3. 3
Teaching and Learning Aims
• There is ignorance,
superstition, stigma and
fear around Mental Illness
• Aetiology, pathogenesis
diagnosis and treatment
are imperfect.
• There is a different
paradigm and a less
rigorous epidemiology
7. 7
Mental illness is common 6 in 10 women and 4 in 10 men
in Western Europe and North America will have a
significant mental illness during their lifetime
Mental illness can affect any one of us
Mental illness occurs in all societies and cultures
15. 15
The Classification of Mental Illness:
The Neuroses
Depression, Anxiety, Mania, Obsessions and compulsions
(usually the patient retains insight and orientation; they
experience deep distress and may commit suicide)
The Psychoses
Schizophrenia, puerperal psychosis
(the patient is disorientated, deluded, and lacking in insight)
The Dementias
Progressive deterioration with loss of recent memory and
deterioration of a normal personality,
They may be primary or more commonly secondary to
another condition e.g. alcohol, stroke
17. 17
The Classification of Mental Illness
Drug Problems
Addictive drugs, (Heroin, Cocaine, Amphetamines,) alcohol
and drug related illness-psychosis, delirium and dementia
Personality Disorders
A personality and behaviour that is damaging to the individual
and/or to society and which is not tolerated by the dominant
culture
Mental subnormality/learning disorders:
Problems around intelligence and ability to learn on the basis
of teaching and experience
23. 23
Canst thou not minister to a mind diseased,
Pluck from the memory a rooted sorrow,
Raze out the written troubles of the brain,
And with some sweet oblivious antidote
Cleanse the stuff’d bosom of that perilous stuff
Which weighs upon the heart?
Macbeth
Editor's Notes
Mental health consists in mood and behaviour appropriate to the situation based upon
INSIGHT
UNDERSTANDING
INTELLIGENCE
PREVIOUS EXPERIENCE
The behaviour will be culturally determined and appropriate to the norms of the society.Thus the response to the death of a severely handicapped child by a mother in Europe may be quite different to that of a refugee mother in Afghanistan with such a child to care for.
The behaviour, the response may be different but in each case quite appropriate
As a clinician, mainly in Primary care, I struggled to care for people with their distress and anxiety around broken relationships, shortage of money and depressing jobs-even unemployment.
I came to the conclusion that Marital Breakdown was a major Public Health Problem.
Mental stress and distress is part of the human predicament, remarkably most of the time human beings survive and recover from incredible experiences-Auschwitz, Rwanda, Childhood abuse.
When the ability to cope is pushed too far then mental anguish and illness may result.
It is then helpful to try to define mental illness and measure the size and shape of the problem, to identify the determinants, to provide rational therapy and effective prevention.
Mental health and illness in the 21st century is in the same position that Clinical Medicine occupied in the late 19th century-the science imperfect, the laboratory of limited usefulness, the therapeutic armamentarium limited and the mode of action of therapies ill understood.
In the 19th Century there was however a considerable skill in history taking, examination and the description of disease.
This ignorance with diagnosis based on clinical skills and treatment on empiricism is changing rapidly. Today there is an increased understanding of brain biochemistry and the ability to visualize brain-activity in health and disease with Computerized Tomography (CT scans), Magnetic Resonance imaging ( MRI) and Positron Emission Tomography(PET). In turn this leads to a rational therapeutics
It is much more difficult to define mental illness than renal failure. There is no convenient laboratory test to distinguish the ill from the not ill.
A rational,pragmatic approach has been effective and even successful with the advent of new medications in the 1950’s , the closure of large institutions-the feared asylums, the development of community support services, a realisation of the chronicity of illness and the need for treatment over months or years.
We all fear madness, for too long psychiatric illness happened to other people but not to us, it was somehow their own fault or failure. Slowly we are learning that we are all vulnerable and during a lifetime nearly half of us will suffer from a significant mental illness
The mode of action of the therapies used-often successfully-in psychiatric practice are ill understood
e.g. Lithium in manic depression,amphetamines in hyperactivity syndrome
Electro-convulsive therapy in depression
Psycho-analysis and psychotherapy
Mental illness is becoming a greater problem in health care
perhaps because of
The particular pattern of modern urban life-work pressures, social demands,the fear of failure,unemployment, loneliness…..
The burden of poverty-2 billion people in the world live on less than 2$ per day
The increasing proportion of elderly people in the population with problems around depression, anxiety and dementia
Mental illness is a major contributor to the Global Burden of Disease
Mental illness accounts for 12% of the disease burden of the world
Mental illness is an increasing problem in prevalence and severity
The % of Disability Lost Years from Mental illness is increasing
In 1990-10% of all DALY’s
In 2000-12% of all DALY’s
In 2020-15% of all DALY’s
Mental illness can be treated effectively
Mental illness can be prevented
At any one time 300-400 million people in the world have a significant mental illness i.e. 5%
Mental health and mental illness is Everybody’s Business-by our actions, activities, deeds and omissions we make the world a better or worse place for others as well as ourselves.
The Golden Rule
“Do to others as you would have them do to you”
The Christian Paradigm
“Love your neighbour as yourself”
“No man is an island.
Ask not for whom the bell tolls.
It tolls for thee” John Donne
Human beings are a mix of Body-Mind-Spirit,and health is maintaining a balance between the three. A disturbance in one may provoke imbalance and disturbance in other parts of the triad.
Even the most physical of diseases will have implications for Mental health-a man who breaks his leg and is laid up for several weeks will be concerned and anxious about his job and his family. Will he be able to return to work and be as fit and able as before? The frightened, anxious person may have anginal attacks, sleep poorly, smoke heavily and abuse alcohol in attempt to anaesthetize some of that pain and distress.
Mental Health is at the heart of the brain/mind interface. Man among all the animals has a consciousness of himself, a curiosity about his world and a spark of the divine in that there is a constant and restless searching for good, truth, god…..He is aware of good and evil and believes in his capacity to make free choice.
The body is there to support the mind and spirit.The human body is a superb machine;it culminates in the brain and arguably it exists for this purpose above all else.Yet there is interaction between mind and body-we are influenced by the biological imperatives-maternal instinct, self preservation, food, sex;our bodies require to be groomed, fed and clothed. A physical illness, a disturbance to our “internal environment”-a change in body temperature, blood sugar, pH may provoke delusion, hallucination or epileptiform convulsions.
Personality will be reflected in behaviour and predilection to a particular mental state.
E.g. Introvert/Extrovert
Practical men and Visionaries
Idle and industrious
Thinkers and Doers
It is possible to do a Personality inventory and classify human beings quite accurately into their predominant personality type and to predict their preferred mode of behaviour in a particular set of circumstances
Why do we behave as we do-the range of human behaviour from Ape to Angel?
Is this a consequence of our innate personality, the situation in which we are with its pressures for uniformity or expectation.(Doctors are expected to stay calm and assert authority in very frightening situations), or previous experience and our own free choice?
To what extent are we influenced by our subconscious mind and by the great stories, ideas and myths of the world? E.g. Good versus Evil
Sigmund Freud,(1856-1939) a man whose ideas still ring controversially and passionately round the world suggested that there are three components in our make -up.
The super-ego (The parent figure) the ideal behaviour we strive for, rational, kindly, moral,thoughtful, logical, just ,fair……..
The ego (The adult figure) reality, a bit messy, trying to make sense of things, sometimes doing evil by mistake when trying to do good, frail and making mistakes but trying again.
The Id (the child) the uncontrolled fun loving primitive, full of lusts and instincts, demanding instant gratification, selfish, poor attention span
It is postulated that when confronted with stressful and painful situations or of deep feelings coming from the id of which we may feel deeply ashamed, we place /push these “off limits” thoughts and ideas into our subconscious in an attempt to forget not only about them but also that we have ever experienced them.
The subconscious mind and its feelings, ideas and problems may surface when we are confronted with a situation, which has resemblance, perhaps, to a previous unhappy and unresolved problem. This produces deep distress and sometimes further inappropriate behaviour. This may manifest in frank mental illness-depression, anxiety, delusion and psychosis
The Classification is arbitrary and essentially clinical. Diagnosis can be difficult and it may take time to be certain of distinguishing between Schizophrenia and Drug intoxication.
A major distinction , based upon the gravity of symptoms and the patient’s grasp upon reality is between the Neuroses and the Psychoses.
The Neurotic patient is aware of himself and his surroundings and is orientated in time and place. He has some insight into his condition.
The Psychotic patient is prey to delusions and hallucinations. He hears voices inside his head, he sees visions, he is deeply disturbed by the threatening world he sees and hears all about him where the most innocent action is construed as a personal attack.
A severely depressed person may become Psychotic although the affective disorders are more often neuroses
The task of Psychiatry is to try to classify mental illness into recognisable categories, to describe the clinical manifestations and epidemiology and to offer treatment options.
The skill is in clinical description and eliciting mood, behaviour, intellectual functioning and insight.
Treatment is pragmatic and often empirical.
In no other branch of medicine is the attitude, personality, cultural awareness, sensitivity and skill of the doctor more critical in
1.eliciting the history and conducting an examination of the “mind and spirit”
2.In helping the patient to understand the problems, to put the problems in to words and to examine options
3.To encourage and support the patient in behavioural change, to give the patient confidence in his/her ability to cope
The boundaries of Psychiatry
There is debate as to the role of Psychiatry in treating disorders of addiction.Psychiatrists are often involved because no other branch of medicine is interested or concerned; but the “medical model” is not so readily accepted and treatment is often unsuccessful.
People with Personality disorders are not seen to be the problem of psychiatry.
The problems are not treatable in the conventional medical sense. Psychiatrists are often asked to play a custodial rather than therapeutic role which is resented.
There are several well known factors which determine mental illness
Infections -Syphilis, HIV
Trauma-post head injury
Neoplasms-Brain tumours may present with personality change and mental distress
Genetics-Huntington’s chorea and dementia
Vascular-post stroke or intermittent arterial embolism
Drug abuse-Korsakoff’s psychosis in chronic alcoholics
but often there is no obvious cause
It is increasingly recognised that mental illness is a chronic and relapsing condition and that treatment may,in consequence be for months, years or even for life.
Previously many patients spent weary years in long-stay care-the mental asylums. They became institutionalised. There was no effective therapy and they were simply looked after in a simple routine, the worst of their symptoms often “burned out’ but by that time they had lost all contact with family, friends ,work etc.
Now many more patients can be cared for in the community after discharge from hospital. They may never need hospital admission or attend day hospital as part of therapy. Community care is expensive in the professional time and effort to look after patients in a social setting rather than an institution. There are more demands upon friends, family and social services but the results are much better. Long term medication, supervised therapy and intense rehabilitation all play their part.
Medication:Anti-depressants, anti-psychotics, anxiolytics, mood stabilisers
Electro-convulsive therapy (ECT)
Psychotherapy-individuala nd group,Psychoanalysis
Psychosurgery-Prefrontal leucotomy, temporal lobe surgery
Mental illness is preventable, mental illness can be effectively treated
The social networks are important in
Primary prevention;
Having a home, being married, having work, friends,beliefs
-a positive self image
Secondary prevention;
early diagnosis,effective treatment, community support
Tertiary prevention;
long term management and care in the community
A gravely mentally ill person may no longer be responsible for their actions.
They may be a danger to themselves-suicide or to others-homicide
It may be necessary to admit such a person, compulsorily-under legal section-to hospital for treatment and care. This is a major step and has to be closely guarded against abuse for to deprive a fellow human being of his/her liberty, perhaps for long periods and force treatment upon an unwilling patient denies an essential human right.
In criminal cases a decision needs to be made if the criminal ,at the time of the deed was in full understanding of the situation and appreciated the gravity of the offence. Very roughly would he/she have still done this action at this time if a policeman had been standing beside him.
Elderly demented patients may no longer be able to manage their own affairs and it may be necessary for the state or a responsible person to take over this task-the power of attorney.
In each case the psychiatric voice is crucial
Mental handicap or learning disability is about those people in the lowest 3% of the IQ curve.
The incidence of severe Mental Handicap is 3 per 1,000 (IQ < 50) and may be the consequence of genetic abnormality, chromosome disorders or severe brain damage.
Moderate handicap (IQ 50-70) is more common among poor deprived populations; with effective parenting, education and care such people can learn to live and live well; without this they will decline into a quasi animal state with associated behavioural problems and frank mental illness
People with learning disability often have other congenital problems-cardiac, orthopaedic, neurological, ophthalmic.
The cause of much mental handicap is unknown The setting up of registers of mentally handicapped people enables the effective provision of health, social and educational services determined by and tailored to their needs.
WHO Website http://www.who.int/whr/2001/main/en/contents.htm
World Health reports 2001
Mental health,New understanding, New hope
