250 to 300 words on being diagnosed with bipolar disease.

SOC313 Family Document
Throughout this class, we will meet two families, the Maldonado’s and the Olson’s. The two families are
considered extended family via Sarah and Joe Miller. We will learn about their relationships, work
environments, and the psychosocial effects related to health challenges faced by each family. You will
use this document for the discussions and written assignments. We begin with the Maldonado family.
Manny and Donna Maldonado have been married for 42 years. Manny is age 65 and Donna is 63. Sarah,
Mike and Becky are the children of Manny and Donna Maldonado. Sarah is the eldest daughter,
followed by her brother, Mike, and her sister, Becky.
?
?
Manny is Hispanic American and owns a 20,000-acre produce farm that has been in his family for
three generations. Although Manny speaks and understands English, he prefers to speak Spanish.
This creates a language barrier between Manny and other family members who do not speak
Spanish. Donna is fluent in Spanish, having learned the language from Manny and his family.
Donna works on the farm with her husband. She has long suffered from mood swings, which is
mostly frustrating to Manny. He says it is “brujeria,” meaning her moods are caused by witchcraft
and “mal d ojo” or “evil eye.” He believes someone put a spell on Donna. When this is believed to
be the case, the person will visit a Curandero (healer) who will perform a healing ritual.
o Sarah works as a nurse, and recently took Family Leave of Medical Absence (FMLA) due to
her children’s recent issues.
o Joe is the President of Illusion Technologies. Joe’s parents are John and Ella Miller. More
details about Joe are shared in the Olson family section below.
? Lucy, age 20, has a history of severe substance use disorder, along with having been
diagnosed with bipolar disorder. In the past two years, Lucy has had four different jobs.
o
o
o
She is unable to hold a job long-term. She now works on her grandparent’s produce
farm.
? Josh, age 17, has been sneaking away with friends, smoking marijuana and skipping
school.
? Evan, age 10, was recently diagnosed with leukemia; however, he has not yet started
treatments. Evan’s doctors have recommended chemotherapy, radiation, and a bone
marrow transplant. Sarah and Joe intend to follow this treatment plan.
Mike Maldonado is age 36. He currently works for a state University as a tenured faculty of
the College of Agriculture and Life Sciences. Mike was recently diagnosed with HIV.
Dan was Mike’s husband. He recently passed away at the age of 38 due to an AIDS-related
illness. They were married for 10 years. Mike and Dan did not have any children.
Becky is age 33. She is divorced and working on the family produce farm as well as
attending a local college at night to complete her bachelor’s degree in Child Psychology. She
has one child, Abe.
? Abe is age 12. He is a good student, but his behavior has changed recently, showing
anger and defiance towards both of his parents and several teachers at school. His
mother, Becky, has been treating Abe’s behavioral changes with diet and alternative
medicines.
Next, we will meet the Olson family.
Frederic Olson was married to Mary Olson. Mary passed away 10 years ago at the age of 77. Frederic is
age 87. Ella is the only child of Frederic and Mary Olson.
?
?
Fredric has pronounced symptoms from Parkinson’s disease. He has tremors and balance problems,
along with muscle stiffness and gait (manor of walking) changes. He struggles to begin any
movement. However, once he is moving, he cannot stop easily. His gait has changed to smaller
steps and shuffling.
As he progresses through the stages of the disease, Frederic needs increasing assistance with his
activities of daily living (ADLs), which entails bathing, dressing, food preparation, eating, taking
medications, et cetera. He recently moved to an Assisted Living community and only leaves the
facility for medical appointments. The family visits Grandpa Frederic on an alternating schedule at
his new home every week. The Assisted Living community has regularly scheduled social events in
which Grandpa Frederic actively participates.
o Ella is married to John Miller. Ella and John are both 70 years old. John and Manny
Maldonado are best friends. Ella and Manny grew up together on their neighboring farms.
Ella and John recently sold their 10,000-acre farm to the Maldonado family since the two
farms were adjacent to each other.
o Ella has been trying to heal herself from breast cancer using a variety of natural means. She
grew up on a farm and was accustomed to using home remedies. Therefore, Ella is not
willing to utilize Western medicine practices.
o While the alternative health care methods kept Ella in remission for a few years, recently
she learned the cancer has returned. In addition, the cancer has metastasized to her lungs
and bones. Ella has chosen to forego Western medical treatment options such as
chemotherapy, radiation, and pharmacological breast cancer treatment medications. She
has requested to live out her last days at home. Ella has agreed to be admitted to Hospice
home care, with John as her primary caregiver. Ella and John are seeking quality palliative
end of life care.
o John, Ella’s husband, is of Native American origin. He is well educated and uses Western
medicine, but relies heavily on Native American methods, such as meditation and banishing
bad spirits from their home. John speaks fluent Spanish, having learned the language as a
child.
o John is an attorney for the Maldonado produce farm and his son’s company, Illusion
Technologies.
o John and Ella’s children are Sam, age 50, Lila, age 45, and Joe, age 43.
? Sam is divorced and has no children. He works as a foreman on the Maldonado produce
farm. He is an alcoholic and has been diagnosed with severe substance use disorder due
to his alcohol addiction. His alcohol use is affecting his position as the foreman. Over
the past few months, he has experienced emotional outbursts, missed work, and started
arguments with the workers, third-party wholesalers, and Al Goldberg (Olson family).
?
?
?
?
Sam has been upset that his parents sold the family farm to the Maldonado family
instead of passing it down to him.
Lila, age 47, is married to Al Goldberg. She is a Social Worker for the state. Her job is
very stressful as her caseload includes at-risk children. There is a great deal of
documentation required; therefore, she works many 10 to 12 hour days. Lila is
overweight and has Type II diabetes. She has not controlled her weight or diabetes well.
Recently, her doctor changed her medication. She is now taking daily insulin injections
to help manage her diabetes.
Al, age 47, Lila’s husband, is the general manager of the Maldonado family produce
farm. Al had first option for buying the Olson family farm. He opted out of purchasing
the farm and agreed with the sale to the Maldonado family. He has no known health
issues; however, due to an early childhood trauma, he is afraid of hospitals and funeral
homes.
? Alisha is Lila and Al’s only child. She is 20 years old and is currently attending college
full time on a nursing scholarship. The college campus is an hour away from her
parent’s home. She lives on campus in the dorms, does not work at this time, and
has no known health problems.
Joe, who is Sarah (from the Maldonado family) Miller’s husband, is the President of
Illusion Technologies, a rapidly growing company with 50 employees. He has a patent
pending on two security-based software programs that could be worth millions. He and
his father are in negotiations to purchase land to build a state-of-the-art office building.
Sarah, Joe’s wife, is a nurse and recently took a Family Medical Leave of Absence (FMLA)
due to the health and behavioral problems with her children. Details about Joe and
Sara’s children are shared in the Maldonado family section.
The family members share a long history of friendship and love of farming. They have shared many life
events, such as holidays, births, and deaths. Their families have been intertwined for generations
through the raising of the children and grandchildren. For the most part, the families get along well.
However, even though they share some of the same cultural traditions and backgrounds, they do clash
from time to time. For instance, some of the Olson family members are not in full agreement with Ella’s
use of home remedies and alternative treatments for her breast cancer. However, the Maldonado
family understands and supports her choices. Further, Ella is encouraging Sarah Miller and Mike
Maldonado to pursue Complementary and Alternative Medicine (CAM) to treat Evan’s leukemia and
Mike’s HIV. The members of both families are dealing with very busy schedules and major health
challenges.
7
Mental Health Disorders
BSIP/UIG/Getty Images
Learning Objectives
1. Understand the evolution of societal perspectives about individuals with mental health disorders
2. Identify the basic physical and environmental elements related to different mental health disorders
3. Describe how mental health disorders affect different individual, familial, and social domains
4. Explain the connections between age groups and the prevalence of different mental health disorders
5. Compare and contrast different treatment approaches and identify which best address the different
mental health disorders
6. Describe how stigma and health disparities affect diagnoses and treatments of mental disorders
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Section 7.2 History
CHAPTER 7
7.1 Introduction to Mental Health Disorders
W
hat is mental health? It isn’t just the absence of mental disorders. The World Health
Organization (WHO) defined mental health as follows:
A state of well-being in which every individual realizes his or her own potential,
can cope with the normal stresses of life, can work productively and fruitfully, and
is able to make a contribution to her or his community. (WHO, 2011b. Copyright
© World Health Organization [WHO]. Used by permission.)
(For a short video produced by the WHO about the global reach of mental illness, go to http://
www.youtube.com/watch?v=L8iRjEOH41c.) In the following sections, we examine the different
common mental disorders in the order that they are likely to appear across the lifespan, from early
childhood (neurodevelopmental disorders) to late adulthood (dementia).
7.2 History
M
ental disorders have been recognized from the beginning of human society. In some
periods and cultures, people with mental disorders had recognized roles, for example,
a shaman or fortune-teller. In other periods and cultures, people with mental disorders
were driven from society. Ideas about causation and treatment have also varied. One frequently
held idea was that mental disorders were caused by evil spirits. Evidence shows that prehistoric
people treated mental disorders by cutting a hole in the skull of the afflicted person, a process
called trepanation, to allow evil spirits to escape (Clower & Finger, 2001).
Written accounts of mental disorders are found in Egyptian manuscripts from 1550 BCE. Egyptians
recognized the brain as the site responsible for mental function and described both depression
and mood changes (Nasser, 1987). Among the Greeks, Pythagoras (sixth century BCE) and Hippocrates (fifth century BCE, from whom we get the Hippocratic Oath that physicians should “do no
harm”) understood that the brain was the center of thought, intelligence, and emotions (Millon,
Grossman, & Meagher, 2004). The Romans built upon Greek approaches to mental disorders,
and physicians such as Claudius Galen (second century CE) supported diagnoses based on observation and humane treatment of the mentally disturbed. Most Greco-Roman understanding of
mental disorders had been forgotten in Europe by the early Common Era until the 17th century.
Instead, European medical understanding of mental disorders was based on faith healing, magic,
and superstition (Millon et al., 2004). During a long dark period in western Europe, medical understanding of mental disorders was kept alive in the Islamic world. The first known psychiatric hospital was built in Bagdad, Iraq, in 705 CE (Murad & Gordon, 2002). Also, in Byzantium, the successor
to the Roman Empire, special provisions were made for handling the criminally insane differently
from other offenders (Tzeferakos, Vlahou, Troianos, & Douzenis, 2011).
In Europe, people with mental disorders were generally cared for by relatives. Only those who could
not be cared for by relatives might be placed in a public institution. A famous example is Bethlem
Royal Hospital (universally known as “Bedlam”), which was granted by Henry VIII to the City of
London in 1547 as the first asylum for people with mental disorders. Bedlam became notorious
for the poor treatment of patients and the practice of allowing fee-paying spectators, which was
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Section 7.2 History
CHAPTER 7
discontinued in 1770 (Bedlam,
2013). Bedlam became a synonym for mental hospitals and
generally for confusion or uproar.
Philippe Pinel (1745–1826)
played a large part in reforming the treatment of people
with severe mental disorders in
France. He became head physician of Bicêtre, the public asylum
for men near Paris, in 1793 and
presented his Memoir on Madness to the Society for Natural
Mary Evans Picture Library/Everett Collection
History in 1794. In it he explained
his theory of “psychologic treatPhillipe Pinel helped reform the treatment of people with
ment,” which was also called the
mental disorders in France. In this image he is shown ordering
“moral treatment.” Pinel believed
the manacles removed from patients at Salpêtrière.
it possible to cure mental illness,
and that to do so, it was necessary to first diagnose the patient by careful observation, gain understanding of the events precipitating the illness, and write an accurate case history. Pinel thought it was possible to “dominate agitated madmen while respecting human rights” (Weiner, 1992, p. 725). His assistant, who succeeded
him at Bicêtre, removed the chains from male inmates in 1797, replacing them with more humane
strait jackets when needed. Pinel did the same at the public women’s asylum, Salpêtrière, in 1800.
Benjamin Rush (1745–1813) played a similar role in psychiatric reform in the United States, where
he is known as the father of American psychiatry. Rush believed that mental disorders could be
diagnosed, classified, and treated humanely. His Observations and Inquiries Upon the Diseases
of the Mind, published in 1812, was the first psychiatric textbook printed in the United States.
Rush improved patients’ living conditions and removed their cuffs and chains (Penn Medicine,
n.d.-a; n.d.-b).
The Industrial Revolution changed family life and made it more difficult for families to care for
those with mental disorders at home, giving rise to community asylums (Wright, 1997). For the
first time, women began to work outside the home and so were unavailable to care for family
members with mental disorders. At the same time, an interest in the geographic or sociologic
distribution of disease, or epidemiology, became popular in the United States. As a result, the
1840 federal census was the first one to collect data on mental disorders. However, it counted only
those in institutions. A major problem was the lack of a shared language of definitions for mental
disorders, so it was impossible to track how many people with what kind of disorder were housed
in institutions across the country. In addition, the rate of institutionalization depended heavily on
the number of places available in a given community, as well as the willingness of families to allow
a stigmatizing diagnosis and the community’s tolerance for deviant behavior (Horwitz & Grob,
2011). As a result, the statistics collected were neither accurate nor scientifically useful.
Psychiatrists in the 1800s believed that the rise of industrial civilization increased the prevalence
of mental illness. Their conclusion was not based on statistics but rather on their moral and religious beliefs. However, the increasingly sophisticated censuses of the early 1900s proved them
wrong; the data collected also showed that immigrants from eastern and southern Europe were
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Section 7.2 History
CHAPTER 7
not particularly prone to insanity, as was generally assumed at the time (Horwitz & Grob, 2011).
For a history of the asylum and attitudes toward the mentally ill, as well as the implications for
policy change, consider reading Madhouses, Mad-Doctors and Madmen: The Social History of Psychiatry in the Victorian Era, edited by Andrew T. Scull.
By 1917, the American Medico-Psychological Association (which became the American Psychiatric
Association [APA] a short time later) called for uniform classification of mental diseases. Interest in
studying exclusively those with mental illness who were confined to institutions gradually shifted,
and by the late 1930s interest in the contribution of social and environmental factors to mental
illness in the community was rising. One particularly influential publication was Mental Disorders
in Urban Areas (Faris & Dunham, 1939), which made the connection between community conditions and severe mental illness. Although much of what the authors concluded was later proved
wrong, the effort to connect where someone lives and mental illness was an important advance.
World Wars I and II brought more data. As Horowitz and Grob (2011) concluded, “Psychiatric
casualties soared among soldiers who were seemingly normal before entering combat. The policy lesson seemed clear: environmental conditions rather than individual predispositions were
the primary causes of mental disorder” (p. 639). The mental disorders that appeared in normal
soldiers exposed to combat convinced mental health practitioners that social and environmental
factors play a large role in the development of mental disorders. During the period after WWII,
the newly formed National Institute of Mental Health (NIMH) was given responsibility for funding
research into the connection between social and environmental variables and mental disorders.
The movement to establish a uniform classification of mental diseases resulted in the publication
of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. The
first version (DSM-I) used the term reaction to refer to diagnoses, which reflected the theoretical
beliefs of Adolf Meyers that mental disorders were reactions of the personality to psychological,
social, and biological factors. Later editions of the DSM dropped this terminology along with the
mindset that mental disorders result from the interaction of all three spheres of life (APA, 2012).
Development of antipsychotic medications for treating severe mental disturbance played a role
in this turnabout (see “Prevention and Treatment Approaches to Mental Disorders” later in this
chapter). For the first time, people who previously had to be confined to an institution could be
treated in a community setting. The release of people with mental disorders from institutions,
known as deinstitutionalization, started in the mid-1950s and grew dramatically in the 1960s and
1970s. The idea was that people with mental disorders could be better treated and cared for in
their communities. The assumption was that sufficient funding for community mental health centers to deal with those who needed guidance and treatment would be available. However, funding for community centers and treatment specialists has fallen short of needs ever since, leaving
many vulnerable people to depend on their families or the social service system, or worse, the
prison system. Concepts of causality made an about-face during the late 1960s and early 1970s,
when the Nixon administration together with Congress decided NIMH should not fund research
on social problems such as poverty, racism, and violence (Horwitz & Grob, 2011). Focus instead
turned to how disturbance within the individual affected society.
As of 2013, the debate about how best to treat and ensure compliance by the mentally ill is as
sharp as ever. A series of violent shooting rampages on innocent victims (e.g., the Newtown, Connecticut, massacre) have brought to light the anguish of families of mentally ill and potentially
violent or suicidal people. How to protect the public while ensuring the civil rights of mentally ill
people is a difficult balancing act. The Health Insurance Portability and Accountability Act (HIPAA)
of 1996 made it much more difficult to institutionalize those in danger of harming themselves
or others, because it requires the affected person’s permission for anyone else to talk to mental
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Section 7.3 Definitions and Familial and Biological Basis
CHAPTER 7
health providers about him or her. A social worker who has had to hospitalize his mother and
sister a number of times remarked that someone who is paranoid is not likely to give anyone,
even family, permission to talk. The pendulum of patients’ rights has indeed swung to the other
side, and HIPAA has made the family’s attempt to help much more difficult. In January 2013, in
response to the shootings in Newtown, Connecticut, and Aurora, Colorado, the U.S. Department
of Health and Human Services (HHS) issued a letter to the nation’s health care providers, making
it clear that reporting someone they believe to be a danger to either themselves or others is not a
violation of HIPAA rules (Rodriguez, 2013). Unfortunately, to date, very few health care providers
appear to be aware of this.
We can see how through the ages responsibility and blame for mental disorders has shifted from
“evil spirits” to social conditions and experience and to the individual. Now let’s look at definitions
for many of the major mental disorders.
7.3 Definitions and Familial and Biological Basis
O
ne of the difficulties in studying mental health and treatment of mental disorders is finding a common language. Without a common language, it is impossible to answer questions about how disorders arise, how they are related, and how they are best treated.
This section discusses current definitions of some of the major mental disorders and lists short
descriptions for some of the others. It also discusses the role that family environment, genetic
makeup, resilience, environment, and supportive social interactions, particularly within the family,
play in various mental disorders.
Only recently have researchers begun to examine what accounts for people growing up in particularly difficult circumstances who nonetheless do very well in life—those who are particularly
resilient. For instance, some scientists have looked at children who experienced extreme neglect
or abuse and yet appeared to function well (Cicchetti, 2010). Others examined structural and functional brain differences between people with bipolar disorder, their relatives, and healthy controls
(Frangou, 2011).
Case Study: The Diagnostic and Statistical Manual of Mental Disorders
Our understanding is constantly changing, and the DSM reflects changes in society. For instance, homosexuality was considered a mental disorder until 1973. Another cultural shift can be seen when the
2013 fifth edition (DSM-5) replaced the term gender identity disorder with gender dysphoria, suggesting that the problem is not one of gender mismatch but rather the resulting emotional distress. Exactly
how disorders are defined may depend upon the particular work environment, as well as the norms
and values of society, which are always changing. So treat the definitions in this chapter as a general
guide, rather than a dictionary.
The DSM, published by the APA, provides criteria for mental disorders that are used by clinicians, insurance companies, policy makers, and researchers in the United States and around the world. The DSM-5
was approved in December 2012 and formally adopted on May 18, 2013, at the 166th annual meeting
of the APA with much fanfare and controversy. The DSM-5 is the first major update since publication of
DSM-IV in 1994, and much was expected of it.
(continued)
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Section 7.3 Definitions and Familial and Biological Basis
CHAPTER 7
Case Study: The Diagnostic and Statistical Manual of Mental Disorders
(continued)
According to Dr. Thomas Insel, director of the NIMH, the problem with the DSM is that it classifies mental disorders by clinical symptoms, which he thinks are not sufficient for diagnosing disease:
While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating
a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The
weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma,
or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms,
not any objective laboratory measure. In the rest of medicine, this would be equivalent to
creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed,
symptom-based diagnosis, once common in other areas of medicine, has been largely
replaced in the past half century as we have understood that symptoms alone rarely indicate
the best choice of treatment. (Insel, 2013)
Dr. Insel pointed out the difference between having a shared definition so that various people are
talking about the same thing, which is reliability, and being logically or factually correct (evidence
based), which is validity.
The NIMH is the major funding source for research in mental health and mental illness for the entire
United States and much of the world. An important goal of the NIMH is to transform diagnosis of mental
illness so that it is based on biology, not on symptoms or subjective criteria. This goal can be achieved
by incorporating cognitive science, genetics, imaging, and other information into the Research Domain
Criteria, which is envisioned as a 10-year project (Insel & Lieberman, 2013). In other words, DSM-5 may
be flawed when it comes to applying it to research, but it is still the best tool available for diagnosing
mental disorders.
Some changes in DSM-5 include classifying attention deficit hyperactivity disorder (ADHD) as a neurodevelopmental disorder instead of a disruptive disorder. Also, several criteria within posttraumatic
stress disorder (PTSD), tra

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