The Six Levels of Mental Disorders
Recently, a person with a mental disorder in Xiaowu Township, Xiaochang County, Hubei Province, attacked people with a knife during an episode, killing eight people, including his mother, in a devastating incident. The patient, a 53-year-old man surnamed Lu, was preliminarily classified as a level-3 mental-disorder patient. He was in an acute episode at the time and was about to be sent to hospital, but before that could happen, the tragedy occurred. The incident has drawn wide public attention and become headline news; it is also one of the deadliest single attacks by a mentally ill person in China.
So what is a level-3 mental disorder? Mental disorders are generally classified into six levels according to the degree of impairment of social functioning.
1/Level 0: The patient's condition is mild; he can still care for himself and has only emotional problems that cause his own distress. There is essentially no dangerousness.
2/Level 1: During episodes, the patient's thinking and speech are disorganized; he shouts and screams, with disturbances of cognition, mood, and affect, disrupting other people's lives.
3/Level 2: During episodes, thinking and speech are disorganized, with cognitive, mood, and affective disturbances and violent tendencies, mostly confined to the family.
4/Level 3: During episodes, thinking and speech are disorganized, with cognitive, mood, and affective disturbances and violent tendencies both at home and in society. The patient ignores dissuasion and, once enraged, cannot be stopped.
5/Level 4: During episodes, the patient beats people, destroys property, or smashes public property, and dissuasion is ineffective.
6/Level 5: During episodes, the patient's behavior seriously threatens the personal safety of others. In addition to violent behavior, the patient is prone to arson and damage to public property, and dissuasion is ineffective.
How many people with mental disorders are there in China? The real number may be startling. On May 25, 2018, the National Health Commission's Disease Prevention and Control Bureau announced at a national work conference on management and treatment of severe mental disorders that, by the end of 2017, out of China's population of 1.39008 billion, 243.264 million people had a mental disorder, a total prevalence of 17.5%. Among them, more than 16 million had severe mental disorders, a prevalence exceeding 1%. And this number is still growing year by year.
Besides the Hubei knife attack, recent headlines have included a spate of jumpings from bridges in a certain city; those who jumped were also, medically speaking, mental-disorder patients. Overwhelmed by life's pressures and unable to regulate their emotions, they sank into pessimism and despair and ended their suffering through self-destruction — a great pity.
Mental disorders are related to both biological heredity and environmental influences. Some mild mental disorders, if not treated and helped in time, may develop into severe ones. For example, patients with depression are mostly at level 1/0 and pose little danger to society. But if, after onset, they are not taken seriously and are allowed to develop unchecked, they may progress into aggressive bipolar disorder.
Mental disorders follow certain patterns; mastering these patterns and hospitalizing patients in time can prevent tragedies. For example, a bipolar patient who suddenly talks much, makes many plans, or reaches out unusually closely to the outside world may seem to have become more active about life, but this is exactly when patients and families must be highly alert, because it is often a prodrome of a manic episode. The patient may soon enter mania, with cognitive disturbance; once in the manic phase, he or she will engage in a series of impulsive acts that bring loss to self, family, and society.
Except for the severely mentally ill, who are treated in psychiatric hospitals, most other patients live at home or wander the streets. Other family members in a household with a mentally ill relative need to learn professional knowledge about the illness and master certain skills in order to get along with the patient better. Patients themselves should also learn relevant knowledge to improve their quality of life.
Mental disorders are not a matter of the patient "not thinking straight." In the 21st century, if we still naively regard mental disorder as simply a matter of the patient not thinking optimistically enough, believing that if they just cheer up everything will be fine, then we are benighted and no better than illiterates. A mental disorder is first of all a disease of a damaged brain: the patient's brain structure, neurotransmitters, and cognition all differ from those of normal people. It requires professional assessment by a psychiatrist followed by comprehensive treatment combining physical therapy, medication, and psychological counseling.
But we are a developing country. Families of mentally ill patients are often poorer than average, and treatment of mental disorders is expensive, so most mentally ill patients do not receive family attention. Relatives usually think the patient simply has a bad personality or character flaw, and the public further interprets the patient's words and deeds as problems of character and morality. This causes severe delay between a patient's first episode and first psychiatric visit, and creates a strong "stigma of illness" that makes patients ashamed to seek care. Some patients never receive effective diagnosis or treatment in their lifetime; severe cases die by suicide or end up wandering the streets.
Generally speaking, if a person is chronically in a state of irritability, anxiety, depression, sadness, panic, or mental confusion, always feels misunderstood, is easily provoked by a trivial remark, has great difficulty building and maintaining relationships, frequently conflicts with those around him, or avoids contact with others, then that person's mental health is poor. Family members should pay more attention to such a relative. Some people are simply in a temporary stress-trauma state (caused by a broken relationship, job loss, overwork, or extreme fright), and with family companionship will naturally improve after a while. Others will experience recurring episodes that do not resolve on their own; these should seek medical attention promptly.
Some mental disorders are congenital. Because mental illness is heritable, more than half of mentally ill patients come from families with mental illness, indicating high heritability. For example, former British Prime Minister Winston Churchill, his father, and his grandfather all had depression; the famous writer Ernest Hemingway and his father also had depression; the great scientist Isaac Newton and his mother, and the philosopher Arthur Schopenhauer and his mother, were also mentally disordered.
Other mental disorders are acquired. The most famous acquired one is post-traumatic stress disorder (PTSD). It was first identified in Vietnam War veterans: many American soldiers who returned from Vietnam developed a series of psychiatric problems, which drew academic attention and promoted the development of psychiatry. John Rambo, the protagonist of the film First Blood starring Sylvester Stallone, is a Vietnam veteran with PTSD; environmental cues repeatedly awaken his traumatic battlefield experiences, plunging him into frenzy and driving him to kill at the slightest provocation.
Another American film, Psycho (1960), was the first film to take mental-disorder patients as its subject and has become a classic of cinema. Its protagonist, Norman, is a schizophrenic; under his mother's pathological upbringing, he split into two personalities — one his mother's, the other his own. Outwardly kind and polite, once he switches into the pathological personality, he becomes a murderer.
The novelist Fyodor Dostoevsky is renowned for his psychological portrayals; most protagonists in his works have mental disorders. These characters have long lived troubled lives, suffered severe or prolonged abuse, and eventually formed pathological personalities. Dostoevsky himself had epilepsy, and epilepsy-induced mental disorder is one of the six major severe mental disorders. This particular experience let Dostoevsky understand pathological psychology deeply, giving his novels their unique character.
With medical progress, people have come to recognize that mental disorders, like the common cold or cancer, are a physical illness, not the patient "not thinking straight." Trying to reason with a truly mentally ill patient as if they were normal only pours oil on the fire; such persuasion cannot help and may instead stimulate the patient and worsen emotional reactions. Because mentally ill patients have innate brain-structure abnormalities or brain trauma, their thought patterns differ from normal people. They need both medication and professional help to sort out their cognition; only this comprehensive treatment can calm their emotions.
So if there is a mentally ill patient in the family, relatives must not believe they can talk the patient into recovery. The best course is to take the patient to a professional mental health center. In addition, China has a dedicated Law on the Protection of Disabled Persons: severe mental disorders qualify as psychiatric disability, and the state provides a monthly subsidy (currently 320–400 yuan) to guarantee basic living. Psychiatric-disability patients also receive free treatment and living costs in psychiatric hospitals. This is a major support for severe mental-disorder patients living in poor families.
Mental disorders require the attention of all society. Only when everyone gives enough attention and care and takes mental disorders seriously can this problem be better addressed and the tragedies it causes be reduced. Over years of working with all kinds of patients, I have treated a large number of primary and secondary mental-disorder patients (having a chronic disease that one cannot self-heal, whether in oneself or a family member, is a major trigger) and have participated in many suicide interventions; I have a deep grasp of their harm. It goes without saying that medical staff, under heavy work pressure, are themselves a high-risk group for mental disorders: the prevalence of depression among doctors is twice the social average. Our own physical and mental health deserves equal attention.
Creating a harmonious and friendly social environment, advocating healthy lifestyles, improving individual emotion-regulation abilities, and promoting a more scientific public understanding of mental disorders are all effective ways to reduce their harm. Mental disorders affect the happiness of countless families; only when all of society acts together can we reduce their burden.