mtal health & distress

Define mental health

A state of wellbeing in which an individual realises their potential, can cope with normal stresses, can work productively and is able to contribute to their community

Describe distress

Has a wider scope than mental illness, experiences in a person’s internal life that are troubling, confusing or unusual

Define psychiatry

The medical speciality devoted to the study, diagnosis, treatment and prevention of mental disorders

Define clinical psychology

A relatively new branch of psychology which aims to use psychological theory, methods and clinical knowledge to understand, reduce stress and enhance/promote psychological wellbeing

How is mental illness viewed from the perspective of psychiatry

See mental disorder as a syndrome characterised by clinically significant disturbance in an individuals cognition, emotion regulation or behaviour that reflects a dysfunction in psychological, biological or developmental processes underlying mental function.

Mental disorders associated with significant distress in social, occupational activities

Outline mental/psychological distress from a psychological perspective

Psychological distress is a state of emotional suffering associated with stressors and demands that are difficult to cope with in daily life.

This may involve; perceived inability to cope, changes in emotional status, discomfort, communication of discomfort and harm

Outline categorical classifications of mental disorders

Assumes there is a sharp dissptinction between normal and abnormal, yes or no approach assuming all abnormal is distinct from normal.

E.g. mental disorders according to the DSM-5 are clinically significant behavioural or psychological patterns and must not be an expected response to common stressors

How do categorical classifications distinguish between normal and abnormal experiences?

• Social approach; activities or characteristics that are approved according to certain cultural norm vs disapproved

• Medical approach; activities or characteristics that contribute or endanger life and wellbeing

• Statistical approach; unusual or usual behaviours in a certain population

What is a limitation of categorical classifications of mental disorders

Leads to contradictions e.g. many mental health difficulties are statistically common but still cause harm

Outline dimensional or continuum approaches to the classification of mental health disorders

Do not presume a sharp divide between normal and abnormal, distressing experiences lie on a continuum of functioning, not just poor or good mental health.

MH is dynamic and fluctuates depending on things that happen to us - e.g. sharp increase in mental health difficulties in response to Covid-19

When do experiences become an issue according to the dimensional approach to mental health classification

• When present for a prolonged period of time without getting better

• Perceived as distressing and uncontrollable and the person cannot find useful ways to minimise or tolerate these experiences

• Cause disruption to social and occupational functioning, or more generally interfere with the persons goals and values

Outline the medical (biomedical) model of MH & distress

• Assumption that mental health difficulties are the result of physical problems e.g. abnormal brain function, chemical imbalance & should be treated medically

• Strong emphasis on biological accounts of mental health difficulties e.g. genetic contribution, brain anomalies etc

Outline the bio-psycho-social model

• Proposed by Engel as an alternative to biomedical models

• Biological, psychological and social determinants of mental health combined - complex interaction

• Interventions should address all these components

How do individuals with lived experience define recovery

Doesn’t necessarily mean the disappearance of symptoms, emphasis on personal recovery - e.g. building resilience, control over problems, ability to lead a meaningful life

Outline the DSM-5

• APA

• Diagnoses using an operational criteria & polythetic system ( characteristics shared by members in a group but not essential to be part of group)

Outline the ICD-11

• Published by WHO

• Physical and mental health

• Provides diagnostic descriptions and guidance but does not employ operational criteria

Uses of diagnostic manuals for health services and clinicians

• To facilitate clinical assessment

• To aid communication using common language

• To guide treatment decisions

• Facilitates research

Uses of diagnostic manuals for individuals who receive a diagnosis

• Gives a name to difficulties

• Allows individuals to look it up online

• Offers meaning, understanding and explanation

• Builds community

Outline the rosenhan experiment and its implications

Pseudo patients recieved diagnoses and weren’t able to leave as quickly as expected 8-52 days, limited treatment whilst admitted , whatever they did was taken as evidence of psychiatric disorder

Brings into question the validity of the classification system.

& follow up, hospital challenged to send more pseudo patients and identified 41/193 as false when there were none

Outline inter-rater reliability in diagnostic terms

Whether 2 clinicians will diagnose the same person with the same diagnostic category.

Measured with ‘kappa values’ 0.8 being perfect reliability, 0.2-0.4 acceptable

What does validity mean within a classification system? What does research suggest about this?

To be valid the classification system should be useful in predicting course and outcome to that particular condition

Research suggests that specific diagnoses are not the best predictor of outcomes under many circumstances, presence and severity described during clinical assessments was more important.

Define construct validity & evidence

Do the symptoms of specific psychiatric diagnoses correlate with eachother? Evidence might suggest that they do not - diff clusters of symptoms of schizophrenia/psychotic symptoms, individuals with those symptoms could come under any of those clusters but present very different

So, those with same diagnosis may require very different support

Outline how comorbidity may bring into question validity

More than 50% of those diagnosed with a mental disorder in a given year meet the criteria for multiple diagnoses

Diagnoses therefore may not be distinct separate entities

How much is diagnosis used in ‘service entry criteria’ in the UK

Though commonly thought of as essential for helping mental health services decide on who to accept or decline as clients. However more services accept referrals on the basis of need, severity/complexity of distress and the skills of their staff

Why might diagnoses not be helpful for the individual?

• Labelling and stigma e.g. language from the biomedical model (disorder symptoms)

• Pathologizes normal responses

• Contributes to power imbalance between clients and clinicians

How might there be embedded culture bias in the diagnostic system?

‘Psy’ disciplines first developed in the 1800s, based on enlightenment ideas - institutional racism

Inequality in MH diagnosis and care e.g. schizophrenia diagnosed more frequently in black individuals

How is gender bias embedded in diagnostic systems?

Hysterical personality in the DSM until 1980, 75% of those given BPD diagnosis are female - link to childhood sexual abuse

• some researchers suggest that instead of seeing women’s distress as symptoms of BPD, we should understand the difficulties as a response to societal sexual violence and oppression

What may be the problem with adverse life experiences and diagnostic manuals?

Trauma only mentioned in PTSD diagnosis, few use ICD codes to record adversity - people may not receive support from underlying issues

How many adults have PTE (potentially traumatising experience)?

Most adults have one or more PTE, 90% of US adults , most people exposed to stressful/traumatic events do not develop a mental disorder

How do adverse experiences affect likelihood of having mental health difficulties?

Individuals with depression are 2.5-9x more likely to have experienced a major stressful life event before the first onset of depression

Define ‘events’ in terms of trauma

A predefined group of events or experiences, typically extremely stressful if experienced or witnessed

Define psychological/complex trauma

An emotional or physiological response to an intensely distressing event which can have lasting psychological, emotional and social impact

Define developmental trauma

Childhood trauma characterised by various forms of disregulation, but often doesn’t fit the PTSD criteria based on defined stressors (low or no recollection) and may not have some PTSD symptoms

When are stressful experiences more likely to lead to MH difficulties?

• Repeated/multiple or prolonged, when escape is difficult

• Interpersonal, involving people close to the individual

• Happen at critical developmental stage

Outline stress proliferation theory

A stressor or set of stressors expand or develop within and beyond a situation, result in new stressors not originally present, early life stressors may increase MH risk by creating further stressors

What is the prevalence of ACEs (adverse childhood experiences)

Experiencing +1 ACE is common among adults; in the UK it is 47% and in low and middle income countries it is more prevalent e.g. in China it is 75%

8% of UK adults have experienced 4+ ACEs, but there are gender differences e.g. females more likely to be subjected to sexual abuse

How do ACEs correlate with common MH difficulties

People exposed to childhood adversities 3x more likely to develop psychosis, those who experienced 5 types of childhood trauma are 53x more likely to have experienced psychosis

The effect of childhood emotional abuse on MH issues

Those with bipolar disorder 4x more likely to report childhood emotional abuse, those with borderline personality disorder 14x more likely to report childhood adversities and 38x more likely to report childhood abuse

How do adverse experiences affect our mental health?

• Cognitive/emotional - dysregulation, negative beliefs about self, maladaptive thinking styles

• Physiological - stress affects the neuroendocrine system (e.g. HPA axis)

• Behavioural - health harming behaviours such as drinking alcohol to cope

• Social - difficulties in relationships and trusting others

What are the limitations of evidence for ACEs

• most ACE/lifetime studies rely on retrospective self-report may lead to under-estimates or under-reporting

• Many studies rely on life event counts - for example whether multiple adversities in one episode count as one or more event, whether or not the individual perceives the events as traumatic etc

• Predisposing biological or genetic factors are typically not considered

Outline from a structured sociological perspective negative life events

Society contributes to mental health difficulties through social inequalities, poverty and discrimination

Individuals belonging to minorities have elevated mental health risks - increasing evidence suggests role of discrimination e.g. ethnic minorities have an increased psychosis risk, young homeless people who report discrimination report more distress and suicidal ideation.

In the UK, levels of psychotic disorders are 9x higher in people in the lowest 5th income than the highest

What factors may act as a buffer to counteract the impact of life adversities

• Goal orientation, e.g. confidence, academic aspiration, life satisfaction

• Social support, e.g. family cohesion, emotional support

• Cognition and cognitive strategies, greater perceived self efficacy and control, less rumination and negative affect

What is the relationship between lifetime adverse events and mental health

Research found a dose-response relationship, as events accumulated, emotional distress increased

Found a slight U-curve which supported a resilience effect, low levels of adverse effects more protective than none at all

Define trauma-informed care

Encourages mental health professionals to assume that all individuals who access mental health services might have experienced important adverse life effects

Define transdiagnostic

Across diagnoses, previously, mental health issues were understood without dividing them e.g. the humanistic approach

Transdiagnoses first applied to cognitive therapy across eating disorders but now applies to all mental health diagnoses

Outline the elevated rates of non-diagnostic symptoms

Although individuals are diagnosed with one category, they score very high on symptom clusters related to

Outline instability in diagnosis

Some people recover from their diagnosis e.g. one study found only 29% of personality disorders were stable, 70% of schizophrenia cases

Caspi et al.’s ‘p factor’

One underlying dimension that summarised an individuals propensity to develop common psychopathologies, p factor correlated with greater impairment, greater childhood mistreatment and poorer brain function in early life

What factors may be transdiagnostic?

• Biological

• Social

• Brain circuitry

How may biology be transdiagnostic?

Many disorders have shared genetic factors/vulnerabilities e.g. schizophrenia, bipolar disorder, ADHD and depression

How may social factors be transdiagnostic

Shared interpersonal factors e.g. expressed emotion predicts relapse in bipolar disorder, schizophrenia, anxiety, depression and others

Explain how brain circuitry may be transdiagnostic

Structurally, grey matter loss converged across diagnoses in 3 regions

Functional patterns, assessing areas of the brain that were active and differentiate people with mental health difficulties, found overlapping areas across disorders

What do those with lived experience report from the recovery process?

• Group of university students reported natural recovery process

• Themes of loss of control at the rock bottom and regaining control through recovery

Outline the role of control from a biological perspective

Control keeps our cells alive, homeostasis, e.g. body temperature, blood sugar levels control happens automatically

Outline perceptual load theory

• Developed by William Powers - explains how control works and is used more widely than in just psychology and proposes psychological distress is the loss of control due to unresolved goal conflict (e.g. due to injury etc)

• Individuals have various goals and preferred states, when these do not match experienced states we expereince error which control systems constantly aim to reduce

Outline goal conflict

Can arise when an individual strives to persue incompatible goals, when conflict remains unresolved it can lead to psychological distress

Outline method of levels therapy

A talking therapy based on the principles of perceptual control theory (PCT)

• Pct suggests individuals experience distress as a result of reduced control over important goals in their lives

• MOL directs individuals attention to important goals and identify conflicting goals

• Goal for therapist is keeping individual talking and notice disruption

What methods do behaviour genetics use?

Family studies, twin studies, adoption studies

What are limitations of family & twin studies

• Shared environment factors e.g. poverty

• Non-genetic factors affect MZ and DZ twins, e.g. mz treated more similarly

Outline brain imaging studies

Measure brain structure/functioning/connectivity, comparing those with a MD with those without (control)

• brain imaging differences linked to mental disorders include; heightened or reduced activation of parts of the brain, enlarged or reduced volume, altered connectivity between regions

Outline genetic association studies

examine the presence of specific gene variants in very large samples which include individuals with specific MD and compare them to individuals without the MD or an unaffected family member

Role of hippocampus and how it links to mh disorders

Links to perceptual systems with memory, especially the transfer of ST-LT memory, enocoding emotional context of events from amygdala

• Enlarged in depression and damaged in Alzheimer’s

Role of amygdala and how it links to mh disorders

Generates emotional responses from senses, especially fear and anger

• Associated with psychosis (over/underactive)

Role of hypothalamus and how it links to mh disorders

Small structure at brains base, regulates hormones, head of HPA system/stress regulation, regulates non conscious processes such as circadian rhythm, appetite and reward system

• Linked to long term depression

Role of thalamus and how it links to mh disorders

Hub relaying incoming sensory info for cognition/emotion processing; information is sorted integrated edited and routed

• Heightened or reduced activation, enlarged or reduced volume, altered connectivity between brain regions linked to psychosis

Role of prefrontal cortex and how it links to mh disorders

Planning, decision making, working memory, regulating social behaviour & evaluation

• linked to depression

How are the hippocampus and temporal lobes limited to hallucinations

• Hippocampus - reduced activity linked with visual hallucinations

• Temporal lobes - linked to auditory hallucinations

What is a limitation of biological studies of mental health

Brain differences may be caused BY mental health difficulties e.g. links to lack of exercise

Describe polymorphisms

Very few genes differ between people, but for many genes (polymorphic genes), account for our individual differences

What ‘clusters’ of polymorphisms did Lee et al. Identify

• Mood and psychotic disorders

• Disorders with compulsive behaviours

• Early onset neurodevelopments, disorders

Limitations of polygenic studies

• Causal effects can only be implied as it would be unethical to manipulate and environmental factors can’t be ruled out

• Can’t differentiate if brain differences are due to genetics or environment

• Most data is from those with European ancestry

Epigenetics

Gene expression is affected by experience, epigenetic changes can switch genes on or off

Phenomenology

The study of lived experience, first person accounts, qualitative methods, experts-by-experience

Prevalence and description of low mood / depression

• 16% of adults 16+ in GB reported moderate to severe depression

• Prevalence rates range from 10-84.5%

• Difficulties linked to sadness

When does sadness become a problem ?

• When it is present for a prolonged period of time

• When it’s perceived as distressing or uncomfortable

• When it causes disruption to social and occupational functioning, or more generally it interferes with the persons goals and values

Outline emotional, physiological, behavioural and cognitive changes associated with depression

• Emotional - sadness, guilt, hopelessness

• Physiological - alteration in sleeping and eating behaviours

• Behavioural - crying, reduced activity

• Cognitive - negative thoughts and beliefs about the world and future, rumination

Becks negative triad

Negative view of self, world and future

outline Abrahmson’s attribution theory of depression

Internal stable and global attributional style to make sense of negative life experiences

Rumination

Compulsively focused attention on the symptoms of one’s distress, and on its possible causes and consequences, as opposed to its solutions

Outline anxiety and its prevalence

16% of adults in England 16+, difficulties linked to fear, response to perceived threat

fear becomes a problem when it’s present for a long time, distressing and uncomfortable or disrupts functioning

Emotional, physiological, behavioural and cognitive changes associated with anxiety

• Emotional, fear and associated emotions

• Physiological, sweating, increased heart rate

• Behavioural, fight or glight, freezing, hypervigilance

• Cognitive, fearful mental images, worrying

Outline 3 theories of anxiety

• Catastrophic appraisals, overestimation of threat

• Attentional processes, selective attention towards threat related information

• Safety seeking behaviours and avoidance

Outline emotional, physiological, behavioural and cognitive changes related to trauma

• Emotional, intense emotions, feelings of guilt, shame , detachment

• Physiological, hyper arousal, alertness, pain, nausea

• Behavioural, avoidance of external reminders, difficulty sleeping

• Cognitive, re-experiencing, flashbacks, nightmares, avoidance

Outline Psychological theory associated with trauma

• Intense emotional distress and other cognitive reactions during the traumatic event disrupt normal memory encoding

• Trauma memories are stored in fragmented decontextualised ways

Describe and outline the prevalence of mania & hypomania

Lifetime prevalence of mania is 4-9% , 0.5-1,5% can recieve bipolar diagnosis

Common mood swings, episodes of mania and hypomania are often though not always concurrent with depression and low mood

What’s the difference between bipolar I and bipolar II

• Bipolar I, at least one manic episode, major depressive episodes typical but not necessary for diagnosis

• Bipolar II, at least one hypomanic episode and one major depressive episode

• Outline the emotional, physiological, behavioural and cognitive changes associated with hypomania and mania

• Emotional, intense elated but also agitated mood

• Physiological, decreased need for sleep, increased sense of energy, psychomotor agitation

• Behavioural, excessive involvement in pleasurable risk taking activities

• Cognitive, inflated self esteem, racing thoughts and distractability

Define psychosis

Loss of contact with reality, including the persons ability to think clearly, telling the difference between reality and inner experiences

define source monitoring biases

The ability to distinguish between internal and external cognitive events - stress can disrupt

Associated with hallucinations

Outline theory of mind difficulties

Not understanding others mental states

Outline psychological risk factors associated with psychosis

• Trauma and victimisation

• Stressful life events

• Critical/unsupportive social relationships

• Urbanity, living in an urban environment

• Migrant status

• Social inequality and poverty

Outline personality disorders

The collection of enduring behavioural and psychological traits that distinguish human beings - personality differences are seen as maladaptive and enduring patterns of behaviour, thought and inner experiences etc. Evident in 2 main areas;

• Expression and self regulation of distressing emotions

• Interpersonal relationships

Outline some common experiences of those diagnosed with personality disorders

• Experiencing intense and overwhelming negative feelings e.g. depression and anxiety

• Difficulties in managing overwhelming feelings, often using self harm or drug abuse

• Difficulties maintaining close relationships

Outline the attachment theory of personality disorders

Insecure attachment styles have been extensively linked to personality difficulties also emotional neglect, dismissing family environments and adverse early life experiences

Disease-centred model of how psychiatric drugs work

Correcting a defective/diseased brain, or chemical imbalance in the brain - drug treatment makes your brain more ‘normal’ (assumption of abnormality), reverses the underlying abnormality or imbalance much like physical medicine

• Names reinforce this message e.g. antidepressants

Drug-centred model of how psychiatric drugs work

All psychoactive drugs alter the functioning of the nervous system, drugs create an abnormal brain state, drugs do not specifically and uniquely target psychiatric symptoms e.g. alcohol use reducing anxiety does not mean individuals have an alcohol deficiency

How do psychoactive drugs work?

Chemical compounds work on the central nervous system to produce changes in perception, mood, consciousness and behaviour

• Activation of brain systems is dependent on activity of individual neurons, this is mediated by the amount of NT available at the post synaptic receptor site

Outline agonist drugs

Increase the action of a NT by increasing its availability by preventing re-uptake at the synapses, preventing degradation within the synaptic cleft or replacing low levels of a particular NT with its pharmacological equivalent

Outline antagonist drugs

Inhibit the action of a NT by decreasing the availability of the NT or replacing the active transmitters with an inert chemical

Outline antidepressants

Work by correcting deficiency of NTs e.g. noradrenaline and serotonin

• Used for moderate to severe depression

• Associated with serious side effects, nausea, increase in suicidality in young people

• 56% experience withdrawal effects, 46% severe and 40% feel addicted