecognized and interfere with effective self-care. Barriers include knowledge deficits, undesirable self-care regimens, different instructions from multiple providers, and limitations to access related to income or disability. Psychosocial factors such as motivation, anxiety, depression, confidence can also serve as barriers. High costs may prevent some individuals from acquiring monitoring equipment to keep track of symptoms. Lack of knowledge on the implications of physiological symptoms such as high blood glucose levels may reduce an individual's motivation to practice self-care monitoring. Fear of outcomes/fear of using equipment such as needles may deter patients from practicing self-care monitoring due to the resulting anxiety, or avoidant behaviors. Lack of family support may affect consistency in monitoring self-care due to the lack of reminders or encouragement. The presence of co-morbid conditions makes performing self-care monitoring particularly difficult. For example, the shortness of breath from COPD can prevent a diabetic patient from physical exercise. Symptoms of chronic illnesses should be considered when performing self-care maintenance behaviors. Interventions to improve monitoring behaviors Because self-care monitoring is conducted primarily by patients, with input from caregivers, it is necessary to work with patients closely on this topic. Providers should assess the current self-care monitoring regimen and build off this to create an individualized plan of care. Knowledge and education specifically designed for the patient's level of understanding has been said to be central to self-care monitoring. When patients understand the symptoms that correspond with their disease, they can learn to recognize these symptoms early on. Then they can self-manage their disease and prevent complications. Additional research to improve self-care monitoring is underway in the following fields: Mindfulness: Mindfulness and meditation, when incorporated into a one-day education program for diabetic patients, have been shown to improve diabetic control in a 3-month follow-up in comparison to those who received the education without a focus on mindfulness. Decision-making: How a patient's decision making capacity can be encouraged/improved with the support of their provider, leading to better self-care monitoring and outcomes. Self-efficacy: Self-efficacy has been shown to be more closely linked to a patient's ability to perform self-care than health literacy or knowledge. Wearable technology: How self-care monitoring is evolving with technology like wearable activity monitors. Management Self-care management is defined as the response to signs and symptoms when they occur. Self-care management involves the evaluation of physical and emotional changes and deciding if these changes need to be addressed. Changes may occur because of illness, treatment, or the environment. Once treatment is complete, it should be evaluated to judge whether it would be useful to repeat in the future. Treatments are based on the signs and symptoms experienced. Treatments are usually specific to the illness. Self-care management includes recognizing symptoms, treating the symptoms, and evaluating the treatment. Self-care management behaviors are symptom- and disease-specific. For example, a patient with asthma may recognize the symptom of shortness of breath. This patient can manage the symptom by using an inhaler and seeing if their breathing improves. A patient with heart failure manages their condition by recognizing symptoms such as swelling and shortness of breath. Self-care management behaviors for heart failure may include taking a water pill, limiting fluid and salt intake, and seeking help from a healthcare provider. Regular self-care monitoring is needed to identify symptoms early and judge the effectiveness of treatments. Some examples include: Inject insulin in response to high blood sugar and then re-check to evaluate if blood glucose lowered Use social support and healthy leisure activities to fight feelings of social isolation. This has been shown to be effective for patients with chronic lung disease Barriers to management Access to care Access to care is a major barrier affecting self-care management. Treatment of symptoms might require consultation with a healthcare provider. Access to the health-care system is largely influenced by providers. Many people with a chronic illness do not have access to providers within the health-care system for several reasons. Three major barriers to care include: insurance coverage, poor access to services, and being unable to afford costs. Without access to trained health care providers, outcomes are typically worse. Financial constraints Financial barriers impact self-care management. The majority of insurance coverage is provided by employers. Loss of employment is frequently accompanied by loss of health insurance and inability to afford health care. In patients with diabetes and chronic heart disease, financial barriers are associated with poor access to care, poor quality of care, and vascular disease. As a result, these patients have reduced rates of medical assessments, measurements of Hemoglobin A1C (a marker that assesses blood glucose levels over the last 3 months), cholesterol measurements, eye and foot examinations, diabetes education, and aspirin use. Research has found that people in higher social classes are better at self-care management of chronic conditions. In addition, people with lower levels of education often lack resources to effectively engage in self-management behaviors. Age Elderly patients are more likely to rate their symptoms differently and delay seeking care longer when they have symptoms. An elderly person with heart failure will experience the symptom of shortness of breath differently than someone with heart failure who is younger. Providers should be aware of the potential delay in provider-seeking behavior in elderly patients which could worsen their overall condition. Prior experience Prior experience contributes to the development of skills in self-care management. Experience helps the patient develop cues and patterns that they can remember and follow, leading to reasonable goals and actions in repeat situations. A patient who has skills in self-management knows what to do during repeated symptomatic events. This could lead to them recognizing their symptoms earlier, and seeking a provider sooner. Health care literacy Health care literacy is another factor affecting self-care management. Health care literacy is the amount of basic health information people can understand. Health care literacy is the major variable contributing to differences in patient ratings of self-management support. Successful self-care involves understanding the meaning of changes in one's body. Individuals who can identify changes in their bodies are then able to come up with options and decide on a course of action. Health education at the patient's literacy level can increase the patient's ability to problem solve, set goals, and acquire skills in applying practical information. A patient's literacy can also affect their rating of healthcare quality. A poor healthcare experience may cause a patient to avoid returning to that same provider. This creates a delay in acute symptom management. Providers must consider health literacy when designing treatment plans that require self-management skills. Co-morbid conditions A patient with multiple chronic illnesses (multimorbidity) may experience compounding effects of their illnesses. This can include worsening of one condition by the symptoms or treatment of another. People tend to prioritize one of their conditions. This limits the self-care management of their other illnesses. One condition may have more noticeable symptoms than others. Or the patient may be more emotionally connected to one illness, for example, the one they have had for a long time. If providers are unaware of the effect of having multiple illnesses, the patient's overall health may fail to improve or worsen as a result of therapeutic efforts. Interventions to improve management There are many ways for patients and healthcare providers to work together to improve patients and caregivers' self-care management. Stoplight and skill teaching allow patients and providers to work together to develop decision-making strategies. Stoplight Stoplight is an action plan for the daily treatment of a patient's chronic illness created by the healthcare team and the patient. It makes decision making easier by categorizing signs and symptoms and determining the appropriate actions for each set. It separates signs and symptoms into three zones: Green is the safe zone, meaning the patient's signs and symptoms are what is typically expected. The patient should continue with their daily self-care tasks, such as taking daily medications and eating a healthy diet. Yellow is the caution zone, meaning the patient's signs and symptoms should be monitored as they are abnormal, but they are not yet dangerous. Some actions may need to be taken in this zone to go back to the green zone, for instance taking additional medication. The patient may need to contact their healthcare team for advice. Red is the danger zone, meaning the patient's signs and symptoms show that something is dangerously wrong. If in this category the patient needs to take actions to return to the green category, such as taking an emergency medication, as well as contact their healthcare team immediately. They may also need to contact emergency medical assistance. The stoplight plan helps patients to make decisions about what actions to take for different signs and symptoms and when to contact their healthcare team with a problem. The patient and their provider will customize certain signs and symptoms that fit in each stoplight category. Skills teaching Skills teaching is a learning opportunity between a healthcare provider and a patient where a patient learns a skill in self-care unique to his or her chronic illness. Some of these skills may be applied to the daily management of the symptoms of a chronic illness. Other skills may be applied when there is an exacerbation of a symptom. A patient newly diagnosed with persistent asthma might learn about taking oral medicine for daily management, control of chronic symptoms, and prevention of an asthma attack. However, there may come a time when the patient might be exposed to an environmental trigger or stress that causes an asthma attack. When unexpected symptoms such as wheezing occur, the skill of taking daily medicines and the medicine that is taken may change. Rather than taking oral medicine daily, an inhaler is needed for quick rescue and relief of symptoms. Knowing to choose the right medication and knowing how to take the medicine with an inhaler is a skill that is learned for the self-care management of asthma. In skills teaching, the patient and provider need to discuss skills and address any lingering questions. The patient needs to know when and how a skill is to be implemented, and how the skill may need to be changed when the symptom is different from normal. See the summary of tactical and situational skills above. Learning self-care management skills for the first time in the care of a chronic illness is not easy, but with patience, practice, persistence, and experience, personal mastery of self-care skills can be achieved. Support can include: Self-care information on health and human body systems, lifestyle and healthy eating. Support to capture, manage, interpret, and report observations of daily living (ODLs), the tracking of trends, and the use of the resulting information as clues for self-care action and decision making. Information prescriptions providing personalised information and instructions to enable an individual to self-care and take control of their health Self-care and self-monitoring devices and assistive technology. Medication therapy management Self-care skills and life skills training programmes and courses for people. Advice from licensed counselors, clinical social workers, psychotherapists, pharmacists, physiotherapists and complementary therapists. Self-care support networks which can be face to face or virtual, and made up of peers or people who want to provide support to others or receive support and information from others (including a self-care primer for provider/consumer convergence). Self-care in philosophy Black feminist philosophy The notion of self-care as a revolutionary act in the context of social trauma was developed as a social justice practice in Black feminist thought in the US. Notably, civil rights activist and poet Audre Lorde wrote that in the context of multiple oppressions as a black woman, "caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare." Lorde’s philosophy states that as an oppressed community member, the preservation of her identity through acts that energize and sustain her is a form of activism and resistance. This self-care focuses on any acts which are healing and beneficial to one’s survival and thereby enable resistance. This initial interpretation of self-care differs from the popularized version seen today. With the rise in social media and capitalist marketing, a more whitewashed and commercialized interpretation has shifted what is normally considered self-care. Differing from Lorde’s definition, new self-care interpretations center on the indulgence of self in accordance with white beauty standards and trends. Examples of this can be the purchasing of feminine beauty goods or sharing of activities or dietary fads. In addition to this difference, modern day self-care as advertised on social media ignores the communal aspect of care which Lorde thought to be essential. With the rise of the term in the medical usages, for instance, to combat anxiety, as well as the commercialization of products with linkages with self-care, the association of the term with black feminism has fallen away in clinical and popular usage. However, in feminist and queer theory, the link to Lorde and other scholars is retained. Western philosophy In one interpretation, French philosopher Michel Foucault understood the art of living (French art de vivre, Latin ars vivendi) and the care of self (French le souci de soi) to be central to philosophy. The third volume of his three-volume study The History of Sexuality, published in 1976, is dedicated to this notion. For Foucault, the notion of care for the self (epimeleia heautou,) following a traditionally Western (Ancient Greek and Roman) interpretation of self-care comprises an attitude towards the self, others, and the world, as well as a certain form of attention. For Foucault, the pursuit of the care for one's own well-being also comprises self-knowledge (gnōthi seauton). Later on, the self-care deficit nursing theory was developed by Dorothea Orem between 1959 and 2001. This popular Western theory centers on the medical facet of self-care, and explores the use professional care and an orientation towards resources. Under Orem's model self-care has limits when its possibilities have been exhausted therefore making professional care legitimate. These deficits in self-care are seen as shaping the best role a nurse may provide. There are two phases in Orem's self-care: the investigative and decision-making phase, and the production phase. Under this theory, Orem begins to assess the importance of others and support in a more communal form of self-care, while still centering on the physical and medical aspects of care as opposed to the more spiritual or radical political resistance theories. This idea of communal care was pioneered by the Black feminist community in an effort to preserve themselves and resist oppression. See also Executive functioning Integrative medicine Public space Shelter (building) References External links Self-care in England COMPAR-EU, EU funded project (Horizon2020) on self-management Global Self-Care Federation Association of the European Self-Care Industry Self

Animal psychopathology

Animal psychopathology is the study of mental or behavioral disorders in non-human animals. Historically, there has been an anthropocentric tendency to emphasize the study of animal psychopathologies as models for human mental illnesses. But animal psychopathologies can, from an evolutionary point of view, be more properly regarded as non-adaptive behaviors due to some sort of a cognitive disability, emotional impairment or distress. This article provides a non-exhaustive list of animal psychopathologies. Eating disorders Animals in the wild appear to be relatively free from eating disorders although their body composition fluctuates depending on seasonal and reproductive cycles. However, domesticated animals including farm, laboratory, and pet animals are prone to disorders. Evolutionary fitness drives feeding behavior in wild animals. The expectation is that farm animals also display this behavior, but questions arise if the same principles apply to laboratory and pet animals. Activity anorexia Activity anorexia (AA) is a condition where rats begin to exercise excessively while simultaneously cutting down on their food intake, similar to human anorexia nervosa or hypergymnasia. When given free access to food and an exercise wheel, rats normally develop a balanced routine between exercise and food intake, which turns them into fit rats. However, if food intake is restricted and wheel access is unrestricted, rats begin to exercise more and eat less, resulting in excessive weight loss and, ultimately, death. The running cycles shift so that most of the running is done in hours before feeding is scheduled. In other conditions, AA does not develop. Unrestricted food access and restricted wheel access will not cause any significant change in either feeding or exercise routine. Also, if rats are restricted both in food intake and wheel access, they will adjust accordingly. In fact, if rats are first trained to the feeding schedule and then given unrestricted access to a running wheel, they will not develop AA behavior. Results support the notion that the running interferes with adaptation to the new feeding schedule and is associated with the reward system in the brain. One theory is that running simulates foraging, a natural behavior in wild rats. Laboratory rats therefore run (forage) more in response to food shortages. The effect of semi-starvation on activity has also been studied in primates. Rhesus macaque males become hyperactive in response to long-term chronic food restriction. Thin sow syndrome Thin sow syndrome (TSS) is a behavior observed in stalled sows that is similar to AA where some sows after early pregnancy are extremely active, eat little, and waste away, resulting very often in death. They experience emaciation, hypothermia, a depraved appetite, restlessness, and hyperactivity. The syndrome may mainly be related to social and environmental stressors. Stress in stalled sows is often perceived as the consequence of the restraint of animals that happens in intensive production units. The sows that experience the most restraining conditions are those lactating or pregnant as they have very little room to move around because they are kept in barred gestation crates or tethered for the 16 weeks of pregnancy which prevents natural and social behaviors. However, increased movement and freedom is also stressful for adult sows, which is usually the case after weaning. When placed into groups they fight vigorously, with one dominant sow emerging that eats voraciously. It is also likely that two subordinate sows make up part of the group who actively avoid competitive feeding situations and are bullied by the dominant sow. Affected sows have poor appetite but often show pica, excessive water intake (polydipsia) and are anemic. Studies on the effects of overcrowding were conducted in the 1940s by placing pregnant Norway rats in a room with plenty of water and food and observing the population growth. The population reached a number of individuals and did not grow thereafter; overcrowding produced stress and psychopathologies. Even though there was plenty of water and food, the rats stopped eating and reproducing. Similar effects have also been observed in dense populations of beetles. When overcrowding occurs, female beetles destroy their eggs and turn cannibalistic, eating each other. Male beetles lose interest in the females and although there is plenty of water and food, there is no population growth. Similar effects have been observed in overcrowded situations in jack rabbits and deer. Pica Pica is the ingestion of non-nutritive substances and has so far been poorly documented. In non-human animals in the laboratory it has been examined through the ingestion of kaolin (a clay mineral) by rats. Rats were induced to intake kaolin by administering various emetic stimuli such as copper sulfate, apomorphine, cisplatin, and motion. Rats are unable to vomit when they ingest a substance that is harmful thus pica in rats is analogous to vomiting in other species; it is a way for rats to relieve digestive distress. In some animals pica seems to be an adaptive trait but in others it seems to be a true psychopathology like in the case of some chickens. Chickens can display a type of pica when they are feed-deprived (feeding restriction has been adopted by the egg industry to induce molting). They increase their non-nutritive pecking, such as pecking structural features of their environment like wood or wire on fences or the feathers of other birds. It is a typical response that occurs when feeding is restricted or is completely withdrawn. Some of the non-nutritive pecking may be due to a redirection of foraging related behavior. Another animal that has displayed a more complex pica example are cattle. Cattle eat bones when they have a phosphorus deficiency. However, in some cases they persist on eating bones even after their phosphorus levels have stabilized and they are getting adequate doses of phosphorus in their diet. In this case evidence supports both a physical and psychological adaptive response. Cattle that continue to eat bones after their phosphorus levels are adequate do it because of a psychological reinforcer. "The persistence of pica in the seeming absence of a physiological cause might be due to the fortuitous acquisition of a conditioned illness during the period of physiological insult." Cats also display pica behavior in their natural environments and there is evidence to support that this behavior has a psychological aspect to it. Some breeds (such as the Siamese cat) are more predisposed to showing this type of behavior than other breeds, but several types of breeds have been documented to show pica. Cats have been observed to start by chewing and sucking on non-nutritive substances like wool, cotton, rubber, plastic and even cardboard and then progress into ingestion of these substances. This type of behavior occurs through the first four years of a cat's life but it is primarily observed during the first two months of life when cats are introduced into new homes is most common. Theories explaining why this behavior becomes active during this time suggest that early weaning and stress as a consequence of separation from the mother and litter-mates and exposure to a new environment are to blame. Eating wool or other substances may be a soothing mechanism that cats develops to cope with the changes. Pica is also observed predominately during 6–8 months of a cat's life when territorial and sexual behaviors emerge. Pica may be induced by these social stressors. Other theories contemplated include pica as a redirection of prey-catching/ingestion behavior as a result of indoor confinement, especially common among oriental breeds due to risk of theft. In natural environments pica has been observed in parrots (such as macaws) and other birds and mammals. Charles Munn has been studying Amazon macaws lick clay from riverbeds in the Amazon to detoxify the seeds they eat. Amazon macaws spend two to three hours a day licking clay. Munn has found that clay helps counter the tannin and alkaloid in the seeds the macaws ingest, a strategy that is also used by native cultures in the Andes Mountains in Peru. Pica also affects domesticated animals. While drugs like Prozac are often able to diminish troublesome behaviors in pet dogs, they don't seem to help with this eating disorder. The following story about Bumbley, a wire fox terrier who appeared on the TV show 20/20 as a result of his eating disorder, is taken from a book by Dr. Nicholas Dodman: Dodman talks about new research relating bulimia and compulsive overeating to seizural behavior in human patients. He suggests that anti-epileptic medication might be a possible treatment for some cases of pica in animals. Behavioral disorders Behavioral disorders are difficult to study in animal models because it is difficult to know what animals are thinking and because animal models used to assess psychopathologies are experimental preparations developed to study a condition. Lacking the ability to use language to study behavioral disorders like depression and stress questions the validity of those studies conducted. It can be difficult to attribute human conditions to non-human animals. Obsessive compulsive disorder (OCD) Obsessive-compulsive behavior in animals, often called "stereotypy" or "stereotypical behavior" can be defined as a specific, unnecessary action (or series of actions) repeated more often than would normally be expected. It is unknown whether animals are able to 'obsess' in the same way as humans, and because the motivation for compulsive acts in non-human animals is unknown, the term "abnormal repetitive behavior" is less misleading. A wide variety of animals exhibit behaviors that can be considered abnormally repetitive. Ritualized and stereotyped behaviors Though obsessive-compulsive behaviors are often considered to be pathological or maladaptive, some ritualized and stereotyped behaviors are beneficial. These are usually known as "fixed action patterns". These behaviors sometimes share characteristics with obsessive-compulsive behavior, including a high degree of similarity in form and use among many individuals and a repetitive dimension. There are many observable animal behaviors with characteristic, highly conserved patterns. One example is grooming behavior in rats. This behavior is defined by a specific sequence of actions that does not normally differ between individual rats. The rat first begins by stroking its whiskers, then expands the stroking motion to include the eyes and the ears, finally moving on to lick both sides of its body. Other behaviors may be added to the end of this chain, but these four actions themselves are fixed. Its ubiquity and high degree of stereotypy suggest that this is a beneficial behavior pattern which has been maintained throughout evolutionary history. Although humans and animals both have pathological stereotyped behaviors, they do not necessarily provide a similar model of OCD. Feather picking in orange-winged amazon parrots has both a genetic component, with the behavior being more likely in one sibling if the other does it, and more common in parrots close to a door when they were housed in groups. The same study found that feather picking was more common in females and that there was no social transmission of the behavior; neighbors of feather picking birds were only more likely to show the behavior as well if they were related. An evolutionary basis Some researchers believe that disadvantageous obsessive compulsive behaviors can be thought of as a normally beneficial process gone too far. Brüne (2006) suggests that change of various origin in striatal and frontal brain circuits, which play a role in predicting needs and threats that may arise in the future, may result in a hyperactive cognitive harm avoidance system, in which a person becomes consciously and unreasonably fearful of an unlikely or impossible event. This may also be true in other animals. Genetic factors Canine compulsions are more common in some breeds and behavioral dispositions are often shared within the same litter. This suggests that there is a genetic factor to the disorder. A questionnaire to dog owners and a blood sample of 181 dogs from four breeds, miniature and standard bull terriers, German shepherds, and Staffordshire bull terriers showed these to be more susceptible to compulsive and repetitive behaviors. It is suggested that the more we learn through studying OCD in dogs, the more we can to understand human biology and the genetics involved in the heredity of susceptibility to disorders such as OCD. A chromosome has been located in dogs that confers a high risk of susceptibility to OCD. Canine chromosome 7 has been found to be most significantly associated with obsessive compulsive disorder in dogs, or more specifically, canine compulsive disorder (CCD). This breakthrough helped further relate OCD in humans to CCD in canines. Canine chromosome 7 is expressed in the hippocampus of the brain, the same area that Obsessive Compulsive Disorder is expressed in human patients. Similar pathways are involved in drug treatment responses for both humans and dogs, offering more research that the two creatures exhibit symptoms and respond to treatment in similar ways. This data can help scientists to discover more effective and efficient ways to treat OCD in humans through the information they find by studying CCD in dogs. Animal models Animals exhibiting obsessive and compulsive behaviors that resemble OCD in humans have been used as a tool for elucidating possible genetic influences on the disease, potential treatments, and to better understand the pathology of this behavior in general. While such models are useful, they are also limited; it is unclear whether the behavior is ego dystonic in animals. That is, it is difficult to evaluate whether an animal is aware that its behavior is excessive and unreasonable and whether this awareness is a source of anxiety. One study done by Simon Vermeier used neuroimaging to investigate serotonergic and dopaminergic neurotransmission in 9 dogs with Canine Compulsive Disorder (CCD) to measure the serotonin 2A receptor availability. When compared to the 15 non-compulsive dogs used as a control group, the dogs with CCD were found to have lower receptor availability as well as lower subcortical perfusion and hypothalamic availability. The results of this study provide evidence that there are imbalanced serotonergic and dopaminergic pathways in dogs. Similarities between other studies about human OCD provide construct validity for this study, which suggests that the research will be valid and useful in continuing to investigate brain activity and drug treatment in Obsessive Compulsive Disorder. Some treatment has been given to dogs with CCD to observe their reactions and how they are similar or different from how humans would react to the same pharmaceutical or behavioral treatment. A combination of the two approaches has been found to be most effective in lowering the intensity and regularity of OCD in both canines and humans. Pharmaceutically, clomipramine was found to be more effective than an alternative chemical, amitriptyline, in treatments for dogs. One study by Karen Overall discovered that by combining behavioral therapy with the more effective clomipramine, the symptoms of Canine Compulsive Disorder decreased by over 50% for all of the dogs involved in the study. Overall acknowledges that OCD is not something that can be completely cured, but studies like this are still important because Obsessive Compulsive Disorder can be controlled effectively enough so it does not interfere with one's life, a valuable and commonly sought after thing for those who have had the disorder. Alicia Graef's article makes several bold claims that dogs are the future in understanding how to better diagnose, recognize, and treat Obsessive Compulsive Disorder in humans. There is evidence supporting her statements, but the connection between CCD and OCD is not clearly understood. So far, studies have proved that effective treatments in dogs are similarly effective for humans, but there are still so many things unknown. Obsessive Compulsive Disorder is a unique mental disorder that cannot be fully cured. It can be controlled and understood, and one possible way of better doing that might be through studying CCD in canines. Studying dogs that exhibit compulsive behaviors has led scientists to genetic breakthroughs in understanding more how biology and genetics factor into Obsessive Compulsive Disorder. By observing and studying how CCD manifests in the brain activity, behaviors, and genes of diagnosed canines, scientists have been able to use their newfound information to develop better diagnostic tests and more readily recognize symptoms and susceptible humans. The similar brain functions and behaviors of dogs with CCD and humans with OCD suggests they have a connection, not only in behavior and symptoms, but in reacting to treatments. Understanding Canine Compulsive Disorder in dogs has helped scientists to better understand and apply their learning to developing new and more effective ways to treat Obsessive Compulsive Disorder in humans. Some examples of ways in which rats and mice, two of the most common animal models, have been used to represent human OCD are provided below. Lever pressing in rats Certain laboratory rat strains that have been created by controlled breeding for many generations show a higher tendency towards compulsive behaviors than other strains. Lewis rats show more compulsive lever pressing behavior than Sprague Dawley or Wistar rats and are less responsive to the anti-compulsive drug paroxetine. In this study, rats were taught to press a lever to receive food in an operant conditioning task. Once food was no longer provided when they pressed the lever, rats were expected to stop pressing it. Lewis rats pressed the lever more often than the other two types, even though they had presumably learned that they would not receive food, and continued to press it more often even after treatment with the drug. An analysis of the genetic differences between the three rat strains might help to identify genes that might be responsible for the compulsive behavior. Rats have also been used to test the possibility of a problem with dopamine levels in the brains of animals that exhibit compulsive checking behavior. After treating rats with quinpirole, a chemical that specifically blocks dopamine D2/D3 receptors, compulsive checking of certain locations in an open field increased. Some components of the checking behavior, such as the level of stereotypy in the path animals took to checked locations, the number of checks, and the length of the checks indicated an increase in compulsivity as doses of quinpirole increased; other components, such as the time taken to return from the checked location to the starting point and the time taken to make that trip remained constant after the initial injection throughout the experiment. This means that there might be both an all-or-none and a sensitization aspect in the biology of the dopamine deficiency model of OCD. In addition, quinpirole might reduce a sense of satisfaction in the rats after they check a location, causing them to return to that location again and again. Estrogen deficiency in male mice Based on findings of changes in OCD symptoms in menstruating women and differences in the development of the disease between men and women, Hill and colleagues set out to research the effect of estrogen deprivation on the development of compulsive behavior in mice. Male mice with an aromatase gene knockout who were unable to produce estrogen showed excessive grooming and wheel running behaviors, but female mice did not. When treated with 17β-estradiol, which replaced estrogen in these mice, the behaviors disappeared. This study also found that COMT protein levels decreased in mice that did not produce estrogen and increased in the hypothalamus after estrogen-replacement treatment. Briefly, the COMT protein is involved in degrading some neurotransmitters, including dopamine, norepinephrine and epinephrine. This data suggests that there may be a hormonal component and a hormone-gene interaction effect that may contribute to obsessive behaviors. Pets Dr. Nicholas Dodman describes a wide variety of OCD-like behaviors in his book Dogs Behaving Badly. Such behaviors typically appear when the dog is placed in a stressful situation, including an environment that is not very stimulating, or in dogs with a history of abuse. Different breeds of dog seem to display different compulsions. Lick granuloma, or licking repeatedly until ulcers form on the skin, affects more large dogs, like Labradors, golden retrievers, Great Danes, and Dobermans, while bull terriers, German shepherds, Old English sheepdogs, Rottweilers, and wire-haired fox terriers, and springer spaniels are more likely to snap at imaginary flies or chase light and shadows. These associations probably have an evolutionary basis, although Dodman does not clearly explain that aspect of the behaviors. Louis Shuster and Nicholas Dodman noticed that dogs often demonstrate obsessive and compulsive behaviors similar to humans. Canine Compulsive Disorder (CCD) is not only specific to certain breeds of dogs, but the breed may affect the specific types of compulsions. For example, bull terriers frequently exhibit obsessively predatory or aggressive behaviors. Breed may factor into the types of compulsions, but some behaviors are more common across the canine spectrum. Most commonly, CCD is seen in canines as they repeat behaviors such as chasing their tails, compulsively chewing on objects, or licking their paws excessively, similar to the common hand-washing compulsion many people with Obsessive Compulsive Disorder have. Hallucinating and attacking the air around their head, as if there were a bug there, is another compulsion that has been seen in some dogs. Circling, hair biting, staring, and sometimes even barking are other examples of behaviors that are considered compulsions in dogs when taken to extreme, repetitive actions. Treatment (pharmaceutical) Dodman advocates the use of exercise, an enriched environment (like providing noises for dogs to listen to while owners are at work), and often Prozac (an SSRI used to treat OCD in humans) as treatments. Shuster and Dodman tested pharmaceutical treatment on canines with CCD to see if it would work as effectively as it does in humans. They used glutamate receptor blockers (memantine) and fluoxetine, commonly known as the antidepressant Prozac, to treat and observe the reactions of 11 dogs with compulsions. Seven of the 11 dogs significantly reduced their compulsions in intensity and frequency after receiving medication. Dodman includes a story about Hogan, a castrated deaf male Dalmatian, and his compulsive behavior. Hogan had a history of neglect and abuse before he was adopted by Connie and Jim, who attempted to improve his behavior by teaching him to respond to American Sign Language. The following are some excerpts from Hogan's file: Addiction Sugar addiction has been examined in laboratory rats and it develops in the same way that drug addiction develops. Eating sugary foods causes the brain to release natural chemicals called opioids and dopamine in the limbic system. Tasty food can activate opioid receptors in the ventral tegmental area and thereby stimulate cells that release dopamine in the nucleus accumbens (NAc). The brain recognizes the intense pleasure derived from the dopamine and opioids release and learns to crave more sugar. Dependence is created through these natural rewards, the sugary treats, and the opioid and dopamine released into the synapses of the mesolimbic system. The hippocampus, the insula and the caudate activate when rats crave sugar, which are the same areas that become active when drug addicts crave the drug. Sugar is good because it provides energy, but if the nervous system goes through a change and the body becomes dependent on the sugar intake, somatic signs of withdrawal begin to appear like chattering teeth, forepaw tremors and head shakes when sugar is not ingested. Morphine tolerance, a measure of addiction, was observed in rats and their tolerance on Morphine was attributed to environmental cues and the systemic effects of the drug. Morphine tolerance does not depend merely on the frequency of pharmacological stimulation, but rather on both the number of pairings of a drug-predictive cue with the systemic effects of the drug. Rats became significantly more tolerant to morphine when they had been exposed to a paired administration than those rats that were not administered a drug-predictive cue along with the morphine. Depression Using dogs, Martin Seligman and his colleagues pioneered the study of depression in the animal model of learned helplessness at the University of Pennsylvania. Dogs were separated into three groups, the control group, group A had control over when they were being shocked and group B had no control over when they were being electrocuted. After the shocking condition, the dogs were tested in a shuttle box where they could escape shock by jumping over a partition. To eliminate an interference effect – that the dogs did not learn responses while being shocked that would interfere with their normal escape behavior – the dogs were immobilized using curare, a paralyzing drug while they were being shocked. Both the control group and group A tended to jump over the partition to escape shock while group B dogs did not jump and would passively take the shock. The dogs in group B perceived that the outcome was not related to their efforts. Consequently, a theory emerged that attributed the behavior of the animals to the effects of the shock as a stressor so extreme that it depleted a neurochemical needed by the animals for movement. After the dogs study the effects of helplessness have been tested in species from fish to cats. Most recently learned helplessness has been studied in rhesus macaques using inescapable shock, evoked through stress situations like forced swimming, behavioral despair tasks, tails suspension and pinch induced catalepsy; situations that render the monkey incapable of controlling the environment. Depression and low mood were found to be of a communicative nature. They signal yielding in a hierarchy conflict or a need for help. Low mood or extreme low mood (also known as depression) can regulate a pattern of engagement and foster disengagement from unattainable goals. "Low mood increases an organism's ability to cope with the adaptive challenges characteristic of unpropitious situations in which effort to pursue a major goal will likely result in danger, loss, bodily damage, or wasted effort." Being apathetic can have a fitness advantage for the organism. Depression has also been studied as a behavioral strategy used by vertebrates to increase their personal or inclusive fitness in the threat of parasites and pathogens. The lack of neurogenesis has been linked to depression. Animals with stress (isolated, cortisol levels) show a decrease in neurogenesis and antidepressants have been discovered to promote neurogenesis. Rene Hen and his colleagues at Columbia University ran a study on rats in which they blocked neurogenesis by applying radiation to the hippocampal area to test the efficacy of antidepressants. Results suggested that antidepressants failed to work when neurogenesis was inhibited. Stress Robert Sapolsky has extensively studied baboons in their natural environment in the Serengeti in Africa. He noticed that baboons have very similar hierarchies in their society as do humans. They spend very few hours searching for food and fulfilling their primary needs, leaving them with time to develop their social network. In primates, mental stresses show up in the body. Primates experience psychological stresses that can elicit physiological responses that, over time, can make them sick. Sapolsky observed the baboons' ranks, personalities and social affiliations, then collected blood samples of the baboons to control the cortisol (stress hormone) levels of the baboons, then matched social position to cortisol levels. Most of the data have been collected from male baboons, because at any given time 80 percent of the females were pregnant. Three factors influenced a baboon's cortisol levels: friendships, perspective, and rank. Baboons had lower levels of cortisol if they 1. played with infants and cultivated friendships, 2. could tell if a situation was a real threat and could tell if they were going to win or lose, and 3. were top ranking. Cortisol levels rise with age and hippocampal cells express fewer hormone receptors on their surface to protect themselves from excess, making it harder to control stress levels. Cortisol levels are elevated in half of people with major depression, it is the hippocampal region that is affected by both. Stress can have negative effects on gastrointestinal function causing ulcers, and it can also decrease sex drive, affect sleeping patterns and elevate blood pressure but it can also stimulate and motivate. When animals experience stress, they are generally more alert than when they are not stressed. It may help them be better aware of unfamiliar environments and possible threats to their life in these environments. Yerkes and Dodson developed a law that explains the empirical relationship between arousal and performance illustrated by an inverted U-shape graph. According to the Yerkes-Dodson Law, performance increases, as does cognitive arousal, but only to a certain point. The downward part of the U-shape is caused by stress and as stress increases so does efficiency and performance, but only to a certain point. When stress becomes too great, performance and efficiency decline. Sapolsky has also studied stress in rats and his results indicate that early experiences in young rats have strong, lasting effects. Rats that were exposed to human handling (a stressful situation) had finely-tuned stress responses that may have lowered their lifetime exposure to stress hormones compared to those that were not handled. In short: stress can be adaptive. The more exposure to stressful situations, the better the rat can handle that situation. Stereotypies Stereotypies are repetitive, sometimes abnormal behaviors like pacing on the perch for birds. There are adaptive stereotypic behaviors such as grooming in cats and preening in birds. Captive parrots commonly perform a range of stereotypies. These behaviors are repeated identically and lack any function or goal. Captive parrots perform striking oral and locomotor stereotypies like pacing on the perch or repetitive play with a certain toy. Feather picking and loud vocalizations can be stereotypies but are not as rigid and may be reactions to confinement, stress, boredom and loneliness as studies have shown that parrots that are in cages closest to the door are the most prone to feather pick or scream. Feather picking is not a true stereotypy and is more like hair pulling in human and loud vocalizations or screaming can be a stereotypy but vocalization is part of a parrot's natural behavior. Captive parrots lack sufficient stimulation. Presumably they suffer from lack of companionship and opportunities to forage. Stereotypies can evolve from the social environment for example the presence or absence of certain social stimuli, social isolation, low feeder space and high stocking density (especially for tail biting in pigs). These behaviors can also be transmitted through social learning. Bank voles, pigeons and pigs when housed next to animals that show stereotypies, pick them up as well as through stimulus enhancement which is what happens in tail biting in pigs and feather pecking by hens. Stereotypies may be coping mechanisms as results suggest from study on tethered and stalled sows. Sows that are tethered and stalled exhibited more stereotypies like licking and rubbing than sows that are in groups outdoors. This abnormal behavior seems to be related to opioid (related to the reward system) receptor density. In sows, prolonged confinement, being tethered or being in gestation crates, results in abnormal behaviors and stereotypies. Mu and kappa receptors are associated with aversion behaviors and mu receptor density is greater in tethered sows than sows that are in groups outdoors. However, sows with stereotypy behaviors experienced a decrease both in Mu and Kappa receptor density in the brain suggesting that inactivity increases Mu receptor density and stereotypy development decrease both kappa and Mu receptor density. It is suggested that captive environment design can help prevent the existence of stereotypies, by creating an enclosure as similar as possible to the animal's natural environment and providing enrichments to stimulate their natural behavior. Self-aggression Rhesus macaques have been observed to display self-aggression (SA) including self-biting, self-clasping, self-slapping, self-rubbing and threatening of body parts. The rhesus macaques observed were individually caged and free of disease. Their self-aggression level rose in stressful and stimulating conditions such as moving from one cage to another. Stump-tailed macaques were studied to examine the source of their SA. SA increased in an impoverished environment and results support that SA may increase sensory input in poor environments. Captive macaques do not socialize the way wild macaques do which may affect SA. When allowed to socialize by putting another macaque in the cage or not putting them in a cage, SA levels in macaques decrease. Results indicate that SA is a form of redirected social aggression. SA is related to frustration and social status, especially in macaques that have an intermediate dominance rank. See also Anthrozoology List of abnormal behaviors in animals References Further reading Anxiety and compulsive disorders in dogs. (2013). PetMD. http://www.petmd.com/dog/conditions/behavioral. Graef, A. (October 2013). Can dogs lead us to a cure for obsessive-compulsive disorder? Care 2 Make a Difference. http://www.care2.com/causes/can-dogs-lead-us-to-a-cure-for-obsessive-compulsive-disorder.html Abnormal behaviour in animals Animal welfare Psychopathology

The Fifth Discipline

The Fifth Discipline: The Art and Practice of the Learning Organization is a book by Peter Senge (a senior lecturer at MIT) focusing on group problem solving using the systems thinking method in order to convert companies into learning organizations that learn to create results that matter as an organization. The five disciplines represent classical approaches (theories and methods) for developing three core and timeless learning capabilities: fostering aspiration, developing reflective conversation, and understanding complexity. Content The Five Disciplines The five disciplines of what the book refers to as a "learning organization" discussed in the book are: "Personal mastery is a discipline of continually clarifying and deepening our personal vision, of focusing our energies, of developing patience, and of seeing reality objectively." "Mental models are deeply ingrained assumptions, generalizations, or even pictures of images that influence how we understand the world and how we take action." "Building shared vision - a practice of unearthing shared pictures of the future that foster genuine commitment and enrollment rather than compliance." "Team learning starts with 'dialogue', the capacity of members of a team to suspend assumptions and enter into genuine 'thinking together'." "Systems thinking - The Fifth Discipline that integrates the other four." Senge describes extensively the role of what he refers to as "mental models," which he says are integral in order to "focus on the openness needed to unearth shortcomings" in perceptions. The book also focuses on "team learning" with the goal of developing "the skills of groups of people to look for the larger picture beyond individual perspectives." In addition to these principles, the author stresses the importance of "personal mastery" to foster "the personal motivation to continually learn how [...] actions affect [the] world." The Learning Disabilities In addition to "disciplines," which Senge suggests are beneficial to what he describes as a "learning organization," Senge also posits several perceived deleterious habits or mindsets, which he refers to as "learning disabilities." "I am my position." "The enemy is out there." The Illusion of Taking Charge The Fixation on Events The Parable of the Boiling frog The Delusion of Learning from Experience The Myth of the Management Team The 11 Laws of the Fifth Discipline Today's problems come from yesterday's "solutions." The harder you push, the harder the system pushes back. Behavior grows better before it grows worse. The easy way out usually leads back in. The cure can be worse than the disease. Faster is slower. Cause and effect are not closely related in time and space. Small changes can produce big results...but the areas of highest leverage are often the least obvious. You can have your cake and eat it too ---but not all at once. Dividing an elephant in half does not produce two small elephants. There is no blame. The Architecture of a Learning Organization How do we learn to create learning organizations? [Extracted from the TFD Fieldbook, pg 15-83. A compelling essay on the conceptual map to guide your own decisions on how to proceed to build Learning Organisations by Dr. Peter Senge] How do you know what to do first, second, or third in thinking strategically about building learning organizations? At its core, learning organizations build great teams – the trust, the relationships, the acceptance, the synergy, and the results that they achieve. It has a strong ability to learn, adjust and change in response to new realities. It can alter functions and departments when demanded by changes in the work environment or by poor performance. The distinguishing characteristics of a learning organization include a learning culture, a spirit of flexibility and experimentation, people orientation, continuous system-level learning, knowledge generation and sharing, and critical, systemic thinking. When we look more closely at the development of such teams, we see that people are changed, often profoundly. There is a deep learning cycle. Team members develop new skills, and capabilities which alter what they can do and understand. As new capabilities develop, so too do new awareness and sensibilities. Over time, as people start to see and experience the world differently, new beliefs and assumptions begin to form, which enables further development of skills and capabilities. This deep learning cycle constitutes the essence of a learning organization – the development not just of new capacities, but of fundamental shifts of mind, individually and collectively. The five basic learning disciplines are the means by which this deep learning cycle is activated. Sustained commitment to the disciplines keeps the cycle going. When this cycle begins to operate, the resulting changes are significant and enduring. The real work of building learning organizations occurs within a "shell", an architecture. What makes up the architecture? - Guiding Ideas. - Theory, methods, and tools. - Innovations in infrastructure. Without guiding ideas, there is no passion, no overarching sense of direction or purpose. Without theory, methods, and tools, people cannot develop the new skills and capabilities required for deep learning. Without innovations in infrastructure, inspiring ideas and powerful tools lack credibility because people have neither the opportunity nor resources to pursue their visions or apply the tools. Leaders intent on developing learning organizations must focus on all three of the architectural design elements. Without all three, the triangle collapses. Reception In 1997, Harvard Business Review identified The Fifth Discipline as one of the seminal management books of the previous 75 years. See also Agile management Learning agenda Organizational learning System archetype References External links 1990 non-fiction books Systems theory books Books about organizations

Health care

Health care, or healthcare, is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health professionals and allied health fields. Medicine, dentistry, pharmacy, midwifery, nursing, optometry, audiology, psychology, occupational therapy, physical therapy, athletic training, and other health professions all constitute health care. The term includes work done in providing primary care, secondary care, tertiary care, and public health. Access to healthcare may vary across countries, communities, and individuals, influenced by social and economic conditions and health policies. Providing health care services means "the timely use of personal health services to achieve the best possible health outcomes". Factors to consider in terms of healthcare access include financial limitations (such as insurance coverage), geographical and logistical barriers (such as additional transportation costs and the ability to take paid time off work to use such services), sociocultural expectations, and personal limitations (lack of ability to communicate with health care providers, poor health literacy, low income). Limitations to health care services affect negatively the use of medical services, the efficacy of treatments, and overall outcome (well-being, mortality rates). Health systems are the organizations established to meet the health needs of targeted populations. According to the World Health Organization (WHO), a well-functioning healthcare system requires a financing mechanism, a well-trained and adequately paid workforce, reliable information on which to base decisions and policies, and well-maintained health facilities to deliver quality medicines and technologies. An efficient healthcare system can contribute to a significant part of a country's economy, development, and industrialization. Health care is an important determinant in promoting the general physical and mental health and well-being of people around the world. An example of this was the worldwide eradication of smallpox in 1980, declared by the WHO, as the first disease in human history to be eliminated by deliberate healthcare interventions. Delivery The delivery of modern health care depends on groups of trained professionals and paraprofessionals coming together as interdisciplinary teams. This includes professionals in medicine, psychology, physiotherapy, nursing, dentistry, midwifery and allied health, along with many others such as public health practitioners, community health workers and assistive personnel, who systematically provide personal and population-based preventive, curative and rehabilitative care services. While the definitions of the various types of health care vary depending on the different cultural, political, organizational, and disciplinary perspectives, there appears to be some consensus that primary care constitutes the first element of a continuing health care process and may also include the provision of secondary and tertiary levels of care. Health care can be defined as either public or private. Primary care Primary care refers to the work of health professionals who act as a first point of consultation for all patients within the health care system. The primary care model supports first-contact, accessible, continuous, comprehensive and coordinated person-focused care. Such a professional would usually be a primary care physician, such as a general practitioner or family physician. Another professional would be a licensed independent practitioner such as a physiotherapist, or a non-physician primary care provider such as a physician assistant or nurse practitioner. Depending on the locality and health system organization, the patient may see another health care professional first, such as a pharmacist or nurse. Depending on the nature of the health condition, patients may be referred for secondary or tertiary care. Primary care is often used as the term for the health care services that play a role in the local community. It can be provided in different settings, such as Urgent care centers that provide same-day appointments or services on a walk-in basis. Primary care involves the widest scope of health care, including all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with all types of acute and chronic physical, mental and social health issues, including multiple chronic diseases. Consequently, a primary care practitioner must possess a wide breadth of knowledge in many areas. Continuity is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and preventive care, health education, and every time they require an initial consultation about a new health problem. The International Classification of Primary Care (ICPC) is a standardized tool for understanding and analyzing information on interventions in primary care based on the reason for the patient's visit. Common chronic illnesses usually treated in primary care may include, for example, hypertension, diabetes, asthma, COPD, depression and anxiety, back pain, arthritis or thyroid dysfunction. Primary care also includes many basic maternal and child health care services, such as family planning services and vaccinations. In the United States, the 2013 National Health Interview Survey found that skin disorders (42.7%), osteoarthritis and joint disorders (33.6%), back problems (23.9%), disorders of lipid metabolism (22.4%), and upper respiratory tract disease (22.1%, excluding asthma) were the most common reasons for accessing a physician. In the United States, primary care physicians have begun to deliver primary care outside of the managed care (insurance-billing) system through direct primary care which is a subset of the more familiar concierge medicine. Physicians in this model bill patients directly for services, either on a pre-paid monthly, quarterly, or annual basis, or bill for each service in the office. Examples of direct primary care practices include Foundation Health in Colorado and Qliance in Washington. In the context of global population aging, with increasing numbers of older adults at greater risk of chronic non-communicable diseases, rapidly increasing demand for primary care services is expected in both developed and developing countries. The World Health Organization attributes the provision of essential primary care as an integral component of an inclusive primary health care strategy. Secondary care Secondary care includes acute care: necessary treatment for a short period of time for a brief but serious illness, injury, or other health condition. This care is often found in a hospital emergency department. Secondary care also includes skilled attendance during childbirth, intensive care, and medical imaging services. The term "secondary care" is sometimes used synonymously with "hospital care". However, many secondary care providers, such as psychiatrists, clinical psychologists, occupational therapists, most dental specialties or physiotherapists, do not necessarily work in hospitals. Some primary care services are delivered within hospitals. Depending on the organization and policies of the national health system, patients may be required to see a primary care provider for a referral before they can access secondary care. In countries that operate under a mixed market health care system, some physicians limit their practice to secondary care by requiring patients to see a primary care provider first. This restriction may be imposed under the terms of the payment agreements in private or group health insurance plans. In other cases, medical specialists may see patients without a referral, and patients may decide whether self-referral is preferred. In other countries patient self-referral to a medical specialist for secondary care is rare as prior referral from another physician (either a primary care physician or another specialist) is considered necessary, regardless of whether the funding is from private insurance schemes or national health insurance. Allied health professionals, such as physical therapists, respiratory therapists, occupational therapists, speech therapists, and dietitians, also generally work in secondary care, accessed through either patient self-referral or through physician referral. Tertiary care Tertiary care is specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital. Examples of tertiary care services are cancer management, neurosurgery, cardiac surgery, plastic surgery, treatment for severe burns, advanced neonatology services, palliative, and other complex medical and surgical interventions. Quaternary care The term quaternary care is sometimes used as an extension of tertiary care in reference to advanced levels of medicine which are highly specialized and not widely accessed. Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care. These services are usually only offered in a limited number of regional or national health care centers. Home and community care Many types of health care interventions are delivered outside of health facilities. They include many interventions of public health interest, such as food safety surveillance, distribution of condoms and needle-exchange programs for the prevention of transmissible diseases. They also include the services of professionals in residential and community settings in support of self-care, home care, long-term care, assisted living, treatment for substance use disorders among other types of health and social care services. Community rehabilitation services can assist with mobility and independence after the loss of limbs or loss of function. This can include prostheses, orthotics, or wheelchairs. Many countries are dealing with aging populations, so one of the priorities of the health care system is to help seniors live full, independent lives in the comfort of their own homes. There is an entire section of health care geared to providing seniors with help in day-to-day activities at home such as transportation to and from doctor's appointments along with many other activities that are essential for their health and well-being. Although they provide home care for older adults in cooperation, family members and care workers may harbor diverging attitudes and values towards their joint efforts. This state of affairs presents a challenge for the design of ICT (information and communication technology) for home care. Because statistics show that over 80 million Americans have taken time off of their primary employment to care for a loved one, many countries have begun offering programs such as the Consumer Directed Personal Assistant Program to allow family members to take care of their loved ones without giving up their entire income. With obesity in children rapidly becoming a major concern, health services often set up programs in schools aimed at educating children about nutritional eating habits, making physical education a requirement and teaching young adolescents to have a positive self-image. Ratings Health care ratings are ratings or evaluations of health care used to evaluate the process of care and health care structures and/or outcomes of health care services. This information is translated into report cards that are generated by quality organizations, nonprofit, consumer groups and media. This evaluation of quality is based on measures of: health plan quality hospital quality of patient experience physician quality quality for other health professionals Access to health care Access to healthcare may vary across countries, communities, and individuals, influenced by social and economic conditions as well as health policies. Providing health care services means "the timely use of personal health services to achieve the best possible health outcomes". Factors to consider in terms of healthcare access include financial limitations (such as insurance coverage), geographical and logistical barriers (such as additional transportation costs and the ability to take paid time off work to use such services), sociocultural expectations, and personal limitations (lack of ability to communicate with health care providers, poor health literacy, low income). Limitations to health care services affects negatively the use of medical services, the efficacy of treatments, and overall outcome (well-being, mortality rates). Related sectors Health care extends beyond the delivery of services to patients, encompassing many related sectors, and is set within a bigger picture of financing and governance structures. Health system A health system, also sometimes referred to as health care system or healthcare system, is the organization of people, institutions, and resources that deliver health care services to populations in need. Industry The healthcare industry incorporates several sectors that are dedicated to providing health care services and products. As a basic framework for defining the sector, the United Nations' International Standard Industrial Classification categorizes health care as generally consisting of hospital activities, medical and dental practice activities, and "other human health activities." The last class involves activities of, or under the supervision of, nurses, midwives, physiotherapists, scientific or diagnostic laboratories, pathology clinics, residential health facilities, patient advocates or other allied health professions. In addition, according to industry and market classifications, such as the Global Industry Classification Standard and the Industry Classification Benchmark, health care includes many categories of medical equipment, instruments and services including biotechnology, diagnostic laboratories and substances, drug manufacturing and delivery. For example, pharmaceuticals and other medical devices are the leading high technology exports of Europe and the United States. The United States dominates the biopharmaceutical field, accounting for three-quarters of the world's biotechnology revenues. Research The quantity and quality of many health care interventions are improved through the results of science, such as advanced through the medical model of health which focuses on the eradication of illness through diagnosis and effective treatment. Many important advances have been made through health research, biomedical research and pharmaceutical research, which form the basis for evidence-based medicine and evidence-based practice in health care delivery. Health care research frequently engages directly with patients, and as such issues for whom to engage and how to engage with them become important to consider when seeking to actively include them in studies. While single best practice does not exist, the results of a systematic review on patient engagement suggest that research methods for patient selection need to account for both patient availability and willingness to engage. Health services research can lead to greater efficiency and equitable delivery of health care interventions, as advanced through the social model of health and disability, which emphasizes the societal changes that can be made to make populations healthier. Results from health services research often form the basis of evidence-based policy in health care systems. Health services research is also aided by initiatives in the field of artificial intelligence for the development of systems of health assessment that are clinically useful, timely, sensitive to change, culturally sensitive, low-burden, low-cost, built into standard procedures, and involve the patient. Financing There are generally five primary methods of funding health care systems: General taxation to the state, county or municipality Social health insurance Voluntary or private health insurance Out-of-pocket payments Donations to health charities In most countries, there is a mix of all five models, but this varies across countries and over time within countries. Aside from financing mechanisms, an important question should always be how much to spend on health care. For the purposes of comparison, this is often expressed as the percentage of GDP spent on health care. In OECD countries for every extra $1000 spent on health care, life expectancy falls by 0.4 years. A similar correlation is seen from the analysis carried out each year by Bloomberg. Clearly this kind of analysis is flawed in that life expectancy is only one measure of a health system's performance, but equally, the notion that more funding is better is not supported. In 2011, the health care industry consumed an average of 9.3 percent of the GDP or US$ 3,322 (PPP-adjusted) per capita across the 34 members of OECD countries. The US (17.7%, or US$ PPP 8,508), the Netherlands (11.9%, 5,099), France (11.6%, 4,118), Germany (11.3%, 4,495), Canada (11.2%, 5669), and Switzerland (11%, 5,634) were the top spenders, however life expectancy in total population at birth was highest in Switzerland (82.8 years), Japan and Italy (82.7), Spain and Iceland (82.4), France (82.2) and Australia (82.0), while OECD's average exceeds 80 years for the first time ever in 2011: 80.1 years, a gain of 10 years since 1970. The US (78.7 years) ranges only on place 26 among the 34 OECD member countries, but has the highest costs by far. All OECD countries have achieved universal (or almost universal) health coverage, except the US and Mexico. (see also international comparisons.) In the United States, where around 18% of GDP is spent on health care, the Commonwealth Fund analysis of spend and quality shows a clear correlation between worse quality and higher spending. Expand the OECD charts below to see the breakdown: "Government/compulsory": Government spending and compulsory health insurance. "Voluntary": Voluntary health insurance and private funds such as households' out-of-pocket payments, NGOs and private corporations. They are represented by columns starting at zero. They are not stacked. The 2 are combined to get the total. At the source you can run your cursor over the columns to get the year and the total for that country. Click the table tab at the source to get 3 lists (one after another) of amounts by country: "Total", "Government/compulsory", and "Voluntary". Administration and regulation The management and administration of health care is vital to the delivery of health care services. In particular, the practice of health professionals and the operation of health care institutions is typically regulated by national or state/provincial authorities through appropriate regulatory bodies for purposes of quality assurance. Most countries have credentialing staff in regulatory boards or health departments who document the certification or licensing of health workers and their work history. Health information technology Health information technology (HIT) is "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making." Health information technology components: Electronic health record (EHR) – An EHR contains a patient's comprehensive medical history, and may include records from multiple providers. Electronic Medical Record (EMR) – An EMR contains the standard medical and clinical data gathered in one's provider's office. Health information exchange (HIE) – Health Information Exchange allows health care professionals and patients to appropriately access and securely share a patient's vital medical information electronically. Medical practice management software (MPM) – is designed to streamline the day-to-day tasks of operating a medical facility. Also known as practice management software or practice management system (PMS). Personal health record (PHR) – A PHR is a patient's medical history that is maintained privately, for personal use. See also :Category:Health care by country Global health Health equity Health policy Healthcare system / Health professionals Tobacco control laws Universal health care References External links Primary care Public services Health Public health Universal health care Health economics Health sciences

Creativity and mental health

Links between creativity and mental health have been extensively discussed and studied by psychologists and other researchers for centuries. Parallels can be drawn to connect creativity to major mental disorders including bipolar disorder, autism, schizophrenia, major depressive disorder, anxiety disorder, OCD and ADHD. For example, studies have demonstrated correlations between creative occupations and people living with mental illness. There are cases that support the idea that mental illness can aid in creativity, but it is also generally agreed that mental illness does not have to be present for creativity to exist. History It has been proposed that there is a link between creativity and mental illness. Major depressive disorder appears among playwrights, novelists, biographers, and artists at a higher rate than the general population. Association between mental illness and creativity first appeared in academic literature in the 1970s, but speculation about a link between "madness" and "genius" dates back at least to the time of Aristotle, to whom Seneca attributes the aphorism "No great mind has ever existed without a touch of madness." The word "genius" may refer to literary genius, creative genius, scholarly genius, "all around" genius, etc. The Ancient Greeks believed that creativity came from the gods, in particular the Muses (the mythical personifications of the arts and sciences, the nine daughters of Zeus). In the Aristotelian tradition, genius was viewed from a physiological standpoint, and it was believed that the same human quality was perhaps responsible for both extraordinary achievement and melancholy. On this topic, Romantic writers had similar ideals, with Lord Byron having pleasantly expressed, "We of the craft are all crazy. Some are affected by gaiety, others by melancholy, but all are more or less touched". Individuals with mental illness are said to display a capacity to see the world in a novel and original way; literally, to see things that others cannot. However, people do not require a mental illness to do so. Studies For many years, the creative arts, from visual arts and writing to music and drama, have been used in therapy for those recovering from mental illness or addiction. Another study found that increased levels of creativity were more common amongst those with schizotypal personality disorder than in people with either schizophrenia or people without mental health diagnoses. While divergent thinking was associated with bilateral activation of the prefrontal cortex, schizotypal individuals were found to have much greater activation of their right prefrontal cortex. This study hypothesized that such individuals are better at accessing both hemispheres, allowing them to make novel associations at a faster rate. Consistent with this hypothesis, ambidexterity is also more common in people with schizotypal personality disorder as well as people with schizophrenia. Three studies by Mark Batey and Adrian Furnham have demonstrated the relationships between schizotypal and hypomanic personality and several different measures of creativity. Specifically, Divergent Thinking Fluency, the Biographical Inventory of Creative Behaviors, as well as Self-rated Creativity. Particularly strong links have been identified between creativity and mood disorders, particularly manic-depressive disorder (a.k.a. bipolar disorder) and depressive disorder (a.k.a. unipolar disorder). In Touched with Fire: Manic-Depressive Illness and the Artistic Temperament, Kay Redfield Jamison summarizes studies of mood-disorder rates in writers, poets and artists. She also explores research that identifies mood disorders in such famous writers and artists as Ernest Hemingway (who shot himself after electroconvulsive treatment), Virginia Woolf (who drowned herself when she felt a depressive episode coming on), composer Robert Schumann (who died in a mental institution), and famed visual artist Michelangelo. A study by Simon Kyaga and others looked at 300,000 people with schizophrenia, bipolar disorder or unipolar depression, and their relatives, and found overrepresentation in creative professions for those with bipolar disorder as well as for undiagnosed siblings of those with schizophrenia or bipolar disorder. There was no overall overrepresentation, but overrepresentation for artistic occupations, among those diagnosed with schizophrenia. There was no association for those with unipolar depression or their relatives. A study involving more than one million people, conducted by Swedish researchers at the Karolinska Institute, reported a number of correlations between creative occupations and mental illnesses. Writers had a higher risk of anxiety and bipolar disorders, schizophrenia, unipolar depression, and substance abuse, and were almost twice as likely as the general population to kill themselves. Dancers and photographers were also more likely to have bipolar disorder. However, as a broader group, those in the creative professions (defined as "scientific and artistic occupations") were no more likely to experience psychiatric disorders than other people, although they were more likely to have a close relative with a disorder, including anorexia and, to some extent, autism, the Journal of Psychiatric Research reports. Research in this area is usually constrained to cross-section data-sets. One of the few exceptions is an economic study of the well-being and creative output of three famous music composers over their entire lifetime. The emotional indicators are obtained from letters written by Wolfgang Amadeus Mozart, Ludwig van Beethoven and Franz Liszt, and the results indicate that negative emotions had a causal impact on the creative production of the artists studied. Psychological stress has also been found to impede spontaneous creativity. In fact, Robert Epstein describes it as a creativity killer. Instead, people must work to cultivate creativity like any other skill. He found that capturing your ideas, seeking out challenges, increasing your knowledge, and surrounding yourself with others who do the same help creativity grow rather than focusing on your stress. A 2005 study at the Stanford University School of Medicine measured creativity by showing children figures of varying complexity and symmetry and asking whether they like or dislike them. The study showed for the first time that a sample of children who either have or are at high risk for bipolar disorder tend to dislike simple or symmetric symbols more. Children with bipolar parents who were not bipolar themselves also scored higher dislike scores. A study by Sally Anne Gross and George Musgrave suggested that high levels of self-reported anxiety and depression amongst musicians might be explained, at least in part, by the nature of their working conditions. Mood and creativity There have been many studies on the correlation between mood and creativity with very different results. Some studies seem to show a correlation between positive mood (affect) and heightened creativity. Other studies show that negative moods seem to be correlated with heightened creativity. One such research paper concludes, "Negative moods signal that the status quo is problematic and that additional effort needs to be exerted to come up with new and useful ideas." The debate is not binary, with some studies saying that both positive and negative emotions play a role in creativity. Additionally, the connection between mood and creativity is rarely direct; rather, being in certain moods forces or fosters people into certain actions that make them more creative at the moment. For instance, negative emotions have been shown to increase the amount a person will reflect and ruminate, which then can cause a person to be more creative. Bipolar disorder Bipolar disorder may stimulate creativity, as manic episodes can include prolonged periods of elevated energy. The first empirical study about this topic was done by Nancy Andreasen in the 1970s. She expected for the correlation to be between Creativity and Schizophrenia. She instead discovered that the correlation was actually between creativity and those with mood disorders. Specifically, that 80% of her sample had experienced at least one major episode. In her follow-up study 15 years later, she found that 43% had been diagnosed with bipolar disorder and 2 had committed suicide. In her book Touched with Fire, American clinical psychologist Kay Redfield Jamison wrote that 38% of writers and poets had been treated for a type of mood disorder, and 89% of creative writers and artists had experienced "intense, highly productive, and creative episodes". These were characterized by "pronounced increases in enthusiasm, energy, self-confidence, speed of mental association, fluency of thought and elevated mood". Although mania is characterized by reckless and possibly self-destructive behavior, in milder forms, the energy and free-flowing thinking of mania can fuel creativity. There is a range of types of bipolar disorder. Individuals with Bipolar I Disorder experience severe episodes of mania and depression with periods of wellness between episodes. The severity of the manic episodes can mean that the person is seriously disabled and unable to express the heightened perceptions and flight of thoughts and ideas in a practical way. Individuals with Bipolar II Disorder experience milder periods of hypomania during which the flight of ideas, faster thought processes and ability to take in more information can be converted to art, poetry or design. In a study done by Shapiro and Weisberg, they found that it was not the depressive episodes, but rather coming out of them that sparked the creativity. Specifically, the self-image that one has during hypomania causing them to be more self-confident and allows them to have the confidence to create. Dutch artist Vincent Van Gogh is widely theorised to have had bipolar disorder. Other notable creative people with bipolar disorder include Carrie Fisher, Demi Lovato, Kanye West, Stephen Fry (who has cyclothymia, a milder and more chronic form of bipolar disorder), Mariah Carey, Jaco Pastorius, Catherine Zeta-Jones, Jean-Claude Van Damme, Ronald Braunstein, and Patty Duke. Schizophrenia People with schizophrenia live with positive, negative, and cognitive symptoms. Positive symptoms (psychotic behaviors that are not present in healthy people) include hallucinations, delusions, thought and movement disorders. Negative symptoms (abnormal functioning of emotions and behavior) include flat affect, anhedonia, among others. Cognitive symptoms include problems with executive functioning, attention, and memory. One artist known for his schizophrenia was the Frenchman Antonin Artaud, founder of the Theatre of Cruelty movement. In Madness and Modernism (1992), clinical psychologist Louis A. Sass noted that many common traits of schizophrenia – especially fragmentation, defiance of authority, and multiple viewpoints – happen to also be defining features of modern art. However, it has been found that those who have it are the most creative either before or after active periods, not during them. Multiple research studies study a link between reduced latent inhibition, and the psychopathology of acute-phase schizophrenia. This is suggestive of a correlation between psychopathology and creativity, but should not be interpreted as a causal relationship. Arguments that support link In a 2002 conversation with Christopher Langan, educational psychologist Arthur Jensen stated that the relationship between creativity and mental disorder "has been well researched and is proven to be a fact", writing that schizothymic characteristics are somewhat more frequent in philosophers, mathematicians, and scientists than in the general population. In a 2015 study, Iceland scientists found that people in creative professions are 25% more likely to have gene variants that increase the risk of bipolar disorder and schizophrenia, with deCODE Genetics co-founder Kári Stefánsson saying, "Often, when people are creating something new, they end up straddling between sanity and insanity. I think these results support the concept of the mad genius." Bipolar disorder Many famous historical figures gifted with creative talents may have been affected by bipolar disorder. Ludwig van Beethoven, Kanye West, Virginia Woolf, Ernest Hemingway, Isaac Newton, Judy Garland, Jaco Pastorius and Robert Schumann are some people whose lives have been researched to discover signs of mood disorder. In many instances, creativity and mania – the overwhelming highs that bipolar individuals often experience – share some common traits, such as a tendency for "thinking outside the box," flights of ideas, the speeding up of thoughts and heightened perception of visual, auditory and somatic stimuli. It has been found that the brains of creative people are more open to environmental stimuli due to smaller amounts of latent inhibition, an individual's unconscious capacity to ignore unimportant stimuli. While the absence of this ability is associated with psychosis, it has also been found to contribute to original thinking. Emotions Many people with bipolar disorder may feel powerful emotions during both depressive and manic phases, potentially aiding in creativity. Because mania and hypomania may decrease social inhibition, performers who have bipolar disorder may become more daring and bold during an episode. Other creators may exhibit characteristics often associated with mental illness that are not necessarily equivalent to a full-blown manic episode. Posthumous diagnosis Some creative people have been posthumously diagnosed as experiencing bipolar or unipolar disorder based on biographies, letters, correspondence, contemporaneous accounts, or other anecdotal material, most notably in Kay Redfield Jamison's book Touched with Fire: Manic-Depressive Illness and the Artistic Temperament. Touched with Fire presents the argument that bipolar disorder, and affective disorders more generally, may be found in a disproportionate number of people in creative professions such as actors, artists, comedians, musicians, authors, performers and poets. Scholars have also speculated that the visual artist Michelangelo lived with depression. In the book Famous Depressives: Ten Historical Sketches, MJ Van Lieburg argues that elements of depression are prominent in some of Michelangelo's sculptures and poetry. Van Lieburg also draws additional support from Michelangelo's letters to his father in which he states: "I lead a miserable existence and reck not of life nor honour – that is of this world; I live wearied by stupendous labours and beset by a thousand anxieties. And thus I lived for some fifteen years now and never an hour's happiness have I had." Positive correlation Several recent clinical studies have also suggested that there is a positive correlation between creativity and bipolar disorder, although the relationship between the two is unclear. Temperament may be an intervening variable. Ambition has also been identified as being linked to creative output in people across the bipolar spectrum. Can Music Make You Sick? Measuring the Price of Musical Ambition by Sally Anne Gross and George Musgrave suggests that high levels of self-reported anxiety and depression amongst musicians can be explained, at least in part, by the nature of musicians' working conditions. Mental illness and divergent thinking In 2017, associate professor of psychiatry Gail Saltz stated that the increased production of divergent thoughts in people with mild-to-moderate mental illnesses leads to greater creative capacities. Saltz argued that the "wavering attention and day-dreamy state" of ADHD, for example, "is also a source of highly original thinking... CEOs of companies such as Ikea and Jetblue have ADHD. Their creativity, out-of-the-box thinking, high energy levels, and disinhibited manner could all be a positive result of their [condition]." Mania risk has also been credited with aiding in creative accomplishments because "when speed of thinking increases, word associations form more freely, as do flight of ideas, because the manic mind is less inclined to filtering details that, in a normal state, would be dismissed as irrelevant." Brain imaging and genetic links Brain imaging studies have consistently reported that low-latent inhibition is associated with originality, creative personalities, and high levels of creative achievement. There have also been genetic studies conducted to consider genetic links between creativity and psychopathology. Several genes that have been flagged as linking to some forms of psychopathology have also been linked to creativity. These include polymorphisms of the DRD2 and DRD4 genes, the 5HT2a gene, and the NRG1 gene. Correlation but not causation Several studies suggest a consistent link between creativity and those with either mild forms of bipolar disorder or family histories of bipolar disorder, but not full-blown Bipolar I Disorder. These findings reiterate that creative individuals are more likely on the mild end of psychosis spectrums, but not repeatedly beyond that point. One study wrote that "only elevated levels of schizotypy and psychosis-proneness found in divergent thinkers or possessing some indicators of schizotypy promotes creative achievement but not full-blown schizophrenia". Another article writes that "it is likely that psychopathology and creativity are closely related; sharing many traits and antecedents but outright psychopathology may be negatively associated with creativity". These correlations could be due, in part, to shared vulnerability factors between creativity and psychopathology, including neural hyper-connectivity, novelty salience, cognitive disinhibition, and emotional lability. There are also shared environmental factors that can simultaneously increase potential for creativity and vulnerability to psychopathology. These factors continue to drive further research, like the study Anxiety and Adverse Life Events in Professional Creative and Early Psychosis Populations (Crabtree et al.). Creativity and mental well-being There is a popular Indian cultural belief that 'deep pain enhances creativity and creative acts may actually help in healing the wounds'. The healing powers of creativity are seen frequently in everyday life, as artistic outlets are often encouraged as a way to improve well-being. For many people, creativity serves to overcome psychic crises, traumatic events and depression. Creativity can also have an incredible impact on mental health and well-being by not only helping people find meaning and significance, but providing an increased sense of purpose. Notable individuals This is a list of individuals whose creative sensibilities have been linked to their mental health. John Nash (1928–2015) was an American economist, noted for his contributions to game theory, who was diagnosed with paranoid schizophrenia. After undergoing several different treatments and therapies over the course of several decades, Nash effectively eschewed further psychiatric intervention and gradually adjusted to dealing with his symptoms without the usage of medications; he eventually returned to his field and earned a Nobel Prize in Economics in 1994. Joanne Greenberg (born 1932) is an American author who wrote I Never Promised You a Rose Garden (1964), an autobiographical account of her teenage years in Chestnut Lodge working with Frieda Fromm-Reichmann. At the time she was diagnosed with schizophrenia, although two psychiatrists who examined Greenberg's self-description in the book in 1981 concluded that she did not have schizophrenia, but had extreme depression and somatization disorder. The narrative constantly puts difference between the protagonist's mental illness and her artistic ability. Greenberg is adamant that her creative skills flourished in spite of, not because of, her condition: This statement from Greenberg originally appeared on the page for Rose Garden at amazon.com and has been quoted in many places including Asylum: A Mid-Century Madhouse and Its Lessons About Our Mentally Ill Today, by Enoch Callaway, M.D. (Praeger, 2007), p. 82. Brian Wilson (born 1942), founding member of American rock band the Beach Boys, has bipolar and schizoaffective disorder. In 2002, after undergoing treatment, he spoke of how medication affects his creativity, explaining: "I haven't been able to write anything for three years. I think I need the demons in order to write, but the demons have gone. It bothers me a lot. I've tried and tried, but I just can't seem to find a melody." Daniel Johnston (1961–2019) was an American singer-songwriter whose music was often attributed to his psychological issues. In a press release issued by his manager, it was requested that reporters refrain from describing Johnston as a "genius" due to the musician's emotional instabilities. The Guardians David McNamee argued that "it's almost taboo to say anything critical about Johnston. This is incredibly patronising. For one thing, it makes any honest evaluation of his work impossible." Marij Kogoj was a Slovenian composer with schizophrenia. Terry A. Davis (1969–2018) was an American computer programmer who singlehandedly created and designed an entire operating system, TempleOS, alongside full 2D and 3D graphics libraries, a programming language (HolyC) and a compiler. Although his remarks were often incomprehensible or abrasive, he was known to be exceptionally lucid if the topic of discussion was computers. He refused medication for his schizophrenia because he believed it limited his creativity. In 2017, the OS was shown as a part of an outsider art exhibition in Bourgogne, France. Kanye West (born 1977) is an American record producer, rapper, singer, and fashion designer who has bipolar disorder. The creativity in his art and his outspoken views on different topics are sometimes attributed in part to him being bipolar. West has said on his disorder, "I can just tell you what I'm feeling at the time, and I feel a heightened connection with the universe when I'm ramping up. It is a health issue. This – it's like a sprained brain, like having a sprained ankle. And if someone has a sprained ankle, you're not going to push on him more. With us, once our brain gets to a point of spraining, people do everything to make it worse." See also Mad genius Savant syndrome Tortured artist Sylvia Plath effect References External links The 'Sylvia Plath' effect by Deborah Smith Bailey from American Psychological Association The Myth of the Mentally Ill Creative blog entry about creativity and mental illness by a professor of psychology and creativity scientist Keith Sawyer A journey into chaos: Creativity and the unconscious by Nancy C Andreasen, Mens Sana Monographs, 2011, 9(1), p 42–53. Bipolar disorder Concepts in aesthetics Concepts in the philosophy of mind Creativity Empathy Mental health Psychological theories Health risks of performing arts

Dual diagnosis

Dual diagnosis (also called co-occurring disorders (COD) or dual pathology) is the condition of having a mental illness and a comorbid substance use disorder. There is considerable debate surrounding the appropriateness of using a single category for a heterogeneous group of individuals with complex needs and a varied range of problems. The concept can be used broadly, for example depression and alcohol use disorder, or it can be restricted to specify severe mental illness (e.g. psychosis, schizophrenia) and substance use disorder (e.g. cannabis use), or a person who has a milder mental illness and a drug dependency, such as panic disorder or generalized anxiety disorder and is dependent on opioids. Diagnosing a primary psychiatric illness in people who use substances is challenging as substance use disorder itself often induces psychiatric symptoms, thus making it necessary to differentiate between substance induced and pre-existing mental illness. Those with co-occurring disorders face complex challenges. They have increased rates of relapse, hospitalization, homelessness, and HIV and hepatitis C infection compared to those with either mental or substance use disorders alone. Differentiating pre-existing and substance induced The identification of substance-induced versus independent psychiatric symptoms or disorders has important treatment implications and often constitutes a challenge in daily clinical practice. Similar patterns of comorbidity and risk factors in individuals with substance induced disorder and those with independent non-substance induced psychiatric symptoms suggest that the two conditions may share underlying etiologic factors. Substance use disorders, including those of alcohol and prescription medications, can induce a set of symptoms which resembles mental illness, which can make it difficult to differentiate between substance induced psychiatric syndromes and pre-existing mental health problems. More often than not psychiatric disorders among people who use alcohol or illicit substances disappear with prolonged abstinence. Substance induced psychiatric symptoms can occur both in the intoxicated state and also during the withdrawal state. In some cases, these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine use. Use of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use and cannabis may trigger panic attacks during intoxication and with use it may cause a state similar to dysthymia. Severe anxiety and depression are commonly induced by sustained alcohol use which in most cases abates with prolonged abstinence. Even moderate sustained use of alcohol may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence. A protracted withdrawal syndrome can also occur with psychiatric and other symptoms persisting for months after cessation of use. Among the currently prevalent medications, benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use. Prospective epidemiological studies do not support the hypotheses that comorbidity of substance use disorders with other psychiatric illnesses is primarily a consequence of substance use or dependence or that increasing comorbidity is largely attributable to increasing use of substances. Yet emphasis is often on the effects of substances on the brain creating the impression that dual disorders are a natural consequence of these substances. However, addictive drugs or exposure to gambling will not lead to addictive behaviors or drug dependence in most individuals but only in vulnerable ones, although, according to some researchers, neuroadaptation or regulation of neuronal plasticity, and molecular changes, may alter gene expression in some cases and subsequently lead to substance use disorders. Research instruments are also often insufficiently sensitive to discriminate between independent, true dual pathology, and substance-induced symptoms. Structured instruments, as Global Appraisal of Individual Needs - Short Screener-GAIN-SS and Psychiatric Research Interview for Substance and Mental Disorders for DSM-IV-PRISM, have been developed to increase the diagnostic validity. While structured instruments can help organize diagnostic information, clinicians must still make judgments on the origin of symptoms. Prevalence Comorbidity of addictive disorders and other psychiatric disorders, i.e., dual disorders, is very common and a large body of literature has accumulated demonstrating that mental disorders are strongly associated with substance use disorders. The 2011 USA National Survey on Drug Use and Health found that 17.5% of adults with a mental illness had a co-occurring substance use disorder; this works out to 7.98 million people. Estimates of co-occurring disorders in Canada are even higher, with an estimated 40-60% of adults with a severe and persistent mental illness experiencing a substance use disorder in their lifetime. A study by Kessler et al. in the United States attempting to assess the prevalence of dual diagnosis found that 47% of clients with schizophrenia had a substance misuse disorder at some time in their life, and the chances of developing a substance misuse disorder was significantly higher among patients with a psychotic illness than in those without a psychotic illness. Another study looked at the extent of substance misuse in a group of 187 chronically mentally ill patients living in the community. According to the clinician's ratings, around a third of the sample used alcohol, street drugs, or both during the six months before evaluation. Further UK studies have shown slightly more moderate rates of substance misuse among mentally ill individuals. One study found that individuals with schizophrenia showed just a 7% prevalence of problematic drug use in the year prior to being interviewed and 21% reported problematic use some time before that. Wright and colleagues identified individuals with psychotic illnesses who had been in contact with services in the London borough of Croydon over the previous 6 months. Cases of alcohol or substance misuse and dependence were identified through standardized interviews with clients and keyworkers. Results showed that prevalence rates of dual diagnosis were 33% for the use of any substance, 20% for alcohol misuse only and 5% for drug misuse only. A lifetime history of any illicit drug use was observed in 35% of the sample. Diagnosis Substance use disorders can be confused with other psychiatric disorders. There are diagnoses for substance-induced mood disorders and substance-induced anxiety disorders and thus such overlap can be complicated. For this reason, the DSM-IV advises that diagnoses of primary psychiatric disorders not be made in the absence of sobriety (of a duration sufficient to allow for any substance-induced post-acute-withdrawal symptoms to dissipate) up to 1 year. Treatment Only a small proportion of those with co-occurring disorders actually receive treatment for both disorders. Therefore, it was argued that a new approach is needed to enable clinicians, researchers and managers to offer adequate assessment and evidence-based treatments to patients with dual pathology, who cannot be adequately and efficiently managed by cross-referral between psychiatric and addiction services as currently configured and resourced. In 2011, it was estimated that only 12.4% of American adults with co-occurring disorders were receiving both mental health and addictions treatment. Clients with co-occurring disorders face challenges accessing treatment, as they may be excluded from mental health services if they admit to a substance use problem and vice versa. There are multiple approaches to treat concurrent disorders. Partial treatment involves treating only the disorder that is considered primary. Sequential treatment involves treating the primary disorder first, and then treating the secondary disorder after the primary disorder has been stabilized. Parallel treatment involves the client receiving mental health services from one provider, and addictions services from another. Integrated treatment involves a seamless blending of interventions into a single coherent treatment package developed with a consistent philosophy and approach among care providers. With this approach, both disorders are considered primary. Integrated treatment can improve accessibility, service individualization, engagement in treatment, treatment compliance, mental health symptoms, and overall outcomes. The Substance Abuse and Mental Health Services Administration in the United States describes integrated treatment as being in the best interests or clients, programs, funders, and systems. Green suggested that treatment should be integrated, and a collaborative process between the treatment team and the patient. Furthermore, recovery should to be viewed as a marathon rather than a sprint, and methods and outcome goals should be explicit. A 2019 Cochrane meta-analysis that included 41 randomized controlled trials found no high-quality evidence in support of any one psycho-social intervention over standard care for outcomes such as remaining in treatment, reduction in substance use and/or improvement in global functioning and mental status. Theories of dual diagnosis There are a number of theories that explain the relationship between mental illness and substance use. Causality The causality theory suggests that certain types of substance use may causally lead to mental illness. There is strong evidence that using cannabis can produce psychotic and affective experiences. When it comes to persisting effects, there is a clear increase in the incidence of psychotic outcomes in people who had used cannabis, even when they had used it only once. More frequent use of cannabis strongly augmented the risk for psychosis. The evidence for affective outcomes is less strong. However, this connection between cannabis and psychosis does not prove that cannabis causes psychotic disorders. The causality theory for cannabis has been challenged as despite explosive increases in cannabis consumption over the past 40 years in western society, the rate of schizophrenia (and psychosis in general) has remained relatively stable. Attention-deficit hyperactivity disorder One in four people who have a substance use disorder also have attention-deficit hyperactivity disorder, which makes the treatment of both conditions more difficult. ADHD is associated with an increased craving for drugs. Having ADHD makes it more likely that an individual will initiate substance misuse at a younger age than their peers. They are also more likely to experience poorer outcomes, such as longer time to remission, and to have increased psychiatric complications from substance misuse. While generally stimulant medications do not seem to worsen substance use, they are known to be non-medically used in some cases. Psychosocial therapy and/or nonstimulant medications and extended release stimulants are ADHD treatment options that reduce these risks. Autism spectrum disorder Unlike ADHD, which significantly increases the risk of substance use disorder, autism spectrum disorder has the opposite effect of significantly reducing the risk of substance use. This is because introversion, inhibition and lack of sensation seeking personality traits, which are typical of autism spectrum disorder, protect against substance use and thus substance use levels are low in individuals who are on the autism spectrum. However, certain forms of substance use disorders, especially alcohol use disorder, can cause or worsen certain neuropsychological symptoms which are common to autism spectrum disorder. This includes impaired social skills due to the neurotoxic effects of alcohol on the brain, especially in the prefrontal cortex area of the brain. The social skills that are impaired by alcohol use disorder include impairments in perceiving facial emotions, prosody perception problems and theory of mind deficits; the ability to understand humour is also impaired in people who consume excessive amounts of alcohol Gambling The inclusion of behavioral addictions like pathological gambling must change our way of understanding and dealing with addictions. Pathological (disordered) gambling has commonalities in clinical expression, etiology, comorbidity, physiology and treatment with substance use disorders (DSM-5). A challenge is to understand the development of compulsivity at a neurochemical level not only for drugs. Past exposure to psychiatric medications theory The past exposure theory suggests that exposure to psychiatric medication alters neural synapses, introducing an imbalance that was not previously present. Discontinuation of the drug is expected to result in symptoms of psychiatric illness which resolve once the drug is restarted. This theory suggests that while it may appear that the medication is working, it is only treating a disorder caused by the medication itself. New exposure to psychiatric medication may lead to heightened sensitivity to the effects of drugs such as alcohol, which has a deteriorating effect on the patient. Self-medication theory The self-medication theory suggests that people with severe mental illnesses misuse substances in order to relieve a specific set of symptoms and counter the negative side-effects of antipsychotic medication. Khantizan proposes that substances are not randomly chosen, but are specifically selected for their effects. For example, using stimulants such as nicotine or amphetamines can be used to combat the sedation that can be caused by higher doses of certain types of antipsychotic medication. Conversely, some people taking medications with a stimulant effect such as the SNRI antidepressants Effexor (venlafaxine) or Wellbutrin (bupropion) may seek out benzodiazepines or opioid narcotics to counter the anxiety and insomnia that such medications sometimes evoke. Some studies show that nicotine administration can be effective for reducing motor side-effects of antipsychotics, with both bradykinesia (stiff muscles) and dyskinesia (involuntary movement) being prevented. Alleviation of dysphoria theory The alleviation of dysphoria theory suggests that people with severe mental illness commonly have a negative self-image, which makes them vulnerable to using psychoactive substances to alleviate these feelings. Despite the existence of a wide range of dysphoric feelings (anxiety, depression, boredom, and loneliness), the literature on self-reported reasons for use seems to lend support for the experience of these feelings being the primary motivator for alcohol use disorder and other drug misuse. Multiple risk factor theory Another theory is that there may be shared risk factors that can lead to both substance use and mental illness. Mueser hypothesizes that these may include factors such as social isolation, poverty, lack of structured daily activity, lack of adult role responsibility, living in areas with high drug availability, and association with people who already misuse drugs. Other evidence suggests that traumatic life events, such as sexual abuse, are associated with the development of psychiatric problems and substance use. The supersensitivity theory The supersensitivity theory proposes that certain individuals who have severe mental illness also have biological and psychological vulnerabilities, caused by genetic and early environmental life events. These interact with stressful life events and can result in either a psychiatric disorder or trigger a relapse into an existing illness. The theory states that although anti-psychotic medication can reduce the vulnerability, substance use may increase it, causing the individual to be more likely to experience negative consequences from using relatively small amounts of substances. These individuals, therefore, are "supersensitive" to the effects of certain substances, and individuals with psychotic illness such as schizophrenia may be less capable of sustaining moderate substance use over time without experiencing negative symptoms. Although there are limitations in the research studies conducted in this area, namely that most have focused primarily on schizophrenia, this theory provides an explanation of why relatively low levels of substance misuse often result in negative consequences for individuals with severe mental illness. Avoiding categorical diagnosis Current nosological approach does not provide a framework for internal (sub-threshold symptoms) or external (comorbidity) heterogeneity of the different diagnostic categories. The prevailing "Neo-Kraepelinian" diagnostic system solely accounts for a categorical diagnosis, therefore not allowing for the possibility of dual diagnosis. There has been substantial criticism to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), due to problems of diagnostic overlap, lack of clear boundaries between normality and disease, a failure to take into account findings from novel research and the lack of diagnostic stability over time. History The traditional method for treating patients with dual diagnosis was a parallel treatment program. In this format, patients received mental health services from one clinician while addressing their substance use with a separate clinician. However, researchers found that parallel treatments were ineffective, suggesting a need to integrate the services addressing mental health with those addressing substance use. During the mid-1980s, a number of initiatives began to combine mental health and substance use disorder services in an attempt to meet this need. These programs worked to shift the method of treatment for substance use from a confrontational approach to a supportive one. They also introduced new methods to motivate clients and worked with them to develop long-term goals for their care. Although the studies conducted by these initiatives did not have control groups, their results were promising and became the basis for more rigorous efforts to study and develop models of integrated treatment. References Further reading Addiction psychiatry Alcohol and health Drug rehabilitation Substance dependence Substance-related disorders 2 (number)

Social stigma

Stigma, originally referring to the visible marking of people considered inferior, has evolved in modern society into a social concept that applies to different groups or individuals based on certain characteristics such as socioeconomic status, culture, gender, race, religion or health status. Social stigma can take different forms and depends on the specific time and place in which it arises. Once a person is stigmatized, they are often associated with stereotypes that lead to discrimination, marginalization, and psychological problems. This process of stigmatization not only affects the social status and behavior of stigmatized persons, but also shapes their own self-perception, which can lead to psychological problems such as depression and low self-esteem. Stigmatized people are often aware that they are perceived and treated differently, which can start at an early age. Research shows that children are aware of cultural stereotypes at an early age, which affects their perception of their own identity and their interactions with the world around them. Description Stigma (plural stigmas or stigmata) is a Greek word that in its origins referred to a type of marking or the tattoo that was cut or burned into the skin of people with criminal records, slaves, or those seen as traitors in order to visibly identify them as supposedly blemished or morally polluted persons. These individuals were to be avoided particularly in public places. Social stigmas can occur in many different forms. The most common deal with culture, gender, race, religion, illness and disease. Individuals who are stigmatized usually feel different and devalued by others. Stigma may also be described as a label that associates a person to a set of unwanted characteristics that form a stereotype. It is also affixed. Once people identify and label one's differences, others will assume that is just how things are and the person will remain stigmatized until the stigmatizing attribute is undetectable. A considerable amount of generalization is required to create groups, meaning that people will put someone in a general group regardless of how well the person actually fits into that group. However, the attributes that society selects differ according to time and place. What is considered out of place in one society could be the norm in another. When society categorizes individuals into certain groups the labeled person is subjected to status loss and discrimination. Society will start to form expectations about those groups once the cultural stereotype is secured. Stigma may affect the behavior of those who are stigmatized. Those who are stereotyped often start to act in ways that their stigmatizers expect of them. It not only changes their behavior, but it also shapes their emotions and beliefs. Members of stigmatized social groups often face prejudice that causes depression (i.e. deprejudice). These stigmas put a person's social identity in threatening situations, such as low self-esteem. Because of this, identity theories have become highly researched. Identity threat theories can go hand-in-hand with labeling theory. Members of stigmatized groups start to become aware that they are not being treated the same way and know they are likely being discriminated against. Studies have shown that "by 10 years of age, most children are aware of cultural stereotypes of different groups in society, and children who are members of stigmatized groups are aware of cultural types at an even younger age." Main theories and contributions Émile Durkheim French sociologist Émile Durkheim was the first to explore stigma as a social phenomenon in 1895. He wrote: Erving Goffman Erving Goffman described stigma as a phenomenon whereby an individual with an attribute which is deeply discredited by their society is rejected as a result of the attribute. Goffman saw stigma as a process by which the reaction of others spoils normal identity. More specifically, he explained that what constituted this attribute would change over time. "It should be seen that a language of relationships, not attributes, is really needed. An attribute that stigmatizes one type of possessor can confirm the usualness of another, and therefore is neither credible nor discreditable as a thing in itself." In Goffman's theory of social stigma, a stigma is an attribute, behavior, or reputation which is socially discrediting in a particular way: it causes an individual to be mentally classified by others in an undesirable, rejected stereotype rather than in an accepted, normal one. Goffman defined stigma as a special kind of gap between virtual social identity and actual social identity: The stigmatized, the normal, and the wise Goffman divides the individual's relation to a stigma into three categories: the stigmatized being those who bear the stigma; the normals being those who do not bear the stigma; and the wise being those among the normals who are accepted by the stigmatized as understanding and accepting of their condition (borrowing the term from the homosexual community). The wise normals are not merely those who are in some sense accepting of the stigma; they are, rather, "those whose special situation has made them intimately privy to the secret life of the stigmatized individual and sympathetic with it, and who find themselves accorded a measure of acceptance, a measure of courtesy membership in the clan." That is, they are accepted by the stigmatized as "honorary members" of the stigmatized group. "Wise persons are the marginal men before whom the individual with a fault need feel no shame nor exert self-control, knowing that in spite of his failing he will be seen as an ordinary other," Goffman notes that the wise may in certain social situations also bear the stigma with respect to other normals: that is, they may also be stigmatized for being wise. An example is a parent of a homosexual; another is a white woman who is seen socializing with a black man (assuming social milieus in which homosexuals and dark-skinned people are stigmatized). A 2012 study showed empirical support for the existence of the own, the wise, and normals as separate groups; but the wise appeared in two forms: active wise and passive wise. The active wise encouraged challenging stigmatization and educating stigmatizers, but the passive wise did not. Ethical considerations Goffman emphasizes that the stigma relationship is one between an individual and a social setting with a given set of expectations; thus, everyone at different times will play both roles of stigmatized and stigmatizer (or, as he puts it, "normal"). Goffman gives the example that "some jobs in America cause holders without the expected college education to conceal this fact; other jobs, however, can lead to the few of their holders who have a higher education to keep this a secret, lest they are marked as failures and outsiders. Similarly, a middle-class boy may feel no compunction in being seen going to the library; a professional criminal, however, writes [about keeping his library visits secret]." He also gives the example of blacks being stigmatized among whites, and whites being stigmatized among blacks. Individuals actively cope with stigma in ways that vary across stigmatized groups, across individuals within stigmatized groups, and within individuals across time and situations. The stigmatized The stigmatized are ostracized, devalued, scorned, shunned and ignored. They experience discrimination in the realms of employment and housing. Perceived prejudice and discrimination is also associated with negative physical and mental health outcomes. Young people who experience stigma associated with mental health difficulties may face negative reactions from their peer group. Those who perceive themselves to be members of a stigmatized group, whether it is obvious to those around them or not, often experience psychological distress and many view themselves contemptuously. Although the experience of being stigmatized may take a toll on self-esteem, academic achievement, and other outcomes, many people with stigmatized attributes have high self-esteem, perform at high levels, are happy and appear to be quite resilient to their negative experiences. There are also "positive stigma": it is possible to be too rich, or too smart. This is noted by Goffman (1963:141) in his discussion of leaders, who are subsequently given license to deviate from some behavioral norms because they have contributed far above the expectations of the group. This can result in social stigma. The stigmatizer From the perspective of the stigmatizer, stigmatization involves threat, aversion and sometimes the depersonalization of others into stereotypic caricatures. Stigmatizing others can serve several functions for an individual, including self-esteem enhancement, control enhancement, and anxiety buffering, through downward-comparison—comparing oneself to less fortunate others can increase one's own subjective sense of well-being and therefore boost one's self-esteem. 21st-century social psychologists consider stigmatizing and stereotyping to be a normal consequence of people's cognitive abilities and limitations, and of the social information and experiences to which they are exposed. Current views of stigma, from the perspectives of both the stigmatizer and the stigmatized person, consider the process of stigma to be highly situationally specific, dynamic, complex and nonpathological. Gerhard Falk German-born sociologist and historian Gerhard Falk wrote: All societies will always stigmatize some conditions and some behaviors because doing so provides for group solidarity by delineating "outsiders" from "insiders". Falk describes stigma based on two categories, existential stigma and achieved stigma. He defines existential stigma as "stigma deriving from a condition which the target of the stigma either did not cause or over which he has little control." He defines Achieved Stigma as "stigma that is earned because of conduct and/or because they contributed heavily to attaining the stigma in question." Falk concludes that "we and all societies will always stigmatize some condition and some behavior because doing so provides for group solidarity by delineating 'outsiders' from 'insiders'". Stigmatization, at its essence, is a challenge to one's humanity- for both the stigmatized person and the stigmatizer. The majority of stigma researchers have found the process of stigmatization has a long history and is cross-culturally ubiquitous. Link and Phelan stigmatization model Bruce Link and Jo Phelan propose that stigma exists when four specific components converge: Individuals differentiate and label human variations. Prevailing cultural beliefs tie those labeled to adverse attributes. Labeled individuals are placed in distinguished groups that serve to establish a sense of disconnection between "us" and "them". Labeled individuals experience "status loss and discrimination" that leads to unequal circumstances. In this model stigmatization is also contingent on "access to social, economic, and political power that allows the identification of differences, construction of stereotypes, the separation of labeled persons into distinct groups, and the full execution of disapproval, rejection, exclusion, and discrimination." Subsequently, in this model, the term stigma is applied when labeling, stereotyping, disconnection, status loss, and discrimination all exist within a power situation that facilitates stigma to occur. Differentiation and labeling Identifying which human differences are salient, and therefore worthy of labeling, is a social process. There are two primary factors to examine when considering the extent to which this process is a social one. The first issue is that significant oversimplification is needed to create groups. The broad groups of black and white, homosexual and heterosexual, the sane and the mentally ill; and young and old are all examples of this. Secondly, the differences that are socially judged to be relevant differ vastly according to time and place. An example of this is the emphasis that was put on the size of the forehead and faces of individuals in the late 19th century—which was believed to be a measure of a person's criminal nature. Linking to stereotypes The second component of this model centers on the linking of labeled differences with stereotypes. Goffman's 1963 work made this aspect of stigma prominent and it has remained so ever since. This process of applying certain stereotypes to differentiated groups of individuals has attracted a large amount of attention and research in recent decades. Us and them Thirdly, linking negative attributes to groups facilitates separation into "us" and "them". Seeing the labeled group as fundamentally different causes stereotyping with little hesitation. "Us" and "them" implies that the labeled group is slightly less human in nature and at the extreme not human at all. Disadvantage The fourth component of stigmatization in this model includes "status loss and discrimination". Many definitions of stigma do not include this aspect, however, these authors believe that this loss occurs inherently as individuals are "labeled, set apart, and linked to undesirable characteristics." The members of the labeled groups are subsequently disadvantaged in the most common group of life chances including income, education, mental well-being, housing status, health, and medical treatment. Thus, stigmatization by the majorities, the powerful, or the "superior" leads to the Othering of the minorities, the powerless, and the "inferior". Whereby the stigmatized individuals become disadvantaged due to the ideology created by "the self," which is the opposing force to "the Other." As a result, the others become socially excluded and those in power reason the exclusion based on the original characteristics that led to the stigma. Necessity of power The authors also emphasize the role of power (social, economic, and political power) in stigmatization. While the use of power is clear in some situations, in others it can become masked as the power differences are less stark. An extreme example of a situation in which the power role was explicitly clear was the treatment of Jewish people by the Nazis. On the other hand, an example of a situation in which individuals of a stigmatized group have "stigma-related processes" occurring would be the inmates of a prison. It is imaginable that each of the steps described above would occur regarding the inmates' thoughts about the guards. However, this situation cannot involve true stigmatization, according to this model, because the prisoners do not have the economic, political, or social power to act on these thoughts with any serious discriminatory consequences. "Stigma allure" and authenticity Sociologist Matthew W. Hughey explains that prior research on stigma has emphasized individual and group attempts to reduce stigma by "passing as normal", by shunning the stigmatized, or through selective disclosure of stigmatized attributes. Yet, some actors may embrace particular markings of stigma (e.g.: social markings like dishonor or select physical dysfunctions and abnormalities) as signs of moral commitment and/or cultural and political authenticity. Hence, Hughey argues that some actors do not simply desire to "pass into normal" but may actively pursue a stigmatized identity formation process in order to experience themselves as causal agents in their social environment. Hughey calls this phenomenon "stigma allure". The "six dimensions of stigma" While often incorrectly attributed to Goffman, the "six dimensions of stigma" were not his invention. They were developed to augment Goffman's two levels – the discredited and the discreditable. Goffman considered individuals whose stigmatizing attributes are not immediately evident. In that case, the individual can encounter two distinct social atmospheres. In the first, he is discreditable—his stigma has yet to be revealed but may be revealed either intentionally by him (in which case he will have some control over how) or by some factor, he cannot control. Of course, it also might be successfully concealed; Goffman called this passing. In this situation, the analysis of stigma is concerned only with the behaviors adopted by the stigmatized individual to manage his identity: the concealing and revealing of information. In the second atmosphere, he is discredited—his stigma has been revealed and thus it affects not only his behavior but the behavior of others. Jones et al. (1984) added the "six dimensions" and correlate them to Goffman's two types of stigma, discredited and discreditable. There are six dimensions that match these two types of stigma: Concealable – the extent to which others can see the stigma Course of the mark – whether the stigma's prominence increases, decreases, or disappears Disruptiveness – the degree to which the stigma and/or others' reaction to it impedes social interactions Aesthetics – the subset of others' reactions to the stigma comprising reactions that are positive/approving or negative/disapproving but represent estimations of qualities other than the stigmatized person's inherent worth or dignity Origin – whether others think the stigma is present at birth, accidental, or deliberate Peril – the danger that others perceive (whether accurately or inaccurately) the stigma to pose to them Types In Unraveling the contexts of stigma, authors Campbell and Deacon describe Goffman's universal and historical forms of Stigma as the following. Overt or external deformities – such as leprosy, clubfoot, cleft lip or palate and muscular dystrophy. Known deviations in personal traits – being perceived rightly or wrongly, as weak willed, domineering or having unnatural passions, treacherous or rigid beliefs, and being dishonest, e.g., mental disorders, imprisonment, addiction, homosexuality, unemployment, suicidal attempts and radical political behavior. Tribal stigma – affiliation with a specific nationality, religion, or race that constitute a deviation from the normative, e.g. being African American, or being of Arab descent in the United States after the 9/11 attacks. Deviance Stigma occurs when an individual is identified as deviant, linked with negative stereotypes that engender prejudiced attitudes, which are acted upon in discriminatory behavior. Goffman illuminated how stigmatized people manage their "Spoiled identity" (meaning the stigma disqualifies the stigmatized individual from full social acceptance) before audiences of normals. He focused on stigma, not as a fixed or inherent attribute of a person, but rather as the experience and meaning of difference. Gerhard Falk expounds upon Goffman's work by redefining deviant as "others who deviate from the expectations of a group" and by categorizing deviance into two types: Societal deviance refers to a condition widely perceived, in advance and in general, as being deviant and hence stigma and stigmatized. "Homosexuality is, therefore, an example of societal deviance because there is such a high degree of consensus to the effect that homosexuality is different, and a violation of norms or social expectation". Situational deviance refers to a deviant act that is labeled as deviant in a specific situation, and may not be labeled deviant by society. Similarly, a socially deviant action might not be considered deviant in specific situations. "A robber or other street criminal is an excellent example. It is the crime which leads to the stigma and stigmatization of the person so affected." The physically disabled, mentally ill, homosexuals, and a host of others who are labeled deviant because they deviate from the expectations of a group, are subject to stigmatization - the social rejection of numerous individuals, and often entire groups of people who have been labeled deviant. Stigma communication Communication is involved in creating, maintaining, and diffusing stigmas, and enacting stigmatization. The model of stigma communication explains how and why particular content choices (marks, labels, peril, and responsibility) can create stigmas and encourage their diffusion. A recent experiment using health alerts tested the model of stigma communication, finding that content choices indeed predicted stigma beliefs, intentions to further diffuse these messages, and agreement with regulating infected persons' behaviors. More recently, scholars have highlighted the role of social media channels, such as Facebook and Instagram, in stigma communication. These platforms serve as safe spaces for stigmatized individuals to express themselves more freely. However, social media can also reinforce and amplify stigmatization, as the stigmatized attributes are amplified and virtually available to anyone indefinitely. Challenging Stigma, though powerful and enduring, is not inevitable, and can be challenged. There are two important aspects to challenging stigma: challenging the stigmatization on the part of stigmatizers and challenging the internalized stigma of the stigmatized. To challenge stigmatization, Campbell et al. 2005 summarise three main approaches. There are efforts to educate individuals about non-stigmatising facts and why they should not stigmatize. There are efforts to legislate against discrimination. There are efforts to mobilize the participation of community members in anti-stigma efforts, to maximize the likelihood that the anti-stigma messages have relevance and effectiveness, according to local contexts. In relation to challenging the internalized stigma of the stigmatized, Paulo Freire's theory of critical consciousness is particularly suitable. Cornish provides an example of how sex workers in Sonagachi, a red light district in India, have effectively challenged internalized stigma by establishing that they are respectable women, who admirably take care of their families, and who deserve rights like any other worker. This study argues that it is not only the force of the rational argument that makes the challenge to the stigma successful, but concrete evidence that sex workers can achieve valued aims, and are respected by others. Stigmatized groups often harbor cultural tools to respond to stigma and to create a positive self-perception among their members. For example, advertising professionals have been shown to suffer from negative portrayal and low approval rates. However, the advertising industry collectively maintains narratives describing how advertisement is a positive and socially valuable endeavor, and advertising professionals draw on these narratives to respond to stigma. Another effort to mobilize communities exists in the gaming community through organizations like: Take This – who provides AFK rooms at gaming conventions plus has a Streaming Ambassador Program to reach more than 135,000 viewers each week with positive messages about mental health, and NoStigmas – whose mission "is to ensure that no one faces mental health challenges alone" and envisions "a world without shame or discrimination related to mental health, brain disease, behavioral disorders, trauma, suicide and addiction" plus offers workplaces a NoStigmas Ally course and individual certifications. Organizational stigma In 2008, an article by Hudson coined the term "organizational stigma" which was then further developed by another theory building article by Devers and colleagues. This literature brought the concept of stigma to the organizational level, considering how organizations might be considered as deeply flawed and cast away by audiences in the same way individuals would. Hudson differentiated core-stigma (a stigma related to the very nature of the organization) and event-stigma (an isolated occurrence which fades away with time). A large literature has debated how organizational stigma relate to other constructs in the literature on social evaluations. A 2020 book by Roulet reviews this literature and disentangle the different concepts in particular differentiating stigma, dirty work, scandals and exploring their positive implications. Current research The research was undertaken to determine the effects of social stigma primarily focuses on disease-associated stigmas. Disabilities, psychiatric disorders, and sexually transmitted diseases are among the diseases currently scrutinized by researchers. In studies involving such diseases, both positive and negative effects of social stigma have been discovered. Stigma in healthcare settings Recent research suggests that addressing perceived and enacted stigma in clinical settings is critical to ensuring delivery of high-quality patient-centered care. Specifically, perceived stigma by patients was associated with longer periods of poor physical or mental health. Additionally, perceived stigma in healthcare settings was associated with higher odds of reporting a depressive disorder. Among other findings, individuals who were married, younger, had higher income, had college degrees, and were employed reported significantly fewer poor physical and mental health days and had lower odds of self-reported depressive disorder. A complementary study conducted in New York City (as opposed to nationwide), found similar outcomes. The researchers' objectives were to assess rates of perceived stigma in clinical settings reported by racially diverse New York City residents and to examine if this perceived stigma was associated with poorer physical and mental health outcomes. They found that perceived stigma was associated with poorer healthcare access, depression, diabetes, and poor overall general health. Research on self-esteem Members of stigmatized groups may have lower self-esteem than those of nonstigmatized groups. A test could not be taken on the overall self-esteem of different races. Researchers would have to take into account whether these people are optimistic or pessimistic, whether they are male or female and what kind of place they grew up in. Over the last two decades, many studies have reported that African Americans show higher global self-esteem than whites even though, as a group, African Americans tend to receive poorer outcomes in many areas of life and experience significant discrimination and stigma. Mental disorders Empirical research on the stigma associated with mental disorders, pointed to a surprising attitude of the general public. Those who were told that mental disorders had a genetic basis were more prone to increase their social distance from the mentally ill, and also to assume that the ill were dangerous individuals, in contrast with those members of the general public who were told that the illnesses could be explained by social and environmental factors. Furthermore, those informed of the genetic basis were also more likely to stigmatize the entire family of the ill. Although the specific social categories that become stigmatized can vary over time and place, the three basic forms of stigma (physical deformity, poor personal traits, and tribal outgroup status) are found in most cultures and eras, leading some researchers to hypothesize that the tendency to stigmatize may have evolutionary roots. The impact of the stigma is significant, leading many individuals to not seek out treatment. For example, evidence from a refugee camp in Jordan suggests that providing mental health care comes with a dilemma: between the clinical desire to make mental health issues visible and actionable through datafication and the need to keep mental health issues hidden and out of the view of the community to avoid stigma. That is, in spite of their suffering the refugees were hesitant to receive mental health care as they worried about stigma. Currently, several researchers believe that mental disorders are caused by a chemical imbalance in the brain. Therefore, this biological rationale suggests that individuals struggling with a mental illness do not have control over the origin of the disorder. Much like cancer or another type of physical disorder, persons suffering from mental disorders should be supported and encouraged to seek help. The Disability Rights Movement recognises that while there is considerable stigma towards people with physical disabilities, the negative social stigma surrounding mental illness is significantly worse, with those suffering being perceived to have control of their disabilities and being responsible for causing them. "Furthermore, research respondents are less likely to pity persons with mental illness, instead of reacting to the psychiatric disability with anger and believing that help is not deserved." Although there are effective mental health interventions available across the globe, many persons with mental illnesses do not seek out the help that they need. Only 59.6% of individuals with a mental illness, including conditions such as depression, anxiety, schizophrenia, and bipolar disorder, reported receiving treatment in 2011. Reducing the negative stigma surrounding mental disorders may increase the probability of affected individuals seeking professional help from a psychiatrist or a non-psychiatric physician. How particular mental disorders are represented in the media can vary, as well as the stigma associated with each. On the social media platform, YouTube, depression is commonly presented as a condition that is caused by biological or environmental factors, is more chronic than short-lived, and different from sadness, all of which may contribute to how people think about depression. Causes Arikan found that a stigmatising attitude to psychiatric patients is associated with narcissistic personality traits. In Taiwan, strengthening the psychiatric rehabilitation system has been one of the primary goals of the Department of Health since 1985. This endeavor has not been successful. It was hypothesized that one of the barriers was social stigma towards the mentally ill. Accordingly, a study was conducted to explore the attitudes of the general population towards patients with mental disorders. A survey method was utilized on 1,203 subjects nationally. The results revealed that the general population held high levels of benevolence, tolerance on rehabilitation in the community, and nonsocial restrictiveness. Essentially, benevolent attitudes were favoring the acceptance of rehabilitation in the community. It could then be inferred that the belief (held by the residents of Taiwan) in treating the mentally ill with high regard, and the progress of psychiatric rehabilitation may be hindered by factors other than social stigma. Artists In the music industry, specifically in the genre of hip-hop or rap, those who speak out on mental illness are heavily criticized. However, according to an article by The Huffington Post, there's a significant increase in rappers who are breaking their silence on depression and anxiety. Addiction and substance use disorders Throughout history, addiction has largely been seen as a moral failing or character flaw, as opposed to an issue of public health. Substance use has been found to be more stigmatized than smoking, obesity, and mental illness. Research has shown stigma to be a barrier to treatment-seeking behaviors among individuals with addiction, creating a "treatment gap". A systematic review of all epidemiological studies on treatment rates of people with alcohol use disorders found that over 80% had not accessed any treatment for their disorder. The study also found that the treatment gap was larger in low and lower-middle-income countries. Research shows that the words used to talk about addiction can contribute to stigmatization, and that the commonly used terms of "abuse" & "abuser" actually increase stigma. Behavioral addictions (i.e. gambling, sex, etc.) are found to be more likely to be attributed to character flaws than substance-use addictions. Stigma is reduced when Substance Use Disorders are portrayed as treatable conditions. Acceptance and Commitment Therapy has been used effectively to help people to reduce shame associated with cultural stigma around substance use treatment. The use of the drug methamphetamine has been strongly stigmatized. An Australian national population study have shown that the proportion of Australians who nominated methamphetamine as a "drug problem" increased between 2001–2019. The epidemiological study provided evidence that levels of under-reporting have increased over the period, which coincided with the deployment of public health campaigns on the dangers of ice that had stigmatizing elements that portrayal of persons who used the drugs in a negative way. The level of under-reporting of methamphetamine use is strongly associated with increasing negative attitudes towards their use over the same period. Poverty Recipients of public assistance programs are often scorned as unwilling to work. The intensity of poverty stigma is positively correlated with increasing inequality. As inequality increases, societal propensity to stigmatize increases. This is in part, a result of societal norms of reciprocity which is the expectation that people earn what they receive rather than receiving assistance in the form of what people tend to view as a gift. Poverty is often perceived as a result of failures and poor choices rather than the result of socioeconomic structures that suppress individual abilities. Disdain for the impoverished can be traced back to its roots in Anglo-American culture where poor people have been blamed and ostracized for their misfortune for hundreds of years. The concept of deviance is at the bed rock of stigma towards the poor. Deviants are people that break important norms of society that everyone shares. In the case of poverty it is breaking the norm of reciprocity that paves the path for stigmatization. Public assistance Social stigma is prevalent towards recipients of public assistance programs. This includes programs frequently utilized by families struggling with poverty such as Head Start and AFDC (Aid To Families With Dependent Children). The value of self-reliance is often at the center of feelings of shame and the fewer people value self reliance the less stigma affects them psychologically. Stigma towards welfare recipients has been proven to increase passivity and dependency in poor people and has further solidified their status and feelings of inferiority. Caseworkers frequently treat recipients of welfare disrespectfully and make assumptions about deviant behavior and reluctance to work. Many single mothers cited stigma as the primary reason they wanted to exit welfare as quickly as possible. They often feel the need to conceal food stamps to escape judgement associated with welfare programs. Stigma is a major factor contributing to the duration and breadth of poverty in developed societies which largely affects single mothers. Recipients of public assistance are viewed as objects of the community rather than members allowing for them to be perceived as enemies of the community which is how stigma enters collective thought. Amongst single mothers in poverty, lack of health care benefits is one of their greatest challenges in terms of exiting poverty. Traditional values of self reliance increase feelings of shame amongst welfare recipients making them more susceptible to being stigmatized. Epilepsy Hong Kong Epilepsy, a common neurological disorder characterized by recurring seizures, is associated with various social stigmas. Chung-yan Guardian Fong and Anchor Hung conducted a study in Hong Kong which documented public attitudes towards individuals with epilepsy. Of the 1,128 subjects interviewed, only 72.5% of them considered epilepsy to be acceptable; 11.2% would not let their children play with others with epilepsy; 32.2% would not allow their children to marry persons with epilepsy; additionally, some employers (22.5% of them) would terminate an employment contract after an epileptic seizure occurred in an employee with unreported epilepsy. Suggestions were made that more effort be made to improve public awareness of, attitude toward, and understanding of epilepsy through school education and epilepsy-related organizations. Media In the early 21st century, technology has a large impact on the lives of people in multiple countries and has shaped social norms. Many people own a television, computer, and a smartphone. The media can be helpful with keeping people up to date on news and world issues and it is very influential on people. Because it is so influential sometimes the portrayal of minority groups affects attitudes of other groups toward them. Much media coverage has to do with other parts of the world. A lot of this coverage has to do with war and conflict, which people may relate to any person belonging from that country. There is a tendency to focus more on the positive behavior of one's own group and the negative behaviors of other groups. This promotes negative Smartphone thoughts of people belonging to those other groups, reinforcing stereotypical beliefs. "Viewers seem to react to violence with emotions such as anger and contempt. They are concerned about the integrity of the social order and show disapproval of others. Emotions such as sadness and fear are shown much more rarely." (Unz, Schwab & Winterhoff-Spurk, 2008, p. 141) In a study testing the effects of stereotypical advertisements on students, 75 high school students viewed magazine advertisements with stereotypical female images such as a woman working on a holiday dinner, while 50 others viewed nonstereotypical images such as a woman working in a law office. These groups then responded to statements about women in a "neutral" photograph. In this photo, a woman was shown in a casual outfit not doing any obvious task. The students that saw the stereotypical images tended to answer the questionnaires with more stereotypical responses in 6 of the 12 questionnaire statements. This suggests that even brief exposure to stereotypical ads reinforces stereotypes. (Lafky, Duffy, Steinmaus & Berkowitz, 1996) Education and culture The aforementioned stigmas (associated with their respective diseases) propose effects that these stereotypes have on individuals. Whether effects be negative or positive in nature, 'labeling' people causes a significant change in individual perception (of persons with the disease). Perhaps a mutual understanding of stigma, achieved through education, could eliminate social stigma entirely. Laurence J. Coleman first adapted Erving Goffman's (1963) social stigma theory to gifted children, providing a rationale for why children may hide their abilities and present alternate identities to their peers. The stigma of giftedness theory was further elaborated by Laurence J. Coleman and Tracy L. Cross in their book entitled, Being Gifted in School, which is a widely cited reference in the field of gifted education. In the chapter on Coping with Giftedness, the authors expanded on the theory first presented in a 1988 article. According to Google Scholar, this article has been cited over 300 times in the academic literature (as of 2022). Coleman and Cross were the first to identify intellectual giftedness as a stigmatizing condition and they created a model based on Goffman's (1963) work, research with gifted students, and a book that was written and edited by 20 teenage, gifted individuals. Being gifted sets students apart from their peers and this difference interferes with full social acceptance. Varying expectations that exist in the different social contexts which children must navigate, and the value judgments that may be assigned to the child result in the child's use of social coping strategies to manage his or her identity. Unlike other stigmatizing conditions, giftedness is unique because it can lead to praise or ridicule depending on the audience and circumstances. Gifted children learn when it is safe to display their giftedness and when they should hide it to better fit in with a group. These observations led to the development of the Information Management Model that describes the process by which children decide to employ coping strategies to manage their identities. In situations where the child feels different, she or he may decide to manage the information that others know about him or her. Coping strategies include disidentification with giftedness, attempting to maintain low visibility, or creating a high-visibility identity (playing a stereotypical role associated with giftedness). These ranges of strategies are called the Continuum of Visibility. Abortion While abortion is very common throughout the world, people may choose not to disclose their use of such services, in part due to the stigma associated with having had an abortion. Keeping abortion experiences secret has been found to be associated with increased isolation and psychological distress. Abortion providers are also subject to stigma. Stigmatization of prejudice Cultural norms can prevent displays of prejudice as such views are stigmatized and thus people will express non-prejudiced views even if they believe otherwise (preference falsification). However, if the stigma against such views is lessened, people will be more willing to express prejudicial sentiments. For example, following the 2008 economic crisis, anti-immigration sentiment seemingly increased amongst the US population when in reality the level of sentiment remained the same and instead it simply became more acceptable to openly express opposition to immigration. Spatial Stigma Spatial stigma refers to stigmas that are linked to ones geographic location. This can be applied to neighborhoods, towns, cities or any defined geographical space. A person's geographic location or place of origin can be a source of stigma. This type of stigma can leade to negative health outcomes. See also Badge of shame Collateral consequences of criminal charges Closure (sociology) Dehumanization Discrimination Guilt by association Health-related embarrassment Identity (social science) Interpersonal theory of suicide Label (sociology) Labeling Labeling theory Leprosy stigma Loser Passing (sociology) Post-assault mistreatment of sexual assault victims Prejudice Scapegoat Self-concealment Self-esteem Self-schema Shame Social alienation Social defeat Social exclusion Stereotype Stereotype threat Stig-9 perceived mental illness stigma questionnaire Stigma management Taboo Time to Change (mental health campaign) Weight stigma Infertility and childlessness stigmas References Citations Sources George Ritzer (2006). Contemporary Social Theory and its Classical Roots: The Basics (Second Edition). McGraw-Hill. Blaine, B. (2007). Understanding The Psychology of Diversity. SAGE Publications Ltd. Summary Carol T. Miller, Ester D. Rothblum, Linda Barbour, Pamela A. Brand and Diane Felicio (September 1989). The University of Vermont. "Social Interactions of Obese and Nonobese Women" Ken Plummer (1975). Sexual stigma: an interactionist account. Routledge. . External links Stigma Research and Action a peer reviewed open access journal in the stigma field Identity politics Labeling theory Social rejection Sociological terminology Stereotypes Shame

Problem-based learning

Problem-based learning (PBL) is a teaching method in which students learn about a subject through the experience of solving an open-ended problem found in trigger material. The PBL process does not focus on problem solving with a defined solution, but it allows for the development of other desirable skills and attributes. This includes knowledge acquisition, enhanced group collaboration and communication. The PBL process was developed for medical education and has since been broadened in applications for other programs of learning. The process allows for learners to develop skills used for their future practice. It enhances critical appraisal, literature retrieval and encourages ongoing learning within a team environment. The PBL tutorial process often involves working in small groups of learners. Each student takes on a role within the group that may be formal or informal and the role often alternates. It is focused on the student's reflection and reasoning to construct their own learning. The Maastricht seven-jump process involves clarifying terms, defining problem(s), brainstorming, structuring and hypothesis, learning objectives, independent study and synthesising. In short, it is identifying what they already know, what they need to know, and how and where to access new information that may lead to the resolution of the problem. The role of the tutor is to facilitate learning by supporting, guiding, and monitoring the learning process. The tutor aims to build students' confidence when addressing problems, while also expanding their understanding. This process is based on constructivism. PBL represents a paradigm shift from traditional teaching and learning philosophy, which is more often lecture-based. The constructs for teaching PBL are very different from traditional classroom or lecture teaching and often require more preparation time and resources to support small group learning. Meaning Wood (2003) defines problem-based learning as a process that uses identified issues within a scenario to increase knowledge and understanding. The principles of this process are listed below: Learner-driven self-identified goals and outcomes Students do independent, self-directed study before returning to larger group Learning is done in small groups of 8–10 people, with a tutor to facilitate discussion Trigger materials such as paper-based clinical scenarios, lab data, photographs, articles or videos or patients (real or simulated) can be used The Maastricht 7-jump process helps to guide the PBL tutorial process Based on principles of adult learning theory All members of the group have a role to play Allows for knowledge acquisition through combined work and intellect Enhances teamwork and communication, problem-solving and encourages independent responsibility for shared learning - all essential skills for future practice Anyone can do it as long it is right depending on the given causes and scenario The Maastricht 7-jump involves seven steps, which are: discuss the case and make sure everyone understands the problem identify the questions that need to be answered to shed light on the case brainstorm what the group already knows and identify potential solutions analyse and structure the results of the brainstorming session formulate learning objectives for the knowledge that is still lacking do independent study, individually or in smaller groups: read articles or books, follow practicals or attend lectures to gain the required knowledge discuss the findings History The PBL process was pioneered by Barrows and Tamblyn at the medical school program at McMaster University in Hamilton in the 1960s. Traditional medical education disenchanted students, who perceived the vast amount of material presented in the first three years of medical school as having little relevance to the practice of medicine and clinically based medicine. The PBL curriculum was developed in order to stimulate learning by allowing students to see the relevance and application to future roles. It maintains a higher level of motivation towards learning, and shows the importance of responsible, professional attitudes with teamwork values. The motivation for learning drives interest because it allows for selection of problems that have real-world application. Problem-based learning has subsequently been adopted by other medical school programs adapted for undergraduate instruction, as well as K-12. The use of PBL has expanded from its initial introduction into medical school programs to include education in the areas of other health sciences, math, law, education, economics, business, social studies, and engineering. PBL includes problems that can be solved in many different ways depending on the initial identification of the problem and may have more than one solution. In 1974, Aalborg University was funded in Denmark and all the programs (engineering, natural and social sciences) were based on PBL. The UNESCO Chair in Problem-Based Learning in Engineering Education is at Aalborg University. Currently its roughly 20,000 students still follow PBL principles. Advantages There are advantages of PBL. It is student-focused, which allows for active learning and better understanding and retention of knowledge. It also helps to develop life skills that are applicable to many domains. It can be used to enhance content knowledge while simultaneously fostering the development of communication, problem-solving, critical thinking, collaboration, and self-directed learning skills. PBL may position students to optimally function using real-world experiences. By harnessing collective group intellect, differing perspectives may offer different perceptions and solutions to a problem. Following are the advantages and limitations of problem-based learning. Enhance student-centred learning In problem-based learning the students are actively involved and they like this method. It fosters active learning, and also retention and development of lifelong learning skills. It encourages self-directed learning by confronting students with problems and stimulates the development of deep learning. Upholds lifelong learning Problem-based learning gives emphasis to lifelong learning by developing in students the potential to determine their own goals, locate appropriate resources for learning and assume responsibility for what they need to know. It also greatly helps them better long term knowledge retention. Prominence on comprehension not facts Problem-based learning focuses on engaging students in finding solutions to real life situations and pertinent contextualized problems. In this method discussion forums collaborative research take the place of lecturing. In-depth learning and constructivist approach PBL fosters learning by involving students with the interaction of learning materials. They relate the concept they study with everyday activities and enhance their knowledge and understanding. Students also activate their prior knowledge and build on existing conceptual knowledge frameworks. Augments self-learning Students themselves resolve the problems that are given to them, they take more interest and responsibility for their learning. They themselves will look for resources like research articles, journals, web materials, text books etc. for their purpose. Thus it equips them with more proficiency in seeking resources in comparison to the students of traditional learning methods. Better understanding and adeptness By giving more significance to the meaning, applicability and relevance to the learning materials it leads to better understanding of the subjects learnt. When students are given more challenging and significant problems are given it makes them more proficient. The real life contexts and problems makes their learning more profound, lasting and also enhance the transferability of skills and knowledge from the classroom to work. Since there is more scope for application of knowledge and skills the transferability is increased. It will be also very helpful to them not only to visualise what it will be like applying that knowledge and expertise on their field of work or profession. Reinforces interpersonal skills and teamwork Project based learning is more of teamwork and collaborative learning. The teams or groups resolve relevant problems in collaboration and hence it fosters student interaction, teamwork and reinforces interpersonal skills. like peer evaluation, working with group dynamic etc. It also fosters in them the leadership qualities, learn to make decision by consensus and give constructive feed back to the team members etc. Self-motivated attitude Researchers say that students like problem-based learning classes rather than the traditional classes. The increase in the percentage of attendance of students and their attitude towards this approach itself makes it very clear that they are self-motivated. In fact it is more fascinating, stimulating and one of the good learning methods because it is more flexible and interesting to students. They enjoy this environment of learning for it is less threatening and they can learn independently. All these aspects make students more self-motivated and they pursue learning even after they leave the school or college. Enriches the teacher-student relationship Since the students are self-motivated, good teamwork, self-directed learning etc. the teachers who have worked in both traditional and project based learning formats prefer project based learning. They also feel that problem-based learning is more nurturing, significant curriculum and beneficial to the cognitive growth of the student. Higher level of learning The PBL students score higher than the students in traditional courses because of their learning competencies, problem solving, self-assessment techniques, data gathering, behavioral science etc. It is because they are better at activating prior knowledge, and they learn in a context resembling their future context and elaborate more on the information presented which helps in better understanding and retention of knowledge. In medical education, PBL cases can incorporate dialogue between patients and physicians, demonstrate the narrative character of the medical encounter, and examine the political economic contributors to disease production. PBL can serve as a platform for a discursive practices approach to culture that emphasizes the emergent, participant-constructed qualities of social phenomena while also acknowledging large-scale social forces. Disadvantages According to Wood (2003), the major disadvantage to this process involves the utilization of resources and tutor facilitation. It requires more staff to take an active role in facilitation and group-led discussion and some educators find PBL facilitation difficult and frustrating. It is resource-intensive because it requires more physical space and more accessible computer resources to accommodate simultaneous smaller group-learning. Students also report uncertainty with information overload and are unable to determine how much study is required and the relevance of information available. Students may not have access to teachers who serve as the inspirational role models that traditional curriculum offers. Time-consuming Although students generally like and gain greater ability to solve real-life problems in problem-based learning courses, instructors of the methodology must often invest more time to assess student learning and prepare course materials, as compared to LBL instructors. Part of this frustration also stems from the amount of time dedicated to presenting new research and individual student findings regarding each specific topic, as well as the disorganised nature of brain-storming Traditional assumptions of the students The problem of the problem-based learning is the traditional assumptions of the students. Most of the students might have spent their previous years of education assuming their teacher as the main disseminator of knowledge. Because of this understanding towards the subject matter students may lack the ability to simply wonder about something in the initial years of problem-based learning. Role of the instructor The instructors have to change their traditional teaching methodologies in order to incorporate problem-based learning. Their task is to question students' knowledge, beliefs, give only hints to correct their mistakes and guide the students in their research. All these features of problem-based learning may be foreign to some instructors; hence they find it difficult to alter their past habits. Pupil's evaluation The instructors have to adapt new assessment methods to evaluate the pupils' achievement. They have to incorporate written examinations with modified essay questions, practical examinations, peer and self assessments etc. Problem-based has also been considered slightly more favourable to female participants, whilst having equivocal impacts on their male counterparts when compared to lecture based learning. Cognitive load Sweller and others published a series of studies over the past twenty years that is relevant to problem-based learning, concerning cognitive load and what they describe as the guidance-fading effect. Sweller et al. conducted several classroom-based studies with students studying algebra problems. These studies have shown that active problem solving early in the learning process is a less effective instructional strategy than studying worked examples (Sweller and Cooper, 1985; Cooper and Sweller, 1987). Certainly active problem solving is useful as learners become more competent, and better able to deal with their working memory limitations. But early in the learning process, learners may find it difficult to process a large amount of information in a short time. Thus the rigors of active problem solving may become an issue for novices. Once learners gain expertise the scaffolding inherent in problem-based learning helps learners avoid these issues. These studies were conducted largely based on individual problem solving of well-defined problems. Sweller (1988) proposed cognitive load theory to explain how novices react to problem solving during the early stages of learning. Sweller, et al. suggests a worked example early, and then a gradual introduction of problems to be solved. They propose other forms of learning early in the learning process (worked example, goal free problems, etc.); to later be replaced by completions problems, with the eventual goal of solving problems on their own. This problem-based learning becomes very useful later in the learning process. Many forms of scaffolding have been implemented in problem-based learning to reduce the cognitive load of learners. These are most useful to enable decreasing ("fading") the amount of guidance during problem solving. A gradual fading of guidance helps learners to slowly transit from studying examples to solving problems. In this case backwards fading was found to be quite effective and assisting in decreasing the cognitive load on learners. Evaluation of the effects of PBL learning in comparison to traditional instructional learning have proved to be a challenge. Various factors can influence the implementation of PBL: extent of PBL incorporation into curriculum, group dynamics, nature of problems used, facilitator influence on group, and the motivation of the learners. There are also various outcomes of PBL that can be measured including knowledge acquisition and clinical competence. Additional studies are needed to investigate all the variables and technological scaffolds, that may impact the efficacy of PBL. Demands of implementing Implementing PBL in schools and Universities is a demanding process that requires resources, a lot of planning and organization. Azer discusses the 12 steps for implementing the "pure PBL" Prepare faculty for change Establish a new curriculum committee and working group Designing the new PBL curriculum and defining educational outcomes Seeking Advice from Experts in PBL Planning, Organizing and Managing Training PBL facilitators and defining the objectives of a facilitator Introducing Students to the PBL Program Using 3-learning to support the delivery of the PBL program Changing the assessment to suit the PBL curriculum Encouraging feedback from students and teaching staff Managing learning resources and facilities that support self-directed learning Continuing evaluation and making changes (pg. 809-812) Cultural difference: Asia Some of the reported difficulties in implementing PBL in these schools include poor participation and difficulty in getting students involved in discussions, due possibly to their Asian reticence. One school reported that students felt that they were compelled to speak as they were being assessed. Some students reported not having enough confidence to seek information independently without guidance from their teachers. The students also found it very time-consuming to seek information themselves, as they still had to cope with the requirements of the traditional curriculum of attending lectures. Some students had difficulty with the language if the PBL discussions were conducted in English, as it was not their working language. Constructivism Problem-based learning addresses the need to promote lifelong learning through the process of inquiry and constructivist learning. PBL is considered a constructivist approach to instruction because it emphasizes collaborative and self-directed learning while being supported by tutor facilitation. Yew and Schmidt, Schmidt, and Hung elaborate on the cognitive constructivist process of PBL: Learners are presented with a problem and through discussion within their group, activate their prior knowledge. Within their group, they develop possible theories or hypotheses to explain the problem. Together they identify learning issues to be researched. They construct a shared primary model to explain the problem at hand. Facilitators provide scaffolding, which is a framework on which students can construct knowledge relating to the problem. After the initial teamwork, students work independently in self-directed study to research the identified issues. The students re-group to discuss their findings and refine their initial explanations based on what they learned. PBL follows a constructivist perspective in learning as the role of the instructor is to guide and challenge the learning process rather than strictly providing knowledge. From this perspective, feedback and reflection on the learning process and group dynamics are essential components of PBL. Students are considered to be active agents who engage in social knowledge construction. PBL assists in processes of creating meaning and building personal interpretations of the world based on experiences and interactions. PBL assists to guide the student from theory to practice during their journey through solving the problem. Supporting evidence Several studies support the success of the constructivist problem-based and inquiry learning methods. One example is a study on a project called GenScope, an inquiry-based science software application, which found that students using the GenScope software showed significant gains over the control groups, with the largest gains shown in students from basic courses. One large study tracked middle school students' performance on high-stakes standardized tests to evaluate the effectiveness of inquiry-based science. The study found a 14 percent improvement for the first cohort of students and a 13 percent improvement for the second cohort of students. The study also found that inquiry-based teaching methods greatly reduced the achievement gap for African-American students. A systematic review of the effects of problem-based learning in medical school on the performance of doctors after graduation showed clear positive effects on physician competence. This effect was especially strong for social and cognitive competencies such as coping with uncertainty and communication skills. Another study from Slovenia looked at whether students who learn with PBL are better at solving problems and if their attitudes towards mathematics were improved compared to their peers in a more traditional curriculum. The study found that students who were exposed to PBL were better at solving more difficult problems; however, there was no significant difference in student attitude towards mathematics. Examples in curricula Malaysia and Singapore In Malaysia, an attempt was made to introduce a problem-based learning model in secondary mathematics, with the aim of educating citizens to prepare them for decision-making in sustainable and responsible development. This model called Problem-Based Learning the Four Core Areas (PBL4C) first sprouted in SEAMEO RECSAM in 2008, and as a result of training courses conducted, a paper was presented at the EARCOME5 conference in 2010, followed by two papers during the 15th UNESCO-APEID conference in 2011. In Singapore, the most notable example of adopting PBL pedagogy in curriculum is Republic Polytechnic, the first polytechnic in Singapore to fully adopt PBL across all diploma courses. Medical schools Several medical schools have incorporated problem-based learning into their curricula following the lead of McMaster University Medical School, using real patient cases to teach students how to think like a clinician. More than eighty percent of medical schools in the United States now have some form of problem-based learning in their programs. Research of 10 years of data from the University of Missouri School of Medicine indicates that PBL has a positive effect on the students' competency as physicians after graduation. In 1998, Western University of Health Sciences opened its College of Veterinary Medicine, with curriculum based completely on PBL. In 2002, UC Berkeley – UCSF Joint Medical Program (JMP), an accredited five year Master of Science/Medical Doctorate Program housed at University of California, Berkeley School of Public Health, began offering a 100% case based curriculum to their students in their pre-clerkship years. The curriculum integrates the basic and preclinical sciences while fostering an understanding of the biological, social, and moral contexts of human health and disease. The students spend their last two clerkship years at University of California, San Francisco. Ecological economics The transdisciplinary field of ecological economics has embraced problem-based learning as a core pedagogy. A workbook developed by Joshua Farley, Jon Erickson, and Herman Daly organizes the problem-solving process into (1) building the problem base, (2) analyzing the problem, (3) synthesizing the findings, and (4) communicating the results. Building the problem base includes choosing, defining, and structuring an ecological economic problem. Analysis is breaking down of a problem into understandable components. Synthesis is the re-integration of the parts in a way that helps better understand the whole. Communication is the translation of results into a form relevant to stakeholders, broadly defined as the extended peer community. (a concept developed in Post-normal science). Other outcomes One of the aims of PBL is the development of self-directed learning (SDL) skills. In Loyens, Magda & Rikers' discussion, SDL is defined as "a process in which individuals take the initiative...in diagnosing their learning needs, formulating goals, identifying human and material resources, choosing and implementing appropriate learning strategies, and evaluating learning outcomes". By being invited into the learning process, students are also invited to take responsibility for their learning, which leads to an increase in self-directed learning skills. In Severiens and Schmidt's study of 305 first year college students, they found that PBL and its focus on SDL led to motivation for students to maintain study pace, led to social and academic integration, encouraged development of cognitive skills, and fostered more study progress than students in a conventional learning setting. PBL encourages learners to take a place in the academic world through inquiring and discovery that is central to problem-based learning. PBL is also argued as a learning method that can promote the development of critical thinking skills. In PBL learning, students learn how to analyze a problem, identify relevant facts and generate hypotheses, identify necessary information/knowledge for solving the problem and make reasonable judgments about solving the problem. Employers have appreciated the positive attributes of communication, teamwork, respect and collaboration that PBL experienced students have developed. These skills provide for better future skills preparation in the ever-changing information explosion. PBL curriculum includes building these attributes through knowledge building, written and interpersonal interactions and through the experience of the problem solving process. Computer-supported collaborative learning Computer-supported PBL can be an electronic version (ePBL) of the traditional face-to-face paper-based PBL or an online group activity with participants located distant apart. ePBL provides the opportunity to embed audios and videos, related to the skills (e.g. clinical findings) within the case scenarios improving learning environment and thus enhance students' engagement in the learning process. Comparing face-to-face setting with strict online PBL, the group activities play the key role in the success of the social interaction in PBL. Online PBL is also seen as more cost-effective. Collaborative PBL has been shown to improve critical thinking scores as compared with individual PBL, and increased students' achievement levels and retention scores. For the instructors, instructional design principles for the instructors regarding the design and development of online PBL must include collaborative characteristics. For example, the scheduling must be conducive to collaborative activities. Additionally, instructors should ensure that the problems should be relevant to real-life experiences, and the nature of solutions and problem contexts. Furthermore, a sound technological infrastructure is paramount. History of online PBL The establishment and application of PBL in teaching and training started as early as in the 1960s. As instructional technology developed over time coupled with the emergence of the internet in the mid-1990s, online education became popular gaining huge attention from organizations and institutions. However, the use of PBL in complete online education does not seem as established based on the relatively scarce references available in the literature. In 2001, the University of Southern Queensland (USQ) was one of the first few faculties that utilized a learning management system (LMS) to facilitate collaboration and group problem-solving. The result showed the significant impact of online PBL on the learning outcomes of students in many aspects including enhancing their communication skills, problem-solving skills and ability to work as a team. The most successful feature of the LMS in terms of user rate was the discussion boards where asynchronous communications took place. Technology has advanced for another decade since then and it should help us take online PBL to a greater height as many more activities such as synchronous online meetings have been made readily available today on numerous platforms. The key focus here is to examine how technology can further facilitate the effective use of PBL online by zooming into the learner needs in each phase of PBL. Tools Collaborative tools The first, and possibly most crucial phase in PBL, is to identify the problem. Before learners can begin to solve a problem, all members must understand and agree on the details of the problem. This consensus forms through collaboration and discussion. With online learning on the rise, it is important that learners can engage in collaborative brainstorming and research through the use of technology. Technology allows for groups to collaborate synchronously or asynchronously from anywhere in the world; schedules and geography no longer prevent collaboration in PBL. Today, there is a plethora of tools available to promote group collaboration online, each with unique strengths and limitations. Learning management systems and cloud-based solutions are the two most popular and accessible technological solution for online collaboration. Learning management systems, such as Canvas, Edmodo, Moodle, Schoology, and itslearning, provide schools and classrooms collaborative tools to support synchronous and asynchronous communication and learning. The learning management systems (LMS) allow for supervision and support by the course administrator or professor. One limitation of these systems is their availability; most LMS are restricted by course enrollment. Students must be enrolled in a particular course or subscribe to a specific class to gain access to the tools and content stored in the system. Cloud-based solutions on the other hand, such as Google Apps, OneNote, and the Office 365 suit offer collaborative tools outside the traditional education setting. Educators of all kinds (K-12 schools, colleges, and universities, vocational training, HR training teams, etc.) can access these cloud-based solutions and collaborate with anyone around the world by simply sharing a link. These tools range in availability from free with an email account to subscription costs based on the suit purchased. In addition to potential financial limitations, these cloud-based systems are always as secure or private as an LMS that requires course enrollment. Both LMS and cloud-based solutions present learners with opportunities to collaborate in a variety of ways while brainstorming the meaning of the problem and developing a plan for research and future collaboration. Research tools Once the problem has been identified, learners move into the second step of PBL: the information gathering phase. In this phase, learners research the problem by gathering background information and researching potential solutions. This information is shared with the learning team and used to generate potential solutions, each with supporting evidence. The most popular online tool for gathering information today is Google, but there are many other search-engines available online. Free search engines, such as Google, Yahoo, or Bing, offer access to seemingly countless links to information. While these research tools provide ample sources of potential information, the quantity can be overwhelming. It also becomes difficult to identify quality sources without adding filters and higher-level search strategies when using these broad search-engines. Libraries are a more selective option and often offer online-databases, but typically require an account or subscription for online access to articles and books. Wolframalpha.com is a smart search-engine with both free and subscription level access options. Wolfram claims to be more than a platform for searching the web, rather, "getting knowledge and answers... by doing dynamic computations based on a vast collection of built-in data, algorithms, and methods." Presentation tools The third most important phase of PBL is resolving the problem, the critical task is presenting and defending your solution to the given problem. Students need to be able to state the problem clearly, describe the process of problem-solving considering different options to overcome difficulties, support the solution using relevant information and data analysis. Being able to communicate and present the solution clearly is the key to the success of this phase as it directly affects the learning outcomes. With the help of technology, presentation has been made much easier and more effective as it can incorporate visual aids of charts, pictures, videos, animations, simulations etc. Ideas and connections between ideas can be clearly demonstrated using different tools. Microsoft PowerPoint 2016, Apple Keynote, Prezi, and Google Slides are among the top-rated presentation applications of 2017. These popular presentation tools have their distinctive features and advantages over one another and can be summarized into three broad types. The first type has almost everything a presenter needs, ranging from tables, charts, picture tools, animations, video tools, add in functions and so forth. Such tools can replace many authoring tools as more complicated functions such as creating simulations, drag and drop etc. are all made possible. Hence, the presentation can be made highly interactive, engaging and compatible with most devices. The best examples are Microsoft PowerPoint and Apple Keynote. However, one drawback is that such tools often come at a subscription charge and need to be installed locally on devices. Both PowerPoint and Keynote point more towards the standard form of slide by slide presentations. Prezi represents the second major type of tools with a storytelling style and less traditional or structured form of presentation that allows one to zoom in and out of any part of the screen. These tools are generally web-based and have collaborative functions of value-add for the PBL process. Nevertheless, this type of tools also charge subscription fees based on privilege levels. The third broad type of tools would be the web-based ones free of charge with less fanciful effects, allowing access to presentations collaboratively online anytime. Google Slides is such an option which is easy to use. Though it has less functions, it offers the convenience of being available anytime anywhere on any online device. This type can be effective when students have limited time to prepare for their presentations as it removes many technical difficulties such as arranging for face-to-face meetings, installing the presentation tool or the time needed to learn to create the presentation. Students can spend more time on meaningful discussions about their problem and solution instead of the presentation itself. P5BL approach P5BL stands for People, Problem, Process, Product and Project Based Learning. The P5BL approach was a learning strategy introduced in Stanford School of Engineering in their P5BL laboratory in 1993 as an initiative to offer their graduate students from the engineering, architecture and construction disciplines to implement their skills in a "cross-disciplinary, collaborative and geographically distributed teamwork experience". In this approach, which was pioneered by Stanford Professor Fruchter, an environment across six universities from Europe, the United States and Japan along with a toolkit to capture and share project knowledge was developed. The students (people) from the three disciplines were assigned a team project that works on solving a problem and delivering an end-product to a client. The main stress of this approach is to have an inter-disciplinary integrated development of deliverables, in order to improve the overall competency and skills of the students. P5BL mentoring is a structured activity that involves situated learning and constructivist learning strategies to foster the culture of practice that would extend beyond the university campus to real life. P5BL is all about encouraging teaching and learning teamwork in the information age, by facilitating team interaction with professors, industry mentors and owners who provide necessary guidance and support for the learning activity. Key advantages of this method are that it familiarizes students with real world problems and improves their confidence in solving these. It also improves their networking skills, thereby establishing rapport with key persons of the industry. They also learn, in an educational setting, the value of teamwork. The method also creates in them an appreciation of interdisciplinary approach. The approach however needs due consideration of the mentoring provided to the students. Appropriate scaffolding should be done by the mentors to ensure that students are successful in attaining their project goals to solve the problem. Communication between the team should also be open and constructive in nature for achieving the necessary milestones. See also Discovery learning Educational psychology Learning by teaching (LdL) POGIL Phenomenon-based learning Project-based learning 21st century skills References Sources External links Interdisciplinary Journal of PBL at Purdue Problem Based Learning for College Physics (CCDMD) Illinois Mathematics and Science Academy's Problem Based Learning Network (PBLN) Problem-Based Learning the Four Core Areas PBL4C Medical education Pedagogy Educational practices

Asymptomatic

Asymptomatic (or clinically silent) is an adjective categorising the medical conditions (i.e., injuries or diseases) that patients carry but without experiencing their symptoms, despite an explicit diagnosis (e.g., a positive medical test). Pre-symptomatic is the adjective categorising the time periods during which the medical conditions are asymptomatic. Subclinical and paucisymptomatic are other adjectives categorising either the asymptomatic infections (i.e., subclinical infections), or the psychosomatic illnesses and mental disorders expressing a subset of symptoms but not the entire set an explicit medical diagnosis requires. Examples An example of an asymptomatic disease is cytomegalovirus (CMV) which is a member of the herpes virus family. "It is estimated that 1% of all newborns are infected with CMV, but the majority of infections are asymptomatic." (Knox, 1983; Kumar et al. 1984) In some diseases, the proportion of asymptomatic cases can be important. For example, in multiple sclerosis it is estimated that around 25% of the cases are asymptomatic, with these cases detected postmortem or just by coincidence (as incidental findings) while treating other diseases. Importance Knowing that a condition is asymptomatic is important because: It may be contagious, and the contribution of asymptomatic and pre-symptomatic infections to the transmission level of a disease helps set the required control measures to keep it from spreading. It is not required that a person undergo treatment. It does not cause later medical problems such as high blood pressure and hyperlipidaemia. Be alert to possible problems: asymptomatic hypothyroidism makes a person vulnerable to Wernicke–Korsakoff syndrome or beri-beri following intravenous glucose. For some conditions, treatment during the asymptomatic phase is vital. If one waits until symptoms develop, it is too late for survival or to prevent damage. Mental health Subclinical or subthreshold conditions are those for which the full diagnostic criteria are not met and have not been met in the past, although symptoms are present. This can mean that symptoms are not severe enough to merit a diagnosis, or that symptoms are severe but do not meet the criteria of a condition. List These are conditions for which there is a sufficient number of documented individuals that are asymptomatic that it is clinically noted. For a complete list of asymptomatic infections see subclinical infection. Balanitis xerotica obliterans Benign lymphoepithelial lesion Cardiac shunt Carotid artery dissection Carotid bruit Cavernous hemangioma Chloromas (Myeloid sarcoma) Cholera Chronic myelogenous leukemia Coeliac disease Coronary artery disease Coronavirus disease 2019 Cowpox Diabetic retinopathy Essential fructosuria Flu or Influenza strains Folliculosebaceous cystic hamartoma Glioblastoma multiforme (occasionally) Glucocorticoid remediable aldosteronism Glucose-6-phosphate dehydrogenase deficiency Hepatitis Hereditary elliptocytosis Herpes Heterophoria Human coronaviruses (common cold germs) Hypertension (high blood pressure) Histidinemia HIV (AIDS) HPV Hyperaldosteronism hyperlipidaemia Hyperprolinemia type I Hypothyroidism Hypoxia (some cases) Idiopathic thrombocytopenic purpura Iridodialysis (when small) Lesch–Nyhan syndrome (female carriers) Levo-Transposition of the great arteries Measles Meckel's diverticulum Microvenular hemangioma Mitral valve prolapse Monkeypox Monoclonal B-cell lymphocytosis Myelolipoma Nonalcoholic fatty liver disease Optic disc pit Osteoporosis Pertussis (whooping cough) Pes cavus Poliomyelitis Polyorchidism Pre-eclampsia Prehypertension Protrusio acetabuli Pulmonary contusion Renal tubular acidosis Rubella Smallpox (extinct since the 1980s) Spermatocele Sphenoid wing meningioma Spider angioma Splenic infarction (though not typically) Subarachnoid hemorrhage Tonsillolith Tuberculosis Type II diabetes Typhus Vaginal intraepithelial neoplasia Varicella (chickenpox) Wilson's disease Millions of women reported lack of symptoms during pregnancy until the point of childbirth or the beginning of labor; they didn't know they were pregnant. This phenomenon is known as cryptic pregnancies. See also Symptomatic Subclinical infection References Medical terminology Symptoms

Assertive community treatment

Assertive community treatment (ACT) is an intensive and highly integrated approach for community mental health service delivery. ACT teams serve individuals who have been diagnosed with serious and persistent forms of mental illness, predominantly but not exclusively the schizophrenia spectrum disorders. ACT service recipients may also have diagnostic profiles that include features typically found in other DSM-5 categories (for example, bipolar, depressive, anxiety, and personality disorders, among others). Many have histories of frequent psychiatric hospitalization, substance abuse, victimization and trauma, arrests and incarceration, homelessness, and additional significant challenges. The symptoms and complications of their mental illnesses have led to serious functioning difficulties in several areas of life, often including work, social relationships, residential independence, money management, and physical health and wellness. By the time they start receiving ACT services, they are likely to have experienced failure, discrimination, and stigmatization, and their hope for the future is likely to be quite low. Definition The defining characteristics of ACT include: a focus on participants (also known as members, consumers, clients, or patients) who require the most help from the service delivery system; an explicit mission to promote the participants' independence, rehabilitation, community integration, and recovery, and in so doing to prevent homelessness, unnecessary hospitalization, and other negative outcomes; an emphasis on home visits and other in vivo (out of the office) interventions, eliminating the need to transfer newly learned skills from an artificial rehabilitation or treatment setting to the "real world" — indeed, this simple feature of the model has had a profound impact on psychiatric rehabilitation in general, because it shifts the burden of “fitting in” from service recipients to service providers, who now find it more difficult to prescribe, and thus to control, the characteristics of the intervention setting; a participant-to-staff ratio that is low enough to allow the ACT "core services team" to perform virtually all of the necessary rehabilitation, treatment, and community support tasks themselves in a coordinated and efficient manner—unlike traditional case managers, who broker or "farm out" most of the work to other service providers; a "total team" or "whole team" approach to intervention, in which all of the staff work with all of the participants, under the supervision and with the active participation of a mental health professional, who serves as the team's leader; an interdisciplinary program of continuous assessment, service planning, and intervention that typically involves — in addition to the team leader — a psychiatrist, social workers, nurses, occupational therapists, co-occurring disorder specialists, vocational rehabilitation specialists, and peer support specialists (individuals who have had personal, successful experience with the recovery process); a willingness to be a “one stop” intervention that takes ultimate professional responsibility for the participants' well-being in all areas of community functioning — including most especially the "nitty-gritty" aspects of everyday life — by providing a comprehensive array of services for every participant and ensuring clear staff-to-staff communication, through such measures as daily team meetings to review the previous 24-hour (or weekend) period and to plan for the coming days and weeks; a conscious effort to help people avoid crisis situations in the first place through careful planning, frequent communication, and flexible staff deployment, or — if the current plan isn't working — to revise it and intervene rapidly and assertively, with the goal of preventing hospitalizations (when possible), loss of housing, and other negative outcomes; and a commitment to work with people on a time-unlimited basis, as long as they still demonstrate the need for this intensive level of professional help, but also to help them move on when they are ready. In the array of standard mental health service types, ACT is considered a "medically monitored non-residential service" (Level 4), making it more intensive than "high-intensity community-based services" (Level 3) but less intensive than "medically monitored residential services" (Level 5), as measured by the widely accepted LOCUS utilization management tool. While ACT is more staff-intensive than most other forms of community treatment, it is viewed as a less restrictive option for carefully selected service recipients, compared to custodial or more heavily supervised alternatives; see Olmstead v. L.C. In general, appropriate candidates are those for whom less intensive approaches have proven unsuccessful or insufficient. Early developments ACT was first developed during the early 1970s, the heyday of deinstitutionalization, when large numbers of patients were being discharged from state-operated psychiatric hospitals to an underdeveloped, poorly integrated "nonsystem" of community services characterized (in the words of one of the model's founders) by serious "gaps" and "cracks." The founders were Leonard I. Stein, Mary Ann Test, Arnold J. Marx, Deborah J. Allness, William H. Knoedler, and their colleagues at the Mendota Mental Health Institute, a state operated psychiatric hospital in Madison, Wisconsin. Also known in the professional literature as the Training in Community Living project, the Program of Assertive Community Treatment (PACT), or simply the "Madison model," this innovation seemed radical at the time but has since evolved into one of the most influential service delivery approaches in the history of community mental health. The original Madison project received the American Psychiatric Association's prestigious Gold Award in 1974. After conceiving the model as a strategy to prevent hospitalization in a relatively heterogeneous sample of prospective state hospital patients, the PACT team turned its attention in the early 1980s to a more narrowly defined target group of young adults with early-stage schizophrenia. Dissemination of the original model Since the late 1970s, the ACT approach has been replicated or adapted widely. The Harbinger program in Grand Rapids, Michigan, is generally recognized as the first replication, and a family-initiated early adaptation in Minnesota, known as Sharing Life in the Community when it was founded in 1976, also traces its origins to the Madison model. Starting in 1978, Jerry Dincin, Thomas F. Witheridge, and their colleagues developed the Bridge assertive outreach program at the Thresholds psychiatric rehabilitation center in Chicago, Illinois—the first big-city adaptation of ACT and the first such program to focus on the most frequently hospitalized segment of the mental health consumer population. In the 1980s and '90s, Thresholds further adapted the approach to serve deaf people with mental illness, homeless people with mental illness, people experiencing psychiatric crises, and people with mental illness who are caught up in the criminal justice system. In British Columbia, an experimental assertive outreach program based on the Thresholds model was established in 1988 and later expanded to additional sites. Outside of North America, one of the first research-based adaptations was an assertive outreach program in Australia. Other replications or adaptations of the ACT approach can be found throughout the English-speaking world and elsewhere. In Wisconsin, the original Madison model was adapted by its founders for the realities of a sparsely populated rural environment. The Veterans Health Administration has adapted the ACT model for use at multiple sites throughout the United States. There are also major program concentrations in Delaware, Florida, Georgia, Idaho, Illinois, Indiana (home of numerous research-based ACT programs and the Indiana ACT Center), Michigan, Minnesota, Missouri, New Jersey, New Mexico, New York, North Carolina (home to the UNC Institute for Best Practices), Ohio, Rhode Island, South Carolina, South Dakota, Texas, Virginia, Australia, Canada, and the United Kingdom, among many other places. In 1998, the National Alliance on Mental Illness (NAMI) published the first manualization of the ACT model, written by two of its original developers, Allness and Knoedler. From 1998 to 2004, NAMI operated an ACT technical assistance center, dedicated to advocacy and training to make the model more widely available, with funding from the U.S. federal government's Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the Department of Health and Human Services. Although most of the early PACT replicates and adaptations were funded by grants from federal, state/provincial, or local mental health authorities, there has been a growing tendency to fund these services through Medicaid and other publicly supported health insurance plans. Medicaid funding has been used for ACT services throughout the United States, starting in the late 1980s, when Allness left PACT to head Wisconsin's state mental health agency and led the development of ACT operational standards. Since then, U.S. and Canadian standards have been developed, and many states and provinces have used them in the development of ACT services for individuals with psychiatric disabilities who would otherwise be dependent on more costly, less effective alternatives. Even though Medicaid has turned out to be a mixed blessing — it can be difficult to demonstrate a person's eligibility for this insurance program, to meet its documentation and claim requirements, or to find supplemental funding for necessary services it will not cover — Medicaid reimbursement has led to a long-overdue expansion of ACT in previously unserved or underserved jurisdictions. Public mental health system planners have attempted to resolve the implementation problems associated with replicating the original Madison approach in sparsely populated rural areas or with low-incidence special populations in urban areas. A related issue for planners is to determine the number of ACT or "ACT-like" programs a particular geographical area needs and can support. Some promising areas for further development are identified below in the section on the future of ACT. Research on ACT and related program models ACT and its variations are among the most widely and intensively studied intervention approaches in community mental health. The original Madison studies by Stein and Test and their colleagues are classics in the field. Another major contributor to the ACT literature is Gary Bond, who completed several studies at Thresholds in Chicago and later developed a major psychiatric rehabilitation research and training program at Indiana University-Purdue University at Indianapolis. Bond has been particularly influential in the development of fidelity measurement scales for ACT and other evidence-based practices. He and his colleagues (especially Robert E. Drake at Dartmouth Medical School) have attempted to consolidate and harmonize several major currents in this continuously developing area of practice, including: the different "styles" of service delivery exemplified by PACT in Madison, Thresholds in Chicago, the Dartmouth model of integrated dual disorders treatment, and other pioneering programs; the various modifications of the original ACT approach over the years to maximize its effectiveness with particular service delivery challenges, such as helping consumers to recover from co-occurring psychiatric and substance use disorders or to choose, get, and keep competitive jobs through a supported employment approach called individual placement and support; the increasingly well-organized efforts to help consumers take charge of their own wellness management and recovery. An evidence review conducted by the AcademyHealth policy center in July 2016, examining the impact of housing-related services and supports on the health outcomes of homeless people enrolled in Medicaid, concluded that ACT reduces self-reported psychiatric symptoms, psychiatric hospital stays, and hospital emergency department visits among people with mental illness and substance use diagnoses. Acclaim and criticism Because of its long track record of success with high-priority service recipients in a wide variety of geographical and organizational settings — as demonstrated by a large and growing body of rigorous outcome evaluation studies — ACT has been recognized by SAMHSA, NAMI, and the Commission on Accreditation of Rehabilitation Facilities, among other recognized arbiters, as an evidence-based practice worthy of widespread dissemination. However, the acclaim for assertive community treatment and related service approaches is not universal. For example, Patricia Spindel and Jo Anne Nugent have argued that the main difficulty with the Program of Assertive Community Treatment (PACT) model and some other case management approaches is that there has been no critical analysis of how personally empowering (as opposed to socially controlling) such programs are. These authors have argued that PACT does not meet the criteria for being an empowerment approach for "working with disadvantaged, labelled, and stigmatized people." Furthermore, they assert, PACT does not have a philosophical base that stresses true individual empowerment. There is much literature, they say, questioning the way in which human services are delivered, but this literature is not considered in evaluations of the PACT approach. Spindle and Nugent conclude that "PACT may be little more than a means of transporting the social control and biomedical functions of the hospital or the institution to the community. For a community mental health system which says that it wants a more progressive approach, PACT simply does not fit the bill." Other concerns have arisen out of the harm reduction/Housing First version of the model, as implemented in the late 2010s. Some clinicians and dual diagnosis specialists have voiced concerns that the model creates a safe environment for increased drug use, resulting in more instances of overdose and even death; they are awaiting an empirical study to confirm these suspicions. Tomi Gomory at Florida State University has also been critical of PACT. He has written: "Advocates of Programs of Assertive Community Treatment (PACT) make numerous claims for this intensive intervention program, including reduced hospitalization, overall cost, and clinical symptomatology, and increased client satisfaction, and vocational and social functioning. However, a reanalysis of the controlled experimental research finds no empirical support for any of these claims." Gomory has asserted that the chief characteristics of PACT are "intensity, assertiveness, or aggressiveness, which may better be identified as coercion. For example, reduced hospitalization in ACT is simply accomplished by having an administrative decision rule not to admit ACT patients into the hospital regardless of symptomatic behavior (the patients are kept and treated in the community) while patients in routine treatment are hospitalized regularly. When this rule is not present the research shows no reduced hospitalization by ACT compared to routine treatment." Madison psychiatrist Ronald J. Diamond has provided support for that position: "The development of Programs for Assertive Community Treatment (PACT), assertive community treatment (ACT) teams and a variety of similar mobile, continuous treatment programs has made it possible to coerce a wide range of behaviors in the community." Gomory has also argued that professional enthusiasm for the medical model is the main driver of PACT expansion, rather than any clear benefit to clients who receive the service. In the professional journal Psychiatric Services, Test and Stein have replied to Gomory's assertions that PACT is inherently coercive and that the research claiming to support it is scientifically invalid, and Gomory, in turn, has answered their reply. Moser and Bond address coercion and the broader concept of "agency control" (practices in which the treatment team maintains supervisory responsibility over consumers) in a discussion of data from 23 ACT programs. Their review shows that "agency control" varies greatly among different programs; it may be particularly high with patients diagnosed in the schizophrenia spectrum who also have active substance use issues. A widely distributed book co-authored by Gomory has called the public's attention to various treatment failures allegedly caused by therapies described in the book as "coercive," including PACT. Future The cost-effectiveness of ACT was relatively easy to demonstrate in the early days, when psychiatric hospital beds were more heavily used than they are now. In the years to come, program planners will have to justify the comparatively high cost of ACT through the continued use of careful admission criteria and rigorous program evaluation. To ensure the best possible service quality on a routine basis, public regulators and payers would also benefit from having fidelity and outcome monitoring tools more easily administered than those currently available. The defining characteristics of the ACT approach will remain an attractive framework for services to meet the needs of special populations, such as individuals whose psychiatric symptoms get them into trouble with the criminal justice system, refugees from foreign countries who struggle with the added burden of mental illness, and children and adolescents with serious emotional disturbances. One major piece of unfinished business in the mental health field is the discovery that people with serious mental illnesses die an average of 25 years earlier than the general public, often from disorders that are inherently preventable or treatable; this public health disaster is a critical issue for ACT providers and the people they serve. Another important area for future program design and evaluation is the use of ACT in combination with other established interventions, such as integrated dual disorder treatment for people with co-occurring mental health and substance use diagnoses, supported employment programs, education for concerned family members, and dialectical behavior therapy for individuals diagnosed with borderline personality disorder. Ironically, the dissemination of separate evidence-based practices, not all of which are easily integrated with each other, has once again made service coordination a pivotal issue in community mental health — as it was during the latter decades of the 20th century, when ACT was created as an antidote to the "nonsystem" of care. See also Deinstitutionalisation Mental illness Psychiatric rehabilitation Notes Psychiatric rehabilitation Psychotherapy by type Deinstitutionalisation

SMART Recovery

SMART Recovery is an international community of peer support groups that help people recover from addictive and problematic behaviors, using a self-empowering and evidence-informed program. SMART stands for Self-Management and Recovery Training. The SMART approach is secular and research-based. SMART has a global reach with a presence established in more than 30 countries. SMART Recovery is effective with a range of addictive and problematic behaviors (alcohol, drugs, gambling, overeating, internet use, etc). Meetings of SMART participants are held throughout the week, both in person and online. These meetings, which tend to run from 60 to 90 minutes each, are confidential, free, and guided by trained facilitators. Facilitators can be volunteers or professionals. Participants in various stages of recovery, or simply curious about pursuing recovery, share lessons and challenges from their own journeys, while exploring, through discussion, a suite of scientifically grounded psychology tools and techniques. The SMART approach is built on the belief that freedom from substance use disorders and behavioral addictions fundamentally requires the exercise of personal choice. The SMART model is built on psychological tools of cognitive behavioral therapy and motivational interviewing. SMART was initially developed by medical professionals seeking more effective methods to treat patients. At the same time, SMART acknowledges that certain individuals can benefit from a blend of approaches, and does not discourage people from using other methods whilst attending SMART meetings. SMART endeavors to be inclusive for all participants. The organization's methods and meetings are congenial to participants who choose treatment with appropriately prescribed medications. SMART recognizes some participants may be seeking to regulate behaviors whilst others may choose abstinence. Throughout its global network of affiliates can be found both large scale SMART Recovery meetings and specific meetings tailored to prison inmates, military personnel, the LBGTQIA+ communities, young adults and family and friends of people engaged in or trying to achieve independence from addictive and problematic behaviors. Methodology SMART Recovery is based on scientific knowledge and is intended to evolve as scientific knowledge evolves. The program uses principles of motivational interviewing, found in motivational enhancement therapy (MET), and techniques taken from rational emotive behavior therapy (REBT), and cognitive-behavioral therapy (CBT), as well as scientifically validated research on treatment. The SMART Recovery Program and meetings are congenial to participants who choose to use appropriately-prescribed medications, including opioid-agonist medications, as part of their recovery programs. The organization's program emphasizes four areas, called the 4-Point Program, in the process of recovery: Building Motivation, Coping with Urges, Problem Solving, and Lifestyle Balance. The "SMART Toolbox" is a collection of various MET, CBT, and REBT methods, or "tools," which address the 4 Points. SMART Recovery can be used as a stand-alone primary recovery support program for those seeking help recovering from addictions, but does not insist on being exclusive. The program does not use the 12 steps that make up the basis of the various "Anonymous" self-help groups (e.g., Alcoholics Anonymous (AA), Narcotics Anonymous (NA), etc.) and is generally listed as an "Alternative to AA" or an "Alternative to the 12 Steps." SMART Recovery believes that each individual finds their own path to recovery. Though listed as an "alternative," it is also suggested as a possible "supplement" to 12-step programs in SMART Recovery's main program publication, The SMART Recovery Handbook. Stages of change SMART Recovery recognizes that participants may be in one or more of various stages of change and that different exercises may be helpful at different stages. Precontemplation – At this stage, the participant may not realize that they have a problem. Contemplation – The participant evaluates the advantages and disadvantages of the addiction by performing a cost/benefit analysis. Determination/Preparation – The participant decides to pursue personal change, and may complete a Change Plan Worksheet. Action – The participant seeks out new ways of handling their addiction behavior. This can include self-help, the support of addiction help group or professional guidance. Maintenance – After a few months, the participant's behavior has been changed and now seeks to maintain their gains. Graduation/Exit – Once a participant has sustained a long period of change, they may choose to move on with their lives and "graduate" from SMART Recovery. Side event: Relapse – Although not inevitable, relapses are a normal part of the change cycle and if handled well, can serve as a learning experience in overcoming an addiction. Meetings SMART Recovery meetings are free for all wishing to attend and are intended to be informational as well as supportive. Over 1500 weekly group meetings led by volunteer facilitators are held worldwide. In addition, the organization provides online resources and support to the volunteers and those attending the groups and one or more daily online meetings. Meetings are also held in correctional facilities in many states, including: Arizona, California, Florida, Indiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New York, Vermont, Virginia, Washington, and Wisconsin. Effectiveness A 2018 longitudinal study compared the self-reported success of SMART Recovery, LifeRing Secular Recovery, Women for Sobriety, and Alcoholics Anonymous. After normalizing for income and other demographic factors, the study saw that SMART Recovery fared worse across the outcomes of alcohol abstinence, alcohol drinking problems, and total abstinence, compared to Alcoholics Anonymous. However, after normalizing for treatment goal, SMART Recovery members who pursued abstinence did as well across all three factors as members of AA. In other words, among AA members and members of SMART Recovery who wanted to abstain, there was no significant difference in the success rate. History The first SMART Recovery meeting was held in the United States in 1994, and the organization established its original headquarters in Mentor, Ohio. As interest grew, SMART meetings spread into Canada, the United Kingdom and Australia. Thirty years later, the expansion is ongoing, with SMART meetings now held in 36 countries and 16 languages. In 2017, SMART Recovery International (SRI) was established. SRI is the governing body for the global SMART Recovery community. SRI is overseen by a Board of international Directors mostly drawn from national SMART Recovery organizations. It receives advice from the SMART Recovery Global Research Committee. SMART affiliates in individual countries maintain their own governance structures as independent entities that are licensed to use the SMART Recovery intellectual property by SMART Recovery International. Specific program offerings can differ among these entities. SMART Recovery relies on funding from voluntary donations, philanthropy and grants. SMART Recovery also offers for sale a Participant Handbook and other related publications. Recognition The following organizations recognize SMART Recovery. United States American Academy of Family Physicians National Institute on Alcohol Abuse and Alcoholism (NIAAA). NIAA is an agency of the National Institutes of Health (NIH), a component of the U.S. Department of Health and Human Services. National Institute on Drug Abuse (NIDA) Substance Abuse and Mental Health Services Administration (SAMHSA) United Kingdom Public Health England National Institute of Health and Care Excellence (NICE) Recovery Orientated Drug Treatment Expert Group (RODT) Advisory Council on the Misuse of Drugs (ACMD) Australia Lifeline (crisis support service) Turning Point Alcohol and Drug Centre See also Addiction recovery groups Alcoholism Cognitive-behavioral therapy (CBT) Community reinforcement approach and family training (CRAFT) Drug addiction LifeRing Secular Recovery Rational emotive behavior therapy (REBT) Rational Recovery Secular Organizations for Sobriety (SOS) Women for Sobriety References Further reading Brown JM. (1998) Self-Regulation and the Addictive Behaviors. in Treating Addictive Behaviors, 2nd ed. Miller WR & Heather N. eds. Plenum Press, NY. Ellis A. & Velten E. (1992) Rational Steps To Quitting Alcohol: When AA Doesn't Work For You. Barricade Books, NY. Gerstein J. (1998) Rational Recovery, SMART Recovery and non-twelve step recovery programs. In Principles Of Addiction Medicine, 2nd ed. American Society of Addiction Medicine, Chevy Chase Mattson ME. (1998) Finding the Right Approach. in Miller WR & Heather N. Treating Addictive Behaviors. 2nd ed. Plenum Press, NY. Myers PL. (2002) Beware of the Man of One Book: Processing Ideology in Addictions Education. J of Teaching in the Addictions. pp 1:69-90 Vuchinich RE & Tucker JA. (1998) Choice, Behavioral Economics, and Addictive Behavior Patterns. in Treating Addictive Behaviors External links Addiction organizations in the United States Support groups Organizations established in 1992 Mentor, Ohio Positive mental attitude Psychiatric rehabilitation Mental health organizations based in Ohio

Alexithymia

Alexithymia, also called emotional blindness, is a neuropsychological phenomenon characterized by significant challenges in recognizing, expressing, sourcing, and describing one's emotions. It is associated with difficulties in attachment and interpersonal relations. While there is no scientific consensus on its classification as a personality trait, medical symptom, or mental disorder, alexithymia is highly prevalent among individuals with autism spectrum disorder (ASD), ranging from 50% to 85% of prevalence. Alexithymia occurs in approximately 10% of the general population and often co-occurs with various mental disorders, particularly with neurodevelopmental disorders. Difficulty in recognizing and discussing emotions may manifest at subclinical levels in men who conform to specific cultural norms of masculinity, such as the belief that sadness is a feminine emotion. This condition, known as normative male alexithymia, can be present in both sexes. Etymology The term alexithymia was introduced by psychotherapists John Case Nemiah and Peter Sifneos in 1973 to describe a particular psychological phenomenon. Its etymology comes from Ancient Greek. The word is formed by combining the alpha privative prefix (, meaning 'not') with (, referring to 'words') and (, denoting 'disposition,' 'feeling,' or 'rage'). The term can be likened to "dyslexia" in its structure. In its literal sense, alexithymia signifies "no words for emotions". This label reflects the difficulty experienced by individuals with this condition in recognizing, expressing, and articulating their emotional experiences. Nonmedical terminology, such as "emotionless" and "impassive", has also been employed to describe similar states. Those who exhibit alexithymic traits or characteristics are commonly referred to as alexithymics or alexithymiacs. Classification Alexithymia is considered to be a personality trait that places affected individuals at risk for other medical and mental disorders, as well as reducing the likelihood that these individuals will respond to conventional treatments to these disorders. The DSM-5 and the ICD-11 classify alexithymia as neither a symptom nor a mental disorder. It is a dimensional personality trait that varies in intensity from person to person. An individual's alexithymia score can be measured with questionnaires such as the Toronto Alexithymia Scale (TAS-20), the Perth Alexithymia Questionnaire (PAQ), the Bermond-Vorst Alexithymia Questionnaire (BVAQ), the Levels of Emotional Awareness Scale (LEAS), the Online Alexithymia Questionnaire (OAQ-G2), the Toronto Structured Interview for Alexithymia (TSIA), or the Observer Alexithymia Scale (OAS). It is distinct from the psychiatric personality disorders, such as antisocial personality disorder. However, there is no consensus on the definition of alexithymia, with debate between cognitive behavioral and psychoanalytic theorists. The cognitive behavioral model (i.e., the attention-appraisal model of alexithymia) defines alexithymia as having three components: difficulty identifying feelings (DIF) difficulty describing feelings (DDF) externally oriented thinking (EOT), characterized by a tendency to not focus attention on emotions. The psychoanalytic model defines alexithymia as having four components: difficulty identifying feelings (DIF) difficulty describing feelings to other people (DDF) a stimulus-bound, externally oriented thinking style (EOT) constricted imaginal processes (IMP) characterized by infrequent daydreaming In empirical research, it is often observed that constricted imaginal processes, defined as a lack of spontaneous imagining (daydreaming; compare aphantasia), when measured, do not statistically correlate with the other components of alexithymia. Such findings have led to ongoing debate in the field about whether IMP is indeed a component of alexithymia. For example, in 2017, Preece and colleagues introduced the attention-appraisal model of alexithymia, where they suggested that IMP be removed from the definition and that alexithymia be conceptually composed only of DIF, DDF, and EOT, as each of these three are specific to deficits in emotion processing. These core differences in the definition of alexithymia, regarding the inclusion or exclusion of IMP, correspond to differences between psychoanalytic and cognitive-behavioral conceptualizations of alexithymia; whereby psychoanalytic formulations tend to continue to place importance on IMP, whereas the attention-appraisal model (presently the most widely used cognitive-behavioral model of alexithymia) excludes IMP from the construct. In practice, since the constricted imaginal processes items were removed from earlier versions of the TAS-20 in the 1990s, the most used alexithymia assessment tools (and consequently most alexithymia research studies) have only assessed the construct in terms of DIF, DDF, and EOT. In terms of the relevance of alexithymic deficits for the processing of negative (e.g., sadness) or positive (e.g., happiness) emotions, the PAQ is presently the only alexithymia measure that enables valence-specific assessments of alexithymia across both negative and positive emotions; recent work with the PAQ has highlighted that alexithymic deficits in emotion processing do often extend across both negative and positive emotions, although people typically report more difficulties for negative emotions. Such findings of valence-specific effects in alexithymia are also supported by brain imaging studies. Studies (using measures of alexithymia assessing DIF, DDF, and EOT) have reported that the prevalence rate of high alexithymia is less than 10% of the population. A less common finding suggests that there may be a higher prevalence of alexithymia amongst males than females, which may be accounted for by difficulties some males have with "describing feelings", but not by difficulties in "identifying feelings", in which males and females show similar abilities. Work with the PAQ has suggested that the alexithymia construct manifests similarly across different cultural groups, and those of different ages (i.e., has the same structure and components). Psychologist R. Michael Bagby and psychiatrist Graeme J. Taylor have argued that the alexithymia construct is inversely related to the concepts of psychological mindedness and emotional intelligence and there is "strong empirical support for alexithymia being a stable personality trait rather than just a consequence of psychological distress". Signs and symptoms Typical deficiencies may include problems identifying, processing, describing, and working with one's own feelings, often marked by a lack of understanding of the feelings of others; difficulty distinguishing between feelings and the bodily sensations of emotional arousal; confusion of physical sensations often associated with emotions; few dreams or fantasies due to restricted imagination; and concrete, realistic, logical thinking, often to the exclusion of emotional responses to problems. Those who have alexithymia also report very logical and realistic dreams, such as going to the store or eating a meal. Clinical experience suggests it is the structural features of dreams more than the ability to recall them that best characterizes alexithymia. Some alexithymic individuals may appear to contradict the above-mentioned characteristics because they can experience chronic dysphoria or manifest outbursts of crying or rage. However, questioning usually reveals that they are quite incapable of describing their feelings or appear confused by questions inquiring about specifics of feelings. According to Henry Krystal, individuals exhibiting alexithymia think in an operative way and may appear to be superadjusted to reality. In psychotherapy, however, a cognitive disturbance becomes apparent as patients tend to recount trivial, chronologically ordered actions, reactions, and events of daily life with monotonous detail. In general, these individuals can, but not always, seem oriented toward things and even treat themselves as robots. These problems seriously limit their responsiveness to psychoanalytic psychotherapy; psychosomatic illness or substance abuse is frequently exacerbated should these individuals enter psychotherapy. A common misconception about alexithymia is that affected individuals are totally unable to express emotions verbally and that they may even fail to acknowledge that they experience emotions. Even before coining the term, Sifneos (1967) noted patients often mentioned things like anxiety or depression. The distinguishing factor was their inability to elaborate beyond a few limited adjectives such as "happy" or "unhappy" when describing these feelings. The core issue is that people with alexithymia have poorly differentiated emotions, limiting their ability to distinguish and describe them to others. This contributes to the sense of emotional detachment from themselves and difficulty connecting with others, making alexithymia negatively associated with life satisfaction even when depression and other confounding factors are controlled for. Associated conditions Alexithymia frequently co-occurs with other disorders. Research indicates that alexithymia overlaps with autism spectrum disorders (ASD). In a 2004 study using the TAS-20, 85% of the adults with ASD fell into the "impaired" category and almost half fell into the "severely impaired" category; in contrast, among the adult control population only 17% were "impaired", none "severely impaired". Fitzgerald & Bellgrove pointed out that, "Like alexithymia, Asperger's syndrome is also characterised by core disturbances in speech and language and social relationships". Hill & Berthoz agreed with Fitzgerald & Bellgrove (2006) and in response stated that "there is some form of overlap between alexithymia and ASDs". They also pointed to studies that revealed impaired theory of mind skill in alexithymia, neuroanatomical evidence pointing to a shared etiology, and similar social skills deficits. The exact nature of the overlap is uncertain. Alexithymic traits in AS may be linked to clinical depression or anxiety; the mediating factors are unknown and it is possible that alexithymia predisposes to anxiety. On the other hand, while the total alexithymia score as well as the difficulty in identifying feelings and externally oriented thinking factors are found to be significantly associated with ADHD, and while the total alexithymia score, the difficulty in identifying feelings, and the difficulty in describing feelings factors are also significantly associated with symptoms of hyperactivity and impulsivity, there is no significant relationship between alexithymia and inattentiveness. There are many more psychiatric disorders that overlap with alexithymia. One study found that 41% of US veterans of the Vietnam War with post-traumatic stress disorder (PTSD) were alexithymic. Another study found higher levels of alexithymia among Holocaust survivors with PTSD compared to those without. Higher levels of alexithymia among mothers with interpersonal violence-related PTSD were found in one study to have proportionally less caregiving sensitivity. This latter study suggested that when treating adult PTSD patients who are parents, alexithymia should be assessed and addressed also with attention to the parent-child relationship and the child's social-emotional development. Single study prevalence findings for other disorders include 63% in anorexia nervosa, 56% in bulimia, 45% to 50% in major depressive disorder, 34% in panic disorder, 28% in social phobia, and 50% in substance abusers. Alexithymia is also exhibited by a large proportion of individuals with acquired brain injuries such as stroke or traumatic brain injury. Alexithymia is correlated with certain personality disorders, particularly schizoid, avoidant, dependent and schizotypal, substance use disorders, some anxiety disorders and sexual disorders as well as certain physical illnesses, such as hypertension, inflammatory bowel disease, diabetes and functional dyspepsia. Alexithymia is further linked with disorders such as migraine headaches, lower back pain, irritable bowel syndrome, asthma, nausea, allergies and fibromyalgia. An inability to modulate emotions is a possibility in explaining why some people with alexithymia are prone to discharge tension arising from unpleasant emotional states through impulsive acts or compulsive behaviors such as binge eating, substance abuse, perverse sexual behavior or anorexia nervosa. The failure to regulate emotions cognitively might result in prolonged elevations of the autonomic nervous system (ANS) and neuroendocrine systems, which can lead to somatic diseases. People with alexithymia also show a limited ability to experience positive emotions leading Krystal and Sifneos (1987) to describe many of these individuals as anhedonic. Alexisomia is a clinical concept that refers to the difficulty in the awareness and expression of somatic, or bodily, sensations. The concept was first proposed in 1979 by Yujiro Ikemi when he observed characteristics of both alexithymia and alexisomia in patients with psychosomatic diseases. Causes It is unclear what causes alexithymia, though several theories have been proposed. Early studies showed evidence that there may be an interhemispheric transfer deficit among people with alexithymia; that is, the emotional information from the right hemisphere of the brain is not being properly transferred to the language regions in the left hemisphere, as can be caused by a decreased corpus callosum, often present in psychiatric patients who have suffered severe childhood abuse. A neuropsychological study in 1997 indicated that alexithymia may be due to a disturbance to the right hemisphere of the brain, which is largely responsible for processing emotions. In addition, another neuropsychological model suggests that alexithymia may be related to a dysfunction of the anterior cingulate cortex. These studies have some shortcomings, however, and the empirical evidence about the neural mechanisms behind alexithymia remains inconclusive. French psychoanalyst Joyce McDougall objected to the strong focus by clinicians on neurophysiological explanations at the expense of psychological ones for the genesis and operation of alexithymia, and introduced the alternative term "disaffectation" to stand for psychogenic alexithymia. For McDougall, the disaffected individual had at some point "experienced overwhelming emotion that threatened to attack their sense of integrity and identity", to which they applied psychological defenses to pulverize and eject all emotional representations from consciousness. A similar line of interpretation has been taken up using the methods of phenomenology. McDougall has also noted that all infants are born unable to identify, organize, and speak about their emotional experiences (the word infans is from the Latin "not speaking"), and are "by reason of their immaturity inevitably alexithymic". Based on this fact McDougall proposed in 1985 that the alexithymic part of an adult personality could be "an extremely arrested and infantile psychic structure". The first language of an infant is nonverbal facial expressions. The parent's emotional state is important for determining how any child might develop. Neglect or indifference to varying changes in a child's facial expressions without proper feedback can promote an invalidation of the facial expressions manifested by the child. The parent's ability to reflect self-awareness to the child is another important factor. If the adult is incapable of recognizing and distinguishing emotional expressions in the child, it can influence the child's capacity to understand emotional expressions. The attention-appraisal model of alexithymia by Preece and colleagues describes the mechanisms behind alexithymia within a cognitive-behavioral framework. Within this model, it is specified that alexithymia levels are due to the developmental level of people's emotion schemas (those cognitive structures used to process emotions) and/or the extent to which people are avoiding their emotions as an emotion regulation strategy. There is a large body of evidence currently supporting the specifications of this model. Molecular genetic research into alexithymia remains minimal, but promising candidates have been identified from studies examining connections between certain genes and alexithymia among those with psychiatric conditions as well as the general population. A study recruiting a test population of Japanese males found higher scores on the Toronto Alexithymia Scale among those with the 5-HTTLPR homozygous long (L) allele. The 5-HTTLPR region on the serotonin transporter gene influences the transcription of the serotonin transporter that removes serotonin from the synaptic cleft, and is well studied for its association with numerous psychiatric disorders. Another study examining the 5-HT1A receptor, a receptor that binds serotonin, found higher levels of alexithymia among those with the G allele of the Rs6295 polymorphism within the HTR1A gene. Also, a study examining alexithymia in subjects with obsessive–compulsive disorder found higher alexithymia levels associated with the Val/Val allele of the Rs4680 polymorphism in the gene that encodes Catechol-O-methyltransferase (COMT), an enzyme which degrades catecholamine neurotransmitters such as dopamine. These links are tentative, and further research will be needed to clarify how these genes relate to the neurological anomalies found in the brains of people with alexithymia. Although there is evidence for the role of environmental and neurological factors, the role and influence of genetic factors for developing alexithymia is still unclear. A single large scale Danish study suggested that genetic factors contributed noticeably to the development of alexithymia. However, some scholars find twin studies and the entire field of behavior genetics to be controversial. Those scholars raise concerns about the "equal environments assumption". Traumatic brain injury is also implicated in the development of alexithymia, and those with traumatic brain injury are six times more likely to exhibit alexithymia. Alexithymia is also associated with newborn circumcision trauma. Relationships Alexithymia can create interpersonal problems because these individuals tend to avoid emotionally close relationships, or if they do form relationships with others they usually position themselves as either dependent, dominant, or impersonal, "such that the relationship remains superficial". Inadequate "differentiation" between self and others by alexithymic individuals has also been observed. Their difficulty in processing interpersonal connections often develops where the person lacks a romantic partner. In a study, a large group of alexithymic individuals completed the 64-item Inventory of Interpersonal Problems (IIP-64) which found that "two interpersonal problems are significantly and stably related to alexithymia: cold/distant and non-assertive social functioning. All other IIP-64 subscales were not significantly related to alexithymia." Chaotic interpersonal relations have also been observed by Sifneos. Due to the inherent difficulties identifying and describing emotional states in self and others, alexithymia also negatively affects relationship satisfaction between couples. In a 2008 study alexithymia was found to be correlated with impaired understanding and demonstration of relational affection, and that this impairment contributes to poorer mental health, poorer relational well-being, and lowered relationship quality. Individuals high on the alexithymia spectrum also report less distress at seeing others in pain and behave less altruistically toward others. Some individuals working for organizations in which control of emotions is the norm might show alexithymic-like behavior but not be alexithymic. However, over time the lack of self-expressions can become routine and they may find it harder to identify with others. Treatment Generally speaking, approaches to treating alexithymia are still in their infancy, with not many proven treatment options available. In 2002, Kennedy and Franklin found that a skills-based intervention is an effective method for treating alexithymia. Kennedy and Franklin's treatment plan involved giving the participants a series of questionnaires, psychodynamic therapies, cognitive-behavioral and skills-based therapies, and experiential therapies. After treatment, they found that participants were generally less ambivalent about expressing their emotion feelings and more attentive to their emotional states. In 2017, based on their attention-appraisal model of alexithymia, Preece and colleagues recommended that alexithymia treatment should try to improve the developmental level of people's emotion schemas and reduce people's use of experiential avoidance of emotions as an emotion regulation strategy (i.e., the mechanisms hypothesized to underlie alexithymia difficulties in the attention-appraisal model of alexithymia). In 2018, Löf, Clinton, Kaldo, and Rydén found that mentalisation-based treatment is also an effective method for treating alexithymia. Mentalisation is the ability to understand the mental state of oneself or others that underlies overt behavior, and mentalisation-based treatment helps patients separate their own thoughts and feelings from those around them. This treatment is relational, and it focuses on gaining a better understanding and use of mentalising skills. The researchers found that all of the patients' symptoms including alexithymia significantly improved, and the treatment promoted affect tolerance and the ability to think flexibly while expressing intense affect rather than impulsive behavior. A significant issue impacting alexithymia treatment is that alexithymia has comorbidity with other disorders. Mendelson's 1982 study showed that alexithymia frequently presented in people with undiagnosed chronic pain. Participants in Kennedy and Franklin's study all had anxiety disorders in conjunction with alexithymia, while those in Löf et al. were diagnosed with both alexithymia and borderline personality disorder. All these comorbidity issues complicate treatment because it is difficult to find people who exclusively have alexithymia. See also Antisocial personality disorder Amplification (psychology) Body-centred countertransference Borderline personality disorder Disaffectation Emotion classification Emotional dysregulation Psychological mindedness Prosopagnosia Reduced affect display Somatization disorder Somatosensory amplification References Further reading External links Agnosia Cognition Neuropsychology Personality traits Symptoms and signs of mental disorders 1970s neologisms

Prodrome

In medicine, a prodrome is an early sign or symptom (or set of signs and symptoms, referred to as prodromal symptoms) that often indicates the onset of a disease before more diagnostically specific signs and symptoms develop. More specifically, it refers to the period between the first recognition of a disease's symptom until it reaches its more severe form. It is derived from the Greek word prodromos, meaning "running before". Prodromes may be non-specific symptoms or, in a few instances, may clearly indicate a particular disease, such as the prodromal migraine aura. For example, fever, malaise, headache and lack of appetite frequently occur in the prodrome of many infective disorders. A prodrome can be the early precursor to an episode of a chronic neurological disorder such as a migraine headache or an epileptic seizure, where prodrome symptoms may include euphoria or other changes in mood, insomnia, abdominal sensations, disorientation, aphasia, or photosensitivity. Such a prodrome occurs on a scale of days to an hour before the episode, where an aura occurs more immediate to it. Prodromal labour, mistakenly called "false labour," refers to the early signs before labour starts. In mental health The prodrome is a period during which an individual experiences some symptoms and/or a change in functioning, which can signal the impending onset of a mental health disorder. It is otherwise known as the prodromal phase when referring to the subsyndromal stage or the early abnormalities in behavior, mood, and/or cognition before illness onset. Early detection of the prodrome can create an opportunity to administer appropriate early interventions quickly to try to delay or decrease the intensity of subsequent symptoms. Schizophrenia Schizophrenia was the first disorder for which a prodromal stage was described. People who go on to develop schizophrenia commonly experience non-specific negative symptoms such as depression, anxiety symptoms, and social isolation. This is often followed by the emergence of attenuated positive symptoms such as problems with communication, perception, and unusual thoughts that do not rise to the level of psychosis. Closer to the onset of psychosis, people often exhibit more serious symptoms like pre-delusional unusual thoughts, pre-hallucinatory perceptual abnormalities or pre-thought disordered speech disturbances. As positive symptoms become more severe, in combination with negative symptoms that may have begun earlier, the individual may meet the diagnostic criteria for schizophrenia. Although a majority of individuals who experience some of the symptoms of schizophrenia will never meet full diagnostic criteria, approximately 20–40% will eventually be diagnosed with schizophrenia. One of the challenges of identifying and treating the prodrome is that it is difficult to predict who, among those with symptoms, are likely to meet full criteria later. Duration The prodromal phase in schizophrenia can last anywhere from several weeks to several years, and comorbid disorders, such as major depressive disorder, are common during this period. Identification/assessments Screening instruments include the Scale of Prodromal Symptoms and the PROD-screen. Signs and symptoms of the prodrome to schizophrenia can be assessed more fully using structured interviews. For example, the Structured Interview for Prodromal Syndromes, and the Comprehensive Assessment of At Risk Mental States (CAARMS) are both valid and reliable methods for identifying individuals likely experiencing the prodrome to schizophrenia or related psychotic-spectrum disorders. There are ongoing research efforts to develop tools for early detection of at-risk individuals. This includes development of risk calculators and methods for large-scale population screening. Interventions Describing the schizophrenia prodrome has been useful in promoting early intervention. Although not all people who are experiencing symptoms consistent with the prodrome will develop schizophrenia, randomized controlled trials suggest that intervening with medication and/or psychotherapy can improve outcomes. Interventions with evidence of efficacy include antipsychotic and antidepressant medications, which can delay conversion to psychosis and improve symptoms, although prolonged exposure to antipsychotics has been associated with adverse effects including Tardive dyskinesia, an irreversible neurological motor disorder. Psychotherapy for individuals and families can also improve functioning and symptomatology; specifically cognitive behavioral therapy (CBT) helps improve coping strategies to decrease positive psychosis symptoms. Additionally, omega-3 fish oil supplements may help reduce prodromal symptoms. Current guidelines suggest that individuals who are at "high risk" for developing schizophrenia should be monitored for at least one to two years while receiving psychotherapy and medication, as needed, to treat their symptoms. Bipolar disorder Symptomology There is also growing evidence that there is a prodromal phase before the onset of bipolar disorder (BD). Although a majority of individuals with bipolar disorder report experiencing some symptoms preceding the full onset of their illness, the prodrome to BD has not yet been described systematically. Descriptive reports of bipolar prodrome symptoms vary and often focus on nonspecific symptoms of psychopathology, making identification of the prodromal phase difficult. The most commonly observed symptoms are too much energy, elated or depressed mood, and alterations in sleep patterns. There are no prospective studies of the prodrome to bipolar disorder, but in the Longitudinal Assessment of Manic Symptoms (LAMS) study, which followed youth with elevated symptoms of mania for ten years, approximately 23% of the sample met BD criteria at the baseline and 13% of which did not meet the criteria for BD at baseline eventually were diagnosed with BD. Duration The reported duration of the prodrome to BD varies widely (mean = 27.1 ± 23 months); for most people, evidence suggests that the prodromal phase is likely to be long enough to allow for intervention. Identification/assessments Symptoms consistent with the prodrome to BD can be identified through semi-structured interviews such as The Bipolar Prodrome Symptom Interview and Scale-Prospective (BPSS-P), and the Semi-structured Interview for Mood Swings and symptom checklists like the Young Mania Rating Scale (YMRS) and the Hamilton Depression Scale (HAM-D). Interventions Early intervention is associated with better outcomes for people with prodromal symptoms of BD. Interventions with some evidence of efficacy include medication (e.g. mood stabilizers, atypical antipsychotics) and psychotherapy. Specifically, family-focused therapy improves emotion regulation and enhances functioning in both adults and adolescents. Interpersonal and Social Rhythm Therapy (IPSRT) may be beneficial for youth at risk of developing BD by helping to stabilize their sleep and circadian patterns. Psychoeducational Psychotherapy (PEP) may be protective in individuals at risk of developing bipolar disorder and are associated with a four-fold reduction in risk for conversion to BD. This research needs to be explored further, however, it is currently thought to produce improvements in decreased stress due to social support and improved functioning through the skills developed in PEP. PEP can prove especially beneficial for individuals presenting transitional mania symptoms as it can assist caregivers in recognizing prodromal mania symptoms and knowing the next steps towards early intervention. The key goals of this type of therapy are to provide psychoeducation about mood disorders and treatments, social support, and to build skills in symptom management, emotion regulation, and problem-solving and communication. This research is in its infancy, further investigations will be necessary to determine which methods lead to the best outcomes and for whom. In neurological conditions Neurodegenerative diseases Several neurodegenerative diseases have a prodromal phase. Early impairments in behavior, personality and language may be detected in Alzheimer's disease. In dementia with Lewy bodies, there is an identifiable set of early signs and symptoms that can appear 15 years or more before dementia develops. The earliest symptoms are constipation and dizziness from autonomic dysfunction, hyposmia (reduced ability to smell), visual hallucinations, and rapid eye movement sleep behavior disorder (RBD). RBD may appear years or decades before other symptoms. In Parkinson's disease the loss of sense of smell may aid in earlier diagnosis. Multiple sclerosis may have a prodromal phase. Migraine The prodromal phase of migraine is not always present, and varies from individual to individual, but can include ocular disturbances such as shimmering lights with reduced vision, altered mood, irritability, depression or euphoria, fatigue, yawning, excessive sleepiness, craving for certain food (e.g. chocolate), stiff muscles (especially in the neck), hot ears, constipation or diarrhea, increased urination, and other visceral symptoms. See also Apophenia Postdrome References External links Early psychosis Symptoms

Therapist

A therapist is a person who offers any kinds of therapy. Therapists are trained professionals in the field of any types of services like psychologists, social workers, counselors, etc. They are helpful in counseling individuals for various mental and physical issues. Meaning Therapist refers to trained professionals engaged in providing services any kind of treatment or rehabilitation. Reasons Therapists can help in addressing a range of issues including: anxiety behavioral issues depression managing life changes eating disorders loneliness grief self-esteem negative thinking chronic illness management sleep disorder gender or sexuality relationships social issues stress addiction suicide or self-harm based thoughts trauma Types Following are various types of therapists. Therapists for addiction Therapists for art Therapists for children Therapists for massage Therapists for marriage and children Therapists for music Therapists for occupation Therapists for physical body Therapists for psychology Therapists for yoga Psychotherapists belong to varied fields like psychologists, social workers, psychiatric nurses, and psychiatrists Specialization Therapist are basically specialized in below areas: Disorders in behavior Mental health of Community Schooling and career Related to rehabilitation Substance based abuse Autism and/or autism awareness Education A therapist or a licensed counselor is required to qualify in state licensure exam and also preferred to have a master's degree in addition to completion of internship with a practicing supervisor. Some bachelor's degree holding counselors also practice under the guidance of licensed therapist or a psychologist. Few counselors prefer to have art therapy or addictions prevention training. Benefits Following are the benefits of consulting a therapist. Improvement of physical and mental health Creating awareness on thoughts and its effect on behaviors Practically understanding the relationship between thoughts and actions Friendly support and understanding In-depth knowledge in experience and behaviors Self awareness Improving social relationships Learning new skills in managing stress Interaction of issues like fear and worries with a neutral person References Therapy

Neurorehabilitation

Neurorehabilitation is a complex medical process which aims to aid recovery from a nervous system injury, and to minimize and/or compensate for any functional alterations resulting from it. Features In case of a serious disability, such as caused by a severe spinal injury or brain damage, the patient and their families' abilities, life style, and projects, are suddenly shattered. In order to cope with this situation, the person and their family must establish and negotiate a "new way of living", both with their changed body and as a changed individual within their wider community. Thus, neurorehabilitation works with the skills and attitudes of the disabled person and their family and friends. It promotes their skills to work at the highest level of independence possible for them. It also encourages them to rebuild self-esteem and a positive mood. Thus, they can adapt to the new situation and become empowered for successful and committed community reintegration. Neurorehabilitation should be: Holistic It should cater for the physical, cognitive, psychological, social and cultural dimensions of the personality, stage of progress and lifestyle of both the patient and their family. Patient-focused Customized health care strategies should be developed, focused on the patient (and family). Inclusive Care-plans should be designed and implemented by multidisciplinary teams made up of highly qualified and motivated practitioners experienced in multidisciplinary teamwork. Participatory The patient and their family's active cooperation is essential. The patient and family must be well-informed, and a trusting relationship with the multidisciplinary team must be built. Sparing Treatment must aim at empowering the patient to maximise independence, and to reduce physical impairment and reliance on mobility aids. Lifelong The patient's various needs throughout their life must be catered for, by ensuring continuity of care all the way through from injury onset to the highest possible level of recovery of function. This may include addressing medical complications of the injury or illness later in life. Resolving Treatment has to include adequate human and material resources for efficiently resolving each patient's problems as they arise. Community-focused. It is necessary to look for the solutions best adapted to the specific characteristics of the community and to further the creation of community resources favouring the best possible community reintegration of the disabled person. Commonly treated conditions Stroke Spinal cord injury Cerebral palsy Parkinson's disease Brain injury Anoxic brain injury Traumatic brain injury Multiple sclerosis Post-polio syndrome Guillain–Barré syndrome How it works By focusing on all aspects of a person's functional independence and well-being, neurorehabilitation offers a series of therapies from the medications, physiotherapy, speech and swallow therapy, psychological therapies, occupational therapies, teaching or re-training patients on mobility skills, communication processes, and other aspects of that person's daily routine. Neurorehabilitation also provides focuses on nutrition, psychological, and creative parts of a person's recovery. Many neurorehabilitation programs, whether offered by hospitals or at private, specialized clinics, have a wide variety of specialists in many different fields to provide the most well rounded treatment of patients. These treatments, over a period of time, and often over the lifetime of a person, allow that individual and that person's family to live the most normal, independent life possible. While the field of neurorehabilitation is relatively new, many therapies are controversial, and while some are considered cutting-edge technology, there may be little research to support whether or not helpful progress is the result. Neurorehabilitation is the culmination of many different fields to provide the best care and education for patients with injuries or diseases affecting their nervous system. Types The most important therapies are those that help people live their everyday lives. These include physiotherapy, occupational therapy, rehabilitation psychology, speech and swallow therapy, vision therapy, and language therapy, and therapies focused on daily function and community re-integration. A particular focus is given to improving mobility and strength, as this is key to a person's independence. Neurorehabilitation is a team work. The specialists who participate include: physiatrist or rehabilitation medicine specialist, neurologist, neurosurgeon, other medical specialists, physiotherapists, occupational therapists, respiratory therapists, prothetist and orthotist, rehabilitation nurse, psychologists, and vocational counselor. Physiotherapy includes helping patients recover the ability of physical actions which includes: balance retraining, gait analysis and transfer training, neuromuscular retraining, orthotics consultations, and aqua therapy. Occupational therapy helps patients in activities of daily living. Some of these include: home modifications and safety training (Fall prevention strategies), cognitive rehabilitation – retraining for memory, attention, processing, and executive functions. It may also include neuro-muscular strengthening and training, and visual perceptual skill development. Rehabilitation psychologists and speech–language pathologists and have begun to provide cognitive rehabilitation as well with goals that emphasize instruction in life-changes that facilitate increased independence. Speech and language therapy includes assisting patients with swallowing and communication issues. Rehabilitation psychology includes helping patients deal with their changed, often dramatically so, circumstances especially coping to a changed identity of self as a result of adaptions and changes necessitated by brain injury. Technological developments Over the last decade with the aid of science and technology, we are more familiar with the human brain and its function than ever before. Development in neuroimaging techniques has greatly enhanced the scope and outcome of neurorehabilitation. Now, scientists are using technology with neurorehabilitation to provide cutting edge improvements to therapies for patients with nervous system issues. In particular, the use of robotics in neurorehabilitation is becoming more and more common. Virtual reality simulations and video games provide patients with an interactive way to explore and re-learn different aspects of their lives and environments while being observed within the safety of their treating therapists and physicians. These devices and simulations, along with other robotic technology, offer patients who have just had strokes, other brain or spinal cord injuries the option of training and physical therapy much sooner than might otherwise be possible, thus shortening the recovery period. See also Rehabilitation psychology Rehabilitation (neuropsychology) Neurophysiotherapy Neuroscience Notes This article incorporates material from the Institut Guttmann, who consents publication licensed by the Free Documentation GNU/GFDL References External links Institut Guttmann Instituto Caren de Neurorehabilitación Infography about Neurorehabilitation World Federation of Neurorehabilitation Clinical neuroscience Neurotrauma

DSM-5

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In 2022, a revised version (DSM-5-TR) was published. In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. However, some providers instead rely on the International Statistical Classification of Diseases and Related Health Problems (ICD), and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions. The DSM-5 is the only DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the only living document version of a DSM. The DSM-5 is not a major revision of the DSM-IV-TR, but the two have significant differences. Changes in the DSM-5 include the re-conceptualization of Asperger syndrome from a distinct disorder to an autism spectrum disorder; the elimination of subtypes of schizophrenia; the deletion of the "bereavement exclusion" for depressive disorders; the renaming and reconceptualization of gender identity disorder to gender dysphoria; the inclusion of binge eating disorder as a discrete eating disorder; the renaming and reconceptualization of paraphilias, now called paraphilic disorders; the removal of the five-axis system; and the splitting of disorders not otherwise specified into other specified disorders and unspecified disorders. Many authorities criticized the fifth edition both before and after it was published. Critics assert, for example, that many DSM-5 revisions or additions lack empirical support; that inter-rater reliability is low for many disorders; that several sections contain poorly written, confusing, or contradictory information; and that the pharmaceutical industry may have unduly influenced the manual's content, given the industry association of many DSM-5 workgroup participants. The APA itself has published that the inter-rater reliability is low for many disorders, including major depressive disorder and generalized anxiety disorder. Changes from DSM-IV The DSM-5 is divided into three sections, using Roman numerals to designate each section. Section I Section I describes DSM-5 chapter organization, its change from the multiaxial system, and Section III's dimensional assessments. The DSM-5 dissolved the chapter that includes "disorders usually first diagnosed in infancy, childhood, or adolescence" opting to list them in other chapters. A note under Anxiety Disorders says that the "sequential order" of at least some DSM-5 chapters has significance that reflects the relationships between diagnoses. The introductory section describes the process of DSM revision, including field trials, public and professional review, and expert review. It states its goal is to harmonize with the International Statistical Classification of Diseases and Related Health Problems (ICD) systems and share organizational structures as much as is feasible. Concern about the categorical system of diagnosis is expressed, but the conclusion is the reality that alternative definitions for most disorders are scientifically premature. DSM-5 replaces the Not Otherwise Specified (NOS) categories with two options: other specified disorder and unspecified disorder to increase the utility to the clinician. The first allows the clinician to specify the reason that the criteria for a specific disorder are not met; the second allows the clinician the option to forgo specification. DSM-5 has discarded the multiaxial system of diagnosis (formerly Axis I, Axis II, Axis III), listing all disorders in Section II. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (Global Assessment of Functioning, known as GAF). The World Health Organization's Disability Assessment Schedule is added to Section III (Emerging measures and models) under Assessment Measures, as a suggested, but not required, method to assess functioning. Section II: diagnostic criteria and codes Neurodevelopmental disorders "Mental retardation" was renamed "intellectual disability (intellectual developmental disorder)". Speech or language disorders are now called communication disorders—which include language disorder (formerly expressive language disorder and mixed receptive-expressive language disorder), speech sound disorder (formerly phonological disorder), childhood-onset fluency disorder (stuttering), and a new condition characterized by impaired social verbal and nonverbal communication called social (pragmatic) communication disorder. Autism spectrum disorder is a new diagnosis that incorporates the former diagnoses of classic autism, Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS)—see . Attention deficit hyperactivity disorder (ADHD) no longer specifies autism as an exclusionary diagnosis. The requisite age of symptom onset was changed from 7 years old to 12 years old, and symptom thresholds were reduced for diagnosis of ADHD as an adolescent or adult. "Specific Learning Disorder" encompasses shortcomings in academic skill development, including dyslexia and dyscalculia. A new sub-category, motor disorders, encompasses developmental coordination disorder, stereotypic movement disorder, and the tic disorders including Tourette syndrome. Schizophrenia spectrum and other psychotic disorders All subtypes of schizophrenia were removed from the DSM-5 (paranoid, disorganized, catatonic, undifferentiated, and residual) in favor of a severity-based rating approach. A major mood episode is required for schizoaffective disorder (for a majority of the disorder's duration after criterion A [related to delusions, hallucinations, disorganized speech or behavior, and negative symptoms such as avolition] is met). Criteria for delusional disorder changed, and it is no longer separate from shared delusional disorder. Catatonia in all contexts requires 3 of a total of 12 symptoms. Catatonia may be a specifier for depressive, bipolar, and psychotic disorders; part of another medical condition; or of another specified diagnosis. Bipolar and related disorders New specifier "with mixed features" can be applied to bipolar I disorder, bipolar II disorder, bipolar disorder NED (not elsewhere defined, previously called "NOS", not otherwise specified) and MDD. Allows other specified bipolar and related disorder for particular conditions. Anxiety symptoms are a specifier (called "anxious distress") added to bipolar disorder and to depressive disorders (but are not part of the bipolar diagnostic criteria). Depressive disorders The bereavement exclusion in DSM-IV was removed from depressive disorders in DSM-5. New disruptive mood dysregulation disorder (DMDD) for children up to age 18 years. Premenstrual dysphoric disorder moved from an appendix for further study, and became a disorder. Specifiers were added for mixed symptoms and for anxiety, along with guidance to physicians for suicidality. The term dysthymia now also would be called persistent depressive disorder. Anxiety disorders For the various forms of phobias and anxiety disorders, DSM-5 removes the requirement that the subject (formerly, over 18 years old) "must recognize that their fear and anxiety are excessive or unreasonable". Also, the duration of at least 6 months now applies to everyone (not only to children). Panic attack became a specifier for all DSM-5 disorders. Panic disorder and agoraphobia became two separate disorders. Specific types of phobias became specifiers but are otherwise unchanged. The generalized specifier for social anxiety disorder (formerly, social phobia) changed in favor of a performance only (i.e., public speaking or performance) specifier. Separation anxiety disorder and selective mutism are now classified as anxiety disorders (rather than disorders of early onset). Obsessive-compulsive and related disorders A new chapter on obsessive-compulsive and related disorders includes four new disorders: excoriation (skin-picking) disorder, hoarding disorder, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. Trichotillomania (hair-pulling disorder) moved from "impulse-control disorders not elsewhere classified" in DSM-IV, to an obsessive-compulsive disorder in DSM-5. A specifier was expanded (and added to body dysmorphic disorder and hoarding disorder) to allow for good or fair insight, poor insight, and "absent insight/delusional" (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may arise with perceived defects or flaws in physical appearance. The DSM-IV specifier "with obsessive-compulsive symptoms" moved from anxiety disorders to this new category for obsessive-compulsive and related disorders. There are two new diagnoses: other specified obsessive-compulsive and related disorder, which can include body-focused repetitive behavior disorder (behaviors like nail biting, lip biting, and cheek chewing, other than hair pulling and skin picking) or obsessional jealousy; and unspecified obsessive-compulsive and related disorder. Trauma- and stressor-related disorders Post traumatic stress disorder (PTSD) is now included in a new section titled "Trauma- and Stressor-Related Disorders." The PTSD diagnostic clusters were reorganized and expanded from a total of three clusters to four based on the results of confirmatory factor analytic research conducted since the publication of DSM-IV. Separate criteria were added for children six years old or younger. For the diagnosis of acute stress disorder and PTSD, the stressor criteria (Criterion A1 in DSM-IV) was modified to some extent. The requirement for specific subjective emotional reactions (Criterion A2 in DSM-IV) was eliminated because it lacked empirical support for its utility and predictive validity. Previously certain groups, such as military personnel involved in combat, law enforcement officers and other first responders, did not meet criterion A2 in DSM-IV because their training prepared them to not react emotionally to traumatic events. Two new disorders that were formerly subtypes were named: reactive attachment disorder and disinhibited social engagement disorder. Adjustment disorders were moved to this new section and reconceptualized as stress-response syndromes. DSM-IV subtypes for depressed mood, anxious symptoms, and disturbed conduct are unchanged. Dissociative disorders Depersonalization disorder is now called depersonalization derealization disorder. Dissociative fugue became a specifier for dissociative amnesia. The criteria for dissociative identity disorder were expanded to include "possession-form phenomena and functional neurological symptoms". It is made clear that "transitions in identity may be observable by others or self-reported". Criterion B was also modified for people who experience gaps in recall of everyday events (not only trauma). Somatic symptom and related disorders Somatoform disorders are now called somatic symptom and related disorders. Patients that present with chronic pain can now be diagnosed with the mental illness somatic symptom disorder with predominant pain; or psychological factors that affect other medical conditions; or with an adjustment disorder. Somatization disorder and undifferentiated somatoform disorder were combined to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms. Somatic symptom and related disorders are defined by positive symptoms, and the use of medically unexplained symptoms is minimized, except in the cases of conversion disorder and pseudocyesis (false pregnancy). A new diagnosis is psychological factors affecting other medical conditions. This was formerly found in the DSM-IV chapter "Other Conditions That May Be a Focus of Clinical Attention". Criteria for conversion disorder (functional neurological symptom disorder) were changed. Feeding and eating disorders Criteria for pica and rumination disorder were changed and can now refer to people of any age. Binge eating disorder graduated from DSM-IV's "Appendix B -- Criteria Sets and Axes Provided for Further Study" into a proper diagnosis. Requirements for bulimia nervosa and binge eating disorder were changed from "at least twice weekly for 6 months" to "at least once weekly over the last 3 months". The criteria for anorexia nervosa were changed; there is no longer a requirement of amenorrhea. "Feeding disorder of infancy or early childhood", a rarely used diagnosis in DSM-IV, was renamed to avoidant/restrictive food intake disorder, and criteria were expanded. Elimination disorders No significant changes. Disorders in this chapter were previously classified under disorders usually first diagnosed in infancy, childhood, or adolescence in DSM-IV. Now it is an independent classification in DSM 5. Sleep–wake disorders "Sleep disorders related to another mental disorder, and sleep disorders related to a general medical condition" were deleted. Primary insomnia became insomnia disorder, and narcolepsy is separate from other hypersomnolence. There are now three breathing-related sleep disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. Circadian rhythm sleep–wake disorders were expanded to include advanced sleep phase syndrome, irregular sleep–wake type, and non-24-hour sleep–wake type. Jet lag was removed. Rapid eye movement sleep behavior disorder and restless legs syndrome are each a disorder, instead of both being listed under "dyssomnia not otherwise specified" in DSM-IV. Sexual dysfunctions DSM-5 has sex-specific sexual dysfunctions. For females, sexual desire and arousal disorders are combined into female sexual interest/arousal disorder. Sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a duration of approximately 6 months and more exact severity criteria. A new diagnosis is genito-pelvic pain/penetration disorder which combines vaginismus and dyspareunia from DSM-IV. Sexual aversion disorder was deleted. Subtypes for all disorders include only "lifelong versus acquired" and "generalized versus situational" (one subtype was deleted from DSM-IV). Two subtypes were deleted: "sexual dysfunction due to a general medical condition" and "due to psychological versus combined factors". Gender dysphoria DSM-IV's gender identity disorder is similar to, but not the same as, gender dysphoria in DSM-5. Separate criteria for children, adolescents and adults that are appropriate for varying developmental states are added. Subtypes of gender identity disorder based on sexual orientation were deleted. Among other wording changes, criterion A and criterion B (cross-gender identification, and aversion toward one's gender) were combined. Along with these changes comes the creation of a separate gender dysphoria in children as well as one for adults and adolescents. The grouping has been moved out of the sexual disorders category and into its own. The name change was made in part due to stigmatization of the term "disorder" and the relatively common use of "gender dysphoria" in the GID literature and among specialists in the area. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight. Disruptive, impulse-control, and conduct disorders Some of these disorders were formerly part of the chapter on early diagnosis, oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified became other specified and unspecified disruptive disorder, impulse-control disorder, and conduct disorders. Intermittent explosive disorder, pyromania, and kleptomania moved to this chapter from the DSM-IV chapter "Impulse-Control Disorders Not Otherwise Specified". Antisocial personality disorder is listed here and in the chapter on personality disorders (but ADHD is listed under neurodevelopmental disorders). Symptoms for oppositional defiant disorder are of three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. The conduct disorder exclusion is deleted. The criteria were also changed with a note on frequency requirements and a measure of severity. Criteria for conduct disorder are unchanged for the most part from DSM-IV. A specifier was added for people with limited "prosocial emotion", showing callous and unemotional traits. People over the disorder's minimum age of 6 may be diagnosed with intermittent explosive disorder without outbursts of physical aggression. Criteria were added for frequency and to specify "impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences". Substance-related and addictive disorders Gambling disorder and tobacco use disorder are new. Substance abuse and substance dependence from DSM-IV-TR have been combined into single substance use disorders specific to each substance of abuse within a new "addictions and related disorders" category. "Recurrent legal problems" was deleted and "craving or a strong desire or urge to use a substance" was added to the criteria. The threshold of the number of criteria that must be met was changed and severity from mild to severe is based on the number of criteria endorsed. Criteria for cannabis and caffeine withdrawal were added. New specifiers were added for early and sustained remission along with new specifiers for "in a controlled environment" and "on maintenance therapy". There are no more polysubstance diagnoses in DSM-5; the substance(s) must be specified. Neurocognitive disorders Dementia and amnestic disorder became major or mild neurocognitive disorder (major NCD, or mild NCD). DSM-5 has a new list of neurocognitive domains. "New separate criteria are now presented" for major or mild NCD due to various conditions. Substance/medication-induced NCD and unspecified NCD are new diagnoses. Personality disorders Personality disorder (PD) previously belonged to a different axis than almost all other disorders, but is now in one axis with all mental and other medical diagnoses. However, the same ten types of personality disorder are retained. There is a call for the DSM-5 to provide relevant clinical information that is empirically based to conceptualize personality as well as psychopathology in personalities. The issue(s) of heterogeneity of a PD is problematic as well. For example, when determining the criteria for a PD it is possible for two individuals with the same diagnosis to have completely different symptoms that would not necessarily overlap. There is also concern as to which model is better for the DSM - the diagnostic model favored by psychiatrists or the dimensional model that is favored by psychologists. The diagnostic approach/model is one that follows the diagnostic approach of traditional medicine, is more convenient to use in clinical settings, however, it does not capture the intricacies of normal or abnormal personality. The dimensional approach/model is better at showing varied degrees of personality; it places emphasis on the continuum between normal and abnormal, and abnormal as something beyond a threshold whether in unipolar or bipolar cases. Paraphilic disorders New specifiers "in a controlled environment" and "in remission" were added to criteria for all paraphilic disorders. A distinction is made between paraphilic behaviors, or paraphilias, and paraphilic disorders. All criteria sets were changed to add the word disorder to all of the paraphilias, for example, pedophilic disorder is listed instead of pedophilia. There is no change in the basic diagnostic structure since DSM-III-R; however, people now must meet both qualitative (criterion A) and negative consequences (criterion B) criteria to be diagnosed with a paraphilic disorder. Otherwise they have a paraphilia (and no diagnosis). Section III: emerging measures and models It includes dimensional measures for the assessment of symptoms, criteria for the cultural formulation of disorders and an alternative proposal for the conceptualization of personality disorders, as well as a description of the currently studied clinical conditions. It presents selected tools and research techniques focused on diagnosis, taking into account the sociocultural context, and also presents a hybrid-dimensional-categorical model of personality disorders. Specific personalities (antisocial, borderline, avoidant, narcissistic, obsessive-compulsive, schizotypal) and non-specific disorders were distinguished. Conditions for further study These conditions and criteria are set forth to encourage future research and are not meant for clinical use. Attenuated psychosis syndrome Depressive episodes with short-duration hypomania Persistent complex bereavement disorder Caffeine use disorder Internet gaming disorder Neurobehavioral disorder associated with prenatal alcohol exposure Suicidal behavior disorder Non-suicidal self-injury Development In 1999, a DSM-5 Research Planning Conference, sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-5 and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers. On July 23, 2007, the APA announced the task force that would oversee the development of DSM-5. The DSM-5 Task Force consisted of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM had a broad range of experience and interests. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests. The DSM-5 field trials included test-retest reliability which involved different clinicians doing independent evaluations of the same patient—a common approach to the study of diagnostic reliability. About 68% of DSM-5 task-force members and 56% of panel members reported having ties to the pharmaceutical industry, such as holding stock in pharmaceutical companies, serving as consultants to industry, or serving on company boards. Revisions and updates Beginning with the fifth edition, it is intended that diagnostic guideline revisions will be added incrementally. The DSM-5 is identified with Arabic rather than Roman numerals, marking a change in how future updates will be created. Incremental updates will be identified with decimals (DSM-5.1, DSM-5.2, etc.), until a new edition is written. The change reflects the intent of the APA to respond more quickly when a preponderance of research supports a specific change in the manual. The research base of mental disorders is evolving at different rates for different disorders. DSM-5-TR A revision of DSM-5, titled DSM-5-TR, was published in March 2022, updating diagnostic criteria and ICD-10-CM codes. The diagnostic criteria for avoidant/restrictive food intake disorder were changed, along with adding entries for prolonged grief disorder, unspecified mood disorder and stimulant-induced mild neurocognitive disorder. Prolonged grief disorder, which had been present in the ICD-11, had criteria agreed upon by consensus in a one day in-person workshop sponsored by the APA. A 2022 study found that higher rates of diagnosis of prolonged grief disorder in the ICD-11 could be explained by the DSM-5-TR criteria requiring symptoms persist for 12 months, and the ICD-11 requiring only 6 months. Three review groups for sex and gender, culture and suicide, along with an "ethnoracial equity and inclusion work group" were involved in the creation of the DSM-5-TR which led to additional sections for each mental disorder discussing sex and gender, racial and cultural variations, and adding diagnostic codes for specifying levels of suicidality and nonsuicidal self-injury for mental disorders. Other changed disorders included: Autism spectrum disorder Bipolar I disorder, Bipolar II disorder, and related bipolar disorders Obsessive–compulsive personality disorder in the alternative DSM-5 model for personality disorders Depressive episodes with short-duration hypomania Intellectual developmental disorder Delusional disorder Disruptive mood dysregulation disorder Brief psychotic disorder Usage The National Board of Medical Examiners (NBME) which is responsible for creating and publishing board exams for medical students around the United States conforms to the use of DSM-5 criteria. Criticism General Robert Spitzer, the head of the DSM-III task force, publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: "When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you're going to have people complaining all over the place that they didn't have the opportunity to challenge anything." Allen Frances, chair of the DSM-IV task force, expressed a similar concern. David Kupfer, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, vice chair of the task force, whose industry ties are disclosed with those of the task force, countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders". They asserted that the development of DSM-5 is the "most inclusive and transparent developmental process in the 60-year history of DSM". The developments to this new version can be viewed on the APA website. During periods of public comment, members of the public could sign up at the DSM-5 website and provide feedback on the various proposed changes. In June 2009, Allen Frances issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle, [...] ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". He writes that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process". His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated. In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that brought thousands into the public debate about the DSM. Approximately 13,000 individuals and mental health professionals signed a petition in support of the letter. Thirteen other American Psychological Association divisions endorsed the petition. In a November 2011 article about the debate in the San Francisco Chronicle, Robbins notes that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences. In 2012, a footnote was added to the draft text which explains the distinction between grief and depression. The DSM-5 has been criticized for purportedly saying nothing about the biological underpinnings of mental disorders. A book-long appraisal of the DSM-5, with contributions from philosophers, historians and anthropologists, was published in 2015. A 2015 essay from an Australian university criticized the DSM-5 for having poor cultural diversity, stating that recent work done in cognitive sciences and cognitive anthropology is still only accepting western psychology as the norm. DSM-5 includes a section on how to conduct a "cultural formulation interview", which gives information about how a person's cultural identity may be affecting expression of signs and symptoms. The goal is to make more reliable and valid diagnoses for disorders subject to significant cultural variation. Gender and Sexual Identity Disorders work group The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, led to an internet petition to remove them. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career, especially advocating the idea that children who are unambiguously male or female anatomically, but seem confused about their gender identity, can be treated by encouraging gender expression in line with their anatomy." According to The Gay City News: The National LGBTQ Task Force issued a statement questioning the APA's decision to appoint Kenneth Zucker and Ray Blanchard to the working group for Gender and Sexual Identity Disorders, stating that, "Kenneth Zucker and Ray Blanchard are clearly out of step with the occurring shift in how doctors and other health professionals think about transgender people and gender variance." Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views." Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'" Financial Conflicts of Interest and Perverse Dependencies The financial association of DSM-5 panel members with industry continues to be a concern for financial conflict of interest. Of the DSM-5 task force members, 69% report having ties to the pharmaceutical industry, an increase from the 57% of DSM-IV task force members. A study of the DSM-5-TR found that 60% of the American physicians contributing to the revised edition received payments from industry. Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the association has not gone far enough in its efforts to be transparent and to protect against industry influence. In a 2009 Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties—an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed". The role of the DSM-5 in protecting the interests of wealthy and politically powerful owners of the means of production in the United States has been criticized as well. Placing the blame for predictable and common psychological distress caused by the deleterious effects of economic inequality in the United States on individuals by attributing it to mental pathology has been criticized as hindering change of the root causes of the distress. The DSM-5's expansive criteria that attribute mental pathology to people with distress or impairment from a wide-ranging constellation of experiences has been criticized for pathologizing an unhelpful number of people that a psychiatric diagnosis is not beneficial for. Borderline personality disorder controversy In 2003, the Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned to change the name and designation of borderline personality disorder in DSM-5. The paper How Advocacy is Bringing BPD into the Light reported that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma." Instead, it proposed the name "emotional regulation disorder" or "emotional dysregulation disorder." There was also discussion about changing borderline personality disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders). The TARA-APD recommendations do not appear to have affected the American Psychiatric Association, the publisher of the DSM. As noted above, the DSM-5 does not employ a multi-axial diagnostic scheme, therefore the distinction between Axis I and II disorders no longer exists in the DSM nosology. The name, the diagnostic criteria for, and description of, borderline personality disorder remain largely unchanged from DSM-IV-TR. British Psychological Society response The British Psychological Society stated in its June 2011 response to DSM-5 draft versions, that it had "more concerns than plaudits." It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflect[ing] current normative social expectations," noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders. It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation." The Society suggested as its primary specific recommendation, a change from using "diagnostic frameworks" to a description based on an individual's specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality: Many of the same criticisms also led to the development of the Hierarchical Taxonomy of Psychopathology, an alternative, dimensional framework for classifying mental disorders. National Institute of Mental Health National Institute of Mental Health director Thomas R. Insel, MD, wrote in an April 29, 2013 blog post about the DSM-5: Insel also discussed an NIMH effort to develop a new classification system, Research Domain Criteria (RDoC), currently for research purposes only. Insel's post sparked a flurry of reaction, some of which might be termed sensationalistic, with headlines such as "Goodbye to the DSM-V", "Federal institute for mental health abandons controversial 'bible' of psychiatry", "National Institute of Mental Health abandoning the DSM", and "Psychiatry divided as mental health 'bible' denounced". Other responses provided a more nuanced analysis of the NIMH Director's post. In May 2013, Insel, on behalf of NIMH, issued a joint statement with Jeffrey A. Lieberman, MD, president of the American Psychiatric Association, that emphasized that DSM-5 "... represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5." Insel and Lieberman say that DSM-5 and RDoC "represent complementary, not competing, frameworks" for characterizing diseases and disorders. However, epistemologists of psychiatry tend to see the RDoC project as a putative revolutionary system that in the long run will try to replace the DSM, its expected early effect being a liberalization of the research criteria, with an increasing number of research centers adopting the RDoC definitions. See also References External links Diagnostic and Statistical Manual of Mental Disorders 2013 books it:Manuale diagnostico e statistico dei disturbi mentali#DSM-5

Baker Act

The Florida Mental Health Act of 1971, commonly known as the "Baker Act," allows for a) short-term, inpatient voluntary and involuntary examination, b) inpatient voluntary and involuntary admission of an individual for assessment and treatment of a mental illness, and c) involuntary outpatient treatment for mental illness. The Florida Department of Children and Families makes resources available online for individuals and families to learn about the Baker Act and to access training about it. There was a 2023 Baker Act User Reference Guide published in the fall of 2023. Reports of data about involuntary examination are available at the Baker Act Reporting Center. Additional specifics about requirements for and carrying out the Baker Act are contained in Florida Administrative Code 65E-5, titled the "Mental Health Act Regulation," which some colloquially refer to as the "rule." Mandatory and suggested forms to use for various activities, as allowed in the Baker Act, are part of a subsection of this Florida Administrative Code, 65E-5.120. History, language, and definitions The 1971 legislation was nicknamed the "Baker Act" after state representative Maxine Baker (D–Miami), who served from 1963 to 1972. She was strongly interested in mental health issues, served as chair of the House Committee on Mental Health, and sponsored the bill. Every state has a mental health statute, with many similar to the Baker Act, but also differences across states in short-term emergency commitment (the equivalent of an involuntary [Baker Act] examination in Florida), long-term involuntary commitment (the equivalent of involuntary inpatient placement in Florida), and involuntary outpatient commitment (the equivalent of involuntary outpatient services in Florida). Words and phrases are defined in the Baker Act as follows. Department: The use of the word "Department" in the Baker Act refers to the Department of Children and Families. Mental illness: An "impairment of the mental or emotional processes that exercise conscious control of one’s actions or of the ability to perceive or understand reality, which impairment substantially interferes with the person’s ability to meet the ordinary demands of living. For the purposes of this part, the term does not include a developmental disability as defined in chapter 393, intoxication, or conditions manifested only by dementia, traumatic brain injury, antisocial behavior, or substance abuse. Treatment Facility: The term "treatment facility" in the Baker Act does not refer generically to any facility that provides treatment. Rather, it is defined as "a state-owned, state-operated, or state-supported hospital, center, or clinic designated by the department for extended treatment and hospitalization, beyond that provided for by a receiving facility, of persons who have a mental illness, including facilities of the United States Government, and any private facility designated by the department when rendering such services to a person pursuant to the provisions of this part. Patients treated in facilities of the United States Government shall be solely those whose care is the responsibility of the United States Department of Veterans Affairs. Some people colloquially refer to "treatment facilities" as defined in the Baker Act as "state hospitals," but the Baker Act does not use the term "state hospital." The nickname has led to the term "Baker Act" being used as a transitive verb and "Baker Acted" being used as a passive-voice verb for invoking the involuntary examination. Short-Term Inpatient Voluntary and Involuntary Examination While much of the focus of the Baker Act is on the involuntary nature of activities allowed, the Baker Act also addresses voluntary aspects of examination and treatment. The word "voluntary" appears 53 times in the Baker Act, while the word "involuntary" appears 224 times. The Baker Act addresses "voluntary admission" (F.S. 394.4625), including the authority to receive patients, discharge of voluntary patients, notice of right to discharge, and transfer to voluntary status from an involuntary status. Websites for Florida Judicial Circuits and Clerks of Court contain information about the Baker Act examination process, including how to pursue an ex-parte order. The Baker Act allows for involuntary examination, which can be initiated by an ex-parte order of a judge, law enforcement officials, or certain health professionals. These health professionals include physicians, clinical psychologists, nurses with certain types of training (psychiatric nurse, APRN), clinical social workers, mental health counselors, and marriage and family therapists. Although not specified in the Baker Act as a professional type that can initiate involuntary examinations, Physicians' Assistants are allowed to initiate involuntary examinations as per a 2008 Florida Attorney General opinion. Forms for law enforcement and health professionals to initiate involuntary examinations and templates for petitions and orders for ex-parte orders for involuntary examinations are available on the Department of Children and Families website. The Florida Judicial Circuits provide information about how to pursue an ex-parte order for involuntary examination. Examinations may last up to 72 hours after a person is deemed medically stable and occur in over 100+ Florida Department of Children and Families-designated receiving facilities statewide. A "receiving facility" is defined in the Baker Act as "a public or private facility or hospital designated by the department to receive and hold or refer, as appropriate, involuntary patients under emergency conditions for mental health or substance abuse evaluation and to provide treatment or transportation to the appropriate service provider. The term does not include a county jail." Note that what some colloquially call "state hospitals" and what the Baker Act calls "treatment facilities" are not receiving facilities, and people are not involuntary examined at these "treatment facilities." Additional details about treatment facilities are included in the Involuntary Inpatient Placement section of this page. Specific criteria must be met in order to initiate involuntary examination. Among those criteria are the following elements, which do not individually qualify an individual as meeting the criteria. To initiate an involuntary examination, the Baker Act requires that there is reason to believe the individual: has a mental illness as defined in section 394.455, Florida Statutes and is refusing voluntary examination after conscientious explanation and disclosure of the purpose of the examination OR is unable to determine for himself/herself whether the examination is necessary AND without care or treatment, said individual is likely to suffer from neglect or refuse to care for himself/herself, and such neglect or refusal poses a real and present threat or substantial harm to his/her well-being and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services OR there is substantial likelihood that without care or treatment the individual will cause serious bodily harm to self and/or others in the near future, as evidenced by recent behavior. Note that the language in the bullets above is taken directly from the Baker Act. The decisive criterion, as stated in the statute, mentions a substantial likelihood that without care or treatment, the person will cause serious bodily harm in the near future. Criteria are not met simply because a person has a mental illness, appears to have mental problems, takes psychiatric medication, has an emotional outburst, or refuses voluntary examination. Furthermore, if there are family members or friends that will help prevent any potential and present threat of substantial harm, the criteria for involuntary examination are also not met. The following may not be used as a basis to initiate an involuntary examination: Developmental disability Intoxication Conditions manifested only by antisocial behavior Conditions manifested only by substance abuse impairment "Substantial likelihood" must involve evidence of recent behavior to justify the substantial likelihood of serious bodily harm in the near future. Moments in the past when an individual may have considered harming themselves or another do not qualify the individual as meeting the criteria. There are many possible outcomes following the involuntary examination of the individual. These include the release of the individual to the community (or other community placement), a petition for involuntary inpatient placement (often called civil commitment), a petition for involuntary outpatient placement (what some call outpatient commitment or assisted outpatient treatment), or voluntary treatment (if the person is competent to consent to voluntary treatment and consents to voluntary treatment, such as specified in case law). The involuntary outpatient placement language in the Baker Act took effect as part of the Baker Act reform in 2004. Inpatient Involuntary Placement People may be placed involuntarily at an inpatient facility. The main section of the Baker Act about involuntary inpatient placement (F.S. 394.467) specifies the criteria for involuntary inpatient placement, as well as the petitioning process, the appointment of counsel, the continuance of the hearing, and the hearing. Note that people may be involuntarily placed for up to 90 days, except that the involuntary placement may be up to 6 months in a treatment facility. The "treatment facilities" at which people may be admitted for involuntary inpatient placement are Florida State Hospital (in Chattahoochee), Northeast Florida State Hospital (in MacClenny), and South Florida State Hospital (in Pembroke Pines). While children may be involuntarily placed at an inpatient facility, children may not be involuntarily placed at state treatment facilities. Involuntary Outpatient Services The Baker Act has allowed for involuntary outpatient services. The criteria for involuntary outpatient services, as well as specifics about petitioning, the appointment of counsel, the continuance of hearings, and hearings, are specified in the Baker Act. Other phrases used historically or currently on a local or national level to describe this legal mechanism are involuntary outpatient commitment and assisted outpatient treatment or AOT. Note that while the phrase "involuntary outpatient services" is used in the Baker Act, the prior phrase that was used in the Baker Act to describe this legal mechanism, "involuntary outpatient placement," still appears on some forms and in the relevant Florida Administrative Code (65E-5.285). Reception An editorial in the Tampa Bay Times wrote "that crisis stabilization is a Band-Aid solution to emotional problems," and the Act should be reformed to allow public defenders to have access to the patient's medical records and ongoing counseling and outpatient mental health treatment should be provided to the patient. See also 5150 (involuntary psychiatric hold), a section of the California Welfare and Institutions Code Laura's Law Kendra's Law Marchman Act References Notes External links Text of the Baker Act Baker Act Reporting Center Health in Florida Mental health law in the United States United States disability legislation Forensic psychology Florida law 1971 in American law 1971 in Florida Involuntary commitment

Medical model

Medical model is the term coined by psychiatrist R. D. Laing in his The Politics of the Family and Other Essays (1971), for the "set of procedures in which all doctors are trained". It includes complaint, history, physical examination, ancillary tests if needed, diagnosis, treatment, and prognosis with and without treatment. The medical model embodies basic assumptions about medicine that drive research and theorizing about physical or psychological difficulties on a basis of causation and remediation. It can be contrasted with other models that make different basic assumptions. Examples include holistic model of the alternative health movement and the social model of the disability rights movement, as well as to biopsychosocial and recovery models of mental disorders. For example, Gregory Bateson's double bind theory of schizophrenia focuses on environmental rather than medical causes. These models are not mutually exclusive. A model is not a statement of absolute reality or a belief system but a tool for helping patients. Thus, utility is the main criterion, and the utility of a model depends on context. Other uses In psychology In psychology, the term medical model refers to the assumption that psychopathology is the result of one's biology, that is to say, a physical/organic problem in brain structures, neurotransmitters, genetics, the endocrine system, etc., as with traumatic brain injury, Alzheimer's disease, or Down's syndrome. The medical model is useful in these situations as a guide for diagnosis, prognosis, and research. However, for most mental disorders, exclusive reliance on the medical model leads to an incomplete understanding, and, frequently, to incomplete or ineffective treatment interventions. The current Diagnostic and Statistical Manual of Mental Disorders (DSM-5), addresses this point in part, stating, The Critical Psychiatry Network, a group of psychiatrists who critique the practice of psychiatry on many grounds, feel that the medical model for mental illness can result in poor treatment choices. Germ theory of disease The rise of modern scientific medicine during the 19th century has a great impact on the development of the medical model. Especially important was the development of the "germ theory" of disease by European medical researchers such as Louis Pasteur and Robert Koch. During the late 19th and early 20th centuries, the physical causes of a variety of diseases were uncovered, which, in turn, led to the development of effective forms of treatment. Concept of "disease" and "injury" The concepts of "disease" and "injury" are central to the medical model. In general, "disease" or "injury" refer to some deviation from normal body functioning that has undesirable consequences for the affected individual. An important aspect of the medical model is that it regards signs (objective indicators such as an elevated temperature) and symptoms (subjective feelings of distress expressed by the patient) as indicative of an underlying physical abnormality (pathology) within the individual. According to the medical model, medical treatment, wherever possible, should be directed at the underlying pathology in an attempt to correct the abnormality and cure the disease. In regard to many mental illnesses, for example, the assumption is that the cause of the disorder lies in abnormalities within the affected individual's brain (especially their brain neurochemistry). That carries the implicit conclusion that disordered behaviors are not learned but are spontaneously generated by the disordered brain. According to the medical model, for treatment (such as drugs), to be effective, it should be directed as closely as possible at correcting the theorized chemical imbalance in the brain of the person with mental illness. Importance of diagnosis Proper diagnosis (that is, the categorization of illness signs and symptoms into meaning disease groupings) is essential to the medical model. Placing the patient's signs and symptoms into the correct diagnostic category can: Provide the physician with clinically useful information about the course of the illness over time (its prognosis); Point to (or at least suggest) a specific underlying cause or causes for the disorder; and Direct the physician to specific treatment or treatments for the condition. For example, if a patient presents to a primary care provider with symptoms of a given illness, by taking a thorough history, performing assessments (such as auscultation and palpation), and, in some cases, ordering diagnostic tests the primary care provider can make a reasonable conclusion about the cause of the symptoms. Based on clinical experience and available evidence, the healthcare professional can identify treatment options that are likely to be successful. Other important aspects Finally, adherence to the medical model has a number of other consequences for the patient and society as a whole, both positive and negative: In the medical model, the physician was traditionally seen as the expert, and patients were expected to comply with the advice. The physician assumes an authoritarian position in relation to the patient. Because of the specific expertise of the physician, according to the medical model, it is necessary and to be expected. However, in recent years, the move towards patient-centered care has resulted in greater patient involvement in many cases. In the medical model, the physician may be viewed as the dominant health care professional, who is the professional trained in diagnosis and treatment. An ill patient should not be held responsible for the condition. The patient should not be blamed or stigmatized for the illness. Under the medical model, the disease condition of the patient is of major importance. Social, psychological, and other "external" factors, which may influence patient behavior, may be given less attention. See also Andersen healthcare utilization model Biomedical model Medical model of disability Reductionism Social constructionism References External links 'Medical model' vs 'social model' British Film Institute Education. Disability Awareness at the University of Sheffield, UK Medical model Open university UK Medical sociology Medical models

Psychiatric survivors movement

The psychiatric survivors movement (more broadly consumer/survivor/ex-patient movement) is a diverse association of individuals who either currently access mental health services (known as consumers or service users), or who have experienced interventions by psychiatry that were unhelpful, harmful, abusive, or illegal. The psychiatric survivors movement arose out of the civil rights movement of the late 1960s and early 1970s and the personal histories of psychiatric abuse experienced by patients. The key text in the intellectual development of the survivor movement, at least in the US, was Judi Chamberlin's 1978 text On Our Own: Patient Controlled Alternatives to the Mental Health System. Chamberlin was an ex-patient and co-founder of the Mental Patients' Liberation Front. Coalescing around the ex-patient newsletter Dendron, in late 1988 leaders from several of the main national and grassroots psychiatric survivor groups felt that an independent, human rights coalition focused on problems in the mental health system was needed. That year the Support Coalition International (SCI) was formed. SCI's first public action was to stage a counter-conference and protest in New York City, in May, 1990, at the same time as (and directly outside of) the American Psychiatric Association's annual meeting. In 2005, the SCI changed its name to MindFreedom International with David W. Oaks as its director. Common themes are "talking back to the power of psychiatry", rights protection and advocacy, self-determination, and building capacity for lived experience leadership. While activists in the movement may share a collective identity to some extent, views range along a continuum from conservative to radical in relation to psychiatric treatment and levels of resistance or patienthood. History Precursors The modern self-help and advocacy movement in the field of mental health services developed in the 1970s, but former psychiatric patients have been campaigning for centuries to change laws, treatments, services and public policies. "The most persistent critics of psychiatry have always been former mental hospital patients", although few were able to tell their stories publicly or to openly confront the psychiatric establishment, and those who did so were commonly considered so extreme in their charges that they could seldom gain credibility. In 1620 in England, patients of the notoriously harsh Bethlem Hospital banded together and sent a "Petition of the Poor Distracted People in the House of Bedlam (concerned with conditions for inmates)" to the House of Lords. A number of ex-patients published pamphlets against the system in the 18th century, such as Samuel Bruckshaw (1774), on the "iniquitous abuse of private madhouses", and William Belcher (1796) with his "Address to humanity, Containing a letter to Dr Munro, a receipt to make a lunatic, and a sketch of a true smiling hyena". Such reformist efforts were generally opposed by madhouse keepers and medics. In the late 18th century, moral treatment reforms developed which were originally based in part on the approach of French ex-patient turned hospital-superintendent Jean-Baptiste Pussin and his wife Margueritte. From 1848 in England, the Alleged Lunatics' Friend Society campaigned for sweeping reforms to the asylum system and abuses of the moral treatment approach. In the United States, The Opal (1851–1860) was a ten volume Journal produced by patients of Utica State Lunatic Asylum in New York, which has been viewed in part as an early liberation movement. Beginning in 1868, Elizabeth Packard, founder of the Anti-Insane Asylum Society, published a series of books and pamphlets describing her experiences in the Illinois insane asylum to which her husband had her committed. Early 20th century A few decades later, another former psychiatric patient, Clifford W. Beers, founded the National Committee on Mental Hygiene, which eventually became the National Mental Health Association. Beers sought to improve the plight of individuals receiving public psychiatric care, particularly those committed to state institutions. His book, A Mind that Found Itself (1908), described his experience with mental illness and the treatment he encountered in mental hospitals. Beers' work stimulated public interest in more responsible care and treatment. However, while Beers initially blamed psychiatrists for tolerating mistreatment of patients, and envisioned more ex-patient involvement in the movement, he was influenced by Adolf Meyer and the psychiatric establishment, and toned down his hostility as he needed their support for reforms. His reliance on rich donors and his need for approval from experts led him to hand over to psychiatrists the organization he helped establish. In the UK, the National Society for Lunacy Law Reform was established in 1920 by angry ex-patients sick of their experiences and complaints being patronisingly discounted by the authorities who were using medical "window dressing" for essentially custodial and punitive practices. In 1922, ex-patient Rachel Grant-Smith added to calls for reform of the system of neglect and abuse she had suffered by publishing "The Experiences of an Asylum Patient". We Are Not Alone (WANA) was founded by a group of patients at Rockland State Hospital in New York (now the Rockland Psychiatric Center) in the mid to late 1940s, and continued to meet as an ex-patient group. Their goal was to provide support and advice and help others make the difficult transition from hospital to community. At this same time, a young social worker in Detroit, Michigan, was doing some pioneering work with psychiatric patients from the “back wards” of Wayne County Hospital. Prior to the advent of psychotropic medication, patients on the “back wards” were generally considered to be "hopelessly sick." John H. Beard began his work on these wards with the conviction that these patients were not totally consumed by illness but retained areas of health. This insight led him to involve the patients in such normal activities as picnics, attending a baseball game, dining at a fine restaurant, and then employment. Fountain House had, by now, recognized that the experience of the illness, together with a poor or interrupted work history often denied members the opportunity to obtain employment. Many lived in poverty and never got the chance to even try working on a job. The hiring of John H. Beard as executive director in 1955 changed all of that. The creation of what we now know to be Transitional Employment transformed Fountain House as many members began venturing from the clubhouse into real jobs for real wages in the community. Importantly, these work opportunities were in integrated settings and not just with other persons with disabilities. The concept of what was normal was pervasive in all of what Fountain House set out to do. Thus, Fountain House became a place of both social and vocational rehabilitation, addressing the disabilities that so often accompany having a serious mental illness and setting the wheels in motion for a life of recovery and not disability. Originated by crusaders in periods of liberal social change, and appealing not so much to other sufferers as to elite groups with power, when the early reformer's energy or influence waned, mental patients were again mostly friendless and forgotten. 1950s to 1970s The 1950s saw the reduction in the use of lobotomy and shock therapy. These used to be associated with concerns and much opposition on grounds of basic morality, harmful effects, or misuse. Towards the 1960s, psychiatric medications came into widespread use and also caused controversy relating to adverse effects and misuse. There were also associated moves away from large psychiatric institutions to community-based services (later to become a full-scale deinstitutionalization), which sometimes empowered service users, although community-based services were often deficient. There has been some discussion within the field about the usefulness of antipsychotic medications in a world with a decreasing tolerance for institutionalization: "With the advent of the modern antipsychotic medications and psychosocial treatments, the great majority are able to live in a range of open settings in the community—with family, in their own apartments, in board-and-care homes, and in halfway houses." Coming to the fore in the 1960s, an anti-psychiatry movement challenged the fundamental claims and practices of mainstream psychiatry. The ex-patient movement of this time contributed to, and derived much from, antipsychiatry ideology, but has also been described as having its own agenda, described as humanistic socialism. For a time, the movement shared aims and practices with "radical therapists", who tended to be Marxist. However, the consumer/survivor/ex-patients gradually felt that the radical therapists did not necessarily share the same goals and were taking over, and they broke away from them in order to maintain independence. By the 1970s, the women's movement, gay rights movement, and disability rights movements had emerged. It was in this context that former mental patients began to organize groups with the common goals of fighting for patients' rights and against forced treatment, stigma and discrimination, and often to promote peer-run services as an alternative to the traditional mental health system. Unlike professional mental health services, which were usually based on the medical model, peer-run services were based on the principle that individuals who have shared similar experiences can help themselves and each other through self-help and mutual support. Many of the individuals who organized these early groups identified themselves as psychiatric survivors. Their groups had names such as Insane Liberation Front and the Network Against Psychiatric Assault. NAPA co-founder Leonard Roy Frank founded (with colleague Wade Hudson) Madness Network News in San Francisco in 1972. In 1971 the Scottish Union of Mental Patients was founded. In 1973 some of those involved founded the Mental Patients' Union in London. Dorothy Weiner and about 10 others, including Tom Wittick, established the Insane Liberation Front in the spring of 1970 in Portland, Oregon. Though it only lasted six months, it had a notable influence in the history of North American ex-patients groups. News that former inmates of mental institutions were organizing was carried to other parts of North America. Individuals such as Howard Geld, known as Howie the Harp for his harmonica playing, left Portland where he been involved in ILF to return to his native New York to help found the Mental Patients Liberation Project in 1971. During the early 1970s, groups spread to California, New York, and Boston, which were primarily antipsychiatry, opposed to forced treatment including forced drugging, shock treatment and involuntary committal. In 1972, the first organized group in Canada, the Mental Patients Association, started to publish In A Nutshell, while in the US the first edition of the first national publication by ex-mental patients, Madness Network News, was published in Oakland, continuing until 1986. Some all-women groups developed around this time such as Women Against Psychiatric Assault, begun in 1975 in San Francisco. In 1978 Judi Chamberlin's book On Our Own: Patient Controlled Alternatives to the Mental Health System was published. It became the standard text of the psychiatric survivors movement, and in it Chamberlin coined the word "mentalism." The major spokespeople of the movement have been described in generalities as largely white, middle-class and well-educated. It has been suggested that other activists were often more anarchistic and anti-capitalist, felt more cut off from society and more like a minority with more in common with the poor, ethnic minorities, feminists, prisoners & gay rights than with the white middle classes. The leaders were sometimes considered to be merely reformist and, because of their "stratified position" within society, to be uncomprehending of the problems of the poor. The "radicals" saw no sense in seeking solutions within a capitalist system that creates mental problems. However, they were united in considering society and psychiatric domination to be the problem, rather than people designated mentally ill. Some activists condemned psychiatry under any conditions, voluntary or involuntary, while others believed in the right of people to undergo psychiatric treatment on a voluntary basis. Voluntary psychotherapy, at the time mainly psychoanalysis, did not therefore come under the same severe attack as the somatic therapies. The ex-patients emphasized individual support from other patients; they espoused assertiveness, liberation, and equality; and they advocated user-controlled services as part of a totally voluntary continuum. However, although the movement espoused egalitarianism and opposed the concept of leadership, it is said to have developed a cadre of known, articulate, and literate men and women who did the writing, talking, organizing, and contacting. Very much the product of the rebellious, populist, anti-elitist mood of the 1960s, they strived above all for self-determination and self-reliance. In general, the work of some psychiatrists, as well as the lack of criticism by the psychiatric establishment, was interpreted as an abandonment of a moral commitment to do no harm. There was anger and resentment toward a profession that had the authority to label them as mentally disabled and was perceived as infantilizing them and disregarding their wishes. 1980s and 1990s By the 1980s, individuals who considered themselves "consumers" of mental health services rather than passive "patients" had begun to organize self-help/advocacy groups and peer-run services. While sharing some of the goals of the earlier movement, consumer groups did not seek to abolish the traditional mental health system, which they believed was necessary. Instead, they wanted to reform it and have more choice. Consumer groups encouraged their members to learn as much as possible about the mental health system so that they could gain access to the best services and treatments available. In 1985, the National Mental Health Consumers' Association was formed in the United States. A 1986 report on developments in the United States noted that "there are now three national organizations ... The ‘conservatives’ have created the National Mental Health Consumers' Association ... The ‘moderates’ have formed the National Alliance of Mental Patients ... The ‘radical’ group is called the Network to Abolish Psychiatry". Many, however, felt that they had survived the psychiatric system and its "treatments" and resented being called consumers. The National Association of Mental Patients in the United States became the National Association of Psychiatric Survivors. "Phoenix Rising: The Voice of the Psychiatrized" was published by ex-inmates (of psychiatric hospitals) in Toronto from 1980 to 1990, known across Canada for its antipsychiatry stance. In late 1988, leaders from several of the main national and grassroots psychiatric survivor groups decided an independent coalition was needed, and Support Coalition International (SCI) was formed in 1988, later to become MindFreedom International. In addition, the World Network of Users and Survivors of Psychiatry (WNUSP), was founded in 1991 as the World Federation of Psychiatric Users (WFPU), an international organisation of recipients of mental health services. An emphasis on voluntary involvement in services is said to have presented problems to the movement since, especially in the wake of deinstitutionalization, community services were fragmented and many individuals in distressed states of mind were being put in prisons or re-institutionalized in community services, or became homeless, often distrusting and resisting any help. Science journalist Robert Whitaker has concluded that patients rights groups have been speaking out against psychiatric abuses for decades - the torturous treatments, the loss of freedom and dignity, the misuse of seclusion and restraints, the neurological damage caused by drugs - but have been condemned and dismissed by the psychiatric establishment and others. Recipients of mental health services demanded control over their own treatment and sought to influence the mental health system and society's views. The movement today In the United States, the number of mental health mutual support groups (MSG), self-help organizations (SHO) (run by and for mental health consumers and/or family members) and consumer-operated services (COS) was estimated in 2002 to be 7,467. In Canada, CSI's (Consumer Survivor Initiatives) are the preferred term. "In 1991 Ontario led the world in its formal recognition of CSI's as part of the core services offered within the mental health sector when it began to formally fund CSI's across the province. Consumer Survivor Initiatives in Ontario Building an Equitable Future' (2009) pg 7. The movement may express a preference for the "survivor" label over the "consumer" label, with more than 60 percent of ex-patient groups reported to support anti-psychiatry beliefs and considering themselves to be "psychiatric survivors." There is some variation between the perspective on the consumer/survivor movement coming from psychiatry, anti-psychiatry or consumers/survivors themselves. The most common terms in Germany are "Psychiatrie-Betroffene" (people afflicted by/confronted with psychiatry) and "Psychiatrie-Erfahrene" (people who have experienced psychiatry). Sometimes the terms are considered as synonymous but sometimes the former emphasizes the violence and negative aspects of psychiatry. The German national association of (ex-)users and survivors of psychiatry is called the Bundesverband Psychiatrie-Erfahrener (BPE). There are many grassroots self-help groups of consumers/survivors, local and national, all over the world, which are an important cornerstone of empowerment. A considerable obstacle to realizing more consumer/survivor alternatives is lack of funding. Alternative consumer/survivor groups like the National Empowerment Center in the US which receive public funds but question orthodox psychiatric treatment, have often come under attack for receiving public funding and been subject to funding cuts. As well as advocacy and reform campaigns, the development of self-help and user/survivor controlled services is a central issue. The Runaway-House in Berlin, Germany, is an example. Run by the Organisation for the Protection from Psychiatric Violence, it is an antipsychiatric crisis centre for homeless survivors of psychiatry where the residents can live for a limited amount of time and where half the staff members are survivors of psychiatry themselves. In Helsingborg, Sweden, the Hotel Magnus Stenbock is run by a user/survivor organization "RSMH" that gives users/survivors a possibility to live in their own apartments. It is financed by the Swedish government and run entirely by users. Voice of Soul is a user/survivor organization in Hungary. Creative Routes is a user/survivor organization in London, England, that among other support and advocacy activities puts on an annual "Bonkersfest". WNUSP is a consultant organization for the United Nations. After a "long and difficult discussion", ENUSP and WNUSP (European and World Networks of Users and Survivors of Psychiatry) decided to employ the term (ex-)users and survivors of psychiatry in order to include the identities of the different groups and positions represented in these international NGOs. WNUSP contributed to the development of the UN's Convention on the Rights of Persons with Disabilities and produced a manual to help people use it entitled "Implementation Manual for the United Nations Convention on the Rights of Persons with Disabilities", edited by Myra Kovary. ENUSP is consulted by the European Union and World Health Organization. In 2007 at a Conference held in Dresden on "Coercive Treatment in Psychiatry: A Comprehensive Review", the president and other leaders of the World Psychiatric Association met, following a formal request from the World Health Organization, with four representatives from leading consumer/survivor groups. The National Coalition for Mental Health Recovery (formerly known as National Coalition for Mental Health Consumer/Survivor Organizations) campaigns in the United States to ensure that consumer/survivors have a major voice in the development and implementation of health care, mental health, and social policies at the state and national levels, empowering people to recover and lead a full life in the community. The United States Massachusetts-based Freedom Center provides and promotes alternative and holistic approaches and takes a stand for greater choice and options in treatments and care. The center and the New York-based Icarus Project (which does not self-identify as a consumer/survivor organization but has participants that identify as such) have published a Harm Reduction Guide To Coming Off Psychiatric Drugs and were recently a featured charity in Forbes business magazine. Mad pride events, organized by loosely connected groups in at least seven countries including Australia, South Africa, the United States, Canada, the United Kingdom and Ghana, draw thousands of participants. For some, the objective is to continue the destigmatization of mental illness. Another wing rejects the need to treat mental afflictions with psychotropic drugs and seeks alternatives to the "care" of the medical establishment. Many members of the movement say they are publicly discussing their own struggles to help those with similar conditions and to inform the general public. Survivor David Oaks, director of MindFreedom, hosted a monthly radio show and the Freedom Center initiated a weekly FM radio show now syndicated on the Pacifica Network, Madness Radio, hosted by Freedom Center co-founder Will Hall. A new International Coalition of National Consumer/User Organizations was launched in Canada in 2007, called Interrelate. Impact Research into consumer/survivor initiatives (CSIs) suggests they can help with social support, empowerment, mental wellbeing, self-management and reduced service use, identity transformation and enhanced quality of life. However, studies have focused on the support and self-help aspects of CSIs, neglecting that many organizations locate the causes of members’ problems in political and social institutions and are involved in activities to address issues of social justice. A 2006 series of studies in Canada compared individuals who participated in CSIs with those who did not. The two groups were comparable at baseline on a wide range of demographic variables, self-reported psychiatric diagnosis, service use, and outcome measures. After a year and a half, those who had participated in CSIs showed significant improvement in social support and quality of life (daily activities), less days of psychiatric hospitalization, and more were likely to have stayed in employment (paid or volunteer) and/or education. There was no significant difference on measures of community integration and personal empowerment, however. There were some limitations to the findings; although the active and nonactive groups did not differ significantly at baseline on measures of distress or hospitalization, the active group did have a higher mean score and there may have been a natural pattern of recovery over time for that group (regression to the mean). The authors noted that the apparent positive impacts of consumer-run organizations were achieved at a fraction of the cost of professional community programs. Further qualitative studies indicated that CSIs can provide safe environments that are a positive, welcoming place to go; social arenas that provide opportunities to meet and talk with peers; an alternative worldview that provides opportunities for members to participate and contribute; and effective facilitators of community integration that provide opportunities to connect members to the community at large. System-level activism was perceived to result in changes in perceptions by the public and mental health professionals (about mental health or mental illness, the lived experience of consumer/survivors, the legitimacy of their opinions, and the perceived value of CSIs) and in concrete changes in service delivery practice, service planning, public policy, or funding allocations. The authors noted that the evidence indicated that the work benefits other consumers/survivors (present and future), other service providers, the general public, and communities. They also noted that there were various barriers to this, most notably lack of funding, and also that the range of views represented by the CSIs appeared less narrow and more nuanced and complex than previously, and that perhaps the consumer/survivor social movement is at a different place than it was 25 years ago. A significant theme that has emerged from consumer/survivor work, as well as from some psychiatrists and other mental health professionals, has been a recovery model which seeks to overturn therapeutic pessimism and to support sufferers to forge their own personal journey towards the life they want to live; some argue, however, that it has been used as a cover to blame people for not recovering or to cut public services. There has also been criticism of the movement. Organized psychiatry often views radical consumerist groups as extremist, as having little scientific foundation and no defined leadership, as "continually trying to restrict the work of psychiatrists and care for the seriously mentally ill", and as promoting disinformation on the use of involuntary commitment, electroconvulsive therapy, stimulants and antidepressants among children, and neuroleptics among adults. However, opponents consistently argue that psychiatry is territorial and profit-driven and stigmatizes and undermines the self-determination of patients and ex-patients. The movement has also argued against social stigma or mentalism by wider society. People in the US, led by figures such as psychiatrists E. Fuller Torrey and Sally Satel, and some leaders of the National Alliance on Mental Illness, have lobbied against the funding of consumer/survivor groups that promote antipsychiatry views or promote social and experiential recovery rather than a biomedical model, or who protest against outpatient commitment. Torrey has said the term "psychiatric survivor" used by ex-patients to describe themselves is just political correctness and has blamed them, along with civil rights lawyers, for the deaths of half a million people due to suicides and deaths on the street. His accusations have been described as inflammatory and completely unsubstantiated, however, and issues of self-determination and self-identity has been said to be more complex than that. See also Aggression in healthcare Alleged Lunatics' Friend Society Anti-psychiatry Commissioners in Lunacy Disability rights movement Disability flag Duplessis Orphans Mad Studies Millfields Charter, an electronic charter regarding prone restraint holds Neurodiversity Neuroplasticity, how the brain changes in the course of a lifetime Outline of the psychiatric survivors movement The Shrink Next Door Critical Psychiatry Network References External links Guide on the History of the Consumer Movement from the National Mental Health Consumers' Self-Help Clearinghouse Cohen, Oryx (2001) Psychiatric Survivor Oral Histories: Implications for Contemporary Mental Health Policy. Center for Public Policy and Administration, University of Massachusetts, Amherst Linda J Morrison. (2006) A Matter of Definition: Acknowledging Consumer/Survivor Experiences through Narrative Radical Psychology Volume Five Shock Treatment - The Killing of Susan Kelly A poem by insulin/electro shock survivor Dorothy Dundas McLean, A. (2003). Recovering Consumers and a Broken Mental Health System in the United States: Ongoing Challenges for Consumers/ Survivors and the New Freedom Commission on Mental Health. Part I: Legitimization of the Consumer Movement and Obstacles to It. International Journal of Psychosocial Rehabilitation. 8, 47-57 McLean, A. (2003) Recovering Consumers and a Broken Mental Health System in the United States: Ongoing Challenges for Consumers/ Survivors and the New Freedom Commission on Mental Health. Part II: Impact of Managed Care and Continuing Challenges International Journal of Psychosocial Rehabilitation. 8, 58–70. Transcript of interview with Peter Breggin, M.D., author of "Toxic Psychiatry," Talking Back To Prozac" and "Brain-Disabling Treatments in Psychiatry: Drugs, Electroshock and the Psychopharmaceutical Complex." Psychiatry chapter from Heart Failure - Diary of a Third Year Medical Student by Michael Greger, M.D. Health movements Identity politics Human rights by issue Anti-psychiatry

General paresis of the insane

General paresis, also known as general paralysis of the insane (GPI), paralytic dementia, or syphilitic paresis is a severe neuropsychiatric disorder, classified as an organic mental disorder, and is caused by late-stage syphilis and the chronic meningoencephalitis and cerebral atrophy that are associated with this late stage of the disease when left untreated. GPI differs from mere paresis, as mere paresis can result from multiple other causes and usually does not affect cognitive function. Degenerative changes caused by GPI are associated primarily with the frontal and temporal lobar cortex. The disease affects approximately 7% of individuals infected with syphilis, and is far more common in developing countries where fewer options for timely treatment are available. It is more common among men. GPI was originally considered to be a type of madness due to a dissolute character, when first identified in the early 19th century. The condition's connection with syphilis was discovered in the late 1880s. Progressively, with the discovery of organic arsenicals such as Salvarsan and Neosalvarsan (1910s), the development of pyrotherapy (1920s), and the widespread availability and use of penicillin in the treatment of syphilis (1940s), the condition was rendered avoidable and curable. Prior to this, GPI was inevitably fatal, and it accounted for as much as 25% of the primary diagnoses for residents in public psychiatric hospitals. Signs and symptoms Symptoms of the disease first appear from 10 to 30 years after infection. Incipient GPI is usually manifested by neurasthenic difficulties, such as fatigue, headaches, insomnia, dizziness, etc. As the disease progresses, mental deterioration and personality changes occur. Typical symptoms include loss of social inhibitions, asocial behavior, gradual impairment of judgment, concentration and short-term memory, euphoria, mania, depression, or apathy. Subtle shivering, minor defects in speech and Argyll Robertson pupil may become noticeable. Delusions, common as the illness progresses, tend to be poorly systematized and absurd. They can be grandiose, melancholic, or paranoid. These delusions include ideas of great wealth, immortality, thousands of lovers, unfathomable power, apocalypsis, nihilism, self-guilt, self-blame, or bizarre hypochondriacal complaints. Later, the patient experiences dysarthria, intention tremors, hyperreflexia, myoclonic jerks, confusion, seizures and severe muscular deterioration. Eventually, the paretic dies bedridden, cachectic and completely disoriented, frequently in a state of status epilepticus. Diagnosis The diagnosis could be differentiated from other known psychoses and dementias by a characteristic abnormality in eye pupil reflexes (Argyll Robertson pupil), and, eventually, the development of muscular reflex abnormalities, seizures, memory impairment (dementia) and other signs of relatively pervasive neurocerebral deterioration. Definitive diagnosis is based on the analysis of cerebrospinal fluid and tests for syphilis. Prognosis Although there were recorded cases of remission of the symptoms, especially if they had not passed beyond the stage of psychosis, these individuals almost invariably experienced relapse within a few months to a few years. Otherwise, the patient was seldom able to return home because of the complexity, severity and unmanageability of the evolving symptom picture. Eventually, the patient would become completely incapacitated, bed ridden, and would die, the process taking about three to five years on average. History While retrospective studies have found earlier instances of what may have been the same disorder, the first clearly identified examples of paresis among the insane were described in Paris after the Napoleonic Wars. General paresis of the insane was first described as a distinct disease in 1822 by Antoine Laurent Jesse Bayle. General paresis most often struck people (men far more frequently than women) between 20 and 40 years of age. By 1877, for example, the superintendent of an asylum for men in New York reported that in his institution this disorder accounted for more than 12% of admissions and more than 2% of deaths. Originally, the cause was believed to be an inherent weakness of character or constitution. While Friedrich von Esmarch and the psychiatrist had asserted as early as 1857 that syphilis caused general paresis (progressive Paralyse), progress toward the general acceptance by the medical community of this idea was only accomplished later by the eminent 19th century syphilographer Jean Alfred Fournier (18321914). In 1913 all doubt about the syphilitic nature of paresis was finally eliminated when Hideyo Noguchi and J. W. Moore demonstrated the syphilitic spirochaetes in the brains of paretics. In 1917 Julius Wagner-Jauregg discovered that malaria therapy (in this case, medical induction of a fever) involving infecting paretic patients with malaria could halt the progression of general paresis. He won a Nobel Prize for this discovery in 1927. After World War II the use of penicillin to treat syphilis made general paresis a rarity: even patients manifesting early symptoms of actual general paresis were capable of full recovery with a course of penicillin. The disorder is now virtually unknown outside developing countries, and even there the epidemiology is substantially reduced. Some notable cases of general paresis: General Ranald S. Mackenzie was retired from the US Army in 1884 for "general paresis of the insane" 5 years before his death in 1889. Theo Van Gogh, brother of painter Vincent van Gogh, died six months after Vincent in 1891 from "dementia parylitica" or what is now called syphilitic paresis. The Chicago gangster Al Capone died of syphilitic paresis, having contracted syphilis in a brothel in 1919, and not having been properly treated for it in time to prevent his later onset of syphilitic paresis. See also Karolina Olsson Neurosyphilis Tabes dorsalis Tuskegee experiment References External links Neurological disorders Sexually transmitted diseases and infections Syphilis

Mentalization

In psychology, mentalization is the ability to understand the mental state – of oneself or others – that underlies overt behaviour. Mentalization can be seen as a form of imaginative mental activity that lets us perceive and interpret human behaviour in terms of intentional mental states (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons). It is sometimes described as "understanding misunderstanding." Another term that David Wallin has used for mentalization is "Thinking about thinking". Mentalization can occur either automatically or consciously. Background While the broader concept of theory of mind has been explored at least since Descartes, the specific term 'mentalization' emerged in psychoanalytic literature in the late 1960s, and became empirically tested in 1983 when Heinz Wimmer and Josef Perner ran the first experiment to investigate when children can understand false belief, inspired by Daniel Dennett's interpretation of a Punch and Judy scene. The field diversified in the early 1990s when Simon Baron-Cohen and Uta Frith, building on the Wimmer and Perner study, and others merged it with research on the psychological and biological mechanisms underlying autism and schizophrenia. Concomitantly, Peter Fonagy and colleagues applied it to developmental psychopathology in the context of attachment relationships gone awry. More recently, several child mental health researchers such as Arietta Slade, John Grienenberger, Alicia Lieberman, Daniel Schechter, and Susan Coates have applied mentalization both to research on parenting and to clinical interventions with parents, infants, and young children. Implications Mentalization has implications for attachment theory and self-development. According to Peter Fonagy, individuals with disorganized attachment style (e.g., due to physical, psychological, or sexual abuse) can have greater difficulty developing the ability to mentalize. Attachment history partially determines the strength of mentalizing capacity of individuals. Securely attached individuals tend to have had a primary caregiver that has more complex and sophisticated mentalizing abilities. As a consequence, these children possess more robust capacities to represent the states of their own and other people's minds. Early childhood exposure to mentalization can protect the individual from psychosocial adversity. This early childhood exposure to genuine parental mentalization fosters development of mentalizing capabilities in the child themselves. There is also suggestion that genuine parental mentalization is beneficial to child learning; when a child feels they are being viewed as an intentional agent, they feel contingently responded to, which promotes epistemic trust and triggers learning in the form of natural pedagogy - this increases the quality of learning in the child. This theory needs further empirical support. Research Mentalization or better mentalizing, has a number of different facets which can be measured with various methods. A prominent method of assessment of Parental Mentalization is the Parental Development Interview (PDI), a 45-question semi-structured interview, investigating parents’ representations of their children, themselves as parents, and their relationships with their children. An efficient self-report measure of Parental Mentalization is the Parental Reflective Functioning Questionnaire (PRFQ) created by Patrick Luyten and colleagues. The PRFQ is a brief, multidimensional assessment of parental reflective functioning (mentalization), aimed to be easy to administer to parents in a wide range of socioeconomic populations. The PRFQ is recommended for use as a screening tool for studies with large populations and does not aim to replace more comprehensive measures, such as the PDI or observer-based measures. A 2024 study investigated the longitudinal impact of mentalizing on well-being and emotion regulation strategies in a non-clinical sample, finding that impairments in mentalizing negatively predicted well-being and positively predicted emotional suppression over one year. Research has also found a link between dopamine levels and the ability to mentalize. In particular, reducing dopamine activity in healthy individuals using the drug haloperidol impaired their mentalizing abilities, suggesting that dopamine plays a direct role in these social cognitive processes. Fourfold dimensions According to the American Psychiatric Association's Handbook of Mentalizing in Mental Health Practice, mentalization takes place along a series of four parameters or dimensions: Automatic/Controlled, Self/Other, Inner/Outer, and Cognitive/Affective. Each dimension can be exercised in either a balanced or unbalanced way, while effective mentalization also requires a balanced perspective across all four dimensions. Automatic/Controlled. Automatic (or implicit) mentalizing is a fast-processing unreflective process, calling for little conscious effort or input; whereas controlled mentalization (explicit) is slow, effortful, and demanding of full awareness. In a balanced personality, shifts from automatic to controlled smoothly occur when misunderstandings arise in a conversation or social setting, to put things right. Inability to shift from automatic mentalization can lead to a simplistic, one-sided view of the world, especially when emotions run high; while conversely inability to leave controlled mentalization leaves one trapped in a 'heavy', endlessly ruminative thought-mode. Self/Other involves the ability to mentalize about one's own state of mind, as well as about that of another. Lack of balance means an overemphasis on either self or other. Inner/Outer: Here problems can arise from an over-emphasis on external conditions, and a neglect of one's own feelings and experience. Cognitive/Affective are in balance when both dimensions are engaged, as opposed to either an excessive certainty about one's own one-sided ideas, or an overwhelming of thought by floods of emotion. See also References Further reading Apperly, I. (2010). Mindreaders: The Cognitive Basis of "Theory of Mind". Hove, UK: Psychology Press. Doherty, M.J. (2009). Theory of Mind: How Children Understand Others' Thoughts and Feelings. Hove, UK: Psychology Press. External links Anthony Bateman's homepage. Mentalization factoids – compiled by Frederick Leonhardt. A summary of mentalization. Developmental psychology Psychological concepts

Stupor

Stupor is the lack of critical mental function and a level of consciousness, in which an affected person is almost entirely unresponsive and responds only to intense stimuli such as pain. The word derives from the Latin stupor ("numbness, insensibility"). Signs and symptoms Stupor is characterised by impaired reaction to external stimuli. Those in a stuporous state are rigid, mute and only appear to be conscious, as the eyes are open and follow surrounding objects. If not stimulated externally, a patient with stupor will appear to be in a sleepy state most of the time. In some extreme cases of severe depressive disorders the patient can become motionless, lose their appetite and become mute. Short periods of restricted responsivity can be achieved by intense stimulation (e.g. pain, bright light, loud noise, shock). Causes Stupor is associated with infectious diseases, complicated toxic states (e.g. heavy metals), severe hypothermia, mental illnesses (e.g. schizophrenia, major depressive disorder), epilepsy, vascular illnesses (e.g. hypertensive encephalopathy), acute stress reaction (shock), neoplasms (e.g. brain tumors), brain disorders (e.g. alzheimers, dementia, fatal insomnia), B12 deficiency, major trauma, alcohol poisoning, vitamin D excess, and other conditions. Lesions of the ascending reticular activation system on height of the pons and metencephalon have been shown to cause stupor. The incidence is higher after left-sided lesions. Management Because stupors are caused by another health condition, treatment focuses on uncovering and treating the cause. Doctors may administer IV antibiotics or fluids to treat infections and nutritional deficits, or conduct an MRI to check for lesions on the brain. See also Torpor Notes References C. Lafosse, Zakboek Neuropsychologische Symptomatologie, p. 37, . External links Symptoms and signs of mental disorders

Behaviour therapy

Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or other people's mental states, influences those behaviours, and consists of techniques based on behaviorism's theory of learning: respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method, but it has a wide range of techniques that can be used to treat a person's psychological problems. Behavioural psychotherapy is sometimes juxtaposed with cognitive psychotherapy. While cognitive behavioural therapy integrates aspects of both approaches, such as cognitive restructuring, positive reinforcement, habituation (or desensitisation), counterconditioning, and modelling. Applied behaviour analysis (ABA) is the application of behaviour analysis that focuses on functionally assessing how behaviour is influenced by the observable learning environment and how to change such behaviour through contingency management or exposure therapies, which are used throughout clinical behaviour analysis therapies or other interventions based on the same learning principles. Cognitive-behavioural therapy views cognition and emotions as preceding overt behaviour and implements treatment plans in psychotherapy to lessen the issue by managing competing thoughts and emotions, often in conjunction with behavioural learning principles. A 2013 Cochrane review comparing behaviour therapies to psychological therapies found them to be equally effective, although at the time the evidence base that evaluates the benefits and harms of behaviour therapies was weak. History Precursors of certain fundamental aspects of behaviour therapy have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Wolpe and Lazarus wrote, The first use of the term behaviour modification appears to have been by Edward Thorndike in 1911. His article Provisional Laws of Acquired Behavior or Learning makes frequent use of the term "modifying behavior". Through early research in the 1940s and the 1950s the term was used by Joseph Wolpe's research group. The experimental tradition in clinical psychology used it to refer to psycho-therapeutic techniques derived from empirical research. It has since come to refer mainly to techniques for increasing adaptive behaviour through reinforcement and decreasing maladaptive behaviour through extinction or punishment (with emphasis on the former). Two related terms are behaviour therapy and applied behaviour analysis. Since techniques derived from behavioural psychology tend to be the most effective in altering behaviour, most practitioners consider behaviour modification along with behaviour therapy and applied behaviour analysis to be founded in behaviourism. While behaviour modification and applied behaviour analysis typically uses interventions based on the same behavioural principles, many behaviour modifiers who are not applied behaviour analysts tend to use packages of interventions and do not conduct functional assessments before intervening. Possibly the first occurrence of the term "behavior therapy" was in a 1953 research project by B.F. Skinner, Ogden Lindsley, Nathan Azrin and Harry C. Solomon. The paper talked about operant conditioning and how it could be used to help improve the functioning of people who were diagnosed with chronic schizophrenia. Early pioneers in behaviour therapy include Joseph Wolpe and Hans Eysenck. In general, behaviour therapy is seen as having three distinct points of origin: South Africa (Wolpe's group), the United States (Skinner), and the United Kingdom (Rachman and Eysenck). Each had its own distinct approach to viewing behaviour problems. Eysenck in particular viewed behaviour problems as an interplay between personality characteristics, environment, and behaviour. Skinner's group in the United States took more of an operant conditioning focus. The operant focus created a functional approach to assessment and interventions focused on contingency management such as the token economy and behavioural activation. Skinner's student Ogden Lindsley is credited with forming a movement called precision teaching, which developed a particular type of graphing program called the standard celeration chart to monitor the progress of clients. Skinner became interested in the individualising of programs for improved learning in those with or without disabilities and worked with Fred S. Keller to develop programmed instruction. Programmed instruction had some clinical success in aphasia rehabilitation. Gerald Patterson used programme instruction to develop his parenting text for children with conduct problems. (see Parent management training.) With age, respondent conditioning appears to slow but operant conditioning remains relatively stable. While the concept had its share of advocates and critics in the west, its introduction in the Asian setting, particularly in India in the early 1970s and its grand success were testament to the famous Indian psychologist H. Narayan Murthy's enduring commitment to the principles of behavioural therapy and biofeedback. While many behaviour therapists remain staunchly committed to the basic operant and respondent paradigm, in the second half of the 20th century, many therapists coupled behaviour therapy with the cognitive therapy, of Aaron Beck, Albert Ellis, and Donald Meichenbaum to form cognitive behaviour therapy. In some areas the cognitive component had an additive effect (for example, evidence suggests that cognitive interventions improve the result of social phobia treatment.) but in other areas it did not enhance the treatment, which led to the pursuit of third generation behaviour therapies. Third generation behaviour therapy uses basic principles of operant and respondent psychology but couples them with functional analysis and a clinical formulation/case conceptualisation of verbal behaviour more inline with view of the behaviour analysts. Some research supports these therapies as being more effective in some cases than cognitive therapy, but overall the question is still in need of answers. Theoretical basis The behavioural approach to therapy assumes that behaviour that is associated with psychological problems develops through the same processes of learning that affects the development of other behaviours. Therefore, behaviourists see personality problems in the way that personality was developed. They do not look at behaviour disorders as something a person has, but consider that it reflects how learning has influenced certain people to behave in a certain way in certain situations. Behaviour therapy is based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. Classical conditioning happens when a neutral stimulus comes right before another stimulus that triggers a reflexive response. The idea is that if the neutral stimulus and whatever other stimulus that triggers a response is paired together often enough that the neutral stimulus will produce the reflexive response. Operant conditioning has to do with rewards and punishments and how they can either increase or decrease certain behaviours. Contingency management programs are a direct product of research from operant conditioning. Current forms Behavioural therapy based on operant and respondent principles has considerable evidence base to support its usage. This approach remains a vital area of clinical psychology and is often termed clinical behavior analysis. Behavioral psychotherapy has become increasingly contextual in recent years. Behavioral psychotherapy has developed greater interest in recent years in personality disorders as well as a greater focus on acceptance and complex case conceptualizations. Functional analytic psychotherapy One current form of behavioural psychotherapy is functional analytic psychotherapy. Functional analytic psychotherapy is a longer duration behaviour therapy. Functional analytic therapy focuses on in-session use of reinforcement and is primarily a relationally-based therapy. As with most of the behavioural psychotherapies, functional analytic psychotherapy is contextual in its origins and nature. and draws heavily on radical behaviourism and functional contextualism. Functional analytic psychotherapy holds to a process model of research, which makes it unique compared to traditional behaviour therapy and cognitive behavioural therapy. Functional analytic psychotherapy has a strong research support. Recent functional analytic psychotherapy research efforts are focusing on management of aggressive inpatients. Assessment Behaviour therapists complete a functional analysis or a functional assessment that looks at four important areas: stimulus, organism, response and consequences. The stimulus is the condition or environmental trigger that causes behaviour. An organism involves the internal responses of a person, like physiological responses, emotions and cognition. A response is the behaviour that a person exhibits and the consequences are the result of the behaviour. These four things are incorporated into an assessment done by the behaviour therapist. Most behaviour therapists use objective assessment methods like structured interviews, objective psychological tests or different behavioural rating forms. These types of assessments are used so that the behaviour therapist can determine exactly what a client's problem may be and establish a baseline for any maladaptive responses that the client may have. By having this baseline, as therapy continues this same measure can be used to check a client's progress, which can help determine if the therapy is working. Behaviour therapists do not typically ask the why questions but tend to be more focused on the how, when, where and what questions. Tests such as the Rorschach inkblot test or personality tests like the MMPI (Minnesota Multiphasic Personality Inventory) are not commonly used for behavioural assessment because they are based on personality trait theory assuming that a person's answer to these methods can predict behaviour. Behaviour assessment is more focused on the observations of a person's behaviour in their natural environment. Behavioural assessment specifically attempts to find out what the environmental and self-imposed variables are. These variables are the things that are allowing a person to maintain their maladaptive feelings, thoughts and behaviours. In a behavioural assessment "person variables" are also considered. These "person variables" come from a person's social learning history and they affect the way in which the environment affects that person's behaviour. An example of a person variable would be behavioural competence. Behavioural competence looks at whether a person has the appropriate skills and behaviours that are necessary when performing a specific response to a certain situation or stimuli. When making a behavioural assessment the behaviour therapist wants to answer two questions: (1) what are the different factors (environmental or psychological) that are maintaining the maladaptive behaviour and (2) what type of behaviour therapy or technique that can help the individual improve most effectively. The first question involves looking at all aspects of a person, which can be summed up by the acronym BASIC ID. This acronym stands for behaviour, affective responses, sensory reactions, imagery, cognitive processes, interpersonal relationships and drug use. Clinical applications Behaviour therapy based its core interventions on functional analysis. Just a few of the many problems that behaviour therapy have functionally analyzed include intimacy in couples relationships, forgiveness in couples, chronic pain, stress-related behaviour problems of being an adult child of a person with an alcohol use disorder, anorexia, chronic distress, substance abuse, depression, anxiety, insomnia and obesity. Functional analysis has even been applied to problems that therapists commonly encounter like client resistance, partially engaged clients and involuntary clients. Applications to these problems have left clinicians with considerable tools for enhancing therapeutic effectiveness. One way to enhance therapeutic effectiveness is to use positive reinforcement or operant conditioning. Although behaviour therapy is based on the general learning model, it can be applied in a lot of different treatment packages that can be specifically developed to deal with problematic behaviours. Some of the more well known types of treatments are: Relaxation training, systematic desensitization, virtual reality exposure, exposure and response prevention techniques, social skills training, modelling, behavioural rehearsal and homework, and aversion therapy and punishment. Relaxation training involves clients learning to lower arousal to reduce their stress by tensing and releasing certain muscle groups throughout their body. Systematic desensitization is a treatment in which the client slowly substitutes a new learned response for a maladaptive response by moving up a hierarchy of situations involving fear. Systematic desensitization is based in part on counter conditioning. Counter conditioning is learning new ways to change one response for another and in the case of desensitization it is substituting that maladaptive behaviour for a more relaxing behaviour. Exposure and response prevention techniques (also known as flooding and response prevention) is the general technique in which a therapist exposes an individual to anxiety-provoking stimuli while keeping them from having any avoidance responses. Virtual reality therapy provides realistic, computer-based simulations of troublesome situations. The modelling process involves a person being subjected to watching other individuals who demonstrate behaviour that is considered adaptive and that should be adopted by the client. This exposure involves not only the cues of the "model person" as well as the situations of a certain behaviour that way the relationship can be seen between the appropriateness of a certain behaviour and situation in which that behaviour occurs is demonstrated. With the behavioural rehearsal and homework treatment a client gets a desired behaviour during a therapy session and then they practice and record that behaviour between their sessions. Aversion therapy and punishment is a technique in which an aversive (painful or unpleasant) stimulus is used to decrease unwanted behaviours from occurring. It is concerned with two procedures: 1) the procedures are used to decrease the likelihood of the frequency of a certain behaviour and 2) procedures that will reduce the attractiveness of certain behaviours and the stimuli that elicit them. The punishment side of aversion therapy is when an aversive stimulus is presented at the same time that a negative stimulus and then they are stopped at the same time when a positive stimulus or response is presented. Examples of the type of negative stimulus or punishment that can be used is shock therapy treatments, aversive drug treatments as well as response cost contingent punishment which involves taking away a reward. Applied behaviour analysis is using behavioural methods to modify certain behaviours that are seen as being important socially or personally. There are four main characteristics of applied behaviour analysis. First behaviour analysis is focused mainly on overt behaviours in an applied setting. Treatments are developed as a way to alter the relationship between those overt behaviours and their consequences. Another characteristic of applied behaviour analysis is how it (behaviour analysis) goes about evaluating treatment effects. The individual subject is where the focus of study is on, the investigation is centred on the one individual being treated. A third characteristic is that it focuses on what the environment does to cause significant behaviour changes. Finally the last characteristic of applied behaviour analysis is the use of those techniques that stem from operant and classical conditioning such as providing reinforcement, punishment, stimulus control and any other learning principles that may apply. Social skills training teaches clients skills to access reinforcers and lessen life punishment. Operant conditioning procedures in meta-analysis had the largest effect size for training social skills, followed by modelling, coaching, and social cognitive techniques in that order. Social skills training has some empirical support particularly for schizophrenia. However, with schizophrenia, behavioural programs have generally lost favour. Some other techniques that have been used in behaviour therapy are contingency contracting, response costs, token economies, biofeedback, and using shaping and grading task assignments. Shaping and graded task assignments are used when behaviour that needs to be learned is complex. The complex behaviours that need to be learned are broken down into simpler steps where the person can achieve small things gradually building up to the more complex behaviour. Each step approximates the eventual goal and helps the person to expand their activities in a gradual way. This behaviour is used when a person feels that something in their lives can not be changed and life's tasks appear to be overwhelming. Another technique of behaviour therapy involves holding a client or patient accountable of their behaviours in an effort to change them. This is called a contingency contract, which is a formal written contract between two or more people that defines the specific expected behaviours that you wish to change and the rewards and punishments that go along with that behaviour. In order for a contingency contract to be official it needs to have five elements. First it must state what each person will get if they successfully complete the desired behaviour. Secondly those people involved have to monitor the behaviours. Third, if the desired behaviour is not being performed in the way that was agreed upon in the contract the punishments that were defined in the contract must be done. Fourth if the persons involved are complying with the contract they must receive bonuses. The last element involves documenting the compliance and noncompliance while using this treatment in order to give the persons involved consistent feedback about the target behaviour and the provision of reinforcers. Token economies is a behaviour therapy technique where clients are reinforced with tokens that are considered a type of currency that can be used to purchase desired rewards, like being able to watch television or getting a snack that they want when they perform designated behaviours. Token economies are mainly used in institutional and therapeutic settings. In order for a token economy to be effective there must be consistency in administering the program by the entire staff. Procedures must be clearly defined so that there is no confusion among the clients. Instead of looking for ways to punish the patients or to deny them of rewards, the staff has to reinforce the positive behaviours so that the clients will increase the occurrence of the desired behaviour. Over time the tokens need to be replaced with less tangible rewards such as compliments so that the client will be prepared when they leave the institution and won't expect to get something every time they perform a desired behaviour. Closely related to token economies is a technique called response costs. This technique can either be used with or without token economies. Response costs is the punishment side of token economies where there is a loss of a reward or privilege after someone performs an undesirable behaviour. Like token economies this technique is used mainly in institutional and therapeutic settings. Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy, habit reversal training, has been found to be highly effective for treating tics. In rehabilitation Currently, there is a greater call for behavioural psychologists to be involved in rehabilitation efforts. Treatment of mental disorders Two large studies done by the Faculty of Health Sciences at Simon Fraser University indicate that both behaviour therapy and cognitive-behavioural therapy (CBT) are equally effective for OCD. CBT is typically considered the "first-line" treatment for OCD. CBT has also been shown to perform slightly better at treating co-occurring depression. Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy (habit reversal training) has been found to be highly effective for treating tics. There has been a development towards combining techniques to treat psychiatric disorders. Cognitive interventions are used to enhance the effects of more established behavioural interventions based on operant and classical conditioning. An increased effort has also been placed to address the interpersonal context of behaviour. Behaviour therapy can be applied to a number of mental disorders and in many cases is more effective for specific disorders as compared to others. Behaviour therapy techniques can be used to deal with any phobias that a person may have. Desensitization has also been successfully applied to other issues such as dealing with anger, if a person has trouble sleeping and certain speech disorders. Desensitization does not occur over night, there is a process of treatment. Desensitization is done on a hierarchy and happens over a number of sessions. The hierarchy goes from situations that make a person less anxious or nervous up to things that are considered to be extreme for the patient. Modelling has been used in dealing with fears and phobias. Fears are thought to develop through observational learning, and so positive modelling, when a person's behaviour is imitated, can used to counter these effects. In a systematic review of 1,677 papers, positive modelling was found to lower fear levels. Modelling has been used in the treatment of fear of snakes as well as a fear of water. Aversive therapy techniques have been used to treat sexual deviations, as well as alcohol use disorder. Exposure and prevention procedure techniques can be used to treat people who have anxiety problems as well as any fears or phobias. These procedures have also been used to help people dealing with any anger issues as well as pathological grievers (people who have distressing thoughts about a deceased person). Virtual reality therapy deals with fear of heights, fear of flying, and a variety of other anxiety disorders. VRT has also been applied to help people with substance abuse problems reduce their responsiveness to certain cues that trigger their need to use drugs. Shaping and graded task assignments has been used in dealing with suicide and depressed or inhibited individuals. This is used when a patient feel hopeless and they have no way of changing their lives. This hopelessness involves how the person reacts and responds to someone else and certain situations and their perceived powerlessness to change that situation that adds to the hopelessness. For a person with suicidal ideation, it is important to start with small steps. Because that person may perceive everything as being a big step, the smaller you start the easier it will be for the person to master each step. This technique has also been applied to people dealing with agoraphobia, or fear of being in public places or doing something embarrassing. Contingency contracting has been used to effectively deal with behaviour problems in delinquents and when dealing with on task behaviours in students. Token economies are used in controlled environments and are found mostly in psychiatric hospitals. They can be used to help patients with different mental illnesses but it doesn't focus on the treatment of the mental illness but instead on the behavioural aspects of a patient. The response cost technique has been used to successfully address a variety of behaviours such as smoking, overeating, stuttering, and psychotic talk. Treatment outcomes Systematic desensitization has been shown to successfully treat phobias about heights, driving, insects as well as any anxiety that a person may have. Anxiety can include social anxiety, anxiety about public speaking as well as test anxiety. It has been shown that the use of systematic desensitization is an effective technique that can be applied to a number of problems that a person may have. When using modelling procedures this technique is often compared to another behavioural therapy technique. When compared to desensitization, the modelling technique does appear to be less effective. However it is clear that the greater the interaction between the patient and the subject he is modelling the greater the effectiveness of the treatment. While undergoing exposure therapy, a person typically needs five sessions to assess the treatment's effectiveness. After five sessions, exposure treatment has been shown to provide benefit to the patient. However, it is still recommended treatment continue beyond the initial five sessions. Virtual reality therapy (VRT) has shown to be effective for a fear of heights. It has also been shown to help with the treatment of a variety of anxiety disorders. Due to the costs associated with VRT in 2007, therapists were still awaiting results of controlled trials investigating VRT, to assess which applications demonstrate the best results. For those with suicidal ideation, treatment depends on how severe the person's depression and sense of hopelessness is. If these things are severe, the person's response to completing small steps will not be of importance to them, because they don't consider the success an accomplishment. Generally, in those without severe depression or fear, this technique has been successful, as completion of simpler activities builds their confidences and allows them to progress to more complex situations. Contingency contracts have been seen to be effective in changing any undesired behaviours of individuals. It has been seen to be effective in treating behaviour problems in delinquents regardless of the specific characteristics of the contract. Token economies have been shown to be effective when treating patients in psychiatric wards who had chronic schizophrenia. The results showed that the contingent tokens were controlling the behaviour of the patients. Response costs has been shown to work in suppressing a variety of behaviours such as smoking, overeating or stuttering with a diverse group of clinical populations ranging from sociopaths to school children. These behaviours that have been suppressed using this technique often do not recover when the punishment contingency is withdrawn. Also undesirable side effects that are usually seen with punishment are not typically found when using the response cost technique. "Third generation" Since the 1980s, a series of new behavioral therapies have been developed. These have been later labeled by Steven C. Hayes as "the third-generation" of behavioural therapy. Under this classification, the first generation of behavioural therapy is that independently developed in the 1950s by Joseph Wolpe, Ogden Lindsley and Hans Eysenck, while the second generation is the cognitive therapy developed by Aaron Beck in the 1970s. Other authors object to the term "third generation" or "third wave" and incorporate many of the "third wave" therapeutic techniques under the general umbrella term of modern cognitive behavioural therapies. This "third wave" of behavioural therapy has sometimes been called clinical behaviour analysis because it has been claimed that it represents a movement away from cognitivism and back toward radical behaviourism and other forms of behaviourism, in particular functional analysis and behavioural models of verbal behaviour. This area includes acceptance and commitment therapy (ACT), cognitive behavioural analysis system of psychotherapy (CBASP) (McCullough, 2000), behavioural activation (BA), dialectical behaviour therapy, functional analytic psychotherapy (FAP), integrative behavioural couples therapy, metacognitive therapy and metacognitive training. These approaches are squarely within the applied behaviour analysis tradition of behaviour therapy. Acceptance and Commitment Therapy (ACT) may be the most well-researched of all the third-generation behaviour therapy models. It is based on relational frame theory. As of March 2022, there are over 900 randomized trials of Acceptance and Commitment Therapy and 60 mediational studies of the ACT literature. ACT has been included in over 275 meta-analyses and systematic reviews. As the result of multiple randomized trials of ACT by the World Health Organization, WHO now distribute ACT-based self-help for "anyone who experiences stress, wherever they live, and whatever their circumstances." As of March 2022, a number of different organizations have stated that Acceptance and Commitment Therapy is empirically supported in certain areas or as a whole according to their standards. These include: American Psychological Association, Society of Clinical Psychology (Div. 12), The World Health Organization, The United Kingdom National Institute for Health and Care Excellence (NICE), Australian Psychological Society, Netherlands Institute of Psychologists: Sections of Neuropsychology and Rehabilitation, Sweden Association of Physiotherapists, SAMHSA's National Registry of Evidence-based Programs and Practices, California Evidence-Based Clearinghouse for Child Welfare, and the U.S. Veterans Affairs/DoD. Functional analytic psychotherapy is based on a functional analysis of the therapeutic relationship. It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement. In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change. Behavioural activation emerged from a component analysis of cognitive behaviour therapy. Researchers hope to prove that it can be complete treatment in its own right. Behavioural activation is based on a matching model of reinforcement. A recent review of the research, supports the notion that the use of behavioural activation is clinically important for the treatment of depression. Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1966) for the difference between contingency-shaped and rule-governed behaviour. It couples this analysis with a thorough functional assessment of the couple's relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness. A review study published in 2008, concluded that at the time, third-generation behavioral psychotherapies did not meet the criteria for empirically supported treatments. Organisations Many organisations exist for behaviour therapists around the world. In the United States, the American Psychological Association's Division 25 is the division for behaviour analysis. The Association for Contextual Behavioral Science is another professional organisation. ACBS is home to many clinicians with specific interest in third generation behaviour therapy. Doctoral-level behaviour analysts who are psychologists belong to American Psychological Association's Division 25 – behaviour analysis. APA offers a diploma in behavioural psychology. The Association for Behavioral and Cognitive Therapies (formerly the Association for the Advancement of Behavior Therapy) is for those with a more cognitive orientation. The ABCT also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis. In addition, the Association for Behavioral and Cognitive Therapies has a special interest group on addictions. Characteristics By nature, behavioural therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behaviour ultimately has), probabilistic (viewing behaviour as statistically predictable), monistic (rejecting mind–body dualism and treating the person as a unit), and relational (analysing bidirectional interactions). Behavioural therapy develops, adds and provides behavioural intervention strategies and programs for clients, and training to people who care to facilitate successful lives in various communities. Training Recent efforts in behavioural psychotherapy have focused on the supervision process. A key point of behavioural models of supervision is that the supervisory process parallels the behavioural psychotherapy provided. See also Behaviour management Covert conditioning Decoupling Matching law Observational learning Professional practice of behaviour analysis References Sources External links Psychotherapy by type Behaviorism fr:Béhaviorisme

Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria. It is an internationally accepted manual on the diagnosis and treatment of mental disorders, though it may be used in conjunction with other documents. Other commonly used principal guides of psychiatry include the International Classification of Diseases (ICD), Chinese Classification of Mental Disorders (CCMD), and the Psychodynamic Diagnostic Manual. However, not all providers rely on the DSM-5 as a guide, since the ICD's mental disorder diagnoses are used around the world, and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions. It is used by researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policymakers. Some mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation. Hospitals, clinics, and insurance companies in the United States may require a DSM diagnosis for all patients with mental disorders. Health-care researchers use the DSM to categorize patients for research purposes. The DSM evolved from systems for collecting census and psychiatric hospital statistics, as well as from a United States Army manual. Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, while removing those no longer considered to be mental disorders. Recent editions of the DSM have received praise for standardizing psychiatric diagnosis grounded in empirical evidence, as opposed to the theory-bound nosology (the branch of medical science that deals with the classification of diseases) used in DSM-III. However, it has also generated controversy and criticism, including ongoing questions concerning the reliability and validity of many diagnoses; the use of arbitrary dividing lines between mental illness and "normality"; possible cultural bias; and the medicalization of human distress. The APA itself has published that the inter-rater reliability is low for many disorders in the DSM-5, including major depressive disorder and generalized anxiety disorder. Distinction from ICD An alternate, widely used classification publication is the International Classification of Diseases (ICD), produced by the World Health Organization (WHO). The ICD has a broader scope than the DSM, covering overall health as well as mental health; chapter 6 of the ICD specifically covers mental, behavioral and neurodevelopmental disorders. Moreover, while the DSM is the most popular diagnostic system for mental disorders in the US, the ICD is used more widely in Europe and other parts of the world, giving it a far larger reach than the DSM. An international survey of psychiatrists in sixty-six countries compared the use of the ICD-10 and DSM-IV. It found the former was more often used for clinical diagnosis while the latter was more valued for research. This may be because the DSM tends to put more emphasis on clear diagnostic criteria, while the ICD tends to put more emphasis on clinician judgement and avoiding diagnostic criteria unless they are independently validated. That is, the ICD descriptions of psychiatric disorders tend to be more qualitative information, such as general descriptions of what various disorders tend to look like. The DSM focuses more on quantitative and operationalized criteria; e.g., to be diagnosed with X disorder, one must fulfill 5 of 9 criteria for at least 6 months. The DSM-IV-TR (4th ed.) contains specific codes allowing comparisons between the DSM and the ICD manuals, which may not systematically match because revisions are not simultaneously coordinated. Though recent editions of the DSM and ICD have become more similar due to collaborative agreements, each one contains information absent from the other. For instance, the two manuals contain overlapping but substantially different lists of recognized culture-bound syndromes. The ICD also tends to focus more on primary-care and low and middle-income countries, as opposed to the DSM's focus on secondary psychiatric care in high-income countries. Antecedents (1840–1949) Census Office, AMA and ISI (1840–1911) The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census, which used a single category: "idiocy/insanity". Three years later, the American Statistical Association made an official protest to the U.S. House of Representatives, stating that "the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation", pointing out that in many towns African Americans were all marked as insane, and calling the statistics essentially useless. The Association of Medical Superintendents of American Institutions for the Insane ("The Superintendents' Association") was formed in 1844. In 1860, during the international statistical congress held in London, Florence Nightingale made a proposal that was to result in the development of the first international model of systematic collection of hospital data. In 1872, the American Medical Association (AMA) published its Nomenclature of Diseases, which included various "Disorders of the Intellect". Its use was short-lived however. Edward Jarvis and later Francis Amasa Walker helped expand the census, from two volumes in 1870 to twenty-five volumes in 1880. In 1888, the Census Office published Frederick H. Wines' 582-page volume called Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880). Wines used seven categories of mental illness, which were also adopted by the Superintendents: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy, mania, melancholia, monomania, and paresis. In 1892, the Superintendents' Association expanded its membership to include other mental health workers, and renamed to the American Medico-Psychological Association (AMPA). In 1893, a French physician, Jacques Bertillon, introduced the Bertillon Classification of Causes of Death at a congress of the International Statistical Institute (ISI) in Chicago. (The ISI had commissioned him to create it in 1891). A number of countries adopted the ISI's system. In 1898, the American Public Health Association (APHA) recommended that United States registrars also adopt the system. In 1900, an ISI conference in Paris reformed the Bertillion Classification, and created the International List of Causes of Death (ILCD). Another conference would be held every ten years, and a new edition of the ILCD would be released. Five were ultimately issued. Non-fatal conditions were not included. In 1903, New York's Bellevue Hospital published "The Bellevue Hospital nomenclature of diseases and conditions", which included a section on "Diseases of the Mind". Revisions were released in 1909 and 1911. It was produced with the assistance of the AMA and Bureau of the Census. APA Statistical Manual (1917) and AMA Standard (1933) In 1917, together with the National Commission on Mental Hygiene (now Mental Health America), the American Medico-Psychological Association developed a new guide for mental hospitals called the Statistical Manual for the Use of Institutions for the Insane. This guide included twenty-two diagnoses. It would be revised several times by the Association, and by the tenth edition in 1942, was titled Statistical Manual for the Use of Hospitals of Mental Diseases. In 1921, the AMPA became the present American Psychiatric Association (APA). The first edition of the DSM notes in its foreword: "In the late twenties, each large teaching center employed a system of its own origination, no one of which met more than the immediate needs of the local institution." In 1933, the AMA's general medical guide the Standard Classified Nomenclature of Disease, (referred to as the Standard), was released. Along with the New York Academy of Medicine, the APA provided the psychiatric nomenclature subsection. It became well adopted in the US within two years. A major revision of the Statistical Manual was made in 1934, to bring it in line with the new Standard. A number of revisions of the Standard were produced, with the last in 1961. Medical 203 (1945) World War II saw the large-scale involvement of U.S. psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. The U.S. armed forces initially used the Standard, but found it lacked appropriate categories for many common conditions that troubled troops. The United States Navy made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present-day concepts of mental disturbance." Under the direction of James Forrestal, a committee headed by psychiatrist Brigadier General William C. Menninger, with the assistance of the Mental Hospital Service, developed a new classification scheme in 1944 and 1945. Issued in War Department Technical Bulletin, Medical, 203 (TB MED 203); Nomenclature and Method of Recording Diagnoses was released shortly after the war in October 1945 under the auspices of the Office of the Surgeon General. It was reprinted in the Journal of Clinical Psychology for civilian use in July 1946 with the new title Nomenclature of Psychiatric Disorders and Reactions. This system came to be known as "Medical 203". This nomenclature eventually was adopted by all the armed forces, and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty." The Veterans Administration also adopted a slightly modified version of the standard in 1947. The further developed Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions was released in 1949. ICD-6 (1948) In 1948, the newly formed World Health Organization took over the maintenance of the ILCD. They greatly expanded it, included non-fatal conditions for the first time, and renamed it the International Statistical Classification of Diseases (ICD). The foreword to the DSM-I states the ICD-6 "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature." Early versions (20th century) DSM-I (1952) The APA Committee on Nomenclature and Statistics was empowered to develop a version of Medical 203 specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the Standards nomenclature, and the VA system's modifications of the Standard to approximately 10% of APA members. 46% of members replied, with 93% approving the changes. After some further revisions, the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. The manual was 130 pages long and listed 106 mental disorders. These included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, egodystonic). The foreword to this edition describes itself as being a continuation of the Statistical Manual for the Use of Hospitals of Mental Diseases. Each item was given an ICD-6 equivalent code, where applicable. The DSM-I centers on three classes of symptoms: psychotic, neurotic, and behavioral.  Within each class of mental disorder, classifying information is provided to differentiate conditions with similar symptoms.  Under each broad class of disorder (e.g. "Psychoneurotic Disorders" or "Personality Disorders"), all possible diagnoses are listed, generally from least to most severe. The 1952 DSM version also includes sections detailing how to record patients' disorders along with their demographic details.  The form includes information like a patient's area of residence, admission status, discharge date/condition, and severity of disorder. See Figure 1. for the form that psychiatrists were asked to utilize for recording preliminary diagnostic information. Furthermore, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality by Irving Bieber and other authors, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was influential in the medical profession. In 1956, however, the psychologist Evelyn Hooker performed a study comparing the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. Her study stunned the medical community and made her a heroine to many gay men and lesbians, but homosexuality remained in the DSM until May 1974. DSM-II (1968) In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was another example of how society labels and controls non-conformists; from behavioural 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. The APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968). It decided to go ahead with a revision of the DSM, which was published in 1968. DSM-II was similar to DSM-I, listed 182 disorders, and was 134 pages long. The term "reaction" was dropped, but the term "neurosis" was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry, although both manuals also included biological perspectives and concepts from Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems that were rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, as opposed to hallucinations or delusions disconnected from reality). Sociological and biological knowledge was incorporated, under a model that did not emphasize a clear boundary between normality and abnormality. The idea that personality disorders did not involve emotional distress was discarded. A study published in Science in 1973, the Rosenhan experiment, received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis. An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool. Spitzer and Fleiss found that different practitioners using the DSM-II rarely agreed when diagnosing patients with similar problems. In reviewing previous studies of eighteen major diagnostic categories, Spitzer and Fleiss concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories". Seventh printing of the DSM-II (1974) As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate at the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled: "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you." This gay activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations as gay activists. Taking into account data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance". DSM-III (1980) The emergence of DSM-III represented a "quantum leap" in terms of the scale and reach of the manual. In 1974, the decision to revise the DSM was made, and psychiatrist Robert Spitzer was selected as chair of the task force. The initial impetus was to make the DSM nomenclature consistent with that of the International Classification of Diseases (ICD). The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. One added goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States. The establishment of consistent criteria was an attempt to facilitate the pharmaceutical regulatory process. The criteria adopted for many of the mental disorders were influenced by the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University School of Medicine and the New York State Psychiatric Institute. However, the influence of clinical psychiatrists, themselves often working with psychoanalytic ideas, were still strong. Other criteria, and potential new categories of disorder, were established by debate, argument and consensus during meetings of the committee chaired by Spitzer. A key aim was to base categorization on colloquial English (which would be easier to use by federal administrative offices), rather than by assumption of cause, although its categorical approach still assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-Kraepelinian"). The psychodynamic view was marginalised, although still influential, in favor of a regulatory or legislative model that emphasised observable symptoms. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than a simple diagnosis. Spitzer argued "mental disorders are a subset of medical disorders", but the task force decided on this statement for the DSM: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome." Personality disorders were placed on axis II along with "mental retardation". The first draft of DSM-III was ready within a year. It introduced many new categories of disorder, while deleting or changing others. A number of unpublished documents discussing and justifying the changes have recently come to light. Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some form; a political compromise reinserted the term in parentheses after the word "disorder" in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance". The gender identity disorder in children (GIDC) diagnosis was introduced in the DSM-III; prior to the DSM-III's publication in 1980, there was no diagnostic criteria for gender dysphoria. Finally published in 1980, DSM-III listed 265 diagnostic categories and was 494 pages long. It rapidly came into widespread international use and has been termed a revolution, or transformation, in psychiatry. When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk: DSM-III-R (1987) In 1987, DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, with significant changes in criteria. Six categories were deleted while others were added. Controversial diagnoses, such as Premenstrual Dysphoric Disorder and Masochistic Personality Disorder, were considered and discarded. (Premenstrual Dysphoric Disorder was later reincorporated in the DSM-5, published in 2013). "Ego-dystonic homosexuality" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which could include "persistent and marked distress about one's sexual orientation." Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated for at least some disorders, "particularly the Personality Disorders, the criteria require much more inference on the part of the observer"[page xxiii]. DSM-IV (1994) In 1994, DSM-IV was published, listing 410 disorders in 886 pages. The task force was chaired by Allen Frances and was overseen by a steering committee of twenty-seven people, including four psychologists. The steering committee created thirteen work groups of five to sixteen members, each work group having about twenty advisers in addition. The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multi-center field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical-significance criterion to almost half of all the categories, which required symptoms causing "clinically significant distress or impairment in social, occupational, or other important areas of functioning". Some personality-disorder diagnoses were deleted or moved to the appendix. DSM-IV definitions The DSM-IV characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom". It also notes that "although this manual provides a classification of mental disorders it must be admitted that no definition adequately specifies precise boundaries for the concept of 'mental disorder." DSM-IV categorization The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries" but isolated, low-grade, and non-criterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers are sometimes used: for example, to specify mild, moderate, or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes. DSM-IV multi-axial system The DSM-IV was organized into a five-part axial system: DSM-IV sourcebooks The DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses, and field trials. The sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and the scientific credibility of contemporary psychiatric classification. DSM-IV-TR (2000) A text revision of DSM-IV, titled DSM-IV-TR, was published in 2000. The diagnostic categories were unchanged as were the diagnostic criteria for all but nine diagnoses. The majority of the text was unchanged; however, the text of two disorders, pervasive developmental disorder not otherwise specified and Asperger's disorder, had significant and/or multiple changes made. The definition of pervasive developmental disorder not otherwise specified was changed back to what it was in DSM-III-R and the text for Asperger's disorder was practically entirely rewritten. Most other changes were to the associated features sections of diagnoses that contained additional information such as lab findings, demographic information, prevalence, and course. Also, some diagnostic codes were changed to maintain consistency with ICD-9-CM. DSM-5 (2013) The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, was approved by the Board of Trustees of the APA on December 1, 2012. Published on May 18, 2013, the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases. The DSM-5 is the first major edition of the manual in 20 years. DSM-5, and the abbreviations for all previous editions, are registered trademarks owned by the American Psychiatric Association. A significant change in the fifth edition is the deletion of the subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual. The deletion of the subsets of autistic spectrum disordernamely, Asperger's syndrome, classic autism, Rett syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specifiedwas also implemented, with specifiers regarding intensity: mild, moderate, and severe. Severity is based on social communication impairments and restricted, repetitive patterns of behavior, with three levels: requiring support requiring substantial support requiring very substantial support During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion. The National Board of Medical Examiners (NBME), which is responsible for creating and publishing board exams for medical students around the United States, conforms to the use of DSM-5 criteria. Future revisions and updates After the release of the fifth edition, the APA communicated that they intended to add subsequent revisions more often, to keep up with research in the field. It is notable that DSM-5 uses Arabic rather than Roman numerals. Beginning with DSM-5, the APA planned to use decimals to identify incremental updates (e.g., DSM-5.1, DSM-5.2) and whole numbers for new editions (e.g., DSM-5, DSM-6), similar to the scheme used for software versioning. DSM-5-TR (2022) A revision of DSM-5, titled DSM-5-TR, was published in March 2022, updating diagnostic criteria and ICD-10-CM codes. The diagnostic criteria for avoidant/restrictive food intake disorder was changed, along with adding entries for prolonged grief disorder, unspecified mood disorder and stimulant-induced mild neurocognitive disorder. Prolonged grief disorder, which had been present in the ICD-11, had criteria agreed upon by consensus in a one day in-person workshop sponsored by the APA. A 2022 study found that higher rates of diagnosis of prolonged grief disorder in the ICD-11 could be explained by the DSM-5-TR criteria requiring symptoms persist for 12 months, and the ICD-11 requiring only 6 months. Three review groups for sex and gender, culture and suicide, along with an "ethnoracial equity and inclusion work group" were involved in the creation of the DSM-5-TR which led to additional sections for each mental disorder discussing sex and gender, racial and cultural variations, and adding diagnostic codes for specifying levels of suicidality and nonsuicidal self-injury for mental disorders. Other changed disorders included: Autism spectrum disorder Bipolar I disorder, Bipolar II disorder, and related bipolar disorders Obsessive–compulsive personality disorder in the alternative DSM-5 model for personality disorders Depressive episodes with short-duration hypomania Intellectual developmental disorder Delusional disorder Disruptive mood dysregulation disorder Brief psychotic disorder DSM Library The APA have supplemented the DSM with supporting works, collectively forming the "DSM Library." As of 2022, the other books in the library are "DSM-5 Handbook of Differential Diagnosis", "DSM-5 Clinical Cases", "DSM-5 Handbook on the Cultural Formulation Interview" and "Guía De Consulta De Los Criterios Diagnósticos Del DSM-5". Criticisms Many criticisms have been leveled against the DSM and its usefulness as a diagnostic manual. Reliability and validity The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliabilitythe degree to which different diagnosticians agree on a diagnosis. Henrik Walter argued that psychiatry as a science can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Neither the issue of reliability or validity was settled. In 2013, shortly before the publication of DSM-5, the director of the National Institute of Mental Health (NIMH), Thomas R. Insel, declared that the agency would no longer fund research projects that relied exclusively on DSM diagnostic criteria, due to its lack of validity. Insel questioned the validity of the DSM classification scheme because "diagnoses are based on a consensus about clusters of clinical symptoms" as opposed to "collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response." Field trials of DSM-5 brought the debate of reliability back into the limelight, as the diagnoses of some disorders showed poor reliability. For example, a diagnosis of major depressive disorder, a common mental illness, had a poor reliability kappa statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78. Diagnosis based on superficial symptoms By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect these disorders based on statistical or clinical patterns. As such, it has been compared to a naturalist's field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. Proponents argue this absence of explanatory classification is necessary, but it presents a problem for researchers as it results in the grouping of individuals who may have little in common except superficial criteria. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and cause of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology." While there is generally a lack of consensus on underlying causation for most psychiatric disorders, some proponents of specific psychopathological paradigms have faulted the DSM for failing to incorporate evidence from other disciplines. For instance, evolutionary psychology distinguishes between genuine cognitive malfunctions and malfunctions due to psychological adaptations (that is learned behaviors may be adaptive in one context but maladaptive in another). However, this distinction is one that is challenged within general psychology. There is also criticism of the strong operationalist viewpoint of the DSM. The DSM relies on operational definitions, which means that intuitive concepts like depression are defined by specific measurable criteria (observable behavior, specific timelines). Some have argued that instead of replacing metaphysical terms like "desire" or "purpose" the DSM chose to legitimize them by giving them operational definitions. However, this may have served only to provide a "reassurance fetish" for mainstream methodological practice, rather than representing a substantial and meaningful alteration of mainstream psychiatric practice. A central problem with the use of superficial symptoms is that psychiatry deals with the phenomena of consciousness, which adds much more complexity than the somatic symptoms and signs used by most of medicine. A 2013 review published in the European Archives of Psychiatry and Clinical Neuroscience gives the example of the problem of superficial characterization of psychiatric signs and symptoms . If a patient says they "feel depressed, sad, or down" there are actually a wide variety of underlying experiences they could be referencing: "not only depressed mood but also, for instance, irritation, anger, loss of meaning, varieties of fatigue, ambivalence, ruminations of different kinds, hyper-reflectivity, thought pressure, psychological anxiety, varieties of depersonalization, and even voices with negative content, and so forth." This criticism is especially pertinent to the structured interview, as simple "yes or no" questions may not be specific enough to truly confirm or deny the diagnostic criterion at issue. That is, whether a patient says yes or no will rely on their own understanding of the meaning of the various words in the question as well as their own interpretation of their experience. There is thus danger in being overconfident in the face value of the answers. The authors of the 2013 review give an example: A patient who was being administered the Structured Clinical Interview for the DSM-IV Axis I Disorders denied thought insertion, but during a "conversational, phenomenological interview", a semi-structured interview tailored to the patient, the same patient admitted to experiencing thought insertion, along with a delusional elaboration. The authors suggested 2 reasons for this discrepancy: either the patient did not "recognize his own experience in the rather blunt, implicitly either/or formulation of the structured-interview question", or the experience did not "fully articulate itself" until the patient started talking about his experiences. Obscuring root causes Economic causes The DSM-5 has been criticized for overlooking capitalism’s interconnectivity with pathology. One example is the development and treatment of diagnoses: around 69% of psychiatrists involved in the development of the DSM-5 were reported to have financial ties to the pharmaceutical industry. These ties situate many care services within the medical-industrial complex, a framework that prioritizes profit instead of the care of individuals. Lane found the medical-industrial complex intertwined with setting the parameters to diagnose conditions such as social anxiety disorder. Other authors have supported similar findings. Kincaid and Sullivan estimate that the cost of the industry surrounding diagnosis will rise to around six trillion dollars by 2030. Scholars differ in the extent of capitalism's influence on diagnosis. Davies supports the social model of disability in explaining that diagnosis at present relies on considering conditions a consequence of a “broken brain.” His wider logic on mental illness in response to societal issues problematizes diagnosis as a tool of the medical-industrial complex. His previous book, Cracked, demonstrates the market interactions within the medical-industrial complex, as diagnosis becomes a source for monetization. Others find that the dependency of patients on their psychiatric care providers makes the industry vulnerable to economic exploitation under capitalism. These individuals argue that diagnosis is manipulated, but not caused, by capitalistic forces. Academics have critiqued the directness of the association between the medical model, capitalism, and diagnosis, but generally agree that characteristics of the capitalist system contribute to poor mental health. Institutional causes Diagnoses of mental conditions have been used to obscure institutional practices of discrimination. Late nineteenth-century diagnoses of white women with hysteria, for instance, were said to be caused by “overcivilization,” shaped by racially discriminatory Social Darwinism. Similarly, American physician Samuel Cartwright coined "drapetomania" in 1851 as a mental condition which "caused" slaves to escape captivity. In the present day, Brinkmann finds that “contemporary diagnostic cultures,” whereby humans assess their conditions through a psychiatric lens, can “risk losing sight of the larger historical and social forces that affect [their] lives.” Contemporary diagnostic cultures help explain how diagnosis reflect larger historical biases. Critics have argued that the DSM-5's criteria pathologize a wide range of people with distress or impairment. Chapman et al. discuss the implications for obscuring distress in the incarceration and confinement of "intellectually disabled" populations; they argue that "differentiation based on psychiatric and intellectual disability" is arbitrarily set and altered based on capitalism's needs for "mobile and free workers." Metzl demonstrates that the shifting diagnostic parameters of schizophrenia became a method for institutionalizing Black men during the Civil Rights Movement. In sum, those who have experienced “domination” or “exploitation” based on an identity trait are more likely to be pathologized through diagnosis. Overdiagnosis Allen Frances, an outspoken critic of DSM-5, states that "normality is an endangered species," because of "fad diagnoses" and an "epidemic" of over-diagnosing, and suggests that the "DSM-5 threatens to provoke several more [epidemics]." Some researchers state that changes in diagnostic criteria, following each published version of the DSM, reduce thresholds for a diagnosis, which results in increases in prevalence rates for ADHD and autism spectrum disorder. Bruchmüller, et al. (2012) suggest that as a factor that may lead to overdiagnosis are situations when the clinical judgment of the diagnostician regarding a diagnosis (ADHD) is affected by heuristics. Dividing lines Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence. In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder. Because an individual's degree of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life. Cultural bias Psychiatrists have argued that published diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that researchers and service-providers often discount the cultural and ethnic diversity of individuals. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criterion-set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman contends that Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that 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, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Other cross-cultural critics largely share Kleinman's negative view toward the culture-bound syndrome, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented. Mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations. One result of this dissatisfaction was the development of the Azibo Nosology by Daudi Ajani Ya Azibo as an alternative to the DSM in treating patients of the African diaspora. Historically, the DSM tended to avoid issues involving religion; the DSM-5 relaxed this attitude somewhat. Medicalization and financial conflicts of interest There was extensive analysis and comment on DSM-IV (published in 1994) in the years leading up to the 2013 publication of DSM-5. It was alleged that the way the categories of DSM-IV were structured, as well as the substantial expansion of the number of categories within it, represented increasing medicalization of human nature, very possibly attributable to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. In 2005, then APA President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model". It was reported that of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had financial relationships with the pharmaceutical industry during the period 1989–2004, raising the prospect of a direct conflict of interest. The same article concluded that the connections between panel members and the drug companies were particularly strong involving those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry. William Glasser referred to DSM-IV as having "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money". A 2012 article in The New York Times commented sharply that DSM-IV (then in its 18th year), through copyrights held closely by the APA, had earned the Association over $100 million. However, although the number of identified diagnoses had increased by more than 300% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argued that this almost entirely represented greater specification of the forms of pathology, thereby allowing better grouping of similar patients. Potential harm of labels A core function of the DSM is the categorization of people's experiences into diagnoses based on symptoms. However, there is disagreement about the use of diagnoses as labels. Some individuals are relieved to find they have a recognized condition that they can apply a name to, and this has led to many people self-diagnosing. Others, however, question the accuracy of diagnosis, or feel they have been given a label that invites social stigma and discrimination (the terms "mentalism" and "sanism" have been used to describe such discriminatory treatment). Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result. Some members of the psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnoses, or the assumed implications, or against the DSM system in general. Additionally, it has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and such content can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity. Critiques of DSM-5 Psychiatrist Allen Frances has been critical of proposed revisions to the DSM–5. In a 2012 New York Times editorial, Frances warned that if this DSM version is issued unamended by the APA, "it will medicalize normality and result in a glut of unnecessary and harmful drug prescription." In a December 2012, blog post on Psychology Today, Frances provides his "list of DSM 5's ten most potentially harmful changes:" Disruptive Mood Dysregulation Disorder, for temper tantrums Major Depressive Disorder, includes normal grief Minor Neurocognitive Disorder, for normal forgetfulness in old age Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants Binge Eating Disorder, for excessive eating Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services First-time drug users will be lumped in with addicts Behavioral Addictions, making a "mental disorder of everything we like to do a lot." Generalized Anxiety Disorder, includes everyday worries Post-traumatic stress disorder, changes "opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings." A group of 25 psychiatrists and researchers, among whom were Frances and Thomas Szasz, have published debates on what they see as the six most essential questions in psychiatric diagnosis: Are they more like theoretical constructs or more like diseases? How to reach an agreed definition? Should the DSM-5 take a cautious or conservative approach? What is the role of practical rather than scientific considerations? How should it be used by clinicians or researchers? Is an entirely different diagnostic system required? In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Over 15,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other APA divisions have endorsed the petition. Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences. Cultural responses to the DSM There are several works written in recent years by scholars of the disabled community that specifically critique the cultural impact of the DSM V. These pieces criticize the DSM V from different cultural perspectives, integrating the experiences of disabled people identifying as crip, feminists, Asian Americans, Black Americans and other marginalized viewpoints. DSM CRIP DSM CRIP is a collection of essays by various authors that explore the critiques of the DSM V from feminist and crip perspectives. These essays tackle the critiques of the DSM using specific diagnoses  such as gender dysphoria, transvestic disorder, complex somatic symptom disorder, hypoactive sexual desire disorder, schizophrenia and autism. These are used as case studies to tackle the topics of the potential harm of labels, overmedicalization, overdiagnosis, pathologizing normality and various other critiques informed by the feminist and crip lens. Open in Emergency Open in Emergency is a multimedia collaborative project of the Asian American Literary Review that takes the lens of an Asian American Experience and redefines wellness in terms of care instead of focusing on diagnosis, unlike the original DSM V.  This included mock versions of DSM diagnoses such as gender dysphoria, social anxiety disorder and cannabis use disorder that mean to recharacterize the disorders under the lens of wellness and care. The project was said to contextualize mental disorders with their relationship to structures of power like patriarchy, colonialism and violence (here). The Protest Psychosis: How Schizophrenia became a Black disease The Protest Psychosis: How Schizophrenia became a Black disease is a critically acclaimed book that was written to analyze the history of schizophrenia and how perceptions of the condition have changed. In this book, Metzl shows how the condition of schizophrenia was experienced against the backdrop of the Civil Rights Movement. This book was recognized by the Disability Studies Quarterly academic journal as an excellent analysis of schizophrenia's link to black history. See also Chinese Classification and Diagnostic Criteria of Mental Disorders Classification of mental disorders Diagnostic classification and rating scales used in psychiatry DSM-IV codes Global Assessment of Functioning (GAF) Scale International Statistical Classification of Diseases and Related Health Problems (ICD) Kraepelinian dichotomy Psychodynamic Diagnostic Manual Relational disorder (proposed DSM-5 new diagnosis) Research Domain Criteria (RDoC), a framework being developed by the National Institute of Mental Health Rosenhan experiment Structured Clinical Interview for DSM-IV (SCID) Homosexuality in DSM Notes References Further reading External links Official DSM-5 development website Diagnostic Criteria from DSM-IV-TR Diagnostic Criteria from DSM-IV-TR The Multiaxial System of Diagnosis in DSM-IV Criteria American Psychiatric Association Data coding framework Medical manuals Medical statistics Psychiatric assessment Classification of mental disorders Psychiatric diagnosis Psychopathology Publications established in 1952 Statistical data coding

Music therapy

Music therapy, an allied health profession, "is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program." It is also a vocation, involving a deep commitment to music and the desire to use it as a medium to help others. Although music therapy has only been established as a profession relatively recently, the connection between music and therapy is not new. Music therapy is a broad field. Music therapists use music-based experiences to address client needs in one or more domains of human functioning: cognitive, academic, emotional/psychological; behavioral; communication; social; physiological (sensory, motor, pain, neurological and other physical systems), spiritual, aesthetics. Music experiences are strategically designed to use the elements of music for therapeutic effects, including melody, harmony, key, mode, meter, rhythm, pitch/range, duration, timbre, form, texture, and instrumentation. Some common music therapy practices include developmental work (communication, motor skills, etc.) with individuals with special needs, songwriting and listening in reminiscence, orientation work with the elderly, processing and relaxation work, and rhythmic entrainment for physical rehabilitation in stroke survivors. Music therapy is used in medical hospitals, cancer centers, schools, alcohol and drug recovery programs, psychiatric hospitals, nursing homes, and correctional facilities. Music therapy is distinctive from Musopathy, which relies on a more generic and non-cultural approach based on neural, physical, and other responses to the fundamental aspects of sound. Music therapy might also be described as Sound Healing. Extensive studies have been made with this description Music therapy aims to provide physical and mental benefit. Music therapists use their techniques to help their patients in many areas, ranging from stress relief before and after surgeries to neuropathologies such as Alzheimer's disease. Studies on patients diagnosed with mental health disorders such as anxiety, depression, and schizophrenia have associated some improvements in mental health after music therapy. The National Institute for Health and Care Excellence (NICE) have claimed that music therapy is an effective method in helping individuals experiencing mental health issues, and more should be done to offer those in need this type of help. Uses Children and adolescents Music therapy may be suggested for adolescent populations to help manage disorders usually diagnosed in adolescence, such as mood/anxiety disorders and eating disorders, or inappropriate behaviors, including suicide attempts, withdrawal from family, social isolation from peers, aggression, running away, and substance abuse. Goals in treating adolescents with music therapy, especially for those at high risk, often include increased recognition and awareness of emotions and moods, improved decision-making skills, opportunities for creative self expression, decreased anxiety, increased self-confidence, improved self-esteem, and better listening skills. There is some evidence that, when combined with other types of rehabilitation, music therapy may contribute to the success rate of sensorimotor, cognitive, and communicative rehabilitation. For children and adolescents with major depressive or anxiety disorders, there is moderate to low quality evidence that music therapy added to the standard treatment may reduce internalizing symptoms and may be more effective than treatment as usual (without music therapy). Methods Among adolescents, group meetings and individual sessions are the main methods for music therapy. Both methods may include listening to music, discussing concerning moods and emotions in or toward music, analyzing the meanings of specific songs, writing lyrics, composing or performing music, and musical improvisation. Private individual sessions can provide personal attention and are most effective when using music preferred by the patient. Using music that adolescents can relate to or connect with can help adolescent patients view the therapist as safe and trustworthy, and to engage in therapy with less resistance. Music therapy conducted in groups allows adolescent individuals to feel a sense of belonging, express their opinions, learn how to socialize and verbalize appropriately with peers, improve compromising skills, and develop tolerance and empathy. Group sessions that emphasize cooperation and cohesion can be effective in working with adolescents. Music therapy intervention programs typically include about 18 sessions of treatment. The achievement of a physical rehabilitation goal relies on the child's existing motivation and feelings towards music and their commitment to engage in meaningful, rewarding efforts. Regaining full functioning also confides in the prognosis of recovery, the condition of the client, and the environmental resources available. Both techniques use systematic processes where the therapists assist the client by using musical experiences and connections that collaborate as a dynamic force of change toward rehabilitation. Assessment Assessment includes obtaining a full medical history, musical (ability to duplicate a melody or identify changes in rhythm, etc.) and non-musical functioning (social, physical/motor, emotional, etc.). Premature infants Premature infants are those born at 37 weeks after conception or earlier. They are subject to numerous health risks, such as abnormal breathing patterns, decreased body fat and muscle tissue, as well as feeding issues. The coordination for sucking and breathing is often not fully developed, making feeding a challenge. Offering musical therapy to premature infants while they are in the neonatal intensive care unit (NICU) aims to both mask unwanted auditory stimuli, stimulate infant development, and promote a calm environment for families. While there are no reported adverse effects from music therapy, the evidence supporting music therapy's beneficial effects for infants is weak as many of the clinical trials that have been performed either had mixed results or were poorly designed. There is no strong evidence to suggest that music therapy improves an infant's oxygen therapy, improves sucking, or improves development when compared to usual care. There is some weaker evidence that music therapy may decrease an infants' heart rate. There is no evidence to indicate that music therapy reduces anxiety in parents of preterm infants in the NICU or information to understand what type of music therapy may be more beneficial or how for how long. Medical disorders Music may both motivate and provide a sense of distraction. Rhythmic stimuli has been found to help balance training for those with a brain injury. Singing is a form of rehabilitation for neurological impairments. Neurological impairments following a brain injury can be in the form of apraxia – loss to perform purposeful movements, dysarthria, muscle control disturbances (due to damage of the central nervous system), aphasia (defect in expression causing distorted speech), or language comprehension. Singing training has been found to improve lung, speech clarity, and coordination of speech muscles, thus, accelerating rehabilitation of such neurological impairments. For example, melodic intonation therapy is the practice of communicating with others by singing to enhance speech or increase speech production by promoting socialization, and emotional expression. Autism Music may help people with autism hone their motor and attention skills as well as healthy neurodevelopment of socio-communication and interaction skills. Music therapy may also contribute to improved selective attention, speech production, and language processing and acquisition in people with autism. Music therapy may benefit the family as a whole. Some family members of children with autism claim that music therapy sessions have allowed their child to interact more with the family and the world. Music therapy is also beneficial in that it gives children an outlet to use outside of the sessions. Some children after participating in music therapy may want to keep making music long after the sessions end. Heart disease Listening to music may improve heart rate, respiratory rate, and blood pressure in those with coronary heart disease (CHD). Stroke Music may be a useful tool in the recovery of motor skills. Dementia Like many of the other disorders mentioned, some of the most common significant effects of the disorder can be seen in social behaviors, leading to improvements in interaction, conversation, and other such skills. A study of over 330 subjects showed that music therapy produces highly significant improvements in social behaviors, overt behaviors like wandering and restlessness, reductions in agitated behaviors, and improvements to cognitive defects, measured with reality orientation and face recognition tests. The effectiveness of the treatment seems to be strongly dependent on the patient and the quality and length of treatment. A group of adults with dementia participated in group music therapy. In the group, these adults engaged in singing, drumming, improvisation, and movement. Each of these activities engaged the adults in different ways. The singing aided with memory, as these adults improved memorization skills in by taking out specific words in the chorus of a song and by repeating phrases back to the music therapist when the therapist sang a phrase of a song to them. Drumming led to increased socialization of the group, as it allowed the patients collaborate to create particular rhythms. Improvisation allowed the patients to get out of their comfort zone and taught them how to better deal with anxiety. Lastly, movement with either one arm or two increased social interaction between the patients. Another meta-study examined the proposed neurological mechanisms behind music therapy's effects on these patients. Many authors suspect that music has a soothing effect on the patient by affecting how noise is perceived: music renders noise familiar, or buffers the patient from overwhelming or extraneous noise in their environment. Others suggest that music serves as a sort of mediator for social interactions, providing a vessel through which to interact with others without requiring much cognitive load. Aphasia Broca's aphasia, or non-fluent aphasia, is a language disorder caused by damage to Broca's area and surrounding regions in the left frontal lobe. Those with non-fluent aphasia are able to understand language fairly well, but they struggle with language production and syntax. Neurologist Oliver Sacks studied neurological oddities in people, trying to understand how the brain works. He concluded that people with some type of frontal lobe damage often "produced not only severe difficulties with expressive language (aphasia) but a strange access of musicality with incessant whistling, singing and a passionate interest in music. For him, this was an example of normally suppressed brain functions being released by damage to others". Sacks had a genuine interest in trying to help people affected with neurological disorders and other phenomena associated with music, and how it can provide access to otherwise unreachable emotional states, revivify neurological avenues that have been frozen, evoke memories of earlier, lost events or states of being and attempts to bring those with neurological disorders back to a time when the world was much richer for them. He was a firm believer that music has the power to heal. Melodic intonation therapy (MIT), developed in 1973 by neurological researchers Sparks, Helm, and Albert, is a method used by music therapists and speech–language pathologists to help people with communication disorders caused by damage to the left hemisphere of the brain by engaging the singing abilities and possibly engaging language-capable regions in the undamaged right hemisphere. While unable to speak fluently, patients with non-fluent aphasia are often able to sing words, phrases, and even sentences they cannot express otherwise. MIT harnesses the singing ability of patients with non-fluent aphasia as a means to improve their communication. Although its exact nature depends on the therapist, in general MIT relies on the use of intonation (the rising and falling of the voice) and rhythm (beat/speed) to train patients to produce phrases verbally. In MIT, common words and phrases are turned into melodic phrases, generally starting with two step sing-song patterns and eventually emulating typical speech intonation and rhythmic patterns. A therapist will usually begin by introducing an intonation to their patient through humming. They will accompany this humming with a rhythm produced by the tapping of the left hand. At the same time, the therapist will introduce a visual stimuli of the written phrase to be learned. The therapist then sings the phrase with the patient, and ideally the patient is eventually able to sing the phrase on their own. With much repetition and through a process of "inner-rehearsal" (practicing internally hearing one's voice singing), a patient may eventually be able to produce the phrase verbally without singing. As the patient advances in therapy, the procedure can be adapted to give them more autonomy and to teach them more complex phrases. Through the use of MIT, a non-fluent aphasic patient can be taught numerous phrases which aid them to communicate and function during daily life. The mechanisms of this success are yet to be fully understood. It is commonly agreed that while speech is lateralized mostly to the left hemisphere (for right-handed and most left-handed individuals), some speech functionality is also distributed in the right hemisphere. MIT is thought to stimulate these right language areas through the activation of music processing areas also in the right hemisphere Similarly, the rhythmic tapping of the left hand stimulates the right sensorimotor cortex to further engage the right hemisphere in language production. Overall, by stimulating the right hemisphere during language tasks, therapists hope to decrease dependence on the left hemisphere for language production. While results are somewhat contradictory, studies have in fact found increased right hemispheric activation in non-fluent aphasic patients after MIT. This change in activation has been interpreted as evidence of decreased dependence on the left hemisphere. There is debate, however, as to whether changes in right hemispheric activation are part of the therapeutic process during/after MIT, or are simply a side effect of non-fluent aphasia. In hopes of making MIT more effective, researchers are continually studying the mechanisms of MIT and non-fluent aphasia. Cancer There is tentative evidence that music interventions led by a trained music therapist may have positive effects on psychological and physical outcomes in adults with cancer. The effectiveness of music therapy for children with cancer is not known. Mental health There is weak evidence to suggest that people with schizophrenia may benefit from the addition of music therapy along with their other standard treatment regieme. Potential improvements include decreased aggression, less hallucinations and delusions, social functioning, and quality of life of people with schizophrenia or schizophrenia-like disorders. In addition, moderate-to-low-quality evidence suggests that music therapy as an addition to standard care improves the global state, mental state (including negative and general symptoms). Further research using standardized music therapy programs and consistent monitoring protocols are necessary to understand the effectiveness of this approach for adults with schizophrenia. Music therapy may be a useful tool for helping treat people with post-traumatic stress disorder however more rigorous empirical study is required. For adults with depressive symptoms, there is some weak evidence to suggest that music therapy may help reduce symptoms and recreative music therapy and guided imagery and music being superior to other methods in reducing depressive symptoms. In the use of music therapy for adults, there is "music medicine" which is called for listening to prerecorded music as treated like a medicine. Music Therapy also uses "Receptive music therapy" using "music-assisted relaxation" and using images connecting to the music. There is some discussion on the process of change facilitated by musical activities on mental wellness. Scholars proposed a six-dimensional framework, which contains emotional, psychological, social, cognitive, behavioral and spiritual aspects. Through conducting interview sessions with mental health service users (with mood disorders, anxiety disorders, schizophrenia and other psychotic disorders), their study showed the relevance of the six-dimensional framework. Impact on general mental health Music therapy has been used to help bring improvements to mental health among people of all age groups. It has been used as far back as the 1830s. One example of a mental hospital that used music therapy to aid in the healing process of their patients includes the Hanwell Lunatic Asylum. This mental hospital provided "music and movement sessions and musical performances" as well as "group and individual music therapy for patients with serious mental illness or emotional problems." Two main categories of music therapy were used in this study; analytic music therapy and Nordoff-Robbins music therapy. Analytic music therapy involves both words and music, while Nordoff-Robbins music therapy places great emphasis on assessing how clients react to music therapy and how the use of this type of therapy can be constantly altered and shifted to allow it to benefit the client the most. Bereavement The DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders) lists bereavement as a mental health diagnosis when the focus of clinical attention is related to the loss of a loved one and when symptoms of Major Depressive Disorder are present for up to two months. Music therapy models have been found to be successful in treating grief and bereavement (Rosner, Kruse & Hagl, 2010).In many countries, including the United States, music therapists do not diagnose, therefore diagnosing a bereavement-related disorder would not be within their scope of practice. Grief treatment for adolescents Grief treatment is very valuable within the adolescent age group. Just as adults and the elderly struggle with grief from loss, relationship issues, job-related stress, and financial issues, so do adolescents also experience grief from disappointments that occur early on in life, however different these disappointing life events may be. For example, many people of adolescent age experience life-altering events such as parental divorce, trauma from emotional or physical abuse, struggles within school, and loss. If this grief is not acted upon early on through the use of some kind of therapy, it can alter the entire course of an adolescent's life. In one particular study on the impact of music therapy on grief management within adolescents used songwriting to allow these adolescents to express what they were feeling through lyrics and instrumentals. In the article Development of the Grief Process Scale through music therapy songwriting with bereaved adolescents, the results of the study demonstrate that in all of the treatment groups combined, the mean GPS (grief process scale) score decreased by 43%. The use of music therapy songwriting allowed these adolescents to become less overwhelmed with grief and better able to process it as demonstrated by the decrease in mean GPS score. Empirical evidence Since 2017, providing evidence-based practice is becoming more and more important and music therapy has been continuously critiqued and regulated to provide that desired evidence-based practice. A number of research studies and meta-analyses have been conducted on, or included, music therapy and all have found that music therapy has at least some promising effects, especially when used for the treatment of grief and bereavement. The AMTA has largely supported the advancement of music therapy through research that would promote evidenced-based practice. With the definition of evidence-based health care as "the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services, current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factors". Both qualitative and quantitative studies have been completed and both have provided evidence to support music therapy in the use of bereavement treatment. One study that evaluated a number of treatment approaches found that only music therapy had significant positive outcomes where the others showed little improvement in participants (Rosner, Kruse & Hagl, 2010). Furthermore, a pilot study, which consisted of an experimental and control group, examined the effects of music therapy on mood and behaviors in the home and school communities. It was found that there was a significant change in grief symptoms and behaviors with the experimental group in the home, but conversely found that there was no significant change in the experimental group in the school community, despite the fact that mean scores on the Depression Self-Rating Index and the Behavior Rating Index decreased (Hilliard, 2001). Yet another study completed by Russel Hilliard (2007), looked at the effects of Orff-based music therapy and social work groups on childhood grief symptoms and behaviors. Using a control group that consisted of wait-listed clients, and employing the Behavior Rating Index for Children and the bereavement Group Questionnaire for Parents and Guardians as measurement tools, it was found that children who were in the music therapy group showed significant improvement in grief symptoms and also showed some improvement in behaviors compared to the control group, whereas the social work group also showed significant improvement in both grief and behaviors compared to the control group. The study concludes with support for music therapy as a medium from bereavement groups for children (Hilliard, 2007). Though there has been research done on music therapy, and though the use of it has been evaluated, there remain a number of limitations in these studies and further research should be completed before absolute conclusions are made, though the results of using music therapy in the treatment have consistently shown to be positive. Music therapy practice is working together with clients, through music, to promote healthy change (Bruscia, 1998). The American Music Therapy Association (AMTA) has defined the practice of music therapy as "a behavioral science concerned with changing unhealthy behaviors and replacing them with more adaptive ones through the use of musical stimuli". Interventions Though music therapy practice employs a large number of intervention techniques, some of the most commonly used interventions include improvisation, therapeutic singing, therapeutic instrumental music playing, music-facilitated reminiscence and life review, songwriting, music-facilitated relaxation, and lyric analysis. While there has been no conclusive research done on the comparison of interventions (Jones, 2005; Silverman, 2008; Silverman & Marcionetti, 2004), the use of particular interventions is individualized to each client based upon thorough assessment of needs, and the effectiveness of treatment may not rely on the type of intervention (Silverman, 2009). Improvisation in music therapy allows for clients to make up, or alter, music as they see fit. While improvisation is an intervention in a methodical practice, it does allow for some freedom of expression, which is what it is often used for. Improvisation has several other clinical goals as well, which can also be found on the Improvisation in music therapy page, such as: facilitating verbal and nonverbal communication, self-exploration, creating intimacy, teamwork, developing creativity, and improving cognitive skills. Building on these goals, Botello and Krout designed a cognitive behavioral application to assess and improve communication in couples. Further research is needed before the use of improvisation is conclusively proven to be effective in this application, but there were positive signs in this study of its use. Singing or playing an instrument is often used to help clients express their thoughts and feelings in a more structured manner than improvisation and can also allow participation with only limited knowledge of music. Singing in a group can facilitate a sense of community and can also be used as group ritual to structure a theme of the group or of treatment (Krout, 2005). Research that compares types of music therapy intervention has been inconclusive. Music Therapists use lyric analysis in a variety of ways, but typically lyric analysis is used to facilitate dialogue with clients based on the lyrics, which can then lead to discussion that addresses the goals of therapy. Types of music therapy Two fundamental types of music therapy are receptive music therapy and active music therapy (also known as expressive music therapy). Active music therapy engages clients or patients in the act of making music, whereas receptive music therapy guides patients or clients in listening or responding to live or recorded music. Either or both can lead to verbal discussions, depending on client needs and the therapist's orientation. Receptive Receptive music therapy involves listening to recorded or live genres of music such as classical, rock, jazz, and/or country music. In Receptive music therapy, patients are the recipient of the music experience, meaning that they are actively listening and responding to the music rather than creating it. During music sessions, patients participate in song discussion, music relaxation, and are given the ability to listen to their preferred music genre. It can improve mood, decrease stress, decrease pain, enhance relaxation, and decrease anxiety; this can help with coping skills. There is also evidence of biochemical changes (e.g., lowered cortisol levels). Active In active music therapy, patients engage in some form of music-making (e.g., vocalizing, rapping, chanting, singing, playing instruments, improvising, song writing, composing, or conducting). Researchers at Baylor, Scott, and White Universities are studying the effect of harmonica playing on patients with COPD to determine if it helps improve lung function. Another example of active music therapy takes place in a nursing home in Japan: therapists teach the elderly how to play easy-to-use instruments so they can overcome physical difficulties. Models and approaches Music therapist Kenneth Bruscia stated "A model is a comprehensive approach to assessment, treatment, and evaluation that includes theoretical principles, clinical indications and contraindications, goals, methodological guidelines and specifications, and the characteristic use of certain procedural sequences and techniques." In the literature, the terms model, orientation, or approach might be encountered and may have slightly different meanings. Regardless, music therapists use both psychology models and models specific to music therapy. The theories these models are based on include beliefs about human needs, causes of distress, and how humans grow or heal. Models developed specifically for music therapy include analytical music therapy, Benenzon, the Bonny Method of Guided Imagery and Music (GIM), community music therapy, Nordoff-Robbins music therapy (creative music therapy), neurologic music therapy, and vocal psychotherapy. Psychological orientations used in music therapy include psychodynamic, cognitive behavioral, humanistic, existential, and the biomedical model. The Bonny Method of Guided Imagery and Music To be trained in this method, students are required to be healthcare professionals. Some courses are only open to music therapists and mental health professionals. Music educator and therapist Helen Lindquist Bonny (1921–2010) developed an approach influenced by humanistic and transpersonal psychological views, known as the Bonny Method of guided imagery in music (BGIM or GIM). Guided imagery refers to a technique used in natural and alternative medicine that involves using mental imagery to help with the physiological and psychological ailments of patients. The practitioner often suggests a relaxing and focusing image, and through the use of imagination and discussion, they aim to find constructive solutions to manage their problems. Bonny applied this psychotherapeutic method to the field of music therapy by using music as the means of guiding the patient to a higher state of consciousness where healing and constructive self-awareness can take place. Music is considered a "co-therapist" because of its importance. GIM with children can be used in one-on-one or group settings, and involves relaxation techniques, identification and sharing of personal feeling states, and improvisation to discover the self, and foster growth. The choice of music is carefully selected for the client based on their musical preferences and the goals of the session. The piece is usually classical, and it must reflect the age and attention abilities of the child in length and genre. A full explanation of the exercises must be offered at their level of understanding. Nordoff-Robbins Paul Nordoff, a Juilliard School graduate and Professor of Music, was a pianist and composer who, upon seeing disabled children respond so positively to music, gave up his academic career to further investigate the possibility of music as a means for therapy. Clive Robbins, a special educator, partnered with Nordoff for over 17 years in the exploration and research of music's effects on disabled children—first in the UK, and then in the United States in the 1950s and 60s. Their pilot projects included placements at care units for autistic children and child psychiatry departments, where they put programs in place for children with mental disorders, emotional disturbances, developmental delays, and other handicaps. Their success at establishing a means of communication and relationship with children with cognitive impairments at the University of Pennsylvania gave rise to the National Institutes of Health's first grant given of this nature, and the 5-year study "Music therapy project for psychotic children under seven at the day care unit" involved research, publication, training and treatment. Several publications, including Therapy in Music for Handicapped Children, Creative Music Therapy, Music Therapy in Special Education, as well as instrumental and song books for children, were released during this time. Nordoff and Robbins's success became known globally in the mental health community, and they were invited to share their findings and offer training on an international tour that lasted several years. Funds were granted to support the founding of the Nordoff Robbins Music Therapy Centre in Great Britain in 1974, where a one-year graduate program for students was implemented. In the early eighties, a center was opened in Australia, and various programs and institutes for music therapy were founded in Germany and other countries. In the United States, the Nordoff-Robbins Center for Music Therapy was established at New York University in 1989 Today, Nordoff-Robbins is a music therapy Theoretical Model / Approach. The Nordoff-Robbins approach, based on the belief that everyone is capable of finding meaning in and benefiting from musical experience, is now practiced by hundreds of therapists internationally. This approach focuses on treatment through the creation of music by both therapist and client together. The therapist uses various techniques so that even the most low functioning individuals can actively participate. Orff Gertrude Orff developed Orff Music Therapy at the Kinderzentrum München. Both the clinical setting of social pediatrics and the Orff Schulwerk (schoolwork) approach in music education (developed by German composer Carl Orff) influence this method, which is used with children with developmental problems, delays, and disabilities. Theodor Hellbrügge developed the area of social pediatrics in Germany after the Second World War. He understood that medicine alone could not meet the complex needs of developmentally disabled children. Hellbrügge consulted psychologists, occupational therapists and other mental healthcare professionals whose knowledge and skills could aid in the diagnostics and treatment of children. Gertrude Orff was asked to develop a form of therapy based on the Orff Schulwerk approach to support the emotional development of patients. Elements found in both the music therapy and education approaches include the understanding of holistic music presentation as involving word, sound and movement, the use of both music and play improvisation as providing a creative stimulus for the child to investigate and explore, Orff instrumentation, including keyboard instruments and percussion instruments as a means of participation and interaction in a therapeutic setting, and the multisensory aspects of music used by the therapist to meet the particular needs of the child, such as both feeling and hearing sound. Corresponding with the attitudes of humanistic psychology, the developmental potential of the child, as in the acknowledgement of their strengths as well as their handicaps, and the importance of the therapist-child relationship, are central factors in Orff music therapy. The strong emphasis on social integration and the involvement of parents in the therapeutic process found in social pediatrics also influence theoretical foundations. Knowledge of developmental psychology puts into perspective how developmental disabilities influence the child, as do their social and familial environments. The basis for interaction in this method is known as responsive interaction, in which the therapist meets the child at their level and responds according to their initiatives, combining both humanistic and developmental psychology philosophies. Involving the parents in this type of interaction by having them participate directly or observe the therapist's techniques equips the parents with ideas of how to interact appropriately with their child, thus fostering a positive parent-child relationship. Cultural aspects Through the ages music has been an integral component of rituals, ceremonies, healing practices, and spiritual and cultural traditions. Further, Michael Bakan, author of World Music: Traditions and Transformations, states that "Music is a mode of cultural production and can reveal much about how the culture works," something ethnomusicologists study. Cultural considerations in music therapy services, education, and research The 21st century is a culturally pluralistic world. In some countries, such as the United States, an individual may have multiple cultural identities that are quite different from the music therapist's. These include race; ethnicity, culture, and/or heritage; religion; sex; ability/disability; education; or socioeconomic status. Music therapists strive to achieve multicultural competence through a lifelong journey of formal and informal education and self-reflection. Multicultural therapy "uses modalities and defines goals consistent with the life experiences and cultural values of clients" rather than basing therapy on the therapist's worldview or the dominant culture's norms. Empathy in general is an important aspect of any mental health practitioner and the same is true for music therapists, as is multicultural awareness. It is the added complexity to cultural empathy that comes from adding music that provides both the greater risk and potential to provide exceptional culturally sensitive therapy (Valentino, 2006). An extensive knowledge of a culture is really needed to provide this effective treatment as providing culturally sensitive music therapy goes beyond knowing the language of speech, the country, or even some background about the culture. Simply choosing music that is from the same country of origin or that has the same spoken language is not effective for providing music therapy as music genres vary as do the messages each piece of music sends. Also, different cultures view and use music in various ways and may not always be the same as how the therapist views and uses music. Melody Schwantes and her colleagues wrote an article that describes the effective use of the Mexican "corrido" in a bereavement group of Mexican migrant farm workers (Schwantes, Wigram, Lipscomb & Richards, 2011). This support group was dealing with the loss of two of their coworkers after an accident they were in and so the corrido, a song form traditionally used for telling stories of the deceased. An important element that was also mentioned was that songwriting has shown to be a large cultural artifact in many cultures, and that there are many subtle messages and thoughts provided in songs that would otherwise be hard to identify. Lastly, the authors of this study stated that "Given the position and importance of songs in all cultures, the example in this therapeutic process demonstrates the powerful nature of lyrics and music to contain and express difficult and often unspoken feelings" (Schwantes et al., 2011). Usage by region African continent In 1999, the first program for music therapy in Africa opened in Pretoria, South Africa. Research has shown that in Tanzania patients can receive palliative care for life-threatening illnesses directly after the diagnosis of these illnesses. This is different from many Western countries, because they reserve palliative care for patients who have an incurable illness. Music is also viewed differently between Africa and Western countries. In Western countries and a majority of other countries throughout the world, music is traditionally seen as entertainment whereas in many African cultures, music is used in recounting stories, celebrating life events, or sending messages. Australia Music for healing in ancient times One of the first groups known to heal with sound were the aboriginal people of Australia. The modern name of their healing tool is the didgeridoo, but it was originally called the yidaki. The yidaki produced sounds that are similar to the sound healing techniques used in modern day. The sound of the didgeridoo produces a low, bass frequency. For at least 40,000 years, the healing tool was believed to assist in healing "broken bones, muscle tears and illnesses of every kind". However, here are no reliable sources stating the didgeridoo's exact age. Archaeological studies of rock art in Northern Australia suggest that the people of the Kakadu region of the Northern Territory have been using the didgeridoo for less than 1,000 years, based on the dating of paintings on cave walls and shelters from this period. A clear rock painting in Ginga Wardelirrhmeng, on the northern edge of the Arnhem Land plateau, from the freshwater period (that had begun 1500 years ago) shows a didgeridoo player and two songmen participating in an Ubarr ceremony. In modern times – an allied health profession 1949 in Australia, music therapy (not clinical music therapy as understood today) was started through concerts organized by the Australian Red Cross along with a Red Cross Music Therapy Committee. The key Australian body, the Australian Music Therapy Association (AMTA), was founded in 1975. Canada History: c. 1940 – present For earlier history related to Western traditions, see sub-section. In 1956, Fran Herman, one of Canada's music therapy pioneers, began a 'remedial music' program at the Home For Incurable Children, now known as the Holland Bloorview Kids Rehabilitation Hospital, in Toronto. Her group 'The Wheelchair Players' continued until 1964, and is considered to be the first music therapy group project in Canada. Its production "The Emperor's Nightingale" was the subject of a documentary film. Composer/pianist Alfred Rosé, a professor at the University of Western Ontario, also pioneered the use of music therapy in London, Ontario, at Westminster Hospital in 1952 and at the London Psychiatric Hospital in 1956. Two other music therapy programs were initiated during the 1950s; one by Norma Sharpe at St. Thomas Psychiatric Hospital in St. Thomas, Ontario, and the other by Thérèse Pageau at the Hôpital St-Jean-de-Dieu (now Hôpital Louis-Hippolyte Lafontaine) in Montreal. A conference in August 1974, organized by Norma Sharpe and six other music therapists, led to the founding of the Canadian Music Therapy Association, which was later renamed the Canadian Association for Music Therapy (CAMT). As of 2009, the organization had over 500 members. Canada's first music therapy training program was founded in 1976, at Capilano College (now Capilano University) in North Vancouver, by Nancy McMaster and Carolyn Kenny. China The relationship between music therapy and health has long been documented in ancient China. It is said that in ancient times, really good traditional Chinese medicine did not use acupuncture or traditional Chinese medicine, but music: at the end of a song, people were safe when they were discharged. As early as before the Spring and Autumn period and the Warring States period, the Yellow Emperor's Canon of internal medicine believed that the five tones (Palace, Shang, horn, emblem and feather) belonged to the five elements (gold, wood, water, fire and earth), and were associated with five basic emotions (joy, anger, worry, thought and fear), that is, the five chronicles. Different music such as palace, Shang, horn, micro and feather were used to target different diseases. More than 2000 years ago, the book Yue Ji also talked about the important role of music in regulating life harmony and improving health; "Zuo Zhuan" recorded the famous doctors of the state of Qin and the discussion that music can prevent and treat diseases: "there are six or seven days, the hair is colorless, the emblem is five colors, and sex produces six diseases." It is emphasized that silence should be controlled and appropriate in order to have a beneficial regulating effect on the human body; The book "the soul and the body flow, the spirit also flows"; Zhang Jingyue and Xu Lingtai, famous medical experts in the Ming and Qing Dynasties, also specially discussed phonology and medicine in the "classics with wings" and "Yuefu Chuansheng". For example, Liu Xueyu, one of the emperors of the Tang Dynasty, cured some stubborn diseases through the records of music in the Tang Dynasty. Chinese contemporary music therapy began in the 1980s. In 1984, Professor Zhang Boyuan of the Department of psychology of Peking University published the experimental report on the research of physical and mental defense of music, which was the first published scientific research article on music therapy in China; In 1986, Professor Gao Tian of Beijing Conservatory of music published his paper "Research on the relieving effect of music on pain"; In 1989, the Chinese society of therapeutics was officially established; In 1994, pukaiyuan published his monograph music therapy; In 1995, he Huajun and Lu Tingzhu published a monograph music therapy; In 2000, Zhang Hongyi edited and published fundamentals of music therapy; In 2002, fan Xinsheng edited and published music therapy; In 2007, Gao Tian edited and published the basic theory of music therapy. In short, Chinese music therapy has made rapid progress in theoretical research, literature review and clinical research. In addition, the music therapy methods under the guidance of ancient Chinese music therapy theory and traditional Chinese medicine theory with a long history have attracted worldwide attention. The prospect of Chinese music therapy is broad. Germany The Germany Music Therapy Society defines music therapy as the "targeted use of music as part of a therapeutic relationship to restore, maintain and promote mental, physical and cognitive health []." India The roots of musical therapy in India can be traced back to ancient Hindu mythology, Vedic texts, and local folk traditions. It is very possible that music therapy has been used for hundreds of years in Indian culture. In the 1990s, another dimension to this, known as Musopathy, was postulated by Indian musician Chitravina Ravikiran based on fundamental criteria derived from acoustic physics. The Indian Association of Music Therapy was established in 2010 by Dr. Dinesh C. Sharma with a motto "to use pleasant sounds in a specific manner like drug in due course of time as green medicine". He also published the International Journal of Music Therapy (ISSN 2249-8664) to popularize and promote music therapy research on an international platform. Suvarna Nalapat has studied music therapy in the Indian context. Her books Nadalayasindhu-Ragachikitsamrutam (2008), Music Therapy in Management Education and Administration (2008) and Ragachikitsa (2008) are accepted textbooks on music therapy and Indian arts. The Music Therapy Trust of India is another venture in the country. It was started by Margaret Lobo. She is the founder and director of the Otakar Kraus Music Trust and her work began in 2004. Lebanon In 2006, Hamda Farhat introduced music therapy to Lebanon, developing and inventing therapeutic methods such as the triple method to treat hyperactivity, depression, anxiety, addiction, and post traumatic stress disorder. She has met with great success in working with many international organizations, and in the training of therapists, educators, and doctors. The Lebanese Association Of Music Therapy L.A.M.T ref number 65 is the only reference at Lebanon, the president Dr Hamda farhat, members administer Dr Antoine chartouni, Dr Elia Francis Safi TRAINING and Formation Norway Norway is recognized as an important country for music therapy research. Its two major research centers are the Center for Music and Health with the Norwegian Academy of Music in Oslo, and the Grieg Academy Centre for Music Therapy (GAMUT), at University of Bergen. The former was mostly developed by professor Even Ruud, while professor Brynjulf Stige is largely responsible for cultivating the latter. The center in Bergen has 18 staff, including 2 professors and 4 associate professors, as well as lecturers and PhD students. Two of the field's major international research journals are based in Bergen: Nordic Journal for Music Therapy and Voices: A World Forum for Music Therapy. Norway's main contribution to the field is mostly in the area of "community music therapy", which tends to be as much oriented toward social work as individual psychotherapy, and music therapy research from this country uses a wide variety of methods to examine diverse methods across an array of social contexts, including community centers, medical clinics, retirement homes, and prisons. Nigeria The origins of Musical therapy practices in Nigeria is unknown, however the country is identified to have a lengthy lineage and history of musical therapy being utilized throughout the culture. The most common people associated with music therapy are herbalists, Witch doctors, and faith healers according to Professor Charles O. Aluede of Ambrose Alli University (Ekpoma, Edo State, Nigeria). Applying music and thematic sounds to the healing process is believed to help the patient overcome true sickness in his/her mind which then will seemingly cure the disease. Another practice involving music is called "Igbeuku", a religious practice performed by faith healers. In the practice of Igbeuku, patients are persuaded to confess their sins which cause themselves serve discomfort. Following a confession, patients feel emotionally relieved because the priest has announced them clean and subjected them to a rigorous dancing exercise. The dancing exercise is a "thank you" for the healing and tribute to the spiritual greater beings. The dance is accompanied by music and can be included among the unorthodox medical practices of Nigerian culture. While most of the music therapy practices come in the medical field, musical therapy is often used in the passing of a loved one. The use of song and dance in a funeral setting is very common across the continent but especially in Nigeria. Songs allude to the idea the finally resting place is Hades (hell). The music helps alleviate the sorrows felt by the family members and friends of the lost loved one. Along with music therapy being a practice for funeral events, it is also implemented to those dying as a last resort tactic of healing. The Esan of Edo State of Nigeria, in particular, herbalists perform practices with an Oko – a small aerophone made of elephant tusk which is blown into dying patients' ears to resuscitate them. Nigeria is full of interesting cultural practices in which contribute a lot to the music therapy world. South Africa There are longstanding traditions of music healing, which in some ways may be very different than music therapy. Mercédès Pavlicevic (1955–2018), an international music therapist, along with Kobie Temmingh, pioneered the music therapy program at the University of Pretoria, which debuted with a master's degree program in 1999. She noted the differences in longstanding traditions and other ways of viewing healing or music. A Nigerian colleague felt "that music in Africa is healing, and what is music therapy other than some colonial import?" Pavlicevic noted that "in Africa there is a long tradition of music healing" and asked "Can there be a synthesis of these two music-based practices towards something new?... I am not altogether convinced that African music healing and music therapy are especially closely related [emphasis added]. But I am utterly convinced that music therapy can learn an enormous amount from the African worldview and from music-making in Africa – rather than from African music-healing as such." The South African Music Therapy Association can provide information to the public about music therapy or educational programs in South Africa. South Africa was selected to host the 16th World Congress of Music Therapy in July 2020, a triennial World Federation of Music Therapy event. Due to the coronavirus pandemic (SARS-CoV-2) the congress was moved to an online event. United States Credential National board certification (current as of 2021): MT-BC (Music Therapist-Board Certified, also written as Board Certified Music Therapist) State license or registration: varies by state, see below The credentials listed below were previously conferred by the former national organizations AAMT and NAMT; these credentials have not been available since 1998. CMT (Certified Music Therapist) ACMT (Advanced Certified Music Therapist) RMT (Registered Music Therapist). There are other countries that use RMT as a credential, such as Australia, that is different from the U.S. credential. The states of Georgia, Illinois, Iowa, Maryland, North Dakota, Nevada, New Jersey, Oklahoma, Oregon, Rhode Island, and Virginia have established licenses for music therapists, while in Wisconsin, music therapists must be registered, and in Utah hold state certification. In the State of New York, the Creative Arts Therapy license (LCAT) incorporates the music therapy credential within their licensure, a mental health license that requires a master's degree and post-graduate supervision. The states of California and Connecticut have title protection for music therapists, meaning only those with the MT-BC credential can use the title "Board Certified Music Therapist". Professional association The American Music Therapy Association (AMTA). Education Publication on music therapy education and training has been detailed in both single author (Goodman, 2011) and edited (Goodman, 2015, 2023) volumes. The register of the European Music Therapy Confederation lists all educational training programs throughout Europe. A music therapy degree candidate can earn an undergraduate, master's or doctoral degree in music therapy. Many AMTA approved programs in the United States offer equivalency and certificate degrees in music therapy for students that have completed a degree in a related field. Some practicing music therapists have held PhDs either in music therapy or in fields related to music therapy. A music therapist typically incorporates music therapy techniques with broader clinical practices such as psychotherapy, rehabilitation, and other practices depending on client needs. Music therapy services rendered within the context of a social service, educational, or health care agency are often reimbursable by insurance or other sources of funding for individuals with certain needs. A degree in music therapy requires proficiency in guitar, piano, voice, music theory, music history, reading music, improvisation, as well as varying levels of skill in assessment, documentation, and other counseling and health care skills depending on the focus of the particular university's program. 1200 hours of clinical experience are required, some of which are gained during an approximately six-month internship that takes place after all other degree requirements are met. After successful completion of educational requirements, including internship, music therapists can apply to take, take, and pass the Board Certification Examination in Music Therapy. Board Certification Examination in Music Therapy The current national credential is MT-BC (Music Therapist-Board Certified). It is not required in all states. To be eligible to apply to take the Board Certification Examination in Music Therapy, an individual must successfully complete a music therapy degree from a program accredited by AMTA at a college or university (or have a bachelor's degree and complete all of the music therapy course requirements from an accredited program), which includes successfully completing a music therapy internship. To maintain the credential, 100 units of continuing education must be completed every five years. The board exam is created by and administered through The Certification Board for Music Therapists. History: –present For earlier history related to Western traditions, see sub-section. From a western viewpoint, music therapy in the 20th and 21st centuries (as of 2021), as an evidence-based, allied healthcare profession, grew out of the aftermath of World Wars I and II, when, particularly in the United Kingdom and United States, musicians would travel to hospitals and play music for soldiers suffering from with war-related emotional and physical trauma. Using music to treat the mental and physical ailments of active duty military and veterans was not new. Its use was recorded during the U.S. Civil War and Florence Nightingale used it a decade earlier in the Crimean War. Despite research data, observations by doctors and nurses, praise from patients, and willing musicians, it was difficult to vastly increase music therapy services or establish lasting music therapy education programs or organizations in the early 20th century. However, many of the music therapy leaders of this time period provided music therapy during WWI or to its veterans. These were pioneers in the field such as Eva Vescelius, musician, author, 1903 founder of the short-lived National Therapeutic Society of New York and the 1913 Music and Health journal, and creator/teacher of a musicotherapy course; Margaret Anderton, pianist, WWI music therapy provider for Canadian soldiers, a strong believer in training for music therapists, and 1919 Columbia University musicotherapy teacher; Isa Maud Ilsen, a nurse and musician who was the American Red Cross Director of Hospital Music in WWI reconstruction hospitals, 1919 Columbia University musicotherapy teacher, 1926 founder of the National Association for Music in Hospitals, and author; and Harriet Ayer Seymour, music therapist to WWI veterans, author, researcher, lecturer/teacher, founder of the National Foundation for Music Therapy in 1941, author of the first music therapy textbook published in the US. Several physicians also promoted music as a therapeutic agent during this time period. In the 1940s, changes in philosophy regarding care of psychiatric patients as well as the influx of WWII veterans in Veterans Administration hospitals renewed interest in music programs for patients. Many musicians volunteered to provide entertainment and were primarily assigned to perform on psychiatric wards. Positive changes in patients' mental and physical health were noted by nurses. The volunteer musicians, many of whom had degrees in music education, becoming aware of the powerful effects music could have on patients realized that specialized training was necessary. The first music therapy bachelor's degree program was established in 1944 with three others and one master's degree program quickly following: "Michigan State College [now a University] (1944), the University of Kansas [master's degree only] (1946), the College of the Pacific (1947), The Chicago Musical College (1948) and Alverno College (1948)." The National Association for Music Therapy (NAMT), a professional association, was formed in 1950. In 1956 the first music therapy credential in the US, Registered Music Therapist (RMT), was instituted by the NAMT. The American Music Therapy Association (AMTA) was founded in 1998 as a merger between the National Association for Music Therapy (NAMT, founded in 1950) and the American Association for Music Therapy (AAMT, founded in 1971). United Kingdom Live music was used in hospitals after both World Wars as part of the treatment program for recovering soldiers. Clinical music therapy in Britain as it is understood today was pioneered in the 1960s and 1970s by French cellist Juliette Alvin whose influence on the current generation of British music therapy lecturers remains strong. Mary Priestley, one of Juliette Alvin's students, created "analytical music therapy". The Nordoff-Robbins approach to music therapy developed from the work of Paul Nordoff and Clive Robbins in the 1950/60s. Practitioners are registered with the Health Professions Council and, starting from 2007, new registrants must normally hold a master's degree in music therapy. There are master's level programs in music therapy in Manchester, Bristol, Cambridge, South Wales, Edinburgh and London, and there are therapists throughout the UK. The professional body in the UK is the British Association for Music Therapy In 2002, the World Congress of Music Therapy, coordinated and promoted by the World Federation of Music Therapy, was held in Oxford on the theme of Dialogue and Debate. In November 2006, Dr. Michael J. Crawford and his colleagues again found that music therapy helped the outcomes of schizophrenic patients. Military: active duty, veterans, family members History Music therapy finds its roots in the military. The United States Department of War issued Technical Bulletin 187 in 1945, which described the use of music in the recovery of military service members in Army hospitals. The use of music therapy in military settings started to flourish and develop following World War II and research and endorsements from both the United States Army and the Surgeon General of the United States. Although these endorsements helped music therapy develop, there was still a recognized need to assess the true viability and value of music as a medically based therapy. Walter Reed Army Medical Center and the Office of the Surgeon General worked together to lead one of the earliest assessments of a music therapy program. The goal of the study was to understand whether "music presented according to a specific plan" influenced recovery among service members with mental and emotional disorders. Eventually, case reports in reference to this study relayed not only the importance but also the impact of music therapy services in the recovery of military service personnel. The first university sponsored music therapy course was taught by Margaret Anderton in 1919 at Columbia University. Anderton's clinical specialty was working with wounded Canadian soldiers during World War II, using music-based services to aid in their recovery process. Today, Operation Enduring Freedom and Operation Iraqi Freedom have both presented an array of injuries; however, the two signature injuries are post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). These two signature injuries are increasingly common among millennial military service members and in music therapy programs. A person diagnosed with PTSD can associate a memory or experience with a song they have heard. This can result in either good or bad experiences. If it is a bad experience, the song's rhythm or lyrics can bring out the person's anxiety or fear response. If it is a good experience, the song can bring feelings of happiness or peace which could bring back positive emotions. Either way, music can be used as a tool to bring emotions forward and help the person cope with them. Methods Music therapists work with active duty military personnel, veterans, service members in transition, and their families. Music therapists strive to engage clients in music experiences that foster trust and complete participation over the course of their treatment process. Music therapists use an array of music-centered tools, techniques, and activities when working with military-associated clients, many of which are similar to the techniques used in other music therapy settings. These methods include, but are not limited to: group drumming, listening, singing, and songwriting. Songwriting is a particularly effective tool with military veterans struggling with PTSD and TBI as it creates a safe space to, "... work through traumatic experiences, and transform traumatic memories into healthier associations". Programs Music therapy in the military is seen in programs on military bases, VA healthcare facilities, military treatment facilities, and military communities. Music therapy programs have a large outreach because they exist for all phases of military life: pre-mobilization, deployment, post-deployment, recovery (in the case of injury), and among families of fallen military service personnel. The Exceptional Family Member Program (EFMP) also exists to provide music therapy services to active duty military families who have a family member with a developmental, physical, emotional, or intellectual disorder. Currently, programs at the Davis–Monthan Air Force Base, Resounding Joy, Inc., and the Music Institute of Chicago partner with EFMP services to provide music therapy services to eligible military family members. Music therapy programs primarily target active duty military members and their treatment facility to provide reconditioning among members convalescing in Army hospitals. Although, music therapy programs not only benefit the military but rather a wide range of clients including the U.S. Air Force, American Navy, and U.S. Marines Corp. Individuals exposed to trauma benefit from their essential rehabilitative tools to follow the course of recovery from stress disorders. Music therapists are certified professionals who possess the abilities to determine appropriate interventions to support one recovering from a physically, emotionally, or mentally traumatic experience. In addition to their skills, they play an integral part throughout the treatment process of service members diagnosed with post-traumatic stress or brain injuries. In many cases, self-expression through songwriting or using instruments help restore emotions that can be lost following trauma. Music has a significant effect on troops traveling overseas or between bases because many soldiers view music to be an escape from war, a connection to their homeland and families, or as motivation. By working with a certified music therapist, marines undergo sessions re-instituting concepts of cognition, memory attention, and emotional processing. Although programs primarily focus on phases of military life, other service members such as the U.S. Air Force are eligible for treatment as well. For instance, during a music therapy session, a man begins to play a song to a wounded Airmen. The Airmen says "[music] allows me to talk about something that happened without talking about it". Music allows the active duty airmen to open up about previous experiences while reducing his anxiety level. History The use of music to soothe grief has been used since the time of David and King Saul. In I Samuel, David plays the lyre to make King Saul feel relieved and better. It has since been used all over the world for treatment of various issues, though the first recorded use of official "music therapy" was in 1789 – an article titled "Music Physically Considered" by an unknown author was found in Columbian Magazine. The creation and expansion of music therapy as a treatment modality thrived in the early to mid 1900s and while a number of organizations were created, none survived for long. It was not until 1950 that the National Association for Music Therapy was founded in New York that clinical training and certification requirements were created. In 1971, the American Association for Music Therapy was created, though at that time called the Urban Federation of Music Therapists. The Certification Board for Music Therapists was created in 1983 which strengthened the practice of music therapy and the trust that it was given. In 1998, the American Music Therapy Association was formed out of a merger between National and American Associations and as of 2017 is the single largest music therapy organization in the world (American music therapy, 1998–2011). Ancient flutes, carved from ivory and bone, were found by archaeologists, that were determined to be from as far back as 43,000 years ago. He also states that "The earliest fragment of musical notation is found on a 4,000-year-old Sumerian clay tablet, which includes instructions and tuning for a hymn honoring the ruler Lipit-Ishtar. But for the title of oldest extant song, most historians point to "Hurrian Hymn No. 6," an ode to the goddess Nikkal that was composed in cuneiform by the ancient Hurrian's sometime around the 14th century B.C.". Western cultures Music and healing Music has been used as a healing implement for centuries. Apollo is the ancient Greek god of music and of medicine and his son Aesculapius was said to cure diseases of the mind by using song and music. By 5000 BC, music was used for healing by Egyptian priest-physicians. Plato said that music affected the emotions and could influence the character of an individual. Aristotle taught that music affects the soul and described music as a force that purified the emotions. Aulus Cornelius Celsus advocated the sound of cymbals and running water for the treatment of mental disorders. Music as therapy was practiced in the Bible when David played the harp to rid King Saul of a bad spirit (1 Sam 16:23). As early as 400 B.C., Hippocrates played music for mental patients. In the thirteenth century, Arab hospitals contained music-rooms for the benefit of the patients. In the United States, Native American medicine men often employed chants and dances as a method of healing patients. The Turco-Persian psychologist and music theorist al-Farabi (872–950), known as Alpharabius in Europe, dealt with music for healing in his treatise Meanings of the Intellect, in which he discussed the therapeutic effects of music on the soul. In his De vita libri tres published in 1489, Platonist Marsilio Ficino gives a lengthy account of how music and songs can be used to draw celestial benefits for staying healthy. Robert Burton wrote in the 17th century in his classic work, The Anatomy of Melancholy, that music and dance were critical in treating mental illness, especially melancholia. The rise of an understanding of the body and mind in terms of the nervous system led to the emergence of a new wave of music for healing in the eighteenth century. Earlier works on the subject, such as Athanasius Kircher's Musurgia Universalis of 1650 and even early eighteenth-century books such as Michael Ernst Ettmüller's 1714 Disputatio effectus musicae in hominem (Disputation on the Effect of Music on Man) or Friedrich Erhardt Niedten's 1717 Veritophili, still tended to discuss the medical effects of music in terms of bringing the soul and body into harmony. But from the mid-eighteenth century works on the subject such as Richard Brocklesby's 1749 Reflections of Antient and Modern Musick, the 1737 Memoires of the French Academy of Sciences, or Ernst Anton Nicolai's 1745 (The Connection of Music to Medicine), stressed the power of music over the nerves. Music therapy: 17th – 19th century After 1800, some books on music and medicine drew on the Brunonian system of medicine, arguing that the stimulation of the nerves caused by music could directly improve or harm health. Throughout the 19th century, an impressive number of books and articles were authored by physicians in Europe and the United States discussing use of music as a therapeutic agent to treat both mental and physical illness. Music therapy: 1900 – From a western viewpoint, music therapy in the 20th and 21st centuries (as of 2021), as an evidence-based, allied healthcare profession, grew out of the aftermath of World Wars I and II. Particularly in the United Kingdom and United States, musicians would travel to hospitals and play music for soldiers with war-related emotional and physical trauma. Using music to treat the mental and physical ailments of active duty military and veterans was not new. Its use was recorded during the US Civil War and Florence Nightingale used it a decade earlier in the Crimean War. Despite research data, observations by doctors and nurses, praise from patients, and willing musicians, it was difficult to vastly increase music therapy services or establish lasting music therapy education programs or organizations in the early 20th century. However, many of the music therapy leaders of this time period provided music therapy during WWI or to its veterans. These were pioneers in the field such as Eva Vescelius, musician, author, 1903 founder of the short-lived National Therapeutic Society of New York and the 1913 Music and Health journal, and creator/teacher of a musicotherapy course; Margaret Anderton, pianist, World War I music therapy provider for Canadian soldiers, a strong believer in training for music therapists, and 1919 Columbia University musicotherapy teacher; Isa Maud Ilsen, a nurse and musician who was the American Red Cross Director of Hospital Music in World War I reconstruction hospitals, 1919 Columbia University musicotherapy teacher, 1926 founder of the National Association for Music in Hospitals, and author; and Harriet Ayer Seymour, music therapist to World War I veterans, author, researcher, lecturer/teacher, founder of the National Foundation for Music Therapy in 1941, author of the first music therapy textbook published in the United States. Several physicians also promoted music as a therapeutic agent during this time period. In the United States, the first music therapy bachelor's degree program was established in 1944 at Michigan State College (now Michigan State University). For history from the early 20th century to the present, see continents or individual countries in section. See also References Bibliography American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, D.C.: Author. Gibson, David (2018). The Complete Guide to Sound Healing (2nd ed.), Sound of Light. Goodman,K.D.(2011) Music therapy education and training: From theory to practice . Charles C . Thomas K.D.Goodman,Ed. (2015) International perspectives in music therapy education and training. Charles C Thomas K.D. Goodman (Ed.) (2023) Developing issues in world music therapy education and training: A plurality of views. Charles C Thomas. Hilliard, R. E. (2001). The effects of music therapy-based bereavement groups on mood and behavior of grieving children: A pilot study. Journal of Music Therapy, 38(4), 291–306. Hilliard, R. E. (2007). The effects of orff-based music therapy and social work groups on childhood grief symptoms and behaviors. Journal of Music Therapy, 44(2), 123–38. Jones, J. D. (2005). A comparison of songwriting and lyric analysis techniques to evoke emotional change in a single session with people who are chemically dependent, journal of Music Therapy, 42, 94–110. Krout, R. E. (2005). Applications of music therapist-composed songs in creating participant connections and facilitating goals and rituals during one-time bereavement support groups and programs. Music Therapy Perspectives, 23(2), 118–128. Lindenfelser, K. J., Grocke, D., & McFerran, K. (2008). Bereaved parents' experiences of music therapy with their terminally ill child. Journal of Music Therapy, 45(3), 330–48. Rosner, R, Kruse, J., & Hagl, M. (2010). A meta‐analysis of interventions for bereaved children and adolescents. Death Studies, 34(2), 99 – 136. Schwantes, M., Wigram, T., McKinney, C., Lipscomb, A., & Richards, C. (2011). The Mexican corrido and its use in a music therapy bereavement group. The Australian Journal of Music Therapy, 22, 2–20. Silverman, M. J. (2008). Quantitative comparison of cognitive behavioral therapy and music therapy research: A methodological best-practices analysis to guide future investigation for adult psychiatric patients. Journal of Music Therapy, 45(4), 457–506. Silverman, M. J. (2009). The use of lyric analysis interventions in contemporary psychiatric music therapy: Descriptive results of songs and objectives for clinical practice. Music Therapy Perspectives, 27(1), 55–61. Silverman, M. J., & Marcionetti, M. J. (2004). Immediate effects of a single music therapy intervention on persons who are severely mentally ill. Arts in Psychotherapy, 31, 291–301. Valentino, R. E. (2006). Attitudes towards cross-cultural empathy in music therapy. Music Therapy Perspectives, 24(2), 108–114. Whitehead-Pleaux, A. M., Baryza, M.J., & Sheridan, R.L. (2007). Exploring the effects of music therapy on pediatric pain: phase 1. The Journal of Music Therapy, 44(3), 217–41. Further reading Aldridge, David ( 2000). Music Therapy in Dementia Care, London: Jessica Kingsley Publishers. Boynton, Dori, compiler (1991). Lady Boynton's "New Age" Dossiers: a Serendipitous Digest of News and Articles on Trends in Modern Day Mysticism and Decadence. New Port Richey, Flor.: Lady D. Boynton. 2 vol. N.B.: Anthology of reprinted articles, pamphlets, etc. on New Age aspects of speculation in psychology, philosophy, music (especially music therapy), religion, sexuality, etc. Bruscia, Kenneth E. "Frequently Asked Questions About Music Therapy". Boyer College of Music and Dance, Music Therapy Program, Temple University, 1993. Bunt, Leslie; Stige, Brynjulf (2014). Music Therapy: An Art Beyond Words. (Second edition.) London: Routledge. . Davis, William B., Kate E. Gfeller, and Michael H. Thaut (2008). An Introduction to Music Therapy: Theory and Practice. Third ed. Silver Springs, MD: American Music Therapy Association. Erlmann, Veit (ed.) Hearing Cultures. Essays on Sound, Listening, and Modernity, New York: Berg Publishers, 2004. Cf. especially Chapter 5, "Raising Spirits and Restoring Souls". Gibson, David (2018). The Complete Guide to Sound Healing. (2nd ed.) Sound of Light. Gold, C., Heldal, T.O., Dahle, T., Wigram, T. (2006). "Music therapy for schizophrenia or schizophrenia-like illnesses", Cochrane Database of Systematic Reviews, Issue 4. Harbert, Wilhelmina K., (1947). "Some principles, practices and techniques in musical therapy". University of the Pacific Dissertations. Hart, Hugh. (March 23, 2008) The New York Times "A Season of Song, Dance and Autism". Section: AR; p. 20. La Musicothérapie: thémathèque. Montréal, Bibliothèque du personnel, Hôpital Rivière-des-Prairies, 1978. Levinge, Alison (2015). The Music of Being: Music Therapy, Winnicott and the School of Object Relations. London: Jessica Kingsley Publishers. . Marcello Sorce Keller, "Some Ethnomusicological Considerations about Magic and the Therapeutic Uses of Music", International Journal of Music Education, 8/2 (1986), 13–16. Pellizzari, Patricia y colaboradores: Flavia Kinisberg, Germán Tuñon, Candela Brusco, Diego Patles, Vanesa Menendez, Julieta Villegas, y Emmanuel Barrenechea (2011). "Crear Salud", aportes de la Musicoterapia preventiva-comunitaria. Patricia Pellizzari Ediciones. Buenos Aires Ruud, Even (2010). Music Therapy: A Perspective from the Humanities. Barcelona Publishers. . Vladimir Simosko. Is Rock Music Harmful? Winnipeg: 1987 Vladimir Simosko. Jung, Music, and Music Therapy: Prepared on the Occasion of the "C.G. Jung and the Humanities" Colloquium, 1987. Winnipeg: The Colloqium Vomberg, Elizabeth. Music for the Physically Disabled Child: a Bibliography. Toronto: 1978. External links Sound Healing: Therapeutic Frequencies for Mind and Body Rehabilitation medicine

Social model of disability

The social model of disability identifies systemic barriers, derogatory attitudes, and social exclusion (intentional or inadvertent), which make it difficult or impossible for disabled people to attain their valued functionings. The social model of disability diverges from the dominant medical model of disability, which is a functional analysis of the body as a machine to be fixed in order to conform with normative values. As the medical model of disability carries with it a negative connotation, with negative labels associated with disabled people. The social model of disability seeks to challenge power imbalances within society between differently-abled people and seeks to redefine what disability means as a diverse expression of human life. While physical, sensory, intellectual, or psychological variations may result in individual functional differences, these do not necessarily have to lead to disability unless society fails to take account of and include people intentionally with respect to their individual needs. The origin of the approach can be traced to the 1960s, and the specific term emerged from the United Kingdom in the 1980s. The social model of disability is based on a distinction between the terms impairment and disability. In this model, the word impairment is used to refer to the actual attributes (or lack of attributes) that affect a person, such as the inability to walk or breathe independently. It seeks to redefine disability to refer to the restrictions caused by society when it does not give equitable social and structural support according to disabled peoples' structural needs. As a simple example, if a person is unable to climb stairs, the medical model focuses on making the individual physically able to climb stairs. The social model tries to make stair-climbing unnecessary, such as by making society adapt to their needs, and assist them by replacing the stairs with a wheelchair-accessible ramp. According to the social model, the person remains disabled with respect to climbing stairs, but the disability is negligible and no longer disabling in that scenario, because the person can get to the same locations without climbing any stairs. It celebrates a non-conformist approach to the concept of disability and confronts deficit thinking of disability, which is argued to sit alongside the lines of activism and identity of pride for individuals with disabilities. History Disability rights movement There is a hint from before the 1970s that the interaction between disability and society was beginning to be considered. British politician and disability rights campaigner Alf Morris wrote in 1969 (emphasis added):The history of the social model of disability begins with the history of the disability rights movement. Around 1970, various groups in North America, including sociologists, disabled people, and disability-focused political groups, began to pull away from the accepted medical lens of viewing disability. Instead, they began to discuss things like oppression, civil rights, and accessibility. This change in discourse resulted in conceptualizations of disability that was rooted in social constructs. In 1975, the UK organization Union of the Physically Impaired Against Segregation (UPIAS) claimed: "In our view it is society which disables physically impaired people. Disability is something imposed on top of our impairments by the way we are unnecessarily isolated and excluded from full participation in society." This became known as the social interpretation, or social definition, of disability. Mike Oliver Following the UPIAS "social definition of disability", in 1983 the disabled academic Mike Oliver coined the phrase social model of disability in reference to these ideological developments. Oliver focused on the idea of an individual model (of which the medical was a part) versus a social model, derived from the distinction originally made between impairment and disability by the UPIAS. Oliver focused on the idea of an individual model versus a social model. Oliver's seminal 1990 book The Politics of Disablement is widely cited as a major moment in the adoption of this model. The book included just three pages about the social model of disability. Developments The "social model" was extended and developed by academics and activists in Australia, the UK, the US, and other countries to include all disabled people, including those who have learning disabilities, intellectual disabilities, or emotional, mental health or behavioural problems. Tool for cultural analysis The social model has become a key tool in the analysis of the cultural representation of disability; from literature, to radio, to charity-imagery to cinema. The social model has become the key conceptual analysis in challenging, for examples, stereotypes and archetypes of disabled people by revealing how conventional imagery reinforces the oppression of disabled people. Key theorists include Paul Darke (cinema), Lois Keith (literature), Leonard Davis (Deaf culture), Jenny Sealey (theatre) and Mary-Pat O'Malley (radio). Components and usage A fundamental aspect of the social model concerns equality. The struggle for equality is often compared to the struggles of other socially marginalized groups. Equal rights are said to empower people with the "ability" to make decisions and the opportunity to live life to the fullest. A related phrase often used by disability rights activists, as with other social activism, is "Nothing About Us Without Us". The social model of disability focuses on changes required in society. These might be in terms of: Attitudes, for example a more positive attitude towards certain mental traits or behaviors, or not underestimating the potential quality of life of disabled people, Social support, for example help dealing with barriers; resources, aids, or positive discrimination to provide equal access, for example providing someone to explain work culture for an autistic employee. Information, for example using suitable formats (e.g. braille), levels (e.g. simplicity of language) or coverage (e.g. explaining issues others may take for granted), Physical structures, for example buildings with sloped access and elevators, or Flexible work hours for people with circadian rhythm sleep disorders. Limitations and criticisms Oliver did not intend the social model of disability to be an all-encompassing theory of disability, but rather a starting point in reframing how society views disability. This model was conceived of as a tool that could be used to improve the lives of disabled people, rather than a complete explanation for every experience and circumstance. An unintended consequence Oliver foresaw of the adoption of the social model of disability in politics was the undermining of the efforts of disabled people seeking social justice. A primary criticism of the social model is its centring of the experiences of individuals with physical impairments, which has resulted in overlooking other forms of disability, such as mental health conditions. A secondary criticism relates to how the social model underplays impairments' impacts. That is, the focus on how the social environment can cause disablement may ignore the fact that impairments "can be restrictive, painful and unpleasant". Conversely, some argue against the language of impairment, indicating that some disabilities are purely social and that no impairment exists, such as within the Deaf community. This relates to a critique regarding the belief of a species norm, wherein there is a "normal" human body, and all variations to the norm may be considered "impairments". Some activists and academic argue that this reliance on a species norm still implies that impairments are deficits, meaning this model is still strongly connected to deficit models of disability. That is, to be considered disabled, an individual must state they have an impairment, which implies, to some degree, that they are damaged. To an extent can have impacts on how government can distribute benefits on ground of impairments that may be more significant and those that are not. Thus, some needs are not met on the basis of not having an impairment significant enough to receive aid, which can be a negative application of the social model within government policy. Newer paradigms, such as Mad studies and neurodiversity studies, recognize a broad spectrum of human experience without a focus on a species norm and thus, deviances from that norm that may be considered impairments or deficits. The social model has also been criticized for not promoting the normal differences between disabled people, who can be any age, gender, race, and sexual orientation, and instead presenting them as a monolithic, insufficiently individuated group of people. Despite these criticisms, academics whose work involves disability indicate that the social model is still beneficial in helping people begin to rethink disability beyond deficit. As Finkelstein states: "A good model can enable us to see something which we do not understand because in the model it can be seen from different viewpoints [...] that can trigger insights that we might not otherwise develop." As an identity In the late 20th century and early 21st century, the social model of disability became a dominant identity for disabled people in the UK. Under the social model of disability, a disability identity is created by "the presence of impairment, the experience of disablism and self- identification as a disabled person." The social model of disability implies that attempts to change, "fix", or "cure" individuals, especially when used against the wishes of the individual, can be discriminatory and prejudiced. This attitude, which may be seen as stemming from a medical model and a subjective value system, can harm the self-esteem and social inclusion of those constantly subjected to it (e.g. being told they are not as good or valuable, in an overall and core sense, as others). Some communities have actively resisted "treatments", while, for example, defending a unique culture or set of abilities. In the Deaf community, sign language is valued even if most people do not know it, and some parents argue against cochlear implants for deaf infants who cannot consent to them. Autistic people may say that their "unusual" behavior, which they say can serve an important purpose to them, should not have to be suppressed to please others. They argue instead for acceptance of neurodiversity and accommodation to different needs and goals. Some people diagnosed with a mental disorder argue that they are just different and do not necessarily conform. The biopsychosocial model of disease/disability is an attempt by practitioners to address this. The label "neurodiversity" has been used by various mental-disability rights advocates within the context of the social model of disability. The label, originally associated with autism, has been applied to other neurodevelopmental conditions, such as attention deficit hyperactivity disorder, developmental speech disorders, dyslexia, dysgraphia, dyspraxia, dyscalculia, dysnomia, intellectual disability, and Tourette syndrome, as well as schizophrenia, bipolar disorder, and some mental health conditions such as schizoaffective disorder, antisocial personality disorder, dissociative disorders, and obsessive–compulsive disorder. The social model itself from the language that implies those who are neurodiverse are living behind barriers that inhibit participation in everyday life. Language associated with warfare such as "battling" or "combatting" is thus replaced with language that de-pathologizes neurodiversity. Advocates for a social model of disability argue instead that neurodiversity should be looked at through the lens of societal or relational models of disability. The social model implies that practices such as eugenics are founded on social values and a prejudiced understanding of the potential and value of those labeled disabled. "Over 200,000 disabled people were some of the earlier victims of the Holocaust, after Communists, other political enemies, and homosexuals." A 1986 article stated: Economic aspects The social model also relates to economic empowerment, proposing that people can be disabled by a lack of resources to meet their needs. For example, a disabled person may need support services to be able to participate fully in society, and can become disabled if society cuts access to those support services, perhaps in the name of government austerity measures. The social model addresses other issues, such as the underestimation of the potential of disabled people to contribute to society and add economic value to society if they are given equal rights and equally suitable facilities and opportunities as others. Economic research on companies that attempt to accommodate disability in their workforce suggest they outperform competitors. In Autumn 2001, the UK Office for National Statistics identified that approximately one-fifth of the working-age population was disabled, equating to an estimated 7.1 million disabled people, compared to an estimated 29.8 million nondisabled people. This analysis also provided insight into some of the reasons why disabled people were not in the labor market, such as that the reduction in disability benefits in entering the labor market would not make it worthwhile to enter into employment. A three-pronged approach was suggested: "incentives to work via the tax and benefit system, for example through the Disabled Person's Tax Credit; helping people back into work, for example via the New Deal for Disabled People; and tackling discrimination in the workplace via anti-discrimination policy. Underpinning this are the Disability Discrimination Act (DDA) 1995 and the Disability Rights Commission." Canada and the United States have operated under the premise that social assistance benefits should not exceed the amount of money earned through labour in order to give citizens an incentive to search for and maintain employment. This has led to widespread poverty amongst disabled citizens. In the 1950s, disability pensions were established and included various forms of direct economic assistance; however, compensation was low. Since the 1970s, both governments have viewed unemployed, disabled citizens as excess labor due to continuous high unemployment rates and have made minimal attempts to increase employment, keeping disabled people at poverty-level incomes due to the 'incentive' principle. Poverty is the most debilitating circumstance disabled people face, resulting in the inability to afford proper medical, technological and other assistance necessary to participate in society. Law and public policy In the United Kingdom, the Disability Discrimination Act 1995 defines disability using the medical model – disabled people are defined as people with certain conditions or limitations on their ability to carry out "normal day-to-day activities." But the requirement of employers and service providers to make "reasonable adjustments" to their policies or practices, or physical aspects of their premises, follows the social model. By making adjustments, employers and service providers are removing the barriers that disable, according to the social model. In 2006, amendments to the act called for local authorities and others to actively promote disability equality; this was enforced via the formation of the Disability Equality Duty in December 2006. In 2010, the Disability Discrimination Act 1995 was amalgamated into the Equality Act 2010, along with other pertinent discrimination legislation. The Equality Act 2010 extends the law on discrimination to indirect discrimination. For example, if a carer of a disabled person is discriminated against, this is now also unlawful. Since October 2010, when it came into effect, employers may not legally ask questions about illness or disability at interviews for a job or for a referee to comment on such in a reference, except where there is a need to make reasonable adjustments for an interview to proceed. Following an offer of a job, an employer can lawfully ask such questions. In the United States, the Americans with Disabilities Act of 1990 (ADA), is a wide-ranging civil rights law that prohibits discrimination based on disability in a wide range of settings. The ADA was the first civil rights law of its kind in the world and affords protections against discrimination to disabled Americans. The law was modeled after the Civil Rights Act of 1964, which made discrimination based on race, religion, sex, national origin, and other characteristics illegal. It requires that mass transportation, commercial buildings, and public accommodations be accessible to disabled people. In 2007, the European Court of Justice in the Chacón Navas v Eurest Colectividades SA court case, defined disability narrowly according to a medical definition that excluded temporary illness, when considering the Directive establishing a general framework for equal treatment in employment and occupation (Council Directive 2000/78/EC). The directive did not provide for any definition of disability, despite discourse in policy documents previously in the EU about endorsing the social model of disability. This allowed the Court of Justice to take a narrow medical definition. Technology Over the last several decades, technology has transformed networks, services, and communication by promoting the rise of telecommunications, computer use, etc. This Digital Revolution has changed how people work, learn, and interact, moving these basic human activities to technological platforms. However, many people who use such technology experience a form of disability. Even if it is not physically visible, those with, for example cognitive impairments, hand tremors, or vision impairments, have some form of disability that prohibit them from fully accessing technology in the way that those without a "technological disability" do. In Disability and New Media, Katie Ellis and Mike Kent state that "technology is often presented as a source of liberation; however, developments associated with Web 2.0 show that this is not always the case". They go on to state that the technological advancement of Web 2.0 is tethered to social ideology and stigma which "routinely disables people with disability". In Digital Disability: The Social Construction of Disability in New Media, Gregg Goggin and Christopher Newell call for an innovative understanding of new media and disability issues. They trace developments ranging from telecommunications to assistive technologies to offer a technoscience of disability, which offers a global perspective on how disabled people are represented as users, consumers, viewers, or listeners of new media, by policymakers, corporations, programmers, and disabled people themselves. Social construction of disability The social construction of disability comes from a paradigm that suggests that society's beliefs about a particular community, group, or population are grounded in the power structures inherent in that society at any given time. The social expectations surrounding concepts, such as disability, thereby enabling a social construct around what society deems disabled and healthy, often based more on observations or value judgements rather than scientific discovery, which can perpetuate biases. Ideas surrounding disability stem from societal attitudes, often connected to who is deserving or undeserving, and deemed productive to society at any given time. For example, in the medieval period, a person's moral behavior established disability. Disability was a divine punishment or side effect of a moral failing; being physically or biologically different was not enough to be considered disabled. Only during the Age of Enlightenment did society change its definition of disability to be more related to biology. However, what most Western Europeans considered to be healthy determined the new biological definition of health. 2000 Paralympics While the Olympics were covered live throughout the entire event, the Paralympics were not seen as important enough for the same live coverage before the initial showing. By separating the Olympics and Paralympics, and thus indicating that one is less valuable than the other, disability is socially constructed. Applications Applying the social model of disability can change goals and care plans. For example, with the medical model of disability, the goal may be to help a child acquire typical abilities and to reduce impairment. With the social model, the goal may be to have a child be included in the normal life of the community, such as attending birthday parties and other social events, regardless of the level of function. In doing so would create a new norm associated with differently abled people as well as neurodiverse people as well. Allowing for this kind of diversity to be viewed as both valuable and desirable for society. As well, this could include designed spaces and aides that could assist disabled people through the context of universal design, which could help normalize disability through the creation of inclusive spaces. Education It has been suggested that disability education tries to restore the idea of a moral community, one in which the members question what constitutes a good life, reimagine education, see physical and mental conditions as part of a range of abilities, consider that different talents are distributed in different ways, and understand that all talents should be recognized. In this system, all students would be included in the educational network instead of being set apart as special cases, and it would be acknowledged that all humans have individual needs. See also Ableism Assisted living Autism-friendly Capability approach Convention on the Rights of Persons with Disabilities Curb cut effect Deaf rights movement Disability in the media Disability justice Equality Act Inclusion (disability rights) Inspiration porn Medical industrial complex Medicalization Models of deafness Neurodiversity and labor rights Normalization (people with disabilities) People-first language Redundant elevators Sensory friendly Services and supports for people with disabilities Sexuality and disability Social constructionism Survivorship bias Universal design Web accessibility Further reading References External links UK Disability Rights Commission: The Social Model of Disability. Accessed 2009-10-15. Article on Disability Perspectives and Data Sources from Government of Canada. Disability Disability rights Disability studies Accessibility Medical sociology Medical models Political theories Sociological theories Social theories Social constructionism Articles containing video clips

Vicarious traumatization

Vicarious trauma (VT) is a term invented by Irene Lisa McCann and Laurie Anne Pearlman that is used to describe how work with traumatized clients affects trauma therapists. The phenomenon had been known as secondary traumatic stress, a term coined by Charles Figley. In vicarious trauma, the therapist experiences a profound worldview change and is permanently altered by empathetic bonding with a client. This change is thought to have three requirements: empathic engagement and exposure to graphic, traumatizing material; exposure to human cruelty; and the reenactment of trauma in therapy. This can produce changes in a therapist's spirituality, worldview, and self-identity. Vicarious trauma is a subject of debate by theorists, with some saying that it is based on the concepts of countertransference and compassion fatigue. McCann and Pearlman say that there is probably a relationship to these constructs, but vicarious trauma is distinct. Understanding of the phenomenon is evolving. Signs and symptoms Symptoms of vicarious trauma align with those of primary trauma. As professionals attempt to connect with their clients emotionally, the symptoms of vicarious trauma can create emotional disturbances such as sadness, grief, irritability, and mood swings. Signs and symptoms of vicarious trauma parallel those of direct trauma, although they tend to be less intense. Workers with personal-trauma histories may be more vulnerable to VT, although research findings are mixed. Common signs and symptoms include social withdrawal, mood swings, aggression, increased sensitivity to violence, somatic symptoms, sleep difficulties, intrusive imagery, cynicism, sexual difficulties, difficulty managing boundaries with clients, and relationship difficulties which reflect problems with security, trust, esteem, intimacy, and control. Contributing factors Vicarious trauma, conceptually based in constructivism, arises from interaction between individuals and their situations. A helper's personal history (including prior traumatic experiences), coping strategies, support network, and other things interact with his or her situation (including work setting, nature of the work, and clientele served) and may trigger vicarious trauma. Individuals respond and adapt to, and cope with, VT differently. It has been suggested that traumatization occurs when one's view of the world, or a feeling of safety, is shattered by hearing about the experiences of a client. This exposure to trauma can interrupt a clinician's daily functioning, reducing their effectiveness. Anything that interferes with a helper's ability to fulfill his or her responsibility to assist traumatized clients can contribute to vicarious trauma. Many human-service workers report that administrative and bureaucratic factors that are an impediment to their effectiveness influence work satisfaction. Negative aspects of an organization such as reorganization, downsizing in the name of change management, and a lack of resources in the name of lean management contribute to burned-out workers. Vicarious trauma has also been attributed to the stigmatization of mental-health care by service providers. Stigma leads to an inability to engage in self-care; the service provider may reach burnout and become more likely to experience VT. Research has begun to indicate that vicarious trauma is more prominent in those with a prior history of trauma and adversity. A mental-health provider's defense style might pose a risk factor for vicarious traumatization; mental-health providers with self-sacrificing defense styles have been found to experience increased vicarious traumatization. Among EMS personnel, previous-veteran status increased the likelihood of experiencing vicarious trauma. Related concepts Although the term "vicarious trauma" has been used interchangeably with "compassion fatigue", "secondary traumatic stress disorder," "burnout," "countertransference" and "work-related stress," differences exist: Unlike compassion fatigue, VT is a theory-based construct. Observable symptoms can begin the process of discovering contributing factors and related signs, symptoms, and adaptations. VT specifies psychological domains that can be affected, rather than specific symptoms. This may more accurately guide preventive measures and interventions, and allow for the accurate development of interventions for multiple domains (such as changes in the balance between psychotherapy and other work-related tasks and changes in self-care practices). Countertransference is a psychotherapist's response to a particular client. VT refers to responses across clients and time. Unlike burnout, countertransference and work-related stress, VT is specific to trauma workers; a helper will experience trauma-specific difficulties, such as intrusive imagery, that are not part of burnout or countertransference. Burnout and vicarious traumatization overlap regarding emotional exhaustion. A worker may experience both VT and burnout, and each has its own remedies. VT and countertransference may also co-occur, intensifying each other. Unlike vicarious trauma, countertransference can provide psychotherapists with important information about their clients. Work-related stress is a generic term without a theoretical basis, specific signs and symptoms, contributing factors, or remedies. Burnout and vicarious trauma can co-exist. Countertransference responses may increase vicarious trauma. Vicarious post-traumatic growth is not a theory-based construct, but is based on self-reported signs. Body-centred countertransference Mechanism The posited mechanism for vicarious traumatization is empathy. Different forms of empathy may have different effects on helpers. Batson and his colleagues have conducted research that might aid trauma helpers in managing empathic connection constructively. Measurement VT has been measured in a variety of ways. Vicarious trauma is a multifaceted construct, requiring a multifaceted assessment. Aspects of VT that would need to be measured for a full assessment include self-capacities, ego resources, frame of reference (identity, world view, and spirituality), psychological needs, and trauma symptoms. They include: Psychological needs, using the Trauma and Attachment Belief Scale Self-capacities, using the Inner Experience Questionnaire or the Inventory of Altered Self-Capacities Trauma symptoms, using the PTSD Checklist, Impact of Events Scale, Impact of Events Scale-Revised, children's revised Impact of Events Scale (Arabic Version), Trauma Symptom Inventory, Detailed Assessment of Posttraumatic Stress, or the World Assumptions Scale Secondary Traumatic Stress Scale is a 17-item, five-point Likert scale that distinguishes between PTSD measures by framing the questions as stressors from exposure to clients. The Professional Quality of Life (ProQol) version five, with 30 questions on a five-point Likert scale, measures compassion fatigue and secondary trauma. Vicarious traumatization may be addressed with awareness, balance, and connection. One set of approaches is coping strategies, which include self-care, rest, escape, and play. A second set of approaches can be grouped as transforming strategies, which aim to help workers create community and find meaning through the work. Within each category, strategies may be applied in one's personal and professional lives. Organizations that provide trauma services can also play a role in mitigating vicarious trauma. Many simple things increase happiness, which lessens the impact of vicarious traumatization. People who are more socially connected tend to be happier. People who consciously practice gratitude are also shown happier. Creative endeavors that are detached from work also increase happiness. Self-care practices such as yoga, qigong, and sitting meditation have been found helpful. Harvard Business Review, in a case study of traumatization, noted the importance of an organizational culture which values social workers and counselors. Research indicates that clinicians exposed to vicarious trauma need targeted interventions such as respite, increasing self-efficacy, and appropriate professional support increase their resilience and act as a buffer against vicarious trauma. Prognosis Children have been found to experience vicarious trauma from trauma experienced by their caregivers and peers. Girls experience VT more than boys, and socioeconomic status and race have been found to predict vicarious trauma symptoms. Counselors and other mental-health professionals have been found to experience vicarious trauma when working with veterans and others who have experienced trauma. Factors that predict vicarious-trauma severity include professional trauma, level of peer supervision, population served by the clinician, defense mechanisms of the therapist, emotional coping strategies, and social-support availability. Foster parents have also been found to experience vicarious trauma related to the trauma of their children. Several studies have found that foster parents experience vicarious trauma, burnout and compassion fatigue, and report emotional disengagement (a common symptom of VT) as a coping strategy. See also Allostatic load Emotional labor Historical trauma W. H. R. Rivers Secondary traumatic stress Vicarious trauma after viewing media References Further reading External links University of Pennsylvania Positive Psychology Center Vicarious Trauma Among Therapists, University of Alberta Counseling Types of mental disorders

Situation, task, action, result

The situation, task, action, result (STAR) format is a technique used by interviewers to gather all the relevant information about a specific capability that the job requires. Situation: The interviewer wants you to present a recent challenging situation in which you found yourself. Task: What were you required to achieve? The interviewer will be looking to see what you were trying to achieve from the situation. Some performance development methods use “Target” rather than “Task”. Job interview candidates who describe a “Target” they set themselves instead of an externally imposed “Task” emphasize their own intrinsic motivation to perform and to develop their performance. Action: What did you do? The interviewer will be looking for information on what you did, why you did it and what the alternatives were. Results: What was the outcome of your actions? What did you achieve through your actions? Did you meet your objectives? What did you learn from this experience? Have you used this learning since? The STAR technique is similar to the SOARA technique (Situation, Objective, Action, Result, Aftermath). The STAR technique is also often complemented with an additional R on the end STARR or STAR(R) with the last R resembling reflection. This R aims to gather insight and interviewee's ability to learn and iterate. Whereas the STAR reveals how and what kind of result on an objective was achieved, the STARR with the additional R helps the interviewer to understand what the interviewee learned from the experience and how they would assimilate experiences. The interviewee can define what they would do (differently, the same, or better) next time being posed with a situation. Common questions that the STAR technique can be applied to include conflict management, time management, problem solving and interpersonal skills. References External links The ‘STAR’ technique to answer behavioral interview questions The STAR method explained Job interview Logical consequence Schedule (project_management)

Nomothetic

Nomothetic literally means "proposition of the law" (Greek derivation) and is used in philosophy, psychology, and law with differing meanings. Etymology In the general humanities usage, nomothetic may be used in the sense of "able to lay down the law", "having the capacity to posit lasting sense" (from , from nomothetēs νομοθέτης "lawgiver", from νόμος "law" and the Proto-Indo-European etymon nem- meaning to "take, give, account, apportion")), e.g., 'the nomothetic capability of the early mythmakers' or 'the nomothetic skill of Adam, given the power to name things.' In psychology In psychology, nomothetic refers to research about general principles or generalizations across a population of individuals. For example, the Big Five model of personality and Piaget's developmental stages are nomothetic models of personality traits and cognitive development respectively. In contrast, idiographic refers to research about the unique and contingent aspects of individuals, as in psychological case studies. In psychological testing, nomothetic measures are contrasted to ipsative or idiothetic measures, where nomothetic measures are measures that are observed on a relatively large sample and have a more general outlook. In other fields In sociology, nomothetic explanation presents a generalized understanding of a given case, and is contrasted with idiographic explanation, which presents a full description of a given case. Nomothetic approaches are most appropriate to the deductive approach to social research inasmuch as they include the more highly structured research methodologies which can be replicated and controlled, and which focus on generating quantitative data with a view to explaining causal relationships. In anthropology, nomothetic refers to the use of generalization rather than specific properties in the context of a group as an entity. In history, nomothetic refers to the philosophical shift in emphasis away from traditional presentation of historical text restricted to wars, laws, dates, and such, to a broader appreciation and deeper understanding. See also Nomothetic and idiographic Nomological References Sociological terminology

Mental energy

Mental energy may be understood as the ability or willingness to engage in cognitive work. It is distinct from physical energy, and has mood, cognition, and motivation domains. Concepts closely related to mental energy include vigor and fatigue. Mental energy is not well-defined, and the scientific literature on mental energy is quite limited. A variety of measures for assessing aspects of mental energy exist. Many people complain of low mental energy, which can interfere with work and daily activities. Low mental energy and fatigue are major public health concerns. People may pursue remedies or treatment for low mental energy. Seeking to improve mental energy is a common reason that people take dietary supplements. Neurotransmitters Many different neurotransmitters have been theoretically implicated in the control of mental energy. This has often been based on the effects of drugs acting on these neurotransmitters. These neurotransmitters include dopamine, norepinephrine, orexin, serotonin, histamine, acetylcholine, adenosine, and glutamate. Hormones, including glucocorticoids like cortisol, as well as cytokines, have also been found to regulate mental energy. Food, drugs, sleep, diseases Mental energy can be affected by factors such as drugs, sleep, and disease. Drugs Drugs that may increase mental energy include caffeine, modafinil, psychostimulants like amphetamines and methylphenidate, and corticosteroids like hydrocortisone and dexamethasone. Drugs that may decrease mental energy include sedatives and hypnotics like antihistamines, benzodiazepines, and melatonin, as well as dopamine receptor antagonists like antipsychotics. Foods, beverages etc There are many marketing claims of foods, beverages, and dietary supplements improving mental energy, but data to substantiate such claims are limited or absent. Sleep Sleep deprivation may decrease mental energy in an exposure-dependent manner. Disease Various disease states, such as cardiac disease, cancer, stroke, HIV/AIDS, multiple sclerosis, Parkinson's disease, and certain mental health conditions like depression, may be associated with decreased mental energy. Chronic fatigue syndrome is characterized by a lack of the energy needed for the basic activities of daily life. See also Disorders of diminished motivation References Mental states Subjective experience

Self-regulation theory

Self-regulation theory (SRT) is a system of conscious, personal management that involves the process of guiding one's own thoughts, behaviors and feelings to reach goals. Self-regulation consists of several stages. In the stages individuals must function as contributors to their own motivation, behavior, and development within a network of reciprocally interacting influences. Roy Baumeister, one of the leading social psychologists who have studied self-regulation, claims it has four components: standards of desirable behavior, motivation to meet standards, monitoring of situations and thoughts that precede breaking said standards and lastly, willpower. Baumeister along with other colleagues developed three models of self-regulation designed to explain its cognitive accessibility: self-regulation as a knowledge structure, strength, or skill. Studies have been conducted to determine that the strength model is generally supported, because it is a limited resource in the brain and only a given amount of self-regulation can occur until that resource is depleted. SRT can be applied to: Impulse control, the management of short-term desires. People with low impulse control are prone to acting on immediate desires. This is one route for such people to find their way to jail as many criminal acts occur in the heat of the moment. For non-violent people it can lead to losing friends through careless outbursts, or financial problems caused by making too many impulsive purchases. The cognitive bias known as illusion of control. To the extent that people are driven by internal goals concerned with the exercise of control over their environment, they will seek to reassert control in conditions of chaos, uncertainty or stress. Failing genuine control, one coping strategy will be to fall back on defensive attributions of control—leading to illusions of control (Fenton-O'Creevy et al., 2003). Goal attainment and motivation Sickness behavior SRT consists of several stages. First, the patient deliberately monitors one's own behavior and evaluates how this behavior affects one's health. If the desired effect is not realized, the patient changes personal behavior. If the desired effect is realized, the patient reinforces the effect by continuing the behavior. (Kanfer 1970;1971;1980) Another approach is for the patient to realize a personal health issue and understand the factors involved in that issue. The patient must decide upon an action plan for resolving the health issue. The patient will need to deliberately monitor the results in order to appraise the effects, checking for any necessary changes in the action plan. (Leventhal & Nerenz 1984) Another factor that can help the patient reach his/her own goal of personal health is to relate to the patient the following: Help them figure out the personal/community views of the illness, appraise the risks involved and give them potential problem-solving/coping skills. Four components of self-regulation described by Baumeister et al. (2007) are: Standards: Of desirable behavior. Motivation: To meet standards. Monitoring: Of situations and thoughts that precede breaking standards. Willpower: Internal strength to control urges History and contributors Albert Bandura There have been numerous researchers, psychologists and scientists who have studied self-regulatory processes. Albert Bandura, a cognitive psychologist had significant contributions focusing on the acquisition of behaviors that led to the social cognitive theory and social learning theory. His work brought together behavioral and cognitive components in which he concluded that "humans are able to control their behavior through a process known as self-regulation." This led to his known process that contained: self observation, judgment and self response. Self observation (also known as introspection) is a process involving assessing one's own thoughts and feelings in order to inform and motivate the individual to work towards goal setting and become influenced by behavioral changes. Judgement involves an individual comparing his or her performance to their personal or created standards. Lastly, self-response is applied, in which an individual may reward or punish his or herself for success or failure in meeting standard(s). An example of self-response would be rewarding oneself with an extra slice of pie for doing well on an exam. Dale Schunk According to Schunk (2012), Lev Vygotsky who was a Russian psychologist and was a major influence on the rise of constructivism, believed that self-regulation involves the coordination of cognitive processes such as planning, synthesizing and formulating concepts (Henderson & Cunningham, 1994); however, such coordination does not proceed independently of the individual's social environment and culture. In fact, self-regulation is inclusive of the gradual internalization of language and concepts. Schunk's Learning Theories: An Educational Perspective is stated to give a contemporary and historical overview of learning theories for undergraduate and graduate learners Roy Baumeister As a widely studied theory, SRT was also greatly impacted by the well-known social psychologist Roy Baumeister. He described the ability to self-regulate as limited in capacity and through this he coined the term ego depletion. The four components of self-regulation theory described by Roy Baumeister are standards of desirable behavior, motivation to meet standards, monitoring of situations and thoughts that precede breaking standards and willpower, or the internal strength to control urges. In Baumeister's paper titled Self-Regulation Failure: An Overview, he express that self-regulation is complex and multifaceted. Baumeister lays out his “three ingredients” of self-regulation as a case for self-regulation failure. Research Many studies have been done to test different variables regarding self-regulation. Albert Bandura studied self-regulation before, after and during the response. He created the triangle of reciprocal determinism that includes behavior, environment and the person (cognitive, emotional and physical factors) that all influence one another. Bandura concluded that the processes of goal attainment and motivation stem from an equal interaction of self-observation, self-reaction, self-evaluation and self-efficacy. In addition to Bandura's work, psychologists Muraven, Tice and Baumeister conducted a study for self control as a limited resource. They suggested there were three competing models to self-regulation: self-regulation as a strength, knowledge structure and a skill. In the strength model, they indicated it is possible self-regulation could be considered a strength because it requires willpower and thus is a limited resource. Failure to self-regulate could then be explained by depletion of this resource. For self-regulation as a knowledge structure, they theorized it involves a certain amount of knowledge to exert self control, so as with any learned technique, failure to self-regulate could be explained by insufficient knowledge. Lastly, the model involving self-regulation as a skill referred to self-regulation being built up over time and unable to be diminished; therefore, failure to exert would be explained by a lack of skill. They found that self-regulation as a strength is the most feasible model due to studies that have suggested self-regulation is a limited resource. Dewall, Baumeister, Gailliot and Maner performed a series of experiments instructing participants to perform ego depletion tasks to diminish the self-regulatory resource in the brain, that they theorized to be glucose. This included tasks that required participants to break a familiar habit, where they read an essay and circled words containing the letter 'e' for the first task, then were asked to break that habit by performing a second task where they circled words containing 'e' and/or 'a'. Following this trial, participants were randomly assigned to either the glucose category, where they drank a glass of lemonade made with sugar, or the control group, with lemonade made from Splenda. They were then asked their individual likelihoods of helping certain people in hypothetical situations, for both kin and non-kin and found that excluding kin, people were much less likely to help a person in need if they were in the control group (with Splenda) than if they had replenished their brain glucose supply with the lemonade containing real sugar. This study also supports the model for self-regulation as a strength because it confirms it is a limited resource. Baumeister and colleagues expanded on this and determined the four components to self-regulation. Those include standards of desirable behavior, motivation to meet these standards, monitoring of situations and thoughts that precede breaking standards and willpower. Applications and examples Impulse control in self-regulation involves the separation of our immediate impulses and long-term desires. We can plan, evaluate our actions and refrain from doing things we will regret. Research shows that self-regulation is a strength necessary for emotional well-being. Violation of one's deepest values results in feelings of guilt, which will undermine well-being. The illusion of control involves people overestimating their own ability to control events. Such as, when an event occurs an individual may feel greater a sense of control over the outcome that they demonstrably do not influence. This emphasizes the importance of perception of control over life events. The self-regulated learning is the process of taking control and evaluating one's own learning and behavior. This emphasizes control by the individual who monitors, directs and regulates actions toward goals of information. In goal attainment self-regulation it is generally described in these four components of self-regulation. Standards, which is the desirable behavior. Motivation, to meet the standards. Monitoring, situations and thoughts that precede breaking standards. Willpower, internal strength to control urges. Illness behavior in self-regulation deals with issues of tension that arise between holding on and letting go of important values and goals as those are threatened by disease processes. Also people who have poor self-regulatory skills do not succeed in relationships or cannot hold jobs. Sayette (2004) describes failures in self-regulation as in two categories: under regulation and misregualtion. Under regulation is when people fail to control oneself whereas misregualtion deals with having control but does not bring up the desired goal (Sayette, 2004). Criticisms/challenges One challenge of self-regulation is that researchers often struggle with conceptualizing and operationalizing self-regulation (Carver & Scheier, 1990). The system of self-regulation comprises a complex set of functions, including research cognition, problem solving, decision making and meta cognition. Ego depletion refers to self control or willpower drawing from a limited pool of mental resources. If an individual has low mental activity, self control is typically impaired, which may lead to ego depletion. Self control plays a valuable role in the functioning of self in people. The illusion of control involves the overestimation of an individual's ability to control certain events. It occurs when someone feels a sense of control over outcomes although they may not possess this control. Psychologists have consistently emphasized the importance of perceptions of control over life events. Heider proposed that humans have a strong motive to control their environment. Reciprocal determinism is a theory proposed by Albert Bandura, stating that a person's behavior is influenced both by personal factors and the social environment. Bandura acknowledges the possibility that individual's behavior and personal factors may impact the environment. These can involve skills that are either under or overcompensating the ego and will not benefit the outcome of the situation. Recently, Baumeister's strength model of ego depletion has been criticized in multiple ways. Meta-analyses found little evidence for the strength model of self-regulation and for glucose as the limited resource that is depleted. A pre-registered trial did not find any evidence for ego depletion. Several commentaries have raised criticism on this particular study. In summary, many central assumptions of the strength model of self-regulation seem to be in need of revision, especially the view of self-regulation as a limited resource that can be depleted and glucose as the fuel that is depleted seems to be hardly defensible without major revisions. Conclusion Self-regulation can be applied to many aspects of everyday life, including social situations, personal health management, impulse control and more. Since the strength model is generally supported, ego depletion tasks can be performed to temporarily tax the amount of self-regulatory capabilities in a person's brain. It is theorized that self-regulation depletion is associated with willingness to help people in need, excluding members of an individual's kin. Many researchers have contributed to these findings, including Albert Bandura, Roy Baumeister and Robert Wood. See also Rubicon model Emotional self-regulation References Self-control

Adaptive behavior

Adaptive behavior is behavior that enables a person (usually used in the context of children) to cope in their environment with greatest success and least conflict with others. This is a term used in the areas of psychology and special education. Adaptive behavior relates to everyday skills or tasks that the "average" person is able to complete, similar to the term life skills. Nonconstructive or disruptive social or personal behaviors can sometimes be used to achieve a constructive outcome. For example, a constant repetitive action could be re-focused on something that creates or builds something. In other words, the behavior can be adapted to something else. In contrast, maladaptive behavior is a type of behavior that is often used to reduce one's anxiety, but the result is dysfunctional and non-productive coping. For example, avoiding situations because you have unrealistic fears may initially reduce your anxiety, but it is non-productive in alleviating the actual problem in the long term. Maladaptive behavior is frequently used as an indicator of abnormality or mental dysfunction, since its assessment is relatively free from subjectivity. However, many behaviors considered moral can be maladaptive, such as dissent or abstinence. Adaptive behavior reflects an individual's social and practical competence to meet the demands of everyday living. Behavioral patterns change throughout a person's development, life settings and social constructs, evolution of personal values, and the expectations of others. It is important to assess adaptive behavior in order to determine how well an individual functions in daily life: vocationally, socially and educationally. Examples A child born with cerebral palsy will most likely have a form of hemiparesis or hemiplegia (the weakening, or loss of use, of one side of the body). In order to adapt to one's environment, the child may use these limbs as helpers, in some cases even adapt the use of their mouth and teeth as a tool used for more than just eating or conversation. Frustration from lack of the ability to verbalize one's own needs can lead to tantrums. In addition, it may lead to the use of signs or sign language to communicate needs. Core problems Limitations in self-care skills and social relationships, as well as behavioral excesses, are common characteristics of individuals with mental disabilities. Individuals with mental disabilities—who require extensive supports—are often taught basic self-care skills such as dressing, eating, and hygiene. Direct instruction and environmental supports, such as added prompts and simplified routines, are necessary to ensure that deficits in these adaptive areas do not limit one's quality of life. Most children with milder forms of mental disabilities learn how to take care of their basic needs, but they often require training in self-management skills to achieve the levels of performance necessary for eventual independent living. Making and sustaining personal relationships present significant challenges for many persons with mental disabilities. Limited cognitive processing skills, poor language development, and unusual or inappropriate behaviors can seriously impede interactions with others. Teaching students with mental disabilities appropriate social and interpersonal skills is an important function of special education. Students with mental disabilities often exhibit behavior problems than students who do not have the similar disabilities. Some behaviors observed by students with mental disabilities are difficulty accepting criticism, limited self-control, and inappropriate behaviors. The greater the severity of the mental disabilities, generally the higher the incidence of behavioral problems. Problems with assessing long-term and short-term adaptation One problem with assessments of adaptive behavior is that a behavior that appears adaptive in the short run can be maladaptive in the long run and vice versa. For example, in the case of a group with rules that insist on drinking harmful amounts of alcohol both abstinence and moderate drinking (moderate as defined by actual health effects, not by socially constructed rules) may seem maladaptive if assessments are strictly short term, but an assessment that focuses on long-term survival would instead find that it was adaptive and that it was obedience under the drinking rule that was maladaptive. Such differences between short term effects and long-term effects in the context of harmful consequences of short-term compliance with destructive rules are argued by some researchers to show that assessments of adaptive behavior are not as unproblematic as is often assumed by psychiatry. Adaptive behaviors in education In education, adaptive behavior is defined as that which (1) meets the needs of the community of stakeholders (parents, teachers, peers, and later employers) and (2) meets the needs of the learner, now and in the future. Specifically, these behaviors include such things as effective speech, self-help, using money, cooking, and reading, for example. Training in adaptive behavior is a key component of any educational program, but is critically important for children with special needs. The US Department of Education has allocated billions of dollars ($12.3 billion in 2008) for special education programs aimed at improving educational and early intervention outcomes for children with disabilities. In 2001, the United States National Research Council published a comprehensive review of interventions for children and adults diagnosed with autism. The review indicates that interventions based on applied behavior analysis have been effective with these groups. Adaptive behavior includes socially responsible and independent performance of daily activities. However, the specific activities and skills needed may differ from setting to setting. When a student is going to school, school and academic skills are adaptive. However, some of those same skills might be useless or maladaptive in a job settings, so the transition between school and job needs careful attention. Specific skills Adaptive behavior includes the age-appropriate behaviors necessary for people to live independently and to function safely and appropriately in daily life. Adaptive behaviors include life skills such as grooming, dressing, safety, food handling, working, money management, cleaning, making friends, social skills, and the personal responsibility expected of their age, social group and wealth group. Specifically relevant are community access skills and peer access and retention skills, and behaviors which act as barriers to such access. These are itemised below. Community access skills Bus riding Independent walking Coin summation Ordering food in a restaurant Vending machine use Eating in public places Pedestrian safety Peer access and retention Clothing selection skills Appropriate mealtime behaviors Toy play skills and playful activities Oral hygiene and tooth brushing Soccer play Adaptive behaviors are considered to change due to the persons culture and surroundings. Professors have to delve into the students technical and comprehension skills to measure how adaptive their behavior is. Barriers to access to peers and communities Diurnal bruxism Controlling rumination and vomiting Pica Adaptive skills Every human being must learn a set of skills that is beneficial for the environments and communities they live in. Adaptive skills are stepping stones toward accessing and benefiting from local or remote communities. This means that, in urban environments, to go to the movies, a child will have to learn to navigate through the town or take the bus, read the movie schedule, and pay for the movie. Adaptive skills allow for safer exploration because they provide the learner with an increased awareness of their surroundings and of changes in context, that require new adaptive responses to meet the demands and dangers of that new context. Adaptive skills may generate more opportunities to engage in meaningful social interactions and acceptance. Adaptive skills are socially acceptable and desirable at any age and regardless of gender (with the exception of sex specific biological differences such as menstrual care skills). Learning adaptive skills Adaptive skills encompass a range of daily situations and they usually start with a task analysis. The task analysis will reveal all the steps necessary to perform the task in the natural environment. The use of behavior analytic procedures has been documented, with children, adolescents and adults, under the guidance of behavior analysts and supervised behavioral technicians. The list of applications has a broad scope and it is in continuous expansion as more research is carried out in applied behavior analysis (see Journal of Applied Behavior Analysis, The Analysis of Verbal Behavior). Practopoietic theory According to practopoietic theory, creation of adaptive behavior involves special, poietic interactions among different levels of system organization. These interactions are described on the basis of cybernetic theory in particular, good regulator theorem. In practopoietic systems, lower levels of organization determine the properties of higher levels of organization, but not the other way around. This ensures that lower levels of organization (e.g., genes) always possess cybernetically more general knowledge than the higher levels of organization—knowledge at a higher level being a special case of the knowledge at the lower level. At the highest level of organization lies the overt behavior. Cognitive operations lay in the middle parts of that hierarchy, above genes and below behavior. For behavior to be adaptive, at least three adaptive traverses are needed. See also Adaptive Behavior – journal Character Evolutionary mismatch Vineland Social Maturity Scale References External links BACB (Behavior Analyst Certification Board) Human behavior Behavioral concepts Developmental psychology Evolutionary psychology

World Professional Association for Transgender Health

The World Professional Association for Transgender Health (WPATH), formerly the Harry Benjamin International Gender Dysphoria Association (HBIGDA), is a professional organization devoted to the understanding and treatment of gender identity and gender dysphoria, and creating standardized treatment for transgender and gender variant people. WPATH was founded in 1979 and named HBIGDA in honor of Harry Benjamin during a period where there was no clinical consensus on how and when to provide gender-affirming care. WPATH is mostly known for the Standards of Care for the Health of Transgender and Gender Diverse People (SOC). Early versions of the SOC mandated strict gatekeeping of transition by psychologists and psychiatrists and framed transgender identity as a mental illness. Beginning in approximately 2010, WPATH began publicly advocating the depsychopathologization of transgender identities and the 7th and 8th versions of the SOC took an approach that was more evidence-based. Standards of Care WPATH develops, publishes and reviews guidelines for persons with gender dysphoria, under the name of Standards of Care for the Health of Transgender and Gender Diverse People, the overall goal of the SOC is to provide clinical guidance for health professionals to assist transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. To keep up with increasing scientific evidence, WPATH periodically commissions an update to the Standards of Care and the WPATH Guideline Steering Committee oversees the guideline development process. The first version of the Standards of Care were published in 1979. Versions were released in 1979 (1st), 1980 (2nd), 1981 (3rd), 1990 (4th), 1998 (5th), 2001 (6th), and 2012 (7th). WPATH released Version 8, the latest edition, in 2022; it is described as being based upon a “more rigorous and methodological evidence-based approach than previous versions.” SOC is an internationally accepted and influential document outlining how to provide patients with transition related care. Early versions of the SOC focused gender transition towards psychologists and psychiatrists and framed transgender identity as a mental illness. Beginning in approximately 2010, with pushing from trans activists the WPATH began publicly advocating the depsychopathologization of transgender identities in the 7th version of the SOC. History Background Medical treatment for gender dysphoria was publicized in the early 1950s by accounts such as those of Christine Jorgensen. During this period, the majority of literature on gender diversity was pathologizing, positing dysfunctional families as the causes of dysphoria and recommending reparative therapy and psychoanalysis, such as Robert Stoller's work. Others such as George Rekers and Ole Ivar Lovaas recommended behavioral treatments to extinguish cross-sex identification and reinforce gender-normative behaviors. Knowledge on various aspects of transition related care had existed for decades, but there was no clinical consensus on the care pathways for transgender people. In 1966, Harry Benjamin published The Transsexual Phenomenon, arguing that since there was no cure for transsexualism, it was in the best interests of transsexuals and society to aid in sex reassignment and in the same year the Johns Hopkins Gender Clinic was opened by John Money. In 1969, Reed Erickson, a wealthy transgender man who played a large role in funding research and clinics for trans healthcare through the Erickson Educational Foundation, funded Richard Green and Money's book Transsexualism and Sex Reassignment, a multidisciplinary volume exploring instructions on medical care as well as social and clinical aspects, which was dedicated to Benjamin. The same year, he funded the 1st International Symposium on Gender Identity in London. The 4th conference, taking place in 1975, was the first to use Benjamin's name in the title. 1979-2000 The Harry Benjamin International Gender Dysphoria Association and Standards of Care (SOC) were conceived during the 5th International Gender Dysphoria Symposium (IGDS) in 1977. The organization was named in honor of Benjamin and supported a mixture of psychological and medical treatment. The founding committee was entirely American and consisted of Jack Berger, Richard Green, Donald R. Laub, Charles Reynolds Jr., Paul A. Walker, Leo Wollman, and transgender activist Jude Patton with Walker serving as president; The first SOC committee included all founding committee members with the exception of Patton, a vote by attendees having opposed a "consumer" board member. The Articles of Incorporation were approved in 1979 at the 6th IGDS and HBIGDA was legally incorporated 7 months later. The initial Standards of Care, The hormonal and surgical sex reassignment of gender dysphoric persons, were published in 1979 and served both as clinical guidelines for treating patients and to protect those who provided the treatments. Versions 2, 3, and 4 of the SOC were published in 1980, 1981 and 1990 respectively under the same name with few changes. These versions of the SOC followed the gatekeeping model laid out by Benjamin, where clinicians set strict eligibility requirements, requiring evaluations from separate mental health professionals and compulsory psychotherapy. WPATH played a large role in the addition of "Gender Identity Disorder" to the DSM-III in 1980. These versions used the DSM-III's criteria for the diagnoses of "Transsexualism" and "Gender Identity Disorder of Childhood", which had largely been authored by Richard Green. This led to feedback loops in research where the diagnostic criteria were thought correct since transgender people provided the narratives expected of them to access care. In the 1990's, WPATH was struggling to operate due to criticisms of their SOC in the trans community such as the requirement of the real life test, where patients had to socially transition for up to a year prior to hormones. These critiques developed into a trans-led Advocacy and Liason committee, marking the first time trans people were officially and actively consulted regarding their treatment. The 5th version, published in 1998, was titled the "Standards of Care for Gender Identity Disorders" to be consistent with the DSM-III. It recommended but did not require psychotherapy and stated that while GID was a mental disorder, that was not a license for stigma. 2001 - present The Standards of Care (SOC) 6 was published in 2001 and offered more flexibility and individualized care but continued to use the phrase "gender identity disorder". At the same time transgender people increasingly complained of having to "jump through hoops". SOC 6 also did not include significant changes to the tasks mental health professionals were required to take or in the general recommendations for content of the letters of readiness. An important change in the eligibility criteria for GAH allowed providers to prescribe hormones even if patients had not undergone RLT or psychotherapy if it was for harm reduction purposes. A notable change in version six separated the eligibility and readiness criteria for top and bottom surgery allowing some patients, particularly individuals assigned female at birth, to receive a mastectomy. In 2006, the organization changed its name from the Harry Benjamin International Gender Dysphoria Association (HBIGDA) to the World Professional Association for Transgender Health (WPATH). In 2007, Stephen Whittle became the first transgender president of the organization. In 2010, WPATH published the "depath statement", urging the "depsychopathologisation of gender variance worldwide" by governments and medical bodies. Shortly afterwards it released the "Identity Recognition Statement", urging governmental and medical bodies to endorse gender self-identification and no longer require surgery or sterilization as a prerequisite. The SOC 7, published in 2011, was more evidence-based than the previous versions and first to include an international advisory committee of transgender community leaders. It changed the name to the "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People", began to use the phrase "gender dysphoria", and marked a shift from conceiving gender as a binary to a spectrum. Differences between the 6th and the 7th versions were significant with the 7th version of the SOC including gender affirming care in female-to-male persons. The updated SOC also had a significant departure from previous versions. Including being the first version to include references, changes in guidelines where not everyone with gender concerns requires a diagnosis, replacing the requirement of the real life test and psychotherapy prior to hormone treatment or surgery with “persistent well documented gender dysphoria”, criteria for hysterectomy or orchiectomy treatment, and an expansion of the effects of hormone therapy. WPATH acknowledged the importance and changes in the 7th SOC saying that “Changes in this version are based upon significant cultural shifts, advances in clinical knowledge, and appreciation of the many health care issues that can arise for transsexual, transgender, and gender nonconforming people beyond hormone therapy and surgery”. In 2022 the current edition of the Standards of Care 8 was published. The guidelines note that the complexity of the assessment process may differ from patient to patient, based on the type of gender affirming care requested and the specific characteristics of the patient. The updates to SOC 8 shifted the ethical focus of evaluations toward one of shared decision making and informed consent by removing the requirement of a second letter from a mental health professional and the requirement that the provider must have a doctoral level degree. Changes in this edition included a shift away from requiring multiple letters from mental health professionals for surgery, introduces the term gender incongruence, and the treatment of adolescents. Organization Membership Professionals include anyone working in disciplines such as medicine, psychology, law, social work, counseling, psychotherapy, family studies, sociology, anthropology, speech and voice therapy and sexology. Non-professionals may also join, paying the same membership fee, but without voting privileges. The organization is funded by its membership and by donations and grants from non-commercial sources. The current president of the organization is Marci Bowers. Regional organizations WPATH is affiliated with several regional organizations, including the European Professional Association for Transgender Health, the United States Professional Association for Transgender Health and ASIAPATH. References Transgender health care International LGBTQ organizations LGBTQ professional associations Transgender organizations in the United States International medical and health organizations Non-profit organizations based in Illinois Organizations established in 1979 Transgender studies

Rapport

Rapport is a close and harmonious relationship in which the people or groups concerned are "in sync" with each other, understand each other's feelings or ideas, and communicate smoothly. The word derives from the French verb which means literally to carry something back (in the sense of how people relate to each other: what one person sends out the other sends back). For example, people with rapport may realize that they share similar values, beliefs, knowledge, or behaviors around politics, music, or sports. This may also mean that they engage in reciprocal behaviors such as posture mirroring or increased coordination in their verbal and nonverbal interactions. Rapport has been shown to have benefits for psychotherapy and medicine, negotiation, education, and tourism, among others. In each of these cases, the rapport between members of a dyad (e.g. a teacher and student or doctor and patient) allows the participants to coordinate their actions and establish a mutually beneficial working relationship, or what is often called a "working alliance". In consumer-oriented guided group activities (e.g., a cooking class, a wine tour, and hiking group), rapport is not only dyadic and customer-employee oriented, but also customer-customer and group-oriented as customers consume and interact with each other in a group for an extended period. Building rapport There are a number of techniques that are supposed to be beneficial in building rapport. These include matching body language (i.e., posture, gesture, etc.); indicating attentiveness through maintaining eye contact; and matching tempo, terminology, and breathing rhythm. In conversation, some verbal behaviors associated with increased rapport are the use of positivity (or, positive "face management"), sharing personal information of gradually increasing intimacy (or, "self-disclosure"), and reference to shared interests or experiences. Building rapport can improve community-based research tactics, assist in finding a partner, improve student-teacher relationships, and allow employers to gain trust in employees. Building rapport takes time. Extroverts tend to have an easier time building rapport than introverts. Extraversion accelerates the process due to an increase in confidence and skillfulness in social settings. Methods Coordination Coordination, also called "mirroring" means getting into rhythm with another person, or resembling their verbal or nonverbal behaviors: Emotional mirroring Empathizing with someone's emotional state by being on 'their side'. One listens for key words and problems so one can address and question them to better one's understanding of what the other person is saying and demonstrate empathy towards them. Posture mirroring Matching the tone of a person's body language not through direct imitation (as this can appear as mockery) but through mirroring the general message of their posture and energy. Tone and tempo mirroring Matching the tone, tempo, inflection, and volume of another person's voice. Mutual attentiveness Another way to build rapport is for each partner to indicate their attentiveness to the other. This attentiveness may take the form of nonverbal attentiveness, such as looking at the other person, nodding at appropriate moments, or physical proximity, as seen in work on teachers' "immediacy" behaviors in the classroom. Attentiveness might also be demonstrated through reciprocation of nonverbal behaviors like smiling or nodding, in a similar way to the coordination technique, or in the reciprocal sharing of personal details about the other person that signal one's knowledge and attentiveness to their needs. Commonality Commonality is the technique of deliberately finding something in common with a person in order to build a sense of camaraderie and trust. This is done through references to shared interests, dislikes, and experiences. By sharing personal details or self-disclosing personal preferences or information, interlocutors can build commonality, and thus increase rapport. Face management Another way to build rapport is through "positive face management", (or, more simply: positivity). According to some psychologists, we have a need to be seen in a positive light, known as our "face". By managing each other's "face", boosting it when necessary, or reducing negative impacts to it, we build rapport with others. Benefits A number of benefits from building interpersonal rapport have been proposed, all of which concern smoother interactions, improved collaboration, and improved interpersonal outcomes, though the specifics differ by the domain. These domains include but are not limited to healthcare, education, business, and social relationships. In the health domain, provider-patient rapport is often called the "therapeutic alliance" or "therapeutic relationship"—the collaboration quality between provider and patient—which can predict therapy outcomes or patients' treatment adherence. In education, teacher-student rapport is predictive of students' participation in the course, their course retention, their likelihood to take a course in that domain again, and has sometimes been used to predict course outcomes. Some have argued that teacher-student rapport is an essential element of what makes an effective teacher, or the ability to manage interpersonal relationships and build a positive, pro-social, atmosphere of trust and reduced anxiety. Student-student rapport, on the other hand, while largely out of the teacher's ability to control, is also predictive of reduced anxiety in the course, feelings of a supportive class culture, and improved participation in class discussions. In these relationships, intentionally building rapport through individual meetings has shown an increase in student engagement and level of comfort in the classroom. In negotiation, rapport is beneficial for reaching mutually beneficial outcomes, as partners are more likely to trust each other and be willing to cooperate and reach a positive outcome. However, interpersonal rapport in negotiation can lead to unethical behavior, particularly in impasse situations, where the interpersonal rapport may influence the negotiators to behave unethically. In terms of social relationships such as friendship and romantic relationships, establishing rapport can build trust, increase feelings of closeness, and eliminate certain misunderstandings. Rapport is necessary in establishing satisfaction and understanding acceptable behaviors in an interpersonal relationship. Friendships and romantic relationships can overlap with other domains. The study of rapport To better study how rapport can lead to the above benefits, researchers generally adopt one of three main approaches: self-report surveys given to the participants, third-party observations from a naive observer, and some form of automated computational detection, using computer vision and machine learning. Self-report surveys typically consist of a set of questions given at the end of an interpersonal interaction, asking the participants to reflect on their relationship with another person and rate various aspects of that relationship, typically on a Likert scale. Though this is the most common approach, it suffers from unreliability of self-report data, such as the issue of separating participants' reflection on a single interaction with their relationship with the other person more broadly. A third-party observer can give a rapport rating to a particular segment (often called a "slice") of such an interaction. Other recent work uses techniques from computer vision, machine learning, and artificial intelligence to computationally detect the level of rapport between members of a dyad. Rapport and Technology In the 21st century, online communication has had a huge impact on how business is conducted and how relationships are formed. In the era of Covid-19 and the shift to remote work and schooling, the way in which rapport is built has evolved. Communicating solely through online channels challenges rapport building. Challenges include technical difficulties interrupting video calls and direct messaging, interruptions and distractions from the user's home, a lack of intimacy and the ability to observe one another, lack of eye contact, mundane interactions, and the "pressure of presence". See also References Further reading Chapter 8. Communicating to establish rapport – Patient Practitioner Interaction: An Experiential Manual for Developing the Art of Health Care. Carol M. Davis, Helen L. Masin – Human communication Semiotics Interpersonal relationships Nonverbal communication Social graces

Spiral Dynamics

Spiral Dynamics (SD) is a model of the evolutionary development of individuals, organizations, and societies. It was initially developed by Don Edward Beck and Christopher Cowan based on the emergent cyclical theory of Clare W. Graves, combined with memetics. A later collaboration between Beck and Ken Wilber produced Spiral Dynamics Integral (SDi). Several variations of Spiral Dynamics continue to exist, both independently and incorporated into or drawing on Wilber's Integral theory. Spiral Dynamics has applications in management theory and business ethics, and as an example of applied memetics. However, it lacks mainstream academic support. Overview Spiral Dynamics describes how value systems and worldviews emerge from the interaction of "life conditions" and the mind's capacities. The emphasis on life conditions as essential to the progression through value systems is unusual among similar theories, and leads to the view that no level is inherently positive or negative, but rather is a response to the local environment, social circumstances, place and time. Through these value systems, groups and cultures structure their societies and individuals integrate within them. Each distinct set of values is developed as a response to solving the problems of the previous system. Changes between states may occur incrementally (first order change) or in a sudden breakthrough (second order change). The value systems develop in a specific order, and the most important question when considering the value system being expressed in a particular behavior is why the behavior occurs. Overview of the levels Development of the theory University of North Texas (UNT) professor Don Beck sought out Union College psychology professor Clare W. Graves after reading about his work in The Futurist. They met in person in 1975, and Beck, soon joined by UNT faculty member Chris Cowan, worked closely with Graves until his death in 1986. Beck made over 60 trips to South Africa during the 1980s and 1990s, applying Graves's emergent cyclical theory in various projects. This experience, along with others Beck and Cowan had applying the theory in North America, motivated the development of Spiral Dynamics. Beck and Cowan first published their extension and adaptation of Graves's emergent cyclical theory in Spiral Dynamics: Mastering Values, Leadership, and Change (Exploring the New Science of Memetics) (1996). They introduced a simple color-coding for the eight value systems identified by Graves (and a predicted ninth) which is better known than Graves's letter pair identifiers. Additionally, Beck and Cowan integrated ideas from the field of memetics as created by Dawkins and further developed by Csikszentmihalyi, identifying memetic attractors for each of Graves's levels. These attractors, which they called "VMemes", are said to bind memes into cohesive packages which structure the world views of both individuals and societies. Diversification of views While Spiral Dynamics began as a single formulation and extension of Graves's work, a series of disagreements and shifting collaborations have produced three distinct approaches. By 2010, these had settled as Christopher Cowan and Natasha Todorovic advocating their trademarked "SPIRAL DYNAMICS®" as fundamentally the same as Graves's emergent cyclical theory, Don Beck advocating Spiral Dynamics Integral (SDi) with a community of practice around various chapters of his Centers for Human Emergence, and Ken Wilber subordinating SDi to his similarly but-not-identically colored Integral AQAL "altitudes", with a greater focus on spirituality. This state of affairs has led to practitioners noting the "lineage" of their approach in publications. Timeline The following timeline shows the development of the various Spiral Dynamics factions and the major figures involved in them, as well as the initial work done by Graves. Splits and changes between factions are based on publications or public announcements, or approximated to the nearest year based on well-documented events. Vertical bars indicate notable publications, which are listed along with a few other significant events after the timeline. Bolded years indicate publications that appear as vertical bars in the chart above: 1966: Graves: first major publication (in The Harvard Business review) 1970: Graves: peer reviewed publication in Journal of Humanistic Psychology 1974: Graves: article in The Futurist (Beck first becomes aware of Graves's theory; Cowan a bit later) 1977: Graves abandons manuscript of what would later become The Never Ending Quest 1979: Beck and Cowan found National Values Center, Inc. (NVC) 1981: Beck and Cowan resign from UNT to work with Graves; Beck begins applying theory in South Africa 1986: Death of Clare Graves 1995: Wilber: Sex, Ecology, Spirituality (introduces quadrant model, first mention of Graves's ECLET) 1996: Beck and Cowan: Spiral Dynamics: Mastering Values, Leadership, and Change 1998: Cowan and Todorovic form NVC Consulting (NVCC) as an "outgrowth" of NVC 1998: Cowan files for "Spiral Dynamics" service mark, registered to NVC 1999: Beck (against SD as service mark) and Cowan (against Wilber's Integral theory) cease collaborating 1999: Wilber: The Collected Works of Ken Wilber, Vol. 4: Integral Psychology (first Spiral Dynamics reference) 2000: Cowan and Todorovic: "Spiral Dynamics: The Layers of Human Values in Strategy" in Strategy & Leadership (peer reviewed) 2000: Wilber: A Theory of Everything (integrates SD with AQAL, defines MGM: "Mean Green Meme") 2000: Wilber founds the Integral Institute with Beck as a founding associate around this time 2002: Beck: "SDi: Spiral Dynamics in the Integral Age" (launches SDi as a brand) 2002: Todorovic: "The Mean Green Hypothesis: Fact or Fiction?" (refutes MGM) 2002: Graves; William R. Lee (annot.); Cowan and Todorovic (eds.): Levels of Human Existence, transcription of Graves's 1971 three-day seminar 2004: Beck founds the Center for Human Emergence (CHE), 2005: Beck, Elza S. Maalouf and Said E. Dawlabani found the Center for Human Emergence Middle East 2005: Graves; Cowan and Todorovic (eds.): The Never Ending Quest 2005: Beck and Wilber cease collaborating around this time, disagreeing on Wilber's changes to SDi 2006: Wilber: Integral Spirituality (adds altitudes colored to align with both SDi and chakras) 2009: NVC dissolved as business entity, original SD service mark (officially registered to NVC) canceled 2010: Cowan and Todorovic re-file for SD service mark and trademark, registered to NVC Consulting 2015: Death of Chris Cowan 2017: Wilber: Religion of Tomorrow (further elaborates on the altitude concept and coloring) 2018: Beck et al.: Spiral Dynamics in Action 2022: Death of Don Beck Cowan and Todorovic's "Spiral Dynamics" Chris Cowan's decision to trademark "Spiral Dynamics" in the US and form a consulting business with Natasha Todorovic contributed to the split between Beck and him in 1999. Cowan and Todorovic subsequently published an article on Spiral Dynamics in the peer-reviewed journal Strategy & Leadership, edited and published Graves's unfinished manuscript, and generally took the position that the distinction between Spiral Dynamics and Graves's ECLET is primarily one of terminology. Holding this view, they opposed interpretations seen as "heterodox." In particular, Cowan and Todorovic's view of Spiral Dynamics stands in opposition to that of Ken Wilber. Wilber biographer Frank Visser describes Cowan as a "strong" critic of Wilber and his Integral theory, particularly the concept of a "Mean Green Meme." Todorovic produced a paper arguing that research refutes the existence of the "Mean Green Meme" as Beck and particularly Wilber described it. Beck's "Spiral Dynamics integral" (SDi) By early 2000, Don Beck was corresponding with integral philosopher Ken Wilber about Spiral Dynamics and using a "4Q/8L" diagram combining Wilber's four quadrants with the eight known levels of Spiral Dynamics. Beck officially announced SDi as launching on January 1, 2002, aligning Spiral Dynamics with integral theory and additionally citing the influence of John Petersen of the Arlington Institute and Ichak Adizes. By 2006, Wilber had introduced a slightly different color sequence for his AQAL "altitudes", diverging from Beck's SDi and relegating it to the values line, which is one of many lines within AQAL. Later influences on SDi include the work of Muzafer Sherif and Carolyn Sherif in the fields of realistic conflict and social judgement, specifically their Assimilation Contrast Effect model and Robber's Cave study SD/SDi and Ken Wilber's Integral Theory Ken Wilber briefly referenced Graves in his 1986 book (with Jack Engler and Daniel P. Brown) Transformations of Consciousness, and again in 1995's Sex, Ecology, Spirituality which also introduced his four quadrants model. However, it was not until the "Integral Psychology" section of 1999's Collected Works: Volume 4 that he integrated Gravesian theory, now in the form of Spiral Dynamics. Beck and Wilber began discussing their ideas with each other around this time. AQAL "altitudes" By 2006, Wilber was using SDi only for the values line, one of many lines in his All Quadrants, All Levels/Lines (AQAL) framework. In the book Integral Spirituality published that year, he introduced the concept of "altitudes" as an overall "content-free" system to correlate developmental stages across all of the theories on all of the lines integrated by AQAL. The altitudes used a set of colors that were ordered according to the rainbow, which Wilber explained was necessary to align with color energies in the tantric tradition. This left only Red, Orange, Green, and Turquoise in place, changing all of the other colors to greater or lesser degrees. Furthermore, where Spiral Dynamics theorizes that the 2nd tier would have six stages repeating the themes of the six stages of the 1st tier, in the altitude system the 2nd tier contains only two levels (corresponding to the first two SD 2nd tier levels) followed by a 3rd tier of four spiritually-oriented levels inspired by the work of Sri Aurobindo. Beck and Cowan each consider this 3rd tier to be non-Gravesian. Wilber critic Frank Visser notes that while Wilber gives a correspondence of his altitude colors to chakras, his correspondence does not actually match any traditional system for coloring chakras, despite Wilber's assertion that using the wrong colors would "backfire badly when any actual energies were used." He goes on to note that Wilber's criticism of the SD colors as "inadequate" ignores that they were not intended to correlate with any system such as chakras. In this context, Visser expresses sympathy for Beck and Cowan's dismay over what Visser describes as "vandalism" regarding the color scheme, concluding that the altitude colors are an "awkward hybrid" of the SD and rainbow/chakra color systems, both lacking the expressiveness of the former and failing to accurately correlate with the latter. Criticism and limitations As an extension of Graves's theory, most criticisms of that theory apply to Spiral Dynamics as well. Likewise, to the extent that Spiral Dynamics Integral incorporates Ken Wilber's integral theory, criticism of that theory, and the lack of mainstream academic support for it are also relevant. In addition, there have been criticisms of various aspects of SD and/or SDi that are specific to those extensions. Nicholas Reitter, writing in the Journal of Conscious Evolution, observes: On the other hand, the SD authors seem also to have magnified some of the weaknesses in Graves' approach. The occasional messianism, unevenness of presentation and constant business-orientation of Graves' (2005) manuscript is transmuted in the SD authors' book (Beck and Cowan 1996) into a sometimes- bewildering array of references to world history, pop culture and other topics, often made in helter-skelter fashion. Spiral Dynamics has been criticized by some as appearing to be like a cult, with undue prominence given to the business and intellectual property concerns of its leading advocates. Metamodernists Daniel Görtz and Emil Friis, writing as Hanzi Freinacht, who created a multi-part system combining aspects of SD with other developmental measurements dismissed the Turquoise level, saying that while there will eventually be another level, it does not currently exist. They argue that attempts to build Turquoise communities are likely to lead to the development of "abusive cults" Psychologist Keith Rice, discussing his application of SDi in individual psychotherapy, notes that it encounters limitations in accounting for temperament and the unconscious. However, regarding SDi's "low profile among academics," he notes that it can easily be matched to more well-known models "such as Maslow, Loevinger, Kohlberg, Adorno, etc.," in order to establish trust with clients. Influence and applications Spiral Dynamics has influenced management theory, which was the primary focus of the 1996 Spiral Dynamics book. John Mackey and Rajendra Sisodia write that the vision and values of conscious capitalism as they articulate it are consistent with the "2nd tier" VMEMES of Spiral Dynamics. Rica Viljoen's case study of economic development in Ghana demonstrates how understanding the Purple VMEME allows for organizational storytelling that connects with diverse (non-Western) worldviews. Spiral Dynamics has also been noted as an example of applied memetics. In his chapter, "'Meme Wars': A Brief Overview of Memetics and Some Essential Context" in the peer-reviewed book Memetics and Evolutionary Economics, Michael P. Schlaile includes Spiral Dynamics in the "organizational memetics" section of his list of "enlightening examples of applied memetics." Schlaile also notes Said Dawlabani's SDi-based "MEMEnomics" as an alternative to his own "economemetics" in his chapter examining memetics and economics in the same book. Elza Maalouf argues that SDi provides a "memetic" interpretation of non-Western cultures that Western NGOs often lack, focusing attention on the "indigenous content" of the culture's value system. One of the main applications of Spiral Dynamics is to inform more nuanced and holistic systems change strategies. Just like categories in any other framework, the various levels can be seen as memetic lenses to look at the world through in order to help those leading change take a bird's eye view in understanding the diverse perspectives on a singular topic. At best, Spiral Dynamics can help us to synthesize these perspectives and recognize the strength in having a diversity of worldviews and aim to create interventions that take into consideration the needs and values of individuals at every level of the spiral. Spiral Dynamics continues to influence integral philosophy and spirituality, and the developmental branch of metamodern philosophy. Both integralists and metamodernists connect their philosophies to SD's Yellow VMEME. Integralism also identifies with Turquoise and eventually added further stages not found in SD or SDi, while metamodernism dismisses Turquoise as nonexistent. SDi has also been referenced in the fields of education, urban planning, and cultural analysis. Notes Works cited (Note on page ii: "This study was approved by Indiana University Institutional Review Board (IRB)." Note also that a previous report was published as: Nasser, Ilham (June 2020). "Mapping the Terrain of Education 2018–2019: A Summary Report". Journal of Education in Muslim Societies. Indiana University Press. 1 (2): 3–21. doi:10.2979/jems.1.2.08, but is not freely downloadable.) Developmental psychology

Adjustment disorder

Adjustment disorder is a maladaptive response to a psychosocial stressor. It is classified as a mental disorder. The maladaptive response usually involves otherwise normal emotional and behavioral reactions that manifest more intensely than usual (considering contextual and cultural factors), causing marked distress, preoccupation with the stressor and its consequences, and functional impairment. Diagnosis of adjustment disorder is common. Lifetime prevalence estimates for adults range from five percent to 21%. Adult women are diagnosed twice as often as men. Among children and adolescents, girls and boys are equally likely to be diagnosed with an adjustment disorder. Adjustment disorder was introduced into the Diagnostic and Statistical Manual of Mental Disorders in 1980 (DSM-III). Other names for adjustment disorder are stress response syndrome (new name as of 2013) and situational depression since it is one of the most common symptoms. Signs and symptoms Some emotional signs of adjustment disorder are: sadness, hopelessness, lack of enjoyment, crying spells, nervousness, anxiety, desperation, feeling overwhelmed and thoughts of suicide, performing poorly in school/work etc. Common characteristics of adjustment disorder include mild depressive symptoms, anxiety symptoms, and traumatic stress symptoms or a combination of the three. According to the DSM-5, there are six types of adjustment disorder, which are characterized by the following predominant symptoms: depressed mood, anxiety, mixed depression and anxiety, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified. However, the criteria for these symptoms are not specified in greater detail. Adjustment disorder may be acute or chronic, depending on whether it lasts more or less than six months. According to the DSM-5, if the adjustment disorder lasts less than six months, then it may be considered acute. If it lasts more than six months, it may be considered chronic. Moreover, the symptoms cannot last longer than six months after the stressor(s), or its consequences, have terminated. However, the stress-related disturbance does not only exist as an exacerbation of a pre-existing mental disorder. Unlike major depression, the disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation. The condition is different from anxiety disorder, which lacks the presence of a stressor, or post-traumatic stress disorder and acute stress disorder, which usually are associated with a more intense stressor. Suicidal behavior is prominent among people with adjustment disorder of all ages, and up to one-fifth of adolescent suicide victims may have an adjustment disorder. Bronish and Hecht (1989) found that 70% of a series of patients with adjustment disorder attempted suicide immediately before their index admission and they remitted faster than a comparison group with major depression. Asnis et al. (1993) found that adjustment disorder patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression. According to a study on 82 adjustment disorder patients at a clinic, Bolu et al. (2012) found that 22 (26.8%) of these patients were admitted due to suicide attempt, consistent with previous findings. In addition, it was found that 15 of these 22 patients chose suicide methods that involved high chances of being saved. Henriksson et al. (2005) states statistically that the stressors are of one-half related to parental issues and one-third in peer issues. One hypothesis about adjustment disorder is that it may represent a sub-threshold clinical syndrome. The syndrome of occupational burnout is considered to be adjustment disorder by some national health authorities. Subtypes and their symptoms Adjustment disorder has six different subtypes, and they are all based on what the main symptoms are. Those subtypes are as follows: With depressed mood: depression, hopelessness, lack of interest or joy from previously enjoyed hobbies, tearfulness With anxiety: anxiousness, being overwhelmed, trouble concentrating, worry, separation anxiety (common in children) With anxiety and depressed mood: combination of symptoms from both subtypes above With disturbance of conduct: acting destructive, reckless behavior, rebellious With mixed disturbance of emotions and conduct: combination of symptoms from both subtypes above Unspecified: symptoms that do not fall into above subtypes; often include physical symptoms and withdrawal from everyday activities Risk factors Those exposed to repeated trauma are at greater risk, even if that trauma is in the past. Age can be a factor due to young children having fewer coping resources and because they are less likely to realize the consequences of a potential stressor. A stressor is generally an event of a serious, unusual nature that an individual or group of individuals experience. Adjustment disorders can come from a wide range of stressors that can be traumatic or relatively minor, like the loss of a girlfriend/boyfriend, a poor report card, or moving to a new neighborhood. It is thought that the more often the stressor occurs, the more likely it is to produce adjustment disorder. The objective nature of the stressor is of secondary importance. A stressor gains its pathogenic potential when the patient perceives it as stressful. The identification of a causal stressor is necessary if a diagnosis of adjustment disorder is to be made. There are certain stressors that are more common in different age groups: Adulthood: Marital conflict Financial conflict Health issues with oneself, partner, or dependent children Personal tragedy such as death or personal loss Loss of job or unstable employment conditions e.g., corporate takeover or redundancy Adolescence and childhood: Family conflict or parental separation School problems or changing schools Sexuality issues Death, illness, or trauma in the family In a study conducted from 1990 to 1994 on 89 psychiatric outpatient adolescents, 25% had attempted suicide in which 37.5% had misused alcohol, 87.5% displayed aggressive behaviour, 12.5% had learning difficulties, and 87.5% had anxiety symptoms. Diagnosis DSM-5 classification The basis of the diagnosis is the presence of a precipitating stressor and a clinical evaluation of the possibility of symptom resolution on removal of the stressor due to the limitations in the criteria for diagnosing adjustment disorder. In addition, the diagnosis of adjustment disorder is less clear when patients are exposed to stressors long-term, because this type of exposure is associated with adjustment disorder and major depressive disorder (MDD) and generalized anxiety disorder (GAD). Some signs and criteria used to establish a diagnosis are important. First, the symptoms must clearly follow a stressor. The symptoms should be more severe than would be expected. There should not appear to be other underlying disorders. The symptoms that are present are not part of a normal grieving for the death of family member or other loved one. Adjustment disorders have the ability to be self-limiting. Within five years of when they are originally diagnosed, approximately 20–50% go on to be diagnosed with psychiatric disorders that are more serious. ICD-11 classification International Statistical Classification of Diseases and Related Health Problems (ICD), assigns codes to classify diseases, symptoms, complaints, social behaviors, injuries, and such medical-related findings. ICD-11 classifies adjustment disorder (6B43) under "Disorders specifically associated with stress". Treatment Individuals with an adjustment disorder and depressive or anxiety symptoms may benefit from treatments usually used for depressive or anxiety disorders. The use of different therapies can be beneficial for any age group. There is also a list of medications that can be used to help people with adjustment disorder whose symptoms are too severe for therapy alone. If a person is considering taking medication, they should talk to their doctor. Specific treatment is based on factors of each individual separately. These factors include but are not limited to age, severity of symptoms, type of adjustment disorder, and personal preference. Different ways to help with the disorder include: individual psychotherapy family therapy peer group therapy medication In addition to professional help, parents and caregivers can help their children with their difficulty adjusting by: offering encouragement to talk about their emotions offering support and understanding reassuring the child that their reactions are normal involving the child's teachers to check on their progress in school letting the child make simple decisions at home, such as what to eat for dinner or what show to watch on television having the child engage in a hobby or activity they enjoy Criticism Like many of the items in the DSM, adjustment disorder receives criticism from a minority of the professional community as well as those in semi-related professions outside the healthcare field. First, there has been criticism of its classification. It has been criticized for its lack of specificity of symptoms, behavioral parameters, and close links with environmental factors. Relatively little research has been done on this condition. An editorial in the British Journal of Psychiatry described adjustment disorder as being so "vague and all-encompassing… as to be useless," but it has been retained in the DSM-5 because of the belief that it serves a useful clinical purpose for clinicians seeking a temporary, mild, non-stigmatizing label, particularly for patients who need a diagnosis for insurance coverage of therapy. In the US military there has been concern about its diagnosis in active duty military personnel. When the cause of substantial distress is harm caused by unjust social systems, it may be considered that the true disorder requiring intervention lies in the systems causing the problem rather than in the individual who is distressed by them. In relation to the COVID-19 pandemic A study was conducted in Poland during the first phase of the pandemic. The study used self-report surveys to measure the prevalence and severity of symptoms of adjustment disorder compared to PTSD, depression, and anxiety. The data was collected in the first quarantine period between March 25 to April 27, 2020. Results from the study: The COVID-19 pandemic was a highly stressful event for 75% of the participants and the most powerful predictor of adjustment disorder. 49% reported an increase in adjustment disorder symptoms, which were more common among females and those without a full-time job; 14% of the sample met the criteria for a diagnosis of adjustment disorder. A significant proportion of the sample was also positive for generalized anxiety (44%) and depression (26%): the presumptive diagnosis rate of PTSD was 2.4% References Further reading Adjustment disorders Stress-related disorders

Delirium tremens

Delirium tremens (DTs; ) is a rapid onset of confusion usually caused by withdrawal from alcohol. When it occurs, it is often three days into the withdrawal symptoms and lasts for two to three days. Physical effects may include shaking, shivering, irregular heart rate, and sweating. People may also hallucinate. Occasionally, a very high body temperature or seizures (colloquially known as "rum fits") may result in death. Delirium tremens typically occurs only in people with a high intake of alcohol for more than a month, followed by sharply reduced intake. A similar syndrome may occur with benzodiazepine and barbiturate withdrawal. In a person with delirium tremens, it is important to rule out other associated problems such as electrolyte abnormalities, pancreatitis, and alcoholic hepatitis. Prevention is by treating withdrawal symptoms using similarly acting compounds to taper off the use of the precipitating substance in a controlled fashion. If delirium tremens occurs, aggressive treatment improves outcomes. Treatment in a quiet intensive care unit with sufficient light is often recommended. Benzodiazepines are the medication of choice with diazepam, lorazepam, chlordiazepoxide, and oxazepam all commonly used. They should be given until a person is lightly sleeping. Nonbenzodiazepines are often used as adjuncts to manage the sleep disturbance associated with condition. The antipsychotic haloperidol may also be used in order to combat the overactivity and possible excitotoxicity caused by the withdrawal from a GABA-ergic substance. Thiamine (vitamin B1) is recommended to be given intramuscularly, because long-term high alcohol intake and the often attendant nutritional deficit damages the small intestine, leading to a thiamine deficiency, which sometimes cannot be rectified by supplement pills alone. Mortality without treatment is between 15% and 40%. Currently death occurs in about 1% to 4% of cases. About half of people with alcoholism will develop withdrawal symptoms upon reducing their use. Of these, 3% to 5% develop DTs or have seizures. The name delirium tremens was first used in 1813; however, the symptoms were well described since the 1700s. The word "delirium" is Latin for "going off the furrow," a plowing metaphor for disordered thinking. It is also called the shaking frenzy and Saunders-Sutton syndrome. There are numerous nicknames for the condition, including "the DTs" and "seeing pink elephants". Signs and symptoms The main symptoms of delirium tremens are nightmares, agitation, global confusion, disorientation, visual and auditory hallucinations, tactile hallucinations, fever, high heart rate, high blood pressure, heavy sweating, and other signs of autonomic hyperactivity. These symptoms may appear suddenly but typically develop two to three days after the stopping of heavy drinking, being worst on the fourth or fifth day. These symptoms are characteristically worse at night. For example, in Finnish, this nightlike condition is called , , for its sweatiness, general unease, and hallucinations tending towards the unseemly and frightening. In general, DT is considered the most severe manifestation of withdrawal from alcohol or other GABAergic drugs, and can occur between the second and tenth days after the last drink. It often overcomes the patient by surprise, because a brief period of uneventful sobriety of 1–2 days tends to precede it, it can fully manifest itself within a single hour, and unlike most other alcohol withdrawal symptoms, it is generally not relieved by more alcohol. Other common symptoms include intense perceptual disturbance such as visions or feelings of insects, snakes, or rats. These may be hallucinations or illusions related to the environment, e.g., patterns on the wallpaper or in the peripheral vision that the patient falsely perceives as a resemblance to the morphology of an insect, and are also associated with tactile hallucinations such as sensations of something crawling on the subject—a phenomenon known as formication. Delirium tremens usually includes feelings of "impending doom". Anxiety and expecting imminent death are common DT symptoms. DT can sometimes be associated with severe, uncontrollable tremors of the extremities, and secondary symptoms such as anxiety, panic attacks, and paranoia. Confusion is often noticeable to onlookers as those with DT will have trouble forming simple sentences or making basic logical calculations. DT should be distinguished from alcoholic hallucinosis, the latter of which occurs in approximately 20% of hospitalized alcoholics and does not carry a significant risk of mortality. In contrast, DT occurs in 5–10% of alcoholics and carries up to 15% mortality with treatment and up to 35% mortality without treatment. The most common conditions leading to death in patients with DTs are respiratory failure and cardiac arrhythmias. Causes Delirium tremens is mainly caused by a long period of drinking being stopped abruptly. Withdrawal leads to a biochemical regulation cascade. Delirium tremens is most common in people who are in alcohol withdrawal, especially in those who drink 10–11 standard drinks (equivalent of of beer, of wine or of distilled beverage) daily. Delirium tremens commonly affects those with a history of habitual alcohol use or alcoholism that has existed for more than 10 years. Pathophysiology Delirium tremens is a component of alcohol withdrawal hypothesized to be the result of compensatory changes in response to chronic heavy alcohol use. Alcohol positively allosterically modulates the binding of GABA, enhancing its effect and resulting in inhibition of neurons projecting into the nucleus accumbens, as well as inhibiting NMDA receptors. This combined with desensitization of alpha-2 adrenergic receptors, results in a homeostatic upregulation of these systems in chronic alcohol use. When alcohol use ceases, the unregulated mechanisms result in hyperexcitability of neurons as natural GABAergic systems are down-regulated and excitatory glutamatergic systems are upregulated. This combined with increased noradrenergic activity results in the symptoms of delirium tremens. Diagnosis Diagnosis is mainly based on symptoms. In a person with delirium tremens, it is important to rule out other associated problems, such as electrolyte abnormalities, pancreatitis, and alcoholic hepatitis. Treatment Delirium tremens due to alcohol withdrawal can be treated with benzodiazepines. High doses may be necessary to prevent death. Amounts given are based on the symptoms. Typically the person is kept sedated with benzodiazepines, such as diazepam, lorazepam, chlordiazepoxide, or oxazepam. In some cases antipsychotics, such as haloperidol may also be used. Older drugs such as paraldehyde and clomethiazole were formerly the traditional treatment but have now largely been superseded by the benzodiazepines. Acamprosate is occasionally used in addition to other treatments, and is then carried on into long-term use to reduce the risk of relapse. If status epilepticus occurs it is treated in the usual way. It can also be helpful to provide a well lit room as people often have hallucinations. Alcoholic beverages can also be prescribed as a treatment for delirium tremens, but this practice is not universally supported. High doses of thiamine often by the intravenous route is also recommended. Delirium tremens in literature French writer Émile Zola's novel The Drinking Den (L'Assommoir) includes a character – Coupeau, the main character Gervaise's husband – who has delirium tremens by the end of the book. In English Writer Mona Caird's feminist novel The Daughters of Danaus (1894), "[a]s for taking enfeeblement as a natural dispensation," the character Hadria "would as soon regard delirium tremens in that light." American writer Mark Twain describes an episode of delirium tremens in his book The Adventures of Huckleberry Finn (1884). In chapter 6, Huck states about his father, "After supper pap took the jug, and said he had enough whisky there for two drunks and one delirium tremens. That was always his word." Subsequently, Pap Finn runs around with hallucinations of snakes and chases Huck around their cabin with a knife in an attempt to kill him, thinking Huck is the "Angel of Death". One of the characters in Joseph Conrad's novel Lord Jim experiences "DTs of the worst kind" with symptoms that include seeing millions of pink frogs. English author M. R. James mentions delirium tremens in his 1904 ghost story 'Oh, Whistle, and I'll Come to You, My Lad'. Professor Parkins while staying at the Globe Inn when in coastal Burnstow to "improve his game" of golf, despite being "a convinced disbeliever in what is called the 'supernatural, when face to face with an entity in his "double-bed room" during the story's climax, is heard "uttering cry upon cry at the utmost pitch of his voice" though later "was somehow cleared of the ready suspicion of delirium tremens". American writer Jack Kerouac details his experiences with delirium tremens in his book Big Sur. English author George Eliot provides a case involving delirium tremens in her novel Middlemarch (187172). Alcoholic scoundrel John Raffles, both an abusive stepfather of Joshua Riggs and blackmailing nemesis of financier Nicholas Bulstrode, dies, whose "death was due to delirium tremens" while at Peter Featherstone's Stone Court property. Housekeeper Mrs. Abel provides Raffles' final night of care per Bulstrode's instruction whose directions given to Abel stand adverse to Tertius Lydgate's orders. Delirium tremens in film and TV In the 1945 film The Lost Weekend, Ray Milland won the Academy Award for Best Actor for his depiction of a character who experiences delirium tremens after being hospitalized, hallucinating that he saw a bat fly in and eat a mouse poking through a wall. The M*A*S*H TV series episode "Bottoms Up" (season 9, episode 15, aired on March 2, 1981) featured a side story about a nurse (Capt. Helen Whitfield) who was found to be drinking heavily off-duty. By the culmination of the episode, after a confrontation by Maj. Margaret Houlihan, the character swears off alcohol and presumably quits immediately. At mealtime, roughly 48 hours later, Whitfield becomes hysterical upon being served food in the Mess tent, claiming that things are crawling onto her from it. Margaret and Col. Sherman Potter subdue her. Potter, having recognized the symptoms of delirium tremens orders 5 ml of paraldehyde from a witnessing nurse. During the filming of the 1975 film Monty Python and the Holy Grail, Graham Chapman developed delirium tremens due to the lack of alcohol on the set. It was particularly bad during the filming of the bridge of death scene where Chapman was visibly shaking, sweating and could not cross the bridge. His fellow Pythons were astonished as Chapman was an accomplished mountaineer. In the 1995 film Leaving Las Vegas, Nicolas Cage plays a suicidal alcoholic who rids himself of all his possessions and travels to Las Vegas to drink himself to death. During his travels, he experiences delirium tremens on a couch after waking up from a binge and crawls in pain to the refrigerator for more vodka. Cage's performance as Ben Sanderson in the film won the Academy Award for Best Actor in 1996. Delirium tremens in music Irish singer-songwriter Christy Moore has a song on his 1985 album, Ordinary Man, called "Delirium Tremens" which is a satirical song, directed towards the leaders in Irish politics and culture. Some of the people mentioned in the song include Charles Haughey (former Fianna Fáil leader), Ruairi Quinn (at the time a Labour TD, later the party leader), Dick Spring (former Labour Party leader) and Roger Casement (who was captured bringing German guns to Ireland for the 1916 Easter Rising). English band Brotherly has a song called "DTs" on their album One Sweet Life. Russian composer Modest Mussorgsky (1839-1881) died of delirium tremens. Delirium tremens in popular culture Nicknames for delirium tremens include "the DTs", "the shakes", "the oopizootics", "barrel-fever", "the blue horrors", "the rat's", "bottleache", "bats", "the drunken horrors", "seeing pink elephants", "gallon distemper", "quart mania", "janky jerks", "heebie jeebies", "pink spiders", and "riding the ghost train", as well as "ork orks", "the zoots", "the 750 itch", and "pint paralysis". Another nickname is "the Brooklyn Boys", found in Eugene O'Neill's one-act play Hughie set in Times Square in the 1920s. Delirium tremens was also given an alternate medical definition since at least the 1840s, being known as mania a potu, which translates to 'mania from drink'. The Belgian beer "Delirium Tremens," introduced in 1988, is a direct reference and also uses a pink elephant as its logo to highlight one of the symptoms of delirium tremens. See also Alcohol dementia Alcohol detoxification Delusional parasitosis Excited delirium On the wagon References External links Why Does Alcohol Cause the Shakes? | Alcohol Withdrawal Syndrome Tremors | Dr Peter MCcann MCC, MBBS | Castle Craig Hospital Causes of death Health effects of alcohol Addiction psychiatry Intensive care medicine Neurological disorders Latin medical words and phrases Medical emergencies Alcohol abuse Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate

Medical diagnosis

Medical diagnosis (abbreviated Dx, Dx, or Ds) is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as a diagnosis with the medical context being implicit. The information required for a diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures, such as medical tests, are also done during the process. Sometimes the posthumous diagnosis is considered a kind of medical diagnosis. Diagnosis is often challenging because many signs and symptoms are nonspecific. For example, redness of the skin (erythema), by itself, is a sign of many disorders and thus does not tell the healthcare professional what is wrong. Thus differential diagnosis, in which several possible explanations are compared and contrasted, must be performed. This involves the correlation of various pieces of information followed by the recognition and differentiation of patterns. Occasionally the process is made easy by a sign or symptom (or a group of several) that is pathognomonic. Diagnosis is a major component of the procedure of a doctor's visit. From the point of view of statistics, the diagnostic procedure involves classification tests. Medical uses A diagnosis, in the sense of diagnostic procedure, can be regarded as an attempt at classification of an individual's condition into separate and distinct categories that allow medical decisions about treatment and prognosis to be made. Subsequently, a diagnostic opinion is often described in terms of a disease or other condition. (In the case of a wrong diagnosis, however, the individual's actual disease or condition is not the same as the individual's diagnosis.) A total evaluation of a condition is often termed a diagnostic workup. A diagnostic procedure may be performed by various healthcare professionals such as a physician, physiotherapist, dentist, podiatrist, optometrist, nurse practitioner, healthcare scientist or physician assistant. This article uses diagnostician as any of these person categories. A diagnostic procedure (as well as the opinion reached thereby) does not necessarily involve elucidation of the etiology of the diseases or conditions of interest, that is, what caused the disease or condition. Such elucidation can be useful to optimize treatment, further specify the prognosis or prevent recurrence of the disease or condition in the future. The initial task is to detect a medical indication to perform a diagnostic procedure. Indications include: Detection of any deviation from what is known to be normal, such as can be described in terms of, for example, anatomy (the structure of the human body), physiology (how the body works), pathology (what can go wrong with the anatomy and physiology), psychology (thought and behavior) and human homeostasis (regarding mechanisms to keep body systems in balance). Knowledge of what is normal and measuring of the patient's current condition against those norms can assist in determining the patient's particular departure from homeostasis and the degree of departure, which in turn can assist in quantifying the indication for further diagnostic processing. A complaint expressed by a patient. The fact that a patient has sought a diagnostician can itself be an indication to perform a diagnostic procedure. For example, in a doctor's visit, the physician may already start performing a diagnostic procedure by watching the gait of the patient from the waiting room to the doctor's office even before she or he has started to present any complaints. Even during an already ongoing diagnostic procedure, there can be an indication to perform another, separate, diagnostic procedure for another, potentially concomitant, disease or condition. This may occur as a result of an incidental finding of a sign unrelated to the parameter of interest, such as can occur in comprehensive tests such as radiological studies like magnetic resonance imaging or blood test panels that also include blood tests that are not relevant for the ongoing diagnosis. Procedure General components which are present in a diagnostic procedure in most of the various available methods include: Complementing the already given information with further data gathering, which may include questions of the medical history (potentially from other people close to the patient as well), physical examination and various diagnostic tests. A diagnostic test is any kind of medical test performed to aid in the diagnosis or detection of disease. Diagnostic tests can also be used to provide prognostic information on people with established disease. Processing of the answers, findings or other results. Consultations with other providers and specialists in the field may be sought. There are a number of methods or techniques that can be used in a diagnostic procedure, including performing a differential diagnosis or following medical algorithms. In reality, a diagnostic procedure may involve components of multiple methods. Differential diagnosis The method of differential diagnosis is based on finding as many candidate diseases or conditions as possible that can possibly cause the signs or symptoms, followed by a process of elimination or at least of rendering the entries more or less probable by further medical tests and other processing, aiming to reach the point where only one candidate disease or condition remains as probable. The result may also remain a list of possible conditions, ranked in order of probability or severity. Such a list is often generated by computer-aided diagnosis systems. The resultant diagnostic opinion by this method can be regarded more or less as a diagnosis of exclusion. Even if it does not result in a single probable disease or condition, it can at least rule out any imminently life-threatening conditions. Unless the provider is certain of the condition present, further medical tests, such as medical imaging, are performed or scheduled in part to confirm or disprove the diagnosis but also to document the patient's status and keep the patient's medical history up to date. If unexpected findings are made during this process, the initial hypothesis may be ruled out and the provider must then consider other hypotheses. Pattern recognition In a pattern recognition method the provider uses experience to recognize a pattern of clinical characteristics. It is mainly based on certain symptoms or signs being associated with certain diseases or conditions, not necessarily involving the more cognitive processing involved in a differential diagnosis. This may be the primary method used in cases where diseases are "obvious", or the provider's experience may enable him or her to recognize the condition quickly. Theoretically, a certain pattern of signs or symptoms can be directly associated with a certain therapy, even without a definite decision regarding what is the actual disease, but such a compromise carries a substantial risk of missing a diagnosis which actually has a different therapy so it may be limited to cases where no diagnosis can be made. Diagnostic criteria The term diagnostic criteria designates the specific combination of signs and symptoms, and test results that the clinician uses to attempt to determine the correct diagnosis. Some examples of diagnostic criteria, also known as clinical case definitions, are: Amsterdam criteria for hereditary nonpolyposis colorectal cancer McDonald criteria for multiple sclerosis ACR criteria for systemic lupus erythematosus Centor criteria for strep throat Clinical decision support system Clinical decision support systems are interactive computer programs designed to assist health professionals with decision-making tasks. The clinician interacts with the software utilizing both the clinician's knowledge and the software to make a better analysis of the patients data than either human or software could make on their own. Typically the system makes suggestions for the clinician to look through and the clinician picks useful information and removes erroneous suggestions. Some programs attempt to do this by replacing the clinician, such as reading the output of a heart monitor. Such automated processes are usually deemed a "device" by the FDA and require regulatory approval. In contrast, clinical decision support systems that "support" but do not replace the clinician are deemed to be "Augmented Intelligence" if it meets the FDA criteria that (1) it reveals the underlying data, (2) reveals the underlying logic, and (3) leaves the clinician in charge to shape and make the decision. Other diagnostic procedure methods Other methods that can be used in performing a diagnostic procedure include: Usage of medical algorithms An "exhaustive method", in which every possible question is asked and all possible data is collected. Adverse effects Diagnosis problems are the dominant cause of medical malpractice payments, accounting for 35% of total payments in a study of 25 years of data and 350,000 claims. Overdiagnosis Overdiagnosis is the diagnosis of "disease" that will never cause symptoms or death during a patient's lifetime. It is a problem because it turns people into patients unnecessarily and because it can lead to economic waste (overutilization) and treatments that may cause harm. Overdiagnosis occurs when a disease is diagnosed correctly, but the diagnosis is irrelevant. A correct diagnosis may be irrelevant because treatment for the disease is not available, not needed, or not wanted. Errors Most people will experience at least one diagnostic error in their lifetime, according to a 2015 report by the National Academies of Sciences, Engineering, and Medicine. Causes and factors of error in diagnosis are: the manifestation of disease are not sufficiently noticeable a disease is omitted from consideration too much significance is given to some aspect of the diagnosis the condition is a rare disease with symptoms suggestive of many other conditions the condition has a rare presentation Lag time When making a medical diagnosis, a lag time is a delay in time until a step towards diagnosis of a disease or condition is made. Types of lag times are mainly: Onset-to-medical encounter lag time, the time from onset of symptoms until visiting a health care provider Encounter-to-diagnosis lag time, the time from first medical encounter to diagnosis Lag time due to delays in reading x-rays have been cited as a major challenge in care delivery. The Department of Health and Human Services has reportedly found that interpretation of x-rays is rarely available to emergency room physicians prior to patient discharge. Long lag times are often called "diagnostic odyssey". History The first recorded examples of medical diagnosis are found in the writings of Imhotep (2630–2611 BC) in ancient Egypt (the Edwin Smith Papyrus). A Babylonian medical textbook, the Diagnostic Handbook written by Esagil-kin-apli (fl.1069–1046 BC), introduced the use of empiricism, logic and rationality in the diagnosis of an illness or disease. Traditional Chinese Medicine, as described in the Yellow Emperor's Inner Canon or Huangdi Neijing, specified four diagnostic methods: inspection, auscultation-olfaction, inquiry and palpation. Hippocrates was known to make diagnoses by tasting his patients' urine and smelling their sweat. Word Medical diagnosis or the actual process of making a diagnosis is a cognitive process. A clinician uses several sources of data and puts the pieces of the puzzle together to make a diagnostic impression. The initial diagnostic impression can be a broad term describing a category of diseases instead of a specific disease or condition. After the initial diagnostic impression, the clinician obtains follow up tests and procedures to get more data to support or reject the original diagnosis and will attempt to narrow it down to a more specific level. Diagnostic procedures are the specific tools that the clinicians use to narrow the diagnostic possibilities. The plural of diagnosis is diagnoses. The verb is to diagnose, and a person who diagnoses is called a diagnostician. Etymology The word diagnosis is derived through Latin from the Greek word διάγνωσις (diágnōsis) from διαγιγνώσκειν (diagignṓskein), meaning "to discern, distinguish". Society and culture Social context Diagnosis can take many forms. It might be a matter of naming the disease, lesion, dysfunction or disability. It might be a management-naming or prognosis-naming exercise. It may indicate either degree of abnormality on a continuum or kind of abnormality in a classification. It is influenced by non-medical factors such as power, ethics and financial incentives for patient or doctor. It can be a brief summation or an extensive formulation, even taking the form of a story or metaphor. It might be a means of communication such as a computer code through which it triggers payment, prescription, notification, information or advice. It might be pathogenic or salutogenic. It is generally uncertain and provisional. Once a diagnostic opinion has been reached, the provider is able to propose a management plan, which will include treatment as well as plans for follow-up. From this point on, in addition to treating the patient's condition, the provider can educate the patient about the etiology, progression, prognosis, other outcomes, and possible treatments of her or his ailments, as well as providing advice for maintaining health. A treatment plan is proposed which may include therapy and follow-up consultations and tests to monitor the condition and the progress of the treatment, if needed, usually according to the medical guidelines provided by the medical field on the treatment of the particular illness. Relevant information should be added to the medical record of the patient. A failure to respond to treatments that would normally work may indicate a need for review of the diagnosis. Nancy McWilliams identifies five reasons that determine the necessity for diagnosis: diagnosis for treatment planning; information contained in it related to prognosis; protecting interests of patients; a diagnosis might help the therapist to empathize with his patient; might reduce the likelihood that some fearful patients will go-by the treatment. Types Sub-types of diagnoses include: Clinical diagnosis A diagnosis made on the basis of medical signs and reported symptoms, rather than diagnostic tests Laboratory diagnosis A diagnosis based significantly on laboratory reports or test results, rather than the physical examination of the patient. For instance, a proper diagnosis of infectious diseases usually requires both an examination of signs and symptoms, as well as laboratory test results and characteristics of the pathogen involved. Radiology diagnosis A diagnosis based primarily on the results from medical imaging studies. Greenstick fractures are common radiological diagnoses. Electrography diagnosis A diagnosis based on measurement and recording of electrophysiologic activity. Endoscopy diagnosis A diagnosis based on endoscopic inspection and observation of the interior of a hollow organ or cavity of the body. Tissue diagnosis A diagnosis based on the macroscopic, microscopic, and molecular examination of tissues such as biopsies or whole organs. For example, a definitive diagnosis of cancer is made via tissue examination by a pathologist. Principal diagnosis The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. Many patients have additional diagnoses. Admitting diagnosis The diagnosis given as the reason why the patient was admitted to the hospital; it may differ from the actual problem or from the discharge diagnoses, which are the diagnoses recorded when the patient is discharged from the hospital. Differential diagnosis A process of identifying all of the possible diagnoses that could be connected to the signs, symptoms, and lab findings, and then ruling out diagnoses until a final determination can be made. Diagnostic criteria Designates the combination of signs, symptoms, and test results that the clinician uses to attempt to determine the correct diagnosis. They are standards, normally published by international committees, and they are designed to offer the best sensitivity and specificity possible, respect the presence of a condition, with the state-of-the-art technology. Prenatal diagnosis Diagnosis work done before birth Diagnosis of exclusion A medical condition whose presence cannot be established with complete confidence from history, examination or testing. Diagnosis is therefore by elimination of all other reasonable possibilities. Dual diagnosis The diagnosis of two related, but separate, medical conditions or comorbidities. The term almost always referred to a diagnosis of a serious mental illness and a substance use disorder, however, the increasing prevalence of genetic testing has revealed many cases of patients with multiple concomitant genetic disorders. Self-diagnosis The diagnosis or identification of a medical conditions in oneself. Self-diagnosis is very common. Remote diagnosis A type of telemedicine that diagnoses a patient without being physically in the same room as the patient. Nursing diagnosis Rather than focusing on biological processes, a nursing diagnosis identifies people's responses to situations in their lives, such as a readiness to change or a willingness to accept assistance. Computer-aided diagnosis Providing symptoms allows the computer to identify the problem and diagnose the user to the best of its ability. Health screening begins by identifying the part of the body where the symptoms are located; the computer cross-references a database for the corresponding disease and presents a diagnosis. Overdiagnosis The diagnosis of "disease" that will never cause symptoms, distress, or death during a patient's lifetime Wastebasket diagnosis A vague, or even completely fake, medical or psychiatric label given to the patient or to the medical records department for essentially non-medical reasons, such as to reassure the patient by providing an official-sounding label, to make the provider look effective, or to obtain approval for treatment. This term is also used as a derogatory label for disputed, poorly described, overused, or questionably classified diagnoses, such as pouchitis and senility, or to dismiss diagnoses that amount to overmedicalization, such as the labeling of normal responses to physical hunger as reactive hypoglycemia. Retrospective diagnosis The labeling of an illness in a historical figure or specific historical event using modern knowledge, methods and disease classifications. See also Diagnosis codes Diagnosis-related group Diagnostic and Statistical Manual of Mental Disorders Doctor-patient relationship Etiology (medicine) International Statistical Classification ofDiseases and Related Health Problems (ICD) Medical classification Merck Manual of Diagnosis and Therapy Medical error Nosology Nursing diagnosis Pathogenesis Pathology Prediction Preimplantation genetic diagnosis Prognosis Sign (medicine) Symptom Lists List of diagnostic classification and rating scales used in psychiatry List of diseases List of disorders List of medical symptoms :Category:Diseases References External links Medical terminology Nosology

Syndrome

A syndrome is a set of medical signs and symptoms which are correlated with each other and often associated with a particular disease or disorder. The word derives from the Greek σύνδρομον, meaning "concurrence". When a syndrome is paired with a definite cause this becomes a disease. In some instances, a syndrome is so closely linked with a pathogenesis or cause that the words syndrome, disease, and disorder end up being used interchangeably for them. This substitution of terminology often confuses the reality and meaning of medical diagnoses. This is especially true of inherited syndromes. About one third of all phenotypes that are listed in OMIM are described as dysmorphic, which usually refers to the facial gestalt. For example, Down syndrome, Wolf–Hirschhorn syndrome, and Andersen–Tawil syndrome are disorders with known pathogeneses, so each is more than just a set of signs and symptoms, despite the syndrome nomenclature. In other instances, a syndrome is not specific to only one disease. For example, toxic shock syndrome can be caused by various toxins; another medical syndrome named as premotor syndrome can be caused by various brain lesions; and premenstrual syndrome is not a disease but simply a set of symptoms. If an underlying genetic cause is suspected but not known, a condition may be referred to as a genetic association (often just "association" in context). By definition, an association indicates that the collection of signs and symptoms occurs in combination more frequently than would be likely by chance alone. Syndromes are often named after the physician or group of physicians that discovered them or initially described the full clinical picture. Such eponymous syndrome names are examples of medical eponyms. Recently, there has been a shift towards naming conditions descriptively (by symptoms or underlying cause) rather than eponymously, but the eponymous syndrome names often persist in common usage. The defining of syndromes has sometimes been termed syndromology, but it is usually not a separate discipline from nosology and differential diagnosis generally, which inherently involve pattern recognition (both sentient and automated) and differentiation among overlapping sets of signs and symptoms. Teratology (dysmorphology) by its nature involves the defining of congenital syndromes that may include birth defects (pathoanatomy), dysmetabolism (pathophysiology), and neurodevelopmental disorders. Subsyndromal When there are a number of symptoms suggesting a particular disease or condition but does not meet the defined criteria used to make a diagnosis of that disease or condition. This can be a bit subjective because it is ultimately up to the clinician to make the diagnosis. This could be because it has not advanced to the level or passed a threshold or just similar symptoms cause by other issues. Subclinical is synonymous since one of its definitions is "where some criteria are met but not enough to achieve clinical status"; but subclinical is not always interchangeable since it can also mean "not detectable or producing effects that are not detectable by the usual clinical tests"; i.e., asymptomatic. Usage General medicine In medicine, a broad definition of syndrome is used, which describes a collection of symptoms and findings without necessarily tying them to a single identifiable pathogenesis. Examples of infectious syndromes include encephalitis and hepatitis, which can both have several different infectious causes. The more specific definition employed in medical genetics describes a subset of all medical syndromes. Psychiatry and psychopathology Psychiatric syndromes often called psychopathological syndromes (psychopathology refers both to psychic dysfunctions occurring in mental disorders, and the study of the origin, diagnosis, development, and treatment of mental disorders). In Russia those psychopathological syndromes are used in modern clinical practice and described in psychiatric literature in the details: asthenic syndrome, obsessive syndrome, emotional syndromes (for example, manic syndrome, depressive syndrome), Cotard's syndrome, catatonic syndrome, hebephrenic syndrome, delusional and hallucinatory syndromes (for example, paranoid syndrome, paranoid-hallucinatory syndrome, Kandinsky-Clérambault's syndrome also known as syndrome of psychic automatism, hallucinosis), paraphrenic syndrome, psychopathic syndromes (includes all personality disorders), clouding of consciousness syndromes (for example, twilight clouding of consciousness, amential syndrome also known as amentia, delirious syndrome, stunned consciousness syndrome, oneiroid syndrome), hysteric syndrome, neurotic syndrome, Korsakoff's syndrome, hypochondriacal syndrome, paranoiac syndrome, senestopathic syndrome, encephalopathic syndrome. Some examples of psychopathological syndromes used in modern Germany are psychoorganic syndrome, depressive syndrome, paranoid-hallucinatory syndrome, obsessive-compulsive syndrome, autonomic syndrome, hostility syndrome, manic syndrome, apathy syndrome. Münchausen syndrome, Ganser syndrome, neuroleptic-induced deficit syndrome, olfactory reference syndrome are also well-known. History The most important psychopathological syndromes were classified into three groups ranked in order of severity by German psychiatrist Emil Kraepelin (1856—1926). The first group, which includes the mild disorders, consists of five syndromes: emotional, paranoid, hysterical, delirious, and impulsive. The second, intermediate, group includes two syndromes: schizophrenic syndrome and speech-hallucinatory syndrome. The third includes the most severe disorders, and consists of three syndromes: epileptic, oligophrenic and dementia. In Kraepelin's era, epilepsy was viewed as a mental illness; Karl Jaspers also considered "genuine epilepsy" a "psychosis", and described "the three major psychoses" as schizophrenia, epilepsy, and manic-depressive illness. Medical genetics In the field of medical genetics, the term "syndrome" is traditionally only used when the underlying genetic cause is known. Thus, trisomy 21 is commonly known as Down syndrome. Until 2005, CHARGE syndrome was most frequently referred to as "CHARGE association". When the major causative gene (CHD7) for the condition was discovered, the name was changed. The consensus underlying cause of VACTERL association has not been determined, and thus it is not commonly referred to as a "syndrome". Other fields In biology, "syndrome" is used in a more general sense to describe characteristic sets of features in various contexts. Examples include behavioral syndromes, as well as pollination syndromes and seed dispersal syndromes. In orbital mechanics and astronomy, Kessler syndrome refers to the effect where the density of objects in low Earth orbit (LEO) is high enough that collisions between objects could cause a cascade in which each collision generates space debris that increases the likelihood of further collisions. In quantum error correction theory syndromes correspond to errors in code words which are determined with syndrome measurements, which only collapse the state on an error state, so that the error can be corrected without affecting the quantum information stored in the code words. Naming There is no set common convention for the naming of newly identified syndromes. In the past, syndromes were often named after the physician or scientist who identified and described the condition in an initial publication. These are referred to as "eponymous syndromes". In some cases, diseases are named after the patient who initially presents with symptoms, or their home town (Stockholm syndrome). There have been isolated cases of patients being eager to have their syndromes named after them, while their physicians are hesitant. When a syndrome is named after a person, there is some difference of opinion as to whether it should take the possessive form or not (e.g. Down syndrome vs. Down's syndrome). North American usage has tended to favor the non-possessive form, while European references often use the possessive. A 2009 study demonstrated a trend away from the possessive form in Europe in medical literature from 1970 through 2008. History Avicenna, in The Canon of Medicine (published 1025) helped lay the groundwork for the idea of a syndrome and pioneered in the diagnosis of a specific disease. The concept of a medical syndrome was further developed in the 17th century by Thomas Sydenham. Underlying cause Even in syndromes with no known etiology, the presence of the associated symptoms with a statistically improbable correlation normally leads the researchers to hypothesize that there exists an unknown underlying cause for all the described symptoms. See also List of syndromes Toxidrome Symptom Sequence (medicine) Characteristics of syndromic ASD conditions References External links Whonamedit.com - a repository of medical eponyms Medical terminology

Unsolved problems in medicine

This article discusses notable unsolved problems in medicine. Many of the problems relate to how drugs work (the so-called mechanism of action), and to diseases with an unknown cause, the so-called idiopathic diseases. Definition of "disease" There is no overarching, clear definition of what a disease is. On one hand, there is a scientific definition which is tied to a physiological process, and on the other hand, there is the subjective suffering of a patient and the loss of their life quality. Both approaches do not need to match, and they can even be contradictory. For example, when a patient seeks medical help because of a severe flu, the doctor will not care about the specific virological and immunological process behind the clearly visible suffering. This is contrasted by many hemochromatosis patients who will neither see suffering nor a change in his life quality, while the disease-causing process is severe and often deadly if left untreated. Similarly, many cancers in their very early stages are asymptomatic (e.g. pancreatic cancer) and the patient still feels healthy, which delays seeking treatment. Sometimes, cultural factors also play a role in defining "disease". Erectile dysfunction was long seen as a negative but non-pathological state. The introduction of effective treatments has led to its acceptance as a disease. Even more difficulties arise when it comes to mental disorders. Depressions and anxiety disorders cause significant subjective suffering in the patient, but do not harm third persons. On the contrary, a narcissistic disorder or an impulse-control disorder does not cause any suffering in the patient, though the maintenance of healthy interpersonal relationships will be affected, and third persons can be harmed. There is also debate on whether non-normal behavior like paraphilias should be classified as a disease if they neither cause subjective suffering in the patient, nor endanger third persons. Evidence-based medicine Evidence-based medicine (EBM) has become the central paradigm in medical practice and research. However, debate continues around EBM and about how results obtained from large samples of patients can be applied to the individual. Psychiatry and psychology Lack of reliable diagnoses in some disorders Though manuals like the DSM have covered a lot of ground when it comes to defining mental illnesses, in some disorders the reliability of diagnosis is still very poor. For example, inter-rater reliability in cases of dementia is very high, with a kappa value of 0.78, while major depressive disorder is often diagnosed differently by independent experts who see the same patient, with a kappa value of just 0.28. Cultural issues in defining mental disorders Some mental illnesses like paraphilias are still defined by societal and cultural norms, rather than putting the individual's well-being in focus. For example, DSM defined homosexuality as a mental illness, until the American Psychiatric Association decided otherwise in 1973. As Richard Green pointed out in a review on pedophilia, psychiatry should identify unhealthy mental processes and treat them, and not focus on cultural norms, moral questions or legal issues. As textbooks and handbooks like DSM are usually written by Western authors, a culturally neutral definition of mental diseases is an unsolved problem. Though newer editions of the DSM “respect” non-Western cultures by mentioning culture-specific symptom presentations (e.g. a very long time of mourning is regarded as a sign of depression in some cultures, but not in others), the inclusion of cultural factors into diagnostic criteria is seen as a political decision, but not a scientifically founded one. The Western viewpoint when defining mental illnesses also creates a cultural blind spot: Manuals rarely discuss how Western lifestyles and cultures may modify or hide symptoms of mental illnesses. Still no causal classification of mental disorders A patient with a paralysis is referred to an oncologist if the condition is caused by a cancer metastasis in the spinal cord; a treatment by a neurologist is a secondary consideration. Likewise, renal insufficiency is sometimes caused by heart problems, and the treatment is thus led by a cardiologist. In psychiatry, however, grouping mental disorders by their cause is still an unsolved problem. Psychiatric textbooks and manuals cluster disorders by symptoms, which is thought to impede the search for effective treatments. This has been compared to an ornithologist's field guide: It allows you to identify birds, but it does not tell you why a species exists in biotope A but not B. Diseases with unknown cause There are numerous diseases for which causes are not known. There are others for which the etiology is fully or partially understood, but for which effective treatments are not yet available. Idiopathic is a descriptive term used in medicine to denote diseases with an unknown cause or mechanism of apparent spontaneous origin. Examples of idiopathic diseases include: Idiopathic pulmonary fibrosis, Idiopathic intracranial hypertension, and Idiopathic pulmonary haemosiderosis. Another example is that the cause of aggressive periodontitis – resulting in rapid bone loss and teeth in need of extraction – is still unknown. Mechanisms of action It is sometimes unknown how drugs work. Often it is possible to study gene expression in a model organism, and determine the genes that are inhibited by a certain substance, and make further inferences from this data. A classical example of an unknown mechanism of action is the mechanism of general anesthesia. Other examples are paracetamol, antidepressants and lithium. See also List of unsolved problems in biology List of unsolved problems in neuroscience References medicine Medical lists

Environment, health and safety

Environment, health and safety (EHS) (or health, safety and environment –HSE–, or safety, health and environment –SHE–) is an interdisciplinary field focused on the study and implementation of practical aspects environmental protection and safeguard of people's health and safety, especially in an occupational context. It is what organizations must do to make sure that their activities do not cause harm. Commonly, quality - quality assurance and quality control - is adjoined to form HSQE or equivalent initialisms. From a safety standpoint, EHS involves creating organized efforts and procedures for identifying workplace hazards and reducing accidents and exposure to harmful situations and substances. It also includes training of personnel in accident prevention, accident response, emergency preparedness, and use of protective clothing and equipment. From a health standpoint, EHS involves creating the development of safe, high-quality, and environmentally friendly processes, working practices and systemic activities that prevent or reduce the risk of harm to people in general, operators, or patients. From an environmental standpoint, EHS involves creating a systematic approach to complying with environmental regulations, such as managing waste or air emissions all the way to helping site's reduce the carbon footprint. The activities of an EHS working group might focus on: Exchange of know-how regarding health, safety and environmental aspects of a material Promotion of good working practices, such as post-use material collection for recycling Regulatory requirements play an important role in EHS discipline and EHS managers must identify and understand relevant EHS regulations, the implications of which must be communicated to executive management so the company can implement suitable measures. Organizations based in the United States are subject to EHS regulations in the Code of Federal Regulations, particularly CFR 29, 40, and 49. Still, EHS management is not limited to legal compliance and companies should be encouraged to do more than is required by law, if appropriate. Other names Notwithstanding the individual importance of these attributes, the various institutions and authors have accented the acronyms differently. Successful HSE programs also include measures to address ergonomics, air quality, and other aspects of workplace safety that could affect the health and well-being of employees and the overall community. Another researcher transformed it as SHE in 1996, while exploring the "concept of 'human quality' in terms of living standards that must follow later than the health.....[as per the] paradigm of SHEQ, ....raising up the importance of environment to the 'safety of people as a prime consideration'". It is because "Safety First" is called in for the commitment to transform the safety culture of countries. Quality is "fitness for purpose", and without it, each and every endeavour will be futile. Abbreviations used include: History The chemical industry introduced the first formal EHS management approach in 1985 as a reaction to several catastrophic accidents (like the Seveso disaster of July 1976 and the Bhopal disaster of December 1984). This worldwide voluntary initiative, called "Responsible Care", started by the Chemistry Industry Association of Canada (formerly the Canadian Chemical Producers' Association - CCPA), operates in about 50 countries, with central coordination provided by the International Council of Chemical Associations (ICCA). It involves eight fundamental features which ensure plant and product safety, occupational health and environmental protection, but which also try to demonstrate by image-building campaigns that the chemical industry acts in a responsible manner. Being an initiative of the ICCA, it is restricted to the chemical industry. Since the 1990s, general approaches to EHS management that may fit any type of organisation have appeared in international standards such as: The Valdez Principles, that have been formulated to guide and evaluate corporate conduct towards the environment. The Eco-Management and Audit Scheme (EMAS), developed by the European Commission in 1993 ISO 14001 for environmental management in 1996 ISO 45001 for occupational health and safety management in 2018, preceded by OHSAS 18001 1999 In 1998 the International Finance Corporation established EHS guidelines. Topics General topics covered by EHS include: Environmental Air emissions and ambient air quality Energy conservation Wastewater and ambient water quality Water conservation Waste management Noise Contaminated land Occupational health and safety Physical hazards Chemical hazards Biological hazards Radiological hazards Special hazard environments Personal protective equipment (PPE) Communication and training Monitoring Community health and safety Water quality and availability Structural safety of project infrastructure Life and fire safety (LFS) Traffic safety Transport of hazardous materials Disease prevention Emergency preparedness and response Regulatory agencies Canada Canadian Centre for Occupational Health and Safety (CCOHS) United Kingdom The Health and Safety Executive The Environment Agency Local authorities United States Federal / international Occupational Safety and Health Administration (OSHA) Environmental Protection Agency (EPA) Nuclear Regulatory Commission (NRC) Mine Safety and Health Administration (MSHA) Bureau of Safety and Environmental Enforcement (BSEE) State California Division of Occupational Safety and Health, New York Department of Health, Safety and Health Council of North Carolina, etc. Local Municipal fire departments (building code inspections) Zambia Environmental Management Agency (ZEMA) Radiation Protection Authority Occupational Health and Safety Institute Mines Safety Department Publications EHS Today Environmental Leader ISHN OHS Safety+Health Magazine – National Safety Council See also Environmental security Occupational safety and health National Safety Council Robert W. Campbell Award, an Award for Business Excellence through EHS Management. Safety engineering References External links NAEM, the premier Association for EHS Management: What is EHS? International Finance Corporation: World Bank Group Environmental, Health, and Safety Guidelines International Network for Environmental Management Environmental protection Health Safety

Activities of daily living

Activities of daily living (ADLs) is a term used in healthcare to refer to an individual's daily self-care activities. Health professionals often use a person's ability or inability to perform ADLs as a measure of their functional status. The concept of ADLs was originally proposed in the 1950s by Sidney Katz and his team at the Benjamin Rose Hospital in Cleveland, Ohio. Since then, numerous researchers have expanded on the concept of ADLs. For instance, many indexes that assess ADLs now incorporate measures of mobility. In 1969, Lawton and Brody developed the concept of Instrumental Activities of Daily Living (IADLs) to capture the range of activities that support independent living. These are often utilized in caring for individuals with disabilities, injuries, and the elderly. Younger children often require help from adults to perform ADLs, as they have not yet developed the skills necessary to perform them independently. Aging and disabilities, affecting individuals across different age groups, can significantly alter a person's daily life. Such changes must be carefully managed to maintain health and well-being. Common activities of daily living (ADLs) include feeding oneself, bathing, dressing, grooming, working, homemaking, and managing personal hygiene after using the toilet. A number of national surveys have collected data on the ADL status of the U.S. population. Although basic definitions of ADLs are established, what specifically constitutes a particular ADL can vary for each individual. Cultural background and education level are among the factors that can influence a person's perception of their functional abilities. ADLs are categorized into basic self-care tasks (typically learned in infancy) or instrumental tasks generally learned throughout adolescence. A person who cannot perform essential ADLs may have a poorer quality of life or be unsafe in their current living conditions; therefore, they may require the help of other individuals and/or mechanical devices. Examples of mechanical devices to aid in ADLs include electric lifting chairs, bathtub transfer benches and ramps to replace stairs. Basic Basic ADLs consist of self-care tasks that include: Bathing and showering Personal hygiene and grooming, which encompasses brushing, combing, and styling hair Dressing Toilet hygiene, which involves getting to the toilet, cleaning oneself, and getting back up Functional mobility, often referred to as "transferring." This includes the ability to walk, get in and out of bed, and get into and out of a chair. The broader definition covers moving from one place to another while performing activities and is useful for people with varying physical abilities who can still move around independently. Self-feeding, which is limited to the act of eating itself, as opposed to assisted feeding The Functional Independence Measure (FIM) is a tool developed in 1983 that uses a 0 to 7 scale to evaluate different ADLs based on the level of assistance required. A score of 7 indicates that the individual is independent, while a score of 0 signifies that the individual cannot perform the activity without assistance. The specific breakdown of the scale is shown below: 7 - Complete Independence 6 - Modified Independence 5 - Supervision or Setup 4 - Minimal Assistance 3 - Moderate Assistance 2 - Maximal Assistance 1 - Total Assistance 0 - Activity Does Not Occur While not widely used, the mnemonic "DEATH" can be helpful for recalling different ADLs: Dressing/bathing, Eating, Ambulating (moving/walking), Toileting, and Hygiene. Instrumental Instrumental activities of daily living (IADLs) are not essential for basic day-to-day functioning, but they enable an individual to maintain a level of independence in a community. Cleaning and maintaining the house Managing money Moving within the community Preparing meals Shopping for groceries and other necessities Taking prescribed medications Using the telephone or other forms of communication Occupational therapists often evaluate IADLs during patient assessments. The American Occupational Therapy Association identifies 12 types of IADLs, which may be performed individually or as co-occupations with others. Care of others (including selecting and supervising caregivers) Care of pets Child rearing Communication management Community mobility Financial management Health management and maintenance Home establishment and maintenance Meal preparation and cleanup Religious observances Safety procedures and emergency responses Shopping Therapy Occupational therapists evaluate and use therapeutic interventions to rebuild the skills required to maintain, regain, or increase a person's independence in all Activities of Daily Living may have diminished due to physical or mental health conditions, injuries, or age-related impairments. Physical therapists employ exercises to help patients maintain and improve independence in ADLs. The exercise program is tailored to the patient's specific deficits, which may include walking speed, strength, balance, and coordination. A slow walking speed has been linked to an increased risk of falls; thus, exercises that enhance walking speed are crucial for safer and more functional ambulation. After initiating an exercise program, it is important to maintain the routine. Otherwise, the benefits will be lost. For frail patients, regular exercise is vital in preserving functional independence and preventing the need for external assistance or placement in a long-term care facility. Assistance Skills in assisting with ADLs are required in nursing and other professions, such as nursing assistants in hospitals, nursing homes, assisted living facilities, and other long-term care settings. This includes assisting in patient mobility, such as repositioning an activity-intolerant patient in bed. Hygiene assistance may involve giving bed baths and helping with urinary and bowel elimination. Personal care assistants are required to adhere to established standards of care. Personal assistance is defined as wagered support of 20 or more hours a week for people with impairments. A 2008 review suggested that personal assistance may offer benefits to some elderly individuals and their informal caretakers. Further research is required to evaluate the efficiency of different personal assistance models and their overall costs. Caretaker requirements In community residential care settings, it is essential for personal assistants, doctors, and nurses to recognize that illness can alter a patient's mental state, affecting their reactions to change and possibly leading to behaviors such as fussiness or capriciousness. Providing care with patience, tact, concentration, discipline, and compassion is crucial to building trust with patients, maintaining their confidence, and supporting the success of their treatment and recovery. Because nursing care requires a great deal of attention and energy, nursing staff in some countries are often required to have national license as nurses, such as having passed the NCLEX. Nursing care is usually divided into general and specialized care. Particular difficulties arise when caring for the severely ill. A healthy workspace is an important factor. If caregivers are mistreated or burnt out, it can lead to residents being neglected and mistreated. Special care needs Mobility Patients who are immobile should be repositioned at least every two hours to prevent the development of pressure ulcers, commonly known as bed sores. Repositioning hospitalized patients also offers additional benefits, such as a reduced risk of deep vein thrombosis, fewer pressure ulcers, and less functional decline. To protect the patient's head from injury during repositioning, a pillow is commonly placed at the head of the bed. To move a bedridden patient up in bed, caregivers utilize either a friction-reducing sheet or a draw sheet. Bathing A bed bath involves using a bath blanket to cover the patient, ensuring that only the area being washed is exposed at any given time. This practice maintains privacy and keeps the patient warm. Typically, the eyes are cleansed first, using water without soap to prevent irritation. Each eye should be cleaned from the inner corner near the nose outward, to avoid transferring debris to the tear duct. A clean section of the cloth is used, or the cloth is rinsed before cleaning the second eye, to prevent the spreading of any organisms. After washing, each area is dried before moving on to the next. Perineal care follows a specific protocol to minimize the transfer of microorganisms. The perineum should be washed from the least contaminated area to the most contaminated area. In females, this involves spreading the labia and washing from the pubic area toward the anal area, never in reverse. For males, the tip of the penis is cleansed first, moving away from the urethral opening (meatus). If the male is uncircumcised, the foreskin is gently retracted, washed, and then promptly returned to its original position to prevent restricting circulation. For children, the foreskin is not retracted to avoid injury. Toileting A bedpan is used for bed-bound patients for bowel elimination as well as urinary elimination for females. The head of the bed is raised to assist in voiding or defecating. Dressing For individuals with one side weaker than the other (e.g., due to a stroke), it is recommended to dress the weaker side first using the stronger arm. Conversely, when undressing, the stronger side should be undressed first. When making an occupied bed, for instance for patients who cannot or have difficulty getting out of bed, the bed is made one side at a time. However, for patients for whom rolling to the side is contraindicated, such as those recovering from hip replacement surgery, the process is modified. These patients are assisted into a sitting position while the caregiver makes the top half of the bed. Once completed, the patient is then helped to lie back while the bottom half of the bed is made. Feeding To maintain self-esteem, patients are involved as much as possible in their care. Their preferences for the order of consuming their meal items are respected. Condiments are provided, and food is prepared according to each patient's preferences. Adequate liquid is supplied with the meal. Necessary aids such as dentures, hearing aids, and glasses are put in place before mealtime. Oral hygiene is important after eating and includes brushing teeth, cleaning dentures, and using mouthwash. For those with dysphagia, patients must be placed on aspiration precautions. The feeding rate and bite sizes are tailored to each patient's tolerance. Dietary modifications, as recommended by a nutrition consultation, can include chopping, mincing, pureeing, or adding thickeners to make swallowing easier. For patients with visual impairments, a clock face analogy is commonly used to describe the position of meal items. When not contraindicated by dysphagia, straws are provided to help prevent spills. Suicide precautions For individuals on suicide watch, meals are provided in plastic or paper containers accompanied by plastic utensils (excluding knives), and the use of sharp objects is permitted only under continuous staff supervision. Bed making A fitted sheet is placed over the mattress of a hospital bed. Often, a draw sheet (also known as a lift sheet) is laid on top of the fitted sheet at the center, where it will lie beneath the patient's midsection. The draw sheet is commonly used to assist in lifting or repositioning the patient. Sheets positioned under the patient are securely tucked in to prevent the formation of wrinkles, which can contribute to skin breakdown. A top sheet and a blanket are then placed over the bed, with the corners neatly mitered. Wound care Wound dressings can be categorized into several types, including hydrocolloid, hydrogel, alginate, collagen, foam, transparent, and cloth dressings. Evaluation Several evaluation tools are available to assess Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL), including the Katz ADL scale, the Older Americans Resources and Services (OARS) ADL/IADL scale, the Lawton IADL scale, and the Bristol Activities of Daily Living Scale. In the domain of disability, measures have been developed to capture functional recovery in performing basic activities of daily living. Amongst them, some measures like the Functional Independence Measure are designed for assessment across a wide range of disabilities. Others like the Spinal Cord Independence Measure are designed to evaluate participants in a specific type of disability. Most models of health care service use ADL evaluations in their practice, including the medical (or institutional) models, such as the Roper–Logan–Tierney model of nursing, and the resident-centered models, such as the Program of All-Inclusive Care for the Elderly (PACE). Pervasive computing technology was considered to determine the wellness of the elderly living independently in their homes. The framework of the intelligent system consists of monitoring important daily activities through the observation of everyday object usage. The improved wellness indices helped in reducing false warnings related to the daily activities of elderly living. Research ADL evaluations are increasingly used in epidemiological studies as a measure of health in later life that does not focus exclusively on specific ailments. Unlike studies investigating specific disease outcomes, research employing ADL assessments is sensitive to a wider range of health effects, including those with lower levels of impact. ADL is measured on a continuous scale, which simplifies the research process. Sidney Katz conducted a study of 64 hip fracture patients over an 18-month period, collecting comprehensive data on their treatments, progression, and outcomes. Analysis of the data revealed that the patients perceived as most independent were able to perform a range of basic activities, from the more complex task of bathing to the simpler one of feeding themselves. Based on these findings, Katz developed a scale to evaluate a patient's capacity for living. This scale was first published in the 1963 Journal of the American Medical Association and has been cited over 1,000 times since its publication. Although the scale offers a standardized measure of psychological and biological function, the process of arriving at this assumption has been criticized. Specifically, Porter has argued for a phenomenological approach noting that: Porter emphasizes the possible disease-specific nature of ADLs (being derived from hip-fracture patients), the need for an objective definition of ADLs, and the possible value of adding additional functional measures. A systematic review examined the effectiveness of programmes designed to teach activities of daily living skills, specifically to individuals with schizophrenia: See also Schwab and England ADL scale Global Assessment of Functioning Long term care insurance References Occupational therapy Nursing Caregiving Self-care

Diogenes syndrome

Diogenes syndrome, also known as senile squalor syndrome, is a disorder characterized by extreme self-neglect, domestic squalor, social withdrawal, apathy, compulsive hoarding of garbage or animals, and a lack of shame. Affected people may also display symptoms of catatonia. The condition was first recognized in 1966 and designated Diogenes syndrome by Clark et al. The name derives from Diogenes of Sinope, an ancient Greek philosopher, a Cynic and an ultimate minimalist, who allegedly lived in a large jar in Athens. Not only did he not hoard, but he actually sought human company by venturing daily to the Agora. Therefore, this eponym is considered to be a misnomer. Other possible terms are senile breakdown, Plyushkin's Syndrome (after the Gogol character), social breakdown and senile squalor syndrome. Frontal lobe impairment may play a part in the causation (Orrell et al., 1989). Presentation Diogenes syndrome is a disorder that involves hoarding of rubbish and severe self-neglect. In addition, the syndrome is characterized by domestic squalor, syllogomania, social alienation, and refusal of help. It has been shown that the syndrome is caused as a reaction to stress that was experienced by the patient. The time span in which the syndrome develops is undefined, though it is most accurately distinguished as a reaction to stress that occurs late in life. In most instances, patients were observed to have an abnormal possessiveness and in a disordered manner. These symptoms suggest damage to the prefrontal areas of the brain, due to its relation to decision making. In contrast, there have also been cases where the hoarded objects were arranged in a methodical manner, which may suggest a cause other than brain damage. Although most patients have been observed to come from homes with poor conditions, and many had been faced with poverty for a long period of time, these similarities are not considered a definite cause to the syndrome. Research showed that some of the participants with the condition had solid family backgrounds as well as successful professional lives. Half of the patients were of higher intelligence level. This indicates the Diogenes syndrome does not exclusively affect those experiencing poverty or those who had traumatic childhood experiences. The severe neglect that they bring on themselves usually results in physical collapse or mental breakdown. Most individuals with the syndrome do not get identified until they face this stage of collapse, due to their predilection to refuse help from others. Personality traits that can be seen frequently in patients diagnosed with Diogenes syndrome are aggressiveness, stubbornness, suspicion of others, unpredictable mood swings, emotional instability and deformed perception of reality. Secondary DS is related to mental disorders. The direct relation of the patients' personalities to the syndrome is unclear, though the similarities in character suggest potential avenues for investigation. Diagnosis Individuals with Diogenes syndrome generally display signs of collectionism, hoarding, or compulsive disorder. Individuals who have had damage to the brain, particularly the frontal lobe, may be at more risk to developing the syndrome. The frontal lobes are of particular interest, because they are known to be involved in higher order cognitive processes, such as reasoning, decision-making and conflict monitoring. Diogenes syndrome tends to occur among the elderly. People with this disorder tend to have significant functional problems correlated with morbidity and mortality. Management It is ethically difficult when it comes to dealing with diagnosed patients, for many of them deny their poor conditions and refuse to accept treatment. The main objectives of the doctors are to help improve the patient's lifestyle and wellbeing, so health care professionals must decide whether or not to force treatment onto their patient. In some cases, especially those including the inability to move, patients have to consent to help, since they cannot manage to look after themselves. Hospitals or nursing homes are often considered the best treatment under those conditions. When under care, patients must be treated in a way in which they can learn to trust the health care professionals. In order to do this, the patients should be restricted in the number of visitors they are allowed, and be limited to one nurse or social worker. Some patients respond better to psychotherapy, while others to behavioral treatment or terminal care. Results after hospitalization tend to be poor. Research on the mortality rate during hospitalization has shown that approximately half the patients die while in the hospital. A quarter of the patients are sent back home, while the other quarter are placed in long-term residential care. Patients under care in hospitals and nursing homes often slide back into relapse or face death. There are other approaches to improve the patient's condition. Day care facilities have often been successful with maturing the patient's physical and emotional state, as well as helping them with socialization. Other methods include services inside the patient's home, such as the delivery of food. History The origin of the syndrome is unknown, although the term "Diogenes" was coined by A. N. G. Clarke et al. in the mid‑1970s and has been commonly used since then. Diogenes syndrome was acknowledged more prominently as a media phenomenon in popular media rather than medical literature. The primary description of this syndrome has only been mentioned recently by geriatricians and psychiatrists. See also Borderline personality disorder Obsessive-compulsive disorder Collyer brothers Compulsive hoarding References Further reading Post F. "Functional disorders: 1. Description, incidence and recognition". In: Levy R, Post F, eds. The psychiatry of late life. Oxford: Blackwell, 1982;180-1. External links 'Husband let wife starve to death' – BBC News item, Friday, 28 March 2008 Syndromes Geriatric psychiatry Compulsive hoarding

Homicidal ideation

Homicidal ideation is a common medical term for thoughts about homicide. There is a range of homicidal thoughts which spans from vague ideas of revenge to detailed and fully formulated plans without the act itself. Most people who have homicidal ideation do not commit homicide. 50–91% of people surveyed on university grounds in various places in the United States admit to having had a homicidal fantasy. Homicidal ideation is common, accounting for 10–17% of patient presentations to psychiatric facilities in the United States. Homicidal ideation is not a disease itself, but may result from other illnesses such as delirium and psychosis. Psychosis, which accounts for 89% of admissions with homicidal ideation in one US study, includes substance-induced psychosis (e.g. amphetamine psychosis) and the psychoses related to schizophreniform disorder and schizophrenia. Delirium is often drug induced or secondary to general medical illness(es). It may arise in association with personality disorders or it may occur in people who do not have any detectable illness. In fact, surveys have shown that the majority of people have had homicidal fantasies at some stage in their life. Many theories have been proposed to explain this. Diagnosis Violence risk Homicidal ideation is noted to be an important risk factor when trying to identify a person's risk for violence. This type of assessment is routine for psychiatric patients or any other patients presenting to hospital with mental health complaints. There are many associated risk factors which include: history of violence and any thoughts of committing harm, poor impulse control and an inability to delay gratification, impairment or loss of reality testing, especially with delusional beliefs or command hallucinations, the feeling of being controlled by an outside force, the belief that other people wish to harm them, the perception of rejection or humiliation at the hands of others, being under the influence of substances or a history of antisocial personality disorder, frontal lobe dysfunction or head injury. Associated psychopathology People who have homicidal ideation are at higher risk of other psychopathology than the normal population. This includes suicidal ideation, psychosis, delirium, or intoxication. Homicidal ideation may arise in relation to behavioural conditions such as personality disorder (particularly conduct disorder, narcissistic personality disorder and antisocial personality disorder). A study in Finland showed an increased risk of violence from people who have antisocial personality disorder, which is greater than the risk of violence from people who have schizophrenia. The same study also cites that many other mental disorders are not associated with an increased risk of violence, of note: depression, anxiety disorders and intellectual disability. Homicidal ideation may arise in people who are otherwise quite well, as is demonstrated by the fact that the greater majority of people within the general population have had homicidal fantasies. When triggering factors are sought regarding homicidal fantasies the majority seem to be linked in some way to the disruption of a couple relationship. Either jealousy or revenge, greed/lust or even fear and self-defense prompt homicidal thoughts and actions in the majority of cases. In a minority of cases, homicides and acts of violence may be related to mental disorder. These homicides and fantasies do not seem to have the same underlying triggers as those by people without a mental disorder, but when these trigger factors are present the risk for violence is greater than usual. People who present with homicidal ideation also have a higher risk of suicide. This shows the need for an assessment of suicide risk in people with thoughts of violence towards others. Spurious and fictitious homicidal ideation Sometimes people claiming to have homicidal ideation do not actually have homicidal thoughts but merely claim to have them. They may do this for a variety of reasons, e.g. to gain attention, to coerce a person or people for or against some action, or to avoid social or legal obligation (sometimes by gaining admission to a hospital) — see malingering or factitious disorder. Theories A number of theories have been proposed to explain the phenomenon of homicidal ideation or homicide itself. Many of these theories seem to overlap. They often are not mutually exclusive. At present no single theory explains all the phenomena noted in homicide, although many theories go some way to explaining several areas. Most of these theories follow the reasoning of theories studied in criminology. A brief synopsis of theories specific to homicide follows. Homicide adaptation This is the most recent of evolutionary theories. It claims to explain most of the phenomena associated with homicide. It states that humans have evolved with adaptations that enable us to think of and/or plan homicide. We come up with the idea as a possible answer to our problem position (threat to ourselves, our mate or our resources) and include a range of thought processes regarding killer and victim (degree of relatedness, relative status, gender, reproductive values, size and strength of families, allies and resources) and the potential costs of making use of such a high penalty strategy as homicide. If homicide is determined to be the best solution strategy, then it might be functional. By-product hypothesis ("slip up") According to this hypothesis, homicide is considered to be a mistake or over-reaction. Normal psychological mechanisms for control of property, partner or personal safety may not appear to be sufficient under certain stressful circumstances and abnormal mechanisms develop. Particularly extreme expressions of this may occur leading to homicide where in the normal state the perpetrator would not behave in this manner. Management Not much information is available regarding the management of patients with homicidal thoughts. In Western countries, the management of such people lies within the realms of the police force and the health system. It is generally agreed upon that people with homicidal thoughts who are thought to be at high risk of acting them out should be recognized as needing help. They should be brought swiftly to a place where an assessment can be made and any underlying medical or mental disorder should be treated. References External links Deadly Dreams - Analysis of homicidal ideation in school shooters. (Scientific American, 1 August 2007) Medical terminology Homicide

Internet addiction disorder

Internet addiction "disorder" (IAD), also known as problematic internet use or pathological internet use, is a problematic compulsive use of the internet, particularly on social media, that impairs an individual's function over a prolonged period of time. Young people are at particular risk of developing internet addiction disorder, with case studies highlighting students whose academic performance declines as they spend more time online. Some experience health consequences from loss of sleep as they stay up to continue scrolling, chatting, and gaming. Excessive Internet use is not recognized as a disorder by the World Health Organization, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the International Classification of Diseases (ICD-11). However, gaming disorder appears in the ICD-11. Controversy around the diagnosis includes whether the disorder is a separate clinical entity, or a manifestation of underlying psychiatric disorders. Definitions are not standardized or agreed upon, complicating the development of evidence-based recommendations. Many different theoretical models have been developed and employed for many years in order to better explain predisposing factors to this disorder. Models such as the cognitive-behavioral model of pathological Internet have been used to explain IAD for more than 20 years. Newer models, such as the Interaction of Person-Affect-Cognition-Execution model, have been developed more recently and are starting to be applied in more clinical studies. Users under 30 access the Internet more than other age groups and experience a higher risk of overuse. In 2011 the term "Facebook addiction disorder" (FAD) emerged. FAD is characterized by compulsive use of Facebook. A 2017 study investigated a correlation between excessive use and narcissism, reporting "FAD was significantly positively related to the personality trait narcissism and to negative mental health variables (depression, anxiety, and stress symptoms)". In 2020, the documentary The Social Dilemma, reported concerns of mental health experts and former employees of social media companies over social media's pursuit of addictive use. For example, when a user has not visited Facebook for some time, the platform varies its notifications, attempting to lure them back. It also raises concerns about the correlation between social media use and child and teen suicidality. Turning off social media notifications may help reduce social media use. For some users, changes in web browsing can be helpful in compensating for self-regulatory problems. For instance, a study involving 157 online learners on massive open online courses examined the impact of such an intervention. The study reported that providing support in self-regulation was associated with a reduction in time spent online, particularly on entertainment. Consequences Mental health consequences A longitudinal study of Chinese high school students (2010) suggests that individuals with moderate to severe risk of Internet addiction are 2.5 times more likely to develop depressive symptoms than their IAD-free counterparts. Researchers studied pathological or uncontrolled Internet use, and later mental health problems in one thousand and forty-one teenage students in China. The students were free of depression and anxiety at the start of the study. Nine months later, the youngsters were evaluated again for anxiety and depression, and eighty-seven were judged as having developed depression. Eight reported significant anxiety symptoms. Another longitudinal study of high school students from Helsinki found that problematic internet usage and depressive symptoms may produce a positive feedback loop. Problematic internet usage is also associated with increased risk of substance abuse. A representative study of the German population (N = 2512) from the medical center at the University of Mainz found pathological usage to be associated with negative psychosocial and health consequences in addicted users compared to regular users. Social consequences Internet addiction increases the risk of many negative social and health outcomes, including poor academic performance, harmful personality effects, anxiety and depression. The best-documented evidence of Internet addiction so far is time-disruption, which subsequently results in interference with regular social life, including academic, professional performance and daily routines. Some studies also reveal that IAD can lead to disruption of social relationships in Europe and Taiwan. It is, however, also noted by others that IAD is beneficial for peer relations in Taiwan. Keith W. Beard (2005) states that "an individual is addicted when an individual's psychological state, which includes both mental and emotional states, as well as their scholastic, occupational and social interactions, is impaired by the overuse of [Internet]". As a result of its complex nature, some scholars do not provide a definition of Internet addiction disorder and throughout time, different terms are used to describe the same phenomenon of excessive Internet use. Internet addiction disorder is used interchangeably with problematic Internet use, pathological Internet use, and Internet addictive disorder. In some cases, this behavior is also referred to as Internet overuse, problematic computer use, compulsive Internet use, Internet abuse, harmful use of the Internet, and Internet dependency. Mustafa Savci and Ferda Aysan, reviewed existing research on internet addiction and identified a number of social and emotional factors that have been linked to this phenomenon. These include loneliness, social anxiety, depression, and low self-esteem. They argued that these factors can lead individuals to use the internet as a way of coping with negative emotions or social isolation, which can in turn lead to addictive behavior. Sign and symptoms Physical symptoms Physical symptoms include a weakened immune system due to lack of sleep, loss of exercise, and increased risk for carpal tunnel syndrome. Additionally, headaches, eye and back strain are common for those struggling with IAD. Psychological and social symptoms Depending on the type of IAD (i.e., overuse of social media, gaming, gambling, etc.) will affect the types of symptoms experienced. For example, overuse of social media can lead to disruption in real-world relationships. The overuse of video games can lead to a neglecting family, home, and work-related responsibilities. Additionally, the overconsumption of pornographic content can create interpersonal and relational problems and can negatively affect mental health. Symptoms of withdrawal might include agitation, depression, anger and anxiety when the person is away from technology. These psychological symptoms might even turn into physical symptoms such as rapid heartbeat, tense shoulders and shortness of breath. Theoretical model Current researchers have proposed different theoretical models of IAD from different perspectives. Theories based on the characteristics of the Internet ACE model This theory suggests that addiction is caused by the characteristics of the Internet itself, including anonymity, convenience and escape, referred to as the ACE model. Anonymity means that individuals are able to hide their true identity and personal information on the Internet and are thus freer to do what they want. Because of this anonymity, it is difficult to regulate what individuals do on the Internet, thus creating an Internet addiction. Convenience may be a benefit of the development of the Internet, as people can do certain things such as shopping online and watching movies without leaving their homes. However, this convenience can also lead to addiction and dependence on the Internet. Escape refers to the ability of users to find solace when faced with difficulty or irritation online because the Internet offers a free virtual environment that entices people away from the actual world. Originally the ACE Model was used to describe Internet pornography addiction, but now it is applied to the whole field of IAD. Reduced social cues The invention of email and SMS made online chatting a reality. However, in online communication, the individual's ability to judge the mood, tone and content of the other person is reduced because the necessary social cues, such as situational and personal cues, are missing. As online norms are currently imperfect, it is difficult to regulate individuals' behaviors on the Internet, and the anonymity of the Internet can make individuals' perceptions of themselves and others diminish, resulting in some anti-social behavior. Consequently, this can lead to inappropriate Internet use and addiction without proper restraints. Theories based on interaction orientation Cognitive-behavioral model of pathological Internet use This model defines IAD as pathological Internet use (PIU). In 2001, the cognitive-behavioral model for excessive use of the Internet was created. This model proposed that already existing psychosocial problems (e.g., depression, anxiety, substance abuse) were more likely to lead to the development of excessive and maladaptive behaviors related to the Internet. Importantly, Davis categorized problematic behaviors on the Internet into two categories: specific pathological Internet use (SPIU) and generalized pathological Internet use (GPIU). SPIU behaviors include frequently accessing things such as pornography or other sexually explicit material, stock trading, and online gambling. GPIU behaviors simply include fixating on the Internet itself, rather than particular materials that are accessed through the Internet. Additionally, people engaged in GPIU behaviors are drawn by the different forms of communication that the Internet allows them to engage in. In general, the Internet would lead to maladaptive cognitions, and predisposed vulnerability could reinforce this relationship. Moreover, the higher the individual's level of adaptation to undesirable behavior, the more likely pathological Internet use is to occur, which also means a higher level of addiction to the Internet. I-PACE Model This is a integrative theoretical framework model that specifically focuses on Internet Gaming Disorder (IGD). As compulsive gaming on the Internet can be a constituting factor of Internet Addiction Disorder, this model can be seen as applicable. The I-PACE model, which stands for Interaction of Person-Affect-Cognition-Execution model, focuses on the process of predisposing factors and current behaviors leading to compulsive use of the Internet. This model considers pre-disposing factors such as early childhood experiences, personality, cognitive-situational reactions, social cognition, and pre-disposition to mental illness as factors that may play into the development of Internet Gaming Disorder. Game addiction and flow experience The flow experience is an emotional experience in which an individual shows a strong interest in an event or object that drives the individual to become fully engaged in it. It was first introduced by Csikszentmihalyi in the 1960s, and he also proposed a systematic model of the flow experience. According to his theory, the flow experience comes from performing challenges at a level similar to the individual's own, which means that people could fully commit to the challenge and do their best to complete it. When individuals are faced with a challenge that is too different from their own level, they may lose interest because it is too easy or too difficult. Online games are a real-life application of this model. Based on Csikszentmihalyi's theory, the theory called GameFlow suggests 8 characteristics that can create a sense of immersion in players: concentration, challenge, skills, control, clear goals, feedback, immersion, and social interaction. With these elements, games would be really addictive and result in Internet addiction. Theories based on development orientation The word "development" has two meanings in this context; both the process and stages of development of Internet addictive behavior, and the development of the individual throughout the life cycle. John Grohol's 3-stage model The 3-stage model proposed by John Grohol suggests that Internet users would go through three stages: The Internet fascinates those new to it. In the first stage, users might be excited and curious about the Internet, leading to an increase in the amount of time spent on the Internet. Users start avoiding something addictive. After devoting a long time to using the Internet, individuals might realize that they should not spend too much time on the Internet, so they may reject games or websites that might be addictive. Users achieve a balance between surfing and other activities. In the last stage, people might be able to manage their time online well and develop healthy online habits. John suggested that the reason why many people were addicted to the Internet was that they were struggling with the first stage and needed help. Also, he believed that everyone would get to the final stage in the end, and it just took a different amount of time. Effects of COVID-19 A study conducted by Nassim Masaeli and Hadi Farhadi found that the prevalence of internet-based addictive behaviors during the COVID-19 pandemic has increased compared to pre-pandemic levels. Specifically, the prevalence of IAD ranged from 4.7% to 51.6%, SMA ranged from 9.7% to 47.4%, and gaming addiction ranged from 4.4% to 32.4%. The authors also identified several risk factors that contribute to the development of internet-based addictive behaviors during the pandemic, including boredom, stress, anxiety, and social isolation. They also highlighted the importance of interventions to prevent and treat internet-based addictive behaviors during the pandemic. These interventions can include psychological therapies, educational interventions, and pharmacological treatments. The authors recommended that these interventions should be tailored to specific age groups and populations to maximize their effectiveness. Another study that looked further into the effect of COVID-19 on the prevalence of IAD was "Internet Addiction Increases in the General Population During COVID‐19". The study looked at how the likely increase in stress related to COVID-19 induced quarantine contributed to an increase in IAD among the Chinese population. The study was conducted among 20,472 participants who were asked to fill out the Internet Addiction Test (IAT) online. The study ultimately shows that the overall prevalence of Internet addiction amounted to 36.7% among the general, and according to IAT scores the level of severe Internet addiction was 2.8%. The conclusion drawn was that the pandemic increased the prevalence and severity of Internet addiction among the general population in China Related disorders Problem gambling (online gambling disorder) Risks to gamblers and their families of problematic gambling have increased with the advent of online gambling. This is particularly true for minors. Video game addiction Video game addiction (VGA), also known as gaming disorder or internet gaming disorder, is generally defined as a psychological addiction that is problematic, compulsive use of video games that results in significant impairment to an individual's ability to function in various life domains over a prolonged period of time. Internet sex addiction Internet sex addiction, also known as cybersex addiction, has been proposed as a sexual addiction characterized by virtual Internet sexual activity that causes serious negative consequences to one's physical, mental, social, and financial well-being. Compulsive talking (communication addiction disorder) Communication addiction disorder (CAD) is a supposed behavioral disorder related to the necessity of being in constant communication with other people, even when there is no practical necessity for such communication. CAD has been linked to Internet addiction. Users become addicted to the social elements of the Internet, such as Facebook and YouTube. Users become addicted to one-on-one or group communication in the form of social support, relationships, and entertainment. However, interference with these activities can result in conflict and guilt. This kind of addiction is called problematic social media use. Social network addiction is a dependence of people by connection, updating, and control of their and their friend's social network page. For some people, in fact, the only important thing is to have a lot of friends in the network regardless if they are offline or only virtual; this is particularly true for teenagers as a reinforcement of egos. Sometimes teenagers use social networks to show their idealized image to others. However, other studies claim that people are using social networks to communicate their real personality and not to promote their idealized identity. Compulsive VR use Compulsive VR use (colloquially virtual-reality addiction) is a compulsion to use virtual reality or virtual, immersive environments. Currently, interactive virtual media (such as social networks) are referred to as virtual reality, whereas future virtual reality refers to computer-simulated, immersive environments or worlds. Experts warn about the dangers of virtual reality, and compare the use of virtual reality (both in its current and future form) to the use of drugs, bringing with these comparisons the concern that, like drugs, users could possibly become addicted to virtual reality. Video streaming addiction Video streaming addiction is an addiction to watching online video content, such as those accessed through free online video sharing sites such as YouTube, subscription streaming services such as Netflix, as well as livestreaming sites such as Twitch. The social nature of the internet has a reinforcing effect on the individual's consumption habits, as well as normalizing binge-watching behavior for enthusiasts of particular television series. Risk factors Interpersonal difficulties It is argued that interpersonal difficulties such as introversion, social problems, and poor face-to-face communication skills often lead to internet addiction. Internet-based relationships offer a safe alternative for people with aforementioned difficulties to escape from the potential rejections and anxieties of interpersonal real-life contact. Social factors There are several social risk factors that have been found to be associated with adult internet addiction such as low income, being a student or unemployed and/or unmarried or in an unstable partnership. Individuals who lack sufficient social connection and social support are found to run a higher risk of Internet addiction. They resort to virtual relationships and support to alleviate their loneliness. As a matter of fact, the most prevalent applications among Internet addicts are chat rooms, interactive games, instant messaging, or social media. Some empirical studies reveal that conflict between parents and children and not living with a mother significantly associated with IA after one year. Protective factors such as quality communication between parents and children and positive youth development are demonstrated, in turn, to reduce the risk of IA. Psychological factors Prior addictive or psychiatric history are found to influence the likelihood of being addicted to the Internet. Some individuals with prior psychiatric problems such as depression and anxiety turn to compulsive behaviors to avoid the unpleasant emotions and situation of their psychiatric problems and regard being addicted to the Internet a safer alternative to substance addictive tendency. But it is generally unclear from existing research which is the cause and which is the effect partially due to the fact that comorbidity is common among Internet addicts. The most common co-morbidities that have been linked to IAD are major depression and attention deficit hyperactivity disorder (ADHD). The rate of ADHD and IAD associating is as high as 51.6%. Internet addicts with no previous significant addictive or psychiatric history are argued to develop an addiction to some of the features of Internet use: anonymity, easy accessibility, and its interactive nature. Neurobiological factors There are many neurobiological factors that contribute to addiction, with male gender being a risk factor. Like most other psychopathological conditions, Internet addiction belongs to the group of multifactorial polygenic disorders. For each specific case, there is a unique combination of inherited characteristics (nervous tissue structure, secretion, degradation, and reception of neuromediators), and many are extra-environment factors (family-related, social, and ethnic-cultural). One of the main challenges in the development of the bio-psychosocial model of Internet addiction is to determine which genes and neuromediators are responsible for increased addiction susceptibility. A study conducted by Aviv Weinstein and Michel Lejoyeux (2020) titled "Neurobiological mechanisms underlying internet gaming disorder" highlights that IGD is associated with alterations in brain regions involved in reward processing, impulse control, decision-making, and executive functioning. These changes in neural activity may result in the persistent and excessive use of internet gaming and may contribute to the development of IGD. The study also highlights the role of neurotransmitters, such as dopamine, in the reinforcement and reward-seeking behavior associated with IGD. They suggest that the neurobiological mechanisms involved in IGD are similar to those observed in substance use disorders, and they propose a framework for understanding IGD as a behavioral addiction. The authors also discuss the potential implications of these findings for the treatment of IGD, suggesting that interventions targeting the neurobiological mechanisms underlying IGD may be effective in reducing problematic internet gaming behaviors. Other factors Parental educational level, age at first use of the Internet, and the frequency of using social networking sites and gaming sites are found to be positively associated with excessive Internet use among adolescents in some European countries, as well as in the USA. Diagnosis Diagnosis of Internet addiction disorder is empirically difficult. Various screening instruments have been employed to detect Internet addiction disorder. Current diagnoses are faced with multiple obstacles. Initial indicators A study conducted by Lori C. Soule, L. Wayne Shell, and Betty A. Kleen (2003) titled "Exploring Internet Addiction: Demographic Characteristics and Stereotypes of Heavy Internet Users" found that heavy internet users were more likely to be male and younger than non-heavy users. The study also found that heavy internet users were more likely to use the internet for gaming and entertainment purposes, rather than for work or education. It also went on further to suggest that heavy internet use may be related to certain personality traits, such as sensation-seeking and impulsivity, and highlight the need for further research to better understand the psychological factors that contribute to internet addiction. The study also highlights the need for interventions that target specific groups, such as young males who are heavy internet users, and that address the underlying factors that contribute to problematic internet use behaviors. Difficulties Given the newness of the Internet and the inconsistent definition of Internet addiction disorder, practical diagnosis is far from clear-cut. With the first research initiated by Kimberly S. Young in 1996, the scientific study of Internet addiction has merely existed for more than 20 years. A few obstacles are present in creating an applicable diagnostic method for Internet addiction disorder. Wide and extensive use of the Internet: Diagnosing Internet addiction is often more complex than substance addiction as internet use has largely evolved into being an integral or necessary part of human lives. The addictive or problematic use of the internet is thus easily masked or justified. Also, the Internet is largely a pro-social, interactive, and information-driven medium, while other established addiction behaviors such as gambling are often seen as a single, antisocial behavior that has very little socially redeeming value. Many so-called Internet addicts do not experience the same damage to health and relationships that are common to established addictions. High comorbidity: Internet addiction is often accompanied by other psychiatric disorders such as personality disorder and intellectual disability. It is found that Internet addiction is accompanied by other DSM-IV diagnosis 86% of the time. In one study conducted in South Korea, 30% of the identified Internet addicts have accompanying symptoms such as anxiety or depression and another 30% have a second disorder such as attention deficit hyperactivity disorder (ADHD). Another study in South Korea found an average of 1.5 other diagnoses among adolescent internet addicts. Further, it is noted in the United States that many patients only resort to medical help when experiencing difficulties they attribute to other disorders. For many individuals, overuse or inappropriate use of the Internet is a manifestation of their depression, social anxiety disorders, impulse control disorders, or pathological gambling. It generally remains unclear from existing literature whether other psychiatric disorders is the cause or manifest of Internet addiction. Despite the advocacy of categorizing Internet addiction as an established illness, neither DSM-IV (1995) nor DSM-5 (2013) considers Internet addiction as a mental disorder. A subcategory of IAD, Internet gaming disorder is listed in DSM-5 as a condition that requires more research in order to be considered as a full disorder in May 2013. The WHO's International Classification of Diseases (ICD-11) recognizes gaming disorder as an illness category. There is still considerable controversy over whether IAD should be included in the DSM-5 and recognized as a mental disease in general. Screening instruments DSM-based instruments Most of the criteria utilized by research are adaptations of listed mental disorders (e.g., pathological gambling) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) handbook. Ivan K. Goldberg, who first broached the concept of Internet addiction in 1995, adopted a few criteria for IAD on the basis of DSM-IV, including "hoping to increase time on the network" and "dreaming about the network." By adapting the DSM-IV criteria for pathological gambling, Kimberly S. Young (1998) proposed one of the first integrated sets of criteria, Diagnostic Questionnaire (YDQ), to detect Internet addiction. A person who fulfills any five of the eight adapted criteria would be regarded as Internet addicted: Preoccupation with the Internet; A need for increased time spent online to achieve the same amount of satisfaction; Repeated efforts to curtail Internet use; Irritability, depression, or mood liability when Internet use is limited; Staying online longer than anticipated; Putting a job or relationship in jeopardy to use the Internet; Lying to others about how much time is spent online; and Using the Internet as a means of regulating mood. While Young's YDQ assessment for IA has the advantage of simplicity and ease of use, Keith W. Beard and Eve M. Wolf (2001) further asserted that all of the first five (in the order above) and at least one of the final three criteria (in the order above) be met to delineate Internet addiction in order for a more appropriate and objective assessment. Young further extended her eight-question YDQ assessment to the now most widely used Internet Addiction Test (IAT), which consists of 20 items with each on a five-point Likert scale. Questions included on the IAT expand upon Young's earlier eight-question assessment in greater detail and include questions such as "Do you become defensive or secretive when anyone asks you what you do online?" and "Do you find yourself anticipating when you go online again?". A complete list of questions can be found in Dr. Kimberly S. Young's 1998 book Caught in the Net: How to Recognize the Signs of Internet Addiction and A Winning Strategy for Recovery and Laura Widyanto and Mary McMurran's 2004 article titled The Psychometric Properties of the Internet Addiction Test. The Test score ranges from 20 to 100 and a higher value indicates a more problematic use of the Internet: 20–39 = average Internet users, 40–69 = potentially problematic Internet users, and 70–100 = problematic Internet users. Over time, a considerable number of screening instruments have been developed to diagnose Internet addiction, including the Internet Addiction Test (IAT), the Internet-Related Addictive Behavior Inventory (IRABI), the Chinese Internet Addiction Inventory (CIAI), the Korean Internet Addiction Self-Assessment Scale (KS Scale), the Compulsive Internet Use Scale (CIUS), the Generalized Problematic Internet Use Scale (GPIUS), the Internet Consequences Scale (ICONS), and the Problematic Internet Use Scale (PIUS). Among others, the Internet Addiction Test (IAT) by Young (1998) exhibits good internal reliability and validity and has been used and validated worldwide as a screening instrument. Although the various screening methods are developed from diverse contexts, four dimensions manifest themselves across all instruments: Excessive use: compulsive Internet use and excessive online time-use; Withdrawal symptoms: withdrawal symptoms including feelings such as depression and anger, given restricted Internet use; Tolerance: the need for better equipment, increased internet use, and more applications/software; Negative repercussions: Internet use caused negative consequences in various aspects, including problematic performance in social, academic, or work domains. More recently, researchers Mark D. Griffiths (2000) and Jason C. Northrup and colleagues (2015) claim that Internet per se is simply the medium and that the people are in effect addicted to processes facilitated by the Internet. Based on Young's Internet Addiction Test (IAT), Northrup and associates further decompose the internet addiction measure into four addictive processes: Online video game playing, online social networking, online sexual activity, and web surfing. The Internet Process Addiction Test (IPAT) is created to measure the processes to which individuals are addicted. Screening methods that heavily rely on DSM criteria have been accused of lacking consensus by some studies, finding that screening results generated from prior measures rooted in DSM criteria are inconsistent with each other. As a consequence of studies being conducted in divergent contexts, studies constantly modify scales for their own purposes, thereby imposing a further challenge to the standardization in assessing Internet addiction disorder. Single-question instruments Some scholars and practitioners also attempt to define Internet addiction by a single question, typically the time-use of the Internet. The extent to which Internet use can cause negative health consequences is, however, not clear from such a measure. The latter of which is critical to whether IAD should be defined as a mental disorder. Neuroimaging techniques Emergent neuroscience studies investigated the influence of problematic, compulsive use of the internet on the human brain. Following anecdotal reports and the conclusion by Kimberly S. Young (1998), neuroimaging studies revealed that IAD contributes to structural and functional abnormalities in the human brain, similar to other behavioral and substance additions. Therefore, objective non-invasive neuroimaging can contribute to the preliminary diagnosis and treatment of IAD. Electroencephalography-based diagnosis Using electroencephalography (EEG) readings allows identifying abnormalities in the electrical activity of the human brain caused by IAD. Studies revealed that individuals with IAD predominantly demonstrate increased activity in the theta and gamma band and decreased delta, alpha, and beta activity. Following these findings, studies identified a correlation between the differences in the EEG readings and the severity of IAD, as well as the extent of impulsivity and inattention. Classification As many scholars have pointed out, the Internet serves merely as a medium through which tasks of divergent nature can be accomplished. Treating disparate addictive behaviors under the same umbrella term is highly problematic. Kimberly S. Young (1999) asserts that Internet addiction is a broad term which can be decomposed into several subtypes of behavior and impulse control problems, namely, Cybersexual addiction: compulsive use of adult websites for cybersex and cyberporn (see Internet sex addiction) Cyber-relationship addiction: Over-involvement in online relationships Net compulsions: Obsessive online gambling, shopping or day-trading Information overload: Compulsive web surfing or database searches Computer addiction: Obsessive computer game playing (see Video game addiction) For a more detailed description of related disorders please refer to the related disorders section above. Public concern Internet addiction has raised great public concern in Asia and some countries consider Internet addiction as one of the major issues that threatens public health, in particular among adolescents. A study conducted by David S. Bickham (2021) titled "Current Research and Viewpoints on Internet Addiction in Adolescents" found that internet addiction is a growing concern among adolescents, with many spending a significant amount of time online and exhibiting problematic use behaviors, such as compulsive internet use and withdrawal symptoms when offline. The study also highlighted that certain demographic factors, such as gender and socioeconomic status, may be associated with higher rates of internet addiction. Bickham further discussed the various factors that may contribute to the development of internet addiction, including individual factors such as depression, anxiety, and poor self-regulation, as well as environmental factors such as parental monitoring and peer influence. The study also discussed the potential negative consequences of internet addiction, such as poor academic performance, disrupted sleep patterns, and social isolation. Treatment Current interventions and strategies used as treatments for Internet addiction stem from those practiced in substance abuse disorder. In the absence of "methodologically adequate research", treatment programs are not well corroborated. Psychosocial treatment is the approach most often applied. In practice, rehab centers usually devise a combination of multiple therapies. Psychosocial treatment Cognitive behavioral therapy The cognitive behavioral therapy with Internet addicts (CBT-IA) is developed in analogy to therapies for impulse control disorder. Several key aspects are embedded in this therapy: Learning time management strategies; Recognizing the benefits and potential harms of the Internet; Increasing self-awareness and awareness of others and one's surroundings; Identifying "triggers" of Internet "binge behavior", such as particular Internet applications, emotional states, maladaptive cognitions, and life events; Learning to manage emotions and control impulses related to accessing the Internet, such as muscles or breathing relaxation training; Improving interpersonal communication and interaction skills; Improving coping styles; Cultivating interests in alternative activities. Three phases are implemented in the CBT-IA therapy: Behavior modification to control Internet use: Examine both computer behavior and non-computer behavior and manage Internet addicts' time online and offline; Cognitive restructuring to challenge and modify cognitive distortions: Identify, challenge, and modify the rationalizations that justify excessive Internet use; Harm reduction therapy to address co-morbid issues: Address any co-morbid factors associated with Internet addiction, sustain recovery, and prevent relapse. Symptom management of CBT-IA treatment has been found to sustain six months post-treatment. There have also been promising CBT-short-term treatments for internet and computer game addiction such as STICA, which is the first randomized clinical trial across multiple clinics that looked at a treatment for internet addiction. However further investigation with a bigger sample size on long-term efficacy is needed. Motivational interviewing The motivational interviewing approach is developed based on therapies for alcohol abusers. This therapy is a directive, patient-centered counseling style for eliciting behavior change through helping patients explore and resolve ambivalence with a respectful therapeutic manner. It does not, however, provide patients with solutions or problem solving until patients' decision to change behaviors. Several key elements are embedded in this therapy: Asking open-ended questions; Giving affirmations; Reflective listening Other psychosocial treatment therapies include reality therapy, Naikan cognitive psychotherapy, group therapy, family therapy, and multimodal psychotherapy. Medication IAD may be associated with a co-morbidity, so treating a related disorder may also help in the treatment of IAD. When individuals with IAD were treated with certain antidepressants, the time online was reduced by 65% and cravings of being online also decreased. The antidepressants that have been most successful are selective serotonin reuptake inhibitors (SSRIs) such as escitalopram and the atypical antidepressant bupropion. A psychostimulant, methylphenidate, was also found to have beneficial effects. However, the available evidence on treatment of IAD is of very low quality at this time and well-designed trials are needed. 12-step recovery programs Gaming Addicts Anonymous, founded in 2014 is a 12-step program focused on recovery from computer gaming addiction. Internet and Technology Addicts Anonymous (ITAA), founded in 2017, is a 12-step program supporting users coping with the problems resulting from compulsive internet and technology use. Some common sub-addictions include smartphone addiction, binge watching addiction, and social media addiction. There are face-to-face meetings in some cities. Telephone / online meetings take place every day of the week, at various times (and in various languages) that allow people worldwide to attend. Similar to 12-step fellowships related to behavioral addictions, such as Overeaters Anonymous, Workaholics Anonymous, or Sex and Love Addicts Anonymous, most members do not define sobriety as avoiding all technology use altogether. Instead, most ITAA members come up with their own definitions of abstinence or problem behaviors, such as not using the computer or internet at certain hours or locations or not going to certain websites or categories of websites that have proven problematic in the past. They refer to these problematic behaviors as "bottom lines". In contrast, "top lines" are activities, both online and offline, they can do to enhance self esteem without falling into compulsive use. "Middle lines" are behaviors that may be OK sometimes, but can lead to bottom lines if a user is not careful. Meetings provide a source of live support for people, to share struggles and victories, and to learn to better function in life once less of it is spent on problematic technology use. Media Addicts Anonymous (MAA), founded in 2020, is a 12-step program focused on recovery from media addiction. All forms of media sobriety are supported, including abstinence from electronic media, films, radio, newspapers, magazines, books, and music. Prevalence Different samples, methodologies, and screening instruments are employed across studies. Terminology The notion of "Internet addictive disorder" was initially conjured up by Ivan K. Goldberg in 1995 as a joke to parody the complexity and rigidity of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM). In his first narration, Internet addictive disorder was described as having the symptoms of "important social or occupational activities that are given up or reduced because of Internet use", "fantasies or dreams about the Internet", and "voluntary or involuntary typing movements of the fingers". The definition of Internet addiction disorder has troubled researchers ever since its inception. In general, no standardized definition has been provided despite that the phenomenon has received extensive public and scholar recognition. Below are some of the commonly used definitions. In 1998, Jonathan J. Kandell defined Internet addiction as "a psychological dependence on the Internet, regardless of the type of activity once logged on." English psychologist Mark D. Griffiths (1998) conceived Internet addiction as a subtype of broader technology addiction, and also a subtype of behavioral addictions. In recent years, the validity of the term "Internet addiction" as a single psychological construct has been criticized. New empirical evidence is emerging to support this view. Public concern Internet addiction has raised great public concern in Asia and some countries consider Internet addiction as one of the major issues that threatens public health, in particular among adolescents. China Internet addiction is commonly referred to as "electronic opium" or "electronic heroin" in China. A government entity in China became the first government body worldwide to recognize the internet addiction when it established "Clinical Diagnostic Criteria for Internet Addiction" in 2008. China's Ministry of Health does not formally recognize Internet addiction as a medical condition. As a result of public outcry over parent-child online gaming conflicts, the government issued legislation. In 2002, the government passed legislation which forbid Internet cafes from allowing minors. The Law on Protection of Minors was amended in 2006 to state that the family and the state should guide minors' online behavior. These amendments place "indulgence in the Internet" on par with misbehaviors like smoking and vagrancy. The government has enacted other policies to regulate adolescents' Internet use, including limiting daily gaming time to 3 hours and requiring users' identification in online video games. Mistreatment and abuse in China Internet addiction centers in China are private or semi-private. The first such treatment center was founded in 2005. In the absence of guidance from the Ministry of Health and a clear definition of Internet addiction, dubious treatment clinics have sprouted up in the country. As part of the treatment, some clinics and camps impose corporal punishment upon patients of Internet addiction and some conducted electroconvulsive therapy (ECT) against patients, the latter of which has caused wide public concern and controversy. Several forms of mistreatment have been well-documented by news reports. One of the most commonly used treatments for Internet-addicted adolescents in China is inpatient care, either in a legal or illegal camp. It is reported that children were sent to these camps against their will. Some are seized and bound by staff of the camp, some are drugged by their parents, and some are tricked into treatment. In many camps and clinics, corporal punishment is frequently used in the treatment of Internet addiction disorder. The types of corporal punishment practiced include, but not limited to, kilometers-long hikes, intense squats, standing, starving, and confinement. After physical abuse caused the death of an adolescent at a treatment camp in 2009, the Chinese government officially prohibited the use physical violence in such places. However, multiple cases of abuse and deaths at such facilities continue to be reported. Among Internet addiction rehab centers that use corporal punishment in treatment, Yuzhang Academy in Nanchang, Jiangxi Province, is the most notorious. In 2017, the academy was accused of using severe corporal punishment against students, the majority of which are Internet addicts. Former students claimed that the academy hit problematic students with iron rulers, "whip them with finger-thick steel cables", and lock students in small cells week long. Several suicidal cases emerged under the great pressure. In November 2017, the academy stopped operating after extensive media exposure and police intervention. Electroconvulsive therapy In China, electroconvulsive therapy (ECT) is legally used for schizophrenia and mood disorders. Its use in treating adolescent Internet addicts has raised great public concern and stigmatized the legal use of ECT. The most reported and controversial clinic treating Internet addiction disorder is perhaps the Linyi Psychiatric Hospital in Shandong Province. Its center for Internet addiction treatment was established in 2006 by Yang Yongxin. Various interviews of Yongxin Yang confirm that Yang has created a special therapy, ("brain-waking") therapy, to treat Internet addiction. As part of the therapy, electroconvulsive therapy is implemented with currents of 1–5 milliampere. As Yang put it, the electroconvulsive therapy only involves sending a small current through the brain and will not harm the recipient. As a psychiatric hospital, patients are deprived of personal liberty and are subject to electroconvulsive treatment at the will of hospital staffs. And before admission, parents have to sign contracts in which they deliver their guardianship of kids partially to the hospital and acknowledge that their kids will receive ECT. Frequently, ECT is employed as a punishment method upon patients who breaks any of the center's rules, including "eating chocolate, locking the bathroom door, taking pills before a meal and sitting on Yang's chair without permission". It is reported in a CCTV-12 segment that a DX-IIA electroconvulsive therapy machine is utilized to correct Internet addiction. The machine was, later on, revealed to be illegal, inapplicable to minor and can cause great pain and muscle spasm to recipients. Many former patients in the hospital later on stood out and reported that the ECT they received in the hospital was extremely painful, tore up their head, and even caused incontinence. An Interview of the Internet addiction treatment center in Linyi Psychiatric Hospital is accessible via the following link. Since neither the safety nor the effectiveness of the method was clear, the Chinese Ministry of Health banned electroconvulsive therapy in treating Internet addiction disorder in 2009. Drug In Yang's clinic, patients are forced to take psychiatric medication in addition to Jiewangyin, a type of medication invented by himself. Neither the effectiveness nor applicability of the medication has been assessed, however. Physical abuse and death At clinics and rehab centers, at least 12 cases of physical abuse have been revealed by media in the recent years including seven deaths. In 2009, a 15-year-old, Senshan Deng, was found dead eight hours after being sent to an Internet-addiction center in Nanning, Guangxi Province. It is reported that the teenager was beaten by his trainers during his stay in the center. In 2009, another 14-year-old teenager, Liang Pu, was taken to hospital with water in the lungs and kidney failure after a similar attack in Sichuan Province. In 2014, a 19-year-old, Lingling Guo, died in an Internet-addiction center with multiple injuries on head and neck in Zhengzhou, Henan Province. In 2016, after escaping from an Internet addiction rehab center, a 16-year-old girl tied up and starved her mother to death as revenge for being sent to treatment in Heilongjiang Province. In August 2017, an 18-year-old boy, Li Ao, was found dead with 20 external scars and bruises two days after his parents sent him to a military-style boot camp in Fuyang city, Anhui Province. South Korea Being almost universally connected to the Internet and boasting online gaming as a professional sport, South Korea deems Internet addiction one of the most serious social issues and describes it as a "national crisis". Nearly 80% of the South Korean population have smartphones. As of 2013, according to government data, about two million of the country's population (less than 50 million) have Internet addiction problem, and approximately 680,000 10–19-year-olds are addicted to the Internet, accounting for roughly 10% of the teenage population. Even the very young generation are faced with the same problem: Approximately 40% of South Korean children between age three to five are using smartphones over three times per week. According to experts, if children are constantly stimulated by smartphones during infancy period, their brain will struggle to balance growth and the risk of Internet addiction. It is believed that due to Internet addiction, many tragic events have happened in South Korea: A mother, tired of playing online games, killed her three-year-old son. A couple, obsessed with online child-raising games, let their young daughter die of malnutrition. A 15-year-old teenager killed his mother for not letting him play online games and then committed suicide. One Internet gaming addict stabbed his sister after playing violent games. Another addict killed one and injured seven others. In response, the South Korea government has launched the first Internet prevention center in the world, the Jump Up Internet Rescue School, where the most severely addicted teens are treated with full governmental financial aid. As of 2007, the government has built a network of 140 Internet-addiction counseling centers besides treatment programs at around 100 hospitals. Typically, counselor- and instructor-led music therapy and equine therapy and other real-life group activities including military-style obstacle courses and therapeutic workshops on pottery and drumming are used to divert IAs' attention and interest from screens. In 2011, the Korean government introduced the "Shutdown Law", also known as the "Cinderella Act", to prevent children under 16 years old from playing online games from midnight (12:00) to 6 a.m. Japan Many cases of social withdrawal have been occurring in Japan since the late 1990s which inclines people to stay indoors most of the time. The term used for this is hikikomori, and it primarily affects the youth of Japan in that they are less inclined to leave their residences. Internet addiction can contribute to this effect because of how it diminishes social interactions and gives young people another reason to stay at home for longer. Many of the hikikomori people in Japan are reported to have friends in their online games, so they will experience a different kind of social interaction which happens in a virtual space. US lawsuits Numerous lawsuits have been filed in US courts by US states, US school districts and others asserting that social media platforms are deliberately designed to be addictive to minors and seeking damages. These lawsuits include: In October of 2023, several public school systems in Maryland joined together to sue Meta Platforms, Snapchat, ByteDance and Google, claiming that these companies knowingly cause harm to students by providing addictive social media platforms. This lawsuit was one of many filed in the US as part of a mass action with many other entities around the US filing similar lawsuits. According to attorneys representing the plaintiffs, these lawsuits, may or may not be combined into a class action. These lawsuits were in part inspired by the success of a similar lawsuit against Juul Labs, makers of electronic cigarettes that were marketed to minors. It is expected that the defendant social media companies will seek to have these cases dismissed. In October of 2023, Washington DC, Maryland, and Virginia filed Federal and State lawsuits against Facebook and Instagram claiming that those platforms are designed to get children and teens addicted to social media. Meta Platforms, the parent company of Facebook and Instagram, responded that they have implemented many safety features and are disappointed that the states have not worked cooperatively with them. In February of 2024, the city of New York et al. filed a lawsuit in the California Superior Court against Facebook, Instagram, TikTok, Snapchat, and YouTube, seeking to have the companies' behaviour declared a public nuisance and seeking monetary damages. The tech companies have responded that they have policies and procedures in place to insure public safety. See also Addictive personality Criticism of Facebook Cyberslacking Digital addict Digital detox Digital media use and mental health Evolutionary mismatch Instagram's impact on people List of repetitive strain injury software (i.e. break reminders) Media multitasking Nomophobia (i.e., fear of being without a phone) Psychological effects of Internet use Soft addiction Terminally online Workaholic References Further reading External links The NoSurf community on Reddit maintains a list of resources and strategies helpful for people trying to decrease their internet usage. Digital media use and mental health addiction disorder Pornography Behavioral addiction Human–computer interaction

Controversies about psychiatry

Psychiatry is, and has historically been, viewed as controversial by those under its care, as well as sociologists and psychiatrists themselves. There are a variety of reasons cited for this controversy, including the subjectivity of diagnosis, the use of diagnosis and treatment for social and political control including detaining citizens and treating them without consent, the side effects of treatments such as electroconvulsive therapy, antipsychotics and historical procedures like the lobotomy and other forms of psychosurgery or insulin shock therapy, and the history of racism within the profession in the United States. In addition, there are a number of groups who are either critical towards psychiatry or entirely hostile to the field. The Critical Psychiatry Network is a group of psychiatrists who are critical of psychiatry. Additionally, there are self-described psychiatric survivor groups such as MindFreedom International and religious groups such as Scientologists that are critical towards psychiatry. Challenges to conceptions of mental illness Since the 1960s there have been challenges to the concept of mental illness. Sociologists Erving Goffman and Thomas Scheff argued that mental illness was merely another example of how society labels and controls non-conformists, behavioral psychologists challenged psychiatry's fundamental reliance on unchallengable or unfalsifiable concepts, and gay rights activists criticized the APA's inclusion of homosexuality as a mental disorder in the DSM. As societal views on homosexuality have changed in recent decades, it is no longer considered a mental illness and is more widely accepted by society. As another example that challenged conceptions of mental illness, a widely publicized study by Professor David Rosenhan, known as the Rosenhan experiment, was viewed as an attack on the efficacy of psychiatric diagnosis. Medicalization Medicalization, a concept in medical sociology, is the process by which human conditions and problems come to be defined and treated as medical conditions, and thus become the subject of medical study, diagnosis, prevention, or treatment. Medicalization can be driven by new evidence or hypotheses about conditions, by changing social attitudes or economic considerations, or by the development of new medications or treatments. For many years, several psychiatrists, such as David Rosenhan, Peter Breggin, Paula Caplan, Thomas Szasz, and critics outside the field of psychiatry, such as Stuart A. Kirk, have "been accusing psychiatry of engaging in the systematic medicalization of normality". More recently these concerns have come from insiders who have worked for the APA themselves (e.g., Robert Spitzer, Allen Frances). For example, in 2013, Allen Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests". The concept of medicalization was devised by sociologists to explain how medical knowledge is applied to behaviors which are not self-evidently medical or biological. The term medicalization entered the sociology literature in the 1970s in the works of Irving Zola, Peter Conrad, and Thomas Szasz, among others. These sociologists viewed medicalization as a form of social control in which medical authority expanded into domains of everyday existence, and they rejected medicalization in the name of liberation. This critique was embodied in works such as Conrad's "The discovery of hyperkinesis: notes on medicalization of deviance", published in 1973 (hyperkinesis was the term then used to describe what we might now call ADHD), and Szasz's "The Myth of Mental Illness." These sociologists did not believe medicalization to be a new phenomenon, arguing that medical authorities had always been concerned with social behavior and traditionally functioned as agents of social control (Foucault, 1965; Szasz, 1970; Rosen). However, these authors took the view that increasingly sophisticated technology had extended the potential reach of medicalization as a form of social control, especially in terms of "psychotechnology" (Chorover, 1973). In the 1975 book Limits to medicine: Medical nemesis (1975), Ivan Illich put forth one of the earliest uses of the term "medicalization". Illich, a philosopher, argued that the medical profession harms people through iatrogenesis, a process in which illness and social problems increase due to medical intervention. Illich saw iatrogenesis occurring on three levels: the clinical, involving serious side effects worse than the original condition; the social, whereby the general public is made docile and reliant on the medical profession to cope with life in their society; and the structural, whereby the idea of aging and dying as medical illnesses effectively "medicalized" human life and left individuals and societies less able to deal with these natural processes. Marxists such as Vicente Navarro (1980) linked medicalization to an oppressive capitalist society. They argued that medicine disguised the underlying causes of disease, such as social inequality and poverty, and instead presented health as an individual issue. Others examined the power and prestige of the medical profession, including use of terminology to mystify and of professional rules to exclude or subordinate others. Some argue that in practice the process of medicalization tends to strip subjects of their social context, so they come to be understood in terms of the prevailing biomedical ideology, resulting in a disregard for overarching social causes such as unequal distribution of power and resources. A series of publications by Mens Sana Monographs have focused on medicine as a corporate capitalist enterprise. Political abuse In unstable countries, political prisoners are sometimes confined and abused in mental institutions. The diagnosis of mental illness allows the state to hold persons against their will and insist upon therapy in their interest and in the broader interests of society. In addition, receiving a psychiatric diagnosis can in and of itself be regarded as oppressive. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials. The use of hospitals instead of jails prevents the victims from receiving legal aid before the courts, makes indefinite incarceration possible, and discredits the individuals and their ideas. In that manner, whenever open trials are undesirable, they are avoided. Examples of political abuse of the power, entrusted in physicians and particularly psychiatrists, are abundant in history and seen during the Nazi era and the Soviet rule when political dissenters were labeled as "mentally ill" and subjected to inhumane "treatments." In the period from the 1960s up to 1986, abuse of psychiatry for political purposes was reported to be systematic in the Soviet Union, and occasional in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia. The practice of incarceration of political dissidents in mental hospitals in Eastern Europe and the former USSR damaged the credibility of psychiatric practice in these states and entailed strong condemnation from the international community. Political abuse of psychiatry also takes place in the People's Republic of China and in Russia. Psychiatric diagnoses such as the diagnosis of 'sluggish schizophrenia' in political dissidents in the USSR were used for political purposes. History of racism in psychiatry in the United States The history of racism in psychiatry dates back to the days of slavery and segregation in the United States. Such racism in psychiatry exemplifies the concept of scientific racism, which falsely alleges that science and other empirical evidence supports racism and proves certain racial inferiorities. Diagnosis Psychiatric diagnoses were influenced by Black people's status as free or enslaved. Enslaved people were not considered civilized enough to be diagnosed with insanity, while free Black people were over-diagnosed with insanity, having much higher diagnosis rates than white people. Specific diagnoses in the 19th century were crafted specifically to fit Black people – drapetomania and dysesthesia aethiopica, disorders meant to explain why slaves ran away and why they were lazy or lacked a strong work ethic, respectively, and justify the institution of slavery. Prominent political figures such as John C. Calhoun used this supposed evidence to argue for slavery, arguing that free Black people could not be entrusted with their lives and would ultimately develop lunacy. All in all, throughout the 19th century, psychiatric diagnoses and scientifically racist theories were used to medicalize Blackness and uphold systems of slavery and racism, further constraining the rights, freedom, and humanity of Black people. Scientific racism Proponents of scientific racism have historically attempted to "prove" that Black people are physiologically and cognitively inferior to white people based on faulty assumptions and prejudices. Perpetuated by the inaccurate application of biodeterminism, specialists in neuroanatomy and psychiatry compared disproportionate numbers of brains from Black and white individuals to support their racial agendas based on "science." Compulsory sterilization The proportion of Black individuals confined in establishments for "flawed and imbecile" patients increased throughout the late 19th and early 20th century. Psychiatry contributed towards the inaccurate and racist belief that if they were left to their respective means, they would not be able to remain in decent condition. At the beginning of the 20th century, Black people were disproportionally sterilized in eugenics programs that compulsorarily sterilized those classed as feebleminded or who received welfare payments. The premise that the genes of those deemed mentally ill were undesirable was used to justify sterilization which was frequently supervised by physicians, including psychiatrists. Hospitals Segregation within mental institutions and hospitals is another example of the history of racism within psychiatry. Many psychiatric hospitals in the 19th century either excluded or segregated Black patients or admitted Black slaves to work at the hospital in exchange for care. The founding fathers of psychiatry themselves supported the notion that Black people were inferior, lower class citizens that must be treated separately and differently from white patients. With time, racial segregation within hospitals became interspersed with entirely separate hospitals for white and Black patients, each with differential treatment and quality of care. Political figures in the post-Civil War era argued that emancipation had led to a significant increase in insanity cases amongst Black individuals, and they cited the need to accommodate this increase via segregated and Black-only insane asylums. Many hospitals, especially in the southern United States, did not admit Black patients until they were eventually mandated to do so. The last segregated hospital opened in 1933. Popular arguments also circulated that Black patients were more difficult to take care of in mental institutions, making psychiatric care for them more difficult and justifying the need for segregated facilities. Until the late 1960s, many hospitals remained segregated. This affected the experiences of racial minorities accessing psychiatric care in mental institutions and hospitals in the United States. When Lyndon B. Johnson's administration stated that no segregated hospital would receive federal Medicare funds, hospitals began to integrate quickly in order to be able to continue to access such funding. In January 1966, around two-thirds of Southern hospitals were segregated facilities and many Northern facilities remain segregated in-effect. One year later, by January 1967, there were very few hospitals in the United States that remained segregated. Segregation within mental institutions and hospitals is one example of the history of racism within psychiatry. In the profession Black psychiatrists often experienced racism as practitioners within the field. Some of this history is detailed in Jeanne Spurlock's book titled Black Psychiatrists and American Psychiatry, published in 1999, in which she profiles Black psychiatrists who were influential in American psychiatry and their experiences in the profession. During the Civil Rights Movement, Black psychiatrists expressed concerns to the APA that the needs of Black communities and Black psychiatrists were being ignored by the professional organization. In 1969, a contingent of Black psychiatrists presented a list of 9 concerns to the APA Board of Trustees regarding experiences of structural racism in the field. Their '9 points' represented a wide array of experiences of discrimination, both from the experiences of practitioners and patients, and on the institutional and individual level and the group demanded change from within the APA. For example, they called for more Black leaders on APA committees as well as the desegregation of all mental health facilities, both public and private, in the United States. As of 2020, within psychiatry, historically underrepresented groups continue to be less represented as residents, faculty, and practicing physicians in comparison to their proportion in the U.S. population. Nature of diagnosis Arbitrariness Psychiatry has been criticized for its broad range of mental diseases and disorders. Which diagnoses exist and are considered valid have changed over time depending on society's norms. Homosexuality was considered a mental illness but due to changing attitudes, it is no longer recognised as an illness. Historic disorders that are no longer recognised include orthorexia nervosa, sexual addiction, parental alienation syndrome, pathological demand avoidance, and Internet addiction disorder. New disorders include compulsive hoarding and binge eating disorder. The act of diagnosis itself has been criticized for being arbitrary with some conditions being overdiagnosed. Individuals may be diagnosed with a mental disorder despite having been perceived as having no issues with their behavior. In Virginia, U.S., it was found up to 33% of white boys are diagnosed with ADHD leading to alarm in the medical community. Thomas Szasz argued that mental health diagnoses were used as a form of labelling violations of societies norms. Bill Fullford, introduced the idea of "value-laden" mental health diagnosis with mental health lying between physical health and a moral judgment. Under this system personality disorders are seen as not very factual and very value-laden while delirium is quite factual and not very value-laden. Biological basis In 2013, psychiatrist Allen Frances said that he believes that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests". Mary Boyle argues that psychiatry is actually the study of behavior, but acts as if it is the study of the brain based on a presumed connection between patterns of behavior and the biological function of the brain. She argues that in the case of schizophrenia it is the bizarre behavior of individuals that justifies the presumption of a biological cause for this behavior rather than the existence of any evidence. She argues that the concept of schizophrenia and its biological basis serves a social function for psychiatrists. She views the concept of schizophrenia as necessary for psychiatry to be considered as a medical field, that the claimed biological link gives psychiatrists protection from accusations of social control, and that the belief in the biological basis for schizophrenia is maintained through secondary source's misrepresentation of underlying data. She argues that schizophrenia and its biological basis also gives families, psychiatrists and society as a whole the ability to avoid blame for the damage they cause individuals and the ineffectiveness of treatment. Schizophrenia diagnosis Underlying issues associated with schizophrenia would be better addressed as a spectrum of conditions or as individual dimensions along which everyone varies rather than by a diagnostic category based on an arbitrary cut-off between normal and ill. This approach appears consistent with research on schizotypy, and with a relatively high prevalence of psychotic experiences, mostly non-distressing delusional beliefs, among the general public. In concordance with this observation, psychologist Edgar Jones, and psychiatrists Tony David and Nassir Ghaemi, surveying the existing literature on delusions, pointed out that the consistency and completeness of the definition of delusion have been found wanting by many; delusions are neither necessarily fixed nor false, and need not involve the presence of incontrovertible evidence. Nancy Andreasen has criticized the current DSM-IV and ICD-10 criteria for sacrificing diagnostic validity for the sake of artificially improving reliability. She argues that overemphasis on psychosis in the diagnostic criteria, while improving diagnostic reliability, ignores more fundamental cognitive impairments that are harder to assess due to large variations in presentation. This view is supported by other psychiatrists. In the same vein, Ming Tsuang and colleagues argue that psychotic symptoms may be a common end-state in a variety of disorders, including schizophrenia, rather than a reflection of the specific etiology of schizophrenia, and warn that there is little basis for regarding DSM's operational definition as the "true" construct of schizophrenia. Neuropsychologist Michael Foster Green went further in suggesting the presence of specific neurocognitive deficits may be used to construct phenotypes that are alternatives to those that are purely symptom-based. These deficits take the form of a reduction or impairment in basic psychological functions such as memory, attention, executive function and problem solving. The exclusion of affective components from the criteria for schizophrenia, despite their ubiquity in clinical settings, has also caused contention. This exclusion in the DSM has resulted in a "rather convoluted" separate disorder—schizoaffective disorder. Citing poor interrater reliability, some psychiatrists have totally contested the concept of schizoaffective disorder as a separate entity. The categorical distinction between mood disorders and schizophrenia, known as the Kraepelinian dichotomy, has also been challenged by data from genetic epidemiology. Jonathan Metzl, in his book The Protest Psychosis, argues that the Ionia State Hospital in Ionia, Michigan disproportionately diagnosed African Americans with schizophrenia because of their civil rights activism. ADHD ADHD, its diagnosis, and its treatment have been controversial since the 1970s. The controversies involve clinicians, teachers, policymakers, parents, and the media. Positions range from the view that ADHD is within the normal range of behavior to the hypothesis that ADHD is a genetic condition. Other areas of controversy include the use of stimulant medications in children, the method of diagnosis, and the possibility of overdiagnosis. In 2012, the National Institute for Health and Care Excellence, while acknowledging the controversy, states that the current treatments and methods of diagnosis are based on the dominant view of the academic literature. In 2014, Keith Conners, one of the early advocates for recognition of the disorder, spoke out against overdiagnosis in an article in The New York Times. In contrast, a 2014 peer-reviewed medical literature review indicated that ADHD is underdiagnosed in adults. With widely differing rates of diagnosis across countries, states within countries, races, and ethnicities, some suspect factors other than the presence of the symptoms of ADHD are playing a role in diagnosis. Some sociologists consider ADHD to be an example of the medicalization of deviant behavior, that is, the turning of the previously issue of school performance into a medical one. Most healthcare providers accept ADHD as a genuine disorder, at least in the small number of people with severe symptoms. Among healthcare providers the debate mainly centers on diagnosis and treatment in the much larger number of people with less severe symptoms. , 8% of all United States Major League Baseball players had been diagnosed with ADHD, making the disorder common among this population. The increase coincided with the League's 2006 ban on stimulants, which has raised concern that some players are mimicking or falsifying the symptoms or history of ADHD to get around the ban on the use of stimulants in sport. Treatment Psychosurgery Psychosurgery is brain surgery with the aim of changing an individual's behavior or psychological function. Historically, this was achieved through ablative psychosurgery that removed or deliberately damaged (lesioning) a section of the brain, but more recently deep brain stimulation is used to remotely stimulate sections of the brain. One such practice was the lobotomy, that was used between the 1930s and 1950s, for which one its creators, António Egas Moniz, received a Nobel Prize in 1949. The lobotomy fell out of favor in by 1960s and 1970s. Other forms of ablative psychosurgery were in use in the UK in the late 1970s to treat psychotic and mood disorders. Bilateral cingulotomy was used to treat substance abuse disorder in Russia until 2002. Deep brain stimulation is used in China to treat substance abuse disorders. In the US, the lobotomy, while initially received with positivity in the late 1930s, came to be seen more negative in the late 1940s and early 1950s. The New York Times discussed the personality changes of lobotomy in 1947, and in the same year the Science Digest reported on papers questioning the effects of lobotomy on personality and intelligence. The lobotomy was prominently depicted a means to control nonconformity in the 1962 book One Flew Over the Cuckoo's Nest. Psychosurgery was criticized in the US in the late 1960s and 1970s by psychiatrist Peter Breggin. He identified all psychosurgery with the lobotomy as a rhetorical device to criticize the practice of psychosurgery more broadly. He stated that "psychosurgery is a crime against humanity, a crime that cannot be condoned on medical, ethical, or legal grounds". Psycho-surgeons William Beecher Scoville and Petter Lindström said that Breggin's critique was emotional and not based on facts. Psychosurgery was investigated by the US Senate in the 1973 by the Health Subcommittee of the Senate's Committee on Labor and Public Welfare chaired by Senator Edward Kennedy due to growing concern about the ethical boundaries of science and medicine. At this committee Breggin argued that newer forms of psychosurgery were the same as the lobotomy since it had the same effects "emotional blunting, passivity, reduced capacity to learn" and said that psycho-surgeons "represent the greatest future threat that we are going to face for our traditional American values", arguing that if the US became a totalitarian regime lobotomy and psychosurgery would be the equivalent of the secret police. The subcommittee published a report in 1977 suggesting that data should be carefully collected about psychosurgery and that it should not be performed upon children or prisoners. Electroconvulsive therapy Electroconvulsive therapy is a therapy method which was used widely between the 1930s and 1960s and is, in a modified form, still used today. Electroconvulsive therapy was one treatment that the anti-psychiatry movement wanted to be eliminated from psychiatric practice. Their arguments were that ECT damages the brain, and was used as punishment or as a threat to keep the patients "in line". Since then, ECT has improved considerably, and is now performed under general anesthesia in a medically supervised environment. The National Institute for Health and Care Excellence recommends ECT for the short-term treatment of severe, treatment-resistant depression, and advises against its use in schizophrenia. According to the Canadian Network for Mood and Anxiety Treatments, ECT is more efficacious for the treatment of depression than antidepressants, with a response rate of 90% in first line treatment and 50-60% in treatment-resistant patients. The most common side effects of ECT include headache, muscle soreness, confusion, and temporary loss of recent memory. Patients may also experience permanent amnesia. Marketing of antipsychotic drugs Psychiatry has greatly benefitted by advances in pharmacotherapy. However, the close relationship between those prescribing psychiatric medication and pharmaceutical companies, and the risk of a conflict of interest, is also a source of concern. This relationship is often described as being part of the medical-industrial complex. This marketing by the pharmaceutical industry has an influence on practicing psychiatrists, which affects prescription. Child psychiatry is one of the areas in which prescription of psychotropic medication has grown massively. In the past, prescription of these medications for children was rare, but nowadays child psychiatrists prescribe psychotropic substances, such as Ritalin, on a regular basis to children. Joanna Moncrieff has argued that antipsychotic drug treatment is often undertaken as a means of control rather than to treat specific symptoms experienced by the patient. Moncreiff has further argued, in the controversial and non-peer reviewed journal Medical Hypotheses, that the evidence for antipsychotics from discontinuation-relapse studies may be flawed, because they do not take into account that antipsychotics may sensitize the brain and provoke psychosis if discontinued, which may then be wrongly interpreted as a relapse of the original condition. Use of this class of drugs has a history of criticism in residential care. As the drugs used can make patients calmer and more compliant, critics claim that the drugs can be overused. Outside doctors can feel pressure from care home staff. In an official review commissioned by UK government ministers it was reported that the needless use of antipsychotic medication in dementia care was widespread and was linked to 1800 deaths per year. In the US, the government has initiated legal action against the pharmaceutical company Johnson & Johnson for allegedly paying kickbacks to Omnicare to promote its antipsychotic risperidone (Risperdal) in nursing homes. There has also been controversy about the role of pharmaceutical companies in marketing and promoting antipsychotics, including allegations of downplaying or covering up adverse effects, expanding the number of conditions or illegally promoting off-label usage; influencing drug trials (or their publication) to try to show that the expensive and profitable newer atypicals were superior to the older cheaper typicals that were out of patent. Following charges of illegal marketing, settlements by two large pharmaceutical companies in the US set records for the largest criminal fines ever imposed on corporations. One case involved Eli Lilly and Company's antipsychotic Zyprexa, and the other involved Bextra. In the Bextra case, the government also charged Pfizer with illegally marketing another antipsychotic, Geodon. In addition, Astrazeneca faces numerous personal-injury lawsuits from former users of Seroquel (quetiapine), amidst federal investigations of its marketing practices. By expanding the conditions for which they were indicated, Astrazeneca's Seroquel and Eli Lilly's Zyprexa had become the biggest selling antipsychotics in 2008 with global sales of $5.5 billion and $5.4 billion respectively. Harvard medical professor Joseph Biederman conducted research on bipolar disorder in children that led to an increase in such diagnoses. A 2008 Senate investigation found that Biederman also received $1.6 million in speaking and consulting fees between 2000 and 2007— some of them undisclosed to Harvard— from companies including the makers of antipsychotic drugs prescribed for children with bipolar disorder. Johnson & Johnson gave more than $700,000 to a research center that was headed by Biederman from 2002 to 2005, where research was conducted, in part, on Risperdal, the company's antipsychotic drug. Biederman has responded saying that the money did not influence him and that he did not promote a specific diagnosis or treatment. In 2004, University of Minnesota research participant Dan Markingson committed suicide while enrolled in an industry-sponsored pharmaceutical trial comparing three FDA-approved atypical antipsychotics: Seroquel (quetiapine), Zyprexa (olanzapine), and Risperdal (risperidone). Writing on the circumstances surrounding Markingson's death in the study, which was designed and funded by Seroquel manufacturer AstraZeneca, University of Minnesota Professor of Bioethics Carl Elliott noted that Markingson was enrolled in the study against the wishes of his mother, Mary Weiss, and that he was forced to choose between enrolling in the study or being involuntarily committed to a state mental institution. Further investigation revealed financial ties to AstraZeneca by Markingson's psychiatrist, Dr. Stephen C. Olson, oversights and biases in AstraZeneca's trial design, and the inadequacy of university Institutional Review Board (IRB) protections for research subjects. A 2005 FDA investigation cleared the university. Nonetheless, controversy around the case has continued. Mother Jones resulted in a group of university faculty members sending a public letter to the university Board of Regents urging an external investigation into Markingson's death. Pharmaceutical companies have also been accused of attempting to set the mental health agenda through activities such as funding consumer advocacy groups. In an effort to reduce the potential for hidden conflicts of interest between researchers and pharmaceutical companies, the US Government issued a mandate in 2012 requiring that drug manufacturers receiving funds under the Medicare and Medicaid programs collect data, and make public, all gifts to doctors and hospitals. Anti-psychiatry The term anti-psychiatry was coined by psychiatrist David Cooper in 1967 and is understood in current psychiatry to mean opposition to psychiatry's perceived role aspects of treatment. The anti-psychiatry message is that psychiatric treatments are "ultimately more damaging than helpful to patients". Psychiatry is seen to involve an "unequal power relationship between doctor and patient", and advocates of anti-psychiatry claim a subjective diagnostic process, leaving much room for opinions and interpretations. Every society, including liberal Western society, permits compulsory treatment of mental patients. The World Health Organization (WHO) recognizes that "poor quality services and human rights violations in mental health and social care facilities are still an everyday occurrence in many places", but has recently taken steps to improve the situation globally. Electroconvulsive therapy is a therapy method, which was used widely between the 1930s and 1960s and is, in a modified form, still in use today. Valium and other sedatives have arguably been over-prescribed, leading to a claimed epidemic of dependence. These are a few of the arguments that the anti-psychiatry movement use to highlight the harms of psychiatric practice. Multiple authors are well known for the movement against psychiatry, including those who have been practicing psychiatrists. The most influential was R.D. Laing, who wrote a series of books, including; The Divided Self. Thomas Szasz rose to fame with the book The Myth of Mental Illness. Michael Foucault challenged the very basis of psychiatric practice and cast it as repressive and controlling. The term "anti-psychiatry" itself was coined by David Cooper in 1967. The founder of the non-psychiatric approach to psychological suffering is Giorgio Antonucci. Divergence within psychiatry generated the anti-psychiatry movement in the 1960s and 1970s, and is still present. Issues remaining relevant in contemporary psychiatry are questions of; freedom versus coercion, mind versus brain, nature versus nurture, and the right to be different. Psychiatric survivors movement The psychiatric survivors movement arose out of the civil rights ferment of the late 1960s and early 1970s and the personal histories of psychiatric abuse experienced by some ex-patients rather than the intradisciplinary discourse of antipsychiatry. The key text in the intellectual development of the survivor movement, at least in the US, was Judi Chamberlin's 1978 text, On Our Own: Patient Controlled Alternatives to the Mental Health System. Chamberlin was an ex-patient and co-founder of the Mental Patients' Liberation Front. Coalescing around the ex-patient newsletter Dendron, in late 1988 leaders from several of the main national and grassroots psychiatric survivor groups felt that an independent, human rights coalition focused on problems in the mental health system was needed. That year the Support Coalition International (SCI) was formed. SCI's first public action was to stage a counter-conference and protest in New York City, in May, 1990, at the same time as (and directly outside of) the American Psychiatric Association's annual meeting. In 2005 the SCI changed its name to Mind Freedom International with David W. Oaks as its director. References Cited texts

Modus operandi

A (often shortened to M.O. or MO) is an individual's habits of working, particularly in the context of business or criminal investigations, but also generally. It is a Latin phrase, approximately translated as . Term The term is often used in police work when discussing crime and addressing the methods employed by criminals. It is also used in criminal profiling, where it can help in finding clues to the offender's psychology. It largely consists of examining the actions used by the individuals to execute the crime, prevent its detection and facilitate escape. A suspect's modus operandi can assist in their identification, apprehension, or repression, and can also be used to determine links between crimes. In business, modus operandi is used to describe a firm's preferred means of executing business and interacting with other firms. Plural The plural is . The word is a gerund in the genitive case, "of operating"; gerunds can never be pluralised in Latin, as opposed to gerundives. When a noun with an attribute in the genitive is pluralised, only the head noun normally changes, just as in English with "of": "a fact of life, two facts of life" (unlike, for instance, in French). See also References Further reading Levinson, D. Encyclopedia of Crime and Punishment (SAGE, 2002). . Carlo, P. The Night Stalker: The Life and Crimes of Richard Ramirez (Pinnacle Books 1996). . External links Criminal investigation Criminology Latin words and phrases Offender profiling

Serious mental illness

Serious mental illness (SMI) is characterized as any mental health condition that impairs seriously or severely from one to several significant life activities, including day to day functioning. Five common examples of SMI include bipolar disorders, borderline personality disorder, psychotic disorders (i.e. schizophrenia), post-traumatic stress disorders, and major depressive disorders. People having SMI experience symptoms that prevent them from having experiences that contribute to a good quality of life, due to social, physical, and psychological limitations of their illnesses. In 2021, there was a 5.5% prevalence rate of U.S. adults diagnosed with SMI, with the highest percentage being in the 18 to 25 year-old group (11.4%). Also in the study, 65.4% of the 5.5% diagnosed adults with SMI received mental health care services. SMI is a subset of AMI, an abbreviation for any mental illness. Hospitalizations Many people living with SMI experience institutional recidivism, which is the process of being admitted and readmitted into the hospital. This cycle is due in part to a lack of support being available for people living with SMI after being released from the hospital, frequent encounters between them and the police, as well as miscommunication between clinicians and police officers. There are also instances where poor insight into one's mental illness has resulted in increased psychiatric symptoms which ultimately leads to hospitalization and a lower quality of life generally. Highly symptomatic patients are more likely to seek emergency room services. Patients with schizophrenia have the lowest risk of being hospitalized, likely due to frequent encounters with case managers to manage the chronic and persistent symptoms of schizophrenia. To reduce the occurrence of institutional recidivism, the Georgia chapter of the National Alliance on Mental Illness (NAMI) created the Opening Doors to Recovery (ODR) program. ODR established a treatment team of licensed mental health professionals, peer specialists, and family peer specialists (a family member of someone who has SMI) to reduce institutional recidivism by providing treatment, ensuring safe housing, and supporting their recovery. SMI patients who were enrolled in ODR had less hospitalizations and fewer days in the hospital compared to their hospitalizations prior to enrollment. Older adults with SMI are more likely to seek medical services and have longer hospital stays than patients who regularly see a doctor. People with SMI seek medical services for a variety of non-mental health conditions, including diabetes, coronary artery disease, congestive heart failure, urinary conditions, pneumonia, chronic obstructive pulmonary disease, thyroid disease, digestive conditions and cancer. This may be due to poor lifestyle habits, associated with reduced mental health, such as smoking, poor diet, and lack of exercise. People with SMI typically take antipsychotic medications to manage their condition, however, second-generation antipsychotics can cause poor glycemic control for patients with diabetes, furthering complications in this population. Second-generation antipsychotics, also known as atypical antipsychotics are medications used to effectively treat the positive (e.g. hallucinations and delusions) and negative (e.g. flat affect and lack of motivation) symptoms of schizophrenia. This means that people with both SMI and diabetes are more frequently readmitted to hospitals one month after their initial hospitalization. Notably, patients with SMI have increasing reports of falls and substance abuse, including alcoholism. Homelessness Adults with SMI are 25 to 50 percent more likely to experience homelessness compared to the general population. One predictor of homelessness is poor therapeutic alliance with case managers. Adults with SMI often lack social support from family, friends and the community, which can put them at risk for experiencing homelessness. In 2019, the U.S. Department of Housing and Urban Development reported that there are 52,243 people living with SMI who were living on the street. During that time, 15,153 people with SMI were in transitional housing, which is temporary housing when people are transitioning from emergency shelters to permanent housing. 48,783 people with SMI were living in emergency shelters. People with SMI who experience homelessness have even greater difficulty accessing mental health and primary care services due to cost, lack of transportation, and lack of consistent access to a charged cell phone. These difficulties can add additional stress, which may be why people with SMI experience a high rate of suicidal ideation and suicide attempts. When surveyed, 8% of people with SMI who were homeless reported that they had made a suicide attempt in the past 30 days. Researchers found that the housing first approach to ending homelessness improved quality of life and psychosocial functioning faster than treatment as usual, also known as standard treatment. In addition, researchers found that SMI patients remained homeless for longer and had fewer housing stability when receiving mental health services in the absence of receiving housing. Combining housing first with Assertive Community Treatment leads to improved quality of life one year after initially starting housing first compared to just receiving outpatient mental health services. Additionally, housing first reduced number of days hospitalized and number of emergency room visits for people with SMI. Stigma People with SMI often experience stigma due to frequently stigmatizing representations of people with SMI in the media that portrays them as violent, criminals, and accountable for their condition because of weak character. People with SMI experience two kinds of stigma; public stigma and self-stigma. Public stigma refers to negative beliefs/perceptions that the public has about SMI; such as people with SMI should be feared, are irresponsible, that they should be responsible for their life decisions, and that they are childlike, needing constant care. Self-stigma refers to prejudice that an individual with SMI may feel about themselves, such as "I am dangerous. I am afraid of myself." In a study conducted on patients who were involuntarily hospitalized, researchers found that poor quality of life and low self-esteem could be predicted by high levels of self-stigma and fewer experiences of empowerment. Self-stigma can be reduced by increasing empowerment in individuals with SMI through counseling and/or peer support and other self-disclosing of their own struggles with mental illness. People who suffer from SMI can reduce the amount of stigma that they experience by maintaining insight into their condition with the assistance of social supports. Consumer services, such as drop-in centers, peer support, mentoring services, and educational programs can increase empowerment in individuals with SMI. References Mental disorders Abnormal psychology Psychiatric assessment

Psychosis

Psychosis is a condition of the mind or psyche that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are disorganized thinking and incoherent speech and behavior that is inappropriate for a given situation. There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities. Psychosis can have serious adverse outcomes. Psychosis can have several different causes. These include mental illness, such as schizophrenia or schizoaffective disorder, bipolar disorder, sensory deprivation, Wernicke–Korsakoff syndrome or cerebral beriberi and in rare cases major depression (psychotic depression). Other causes include: trauma, sleep deprivation, some medical conditions, certain medications, and drugs such as alcohol, cannabis, hallucinogens, and stimulants. One type, known as postpartum psychosis, can occur after giving birth. The neurotransmitter dopamine is believed to play an important role. Acute psychosis is termed primary if it results from a psychiatric condition and secondary if it is caused by another medical condition or drugs. The diagnosis of a mental-health condition requires excluding other potential causes. Testing may be done to check for central nervous system diseases, toxins, or other health problems as a cause. Treatment may include antipsychotic medication, psychotherapy, and social support. Early treatment appears to improve outcomes. Medications appear to have a moderate effect. Outcomes depend on the underlying cause. In the United States about 3% of people develop psychosis at some point in their lives. The condition has been described since at least the 4th century BC by Hippocrates and possibly as early as 1500 BC in the Egyptian Ebers Papyrus. Signs and symptoms Hallucinations A hallucination is defined as sensory perception in the absence of external stimuli. Hallucinations are different from illusions and perceptual distortions, which are the misperception of external stimuli. Hallucinations may occur in any of the senses and take on almost any form. They may consist of simple sensations (such as lights, colors, sounds, tastes, or smells) or more detailed experiences (such as seeing and interacting with animals and people, hearing voices, and having complex tactile sensations). Hallucinations are generally characterized as being vivid and uncontrollable. Auditory hallucinations, particularly experiences of hearing voices, are the most common and often prominent feature of psychosis. Up to 15% of the general population may experience auditory hallucinations (though not all are due to psychosis). The prevalence of auditory hallucinations in patients with schizophrenia is generally put around 70%, but may go as high as 98%. Reported prevalence in bipolar disorder ranges between 11% and 68%. During the early 20th century, auditory hallucinations were second to visual hallucinations in frequency, but they are now the most common manifestation of schizophrenia, although rates vary between cultures and regions. Auditory hallucinations are most commonly intelligible voices. When voices are present, the average number has been estimated at three. Content, like frequency, differs significantly, especially across cultures and demographics. People who experience auditory hallucinations can frequently identify the loudness, location of origin, and may settle on identities for voices. Western cultures are associated with auditory experiences concerning religious content, frequently related to sin. Hallucinations may command a person to do something potentially dangerous when combined with delusions. So-called "minor hallucinations", such as extracampine hallucinations, or false perceptions of people or movement occurring outside of one's visual field, frequently occur in neurocognitive disorders, such as Parkinson's disease. Visual hallucinations occur in roughly a third of people with schizophrenia, although rates as high as 55% are reported. The prevalence in bipolar disorder is around 15%. Content commonly involves animate objects, although perceptual abnormalities such as changes in lighting, shading, streaks, or lines may be seen. Visual abnormalities may conflict with proprioceptive information, and visions may include experiences such as the ground tilting. Lilliputian hallucinations are less common in schizophrenia, and are more common in various types of encephalopathy, such as peduncular hallucinosis. A visceral hallucination, also called a cenesthetic hallucination, is characterized by visceral sensations in the absence of stimuli. Cenesthetic hallucinations may include sensations of burning, or re-arrangement of internal organs. Delusions Psychosis may involve delusional beliefs. A delusion is a fixed, false idiosyncratic belief, which does not change even when presented with incontrovertible evidence to the contrary. Delusions are context- and culture-dependent: a belief that inhibits critical functioning and is widely considered delusional in one population may be common (and even adaptive) in another, or in the same population at a later time. Since normative views may contradict available evidence, a belief need not contravene cultural standards in order to be considered delusional. Prevalence in schizophrenia is generally considered at least 90%, and around 50% in bipolar disorder. The DSM-5 characterizes certain delusions as "bizarre" if they are clearly implausible, or are incompatible with the surrounding cultural context. The concept of bizarre delusions has many criticisms, the most prominent being judging its presence is not highly reliable even among trained individuals. A delusion may involve diverse thematic content. The most common type is a persecutory delusion, in which a person believes that an entity seeks to harm them. Others include delusions of reference (the belief that some element of one's experience represents a deliberate and specific act by or message from some other entity), delusions of grandeur (the belief that one possesses special power or influence beyond one's actual limits), thought broadcasting (the belief that one's thoughts are audible) and thought insertion (the belief that one's thoughts are not one's own). A delusion may also involve misidentification of objects, persons, or environs that the afflicted should reasonably be able to recognize; such examples include Cotard's syndrome (the belief that oneself is partly or wholly dead) and clinical lycanthropy (the belief that oneself is or has transformed into an animal). The subject matter of delusions seems to reflect the current culture in a particular time and location. For example, in the US, during the early 1900s syphilis was a common topic, during the Second World War Germany, during the Cold War communists, and in recent years, technology has been a focus. Some psychologists, such as those who practice the Open Dialogue method, believe that the content of psychosis represents an underlying thought process that may, in part, be responsible for psychosis, though the accepted medical position is that psychosis is due to a brain disorder. Historically, Karl Jaspers classified psychotic delusions into primary and secondary types. Primary delusions are defined as arising suddenly and not being comprehensible in terms of normal mental processes, whereas secondary delusions are typically understood as being influenced by the person's background or current situation (e.g., ethnicity; also religious, superstitious, or political beliefs). Disorganization of speech/thought or behavior Disorganization is split into disorganized speech (or thought), and grossly disorganized motor behavior. Disorganized speech or thought, also called formal thought disorder, is disorganization of thinking that is inferred from speech. Characteristics of disorganized speech include rapidly switching topics, called derailment or loose association; switching to topics that are unrelated, called tangential thinking; incomprehensible speech, called word salad or incoherence. Disorganized motor behavior includes repetitive, odd, or sometimes purposeless movement. Disorganized motor behavior rarely includes catatonia, and although it was a historically prominent symptom, it is rarely seen today. Whether this is due to historically used treatments or the lack thereof is unknown. Catatonia describes a profoundly agitated state in which the experience of reality is generally considered impaired. There are two primary manifestations of catatonic behavior. The classic presentation is a person who does not move or interact with the world in any way while awake. This type of catatonia presents with waxy flexibility. Waxy flexibility is when someone physically moves part of a catatonic person's body and the person stays in the position even if it is bizarre and otherwise nonfunctional (such as moving a person's arm straight up in the air and the arm staying there). The other type of catatonia is more of an outward presentation of the profoundly agitated state described above. It involves excessive and purposeless motor behaviour, as well as an extreme mental preoccupation that prevents an intact experience of reality. An example is someone walking very fast in circles to the exclusion of anything else with a level of mental preoccupation (meaning not focused on anything relevant to the situation) that was not typical of the person prior to the symptom onset. In both types of catatonia, there is generally no reaction to anything that happens outside of them. It is important to distinguish catatonic agitation from severe bipolar mania, although someone could have both. Negative symptoms Negative symptoms include reduced emotional expression, decreased motivation (avolition), and reduced spontaneous speech (poverty of speech, alogia). Individuals with this condition lack interest and spontaneity, and have the inability to feel pleasure (anhedonia). Altered Behavioral Inhibition System functioning could possibly cause reduced sustained attention in psychosis and overall contribute to more negative reactions. Psychosis in adolescents Psychosis is rare in adolescents. Young people who have psychosis may have trouble connecting with the world around them and may experience hallucinations or delusions. Adolescents with psychosis may also have cognitive deficits that may make it harder for the youth to socialize and work. Potential impairments include reduced speed of mental processing, ability to focus without getting distracted (limited attention span), and deficits in verbal memory. If an adolescent is experiencing psychosis, they most likely have comorbidity, meaning that they could have multiple mental illnesses. Because of this, it may be difficult to determine whether it is psychosis or autism spectrum disorder, social or generalized anxiety disorder, or obsessive-compulsive disorder. Causes The symptoms of psychosis may be caused by serious psychiatric disorders such as schizophrenia, a number of medical illnesses, and trauma. Psychosis may also be temporary or transient, and be caused by medications or substance use disorder (substance-induced psychosis). Normal states Brief hallucinations are not uncommon in those without any psychiatric disease, including healthy children. Causes or triggers include: Falling asleep and waking: hypnagogic and hypnopompic hallucinations Bereavement, in which hallucinations of a deceased loved one are common Severe sleep deprivation Extreme stress (see below) Trauma and stress Traumatic life events have been linked with an elevated risk of developing psychotic symptoms. Childhood trauma has specifically been shown to be a predictor of adolescent and adult psychosis. Individuals with psychotic symptoms are three times more likely to have experienced childhood trauma (e.g., physical or sexual abuse, physical or emotional neglect) than those in the general population. Increased individual vulnerability toward psychosis may interact with traumatic experiences promoting an onset of future psychotic symptoms, particularly during sensitive developmental periods. Importantly, the relationship between traumatic life events and psychotic symptoms appears to be dose-dependent in which multiple traumatic life events accumulate, compounding symptom expression and severity. However, acute, stressful events can also trigger brief psychotic episodes. Trauma prevention and early intervention may be an important target for decreasing the incidence of psychotic disorders and ameliorating its effects. A healthy person could become psychotic if he is placed in an empty room with no light and sound after 15 minutes, a phenomenon known as sensory deprivation. Neuroticism, a personality trait associated with vulnerability to stressors, is an independent predictor of the development of psychosis. Psychiatric disorders From a diagnostic standpoint, organic disorders were believed to be caused by physical illness affecting the brain (that is, psychiatric disorders secondary to other conditions) while functional disorders were considered disorders of the functioning of the mind in the absence of physical disorders (that is, primary psychological or psychiatric disorders). Subtle physical abnormalities have been found in illnesses traditionally considered functional, such as schizophrenia. The DSM-IV-TR avoids the functional/organic distinction, and instead lists traditional psychotic illnesses, psychosis due to general medical conditions, and substance-induced psychosis. Primary psychiatric causes of psychosis include the following: schizophrenia mood disorders including psychotic depression and bipolar disorder in the manic and mixed episodes of bipolar I disorder and depressive episodes of both bipolar I and bipolar II schizoaffective disorder delusional disorder brief psychotic disorder schizophreniform disorder Psychotic symptoms may also be seen in: Personality disorders including Schizotypal personality disorder and borderline personality disorder Post-traumatic stress disorder obsessive–compulsive disorder dissociative identity disorder. Subtypes Subtypes of psychosis include: Postpartum psychosis, occurring shortly after giving birth, primarily associated with maternal bipolar disorder Monothematic delusions Myxedematous psychosis Stimulant psychosis Tardive psychosis Shared psychosis Cycloid psychosis Cycloid psychosis is typically an acute, self-limiting form of psychosis with psychotic and mood symptoms that progress from normal to full-blown, usually between a few hours to days, and not related to drug intake or brain injury. While proposed as a distinct entity, clinically separate from schizophrenia and affective disorders, cycloid psychosis is not formally acknowledged by current ICD or DSM criteria. Its unclear place in psychiatric nosology has likely contributed to the limited scientific investigation and literature on the topic. Postpartum psychosis Postpartum psychosis is a rare yet serious and debilitating form of psychosis. Symptoms range from fluctuating moods and insomnia to mood-incongruent delusions related to the individual or the infant. Women experiencing postpartum psychosis are at increased risk for suicide or infanticide. Many women who experience first-time psychosis from postpartum often have bipolar disorder, meaning they could experience an increase of psychotic episodes even after postpartum. Medical conditions A very large number of medical conditions can cause psychosis, sometimes called secondary psychosis. Examples include: disorders causing delirium (toxic psychosis), in which consciousness is disturbed neurodevelopmental disorders and chromosomal abnormalities, including velocardiofacial syndrome neurodegenerative disorders, such as Alzheimer's disease, dementia with Lewy bodies, and Parkinson's disease focal neurological disease, such as stroke, brain tumors, multiple sclerosis, and some forms of epilepsy malignancy (typically via masses in the brain, paraneoplastic syndromes) infectious and postinfectious syndromes, including infections causing delirium, viral encephalitis, HIV/AIDS, malaria, syphilis endocrine disease, such as hypothyroidism, hyperthyroidism, Cushing's syndrome, hypoparathyroidism and hyperparathyroidism; sex hormones also affect psychotic symptoms and sometimes giving birth can provoke psychosis, termed postpartum psychosis inborn errors of metabolism, such as Wilson's disease, porphyria, and homocysteinemia. nutritional deficiency, such as vitamin B12 deficiency other acquired metabolic disorders, including electrolyte disturbances such as hypocalcemia, hypernatremia, hyponatremia, hypokalemia, hypomagnesemia, hypermagnesemia, hypercalcemia, and hypophosphatemia, but also hypoglycemia, hypoxia, and failure of the liver or kidneys autoimmune and related disorders, such as systemic lupus erythematosus (lupus, SLE), sarcoidosis, Hashimoto's encephalopathy, anti-NMDA-receptor encephalitis, and non-celiac gluten sensitivity poisoning by a range of plants, fungi, metals, organic compounds, and a few animal toxins sleep disorders, such as in narcolepsy (in which REM sleep intrudes into wakefulness) parasitic diseases, such as neurocysticercosis Psychoactive drugs Various psychoactive substances (both legal and illegal) have been implicated in causing, exacerbating, or precipitating psychotic states or disorders in users, with varying levels of evidence. This may be upon intoxication for a more prolonged period after use, or upon withdrawal. Individuals who experience substance-induced psychosis tend to have a greater awareness of their psychosis and tend to have higher levels of suicidal thinking compared to those who have a primary psychotic illness. Drugs commonly alleged to induce psychotic symptoms include alcohol, cannabis, cocaine, amphetamines, cathinones, psychedelic drugs (such as LSD and psilocybin), κ-opioid receptor agonists (such as enadoline and salvinorin A) and NMDA receptor antagonists (such as phencyclidine and ketamine). Caffeine may worsen symptoms in those with schizophrenia and cause psychosis at very high doses in people without the condition. Cannabis and other illicit recreational drugs are often associated with psychosis in adolescents and cannabis use before 15 years old may increase the risk of psychosis in adulthood. Alcohol Approximately three percent of people with alcoholism experience psychosis during acute intoxication or withdrawal. Alcohol related psychosis may manifest itself through a kindling mechanism. The mechanism of alcohol-related psychosis is due to the long-term effects of alcohol consumption resulting in distortions to neuronal membranes, gene expression, as well as thiamine deficiency. It is possible that hazardous alcohol use via a kindling mechanism can cause the development of a chronic substance-induced psychotic disorder, i.e. schizophrenia. The effects of an alcohol-related psychosis include an increased risk of depression and suicide as well as causing psychosocial impairments. Delirium tremens, a symptom of chronic alcoholism that can appear in the acute withdrawal phase, shares many symptoms with alcohol-related psychosis suggesting a common mechanism. Cannabis According to current studies, cannabis use is associated with increased risk of psychotic disorders, and the more often cannabis is used the more likely a person is to develop a psychotic illness. Furthermore, people with a history of cannabis use develop psychotic symptoms earlier than those who have never used cannabis. Some debate exists regarding the causal relationship between cannabis use and psychosis with some studies suggesting that cannabis use hastens the onset of psychosis primarily in those with pre-existing vulnerability. Indeed, cannabis use plays an important role in the development of psychosis in vulnerable individuals, and cannabis use in adolescence should be discouraged. Some studies indicate that the effects of two active compounds in cannabis, tetrahydrocannabinol (THC) and cannabidiol (CBD), have opposite effects with respect to psychosis. While THC can induce psychotic symptoms in healthy individuals, limited evidence suggests that CBD may have antipsychotic effects. Methamphetamine Methamphetamine induces a psychosis in 26–46 percent of heavy users. Some of these people develop a long-lasting psychosis that can persist for longer than six months. Those who have had a short-lived psychosis from methamphetamine can have a relapse of the methamphetamine psychosis years later after a stressful event such as severe insomnia or a period of hazardous alcohol use despite not relapsing back to methamphetamine. Individuals who have a long history of methamphetamine use and who have experienced psychosis in the past from methamphetamine use are highly likely to re-experience methamphetamine psychosis if drug use is recommenced. Methamphetamine-induced psychosis is likely gated by genetic vulnerability, which can produce long-term changes in brain neurochemistry following repetitive use. Medication Administration, or sometimes withdrawal, of a large number of medications may provoke psychotic symptoms. Drugs that can induce psychosis experimentally or in a significant proportion of people include: stimulants, such as amphetamine and other sympathomimetics, dopamine agonists, ketamine, corticosteroids (often with mood changes in addition), and some anticonvulsants such as vigabatrin. Pathophysiology Neuroimaging The first brain image of an individual with psychosis was completed as far back as 1935 using a technique called pneumoencephalography (a painful and now obsolete procedure where cerebrospinal fluid is drained from around the brain and replaced with air to allow the structure of the brain to show up more clearly on an X-ray picture). Both first episode psychosis, and high risk status is associated with reductions in grey matter volume (GMV). First episode psychotic and high risk populations are associated with similar but distinct abnormalities in GMV. Reductions in the right middle temporal gyrus, right superior temporal gyrus (STG), right parahippocampus, right hippocampus, right middle frontal gyrus, and left anterior cingulate cortex (ACC) are observed in high risk populations. Reductions in first episode psychosis span a region from the right STG to the right insula, left insula, and cerebellum, and are more severe in the right ACC, right STG, insula and cerebellum. Another meta analysis reported bilateral reductions in insula, operculum, STG, medial frontal cortex, and ACC, but also reported increased GMV in the right lingual gyrus and left precentral gyrus. The Kraepelinian dichotomy is made questionable by grey matter abnormalities in bipolar and schizophrenia; schizophrenia is distinguishable from bipolar in that regions of grey matter reduction are generally larger in magnitude, although adjusting for gender differences reduces the difference to the left dorsomedial prefrontal cortex, and right dorsolateral prefrontal cortex. During attentional tasks, first episode psychosis is associated with hypoactivation in the right middle frontal gyrus, a region generally described as encompassing the dorsolateral prefrontal cortex (dlPFC).Altered Behavioral Inhibition System functioning could possibly cause reduced sustained attention in psychosis and overall contribute to more negative reactions. In congruence with studies on grey matter volume, hypoactivity in the right insula, and right inferior parietal lobe is also reported. During cognitive tasks, hypoactivities in the right insula, dACC, and the left precuneus, as well as reduced deactivations in the right basal ganglia, right thalamus, right inferior frontal and left precentral gyri are observed. These results are highly consistent and replicable possibly except the abnormalities of the right inferior frontal gyrus. Decreased grey matter volume in conjunction with bilateral hypoactivity is observed in anterior insula, dorsal medial frontal cortex, and dorsal ACC. Decreased grey matter volume and bilateral hyperactivity is reported in posterior insula, ventral medial frontal cortex, and ventral ACC. Hallucinations Studies during acute experiences of hallucinations demonstrate increased activity in primary or secondary sensory cortices. As auditory hallucinations are most common in psychosis, most robust evidence exists for increased activity in the left middle temporal gyrus, left superior temporal gyrus, and left inferior frontal gyrus (i.e. Broca's area). Activity in the ventral striatum, hippocampus, and ACC are related to the lucidity of hallucinations, and indicate that activation or involvement of emotional circuitry are key to the impact of abnormal activity in sensory cortices. Together, these findings indicate abnormal processing of internally generated sensory experiences, coupled with abnormal emotional processing, results in hallucinations. One proposed model involves a failure of feedforward networks from sensory cortices to the inferior frontal cortex, which normally cancel out sensory cortex activity during internally generated speech. The resulting disruption in expected and perceived speech is thought to produce lucid hallucinatory experiences. Delusions The two-factor model of delusions posits that dysfunction in both belief formation systems and belief evaluation systems are necessary for delusions. Dysfunction in evaluations systems localized to the right lateral prefrontal cortex, regardless of delusion content, is supported by neuroimaging studies and is congruent with its role in conflict monitoring in healthy persons. Abnormal activation and reduced volume is seen in people with delusions, as well as in disorders associated with delusions such as frontotemporal dementia, psychosis and Lewy body dementia. Furthermore, lesions to this region are associated with "jumping to conclusions", damage to this region is associated with post-stroke delusions, and hypometabolism this region associated with caudate strokes presenting with delusions. The aberrant salience model suggests that delusions are a result of people assigning excessive importance to irrelevant stimuli. In support of this hypothesis, regions normally associated with the salience network demonstrate reduced grey matter in people with delusions, and the neurotransmitter dopamine, which is widely implicated in salience processing, is also widely implicated in psychotic disorders. Specific regions have been associated with specific types of delusions. The volume of the hippocampus and parahippocampus is related to paranoid delusions in Alzheimer's disease, and has been reported to be abnormal post mortem in one person with delusions. Capgras delusions have been associated with occipito-temporal damage, and may be related to failure to elicit normal emotions or memories in response to faces. Negative symptoms Psychosis is associated with ventral striatal (VS), which is the part of the brain that is involved with the desire to naturally satisfy the body's needs. When high reports of negative symptoms were recorded, there were significant irregularities in the left VS. Anhedonia, the inability to feel pleasure, is a commonly reported symptom in psychosis; experiences are present in most people with schizophrenia. Anhedonia arises as a result of the inability to feel motivation and drive towards both the desire to engage in as well as to complete tasks and goals. Previous research has indicated that a deficiency in the neural representation in regards to goals and the motivation to achieve them, has demonstrated that when a reward is not present, a strong reaction is noted in the ventral striatum; reinforcement learning is intact when contingencies about stimulus-reward are implicit, but not when they require explicit neural processing; reward prediction errors are what the actual reward is versus what the reward was predicted to be. In most cases positive prediction errors are considered an abnormal occurrence. A positive prediction error response occurs when there is an increased activation in a brain region, typically the striatum, in response to unexpected rewards. A negative prediction error response occurs when there is a decreased activation in a region when predicted rewards do not occur. Anterior Cingulate Cortex (ACC) response, taken as an indicator of effort allocation, does not increase with reward or reward probability increase, and is associated with negative symptoms; deficits in Dorsolateral Prefrontal Cortex (dlPFC) activity and failure to improve performance on cognitive tasks when offered monetary incentives are present; and dopamine mediated functions are abnormal. Neurobiology Psychosis has been traditionally linked to the overactivity of the neurotransmitter dopamine. In particular to its effect in the mesolimbic pathway. The two major sources of evidence given to support this theory are that dopamine receptor D2 blocking drugs (i.e., antipsychotics) tend to reduce the intensity of psychotic symptoms, and that drugs that accentuate dopamine release, or inhibit its reuptake (such as amphetamines and cocaine) can trigger psychosis in some people (see stimulant psychosis). NMDA receptor dysfunction has been proposed as a mechanism in psychosis. This theory is reinforced by the fact that dissociative NMDA receptor antagonists such as ketamine, PCP and dextromethorphan (at large overdoses) induce a psychotic state. The symptoms of dissociative intoxication are also considered to mirror the symptoms of schizophrenia, including negative symptoms. NMDA receptor antagonism, in addition to producing symptoms reminiscent of psychosis, mimics the neurophysiological aspects, such as reduction in the amplitude of P50, P300, and MMN evoked potentials. Hierarchical Bayesian neurocomputational models of sensory feedback, in agreement with neuroimaging literature, link NMDA receptor hypofunction to delusional or hallucinatory symptoms via proposing a failure of NMDA mediated top down predictions to adequately cancel out enhanced bottom up AMPA mediated predictions errors. Excessive prediction errors in response to stimuli that would normally not produce such a response is thought to root from conferring excessive salience to otherwise mundane events. Dysfunction higher up in the hierarchy, where representation is more abstract, could result in delusions. The common finding of reduced GAD67 expression in psychotic disorders may explain enhanced AMPA mediated signaling, caused by reduced GABAergic inhibition. The connection between dopamine and psychosis is generally believed to be complex. While dopamine receptor D2 suppresses adenylate cyclase activity, the D1 receptor increases it. If D2-blocking drugs are administered, the blocked dopamine spills over to the D1 receptors. The increased adenylate cyclase activity affects genetic expression in the nerve cell, which takes time. Hence antipsychotic drugs take a week or two to reduce the symptoms of psychosis. Moreover, newer and equally effective antipsychotic drugs actually block slightly less dopamine in the brain than older drugs whilst also blocking 5-HT2A receptors, suggesting the 'dopamine hypothesis' may be oversimplified. Soyka and colleagues found no evidence of dopaminergic dysfunction in people with alcohol-induced psychosis and Zoldan et al. reported moderately successful use of ondansetron, a 5-HT3 receptor antagonist, in the treatment of levodopa psychosis in Parkinson's disease patients. A review found an association between a first-episode of psychosis and prediabetes. Prolonged or high dose use of psychostimulants can alter normal functioning, making it similar to the manic phase of bipolar disorder. NMDA antagonists replicate some of the so-called "negative" symptoms like thought disorder in subanesthetic doses (doses insufficient to induce anesthesia), and catatonia in high doses. Psychostimulants, especially in one already prone to psychotic thinking, can cause some "positive" symptoms, such as delusional beliefs, particularly those persecutory in nature. Culture Cross-cultural studies into schizophrenia have found that individual experiences of psychosis and 'hearing voices' vary across cultures. In countries such as the United States where there exists a predominantly biomedical understanding of the body, the mind and in turn, mental health, subjects were found to report their hallucinations as having 'violent content' and self-describing as 'crazy'. This lived experience is at odds with the lived experience of subjects in Accra, Ghana, who describe the voices they hear as having 'spiritual meaning' and are often reported as positive in nature; or subjects in Chennai, India, who describe their hallucinations as kin, family members or close friends, and offering guidance. These differences are attributed to 'social kindling' or how one's social context shapes how an individual interprets and experiences sensations such as hallucinations. This concept aligns with pre-existing cognitive theory such as reality modelling and is supported by recent research that demonstrates that individuals with psychosis can be taught to attend to their hallucinations differently, which in turn alters the hallucinations themselves. Such research creates pathways for social or community-based treatment, such as reality monitoring, for individuals with schizophrenia and other psychotic disorders, providing alternatives to, or supplementing traditional pharmacologic management. Cross-cultural studies explore the way in which psychosis varies in different cultures, countries and religions. The cultural differences are based on the individual or shared illness narratives surrounding cultural meanings of illness experience. In countries such as India, Cambodia and Muslim majority countries, they each share alternative epistemologies. These are known as knowledge systems that focus on the connections between mind, body, culture, nature, and society. Cultural perceptions of mental disorders such as psychosis or schizophrenia are believed to be caused by jinn (spirits) in Muslim majority countries. Furthermore, those in Arab-Muslim societies perceive those who act differently than the social norm as "crazy" or as abnormal behaviour. This differs from the lived experience of individuals in India and how they attain their perspectives on mental health issues through a variety of spiritual and healing traditions. In Cambodia, hallucinations are linked with spirit visitation, a term they call "cultural kindling". These examples of differences are attributed to culture and the way it shapes conceptions of mental disorders. These cultural differences can be useful in bridging the gap of cultural understanding and psychiatric signs and symptoms. Diagnosis To make a diagnosis of a mental illness in someone with psychosis other potential causes must be excluded. An initial assessment includes a comprehensive history and physical examination by a health care provider. Tests may be done to exclude substance use, medication, toxins, surgical complications, or other medical illnesses. A person with psychosis is referred to as psychotic. Delirium should be ruled out, which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness, indicating other underlying factors, including medical illnesses. Excluding medical illnesses associated with psychosis is performed by using blood tests to measure: thyroid-stimulating hormone to exclude hypo- or hyperthyroidism, vitamin B12 serum and urinary MMA to role out pernicious anemia or vitamin B12 deficiency, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection. Other investigations include: EEG to exclude epilepsy, and an MRI or CT scan of the head to exclude brain lesions. Because psychosis may be precipitated or exacerbated by common classes of medications, medication-induced psychosis should be ruled out, particularly for first-episode psychosis. Both substance- and medication-induced psychosis can be excluded to a high level of certainty, using toxicology screening. Because some dietary supplements may also induce psychosis or mania, but cannot be ruled out with laboratory tests, a psychotic individual's family, partner, or friends should be asked whether the patient is currently taking any dietary supplements. Common mistakes made when diagnosing people who are psychotic include: Not properly excluding delirium, Not appreciating medical abnormalities (e.g., vital signs), Not obtaining a medical history and family history, Indiscriminate screening without an organizing framework, Missing a toxic psychosis by not screening for substances and medications, Not asking their family or others about dietary supplements, Premature diagnostic closure, and Not revisiting or questioning the initial diagnostic impression of primary psychiatric disorder. Only after relevant and known causes of psychosis are excluded, a mental health clinician may make a psychiatric differential diagnosis using a person's family history, incorporating information from the person with psychosis, and information from family, friends, or significant others. Types of psychosis in psychiatric disorders may be established by formal rating scales. The Brief Psychiatric Rating Scale (BPRS) assesses the level of 18 symptom constructs of psychosis such as hostility, suspicion, hallucination, and grandiosity. It is based on the clinician's interview with the patient and observations of the patient's behavior over the previous 2–3 days. The patient's family can also answer questions on the behavior report. During the initial assessment and the follow-up, both positive and negative symptoms of psychosis can be assessed using the 30 item Positive and Negative Symptom Scale (PANSS). The DSM-5 characterizes disorders as psychotic or on the schizophrenia spectrum if they involve hallucinations, delusions, disorganized thinking, grossly disorganized motor behavior, or negative symptoms. The DSM-5 does not include psychosis as a definition in the glossary, although it defines "psychotic features", as well as "psychoticism" with respect to personality disorder. The ICD-10 has no specific definition of psychosis. The PSQ (Psychosis Screening Questionnaire) is the most common tool in detecting psychotic symptoms and it includes five root questions that assess the presence of PLE (mania, thought insertion, paranoia, strange experiences and perceptual disturbances) The different tools used to assess symptom severity include the Revised Behavior and Symptom Identification Scale (BASIS-R), a 24-item self-report instrument with six scales: psychosis, depression/functioning, interpersonal problems, alcohol/drug use, self-harm, and emotional lability. The Symptom Checklist-90-Revised (SCL-90-R), a 90-item self assessment tool that measures psychoticism and paranoid ideation in addition to seven other symptom scales. Finally, the Brief Symptom Inventory (BSI), a 53-item self-administered scale developed from the SCL-90-R. The BSI has good psychometric properties and is an acceptable brief alternative to the SCL-90-R. These seem to be the most accurate tools at the moment, but a research in 2007 that focused on quantifying self-reports of auditory verbal hallucinations (AVH) in persons with psychosis, suggest that The Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ) is also potentially a reliable and useful measure for specifically quantifying AVHs in relation to psychosis. Factor analysis of symptoms generally regarded as psychosis frequently yields a five factor solution, albeit five factors that are distinct from the five domains defined by the DSM-5 to encompass psychotic or schizophrenia spectrum disorders. The five factors are frequently labeled as hallucinations, delusions, disorganization, excitement, and emotional distress. The DSM-5 emphasizes a psychotic spectrum, wherein the low end is characterized by schizoid personality disorder, and the high end is characterized by schizophrenia. Prevention The evidence for the effectiveness of early interventions to prevent psychosis appeared inconclusive. But psychosis caused by drugs can be prevented. Whilst early intervention in those with a psychotic episode might improve short-term outcomes, little benefit was seen from these measures after five years. However, there is evidence that cognitive behavioral therapy (CBT) may reduce the risk of becoming psychotic in those at high risk, and in 2014 the UK National Institute for Health and Care Excellence (NICE) recommended preventive CBT for people at risk of psychosis. Treatment The treatment of psychosis depends on the specific diagnosis (such as schizophrenia, bipolar disorder or substance intoxication). The first-line treatment for many psychotic disorders is antipsychotic medication, which can reduce the positive symptoms of psychosis in about 7 to 14 days. For youth or adolescents, treatment options include medications, psychological interventions, and social interventions. Medication The choice of which antipsychotic to use is based on benefits, risks, and costs. It is debatable whether, as a class, typical or atypical antipsychotics are better. Tentative evidence supports that amisulpride, olanzapine, risperidone and clozapine may be more effective for positive symptoms but result in more side effects. Typical antipsychotics have equal drop-out and symptom relapse rates to atypicals when used at low to moderate dosages. There is a good response in 40–50%, a partial response in 30–40%, and treatment resistance (failure of symptoms to respond satisfactorily after six weeks to two or three different antipsychotics) in 20% of people. Clozapine is an effective treatment for those who respond poorly to other drugs ("treatment-resistant" or "refractory" schizophrenia), but it has the potentially serious side effect of agranulocytosis (lowered white blood cell count) in less than 4% of people. Most people on antipsychotics get side effects. People on typical antipsychotics tend to have a higher rate of extrapyramidal side effects while some atypicals are associated with considerable weight gain, diabetes and risk of metabolic syndrome; this is most pronounced with olanzapine, while risperidone and quetiapine are also associated with weight gain. Risperidone has a similar rate of extrapyramidal symptoms to haloperidol. Psychotherapy Psychological treatments such as acceptance and commitment therapy (ACT) are possibly useful in the treatment of psychosis, helping people to focus more on what they can do in terms of valued life directions despite challenging symptomology. Metacognitive training (MCT) is associated with reduced delusions, hallucinations and negative symptoms as well as improved self-esteem and functioning in individuals with schizophrenia spectrum disorders. There are many psychosocial interventions that seek to treat the symptoms of psychosis: need adapted treatment, Open Dialogue, psychoanalysis/psychodynamic psychotherapy, major role therapy, soteria, psychosocial outpatient and inpatient treatment, milieu therapy, and cognitive behavioral therapy (CBT). In relation to the success of CBT for psychosis, a randomized controlled trial for a Web-based CBTp (Cognitive Behavioral Therapy for Psychosis) skills program named Coping With Voices (CWV) suggest that the program has promise for increasing access to CBTp. It also associated benefits in the management of distressing psychotic symptoms and improved social functioning. When CBT and the other psychosocial interventions these are used without antipsychotic medications, they may be somewhat effective for some people, especially for CBT, need-adapted treatment, and soteria. Early intervention Early intervention in psychosis is based on the observation that identifying and treating someone in the early stages of a psychosis can improve their longer term outcome. This approach advocates the use of an intensive multi-disciplinary approach during what is known as the critical period, where intervention is the most effective, and prevents the long-term morbidity associated with chronic psychotic illness. Systematic reform Addressing systematic reform is essential to creating effective prevention as well as supporting treatments and recovery for those with psychosis. Waghorn et al. suggest that education interventions can be a building block to support those with psychosis to successfully participate in society. In their study they analyse the relationship between successful education attainment and psychosis. Findings suggest proportionately more school aged persons with psychosis discontinued their education, compared to those without psychosis. Waghorn et al. finds that specialised supported education for those with psychotic disorders can help lead to successful education attainment. Additionally, future employment outcomes are relative to such education attainment. Established approaches to supported education in the US include three basic models, self-contained classrooms, onsite support model and the mobile support model. Each model includes the participation of mental health service staff or educational facility staff in the student's education arrangements. Potential benefits of specialised supported education found from this study include coordination with other service providers (e.g. income support, housing, etc.) to prevent disrupting education, providing specialised career counselling, development of coping skills in the academic environment. These examples provide beneficial ways for people with psychosis to finish studies successfully as well as counter future experiences of psychosis. History Etymology The word psychosis was introduced to the psychiatric literature in 1841 by Karl Friedrich Canstatt in his work Handbuch der Medizinischen Klinik. He used it as a shorthand for 'psychic neurosis'. At that time neurosis meant any disease of the nervous system, and Canstatt was thus referring to what was considered a psychological manifestation of brain disease. Ernst von Feuchtersleben is also widely credited as introducing the term in 1845, as an alternative to insanity and mania. The term stems from Modern Latin psychosis, "a giving soul or life to, animating, quickening" and that from Ancient Greek ψυχή, "soul" and the suffix -ωσις (-), in this case "abnormal condition". In its adjective form "psychotic", references to psychosis can be found in both clinical and non-clinical discussions. However, in a non-clinical context, "psychotic" is a nonspecific colloquialism used to mean "insane". Classification The word was also used to distinguish a condition considered a disorder of the mind, as opposed to neurosis, which was considered a disorder of the nervous system. The psychoses thus became the modern equivalent of the old notion of madness, and hence there was much debate on whether there was only one (unitary) or many forms of the new disease. One type of broad usage would later be narrowed down by Koch in 1891 to the 'psychopathic inferiorities'—later renamed abnormal personalities by Schneider. The division of the major psychoses into manic depressive illness (now called bipolar disorder) and dementia praecox (now called schizophrenia) was made by Emil Kraepelin, who attempted to create a synthesis of the various mental disorders identified by 19th-century psychiatrists, by grouping diseases together based on classification of common symptoms. Kraepelin used the term 'manic depressive insanity' to describe the whole spectrum of mood disorders, in a far wider sense than it is usually used today. In Kraepelin's classification this would include 'unipolar' clinical depression, as well as bipolar disorder and other mood disorders such as cyclothymia. These are characterised by problems with mood control and the psychotic episodes appear associated with disturbances in mood, and patients often have periods of normal functioning between psychotic episodes even without medication. Schizophrenia is characterized by psychotic episodes that appear unrelated to disturbances in mood, and most non-medicated patients show signs of disturbance between psychotic episodes. Treatment Written record of supernatural causes and resultant treatments can be traced back to the New Testament. Mark 5:8–13 describes a man displaying what would today be described as psychotic symptoms. Christ cured this "demonic madness" by casting out the demons and hurling them into a herd of swine. Exorcism is still utilized in some religious circles as a treatment for psychosis presumed to be demonic possession. A research study of out-patients in psychiatric clinics found that 30 percent of religious patients attributed the cause of their psychotic symptoms to evil spirits. Many of these patients underwent exorcistic healing rituals that, though largely regarded as positive experiences by the patients, had no effect on symptomology. Results did, however, show a significant worsening of psychotic symptoms associated with exclusion of medical treatment for coercive forms of exorcism. The medical teachings of the fourth-century philosopher and physician Hippocrates of Cos proposed a natural, rather than supernatural, cause of human illness. In Hippocrates' work, the Hippocratic corpus, a holistic explanation for health and disease was developed to include madness and other "diseases of the mind". Hippocrates writes: Hippocrates espoused a theory of humoralism wherein disease is resultant of a shifting balance in bodily fluids including blood, phlegm, black bile, and yellow bile. According to humoralism, each fluid or "humour" has temperamental or behavioral correlates. In the case of psychosis, symptoms are thought to be caused by an excess of both blood and yellow bile. Thus, the proposed surgical intervention for psychotic or manic behavior was bloodletting. 18th-century physician, educator, and widely considered "founder of American psychiatry", Benjamin Rush, also prescribed bloodletting as a first-line treatment for psychosis. Although not a proponent of humoralism, Rush believed that active purging and bloodletting were efficacious corrections for disruptions in the circulatory system, a complication he believed was the primary cause of "insanity". Although Rush's treatment modalities are now considered antiquated and brutish, his contributions to psychiatry, namely the biological underpinnings of psychiatric phenomenon including psychosis, have been invaluable to the field. In honor of such contributions, Benjamin Rush's image is in the official seal of the American Psychiatric Association. Early 20th-century treatments for severe and persisting psychosis were characterized by an emphasis on shocking the nervous system. Such therapies include insulin shock therapy, cardiazol shock therapy, and electroconvulsive therapy. Despite considerable risk, shock therapy was considered highly efficacious in the treatment of psychosis including schizophrenia. The acceptance of high-risk treatments led to more invasive medical interventions including psychosurgery. In 1888, Swiss psychiatrist Gottlieb Burckhardt performed the first medically sanctioned psychosurgery in which the cerebral cortex was excised. Although some patients showed improvement of symptoms and became more subdued, one patient died and several developed aphasia or seizure disorders. Burckhardt would go on to publish his clinical outcomes in a scholarly paper. This procedure was met with criticism from the medical community and his academic and surgical endeavors were largely ignored. In the late 1930s, Egas Moniz conceived the leucotomy (AKA prefrontal lobotomy) in which the fibers connecting the frontal lobes to the rest of the brain were severed. Moniz's primary inspiration stemmed from a demonstration by neuroscientists John Fulton and Carlyle's 1935 experiment in which two chimpanzees were given leucotomies and pre- and post-surgical behavior was compared. Prior to the leucotomy, the chimps engaged in typical behavior including throwing feces and fighting. After the procedure, both chimps were pacified and less violent. During the Q&A, Moniz asked if such a procedure could be extended to human subjects, a question that Fulton admitted was quite startling. Moniz would go on to extend the controversial practice to humans with various psychotic disorders, an endeavor for which he received a Nobel Prize in 1949. Between the late 1930s and early 1970s, the leucotomy was a widely accepted practice, often performed in non-sterile environments such as small outpatient clinics and patient homes. Psychosurgery remained standard practice until the discovery of antipsychotic pharmacology in the 1950s. The first clinical trial of antipsychotics (also commonly known as neuroleptics) for the treatment of psychosis took place in 1952. Chlorpromazine (brand name: Thorazine) passed clinical trials and became the first antipsychotic medication approved for the treatment of both acute and chronic psychosis. Although the mechanism of action was not discovered until 1963, the administration of chlorpromazine marked the advent of the dopamine antagonist, or first generation antipsychotic. While clinical trials showed a high response rate for both acute psychosis and disorders with psychotic features, the side effects were particularly harsh, which included high rates of often irreversible Parkinsonian symptoms such as tardive dyskinesia. With the advent of atypical antipsychotics (also known as second generation antipsychotics) came a dopamine antagonist with a comparable response rate but a far different, though still extensive, side-effect profile that included a lower risk of Parkinsonian symptoms but a higher risk of cardiovascular disease. Atypical antipsychotics remain the first-line treatment for psychosis associated with various psychiatric and neurological disorders including schizophrenia, bipolar disorder, major depressive disorder, anxiety disorders, dementia, and some autism spectrum disorders. Dopamine is now one of the primary neurotransmitters implicated in psychotic symptomology. Blocking dopamine receptors (namely, the dopamine D2 receptors) and decreasing dopaminergic activity continues to be an effective but highly unrefined effect of antipsychotics, which are commonly used to treat psychosis. Recent pharmacological research suggests that the decrease in dopaminergic activity does not eradicate psychotic delusions or hallucinations, but rather attenuates the reward mechanisms involved in the development of delusional thinking; that is, connecting or finding meaningful relationships between unrelated stimuli or ideas. The author of this research paper acknowledges the importance of future investigation: Freud's former student Wilhelm Reich explored independent insights into the physical effects of neurotic and traumatic upbringing, and published his holistic psychoanalytic treatment with a schizophrenic. With his incorporation of breathwork and insight with the patient, a young woman, she achieved sufficient self-management skills to end the therapy. Lacan extended Freud's ideas to create a psychoanalytic model of psychosis based upon the concept of "foreclosure", the rejection of the symbolic concept of the father. Psychiatrist David Healy has criticised pharmaceutical companies for promoting simplified biological theories of mental illness that seem to imply the primacy of pharmaceutical treatments while ignoring social and developmental factors that are known important influences in the etiology of psychosis. Society and culture Disability The classification of psychosis as a social disability is a common occurrence. Psychosis is considered to be among the top 10 causes of social disability among adult men and women in developed countries. And the traditional, negative narrative around disability has been shown to strongly and adversely influence the pathways through employment and education for people experiencing psychosis. Social disability by way of social disconnection is a significant public health concern and is associated with a broad range of negative outcomes, including premature mortality. Social disconnection refers to the ongoing absence of family or social relationships with marginal participation in social activities. Research on psychosis found that reduced participation in social networks, not only negatively effects the individual on a physical and mental level, it has been shown that failure to be included in social networks influences the individual's ability to participate in the wider community through employment and education opportunities. Equal opportunity to participate in meaningful relationships with friends, family and partners, as well as engaging in social constructs such as employment, can provide significant physical and mental value to people's lives. And how breaking the disability mindset around people experiencing psychosis is imperative for their overall, long-term health and well-being as well as the contributions they are able to make to their immediate social connections and the wider community. Research Further research in the form of randomized controlled trials is needed to determine the effectiveness of treatment approaches for helping adolescents with psychosis. Through 10 randomized clinical trials, studies showed that Early Intervention Services (EIS) for patients with early-phase schizophrenia spectrum disorders have generated promising outcomes. EIS are specifically intended to fulfill the needs of patients with early-phase psychosis. In addition, one meta-analysis that consisted of four randomized clinical trials has examined and discovered the efficacy of EIS to Therapy as Usual (TAU) for early-phase psychosis, revealing that EIS techniques are superior to TAU. A study suggests that combining cognitive behavioral therapy (CBT) with SlowMo, an app that helps notice their "unhelpful quick-thinking", might be more effective for treating paranoia in people with psychosis than CBT alone. References Bibliography Further reading Personal accounts [Semi-autobiographical] External links National Institute of Mental Health 1840s neologisms Wikipedia medicine articles ready to translate

Mentalism

Mentalism is a performing art in which its practitioners, known as mentalists, appear to demonstrate highly developed mental or intuitive abilities. Mentalists perform a theatrical act that includes special effects that may appear to employ psychic or supernatural forces but that are actually achieved by "ordinary conjuring means", natural human abilities (i.e. reading body language, refined intuition, subliminal communication, emotional intelligence), and an in-depth understanding of key principles from human psychology or other behavioral sciences. Performances may appear to include hypnosis, telepathy, clairvoyance, divination, precognition, psychokinesis, mediumship, mind control, memory feats, deduction, and rapid mathematics. Mentalism is commonly classified as a subcategory of magic and, when performed by a stage magician, may also be referred to as mental magic. However, many professional mentalists today may generally distinguish themselves from magicians, insisting that their art form leverages a distinct skillset. Instead of doing "magic tricks", mentalists argue that they produce psychological experiences for the mind and imagination, and expand reality with explorations of psychology, suggestion, and influence. Mentalists are also often considered psychic entertainers, although that category also contains non-mentalist performers such as psychic readers and bizarrists. Some well-known magicians, such as Penn & Teller, and James Randi, argue that a key differentiation between a mentalist and someone who purports to be an actual psychic is that the former is open about being a skilled artist or entertainer who accomplishes their feats through practice, study, and natural means, while the latter may claim to actually possess genuine supernatural, psychic, or extrasensory powers and, thus, operates unethically. Renowned mentalist Joseph Dunninger, who also worked to debunk fraudulent mediums, captured this key sentiment when he explained his impressive abilities in the following way: "Any child of ten could do this – with forty years of experience." Like any performing art, mentalism requires years of dedication, extensive study, practice, and skill to perform well. Background Much of what modern mentalists perform in their acts can be traced back directly to "tests" of supernatural power that were carried out by mediums, spiritualists, and psychics in the 19th century. However, the history of mentalism goes back even further. Accounts of seers and oracles can be found in the Old Testament of the Bible and in works about ancient Greece. Paracelsus reiterated the theme, so reminiscent of the ancient Greeks, that three principias were incorporated into humanity: the spiritual, the physical, and mentalistic phenomena. The mentalist act generally cited as one of the earliest on record in the modern era was performed by diplomat and pioneering sleight-of-hand magician Girolamo Scotto in 1572. The performance of mentalism may utilize conjuring principles including sleights, feints, misdirection, and other skills of street or stage magic. Nonetheless, modern mentalists also now increasingly incorporate insights from human psychology and behavioral sciences to produce unexplainable experiences and effects for their audiences. Changing with the times, some mentalists incorporate an iPhone into their routine. Techniques Principle: sleight of hand and other traditional magicians' techniques Mentalists typically seek to explain their effects as manifestations of psychology, hypnosis, an ability to influence by subtle verbal cues, an acute sensitivity to body language, etc. These are all genuine phenomena, but they are not sufficiently reliable or impressive to form the basis of a mentalism performance. These are in fact fake explanations - part of the mentalist's misdirection - and the true method being employed is classic magicians' trickery. Written "billet" A characteristic feature of "mind-reading" by a mentalist is that the spectator must write the thought down. Various justifications are given for this - in order to enable the spectator to focus on the thought, or in order to show it to other audience members etc. - but the real reason is to enable the mentalist then secretly to access the written-down information. There are various techniques which the mentalist can use. A classic method is the "centre tear". The spectator is asked to commit her thought to writing on a small piece of paper (referred to by mentalists as a "billet"). She is told to write the thought in the centre of the billet, and sometimes a circle or a line will be added by the mentalist onto the billet to make sure she writes in the middle. She is then instructed to fold the billet up so that the writing cannot be seen by the mentalist. The mentalist then takes the billet and tears it into small pieces, which he may then burn or throw away or return to the spectator's hand "for safe-keeping". Secretly, during the tearing process, the mentalist tears out and secretes the centre part of the billet which bears the written thought, and later finds an opportunity to read it covertly. Alternatively the mentalist may covertly peek at the written thought. There are a large number of detailed choreographies used by mentalists to achieve a peek. One popular version - known as the "acidus novus" peek - requires the spectator to write her thought on the bottom right-hand corner of the billet. Typically the mentalist will fill up the other 3 quadrants of the billet with writing so that only the bottom right-hand quadrant is left clear. Once the thought is written and the billet folded, the mentalist will hold the billet up to the light to demonstrate that no writing can be seen through the paper. In the course of this action he is able, unobserved by the audience, to slip his thumb between the folds of the billet and expose a view of the bottom right-hand quadrant. He then gestures with the billet, bringing it at eye-level across his field of vision, and in so-doing is able secretly to peek at the spectator's written thought. This is only one of a number of such peek choreographies. Some involve placing the billet in a gimmicked wallet, which allows the mentalist covertly to see the writing. Others employ sleights of hand derived from card or coin magic. Modern gimmicks In addition to these traditional magicians' techniques, there is today a huge range of electronic, computer and other gimmicks available to the mentalist. These include dice which secretly transmit the numbers thrown, decks of cards which secretly transmit the cards chosen, notepads which secretly transmit what has been written etc. Smartphones have added an additional range of possibilities. For example, the mentalist can use concealed NFC tags to covertly download onto a spectator’s phone a fake version of a popular website such as Google Images, which allows him to know an image which the spectator believes has been chosen secretly. Nail writing and its technological equivalents Where a mind-reading performance does not involve the spectator writing the secret thought down, generally the method employed is that the mentalist purports to predict the secret thought by (apparently) writing an unseen prediction, often behind a clipboard or other hard surface, then he asks the spectator to reveal the thought, and the mentalist at that point quickly and covertly writes or completes his prediction using a nail writer or swami gimmick. These are small devices which allow the mentalist to write unseen with his thumb under cover of a clipboard or in his pocket. Again, these traditional magicians’ devices have now been supplemented by technology. The mentalist can now buy blackboards and whiteboards which are capable of writing (apparently) handwritten messages fed to them remotely, small printers which can print a spectator’s chosen number and feed the printed paper into an (apparently) sealed jar, and a host of other technological gadgets which make it appear that the mentalist predicted the spectator’s thought, when in fact he simply waited for it to be disclosed by the spectator and then created the evidence of his “prediction”. Pre-show work Many mentalism effects rely on pre-show work. This involves the mentalist or his assistant interacting with certain members of the audience before the performance begins. This can be in a pre-show reception, or in the auditorium itself as the audience take their seats, or even in the queue outside the performance venue before the performance. Pre-show work can take a number of forms. One type involves the mentalist talking to a spectator whom he will later, during his performance, involve in one of his effects. In this case the mentalist sets up the trick by covertly obtaining information from the spectator which he will later reveal during the performance. The interaction with the spectator may be made to seem like a casual “meet the audience” conversation, with no warning that the spectator is later to be involved in the performance. Alternatively, the mentalist may tell the spectator that he intends to involve her in his show. In that case the pre-show interaction is usually characterised as preparation “to save time during the show” or similar. Either way, the mentalist will use the occasion to obtain information from the spectator covertly for later revelation, either by traditional sleight of hand methods such as a billet peek, or by using electronic gimmickry such as a Parapad. Alternatively, the mentalist may ask the spectator to make a choice (eg a number, a playing card, a selection from a list of items) and to recall that choice when later asked to participate during the performance. Typically the spectator will believe she has a free choice, but in fact it will be a choice forced by the mentalist, This can be done in a number of ways. One popular method is a proprietary device called a Svenpad. This is a notepad in which every second page is imperceptibly shorter. The long pages each have written on them an item from a list of choices (eg film stars, holiday destinations etc), but the short pages each have the same item - the force choice - written on them. When riffled from front to back only the long pages are visible, showing the full range of different choices. But when riffled from back to front only the short pages are visible, each bearing the force selection. Other forcing methods include trick decks of cards, where all the cards are the same. During the performance itself, when the mentalist involves the spectator in his effect, he will usually aim by careful use of language to avoid any mention of the pre-show interaction to the wider audience, either by himself or the chosen spectator. His aim is to suggest that he and the spectator have not previously met. When the spectator’s covertly obtained information or forced choice is revealed, this greatly enhances the effect from the point of view of the wider audience. It will usually seem that the mentalist has elicited a wholly uncommunicated thought from a random audience member. The chosen spectator herself, having participated in the pre-show encounter, perceives a different and less spectacular effect. This is an example of dual reality (discussed below) in mentalism. Suggestion This technique involves implanting an idea, thought, or impression in the mind of the spectator or participant. The mentalist does this by using subtle verbal cues, gestures, body language, and sometimes visual aids to influence their thoughts. For instance, asking someone to "think of any card in a normal deck" automatically plants the general idea of a playing card in their mind. Similarly, asking them to "visualize the card clearly in your mind" can put the image of a particular card in their imagination. Misdirection Also known as diversion, this technique aims to divert the audience's attention away from the secret method or process behind a mentalism effect. Magicians and mentalists frequently use grand gestures, animated movement, music, and chatter to distract attention from a sneaky maneuver that sets up the trick. For example, a mentalist may engage in lively conversation while secretly writing something on his palm. Or he may dramatically throw his jacket on a chair to cover up a hidden assistant in the audience. Cold reading This technique involves making calculated guesses and drawing logical conclusions about a person by carefully observing their appearance, responses, mannerisms, vocal tones, and other unconscious reactions. Mentalists leverage these cues along with high probability assumptions about human nature to come up with surprisingly accurate character insights and details about someone. They can then present this as if they magically knew the information through psychic powers. Hot reading Hot reading refers to the practice of gathering background information about the audience or participants before doing a mentalism act or seance. Mentalists can then astonish spectators by revealing something they could not possibly have known otherwise. However, doing hot readings without informing the audience is considered unethical. Ethical mentalists only do hot readings if they explicitly disclose it, or do it for entertainment with the participant's consent. Psychological manipulation Master mentalists have an in-depth understanding of human psychology which allows them to subtly manipulate thoughts, emotions, and behaviors. They use verbal suggestion, social pressure, visual cues and mental framing to influence perceptions and reactions. This lets them guide participants towards the responses, outcomes or choices they want. For instance, a mentalist may hint that choosing a certain number will lead to something positive. Dual reality This principle involves structuring a routine to present different experiences to the observer versus the participant. For example, a mentalist may have an audience member pick a "random" card that is actually forced by the mentalist's assistant. The participant believes they freely chose any card, while the audience knows it's manipulated. Subtle artistry The most skilled mentalists ensure their performances seem completely natural, organic and unrehearsed even though they are carefully planned. They structure their acts, patter and effects to come across as pure luck, coincidence or chance rather than as clever illusions or tricks. This 'invisible' artistry maintains the mystique around mentalist performances. Performance approaches Styles of mentalist presentation can vary greatly. In this vein, Penn & Teller explain that "[m]entalism is a genre of magic that exists across a spectrum of morality." In the past, at times, some performers such as Alexander and Uri Geller have promoted themselves as genuine psychics. Some contemporary performers, such as Derren Brown, explain that their results and effects are from using natural skills, including the ability to master magic techniques and showmanship, read body language, and influence audiences with psychological principles, such as suggestion. In this vein, Brown explains that he presents and stages "psychological experiments" through his performances. Mentalist and psychic entertainer Banachek also rejects that he possesses any supernatural or actual psychic powers, having worked with the James Randi Educational Foundation for many years to investigate and debunk fake psychics. He is clear with the public that the effects and experiences he creates through his stage performance are the result of his highly developed performance skills and magic techniques, combined with psychological principles and tactics. Max Maven often presented his performances as creating interactive mysteries and explorations of the mysterious dimensions of the human mind. He is described as a "mentalist and master magician" as well as a "mystery theorist." Other mentalists and allied performers also promote themselves as "mystery entertainers". There are mentalists, including Maurice Fogel, Kreskin, Chan Canasta, and David Berglas, who make no specific claims about how effects are achieved and may leave it up to the audience to decide, creating what has been described as "a wonderful sense of ambiguity about whether they possess true psychic ability or not." Contemporary mentalists often take their shows onto the streets and perform tricks to a live, unsuspecting audience. They do this by approaching random members of the public and ask to demonstrate so-called supernatural powers. However, some performers such as Derren Brown who often adopt this method of performance tell their audience before the trick starts that everything they see is an illusion and that they are not really "having their mind read." This has been the cause of a lot of controversy in the sphere of magic as some mentalists want their audience to believe that this type of magic is "real" while others think that it is morally wrong to lie to a spectator. Distinction from magicians Professional mentalists generally do not mix "standard" magic tricks with their mental feats. Doing so associates mentalism too closely with the theatrical trickery employed by stage magicians. Many mentalists claim not to be magicians at all, arguing that it is a different art form altogether. The argument is that mentalism invokes belief and imagination that, when presented properly, may allow the audience to interpret a given effect as "real" or may at least provide enough ambiguity that it is unclear whether it is actually possible to somehow achieve. This lack of certainty about the limits of what is real may lead individuals in an audience to reach different conclusions and beliefs about mentalist performers' claims – be they about their various so-called psychic abilities, photographic memory, being a "human calculator", power of suggestion, NLP, or other skills. In this way, mentalism may play on the senses and a spectator's perception or understanding of reality in a different way than conjuring techniques utilized in stage magic. Magicians often ask the audience to suspend their disbelief, ignore natural laws, and allow their imagination to play with the various tricks they present. They admit that they are tricksters from the outset, and they know that the audience understands that everything is an illusion. Everyone knows that the magician cannot really achieve the impossible feats shown, such as sawing a person in half and putting them back together without injury, but that level of certainty does not generally exist among the mentalist's audience. Still, other mentalists believe it is unethical to portray their powers as real, adopting the same presentation philosophy as most magicians. These mentalists are honest about their deceptions, with some referring to this as "theatrical mentalism". However, some magicians do still mix mentally-themed performance with magic illusions. For example, a mind-reading stunt might also involve the magical transposition of two different objects. Such hybrid feats of magic are often called mental magic by performers. Magicians who routinely mix magic with mental magic include David Copperfield, David Blaine, The Amazing Kreskin, and Dynamo. Notable mentalists Lior Suchard The Amazing Kreskin Uri Geller Joseph Dunninger Derren Brown Alexander Theodore Annemann Banachek Keith Barry Guy Bavli David Berglas Nixon Pulladan Paul Brook Akshay Laxman Chan Canasta Bob Cassidy The Clairvoyants Corinda Anna Eva Fay Glenn Falkenstein Maurice Fogel Haim Goldenberg Burling Hull Al Koran Nina Kulagina Max Maven Gerry McCambridge Alexander J. McIvor-Tyndall Wolf Messing Alain Nu Marc Paul Richard Osterlind The Piddingtons Oz Pearlman Princess Mysteria Marc Salem The Zancigs Historical figures Mentalism techniques have, on occasion, been allegedly used outside the entertainment industry to influence the actions of prominent people for personal and/or political gain. Famous examples of accused practitioners include: Erik Jan Hanussen, alleged to have influenced Adolf Hitler Grigori Rasputin, alleged to have influenced Tsaritsa Alexandra Wolf Messing, alleged to have influenced Joseph Stalin Count Alessandro di Cagliostro, accused of influencing members of the French aristocracy in the Affair of the Diamond Necklace In Albert Einstein's preface to Upton Sinclair's 1930 book on telepathy, Mental Radio, he supported his friend's endeavor to test the abilities of purported psychics and skeptically suggested: "So if somehow the facts here set forth rest not upon telepathy, but upon some unconscious hypnotic influence from person to person, this also would be of high psychological interest." As such, Einstein here alluded to techniques of modern mentalism. In popular culture See also Cold reading Memory sport Mnemonist Scientific skepticism Thirteen Steps To Mentalism The Mentalist Muscle memory References Further reading H. J. Burlingame. (1891). Mind-Readers and Their Tricks. In Leaves from Conjurers' Scrap books: Or, Modern Magicians and Their Works. Chicago: Donohue, Henneberry & Co. pp. 108–127 Derren Brown (2007). Tricks of the Mind. Transworld Press. United Kingdom. Steve Drury (2016). Beyond Knowledge. Drury. Max Maven (1992). Max Maven's Book of Fortunetelling. Prentice Hall General; 1st edition. William V. Rauscher. (2002). Mind Readers: Masters of Deception. Mystic Light Press. Barry H. Wiley. (2012). The Thought Reader Craze: Victorian Science at the Enchanted Boundary. McFarland. External links

The Mask of Sanity

The Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic Personality is a book written by American psychiatrist Hervey M. Cleckley, first published in 1941, describing Cleckley's clinical interviews with patients in a locked institution. The text is considered to be a seminal work and the most influential clinical description of psychopathy in the twentieth century. The basic elements of psychopathy outlined by Cleckley are still relevant today. The title refers to the normal "mask" that conceals the mental disorder of the psychopathic person in Cleckley's conceptualization. Cleckley describes the psychopathic person as outwardly a perfect mimic of a normally functioning person, able to mask or disguise the fundamental lack of internal personality structure, an internal chaos that results in repeatedly purposeful destructive behavior, often more self-destructive than destructive to others. Despite the seemingly sincere, intelligent, even charming external presentation, internally the psychopathic person does not have the ability to experience genuine emotions. Cleckley questions whether this mask of sanity is voluntarily assumed to intentionally hide the lack of internal structure, but concludes it hides a serious, but yet imprecisely unidentified, semantic neuropsychiatric defect. Six editions of the book were produced in total, the final shortly after his death. An expanded fifth edition of the book had been published in 1976 and was re-released by his heirs in 1988 for non-profit educational use. History In the 1800s, Philippe Pinel first used the French term manie sans delire ("mania without delirium") to designate those individuals engaging in deviant behavior but exhibiting no signs of a cognitive disorder such as hallucinations or delusions. Although the meaning of the term has changed through numerous writings on the subject over time, the writing of Cleckley and his use of the label "psychopath" in The Mask of Sanity brought the term into popular usage. Editions The first edition was published in 1941, with the subtitle then being 'An attempt to re-interpret' rather than as later 'to clarify'. Cleckley says in the preface that the book "grew out of an old conviction which increased during several years while I sat at staff meetings in a large neuropsychiatric hospital". He added that after commencing full-time teaching duties he found similar patients to be as prevalent in a general hospital, outpatient clinic and the community. In later editions he explains that the basic concepts presented in 1941 were based primarily on "adult male psychopaths hospitalized in a closed institution" for several years. Cleckley had worked for a number of years at a United States Veterans (military) Administration hospital, before taking up full-time teaching responsibilities at the University of Georgia School of Medicine. The second edition published in 1950, Cleckley has described as a "new and much larger book", based on more diverse clinical observations, feedback and literature reviews. The third edition in 1955 he describes as having fewer changes and additions, but important clarifications to key concepts such as the hypothesis of a core semantic deficit. A fourth edition was published in 1964. A fifth edition was published in 1976 and is generally considered to be the definitive culmination of Cleckley's work. The preface does not specify the changes made. Unlike the first edition it states: "Dr. Corbett H. Thigpen, my medical associate of many years, has played a major part in the development and the revision of this work." Cleckley also states that it could not have been written without the assistance and contributions of Thigpen's wife and his own (first), both called Louise. A sixth edition was published shortly after Cleckley's death in 1984, but is described by others as having minimal substantive changes. Several further years after Cleckley's death, another fifth edition was released for non-profit educational use by Emily S. Cleckley, his second wife, naming her as well as Hervey M. Cleckley and copyrighted 1988 to her rather than Mosby as for all prior initial releases (which have been repeat published in various different years). Description The Mask of Sanity, fifth edition, presents clinical theories as well as case studies, written in the form of dramatic, novelistic descriptions of 13 individuals, an amalgamation of those he had observed. Initial outline The Mask of Sanity begins in Section One, "An Outline of the Problem", by considering the concept of sanity, which Cleckley describes as protean. The first words of the book are a possibly untrue anecdote ending with the line, capitalized and centered in large font, "WHO'S LOONEY NOW?" Cleckley suggests that everyone "behaves at times with something short of complete rationality and good judgment". He notes that many types of people hold beliefs that he and much of society would consider irrational, such as mysticism, pseudoscience, praising of unintelligible or immoral works (e.g. acclaim for the novel Finnegans Wake containing only "erudite gibberish" or for the writing of André Gide on pederasty), and religious faith. He argues, however, that these are personal freedoms and such groups are usually capable of leading useful lives in harmony with others. This he says distinguishes it from psychosis once fully developed and from psychopathy. Classification schemes Cleckley also addresses the confusing traditions of classification in the area of psychopathy, a term he admits is itself confusing and not being used in line with its etymological meaning ('mental sickness'), though adopts it as the most familiar and apparently durable. He considers the terms sociopathic personality and antisocial personality, as adopted by the Diagnostic and Statistical Manual of Mental Disorders; the relationship to the overall category of personality disorder; and the earlier widespread concept of "constitutional psychopathic inferiority", disputing its hereditary assumptions. He states that the main purpose of the book is to bring a few cases before other psychiatrists, and also to raise the profile among the public, to enable better management of psychopaths. He criticizes the 'doctrine of permissiveness', and refers with regret to the lack of prominence of psychopathy in psychiatric textbooks. Prevalence Cleckley argues under a subsection titled "Not as single spies but in battalions" (a phrase appearing in Hamlet), that although reliable statistics are hard to come by, there are various reasons to suspect both psychiatric and prison admission rates are an underestimate, and the incidence of the condition is in his opinion "exceedingly high". He does present some statistics from a survey whereby he and nine other psychiatrists diagnosed 1/8th of patients as having psychopathic personality without any other mental disorder that might explain the condition, and considers that quite a few others classified as alcoholic or drug addicted would actually have qualified too. Their survey is further detailed in the book's appendix, where Cleckley clarifies it took place between 1937 and 1939 at a federal Veterans Administration hospital, located on the Southeastern seaboard, for the care of ex-service men, mainly from World War I. He critiques the 'benign policy' of the VA of not diagnosing more psychopathic personality due to giving the benefit of the doubt to issues such as neurasthenia, hysteria, psychasthenia, posttraumatic neuroses, or cerebral trauma from skull injuries and concussions. He concludes they have "records of the utmost folly and misery and idleness over many years" and if considering the number in every community who are protected by relatives, "the prevalence of this disorder is seen to be appalling." Method Finally, Cleckley asserts that the account provided in his book will accord with the scientific method, as pointed out by Karl Pearson in The Grammar of Science, which he loosely summarizes as: to record observed facts; group them together by correlation as distinguished from other facts; to try to summarize or explain in a way that indicates the significance. He also says his method takes inspiration from that used in an earlier work, The Psychology of Insanity, by English physician Bernard Hart (First edition published in 1912 and now open access.). Characteristics In Section Two, "The Material", Cleckley presents a typical "full" psychopath's behavior in a series of 15 vignettes (originally nine in the first edition, and all male). For example, the psychopath can typically tell vivid, lifelike, plausible stories that are completely fraudulent, without evincing any element of delusion. When confronted with a lie, the psychopath is unflappable and can often effortlessly pass it off as a joke. In another typical case history, the psychopath is hospitalized for psychiatric treatment but because of his constant trouble-making, leaving wards in an uproar, the hospital is finally forced to turn him over to the police. Eventually, the police become so sick of his repeated antics that they try to hospitalize him again. Also included are six vignettes of "Incomplete manifestations or suggestions of the disorder" in non-patients, such as "The businessman", "The gentleman" or "The physician". Differentiation In Section Three, 'Cataloging the material', Cleckley continues the conceptual outline started in Section One, now termed 'Orientation'. He criticises the tenets of faculty psychology (now known as modularity of mind), arguing that such things as intelligence, morality and emotions are not separate parts in the brain but separate concepts we apply. He believes psychopaths would have been included in the 19th century concepts of 'mania without insanity' by Philippe Pinel and Prichard's moral insanity, but rejects their faculty basis. He notes the confusingly broad literal meaning and practical usage of the terms psychopathic personality or personality disorder, giving the example of the most authoritative textbook of the second quarter of the century, Psychopathic Personalities, by German psychiatrist Eugen Kahn. He rails against the counterculture antihero and gives as an example the novelist Alan Harrington for suggesting a socially necessary role for psychopathy in modern times, calling the idea "perverse and degenerate". He also criticizes Freudian-inspired ideas about antisocial acts being caused by unconscious guilt. He also disagrees with theories of neurotic, emotional or paranoid problems in subtypes of psychopathy, as in his concept there is always a relative or complete lack of this. He says the new DSM "personality disorder, antisocial type" offers an accurate term equivalent to psychopathy which he thinks will also continue as a term for a long time. Psychosis Cleckley then considers how schizophrenia is different from psychopathy, having a defect in theoretical reasoning. He notes that schizoid disorders may appear more similar, and might be more accurately called "masked schizophrenia", which he notes can sometimes be difficult to differentiate from psychopathy. He also notes other 'disguises' of severe personality disorder, such as "cryptic depression" or "pseudoneurotic schizophrenia" or "pseudopsychopathic schizophrenia". He finds the diagnosis of "psychosis with psychopathic personality" unnecessarily confusing. He declares, "There is little point in devoting space to detailed accounts of paranoid or cyclothymic personalities." In the first edition Cleckley described his psychopathic patients as "frankly and unquestionably psychotic", but modified this in later editions. In the fifth edition he describes long ago changing his opinion and now agreeing with the psychiatrist Richard L. Jenkins that this would stretch the definition of psychosis too far. However at various other points it is still suggested that, despite "traditional" classification, the extent of the inner abnormality and associated dysfunction in psychopathy is such that it might be considered a psychosis in many respects. Criminality Cleckley draws important distinctions between the psychopath and non-psychopathic criminal. He states that the psychopath very seldom takes much advantage of any gain, has an obscure or inconsistent purpose, usually puts himself unnecessarily in a shameful position as much as causing trouble for others; and usually does not commit the most serious or violent crimes, but usually does end up harming himself. However, despite the general picture of weak-willed and inconsistent antisocial behavior, he also states, at least in later editions, that some may develop drives towards the most serious or sadistic crimes. He suggests this is a somewhat separate additional pathology but does not explain why or how. Cleckely considers that the concept of delinquency has much in common with his concept of psychopathy, and argues that it could be considered a mild version if it continues for a long time and is generalized. He notes that many respectable mature productive citizens can look back on short periods of unprovoked social misconduct, including such things as property damage, racism, bestiality, voyeurism, rebellion, and promiscuity. On the other hand, he notes prolonged but prescribed behavioral disorder in the case of a woman who remained for some time "irrationally promiscuous and bisexual", but who had plausible psychological reasons for her behavior and was otherwise functional in her work and life. He also notes he no longer considers that homosexuality should be classed as sexual psychopathy, on the grounds that many homosexuals seem to be able to live productive lives in society. He considers that sexual fetishes are not particularly consistent with psychopaths, as the latter tend to have weak drives. He then states that psychopathy can be associated with particular sadistic drives and often be responsible for the most serious sex crimes. Other conditions He distinguishes psychopaths from non-psychopathic alcoholics, who by contrast have a purpose for drinking such as to avoid reality, and may want and try to change, whereas the psychopath appears to drink simply to behave outrageously and get into trouble. He also separates psychoneurotics (though accepts there may sometimes be overlap) and "mental defectives" (who unlike the psychopath will test poorly on theoretical intelligence tests as well as in behavior in life). The psychopath does not suffer from any obvious mental disorder but in the end seems to deliberately court failure and disaster for no obvious reason and despite intelligence, in what Cleckley calls a social and spiritual suicide. Cleckley then considers whether psychopathy may be erratic genius. In surveying some noted literary works embodying what he describes as "malignantly perverse attitudes", such as by Paul Verlaine, Dostoevski, Marquis de Sade, Baudelaire and Swinburne (some associated with the Decadent movement), he suggests that it might be a form of psychopathy, and might appeal to similarly disordered people or to "new cults of intellectual defeatists and deviates" such as certain avant garde groups. However he concludes that such artworks and sexual deviations are more likely due to schizoid disorder with misanthropy and life perversion, whereas the "true psychopath" would not labor to produce art extolling pathologic or perverse attitudes; on the contrary, they would tend to superficially proclaim belief in a normal, moral life. However, Cleckley then suggests that initial potential for greatness and emotional depth may cause problems, such as being more affected by problems in life, that then leads into psychopathy. Fiction and ancient history Cleckley then surveys numerous characters in fictional works that he considers to be portrayals of psychopathy. He concludes by addressing figures in history, excluding Adolf Hitler and others from his definition but highlighting Alcibiades, a military general and politician in Ancient Greece. He describes a fascination with him growing out an old conviction in the "paradoxical" nature of his life, since learning of it in high school. He concludes that Alcibiades "had the gift of every talent except that of using them consistently to achieve any sensible aim or in behalf of any discernible cause" and he "may have been a spectacular example of...the psychopath", that "still inexplicable pattern of human life". Profile Cleckley then summarizes the material and provides a 'clinical profile', describing 16 behavioral characteristics of a psychopath (reduced from 21 in the first edition): Superficial charm and good intelligence Absence of delusions and other signs of irrational thinking Absence of nervousness or psychoneurotic manifestations Unreliability Untruthfulness and insincerity Lack of remorse and shame Inadequately motivated antisocial behavior Poor judgment and failure to learn by experience Pathologic egocentricity and incapacity for love General poverty in major affective reactions Specific loss of insight Unresponsiveness in general interpersonal relations Fantastic and uninviting behavior with drink and sometimes without Suicide threats rarely carried out Sex life impersonal, trivial, and poorly integrated Failure to follow any life plan. Some of the criteria have obvious psychodynamic implications, such as a lack of remorse, poor judgment, failure to learn from experience, pathological egocentricity, lack of capacity for love, a general poverty in major affective reactions, and lack of insight into his own condition. Starting in 1972, newer editions of the book reflected a closer alliance with Kernberg's (1984) borderline level of personality organization, specifically defining the structural criteria of the psychopath's identity integration, defensive operations and reality testing. Pathology and causes In Section Four, "Some Questions Still Without Answers", Cleckley discusses his concept of "semantic" dementia (used today to refer to a medical disorder unconnected to Cleckley's meaning) or, in later editions, semantic disorder or deficit. He referred to a hypothesized neurological condition which would be the underlying pathology linking together and explaining all the different personalities classed as psychopathy by Cleckley. By semantic he meant the ability to emotionally experience or understand "the meaning of life as lived by ordinary people". He acknowledged there was no proof or even evidence that this was the underlying condition, but believed that it helped explain the traits and behaviors he observed. As an example to explain the kind of distinction he was drawing between an ability to appear superficially normal despite a core deficit in meaning, he made an analogy to a neurological language disorder known as semantic aphasia. Cleckley concludes from his clinical experience that the cause of the disorder of psychopathy is probably not, in general, demonstrably psychodynamic or even psychogenic, although life influences may play a role in some cases and he notes the progression of the disorder can seem like a kind of social and spiritual (but not actual) suicide, or "semi-suicide". He suggests rather that a subtle yet profound defect at a fundamental biological level, probably inborn in some sense but not hereditary (gives the example of agenesis of the embryo) could be the main cause. He admits "This, too, is still a speculative concept and is not supported by demonstrable evidence." Having called it a defect, he notes that it would be "one that affects complex mechanisms of integration in a subtle and abstruse manner", and as such could actually sometimes be a positive trait or ability which could nevertheless end up bringing about personal problems in society. Treatment or control Cleckley writes in the fifth edition that he remains, since before the first edition, profoundly struck both by the lack of response to treatment of those he classes as psychopathic, and by the legal difficulty of trying to detain them in hospital. While noting the issue of the protection of liberty, he argues that better ways must be found to do the latter for their own good and that of society, on the primary basis of demonstrated disability and need, perhaps within psychiatric units but segregated from other patients. He notes that neither psychological therapy or physical methods such as shock therapy or lobotomy appear to be a real solution to the problem, but suggests that more opportunity to control and direct the person may help psychiatrists treat them in the long-run. He also considers the issue of competency hearings and the insanity defense when crimes are committed. He expresses concern that his prior equating of psychopathy with psychosis was not intended to imply that psychopaths should be automatically found not guilty. However he also expresses dissatisfaction with sending psychopaths to prison which he believes will inevitably fail to correct the behaviour due to the underlying abnormality or masked 'insanity'. Reception and legacy Cleckley's work is often considered a seminal contribution to the psychiatric definition of psychopathy, and continues to act as a cornerstone to subsequent lines of research and clinical practice. The label "psychopath" as used by Cleckley has also been embraced by popular culture, and is often applied to serial killers and other violent criminals, irrespective of whether they qualify; for this reason the imprecise popular use had been deplored. Therefore, although in popular culture the term is common, that usage has little technical relevance to criminology, forensic psychology or psychiatry. However, Robert D. Hare, a psychologist working in criminology, developed an influential Psychopathy Checklist based on the psychopath construct developed by Cleckley. Later two items were removed from the checklist in order to more clearly represent the structure of a two-factor analysis. Grandiosity, impulsivity and juvenile delinquency were not in Cleckley's criteria but were put into Hare's, who left out Cleckley's core criteria of no significant irrational thinking or anxiety. Hare has written that The Mask of Sanity has such detailed and complex descriptions and speculations that it can support a variety of different interpretations. He suggests it is necessary to interpret it with supporting evidence, though notes that it has virtually no empirical data to enable this. There has been continued disagreement about the extent to which Cleckley's concept of psychopathy is antisocial or criminal. Some point out that the core personality was not described by Cleckley as usually particularly hostile or aggressive, unlike in Hare's later concept. Others point out that persistent antisocial behavior was considered characteristic, and "Without exception, all the individuals represented in his case histories engage in repeated violations of the law—including truancy, vandalism, theft, fraud, forgery, fire-setting, drunkenness and disorderly conduct, assault, reckless driving, drug offences, prostitution, and escape." Some researchers have concluded from a convergence of findings that Cleckley's concept is probably not a distinct clinical entity, although may represent one important dimension of personality disorder, and has failed to clarify the field in the way he hoped. Criticisms include that his work was scientifically limited, biased by social value judgments, that there has been a failure to distinguish the hypothesized emotional deficit from that associated with other disorders and to evidence its hypothesized semantic nature or neurological basis, or to put it in the context of any theory of motivation. One early psychoanalytic reviewer described the Cleckley's viewpoint as presenting a paradox, in that his "keen clinical observations" were not integrated into a meaningful psychological model. Cleckley questions the usefulness of psychoanalytic approaches, while at the same time he uses some psychoanalytic explanatory concepts. The rich clinical detail is not developed into a systematic psychological theory. Perri and Lichtenwald have argued that Cleckley was blinded by cultural myths about male aggression and female innocence, and thus tended to overlook or minimize psychopathic behaviors in women. The committee for the 1980 DSM-III, in attempting to develop a basis for the antisocial personality disorder diagnosis, had made efforts to combine the work of Lee Robins's 1966 criteria (actually from Eli Robins) of behavioral acts, with trait-oriented items based on the work of Cleckley. The compromise was to list the behaviors as the actual diagnostic criteria, but cover Cleckley's core traits in the "associated features" text description. Somewhat paradoxically, Cleckley regarded the DSM category as equivalent to his concept of psychopathy, while Hare considers his concept, which was based on Cleckley's, to be different from the DSM since the third version and to be more similar to the ICD's continuing category of "Dissocial Personality Disorder". In the DSM-V this is now a "psychopathy specifier", for antisocially disordered persons who are particularly lacking in anxiety and who have a bold style. See also American Psycho One Flew Over the Cuckoo's Nest Snakes in Suits: When Psychopaths Go to Work The Mind of Adolf Hitler Notes References External links Semi-Suicides Time Magazine, 1941 (requires subscription) – Cleckley's semantic dementia 1941 non-fiction books Books about psychopathy

Management of borderline personality disorder

The mainstay of management of borderline personality disorder is various forms of psychotherapy with medications being found to be of little use. Psychotherapy There has traditionally been skepticism about the psychological treatment of personality disorders, but several specific types of psychotherapy for BPD have developed in recent years. There is growing evidence for the role of psychotherapy in the treatment of people with BPD, with indications that both comprehensive and non-comprehensive psychotherapeutic interventions may have a beneficial effect. Supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD. Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years. Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD, though drop-out rates may be problematic. Dialectical behavioral therapy University of Washington psychology professor Marsha Linehan is credited with developing the first empirically supported standard treatment for BPD, termed dialectical behavioral therapy (DBT). DBT grew dramatically in popularity among mental health professionals following the publication of Linehan's treatment manuals for DBT in 1993. DBT was originally developed as an intervention for patients who meet criteria for BPD and particularly those who are highly suicidal. DBT draws its principles from behavioral science (including cognitive-behavioral techniques), dialectical philosophy and Zen practice. The treatment emphasizes balancing acceptance and change (hence dialectic), with the overall goal of helping patients not just survive but build a life worth living. Treatment is delivered in four stages, with self-harm and other life-threatening issues taking priority. In the second stage, patients are encouraged to experience the painful emotions that they have been avoiding. Stage three addresses problems of living such as career and marital problems. Finally, stage four focuses on helping clients feel complete and reducing feelings of emptiness and boredom. DBT encompasses four modes of therapy: The first mode is traditional individual therapy between a single therapist and client. The second mode of therapy is skills training; a core component of DBT is learning new behavioral skills, including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skill), coping adaptively with distress and crises, and identifying and regulating emotional reactions. The third mode of therapy used is skills generalization, which focuses on helping clients integrate the skills taught in DBT into real-life situations. This usually involves coaching in the form of telephone contact outside of normal therapy hours. The calls are usually brief interactions focused on helping clients apply specific skills to circumstances they are experiencing. The fourth mode of therapy is the use of a consultation team designed to support the therapists. These teams have several important functions including reducing therapist burnout, providing therapy for the therapists, improving empathy for clients and providing ongoing consultations for client difficulties. The goal of all DBT treatment approaches is to reduce the ineffective action tendencies linked to dysregulated emotions. DBT is based on a biosocial theory of personality functioning in which the core problem is seen as the breakdown of the patient's cognitive, behavioral and emotional regulation systems when experiencing intense emotions. The etiology of BPD is seen as a biological predisposition toward emotional dysregulation combined with a perceived invalidating social environment. DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient. Several random controlled trials comparing DBT to other forms of cognitive-behavioral treatments have favored the use of DBT to treat borderline patients. Specifically, DBT has been found to significantly reduce self-injury, suicidal behavior, impulsivity, self-rated anger and the use of crisis services among borderline patients. These reductions have been found even when controlling for other treatment factors such as therapist experience, affordability of treatment, gender of therapist and the number of hours spent in individual therapy. In a meta-analysis it was found that DBT was moderately effective. However, none of the studied therapies (including CBT) "fulfilled the criteria for empirically supported treatment." The additional efficacy in the overall treatment of BPD is less clear; future research is needed to isolate the specific components of DBT that are most effective in treating BPD. Furthermore, little research has examined the efficacy of DBT in treating male and minority patients with BPD. Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook. Schema therapy Schema therapy (also called schema-focused therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with object relations and gestalt approaches. It directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy and traumatic childhood experiences. It was developed by Jeffrey Young and became established in the 1990s. Limited recent research suggests it is significantly more effective than transference-focused psychotherapy, with half of individuals with borderline personality disorder assessed as having achieved full recovery after four years, with two-thirds showing clinically significant improvement. Another very small trial has also suggested efficacy. Cognitive behavioral therapy Cognitive behavioral therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year. Psychoanalysis It is in the DSM-IV that the term took two orientations: one psychiatric, and the other behavioral, included in a psychoanalytic psychopathology. According to this split, the diagnosis takes on, or a character of symptoms to be eradicated, or a particular type of patient of psychoanalysts. Psychodynamic psychotherapy generally Psychodynamic psychotherapy (PP) are different types of psychotherapy derived from psychoanalysis. The duration of psychodynamic psychotherapy ranges from 10 to 25 sessions (short term psychodynamic psychotherapy) to over 200 sessions. The main emphasis of these measures are very different. Similar treatment principles mainly focus on one or several target problems by using the foundation of modern psychoanalytic theory. Results of meta-analysis show that psychodynamic psychotherapy has large effects in the treatment of personality disorders. The results indicate that psychodynamic psychotherapy causes long term changes in personality disorders. Transference-focused psychotherapy Transference-focused psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of Otto Kernberg on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP. In session the therapist works on the relationship between the patient and the therapist. The main focus is on the patient's emotions concerning their relationship with the therapist and the therapist's use of psychodynamic techniques (e.g., interpretation). The therapist will try to explore and clarify aspects of this relationship so the underlying object relations dyads become clear. Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes, and that TFP in comparison to dialectical behavioral therapy and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure attachment style. Furthermore, TFP has been shown to be as effective as DBT in improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior. Limited research suggests that TFP appears to be less effective than schema-focused therapy, while being more effective than no treatment. Cognitive analytic therapy Cognitive analytic therapy combines cognitive and psychoanalytic approaches and has been adapted for use with individuals with BPD with mixed results. Mentalization-based treatment Mentalization-based treatment, developed by Peter Fonagy and Antony Bateman, rests on the assumption that people with BPD have a disturbance of attachment due to problems in the early childhood parent-child relationship. Fonagy and Bateman hypothesize that inadequate parental mirroring and attunement in early childhood lead to a deficit in mentalization, "the capacity to think about mental states as separate from, yet potentially causing actions"; in other words the capacity to intuitively understand the thoughts, intentions and motivations of others, and the connections between one's own thoughts, feelings and actions. Mentalization failure is thought to underlie BPD patients' problems with impulse control, mood instability and difficulties sustaining intimate relationships. Mentalization based treatment aims to develop patients' self-regulation capacity through a psychodynamically informed multi-modal treatment program that incorporates group psychotherapy and individual psychotherapy in a therapeutic community, partial hospitalization or outpatient context. In a randomized controlled trial, a group of BPD patients received 18 months of intensive partial-hospitalization MBT followed by 18 months of group psychotherapy, and were followed up over five years. The treatment group showed significant benefits across a range of measures including number of suicide attempts, reduced time in hospital and reduced use of medication. Marital or family therapy Marital therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family therapy or family psychoeducation can help educate family members regarding BPD, improve family communication and problem solving, and provide support to family members in dealing with their loved one's illness. Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from overinvolved families are often actively struggling with a dependency issue by denial or by anger at their parents. Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing. Medication The UK's National Institute for Health and Clinical Excellence (NICE) in 2009 advises against the use of medication for treating borderline personality disorder, recommending that they only be considered for comorbid conditions. A Cochrane review from 2006 arrived at the same conclusion, but a 2010 update found that some pharmacological interventions (second generation antipsychotics, mood stabilisers and dietary supplementation with omega 3 fatty acids) might provide beneficial effects. However, the authors warned that total BPD severity is not significantly influenced by any drug and that the evidence generated by the review was based on single study effect estimates. No promising results were available for the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment. Antidepressants Selective serotonin reuptake inhibitor (SSRI) antidepressants have been shown in randomized controlled trials to improve the attendant symptoms of anxiety and depression, such as anger and hostility, associated with BPD in some patients. According to Listening to Prozac, it takes a higher dose of an SSRI to treat mood disorders associated with BPD than depression alone. It also takes about three months for benefit to appear, compared to the three to six weeks for depression. Antipsychotics The newer atypical antipsychotics are claimed to have an improved adverse effect profile than the typical antipsychotics. Antipsychotics are also sometimes used to treat distortions in thinking or false perceptions. One meta-analysis of two randomly controlled trials, four non-controlled open-label studies and eight case reports has suggested that several atypical antipsychotics, including olanzapine, clozapine, quetiapine and risperidone, may help BPD patients with psychotic-like, impulsive or suicidal symptoms. However, there are numerous adverse effects of antipsychotics, notably tardive dyskinesia (TD). Atypical antipsychotics are known for often causing considerable weight gain, with associated health complications. Mood stabilizers Mood stabilizers are anticonvulsant drugs used for both epilepsy and reduction in mood variations in patients with excessive and often dangerous mood variabilities. Often, the goal of the anticonvulsants are to bring certain areas of the brain to equilibrium and control outbursts and seizures. Mood stabilizers (used primarily to treat bipolar disorder) such as lithium or lamotrigine may be of some use to help depressed or labile periods, as well as rapid changes in mood. A random controlled trial by Lieb (2010) found mood stabilizer valproate semisodium showed a significant decrease in interpersonal conflicts and depression. It was also found that topiramate showed a significant decrease in interpersonal issues and depression. Lamotrigine showed a significant decrease in impulsivity and anger-related behaviors. Carbamazepine showed no significant effects on patients with BPD. Mood stabilizers are often used to treat comorbid disorders in BPD patients. There is currently no medicine with an overall significant effect on BPD as a whole. Services and recovery Individuals with BPD sometimes use mental health services extensively. People with this diagnosis accounted for about 20 percent of psychiatric hospitalizations in one survey. The majority of BPD patients continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time. Experience of services varies. Assessing suicide risk can be a challenge for mental health services (and patients themselves tend to underestimate the lethality of self-injurious behaviours) with typically a chronically elevated risk of suicide much above that of the general population and a history of multiple attempts when in crisis. Particular difficulties have been observed in the relationship between care providers and individuals diagnosed with BPD. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with, and more difficult than other client groups. On the other hand, those with the diagnosis of BPD have reported that the term "BPD" felt like a pejorative label rather than a helpful diagnosis, that self-destructive behaviour was incorrectly perceived as manipulative, and that they had limited access to care. Attempts are made to improve public and staff attitudes. Combining pharmacotherapy and psychotherapy In practice, psychotherapy and medication may often be combined, but there are limited data on clinical practice. Efficacy studies often assess the effectiveness of interventions when added to "treatment as usual" (TAU), which may involve general psychiatric services, supportive counselling, medication and psychotherapy. One small study, which excluded individuals with a comorbid Axis 1 disorder, has indicated that outpatients undergoing dialectical behavioral therapy and taking the antipsychotic olanzapine show significantly more improvement on some measures related to BPD, compared to those undergoing DBT and taking a placebo pill, although they also experienced weight gain and raised cholesterol. Another small study found that patients who had undergone DBT and then took fluoxetine (Prozac) showed no significant improvements, whereas those who underwent DBT and then took a placebo pill did show significant improvements. Difficulties in therapy There can be unique challenges in the treatment of BPD, such as hospital care. In psychotherapy, a client may be unusually sensitive to rejection and abandonment and may react negatively (e.g., by harming themselves or withdrawing from treatment) if they sense this. In addition, clinicians may emotionally distance themselves from individuals with BPD for self-protection or due to the stigma associated with the diagnosis, leading to a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist can contribute. Some psychotherapies, including DBT, were developed partly to overcome problems with interpersonal sensitivity and maintaining a therapeutic relationship. Adherence to medication regimens is also a problem, due in part to adverse effects, with drop-out rates of between 50 percent and 88 percent in medication trials. Comorbid disorders, particularly substance use disorders, can complicate attempts to achieve remission. Other strategies Psychotherapies and medications form a part of the overall context of mental health services and psychosocial needs related to BPD. The evidence base is limited for both, and some individuals may forego them or not benefit (enough) from them. It has been argued that diagnostic categorization can have limited utility in directing therapeutic work in this area, and that in some cases it is only with reference to past and current relationships that "borderline" behavior can be understood as partly adaptive and how people can best be helped. Numerous other strategies may be used, including alternative medicine techniques (see List of branches of alternative medicine); exercise and physical fitness, including team sports; occupational therapy techniques, including creative arts; having structure and routine to the days, particularly through employment - helping feelings of competence (e.g. self-efficacy), having a social role and being valued by others, boosting self-esteem. Group-based psychological services encourage clients to socialize and participate in both solitary and group activities. These may be in day centers. Therapeutic communities are an example of this, particularly in Europe; although their usage has declined many have specialised in the treatment of severe personality disorder. Psychiatric rehabilitation services aimed at helping people with mental health problems reduce psychosocial disability, engage in meaningful activities and avoid stigma and social exclusion may be of value to people who have BPD. There are also many mutual-support or co-counseling groups run by and for individuals with BPD. Services, or individual goals, are increasingly based on a recovery model that supports and emphasizes an individual's personal journey and potential. Data indicate that the diagnosis of BPD is more variable over time than the DSM implies. Substantial percentages (for example around a third, depending on criteria) of people diagnosed with BPD achieve remission within a year or two. A longitudinal study found that, six years after being diagnosed with BPD, 56 percent showed good psychosocial functioning, compared to 26 percent at baseline. Although vocational achievement was more limited even compared to those with other personality disorders, those whose symptoms had remitted were significantly more likely to have a good relationship with a spouse/partner and at least one parent, good work/school performance, a sustained work/school history, good global functioning and good psychosocial functioning. References Borderline personality disorder

Vergangenheitsbewältigung

Vergangenheitsbewältigung (, "struggle of overcoming the past" or "work of coping with the past") is a German compound noun describing processes that since the later 20th century have become key in the study of post-1945 German literature, society, and culture. The German Duden lexicon defines Vergangenheitsbewältigung as "public debate within a country on a problematic period of its recent history—in Germany on National Socialism, in particular"—where "problematic" refers to traumatic events that raise sensitive questions of collective culpability. In Germany, the word originally referred to anger and remorse about the war crimes of the Wehrmacht, the Holocaust, and related events of the early and mid-20th century, including World War II. In the sense of a quest for a new German identity, the word can refer to the psychological process of denazification. After the reunification of 1990 (the accession of the former German Democratic Republic into the current Federal Republic of Germany) and the fall of the Soviet Union in 1991, Vergangenheitsbewältigung also referred to coming to terms with East German Communism. Historical development Vergangenheitsbewältigung describes the attempt to analyze, digest and learn to live with the past, in particular the Holocaust. The focus on learning is much in the spirit of philosopher George Santayana's oft-quoted observation that "those who forget the past are condemned to repeat it". It is a technical term also used in English that was coined after 1945 in West Germany, relating specifically to the atrocities committed in Nazi Germany, and to both historical and contemporary concerns about the extensive degree to which Nazism compromised and co-opted many German cultural, religious, and political institutions. The term therefore deals at once with the concrete responsibility of the German state (West Germany assumed the legal obligations of the Reich) and of individual Germans for what took place "under Hitler", and with questions about the roots of legitimacy in a society whose development of the Enlightenment collapsed in the face of Nazi ideology. After denazification Historically, Vergangenheitsbewältigung often is seen as the logical "next step" after a denazification drive under both the Allied Occupation and by the Christian Democratic Union government of Konrad Adenauer, and began in the late 1950s and early 1960s, roughly the period in which the work of the Wiederaufbau (reconstruction) became less absorbing and urgent. Having replaced the institutions and power structures of Nazism, the aim of liberal Germans was to deal with the guilt of recent history. Vergangenheitsbewältigung is marked by learning from the past in ways such as honestly admitting that such a past did indeed exist, attempting to remedy as far as possible the wrongs committed, and attempting to move on from that past. Religion and education The German churches, of which only a minority played a significant role in the resistance to Nazism, have led the way in this process. They have notably developed a unique German postwar theology of repentance. At the regular mass church rallies, the Lutheran Kirchentag and the Catholic Katholikentag, for example, have developed this theme as a leitmotiv of Christian youth. Vergangenheitsbewältigung has been expressed by the society through its schools, where in most German states the centrally-written curriculum provides each child with repeated lessons on different aspects of Nazism in German history, politics and religion classes from the fifth grade onwards, related to their maturity. Associated school trips may have destinations of concentration camps. Jewish Holocaust survivors are often invited to schools as guest speakers, though the passage of time limits these opportunities as their generation has aged. Philosophy In philosophy, Theodor Adorno's writings include the lecture "Was bedeutet: Aufarbeitung der Vergangenheit?" ("What is meant by 'working through the past'?"), a subject related to his thinking of "after Auschwitz" in his later work. He delivered the lecture on 9 November 1959 at a conference on education held in Wiesbaden. Writing in the context of a new wave of antisemitic attacks against synagogues and Jewish community institutions occurring in West Germany at that time, Adorno rejected the contemporary catch phrase "working through the past" as misleading. He argued that it masked a denial, rather than signifying the kind of critical self-reflection that Freudian theory called for in order to "come to terms" with the past. Adorno's lecture is often seen as consisting in part of a variably implicit and explicit critique of the work of Martin Heidegger, whose formal ties to the Nazi Party are well known. Heidegger had attempted to provide a historical conception of Germania as a philosophical notion of German origin and destiny (later he would speak of "the West"). Alexander García Düttmann's Das Gedächtnis des Denkens. Versuch über Heidegger und Adorno (The Memory of Thought: An Essay on Heidegger and Adorno, translated by Nicholas Walker) attempts to treat the philosophical value of these seemingly opposed and certainly incompatible terms "Auschwitz" and "Germania" in the philosophy of both men. Culture In the cultural sphere, the term Vergangenheitsbewältigung is associated with a movement in German literature whose notable authors include Günter Grass and Siegfried Lenz. Lenz's novel Deutschstunde and Grass's Danziger Trilogie both deal with childhoods under Nazism. The erection of public monuments to Holocaust victims has been a tangible commemoration of Germany's Vergangenheitsbewältigung. Concentration camps, such as Dachau, Buchenwald, Bergen-Belsen and Flossenbürg, are open to visitors as memorials and museums. Most towns have plaques on walls marking the spots where particular atrocities took place. When the seat of government was moved from Bonn to Berlin in 1999, an extensive "Holocaust memorial", designed by architect Peter Eisenman, was planned as part of the extensive development of new official buildings in the district of Berlin-Mitte; it was opened on 10 May 2005. The informal name of this memorial, the Holocaust-Mahnmal, is significant. It does not translate easily: "Holocaust Cenotaph" would be one sense, but the noun Mahnmal, which is distinct from the term Denkmal (typically used to translate "memorial") carries the sense of "admonition", "urging", "appeal", or "warning", rather than "remembrance" as such. The work is formally known as Das Denkmal für die ermordeten Juden Europas (English translation, "The Memorial for the Murdered Jews of Europe"). Some controversy attaches to it precisely because of this formal name and its exclusive emphasis on Jewish victims. As Eisenman acknowledged at the opening ceremony, "It is clear that we won't have solved all the problemsarchitecture is not a panacea for evilnor will we have satisfied all those present today, but this cannot have been our intention." Actions of other European countries In Austria, ongoing arguments about the nature and significance of the Anschluss, and unresolved disputes about legal expressions of obligation and liability, have led to very different concerns, and to a far less institutionalized response by the government. Since the late 20th century, observers and analysts have expressed concerns about the ascent of "Haiderism". Poland has maintained a museum, archive, and research institute at Oświęcim ever since a 2 July 1947 act of the Polish Parliament. In the same year, Czechoslovakia established what was known as the "National Suffering Memorial" and later as the Terezín memorial in Terezín, Czech Republic. This site during the Holocaust was known as the concentration camp of Theresienstadt. In the context of varying degrees of Communist orthodoxy in both countries during the period of Soviet domination of Eastern Europe through much of the late 20th century, historical research into the Holocaust was politicized to varying degrees. Marxist doctrines of class struggle were often overlaid onto generally received histories, which tended to exclude both acts of collaboration and antisemitism in these nations. The advance of the Einsatzgruppen, Aktion Reinhardt, and many other significant events in the Holocaust occurred in German-occupied Europe, outside the present-day borders of the Federal Republic. The history of the memorials and archives which have been erected at these sites in eastern Europe is associated with the Communist regimes that ruled these areas for more than four decades after World War II. The Nazis promoted an idea of an expansive German nation extending into territories where ethnic Germans had previously settled. They invaded and controlled much of Central and Eastern Europe, unleashing violence against various Slavic groups, as well as Jews, Communists, prisoners of war, etc. After the war, the eastern European nations expelled German settlers as well as long settled ethnic Germans (the Volksdeutsche) as a reaction to Nazi Germany's attempt to claim the eastern lands on behalf of ethnic Germans. Analogous processes elsewhere In some of its aspects, Vergangenheitsbewältigung can be compared to the attempts of other democratic countries to raise consciousness and come to terms with earlier periods of governmental and insurgency abuses, such as the South African Truth and Reconciliation Commission, which investigated human rights abuses by both the National Party Government in South Africa under apartheid and by senior members of the African National Congress including Winnie Mandela and by the ANC's paramilitary wing, Umkhonto we Sizwe. Comparisons have been made with the Soviet process of glasnost and perestroika, though this was less focused on the past than achieving a level of open criticism necessary for progressive reform to take place. It was widely assumed during this time that the Communist Party of the Soviet Union would maintain its monopoly on power. American journalist David Remnick has argued that once Memorial was founded by former Soviet dissidents in 1987 and began independently researching and publicizing accurate historical information about Soviet war crimes and the location of mass graves containing the victims of the Red Terror, Stalinism, and the Gulag; the clock began ticking on the continued survival of the Communist system. Since the collapse of the Soviet Union, the continuing efforts in nations of eastern Europe and the independent states of the former Soviet Union to research and publicize the Communist and Stalinist past, as well as its countless human rights abuses, is sometimes referred to as a post-communist equivalent to Vergangenheitsbewältigung. The well-documented history of Japanese war crimes, both before and during World War II is something the then-future Emperor Naruhito expressed his concerns about in February 2015, regarding how accurately such events are remembered in 21st century Japan. See also Functionalism versus intentionalism Bottom-up approach of the Holocaust Nazi foreign policy debate Auschwitz bombing debate Culture of Remembrance - Erinnerungskultur in German Historiography of Germany Historikerstreit Clean Wehrmacht Sonderweg Victim theory, a theory that Austria was a victim of Nazism following the Anschluss Street name controversy Transitional justice Transitional Justice Institute Truth-seeking Debate over the atomic bombings of Hiroshima and Nagasaki "I Apologize" campaign, a grassroots' initiative in Turkey German nationality law: Victims of Nazi persecution Stolpersteine, memorial-blocks placed outside the former homes of concentration camp victims Pact of forgetting War guilt question Notes References Sources Frei, Norbert; Vergangenheitspolitik. Die Anfänge der Bundesrepublik und die NS-Vergangenheit. Munich: C.H. Beck, 1996. [In English as Adenauer's Germany and the Nazi Past: The Politics of Amnesty and Integration. New York: Columbia University Press] Geller, Jay Howard; Jews in Post-Holocaust Germany. Cambridge: Cambridge University Press, 2005. Herf, Jeffrey; Divided Memory: The Nazi Past in the Two Germanys. Cambridge: Harvard University Press, 1997. Maier, Charles S.; The Unmasterable Past: History, Holocaust, and German National Identity. Cambridge: Harvard University Press, 1988. Maislinger, Andreas; Coming to Terms with the Past: An International Comparison. In Nationalism, Ethnicity, and Identity. Cross National and Comparative Perspectives, ed. Russel F. Farnen. New Brunswick and London: Transaction Publishers, 2004. Moeller, Robert G.; War Stories: The Search for a Usable Past in the Federal Republic of Germany. Berkeley: University of California Press, 2001. Moeller, Robert G. (ed.); West Germany Under Construction: Politics, Society and Culture in the Adenauer Era. Ann Arbor: University of Michigan Press, 1997. Pross, Christian; Paying for the Past: The Struggle over Reparations for Surviving Victims of the Nazi Terror. Baltimore: Johns Hopkins University Press, 1998. Transitional Justice and Dealing with the Past", in: Berghof Glossary on Conflict Transformation. 20 notions for theory and practice. Berlin: Berghof Foundation, 2012. German literature German philosophy Holocaust historiography Aftermath of the Holocaust Truth and reconciliation commissions German words and phrases Reconciliation

Cognitive skill

Cognitive skills are skills of the mind, as opposed to other types of skills such as motor skills or social skills. Some examples of cognitive skills are literacy, self-reflection, logical reasoning, abstract thinking, critical thinking, introspection and mental arithmetic. Cognitive skills vary in processing complexity, and can range from more fundamental processes such as perception and various memory functions, to more sophisticated processes such as decision making, problem solving and metacognition. Specialisation of functions Cognitive science has provided theories of how the brain works, and these have been of great interest to researchers who work in the empirical fields of brain science. A fundamental question is whether cognitive functions, for example visual processing and language, are autonomous modules, or to what extent the functions depend on each other. Research evidence points towards a middle position, and it is now generally accepted that there is a degree of modularity in aspects of brain organisation. In other words, cognitive skills or functions are specialised, but they also overlap or interact with each other. Deductive reasoning, on the other hand, has been shown to be related to either visual or linguistic processing, depending on the task; although there are also aspects that differ from them. All in all, research evidence does not provide strong support for classical models of cognitive psychology. Cognitive functioning Cognitive functioning refers to a person's ability to process thoughts. It is defined as "the ability of an individual to perform the various mental activities most closely associated with learning and problem-solving. Examples include the verbal, spatial, psychomotor, and processing-speed ability." Cognition mainly refers to things like memory, speech, and the ability to learn new information. The brain is usually capable of learning new skills in the aforementioned areas, typically in early childhood, and of developing personal thoughts and beliefs about the world. Old age and disease may affect cognitive functioning, causing memory loss and trouble thinking of the right words while speaking or writing ("drawing a blank"). Multiple sclerosis (MS), for example, can eventually cause memory loss, an inability to grasp new concepts or information, and depleted verbal fluency. Humans generally have a high capacity for cognitive functioning once born, so almost every person is capable of learning or remembering. Intelligence is tested with IQ tests and others, although these have issues with accuracy and completeness. In such tests, patients may be asked a series of questions, or to perform tasks, with each measuring a cognitive skill, such as level of consciousness, memory, awareness, problem-solving, motor skills, analytical abilities, or other similar concepts. Early childhood is when the brain is most malleable to orientate to tasks that are relevant in the person's environment. See also Adaptive behavior Adaptive functioning Intelligence Quotient (IQ) Cognition Cognitive Abilities Test Jungian cognitive functions Notes References NCME - Glossary of Important Assessment and Measurement Terms [cognitive ability] Cognition Skills

Autism

Autism, also called autism spectrum disorder (ASD), is a neurodevelopmental disorder characterized by symptoms of deficient reciprocal social communication and the presence of restricted, repetitive, and inflexible patterns of behavior. Autism generally affects a person's ability to understand and connect with others, as well as their adaptability to everyday situations, with its severity and support needs varying widely across the spectrum. For example, some are nonspeaking, while others have proficient spoken language. A formal diagnosis of ASD according to either the DSM-5 or the World Health Organization's ICD-11 criteria requires not merely the presence of ASD symptoms, but symptoms that cause significant impairment in multiple domains of functioning, in addition to being atypical or excessive for the individual's age and sociocultural context. Common signs of ASD include difficulty with social interaction and verbal and nonverbal communication, along with perseverative interests, stereotypic body movements, rigid routines, and hyper- or hypo-reactivity to sensory input. The DSM-5 and ICD-11 classify autism as a neurodevelopmental disorder, but the autism rights movement (and some researchers) see autistic people as part of humanity's natural neurodiversity. From this point of view, autistic people may also be diagnosed with a disability of some sort, but that disability may be rooted in the systemic structures of a society rather than in the person; thus, proponents argue that autistic people should be accommodated rather than cured. On the contrary, other scientists argue that ASD impairs functioning in many ways that are inherent to the disorder itself and unrelated to society. The neurodiversity perspective has led to significant controversy among those who are autistic and advocates, practitioners, and charities. There are many theories about the causes of autism; it is highly heritable and mainly genetic, but many genes are involved, and environmental factors may also be relevant. Autism frequently co-occurs with attention deficit hyperactivity disorder (ADHD), epilepsy and intellectual disability, and research indicates that autistic people have significantly higher rates of LGBTQ+ identities and feelings than the general population. Disagreements persist about what should be included as part of the diagnosis, whether there are meaningful subtypes or stages of autism, and the significance of autism-associated traits in the wider population. The combination of broader criteria, increased awareness, and the potential increase of actual prevalence, has led to considerably increased estimates of autism prevalence since the 1990s. The World Health Organization estimates about 1 in 100 children had autism between 2012 and 2021, as that was the average estimate in studies during that period, with a trend of increasing prevalence over time. This increasing prevalence has reinforced the myth perpetuated by anti-vaccine activists that autism is caused by vaccines. Boys are also significantly far more frequently diagnosed than girls. There is no cure for autism. Some advocates of autistic people argue that efforts to find a cure are misguided and even harmful. Early intervention services based on applied behavior analysis (ABA) aim to teach children self-care and normative social and language skills. Some in the autism rights movement consider ABA therapy unethical and unhelpful due to a perception that it emphasizes normalization instead of acceptance and its potential for causing harms. Curtailing self-soothing behaviors is potentially classifiable as a form of abuse. Speech and occupational therapy, as well as augmentative and alternative modes of communication, are effective adjunctive therapies. Pharmacological treatments may also be useful; the atypical antipsychotics risperidone and aripiprazole have shown to alleviate comorbid irritability, though they tend to be associated with sedation and weight gain. Melatonin supplementation has been shown to improve insomnia related to autism. Stimulant therapy may improve mental processing speed when there is comorbid ADHD. Classification Spectrum model Before the DSM-5 (2013) and ICD-11 (2022) diagnostic manuals were adopted, ASD was found under the diagnostic category pervasive developmental disorder. The previous system relied on a set of closely related and overlapping diagnoses such as Asperger syndrome and the syndrome formerly known as Kanner syndrome. This created unclear boundaries between the terms, so for the DSM-5 and ICD-11, a spectrum approach was taken. The new system is also more restrictive, meaning fewer people qualify for diagnosis. The DSM-5 and ICD-11 use different categorization tools to define this spectrum. DSM-5 uses a "level" system, which ranks how in need of support the patient is, level 1 being the mildest and level 3 the severest, while the ICD-11 system has two axes, intellectual impairment and language impairment, as these are seen as the most crucial factors. Autism is currently defined as a highly variable neurodevelopmental disorder that is generally thought to cover a broad and deep spectrum, manifesting very differently from one person to another. Some have high support needs, may be nonspeaking, and experience developmental delays; this is more likely with other co-existing diagnoses. Others have relatively low support needs; they may have more typical speech-language and intellectual skills but atypical social/conversation skills, narrowly focused interests, and wordy, pedantic communication. They may still require significant support in some areas of their lives. The spectrum model should not be understood as a continuum running from mild to severe, but instead means that autism can present very differently in each person. How it presents in a person can depend on context, and may vary over time. While the DSM and ICD greatly influence each other, there are also differences. For example, Rett syndrome was included in ASD in the DSM-5, but in the ICD-11 it was excluded and placed in the chapter on Developmental Anomalies. The ICD and the DSM change over time, and there has been collaborative work toward a convergence of the two since 1980 (when DSM-III was published and ICD-9 was current), including more rigorous biological assessment—in place of historical experience—and a simplification of the classification system. As of 2023, empirical and theoretical research is leading to a growing consensus among researchers that the established ASD criteria are ineffective descriptors of autism as a whole, and that alternative research approaches must be encouraged, such as going back to autism prototypes, exploring new causal models of autism, or developing transdiagnostic endophenotypes. Proposed alternatives to the current disorder-focused spectrum model deconstruct autism into at least two separate phenomena: (1) a non-pathological spectrum of behavioral traits in the population, and (2) the neuropathological burden of rare genetic mutations and environmental risk factors potentially leading to neurodevelopmental and psychological disorders, (3) governed by an individual's cognitive ability to compensate. ICD The World Health Organization's International Classification of Diseases (11th Revision), ICD-11, was released in June 2018 and came into full effect as of January 2022. It describes ASD as follows: ICD-11 was produced by professionals from 55 countries out of the 90 involved and is the most widely used reference worldwide. DSM The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), released in 2022, is the current version of the DSM. It is the predominant mental health diagnostic system used in the United States and Canada, and is often used in Anglophone countries. Its fifth edition, DSM-5, released in May 2013, was the first to define ASD as a single diagnosis, which is still the case in the DSM-5-TR. ASD encompasses previous diagnoses, including the four traditional diagnoses of autism—classic autism, Asperger syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS)—and the range of diagnoses that included the word "autism". Rather than distinguishing among these diagnoses, the DSM-5 and DSM-5-TR adopt a dimensional approach with one diagnostic category for disorders that fall under the autism spectrum umbrella. Within that category, the DSM-5 and the DSM include a framework that differentiates each person by dimensions of symptom severity, as well as by associated features (i.e., the presence of other disorders or factors that likely contribute to the symptoms, other neurodevelopmental or mental disorders, intellectual disability, or language impairment). The symptom domains are (a) social communication and (b) restricted, repetitive behaviors, and there is the option of specifying a separate severity—the negative effect of the symptoms on the person—for each domain, rather than just overall severity. Before the DSM-5, the DSM separated social deficits and communication deficits into two domains. Further, the DSM-5 changed to an onset age in the early developmental period, with a note that symptoms may manifest later when social demands exceed capabilities, rather than the previous, more restricted three years of age. These changes remain in the DSM-5-TR. Common characteristics Pre-diagnosis For many autistic people, characteristics first appear during infancy or childhood and follow a steady course without remission (different developmental timelines are described in more detail below). Autistic people may be severely impaired in some respects but average, or even superior, in others. Clinicians consider assessment for ASD when a patient shows: regular difficulties in social interaction or communication restricted or repetitive behaviors (often called "stimming") resistance to changes or restricted interests These features are typically assessed with the following, when appropriate: problems in obtaining or sustaining employment or education difficulties in initiating or sustaining social relationships connections with mental health or learning disability services a history of neurodevelopmental conditions (including learning disabilities and ADHD) or mental health conditions There are many signs associated with autism; the presentation varies widely: {| class="wikitable" style="width:55em;border:solid 1px #999999; margin:0 0 1em 1em;" |- !Common signs for autism spectrum disorder |- | abnormalities in eye contact little or no babbling as an infant not showing interest in indicated objects delayed language skills (e.g., having a smaller vocabulary than peers or difficulty expressing themselves in words) reduced interest in other children or caretakers, possibly with more interest in objects difficulty playing reciprocal games (e.g., peek-a-boo) hyper- or hypo-sensitivity to or unusual response to the smell, texture, sound, taste, or appearance of things resistance to changes in routine repetitive, limited, or otherwise unusual usage of toys (e.g., lining up toys) repetition of words or phrases (echolalia) repetitive motions or movements, including stimming |} Broader autism phenotype The broader autism phenotype describes people who may not have ASD but do have autistic traits, such as abnormalities in eye contact and stimming. Social and communication skills According to the medical model, autistic people experience social communications impairments. Until 2013, deficits in social function and communication were considered two separate symptom domains. The current social communication domain criteria for autism diagnosis require people to have deficits across three social skills: social-emotional reciprocity, nonverbal communication, and developing and sustaining relationships. A deficit-based view predicts that autistic–autistic interaction would be less effective than autistic–non-autistic interactions or even non-functional. But recent research has found that autistic–autistic interactions are as effective in information transfer as interactions between non-autistics are, and that communication breaks down only between autistics and non-autistics. Also contrary to social cognitive deficit interpretations, recent (2019) research recorded similar social cognitive performances in autistic and non-autistic adults, with both of them rating autistic individuals less favorably than non-autistic individuals; however, autistic individuals showed more interest in engaging with autistic people than non-autistic people did, and learning of a person's ASD diagnosis did not influence their interest level. Thus, there has been a recent shift to acknowledge that autistic people may simply respond and behave differently than people without ASD. So far, research has identified two unconventional features by which autistic people create shared understanding (intersubjectivity): "a generous assumption of common ground that, when understood, led to rapid rapport, and, when not understood, resulted in potentially disruptive utterances; and a low demand for coordination that ameliorated many challenges associated with disruptive turns." Autistic interests, and thus conversational topics, seem to be largely driven by an intense interest in specific topics (monotropism). Historically, autistic children were said to be delayed in developing a theory of mind, and the empathizing–systemizing theory has argued that while autistic people have compassion (affective empathy) for others with similar presentation of symptoms, they have limited, though not necessarily absent, cognitive empathy. This may present as social naïvety, lower than average intuitive perception of the utility or meaning of body language, social reciprocity, or social expectations, including the habitus, social cues, and some aspects of sarcasm, which to some degree may also be due to comorbid alexithymia. But recent research has increasingly questioned these findings, as the "double empathy problem" theory (2012) argues that there is a lack of mutual understanding and empathy between both non-autistic persons and autistic individuals. As communication is bidirectional, research on communication difficulties has since also begun to study non-autistic behavior, with researcher Catherine Crompton writing in 2020 that non-autistic people "struggle to identify autistic mental states, identify autistic facial expressions, overestimate autistic egocentricity, and are less willing to socially interact with autistic people. Thus, although non-autistic people are generally characterised as socially skilled, these skills may not be functional, or effectively applied, when interacting with autistic people." Any previously observed communication deficits of autistic people may thus have been constructed through a neurotypical bias in autism research, which has come to be scrutinized for "dehumanization, objectification, and stigmatization". Recent research has proposed that autistics' lack of readability and a neurotypical lack of effort to interpret atypical signals may cause a negative interaction loop, increasingly driving both groups apart into two distinct groups with different social interaction styles. Differences in verbal communication begin to be noticeable in childhood, as many autistic children develop language skills at an uneven pace. Verbal communication may be delayed or never develop (nonverbal autism), while reading ability may be present before school age (hyperlexia). Reduced joint attention seem to distinguish autistic from non-autistic infants. Infants may show delayed onset of babbling, unusual gestures, diminished responsiveness, and vocal patterns that are not synchronized with the caregiver. In the second and third years, autistic children may have less frequent and less diverse babbling, consonants, words, and word combinations; their gestures are less often integrated with words. Autistic children are less likely to make requests or share experiences and more likely to simply repeat others' words (echolalia). The CDC estimated in 2015 that around 40% of autistic children do not speak at all. Autistic adults' verbal communication skills largely depend on when and how well speech is acquired during childhood. Autistic people display atypical nonverbal behaviors or show differences in nonverbal communication. They may make infrequent eye contact, even when called by name, or avoid it altogether. This may be due to the high amount of sensory input received when making eye contact. Autistic people often recognize fewer emotions and their meaning from others' facial expressions, and may not respond with facial expressions expected by their non-autistic peers. Temple Grandin, an autistic woman involved in autism activism, described her inability to understand neurotypicals' social communication as leaving her feeling "like an anthropologist on Mars". Autistic people struggle to understand the social context and subtext of neurotypical conversational or printed situations, and form different conclusions about the content. Autistic people may not control the volume of their voice in different social settings. At least half of autistic children have atypical prosody. What may look like self-involvement or indifference to non-autistic people stems from autistic differences in recognizing how other people have their own personalities, perspectives, and interests. Most published research focuses on the interpersonal relationship difficulties between autistic people and their non-autistic counterparts and how to solve them through teaching neurotypical social skills, but newer research has also evaluated what autistic people want from friendships, such as a sense of belonging and good mental health. Children with ASD are more frequently involved in bullying situations than their non-autistic peers, and predominantly experience bullying as victims rather than perpetrators or victim-perpetrators, especially after controlling for comorbid psychopathology. Prioritizing dependability and intimacy in friendships during adolescence, coupled with lowered friendship quantity and quality, often lead to increased loneliness in autistic people. As they progress through life, autistic people observe and form a model of social patterns, and develop coping mechanisms, referred to as "masking", which have recently been found to come with psychological costs and a higher increased risk of suicidality. Restricted and repetitive behaviors ASD includes a wide variety of characteristics. Some of these include behavioral characteristics which widely range from slow development of social and learning skills to difficulties creating connections with other people. Autistic people may experience these challenges with forming connections due to anxiety or depression, which they are more likely to experience, and as a result isolate themselves. Other behavioral characteristics include abnormal responses to sensations (such as sights, sounds, touch, taste and smell) and problems keeping a consistent speech rhythm. The latter problem influences social skills, leading to potential problems in understanding for interlocutors. Autistic people's behavioral characteristics typically influence development, language, and social competence. Their behavioral characteristics can be observed as perceptual disturbances, disturbances of development rate, relating, speech and language, and motility. The second core symptom of autism spectrum is a pattern of restricted and repetitive behaviors, activities, and interests. In order to be diagnosed with ASD under the DSM-5-TR, a person must have at least two of the following behaviors: Repetitive behaviors – Repetitive behaviors such as rocking, hand flapping, finger flicking, head banging, or repeating phrases or sounds. These behaviors may occur constantly or only when the person gets stressed, anxious, or upset. These behaviors are also known as stimming. Resistance to change – A strict adherence to routines such as eating certain foods in a specific order or taking the same path to school every day. The person may become distressed if there is a change or disruption to their routine. Restricted interests – An excessive interest in a particular activity, topic, or hobby, and devoting all their attention to it. For example, young children might completely focus on things that spin and ignore everything else. Older children might try to learn everything about a single topic, such as the weather or sports, and perseverate or talk about it constantly. Sensory reactivity – An unusual reaction to certain sensory inputs, such as negative reaction to specific sounds or textures, fascination with lights or movements, or apparent indifference to pain or heat. Autistic people can display many forms of repetitive or restricted behavior, which the Repetitive Behavior Scale-Revised (RBS-R) categorizes as follows. Stereotyped behaviors: Repetitive movements, such as hand flapping, head rolling, or body rocking. Compulsive behaviors: Time-consuming behaviors intended to reduce anxiety, that a person feels compelled to perform repeatedly or according to rigid rules, such as placing objects in a specific order, checking things, or handwashing. Sameness: Resistance to change; for example, insisting that the furniture not be moved or refusing to be interrupted. Ritualistic behavior: Unvarying pattern of daily activities, such as an unchanging menu or a dressing ritual. This is closely associated with sameness and an independent validation has suggested combining the two factors. Self-injurious behaviors: Behaviors such as eye-poking, skin-picking, hand-biting and head-banging. Self-injury Self-injurious behaviors are relatively common in autistic people, and can include head-banging, self-cutting, self-biting, and hair-pulling. Some of these can result in serious injury or death. Following are theories about the cause of self-injurious behavior in children with developmental delay, including autistic children: Frequency or continuation of self-injurious behavior can be influenced by environmental factors (e.g., reward in return for halting self-injurious behavior). This theory does not apply to younger children with autism. There is some evidence that frequency of self-injurious behavior can be reduced by removing or modifying environmental factors that reinforce the behavior. Higher rates of self-injury are also noted in socially isolated autistic people. Studies have shown that socialization skills are related factors to self-injurious behavior for autistic people. Self-injury could be a response to modulate pain perception when chronic pain or other health problems that cause pain are present. An abnormal basal ganglia connectivity may predispose to self-injurious behavior. The suicide rate for verbal autistics is nine times that of the general population. Burnout Studies have supported the common belief that autistic people become exhausted or burnt out in some situations. Other features Autistic people may have symptoms that do not contribute to the official diagnosis, but that can affect the person or the family. Some autistic people show unusual or notable abilities, ranging from splinter skills (such as the memorization of trivia) to rare talents in mathematics, music, or artistic reproduction, which in exceptional cases are considered a part of the savant syndrome. One study describes how some autistic people show superior skills in perception and attention relative to the general population. Sensory abnormalities are found in over 90% of autistic people, and are considered core features by some. More generally, autistic people tend to show a "spiky skills profile", with strong abilities in some areas contrasting with much weaker abilities in others. Differences between the previously recognized disorders under the autism spectrum are greater for under-responsivity (for example, walking into things) than for over-responsivity (for example, distress from loud noises) or for sensation seeking (for example, rhythmic movements). An estimated 60–80% of autistic people have motor signs that include poor muscle tone, poor motor planning, and toe walking; deficits in motor coordination are pervasive across ASD and are greater in autism proper. Pathological demand avoidance can occur. People with this set of autistic symptoms are more likely to refuse to do what is asked or expected of them, even to activities they enjoy. Unusual or atypical eating behavior occurs in about three-quarters of children with ASD, to the extent that it was formerly a diagnostic indicator. Selectivity is the most common problem, although eating rituals and food refusal also occur. Problematic digital media use Possible causes Exactly what causes autism remains unknown. It was long mostly presumed that there is a common cause at the genetic, cognitive, and neural levels for the social and non-social components of ASD's symptoms, described as a triad in the classic autism criteria. But it is increasingly suspected that autism is instead a complex disorder whose core aspects have distinct causes that often cooccur. It is unlikely that ASD has a single cause; many risk factors identified in the research literature may contribute to ASD. These include genetics, prenatal and perinatal factors (meaning factors during pregnancy or very early infancy), neuroanatomical abnormalities, and environmental factors. It is possible to identify general factors, but much more difficult to pinpoint specific ones. Given the current state of knowledge, prediction can only be of a global nature and so requires the use of general markers. Biological subgroups Research into causes has been hampered by the inability to identify biologically meaningful subgroups within the autistic population and by the traditional boundaries between the disciplines of psychiatry, psychology, neurology and pediatrics. Newer technologies such as fMRI and diffusion tensor imaging can help identify biologically relevant phenotypes (observable traits) that can be viewed on brain scans, to help further neurogenetic studies of autism; one example is lowered activity in the fusiform face area of the brain, which is associated with impaired perception of people versus objects. It has been proposed to classify autism using genetics as well as behavior. Syndromic autism and non-syndromic autism Autism spectrum disorder (ASD) can be classified into two categories: "syndromic autism" and "non-syndromic autism". Syndromic autism refers to cases where ASD is one of the characteristics associated with a broader medical condition or syndrome, representing about 25% of ASD cases. The causes of syndromic autism are often known, and monogenic disorders account for approximately 5% of these cases. Non-syndromic autism, also known as classic or idiopathic autism, represents the majority of cases, and its cause is typically polygenic and unknown. Genetics Autism has a strong genetic basis, although the genetics of autism are complex and it is unclear whether ASD is explained more by rare mutations with major effects, or by rare multi-gene interactions of common genetic variants. Complexity arises due to interactions among multiple genes, the environment, and epigenetic factors which do not change DNA sequencing but are heritable and influence gene expression. Many genes have been associated with autism through sequencing the genomes of affected people and their parents. But most of the mutations that increase autism risk have not been identified. Typically, autism cannot be traced to a Mendelian (single-gene) mutation or to a single chromosome abnormality, and none of the genetic syndromes associated with ASD have been shown to selectively cause ASD. Numerous genes have been found, with only small effects attributable to any particular gene. Most loci individually explain less than 1% of cases of autism. , it appeared that between 74% and 93% of ASD risk is heritable. After an older child is diagnosed with ASD, 7% to 20% of subsequent children are likely to be as well. If parents have one autistic child, they have a 2% to 8% chance of having a second child who is autistic. If the autistic child is an identical twin, the other will be affected 36% to 95% of the time. A fraternal twin is affected up to 31% of the time. The large number of autistic people with unaffected family members may result from spontaneous structural variation, such as deletions, duplications or inversions in genetic material during meiosis. Hence, a substantial fraction of autism cases may be traceable to genetic causes that are highly heritable but not inherited: that is, the mutation that causes the autism is not present in the parental genome. , understanding of genetic risk factors had shifted from a focus on a few alleles to an understanding that genetic involvement in ASD is probably diffuse, depending on a large number of variants, some of which are common and have a small effect, and some of which are rare and have a large effect. The most common gene disrupted with large effect rare variants appeared to be CHD8, but less than 0.5% of autistic people have such a mutation. The gene CHD8 encodes the protein chromodomain helicase DNA binding protein 8, which is a chromatin regulator enzyme that is essential during fetal development. CHD8 is an adenosine triphosphate (ATP)–dependent enzyme. The protein contains an Snf2 helicase domain that is responsible for the hydrolysis of ATP to adenosine diphosphate (ADP). CHD8 encodes a DNA helicase that functions as a repressor of transcription, remodeling chromatin structure by altering the position of nucleosomes. CHD8 negatively regulates Wnt signaling. Wnt signaling is important in the vertebrate early development and morphogenesis. It is believed that CHD8 also recruits the linker histone H1 and causes the repression of β-catenin and p53 target genes. The importance of CHD8 can be observed in studies where CHD8-knockout mice died after 5.5 embryonic days because of widespread p53-induced apoptosis. Some studies have determined the role of CHD8 in autism spectrum disorder (ASD). CHD8 expression significantly increases during human mid-fetal development. The chromatin remodeling activity and its interaction with transcriptional regulators have shown to play an important role in ASD aetiology. The developing mammalian brain has conserved CHD8 target regions that are associated with ASD risk genes. The knockdown of CHD8 in human neural stem cells results in dysregulation of ASD risk genes that are targeted by CHD8. Recently CHD8 has been associated with the regulation of long non-coding RNAs (lncRNAs), and the regulation of X chromosome inactivation (XCI) initiation, via regulation of Xist long non-coding RNA, the master regulator of XCI, though competitive binding to Xist regulatory regions. Some ASD is associated with clearly genetic conditions, like fragile X syndrome, but only around 2% of autistic people have fragile X. Hypotheses from evolutionary psychiatry suggest that these genes persist because they are linked to human inventiveness, intelligence or systemising. Current research suggests that genes that increase susceptibility to ASD are ones that control protein synthesis in neuronal cells in response to cell needs, activity and adhesion of neuronal cells, synapse formation and remodeling, and excitatory to inhibitory neurotransmitter balance. Therefore, although up to 1,000 different genes are thought to increase the risk of ASD, all of them eventually affect normal neural development and connectivity between different functional areas of the brain in a similar manner that is characteristic of an ASD brain. Some of these genes are known to modulate production of the GABA neurotransmitter, the nervous system's main inhibitory neurotransmitter. These GABA-related genes are under-expressed in an ASD brain. On the other hand, genes controlling expression of glial and immune cells in the brain, e.g. astrocytes and microglia, respectively, are over-expressed, which correlates with increased number of glial and immune cells found in postmortem ASD brains. Some genes under investigation in ASD pathophysiology are those that affect the mTOR signaling pathway, which supports cell growth and survival. All these genetic variants contribute to the development of the autism spectrum, but it cannot be guaranteed that they are determinants for the development. ASD may be under-diagnosed in women and girls due to an assumption that it is primarily a male condition, but genetic phenomena such as imprinting and X linkage have the ability to raise the frequency and severity of conditions in males, and theories have been put forward for a genetic reason why males are diagnosed more often, such as the imprinted brain hypothesis and the extreme male brain theory. Early life Several prenatal and perinatal complications have been reported as possible risk factors for autism. These risk factors include maternal gestational diabetes, maternal and paternal age over 30, bleeding during pregnancy after the first trimester, use of certain prescription medication (e.g. valproate) during pregnancy, and meconium in the amniotic fluid. Research is not conclusive on the relation of these factors to autism, but each of them has been identified more frequently in children with autism compared to their siblings who do not have autism and other typically developing youth. While it is unclear if any single factors during the prenatal phase affect the risk of autism, complications during pregnancy may be a risk. There are also studies being done to test whether certain types of regressive autism have an autoimmune basis. Maternal nutrition and inflammation during preconception and pregnancy influences fetal neurodevelopment. Intrauterine growth restriction is associated with ASD, in both term and preterm infants. Maternal inflammatory and autoimmune diseases may damage fetal tissues, aggravating a genetic problem or damaging the nervous system. Systematic reviews and meta-analyses have found that maternal prenatal infections, prenatal antibiotic exposure, and post-term pregnancies are associated with increased risk of ASD in children. Exposure to air pollution during child pregnancy, especially heavy metals and particulates, may increase the risk of autism. Environmental factors that have been claimed without evidence to contribute to or exacerbate autism include certain foods, infectious diseases, solvents, PCBs, phthalates and phenols used in plastic products, pesticides, brominated flame retardants, alcohol, smoking, illicit drugs, vaccines, and prenatal stress. Some, such as the MMR vaccine, have been completely disproven. Disproven vaccine hypothesis Parents may first become aware of ASD symptoms in their child around the time of a routine vaccination. This has led to unsupported and disproven theories blaming vaccine "overload", the vaccine preservative thiomersal, or the MMR vaccine for causing autism spectrum disorder. In 1998, British physician and academic Andrew Wakefield led a fraudulent, litigation-funded study that suggested that the MMR vaccine may cause autism. Two versions of the vaccine causation hypothesis were that autism results from brain damage caused by either the MMR vaccine itself, or by mercury used as a vaccine preservative. No convincing scientific evidence supports these claims. They are biologically implausible, and further evidence continues to refute them, including the observation that the rate of autism continues to climb despite elimination of thimerosal from most routine vaccines given to children from birth to 6 years of age. A 2014 meta-analysis examined ten major studies on autism and vaccines involving 1.25 million children worldwide; it concluded that neither the vaccine preservative thimerosal (mercury), nor the MMR vaccine, which has never contained thimerosal, lead to the development of ASDs. Despite this, misplaced parental concern has led to lower rates of childhood immunizations, outbreaks of previously controlled childhood diseases in some countries, and the preventable deaths of several children. Etiological hypotheses Several hypotheses have been presented that try to explain how and why autism develops by integrating known causes (genetic and environmental effects) and findings (neurobiological and somatic). Some are more comprehensive, such as the Pathogenetic Triad, which proposes and operationalizes three core features (an autistic personality, cognitive compensation, neuropathological burden) that interact to cause autism, and the Intense World Theory, which explains autism through a hyper-active neurobiology that leads to an increased perception, attention, memory, and emotionality. There are also simpler hypotheses that explain only individual parts of the neurobiology or phenotype of autism, such as mind-blindness (a decreased ability for theory of mind), the weak central coherence theory, or the extreme male brain and empathising–systemising theory. Evolutionary hypotheses Research exploring the evolutionary benefits of autism and associated genes has suggested that autistic people may have played a "unique role in technological spheres and understanding of natural systems" in the course of human development. It has been suggested that autism may have arisen as "a slight trade off for other traits that are seen as highly advantageous", providing "advantages in tool making and mechanical thinking", with speculation that the condition may "reveal itself to be the result of a balanced polymorphism, like sickle cell anemia, that is advantageous in a certain mixture of genes and disadvantageous in specific combinations". In 2011, a paper in Evolutionary Psychology proposed that autistic traits, including increased spatial intelligence, concentration and memory, could have been naturally selected to enable self-sufficient foraging in a more (although not completely) solitary environment. This is called the "Solitary Forager Hypothesis". A 2016 paper examines Asperger syndrome as "an alternative prosocial adaptive strategy" that may have developed as a result of the emergence of "collaborative morality" in the context of small-scale hunter-gathering, i.e., where "a positive social reputation for making a contribution to group wellbeing and survival" becomes more important than complex social understanding. Some multidisciplinary research suggests that recent human evolution may be a driving force in the rise of a number of medical conditions, including autism, in recent human populations. Studies in evolutionary medicine indicate that as cultural evolution outpaces biological evolution, disorders linked to bodily dysfunction increase in prevalence due to lack of contact with pathogens and negative environmental conditions that once widely affected ancestral populations. Because natural selection favors reproduction over health and longevity, the lack of this impetus to adapt to certain harmful circumstances creates a tendency for genes in descendant populations to over-express themselves, which may cause a wide array of maladies, ranging from mental disorders to autoimmune diseases. Conversely, noting the failure to find specific alleles that reliably cause autism or rare mutations that account for more than 5% of the heritable variation in autism established by twin and adoption studies, research in evolutionary psychiatry has concluded that it is unlikely that there is selection pressure for autism when considering that, like schizophrenics, autistic people and their siblings tend to have fewer offspring on average than non-autistic people, and instead that autism is probably better explained as a by-product of adaptive traits caused by antagonistic pleiotropy and by genes that are retained due to a fitness landscape with an asymmetric distribution. Pathophysiology Diagnosis Conditions correlated or comorbid to autism Autism is correlated or comorbid with several personality traits/disorders. Comorbidity may increase with age and may worsen the course of youth with ASDs and make intervention and treatment more difficult. Distinguishing between ASDs and other diagnoses can be challenging because the traits of ASDs often overlap with symptoms of other disorders, and the characteristics of ASDs make traditional diagnostic procedures difficult. Correlations Research indicates that autistic people are significantly more likely to be LGBT than the general population. There is tentative evidence that gender dysphoria occurs more frequently in autistic people. A 2021 anonymized online survey of 16- to 90-year-olds revealed that autistic males are more likely to identify as bisexual than their non-autistic peers, while autistic females are more likely to identify as homosexual than non-autistic females do. People on the autism spectrum are significantly more likely to be non-theistic than members of the general population. Comorbidities The most common medical condition occurring in autistic people is seizure disorder or epilepsy, which occurs in 11–39% of autistic people. The risk varies with age, cognitive level, and type of language disorder. Tuberous sclerosis, an autosomal dominant genetic condition in which non-malignant tumors grow in the brain and on other vital organs, is present in 1–4% of autistic people. Intellectual disabilities are some of the most common comorbid disorders with ASDs. As diagnosis is increasingly being given to people with higher functioning autism, there is a tendency for the proportion with comorbid intellectual disability to decrease over time. In a 2019 study, it was estimated that approximately 30–40% of people diagnosed with ASD also have intellectual disability. Recent research has suggested that autistic people with intellectual disability tend to have rarer, more harmful, genetic mutations than those found in people solely diagnosed with autism. A number of genetic syndromes causing intellectual disability may also be comorbid with ASD, including fragile X, Down, Prader-Willi, Angelman, Williams syndrome, branched-chain keto acid dehydrogenase kinase deficiency, and SYNGAP1-related intellectual disability. Learning disabilities are also highly comorbid in people with an ASD. Approximately 25–75% of people with an ASD also have some degree of a learning disability. In particular, attention deficit disorder, which is generally more prevalent than autism (ca. 8% vs. 1%), is not directly related, though it is sometimes comorbid with autism. Various anxiety disorders tend to co-occur with ASDs, with overall comorbidity rates of 7–84%. They are common among children with ASD; there are no firm data, but studies have reported prevalences ranging from 11% to 84%. Many anxiety disorders have symptoms that are better explained by ASD itself or are hard to distinguish from ASD's symptoms. Rates of comorbid depression in people with an ASD range from 4–58%. The relationship between ASD and schizophrenia remains a controversial subject under continued investigation, and recent meta-analyses have examined genetic, environmental, infectious, and immune risk factors that may be shared between the two conditions. Oxidative stress, DNA damage and DNA repair have been postulated to play a role in the aetiopathology of both ASD and schizophrenia. Deficits in ASD are often linked to behavior problems, such as difficulties following directions, being cooperative, and doing things on other people's terms. Symptoms similar to those of attention deficit hyperactivity disorder (ADHD) can be part of an ASD diagnosis. Sensory processing disorder is also comorbid with ASD, with comorbidity rates of 42–88%. Starting in adolescence, some people with Asperger syndrome (26% in one sample) fall under the criteria for the similar condition schizoid personality disorder, which is characterized by a lack of interest in social relationships, a tendency towards a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment and apathy. Asperger syndrome was traditionally called "schizoid disorder of childhood". Genetic disorders – about 10–15% of autism cases have an identifiable Mendelian (single-gene) condition, chromosome abnormality, or other genetic syndromes. Several metabolic defects, such as phenylketonuria, are associated with autistic symptoms. Gastrointestinal problems are one of the most commonly co-occurring medical conditions in autistic people. These are linked to greater social impairment, irritability, language impairments, mood changes, and behavior and sleep problems. A 2015 review proposed that immune, gastrointestinal inflammation, malfunction of the autonomic nervous system, gut flora alterations, and food metabolites may cause brain neuroinflammation and dysfunction. A 2016 review concludes that enteric nervous system abnormalities might play a role in neurological disorders such as autism. Neural connections and the immune system are a pathway that may allow diseases originated in the intestine to spread to the brain. Sleep problems affect about two-thirds of autistic people at some point in childhood. These most commonly include symptoms of insomnia, such as difficulty falling asleep, frequent nocturnal awakenings, and early morning awakenings. Sleep problems are associated with difficult behaviors and family stress, and are often a focus of clinical attention over and above the primary ASD diagnosis. Dysautonomia is common in ASD, affecting heart rate and blood pressure and causing symptoms such as brain fog, blurry vision, and bowel dysfunction. It can be diagnosed through a Tilt table test. The frequency of ASD is 10 times higher in mast cell activation syndrome patients than in the general population. This immunological condition causes cardiovascular, dermatological, gastrointestinal, neurological, and respiratory problems. Management There is no treatment as such for autism, and many sources advise that this is not an appropriate goal, although treatment of co-occurring conditions remains an important goal. There is no cure for autism, nor can any of the known treatments significantly reduce brain mutations caused by autism, although those who require little to no support are more likely to experience a lessening of symptoms over time. Several interventions can help children with autism, and no single treatment is best, with treatment typically tailored to the child's needs. Studies of interventions have methodological problems that prevent definitive conclusions about efficacy, but the development of evidence-based interventions has advanced. The main goals of treatment are to lessen associated deficits and family distress, and to increase quality of life and functional independence. In general, higher IQs are correlated with greater responsiveness to treatment and improved treatment outcomes. Behavioral, psychological, education, and skill-building interventions may be used to assist autistic people to learn life skills necessary for living independently, as well as other social, communication, and language skills. Therapy also aims to reduce challenging behaviors and build upon strengths. Intensive, sustained special education programs and behavior therapy early in life may help children acquire self-care, language, and job skills. Although evidence-based interventions for autistic children vary in their methods, many adopt a psychoeducational approach to enhancing cognitive, communication, and social skills while minimizing problem behaviors. While medications have not been found to help with core symptoms, they may be used for associated symptoms, such as irritability, inattention, or repetitive behavior patterns. Non-pharmacological interventions Intensive, sustained special education or remedial education programs and behavior therapy early in life may help children acquire self-care, social, and job skills. Available approaches include applied behavior analysis, developmental models, structured teaching, speech and language therapy, cognitive behavioral therapy, social skills therapy, and occupational therapy. Among these approaches, interventions either treat autistic features comprehensively, or focus treatment on a specific area of deficit. Generally, when educating those with autism, specific tactics may be used to effectively relay information to these people. Using as much social interaction as possible is key in targeting the inhibition autistic people experience concerning person-to-person contact. Additionally, research has shown that employing semantic groupings, which involves assigning words to typical conceptual categories, can be beneficial in fostering learning. There has been increasing attention to the development of evidence-based interventions for autistic young children. Three theoretical frameworks outlined for early childhood intervention include applied behavior analysis (ABA), the developmental social-pragmatic model (DSP) and cognitive behavioral therapy (CBT). Although ABA therapy has a strong evidence base, particularly in regard to early intensive home-based therapy, ABA's effectiveness may be limited by diagnostic severity and IQ of the person affected by ASD. The Journal of Clinical Child and Adolescent Psychology has published a paper deeming two early childhood interventions "well-established": individual comprehensive ABA, and focused teacher-implemented ABA combined with DSP. Many people, including autistic adults, have criticized ABA, calling it unhelpful, unethical, and even abuse. Autistic scholar Nick Walker, who experienced ABA as a child, has said that, through ABA, autistic children are "abused, coerced, and traumatized into imitating the outward behavior of neurotypical children, at the expense of their long-term psychological well-being." Sandoval-Norton et al. also discuss the "unintended but damaging consequences, such as prompt dependency, psychological abuse and compliance" that result in autistic people facing challenges as they transition into adulthood. Some ABA advocates have responded to such critiques that, instead of stopping ABA, there should be movement to increase protections and ethical compliance when working with autistic children. Another evidence-based intervention that has demonstrated efficacy is a parent training model, which teaches parents how to implement various ABA and DSP techniques themselves. Various DSP programs have been developed to explicitly deliver intervention systems through at-home parent implementation. In October 2015, the American Academy of Pediatrics (AAP) proposed new evidence-based recommendations for early interventions in ASD for children under 3. These recommendations emphasize early involvement with both developmental and behavioral methods, support by and for parents and caregivers, and a focus on both the core and associated symptoms of ASD. But a Cochrane review found no evidence that early intensive behavioral intervention (EIBI) is effective in reducing behavioral problems associated with autism in most autistic children, though it did improve IQ and language skills. The Cochrane review acknowledged that this may be due to the low quality of studies available on EIBI and therefore providers should recommend EIBI based on their clinical judgment and the family's preferences. No adverse effects of EIBI treatment were found. A meta-analysis in that same database indicates that due to the heterology in ASD, children progress to differing early intervention modalities based on ABA. ASD treatment generally focuses on behavioral and educational interventions to target its two core symptoms: social communication deficits and restricted, repetitive behaviors. If symptoms continue after behavioral strategies have been implemented, some medications can be recommended to target specific symptoms or co-existing problems such as restricted and repetitive behaviors (RRBs), anxiety, depression, hyperactivity/inattention and sleep disturbance. Melatonin, for example, can be used for sleep problems. Several parent-mediated behavioral therapies target social communication deficits in children with autism, but their efficacy in treating RRBs is uncertain. Education Educational interventions often used include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy and social skills therapy. Among these approaches, interventions either treat autistic features comprehensively, or focalize treatment on a specific area of deficit. The quality of research for early intensive behavioral intervention (EIBI)—a treatment procedure incorporating over 30 hours per week of the structured type of ABA that is carried out with very young children—is low; more vigorous research designs with larger sample sizes are needed. Two theoretical frameworks outlined for early childhood intervention include structured and naturalistic ABA interventions, and developmental social pragmatic models (DSP). One interventional strategy utilizes a parent training model, which teaches parents how to implement various ABA and DSP techniques, allowing for parents to disseminate interventions themselves. Various DSP programs have been developed to explicitly deliver intervention systems through at-home parent implementation. Despite the recent development of parent training models, these interventions have demonstrated effectiveness in numerous studies, being evaluated as a probable efficacious mode of treatment. Early, intensive ABA therapy has demonstrated effectiveness in enhancing communication and adaptive functioning in preschool children; it is also well-established for improving the intellectual performance of that age group. In 2018, a Cochrane meta-analysis database concluded that some recent research is beginning to suggest that because of the heterology of ASD, there are two different ABA teaching approaches to acquiring spoken language: children with higher receptive language skills respond to 2.5 to 20 hours per week of the naturalistic approach, whereas children with lower receptive language skills require 25 hours per week of discrete trial training—the structured and intensive form of ABA. A 2023 randomized control trial study of 164 participants showed similar findings. Similarly, a teacher-implemented intervention that utilizes a more naturalistic form of ABA combined with a developmental social pragmatic approach has been found to be beneficial in improving social-communication skills in young children, although there is less evidence in its treatment of global symptoms. Neuropsychological reports are often poorly communicated to educators, resulting in a gap between what a report recommends and what education is provided. The appropriateness of including children with varying severity of autism spectrum disorders in the general education population is a subject of current debate among educators and researchers. Pharmacological interventions Medications may be used to treat ASD symptoms that interfere with integrating a child into home or school when behavioral treatment fails. They may also be used for associated health problems, such as ADHD, anxiety, or if the person is hurting themself or aggressive with others, but their routine prescription for ASD's core features is not recommended. More than half of US children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics. The atypical antipsychotic drugs risperidone and aripiprazole are FDA-approved for treating associated aggressive and self-injurious behaviors. But their side effects must be weighed against their potential benefits, and autistic people may respond atypically. Side effects may include weight gain, tiredness, drooling, and paradoxical aggression. Some emerging data show positive effects of aripiprazole and risperidone on restricted and repetitive behaviors (i.e., stimming; e.g., flapping, twisting, complex whole-body movements), but due to the small sample size and different focus of these studies and the concerns about their side effects, antipsychotics are not recommended as primary treatment of RRBs. SSRI antidepressants, such as fluoxetine and fluvoxamine, have been shown to be effective in reducing repetitive and ritualistic behaviors, while the stimulant medication methylphenidate is beneficial for some children with comorbid inattentiveness or hyperactivity. There is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD. No known medication is approved for treating autism's core symptoms of social and communication impairments, although animal models indicate that postnatal administration of MDMA may be effective. MDMA has also been investigated alongside psychotherapy to treat social anxiety in autistic adults. Alternative medicine A multitude of alternative therapies have been researched and implemented, and many have resulted in harm to autistic people. A 2020 systematic review on adults with autism provided evidence that mindfulness-based interventions may decrease stress, anxiety, ruminating thoughts, anger, and aggression and improve mental health. Although popularly used as an alternative treatment for autistic people, there is no good evidence to recommend a gluten- and casein-free diet as a standard treatment. A 2018 review concluded that it may be a therapeutic option for specific groups of children with autism, such as those with known food intolerances or allergies, or with food intolerance markers. The authors analyzed the prospective trials conducted to date that studied the efficacy of the gluten- and casein-free diet in children with ASD (4 in total). All of them compared gluten- and casein-free diet versus normal diet with a control group (2 double-blind randomized controlled trials, 1 double-blind crossover trial, 1 single-blind trial). In two of the studies, whose duration was 12 and 24 months, a significant improvement in ASD symptoms (efficacy rate 50%) was identified. In the other two studies, whose duration was 3 months, no significant effect was observed. The authors concluded that a longer duration of the diet may be necessary to achieve the improvement of the ASD symptoms. Other problems documented in the trials carried out include transgressions of the diet, small sample size, the heterogeneity of the participants and the possibility of a placebo effect. In the subset of people who have gluten sensitivity there is limited evidence that suggests that a gluten-free diet may improve some autistic behaviors. The preference that autistic children have for unconventional foods can lead to reduction in bone cortical thickness with this risk being greater in those on casein-free diets, as a consequence of the low intake of calcium and vitamin D; however, suboptimal bone development in ASD has also been associated with lack of exercise and gastrointestinal disorders. In 2005, botched chelation therapy killed a five-year-old child with autism. Chelation is not recommended for autistic people since the associated risks outweigh any potential benefits. Another alternative medicine practice with no evidence is CEASE therapy, a pseudoscientific mixture of homeopathy, supplements, and "vaccine detoxing". Results of a systematic review on interventions to address health outcomes among autistic adults found emerging evidence to support mindfulness-based interventions for improving mental health. This includes decreasing stress, anxiety, ruminating thoughts, anger, and aggression. An updated Cochrane review (2022) found evidence that music therapy likely improves social interactions, verbal communication, and nonverbal communication skills. There has been early research on hyperbaric treatments in children with autism. Studies on pet therapy have shown positive effects. Prevention While infection with rubella during pregnancy causes fewer than 1% of cases of autism, vaccination against rubella can prevent many of those cases. Prognosis There is no evidence of a cure for autism. The degree of symptoms can decrease, occasionally to the extent that people lose their diagnosis of ASD; this occurs sometimes after intensive treatment and sometimes not. It is not known how often this outcome happens, with reported rates in unselected samples ranging from 3% to 25%. Although core difficulties tend to persist, symptoms often become less severe with age. Acquiring language before age six, having an IQ above 50, and having a marketable skill all predict better outcomes; independent living is unlikely in autistic people with higher support needs. Among others, academic Temple Grandin has advised against striving to cure autism, saying that if a cure were found, she would choose to stay the way she is. She wrote, "The skills that people with autism bring to the table should be nurtured for their benefit and [for the benefit of] society", adding, "If you totally get rid of autism, you'd have nobody to fix your computer in the future". The prognosis of autism describes the developmental course, gradual autism development, regressive autism development, differential outcomes, academic performance and employment. Epidemiology The World Health Organization (WHO) estimates about 1 in 100 children had autism during the period from 2012 to 2021 as that was the average estimate in studies published during that period with a trend of increasing prevalence over time. However, the study's 1% figure may reflect an underestimate of prevalence in low- and middle-income countries. The number of people diagnosed has increased considerably since the 1990s, which may be partly due to increased recognition of the condition. While rates of ASD are consistent across cultures, they vary greatly by gender, with boys diagnosed far more frequently than girls: 1 in 70 boys, but only 1 in 315 girls at eight years of age. Girls, however, are more likely to have associated cognitive impairment, suggesting that less severe forms of ASD are likely being missed in girls and women. Prevalence differences may be a result of gender differences in expression of clinical symptoms, with women and girls with autism showing less atypical behaviors and, therefore, less likely to receive an ASD diagnosis. Using DSM-5 criteria, 92% of the children diagnosed per DSM-IV with one of the disorders which is considered part of ASD will still meet the diagnostic criteria of ASD. However, if both ASD and the social (pragmatic) communication disorder categories of DSM-5 are combined, the prevalence of autism is mostly unchanged from the prevalence per the DSM-IV criteria. The best estimate for prevalence of ASD is 0.7% or 1 child in 143 children. Relatively mild forms of autism, such as Asperger's as well as other developmental disorders, are included in the DSM-5 diagnostic criteria. ASD rates were constant between 2014 and 2016 but twice the rate compared to the time period between 2011 and 2014 (1.25 vs 2.47%). A Canadian meta-analysis from 2019 confirmed these effects as the profiles of autistic people became less and less different from the profiles of the general population. In the US, the rates for diagnosed ASD have been steadily increasing since 2000 when records began being kept. While it remains unclear whether this trend represents a true rise in incidence, it likely reflects changes in ASD diagnostic criteria, improved detection, and increased public awareness of autism. In 2012, the NHS estimated that the overall prevalence of autism among adults aged 18 years and over in the UK was 1.1%. A 2016 survey in the United States reported a rate of 25 per 1,000 children for ASD. Rates of autism are poorly understood in many low- and middle-income countries, which affects the accuracy of global ASD prevalence estimates, but it is thought that most autistic people live in low- and middle-income countries. In 2020, the Centers for Disease Control's Autism and Developmental Disabilities Monitoring (ADDM) Network reported that approximately 1 in 54 children in the United States (1 in 34 boys, and 1 in 144 girls) is diagnosed with an autism spectrum disorder (ASD), based on data collected in 2016. This estimate is a 10% increase from the 1 in 59 rate in 2014, a 105% increase from the 1 in 110 rate in 2006, and a 176% increase from the 1 in 150 rate in 2000. Diagnostic criteria for ASD have changed significantly since the 1980s; for example, U.S. special-education autism classification was introduced in 1994. In the UK, from 1998 to 2018, the autism diagnoses increased by 787%. This increase is largely attributable to changes in diagnostic practices, referral patterns, availability of services, age at diagnosis, and public awareness (particularly among women), though unidentified environmental risk factors cannot be ruled out. The available evidence does not rule out the possibility that autism's true prevalence has increased; a real increase would suggest directing more attention and funding toward psychosocial factors and changing environmental factors instead of continuing to focus on genetics. It has been established that vaccination is not a risk factor for autism and is not a cause of any increase in autism prevalence rates, if any change in the rate of autism exists at all. Males have higher likelihood of being diagnosed with ASD than females. The sex ratio averages 4.3:1 and is greatly modified by cognitive impairment: it may be close to 2:1 with intellectual disability and more than 5.5:1 without. Several theories about the higher prevalence in males have been investigated, but the cause of the difference is unconfirmed; one theory is that females are underdiagnosed. The risk of developing autism is greater with older fathers than with older mothers; two potential explanations are the known increase in mutation burden in older sperm, and the hypothesis that men marry later if they carry genetic liability and show some signs of autism. Most professionals believe that race, ethnicity, and socioeconomic background do not affect the occurrence of autism. History Society and culture An autistic culture has emerged, accompanied by the autistic rights and neurodiversity movements, that argues autism should be accepted as a difference to be accommodated instead of cured, although a minority of autistic people might still accept a cure. Worldwide, events related to autism include World Autism Awareness Day, Autism Sunday, Autistic Pride Day, Autreat, and others. Social-science scholars study those with autism in hopes to learn more about "autism as a culture, transcultural comparisons ... and research on social movements." Many autistic people have been successful in their fields. Special interests are commonly found in autistic people, sometimes leading to hobbies, vast collections, and activism. Environmental activist Greta Thunberg has spoken favorably about her autism diagnosis, saying that autism can be a source of life purpose, as well as forming the basis of careers, hobbies, and friendships. Neurodiversity movement Some autistic people, as well as a growing number of researchers, have advocated a shift in attitudes toward the view that autism spectrum disorder is a difference, rather than a disease that must be treated or cured. Critics have bemoaned the entrenchment of some of these groups' opinions. The neurodiversity movement and the autism rights movement are social movements within the context of disability rights, emphasizing the concept of neurodiversity, which describes the autism spectrum as a result of natural variations in the human brain rather than a disorder to be cured. The autism rights movement advocates including greater acceptance of autistic behaviors; therapies that focus on coping skills rather than imitating the behaviors of those without autism; and the recognition of the autistic community as a minority group. Autism rights or neurodiversity advocates believe that the autism spectrum is genetic and should be accepted as a natural variation in the human genome. These movements are not without detractors; a common argument against neurodiversity activists is that most of them have relatively low support needs, or are self-diagnosed, and do not represent the views of autistic people with higher support needs. Jacquiline den Houting explores this critique, determining that the voices of low-support needs autistics are "some of the most influential within the neurodiversity movement, although admittedly these voices are a minority within the advocacy community"; she suggests this is in part a shortcoming of the wider neurotypical community, referencing nonspeaking self-advocate Amy Sequenzia's writing. Pier Jaarsma and Stellan Welin make the argument that only high-functioning autistic people should be included under the neurodiversity banner, as low-functioning autists' condition may rightfully be viewed as a disability. The concept of neurodiversity is contentious in autism advocacy and research groups and has led to infighting. Events Since 2011, the Autistic Self Advocacy Network has celebrated April as Autism Acceptance Month. In 2021, the Autism Society of America urged organizations to retitle Autism Awareness Day as Autism Acceptance Day, to focus on "more fully integrating those 1 in 54 Americans living with autism into our social fabric". Symbols and flags Symbols Over the years, multiple organizations have tried to capture the essence of autism in symbols. In 1963, the board for the National Autistic Society, led by Gerald Gasson, proposed the "puzzle piece" as a symbol for autism, because it fit their view of autism as a "puzzling condition". In 1999, the Autism Society adopted the puzzle ribbon as the universal sign of autism awareness. As of 2023, the puzzle ribbon has negative associations, such as "implications of autistic people as incomplete and...association with autism hate groups". In 2004, neurodiversity advocates Amy and Gwen Nelson conjured the "rainbow infinity symbol". It was initially the logo for their website, Aspies For Freedom. Nowadays, the prismatic colors are often associated with the neurodiversity movement in general. The autism spectrum has also been symbolized by the infinity symbol itself. In 2018, Julian Morgan wrote the article "Light It Up Gold", a response to Autism Speaks' "Light It Up Blue" campaign, launched in 2007. Aurum is Latin for gold, and gold has been used to symbolize autism, since both words start with "Au". The flag implements a gradient to represent the Pride Movement and incorporates a golden infinity symbol as its focal point. Flags An autistic pride flag was created in 2005 by Aspies For Freedom for the first Autistic Pride Day, featuring a rainbow infinity symbol on a white background. As the rainbow infinity on a white background has become increasingly viewed as representative of neurodiversity in general, several designs have been proposed for an autistic-specific flag. In 2023, the People's History Museum featured a 2015 autistic pride design by Joseph Redford, featuring a rainbow infinity symbol, a green background for being true to one's nature, and a purple background for neurodiversity. Caregivers Families who care for an autistic child face added stress from a number of different causes. Parents may struggle to understand the diagnosis and to find appropriate care options. They often take a negative view of the diagnosis, and may struggle emotionally. More than half of parents over age 50 are still living with their child, as about 85% of autistic people have difficulties living independently. Some studies also find decreased earnings among parents who care for autistic children. Siblings of children with ASD report greater admiration and less conflict with the affected sibling than siblings of unaffected children, like siblings of children with Down syndrome. But they reported lower levels of closeness and intimacy than siblings of children with Down syndrome; siblings of autistic people have a greater risk of negative well-being and poorer sibling relationships as adults. See also Outline of autism Animal model of autism Autism and memory Autism in popular culture Autistic art Controversies in autism Global perceptions of autism List of autistic fictional characters List of films about autism Violence and autism Notes References Sources Further reading Gabovitch, Elaine; Dutra, Courtney; Lauer, Emily. (2016). The Healthy People 2020 Roadmap for Massachusetts Children & Youth with ASD/DD: Understanding Needs and Measuring Outcomes (Report). Worcester: UMass Chan Medical School. Retrieved 30 June 2022. eISSN 1873-3379 External links WHO fact sheet on autism Autism spectrum disorders Developmental psychology Learning disabilities

Dysthymia

Dysthymia, also known as persistent depressive disorder (PDD), is a mental and behavioral disorder, specifically a disorder primarily of mood, consisting of similar cognitive and physical problems as major depressive disorder, but with longer-lasting symptoms. The concept was used by Robert Spitzer as a replacement for the term "depressive personality" in the late 1970s. In the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), dysthymia is a serious state of chronic depression, which persists for at least two years (one year for children and adolescents). Dysthymia is not a minor form of major depressive disorder, and for some may be more disabling. As dysthymia is a chronic disorder, those with the condition may experience symptoms for many years before it is diagnosed, if diagnosis occurs at all. As a result, they may believe that depression is a part of their character, so they may not even discuss their symptoms with doctors, family members or friends. In the DSM-5, dysthymia is replaced by persistent depressive disorder. This new condition includes both chronic major depressive disorder and the previous dysthymic disorder. The reason for this change is that there was no evidence for meaningful differences between these two conditions. Signs and symptoms Dysthymia characteristics include an extended period of depressed mood combined with at least two other symptoms which may include insomnia or hypersomnia, fatigue or low energy, eating changes (more or less), low self-esteem, or feelings of hopelessness. Poor concentration or difficulty making decisions are treated as another possible symptom. Irritability is one of the more common symptoms in children and adolescents. Mild degrees of dysthymia may result in people withdrawing from stress and avoiding opportunities for failure. In more severe cases of dysthymia, people may withdraw from daily activities. They will usually find little pleasure in usual activities and pastimes. Diagnosis of dysthymia can be difficult because of the subtle nature of the symptoms and patients can often hide them in social situations, making it challenging for others to detect symptoms. Additionally, dysthymia often occurs at the same time as other psychological disorders, which adds a level of complexity in determining the presence of dysthymia, particularly because there is often an overlap in the symptoms of disorders. There is a high incidence of comorbid illness in those with dysthymia. Suicidal behavior is also a particular problem with those with dysthymia. It is vital to look for signs of major depression, panic disorder, generalised anxiety disorder, alcohol and substance use disorders, and personality disorder. Causes There are no known biological causes that apply consistently to all cases of dysthymia, which suggests diverse origin of the disorder. However, there are some indications that there is a genetic predisposition to dysthymia: "The rate of depression in the families of people with dysthymia is as high as fifty percent for the early-onset form of the disorder". Other factors linked with dysthymia include stress, social isolation, and lack of social support. In a study using identical and fraternal twins, results indicated that there is a stronger likelihood of identical twins both having depression than fraternal twins. This provides support for the idea that dysthymia is in part hereditary. Co-occurring conditions Dysthymia often co-occurs with other mental disorders. A "double depression" is the occurrence of episodes of major depression in addition to dysthymia. Switching between periods of dysthymic moods and periods of hypomanic moods is indicative of cyclothymia, which is a mild variant of bipolar disorder. "At least three-quarters of patients with dysthymia also have a chronic physical illness or another psychiatric disorder such as one of the anxiety disorders, cyclothymia, drug addiction, or alcoholism". Common co-occurring conditions include major depression (up to 75%), anxiety disorders (up to 50%), personality disorders (up to 40%), somatoform disorders (up to 45%) and substance use disorders (up to 50%). People with dysthymia have a higher-than-average chance of developing major depression. A 10-year follow-up study found that 95% of dysthymia patients had an episode of major depression. When an intense episode of depression occurs on top of dysthymia, the state is called "double depression." Double depression Double depression occurs when a person experiences a major depressive episode on top of the already-existing condition of dysthymia. It is difficult to treat, as patients accept these major depressive symptoms as a natural part of their personality or as a part of their life that is outside of their control. The fact that people with dysthymia may accept these worsening symptoms as inevitable can delay treatment. When and if such people seek out treatment, the treatment may not be very effective if only the symptoms of the major depression are addressed, but not the dysthymic symptoms. Patients with double depression tend to report significantly higher levels of hopelessness than is normal. This can be a useful symptom for mental health services providers to focus on when working with patients to treat the condition. Additionally, cognitive therapies can be effective for working with people with double depression in order to help change negative thinking patterns and give individuals a new way of seeing themselves and their environment. It has been suggested that the best way to prevent double depression is by treating the dysthymia. A combination of antidepressants and cognitive therapies can be helpful in preventing major depressive symptoms from occurring. Additionally, exercise and good sleep hygiene (e.g., improving sleep patterns) are thought to have an additive effect on treating dysthymic symptoms and preventing them from worsening. Pathophysiology There is evidence that there may be neurological indicators of early onset dysthymia. There are several brain structures (corpus callosum and frontal lobe) that are different in women with dysthymia than in those without dysthymia. This may indicate that there is a developmental difference between these two groups. Another study, which used fMRI techniques to assess the differences between individuals with dysthymia and other people, found additional support for neurological indicators of the disorder. This study found several areas of the brain that function differently. The amygdala (associated with processing emotions such as fear) was more activated in dysthymia patients. The study also observed increased activity in the insula (which is associated with sad emotions). Finally, there was increased activity in the cingulate gyrus (which serves as the bridge between attention and emotion). A study comparing healthy individuals to people with dysthymia indicates there are other biological indicators of the disorder. An anticipated result appeared as healthy individuals expected fewer negative adjectives to apply to them, whereas people with dysthymia expected fewer positive adjectives to apply to them in the future. Biologically these groups are also differentiated in that healthy individuals showed greater neurological anticipation for all types of events (positive, neutral, or negative) than those with dysthymia. This provides neurological evidence of the dulling of emotion that individuals with dysthymia have learned to use to protect themselves from overly strong negative feelings, compared to healthy people. There is some evidence of a genetic basis for all types of depression, including dysthymia. A study using identical and fraternal twins indicated that there is a stronger likelihood of identical twins both having depression than fraternal twins. This provides support for the idea that dysthymia is caused in part by heredity. A new model has recently surfaced in the literature regarding the HPA axis (structures in the brain that get activated in response to stress) and its involvement with dysthymia (e.g. phenotypic variations of corticotropin releasing hormone (CRH) and arginine vasopressin (AVP), and down-regulation of adrenal functioning) as well as forebrain serotonergic mechanisms. Since this model is highly provisional, further research is still needed. Diagnosis The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), published by the American Psychiatric Association, characterizes dysthymic disorder. The essential symptom involves the individual feeling depressed for the majority of days, and parts of the day, for at least two years. Low energy, disturbances in sleep or in appetite, and low self-esteem typically contribute to the clinical picture as well. Those with the condition have often experienced dysthymia for many years before it is diagnosed. People around them often describe them in words similar to "just a moody person". The following are the diagnostic criteria: During a majority of days for two years or more, the adult patient reports depressed mood, or appears depressed to others for most of the day. When depressed, the patient has two or more of: decreased or increased appetite; decreased or increased sleep (insomnia or hypersomnia); fatigue or low energy; reduced self-esteem; decreased concentration or problems making decisions; feelings of hopelessness or pessimism. During this two-year period, the above symptoms are never absent longer than two consecutive months. During the duration of the two-year period, the patient may have had a perpetual major depressive episode. The patient has not had any manic, hypomanic, or mixed episodes. The patient has never fulfilled criteria for cyclothymic disorder. The depression does not exist only as part of a chronic psychosis (such as schizophrenia or delusional disorder). The symptoms are often not directly caused by a medical illness or by substances, including substance use or other medications. The symptoms may cause significant problems or distress in social, work, academic, or other major areas of life functioning. In children and adolescents, mood can be irritable, and duration must be at least one year, in contrast to two years needed for diagnosis in adults. Early onset (diagnosis before age 21) is associated with more frequent relapses, psychiatric hospitalizations, and more co-occurring conditions. For younger adults with dysthymia, there is a higher co-occurrence in personality abnormalities and the symptoms are likely chronic. However, in older adults with dysthymia, the psychological symptoms are associated with medical conditions and/or stressful life events and losses. Dysthymia can be contrasted with major depressive disorder by assessing the acute nature of the symptoms. Dysthymia is far more chronic (long lasting) than major depressive disorder, in which symptoms may be present for as little as two weeks. Also dysthymia often presents itself at an earlier age than major depressive disorder. Prevention Though there is no clear-cut way to prevent dysthymia from occurring, there are some suggestions to help reduce its effects. Since dysthymia often appears first in childhood, it is important to identify children who may be at risk. It may be beneficial to work with children in helping to control their stress, increase resilience, boost self-esteem, and provide strong social support networks. These tactics may be helpful in warding off or delaying dysthymic symptoms. Treatments Persistent depressive disorder can be treated with psychotherapy and pharmacotherapy. The overall rate and degree of treatment success is somewhat lower than for non-chronic depression, and a combination of psychotherapy and pharmacotherapy shows best results. Therapy Psychotherapy can be effective in treating dysthymia. In a meta-analytic study from 2010, psychotherapy had a small but significant effect when compared to control groups. However, psychotherapy is significantly less effective than pharmacotherapy in direct comparisons. There are many different types of therapy, and some are more effective than others. The empirically most studied type of treatment is cognitive-behavioral therapy. This type of therapy is very effective for non-chronic depression, and it appears to be also effective for chronic depression. Cognitive behavioral analysis system of psychotherapy (CBASP) has been designed specifically to treat PDD. Empirical results on this form of therapy are inconclusive: While one study showed remarkably high treatment success rates, a later, even larger study showed no significant benefit of adding CBASP to treatment with antidepressants. Schema therapy and psychodynamic psychotherapy have been used for PDD, though good empirical results are lacking. Interpersonal psychotherapy has also been said to be effective in treating the disorder, though it only shows marginal benefit when added to treatment with antidepressants. Medications In a 2010 meta-analysis, the benefit of pharmacotherapy was limited to selective serotonin reuptake inhibitors (SSRIs) rather than tricyclic antidepressants (TCA). According to a 2014 meta-analysis, antidepressants are at least as effective for persistent depressive disorder as for major depressive disorder. The first line of pharmacotherapy is usually SSRIs due to their purported more tolerable nature and reduced side effects compared to the irreversible monoamine oxidase inhibitors or tricyclic antidepressants. Studies have found that the mean response to antidepressant medications for people with dysthymia is 55%, compared with a 31% response rate to a placebo. The most commonly prescribed antidepressants/SSRIs for dysthymia are escitalopram, citalopram, sertraline, fluoxetine, paroxetine, and fluvoxamine. It often takes an average of 6–8 weeks before the patient begins to feel these medications' therapeutic effects. Additionally, STAR*D, a multi-clinic governmental study, found that people with overall depression will generally need to try different brands of medication before finding one that works specifically for them. Research shows that 1 in 4 of those who switch medications get better results regardless of whether the second medication is an SSRI or some other type of antidepressant. In a meta-analytic study from 2005, it was found that SSRIs and TCAs are equally effective in treating dysthymia. They also found that MAOIs have a slight advantage over the use of other medication in treating this disorder. However, the author of this study cautions that MAOIs should not necessarily be the first line of defense in the treatment of dysthymia, as they are often less tolerable than their counterparts, such as SSRIs. Tentative evidence supports the use of amisulpride to treat dysthymia but with increased side effects. Combination treatment When pharmacotherapy alone is compared with combined treatment with pharmacotherapy plus psychotherapy, there is a strong trend in favour of combined treatment. Working with a psychotherapist to address the causes and effects of the disorder, in addition to taking antidepressants to help eliminate the symptoms, can be extremely beneficial. This combination is often the preferred method of treatment for those who have dysthymia. Looking at various studies involving treatment for dysthymia, 75% of people responded positively to a combination of cognitive behavioral therapy (CBT) and pharmacotherapy, whereas only 48% of people responded positively to just CBT or medication alone. A 2019 Cochrane review of 10 studies involving 840 participants could not conclude with certainty that continued pharmacotherapy with antidepressants (those used in the studies) was effective in preventing relapse or recurrence of persistent depressive disorder. The body of evidence was too small for any greater certainty although the study acknowledges that continued psychotherapy may be beneficial when compared to no treatment. Treatment resistance Because of dysthymia's chronic nature, treatment resistance is somewhat common. In such a case, augmentation is often recommended. Such treatment augmentations can include lithium pharmacology, thyroid hormone augmentation, amisulpride, buspirone, bupropion, guanfacine, stimulants, and mirtazapine. Additionally, if the person also has seasonal affective disorder, light therapy can be useful in helping augment therapeutic effects. Epidemiology Globally dysthymia occurs in about 105 million people a year (1.5% of the population). It is 38% more common in women (1.8% of women) than in men (1.3% of men). The lifetime prevalence rate of dysthymia in community settings appears to range from 3 to 6% in the United States. However, in primary care settings the rate is higher ranging from 5 to 15 percent. United States prevalence rates tend to be somewhat higher than rates in other countries. See also Anhedonia, a symptom of dysthymia characterized by a decreased or absent ability to experience a sense of pleasure Atypical depression Depression (mood) Major depressive disorder Cyclothymia Blunted affect, a symptom of PTSD, schizophrenia, and ASPD involving decreased or absent emotional response Dysphoria, a state of feeling unwell, unhappy or sad Epigenetics of depression List of medications used to treat major depressive disorder or dysthymia Endorphins References External links NIMH Depression Page Bipolar spectrum Depression (mood) Mood disorders

Digital media use and mental health

The relationships between digital media use and mental health have been investigated by various researchers—predominantly psychologists, sociologists, anthropologists, and medical experts—especially since the mid-1990s, after the growth of the World Wide Web and rise of text messaging. A significant body of research has explored "overuse" phenomena, commonly known as "digital addictions", or "digital dependencies". These phenomena manifest differently in many societies and cultures. Some experts have investigated the benefits of moderate digital media use in various domains, including in mental health, and the treatment of mental health problems with novel technological solutions. The delineation between beneficial and pathological use of digital media has not been established. There are no widely accepted diagnostic criteria, although some experts consider overuse a manifestation of underlying psychiatric disorders. The prevention and treatment of pathological digital media use is also not standardized, although guidelines for safer media use for children and families have been developed. The 2013 fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-11) do not include diagnoses for problematic internet use and problematic social media use; the ICD-11 includes a diagnosis for gaming disorder (commonly known as video game addiction), whereas the DSM-5 does not. Debate over how and when to diagnose these conditions is ongoing as of 2023. The use of the term addiction to refer to these phenomena and diagnoses has been questioned. Digital media and screen time amongst modern social media apps such as Instagram, Tiktok, Snapchat and Facebook have changed how children think, interact and develop in positive and negative ways, but researchers are unsure about the existence of hypothesized causal links between digital media use and mental health outcomes. Those links appear to depend on the individual and the platforms they use. Several large technology firms have made commitments or announced strategies to try to reduce the risks of digital media use. History and terminology The relationship between digital technology and mental health has been investigated from many perspectives. Benefits of digital media use in childhood and adolescent development have been found. Concerns have been expressed by researchers, clinicians and the public in regard to apparent compulsive behaviors of digital media users, as correlations between technology overuse and mental health problems become apparent. Terminologies used to refer to compulsive digital-media-use behaviours are not standardized or universally recognised. They include "digital addiction", "digital dependence", "problematic use", or "overuse", often delineated by the digital media platform used or under study (such as problematic smartphone use or problematic internet use). Unrestrained use of technological devices may affect developmental, social, mental and physical well-being and may result in symptoms akin to other psychological dependence syndromes, or behavioral addictions. The focus on problematic technology use in research, particularly in relation to the behavioural addiction paradigm, is becoming more accepted, despite poor standardization and conflicting research. Internet addiction has been proposed as a diagnosis since the 1998 and social media and its relation to addiction has been examined since 2009. A 2018 Organisation for Economic Co-operation and Development (OECD) report stated there were benefits of structured and limited internet use in children and adolescents for developmental and educational purposes, but that excessive use can have a negative impact on mental well-being. It also noted an overall 40% increase in internet use in school-age children between 2010 and 2015, and that different OECD nations had marked variations in rates of childhood technology use, as well as differences in the platforms used. Hence, why it is so important for adolescents' to be trained to use social media, as it will ensure that users have developed psychologically-informed competencies and skills that will maximize the chances for balanced, safe, and meaningful social media use. The Diagnostic and Statistical Manual of Mental Disorders has not formally codified problematic digital media use in diagnostic categories, but it deemed internet gaming disorder to be a condition for further study in 2013. Gaming disorder, commonly known as video game addiction, has been recognised in the ICD-11. Different recommendations in the DSM and the ICD are due partly to the lack of expert consensus, the differences in emphasis in the classification manuals, as well as difficulties using animal models for behavioural addictions. The utility of the term addiction in relation to the overuse of digital media has been questioned, in regard to its suitability to describe new, digitally mediated psychiatric categories, as opposed to overuse being a manifestation of other psychiatric disorders. Usage of the term has also been criticised for drawing parallels with substance use behaviours. Careless use of the term may cause more problems—both downplaying the risks of harm in seriously affected people, as well as overstating risks of excessive, non-pathological use of digital media. The evolution of terminology relating excessive digital media use to problematic use rather than addiction was encouraged by Panova and Carbonell, psychologists at Ramon Llull University, in a 2018 review. Due to the lack of recognition and consensus on the concepts used, diagnoses and treatments are difficult to standardize or develop. Heightened levels of public anxiety around new media (including social media, smartphones and video games) further obfuscate population-based assessments, as well as posing management dilemmas. Radesky and Christakis, the 2019 editors of JAMA Paediatrics, published a review that investigated "concerns about health and developmental/behavioral risks of excessive media use for child cognitive, language, literacy, and social-emotional development." Due to the ready availability of multiple technologies to children worldwide, the problem is bi-directional, as taking away digital devices may have a detrimental effect, in areas such as learning, family relationship dynamics, and overall development. Problematic use Though associations have been observed between digital media use and mental health symptoms or diagnoses, causality has not been established; nuances and caveats published by researchers are often misunderstood by the general public, or misrepresented by the media. Females are more likely to overuse social media, and males video games. Following from this, problematic digital media use may not be singular constructs, may be delineated based on the digital platform used, or reappraised in terms of specific activities (rather than addiction to the digital medium). Access to means of communication In 1999, 58% of Finnish citizens had a mobile phone, including 75% of 15-17 year olds. In 2000, a majority of U.S. households had at least one personal computer and internet access the following year. In 2002, a majority of U.S. survey respondents reported having a mobile phone. In September and December 2006 respectively, Luxembourg and the Netherlands became the first countries to completely transition from analog to digital television, while the United States commenced its transition in 2008. In September 2007, a majority of U.S. survey respondents reported having broadband internet at home. In January 2013, a majority of U.S. survey respondents reported owning a smartphone. An estimated 40% of U.S. households in 2006 owned a dedicated home video game console, and by 2015, 51 percent of U.S. households owned a dedicated home video game console. In April 2015, one survey of U.S. teenagers ages 13 to 17 reported that nearly three-quarters of them either owned or had access to a smartphone, and 92 percent went online daily, with 24 percent saying they went online "almost constantly." Screen time and mental health Some types of potentially problematic internet use are associated with psychiatric or behavioural problems such as depression, anxiety, hostility, aggression and attention deficit hyperactivity disorder (ADHD). The studies could not determine if causal relationships exist; it was unclear, for example, whether people with depression might overuse the internet because they were already depressed, or if using the internet too much triggered the depression. While overuse of digital media has been associated with depressive symptoms, digital media may also be used in some situations to improve mood. Symptoms of ADHD have been positively correlated with digital media use in a large prospective study. The ADHD symptom of hyperfocus may cause affected individuals to overuse video games, social media, or online chatting; however the correlation between hyperfocus and problematic social media use is weak. A 2018 review found associations between the self-reported mental health symptoms by users of the Chinese social media platform WeChat and excessive platform use. However, the motivations and usage patterns of WeChat users affected overall psychological health, rather than the amount of time spent using the platform. An analysis of data from the Monitoring the Future survey, the Millennium Cohort Study, and the Youth Risk Behavior Surveillance System found that digital technology use (including, playing video games, watching television, using social media, etc.) accounted for only 0.4% of the variation in adolescent well-being. Additional research found little evidence for substantial negative associations for digital screen engagement and adolescent well-being. However, looking exclusively at the effect social media usage has on girls, there was a strong association between using social media and poor mental health. The evidence, although of mainly low to moderate quality, shows an correlation between heavy screen time and a variety of health physical and mental health problems. However, moderate use of digital media is also correlated with benefits for young people in terms of social integration, mental health, and overall well-being. A 2017 UK large-scale study of the "Goldilocks hypothesis"—of avoiding both too much and too little digital media use—was described as the "best quality" evidence to date by experts and non-government organisations (NGOs) reporting to a 2018 UK parliamentary committee. That study concluded that modest digital media use may have few adverse affects, and some positive associations in terms of well-being. Social media and mental health Excessive time spent on social media may be more harmful than digital screen time as a whole, especially for young people. Some research found a "substantial" association between social media use and mental health issues, but most found only a weak or inconsistent relationship. Social media can have both positive and negative effects on mental health; whether the overall affect is harmful or helpful may depend on a variety of factors, including the quality and quantity of social media usage. In the case of over 65s, studies have found high levels of social media usage was associated with postives outcomes overall, such as flourishing, though it remains unclear if social media use is a causative factor. There is a significant association between social media use and depression, with the association especially high for adolescent girls. Proposed diagnostic categories Gaming disorder has been considered by the DSM-5 task force as warranting further study (as the subset internet gaming disorder), and was included in the ICD-11. Concerns have been raised by Aarseth and colleagues over this inclusion, particularly in regard to stigmatization of heavy gamers. Christakis has asserted that internet addiction may be "a 21st century epidemic". In 2018, he commented that childhood Internet overuse may be a form of "uncontrolled experiment[s] on ... children". International estimates of the prevalence of internet overuse have varied considerably, with marked variations by nation. A 2014 meta-analysis of 31 nations yielded an overall worldwide prevalence of six percent. A different perspective in 2018 by Musetti and colleagues reappraised the internet in terms of its necessity and ubiquity in modern society, as a social environment, rather than a tool, thereby calling for the reformulation of the internet addiction model. Some medical and behavioural scientists recommend adding a diagnosis of "social media addiction" (or similar) to the next Diagnostic and Statistical Manual of Mental Disorders update. A 2015 review concluded there was a probable link between basic psychological needs and social media addiction. "Social network site users seek feedback, and they get it from hundreds of people—instantly. It could be argued that the platforms are designed to get users 'hooked'." Internet sex addiction, also known as cybersex addiction, has been proposed as a sexual addiction characterized by virtual internet sexual activity that causes serious negative consequences to one's physical, mental, social, and/or financial well-being. It may be considered a form of problematic internet use. Related phenomena Online problem gambling A 2015 review found evidence of higher rates of mental health comorbidities, as well as higher amounts of substance use, among internet gamblers, compared to non-internet gamblers. Causation, however, has not been established. The review postulates that there may be differences in the cohorts between internet and land-based problem gamblers. Cyberbullying Cyberbullying, bullying or harassment using social media or other electronic means, has been shown to have effects on mental health. Victims may have lower self-esteem, increased suicidal ideation, decreased motivation for usual hobbies, and a variety of emotional responses, including being scared, frustrated, angry, anxious or depressed. These victims may also begin to distance themselves from friends and family members. According to the EU Kids Online project, the incidence of cyberbullying across seven European countries in children aged increased from 8% to 12% between 2010 and 2014. Similar increases were shown in the United States and Brazil. Media multitasking Concurrent use of multiple digital media streams, commonly known as media multitasking, has been shown to be associated with depressive symptoms, social anxiety, impulsivity, sensation seeking, lower perceived social success and neuroticism. A 2018 review found that while the literature is sparse and inconclusive, overall, heavy media multitaskers also have poorer performance in several cognitive domains. One of the authors commented that the data does not "unambiguously show that media multitasking causes a change in attention and memory", therefore it is possible to argue that it is inefficient to multitask on digital media. Distracted road use In March 2023, Accident Analysis & Prevention published a systematic review of 47 samples across 45 studies investigating associations between problematic mobile phone use and road safety outcomes (including 32 samples of drivers, 9 samples of pedestrians, 5 samples with road use type unspecified, and 1 sample of motorcyclists and bicyclists) that found that problematic mobile phone use was associated with greater risk of simultaneous mobile phone use and road use and risk of vehicle collisions and pedestrian collisions or falls. Noise-induced hearing loss Assessment and treatment Rigorous, evidence-based assessment of problematic digital media use is yet to be comprehensively established. This is due partially to a lack of consensus around the various constructs and lack of standardization of treatments. The American Academy of Pediatrics (AAP) has developed a Family Media Plan, intending to help parents assess and structure their family's use of electronic devices and media more safely. It recommends limiting entertainment screen time to two hours or less per day. The Canadian Paediatric Society produced a similar guideline. Ferguson, a psychologist, has criticised these and other national guidelines for not being evidence-based. Other experts, cited in a 2017 UNICEF Office of Research literature review, have recommended addressing potential underlying problems rather than arbitrarily enforcing screen time limits. Different methodologies for assessing pathological internet use have been developed, mostly self-report questionnaires, but none have been universally recognised as a gold standard. For gaming disorder, both the American Psychiatric Association and the World Health Organization (through the ICD-11) have released diagnostic criteria. There is some limited evidence of the effectiveness of cognitive behavioral therapy and family-based interventions for treatment. In randomized controlled trials, medications have not been shown to be effective. A 2016 study of 901 adolescents suggested mindfulness may assist in preventing and treating problematic internet use. A 2019 UK parliamentary report deemed parental engagement, awareness and support to be essential in developing "digital resilience" for young people, and to identify and manage the risks of harm online. Treatment centres have proliferated in some countries, and China and South Korea have treated digital dependence as a public health crisis, opening 300 and 190 centres nationwide, respectively. Other countries have also opened treatment centres. NGOs, support and advocacy groups provide resources to people overusing digital media, with or without codified diagnoses, including the American Academy of Child and Adolescent Psychiatry. A 2022 study outlines the mechanisms by which media-transmitted stressors affect mental well-being. Authors suggest a common denominator related to problems with the media's construction of reality is increased uncertainty, which leads to defensive responses and chronic stress in predisposed individuals. Associated psychiatric disorders ADHD In April 2018, the International Journal of Environmental Research and Public Health published a systematic review of 24 studies researching associations between internet gaming disorder (IGD) and various psychopathologies that found an 85% correlation between IGD and ADHD. In October 2018, PNAS USA published a systematic review of four decades of research on the relationship between children and adolescents' screen media use and ADHD-related behaviours and concluded that a statistically small relationship between children's media use and ADHD-related behaviours exists. In November 2018, Cyberpsychology published a systematic review and meta-analysis of 5 studies that found evidence for a relationship between problematic smartphone use and impulsivity traits. In October 2020, the Journal of Behavioral Addictions published a systematic review and meta-analysis of 40 studies with 33,650 post-secondary student subjects that found a weak-to-moderate positive association between mobile phone addiction and impulsivity. In January 2021, the Journal of Psychiatric Research published a systematic review of 29 studies including 56,650 subjects that found that ADHD symptoms were consistently associated with gaming disorder and more frequent associations between inattention and gaming disorder than other ADHD scales. In July 2021, Frontiers in Psychiatry published a meta-analysis reviewing 40 voxel-based morphometry studies and 59 functional magnetic resonance imaging studies comparing subjects with IGD or ADHD to control groups that found that IGD and ADHD subjects had disorder-differentiating structural neuroimage alterations in the putamen and orbitofrontal cortex (OFC) respectively, and functional alterations in the precuneus for IGD subjects and in the rewards circuit (including the OFC, the anterior cingulate cortex, and striatum) for both IGD and ADHD subjects. In March 2022, JAMA Psychiatry published a systematic review and meta-analysis of 87 studies with 159,425 subjects 12 years of age or younger that found a small but statistically significant correlation between screen time and ADHD symptoms in children. In April 2022, Developmental Neuropsychology published a systematic review of 11 studies where the data from all but one study suggested that heightened screen time for children is associated with attention problems. In July 2022, the Journal of Behavioral Addictions published a meta-analysis of 14 studies comprising 2,488 subjects aged 6 to 18 years that found significantly more severe problematic internet use in subjects diagnosed with ADHD to control groups. In December 2022, European Child & Adolescent Psychiatry published a systematic literature review of 28 longitudinal studies published from 2011 through 2021 of associations between digital media use by children and adolescents and later ADHD symptoms and found reciprocal associations between digital media use and ADHD symptoms (i.e. that subjects with ADHD symptoms were more likely to develop problematic digital media use and that increased digital media use was associated with increased subsequent severity of ADHD symptoms). In May 2023, Reviews on Environmental Health published a meta-analysis of 9 studies with 81,234 child subjects that found a positive correlation between screen time and ADHD risk in children and that higher amounts of screen time in childhood may significantly contribute to the development of ADHD. In December 2023, the Journal of Psychiatric Research published a meta-analysis of 24 studies with 18,859 subjects with a mean age of 18.4 years that found significant associations between ADHD and problematic internet use, while Clinical Psychology Review published a systematic review and meta-analysis of 48 studies examining associations between ADHD and gaming disorder that found a statistically significant association between the disorders. Anxiety In April 2018, the International Journal of Environmental Research and Public Health published a systematic review of 24 studies researching associations between internet gaming disorder (IGD) and various psychopathologies that found a 92% correlation between IGD and anxiety and a 75% correlation between IGD and social anxiety. In August 2018, Wiley Stress & Health published a meta-analysis of 39 studies comprising 21,736 subjects that found a small-to-medium association between smartphone use and anxiety. In December 2018, Frontiers in Psychiatry published a systematic review of 9 studies published after 2014 investigating associations between problematic social networking sites (SNS) use and comorbid psychiatric disorders that found a positive association between problematic SNS use and anxiety. In March 2019, the International Journal of Adolescence and Youth published a systematic review of 13 studies comprising 21,231 adolescent subjects aged 13 to 18 years that found that social media screen time, both active and passive social media use, the amount of personal information uploaded, and social media addictive behaviors all correlated with anxiety. In February 2020, Psychiatry Research published a systematic review and meta-analysis of 14 studies that found positive associations between problematic smartphone use and anxiety and positive associations between higher levels of problematic smartphone use and elevated risk of anxiety, while Frontiers in Psychology published a systematic review of 10 studies of adolescent or young adult subjects in China that concluded that the research reviewed mostly established an association between social networks use disorder and anxiety among Chinese adolescents and young adults. In April 2020, BMC Public Health published a systematic review of 70 cross-sectional and longitudinal studies investigating moderating factors for associations for screen-based sedentary behaviors and anxiety symptoms among youth that found that while screen types was the most consistent factor, the body of evidence for anxiety symptoms was more limited than for depression symptoms. In October 2020, the Journal of Behavioral Addictions published a systematic review and meta-analysis of 40 studies with 33,650 post-secondary student subjects that found a weak-to-moderate positive association between mobile phone addiction and anxiety. In November 2020, Child and Adolescent Mental Health published a systematic review of research published between January 2005 and March 2019 on associations between SNS use and anxiety symptoms in subjects between ages of 5 to 18 years that found that increased SNS screen time or frequency of SNS use and higher levels of investment (i.e. personal information added to SNS accounts) were significantly associated with higher levels of anxiety symptoms. In January 2021, Frontiers in Psychiatry published a systematic review of 44 studies investigating social media use and development of psychiatric disorders in childhood and adolescence that concluded that the research reviewed established a direct association between levels of anxiety, social media addiction behaviors, and nomophobia, longitudinal associations between social media use and increased anxiety, that fear of missing out and nomophobia are associated with severity of Facebook usage, and suggested that fear of missing out may trigger social media addiction and that nomophobia appears to mediate social media addiction. In March 2021, Computers in Human Behavior Reports published a systematic review of 52 studies published before May 2020 that found that social anxiety was associated with problematic social media use and that socially anxious persons used social media to seek social support possibly to compensate for a lack of offline social support. In June 2021, Clinical Psychology Review published a systematic review of 35 longitudinal studies published before August 2020 that found that evidence for longitudinal associations between screen time and anxiety among young people was lacking. In August 2021, a meta-analysis was presented at the 2021 International Conference on Intelligent Medicine and Health of articles published before January 2011 that found evidence for a negative impact of social media on anxiety. In January 2022, The European Journal of Psychology Applied to Legal Context published a meta-analysis of 13 cross-sectional studies comprising 7,348 subjects that found a statistically significant correlation between cybervictimization and anxiety with a moderate-to-large effect size. In March 2022, JAMA Psychiatry published a systematic review and meta-analysis of 87 studies with 159,425 subjects 12 years of age or younger that found a small but statistically significant correlation between screen time and anxiety in children, while Adolescent Psychiatry published a systematic review of research published from June 2010 through June 2020 studying associations between social media use and anxiety among adolescent subjects aged 13 to 18 years that established that 78.3% of studies reviewed reported positive associations between social media use and anxiety. In April 2022, researchers in the Department of Communication at Stanford University performed a meta-analysis of 226 studies comprising 275,728 subjects that found a small but positive association between social media use and anxiety, while JMIR Mental Health published a systematic review and meta-analysis of 18 studies comprising 9,269 adolescent and young adult subjects that found a moderate but statistically significant association between problematic social media use and anxiety. In May 2022, Computers in Human Behavior published a meta-analysis of 82 studies comprising 48,880 subjects that found a significant positive association between social anxiety and mobile phone addiction. In August 2022, the International Journal of Environmental Research and Public Health published a systematic review and meta-analysis of 16 studies comprising 8,077 subjects that established a significant association between binge-watching and anxiety. In November 2022, Cyberpsychology, Behavior, and Social Networking published a systematic review of 1,747 articles on problematic social media use that found a strong bidirectional relationship between social media use and anxiety. In March 2023, the Journal of Public Health published a meta-analysis of 27 studies published after 2014 comprising 120,895 subjects that found a moderate and robust association between problematic smartphone use and anxiety. In July 2023, Healthcare published a systematic review and meta-analysis of 16 studies that established correlation coefficients of 0.31 and 0.39 between nomophobia and anxiety and nomophobia and smartphone addiction respectively. In September 2023, Frontiers in Public Health published a systematic review and meta-analysis of 37 studies comprising 36,013 subjects aged 14 to 24 years that found a positive and statistically significant association between problematic internet use and social anxiety, while BJPsych Open published a systematic review of 140 studies published from 2000 through 2020 found that social media use for more than 3 hours per day and passive browsing was associated with increased anxiety. In January 2024, the Journal of Computer-Mediated Communication published a meta-analysis of 141 studies comprising 145,394 subjects that found that active social media use was associated with greater symptoms of anxiety and passive social media use was associated with greater symptoms of social anxiety. In February 2024, Addictive Behaviors published a systematic review and meta-analysis of 53 studies comprising 59,928 subjects that found that problematic social media use and social anxiety are highly and positively correlated, while The Egyptian Journal of Neurology, Psychiatry and Neurosurgery published a systematic review of 15 studies researching associations between problematic social media use and anxiety in subjects from the Middle East and North Africa (including 4 studies with subjects exclusively between the ages of 12 and 19 years) that established that most studies found a significant association. Autism In September 2018, the Review Journal of Autism and Developmental Disorders published a systematic review of 47 studies published from 2005 to 2016 that concluded that associations between autism spectrum disorder (ASD) and screen time was inconclusive. In May 2019, the Journal of Developmental and Behavioral Pediatrics published a systematic review of 16 studies that found that children and adolescents with ASD are exposed to more screen time than typically developing peers and that the exposure starts at a younger age. In April 2021, Research in Autism Spectrum Disorders published a systematic review of 12 studies of video game addiction in ASD subjects that found that children, adolescents, and adults with ASD are at greater risk of video game addiction than those without ASD, and that the data from the studies suggested that internal and external factors (sex, attention and oppositional behavior problems, social aspects, access and time spent playing video games, parental rules, and game genre) were significant predictors of video game addiction in ASD subjects. In March 2022, the Review Journal of Autism and Developmental Disorders published a systematic review of 21 studies investigating associations between ASD, problematic internet use, and gaming disorder where the majority of the studies found positive associations between the disorders. In August 2022, the International Journal of Mental Health and Addiction published a review of 15 studies that found that high rates of video game use in boys and young males with ASD was predominantly explained by video game addiction, but also concluded that greater video game use could be a function of ASD restricted interest and that video game addiction and ASD restricted interest could have an interactive relationship. In December 2022, the Review Journal of Autism and Developmental Disorders published a systematic review of 10 studies researching the prevalence of problematic internet use with ASD that found that ASD subjects had more symptoms of problematic internet use than control group subjects, had higher screen time online and an earlier age of first-time use of the internet, and also greater symptoms of depression and ADHD. In July 2023, Cureus published a systematic review of 11 studies that concluded that earlier and longer screen time exposure for children was associated with higher probability of a child "developing" ASD. In December 2023, JAMA Network Open published a meta-analysis of 46 studies comprising 562,131 subjects that concluded that while screen time may be a developmental cause of ASD in childhood, associations between ASD and screen time were not statistically significant when accounting for publication bias. Bipolar disorder In November 2018, Cyberpsychology published a systematic review and meta-analysis of 5 studies that found evidence for a relationship between problematic smartphone use and impulsivity traits. In October 2020, the Journal of Behavioral Addictions published a systematic review and meta-analysis of 40 studies with 33,650 post-secondary student subjects that found that a weak-to-moderate positive association between mobile phone addiction and impulsivity. In April 2021, a meta-analysis of 3 studies comprising 9,142 subjects was presented at the International Conference on Big Data and Informatization Education that found that problematic internet use is a risk factor for bipolar disorder. In December 2023, the Journal of Psychiatric Research published a meta-analysis of 24 studies with 18,859 subjects with a mean age of 18.4 years that found significant associations between problematic internet use and impulsivity. Depression In April 2018, the International Journal of Environmental Research and Public Health published a systematic review of 24 studies researching associations between internet gaming disorder (IGD) and various psychopathologies that found an 89% correlation between IGD and depression. In July 2018, JMIR Mental Health published a systematic review of 11 studies investigating social media use and depression among lesbian, gay, and bisexual (LGB) users that found that while qualitative research found that social media use could lead to greater social support and less loneliness for LGB users, LGB users were more likely to be cyberbullied than heterosexual users, that cyberbullying of LGB users was associated with depression among victims, and constant monitoring of accounts by LGB users was also found to be a stressor associated with depression. In December 2018, Frontiers in Psychiatry published a systematic review of 9 studies published after 2014 investigating associations between problematic SNS use and comorbid psychiatric disorders that found a positive association between problematic SNS use and depression. In March 2019, the International Journal of Adolescence and Youth published a systematic review of 13 studies comprising 21,231 adolescent subjects aged 13 to 18 years that found that social media screen time, both active and passive social media use, the amount of personal information uploaded, and social media addictive behaviors all correlated with depression. In April 2019, the Journal of Affective Disorders published a meta-analysis assessing associations between SNS use and higher levels of depression that found that greater SNS screen time and frequency of checking SNS accounts had small but statistically significant associations with higher levels of depression, that greater general social comparisons on SNS had a small to moderate association, and greater upward social comparisons on SNS had a moderate association. In November 2019, BMC Public Health published a systematic review and meta-analysis of 12 cross-sectional studies and 7 longitudinal studies that found that screen time-based sedentary behavior is associated with depression risk. In January 2020, Translational Psychiatry published a meta-analysis of 12 prospective studies comprising 128,553 subjects that found that while sedentary behavior and depression risk had a significant positive association, television viewing and other mentally passive sedentary behaviors were positively associated with depression risk but computer use and other mentally active sedentary behaviors were not. In February 2020, Psychiatry Research published a systematic review and meta-analysis of 14 studies that found positive associations between problematic smartphone use and depression and positive associations between higher levels of problematic smartphone use and elevated risk of depression. Also in February 2020, Frontiers in Psychology published a systematic review of 10 studies of adolescent or young adult subjects in China that concluded that the research reviewed mostly established an association between social networks use disorder and depression among Chinese adolescents and young adults. In March 2020, the Review of General Psychology published a meta-analysis that found a small association between social networking service (SNS) use and self-reported depression. In April 2020, BMC Public Health published a systematic review of 70 cross-sectional and longitudinal studies investigating moderating factors for associations for screen-based sedentary behaviors and depression symptoms among youth that found that the most consistent factor was for screen type since television viewing was not as strongly associated with depression symptoms as other screen types. In August 2020, the Journal of Medical Internet Research published an umbrella review of 7 systematic reviews on research investigating associations between depression and use of mobile technologies and social media by adolescents that concluded that while mobile technology and social media may promote social support, excess social comparison and personal involvement (i.e. increased exposure in general, exposure to specific content that promotes depressive symptoms, and the degree of personal information posted on social media) could be associated with symptoms of depression. In October 2020, the Journal of Affective Disorders published a meta-analysis of 12 studies with subjects aged 11 to 18 years that found a small but statistically significant positive correlation between social media use and depressive symptoms among adolescents, while the Journal of Behavioral Addictions published a systematic review and meta-analysis of 40 studies with 33,650 post-secondary student subjects that found a weak-to-moderate positive association between mobile phone addiction and depression. In November 2020, Child and Adolescent Mental Health published a systematic review of research published between January 2005 and March 2019 on associations between SNS use and depression in subjects between ages of 5 to 18 years that found that increased SNS screen time or frequency of SNS use and problematic and addictive SNS use were significantly associated with higher levels of depression symptoms. In January 2021, Frontiers in Psychiatry published a systematic review of 44 studies investigating social media use and development of psychiatric disorders in childhood and adolescence that concluded that passive social media use (e.g. browsing other user photos or scrolling through comments or news feeds) and depression are bidirectionally associated and that problematic social media use and depressive symptoms are mediated by social comparisons. In February 2021, Research on Child and Adolescent Psychopathology published a meta-analysis of 62 studies comprising 451,229 subjects that found SNS screen time and SNS use intensity to have weak but statistically significant associations with depression symptoms, while problematic SNS use was found to have a moderate association with depression symptoms. In March 2021, Youth & Society published a systematic review of 9 studies that found an association between SNS use and adolescent subjective well-being including mood, but that the results over whether the association was positive or negative were mixed. In April 2021, the Journal of Affective Disorders published a systematic review and meta-analysis of 92 studies comprising 15,148 subjects across 25 countries investigating associations between depression and internet gaming disorder found that one-third of the IGD subjects had been diagnosed with depression and major severe depressive symptoms were found in IGD subjects globally without a formal diagnosis in comparison to the general population. In May 2021, Current Psychology published a meta-analysis of 55 studies comprising 80,533 subjects that found a small but positive and statistically significant association between SNS use and self-reported depression symptoms. In June 2021, Clinical Psychology Review published a systematic review of 35 longitudinal studies published before August 2020 that found that an association between screen time and subsequent depressive symptoms among young people was small and varied by device type and use. In July 2021, Translational Medicine Communications published a systematic review of 9 studies published between October 2010 and December 2018 with Instagram user subjects between the ages of 19 and 35 years that found an association between Instagram use and depression symptoms. In January 2022, The European Journal of Psychology Applied to Legal Context published a meta-analysis of 13 cross-sectional studies comprising 7,348 subjects that found a statistically significant correlation between cybervictimization and depression with a moderate-to-large effect size. In February 2022, the International Journal of Social Psychiatry published a meta-analysis of 131 studies comprising 244,676 subjects that found a moderate mean correlation between problematic social media use and depression. In March 2022, Computers in Human Behavior published a systematic review and meta-analysis of 531 cross-sectional or longitudinal studies with subjects aged 10 to 24 years that found a small bidirectional association between online media use and depressive symptoms and that the effect size did not differ between general internet use, smartphone use, social media use, or online gaming, but also found that studies that measured online media use with media addiction scales rather than by screen time found significantly greater associations. Also in March 2022, JAMA Psychiatry published a systematic review and meta-analysis of 87 studies with 159,425 subjects 12 years of age or younger that found a small but statistically significant correlation between screen time and depression in children, while Adolescent Psychiatry published a systematic review of research published from June 2010 through June 2020 studying associations between social media use and depression among adolescent subjects aged 13 to 18 years that established that 82.6% of studies reviewed reported positive associations between social media use and depression. In April 2022, the International Journal of Environmental Research and Public Health published a meta-analysis of 21 cross-sectional studies and 5 longitudinal studies comprising 55,340 adolescent subjects that found that social media screen time had a linear dose–response association with depression risk among adolescents and that depression risk increased by 13% for each additional hour of social media screen time. Also in April 2022, researchers in the Department of Communication at Stanford University performed a meta-analysis of 226 studies comprising 275,728 subjects that found a small but positive association between social media use and depression, while JMIR Mental Health published a systematic review and meta-analysis of 18 studies comprising 9,269 adolescent and young adult subjects that found a moderate but statistically significant association between problematic social media use and depression. In August 2022, the International Journal of Environmental Research and Public Health published a systematic review and meta-analysis of 16 studies comprising 8,077 subjects that established a significant association between binge-watching and depression and a stronger association between binge-watching and depression was found during the COVID-19 pandemic than pre-pandemic. In November 2022, Cyberpsychology, Behavior, and Social Networking published a systematic review of 1,747 articles on problematic social media use that found a strong bidirectional relationship between social media use and depression. In December 2022, Frontiers in Psychiatry published a meta-analysis of 18 cohort studies comprising 241,398 subjects that found that screen time is a predictor of depressive symptoms. In March 2023, the Journal of Public Health published a meta-analysis of 27 studies published after 2014 comprising 120,895 subjects that found a moderate and robust association between problematic smartphone use and depression. In April 2023, Trauma, Violence, & Abuse published a systematic review and meta-analysis of 17 studies comprising 79,202 adolescent subjects between the ages of 10 and 19 years that found that depression was three times more common among cyberbullying victims than control groups. In July 2023, Current Psychology published a meta-analysis of 38 studies comprising 14,935 subjects in Turkey that found a small but positive association between problematic social media use and depression. In September 2023, Clinical Psychological Science published a preregistered review and meta-analysis of 34 articles published between 2018 and 2020 studying associations between adolescent depression and social media use to identify the proportion of samples taken from the Global North and Global South, and found that more than 70% examined Global North populations and that associations in the Global North were positive and significant while associations in the Global South were null and non-significant. In September 2023, BJPsych Open published a systematic review of 140 studies published from 2000 through 2020 that found that social media use for more than 3 hours per day and passive browsing was associated with increased depression in children, adolescents, and young adults. In February 2024, The Egyptian Journal of Neurology, Psychiatry and Neurosurgery published a systematic review of 15 studies researching associations between problematic social media use and depression in subjects from the Middle East and North Africa (including 4 studies with subjects exclusively between the ages of 12 and 19 years) that established that most studies found a significant association. Insomnia In August 2018, Sleep Science and Practice published a systematic review and meta-analysis of 19 studies comprising 253,904 adolescent subjects that found that excessive technology use had a strong and consistent association with reduced sleep duration and prolonged sleep onset latency for adolescents 14 years of age or older. Also in August 2018, Sleep Science published a systematic review of 12 studies investigating associations between exposure to video games, sleep outcomes, and post-sleep cognitive abilities that found the data present in the studies indicated associations between a reduction in sleep duration, increased sleep onset latency, modifications to rapid eye movement sleep and slow-wave sleep, increased sleepiness and self-perceived fatigue, and impaired post-sleep attention span and verbal memory. In October 2019, Sleep Medicine Reviews published a systematic review and meta-analysis of 23 studies comprising 35,684 subjects that found a statistically significant odds ratio for sleep problems and reduced sleep duration for subjects with internet addiction. In February 2020, Psychiatry Research published a systematic review and meta-analysis of 14 studies that found positive associations between problematic smartphone use and poor sleep quality and between higher levels of problematic smartphone use and elevated risk of poor sleep quality. Also in February 2020, Sleep Medicine Reviews published a systematic review of 31 studies examining associations between screen time and sleep outcomes in children younger than 5 years and found that screen time is associated with poorer sleep outcomes for children under the age of 5, with meta-analysis only confirming poor sleep outcomes among children under 2 years. In March 2020, Developmental Review published a systematic review of 9 studies that found a weak-to-moderate association between sleep quantity and quality and problematic smartphone use among adolescents. In October 2020, the International Journal of Environmental Research and Public Health published a systematic review and meta-analysis of 80 studies that found that greater screen time was associated with shorter sleep duration among toddlers and preschoolers, while the Journal of Behavioral Addictions published a systematic review and meta-analysis of 40 studies with 33,650 post-secondary student subjects that found a weak-to-moderate positive association between mobile phone addiction and poor sleep quality. In April 2021, Sleep Medicine Reviews published a systematic review of 36 cross-sectional studies and 6 longitudinal studies that found that 24 of the cross-sectional studies and 5 of the longitudinal studies established significant associations between more frequent social media use and poor sleep outcomes. In June 2021, Frontiers in Psychiatry published a systematic review and meta-analysis of 34 studies comprising 51,901 subjects that established significant associations between problematic gaming and sleep duration, poor sleep quality, daytime sleepiness, and other sleep problems. In September 2021, BMC Public Health published a systematic review of 49 studies investigating associations between electronic media use and various sleep outcomes among children and adolescents 15 years of age or younger that found a strong association with sleep duration and stronger evidence for an association with sleep duration between the ages of 6 and 15 years than for 5 years of age or younger, while evidence for associations between electronic media use with other sleep outcomes was more inconclusive. In December 2021, Frontiers in Neuroscience published a systematic review of 12 studies published from January 2000 to April 2020 that found that adult subjects with higher gaming addiction scores were more likely to have shorter sleep quantity, poorer sleep quality, delayed sleep timing, and greater daytime sleepiness and insomnia scores than subjects with lower gaming addiction scores and non-gamer subjects. In January 2022, Early Childhood Research Quarterly published a systematic review and meta-analysis of 26 studies that found a weak but statistically significant association with increased smartphone and tablet computer use and poorer sleep in early childhood. In May 2022, the Journal of Affective Disorders published a meta-analysis of 29 studies comprising 20,041 subjects that found a weak-to-moderate association between mobile phone addiction and sleep disorder and that adolescents with mobile phone addiction were at higher risk of developing sleep disorder. In August 2022, the International Journal of Environmental Research and Public Health published a systematic review and meta-analysis of 16 studies comprising 8,077 subjects that established a significant association between binge-watching and sleep problems and a stronger association between binge-watching and sleep problems was found during the COVID-19 pandemic than pre-pandemic. In October 2022, Reports in Public Health published a systematic review of 23 studies that found that excessive use of digital screens by adolescents was associated with poor sleep quality, nighttime awakenings, long sleep latency, and daytime sleepiness. In December 2022, Sleep Epidemiology published a systematic review of 18 studies investigating associations between sleep problems and screen time during COVID-19 lockdowns that found that the increased screen time during the lockdowns negatively impacted sleep duration, sleep quality, sleep onset latency, and wake time. In March 2023, the Journal of Clinical Sleep Medicine published a systematic review and meta-analysis of 17 studies comprising 36,485 subjects that found that smartphone overuse was closely associated with self-reported poor sleep quality, sleep deprivation, and prolonged sleep latency. In April 2023, Sleep Medicine Reviews published a systematic review of 42 studies that found digital media use to be associated with shorter sleep duration and poorer sleep quality and bedtime or nighttime use with poor sleep outcomes, but only found associations for general screen use, mobile phone use, computer and internet use, internet, and social media and not for television, game console, and tablet use. In July 2023, Healthcare published a systematic review and meta-analysis of 16 studies that established a correlation coefficient of 0.56 between nomophobia and insomnia. In September 2023, PLOS One published a systematic review and meta-analysis of 16 studies of smartphone addiction and sleep among medical students found that 57% of subjects had poor sleep and 39% of subjects had smartphone addiction with a correlation index of 0.3, while Computers in Human Behavior published a meta-analysis of 23 longitudinal studies comprising 116,431 adolescent subjects that found that adolescent screen time with computers, smartphones, social media, and television are positively associated with negative impacts on sleep health later in life. Narcissism In April 2018, a meta-analysis published in the Journal of Personality found that the positive correlation between grandiose narcissism and social networking sites (SNS) usage was replicated across platforms (including Facebook and Twitter). In July 2018, a meta-analysis published in Psychology of Popular Media found that grandiose narcissism positively correlated with time spent on social media, frequency of status updates, number of friends or followers, and frequency of posting self-portrait digital photographs. In March 2020, the Review of General Psychology published a meta-analysis that found a small-to-moderate association between SNS use and narcissism. In June 2020, Addictive Behaviors published a systematic review finding a consistent, positive, and significant correlation between grandiose narcissism and problematic social media use. OCD In April 2018, the International Journal of Environmental Research and Public Health published a systematic review of 24 studies researching associations between internet gaming disorder (IGD) and various psychopathologies that found a significant correlation between IGD and obsessive–compulsive disorder symptoms in 3 of 4 studies. Mental health benefits Individuals with mental illness can develop social connections over social media, that may foster a sense of social inclusion in online communities. People with mental illness may share personal stories in a perceived safer space, as well as gaining peer support for developing coping strategies. People with mental illness are likely to report avoiding stigma and gaining further insight into their mental health condition by using social media. This comes with the risk of unhealthy influences, misinformation, and delayed access to traditional mental health outlets. Other benefits include connections to supportive online communities, including illness or disability specific communities, as well as the LGBTQIA community. Young cancer patients have reported an improvement in their coping abilities due to their participation in an online community. The uses of social media for healthcare communication include providing reducing stigma and facilitating dialogue between patients and between patients and health professionals. Furthermore, in children, the educational benefits of digital media use are well established. For example, screen-based programs can help increase both independent and collaborative learning. A variety of quality apps and software can also decrease learning gaps and increase skill in certain educational subjects. Other disciplines Digital anthropology Daniel Miller from University College London has contributed to the study of digital anthropology, especially ethnographic research on the use and consequences of social media and smartphones as part of the everyday life of ordinary people around the world. He notes the effects of social media are very specific to individual locations and cultures. He contends "a layperson might dismiss these stories as superficial. But the anthropologist takes them seriously, empathetically exploring each use of digital technologies in terms of the wider social and cultural context." Digital anthropology is a developing field which studies the relationship between humans and digital-era technology. It aims to consider arguments in terms of ethical and societal scopes, rather than simply observing technological changes. Brian Solis, a digital analyst and anthropologist, stated in 2018, "we've become digital addicts: it's time to take control of technology and not let tech control us". Digital sociology Digital sociology explores how people use digital media using several research methodologies, including surveys, interviews, focus groups, and ethnographic research. It intersects with digital anthropology, and studies cultural geography. It also investigates longstanding concerns, and contexts around young people's overuse of "these technologies, their access to online pornography, cyber bullying or online sexual predation". A 2012 cross-sectional sociological study in Turkey showed differences in patterns of internet use that related to levels of religiosity in 2,698 subjects. With increasing religiosity, negative attitudes towards internet use increased. Highly religious people showed different motivations for internet use, predominantly searching for information. A study of 1,296 Malaysian adolescent students found an inverse relationship between religiosity and internet addiction tendency in females, but not males. A 2018 review published in Nature considered that young people may have different experiences online, depending on their socio-economic background, noting lower-income youths may spend up to three hours more per day using digital devices, compared to higher-income youths. They theorized that lower-income youths, who are already vulnerable to mental illness, may be more passive in their online engagements, being more susceptible to negative feedback online, with difficulty self-regulating their digital media use. It concluded that this may be a new form of digital divide between at-risk young people and other young people, pre-existing risks of mental illness becoming amplified among the already vulnerable population. Neuroscience A 2018 neuroscientific review published in Nature found the density of the amygdala, a brain region involved in emotional processing, is related to the size of both offline and online social networks in adolescents. They considered that this and other evidence "suggests an important interplay between actual social experiences, both offline and online, and brain development". The authors postulated that social media may have benefits, namely social connections with other people, as well as managing impressions people have of other people such as "reputation building, impression management, and online self-presentation". It identified "adolescence [as] a tipping point in development for how social media can influence their self-concept and expectations of self and others", and called for further study into the neuroscience behind digital media use and brain development in adolescence. Although brain-imaging modalities are under study, neuroscientific findings in individual studies often fail to be replicated in future studies, similar to other behavioural addictions; as of 2017, the exact biological or neural processes that could lead to excessive digital media use are unknown. Impact on cognition There is research and development about the cognitive impacts of smartphones and digital technology. A group reported that, contrary to widespread belief, scientific evidence does not show that these technologies harm biological cognitive abilities and that they instead only change predominant ways of cognition – such as a reduced need to remember facts or conduct mathematical calculations by pen and paper outside contemporary schools. However, some activities – like reading novels – that require long focused attention-spans and do not feature ongoing rewarding stimulation may become more challenging in general. How extensive online media usage impacts cognitive development in youth is under investigation and impacts may substantially vary by the way and which technologies are being used – such as which and how digital media platforms are being used – and how these are designed. Impacts may vary to a degree such studies have not yet taken into account and may be modulatable by the design, choice and use of technologies and platforms, including by the users themselves. A study suggests that in children aged 8–12 during two years, time digital gaming or watching digital videos can be positively correlated with measures intelligence, albeit correlations with overall screen time (including social media, socializing and TV) were not investigated and 'time gaming' did not differentiate between categories of video games (e.g. shares of games' platform and genre), and digital videos did not differentiate between categories of videos. Impact on social life Worldwide adolescent loneliness in contemporary schools and depression increased substantially after 2012 and a study found this to be associated with smartphone access and Internet use. Mitigation Industry Several technology firms have implemented changes intending to mitigate the adverse effects of excessive use of their platforms. In December 2017, Facebook admitted passive consumption of social media could be harmful to mental health, although they said active engagement can have a positive effect. In January 2018, the platform made major changes to increase user engagement. In January 2019, Facebook's then head of global affairs, Nick Clegg, responding to criticisms of Facebook and mental health concerns, stated they would do "whatever it takes to make this environment safer online especially for youngsters". Facebook admitted "heavy responsibilities" to the global community, and invited regulation by governments. In 2018 Facebook and Instagram announced new tools that they asserted may assist with overuse of their products. In 2019, Instagram, which has been investigated specifically in one study in terms of addiction, began testing a platform change in Canada to hide the number of "likes" and views that photos and videos received in an effort to create a "less pressurised" environment. It then continued this trial in Australia, Italy, Ireland, Japan, Brazil and New Zealand before extending the experiment globally in November of that year. The platform also developed artificial intelligence to counter cyberbullying. In 2018, Alphabet Inc. released an update for Android smartphones, including a dashboard app enabling users to set timers on application use. Apple Inc. purchased a third-party application and then incorporated it in iOS 12 to measure "screen time". Journalists have questioned the functionality of these products for users and parents, as well as the companies' motivations for introducing them. Alphabet has also invested in a mental health specialist, Quartet, which uses machine learning to collaborate and coordinate digital delivery of mental health care. Two activist investors in Apple Inc voiced concerns in 2018 about the content and amount of time spent by youth. They called on Apple Inc. to act before regulators and consumers potentially force them to do so. Apple Inc. responded that they have, "always looked out for kids, and [they] work hard to create powerful products that inspire, entertain, and educate children while also helping parents protect them online". The firm is planning new features that they asserted may allow them to play a pioneering role in regard to young people's health. Public sector In China, Japan, South Korea and the United States, governmental efforts have been enacted to address issues relating to digital media use and mental health. China's Ministry of Culture has enacted several public health efforts from as early as 2006 to address gaming and internet-related disorders. In 2007, an "Online Game Anti-Addiction System" was implemented for minors, restricting their use to 3 hours or less per day. The ministry also proposed a "Comprehensive Prevention Program Plan for Minors' Online Gaming Addiction" in 2013, to promulgate research, particularly on diagnostic methods and interventions. China's Ministry of Education in 2018 announced that new regulations would be introduced to further limit the amount of time spent by minors in online games. In response, Tencent, the owner of WeChat and the world's largest video game publisher, restricted the amount of time that children could spend playing one of its online games, to one hour per day for children 12 and under, and two hours per day for children aged . Effective 2 September 2023, those under the age of 18 can no longer access the Internet on their mobile device between 10 pm and 6 am without parental bypass. Smartphone usage is similarly capped by default at 40 minutes a day for children younger than eight and at two hours for 16- and 17-year-olds. Japan's Ministry of Internal Affairs and Communications coordinates Japanese public health efforts in relation to problematic internet use and gaming disorder. Legislatively, the Act on Development of an Environment that Provides Safe and Secure Internet Use for Young People was enacted in 2008, to promote public awareness campaigns, and support NGOs to teach young people safe internet use skills. South Korea has eight government ministries responsible for public health efforts in relation to internet and gaming disorders. A review article published in Prevention Science in 2018 stated that the "region is unique in that its government has been at the forefront of prevention efforts, particularly in contrast to the United States, Western Europe, and Oceania." Efforts are coordinated by the Ministry of Science and ICT, and include awareness campaigns, educational interventions, youth counseling centres, and promoting healthy online culture. In May 2023, the United States' Surgeon general took the rare measure of issuing an advisory on Social media and mental health. In October, 41 U.S. states commenced legal proceedings against Meta. This included the attorneys general of 33 states filing a combined lawsuit over concerns about the addictive nature of Instagram and its impact on the mental health of young people. Digital mental health care Digital technologies have also provided opportunities for delivery of mental health care online; benefits have been found with computerized cognitive behavioral therapy for depression and anxiety. Mindfulness based online intervention has been shown to have small to moderate benefits on mental health. The greatest effect size was found for the reduction of psychological stress. Benefits were also found regarding depression, anxiety, and well-being. The Lancet commission on global mental health and sustainability report from 2018 evaluated both benefits and harms of technology. It considered the roles of technologies in mental health, particularly in public education; patient screening; treatment; training and supervision; and system improvement. A study in 2019 published in Front Psychiatry in the National Center for Biotechnology Information states that despite proliferation of many mental health apps there has been no "equivalent proliferation of scientific evidence for their effectiveness." Steve Blumenfield and Jeff Levin-Scherz, writing in the Harvard Business Review, claim that "most published studies show telephonic mental health care is as effective as in-person care in treating depression, anxiety and obsessive-compulsive disorder." The also cite a 2020 study done with the Veterans Administration as evidence of this as well. See also Evolutionary psychiatry Instagram Screen time Social aspects of television References Further reading Woods, H. C., & Scott, H. (2016). #Sleepyteens: Social media use in adolescence is associated with poor sleep quality, anxiety, depression and low self‐esteem. Journal of Adolescence, 51(1), 41–49. https://doi.org/10.1016/j.adolescence.2016.05.008 Jones, A., Hook, M., Podduturi, P., McKeen, H., Beitzell, E., & Liss, M. (2022). Mindfulness as a mediator in the relationship between social media engagement and depression in young adults. Personality and Individual Differences, 185. https://doi.org/10.1016/j.paid.2021.111284 White-Gosselin, C.-É., & Poulin, F. (2022). Associations between young adults' social media addiction, relationship quality with parents, and internalizing problems: A path analysis model. Canadian Journal of Behavioural Science / Revue Canadienne Des Sciences Du Comportement. https://doi.org/10.1037/cbs0000326 Hammad, M. A., & Alqarni, T. M. (2021). Psychosocial effects of social media on the Saudi society during the Coronavirus Disease 2019 pandemic: A cross-sectional study. PLoS ONE, 16(3). https://doi.org/10.1371/journal.pone.0248811 External links Anthropology of Social Media: Why We Post, University College London, Free online five-week course, asking "What are the consequences of social media?" Social Media Use and Mental Health: A Review – ongoing review curated by Jean Twenge & Jonathan Haidt. Cultural anthropology Cyberspace Digital media Technology in society Child and adolescent psychiatry Educational psychology

Carper's fundamental ways of knowing

In healthcare, Carper's fundamental ways of knowing is a typology that attempts to classify the different sources from which knowledge and beliefs in professional practice (originally specifically nursing) can be or have been derived. It was proposed by Barbara A. Carper, a professor at the College of Nursing at Texas Woman's University, in 1978. The typology identifies four fundamental "patterns of knowing": Empirical Factual knowledge from science, or other external sources, that can be empirically verified. Personal Knowledge and attitudes derived from personal self-understanding and empathy, including imagining one's self in the patient's position. Ethical Attitudes and knowledge derived from an ethical framework, including an awareness of moral questions and choices. Aesthetic Awareness of the immediate situation, seated in immediate practical action; including awareness of the patient and their circumstances as uniquely individual, and of the combined wholeness of the situation. (Aesthetic in this sense is used to mean "relating to the here and now", from the Greek αἰσθάνομαι (aisthanomai), meaning "I perceive, feel, sense"; the reference is not to the consideration of beauty, art and taste). The emphasis on different ways of knowing is presented as a tool for generating clearer and more complete thinking and learning about experiences, and broader self-integration of classroom education. As such it helped crystallize Johns' (1995) framework for reflective investigation to develop reflective practice. The typology has been seen as leading a reaction against over-emphasis on just empirically derived knowledge, so called "scientific nursing", by emphasising that attitudes and actions that are perhaps more personal and more intuitive are centrally important too, and equally fit for discussion. References Social epistemology Nursing theory

Emotional dysregulation

Emotional dysregulation is characterized by an inability to flexibly respond to and manage emotional states, resulting in intense and prolonged emotional reactions that deviate from social norms, given the nature of the environmental stimuli encountered. Such reactions not only deviate from accepted social norms but also surpass what is informally deemed appropriate or proportional to the encountered stimuli. It is often linked to physical factors such as brain injury, or psychological factors such as adverse childhood experiences, and ongoing maltreatment, including child abuse, neglect, or institutional abuse. Emotional dysregulation may be present in people with psychiatric and neurodevelopmental disorders such as attention deficit hyperactivity disorder, autism spectrum disorder, bipolar disorder, borderline personality disorder, complex post-traumatic stress disorder, and fetal alcohol spectrum disorders. In such cases as borderline personality disorder and complex post-traumatic stress disorder, hypersensitivity to emotional stimuli causes a slower return to a normal emotional state. This is manifested biologically by deficits in the frontal cortices of the brain. As such, the period after a traumatic brain injury such as a frontal lobe disorder can be marked by emotional dysregulation. This is also true of neurodegenerative diseases. Possible manifestations of emotion dysregulation include extreme tearfulness, angry outbursts or behavioral outbursts such as destroying or throwing objects, aggression towards self or others, and threats to kill oneself. Emotion dysregulation can lead to behavioral problems and can interfere with a person's social interactions and relationships at home, in school, or at their place of employment. Etymology The word dysregulation is a neologism created by combining the prefix dys- to regulation. According to Webster's Dictionary, dys- has various roots and is of Greek origin. With Latin and Greek roots, it is akin to Old English , 'apart' and Sanskrit 'bad, difficult'. It is frequently confused with the spelling disregulation, with the prefix dis meaning 'the opposite of' or 'absence of'; while disregulation refers to the removal or absence of regulation, dysregulation refers to ways of regulating that are inappropriate or ineffective. Child psychopathology There are links between child emotional dysregulation and later psychopathology. For instance, ADHD symptoms are associated with problems with emotional regulation, motivation, and arousal. One study found a connection between emotional dysregulation at 5 and 10 months, and parent-reported problems with anger and distress at 18 months. Low levels of emotional regulation behaviors at 5 months were also related to non-compliant behaviors at 30 months. While links have been found between emotional dysregulation and child psychopathology, the mechanisms behind how early emotional dysregulation and later psychopathology are related are not yet clear. Symptoms Smoking, self-harm, eating disorders, and addiction have all been associated with emotional dysregulation. Somatoform disorders may be caused by a decreased ability to regulate and experience emotions or an inability to express emotions in a positive way. Individuals who have difficulty regulating emotions are at risk for eating disorders and substance abuse as they use food or substances as a way to regulate their emotions. Emotional dysregulation is also found in people who have an increased risk of developing a mental disorder, particularly an affective disorder such as depression or bipolar disorder. Childhood Dysregulation is more prevalent in this age group, and is generally seen to decrease as children develop. During early childhood, emotional dysregulation or reactivity is considered to be situational rather than indicative of emotional disorders. It is important to consider parental mood disorders as genetic and environmental determinants. Children of parents with symptoms of depression are less likely to learn strategies for regulating their emotions and are at risk of inheriting a mood disorder. When parents have difficulty with regulating their emotions, they often cannot teach their children to regulate properly. The role of parents in a child's development is acknowledged by attachment theory, which argues that the characteristics of the caregiver-child relationship impact future relationships. Current research indicates that parent-child relationships characterized by less affection and greater hostility may result in children developing emotional regulation problems. If the child's emotional needs are ignored or rejected, they may experience greater difficulty dealing with emotions in the future. Moreover, conflict between parents is linked to increased emotional reactivity or dysregulation in children. Other factors involved include the quality of relationship with peers, the child's temperament, and social or cognitive understanding. Additionally, loss or grief can contribute to emotional dysregulation. Research has shown that failures in emotional regulation may be related to the display of acting out, externalizing disorders, or behavior problems. When presented with challenging tasks, children who were found to have defects in emotional regulation (high-risk) spent less time attending to tasks and more time throwing tantrums or fretting than children without emotional regulation problems (low-risk). High-risk children had difficulty with self-regulation and had difficulty complying with requests from caregivers and were more defiant. Emotional dysregulation has also been associated with childhood social withdrawal. Internalizing behaviors Emotional dysregulation in children can be associated with internalizing behaviors including: exhibiting emotions too intense for a situation; difficulty calming down when upset; difficulty decreasing negative emotions; being less able to calm themselves; difficulty understanding emotional experiences; becoming avoidant or aggressive when dealing with negative emotions; experiencing more negative emotions. Externalizing behaviors Emotional dysregulation in children can be associated with externalizing behaviors including: exhibiting more extreme emotions; difficulty identifying emotional cues; difficulty recognizing their own emotions; focusing on the negative; difficulty controlling their attention; being impulsive; difficulty decreasing their negative emotions; difficulty calming down when upset. Adolescence In adolescents, emotional dysregulation is a risk factor for many mental health disorders including depressive disorders, anxiety disorders, post-traumatic stress disorder, bipolar disorder, borderline personality disorder, substance use disorder, alcohol use disorder, eating disorders, oppositional defiant disorder, and disruptive mood dysregulation disorder. Dysregulation is also associated with self-injury, suicidal ideation, suicide attempts, and risky sexual behavior. Emotional dysregulation is not a diagnosis, but an indicator of an emotional or behavioral problem that may need intervention. Attachment theory and the idea of an insecure attachment is implicated in emotional dysregulation. Greater attachment security correlates with less emotional dysregulation in daughters. Moreover, it has been observed that more female teens struggle with emotional dysregulation than males. Professional treatment, such as therapy or admittance into a psychiatric facility, is recommended. Adulthood Emotional dysregulation tends to present as emotional responses that may seem excessive compared to the situation. Individuals with emotional dysregulation may have difficulty calming down, avoid difficult feelings, or focus on the negative. On average, women tend to score higher on scales of emotional reactivity than men. A study at University College in Ireland found that dysregulation correlates to negative feelings about one's ability to cope with emotions and rumination in adults. They also found dysregulation to be common in a sample of individuals not affected by mental disorders. Part of emotional dysregulation, which is a core characteristic in borderline personality disorder, is affective instability, which manifests as rapid and frequent shifts in mood of high affect intensity and rapid onset of emotions, often triggered by environmental stimuli. The return to a stable emotional state is notably delayed, exacerbating the challenge of achieving emotional equilibrium. This instability is further intensified by an acute sensitivity to psychosocial cues, leading to significant challenges in managing emotions effectively. Impact on relationships Established relationships Relationships are generally linked to better well-being, but dissatisfaction in relationships can lead to increased divorce, worsened health, and potential violence. Emotional dysregulation plays a role in relationship quality and overall satisfaction. It can be difficult for emotionally dysregulated individuals to maintain healthy relationships. People who struggle with emotional dysregulation often externalize, internalize, or dissociate when exposed to stressors. These behaviors are attempts to regulate emotions but often are ineffective in addressing stress in relationships. This commonly presents itself as intense anxiety around relationships, poor ability to set and sustain boundaries, frequent and damaging arguments, preoccupation with loneliness, worries about losing a relationship, and jealous or idealizing feelings towards others. These feelings may be accompanied by support-seeking behaviors such as clinging, smothering, or seeking to control. The counterpart of emotional dysregulation, emotional regulation, strengthens relationships. The ability to regulate negative emotions in particular is linked to positive coping and thus higher relationship satisfaction. Emotional regulation and communication skills are linked to secure attachment, which has been related to higher partner support as well as openness in discussing negative experiences and resolving conflict. On the other hand, emotional dysregulation has a negative impact on relationships. Multiple studies note the effects of emotion dysregulation on relationship quality. One study found that relationship satisfaction is lower in couples that lack impulse control or regulatory strategies. Another study found that both husbands' and wives' emotional reactivity was negatively linked with marriage quality as well as perceptions of partner responsiveness. The literature concludes that dysregulation increases instances of perceived criticism, contributes to physical and psychological violence, and worsens depression, anxiety, and sexual difficulties. Dysregulation has also been observed to lower empathy and decrease relationship satisfaction, quality, and intimacy. Sexual health Research conflicts on whether higher levels of emotional reactivity are linked to increases or decreases in sexual desire. Moreover, this effect could differ between men and women based on observed differences in emotional reactivity between genders. Some research posits that higher emotional reactivity in women is linked to greater sexual attraction in their male partners. However, difficulties in regulating emotions have been linked to poorer sexual health, both in regards to ability and overall satisfaction. Emotional dysregulation plays a role in nonconsensual and violent sexual encounters. Emotional regulation skills prevent verbal coercion by regulating feelings of sexual attraction in men. Consequently, a lack of emotional regulation skills can cause both internalizing and externalizing behaviors in a sexual context. This may mean violence, which can serve as a strategy for regulating emotion. In a non-violent context, insecurely attached individuals may seek to satisfy their need for connection or to resolve relational issues with sex. Communication can also be hindered, as emotional dysregulation has been linked to an inability to express oneself in sexual situations. This can lead to victimization as well as further sexual difficulties. Thus, the ability to both recognize emotions and express negative emotions are important for communication and social adjustment, including within sexual contexts. Mediating effects While personal characteristics and experiences can contribute to externalizing and internalizing behaviors as listed above, emotional regulation has an interpersonal aspect. Couples who effectively co-regulate have higher emotional satisfaction and stability. Openly discussing emotions in the relationship can help to validate feelings of insecurity and encourage closeness. For partners who struggle with emotional dysregulation, there are available treatments. Couple's therapy has shown itself to be an effective method of improving relationship satisfaction and quality by positively impacting the process of emotional regulation in relationships. Protective factors Early experiences with caregivers can lead to differences in emotional regulation. The responsiveness of a caregiver to an infant's signals can help an infant regulate their emotional systems. Caregiver interaction styles that overwhelm a child or that are unpredictable may undermine emotional regulation development. Effective strategies involve working with a child to support developing self-control such as modeling a desired behavior rather than demanding it. The richness of an environment that a child is exposed to helps the development of emotional regulation. An environment must provide appropriate levels of freedom and constraint. The environment must allow opportunities for a child to practice self-regulation. An environment with opportunities to practice social skills without overstimulation or excessive frustration helps a child develop self-regulation skills. Substance use Several variables have been explored to explain the connection between emotional dysregulation and substance use in young adults, such as child maltreatment, cortisol levels, family environment, and symptoms of depression and anxiety. Vilhena-Churchill and Goldstein (2014) explored the association between childhood maltreatment and emotional dysregulation. More severe childhood maltreatment was found to be associated with an increase in difficulty regulating emotion, which in turn was associated with a greater likelihood of coping by using marijuana. Kliewer et al. (2016) performed a study on the relationship between negative family emotional climate, emotional dysregulation, blunted anticipatory cortisol, and substance use in adolescents. Increased negative family emotional climate was found to be associated with high levels of emotional dysregulation, which was then associated with increased substance use. Girls were seen to have blunted anticipatory cortisol levels, which was also associated with an increase in substance use. Childhood events and family climate with emotional dysregulation are both factors seemingly linked to substance use. Prosek, Giordano, Woehler, Price, and McCullough (2018) explored the relationship between mental health and emotional regulation in collegiate illicit substance users. Illicit drug users reported higher levels of depression and anxiety symptoms. Emotional dysregulation was more prominent in illicit drug users in the sense that they had less clarity and were less aware of their emotions when the emotions were occurring. Treatment Many people experience dysregulation and can struggle at times with uncontrollable emotions. Thus, potential underlying issues are important to consider in determining severity. As the ability to appropriately express and regulate emotions is related to better relationships and mental health, parental support can help regulate the emotions of children struggling with emotional dysregulation. Training to help parents address this issue focuses on predictability and consistency. These tenets are thought to provide comfort by creating a sense of familiarity and thus safety. While cognitive behavioral therapy is the most widely prescribed treatment for such psychiatric disorders, a commonly prescribed psychotherapeutic treatment for emotional dysregulation is dialectical behavioral therapy, a psychotherapy which promotes the use of mindfulness, a concept called dialectics, and emphasis on the importance of validation and maintaining healthy behavioral habits. When diagnosed as being part of ADHD, norepinephrine and dopamine reuptake inhibitors such as methylphenidate (Ritalin) and atomoxetine are often used. A few studies have also showed promise in terms of non-pharmacological treatments for people with ADHD and emotional problems, although the research is limited and requires additional inquiry. Eye Movement Desensitization and Reprocessing (EMDR) can help recovery from emotional dysregulation in cases where the dysregulation is a symptom of prior trauma. Outside of therapy, there are helpful strategies to help individuals recognize how they are feeling and put space between an event and their response. These include mindfulness, affirmations, and gratitude journaling. Hypnosis may also help to improve emotional regulation. Movement such as yoga and aerobic exercise can also be therapeutic by aiding with regulation and the ability to understand how one's mind influences behavior. See also Adrenal insufficiency Alexithymia Anxiety Conduct disorder Emotional self-regulation Epigenetics of anxiety and stress–related disorders Pseudobulbar affect Reduced affect display Spiritual crisis WAVE Trust References Sources Borderline personality disorder Child abuse regul, dys Emotional issues Institutional abuse Mood disorders Psychological abuse Symptoms and signs of mental disorders

Disability

Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be cognitive, developmental, intellectual, mental, physical, sensory, or a combination of multiple factors. Disabilities can be present from birth or can be acquired during a person's lifetime. Historically, disabilities have only been recognized based on a narrow set of criteria—however, disabilities are not binary and can be present in unique characteristics depending on the individual. A disability may be readily visible, or invisible in nature. The United Nations Convention on the Rights of Persons with Disabilities defines disability as including: Disabilities have been perceived differently throughout history, through a variety of different theoretical lenses. There are two main models that attempt to explain disability in our society: the medical model and the social model. The medical model serves as a theoretical framework that considers disability as an undesirable medical condition that requires specialized treatment. Those who ascribe to the medical model tend to focus on finding the root causes of disabilities, as well as any cures—such as assistive technology. The social model centers disability as a societally-created limitation on individuals who do not have the same ability as the majority of the population. Although the medical model and social model are the most common frames for disability, there are a multitude of other models that theorize disability. There are many terms that explain aspects of disability. While some terms solely exist to describe phenomena pertaining to disability, others have been centered around stigmatizing and ostracizing those with disabilities. Some terms have such a negative connotation that they are considered to be slurs. A current point of contention is whether it is appropriate to use person-first language (i.e. a person who is disabled) or identity-first language (i.e. a disabled person) when referring to disability and an individual. Due to the marginalization of disabled people, there have been several activist causes that push for equitable treatment and access in society. Disability activists have fought to receive equal and equitable rights under the law—though there are still political issues that enable or advance the oppression of disabled people. Although disability activism serves to dismantle ableist systems, social norms relating to the perception of disabilities are often reinforced by tropes used by the media. Since negative perceptions of disability are pervasive in modern society, disabled people have turned to self-advocacy in an attempt to push back against their marginalization. The recognition of disability as an identity that is experienced differently based on the other multi-faceted identities of the individual is one often pointed out by disabled self-advocates. The ostracization of disability from mainstream society has created the opportunity for a disability culture to emerge. While disabled activists still promote the integration of disabled people into mainstream society, several disabled-only spaces have been created to foster a disability community—such as with art, social media, and sports. History Contemporary understandings of disability derive from concepts that arose during the scientific Enlightenment in the west; prior to the Enlightenment, physical differences were viewed through a different lens. There is evidence of humans during prehistory that looked after people with disabilities. At the Windover Archeological Site, one of the skeletons was a male about 15 years old who had spina bifida. The condition meant that the boy, probably paralyzed below the waist, was taken care of in a hunter-gatherer community. Disability was not viewed as a means of divine punishment and therefore disabled individuals were neither exterminated nor discriminated against for their impairments. Many were instead employed in different levels of Mesopotamian society including working in religious temples as servants of the gods. In Ancient Egypt, staffs were frequently used in society. A common usage for them was for older persons with disabilities to help them walk. Provisions that enabled individuals with impaired mobility to access temples and healing sanctuaries were made in ancient Greece. Specifically, by 370 B.C., at the most important healing sanctuary in the wider area, the Sanctuary of Asclepius at Epidaurus, there were at least 11 permanent stone ramps that provided access to mobility-impaired visitors to nine different structures; evidence that people with disabilities were acknowledged and cared for, at least partly, in ancient Greece. In fact, the Ancient Greeks may not have viewed persons with disability all that differently from more able-bodied individuals as terms describing them in their records appear to be very vague. As long as the disabled person in question could still contribute to society, the Greeks appeared to tolerate them. During the Middle Ages, madness and other conditions were thought to be caused by demons. They were also thought to be part of the natural order, especially during and in the fallout of the Black Death, which wrought impairments throughout the general population. In the early modern period there was a shift to seeking biological causes for physical and mental differences, as well as heightened interest in demarcating categories: for example, Ambroise Pare, in the sixteenth century, wrote of "monsters", "prodigies", and "the maimed". The European Enlightenment's emphases on knowledge derived from reason and on the value of natural science to human progress helped spawn the birth of institutions and associated knowledge systems that observed and categorized human beings; among these, the ones significant to the development of today's concepts of disability were asylums, clinics, and prisons. Contemporary concepts of disability are rooted in eighteenth- and nineteenth-century developments. Foremost among these was the development of clinical medical discourse, which made the human body visible as a thing to be manipulated, studied, and transformed. These worked in tandem with scientific discourses that sought to classify and categorize and, in so doing, became methods of normalization. The concept of the "norm" developed in this time period, and is signaled in the work of the Belgian statistician, sociologist, mathematician, and astronomer Adolphe Quetelet, who wrote in the 1830s of l'homme moyen – the average man. Quetelet postulated that one could take the sum of all people's attributes in a given population (such as their height or weight) and find their average and that this figure should serve as a statistical norm toward which all should aspire. This idea of the statistical norm threads through the rapid take-up of statistics gathering by Britain, the United States, and the Western European states during this time period, and it is tied to the rise of eugenics. Disability, as well as the concepts of abnormal, non-normal, and normalcy, came from this. The circulation of these concepts is evident in the popularity of the freak show, where showmen profited from exhibiting people who deviated from those norms. With the rise of eugenics in the latter part of the nineteenth century, such deviations were viewed as dangerous to the health of entire populations. With disability viewed as part of a person's biological make-up and thus their genetic inheritance, scientists turned their attention to notions of weeding such as "deviations" out of the gene pool. Various metrics for assessing a person's genetic fitness were determined and were then used to deport, sterilize, or institutionalize those deemed unfit. People with disabilities were one of the groups targeted by the Nazi regime in Germany, resulting in approximately 250,000 disabled people being killed during the Holocaust. At the end of the Second World War, with the example of Nazi eugenics, eugenics faded from public discourse, and increasingly disability cohered into a set of attributes that medicine could attend to – whether through augmentation, rehabilitation, or treatment. In both contemporary and modern history, disability was often viewed as a by-product of incest between first-degree relatives or second-degree relatives. Disability scholars have also pointed to the Industrial Revolution, along with the economic shift from feudalism to capitalism, as prominent historical moments in the understanding of disability. Although there was a certain amount of religious superstition surrounding disability during the Middle Ages, disabled people were still able to play significant roles in the rural production based economy, allowing them to make genuine contributions to daily economic life. The Industrial Revolution and the advent of capitalism made it so that people were no longer tied to the land and were then forced to find work that would pay a wage in order to survive. The wage system, in combination with industrialized production, transformed the way bodies were viewed as people were increasingly valued for their ability to produce like machines. Capitalism and the industrial revolution effectively solidified this class of "disabled" people who could not conform to the standard worker's body or level of work power. As a result, disabled people came to be regarded as a problem, to be solved or erased. In the early 1970s, the disability rights movement became established, when disability activists began to challenge how society treated disabled people and the medical approach to disability. Due to this work, physical barriers to access were identified. These conditions functionally disabled them, and what is now known as the social model of disability emerged. Coined by Mike Oliver in 1983, this phrase distinguishes between the medical model of disability – under which an impairment needs to be fixed – and the social model of disability – under which the society that limits a person needs to be fixed. Theory Like many social categories, the concept of "disability" is under heavy discussion amongst academia, the medical and legal worlds, and the disability community. Disability studies The academic discipline focused on theorizing disability is disability studies, which has been expanding since the late twentieth century. The field investigates the past, present, and future constructions of disability, along with advancing the viewpoint that disability is a complex social identity from which we can all gain insight. As disabilities scholar Claire Mullaney puts it, "At its broadest, disability studies encourages scholars to value disability as a form of cultural difference". Scholars of the field focus on a range of disability-related topics, such as ethics, policy and legislation, history, art of the disability community, and more. Notable scholars from the field include Marta Russell, Robert McRuer, Johanna Hedva, Laura Hershey, Irving Zola, and many more. Prominent disability scholar Lennard J. Davis notes that disability studies should not be considered a niche or specialized discipline, but instead is applicable to a wide range of fields and topics. International Classification The International Classification of Functioning, Disability and Health (ICF), produced by the World Health Organization, distinguishes between body functions (physiological or psychological, such as vision) and body structures (anatomical parts, such as the eye and related structures). Impairment in bodily structure or function is defined as involving an anomaly, defect, loss or other significant deviation from certain generally accepted population standards, which may fluctuate over time. Activity is defined as the execution of a task or action. The ICF lists nine broad domains of functioning which can be affected: Learning and applying knowledge General tasks and demands Communication Basic physical mobility, Domestic life, and Self-care (for example, activities of daily living) Interpersonal interactions and relationships Community, social and civic life, including employment Other major life areas In concert with disability scholars, the introduction to the ICF states that a variety of conceptual models have been proposed to understand and explain disability and functioning, which it seeks to integrate. These models include the following: Medical model The medical model views disability as a problem of the person, directly caused by disease, trauma, or other health conditions which therefore requires sustained medical care in the form of individual treatment by professionals. In the medical model, management of the disability is aimed at a "cure", or the individual's adjustment and behavioral change that would lead to an "almost-cure" or effective cure. The individual, in this case, must overcome their disability by medical care. In the medical model, medical care is viewed as the main issue, and at the political level, the principal response is that of modifying or reforming healthcare policy. The medical model focuses on finding causes and cures for disabilities. Causes There are many causes of disability that often affect basic activities of daily living, such as eating, dressing, transferring, and maintaining personal hygiene; or advanced activities of daily living such as shopping, food preparation, driving, or working. However, causes of disability are usually determined by a person's capability to perform the activities of daily life. As Marta Russell and Ravi Malhotra argue, "The 'medicalization' of disablement and the tools of classification clearly played an important role in establishing divisions between the 'disabled' and the 'able-bodied. This positions disability as a problem to be solved via medical intervention, which hinders our understanding about what disability can mean. For the purposes of the Americans with Disabilities Act of 1990, the US Equal Employment Opportunity Commission regulations provide a list of conditions that should easily be concluded to be disabilities: amputation, attention deficit hyperactivity disorder (ADHD), autism, bipolar disorder, blindness, cancer, cerebral palsy, deafness, diabetes, epilepsy, HIV/AIDS, intellectual disability, major depressive disorder, mobility impairments requiring a wheelchair, multiple sclerosis, muscular dystrophy, obsessive–compulsive disorder (OCD), post-traumatic stress disorder (PTSD), spina bifida, and schizophrenia. This is not an exhaustive list and many injuries and medical problems cause disability. Some causes of disability, such as injuries, may resolve over time and are considered temporary disabilities. An acquired disability is the result of impairments that occur suddenly or chronically during the lifespan, as opposed to being born with the impairment. Invisible disabilities may not be obviously noticeable. Cures The medical model focuses heavily on finding treatments, cures, or rehabilitative practices for disabled people. Assistive technology Assistive technology is a generic term for devices and modifications (for a person or within a society) that help overcome or remove a disability. The first recorded example of the use of a prosthesis dates to at least 1800 BC. The wheelchair dates from the 17th century. The curb cut is a related structural innovation. Other examples are standing frames, text telephones, accessible keyboards, large print, braille, and speech recognition software. Disabled people often develop adaptations which can be personal (e.g. strategies to suppress tics in public) or community (e.g. sign language in d/Deaf communities). As the personal computer has become more ubiquitous, various organizations have formed to develop software and hardware to make computers more accessible for disabled people. Some software and hardware, such as Voice Finger, Freedom Scientific's JAWS, the Free and Open Source alternative Orca etc. have been specifically designed for disabled people while other software and hardware, such as Nuance's Dragon NaturallySpeaking, were not developed specifically for disabled people, but can be used to increase accessibility. The LOMAK keyboard was designed in New Zealand specifically for persons with disabilities. The World Wide Web consortium recognized a need for International Standards for Web Accessibility for persons with disabilities and created the Web Accessibility Initiative (WAI). As at Dec 2012 the standard is WCAG 2.0 (WCAG = Web Content Accessibility Guidelines). Social model The social model of disability sees "disability" as a socially created problem and a matter of the full integration of individuals into society. In this model, disability is not an attribute of an individual, but rather a complex collection of conditions, created by the social environment. The management of the problem requires social action and it is the collective responsibility of society to create a society in which limitations for disabled people are minimal. Disability is both cultural and ideological in creation. According to the social model, equal access for someone with an impairment/disability is a human rights concern. The social model of disability has come under criticism. While recognizing the importance played by the social model in stressing the responsibility of society, scholars, including Tom Shakespeare, point out the limits of the model and urge the need for a new model that will overcome the "medical vs. social" dichotomy. The limitations of this model mean that often the vital services and information persons with disabilities face are simply not available, often due to limited economic returns in supporting them. Some say medical humanities is a fruitful field where the gap between the medical and the social model of disability might be bridged. Social construction The social construction of disability is the idea that disability is constructed by social expectations and institutions rather than biological differences. Highlighting the ways society and institutions construct disability is one of the main focuses of this idea. In the same way that race and gender are not biologically fixed, neither is disability. Around the early 1970s, sociologists, notably Eliot Friedson, began to argue that labeling theory and social deviance could be applied to disability studies. This led to the creation of the social construction of disability theory. The social construction of disability is the idea that disability is constructed as the social response to a deviance from the norm. The medical industry is the creator of the ill and disabled social role. Medical professionals and institutions, who wield expertise over health, have the ability to define health and physical and mental norms. When an individual has a feature that creates an impairment, restriction, or limitation from reaching the social definition of health, the individual is labeled as disabled. Under this idea, disability is not defined by the physical features of the body but by a deviance from the social convention of health. The social construction of disability would argue that the medical model of disability's view that a disability is an impairment, restriction, or limitation is wrong. Instead what is seen as a disability is just a difference in the individual from what is considered "normal" in society. Other models The political/relational model is an alternative to and critical engagement with both the social and medical models. This analytic posed by Alison Kafer shows not only how the "problem" of disability "is located in inaccessible buildings, discriminatory attitudes, and ideological systems that attribute normalcy and deviance to particular minds and bodies" but also how mind and bodily impairments can still have disabling effects. Furthermore, the political/relational model frames the medicalization of disabled folks as political in nature given it should always be interrogated. The spectrum model refers to the range of audibility, sensibility, and visibility under which people function. The model asserts that disability does not necessarily mean a reduced spectrum of operations. Rather, disability is often defined according to thresholds set on a continuum of disability. The moral model refers to the attitude that people are morally responsible for their own disability. For example, disability may be seen as a result of bad actions of parents if congenital, or as a result of practicing witchcraft if not. Echoes of this can be seen in the doctrine of karma in Eastern and New Age religions. It also includes notions that a disability gives a person "special abilities to perceive, reflect, transcend, be spiritual". The expert/professional model has provided a traditional response to disability issues and can be seen as an offshoot of the medical model. Within its framework, professionals follow a process of identifying the impairment and its limitations (using the medical model), and taking the necessary action to improve the position of the disabled person. This has tended to produce a system in which an authoritarian, over-active service provider prescribes and acts for a passive client. The tragedy/charity model depicts disabled people as victims of circumstance who are deserving of pity. This, along with the medical model, are the models used by most people with no acknowledged disability to define and explain disability. The legitimacy model views disability as a value-based determination about which explanations for the atypical are legitimate for membership in the disability category. This viewpoint allows for multiple explanations and models to be considered as purposive and viable. The social adapted model states although a person's disability poses some limitations in an able-bodied society, often the surrounding society and environment are more limiting than the disability itself. The economic model defines disability in terms of reduced ability to work, the related loss of productivity and economic effects on the individual, employer and society in general. The empowering model (also, customer model or Supported decision making) allows for the person with a disability and their family to decide the course of their treatment. This turns the professional into a service provider whose role is to offer guidance and carry out the client's decisions. This model "empowers" the individual to pursue their own goals. The market model of disability is minority rights and consumerist model of disability that recognizing disabled people and their stakeholders as representing a large group of consumers, employees, and voters. This model looks to personal identity to define disability and empowers people to chart their own destiny in everyday life, with a particular focus on economic empowerment. Based on US Census data, this model shows that there are 1.2 billion people in the world who consider themselves to have a disability. "This model states that due to the size of the demographic, companies and governments will serve the desires, pushed by demand as the message becomes prevalent in the cultural mainstream." The consumer model of disability is based upon the "rights-based" model and claims that disabled people should have equal rights and access to products, goods, and services offered by businesses. The consumer model extends the rights-based model by proposing that businesses, not only accommodate customers with disabilities under the requirements of legislation but that businesses actively seek, market to, welcome and fully engage disabled people in all aspects of business service activities. The model suggests that all business operations, for example, websites, policies, procedures, mission statements, emergency plans, programs, and services, should integrate access and inclusion practices. Furthermore, these access and inclusion practices should be based on established customer service access and inclusion standards that embrace and support the active engagement of people of all abilities in business offerings. In this regard, specialized products and specialized services become important, such as auxiliary means, prostheses, special foods, domestic help, and assisted living. Different theories revolve around prejudice, stereotyping, discrimination, and stigma related to disability. One of the more popular ones, as put by Weiner, Perry, and Magnusson's (1988) work with attribution theory, physical stigmas are perceived as to be uncontrollable and elicit pity and desire to help, whereas, mental-behavioral stigmas are considered to be controllable and therefore elicit anger and desire to neglect the individuals with disabilities. The 'just-world hypothesis' talks about how a person is viewed as deserving the disability. And because it is the fault of that person, an observer does not feel obligated to feel bad for them or to help them. Terminology People-first language People-first language is one way to talk about disability which some people prefer. Using people-first language is said to put the person before the disability. Those individuals who prefer people-first language would prefer to be called, "a person with a disability". This style is reflected in major legislation on disability rights, including the Americans with Disabilities Act and the UN Convention on the Rights of Persons with Disabilities. "Cerebral Palsy: A Guide for Care" at the University of Delaware describes people-first language: People-first terminology is used in the UK in the form "people with impairments" (such as "people with visual impairments"). However, in the UK, identity-first language is generally preferred over people-first language. The use of people-first terminology has given rise to the use of the acronym PWD to refer to person(s) (or people) with disabilities (or disability). However other individuals and groups prefer identity-first language to emphasize how a disability can impact people's identities. Which style of language used varies between different countries, groups and individuals. Identity-first language Identity-first language describes the person as "disabled". Some people prefer this and argue that this fits the social model of disability better than people-first language, as it emphasizes that the person is disabled not by their body, but by a world that does not accommodate them. This is especially true in the UK, where it is argued under the social model that while someone's impairment (for example, having a spinal cord injury) is an individual property, "disability" is something created by external societal factors such as a lack of accessibility. This distinction between the individual property of impairment and the social property of disability is central to the social model. The term "disabled people" as a political construction is also widely used by international organizations of disabled people, such as Disabled Peoples' International. Using the identity-first language also parallels how people talk about other aspects of identity and diversity. For example: Similarly, Deaf communities in the U.S. reject people-first language in favor of identity-first language. In 2021, the US Association on Higher Education and Disability (AHEAD) announced their decision to use identity-first language in their materials, explaining: "Identity-first language challenges negative connotations by claiming disability directly. Identity-first language references the variety that exists in how our bodies and brains work with a myriad of conditions that exist, and the role of inaccessible or oppressive systems, structures, or environments in making someone disabled." Handicap The term handicap derives from the medieval game Hand-in-cap, in which two players trade possessions, and a third, neutral person judges the difference of value between the possessions. The concept of a neutral person evening up the odds was extended to handicap racing in the mid-18th century, where horses carry different weights based on the umpire's estimation of what would make them run equally. In the early 20th century the word gained the additional meaning of describing a disability, in the sense that a person with a handicap was carrying a heavier burden than normal. This concept, then, adds to the conception of disability as a burden, or individual problem, rather than a societal problem. Accessibility Accessibility is the degree to which a product, service or environment is available for use to the people that need it. People with certain types of disabilities struggle to get equal access to some things in society. For example, a blind person cannot read printed paper ballots, and therefore does not have access to voting that requires paper ballots. Another example can be that a person in a wheelchair cannot ascend stairs and therefore does not have access to buildings without ramps. Accessible access to health clubs and fitness centers has been observed to be especially problematic. Accommodation A change that improves access. For example, if voting ballots are available in braille or on a text-to-speech machine, or if another person reads the ballot to the blind person and recorded the choices, then the blind person would have access to voting. Invisible disability Invisible disabilities, also known as Hidden Disabilities or Non-visible Disabilities (NVD), are disabilities that are not immediately apparent, or seeable. They are often chronic illnesses and conditions that significantly impair normal activities of daily living. Invisible disabilities can hinder a person's efforts to go to school, work, socialize, and more. Some examples of invisible disabilities include intellectual disabilities, autism spectrum disorder, attention deficit hyperactivity disorder, fibromyalgia, mental disorders, asthma, epilepsy, allergies, migraines, arthritis, and chronic fatigue syndrome. Employment discrimination is reported to play a significant part in the high rate of unemployment among those with a diagnosis of mental illness. Episodic disability People with health conditions such as arthritis, bipolar disorder, HIV, or multiple sclerosis may have periods of wellness between episodes of illness. During the illness episodes people's ability to perform normal tasks, such as work, can be intermittent. Disability activism Disability activism itself has led to the revision of appropriate language, when discussing disability and disabled people. For example, the medical classification of 'retarded' has since been disregarded, due to its negative implications. Moreover, disability activism has also led to pejorative language being reclaimed by disabled people. Mairs (1986) explained how disabled people may choose to self-describe themselves as a 'cripple'. This may appear surprising that they are using stereotypically negative language associated with disability to describe themselves; however the purpose is to reclaim the 'disabled identity' from medical professionals, and realign it with the preferred language of disabled people. The reclamation of language demonstrated above positions itself within the social model, as it highlights how as a society we construct concepts and perceptions of disability.Disability activists have drawn attention to the following issues: Rights and policies Rights movement The disability rights movement aims to secure equal opportunities and equal rights for disabled people. The specific goals and demands of the movement are accessibility and safety in transportation, architecture, and the physical environment; equal opportunities in independent living, employment, education, and housing; and freedom from abuse, neglect, and violations of patients' rights. Effective civil rights legislation is sought to secure these opportunities and rights. The early disability rights movement was dominated by the medical model of disability, where emphasis was placed on curing or treating disabled people so that they would adhere to the social norm, but starting in the 1960s, rights groups began shifting to the social model of disability, where disability is interpreted as an issue of discrimination, thereby paving the way for rights groups to achieve equality through legal means. Advocacy for disability issues and accessibility in the republics of the former Soviet Union has become more organized and influential in policymaking. Disability Justice Movement Evolving from the disability rights movement is the Disability Justice movement, which aims to improve the lives of disabled people through prioritizing collective liberation, as opposed to prioritizing legislative change and traditional civil rights. This framework, dubbed the "second wave" of disability rights, seeks to examine the many systems of oppression that are intertwined with ableism, such colonialism, white supremacy, and heteropatriarchal capitalism. The term "Disability Justice" was coined in 2005 by LGBTQ disabled women of color, Mia Mingus, Patricia Berne, and Stacey Milbern, who sought to build an anti-ableist movement with a larger emphasis on intersectionality than mainstream disability rights, as to center marginalized voices. Their group, the Disability Justice Collective, also included notable disability activists such as Sebastian Margaret, Leroy F. Moore Jr., well known for his poetry and founding of the Krip Hop movement, and Eli Clare, well known for popularizing the bodymind concept within disability studies. Convention on the Rights of Persons with Disabilities On December 13, 2006, the United Nations formally agreed on the Convention on the Rights of Persons with Disabilities, the first human rights treaty of the 21st century, to protect and enhance the rights and opportunities of the world's estimated 650 million disabled people. , 182 nations have ratified or accepted accession to the convention. Countries that sign the convention are required to adopt national laws, and remove old ones, so that persons with disabilities will, for example, have equal rights to education, employment, and cultural life; to the right to own and inherit property; to not be discriminated against in marriage, etc.; and to not be unwilling subjects in medical experiments. UN officials, including the High Commissioner for Human Rights, have characterized the bill as representing a paradigm shift in attitudes toward a more rights-based view of disability in line with the social model. International Year of Disabled Persons In 1976, the United Nations began planning for its International Year for Disabled Persons (1981), later renamed the International Year of Disabled Persons. Some disability activists used the Year to highlight various injustices, such as in Australia where beauty pageants were targeted in order to, in the words of activist Leslie Hall, "challenge the notion of beauty" and "reject the charity ethic. The UN Decade of Disabled Persons (1983–1993) featured a World Programme of Action Concerning Disabled Persons. In 1979, Frank Bowe was the only person with a disability representing any country in the planning of IYDP-1981. Today, many countries have named representatives who are themselves individuals with disabilities. The decade was closed in an address before the General Assembly by Robert Davila. Both Bowe and Davila are deaf. In 1984, UNESCO accepted sign language for use in the education of deaf children and youth. Policies in former Soviet Union republics UN programs and OSCE work to align policy and programs in countries that were part of the former Soviet Union with the Convention on the Rights of Persons with Disabilities. Political issues Political rights, social inclusion and citizenship have come to the fore in developed and some developing countries. The debate has, some instances, moved beyond a concern about the perceived cost of maintaining dependent disabled people to finding effective ways to ensure that disabled people can participate in and contribute to society in all spheres of life. In developing nations, where the vast bulk of the estimated 650 million disabled people reside, a great deal of work is needed to address concerns ranging from accessibility and education to self-empowerment, self-supporting employment, and beyond. In the past few decades, the efforts of disability rights activists around the world, focused on obtaining full citizenship for disabled people, have come under academic study and gained some level of public recognition in many places, such as in the United States. There are obstacles in many countries in getting full employment and public perception of disabled people varies. Abuse Disability abuse happens when a person is abused physically, financially, verbally or mentally due to the person having a disability. As many disabilities are not visible (for example, asthma, learning disabilities) some abusers cannot rationalize the non-physical disability with a need for understanding, support, and so on. As the prevalence of disability and the cost of supporting disability increases with medical advancement and longevity in general, this aspect of society becomes of greater political importance. How political parties treat their disabled constituents may become a measure of a political party's understanding of disability, particularly in the social model of disability. Insurance Disability benefit, or disability pension, is a major kind of disability insurance that is provided by government agencies to people who are temporarily or permanently unable to work due to a disability. In the U.S., the disability benefit is provided in the category of Supplemental Security Income. In Canada, it is within the Canada Pension Plan. Following a long nationwide campaign involving hundreds of thousands of people the National Disability Insurance Scheme was introduced in Australia in 2013 to fund a number of supports.In other countries, disability benefits may be provided under social security systems. Costs of disability pensions are steadily growing in Western countries, mainly in Europe and the United States. It was reported that, in the UK, expenditure on disability pensions accounted for 0.9% of gross domestic product (GDP) in 1980; two decades later it had reached 2.6% of GDP. Several studies have reported a link between increased absence from work due to sickness and elevated risk of future disability pension. A study by researchers in Denmark suggests that information on self-reported days of absence due to sickness can be used to effectively identify future potential groups for disability pension. These studies may provide useful information for policymakers, case managing authorities, employers, and physicians. In Switzerland, social policies in the field of disability have been significantly reshaped over the last two decades by reducing the number of allowances awarded and by increasing the recourse to vocational rehabilitation measures. Drawing on interviews conducted with individuals who have been involved in programs set up by Swiss disability insurance, a study highlights their uncertainties and concerns relating to their place in society, as well as their reactions to disability insurance's interventions. Private, for-profit disability insurance plays a role in providing incomes to disabled people, but the nationalized programs are the safety net that catch most claimants. Employment Studies have illustrated a correlation between disability and poverty. Notably, jobs offered to disabled people are scarce. Marta Russell notes that "[a] primary basis for oppression of disabled persons (those who could work with accommodations) is their exclusion from exploitation as wage laborers." Intellectual Disability Many countries have programs which aid intellectually disabled (ID) people to acquire skills needed in the workforce. Such programs include sheltered workshops and adult day care programs. Sheltered programs consist of daytime activities such as gardening, manufacturing, and assembling. These activities facilitate routine-oriented tasks that in turn allow ID people to gain experience before entering the workforce. Similarly, adult day care programs also include day time activities. However, these activities are based in an educational environment where ID people are able to engage in educational, physical, and communication-based tasks which helps facilitate communication, memory, and general living skills. In addition, adult day care programs arranged community activities by scheduling field trips to public places (e.g. zoos, and movie theaters). Despite both programs providing essential skills for intellectually disabled people prior to entering the workforce, researchers have found that ID people prefer to be involved with community-integrated employment. Community-integrated employment opportunities are offered to ID people at minimum or higher wages, in a variety of occupations ranging from customer service, clerical, janitorial, hospitality and manufacturing positions. ID employees work alongside employees without disabilities who are able to assist them with training. All three options allow intellectually disabled people to develop and exercise social skills that are vital to everyday life. However, it is not guaranteed that ID employees receive the same treatment as employees without ID; according to Lindstrom et al., community-integrated employees are less likely to receive raises, and only 26% are able to retain full-time status. Finding a stable workforce poses additional challenges. A study published in the Journal of Applied Research in Intellectual Disability indicated that although finding a job may be difficult, stabilizing a job is even harder. Chadsey-Rusch proposed that securing employment for ID people requires adequate production skills and effective social skills. Other underlying factors for job loss include structural factors and worker-workplace integration. As stated by Kilsby, limited structural factors can affect a multitude of factors in a job, such as a restricted number of hours an ID person is allowed to work. This in return, according to Fabian et al., leads to a lack of opportunity to develop relationships with coworkers or to better integrate within the workplace. Nevertheless, those who are unable to stabilize a job often are left discouraged. According to the same study conducted by JARID, many who had participated found that they had made smaller incomes when compared to their co-workers, had an excess of time throughout their days, because they did not have work. They also had feelings of hopelessness and failure. According to the U.S. National Organization on Disability, not only do ID people face constant discouragement, but many live below the poverty line, because they are unable to find or stabilize employment and because of employee restricting factors placed on ID workers. This renders ID people unable to provide for themselves, including basic necessities such as food, medical care, transportation, and housing. Poverty The poverty rate for working-age people with disabilities is nearly two and a half times higher than that for people without disabilities. Disability and poverty may form a vicious circle, in which physical barriers and stigma of disability make it more difficult to get income, which in turn diminishes access to health care and other necessities for a healthy life. In societies without state funded health and social services, living with a disability could require spending on medication and frequent health care visits, in-home personal assistance, and adaptive devices and clothing, along with the usual costs of living. The World report on disability indicates that half of all disabled people cannot afford health care, compared to a third of abled people. In countries without public services for adults with disabilities, their families may be impoverished. Disasters There is limited research knowledge, but many anecdotal reports, on what happens when disasters impact disabled people. Individuals with disabilities are greatly affected by disasters. Those with physical disabilities can be at risk when evacuating if assistance is not available. Individuals with cognitive impairments may struggle with understanding instructions that must be followed in the event a disaster occurs. All of these factors can increase the degree of variation of risk in disaster situations with disabled individuals. Research studies have consistently found discrimination against individuals with disabilities during all phases of a disaster cycle. The most common limitation is that people cannot physically access buildings or transportation, as well as access disaster-related services. The exclusion of these individuals is caused in part by the lack of disability-related training provided to emergency planners and disaster relief personnel. Disability in society Aging To a certain degree, physical impairments and changing mental states are almost ubiquitously experienced by people as they age. Aging populations are often stigmatized for having a high prevalence of disability. Kathleen Woodward, writing in Key Words for Disability Studies, explains the phenomenon as follows: In Feminist, Queer, Crip, Alison Kafer mentions aging and the anxiety associated with it. According to Kafer, this anxiety stems from ideas of normalcy. She says: Societal norms In contexts where their differences are visible, persons with disabilities often face stigma. People frequently react to disabled presence with fear, pity, patronization, intrusive gazes, revulsion, or disregard. These reactions can, and often do, exclude persons with disabilities from accessing social spaces along with the benefits and resources these spaces provide. Disabled writer/researcher Jenny Morris describes how stigma functions to marginalize persons with disabilities: Additionally, facing stigma can cause harm to the psycho-emotional well-being of the person being stigmatized. One of the ways in which the psycho-emotional health of persons with disabilities is adversely affected is through the internalization of the oppression they experience, which can lead to feeling that they are weak, crazy, worthless or any number of other negative attributes that may be associated with their conditions. Internalization of oppression damages the self-esteem of the person affected and shapes their behaviors in ways that are compliant with dominance of those with no acknowledged disability. Ableist ideas are frequently internalized when disabled people are pressured by the people and institutions around them to hide and downplay their disabled difference, or, "pass". According to writer Simi Linton, the act of passing takes a deep emotional toll by causing disabled individuals to experience loss of community, anxiety and self-doubt. The media play a significant role in creating and reinforcing stigma associated with disability. Media portrayals of disability usually cast disabled presence as necessarily marginal within society at large. These portrayals simultaneously reflect and influence the popular perception of disabled difference. Tropes There are distinct tactics that the media frequently employ in representing disability. These common ways of framing disability are heavily criticized for being dehumanizing and failing to place importance on the perspectives of persons with disabilities. As outlined by disability theorist and rhetorician Jay Timothy Dolmage, ableist media tropes can reflect and continue to perpetuate societal myths about disabled people. Inspiration porn Inspiration porn refers to portrayals of persons with disabilities in which they are presented as being inspiring simply because the person has a disability. These portrayals are criticized because they are created with the intent of making viewers with no acknowledged disability feel better about themselves in comparison to the individual portrayed. Rather than recognizing the humanity of persons with disabilities, inspiration porn turns them into objects of inspiration for an audience composed of those with no acknowledged disability. Supercrip The supercrip trope refers to instances when the media reports on or portray a disabled person who has made a noteworthy achievement but centers on their disability rather than what they actually did. They are portrayed as awe-inspiring for being exceptional compared to others with the same or similar conditions. This trope is widely used in reporting on disabled athletes as well as in portrayals of autistic savants. These representations, notes disability scholar Ria Cheyne, "are widely assumed to be inherently regressive", reducing people to their condition rather than viewing them as full people. Furthermore, supercrip portrayals are criticized for creating the unrealistic expectation that disability should be accompanied by some type of special talent, genius, or insight. Examples of this trope in the media include Dr. Shaun Murphy from The Good Doctor, Marvel's Daredevil, and others. Scholar Sami Schalk argues that the term supercrip has a narrow definition given how widely used the term is. As a result, Schlak provides three categories of supercrip narratives used: The regular supercrip narrative in which a disabled person gains regulation for completing mundane tacts. This is commonly seen as a disabled person being able to accomplish something despite their disability. The glorified supercrip narrative in which a disabled person is praised for succeeding at something even a non-disabled person would not be able to do. This narrative form is commonly used to talk about disabled Paralympic athletes. The superpowered supercrip narrative which appears in functionalized representations of disabled characters. Characters of this narrative type gain superpowers due to their disability. Common examples of this narrative form in action are prosthetics limbs that make one more powerful than expected or have futuristic technology that makes one a cyborg. Disabled villain Characters in fiction that bear physical or mental markers of difference from perceived societal norms are frequently positioned as villains within a text. Lindsey Row-Heyveld shares ways students should be taught to begin to further analyze this issue. Disabled people's visible differences from the abled majority are meant to evoke fear in audiences that can perpetuate the mindset of disabled people being a threat to individual or public interests and well-being. Disability Drop The "disability drop" trope is when a supposedly disabled character is revealed to have been faking, embellishing, or otherwise not actually embodying their claimed disability. Jay Dolmage offers Kevin Spacey's character, Verbal Kint, in the film Usual Suspects as an example of this, and depictions like this can reflect able-bodied society's mistrust of disabled people. In addition, this reveal of a character's nondisabledness often serves as the narrative climax of a story, and the use of disability as a source of conflict in the plot, narrative obstacle, or a device of characterization aligns with other disability studies scholars' theory of "Narrative Prosthesis", a term coined by David T. Mitchell and Sharon Snyder. The Disabled Victim Another frequent occurrence is when someone with a disability is assumed to be miserable or helpless. The Hunchback of Notre Dame's Quasimodo, The Elephant Man's John Merrick, A Christmas Carol's Tiny Tim, and even news broadcasts that refer to people as "victims" or "sufferers" are a few examples of this stereotype. Eternally Innocent Characters with disabilities are frequently portrayed in movies as being angelic or childish. These films include Rain Man (1988), Forrest Gump (1994) and I Am Sam (2001). The innocent and endearing person with a disability often points out the inadequacies of their "normal" adult peers, which helps them achieve salvation. Like all the others, this stereotype perpetuates patronizing perceptions that are simply untrue and are therefore damaging. While there are many disability tropes, disability aesthetics attempts to dispel them by accurately depicting disabled bodies in art and media. Self advocacy Some disabled people have attempted to resist marginalization through the use of the social model in opposition to the medical model; with the aim of shifting criticism away from their bodies and impairments and towards the social institutions that oppress them relative to their abled peers. Disability activism that demands many grievances be addressed, such as lack of accessibility, poor representation in media, general disrespect, and lack of recognition, originates from a social model framework. The creation of 'disability culture' stemmed from the shared experience of stigmatization in broader society. Embracing disability as a positive identity by becoming involved in disabled communities and participating in disability culture can be an effective way to combat internalized prejudice; and can challenge dominant narratives about disability. Intersections The experiences that disabled people have to navigate social institutions vary greatly as a function of what other social categories they may belong to. For example, a disabled man and a disabled woman experience disability differently. This speaks to the concept of intersectionality, which explains that different aspects of a person's identity (such as their gender, race, sexuality, religion, or social class) intersect and create unique experiences of oppression and privilege. The United Nations Convention on the Rights of Persons with Disabilities differentiates between a few kinds of disability intersections, such as the age-disability, race-disability, and gender-disability intersection. However, many more intersections exist. Disability is defined differently by each person; it may be visible or invisible, and multiple intersections often arise from overlapping identity categories. Race Incidence of disability is reported to be greater among several minority communities across the globe, according to a systematic analysis of the Global Burden of Disease Study. Disabled people who are also racial minorities generally have less access to support and are more vulnerable to violent discrimination. A study in the journal Child Development indicated that minority disabled children are more likely to receive punitive discipline in low and middle income countries. Due to the fact that children with disabilities are mistreated more often than those without disability; racialized children in this category are at an even higher risk. With respect to disability in the United States, Camille A. Nelson, writing for the Berkeley Journal of Criminal Law, notes the dual discrimination that racial minorities with disabilities experience from the criminal justice system, expressing that for "people who are negatively racialized, that is people who are perceived as being non-white, and for whom mental illness is either known or assumed, interaction with police is precarious and potentially dangerous." Gender The marginalization of people with disabilities can leave persons with disabilities unable to actualize what society expects of gendered existence. This lack of recognition for their gender identity can leave persons with disabilities with feelings of inadequacy. Thomas J. Gerschick of Illinois State University describes why this denial of gendered identity occurs: To the extent that women and men with disabilities are gendered, the interactions of these two identities lead to different experiences. Women with disabilities face a sort of "double stigmatization" in which their membership to both of these marginalized categories simultaneously exacerbates the negative stereotypes associated with each as they are ascribed to them. However, according to the framework of intersectionality, gender and disability intersect to create a unique experience that is not simply the coincidence of being a woman and having a disability separately, but the unique experience of being a woman with a disability. It follows that the more marginalized groups one belongs to, their experience of privilege or oppression changes: in short, a black woman and a white woman will experience disability differently. According to The UN Woman Watch, "Persistence of certain cultural, legal and institutional barriers makes women and girls with disabilities the victims of two-fold discrimination: as women and as persons with disabilities." As Rosemarie Garland-Thomson puts it, "Women with disabilities, even more intensely than women in general, have been cast in the collective cultural imagination as inferior, lacking, excessive, incapable, unfit, and useless." Socio-economic background Similar to the intersections of race and disability or gender and disability, a person's socio-economic background will also change their experience of disability. A disabled person with a low socio-economic status will experience the world differently, with more obstacles and fewer opportunities, than a disabled person with a high socio-economic status. A good example of the intersection between disability and socio-economic status is access to education, as we know that there are direct links between poverty and disability - often working in a vicious cycle. The costs of special education and caring for a disabled child are higher than for a child with no acknowledged disability, which poses an immense barrier in accessing appropriate education. The inaccessibility of appropriate education (at any stage), can lead to difficulties in finding employment, which often results in the vicious cycle of being 'bound' by one's experience as a poor and disabled person to remain in the same social structure and experience socio-economic exclusion. In short, this vicious cycle exacerbates the lack of economic, social, and cultural capital for disabled people with a low socio-economic background. On the other hand, a disabled person of a high socio-economic status, may have an easier time accessing appropriate (special) education or treatment - for example by having access to better aids, resources, or programmes that can help them succeed. Disability culture Sport The Paralympic Games (meaning "alongside the Olympics") are held after the (Summer and Winter) Olympics. The Paralympic Games include athletes with a wide range of physical disabilities. In member countries, organizations exist to organize competition in the Paralympic sports on levels ranging from recreational to elite (for example, Disabled Sports USA and BlazeSports America in the United States). The Paralympics developed from a rehabilitation program for British war veterans with spinal injuries. In 1948, Sir Ludwig Guttman, a neurologist working with World War II veterans with spinal injuries at Stoke Mandeville Hospital in Aylesbury in the UK, began using sport as part of the rehabilitation programs of his patients. In 2006, the Extremity Games were formed for physically disabled people, specifically limb loss or limb difference, to be able to compete in extreme sports. Demographics Estimates of worldwide and country-wide numbers of disabled people are problematic. The varying approaches taken to defining disability notwithstanding, demographers agree that the world population of individuals with disabilities is very large. For example, in 2012, the World Health Organization estimated a world population of 6.5 billion people. Of those, nearly 650 million people, or 10%, were estimated to be moderately or severely disabled. In 2018 the International Labour Organization estimated that about a billion people, one-seventh of the world population, had disabilities, 80% of them in developing countries, and 80% of working age. Excluding disabled people from the workforce was reckoned to cost up to 7% of gross domestic product. United States According to the Centers for Disease Control's Morbidity and Mortality weekly report, one-fourth of people in the United States are reported to be disabled as of 2016. 10% of young adults were reported to have mental disabilities. The rates of mobility-related issues were highest among middle-aged people and elderly people, with 18.1% and 26.9%, respectively. In terms of race or ethnicity, Asians have the lowest reported rate of disability at around 10%, while Native Americans, the ethnic group with the highest reported incidence, are reported to have a disability rate at an estimated 30% of adults. African Americans had a higher reported disability rate of 25%, compared to 16% for white adults and 17% for Hispanic people. Canada 22.3% of Canadians over 15 are reported to have a disability, or 6,246,640 people, according to the 2017 Canadian Survey on Disability Reports. In Canada, women and older people are more likely to be disabled than working-class men. In comparison to working-age persons between 25 and 65, seniors over 65 reported a disability rate of 38%, which is nearly twice as high. In Canada, women over 15 had a reported disability rate of 24.3%, compared to men's 20%. According to reports from the 2017 Canadian Survey of Disability, South Asians over the age of 15 in Canada had the greatest proportion of disability at 4%, while Latin Americans had a lower rate at 1%. Australia Nearly one in five Australians, or 4.4 million people, were estimated by the Australian Bureau of Statistics to have a disability. A mental or behavioral issue was reported in over 25% of Australians with disabilities. Male prevalence was 17.6 million, while female prevalence was somewhat higher at 17.8 million between the sexes. Age-wise, 11.6% of adults between 0 and 64 in Australia had a disability, compared to 49.6% of seniors 65 and over. 53.4% of Australians aged 15 to 64 who have a disability are employed. United Kingdom According to the House of Commons Library, 14.6 million, or 22%, of the population in the UK, were reported to be disabled in 2020–2021. In the UK, there were 9% of children, 21% of working-age people, and 42% of persons over the state pension age who were disabled or impaired. Approximately 29% of White individuals, 27% of mixed-race people, 22% of Asian people, 21% of Black people, and 19% of people from other ethnic groups were reported as having impairments or disabilities, according to the Life Opportunities Survey, which surveyed 35,875 people in 2011. When compared to men, women are a little more likely than men to have a disability, with 31% of women reportedly having one as opposed to 26% of men, according to results of another survey taken the same year. China According to Twenty-Year Trends in the Prevalence of Disability in China, a medical publication from the National Library of Medicine, there were an estimated 84.6 million Chinese individuals living with a disability in 2006. In a 2006 poll of 83,342 men and 78,137 women, the age groups with the highest reported rates of disability are 18–44-year-old males (22.5%) and 65–74-year-old females (22.8%), according to polls published in the journal that were representative of the country as a whole. In China, the percentage of people with disabilities varies substantially between urban and rural regions, with men and women having reported rates of 72.4% and 72.2%, respectively, in rural China, compared to reported rates of 27.6% and 27.8%, respectively, in urban China. Hearing and speech disabilities are the most commonly reported in China, with men being more affected than women at rates 39.6% and 36.2% among disabled people, respectively. South Korea In South Korea, there were accounted to be 2.517 million people with disabilities in total, or roughly 5.0% of the population, in 2018. When compared to Koreans without disabilities, people with disabilities spent an average of 56.5 days in medical facilities, which was 2.6 more than the national average. 34.9% of the entire workforce was employed in jobs connected to disabilities. Families with disabilities made an average income of 41.53 million won, or 71.3% of total family earnings. According to the Korean 2020 Statistics on the Disabled The majority of persons with disabilities needed help with "cleaning" and "using transportation", among other everyday tasks. Developing nations Disability is more common in developing than in developed nations. The connection between disability and poverty is thought to be part of a "vicious cycle" in which these constructs are mutually reinforcing. See also Accessibility Assistive technology Disability abuse Disability benefits Disability flag Disability hate crime Disadvantaged Frailty syndrome Parents with disabilities Physiological functional capacity Youth and disability Bibliography Vega, Eugenio (2022) Crónica del siglo de la peste. Pandemias, discapacidad y diseño. Madrid, Experimenta Libros. Williamson, Bess (2019). Accessible America. A History of Disability and Design. New York University Press. References Citations Sources Further reading Atherton, Martin, ed. 2017. Deafness, Community and Culture in Britain: Leisure and Cohesion, 1945-95. Manchester University Press. https://www.jstor.org/stable/10.2307/j.ctt21216hx. Bohata, Kirsti, Alexandra Jones, Mike Mantin, and Steven Thompson. 2020. Disability in Industrial Britain: A Cultural and Literary History of Impairment in the Coal Industry, 1880-1948. Manchester (UK): Manchester University Press. Alt URL Long, Vicky, Julie Anderson, and Walton Schalick. 2015. Destigmatising Mental Illness?: Professional Politics and Public Education in Britain, 1870-1970. Oxford: Manchester University Press. https://doi.org/10.7765/9781526103253. McGuire, Coreen. 2020. Measuring Difference, Numbering Normal Setting the Standards for Disability in the Interwar Period. Manchester, UK: Manchester University Press. Jones, Claire L. 2017. Rethinking Modern Prostheses in Anglo-American Commodity Cultures, 1820-1939. Manchester: Manchester University Press. McDonagh, Patrick, C. F. Goodey, and Timothy Stainton, eds. 2018. Intellectual Disability: A Conceptual History, 1200-1900. Manchester: Manchester University Press. Metzler, Irina. Fools and Idiots?: Intellectual Disability in the Middle Ages. Manchester University Press, 2016. Nielsen, Kim E. 2012. A Disability History of the United States. Boston: Beacon Press. O’Brien, Gerald V. 2016. Framing the Moron: The Social Construction of Feeble-Mindedness in the American Eugenic Era. Manchester: Manchester University Press. Robinson, Michael. 2020. Shell-Shocked British Army Veterans in Ireland, 1918-39: A Difficult Homecoming. Manchester: Manchester University Press. Wheatcroft, Sue. 2015. Worth Saving: Disabled Children during the Second World War. Manchester University Press. Schmidt, Marion Andrea. 2020. Eradicating Deafness?: Genetics, Pathology, and Diversity in Twentieth-Century America. Manchester: Manchester University Press. Turner, David M., and Daniel Blackie. 2018. Disability in the Industrial Revolution: Physical Impairment in British Coalmining, 1780-1880. Manchester: Manchester University Press. External links WHO fact sheet on disability Social concepts Articles containing video clips

Camphill Movement

The Camphill Movement is an initiative for social change based on the principles of anthroposophy. Camphill communities are residential communities and schools that provide support for the education, employment, and daily lives of adults and children with developmental disabilities, mental health problems, or other special needs. There are over 100 Camphill communities in more than 20 countries across Europe, North America, Southern Africa and Asia. Founding The movement was founded in 1939 at Kirkton House near Aberdeen by a group that included Austrian paediatrician Karl König. It was König's view that every human being possessed a healthy "inner personality" that was independent of their outer characteristics, including characteristics marking developmental or mental disability, and the role of the school was to recognize, nurture and educate this essential self. The communities' philosophy, anthroposophy, states that "a perfectly formed spirit and destiny belong to each human being." The underlying principles of König's Camphill school were derived from concepts of education and social life outlined decades earlier by anthroposophist Rudolf Steiner (1861–1925).Today there are over 100 communities worldwide, in more than 20 countries, mainly in Europe, but also in North America and Southern Africa. History The Camphill Movement takes its name from Camphill Estate in the Milltimber area of Aberdeen, Scotland, where the Camphill pioneers moved to with their first community for children with special needs in June 1940. Camphill Estate is now a campus of Camphill School Aberdeen. There are six Camphills in the Aberdeen area. The Camphill School Aberdeen was noted in the HMI/Care Commission report for 2007 as meeting "very good" to "excellent" standards, The school also holds Autism Accreditation from the National Autistic Society. The Botton village received the Deputy Prime Minister's Award for Sustainable Communities in 2005; the award cited the community's dedication to the ethos of sustainability and mutual respect, as well as their concrete achievements in these areas. See also List of Camphill Communities References Further reading McKanan, Daniel: 'Camphill and the Future: Spirituality and disability in an evolving communal movement'. University of California Press. 2020. ISBN 978052034902 Jackson, Robin: 'The Austrian provenance of the worldwide Camphill Movement' Journal of Austrian Studies, 46(4): 23–40. 2013. Jackson, Robin: 'Camphill communities: the agricultural impulse' Relational Child and Youth Care Practice, 26(2): 35–41. 2013. 'Discovering Camphill: New perspectives, research and developments' Edited by Robin Jackson, Floris Books, 2011. Jackson, Robin: 'The origin of Camphill and the social pedagogic impulse' Educational Review, 63(1): 95–104. 2011. 'Holistic Special Education: Camphill principles and practice' Edited by Robin Jackson, Floris Books, 2006. The Builders of Camphill: Lives and Destinies of the Founders Edited by Friedwart Bock, Floris Books, 2004 The Lives of Camphill: An Anthology of the Pioneers by Johannes Surkamp Floris Books (23 August 2007) A Candle on the Hill: Images of Camphill Life by Laurens Van der Post (Foreword), Cornelius Pietzner (Editor) Floris Books; 1st Edition (1 March 1990) Village Life: The Camphill Communities Edited by Carlo Pietzner, Cornelius Pietzner and Wanda Root, Simon & Schuster (Juv) (January 1987) External links Camphill movement website Camphill communities in England and Wales Camphill Scotland Official Karl König Institute Rudolf Steiner Archive, An Online Library Hatch Camphill Community International educational organizations Organizations established in 1939 Anthroposophy Special education 1939 establishments in Scotland Intentional communities in the United Kingdom

Borderline personality disorder

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses. People diagnosed with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily due to challenges regulating emotional states to a healthy, stable baseline. Symptoms such as dissociation (a feeling of detachment from reality), a pervasive sense of emptiness, and an acute fear of abandonment are prevalent among those affected. The onset of BPD symptoms can be triggered by events that others might perceive as normal, with the disorder typically manifesting in early adulthood and persisting across diverse contexts. BPD is often comorbid with substance use disorders, depressive disorders, and eating disorders. BPD is associated with a substantial risk of suicide; an estimated 8 to 10 percent of people with BPD die by suicide, with males affected at twice the rate of females. Despite its severity, BPD faces significant stigmatization in both media portrayals and the psychiatric field, potentially leading to its underdiagnosis. The causes of BPD are unclear and complex, implicating genetic, neurological, and psychosocial conditions in its development. A genetic predisposition is evident, with the disorder significantly more common in people with a family history of BPD, particularly immediate relatives. Psychosocial factors, particularly adverse childhood experiences, have been proposed. Neurologically, the underlying mechanism appears to involve the frontolimbic neuronal network of the limbic system. The American Diagnostic and Statistical Manual of Mental Disorders (DSM) classifies BPD as a cluster B personality disorder, alongside antisocial, histrionic, and narcissistic personality disorders. There is a small risk of misdiagnosis, with BPD most commonly confused with a mood disorder, substance use disorder, or other mental health disorders. Therapeutic interventions for BPD predominantly involve psychotherapy, with cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT) the most effective modalities. This psychotherapy can occur one-on-one or in a group. Although pharmacotherapy cannot cure BPD, it may be employed to mitigate associated symptoms, with quetiapine and selective serotonin reuptake inhibitor (SSRI) antidepressants commonly prescribed even though their efficacy is unclear. A 2020 meta-analysis found the use of medications was still unsupported by evidence. In severe cases, hospitalization may be necessitated, even if for only short periods. BPD has a point prevalence of 1.6% and a lifetime prevalence of 5.9% of the global population, with a higher incidence rate among women compared to men in the clinical setting of up to three times. Despite the high utilization of healthcare resources by people with BPD, up to half may show significant improvement over a ten-year period with appropriate treatment. The name of the disorder, particularly the suitability of the term borderline, is a subject of ongoing debate. Initially, the term reflected historical ideas of borderline insanity and later described patients on the border between neurosis and psychosis. These interpretations are now regarded as outdated and clinically imprecise. Signs and symptoms Borderline personality disorder, as outlined in the DSM-5, manifests through nine distinct symptoms, with a diagnosis requiring at least five of the following criteria to be met: Frantic efforts to avoid real or imagined emotional abandonment. Unstable and chaotic interpersonal relationships, often characterized by a pattern of alternating between extremes of idealization and devaluation, also known as 'splitting'. A markedly disturbed sense of identity and distorted self-image. Impulsive or reckless behaviors, including uncontrollable spending, unsafe sexual practices, substance use disorder, reckless driving, and binge eating. Recurrent suicidal ideation or behaviors involving self-harm. Rapidly shifting intense emotional dysregulation. Chronic feelings of emptiness. Inappropriate, intense anger that can be difficult to control. Transient, stress-related paranoid ideation or severe dissociative symptoms. The distinguishing characteristics of BPD include a pervasive pattern of instability in one's interpersonal relationships and in one's self-image, with frequent oscillation between extremes of idealization and devaluation of others, alongside fluctuating moods and difficulty regulating intense emotional reactions. Dangerous or impulsive behaviors are commonly associated with BPD. Additional symptoms may encompass uncertainty about one's identity, values, morals, and beliefs; experiencing paranoid thoughts under stress; episodes of depersonalization; and, in moderate to severe cases, stress-induced breaks with reality or episodes of psychosis. It is also common for individuals with BPD to have comorbid conditions such as depressive or bipolar disorders, substance use disorders, eating disorders, post-traumatic stress disorder (PTSD), and attention-deficit hyperactivity disorder (ADHD). Mood and affect Individuals with BPD exhibit emotional dysregulation. Emotional dysregulation is characterized by an inability in flexibly responding to and managing emotional states, resulting in intense and prolonged emotional reactions that deviate from social norms, given the nature of the environmental stimuli encountered. Such reactions not only deviate from accepted social norms but also surpass what is informally deemed appropriate or proportional to the encountered stimuli. A core characteristic of BPD is affective instability, which manifests as rapid and frequent shifts in mood of high affect intensity and rapid onset of emotions, triggered by environmental stimuli. The return to a stable emotional state is notably delayed, exacerbating the challenge of achieving emotional equilibrium. This instability is further intensified by an acute sensitivity to psychosocial cues, leading to significant challenges in managing emotions effectively. As the first component of emotional dysregulation, individuals with BPD are shown to have increased emotional sensitivity, especially towards negative mood states such as fear, anger, sadness, rejection, criticism, isolation, and perceived failure. This increased sensitivity results in an intensified response to environmental cues, including the emotions of others. Studies have identified a negativity bias in those with BPD, showing a predisposition towards recognizing and reacting more strongly to negative emotions in others, along with an attentional bias towards processing negatively-valenced stimuli. Without effective coping mechanisms, individuals might resort to self-harm, or suicidal behaviors to manage or escape from these intense negative emotions. While conscious of the exaggerated nature of their emotional responses, individuals with BPD face challenges in regulating these emotions. To mitigate further distress, there may be an unconscious suppression of emotional awareness, which paradoxically hinders the recognition of situations requiring intervention. A second component of emotional dysregulation in BPD is high levels of negative affectivity, stemming directly from the individual's emotional sensitivity to negative emotions. This negative affectivity causes emotional reactions that diverge from socially accepted norms, in ways that are disproportionate to the environmental stimuli presented. Those with BPD are relatively unable to tolerate the distress that is encountered in daily life, and they are prone to engage in maladaptive strategies to try to reduce the distress experienced. Maladaptive coping strategies include rumination, thought suppression, experiential avoidance, emotional isolation, as well as impulsive and self-injurious behaviours. American psychologist Marsha Linehan highlights that while the sensitivity, intensity, and duration of emotional experiences in individuals with BPD can have positive outcomes, such as exceptional enthusiasm, idealism, and capacity for joy and love, it also predisposes them to be overwhelmed by negative emotions. This includes experiencing profound grief instead of mere sadness, intense shame instead of mild embarrassment, rage rather than annoyance, and panic over nervousness. Research indicates that individuals with BPD endure chronic and substantial emotional suffering. Emotional dysregulation is a significant feature of BPD, yet Fitzpatrick et al. (2022) suggest that such dysregulation may also be observed in other disorders, like generalized anxiety disorder (GAD). Nonetheless, their findings imply that individuals with BPD particularly struggle with disengaging from negative emotions and achieving emotional equilibrium. Euphoria, or transient intense joy, can occur in those with BPD, but they are more commonly afflicted by dysphoria (a profound state of unease or dissatisfaction), depression, and pervasive distress. Zanarini et al. identify four types of dysphoria characteristic of BPD: intense emotional states, destructiveness or self-destructiveness, feelings of fragmentation or identity loss, and perceptions of victimization. A diagnosis of BPD is closely linked with experiencing feelings of betrayal, lack of control, and self-harm. Moreover, emotional lability, indicating variability or fluctuations in emotional states, is frequent among those with BPD. Although emotional lability may imply rapid alternations between depression and elation, mood swings in BPD are more commonly between anger and anxiety or depression and anxiety. Interpersonal relationships Interpersonal relationships are significantly impacted in individuals with BPD, characterized by a heightened sensitivity to the behavior and actions of others. Individuals with BPD can be very conscious of and susceptible to their perceived or real treatment by others. Individuals may experience profound happiness and gratitude for perceived kindness, yet feel intense sadness or anger towards perceived criticism or harm. A notable feature of BPD is the tendency to engage in idealization and devaluation of others – that is to idealize and subsequently devalue others – oscillating between extreme admiration and profound mistrust or dislike. This pattern, referred to as "splitting," can significantly influence the dynamics of interpersonal relationships. In addition to this external "splitting," patients with BPD typically have internal splitting, i.e. vacillation between considering oneself a good person who has been mistreated (in which case anger predominates) and a bad person whose life has no value (in which case self-destructive or even suicidal behavior may occur). This splitting is also evident in black-and-white or all-or-nothing dichotomous thinking. Despite a strong desire for intimacy, individuals with BPD may exhibit insecure, avoidant, ambivalent, or fearfully preoccupied attachment styles in relationships, complicating their interactions and connections with others. Family members, including parents of adults with BPD, may find themselves in a cycle of being overly involved in the individual's life at times and, at other times, significantly detached, contributing to a sense of alienation within the family unit. Personality disorders, including BPD, are associated with an increased incidence of chronic stress and conflict, reduced satisfaction in romantic partnerships, domestic abuse, and unintended pregnancies. Research indicates variability in relationship patterns among individuals with BPD. A portion of these individuals may transition rapidly between relationships, a pattern metaphorically described as "butterfly-like," characterized by fleeting and transient interactions and "fluttering" in and out of relationships. Conversely, a subgroup, referred to as "attached," tends to establish fewer but more intense and dependent relationships. These connections often form rapidly, evolving into deeply intertwined and tumultuous bonds, indicating a more pronounced dependence on these interpersonal ties compared to those without BPD. Behavior Behavioral patterns associated with BPD frequently involve impulsive actions, which may manifest as substance use disorders, binge eating, unprotected sexual encounters, self-injury among other self-harming practices. These behaviors are a response to the intense emotional distress experienced by individuals with BPD, serving as an immediate but temporary alleviation of their emotional pain. However, such actions typically result in feelings of shame and guilt, contributing to a recurrent cycle. This cycle typically begins with emotional discomfort, followed by impulsive behavior aimed at mitigating this discomfort, only to lead to shame and guilt, which in turn exacerbates the emotional pain. This escalation of emotional pain then intensifies the compulsion towards impulsive behavior as a form of relief, creating a vicious cycle. Over time, these impulsive responses can become an automatic mechanism for coping with emotional pain. Self-harm and suicide Self-harm and suicidal behaviors are core diagnostic criteria for BPD as outlined in the DSM-5. Between 50% and 80% of individuals diagnosed with BPD engage in self-harm, with cutting being the most common method. Other methods, such as bruising, burning, head banging, or biting, are also prevalent. It is hypothesized that individuals with BPD might experience a sense of emotional relief following acts of self-harm. Estimates of the lifetime risk of death by suicide among individuals with BPD range between 3% and 10%, varying with the method of investigation. There is evidence that a significant proportion of males who die by suicide may have undiagnosed BPD. The motivations behind self-harm and suicide attempts among individuals with BPD are reported to differ. Nearly 70% of individuals with BPD engage in self-harm without the intention of ending their lives. Motivations for self-harm include expressing anger, self-punishment, inducing normal feelings or feelings of normality in response to dissociative episodes, and distraction from emotional distress or challenging situations. Conversely, true suicide attempts by individuals with BPD frequently are motivated by the notion that others will be better off in their absence. Sense of self and self-concept Individuals diagnosed with BPD frequently experience significant difficulties in maintaining a stable self-concept. This instability manifests as uncertainty in personal values, beliefs, preferences, and interests. They may also express confusion regarding their aspirations and objectives in terms of relationships and career paths. Such indeterminacy leads to feelings of emptiness and a profound sense of disorientation regarding their own identity. Moreover, their self-perception can fluctuate dramatically over short periods, oscillating between positive and negative evaluations. Consequently, individuals with BPD might adopt their sense of self based on their surroundings or the people they interact with, resulting in a chameleon-like adaptation of identity. Dissociation and cognitive challenges The heightened emotional states experienced by individuals with BPD can impede their ability to concentrate and cognitively function. Additionally, individuals with BPD may frequently dissociate, which can be regarded as a mild to severe disconnection from physical and emotional experiences. Observers may notice signs of dissociation in individuals with BPD through diminished expressiveness in their face or voice, or through an apparent disconnection and insensitivity to emotional cues or stimuli. Dissociation typically arises in response to distressing occurrences or reminders of past trauma, acting as a psychological defense mechanism by diverting attention from the current stressor or by blocking it out entirely. This process, believed to shield the individual from the anticipated overwhelming negative emotions and undesired impulses that the current emotional situation might provoke, is rooted in avoidance of intense emotional pain based on past experiences. While this mechanism may offer temporary emotional respite, it can foster unhealthy coping strategies and inadvertently dull positive emotions, thereby obstructing the individual's access to crucial emotional insights. These insights are essential for informed, healthy decision-making in everyday life. Psychotic symptoms BPD is predominantly characterized as a disorder involving emotional dysregulation, yet psychotic symptoms frequently occur in individuals with BPD, with prevalence estimates ranging between 21% and 54%. These manifestations have historically been labeled as "pseudo-psychotic" or "psychotic-like", implying a differentiation from symptoms observed in primary psychotic disorders. Studies conducted in the 2010s suggest a closer similarity between psychotic symptoms in BPD and those in recognized psychotic disorders than previously understood. The distinction of pseudo-psychosis has faced criticism for its weak construct validity and the potential to diminish the perceived severity of these symptoms, potentially hindering accurate diagnosis and effective treatment. Consequently, there are suggestions from some in the research community to categorize these symptoms as genuine psychosis, advocating for the abolishment of the distinction between pseudo-psychosis and true psychosis. The DSM-5 identifies transient paranoia, exacerbated by stress, as a symptom of BPD. Research has identified the presence of both hallucinations and delusions in individuals with BPD who do not possess an alternate diagnosis that would better explain these symptoms. Further, phenomenological analysis indicates that auditory verbal hallucinations in BPD patients are indistinguishable from those observed in schizophrenia. This has led to suggestions of a potential shared etiological basis for hallucinations across BPD and other disorders, including psychotic and affective disorders. Disability and employment Individuals diagnosed with BPD often possess the capability to engage in employment, provided they secure positions that align with their skill sets and the severity of their condition remains manageable. In certain cases, BPD may be recognized as a disability within the workplace, particularly if the condition's severity results in behaviors that undermine relationships, involve engagement in risky activities, or manifest as intense anger, thereby inhibiting the individual's ability to perform their job role effectively. The United States Social Security Administration officially recognizes BPD as a form of disability, enabling those significantly affected to apply for disability benefits. Causes The etiology, or causes, of BPD is multifaceted, with no consensus on a singular cause. BPD may share a connection with post-traumatic stress disorder (PTSD). While childhood trauma is a recognized contributing factor, the roles of congenital brain abnormalities, genetics, neurobiology, and non-traumatic environmental factors remain subjects of ongoing investigation. Genetics and heritability Compared to other major psychiatric conditions, the exploration of genetic underpinnings in BPD remains novel. Estimates suggest the heritability of BPD ranges from 37% to 69%, indicating that human genetic variations account for a substantial portion of the risk for BPD within the population. Twin studies, which often form the basis of these estimates, may overestimate the perceived influence of genetics due to the shared environment of twins, potentially skewing results. Despite these methodological considerations, certain studies propose that personality disorders are significantly shaped by genetics, more so than many Axis I disorders, such as depression and eating disorders, and even surpassing the genetic impact on broad personality traits. Notably, BPD ranks as the third most heritable among ten surveyed personality disorders. Research involving twin and sibling studies has shown a genetic component to traits associated with BPD, such as impulsive aggression; with the genetic contribution to behavior from serotonin-related genes appearing to be modest. A study conducted by Trull et al. in the Netherlands, which included 711 sibling pairs and 561 parents, aimed to identify genetic markers associated with BPD. This research identified a linkage to genetic markers on chromosome 9 as relevant to BPD characteristics, underscoring a significant genetic contribution to the variability observed in BPD features. Prior findings from this group indicated that 42% of BPD feature variability could be attributed to genetics, with the remaining 58% owing to environmental factors. Among specific genetic variants under scrutiny , the DRD4 7-repeat polymorphism (of the dopamine receptor D4) located on chromosome 11 has been linked to disorganized attachment, and in conjunction with the 10/10-repeat genotype of the dopamine transporter (DAT), it has been associated with issues with inhibitory control, both of which are characteristic of BPD. Additionally, potential links to chromosome 5 are being explored, further emphasizing the complex genetic landscape influencing BPD development and manifestation. Psychosocial factors Adverse childhood experiences Studies based on empiricism have established a strong correlation between adverse childhood experiences such as child abuse, particularly child sexual abuse, and the onset of BPD later in life. Reports from individuals diagnosed with BPD frequently include narratives of extensive abuse and neglect during early childhood, though causality remains a subject of ongoing investigation. These individuals are significantly more prone to recount experiences of verbal, emotional, physical, or sexual abuse by caregivers, alongside a notable frequency of incest and loss of caregivers in early childhood. Moreover, there have been consistent accounts of caregivers invalidating the individuals' emotions and thoughts, neglecting physical care, failing to provide necessary protection, and exhibiting emotional withdrawal and inconsistency. Specifically, female individuals with BPD reporting past neglect or abuse by caregivers have a heightened likelihood of encountering sexual abuse from individuals outside their immediate family circle. The enduring impact of chronic maltreatment and difficulties in forming secure attachments during childhood has been hypothesized to potentially contribute to the development of BPD. From a psychoanalytic perspective, Otto Kernberg has posited that the child's failure to navigate the developmental challenge of differentiating self from others, or as Kernberg terms it achieve the developmental task of psychic clarification of self and other, and failure to overcome the internal divisions caused by splitting may predispose that child to BPD. Invalidating environment Marsha Linehan's biosocial developmental theory posits that BPD arises from the interaction between a child's inherent emotional vulnerability and an invalidating environment. Emotional vulnerability is thought to be influenced by biological and genetic factors that shape the child's temperament. Traditional biomedical constructions of BPD often focus solely on biological factors. Though these factors certainly play a role in the development of borderline personality disorder, they do not provide a complete picture. A biosocial approach considers the interplay between genetic predispositions and environmental stressors, such as childhood trauma, invalidating environments, and social relationships, in shaping the course of the disorder. Invalidating environments are characterized by the neglect, ridicule, dismissal, or discouragement of a child's emotions and needs, and may also encompass experiences of trauma and abuse. Invalidation from caregivers, peers, or authority figures can lead individuals with borderline personality disorder to doubt the legitimacy of their feelings and experiences. This can exacerbate their emotional dysregulation and contribute to a cycle of invalidation, distress, and maladaptive coping strategies. When emotions are consistently dismissed or criticized, individuals with BPD may resort to destructive behaviors such as self-harm, substance abuse, or impulsive actions to cope with their distress, further perpetuating the negative stigma attached to those who suffer from borderline personality disorder. Clinical and cultural perspectives Anthropologist Rebecca Lester raises two perspectives that BPD can be viewed: a clinical perspective where BPD is a “dysfunction of personality”, and an academic perspective that views BPD as a “mechanism of social regulation”. Lester provides the perspective that BPD as a disorder of relationships and communication; that a person with BPD lacks the communication skills and knowledge to interact effectively with others within their society and culture given their life experience. Lester provides the metaphor of the particle-wave duality in quantum physics when dealing with the distinction between cultural and clinical perspectives of BPD. Like the particle-wave-duality, when asking particle-like questions you will get particle-like answers; and if you ask wave-like questions you will get wave-like answers. Lester argues the same applies to BPD; if you ask culturally based questions about the presence of BPD you will get culturally based answers, if you ask clinical personality-based questions it will reinforce personality-based perspectives. Lester advised both perspectives are valid and should work in tandem to provide a greater understanding of BPD culturally and for the individual. In this light, Lester argues the high diagnosis of women than men with BPD goes towards arguing feminist claims. A higher diagnosis BPD in women would be expected in cultures where females are victimised. In this view BPD is seen as a cultural phenomenon. This is understandable when BPD behaviours are viewed as learnt behaviours as a consequence of their experience surviving environments that reinforce worthlessness and their rejection. To Lester these survival techniques evidence humans “resilience, adaptation, creativity”. Behaviours associated with BPD is therefore an inherently human response. Brain and neurobiologic factors Research employing structural neuroimaging techniques, such as voxel-based morphometry, has reported variations in individuals diagnosed with BPD in specific brain regions that have been associated with the psychopathology of BPD. Notably, reductions in volume enclosed have been observed in the hippocampus, orbitofrontal cortex, anterior cingulate cortex, and amygdala, among others, which are crucial for emotional self-regulation and stress management. In addition to structural imaging, a subset of studies utilizing magnetic resonance spectroscopy has investigated the neurometabolic profile within these affected regions. These investigations have focused on the concentrations of various neurometabolites, including N-acetylaspartate, creatine, compounds related to glutamate, and compounds containing choline. These studies aim to show the biochemical alterations that may underlie the symptomatology observed in BPD, offering insights into BPD's neurobiological basis. Neurological patterns Research into BPD has identified that the propensity for experiencing intense negative emotions, a trait known as negative affectivity, serves as a more potent predictor of BPD symptoms than the history of childhood sexual abuse alone. This correlation, alongside observed variations in brain structure and the presence of BPD in individuals without traumatic histories, delineates BPD from disorders such as PTSD that are frequently co-morbid. Consequently, investigations into BPD encompass both developmental and traumatic origins. Research has shown changes in two brain circuits implicated in the emotional dysregulation characteristic of BPD: firstly, an escalation in activity within brain circuits associated with experiencing severe emotional pain, and secondly, a decreased activation within circuits tasked with the regulation or suppression of these intense emotions. These dysfunctional activations predominantly occur within the limbic system, though individual variances necessitate further neuroimaging research to explore these patterns in detail. Contrary to earlier findings, individuals with BPD exhibit decreased amygdala activation in response to heightened negative emotional stimuli compared to control groups. John Krystal, the editor of Biological Psychiatry, commented on these findings, suggesting they contribute to understanding the innate neurological predisposition of individuals with BPD to lead emotionally turbulent lives, which are not inherently negative or unproductive. This emotional volatility is consistently linked to disparities in several brain regions, emphasizing the neurobiological underpinnings of BPD. Mediating and moderating factors Executive function and social rejection sensitivity High sensitivity to social rejection is linked to more severe symptoms of BPD, with executive function playing a mediating role. Executive function—encompassing planning, working memory, attentional control, and problem-solving—moderates how rejection sensitivity influences BPD symptoms. Studies demonstrate that individuals with lower executive function exhibit a stronger correlation between rejection sensitivity and BPD symptoms. Conversely, higher executive function may mitigate the impact of rejection sensitivity, potentially offering protection against BPD symptoms. Additionally, deficiencies in working memory are associated with increased impulsivity in individuals with BPD. Family environment The family environment significantly influences the development of BPD, acting as a mediator for the effects of child sexual abuse. An unstable family environment increases the risk of developing BPD, while a stable environment can provide a protective buffer against the disorder. This dynamic suggests the critical role of familial stability in mitigating or exacerbating the risk of BPD. Diagnosis The clinical diagnosis of BPD can be made through a psychiatric assessment conducted by a mental health professional, ideally a psychiatrist or psychologist. This comprehensive assessment integrates various sources of information to confirm the diagnosis, encompassing the patient's self-reported clinical history, observations made by the clinician during interviews, and corroborative details obtained from family members, friends, and medical records. It is crucial to thoroughly assess patients for co-morbid mental health conditions, substance use disorders, suicidal ideation, and any self-harming behaviors. An effective approach involves presenting the criteria of the disorder to the individual and inquiring if they perceive these criteria as reflective of their experiences. Involving individuals in the diagnostic process may enhance their acceptance of the diagnosis. Despite the stigma associated with BPD and previous notions of its untreatability, disclosing the diagnosis to individuals is generally beneficial. It provides them with validation and directs them to appropriate treatment options. The psychological evaluation for BPD typically explores the onset and intensity of symptoms and their impact on the individual's quality of life. Critical areas of focus include suicidal thoughts, self-harm behaviors, and any thoughts of harming others. The diagnosis relies on both the individual's self-reported symptoms and the clinician's observations. To exclude other potential causes of the symptoms, additional assessments may include a physical examination and blood tests, to exclude thyroid disorders or substance use disorders. The International Classification of Diseases (ICD-10) categorizes the condition as emotionally unstable personality disorder, with diagnostic criteria similar to those in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), where the disorder's name remains unchanged from previous editions. DSM-5 diagnostic criteria The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has eliminated the multiaxial diagnostic system, integrating all disorders, including personality disorders, into Section II of the manual. For a diagnosis of BPD, an individual must meet five out of nine specified diagnostic criteria. The DSM-5 characterizes BPD as a pervasive pattern of instability in interpersonal relationships, self-image, affect, and a significant propensity towards impulsive behavior. Moreover, the DSM-5 introduces alternative diagnostic criteria for BPD in Section III, titled "Alternative DSM-5 Model for Personality Disorders". These criteria are rooted in trait research and necessitate the identification of at least four out of seven maladaptive traits. Marsha Linehan highlights the diagnostic challenges faced by mental health professionals in using the DSM criteria due to the broad range of behaviors they encompass. To mitigate these challenges, Linehan categorizes BPD symptoms into five principal areas of dysregulation: emotions, behavior, interpersonal relationships, sense of self, and cognition. International Classification of Disease (ICD) diagnostic criteria ICD-11 diagnostic criteria The World Health Organization's ICD-11 completely restructured its personality disorder section. It classifies BPD as Personality disorder, Borderline pattern,. The borderline pattern specifier is defined as a personality disturbance marked by instability in interpersonal relationships, self-image, and emotions, as well as impulsivity. ICD-10 diagnostic criteria The ICD-10 (version 2019) identified a condition akin to BPD it termed Emotionally unstable personality disorder (EUPD). This classification described EUPD as a personality disorder with a marked propensity for impulsive behavior without considering potential consequences. Individual with EUPD had noticeably erratic and fluctuating moods and are prone to sudden emotional outbursts, struggling to regulate these rapid shifts in emotion. Conflict and confrontational behavior are common, especially in situations where impulsive actions are criticized or hindered. The ICD-10 recognizes two subtypes of this disorder: the impulsive type, characterized mainly by emotional dysregulation and impulsivity, and the borderline type, which additionally includes disturbances in self-perception, goals, and personal preferences. Those with the borderline subtype also experience a persistent feeling of emptiness, unstable and chaotic interpersonal relationships, and a predisposition towards self-harming behaviors, encompassing both suicidal ideations and suicide attempts. Millon's subtypes Psychologist Theodore Millon proposed four subtypes of BPD, where individuals with BPD would exhibit none, one, or multiple subtypes. The discouraged subtype is characterized by traits such as avoidance, dependency, and internalized anger and emotions. Individuals belonging to this subtype tend to exhibit impulsivity alongside compliance, loyalty, and humility. They often feel vulnerable and perpetually at risk, experiencing emotions such as hopelessness, depression, and a sense of helplessness and powerlessness. The petulant type is characterized by negativism, impatience, restlessness, stubbornness, defiance, angriness, pessimism, and resentment. Individuals of this type tend to feel slighted and disillusioned with ease. The impulsive type is characterized by being captivating, unstable, superficial, erratic, distractible, frenetic, and seductive. When they fear loss, they become agitated, gloomy, and irritable, potentially leading to suicidal thoughts or actions. The self-destructive type is inward-turning, self-punishing, angry, conforming, and displays deferential and ingratiating behaviors. Their behavior tends to deteriorate over time, becoming increasingly high-strung and moody, and they may also be at risk for suicide. Misdiagnosis Individuals with BPD are subject to misdiagnosis due to various factors, notably the overlap (comorbidity) of BPD symptoms with those of other disorders such as depression, PTSD, and bipolar disorder. Misdiagnosis of BPD can lead to a range of adverse consequences. Diagnosis plays a crucial role in informing healthcare professionals about the patient's mental health status, guiding treatment strategies, and facilitating accurate reporting of successful interventions. Consequently, misdiagnosis may deprive individuals of access to suitable psychiatric medications or evidence-based psychological interventions tailored to their specific disorders. Critics of the BPD diagnosis contend that it is indistinguishable from negative affectivity upon undergoing regression and factor analyses. They maintain that the diagnosis of BPD does not provide additional insight beyond what is captured by other diagnoses, positing that it may be redundant or potentially misleading. Adolescence and prodrome The onset of BPD symptoms typically occurs during adolescence or early adulthood, with possible early signs in childhood. Predictive symptoms in adolescents include body image issues, extreme sensitivity to rejection, behavioral challenges, non-suicidal self-injury, seeking exclusive relationships, and profound shame. Although many adolescents exhibit these symptoms without developing BPD, those who do are significantly more likely to develop the disorder and potentially face long-term social challenges. BPD is recognized as a stable and valid diagnosis during adolescence, supported by the DSM-5 and ICD-11. Early detection and treatment of BPD in young individuals are emphasized in national guidelines across various countries, including the US, Australia, the UK, Spain, and Switzerland, highlighting the importance of early intervention. Historically, diagnosing BPD during adolescence was met with caution, due to concerns about the accuracy of diagnosing young individuals, the potential misinterpretation of normal adolescent behaviors, stigma, and the stability of personality during this developmental stage. Despite these challenges, research has confirmed the validity and clinical utility of the BPD diagnosis in adolescents, though misconceptions persist among mental health care professionals, contributing to clinical reluctance in diagnosing and a key barrier to the provision of effective treatment BPD in this population. A diagnosis of BPD in adolescence can indicate the persistence of the disorder into adulthood, with outcomes varying among individuals. Some maintain a stable diagnosis over time, while others may not consistently meet the diagnostic criteria. Early diagnosis facilitates the development of effective treatment plans, including family therapy, to support adolescents with BPD. Differential diagnosis and comorbidity Lifetime co-occurring (comorbid) conditions are prevalent among individuals diagnosed with BPD. Individuals with BPD exhibit higher rates of comorbidity compared to those diagnosed with other personality disorders. These comorbidities include mood disorders (such as major depressive disorder and bipolar disorder), anxiety disorders (including panic disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD)), other personality disorders (notably schizotypal, antisocial, and dependent personality disorder), substance use disorder, eating disorders (anorexia nervosa and bulimia nervosa), attention deficit hyperactivity disorder (ADHD), somatic symptom disorder, and the dissociative disorders. It is advised that a personality disorder diagnosis should be made cautiously during untreated mood episodes or disorders unless a comprehensive lifetime history supports the existence of a personality disorder. Comorbid Axis I disorders A 2008 study stated that 75% of individuals with BPD at some point meet criteria for mood disorders, notably major depression and bipolar I, with a similar percentage for anxiety disorders. The same study stated that 73% of individuals with BPD meet criteria for substance use disorders, and about 40% for PTSD. This challenges the notion that BPD and PTSD are identical, as less than half of those with BPD exhibit PTSD symptoms in their lifetime. The study also noted significant gender differences in comorbidity among individuals with BPD: a higher proportion of males meet criteria for substance use disorders, whereas females are more likely to have PTSD and eating disorders. Additionally, 38% of individuals with BPD were found to meet criteria for ADHD, and 15% for autism spectrum disorder (ASD) in separate studies, highlighting the risk of misdiagnosis due to "lower expressions" of BPD or a complex pattern of comorbidity that might obscure the underlying personality disorder. This complexity in diagnosis underscores the importance of comprehensive assessment in identifying BPD. Mood disorders Seventy-five percent (75%) of individuals with BPD concurrently experience mood disorders, notably major depressive disorder (MDD) or bipolar disorder (BD), complicating diagnostic clarity due to overlapping symptoms. Distinguishing BPD from BD is particularly challenging, as behaviors part of diagnostic criteria for both BPD and BD may emerge during depressive or manic episodes in BD. However, these behaviours are likely to subside as mood normalises in BD to euthymia, but typically are pervasive in BPD. Thus, diagnosis should ideally be deferred until after the mood has stabilised. Differences between BPD and BD mood swings include their duration, with BD episodes typically lasting for at least two weeks at a time, in contrast to the rapid and transient mood shifts seen in BPD. Additionally, BD mood changes are generally unresponsive to environmental stimuli, whereas BPD moods are. For example, a positive event might alleviate a depressive mood in BPD, responsiveness not observed in BD. Furthermore, the euphoria in BPD lacks the racing thoughts and reduced need for sleep characteristic of BD, though sleep disturbances have been noted in BPD. An exception would be individuals with rapid-cycling BD, who can be a challenge to differentiate from the affective lability of individuals with BPD. Historically, BPD was considered a milder form of BD, or part of the bipolar spectrum. However, distinctions in phenomenology, family history, disease progression, and treatment responses refute a singular underlying mechanism for both conditions. Research indicates only a modest association between BPD and BD, challenging the notion of a close spectrum relationship. Premenstrual dysphoric disorder BPD is a psychiatric condition distinguishable from premenstrual dysphoric disorder (PMDD), despite some symptom overlap. BPD affects individuals persistently across all stages of the menstrual cycle, unlike PMDD, which is confined to the luteal phase and ends with menstruation. While PMDD, affecting 3–8% of women, includes mood swings, irritability, and anxiety tied to the menstrual cycle, BPD presents a broader, constant emotional and behavioral challenge irrespective of hormonal changes. Comorbid Axis II disorders Approximately 74% of individuals with BPD also fulfill criteria for another Axis II personality disorder during their lifetime, according to research conducted in 2008. The most prevalent co-occurring disorders are from Cluster A (paranoid, schizoid, and schizotypal personality disorders), affecting about half of those with BPD, with schizotypal personality disorder alone impacting one-third of individuals. Being part of Cluster B, BPD patients also commonly share characteristics with other Cluster B disorders (antisocial, histrionic, and narcissistic personality disorders), with nearly half of individuals with BPD showing signs of these conditions, and narcissistic personality disorder affecting roughly one-third. Cluster C disorders (avoidant, dependent, and obsessive-compulsive personality disorders) have the least comorbidity with BPD, with just under a third of individuals with BPD meeting the criteria for a Cluster C disorder. Management The main approach to managing BPD is through psychotherapy, tailored to the individual's specific needs rather than applying a one-size-fits-all model based on the diagnosis alone. While medications do not directly treat BPD, they are beneficial in managing comorbid conditions like depression and anxiety. Evidence states short-term hospitalization does not offer advantages over community care in terms of enhancing outcomes or in the long-term prevention of suicidal behavior among individuals with BPD. Psychotherapy Long-term, consistent psychotherapy stands as the preferred method for treating BPD and engagement in any therapeutic approach tends to surpass the absence of treatment, particularly in diminishing self-harm impulses. Among the effective psychotherapeutic approaches, dialectical behavior therapy (DBT) and psychodynamic therapies have shown efficacy, although improvements may require extensive time, often years of dedicated effort. Available treatments for BPD include dynamic deconstructive psychotherapy (DDP), mentalization-based treatment (MBT), transference-focused psychotherapy, dialectical behavior therapy (DBT), general psychiatric management, and schema-focused therapy. The effectiveness of these therapies does not significantly vary between more intensive and less intensive approaches. Transference-focused psychotherapy is designed to mitigate absolutist thinking by encouraging individuals to express their interpretations of social interactions and their emotions, thereby fostering more nuanced and flexible categorizations. Dialectical behavior therapy (DBT), on the other hand, focuses on developing skills in four main areas: interpersonal communication, distress tolerance, emotional regulation, and mindfulness, aiming to equip individuals with BPD with tools to manage intense emotions and improve interpersonal relationships. Cognitive behavioral therapy (CBT) targets the modification of behaviors and beliefs through problem identification related to BPD, showing efficacy in reducing anxiety, mood symptoms, suicidal ideation, and self-harming actions. Mentalization-based therapy and transference-focused psychotherapy draw from psychodynamic principles, while DBT is rooted in cognitive-behavioral principles and mindfulness. General psychiatric management integrates key aspects from these treatments and is seen as more accessible and less resource-intensive. Studies suggest DBT and MBT may be particularly effective, with ongoing research into developing abbreviated forms of these therapies to enhance accessibility and reduce both financial and resource burdens on patients and providers. Schema-focused therapy considers early maladaptive schemas, conceptualized as organized patterns that recur throughout life in response to memories, emotions, bodily sensations, and cognitions associated with unmet childhood needs. When activated by events in the patient's life, they manifest as schema modes associated with responses such as feelings of abandonment, anger, impulsivity, self-punitiveness, or avoidance and emptiness. Schema therapy attempts to modify early maladaptive schemas and their modes with a variety of cognitive, experiential, and behavioral techniques such as cognitive restructuring, mental imagery, and behavioral experiments. It also seeks to remove some of the stigma associated with BPD by explaining to clients that most people have maladaptive schemas and modes, but that in BPD, the schemas tend to be more extreme, while the modes shift more frequently. In schema therapy, the therapeutic alliance is based on the concept of limited reparenting: it does not only facilitate treatment, but is an integral part of it as the therapist seeks to model a healthy relationship that counteracts some of the instability, rejection, and deprivation often experienced early in life by BPD patients while helping them develop similarly healthy relationships in their broader personal lives. Additionally, mindfulness meditation has been associated with positive structural changes in the brain and improvements in BPD symptoms, with some participants in mindfulness-based interventions no longer meeting the diagnostic criteria for BPD after treatment. Medications A 2010 Cochrane review found that no medications were effective for the core symptoms of BPD, such as chronic feelings of emptiness, identity disturbances, and fears of abandonment. Some medications might impact isolated symptoms of BPD or those of comorbid conditions. Later reviews in 2017 and 2020 confirmed these findings, with the latter noting a decline in research into medications for BPD treatment and mostly negative results. Quetiapine showed some benefits for BPD severity, psychosocial impairment, aggression, and manic symptoms at doses of 150 mg/day to 300 mg/day. Despite the lack of evidence, SSRIs are still frequently prescribed for BPD. Specific medications have shown varied effectiveness on BPD symptoms: haloperidol and flupenthixol for anger and suicidal behavior reduction; aripiprazole for decreased impulsivity and interpersonal problems; and olanzapine and quetiapine for reducing affective instability, anger, and anxiety, though olanzapine showed less benefit for suicidal ideation than a placebo. Mood stabilizers like valproate and topiramate showed some improvements in depression, impulsivity, and anger, but the effect of carbamazepine was not significant. Of the antidepressants, amitriptyline may reduce depression, but mianserin, fluoxetine, fluvoxamine, and phenelzine sulfate showed no effect. Omega-3 fatty acid may ameliorate suicidality and improve depression. , trials with these medications had not been replicated and the effect of long-term use had not been assessed. Lamotrigine and other medications like IV ketamine for unresponsive depression require further research for their effects on BPD. Given the weak evidence and potential for serious side effects, the UK National Institute for Health and Clinical Excellence (NICE) recommends against using drugs specifically for BPD or its associated behaviors and symptoms. Medications may be considered for treating comorbid conditions within a broader treatment plan. Reviews suggest minimizing the use of medications for BPD to very low doses and short durations, emphasizing the need for careful evaluation and management of drug treatment in BPD. Health care services The disparity between those benefiting from treatment and those receiving it, known as the "treatment gap," arises from several factors. These include reluctance to seek treatment, healthcare providers' underdiagnosis, and limited availability and accessibility to advanced treatments. Furthermore, establishing clear pathways to services and medical care remains a challenge, complicating access to treatment for individuals with BPD. Despite efforts, many healthcare providers lack the training or resources to address severe BPD effectively, an issue acknowledged by both affected individuals and medical professionals. In the context of psychiatric hospitalizations, individuals with BPD constitute approximately 20% of admissions. While many engage in outpatient treatment consistently over several years, reliance on more restrictive and expensive treatment options, such as inpatient admission, tends to decrease over time. Service experiences vary among individuals with BPD. Assessing suicide risk poses a challenge for clinicians, with patients underestimating the lethality of self-harm behaviors. The suicide risk among people with BPD is significantly higher than that of the general population, characterized by a history of multiple suicide attempts during crises. Notably, about half of all individuals who commit suicide are diagnosed with a personality disorder, with BPD being the most common association. In 2014, following the death by suicide of a patient with BPD, the National Health Service (NHS) in England faced criticism from a coroner for the lack of commissioned services to support individuals with BPD. It was stated that 45% of female patients were diagnosed with BPD, yet there was no provision or prioritization for therapeutic psychological services. At that time, England had only 60 specialized inpatient beds for BPD patients, all located in London or the northeast region. Prognosis With treatment, the majority of people with BPD can find relief from distressing symptoms and achieve remission, defined as a consistent relief from symptoms for at least two years. A longitudinal study tracking the symptoms of people with BPD found that 34.5% achieved remission within two years from the beginning of the study. Within four years, 49.4% had achieved remission, and within six years, 68.6% had achieved remission. By the end of the study, 73.5% of participants were found to be in remission. Moreover, of those who achieved recovery from symptoms, only 5.9% experienced recurrences. A later study found that ten years from baseline (during a hospitalization), 86% of patients had sustained a stable recovery from symptoms. Other estimates have indicated an overall remission rate of 50% at 10 years, with 93% of people being able to achieve a 2 year remission and 86% achieving at least a 4 year remission. And a 30% risk of relapse over 10 years (relapse indicating a recurrence of BPD symptoms meeting diagnostic criteria). A meta analysis which followed people over 5 years reported remission rates of 50-70%. Patient personality can play an important role during the therapeutic process, leading to better clinical outcomes. Recent research has shown that BPD patients undergoing dialectical behavior therapy (DBT) exhibit better clinical outcomes correlated with higher levels of the trait of agreeableness in the patient, compared to patients either low in agreeableness or not being treated with DBT. This association was mediated through the strength of a working alliance between patient and therapist; that is, more agreeable patients developed stronger working alliances with their therapists, which in turn, led to better clinical outcomes. In addition to recovering from distressing symptoms, people with BPD can also achieve high levels of psychosocial functioning. A longitudinal study tracking the social and work abilities of participants with BPD found that six years after diagnosis, 56% of participants had good function in work and social environments, compared to 26% of participants when they were first diagnosed. Vocational achievement was generally more limited, even compared to those with other personality disorders. However, those whose symptoms had remitted were significantly more likely to have good relationships with a romantic partner and at least one parent, good performance at work and school, a sustained work and school history, and good psychosocial functioning overall. Epidemiology BPD has a point prevalence of 1.6% and a lifetime prevalence of 5.9% of the global population. Within clinical settings, the occurrence of BPD is 6.4% among urban primary care patients, 9.3% among psychiatric outpatients, and approximately 20% among psychiatric inpatients. Despite the high utilization of healthcare resources by individuals with BPD, up to half may show significant improvement over a ten-year period with appropriate treatment. Regarding gender distribution, women are diagnosed with BPD three times more frequently than men in clinical environments. Nonetheless, epidemiological research in the United States indicates no significant gender difference in the lifetime prevalence of BPD within the general population. This finding implies that women with BPD may be more inclined to seek treatment compared to men. Studies examining BPD patients have found no significant differences in the rates of childhood trauma and levels of current psychosocial functioning between genders. The relationship between BPD and ethnicity continues to be ambiguous, with divergent findings reported in the United States. The overall prevalence of BPD in the U.S. prison population is thought to be 17%. These high numbers may be related to the high frequency of substance use and substance use disorders among people with BPD, which is estimated at 38%. History The coexistence of intense, divergent moods within an individual was recognized by Homer, Hippocrates, and Aretaeus, the latter describing the vacillating presence of impulsive anger, melancholia, and mania within a single person. The concept was revived by Swiss physician Théophile Bonet in 1684 who, using the term folie maniaco-mélancolique, described the phenomenon of unstable moods that followed an unpredictable course. Other writers noted the same pattern, including the American psychiatrist Charles H. Hughes in 1884 and J. C. Rosse in 1890, who called the disorder "borderline insanity". In 1921, Emil Kraepelin identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of BPD. The idea that there were forms of disorder that were neither psychotic nor simply neurotic began to be discussed in psychoanalytic circles in the 1930s. The first formal definition of borderline disorder is widely acknowledged to have been written by Adolph Stern in 1938. He described a group of patients who he felt to be on the borderline between neurosis and psychosis, who very often came from family backgrounds marked by trauma. He argued that such patients would often need more active support than that provided by classical psychoanalytic techniques. The 1960s and 1970s saw a shift from thinking of the condition as borderline schizophrenia to thinking of it as a borderline affective disorder (mood disorder), on the fringes of bipolar disorder, cyclothymia, and dysthymia. In the DSM-II, stressing the intensity and variability of moods, it was called cyclothymic personality (affective personality). While the term "borderline" was evolving to refer to a distinct category of disorder, psychoanalysts such as Otto Kernberg were using it to refer to a broad spectrum of issues, describing an intermediate level of personality organization between neurosis and psychosis. After standardized criteria were developed to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis in 1980 with the publication of the DSM-III. The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "schizotypal personality disorder". The DSM-IV Axis II Work Group of the American Psychiatric Association finally decided on the name "borderline personality disorder", which is still in use by the DSM-5. However, the term "borderline" has been described as uniquely inadequate for describing the symptoms characteristic of this disorder. Etymology Earlier versions of the DSM—before the multiaxial diagnosis system—classified most people with mental health problems into two categories: the psychotics and the neurotics. Clinicians noted a certain class of neurotics who, when in crisis, appeared to straddle the borderline into psychosis. The term "borderline personality disorder" was coined in American psychiatry in the 1960s. It became the preferred term over a number of competing names, such as "emotionally unstable character disorder" and "borderline schizophrenia" during the 1970s. Borderline personality disorder was included in DSM-III (1980) despite not being universally recognized as a valid diagnosis. Controversies Credibility and validity of testimony The credibility of individuals with personality disorders has been questioned at least since the 1960s. Two concerns are the incidence of dissociation episodes among people with BPD and the belief that lying is not uncommon in those diagnosed with the condition. Dissociation Researchers disagree about whether dissociation, or a sense of emotional detachment and physical experiences, impacts the ability of people with BPD to recall the specifics of past events. A 1999 study reported that the specificity of autobiographical memory was decreased in BPD patients. The researchers found that decreased ability to recall specifics was correlated with patients' levels of dissociation, which 'may help them to avoid episodic information that would evoke acutely negative affect'. Gender In a clinic, up to 80% of patients are women, but this might not necessarily reflect the gender distribution in the entire population. According to Joel Paris, the primary reason for gender disparities in clinical settings is that women are more likely to develop symptoms that prompt them to seek help. Statistics indicate that twice as many women as men in the community experience depression. Conversely, men more frequently meet criteria for substance use disorder and psychopathy, but tend not to seek treatment as often. Additionally, men and women with similar symptoms may manifest them differently. Men often exhibit behaviors such as increased alcohol consumption and criminal activity, while women may internalize anger, leading to conditions like depression and self-harm, such as cutting or overdosing. Hence, the gender gap observed in antisocial personality disorder and borderline personality disorder, which may share similar underlying pathologies but present different symptoms influenced by gender. In a study examining completed suicides among individuals aged 18 to 35, 30% of the suicides were attributed to people with BPD, with a majority being men and almost none receiving treatment. Similar findings were reported in another study. In short, men are less likely to seek or accept appropriate treatment, more likely to be treated for symptoms of BPD such as substance use rather than BPD itself (the symptoms of BPD and ASPD possibly deriving from a similar underlying etiology); more likely to wind up in the correctional system due to criminal behavior; and, more likely to commit suicide prior to diagnosis. Among men diagnosed with BPD there is also evidence of a higher suicide rate: "men are more than twice as likely as women—18 percent versus 8 percent"—to die by suicide. There are also sex differences in borderline personality disorder. Men with BPD are more likely to recreationally use substances, have explosive temper, high levels of novelty seeking and have (especially) antisocial, narcissistic, passive-aggressive or sadistic personality traits (male BPD being characterised by antisocial overtones). Women with BPD are more likely to have eating disorders, mood disorders, anxiety and post-traumatic stress. Manipulative behavior Manipulative behavior to obtain nurturance is considered by the DSM-IV-TR and many mental health professionals to be a defining characteristic of borderline personality disorder. In one research study, 88% of therapists reported that they have experienced manipulation attempts from patient(s). Marsha Linehan has argued that doing so relies upon the assumption that people with BPD who communicate intense pain, or who engage in self-harm and suicidal behavior, do so with the intention of influencing the behavior of others. The impact of such behavior on others—often an intense emotional reaction in concerned friends, family members, and therapists—is thus assumed to have been the person's intention. According to Linehan, their frequent expressions of intense pain, self-harming, or suicidal behavior may instead represent a method of mood regulation or an escape mechanism from situations that feel unbearable, however, making their assumed manipulative behavior an involuntary and unintentional response. One paper identified possible reasons for manipulation in BPD: identifying others feelings and reactions, a regulatory function due to insecurity, to communicate ones emotions and connect to others, or to feel as if one is in control, or to allow them to be "liberated" from relationships or commitments. Stigma The features of BPD include: emotional instability, intense and unstable interpersonal relationships, a need for intimacy, and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe people with BPD, such as "difficult", "treatment resistant", "manipulative", "demanding", and "attention seeking", are often used and may become a self-fulfilling prophecy, as negative treatment of these individuals may trigger further self-destructive behavior. Since BPD can be a stigmatizing diagnosis even within the mental health community, some survivors of childhood abuse who are diagnosed with BPD are re-traumatized by the negative responses they receive from healthcare providers. One camp argues that it would be better to diagnose these people with post-traumatic stress disorder, as this would acknowledge the impact of abuse on their behavior. Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society. Regardless, a diagnosis of PTSD does not encompass all aspects of the disorder (see brain abnormalities and terminology). Physical violence The stigma surrounding borderline personality disorder includes the belief that people with BPD are prone to violence toward others. While movies and visual media often sensationalize people with BPD by portraying them as violent, the majority of researchers agree that people with BPD are unlikely to physically harm others. Although people with BPD often struggle with experiences of intense anger, a defining characteristic of BPD is that they direct it inward toward themselves. One 2020 study found that BPD is individually associated with psychological, physical and sexual forms of intimate partner violence (IPV), especially amongst men. In terms of the AMPD trait facets, hostility (negative affectivity), suspiciousness (negative affectivity) and risk taking (disinhibition) were most strongly associated with IPV perpetration for the total sample. In addition, adults with BPD have often experienced abuse in childhood, so many people with BPD adopt a "no-tolerance" policy toward expressions of anger of any kind. Their extreme aversion to violence can cause many people with BPD to overcompensate and experience difficulties being assertive and expressing their needs. This is one reason why people with BPD often choose to harm themselves over potentially causing harm to others. Mental health care providers People with BPD are considered to be among the most challenging groups of patients to work with in therapy, requiring a high level of skill and training for the psychiatrists, therapists, and nurses involved in their treatment. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with and more difficult than other client groups. This largely negative view of BPD can result in people with BPD being terminated from treatment early, being provided harmful treatment, not being informed of their diagnosis of BPD, or being misdiagnosed. With healthcare providers contributing to the stigma of a BPD diagnosis, seeking treatment can often result in the perpetuation of BPD features. Efforts are ongoing to improve public and staff attitudes toward people with BPD. In psychoanalytic theory, the stigmatization among mental health care providers may be thought to reflect countertransference (when a therapist projects his or her own feelings on to a client). This inadvertent countertransference can give rise to inappropriate clinical responses, including excessive use of medication, inappropriate mothering, and punitive use of limit setting and interpretation. Some clients feel the diagnosis is helpful, allowing them to understand that they are not alone and to connect with others with BPD who have developed helpful coping mechanisms. However, others experience the term "borderline personality disorder" as a pejorative label rather than an informative diagnosis. They report concerns that their self-destructive behavior is incorrectly perceived as manipulative and that the stigma surrounding this disorder limits their access to health care. Indeed, mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis. Terminology Because of concerns around stigma, and because of a move away from the original theoretical basis for the term (see history), there is ongoing debate about renaming borderline personality disorder. While some clinicians agree with the current name, others argue that it should be changed, since many who are labelled with borderline personality disorder find the name unhelpful, stigmatizing, or inaccurate. Valerie Porr, president of Treatment and Research Advancement Association for Personality Disorders states that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma". Alternative suggestions for names include emotional regulation disorder or emotional dysregulation disorder. Impulse disorder and interpersonal regulatory disorder are other valid alternatives, according to John G. Gunderson of McLean Hospital in the United States. Another term suggested by psychiatrist Carolyn Quadrio is post traumatic personality disorganization (PTPD), reflecting the condition's status as (often) both a form of chronic post traumatic stress disorder (PTSD) as well as a personality disorder. However, although many with BPD do have traumatic histories, some do not report any kind of traumatic event, which suggests that BPD is not necessarily a trauma spectrum disorder. The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned unsuccessfully to change the name and designation of BPD in DSM-5, published in May 2013, in which the name "borderline personality disorder" remains unchanged and it is not considered a trauma- and stressor-related disorder. Society and culture Literature In literature, characters believed to exhibit signs of BPD include Catherine in Wuthering Heights (1847), Smerdyakov in The Brothers Karamazov (1880), and Harry Haller in Steppenwolf (1927). Film Films have also attempted to portray BPD, with characters in Margot at the Wedding (2007), Mr. Nobody (2009), Cracks (2009), Truth (2013), Wounded (2013), Welcome to Me (2014), and Tamasha (2015) all suggested to show traits of the disorder. The behavior of Theresa Dunn in Looking for Mr. Goodbar (1975) is consistent with BPD, as suggested by Robert O. Friedel. Films like Play Misty for Me (1971) and Girl, Interrupted (1999, based on the memoir of the same name) suggest emotional instability characteristic of BPD, while Single White Female (1992) highlights aspects such as identity disturbance and fear of abandonment. Clementine in Eternal Sunshine of the Spotless Mind (2004) is noted to show classic BPD behavior, and Carey Mulligan's portrayal in Shame (2011) is praised for its accuracy regarding BPD characteristics by psychiatrists. Psychiatrists have even analyzed characters such as Kylo Ren and Anakin Skywalker/Darth Vader from the Star Wars films, noting that they meet several diagnostic criteria for BPD. Television Television series like Crazy Ex-Girlfriend (2015) and the miniseries Maniac (2018) depict characters with BPD. Traits of BPD and narcissistic personality disorders are observed in characters like Cersei and Jaime Lannister from A Song of Ice and Fire (1996) and its TV adaptation Game of Thrones (2011). In The Sopranos (1999), Livia Soprano is diagnosed with BPD, and even the portrayal of Bruce Wayne/Batman in the show Titans (2018) is said to include aspects of the disorder. The animated series Bojack Horseman (2014) also features a main character with symptoms of BPD. Awareness Awareness of BPD has been growing, with the U.S. House of Representatives declaring May as Borderline Personality Disorder Awareness Month in 2008. People with BPD will share their personal experiences of living with the disorder on social media to raise awareness of the condition. Public figures like South Korean singer-songwriter Lee Sun-mi have opened up about their personal experiences with the disorder, bringing further attention to its impact on individuals' lives. See also Affective empathy Hysteria Pseudohallucination Obsessive love disorder Citations General bibliography External links APA DSM 5 Definition of Borderline personality disorder APA Division 12 treatment page for Borderline personality disorder ICD-10 definition of EUPD by the World Health Organization NHS Cluster B personality disorders Wikipedia medicine articles ready to translate Wikipedia neurology articles ready to translate Women and psychology

Clinical mental health counseling

Clinical mental health counseling is a healthcare profession addressing issues such as substance abuse, addiction, relational problems, stress management, as well as more serious conditions such as suicidal ideation and acute behavioral disorders. Practitioners may also assist with occupational growth in neurodivergent populations and behavioral and educational development. Clinical mental health (CMH) counselors include psychologists, psychiatrists, mental health technicians, marriage counselors, social workers, and family therapists. Historical perspectives Origins of counseling In the early 1900s, counseling had not yet developed into treating mental health issues and was more focused on education. Frank Parsons, developed a plan to educate counselors and began the Vocational Guidance Movement. He was concerned with the problems of youth as youth unemployment became a major concern for adolescents as urbanization occurred, and sustainable work and family income generated on family farms was not as prevalent. At this time, counselors were considered vocational, initiating the approach that began to form the more contemporary counseling process. Around the same time, Clifford Beers, a former patient of mental health hospitals, wrote a book exposing the terrible conditions of mental health institutions and advocated for reform. Beers later founded the National Committee for Mental Hygiene, which became the National Mental Health Association. Jessie B. Davis was the first individual to make guidance a regular part of the school curriculum. He was a superintendent or administrator and advocated for what became school guidance and counseling. During the Great Depression, counseling methods and strategies for employment grew as it was greatly needed at the time. In 1932, Brewer wrote a book entitled Education as Guidance, which promoted the broadening of counseling beyond just occupation. He suggested that every teacher share the implementation of counseling and that guidance needed to be in every school curriculum. In the 1940s, Carl Rogers began the development of counseling and psychotherapy. He believed that the client knows best and that only they could explain what their needs are and what direction to go in counseling based on what problems were crucial and needed attention. Rogers clearly indicated that he was not doing psychology and the courses he taught were based in the Department of Education. World War II brought to the forefront the importance of testing and placement as there was a strong need for the selection and training of specialists for the military. Counselors and Psychologists had the necessary skills to fill this much needed role. The Veterans Administration provided professional counseling services to soldiers after their discharge and in 1945, the VA granted stipends and internships for students in counseling and psychology, boosting the support and training available to counselors. This time marked the beginning of government spending on counselor preparation as we know it today. Clinical psychologists were trained to treat and diagnose individuals with chronic disorders, and counseling psychologists were trained to deal with issues presented by people with more severe mental health issues. This led to a new division or category of psychologists and the Division of Counseling and Guidance of the American Psychological Association changed its title to the Division of Counseling Psychology. Professionalization of mental health counseling In the 1950s, flaws in the existing mental health system were being exposed and clinically effective pharmacological treatments were also being developed that could be provided in outpatient settings. This led to a need for community-based clinics, but access to these services was limited. The Community Mental Health Act of 1963 was very important in the development of the counseling profession. After the government analyzed the problems with mental illness and effective treatments, President John F. Kennedy believed that high-quality treatment centers located in the patient's community could lead to the phasing out of state mental hospitals and drastically improve the mental health system in the United States. The national network of community mental health centers created a demand for counselors and the profession began to expand and increase the number of counselors. As the counseling profession grew, there became a need to regulate the quality of services being provided by professionals via state licensure. In 1974, a special committee was appointed by the American Personnel and Guidance Association that focused on counselor licensure. This began the steps towards the first counselor licensure law in Virginia in 1976. By the 1980s, mental health counseling had clearly established itself as a profession with a distinct set of regulations and methods for providing services. According to Gerig, a distinct professional is characterized by "role statements, codes of ethics, accreditation guidelines, competency standards, licensure, certification, and other standards of excellence." The counseling profession as we know it today has established all of these facets of a distinct profession and is being recognized more and more as a valuable and much-needed helping profession in our society. Education, licensure, and certification Licensure Counselor licensure is established by state law and is required of all professional counselors in the United States and U.S. territories. Receiving a license in counseling indicates that one has met the minimum standards to practice counseling in that state. State laws vary in the requirements that must be met to obtain a license. Candidates must have at least received a master's degree, have had post-master's supervised practice, and have passed a national exam. The number of credit hours to be completed varies from one state to another, as does the number of supervised hours that must be completed, and the counselor titles used. Moving from one state to another may require taking additional courses in order to qualify for the license in the other state. Common education requirements In order to become licensed as a Licensed Professional Counselor (LPC) or Licensed Professional Counselor Associate (LPCS), students need to study for many hours in different fields of mental health, general psychology, and others. These usually include: Internship Experience for Certification Orientation to the Counseling Profession Research Career, Vocational, and Lifestyle Development Human growth and Development Social and Cultural Foundations Counseling Theories and Techniques Appraisal from peers Group Work Practicum and Internship Examination requirements The LPC applicant must obtain a passing score on a national exam, such as the National Counselor Exam (NCE), the National Clinical Mental Health Counseling Exam (NCMHCE), or the Certified Rehabilitation Counselor Exam (CRC). The first two exams are offered by the National Board for Certified Counselors (NBCC) and the third exam is offered by the Commission on Rehabilitation Counselor Certification (CRCC). In addition to the national exam, applicants must complete a no-fail Jurisprudence Exam, which covers information on laws and ethical codes. Supervision requirements Applicants must have completed over 3,000 hours of supervised counseling practice. Supervisees should receive one hour of live supervision per forty hours of practice. 2,000 or more hours must involve direct client contact. Certification Certification is a voluntary credential that can be acquired by counselors as well. According to Remley and Herlihy, there are two national certification agencies for the counseling profession. These are the National Board for Certified Counselors (NBCC) and the Commission on Rehabilitation Counselor Certification (CRCC). The NBCC also offers specialty certifications. The information regarding the certifications provided by the NBCC is outlined below. National Certified Counselor (NCC) According to Remley and Herlihy, this certification is granted by the National Board for Certified Counselors (NBCC) after an individual has met certain requirements. These include: Completion of a master's degree in counseling Completion of two years post-master's experience It is important to note that if an individual graduates from a program that is accredited by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP), the two years of post-master's experience requirement is waived. Acquisition of a passing grade on the National Counselor Exam (NCE) Certified Clinical Mental Health Counselor (CCMHC) According to Gerig, counselors seeking the CCMHC specialty credential must meet the following requirements: Obtain the National Certified Counselor (NCC) certification Complete 60 hours of graduate coursework including courses in: Theories of Counseling Psychotherapy Personality Abnormal Psychology and Psychopathology Human Growth and Development Professional Orientation and Ethics Research Testing Social/Cultural Foundations Complete an academic program with 9–15 hours of clinical training in a supervised practicum/internship in a mental health counseling setting Acquire a passing score on the National Clinical Mental Health Counseling Exam (NCMHCE) Submit an audiotape or videotape of a counseling session Master Addictions Counselor According to Gerig, the Master Addictions Counselor (MAC) specialty certification is intended for counselors treating substance abuse and dependence. Counselors seeking this credential must complete the following requirements: Obtain a National Certified Counselor (NCC) certification Document at least 12 semester hours of graduate work in addictions or 500 hours of continuing education units Complete 3 years of supervised experience as an addiction counselor Obtain a passing score on the Examination for Master Addiction Counselors (EMAC) Professional organizations Professional organizations exist to serve many different functions. They provide an assembly for professionals to gather to discuss issues and problems that exist within the profession. Organizations allow the members of a profession to address issues as a group rather than facing these issues independently. Professional organizations provide an outlet for legislative activity and leadership regarding particular issues that affect the profession at all levels. Continuing education is a critical requirement for members of a profession as it ensures that all professionals' skills and expertise are continuously updated to reflect the most current research and recommendations; professional organizations provide this continuing education to their members. These organizations also assist in keeping professionals up to date by providing scholarly journals, books, and media resources to their members. Lastly, professional organizations publish and enforce a code of ethics for their members. The following professional organizations are the primary ones available to those within the clinical mental health counseling profession. American Counseling Association (ACA) American Counseling Association is "a not-for-profit, professional and educational organization that is dedicated to the growth and enhancement of the counseling profession". Headquartered in Alexandria, VA, with 56 chartered branches in the United States, Europe, and Latin America, it was founded in 1952 and is noted to be the world's largest association that exclusively represents professional counselors in a variety of practice settings. ACA is divided into 20 divisions that are tailored to specialized areas and/or principles of counseling. ACA has membership available for all stages of the counseling profession from students to retirees. In addition to the professional and advocacy benefits, ACA also offers its members discounts on malpractice liability, auto, home, and personal insurance products, prescription, lab, and imaging services, and discounts from industry leaders in hotel, travel, credit cards, as well many other consumer services. Members can choose to additionally join one or more of the 20 divisions, which offer their own unique professional benefits. American Mental Health Counselors Association (AMHCA) American Mental Health Counselors Association is an independent nonprofit 501(c)6 professional membership association made up of more than 7,000 clinical mental health counselors. Its mission is "to enhance the profession of clinical mental health counseling through licensing, advocacy, education, and professional development". The American Mental Health Counselors Association (AMHCA) is an independent non-profit, membership-owned, and operated association. The vision of AMHCA is to position clinical mental health counselors to meet the health care needs of those we serve while advancing the profession. The mission of AMHCA is to advance the profession of clinical mental health counseling by setting the standard for collaboration, advocacy, research, ethical practice, and education/training/professional development. AMHCA association bylaws are the rules and regulations enacted by the association to provide a framework for its operation and management. The bylaws define elections, titles, terms of office, and responsibilities of the AMHCA officers of the association, as well as certain responsibilities of the chief executive officer. The bylaws also specify the qualifications, rights, and liabilities of membership, and the powers, duties, and responsibilities of state chapters and affiliate associations/organizations as well as grounds for dissolution of a chapter, the removal of an officer of the AMHCA, or the revocation of a membership. Standing committees are also identified as are certain fiduciary processes, obligations, and limitations. Clinical mental health counselors at all stages of their professional journey, including students, are eligible to join AMHCA. Member benefits also include professional liability insurance plan discounts, continuing education opportunities, networking via AMHCA's annual conference, and a quarterly journal with the latest clinical mental health counseling research. National Board for Certified Counselors (NBCC) National Board for Certified Counselors is a not-for-profit, independent certification organization that was established in 1982. Its primary purposes are "to establish and monitor a national certification system, to identify those counselors who have voluntarily sought and obtained certification, and to maintain a register of those counselors". NBCC has four voluntary certifications, the National Certified Counselor (NCC), Certified Clinical Mental Health Counselor (CCMHC), National Certified School Counselor (NCSC), and Master Addictions Counselor (MAC). The NCC and MAC are both accredited by the National Commission for Certifying Agencies (NCCA). Obtaining National Counselor Certification (NCC) through NBCC, though not required, has many professional benefits including showing the public and employers that you have voluntarily met high national standards for the practice of counseling. Additionally, NCCs receive a number of other benefits including access to low-cost liability insurance, the ability to market oneself using the certification, a free six-month listing in the Therapy Directory, and continuing education credit, among others. The fees paid for certification go towards supporting NBCC's advocacy efforts for the counseling profession. Working environments Community Mental Health Agency This type of counseling setting generally provides a wide array of services, especially depending on particular populations served, as well as geographical settings. Services may include, but are not limited to: individual, family, and group of outpatient talk therapy; twenty-four-hour crisis intervention, or mobile crisis management; rape, sexual abuse, and domestic violence services; testing and assessment for career interests, and broader mental health issues; community psycho-education and outreach; day treatment (for mentally ill and/or developmentally disabled); intensive in-home treatment; jail diversion programs; and case management. In terms of insurance, some agencies are able to take both private and governmental policies. Regarding governmental insurance, this type of coverage is dependent on whether or not the specific agency is approved for federal and/or state funding. When it comes to serving Medicare-covered clients, counselors in the U.S. are still exempt from the list of acceptable providers, thus it is a current issue of great concern in our community. Private practice Although private practices are common in the American mental health counseling community, a licensed counselor often enters this kind of setting after several professional years have passed and following the completion of a master's degree program. Before making the transition into the private setting, many therapists work for a larger community-based agency, hospital, or treatment facility. The advantages include independence in providing therapy; the ability to be more selective when it comes to the clientele and population(s) served; and incorporating unique skills and special training, such as play therapy, EMDR (Eye Movement Desensitization and Reprocessing), etc. However, the act of operating a private practice is akin to running a small business. In order to prosper, it is crucial for the counselor to have proper business and public representation skills. In deciding to hang a shingle, one must be prepared to establish and maintain a respectable presence in his or her community, oftentimes promoting awareness (and thus one's business) on one's own time. Awareness activities include visiting places of worship, community centers, local businesses, etc. to perform psycho-educational workshops. As described in the previous section of Community Mental Health Agencies, the same standards of insurance coverage, as well as sliding scale payment, apply to private practice settings. A big difference is that independent counselors are often responsible for processing their own billing if they do not have an administrative assistant. Alcohol and substance abuse treatment programs (residential and outpatient) In this mental health setting, there are many commonalities shared with the more overarching community agencies. Both environments encompass similar services, such as individual, family, and group outpatient counseling; twenty-four-hour crisis intervention; day treatment for mentally ill and/or developmentally disabled clients; and case management. Although alcohol/substance abuse programs have an obvious focus on recovery and rehabilitation, counseling services also apply to assisting in comorbidity, or dual diagnoses (e.g., bipolar disorder and alcohol dependence). Recovery programs provide specialized group counseling sessions for clients dealing with comorbidity, for gender-specific clientele, and for clients receiving methadone treatment. Clients may enter treatment through self- or family referrals. The majority of clients are ordered to participate in a recovery program by a judge in Drug Court, on account of criminal charges pertaining to drunk driving, possession of illegal substances, etc. The majority of clients receive funding through Medicaid or the state, but private insurance can also be accepted. Both outpatient and residential services last an average of thirty to ninety days. Due to this brief span of time for treatment, counselors strongly encourage their clients struggling with addiction(s) to become regular attendees of local AA and/or NA meetings, and to obtain a sponsor as soon as possible. University and college counseling centers This counseling setting is typically based within a wellness or health center of a school on campus. Ordinarily, there are an average of eight to ten free sessions allocated to every student for each academic year, with each session lasting roughly one hour. It is not uncommon for a client's appointments to occur once every two to three weeks, as the counseling staff serve hundreds to even thousands of students per semester. That being said, therapists in this type of employment setting treat a variety of mental health concerns. The clientele are principally both traditional young adults, and adult students. College and university counseling staff assist students within a broad scope of subject matter, "such as depression, anxiety, self-mutilation, eating disorders, post-traumatic disorders, and self-esteem issues". The strictly designated number of sessions for each student is designed to make the therapy process temporary and brief. However, if a client reveals a more severe mental disorder, the staff are responsible for referring the individual to specialized services in the community. Theoretical orientations to counseling Counseling theories are interrelated principles that describe, explain, predict, and guide the actions of the counselors within different situations. The use of theory provides a tool for counselors to use in order to identify important aspects of and clearly organize a client's story or narrative. These integrated systems are evaluated by multiple criteria: precision and clarity, comprehensiveness, testability, utility, and heuristic value. Counseling theories can be classified into four distinct categories: analytic, humanistic-existential, action-based, and postmodern/multicultural approaches. Analytic approaches Psychodynamic theory, or psychodynamics, involves personality and how it can be analyzed in order to more fully understand the client's presenting problem and quality of life. Both psychoanalytic and psychodynamic approaches to counseling include analyzing or conceptualizing personality, developing and fostering insight on behalf of the client, and then using those insights to create interventions or take action. Jungian analytic theory is based on the idea of a collective unconscious, which is a storing of history, stories, fairy tales, and other experiences that make up the psyche which, in turn, can be used in therapy for psychological healing. The ultimate goal of counselors who utilize this theory is to combine the conscious and unconscious aspects of the self in order to foster a connection with the universe that is whole and complete. See also Analytical psychology. Adlerian individual psychology is used by counselors who believe that each individual develops their own style of life, which helps to make sense of the world around them. Adlerian counselors direct their clients to choose a new lifestyle when the old is faulty or no longer serves its purpose for the client. This approach is brief and directive, with the aim of helping clients develop insight and self-understanding. Humanistic-existential approaches Person centered is an influential theory in counseling. The founder of this theory, Carl Rogers, stated that three conditions are necessary for therapeutic change to occur: a) congruence or genuineness, b) accurate empathy, and c) unconditional positive regard. Many counselors consider therapeutic presence to be a necessary condition, as the goal of person centered therapy is to allow clients to become more fully themselves and experience this through the counseling relationship. Existential theory focuses on the meaning of life, identity crises, confronting lonesomeness, and other anxieties involving "big picture" ideas. Counselors who utilize existential therapy focus on existential roots and emphasize the idea that human beings are ultimately responsible for the choices they make and the actions they take. Gestalt theory involves helping clients become aware of their true selves. This includes present moment awareness of self and environment. Gestalt therapy techniques include active and experiential methods and the main goal of this approach to counseling is a reintegration of the self, including parts that have been metaphorically cutoff. Action-based approaches Behavioral approaches to counseling include techniques such as classical conditioning, operant conditioning, and social learning theory. Behavior therapy oriented counselors tend to conduct their interventions on behaviors that are both observable and measurable. Cognitive-behavioral theory combines both cognitive and behavioral approaches to counseling. In addition to Cognitive Behavioral Therapy, there are numerous other forms of this approach including Multimodal therapy, Rational Emotive Behavior Therapy, Reality therapy, and Mindfulness-based cognitive therapy. Systemic/family approaches to counseling focus on the importance of the larger relational system, such as the family of origin, family of procreation, and other societal groups and communities. Counselors who utilize this theory view client's presenting problems as related to the systems that they are involved in and view symptoms with neutrality in order to help clients create new relational patterns within family therapy and systemic therapy. Postmodern and multicultural approaches Solution based counseling theory is related to systemic family counseling and involves encouraging clients to make small consistent changes in their lives. Solution based theory views the counselor and clients are collaborators in order to create goals and bring about measurable change. This type of theory involves solution focused brief therapy and it is utilized in schools, and managed care environments, among other time-limited environments. Feminist theory is often misinterpretation as being used by counselors who work only with female clients. However, this theory focuses on multiple aspects of identity, such as gender, culture, race, sexual orientation, to name a few. Feminist theory counselors hold the belief that human beings seek connections with others in order to establish growth. This theoretical orientation labels disconnection as the root of the client's presenting problems and the ultimate goal of feminist therapy is to create growth-fostering relationships. Narrative theory involves the idea that each individual operates from a dominant discourse, which is the societal expectations by which human beings live. The purpose of narrative therapy is to focus on separating the person from the problem and guiding clients to choose alternative ways to act and interact with others throughout their daily lives. Collaborative theory is an approach that involves counselor and clients working together to explore and create an understanding of the presenting problems. Counselors with this theoretical orientation use the collaborative therapy technique of mutual puzzling, which is shared inquiry of discovering how the problem occurs and also how to move forward. Reflecting teams are not so much a theory as they are a technique utilized by postmodern counselors. Guidelines for reflecting teams are as follows: client must give permission, client can choose to listen or not to listen to the teams' conversation, conversation should focus on what is seen or heard, conversation should stem from a questioning, speculative perspective, the reflecting team should not address the client or clients directly, and the reflecting team should listen for what is appropriately unusual. Ethics in counseling A code of ethics contains standards of behavior or practice that are agreed upon as acceptable by professionals within a given field. There are multiple ethical codes within the field of counseling that counselors are expected to abide by within their work and professional role. These codes are then enforced by ethics committees and licensure boards. A violation of code may lead to a number of consequences, dependent upon the severity of the violation, and varying in such: one might be placed on probation, suspended, or even have their license revoked. While law clarifies a profession's scope of practice, ethics are important to each profession for a number of reasons. Not only do codes of ethics provide standards to which members of the profession are held accountable, but they also aid in the improvement of provided services. Ethical codes promote professionalism and provide evidence of the intent of members within a profession to regulate and moderate their behavior. They assist in identifying appropriate courses of action for situations that arise without clear and easy resolution. Also, while ethical codes cannot be entirely preventative, they protect consumers from dangerous and/or inappropriate practice. Different professional organizations within each field may have their own personal code of ethics as well, such as the American Counseling Association and the American Mental Health Counselors Association in the profession of counseling. It has been concluded that ethics encompasses five different features: possessing adequate knowledge, skills, and judgment to produce effective interventions; respecting the dignity, freedom, and rights of the client; using power inherent in the counselor's role judiciously and responsibly; conducting oneself in such a way that promotes the public's confidence in the profession; maintaining the client's welfare as the highest priority of the mental health professional. Similarly, six different principle ethics are often considered as crucial to take into account when faced with an ethical decision: the principle of autonomy, which relates to the client's right to control their own life, decisions, future, etc.; non-maleficence, which translates to doing no harm to the client; somewhat oppositely, beneficence, which means doing good for or promoting the welfare of your client; justice, referring to fairness and equality on the part of the professional; fidelity, which requires the professional to fulfill a responsibility of faithfulness and trust; and veracity, which means being truthful and honest with clients. The newest 2014 edition of the American Counseling Association's Code of Ethics contains nine sections that each address a separate area of ethical conduct: the counseling relationship; confidentiality and privacy; professional responsibility; relationships with other professionals; evaluation, assessment, and interpretation; supervision, training, and teaching; research and publication; distance counseling, technology, and social media; and resolving ethical issues. A brief description of some of these predominant realms follows. Confidentiality Confidentiality refers to the respect of a client's privacy. Almost all information that a client reveals during counseling is protected, unless the client intends to cause harm to themselves or others. The client's consent is almost always required for the reveal of information to a third party. Laws of privileged communication within applicable states also further protect the privacy of clients. Where privileged communication is present, confidential information does not need to be disclosed in court without the client's permission. Confidentiality is crucial to create the safety, trust, and honesty required in an effective, beneficial counseling relationship. Outside of privileged communication, there are generally four instances in which confidential information may be released to a third party: if the client allows the counselor to do so with a signed release of information if the client discloses or is suspected to be an imminent threat of safety or danger to self or others, if current abuse or the intent of abuse of another is disclosed, or if a court order or subpoena requires the release of client records or testimony of the counselor. Competence This concept of competence requires proof of minimum competency for a professional, while also striving to practice in an ideal manner. For each credential that a counselor earns, such as a degree and licensure, there are minimum prerequisites of performance that must be met. A counselor may also be competent or incompetent in different types of counseling, working with different populations, or specializing in different theoretical orientations. Competency also needs to be maintained over time and should be self-monitored. Counselors should continue to access and review current research, and continuing education credits can be earned through workshops, seminars, webinars, etc. When this ethical concept is not maintained, a counselor may be risking professional misconduct, and may even face trial for malpractice. Informed consent Informed consent is typically addressed through a form at the beginning of a counseling relationship and pertains to the client's right to be aware of the nature of that relationship and the counseling process itself. Informed consent should be present throughout the entire period that a client is receiving services. This information should be presented both in written form and discussed verbally with the client. A professional disclosure statement is typically provided to the client, which should include but is not limited to counselor credentials, issues of confidentiality, the use of tests and inventories, diagnosis, reports, billing, and therapeutic process. Professional boundaries There are multiple boundaries that could be crossed between a client and a counselor, including physical, psychological, emotional, and social boundaries. Some of these boundary lines may be blurry. For example, there are differing opinions on whether touch is ever appropriate between a counselor and their client. Sexual intercourse, however, is generally uniformly disagreed upon. Dual relationships, where a counselor holds two or more different roles within a client's life at the same time, are also typically avoided, as well as the acceptance of gifts of significant monetary value. Then and now Many Community Mental Health (CMH) specialists operate under the holistic philosophy that in order to reach optimal health and wellness mental health professionals must look not only at the individual but also at the interacting communities and environment that surrounds that individual. The principal philosophy is no longer removing the disordered person from a normal family, social and community settings into a sheltered institutionalized environment but rather to a community-based treatment center for support and rehabilitation. Important dates and figures such as Dorothea Dix in 1843 and the National Mental Health Act of 1946 brought attention to the living situations of the mentally ill and the need for financial funding and more appropriate programs. In 1963 the Community Mental Health Act provided federal funding for CMH services. Thanks to the development of available economic resources, a supply of mental health professionals and multidisciplinary team approaches to mental health has been deinstitutionalized. CMH is now in the era of post deinstitutionalization. The rates of psychiatric patients treated in inpatient facilities have declined and the shift has turned to more cost-effective alternatives. New techniques and models are used to provide care for people that formerly would have been sent to inpatient treatment. Least restrictive treatment environment The idea behind the least restrictive treatment environment is to match the treatment's intensity with the severity of the client's condition so that restrictions to client personal freedom are minimal. This has been achieved by decreasing the clients' average lengths of stay in hospitals and emphasizing stabilization instead of intense therapy. Once stabilized, clients are released to the care of community-based agencies and practitioners for outpatient treatment plans. However, a revolving-door phenomenon occurs when patients are admitted, stabilized, released and then readmitted many times over a short period. Strong communication networks between mental health providers and the hospital must be utilized to help with the revolving–door phenomenon. Case management models Case management models help clients coordinate their schedules while integrating various community services. One of the most comprehensive case management model approaches is the Assertive community treatment approach. Assertive community treatment In the ACT approach, a team of professional counselors, social workers, nurses, rehabilitators and psychiatrists provide comprehensive, community-based treatment and support to clients. The team's caseload is small, and the responsibility is shared among team members. Services may include medication delivery, rehabilitation, and behavioral training in basic adaptive living skills, problems of nonattendance and transportation needs. It also includes 24-hour emergency services, medication management, money management, and assistance with daily living. The recovery and consumer movement This is the belief that mental health consumers should be able to develop control of treatment and end oppressive stigmas. Results of this movement include consumer-developed systems of care, self-help groups, consumer advocacy organizations and the recovery perspective. Support groups like Alcoholics Anonymous (AA) have increased from around 50 in 1942 to well over 58,000 in 2012. Parents without Partners (PWP) started in 1957 with one group of two women and is now the world's largest nonprofit membership organization. Formed in 1976, the National Self-Help Clearinghouse now communicates information about the activities of more than 500,000 self-help groups that now exist in the United States. The National Alliance on Mental Illness (NAMI) is a self-help support group and advocacy organization that consists of over 1,000 local affiliates and 50 state organizations. NAMI advocates for increased funding for research, housing, jobs, rehabilitation, and suitable health insurance. The rise of the recovery perspective in community mental health is changing the underlying philosophy of what it means to be mentally ill. The U.S. government's Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as "a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice with striving to achieve his or her full potential." The ten fundamental components of recover philosophy are: 1) Self-Direction, 2) Person-Centered, 3) Empowerment, 4) Holistic, 5) Non-linear, 6) Strength-based, 7) Peer Support, 8) Respect, 9) Responsibility, and 10) Hope. Under the recovery consumers of mental health care are viewed as capable and responsible persons who can take charge and manage his or her condition. Wellness strategies are implemented in recovery work such as journaling, visiting friends, exercising, nutritious eating, praying, meditation, doing acts of kindness, and practicing gratitude. Consumers in recovery that offer service to their peers in mental health treatment are called Peer support specialist. They often help connect consumers with mental help professionals and are usually trained to counsel. Evidence based treatment Many health professionals argue that counseling is as much art as it is science. Though some might find science-based outcome studies to be not particularly helpful evidence-based treatments are sometimes mandated. This is because professional organizations, third party reimbursors and consumers want more attention given to quality control and accountability. Evidence based treatment is typically a study in which a particular treatment produces change, which was evident in randomized controlled trials, in comparison with another approach or no treatment at all. SAMHSA has developed the National Registry of Evidence-based Programs and Practices. This database provides summaries, target populations, target age demographics, types of outcomes achieved, costs, and expert ratings. Other Evidence-based practice studies and research are used in community counseling to ensure treatment is effective. References External links 2014 ACA Code of Ethics National Board of Certified Counselor's state licensure board directory Counseling Mental health occupations

Dianetics: The Modern Science of Mental Health

Dianetics: The Modern Science of Mental Health, sometimes abbreviated as DMSMH, is a book by L. Ron Hubbard about Dianetics, a pseudoscientific system that would later become part of Scientology. Hubbard claimed to have developed it from a combination of personal experience, basic principles of Eastern philosophy and the work of Sigmund Freud. The book is considered part of Scientology's canon. It is colloquially referred to by Scientologists as Book One. The book launched the movement, which later defined itself as a religion, in 1950. As of 2013, New Era Publications, the international publishing company of Hubbard's works, sells the book in English and in 50 other languages. In this book, Hubbard wrote that he had isolated the "dynamic principle of existence", which he states as the basic command Survive!, and presents his description of the human mind. He identified the source of human aberration as the "reactive mind", a normally hidden but always conscious area of the mind, and certain traumatic memories (engrams) stored in it. Dianetics describes counseling (or auditing) techniques which Hubbard claimed would get rid of engrams and bring major therapeutic benefits. The work was criticized by scientists and medical professionals, who note the work is pseudoscientific and observe that the claims presented in the book are written in superficially scientific language but without evidence. Despite this, Dianetics proved a major commercial success on its publication, although B. Dalton employees have stated these figures were inflated by Hubbard's Scientologist-controlled publisher, who had groups of Scientologists each purchase dozens or even hundreds of copies of Hubbard's books and who sold these back to the same retailers. Adam Clymer, a New York Times executive and journalist, said the newspaper examined the sales patterns of Hubbard's books and uncovered no instances in which vast quantities of books were being sold to single individuals. Background Before the publication of Dianetics, L. Ron Hubbard was a prolific writer for pulp magazines. He attended George Washington University engineering school, but did not graduate. The Church of Scientology considers the book Dianetics: The Modern Science of Mental Health as a representation of Hubbard's concepts of "the human mind, its functions, and the problems related to these functions." Hubbard presented Dianetics as a "therapeutic technique with which can be treated all inorganic mental ills and all organic psychosomatic ills, with the assurance of complete cure in unselected cases." In this body of work, Hubbard also attested that human beings are motivated "only" by survival. According to Hubbard, the ideas in Dianetics were developed over twelve years of research, although many of his friends at the time said this claim is false. The first public outline of those ideas was an article in the pulp magazine Astounding Science Fiction, titled "Dianetics: A new science of the mind" appearing a few weeks before the publication of the book but published in the May 1950 issue of the magazine, the same month the book was published; the book-length article was later published as the book Dianetics: The Evolution of a Science. This advance publicity generated so much interest that in April 1950, Hubbard and Astounding editor John W. Campbell with other interested parties established the Hubbard Dianetic Research Foundation. Hubbard claimed to have written Dianetics in three weeks. His writing speed was assisted by a special IBM typewriter which accepted paper on a continuous roll and which had dedicated keys for common words like the or but. An early version of the book, Abnormal Dianetics, intended for the medical profession, was rejected by numerous publishers as well as the medical profession but was passed in mimeograph form from hand to hand and was later sold under the name Dianetics: The Original Thesis; the same book is published at present as The Dynamics of Life. Like other works by L. Ron Hubbard, Dianetics: The Modern Science of Mental Health has been subject to continuous editing since its inception so that at present it hardly resembles the original 1950 edition. Content According to religion scholar Dorthe Refslund Christensen, in Scientology, DMSMH represents "the most elaborate of Hubbard's presentations on the human mind, its functions, and the problems related to these functions." The opening chapter presents the context of Dianetics as human beings being preoccupied with "finding a science of the mind that could not only isolate the common denominator of life and the goal of thought" but also isolate the only source of "strange illnesses and aberrations". Hubbard claims that the two answers to the question of human misery across time and civilizations have been religion and magical practices and modern psychotherapy that includes the practice of electroshocks and brain surgeries, which according to him, have turned patients into "helpless zombies". Dianetics, he claims is the answer to this dilemma. In the section "How to Read this Book", L. Ron Hubbard suggests to read right on through. An "Important Note" appeared in later editions of the book advising the reader to understand every word read. In the book, Hubbard uses two different and contradictory definitions for the word engram. In Book One, the Goal of Man, chapter 5, summary, Hubbard states the Fundamental Axioms of Dianetics, among which is "The engram is a moment of 'unconsciousness' containing physical pain or painful emotion and all perceptions and is not available to the analytical mind as experience." Later in the text, Hubbard writes of the engram in a footnote on page 74 of Book Two, chapter two, of the 2007 edition of Dianetics: The Modern Science of Mental Health. The footnote reads: "The word engram in Dianetics is used in its severely accurate sense as a 'definite and permanent trace left by a stimulus on the protoplasm of a tissue'. It is considered as a unit group of stimuli impinged solely on the cellular being." In other words, Hubbard takes a definition previously debunked by biology and labels it Dianetics. Dianetics, in and of itself, thus presents nothing that was not already known to science in that area, while adding phenomena and functional systems that have no basis in fact. Robert Todd Carroll, writing in the Skeptic's Dictionary, characterises Hubbard's work as essentially anti-science, in that the claims made in the books are based not on peer-reviewed observation of phenomena, with its attendant blind testing, control groups etc., but rather on an a priori decision that a phenomenon exists–followed by an attempt to prove its validity. In Dianetics, to explain the abilities of a Clear, Hubbard makes use of tropes and special idioms and draws the attention away by pointing to old colloquialisms as the "mind's eye". Hubbard uses such terms as "optimum recall", "optimum individual", "What a Clear can do easily, quite a few people have, from time to time, been partially able to do in the past", "A clear uses imagination in its entirety", "Rationality, as divorced from aberration, can be studied in a Cleared person only", a Clear's intelligence is above normal, a Clear is free from all aberrations and the attributes of a Clear have never been previously included in a study of man and man's inherent abilities. After faithfully attributing all kinds of benefits to the Clear state, Hubbard finally admits "Until we obtain Clears, it remains obscure why such differences should exist" as if no Clear has ever been made or no Clear ever made it. L. Ron Hubbard was extremely apt and able in using these tropes to suit Dianetics presentation of a new reality. Through Dianetics, Hubbard claimed that most illnesses were psychosomatic and caused by engrams, including arthritis, dermatitis, allergies, asthma, coronary difficulties, eye trouble, bursitis, ulcers, sinusitis and migraine headaches. He further claimed that dianetic therapy could treat these illnesses, and also included cancer and diabetes as conditions that Dianetic research was focused on. In 1951, Consumer Report announced a one-month $500 course, based on the recently published Dianetics, open to anyone and intended to produce the Clear, the goal of Dianetic therapy. The report on "a new cult" places Dianetics beyond the scope of medical practice. According to Hubbard, the book Dianetics: The Modern Science of Mental Health follows the original line of research: A) The discovery of the dynamic principle of existence and its meaning. B) The discovery of the source of aberration: the reactive mind. C) Therapy and its application. Hubbard leaves out all the basic philosophy. Dianetics purports to reveal revolutionary discoveries about the source of psychosomatic illness, neuroses and other mental ailments, as well as an exact, infallible way of permanently curing them. Hubbard divides the human mind into an "analytic mind" which supposedly functions perfectly, and a "reactive mind" which is incapable of thinking or making distinctions. When the analytic mind is unconscious, the reactive mind physically records memories called "engrams". As a result of all stimuli it receives, the Reactive Mind is a mass of engrams, feeding the otherwise perfect Analytical Mind incorrect data. Misinterpretation of these Reactive Mind engrams by the analytical mind causes damage later in life. Actually, these engrams cause compulsions and repressions in later life. According to Hubbard, a person is affected in later life by the unconscious effects of these engrams. By a process called "Dianetic auditing", the book promises, people can achieve a superhuman state called "Clear" with superior IQ, morally pure intentions and greatly improved mental and physical health. In August 1950, Hubbard predicted that Clears would become the world's new aristocracy, although he admitted that he had not achieved the state himself. In welcoming expectancy, the Theosophist Magazine compares the Dianetic engram to the Theosophic permanent atom as these atoms receive and retransmit impressions received life after life so that as the ego descends to a new birth, the new incarnation receives the stored impressions of engrams from previous lives. As the appearance of a new science, it was not so explicitly stated in DMSMH but eventually, Hubbard would go into the exploration of past lives with Dianetics. A) The dynamic principle of existence: Survive! According to Hubbard, the basic discovery is not that man survives, but that he is solely motivated by survival. B) The single source of aberration: The Reactive Mind According to Hubbard, the Reactive Mind works solely on a stimulus-response basis and it stores not memories but engrams. In Dianetics, Hubbard mentions the post-hypnotic suggestion. This phenomenon of the post-hypnotic suggestion was described as far back as 1787. The development of Dynamic psychiatry dates back to the encounter between the physician Mesmer and the exorcist Johann Joseph Gassner. According to followers of the school of Dynamic Psychiatry, the advent of hypnotism signaled the discovery of the unconscious. At the Oak Knoll Naval Hospital, where he was being treated for ulcers, Hubbard studied hypnosis, psychological theory and other similar subjects; Hubbard was quite adept at hypnotism. According to Hubbard, it was trying to find what makes hypnotism such a wide variable that led to the discovery of the Reactive Mind. Dr. Roy Grinker and Dr. John Spiegel developed Narcosynthesis which was widely used by psychiatrists in World War II. In the book Dianetics Hubbard mentions Narcosynthesis or drug-hypnosis. However, Hubbard states that the technique of drug-hypnosis has been known for ages, both in ancient Greece and in the Orient. The technique of narcosynthesis is not used in Dianetics even though Hubbard may have been trained in it while in Naval Intelligence. A shot of sodium pentothal is administered as a truth serum. The technique is described on page 150 of the 2007 edition of Dianetics: the modern science of mental health. C) Therapy and its application The medical establishment completely rejected the new "science" for lack of experimental proof. Dianetics has never passed any scientific rigor. In 1953, Harvey Jay Fischer wrote the report Dianetic Therapy: an experimental evaluation concluding that "Dianetic does not systematically favorably or adversely influence the ability to perform" either intellectually, mathematically or resolving personality conflicts. According to Hubbard's son, DMSMH is not the result of any research whatsoever but a man's obsession with abortion and other phenomena of the unconscious, specially the occult and black magic. There is an entire chapter in DMSMH devoted to demonology. To maintain the "scientific" appearance of DMSMH, Hubbard decries the belief in demons. In DMSMH, demons are explained as electronic circuits. However, in Hubbard's later writings, entities begin to appear that possess man's physical body. These entities are spirits which Hubbard calls "thetans". What Hubbard does assert is that demonology is good business. A person is a thetan but the person's physical body is possessed by thetans called body thetans. To be spiritually free, a person would have to audit out all those other thetans in the body and that would take a great deal of time and a great deal of money. In advising the auditor to be uncommunicative, Hubbard was divorcing Dianetics from other psycho-therapies, as in psychoanalysis, where the therapist most obstinately offers a personal interpretation of what is happening in the patient's mind. Scientologist Harvey Jackins said of Dianetics therapy: "The results have been nearly uniform and positive. Apparently, the auditor (listener or therapist) can be very forthright and direct in seeking out the past traumatic experiences which are continuing to mar the rationality and well being of the person. Once located, the exhaustion of the distress and re-evaluation of the experience apparently leads uniformly to dramatic improvement in ability, emotional tone and well-being." Hubbard considered that to maintain silence around unconscious or injured persons is of the utmost importance in the prevention of aberration. After the publication of DMSMH, Hubbard moved to Cuba. There, the signs in every hospital zone are still prominently displayed: Hospital Silence. In a letter dated December 7, 1950, Ernest Hemingway's son Greg writes to his father mentioning that the publisher of Dianetics is coming down to Cuba to present Ernest with a copy in earnest. Hemingway's son's girlfriend is the publisher's daughter; Greg himself is working at the Hubbard Dianetic Research Foundation. On December 14, Hemingway answered: "The Dianetics king never sent the book so I bought one, but Miss Nita borrowed it and it is still outside of the joint. So have not been able to practice jumping back into the womb or any of those popular New York indoor sports and have to just continue to write them as I see them." According to Martin Gardner, the workability of Dianetics lies in the field of faith healing as most neurotics will react positively to something they have faith in. There is nothing extraordinary about Dianetics case histories as it is something quite common in faith healing. Finally, Hubbard gives fair warning to those who attempt to self-audit his DIY (do-it-yourself) Dianetic process. It cannot be done, says Hubbard, because every engram contains analytical attenuation. It is better to learn to audit the technique and apply it to others. Anyone engaged in self-auditing will only succeed in getting sick. However, in later developments of technique application Hubbard would develop "Solo Auditing" where auditor and preclear are one and the same except that in the procedure as always Hubbard would be obeyed to the letter. In Dianetics and Scientology, self-auditing always carries a bad connotation while solo auditing does not. As usual, Hubbard's particular use of nomenclature would win the day. Hubbard says in DMSMH that all civilizations have had two responses to the reality of human misery: first, "religion and magical practices", second, "modern psychotherapy", which according to him, "have exceeded the brutality of magic and religious practices by turning patients into helpless zombies." He also said that because man does not understand himself, he has developed "terrifying weapons", which is the reason that the earth is in war. Hubbard's response to the DSM-IV Hubbard was against the diagnosis of psychiatric disorders, saying it "is so much wasted time", since, "on the one hand, detailed diagnoses does not cure the patient and, on the other hand, the things the auditor needs to know to cure the patient will appear to him or her during auditing: the patient will talk about them." According to Christensen, Hubbard claims that there are only three things that need to be established instead of a diagnosis: "(1) Are his or her 'perceptics' over or under optimum? (2) How is the patient's ability to recall by utilizing the different perceptics? and (3) is he or she 'overusing' his or her imagination by recalling too many things or by too many perceptics?" Commentary on illness and disease Hubbard believed in the ability of Dianetics to cure illnesses, and also claimed that most pathologies had a psychosomatic origin. "Psychosomatic disorders were estimated by Hubbard to include 70 percent of all illnesses and were exemplified by asthma, arthritis, dermatitis, allergies, some coronary difficulties, eye trouble, bursitis, ulcers, sinusitis, migraine headaches etc., while mental disorders were neuroses, psychoses, compulsions, serious depressions, etc." Hubbard later stated that Dianetics had nothing to do with psychosomatic illness: "Dianetics today is a science of ability. It has no traffic with psychosomatic illness or aberration. It does not care a whit about these two things. Dianetics today can be prepared to expect out of an asylum, or off a mount, alike some benefit to mankind." Initial publication Dianetics was first published May 9, 1950, by Hermitage House, at One Madison Ave., a New York-based publisher of psychiatric textbooks whose president, Arthur Ceppos, was also on the Board of Directors of the Hubbard Dianetic Research Foundation. The book became a nationwide bestseller, selling over 150,000 copies within a year. Due to the interest generated, a multitude of "Dianetics clubs" and similar organizations were formed for the purpose of applying Dianetics techniques. Hubbard himself established a nationwide network of Dianetic Research Foundations, offering Dianetics training and processing for a fee. Dianetics blossomed into a national fad and was then denounced by psychologists. The original edition of the book included an introduction by J. A. Winter, M.D., who became the first medical director of the Hubbard Dianetic Research Foundation, an appendix on "The Philosophic Method" by Will Durant (reprinted from The Story of Philosophy, 1926), another on "The Scientific Method" by John W. Campbell and a third appendix by Donald H. Rogers. These contributions are omitted from editions of Dianetics published since about the start of the 1980s. Reception Despite its positive public reception, Dianetics was strongly criticized by scientists and medical professionals for its scientific deficiencies. The American Psychological Association passed a resolution about Dianetics in 1950 referring to "the fact that these claims are not supported by empirical evidence of the sort required for the establishment of scientific generalizations." Dianetics received very negative reviews from the majority of sources. An early review in The New Republic summed up the book as "a bold and immodest mixture of complete nonsense and perfectly reasonable common sense, taken from long-acknowledged findings and disguised and distorted by a crazy, newly invented terminology" and warned of medical risks: "it may prove fatal to have put too much trust in the promises of this dangerous book." Frederick L. Schuman, political science professor at Williams College in Williamstown, Massachusetts became an ardent follower of Dianetics and wrote indignant letters to those who reviewed Dianetics adversely including the New Republic and The New York Times. Schuman wrote a favorable article on Dianetics in the April 1951 issue of Better Homes and Gardens. Dianetics received two favourable reviews from medical doctors. Reviewing the book for Scientific American in 1951, physicist Isidor Isaac Rabi criticized the lack of either evidence or qualification, saying it "probably contains more promises and less evidence per page than has any publication since the invention of printing." An editorial in Clinical Medicine summarized the book as "a rumination of old psychological concepts, ... misunderstood and misinterpreted and at the same time adorned with the halo of the philosopher's stone and of an universal remedy", which had initiated "a new system of quackery of apparently considerable dimensions." According to Consumer Reports, the book over-extends scientific and cybernetic metaphors, and lacks the needed case reports, experimental replication and statistical data to back up its bold claims. Both Consumer Reports and Clinical Medicine also warned of the danger that the book would inspire unqualified people to harmfully intervene in others' mental problems. These warnings were echoed by psychoanalyst Erich Fromm, who contrasted the sophistication of Sigmund Freud's theories with the "oversimplified" and "propagandistic" ideas offered by Dianetics. The latter's extremely mechanistic view of the mind had no need for human values, conscience or any authority other than Hubbard himself. A similar point was made by psychologist Rollo May in The New York Times, arguing that Dianetics unwittingly illustrates the fallacy of trying to understand human nature by invariant mathematical models taken from mechanics. A review by semantics expert S. I. Hayakawa described Dianetics as fictional science, meaning that it borrows several linguistic techniques from science fiction to make fanciful claims seem plausible. Science fiction, he explained, relies on vividly conveying imaginary entities such as Martians and rayguns as though they were commonplace. Hubbard was doing this with his fantastic "discoveries", and the reviewer refers to the possibility that Hubbard might "succeed in concealing the distinction between his facts and his imaginings from himself." The review in The American Journal of Psychiatry made similar observations: "[Hubbard's] previous efforts in the realm of scientific fiction writing have subtly prepared him for that nice ignorance of reality without which he could not have developed this epic. Certain bits of internal evidence such as his insistence on the frequency of abortions, his cruel fathers, his unfaithful mothers, his blundering doctors, his arrogance toward authority, may indicate the author's own systematized paranoid delusions." Science writer Martin Gardner criticized the book's "repetitious, immature style" likening it to the grand pseudoscientific pronouncements of Wilhelm Reich. "Nothing in the book remotely resembles a scientific report", he wrote. Aleksei Shliapov, a columnist at the Russian paper Izvestia, said about Dianetics, "I think that our politicians should acquaint themselves with this book, since here is, as it were, a technology for how to become popular, how to acquire influence among the masses without having to appear a significant personality." More recently, the book has been described by Salon as "a fantastically dull, terribly written, crackpot rant", which covers a lack of credible evidence with mere insistence and The Daily Telegraph called it a "creepy bit of mind-mechanics" which would cause rather than cure depression. When Hubbard wrote the book in 1950, homosexuality was considered a pathological illness and in 1951 the DSM I listed it under Sexual Deviation which stance was reflected in passages of Dianetics where homosexuality is considered a mental illness. Besides the homosexual as sexual pervert, Hubbard also includes things such as lesbianism, sexual sadism and all the catalog of Ellis and Krafft-Ebing as being actually "quite ill physically". Karl Lashley spent decades looking for the engram which he abandoned in 1950 for non-localized memory. This was not the same type of engram described by Hubbard. However, Hubbard derived his ideas and the term "engram", from psychology sources, and biology. Richard Semon coined the term "engram" in 1904 and wrote extensively about it in 1921, decades before the publication of Dianetics. Publication history It is unclear how many editions there have been, but at least 60 printings are said to have been issued by 1988, almost all having been printed by the Church of Scientology and its related organizations. Current editions are published by Bridge Publications and New Era Publications, Scientology-owned imprints. Over twenty million copies have been sold according to the cover of the latest paperback books. The following statement is included on the copyright page of all editions: "This book is part of the works of L. Ron Hubbard, who developed Dianetics spiritual healing technology and Scientology applied religious philosophy. It is presented to the reader as a record of observations and research into the nature of mind and spirit, and not a statement of claims made by the author". According to Bridge Publications, 83 million copies of Dianetics were sold in the forty years after publication. According to Nielsen BookScan, the book has sold 52,000 copies between 2001 and 2005. The book has been very aggressively marketed, often in ways that are unusual for the book industry, for instance appearing as one of the twelve sponsors of the Goodwill Games under a $4 million agreement between Bridge Publications and Turner Broadcasting System. Bridge Publications also sponsors NASCAR racer and Scientologist Kenton Gray, who races as the "Dianetics Racing Team" and whose No. 27 Ford Taurus is decorated with Dianetics logos. Various sources allege that the book's continued sales have been manipulated by the Church of Scientology and its related organizations ordering followers to buy up new editions to boost sales figures. According to a Los Angeles Times exposé published in 1990, "sales of Hubbard's books apparently got an extra boost from Scientology followers and employees of the publishing firm [Bridge Publications]. Showing up at major book outlets like B. Dalton and Waldenbooks, they purchased armloads of Hubbard's works, according to former employees." Members are asked to contribute by placing Dianetics in public libraries. However, Dianetics was not added to the collection of the Brooklyn Public Library on the basis of a negative review. Role in Scientology Scientologists regard the publication of Dianetics: The Modern Science of Mental Health as a key historical event for their movement and the world, and refer to the book as Book One. In Scientology, years are numbered relative to the first publication of the book: 1990, for example, being "40 AD" (After Dianetics). The book is promoted as "a milestone for Man comparable to his discovery of fire and superior to his inventions of the wheel and the arch." Dianetics is still heavily promoted today by the Church of Scientology and has been advertised widely on television and in print. Indeed, it has been alleged that the Church has asked its members to purchase large quantities of the book with their own money, or with money supplied by the Church, for the sole purpose of keeping the book on the New York Times Best Seller list. Hubbard described the book as a key asset for getting people in Scientology: The Church of Scientology has been explicit about using Dianetics' sponsorship of the Goodwill Games to boost Scientology membership. The Church's internal journal for Scientologists, International Scientology News, has stated that: Cover imagery Dianetics uses the image of an exploding volcano, both on the covers of post-1967 editions, and in advertising. A giant billboard built in Sydney, Australia, measured 33 m (100 ft) wide and 10 m (30 ft) high and depicted an erupting volcano with "non-toxic smoke". Hubbard told his marketing staff that this imagery would make the books irresistible to purchasers by reactivating unconscious memories. According to Hubbard, the volcano recalls the incident in which galactic overlord Xenu placed billions of his people around Earth's volcanoes and killed them there by blowing them up with hydrogen bombs. A representative of the Church of Scientology has confirmed in court that the Dianetics volcano is indeed linked with the "catastrophe" wrought by Xenu. Bent Corydon, a former Scientology mission holder, recounted that: See also Scientology bibliography A Doctor's Report on Dianetics References Further reading Corydon, Bent. L. Ron Hubbard: Madman or Messiah?. Lyle Stuart, Inc. (1987) External links Official Dianetics website Dianetics: The Modern Science of Mental Health (official page at Bridge Publications) 1950 books Books published by the Church of Scientology English-language books Pseudoscience literature Self-help books Works by L. Ron Hubbard

Postorgasmic illness syndrome

Postorgasmic illness syndrome (POIS) is a syndrome in which human males have chronic physical and cognitive symptoms following ejaculation. The symptoms usually onset within seconds, minutes, or hours, and last for up to a week. The cause and prevalence are unknown; it is considered a rare disease. Signs and symptoms The distinguishing characteristics of POIS are: the rapid onset of symptoms after ejaculation; the presence of an overwhelming systemic reaction. POIS symptoms, which are called a "POIS attack", can include some combination of the following: cognitive dysfunction, aphasia, severe muscle pain throughout the body, severe fatigue, weakness, and flu-like or allergy-like symptoms, such as sneezing, itchy eyes, and nasal irritation. Additional symptoms include headache, dizziness, lightheadedness, extreme hunger, sensory and motor problems, intense discomfort, irritability, anxiety, gastrointestinal disturbances, craving for relief, susceptibility to nervous system stresses, depressed mood, and difficulty communicating, remembering words, reading and retaining information, concentrating, and socializing. Affected individuals may also experience intense warmth or cold. An online anonymous self-report study found that 80% of respondents always experienced the symptom cluster involving fatigue, insomnia, irritation, and concentration difficulties. The symptoms usually begin within 30 minutes of ejaculation, and can last for several days, sometimes up to a week. In some cases, symptoms may be delayed by 2 to 3 days or may last up to 2 weeks. In some men, the onset of POIS is in puberty, while in others, the onset is later in life. POIS that is manifest from the first ejaculations in adolescence is called primary type; POIS that starts later in life is called secondary type. Many individuals with POIS report lifelong premature ejaculation, with intravaginal ejaculation latency time (IELT) of less than one minute. The 7 clusters of symptoms of criterion 1: General: Extreme fatigue, exhaustion, palpitations, problems finding words, incoherent speech, dysarthria, concentration difficulties, quickly irritated, cannot stand noise, photophobia, depressed mood Flu-like: Feverish, extreme warmth, perspiration, shivery, ill with flu, feeling sick, feeling cold Head: Headache, foggy feeling in the head, heavy feeling in the head Eyes: Burning, red injected eyes, blurred vision, watery, irritating, itching eyes, painful eyes Nose: Congested nose, watery/runny nose, sneezing Throat: Dirty taste in mouth, dry mouth, sore throat, tickling cough, hoarse voice Muscle: Muscle tension behind neck, muscle weakness, pain in muscles, heavy legs, stiff muscles Synonyms and related conditions POIS has been called by a number of other names, including "postejaculatory syndrome", "postorgasm illness syndrome", "post ejaculation sickness", and "post orgasmic sick syndrome". Dhat syndrome is a condition , N. N. Wig first coined the term and described in 1960 in India, with symptoms similar to POIS. Dhat syndrome is thought to be a culture-bound psychiatric condition and is treated with cognitive behavioral therapy along with anti-anxiety and antidepressant drugs. Post-coital tristesse (PCT) is a feeling of melancholy and anxiety after sexual intercourse that lasts anywhere from five minutes to two hours. PCT, which affects both men and women, occurs only after sexual intercourse and does not require an orgasm to occur, and in that its effects are primarily emotional rather than physiological. By contrast, POIS affects only men, consists primarily of physiological symptoms that are triggered by ejaculation and that can last, in some people, for up to a week. While PCT and POIS are distinct conditions, some doctors speculate that they could be related. An array of more subtle and lingering symptoms after orgasm, which do not constitute POIS, may contribute to habituation between mates. They may show up as restlessness, irritability, increased sexual frustration, apathy, sluggishness, neediness, dissatisfaction with a mate, or weepiness over the days or weeks after intense sexual stimulation. Such phenomena may be part of human mating physiology itself. Sexual headache is a distinct condition characterized by headaches that usually begin before or during orgasm. Mechanism The cause of POIS is unknown. Some doctors hypothesize that POIS is caused by an auto-immune reaction. Other doctors suspect a hormone imbalance as the cause. Different causes have also been proposed. None of the proposed causes can fully explain the disease. Allergy hypothesis According to one hypothesis, "POIS is caused by Type-I and Type-IV allergy to the males' own semen". This was conditioned by another study stating "IgE-mediated semen allergy in men may not be the potential mechanism of POIS". Alternatively, POIS could be caused by an auto-immune reaction not to semen, but to a different substance released during ejaculation, such as cytokines. Hormone hypothesis According to another hypothesis, POIS is caused by a hormone imbalance, such as low progesterone, low cortisol, low testosterone, elevated prolactin, hypothyroidism, or low DHEA. POIS could be caused by a defect in neurosteroid precursor synthesis. If so, the same treatment may not be effective for all individuals. Different individuals could have different missing precursors leading to a deficiency of the same neurosteroid, causing similar symptoms. Withdrawal hypothesis The majority of POIS symptoms like fatigue, muscle pains, sweating, mood disturbances, irritability, and poor concentration are also caused by withdrawal from different drug classes and natural reinforcers. It is unknown whether there is a relationship between hypersexuality, pornography addiction, compulsive sexual behavior and POIS. Some evidence indicates that POIS patients have a history of excessive masturbation, suggesting that POIS could be a consequence of sex addiction. There is anecdotal evidence on porn addiction internet forums, that many men experience POIS like symptoms after ejaculation. Other possibilities POIS could be caused by hyperglycemia or by chemical imbalances in the brain. Sexual activity for the first time may set the stage for an associated asthma attack or may aggravate pre-existing asthma. Intense emotional stimuli during sexual intercourse can lead to autonomic imbalance with parasympathetic over-reactivity, releasing mast cell mediators that can provoke postcoital asthma and / or rhinitis in these patients. It is also possible that the causes of POIS are different in different individuals. POIS could represent "a spectrum of syndromes of differing" causes. None of the proposed causes for POIS can fully explain the connection between POIS and lifelong premature ejaculation. Diagnosis There is no generally agreed upon diagnostic criteria for POIS. One group has developed five preliminary criteria for diagnosing POIS. These are: one or more of the following symptoms: sensation of a flu-like state, extreme fatigue or exhaustion, weakness of musculature, experiences of feverishness or perspiration, mood disturbances and / or irritability, memory difficulties, concentration problems, incoherent speech, congestion of nose or watery nose, itching eyes; all symptoms occur immediately (e.g., seconds), soon (e.g., minutes), or within a few hours after ejaculation that is initiated by coitus, and / or masturbation, and / or spontaneously (e.g., during sleep); symptoms occur always or nearly always, e.g., in more than 90% of ejaculation events; most of these symptoms last for about 2–7 days; and disappear spontaneously. POIS is prone to being erroneously ascribed to psychological factors such as hypochondriasis or somatic symptom disorder. An online survey study suggested that only a small number of self-reported POIS fulfill entirely the five criteria. This study proposed to change the Criterion 3 with “In at least one ejaculatory setting (sex, masturbation, or nocturnal emission), symptoms occur after all or almost all ejaculations.” Management There is no standard method of treating or managing POIS. Patients need to be thoroughly examined in an attempt to find the causes of their POIS symptoms, which are often difficult to determine, and which vary across patients. Once a cause is hypothesized, an appropriate treatment can be attempted. At times, more than one treatment is attempted, until one that works is found. Affected individuals typically avoid sexual activity, especially ejaculation, or schedule it for times when they can rest and recover for several days afterwards. In case post-coital tristesse (PCT) is suspected, patients could be treated with selective serotonin reuptake inhibitors. In one patient, the POIS symptoms were so severe, that he decided to undergo removal of the testicles, prostate, and seminal vesicles in order to relieve them. The POIS symptoms were cured by this. Another patient, in whom POIS was suspected to be caused by cytokine release, was successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs) just prior to and for a day or two after ejaculation. The patient took diclofenac 75 mg 1 to 2 hours prior to sexual activity with orgasm, and continued twice daily for 24 to 48 hours. One POIS patient with erectile dysfunction and premature ejaculation had much lower severity of symptoms on those occasions when he was able to maintain penile erection long enough to achieve vaginal penetration and ejaculate inside his partner. The patient took tadalafil to treat his erectile dysfunction and premature ejaculation. This increased the number of occasions on which he was able to ejaculate inside his partner, and decreased the number of occasions on which he experienced POIS symptoms. This patient is thought to have Dhat syndrome rather than true POIS. Two patients, in whom POIS was suspected to be caused by auto-immune reaction to their own semen, were successfully treated by allergen immunotherapy with their own autologous semen. They were given multiple subcutaneous injections of their own semen for three years. Treatment with autologous semen "might take 3 to 5 years before any clinically relevant symptom reduction would become manifest". Treatments are not always successful, especially when the cause of POIS in a particular patient has not been determined. In one patient, all of whose routine laboratory tests were normal, the following were attempted, all without success: ibuprofen, 400 mg on demand; tramadol 50 mg one hour pre-coitally; and escitalopram 10 mg daily at bedtime for 3 months. Epidemiology The prevalence of POIS is unknown. POIS is listed as a rare disease by the American National Institutes of Health and the European Orphanet. It is thought to be underdiagnosed and underreported. POIS seems to affect mostly men from around the world, of various ages and relationship statuses. Women It is possible that a similar disease exists in women, though, as of 2016, there is only one documented female patient. References External links Sexual health Rare syndromes Orgasm Ejaculation Urology Autoimmune diseases

Alcohol dependence

Alcohol dependence is a previous (DSM-IV and ICD-10) psychiatric diagnosis in which an individual is physically or psychologically dependent upon alcohol (also chemically known as ethanol). In 2013, it was reclassified as alcohol use disorder in DSM-5, which combined alcohol dependence and alcohol abuse into this diagnosis. Definition Diagnosis DSM: Alcohol dependence According to the DSM-IV criteria for alcohol dependence, at least three out of seven of the following criteria must be manifest during a 12-month period: Tolerance Withdrawal symptoms or clinically defined alcohol withdrawal syndrome Use in larger amounts or for longer periods than intended Persistent desire or unsuccessful efforts to cut down on alcohol use Time is spent obtaining alcohol or recovering from effects Social, occupational and recreational pursuits are given up or reduced because of alcohol use Use is continued despite knowledge of alcohol-related harm (physical or psychological) Other alcohol-related disorders Because only 3 of the 7 DSM-IV criteria for alcohol dependence are required, not all patients meet the same criteria and therefore not all have the same symptoms and problems related to drinking. Not everyone with alcohol dependence, therefore, experiences physiological dependence. Alcohol dependence is differentiated from alcohol abuse by the presence of symptoms such as tolerance and withdrawal. Both alcohol dependence and alcohol abuse are sometimes referred to by the less specific term alcoholism. However, many definitions of alcoholism exist, and only some are compatible with alcohol abuse. There are two major differences between alcohol dependence and alcoholism as generally accepted by the medical community. Alcohol dependence refers to an entity in which only alcohol is the involved addictive agent. Alcoholism refers to an entity in which alcohol or any cross-tolerant addictive agent is involved. In alcohol dependence, reduction of alcohol, as defined within DSM-IV, can be attained by learning to control the use of alcohol. That is, a client can be offered a social learning approach that helps them to 'cope' with external pressures by re-learning their pattern of drinking alcohol. In alcoholism, patients are generally not presumed to be 'in remission' unless they are abstinent from alcohol. The following elements are the template for which the degree of dependence is judged: Narrowing of the drinking repertoire. Increased salience of the need for alcohol over competing needs and responsibilities. An acquired tolerance to alcohol. Withdrawal symptoms. Relief or avoidance of withdrawal symptoms by further drinking. Subjective awareness of compulsion to drink. Reinstatement after abstinence. Screening AUDIT has replaced older screening tools such as CAGE but there are many shorter alcohol screening tools, mostly derived from the AUDIT. The Severity of Alcohol Dependence Questionnaire (SAD-Q) is a more specific twenty-item inventory for assessing the presence and severity of alcohol dependence. AUDIT The Alcohol Use Disorders Identification Test (AUDIT) is considered the most accurate alcohol screening tool for identifying potential alcohol misuse, including dependence. It was developed by the World Health Organization, designed initially for use in primary healthcare settings with supporting guidance. CAGE The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used method of screening for alcohol dependence. Online version of the CAGE questionnaire SADQ The Severity of Alcohol Dependence Questionnaire (SADQ or SAD-Q) is a 20 item clinical screening tool designed to measure the presence and level of alcohol dependence. Withdrawal Withdrawals from alcohol dependence is a common side effect that occurs when a person with the dependency stops drinking abruptly or even cuts back on their drinking after a prolonged period of indulgence. Withdrawal from alcohol dependence can vary from mild, moderate to severe, depending on several factors such as: how long the person has been drinking, whether they are a binge drinker, whether they relapse chronically, and how much they drink daily. All these factors can vary from one person to the next depending on psychological, environmental, and biological factors. Some common withdrawal side effects are as listed: Mild Nausea Vomiting Rapid heartbeat Elevated blood pressure Fatigue Body aches / tremors Anxiety / Irritability / Depression Fuzzy brain Issues with sleeping Severe Vomiting Hypertensive crisis Seizures / Tremors Delusions / Hallucinations Dehydration Fever Chills / Shakes Extreme mood lability Mental pandemonium Little to no appetite The spectrum of alcohol withdrawal symptoms range from such minor symptoms as insomnia and tremulousness to severe complications such as withdrawal seizures and delirium tremens. Alcohol withdrawal syndrome can be very tricky to diagnose, due to other preliminary conditions that may exist from individual to individual. Treatment Treatments for alcohol dependence can be separated into two groups, those directed towards severely alcohol-dependent people, and those focused for those at risk of becoming dependent on alcohol. Treatment for alcohol dependence often involves utilizing relapse prevention, support groups, psychotherapy, and setting short-term goals. The Twelve-Step Program is also a popular faith-based process used by those wishing to recover from alcohol dependence. The ultimate goal when it comes to treating alcohol dependence or as the DSM-5 now calls it alcohol use disorder, is to help with establishing abstinence from drinking. There are several other benefits that come along with treatment. For some, it is reconnecting with themselves and obtaining self-esteem and confidence, a healthier lifestyle (physically and mentally), creating new relationships with other like-minded people as well as rekindling or mending old relationships if possible. The treatment process consists typically of two parts short-term and long-term. First, there is the path to abstinence and/or recovery. There are several reasons why someone with alcohol use disorder or alcohol dependency would seek treatment. This can either be a personal reason or because of law enforcement. There is a series of different levels of treatment processes depending on the severity subtype. Some would or could benefit from medication treatment with psychosocial treatment, while others could just benefit from psychosocial treatment. Listed below are some different types of treatments that are used with treating alcohol dependency/alcohol use disorder depending on several factors that vary from person to person. Types of treatments: Withdrawals (no medication aid needed) Withdrawals (depending on severity of symptoms, could be accompanied with supervision by medical personal and medication) Psychosocial treatment (counseling, CBT, psychoeducation, assertive community treatment) Alcoholics Anonymous Inpatient or outpatient programs Social services (case management) Al-Anon/Alateen Acceptance and mindfulness-based interventions Acceptance and mindfulness-based interventions show evidence of efficacy in being used to target Alcohol Use Disorder. These types of interventions are often most effectively delivered in group settings, however, they are also proven effective in individual therapy contexts. Overall, this is crucial in helping individuals who are dependent on alcohol because it raises awareness, provides a non-judgemental environment for people to express their thoughts, and allows individuals to be heard and accepted in the present moment. Epidemiology About 12% of American adults have had an alcohol dependence problem at some time in their life. In the UK the NHS estimates that around 9% of men and 4% of UK women show signs of alcohol dependence. Genetic factors A 2015 study found that alcohol dependency may have genetic risk factors. Linkage disequilibrium between an AD-associated GABA receptor gene cluster, GABRB3/GABRG3, and eye color genes, OCA2/HERC2, as well as between AD-associated GRM5 and pigmentation-associated TYR, were all associated with alcohol dependency. GABA downregulation may decrease sensitivity to the toxic effects of alcohol, leading to increased alcohol consumption in blue-eyed individuals. History The term 'alcohol dependence' has replaced 'alcoholism' as a term in order that individuals do not internalize the idea of cure and disease, but can approach alcohol as a chemical they may depend upon to cope with outside pressures. The contemporary definition of alcohol dependence is still based upon early research. There has been considerable scientific effort over the past several decades to identify and understand the core features of alcohol dependence. This work began in 1976, when the British psychiatrist Griffith Edwards and his American colleague Milton M. Gross collaborated to produce a formulation of what had previously been understood as 'alcoholism' – the alcohol dependence syndrome. The alcohol dependence syndrome was seen as a cluster of seven elements that concur. It was argued that not all elements may be present in every case, but the picture is sufficiently regular and coherent to permit clinical recognition. The syndrome was also considered to exist in degrees of severity rather than as a categorical absolute. Thus, the proper question is not 'whether a person is dependent on alcohol', but 'how far along the path of dependence has a person progressed'. See also Alcohol intoxication Alcoholic drink Alcohol-related dementia CRAFFT Screening Test Disulfiram-like drug High-functioning alcoholic Long-term effects of alcohol consumption Paddington alcohol test Notes External links Arnold Little, MD Alcohol Dependence – extensive article SADD – Short Alcohol Dependence Data Questionnaire . A brief, self-administered questionnaire sometimes utilised in individual or group treatments. R.R.Garifullin Using coding therapy to treat alcohol and drug addiction. Manipulations in psychotherapy. Rostov-on-Don, Feniks, 251 p. 2004. 251 p. Drinking culture Alcohol abuse Substance dependence

Factitious disorder

A factitious disorder is a mental disorder in which a person, without a malingering motive, acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms, purely to attain (for themselves or for another) a patient's role. People with a factitious disorder may produce symptoms by contaminating urine samples, taking hallucinogens, injecting fecal material to produce abscesses, and similar behaviour. The word factitious derives from the Latin word factītius, meaning "human-made". Factitious disorder imposed on self (also called Munchausen syndrome) was for some time the umbrella term for all such disorders. Factitious disorder imposed on another (also called Munchausen syndrome by proxy, Munchausen by proxy, or factitious disorder by proxy) is a condition in which a person deliberately produces, feigns, or exaggerates the symptoms of someone in their care. In either case, the perpetrator's motive is to perpetrate factitious disorders, either as a patient or by proxy as a caregiver, in order to attain (for themselves or for another) a patient's role. Malingering differs fundamentally from factitious disorders in that the malingerer simulates illness intending to obtain a material benefit or avoid an obligation or responsibility. Somatic symptom disorders, though also diagnoses of exclusion, are characterized by physical complaints that are not produced intentionally. Etiology What causes factitious disorder is not well understood, however there is a handful of possible motives that drive this pattern of behavior. Individuals may experience a heightened thrill from medical procedures, a desire for attention and care, or feelings of control or accomplishment when deceiving medical professionals. They may partake in this behavior in order to seek and maintain relationships or use the sick-patient role as a coping strategy in response to stressful life events. If an individual did not form a healthy attachment to a caregiver as a child, there is a possibility that the person may develop factitious disorder in order to fulfill the need of receiving care. Attention from medical professionals may act as a replacement in satisfying important needs that the person never received as a child. Individuals may also use invasive or painful tests or procedures as a way to punish oneself for past mistakes or to cope with guilt associated with abuse. This is considered masochistic behavior. Individuals diagnosed with this disorder are more likely to have a history of emotional or physical abuse, neglect, and/or turbulent childhoods. This upbringing can cause an unstable sense of identity and low self-esteem. Abuse may prompt a feeling of lack of control, and the person may use faked symptoms and a fabricated medical history to gain back a sense of autonomy. Those with factitious disorder are also more likely to have experienced a severe illness in childhood, with the early exposure to healthcare being a major contributor to the onset of the disorder. There is a significant correlation found between the comorbidity of factitious disorder and personality disorders, specifically borderline personality disorder. Depressive disorders are also often diagnosed concurrently with factitious disorder. The causality cannot be known about whether one disorder causes the other, but it can be deduced that these diagnoses share similar etiologies and some overlapping symptoms. Each particular case of factitious disorder presents itself differently and is derived from various etiologies. However, there is an overarching belief that patients experience the uncontrollable urge to maintain the sick-patient role, acting as a type of behavioral addiction. This contributes to the prolonged behaviors associated with the disorder. Diagnosis Criteria for diagnosis include intentionally fabricating to produce physical or psychological signs or symptoms and the absence of any other mental disorder. Motivation for their behavior must be to assume the "sick" role, and they do not act sick for personal gain as in the case of malingering sentiments. When the individual applies this pretended sickness to a dependent, for example, a child, it is often referred to as "factitious disorder by proxy". The DSM-5 differentiates among two types: Factitious disorder imposed on self (Munchausen syndrome) Factitious disorder imposed on another (Munchausen syndrome by proxy), defined as: When an individual falsifies illness in another, whether that be a child, pet, or older adult. Factitious disorder imposed on self Factitious disorder imposed on self, previously called Munchausen syndrome, or factitious disorder with predominantly physical signs and symptoms, has specified symptoms. Factitious disorder symptoms may seem exaggerated; individuals undergo major surgery repeatedly, and they "hospital jump" or migrate to avoid detection. Factitious disorder imposed on another Factitious disorder imposed on another, previously Munchausen syndrome by proxy, is the involuntary use of another individual to play the patient role. This disorder is relatively rare. False symptoms have been produced in children by perpetrator caregivers or parents. Less frequently they are produced in one adult by another adult. The disorder produces the "appearance" of illness, which "appearance" may be augmented by the perpetrator by providing an intentionally misleading medical history, or even by tampering with laboratory tests to make the targeted individual appear sick. Occasionally in cases of this disorder, caregivers have been known to actually injure a child or to medically harm another adult in order to ensure that the targeted individual is medically treated. For instance, a mother whose son has celiac disease might knowingly introduce gluten into the son's diet. Such parents may be validated by the attention that they receive from having a sick child. When the disorder occurs between adults, a perpetrator may gain sympathy for their supposedly "heroic efforts" to care for the other targeted adult. For example a wife has been found to have induced a "manufactured" illness in her husband via the surreptitious injection of a harmful substance into her husband. Ganser syndrome Ganser syndrome was once considered a separate factitious disorder, but is now considered a dissociative disorder. It is a disorder of extreme stress or an organic condition. The patient experiences approximation or giving absurd answers to simple questions. The syndrome is sometimes diagnosed as merely malingering—however, it is more often defined as a factitious disorder. This has been seen in prisoners following solitary confinement, and the symptoms are consistent in different prisons, though the patients do not know one another. Symptoms include a clouding of consciousness, somatic conversion symptoms, confusion, stress, loss of personal identity, echolalia, and echopraxia. Individuals also give approximate answers to simple questions such as, "How many legs on a cat?" "Three"; "What's the day after Wednesday?" "Friday"; and so on. The disorder is extraordinarily rare with fewer than 100 recorded cases. While individuals of all backgrounds have been reported with the disorder, there is a higher inclination towards males (75% or more). The average age of those with Ganser syndrome is 32, though it stretches from ages 15–62 years old. Differential diagnosis Factitious disorder should be distinguished from somatic symptom disorder (formerly called somatization disorder), in which the patient is truly experiencing the symptoms and has no intention to deceive. In conversion disorder (previously called hysteria), a neurological deficit appears with no organic cause. The patient, again, is truly experiencing the symptoms and signs and has no intention to deceive. The differential also includes body dysmorphic disorder and pain disorder. Treatment No true psychiatric medications are prescribed for factitious disorder. However, selective serotonin reuptake inhibitors (SSRIs) can help manage underlying problems. Medicines such as SSRIs that are used to treat mood disorders can be used to treat factitious disorder, as a mood disorder may be the underlying cause of factitious disorder. Some authors (such as Prior and Gordon 1997) also report good responses to antipsychotic drugs such as Pimozide. Family therapy can also help. In such therapy, families are helped to better understand patients (the individual in the family with factitious disorder) and that person's need for attention. In this therapeutic setting, the family is urged not to condone or reward the factitious disorder individual's behavior. This form of treatment can be unsuccessful if the family is uncooperative or displays signs of denial and/or antisocial disorder. Psychotherapy is another method used to treat the disorder. These sessions should focus on the psychiatrist's establishing and maintaining a relationship with the patient. Such a relationship may help to contain symptoms of factitious disorder. Monitoring is also a form that may be indicated for the factitious disorder patient's own good; factitious disorder (especially proxy) can be detrimental to an individual's health—if they are, in fact, causing true physiological illnesses. Even faked illnesses and injuries can be dangerous and might be monitored for fear that unnecessary surgery may subsequently be performed. Prognosis Some individuals experience only a few outbreaks of the disorder. However, in most cases, factitious disorder is a chronic long-term condition that is difficult to treat. There are relatively few positive outcomes for this disorder; in fact, treatment provided a lower percentage of positive outcomes than did the treatment of individuals with obvious psychotic symptoms such as people with schizophrenia. In addition, many individuals with factitious disorder do not present for treatment, often insisting their symptoms are genuine. Some degree of recovery, however, is possible. The passage of time seems to help the disorder greatly. There are many possible explanations for this occurrence, although none are currently considered definitive. It may be that a factitious disorder individual has mastered the art of feigning sickness over so many years of practice that the disorder can no longer be discerned. Another hypothesis is that many times a factitious disorder individual is placed in a home, or experiences health issues that are not self-induced or feigned. In this way, the problem with obtaining the "patient" status is resolved because symptoms arise without any effort on the part of the individual. History Previously, the DSM-IV differentiated among three types: Factitious disorders with predominantly psychological signs and symptoms: if psychological signs and symptoms predominate in the clinical presentation Factitious disorders with predominantly physical signs and symptoms: if physical signs and symptoms predominate in the clinical presentation Factitious disorders with combined psychological and physical signs and symptoms: if both psychological and physical signs and symptoms are present and neither predominates in the clinical presentation See also Attention seeking Somatic symptom disorder Victim playing Hypochondriasis References External links