Psychosocial adversity and mental illness: Differentiating distress, contextualizing diagnosis.

Psychiatry has made significant advances in the last century. The use of pharmacological medication to treat mental disorders, refinements in psychological therapies, insights into the genetic, and biological basis and advances in operational diagnosis and classification have changed practice. However, the role of psychosocial stress and the relationship between psychosocial adversity and psychiatric diagnosis remains controversial. This article highlights the challenges and suggests possible solutions.

COMPLEX NATURE OF ADVERSITY

Suicide is a classical outcome of both psychosocial adversity and of mental illness. The standard teaching was that the suicide rate in India was low (11/100,000)[1] and that the majority were secondary to mental illness.[2] However, recent data suggests much higher rates,[345] much lower proportion of suicide attributed to severe mental disorders[6] and evidence of psychosocial adversity (E.g., loneliness, break in relationship, chronic pain, on-going stress) as the risk factors for such deaths.[6] It is widely recognized that, while people with mental disorders kill themselves, a much greater proportion of deaths in the country are impulsive and secondary to psychosocial adversity in people without serious mental illness.

Psychosocial adversity causes mental distress and psychiatric disorders (disease). Such trauma can be acute (E.g., bereavement), recurrent (E.g., domestic violence) or chronic (E.g., poverty). Combinations of such patterns of adversity are also common (E.g., domestic violence in poor women with alcohol dependent partners).

RELATIONSHIP TO VULNERABILITY

The Stress-Vulnerability Model[7] and its many variants[8] have long-postulated a relationship between stress and vulnerability (i.e., genetic, biological, psychological and social). The response to adversity ranges from good coping to hopelessness and despair. Such responses can be self-preserving and adaptive and it can be a sign of normal reaction to stress (E.g., short-lived adjustment difficulties in people with good coping skills who are under severe stress) or it can result in mental disease at the extreme (E.g., acute psychosis precipitated by stress). The Stress-Vulnerability Model argues for the inverse relationship between stress and vulnerability. Lower degrees of stress can result in illness and disease in individuals with greater vulnerability and vice versa. While psychosocial adversity is necessary to cause mental distress, it is not sufficient to cause mental disease.

The clinical significance of the stress is dependent on the context, the severity and nature of the stressor(s), the person's vulnerability, resilience, and response. The complex relationship between the psychosocial adversity, individual vulnerability, and the resultant coping/de-compensation mandates clinical assessment. It also requires a degree of interpretation, given the fact that our understanding of stress and vulnerability is conceptual and abstract rather than concrete and specific.

PSYCHOSOCIAL DETERMINANTS OF MENTAL HEALTH

The role of social determinants and their impact on physical health has been well documented.[9] The result of inequitable distribution of resources, power and money perpetuate a vicious cycle of poverty and ill-health, often spanning generations.[10] Public health reformers who advocated social reform on political, economic, humanitarian, and scientific grounds had long acknowledged, reciprocal relationship between poverty and disease.[11] These social determinants of health significantly affect mental health. Poverty, gender violence, cultural tensions, social discrimination, political oppression, ethnic cleansing, armed conflicts, and forced migration are associated with depression, anxiety and common mental disorders.[12131415] Poverty works through the experience of insecurity, hopelessness, rapid social change, risk of violence and physical illness to produce poor mental-health.[12]

Psychosocial adversity has a major impact on stress-related disorders: Depression, dythymia, adjustment, acute and post-traumatic stress, anxiety, panic, phobia, obsessive compulsive, somatoform, and other common mental disorders.

THE CHALLENGE

Presentations associated with psychosocial adversity, like most clinical phenomena,[16] often lie on a continuum with distress at one end and disease at the other. However, the absence of gold standards for diagnosis of psychiatric disorders, the lack of pathognomonic symptoms and the use of individuals’ perception of unpleasant feelings and phenomena, which form part of the normal range of emotions, makes it difficult to separate distress from depression, anxiety and common mental disorders.[17] The absence of laboratory tests for diagnosis, the focus on clinical symptoms and the use of symptom counts for diagnosis, the discounting of contexts and the dismissal of factors that predict treatment response and outcome (E.g., stress, personality, coping skills and social supports) complicates diagnosis.

The differentiation of a normal adaptive response characterized by mental distress from disease is difficult in many situations. The clinically and statistically significant relationship between psychosocial adversity and mental ill-health (i.e., distress/illness and disease) makes the task of diagnosis difficult. Mental disorder as currently defined, is very broad and includes both distress and disease.[18] The atheoretical approach to psychiatric diagnosis,[181920] which disregards contexts, while increasing reliability, may not necessarily result in valid categories. Misclassification of distress and disorder (disease) is a very real possibility with a high false positive rate for many diagnostic categories. Diagnostic hierarchies, which privilege major depression and marginalize stress-related conditions (E.g., dysthymia, adjustment disorder), medicalize personal and social distress.[2122] The elastic concept of depression and the mechanistic application of diagnostic hierarchies have led to the marginalization of stress-related adjustment difficulties. This has also resulted in the marked heterogeneity within diagnostic heads (E.g., major depression), high rates of placebo response and spontaneous remission and limited impact of medication for mild and moderate conditions.[2324]

The failure to recognize the context has resulted in psychiatric labels for victims of crimes (E.g., women with intimate partner violence). It has also resulted in the use of the same label, post-traumatic stress disorder (PTSD), for perpetrators of violence (E.g., combat veterans) and for victims of crimes, pogroms and genocide.[17] PTSD also assumes a universal response to past trauma, does not consider current context and medicalized reactions to stressful life events. The Diagnostic and Statistical Manual-5 (DSM-5) has now effectively removed the last contextual exclusion, bereavement,[1825] for the diagnosis of major depression resulting in the medicalization of most normal emotional responses to psychosocial adversity.

Nevertheless, despite the many iterations of the DSM, neurobiological, epidemiological, cross-cultural and behavioral validity, as envisaged by Robins and Guze, the early pioneers of operational criteria, remains elusive.[26] Even reliability of diagnosis, the main argument for operational definitions, remains very modest for many categories, with kappa values of 0.2-0.4, now accepted as standard in DSM-5.[27]

The use of operational definitions across specialist and primary care settings is also fraught with difficulty. Psychiatric presentations in primary care are usually milder, less complex, with mixed symptom profiles and often associated with psychosocial adversity compared to those seen in specialist settings, which are more severe and usually associated with higher genetic vulnerability.[28] Physicians, working with patients with such presentations in primary care (E.g., anxiety, depression and common mental disorders), argue that improvement in course and outcome are often related to personal resources and social supports, than to medication.[29] These realities force the general population and general practitioners to choose psychological and social explanatory models of illness over biomedical theories championed by psychiatrists.

Nevertheless, psychiatry also accepts the disadvantages of diagnostic categorization: Indistinct boundaries, overlap between categories, need to force patients into ill-fitting categories, need to follow ill-suited protocols, etc. Consequently, the discipline has attempted to elicit and integrate multiple and interacting causal components to individualize care using the Bio psychosocial model.[30] However, the difficulty in integrating the diverse and contradictory strands (disease with personal, emotional, family, community, culture, spirituality dimensions) has resulted in superficial and idiosyncratic approaches.[31] While eliciting psychological and social causes is possible, managing them is outside the usual range of expertise and the comfort zones of most psychiatrists. As a result, the bio psychosocial model is often praised, but it is the biomedical model, which is practiced. Guidelines to restrict the use of anti-depressants to the more severe forms of depression[32] are often observed in the breach with a steady increase in the use of antidepressant medication.[33]

While psychiatrists focus on objective behavioral criteria and argue for disease models, patients emphasize subjective distress;[34] this widens the disease-illness divide. Framing the issues within such value-laden structural dichotomies (i.e., implicit hierarchies with the objective valued over the subjective, biological perspective over the psychological, the concept of disease over that of illness, etc.) distracts us from the task of trying to understand the complex interaction and interdependence of issues related to mental health and illness.[35]

The difficulty in separating disease from distress places psychiatry in a double bind. Clinicians, who see both disease and distress, realize that individual treatments and therapies may not be effective in relieving personal, social and contextual distress. Diagnostic labels for depression, anxiety and other common mental disorders based on symptoms counts sans psychosocial context medicalize personal and social distress, do not reflect clinical reality and are often counter-productive.

THE WAY FORWARD

The complexity of the challenge mandates the need to examine alternative approaches and solutions. Acknowledging the limitations of current approaches, placing clinical presentations within their psychosocial contexts, using clinical typologies and broadening and refining the research focus would be cardinal for the success of diagnosing and managing individuals with distress and psychiatric disorders. Employing public health approaches would be imperative in reducing the rates of distress and common mental disorders in populations.

Clinical solutions

Normal psychological and emotional reactions secondary to psychosocial adversity will have to be distinguished from abnormal responses (psychiatric disorders). The use of the current taxonomies, with polythetic formats, does not do justice to the complex reactions to psychosocial adversity. This challenge in clinical practice is to delineate normal mental distress from psychiatric disorders; this task mandates the evaluation of psychosocial adversity and context. The use of traditional prototypical typologies-normal responses in well-adjusted individuals under severe stress (adjustment disorders), chronic difficulties in coping with day-to-day stress (dysthymia/generalized anxiety/personality disorders), melancholia/severe depression will allow for good clinical practice. Combining clinical presentations, psychosocial context and a longitudinal life-span perspective will allow for the identification of classical prototypical categories.[36] Distinguishing these categories in individuals will allow for matching management strategies.[21] Moving beyond the current diagnostic strategy with its emphasis on symptom counts, will allow for a comprehensive approach to mental health and illness. While including the context in diagnosis will make the process more complex, it will improve the validity of categories commonly associated with psychosocial adversity.

The diagnostic criteria and classificatory systems have resulted in tensions between clinical needs and academic priorities. Competent clinicians already employ many of these concepts, focus on the context and consider psychosocial adversity in diagnosis and treatment.[37] They emphasize and attempt to distinguish disease and distress, cure and care, treatment and healing. However, the complexity of the issues, the unavailability of reliable and valid measures of context and their limited expertise in research have not resulted in the generation of data to untangle issues. Academia, on the other hand, with its limited exposure to clinical reality, focuses on reliability and usually does not get into the messy world of psychosocial adversity and context. The need to study individual contexts goes against the universal models currently advocated. The academic world view, which discount context in diagnosis, generates mounds of data reinforcing its firmly held beliefs. However, the nature of human distress and mental disease demand comprehensive approaches and solutions, which go beyond narrow disciplinary perspectives.

Nevertheless, the conflicting demands of the different settings, where diagnostic categories and criteria and employed are not easy to resolve. The clinical challenge of differentiating normal distress from disease within clinical settings demands the understanding of the context. On the other hand, genetic and biological research requires narrow definitions in order to identify typical phenotypes. Epidemiological surveys use instruments, which increase the probability of rather than confirming diagnosis. Diagnostic labels for policy and planning, insurance reimbursement and for legal use make different demands on diagnosis. The current position of a single set of operational criteria, as emphasized by the DSM approach, also means that academia priorities trump clinical needs.

Psychiatric diagnosis calls for a renewed focus on measurement of stress and context and its interaction with vulnerability. There is a need to study the impact of context on diagnosis, treatment and on outcome. The issues related to psychosocial adversity and common mental disorders are in some ways analogous to the historical use of Schneider's First Rank Symptoms[38] for the diagnosis of schizophrenia. These symptoms were chosen for their high inter-rater reliability. Today, we also recognize that negative syndrome is crucial to the disease. The reliable measurement of negative symptoms,[39] led to the re-emphasis on the negative syndrome, refocused and advanced psychiatric research in schizophrenia. Similarly, accurate and comprehensive measurement of psychosocial adversity and context will increase our understanding of both disease and distress. It will improve the validity of psychiatric diagnosis.

Populations approaches

The difficulty in separating psychiatric disorders from distress, has implications for populations. The efficient management of psychosocial and contextual adversity calls for population based strategies. The multi-factorial etiology of mental distress and disease mandate the use of multi-sectoral solutions cutting across disciplinary boundaries.[2240] Distress caused by complex social contexts often requires population-based solutions. While, individual treatments can relieve individual distress and common mental disorders, public health interventions are required for impacting rates of these conditions within populations. Tackling the social determinants of health and measuring the impact of interventions will be cardinal. Improving the daily lives of people and meeting their basic needs (E.g., clean water, sanitation, nutrition, immunization, health, education and employments) will reduce population rates of distress and depression.[915] Micro-credit schemes and anti-poverty programs will help by reducing the social class gradient. Education to improve resilience and life skills and programs for gender and social justice will be crucial. Psychiatry should also champion public health and population-based psychosocial and economic interventions in addition to providing support and treatment for individuals.[2240]

The focus on the social context, in addition to individual biology and choice, will allow for examining the structural issues, which affect mental-health of populations (E.g., politics, economics and culture). The focus on the individual and his/her clinical presentation to the complete exclusion of the context fits in with capitalism and its free-market philosophy.[22] The individual's mental state, health and disease are always considered a consequence of individual concerns (E.g., biology and choice) rather than secondary to structural societal issues. Consequently, while poverty is a well-recognized cause of depression, its solution involves individual treatment including the need for medication or individual psychotherapy rather than structural changes to society, culture or the economy. Similarly, issues related to gender justice in patriarchal societies or sexuality in cultures, which uphold the heterosexual life style, are also addressed by management at the individual level. Consequently, psychiatry becomes the hand-maiden, which delivers care for individuals who are diseased or distressed. Psychiatry is then forced to move out of its traditional medical role and biomedical model to manage all mental distress and illness, even that which is produced by psychosocial distress. However, the provision of such care necessarily involves the use of medical and psychiatric labels to justify such input. Consequently, psychological and social distress receives psychiatric labels, which have high inter-rater reliability. However, their disease status is questionable and their response to psychotropic medication is limited. Most general practitioners, clinical psychologists and psychiatrists will acknowledge that individual resilience and social supports have a much greater impact of outcome of mental distress and illness often labeled as depression. The focus on psychosocial adversity and context will also allow for studying the nature and impact of psychosocial adversity and examine issues related to individual and community resilience.

CONCLUSION

Distinguishing psychiatric disorders from normal distress requires the assessment of context and psychosocial adversity. The current approaches to diagnosis and classification, which do not include the evaluation of context, do not do justice to the complexity of the human responses to stress. Diagnosis using symptoms counts sans context while improving reliability may not result in valid categories. There is a definite need to develop and refine instruments to evaluate psychosocial context, stress, supports, resources and coping. Such assessments should inform psychiatric diagnosis and management. In addition, public health strategies should be championed to reduce both distress and common mental disorders associated with psychosocial adversity.

Psychiatric diagnoses and theories, with their technical language, operational criteria, elaborate classificatory systems and empirical data continue lack the predictive power required of hard science.[35] Psychiatric theory is forced to fit the evidence generated, which is in turn based on current biomedical models. Its diagnostic systems and models do not explain many aspects of mental-health and illness. Human cognition, emotion, and behavior are complex, inter-connected and under a variety of influences (E.g., genetics and biology, psychological, social and cultural forces), whose effects cannot be teased out under controlled experimental conditions. Operational diagnostic criteria, with good reliability, are a poor substitute for the lack of robust concurrent and predictive validity.

Psychiatry, at this moment in time, has been compared to biology before Darwin and astronomy before Copernicus. The proposed classifications (DSM-5 and International Classification of Diseases- 11(ICD-11)) should not be reified. The contextualization of psychiatric presentations will allow for a more holistic approach to the recognition and care of people with mental distress and disease.