Mental health and disorder Flashcards
What is mental health?
-Mental health is a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, and is able to make a contribution to his or her community
-Not just the absence of psychological problems
-About half of mental disorders begin before age 14
Worldwide, ~800,000 people die by suicide every year
-Mental disorders increase the risk for physical disorders
-Many health conditions increase the risk for mental disorders
-Stigma prevents many people for seeking mental health care
-There are great inequities in the availability of mental health professional across the world
What is a ‘Mental Disorder’?
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (the DSM-5) is used as the current authoritative listing of mental disorders. It broadly defines mental disorder as:
“clinically significant disturbance in an individual’s cognition, emotion regulation or behaviour…usually associated with significant distress or disability in social, occupational or other important activities”
What is not a Mental Disorder?
The DSM-5 goes on to define what does not constitute a mental disorder:
“an expectable or culturally approved response to a common stressor or loss, such as the death of a love one, is not a mental disorder.”
Categorical vs Dimensional Classification
Categorical
Better clinical and administrative utility - clinicians are often required to make dichotomous decisions.
Easier communication
Dimensional
Closely model lack of sharp boundaries between disorders, between disorders and normality
Have greater capacity to detect change, facilitate monitoring
Can develop treatment-relevant symptom targets- not simply aiming at resolution of disorder (most treatments actually target symptoms, not disorders).
Why Diagnose or Classify Mental Health Issues?
Communication: among clinicians, between science and practice
Clinical: facilitate identification of treatment, and prevention of mental disorders, descriptive of experience, possible etiology and prognosis.
Research: test treatment efficacy and understand etiology
Education: teach psychopathology
Information Management: measure and pay for care
Terminology: Descriptive psychopathology Signs
-objective findings observed by a clinician
Accelerated speech
Poor eye contact
Terminology: Descriptive psychopathology Symptoms
-subjective complaints reported someone experiencing mental health issues.
Low mood
Derealisation
Terminology: Descriptive psychopathology
Syndrome
signs, symptoms and events that occur in a particular pattern and indicate the existence of a disorder
Terminology: Descriptive psychopathology Disorder
A syndrome which can be discriminated from other syndromes;
To be labelled a disorder means there is a distinct course to the syndrome and the age and gender characteristics of the disorder have been described. In some cases prognosis may also be known.
Terminology: Descriptive psychopathology Disease
For a disorder to be labelled a disease, there has to be indications of abnormal physiological processes or structural abnormalities, eg. multi-infarct dementia.
DSM5 Diagnostic Approach
Establish boundary with no mental disorder
Clinical Significance/Cultural Sanction. E.g bereavement vs clinically significant depression
Determine specific primary disorder(s)
Multiple diagnoses possible
Add subtypes/specifiers severity (mild moderate, severe – with or without psychotic features) treatment relevant (poor insight, atypical, etc.) longitudinal course (with/without full inter-episode recovery, seasonal pattern)
Structured Interview
Questions closely mapping onto DSM Diagnostic Criteria.
Screening Section
Detailed assessment sections for each Disorder Category – Individual Disorders
Most widely used: Structured Clinical Interview for DSM Disorders (SCID)
Some other good alternatives, such as the Mini International Neuropsychiatric Interview
Clinical staging model
Model adopted from cancer staging (stages reflecting disease – here disorder – progression).
Based on observations by McGorry and Jackson in schizophrenia.
Focus on identifying those at risk and facilitating early intervention.
Goal of clinical staging model
In most cases, mental disorders develop over time with worsening severity
Staging model aims to define various stages of the development of disorder;
Preventive focus: central goal is to stop emergence of first episode of disorder.
If complete prevention is not possible, then the aim is to prevent progression to later stage, prevent worsening and poor prognosis
Also aims to use more universal interventions that are less costly, less harmful and less intense at earliest stages.
Transdiagnostic model
A move away from notion that each type of mental illness is associated with unique underlying cognitive and potentially neurological factors;
Recognition of shared aetiological and maintenance factors;
May account for high levels of comorbidity between disorders - such as anxiety and depressive disorders
May also provide an explanation why diagnostic specific therapies not effective for all sufferers;
Example - repetitive negative automatic thoughts and anxiety/depression;
Example – perfectionism related to depression, anxiety, eating disorders and some personality disorders.
What mental illness stigma is
the negative or discriminatory attitudes about mental illness
Impacts of stigma about mental illness
Significant barrier to accessing mental health treatment and support, particularly where stigma and social proximity are high.
Internalization of stigma has a negative impact on mental health. For example, reduced self-esteem.
Elements of stigma can impact upon important opportunities across life and psychosocial activities that support recovery.
Levels of Stigma
Taxanomy 4 level model:
- Structural
- public
- personal
- Associate
Structural Stigma
Structural Stigma refers to ingrained stigma manifest at the societal level. Structural Stigma:
is maintained by societal institutions (both government, religious, and private) through policy, law, and prescribed ideologies that restrict opportunities for particular groups.
varies considerably across societies, time, and topics.
applies to mental illness but also extends beyond it to other issues. For example, HIV-AIDS in the 1980’s.
: Public Stigma
Public Stigma refers to stigma exhibited by the public towards those with a mental disorder. Public Stigma:
Manifests in three ways:
Stereotyped attitudes and beliefs. e.g. someone is ‘less than’ – manifest through devaluing language.
Prejudicial emotional responses. e.g. fear.
Discriminatory behaviours. e.g. avoidance of interaction or social exclusion.
Is thought to be particularly harmful, and the driving force behind other aspects of stigma
Self-Stigma
Self-stigma describes how societal and interpersonal stigmatized attitudes, beliefs and behaviour affect individuals. Self-stigma includes:
Direct negative effects and outcomes of stigma. For example: employment or ill-treatment, even within the mental health care system.
Fear or anticipation of stigma, driven by an awareness of public stigma.
Internalization of public stigma
Stigma by Association
Stigma by association is experienced by those associated with someone experiencing a mental disorder. Stigma by association involves aspects of:
Public stigma: expressed negative attitudes and beliefs towards a person associated with someone experiencing a mental disorder
Self-stigma: fear of negative reactions and internalised stigma as regards association with person with a mental disorder.
Mental illness stigma research methods
Often, stigma research involves presentation of vignettes: stories about a person experiencing symptoms of mental disorder.
Vignettes can be written such that they manipulate variables of interest. For example, symptoms, signs or mental disorder labels.
After reading a vignette, participants complete questionnaires. These vignettes assess participants’ stigmatized attitudes and beliefs about the protagonist in vignette.
Attribution Questionnaire
Question revolving 6 Factors Fear/Dangerousness Help/Interact Responsibility Forcing Treatment Empathy Negative Emotion
Effective approaches to stigma reduction
Approaches to stigma reduction that are well-established to be effective include:
Contact: being in contact with someone with mental illness. Positive for both parties and particularly effective for addressing stigma in adulthood.
Education: being educated about mental illness.
This makes sense as familiarity with mental illness is well-established to be associated with decreased stigmatized attitudes and beliefs.
Education-based intervention
Education about mental illness influences stigma reduction by:
Increasing knowledge and understanding. For example, mental disorder, biological contributions, and blame attributions.
Dispelling myth. For example, the violence myth – fear and dangerousness.
Opening societal discourse decreases self-stigma. Observing that it is okay to experience and talk about mental illness. This in turn increases the likelihood of help-seeking, and in turn, recovery.
Definition of Mood, affect and mood disorder
Mood refers to a persons sustained experience of emotion.
Affect refers to the immediate experience and expression of emotion.
Helpful hint: Mood is to affect as climate is to (Melbournian) weather.
Mood disorders (according to DSM-5) involve a depression or elevation of mood as the primary disturbance. Can have other abnormalities (psychosis, anxiety, etc.)
DSM-5 Major Depressive Episode Criteria
Five or more symptoms present for ≥ 2 weeks
Depressed mood
Anhedonia
Decrease or increase in appetite OR significant weight loss or gain
Persistently increased or decreased sleep
Psychomotor agitation or retardation
Fatigue or low energy
Feelings of worthlessness or inappropriate guilt
Decreased concentration or indecisiveness
Recurrent thoughts of death, suicidal ideation, or suicide attempt
DSM-5 Major Depressive Episode Specifiers
Psychotic features (mood congruent or mood incongruent)
Melancholic features
Catatonic features
Postpartum onset
Anxious distress
Seasonal pattern (Seasonal Affective Disorder [SAD] or winter depression)
DSM-5 Major Depressive Disorder Criteria
Presence of a major depressive episode
Episode not better explained by another diagnosis
NO HISTORY of mania, hypomania, or mixed episode (unless substance or medical illness related)
Epidemiology of depression
6.2% of Australians aged between 18-65 meet criteria for MDE/MDD in a 12-month period. The same goes for 2.8% of Australians aged between 4-17.
Lifetime risk greater for biological females than males.
Family history of MDD increases risk 1.5x-3x
Up to 20%-25% of patients with major medical comorbidity (CVA, diabetes, cancer) will develop MDD
Often comorbid with one or more anxiety disorders
Epidemiology of Anxiety Disorders
One in seven Australians is currently experiencing an anxiety disorder.
14.4% of Australians aged 16 to 85 have experienced an anxiety disorder in the last 12 months.
One quarter of Australians will experience an anxiety condition during their lifetime.
26.3% of Australians aged 16 to 85 have experienced an anxiety disorder.
One in six Australians is currently experiencing anxiety or depression or both.
17.0% of Australians aged 16 to 85 have experienced an anxiety and/or mood disorder in the past 12 months.
Panic Disorder*
Recurrent unexpected panic attacks and for a one-month period or more of:
Persistent worry about having additional attacks
Worry about the implications of the attacks
Significant change in behavior because of the attacks
DSM-5 Panic Attack Criteria
A discrete period of intense fear in which 4 of the following Symptoms abruptly develop and peak within 10 minutes: Palpitations or rapid heart rate Sweating Trembling or shaking Shortness of breath Feeling of choking Chest pain or discomfort Chills or hot flushes Nausea Feeling dizzy or faint Derealization or depersonalization Fear of loss of control or going crazy Fear of dying Paresthesias
Panic disorder epidemiology
1-3% of general population; 5-10% of primary care patients —Onset in teens or early 20’s
Female: male 2-3:1
30-50% people affected will have agoraphobia
avoidance of situations where escape would be difficult
50-60% have lifetime major depression
one third with current depression
20-25% have history of substance dependence
Generalized Anxiety Disorder
People living with GAD experience:
Excessive worry more days than not for at least 6 months about a number of events difficult to control the worry.
3 or more of the following symptoms:
restlessness, easily fatigued, difficulty concentrating, irritable, muscle tension, sleep disturbance
Generalized Anxiety Disorder Epidemiology
4-7% of general population
Typical onset in childhood or adolescence
Female at more risk than males
2 to 1
Generalized Anxiety DisorderCo-Morbidity
90% have at least one other lifetime ‘Axis I’ disorder (such as panic disorder or depression. Not neurodevelopmental or personality disorders, although this is possible)
66% have another current such disorder
Worse prognosis over 5 years than panic disorder
Posttraumatic Stress Disorder
The person was exposed to a traumatic event and both of the following were present:
The event involved actual or threatened death or serious injury to self or others
(note conceptualization broadening)
The person’s response involved intense fear, helplessness or horror
Duration of symptoms is >1 month and cause significant distress or impairment in functioning
PTSD continued
The traumatic event is reexperienced via:
recurrent recollections of the event,
nightmares,
flashbacks, intense physiologic distress or physiological reactivity at exposure to cues of the event
Persistent symptoms of increased arousal marked by two or more of the following:
sleep difficulty,
irritability or anger,
difficulty concentrating, hypervigilance,
exaggerated startle response
Persistent avoidance behaviors
Avoidance behaviors are any actions a person takes to escape from difficult thoughts and feelings
Persistent avoidance behaviors marked by three or more of the following:
thoughts about the trauma, activities, places or people that arouse recollections of the trauma,
-inability to recall aspects of the trauma,
-diminished interest in activities,
-feeling of detachment from others,
-restricted range of affect,
-sense of foreshortened future
PTSD Epidemiology
7-9% of general population 60-80% of trauma victims 30% of combat veterans 50-80% of sexual assault victims Increased risk in women, younger people Risk increases with “dose” of trauma, lack of social support, pre-existing mental health issues
Explaining Depression
-The Tripartite Model of Depression and Anxiety (Clark & Watson, 1991)( underlying dimesion lead to symtomp)
-Hi-Top and the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders( internalization of high order dimesion)
-Biopsychosocial approach( cause by both internal and external factor)
-Behavioural Model of Depression( operant conditioning)
-
The ABC Cognitive Model of Emotion and Behaviour
A = Activating Event
What was happening when negative feelings where experienced.
B = Belief
Beliefs or thoughts about the Activating Event
C = Consequence
Feelings (emotions and physiological experience of emotion)
Behaviour performed
Beck’s Cognitive Model of Depression
Schema (beliefs, rules and assumptions) based on early experience
Negative events establish negative/dysfunctional schema
Critical incidents trigger negative schema – governs information processing
Activation of schema leads to negative automatic thoughts (NATs)
The Psychoses - Definition
The term ‘psychosis’ is an umbrella term meaning ‘out of touch with reality’.
Can refer to a variety of clusters of symptoms.
These symptoms can occur not only in schizophrenia spectrum disorders, but also in a range of disorders including:
– organic presentations like dementia.
– Substance use: amphetamine psychosis, and so on.
At the disorder level, psychosis refers to a group of disorders distinguished from one another in terms of:
• symptom configuration (e.g., delusional disorder versus schizophrenia).
– Non-bizarre vs bizarre delusion
• duration (e.g., schizophrenia versus schizophreniform
disorder)– < or > than 6 months
• relative pervasiveness -
schizophrenia
The term ‘schizophrenia’ refers to “split mindedness” or “a mind torn asunder” (Bleuler).
• Schizophrenia it is not multiple personalities as is commonly perceived (DID).
Schizophrenia involves disruption in various aspects of perceiving, thinking, feeling and behaviour. Phenomena associated with schizophrenia can be classified into two major groups of symptoms – positive symptoms and negative symptoms
• Positive symptoms – additive to normal experience.
• Negative symptoms – deficit in normal function.
The Psychoses - Symptoms
Positive symptoms
Hallucinations
• A percept in the absence of environmental stimuli. Hallucinations occur in any sensory modality, of which auditory is the most common then visual.
Delusions
• A false belief. Both “bizarre” and “non-bizarre”.
• Persecutory
• Ideas (delusions) of reference
• Grandiose (plus religious)
• Somatic delusions
• Passivity phenomena, e.g., thought insertion, thought withdrawal, thought broadcasting, delusions of control (made actions, made feelings, made impulses), mind reading.
Positive thought disorder
Clanging - speech pattern based on phonological association
rather than semantic or syntactic.
Circumstantiality – Speech including unnecessary or
irrelevant detail. Goal is eventually reached.
Flight of ideas - Sequence of loosely associated concepts are
articulated. Sometimes rapidly changing from topic to topic.
Derailment - speech train steers off-topic to unrelated things.
Incoherence - word salad. Incomprehensible speech.
Pressure of speech - excessive spontaneous speech production
and rapid rate. Difficult to interrupt.
Negative symptoms
Avolition - lack of motivation to achieve goals
Alogia (negative thought disorder) - includes poverty of speech(less speech than normal), poverty of content of speech (less content than normal - vague), latency of speech and thought
blocking
Anhedonia (inability to experience pleasure)
Affective flattening - dulled emotional expression.
Inattention – disturbance in selective attention.
other sysmptom of schriso
Catatonia – immobility, waxy flexibility, excitement
Incongruent or inappropriate affect – Display incongruent with person’s emotion or inappropriate to context.
Bizarre behaviour – No rational basis.
DSM-5 Schizophrenia Diagnostic Criteria
A. Two or more of the following for a significant portion of time for a 1-month period:
• Delusion
• Hallucination
• Disorganized speech
• Grossly disorganized or catatonic behaviour
• Negative symptoms
B. For a significant proportion of time since onset, disturbance in functioning (self-care, interpersonal, work etc).
C. Continuous signs of disturbance for at least 6 months, with at least one month of active symptoms
D. Schizoaffective disorder/Bipolar ruled out – No mania/mood disturbance or only briefly.
E. Rule out substance or medical condition.
Specify if:
-First episode, currently in:
- acute episode, partial or full remission
-Multiple episodes, currently in:
- acute episode, partial or full remission
-Continuous
-Also – severity of primary symptoms
Schizophrenia - Facts and Figure
Prevalence of schizophrenia is about 1% world wide with some variation in certain regions, e.g, parts of Ireland and Croatia where rates are 2% or more
Sex ratio is 1 male:1 female - but males have an earlier onset in later teens to early 20s
Carries significant disability and handicap in many domains of functioning`
History of schizophrenia
• Descriptions of schizophrenia-like disorders occur
throughout historical and religious texts.
• But when was the first purposeful description?
Benedict Augustine Morel (1860) – ‘demence precoce’
The first attempt at a rigorous description of what we now know as
schizophrenia.
Based on observations of individuals displaying a set of symptoms
and experiencing early onset and deteriorating course.
Emil Kraepelin (1898) – ‘dementia praecox’
A refined and more formal definition
Emphasised early onset and deteriorating course
Differentiated from manic-depressive psychosis and other psychotic illnesses based on clusters of symptoms, onset, course, and outcome.
Symptoms emphasised were hallucinations, delusions, negativism, attentional difficulties, stereotypies, and emotional dysfunction
Paul Eugen Bleuler (1911) - ‘schizophrenia’
A broader definition
Disagreed with Kraepelin – based on his observation that schizophrenia does not necessarily display early onset, deteriorating course and therefore not characteristic of a dementia.
Emphasised breaking of associative threads in thought, affect and action – this seen as the core of the disorder.
Five “A”s were Bleuler’s primary symptoms.
Disturbances in association (cognition); Disturbances in affect;
Ambivalence (conflicting thoughts/feeling
Schneider (1959)
- emphasised ‘first rank symptoms’ and
made the diagnosis on cross section (deemed duration
criteria not necessary!) .
11 first rank symptoms: Hearing one’s voice out loud;
hallucinatory voices talking about him or her; hallucinations
in the form of a running commentary; somatic hallucinations
produced by external agencies; thought withdrawal; thought
insertion; thought broadcasting; delusional perception (ideas
of reference); made feelings, made actions; made impulses.
Problems with Schneider’s approach: these symptoms are
not specific to schizophrenia, found in bipolar disorder too!
Cross-sectional diagnosis a problem too!
Patrick McGorry (late 1980s present).
Over-focus on chronic samples who are only representative of very poor outcome patients and are contaminated by institutionalisation, medication side-effects, etc.
Perhaps we have a biased view of the disorder as a result, especially in terms of outcome.
Need to prospectively study first-episode patients and prodromal patients
Richard Bentall (1990’s - present).
Need to study psychotic symptoms individually, not schizophrenia
as a construct.
The Psychoses – Aetiological Theories
Expressed Negative Emotion
Stress-vulnerability model
Biological models
Example: Genetics including gene-environment
interactions
Expressed Emotion (EE) is a form of family communication
characterised by high levels of criticism, hostility, and emotional overinvolvement that has been found to predict relapse in individuals with
schizophrenia
Personality and Mental Health Issues
Three ways personality relates to mental health issues and disorder:
Vulnerability
Personality disorder
Other personality-related disorder
Vulnerability
People differ in susceptibility to mental health issues and disorders
Genes
Environmental stress
Personality
Rarely does one factor work alone
Genetic effects operate via personality
Genetic effects require environmental contribution
Environmental effects require genetic vulnerability
Diathesis-stress models
Most mental disorders involve the combined action of a personality vulnerability (‘diathesis’) and environmental stress.
From this ‘Diathesis-Stress’ persective:
ーNo disorder without diathesis
-No expression of diathesis without stress
-Both diathesis & stress vary by degrees
-Level of stress required to trigger disorder depends on degree of diathesis
Stress may come in different forms
-Traumatic experiences
-Major life changes (including positive)
-Accumulation of ‘hassles’
-Some diatheses may require specific types of stressor
Specific diatheses: depression
-Dependency (interpersonal sensitivity) Susceptibility to interpersonal stressors
-Autonomy (personal achievement) Susceptibility to achievement stressors
-Self-criticism
-Pessimistic attributional style
Internal = low self-esteem
Stable = hopelessness
Global = helplessness
Specific diatheses: schizophrenia
Schizotypy Social anhedonia Physical anhedonia Perceptual aberration Magical thinking This diathesis may be typological Non-schizotypes may be at zero risk of schizophrenia (a subject of ongoing debate in the literature).
Personality disorders
Some personality attributes can be extreme, inflexible & maladaptive
These can be diagnosed as ‘personality disorders’
10 disorders currently recognized, e.g. …
“Odd” cluster
Dramatic cluster
Anxious cluster
Personality Disorders – Odd Cluster
Paranoid personality disorder: easily slighted; suspicious; bears grudges; reads hidden meanings onto benign remarks; questions loyalty of others; expects to be exploited
Personality Disorder – Dramatic Cluster
Borderline personality disorder: unstable but intense relationships; impulsivity; affective instability; inappropriate and intense anger; recurrent suicidality or self-mutilation; identity disturbance; chronic feelings of emptiness or boredom; frantic attempts to avoid real or imagined abandonment;
Personality Disorder – Anxious Cluster
Obsessive compulsive personality disorder: perfectionistic and this interferes with task performance; preoccupied with rules, details, etc; excessively devoted to work; indecisive, can’t complete tasks; restricted expression of affection; lack of generosity in time, money or gifts; hoards; overly conscientious, scrupulous and inflexible; unreasonable insistence that others do things exactly as s/he insists
Compulsions to perform behaviours in order to alleviate anxiety
Recurrent intrusive or inappropriate thoughts that cause anxiety
Dissociative Identity Disorder
Controversial diagnosis
≥ 2 distinct personalities that switch
1 host personality
1 or more ‘alters’
Alters may differ in many ways
Usually relatively uninhibited, often child-like
May have different allergies, optical prescriptions, handedness
Reasons for controversy of MPD
Apparent explosion of cases
Epidemic, prior under-diagnosis or fad?
Geographic focus on USA
Dramatic/theatrical quality of some people living with DID
Alterations in symptoms
Animals alters, increases in average number of alters
Questionable theories: ritual satanic abuse etc.
MDP theory tramatic
People with MPD usually report suffering extreme trauma
They tend to score high on ‘suggestibility’
Susceptibility to hypnosis
‘Dissociation’ as auto-hypnotic defence in which consciousness is ‘split’ during traumatic stress
Dissociation = ‘internal avoidance’ or compartmentalization
Patients become skilled in this defence & construct alter personalities to deal with complexities of experience
MDP theory social cognitive
The disorder may not be a naturally occurring splitting or fragmentation of the personality
It may instead be caused by therapists and culture
Therapists (poorly skilled) inadvertently may use leading questions in suggestible, unstable people may create apparently distinct personalities: iatrogenic
Culture sanctions this manner of expression of psychological distress through creative mass media and news.
Treatment implications involve ignoring post-traumatic symptomatology.
avoidant, schizoid and schizotypal
Avoidant: easily hurt by criticism, no close friends or confidants, unwilling to get involved with people unless certain of being liked, hyper-sensitive to embarrassment, avoids social settings
Schizoid: no desire for close friends, indifferent to praise and criticism, not caring what other people think, restricted range of affect
Schizotypal: ideas of reference, excessive social anxiety, unusual magical thinking, subtle hallucinatory phenomena, no close or confidants because of social anxiety and suspiciousness
