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Where are mental disorders coming from? Could there be new diagnoses? Why are people afraid of those who are not like themselves? At the end of the series “About Mental…” we talked to psychiatrist Konstantin Minkevich about the nature of mental disorders and society’s attitude towards them.

I want to start right away with this question: what is included in the concept of “mental disorder”?

Mental disorders are disorders of violations of mental activity. These include disorder of perception, behavioral and emotional disorders. That is, changes in mental activity that systematically disturb a person’s mental comfort, well-being, or meaningfully affect their functioning.

It is believed that one of the factors influencing mental illness is heredity. However, what role do external circumstances play? For example, revolutions, wars, bad family situations?

Heredity is only one factor. We cannot talk about a single cause of mental illness. Global external factors, such as wars, or local factors, such as bad family situation, upbringing, environment – all of these factors combine to influence. Different combinations of these factors give or do not give rise to mental illness.

Can a person with “bad” heredity avoid the disease? Is there any set of measures, or is it impossible to prevent it?

Heredity itself is not a verdict, it simply increases the chance of developing the disease. If other factors do not play, a person remains healthy. By contrast, if a person does not have a burdened heredity, but he will be affected by other unfavourable factors, he can still get sick. There is no definite set of measures to prevent a mental disorder. There are general recommendations, psychohygiene. But this does not give guarantees, there is no formula to avoid the development of a mental disorder.

Konstantin, photo from the personal archive of Konstantin Minkevich

In recent years, many disputed diagnoses have emerged. For example, some psychiatrists deny multiple personality disorder. In contrast, where schizophrenia used to be diagnosed, other diagnoses are being made. Which mental illnesses are the least understood? And can new diagnoses emerge, is this possible?

It’s difficult to talk about the least studied. Firstly, there are two main recognised classifications: the American DSM (Diagnostic and Statistical Manual of Mental Disorders) and World Health Organisation ICD (International Classification of Diseases). It is, so to speak, a consensus on what we think or don’t think is mental illness. At the same time, there are some disorders in the classification that raise fewer questions among researchers, and there are others that are less well recognised, not everyone agrees with their existence or the need to single them out in the classification. For example, gambling addiction is included in the ICD but not in the DSM.

This is where academic science differs: there are some researchers who defend the existence of a number of non-chemical addictions who believe that they are worth including in the classification. There are those who believe that they do not exist or that there is no need to include them in the classifications. And each side has its own rationale.

In terms of research, there are disorders like schizophrenia, which have been around since Krepelin’s first classification. However, scientists do not have a clear answer whether it is a disorder, or whether it is a group of disorders that has similar symptomatology. Because many things remain unexplored. At the same time, the clinical picture, prognosis, etc. in schizophrenia is fairly well understood and there is no doubt that it is a disorder.

Disorders that have appeared relatively recently in classifications are more questionable, but not by researchers, but by people who have less to do with psychiatry. For example, Attention Deficit/Hyperactivity Disorder (ADHD) is not universally accepted as a disorder. There are disorders that are more part of popular culture rather than science. To these I would include multiple personality disorder. If it exists, it’s some sporadic cases, but it’s certainly not something common.

What should you do in case you have been misdiagnosed? As I heard, is this a regular problem? Is it difficult to dispute your diagnosis in Belarus and Europe?

Right or wrong diagnosis is a kind of philosophical question. How to understand that the diagnosis is wrong? Of course, there are cases when mistakes are obvious, when a person has some symptoms and is diagnosed with a completely different. But, again, these mistakes are not always clear to the person or his environment. It is often necessary that these doubts be confirmed by another specialist so that he can relate the symptom to the criteria on which a diagnosis can be made and the actual diagnosis. There are also always borderline, controversial cases. When it is clearly difficult to say which diagnosis would be correct. Any diagnosis of mental disorder that is made is ultimately not the truth in the last instance. It is an assumption by the doctor and the medical team as to what is going on with the person. The closer the diagnosis is to the standards of the classifications, the greater the chance that this assumption will meet the requirements of the classifications.

When the question of revising a diagnosis arises, it is difficult for me to say how it happens in Europe, I have not worked in European psychiatry. In Belarus, I think, as in much of the post-Soviet space, it is possible to dispute your diagnosis, but it is not easy.

Konstantin, photo from the personal archive of Konstantin Minkevich

There is a hierarchy in psychiatry. If a doctor or an institution of a higher level makes a diagnosis, its change at a lower level is unlikely to affect the possible social consequences of the existing diagnosis for a person. Therefore, the procedure for revising a diagnosis leads to the institution or doctor who made the diagnosis. For example, if the diagnosis is made in the Republican Scientific and Practical Centre for Mental Health, it will be reviewed only in the Republican Scientific and Practical Center for Mental Health.

A person who goes to revise a medical report can formally insist on it and he has the right to do so, but there is no guarantee that his diagnosis will be revised, of course. But at the same time one cannot say that the revision of a diagnosis is absolutely impossible in Belarus, it’s just that these are complicated procedures – both cancellation and revision. I have met such cases when a person’s diagnosis was cancelled 10 years after it was established.

In your opinion, is there stigmatisation of people with mental illness in society? To what extent has stigmatisation affected Belarusian and European society? What is it connected with?

Stigmatisation, of course, exists everywhere in the world. In Europe, Western Europe, I think it is less. There is more struggle against stigmatisation there, unlike in the post-Soviet countries. Belarus is not the worst place in this respect, but it is not the best either. What is stigmatisation connected with? Mainly due to lack of education, lack of information about mental disorders, their nature, course, peculiarities, etc.. People in general tend to be wary of those who are different from them, whether they are of a different race, religion, sexual orientation or have a mental disorder.

There is such a term “self-stigmatisation”. What is it associated with, and how to deal with it?

Self-stigmatisation is a continuation of stigmatisation, when a person with a mental disorder joins the stigma of society and unjustifiably singles himself out from society, giving himself non-existent negative characteristics.

The main way to deal with this phenomenon is education. Even a more appropriate word is enlightenment. Enlightening society at large and those people who suffer from mental disorders about what mental disorders are, how they manifest themselves; informing them that mental disorders are not a human defect. Instead of a simpler, cruder, more singling out people with mental disorders, a more realistic picture should be formed, implying that mental disorders come in different ways, have their own patterns of course, are episodic, and are permanent.

It is very important to know that with modern measures, proper treatment, accompaniment and social and family support, people with mental disorders can live their lives no worse than those who do not have them.

Konstantin, photo from the personal archive of Konstantin Minkevich

Society often builds barriers to everyone who is not like them: immigrants, outsiders, etc. People with mental illness are no exception, why are they feared?

As I said, people are characterised by a wary, anxious attitude towards those who are unlike themselves. This is a rich, historically evolutionarily complex situation: any outsider can turn out to be an enemy, they are less understood and less predictable. People with mental illness are also less understandable and predictable. And, first of all, we are talking about more severe and visible disorders, such as schizophrenia. Also, people are used to simplifying entities, so it is difficult for them to understand the nuances, moments, complexities of various mental disorders, to realise that it is not a total change of the whole person, but more subtle things, some transient features, individual moments of his life, that mental disorders manifest themselves only in certain specific situations, etc..

Question about addiction: is it a disease? Is the nature of addiction internal or external factors? Is it possible to be cured of this disease or is it forever?

Addiction is usually referred to mental disorders, or rather to behavioural disorders in the first place, not just mental disorders, it is one group. As for factors, it is the same story as with other mental illnesses: heredity, predisposition, upbringing, etc. play a role.

In order for chemical dependence to occur, a person must use a substance from which he can potentially become dependent, this is obvious, it is impossible to become dependent on a substance without using it. However, the use itself does not guarantee the appearance of dependence, it all depends on the substance. There is a difference in the addictiveness of the substance: for nicotine or opiates the risk is extremely high, for benzodiazepines the risk is much lower, alcohol is rather somewhere in the middle.

It is difficult to say whether a person will be addicted to one substance or another. If there is a predisposition, one can be warned to be careful when using, well, or complete abstinence, if possible. One should not experiment with highly addictive substances.

Is there a cure? Again, the question is a bit philosophical. Addiction refers to chronic disorders, and chronic disorders (which are the main area of application of forces of modern medicine) by their nature should not be completely curable, we do not expect them to be, in the sense of how it happens in acute disorders, when a person was healthy, he gets sick, for example, flu, he gets sick for a while and is completely cured and that’s it, he does not have this disease in his body, if he gets sick again, it is another case of disease, for example, another strain of flu.

Chronic diseases are long-lasting and it is more difficult to define what the criteria for cure are and how appropriate it is to talk about cure rather than remission. In one case, if we are talking about chemical dependencies, the criterion of cure would probably be the resumption of the possibility of controlled use, which in most cases does not happen. Nevertheless, addiction, like any disorder, is treatable, therapeutic. And it can be put into remission. If this is impossible or difficult for some reason, harm reduction can be achieved, as in the case of opiate addiction, when methadone substitution therapy or nicotine substitution therapy – patches, gum – is prescribed.