Troubled Minds: understanding and treating mental illness

By Sidney Bloch and Nick Haslam

An authoritative resource for understanding the nature of mental illnesses and for pointing the way to treatment, written by two eminent mental health professionals with almost a century of academic achievement and clinical experience between them.

Many of us take our mental health for granted. But we can feel overwhelmed when confronted by mental illness in ourselves, a family member, or a friend. Troubled Minds is an invaluable guide for anyone whose life has been touched by mental ill-health and who wants to understand and deal effectively with it.

It serves as an ideal introduction to common mental illnesses, developmental disorders, and neurological variations that can lead to distress such as autism, anorexia nervosa, anxiety, depression, alcoholism, post-traumatic stress disorder, and dementia. Innovative chapters cover mental health problems of children and adolescents, and how we have the potential to promote our own mental health and wellbeing.

Bloch and Haslam tell illuminating stories of people they have treated, discuss public figures who have wrestled with mental ill-health, and share their personal experiences. Their book is informed by the latest research, warmed by lived experience and empathy, and seasoned by the insights of philosophers, writers, and artists.

Troubled Minds is essential reading for anyone who seeks deeper psychological insights to help deal with the challenges of contemporary life. It is a balanced and accessible account of a subject that is of profound significance in everyone’s life.

• Language: English
• Publisher: Scribe Publications
• Release date: Aug 29, 2023
• ISBN: 9781761385421

Sidney Bloch

Sidney Bloch AM is emeritus professor in the Department of Psychiatry at the University of Melbourne. His 14 books, many of which have been translated, deal with the psychotherapies, the interface between psychology and cancer, and medical ethics.

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TROUBLED MINDS

Sidney Bloch is Emeritus Professor in Psychiatry at the University of Melbourne. He became a Member of the Order of Australia (AM) in 2016 for significant service to psychiatry and to medical education as an academic and author. His 14 books, many of which have been translated, deal with the psychotherapies, the interface between psychology and cancer, and medical ethics. Several have been published in revised editions. Psychiatric Ethics, for example, has been through five editions since it was launched in 1981. His first book, Russia’s Political Hospitals, won the prestigious Guttmacher Award of the American Psychiatric Association in 1978, and An Anthology of Psychiatric Ethics was recognised with a ‘commendation prize’ from the British Medical Association in 2007. His first book on mental health for the general reader, Understanding Troubled Minds, was recognised by SANE, a leading mental health advocacy organisation, as its Book of the Year in 2012. Sidney was Associate Editor of The British Journal of Psychiatry for over a decade and Editor-in-Chief of the Australian and New Zealand Journal of Psychiatry for a record 13 years.

Nick Haslam is Professor of Psychology at the University of Melbourne. He trained as a clinical psychologist in the US and has taught social and personality psychology for over 25 years. Nick has written extensively on mental health stigma, classification of mental illnesses, and dysfunctional personalities, and is the author or editor of nine books, including Introduction to Personality and Intelligence and Psychology in the Bathroom. He contributes regularly to The Conversation, Inside Story, and Australian Book Review, and has also written for Time, The Monthly, The Guardian, The Washington Post, and two Best Australian Science Writing anthologies. He has been Head of the School of Psychological Sciences at the University of Melbourne, where he co-directs the Mental Health PhD Program.

Scribe Publications

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Published by Scribe 2023

Copyright © Sidney Bloch and Nick Haslam 2023

All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the publishers of this book.

The moral rights of the authors have been asserted.

Cartoons © Michael Leunig. Used with kind permission.

Photographs are of works in the public domain, provided by the Wellcome Collection and Wikimedia Commons.

The advice in this book is not intended to replace the services of trained health professionals or be a substitute for medical advice. You are advised to consult with your health care professional with regard to matters relating to your health, and in particular regarding matters that may require diagnosis or medical attention. Names have been changed, identifying details and backgrounds have been altered, and stories combined out of respect for the privacy of individuals and couples.

Scribe acknowledges Australia’s First Nations peoples as the traditional owners and custodians of this country, and we pay our respects to their elders, past and present.

978 1 922585 87 5 (paperback edition)

978 1 761385 42 1 (ebook)

A catalogue record for this book is available from the National Library of Australia.

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Contents

Preface

1 Setting the scene

Great and desperate cures · The advent of psychological therapies · Defining and classifying mental illness · Why is classification necessary? · The core groups of mental illnesses · How classification is used · The contemporary scene

2 Stress, trauma, and anxiety

Stress and coping · Adjustment disorders · Anxiety disorders · What causes anxiety disorders? · Generalised anxiety disorder (GAD) · Panic disorder · Phobic disorders · Obsessive-compulsive disorder (OCD) · Post-traumatic stress disorder (PTSD) · Acute stress reaction · Treating anxiety disorders

3 The highs and lows of mood

How do we recognise clinical depression? · Mania — the other side of the coin · Why does our mood become troubled? · Psychological and social factors · How do we integrate the possible causes of the highs and lows of mood? · Treating depression · Treating mania · Treating bipolar disorder

4 The mind talking through the body

The mind in the body · Why the mysterious leap from mind to body? · Who is likely to express emotional distress through their body? · How do we approach the mind talking through the body? · Conversion disorder · Somatic symptom disorder (SSD) · Illness anxiety disorder (IAD) · Body dysmorphic disorder (BDD) · Factitious disorder and malingering · Treating both body and mind

5 Eating disorders

Anorexia nervosa · Treating anorexia nervosa · Bulimia nervosa · Binge-eating disorder (BED) · Avoidant/restrictive food-intake disorder (ARFID)

6 Personality and its variations

Types of personality disorder · How common are personality disorders? · What leads to personality disorders? · Approaches to identifying personality disorders · Specific personality disorders · Treating personality disorders

7 Schizophrenia and other psychoses

Schizophrenia · What causes schizophrenia? · Treating schizophrenia · Psychosis and mood disorders · Reactive psychosis · Delusional disorder · Drug-induced psychosis

8 Substance use

What is problematic substance use? · What causes problematic substance use? · The cycle of substance use · Likely outcomes · Seeking help · Treating substance use · Different forms of substance use

9 Suicide

Defining suicide and related behaviours · How common is suicide? · What leads to suicide? · Suicide and mental illness · How do we try to help? · Prevention at the general population level · Deliberate self-harm (DSH) · Treating and preventing DSH

10 Mental ill-health in children and adolescents

The role of childhood development · Development and clinical problems · The approach of mental health professionals in working with children · Diagnosing and categorising clinical problems in childhood and adolescence · Problems in infancy and early childhood (0–5 years) · Problems of primary-school children (6–12 years) · Problems of adolescence (13–18 years) · Maltreatment in childhood and adolescence · Preventing mental ill-health in children and adolescents

11 Mental ill-health in women

The menstrual cycle · Motherhood · Pregnancy loss and infertility · Menopause · The older woman · The abused woman

12 Mental ill-health in the elderly

The role of the mental health professional · The dementias · How are patients affected? · Dementia through the eyes of the carer · Treating dementia · Caring for the carer · Other mental illnesses encountered in the elderly · Abuse of the elderly

13 The biological therapies

Drugs used to treat the mentally ill · The role of the pharmacist · Brain-stimulation therapies

14 The psychotherapies

The core features of psychotherapy · Therapies for specific goals · Therapies by approach · Therapies for two or more people · Counselling and psychotherapy — how do they differ?

15 Promoting our mental health

General principles and strategies to promote mental health · Grappling with life’s stresses · Ways of relaxing · Cultivating a sense of self · The family and mental health · Friends and mental health · Work and mental health · When things go awry · Detecting change early · When vulnerability persists · When mental ill-health becomes long-term · Family and friends as carers · A concluding note on hope and reality

Acknowledgements

Preface

Many of us take our mental health for granted, but anyone can feel overwhelmed, even devastated, when confronted by mental illness in ourselves, a family member, or a friend. The figures are astonishing. Even when using rigorous criteria, surveys consistently find that one in five people have suffered from a mental disorder such as anxiety, depression, traumatic stress, anorexia nervosa, or substance abuse during the previous 12 months. Moreover, a quarter of them have more than one psychological condition.

Although we may sense a compelling need to seek professional help, we may be ambivalent about taking this step — a sizeable proportion do not — out of a concern that we will be labelled as inadequate and that we should have the resources to cope. A pervasive feeling of stigma, with its associated discrimination and stereotyping in even the most informed society, is another potent factor in concealing what we are experiencing. Erroneous beliefs and distorted knowledge about afflictions of the mind, derived in large measure from their inaccurate portrayal in film, literature, the graphic arts, and the media still contribute to the perpetuation of shame.

This appalling situation has dogged mental health professionals for years despite their unceasing effort to influence those amenable to treatment. After working in the sphere of mental health as both practitioners and academics, we (Sidney and Nick) felt that our patients, their families, and the community as whole would benefit from the availability of a reader-friendly, well-informed, objective account of the range of mental illnesses that can befall us all as well as scientifically validated interventions to treat them. Further, we were convinced that the text should be based on a mutually respectful partnership between patient and clinician.

We searched conscientiously for a book of this kind. What we found instead were literally hundreds of texts (usually referred to as self-help books) written by either people who have developed a keen interest in a sphere of mental ill-health (in many cases derived from their own personal experience) or by professionals in the field who have addressed the subject in their own distinctive way, often to the extent of riding a hobby horse. Given our clinical work with patients, our training of a host of younger colleagues, and our involvement in research studies — experience amounting to a total of almost 80 years between us — we surmise that this sort of literature has the unintended risk of raising patients’ expectations by promising them too much and then leaving them disappointed, even disillusioned. We have been particularly sceptical of books that include in their title How to … for instance … Live Fulfilling Lives, Deal Effectively with Stress, Feel Happy, or Develop Intimate Relationships. If only it were that straightforward. Alas, people with troubled minds do not respond to ‘quick fixes’. (Neither, for that matter, do a huge proportion of patients with such physical conditions as diabetes, asthma, heart disease, and arthritis.)

Acknowledging the complexity of human nature and its aberrations comprising biological, emotional, social, and cultural dimensions, we have opted to meet the challenge afresh, by describing the quintessential features of mental illness and its treatment with the overriding caveat that we keep our own biases in check and prepare as honest, accurate, and up-to-date an account of the subject as possible. Furthermore, we will not promise ready-made solutions, but offer clear pathways to enable you to understand the nature of various disorders and of their treatment with the seriousness the process warrants. On the other hand, we do not hesitate to highlight any progress that has been made.

You may be puzzled why we have selected the phrase troubled minds for the book’s title. The terms remind us of the blurred boundary between our reactions to the vicissitudes of life to which we are all exposed and the more serious repercussions of diagnosable psychiatric conditions. The distinction between mental health and mental illness is not a matter for easy definition and, by its nature, cannot be so, because we still lack objective tests for virtually all the disorders we treat. We wrestle with this vital matter in the very first chapter when attempting to delineate conditions that are beyond ordinary day-to-day stresses and strains and require professional attention.

We have also struggled to find the right word in the subtitle to reflect one of principal features of the clinical encounter. The term we have settled on, understanding, appeals to us, since it is crucial, firstly, to understand that the level of emotional distress and the inability to function in mental illness are more severe than the usual responses to the demands of life and thus require expert help, and secondly, to understand the rationale for the treatment that mental health professionals recommend.

When we use the term understanding, we are referring to two complementary processes — emotional and intellectual. The first enables us to identify with our internal psychological world, principally through getting in touch with our feelings; the second refers to making sense of the nature of our troubled mental state.

A parallel approach to this distinction is to highlight the role of the humanities alongside that of the sciences. The main pursuit in the scientific domain is the study of the brain, involving disciplines such as neuro-genetics, neuro-imaging, neurobiology, bioengineering, and psychopharmacology. We have learned more about how the brain functions since the 1960s than in all preceding centuries thanks to the development of sophisticated technology and advances in research methodology (as you will note throughout the book). Psychology and social sciences have also contributed impressively to new knowledge. Although there is still a long way to go when it comes to identifying the causes of most mental illnesses, we are certainly on the right track and can feel optimistic about future progress.

Yet the humanities remain an important source of understanding mental illness. Thus, Shakespeare’s penetrating insights into the vicissitudes of ageing in King Lear; Edvard Munch’s painting The Scream, which he describes as the depiction of a psychotic mind; the Book of Job on the nature of suffering; Leo Tolstoy’s perceptiveness of the spiritual dimension of human beings in his essays and novels; Franz Schubert’s grief-laden song cycle Winterreise; and the insights of such great philosophers as Aristotle and David Hume — all tell us as much about the vagaries of the human condition as the systematic findings of the scientist. We have woven this dimension into the text through the writings of, among others, national leaders like Abraham Lincoln and Winston Churchill, novelists such as Virginia Woolf and William Styron, and poets like Théophile Gautier and Sandy Jeffs.

We have alluded to the range of mental illnesses to which we are vulnerable. We cannot possibly do justice to the dozens of diagnoses listed in the two principal classifications applied by mental health professionals. Nevertheless, we address many of them, especially those we encounter more commonly.

A few illustrations convey a sense of the extensive terrain of mental illnesses, developmental disorders, and neurological variations: autism and ADHD in children, anorexia nervosa in young women, depression in a new mother, alcohol addiction in men undergoing a midlife crisis, PTSD in the military, and dementia in the elderly.

After an overview of the field through an historical lens, we describe the principal clinical disorders that occur across the life span. We then address mental ill-health in children and adolescents, the elderly, and women. An account follows of the biological and psychological treatments used for these conditions. In the final chapter, we address the pivotal issue of every one of us taking an active role in promoting our own mental health and wellbeing, or contributing to our recovery or improvement should we become ill.

Throughout, we share illuminating case studies of people that we or our colleagues have treated. These cases have either been shared with the subject’s consent or been created from composite cases, with the subjects thickly disguised and identifying features removed.

Each chapter is followed by recommended readings for those who wish to delve further into an aspect of the subject covered.

Regarding references, we have avoided cluttering the text with publication details of books we have cited or from which we have quoted; online search engines will enable you to track them down readily.

We hope Troubled Minds will help people who have suffered or are suffering from mental ill-health, as well as their families and carers. We have written the book in such a way that members of the lay community who are intrigued by the subject will be able to learn more about its diverse features. Similarly, that professionals working in mental health or general healthcare settings (especially family doctors, who are often the first port of call) will find it a useful resource in their clinical work. Finally, we hope that teachers, human-resources personnel, and staff in NGOs such as Lifeline, Beyond Blue, and SANE will find that the book enhances their counselling.

1

Setting the scene

Attempts to understand and treat mental illness go back centuries. Possibly the earliest account of a disturbed mind is recorded in a 3,500-year-old Hindu text that describes a man who is ‘gluttonous, filthy, walks naked, has lost his memory and moves about in an uneasy manner’. In the first Book of Samuel, we read that King David simulated madness to gain safety: ‘And he changed his behaviour … and feigned himself mad in their hands, and scrabbled on the doors of the gate, and let his spittle fall down upon his beard.’ In the Book of Daniel, we find a vivid description of King Nebuchadnezzar’s mental state: ‘And he was driven from men, and did eat grass as oxen, and his body was wet with the dew of heaven, till his hairs were grown like eagles’ feathers, and his nails like birds’ claws.’

The ancient Greeks made early attempts to explain madness. In the fifth century BC, Hippocrates viewed it as seated in the brain and influenced by four bodily fluids: blood, phlegm, black bile, and yellow bile. The Greek physician Galen, who practised in Rome 600 years later, argued that depression was caused by an excess of black bile (hence the term ‘melancholia’, from melan, black, and khole, bile). His contemporary, Aretaeus of Cappadocia, colourfully described how, if black bile moves upwards in the body, ‘it forms melancholy; for it produces flatulence and belches of a fetid and fishy nature, and it sends rumbling wind downwards, and disturbs the understanding.’

During the Middle Ages, the monasteries preserved the view of madness as an illness and of those afflicted as sick rather than sinful. At the same time, the more sinister belief that the principal cause of the troubled mind was possession by spirits or the devil prevailed. Sufferers were taken to sanctioned healers for exorcisms, a practice still carried out today in some cultures. People who failed to respond to such treatment might then seek out a celebrated expert. Consider Hwaetred, a young man living in what is now England in the seventh century, who became tormented by an ‘evil spirit’. So terrible was his madness that he attacked others with his teeth and killed three men with an axe when they tried to restrain him. Taken to several sacred shrines, he obtained no relief. His despairing parents then heard of Guthlac, a monk who lived a hermit life north of Cambridge. After three days of prayer and fasting, Hwaetred was purportedly cured.

Death by public drowning was once the not-uncommon fate of mentally ill women branded as witches (from The Remarkable Confession and Last Dying Words of Thomas Colley, undated).

Over time, the role of religious authorities in mental illness dwindled, and the medical profession claimed the exclusive practice of the healing arts. Insanity once again came to be seen more as a physically based malady rather than a spiritual taint. Even so, life for the mentally ill could be appalling. During the 17th century, religiously inspired persecution of the mentally ill was justified by the clerical hierarchy, and treatment was often some combination of neglect and bestial restraint. Psychiatrists Martin Roth and Jerome Kroll describe the insane in this period as ‘miserable individuals, wandering around in village and in forest, taken from shrine to shrine, sometimes tied up when they became too violent’.

The Bethlehem Royal Hospital, typical of the asylums in which psychiatry was born (an engraving by Robert White, c. 1700).

The late 18th century was a watershed in the history of psychiatry. The insanity of England’s King George III revealed society’s ambivalence to the mentally ill (vividly captured in the 1994 film The Madness of King George). In France, Philippe Pinel released the chains that had fettered the ‘lunatic’ for centuries, ushering in an unprecedented phase of benevolent institutional care. Moral therapy, a form of individualised care in small hospital settings, was promoted by English Quakers at the York Retreat and gradually supplanted inhumane physical treatments such as purging, bleeding, and dunking in cold water.

As populations grew and urbanised, the sheer numbers of mentally ill people in burgeoning city slums demanded action. An institutional solution emerged. Asylums (from the Greek word meaning ‘refuge’) were built in rural settings with the best of intentions, planned to be havens in which patients would receive humane care. In the serenity of the countryside, and through carrying out undemanding tasks, they could be distracted from their internal torment and find dignity far from the bustling crowd. Daniel Defoe, the English writer, remained unconvinced: ‘This is the height of barbarity and injustice in a Christian country; it is a clandestine Inquisition, nay worse.’

Though conceived in a spirit of optimism, asylums tended to deteriorate into centres of hopelessness and demoralisation. They soon became overcrowded dumps. Institutions built for a few hundred people were soon holding thousands. Very few residents were discharged; many stayed for decades. Brutal oppression replaced anything that might have resembled treatment; malnutrition and infectious disease became rife. In the grim environment, people were shut away and forgotten. With them out of sight and out of mind, a loss of public interest and political neglect became the norms.

The brooding building on the hill came to symbolise the stigma and fear attached to mental illness. By the mid-19th century, critics were voicing concerns that asylums had become human warehouses that entrenched mental illness rather than curing it. The combination of powerless patients, hospitals run more for the convenience of staff than for the benefit of the sick, inadequate inspection by state bodies, and lack of resources led at times to quite disgraceful conditions. Unwittingly, the spread of asylums also triggered the movement of psychiatry away from the mainstream of medicine.

William Hogarth’s engraving of a scene in Bedlam, London’s notorious asylum (from The Rake’s Progress, 1735).

The conditions of the asylums are evocatively described in Henry Handel Richardson’s Australian novel, The Fortunes of Richard Mahony. We read of Richard’s decline, probably from syphilis affecting the brain, which at that time afflicted a large proportion of mental patients. Towards the end of the novel, his wife comes to visit him in the asylum:

She hung her head … while the warder told the tale of Richard’s misdeeds. 97B was, he declared, not only disobedient and disorderly, he was extremely abusive, dirty in his habits … he refused to wash himself, or to eat his food … she had to keep a grip on her mind to hinder it from following the picture up: Richard, forced by this burly brute to grope on the floor for his spilt food, to scrape it together, and either eat it or have it thrust down his throat … There was not only feeding by force, the straitjacket, the padded cell. There were drugs and injections, given to keep a patient quiet and ensure his warders their freedom.

Great and desperate cures

In the asylum, psychiatry turned into a modern medical discipline. The accumulation of thousands of patients provided the first opportunity to study mental illness systematically and to develop theories about its causes. The idea that these conditions were due to brain alterations, and especially degenerative processes, became dominant, encouraged by the discovery of the cerebral pathology associated with neurosyphilis and Alzheimer’s dementia. A similar degenerative process was proposed by the great German psychiatrist Emil Kraepelin to cause dementia praecox — later to be renamed ‘schizophrenia’ — leading to pessimism about the possibility of recovery.

But the priority for asylums was to relieve the suffering of overwhelming numbers of disturbed patients. Psychiatrists grasped for ‘great and desperate cures’. Henry Rollin, an English psychiatrist and medical historian, captures the intense zeal:

The physical treatment of the frankly psychotic during these centuries makes spine-chilling reading. Evacuation by vomiting, purgatives, sweating, blisters, and bleeding were considered essential … There was indeed no insult to the human body, no trauma, no indignity which was not at one time or other piously prescribed for the unfortunate victim.

Treatments were sometimes based on rational grounds. Malaria therapy, for instance, was launched as a treatment for neurosyphilis by the Viennese psychiatrist Julius Wagner-Jauregg in 1917, earning him a Nobel Prize ten years later. The high fever caused by the malarial parasite disabled the spirochete that caused neurosyphilis, but the hope that it would be equally effective for other forms of psychosis was soon dashed. The wished-for panacea was not to be.

Insulin-coma therapy was introduced by Manfred Sakel in the 1930s in Vienna and was soon being used in many countries to treat schizophrenia. An insulin injection was administered six days a week for several weeks, producing a state of light coma lasting about an hour, because of reduced glucose reaching the brain. Many years later, an investigation carried out in the Institute of Psychiatry in London, a leading research centre at the time, showed conclusively that the coma itself was of no therapeutic value. Any positive change was probably due to the staff’s painstaking care.

The first widely available and effective biological treatments for mental illness were developed in the asylum. The discovery in 1938 of electroconvulsive therapy (ECT) by Ugo Cerletti and Lucio Bini, two Italian psychiatrists, led to a dramatically effective treatment for people with severe depression. ECT was eagerly adopted in practice, but its history illustrates a typical pattern of treatment in psychiatry: unbridled early enthusiasm is later tempered by a protracted process of scientific evaluation. The same can be said of the use of brain surgery to modify psychiatric symptoms. This was pioneered in 1936 by Portuguese neurologist António Egas Moniz (another Nobel Prize winner in the field of psychiatry) and surgeon Almeida Lima, and remains controversial in psychiatry to this day.

A momentous breakthrough was the discovery in 1949 by John Cade, an Australian psychiatrist, of lithium as a treatment for manic excitement. The lithium story reveals how the incorporation of a new medication into psychiatric practice is not always smooth. Several American and Danish psychiatrists had experimented with lithium in the 1870s and 1890s, only to have their work ignored until Cade’s rediscovery, and it was then a further 18 years before lithium was shown to prevent the recurrence of severe changes of mood, its primary clinical use now.

Major tranquillisers were added to the growing range of psychiatric medications after being discovered fortuitously in 1953. An antihistamine used to calm patients undergoing surgery was shown to reduce the torment of psychotic patients, but without making them sleepy. Shortly after this, the American psychiatrist Nathan Kline discovered that a drug being tested for its effect in patients with tuberculosis had antidepressant properties — the forerunner of medications for depression. All these drugs radically transformed the practice of psychiatry. (See Chapter 13.)

The advent of psychological therapies

A very different aspect of mental health care arose in the 1890s, outside the asylum. Concerned with neurotic conditions, the new treatment grew chiefly out of neurology but was also influenced by a scientific interest in hypnosis and the unconscious. Sigmund Freud conceived of a dynamic model of the mind in which, through the mechanism of repression, painful or threatening emotions, memories, and impulses are prevented from escaping into conscious awareness. Psychoanalysis grew to become an integrated set of concepts about normal and disturbed mental functioning and personality development and spawned a novel method of psychologically based treatment. Psychoanalysis emerged as a major theoretical underpinning of contemporary ‘talking cures’ (psychotherapies), and its influence spread far beyond treating mental ill-health.

Both world wars profoundly influenced the field. The high incidence of ‘shell shock’ in World War I drove home the lesson that mental illness could affect not only those genetically predisposed, but even the supposedly robust; it soon emerged that anyone exposed to traumatic experiences was vulnerable. A positive outcome from World War II was the development of techniques for screening large numbers of recruits, which revealed the substantial prevalence of emotional problems among