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7/23/2019 Essential Psychopathology http://slidepdf.com/reader/full/essential-psychopathology 1/26 0 ESSENTIAL PSYCHOPATHOLOGY or MENTAL ILLNESS: WHAT IS ACTUALLY GOING ON A brief introduction for Medical Students By Tom Dalton BMedSc, RCPsych Pathfinder Fellow Contents INTRODUCTION .................................................................................................................................................................................... 1 COMPULSION ......................................................................................................................................................................................... 1 ADDICTION ............................................................................................................................................................................................. 2 OBSESSIVE-COMPULSIVE DISORDER .......................................................................................................................................... 3 EATING DISORDERS ............................................................................................................................................................................ 5 SELF-HARM............................................................................................................................................................................................. 9 DEPRESSION ....................................................................................................................................................................................... 11 ANXIETY ................................................................................................................................................................................................ 13 PSYCHOSIS AND SCHIZOPHRENIA ............................................................................................................................................ 15 PERSONALITY DISORDER ............................................................................................................................................................. 17 BIPOLAR DISORDER ........................................................................................................................................................................ 18 ARE PSYCH PATIENTS DANGEROUS? ...................................................................................................................................... 19 A NOTE ABOUT PSYCHIATRIC DIAGNOSIS ............................................................................................................................ 20 ANTIDEPRESSANTS AND CBT ..................................................................................................................................................... 20 A VERY ABRIDGED SUMMARY .................................................................................................................................................... 22 FOOTNOTES......................................................................................................................................................................................... 23
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Essential Psychopathology

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    ESSENTIAL PSYCHOPATHOLOGYor

    MENTAL ILLNESS: WHAT IS ACTUALLY GOING ONA brief introduction for Medical Students

    By Tom Dalton BMedSc, RCPsych Pathfinder Fellow

    Contents

    INTRODUCTION .................................................................................................................................................................................... 1

    COMPULSION ......................................................................................................................................................................................... 1

    ADDICTION ............................................................................................................................................................................................. 2

    OBSESSIVE-COMPULSIVE DISORDER .......................................................................................................................................... 3

    EATING DISORDERS ............................................................................................................................................................................ 5

    SELF-HARM............................................................................................................................................................................................. 9

    DEPRESSION ....................................................................................................................................................................................... 11

    ANXIETY ................................................................................................................................................................................................ 13

    PSYCHOSIS AND SCHIZOPHRENIA ............................................................................................................................................ 15

    PERSONALITY DISORDER ............................................................................................................................................................. 17

    BIPOLAR DISORDER ........................................................................................................................................................................ 18

    ARE PSYCH PATIENTS DANGEROUS? ...................................................................................................................................... 19

    A NOTE ABOUT PSYCHIATRIC DIAGNOSIS ............................................................................................................................ 20

    ANTIDEPRESSANTS AND CBT ..................................................................................................................................................... 20

    A VERY ABRIDGED SUMMARY .................................................................................................................................................... 22

    FOOTNOTES......................................................................................................................................................................................... 23

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    1

    INTRODUCTION

    The idea that Psychiatry is woolly and unscientific, without defined disease processes like other

    areas of Medicine, is a misconception. Below is a selection of key concepts in psychopathology which

    should give you a decent grasp of what psychiatric illnesses are, and how they develop.

    Please be aware that like most disease processes we are taught, these are simplified and not

    entirely generalizable to all our patients and they are only a fraction of the whole story. I have aimed

    to condense some ideas which I believe to be especially important, but bear in mind that I am by nomeans a qualified expert, and you should only use these basic concepts as a starting-point.

    See footnotes for illustrative details and tasteless banter.

    Any questions, feel free to email me ontom_rollo@hotmail.co.uk

    COMPULSION

    Compulsion means being forced to do something, and as a disease process it underlies many

    psychiatric disorders. It is part of the reason psychiatrists have the Mental Health Act allowing them to

    treat patients against their will because in many cases the will they are overruling is the will of thedisease, not of the person. It is also the answer to various perplexing questions in Psych why do these

    people continue to engage in all these bizarre and destructive behaviours? Compulsion arises for many

    reasons, but below is an overview of perhaps the most important:

    NEGATIVE REINFORCEMENT

    This occurs when a person is experiencing persistent distress (pain, low mood, anxiety) and a

    certain action causes the suffering to stop temporarily.

    This moment of relief is a powerful neurological/psychological event; in rudimentary

    physiological terms it is thought to correlate to a spike in dopamine release.

    It causes the brain to learn, on an unconscious level, that that action is beneficial/rewarding.

    This association becomes written into the neural circuitry mediating motivation.

    The greater the amount of relief and the more frequently the action is repeated, the stronger the

    unconscious motivation becomes: and at a conscious level it causes the person to want it.

    The action may or may not be actually enjoyable, it may be harmless or destructive, and they

    may or may not consciously realise that it makes them feel less bad (in fact, often they know it is

    harmful and they want to resist it)

    But they gradually come to crave it whenever they experience a negative emotional state,

    because of this forceful, unconscious drive for them to respond in this way.

    In severe cases, the degree to they are able to choose notdo it is so diminished as to be almost

    non-existent.

    It is often difficult to tease apart the extent to which the impulse is fully irresistible, or simply not

    resisted due to lack of willpower, but it is crucial to bear in mind thatin many cases the former is

    true.

    Compulsion is in many cases more complex than this it also involves the formation of habit, whereby a

    behaviour becomes automatic simply through repetition (in addition to, or apart from, the effects of

    negative reinforcement). Pre-existing personality traits are also important for instance impulsivity

    (likelihood of enacting urges) and sensation seeking (readiness to seek novel or rewarding stimuli).

    I will now provide an overview of some other psychiatric conditions which feature compulsion as a

    principle disease mechanism, and which are often poorly understooddue to a lack of awareness of this.

    mailto:tom_rollo@hotmail.co.ukmailto:tom_rollo@hotmail.co.ukmailto:tom_rollo@hotmail.co.ukmailto:tom_rollo@hotmail.co.uk
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    ADDICTION

    In very general terms, addiction is a compulsion double-whammy: powerful negative reinforcement

    combined with the effects of compounds the brain did not evolve to cope with . This is then usually

    added to difficult, unstable and generally shit social circumstances which are largely responsible for

    sustaining the problem.

    Hard drugs such as opiates and cocaine basically work by binding directlyinto the neurobiological

    circuits which mediate desire, reward, relief, motivation. They directly produce these experiences by hijacking this system, short-circuiting and distorting

    the structures in charge of decision-making.

    As a consequence, the brain quickly learns to want them intensely. The person craves the

    substance without even being fully aware why. 1

    After multiple exposures, even though the substances no longer produce euphoria, the person

    craves them all the more strongly in fact, they have a diminished ability to want anything else.

    When the drug is not present, the person is in a state of persistent distress (tension, anxiety,

    misery, pain) due to physical and psychological withdrawal, which is relieved by using the drug

    in this way, strong negative reinforcementis a crucial factor.

    As discussed, the brain learns to crave the drug whenever experiencing a negative emotional

    state. If you are an addict, judged and rejected by society, quite probably unemployed and

    homeless, this is a lot of the time.

    In the case of less potent substances such as nicotine or alcohol, where the effect is temporary

    relaxation and a blunting of anxiety, negative reinforcement is much more central.

    Needless to say, positive reinforcement brought about by euphoric feelings is also a key mechanism

    in most drug addiction.

    This is why the choice of the addict to keep using, even when it is obviously destroying their life, is an

    extremely strongly coerced choice; it is hardly a choice at all, because that persons brain is diseased.

    T2 diabetes and lung cancer are diseases which we treat, even though often they are partly brought

    about through choices addiction is much the same. However it is far more often regarded as a choice

    rather than an illness, and consequently receives far less empathy and fewer resources.

    footballspeak.com

    www.recoveryconnection.org

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    3

    OBSESSIVE-COMPULSIVE DISORDER

    The term OCD is often conflated with simply being fastidious/perfectionist; this is entirely

    wrong. The word obsessive is also misleading, as it seems to imply a voluntary preoccupation; this is

    also wrong. OCD is a disease characterised by states of extreme distress/panic, and massive disability.

    To understand OCD, try to imagine something which is extremely unpleasant to think about, for instance:

    o

    Dyingo Your family dying; you killing them

    o Being violent or sexually aggressive to people you care about

    o Being infected or contracting a debilitating/life-limiting illness

    o Being totally out of control of your life, having no stability or security

    o Going to Hell when you die

    o Being hated by everyone you know; i.e. being charged with paedophilia

    any thought or idea which is profoundly uncomfortable to hold in your mind. In a moment you will

    forget itand think about something else; in essence an obsession is where you cannot do this.

    OCD can be thought of primarily as a disorder of becoming unable to control your thoughts.

    Due to a combination of very interesting neurobiological and psychosocial reasons (which I can go

    over if anyones interested) sufferers have a diminished ability to stop themselves ruminating

    on whatever extremely unpleasant idea it may be (can be anything which is distressing, the above

    are just some common examples).

    The exact content of the obsessions varies enormously between individuals; they are often related

    to an act, for instance the thought that something catastrophic might occur as a result of something

    one (or a bystander) has done, said or thought.

    Just as the more you practise something the more naturally/unconsciously you are able to do it, so

    the more someone thinks about the distressing idea, the more frequently it intrudes, even though

    they dont want it to (seeAnxiety). As the illness develops, the person finds the thoughts intrude constantly, causing a high level of

    distress(as you can imagine if you try to hold any of the above ideas in your mind).

    The person knowsthese are just their own thoughts, and that it is not rationalto ruminate on

    them to this extent, however this knowledge has little or no impact on stopping the thoughts .

    They will often be distressed primarily because they recognise that the thoughts are intrusive and

    irrational.

    Often the person feels very ashamed that they are ruminating on these unpleasant ideas. This is

    especially true of violent or sexual intrusive thoughts, which are of course totally at odds with the

    persons character(which is precisely why they find those thoughts so unpleasant to start with).

    As a doctor, great sensitivity is therefore required, and an understanding that these thoughts do

    not reflect the patients actual character.

    www.ocduk.org

    www.keepcalm-o-matic.co

    .uk

    www.seriouslymen.com

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    Given this persistent state of distresscaused by the thoughts, no prizes for guessing which behavioural

    mechanism gives rise to the compulsions:

    Certain actions may temporarily reassure the person, thus briefly assuaging this distress.

    The actions may appear logically related to the obsession, for instance washing to reduce

    feelings of being contaminated/fears of contracting a serious illness, or checkingthe house for fire-

    hazards to reassure fears of burning self or family to death; or alternatively it may appear

    unrelated, such as counting or arrangingthings because of fears that not doing so will somehowresult in a catastrophic event (this is known as magical thinking and is an obsessional

    equivalent of ordinary superstition).

    Because the uncontrollable intrusive thoughts always recur, the reassurance is only temporary,

    and the person then feels the need to repeat it, over and over again, because nothing else will

    reduce the feeling of panic.

    So, you guessed it, repeated negative reinforcement over time causes the action to become

    habitual an uncontrollable urge which the person is unable to prevent themselves enacting.

    Eventually people are rendered housebound, unable to work or study, and hugely disabled by these

    compulsions.

    Interestingly, in many cases these compulsions develop without being driven by a specific obsessive fear

    about something bad happening in these cases the distress is caused simply by a powerful feeling of a

    certain thing not being quite right. This is a bit like ordinary perfectionism/feeling annoyed at things

    not being a certain way; but if that can be likened to an itch, the equivalent in OCD is like an all-consuming,

    excoriating pruritus which makes you want to tear your skin off. The person is unable to stop themselves

    putting whatever it is right, or they experience extreme panic.

    OCD often presents late, and is the 10thmost debilitating illness of any kind(WHO GBD 1998), so its

    one not to miss.

    www.nature.com - The theoretical basis of obsessive-compulsive behaviour.

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    EATING DISORDERS

    Eating disorders appear to make very little sense. Why would anybody want to make themselves

    sick deliberately, or starve themselves to death? Loads of people are on diets, are those with EDs just

    much vainer and more determined than anyone else? Isnt a compulsive eater just another overweight

    person who needs to get some self-control? Why cant all these people just eat normally like the rest of us?

    In reality, eating disorders are not really about food. Nor are they really about looking a certain

    way, and they certainly have nothing to do with vanity. In most cases they are ultimately aboutpathologically low self-worth, and feeling unsafe:

    LOW SELF-WORTH

    This can range from constantly feeling that you are not good enough, to viewing yourself with

    utter loathing and disgust, unable to think of anything but how worthless you are, to the point

    where you can hardly tolerate the fact that you even exist (see Depression).

    When you have negative attitudes towards yourself it is often automatic to direct this discontent

    onto your body, because your body is tangible, its what everyone sees, and were persistently told

    by popular culture that its not good enough.

    Add to this the way society views food and weight:o Unhealthy food is a treat and it makes us feel good

    o We also feel guiltyfor eating it, it is a sin/syn, a weakness, an indulgence

    o People who are overweighthave overindulged, they are disgusting, they are a burden

    o Thinnessmeans beauty, health, self-control, and we are praised for losing weight.

    In this way food and weight often become a central component of how we view ourselves, and so

    when we have very low self-worth it can manifest in pathological eating behaviours.

    FEELING UNSAFE

    Often this is referred to as feeling out of control, however it is perhaps easier to conceptualise it as

    feeling unsafe, as the prevailing characteristic is a state of panic.

    Under considerable persistent stress, some people can begin to feel that everything in their life is

    unpredictable, unstable, and they have no control over it; naturally this is a very distressing state

    (underpinned by a feeling of threat from the unknown); it has been likened to balancing on the

    edge of a terrifying abyss.

    What we eat, and our weight, is something we can have control of, and often people experiencing

    this state will feel a sense of reassurancefrom this amid the perceived chaos it is something they

    can still feel they have agency over.

    Controlling diet therefore lessens the state of panic, and so this behaviour is negatively

    reinforced.

    Eating disorders take many forms: Bulimia Nervosa, Compulsive Eating and Anorexia Nervosa, among

    others. The largest category is Eating Disorder Not Otherwise Specified (EDNOS), for patients who dont

    exactly fit the criteria for the more specific diagnoses (but are no less severely ill). Explanations of eating

    disorders always begin with Anorexia Nervosa there is little reason for this2, because the others are

    considerably more common and even less well understood. Two important general points:

    People with eating disorders can be any size, and in fact are more likely to be normal weight or

    above than underweight (because dangerously-low-weight-AN is actually comparatively rare). I

    have heard actual doctors say you dont looklike you have an ED NEVER SAY THIS. IT IS VERY

    DAMAGING AND ALL SHADES OF WRONG.

    Men get eating disorders too. In fact EDs in men are much more common than previously thought,and may actually approach rates in women, but are very often concealed due to stigma.

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    BULIMIA NERVOSA

    As you may know, BN is characterised by binges (eating a large amount of food in one go, typically

    associated with a sense of losing control) and purging behaviour(such as vomiting or using laxatives).

    Naturally, this behaviour is hard to understand, but it makes much more sense in the context of the illness:

    Speaking generally, sufferers of BN have very low self-worth, which may have partly manifested as

    feeling that they are fat (society tells us that being fat is bad).

    They (and indeed you) may perceive that their behaviour is fuelled by the desire to lose weight, but

    it is more true to say it is fuelled by the powerful feelings of inadequacy, guilt, shame, and self-

    loathingentailed in the binge/purge cycle. The act of purgingis at the centre of this.

    Sufferers of BN purge because the knowledge that they have eaten fills them with panicit means

    they have lost control of themselves, they have failed, they cant even lose weight properly, and now

    all that food is going to make them fat, and thats the worst thing to be.

    o Needless to say, this thinking is distortedthatsa hallmark of the illness (see Depression)

    It is worth pointing out that nobody thinks vomiting or using laxatives is pleasant. But the feelings

    of self-loathing are so strong that sufferer is driven to do it.

    When the hated food has been expunged, they feel safe again, back in control the state of distress

    is relieved. Lo and behold, compulsion driven by negative reinforcement rears its ugly head

    again.

    They come to crave purging it becomes the go-to means of coping with negative, a symbolic

    means of getting rid of the things you hate about yourself (though the sufferer often does not have

    insight into this).

    Bingingoccurs for several reasons:

    o

    It is partly driven by the desire to subsequently purge

    o It is also driven by hunger, because in between binges sufferers will often restrict their diet

    and exercise excessively (itself a form of purging burning off the hated food)

    o Once the sufferer starts to eat, there is typically a great sense of having failed and lost

    control

    o Because of the distorted depressive thinking, there will often be feelings that there is

    therefore no point in even trying, they might as well just eat and eat until they die

    Unfortunately, every step of this cycle is loaded with more guilt, shame and self-loathing. Sufferers do not

    see that their behaviour is driven by the emotional forces discussed only Ive failed to restrict properly

    like someone with a real eating disorder, Ive eaten large quantities of food because I cant even control

    myself, and Ive made myself sick or used laxatives which is just disgusting.

    Needless to say, it is hard to tell anyone else about this illness, and often people react badly when they do,

    so it remains hidden and gets worse.

    shetakesflight.tumblr

    .co

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    ANOREXIA NERVOSA

    AN is characterised by extreme restriction of food intake. It is one of the most dangerous psychiatric

    conditions, with a mortality rate of 20%. People often ask of low-weight anorexics but why dont they

    just eat? hopefully the obvious stupidity of this question will become clear below:

    Like BN, AN often begins during aperiod of intense feelings of low self-worth/not being good

    enoughand feeling unsafe/out of controlfor instance, feeling under a lot of pressure at school,

    being bullied, feeling trapped in this very stressful situation.

    Someone may then start on a diet (perhaps they perceive that one of the reasons they dont like

    themselves is related to weight), and they find that being able to override hunger and make the

    numbers on the scale go down gives them a longed-for sense of achievement/control/safety.

    At least heres something(they may think) that Im not a failure at.

    As discussed, this diet restriction is thus negatively reinforcedand so becomes more ingrained,

    and eventually an uncontrollable compulsion.

    It may be further driven by others complimenting them on their weight-loss typically this is

    enormously triggeringfor AN sufferers, and reinforces the illness.

    The sufferer may set low weight targets for themselves, but these are often meaningless, in thatnew lower ones are continuously set when they are reached; this is because it is the act of

    restriction and weight lossitself which motivates them.

    As the brain becomes increasingly starved, thought and behaviour become more illogical.

    Perceptions of food and weight become more distorted3, and insight is often poor.

    o Irrational beliefs which may develop include: being unable to even touch food for fear of

    absorbing calories; that eating one thing will suddenly cause massive weight gain

    Another prominent feature is innumerable rules relating to food (what can be eaten

    when/where/how) which must be obeyed in order to feel safe . The rules are often not logical,

    and relate not only to weight but also fear of unknown ingredients which are outside your control.

    Because losing weight has become the only source of comfort/validation/safety, so the idea of

    eating and gaining weight becomes the most terrifying thing imaginableas it means the loss of

    the one and only good thing. It is no exaggeration to say that that a sufferer of severe AN would

    quite possibly rather put a red-hot poker in their eye than eat a high-calorie meal.

    Sufferers often become manipulativelying, pretending to have eaten, and concealing the weight

    loss even though this is very out-of-character. This is a result of the disease; the brain-starvation

    combined with a completely overriding fear of food which they will do anything to avoid.

    An important truth of AN is that the disease becomes simultaneously a bully and best friend:

    o What started out as a means to feel in control eventually removes all control from the

    person, occupying the sufferers every waking thoughtand dictating their behaviour.o However at the same time it makes them feel safe, it is the thing they can turn to when they

    feel panicked, it seems to be the only thing that makes them feel good about themselves .

    For this reason it is extremely difficult to resist.

    It is worth pointing out that (although obviously actually suffering from AN is worse), it is a truly

    harrowing illness for family members. Speaking from personal experience, watching helplessly as

    one you love gradually, inexorably starves themselves is one of the worst things ever.

    Furthermore, matters are often complicated by family conflict parents often do not understand why

    their child is doing this, and will try to simply coerce them into eating, creating a high-stress home

    environment which actually drives the sufferer further into the welcoming arms of their ED.

    AN and BN are two distinct diseases which are not interchangeable. However, people often have

    elements of both, possibly leading to a diagnosis of Atypical AN, Atypical BN or EDNOS.

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    COMPULSIVE EATING

    Oh, so now youre going to tell us that all overweight people are actually mentally ill and we should feel

    sorry for them instead of just tell them to keep away from Greggs?

    Well no but you are about to spend your entire working life persuading people to lose weight, and if

    you dont understand the basic psychology of compulsive eating you may not get very far. This isnt to say

    all of your overweight patients will have a compulsive eating disorder (although many of them may do),

    but rather that doctors need to appreciate that there is much more to obesity than simple greed, and

    tackling it meaningfully therefore cannot be achieved by simply telling people to eat less. Food can

    become an addiction:

    As discussed, overweight people are generally cast as the villains of modern society, especially by

    healthcare workers who have to face the Obesity Epidemic.

    Maybe to some extent this provides a healthy pressure for everyone to lose weight; however it can

    often have the opposite effect.

    All you need is to be a little overweight already, and a good dollop of low self-worthwhich, as

    discussed previously and below, distorts peoples thinking.

    So you feel pretty crap about yourself (youre in a state of low mood/distress), and this is tied upwith your weight: I look bad, Ive become what everyone hates and Ill get all these health problems.

    Now add into the mix the fact that high-calorie foods are rewarding:

    o They are widely used as treatsor prizes, and so are associated with feeling good

    o We are programmed to want them: when they are scarce (i.e. the whole of human

    evolutionary history) they are a valuable source of energy, so consuming them kicks off all

    the neural reward circuitry and gives us a sense of pleasure

    And we all know what happens when we take a persistent state of distressand add a behaviour

    or substance which temporarily makes you feel better

    Of course, indulging in the tasty food makes us feel guilty, and perhaps helps motivate us to change

    our behaviour. However, if guilt is part of the background noise of your mind, reinforces your

    negative beliefs about yourself and only serves to drive your mood lower, then the whole situation

    will worsen and you will be increasingly driven to adopt a coping mechanism, which over time

    becomes a compulsion, and hey presto.

    So, to what extent should you think to yourself that overweight people are greedy and weak-willed, or

    consider them victims of an illness? To be honest, I dont care 4its all about how you respond to them

    and enable them to reach a healthy weight.

    As Im sure you can imagine, but just in case its not 100% clear: making them feel bad will only make

    it worse, because it will further drive the low self-worth which is the actual root of the problem.

    Positivity and encouragement is needed, and optimal management of clinical depression if this is present.

    EATING DISORDERS - CONCLUSION

    So weve discussed that in many ways eating disorders are a lot like many addictions they begin as a

    way to cope with a persistent state of distress, and subsequently cause more distress, and this self-

    feeding cyclegradually drives the sufferer into states of mind and behaviours which are very far from

    normal (and consequently difficult to understand).

    However, the problem with eating disorders is that going cold turkey is not an option you have to

    face the addiction three times a day, every day. For this reason the maladaptive behaviours of the

    disorder become powerfully reinforced through daily repetition, and overcoming them requires an

    intense and sustained effort. People often recover but it is not easy (see CBT).

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    SELF-HARM

    Non-suicidal self-injury is stupendously poorly understood by many healthcare professionals. We are

    taught nothing about it during the MBChB course, so all we have to go on is what we learned at school

    (usually that cutting is a lame attempt at suicide, or just attention-seeking). This state of affairs is frankly

    unacceptable, as non-suicidal self-injury is often a sign of serious psychiatric disorder, is thought to

    affect more than 1 in 10 young people, and is on the rise.

    WHY DO PEOPLE SELF-HARM?Some people try to kill themselves, through various means. This, at least, is reasonably well-taught.

    However, self-harm is much bigger than thatvery often it has no suicidal intentbehind it, and is a

    means of coping. But why would people injure themselves to cope? Doesnt that just cause more pain?

    Im just going to tell you now to get it over with the answer is compulsion driven by negative

    reinforcementplus some other things.

    Non-suicidal self-injury is stereotypically cutting, but can also take the form of burning, hitting,

    scratching, pinching, hair-pulling, skin-picking, ingesting objects you name it.

    It may involve varying degrees of tissue damage, but is typically relatively superficial, although

    often escalatesand can lead to accidental suicide. If you are feeling resilient, typing self harm into Google Images gives some idea of the typical

    presentation (mosty cutting).

    The reasons for starting to self-injure are varied and complex:

    o A significant part of it is self-hatredand remember, self-hatred is a distorted mental state

    which causes some bizarre and illogical thoughts and behaviour.

    o A person may consciously or unconsciously hate themselves or their body, and therefore

    have an urge to damage it. This could be in a state of anger and frustration with

    themselves, or may be enacted without them even thinking about it.

    o It may be an attempt to express the intensely horrible way you feel inside to yourself or

    others

    When people self-injure, they very often describe a sense ofrelief, a release of tension.

    o This is largely because tissue damage activates the injury response, whereby endogenous

    opioids are released in the CNS to numb the pain temporarily (and, evolutionarily speaking,

    to allow you to escape from whatever attacked you). This is why, in the shock of an injury, we

    can often feel oddly calm and without pain for a few minutes.

    o This injury response has the interesting effect of also numbing emotional pain and distress

    temporarily (again, to allow us to cope immediately during dangerous situations).

    o If you are experiencing a intense distress (depression, anxiety), injuring yourself can

    therefore have the paradoxical effect of making you feel better(not goodjust less shit).

    There are a number of other psychological aspects; people often find that seeing the injury feels

    right, orjolts them back to realityfrom out of a state of emptiness (see Depression).

    Needless to say, self-injury is a strange thing to do, so people very often keep it completely hidden.

    In this way it continues to be reinforced and escalates in private, and treatment-seeking is late.

    The important thing to remember is that even minor self-injuriesare often a sign of severe distress

    and warrant full investigation. Also keep in mind that this behaviour is a compulsionand cannot fully be

    considered a choice often it may occur during a state of dissociation or fugue.5

    It is also worth mentioning that suicidal intent (or lack of) is not binarypeople may self-harm without

    specifically intending to die, but at the same time feel that they wouldnt mind if they accidentally did.

    The psychological distortion of self-hatred creates ambiguous feelings about dyingnot caring aboutyourself, combined with a lack of motivation to take suicidal action (we will discuss in Depressionhow

    this state of mind comes about).

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    End of Part 1

    For some light relief, here are some Garfield comics about coffee

    And here is a great quotation about Psychiatry:

    Psychiatry is all biological and all social.

    There is no mental function without brain and social context.

    To ask how much of mind is biological and how much social

    is as meaningless as to ask how much of the area of a rectangle is

    due to its width and how much to its height- Leon Eisenberg

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    Part 2

    DEPRESSION

    Do not underestimate what a massive deal depression is. It is the leading cause of disability worldwide,

    you will encounter it in all branches of Medicine, and in terms of its impact on quality of life its basically

    the most important physical or mental illness you need to understand.6And yet people labour under

    the totally misguided impression that its not really an illness and sufferers just need to chin up and take

    some exercise

    Speaking as someone who has not yet suffered from depression, I dont believe its possible to fully

    appreciate what its like without experiencing it. However, as doctors it is essential we try bloody hard

    to understand it, for the sake of about a third of all our patients. You cannot empathise and respond

    appropriately without that understanding. Below is a brief introduction covering some basic points, but

    bear in mind that depression is tremendously complexand variable.

    DEPRESSION IS NOT SADNESS/LOW MOOD

    Sadness is part of ordinary mental function; depression is a broken way of perceiving and interpreting

    the world. For the sufferer, reality is distorted(subtly but pervasively).

    What perhaps defines depression is not sadness but rather a state of suffering.

    Imagine the feeling when youre having a really crap day and then the consultant on the ward-

    round makes you look stupid, and you just want the ground to swallow you up you desperately

    want to not be there, your mind is in a state of distress and you just want it to stop.

    Now do your best to imagine that, but worse than youve ever experienced, and all the time.

    Depression is also often experienced as emptinesswhere ordinary thoughts would normally be,

    such as planning and looking forward to things, there is only a blank, cloying greyness, without

    anything motivating or exciting.

    It is very much an altered state of mind, which changes the way you think and the way you behave to

    all intents and purposes it changes your personality (temporarily).

    WHAT IS ACTUALLY GOING ON

    Like many complex, chronic health problems, the exact mechanism has not yet been pinned down.

    What we know is that various interrelated mental functions spiral into the depressive state

    together

    o Subjective mood(obviously) sinks

    o There is increasing rumination on, and selective attention to, negative thoughts

    o Beliefs of very low self-worthand hopelessnessabout the future develop

    o General motivation decreases, and various other biological/psychological changes

    Cognitive bias developsthis is important.o None of us actually perceive the world/reality exactly as it is.

    o To help make sense of the world, our brains make a whole load of assumptionsabout the

    continuous stream of sensory/social information we perceive fitting everything into

    simplified modelsto help recognise and categorise things quickly and efficiently.

    o This process is unconscious.

    o In Depression, a central disease process is that these assumptions become biased, the models

    become distorted, so events are interpreted quite differently.

    o This is not deliberate, and the person is unaware of it.

    o From the perspective of the depressive, the world really is against them. Their future really

    does contain no happiness or meaning. Their exploits truly are all doomed to fail.

    o

    They come to believe this because they see evidence of this everywhere they look they

    are simply facts, like the sun is shining today, it will probably be warm.

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    I hope this makes clearer why suffering from depression entails truly and unshakeably believing that you

    are worthless, despicable and better off dead, and that there is simply no point in you moving or even

    existing because these facts are clear as day to the sufferer.

    Furthermore, you see why cheerily telling someone that things are actually fine (and they just need to get

    some exercise) rarely has much impact.

    WHY DOES THIS HAPPEN

    In general terms, a combination of external factors (serious or prolonged life stressors) and internalfactors (natural psychological makeup, genetic and neurobiological influences on mood and the way

    experiences are processed) can cause depression to gradually developfrom ordinary low mood.

    One theory is that (like many illnesses) it is a protective mechanism gone wrong if a person who is

    under great pressure/distress enters a state of suffering and has to withdraw from their ordinary role,

    this may allow time for recovery and prompt social support.

    Depression is not a choice. To some extent one can choose to be optimistic or not, but the altered mental

    state of depression is without doubt an illness, superimposed onto normal thinking.

    DEPRESSION NATURALLY RESISTS TREATMENT

    This is the really problematic thing about depression. Just like cancer, which is so challenging to curebecause the disease you have to obliterate is the bodys own cells, so in depression the very nature of the

    illness is precisely the reason it is difficult to treat.

    Depression by definition erodes motivation, and it stops you caring about yourself and these are

    exactly the resources you need to draw on to recover from an illness like depression. It also creates

    problems with many aspects of mental function and extinguishes positive/hopeful attitudes about the

    future. A healthy-minded person might have no problem engaging in CBT, taking their tablets regularly,

    and generally orienting themselves towards the goal of recovery however, depression directly

    interferes with these things, which makes the task of recovery doubly hard.

    People with depression will often appear to stop bothering with their treatment, and may then get

    discharged (this makes about as much sense as discharging a severe asthmatic because PRN salbutamol

    isnt working).

    BE VIGILANT FOR DEPRESSION AT ALL TIMES

    Were all taught the Red Flags for cancer we constantly have it in the back of our minds in any history,

    because of course its a terrible and life-limiting illness that no doctor should miss, and needs to be caught

    early. This is well and good and equally true of Depression. Depression totally wrecks lives. You dont

    need a painful, debilitating physical illness or appalling social situation if all that suffering is simply there,

    in distilled form, in your brain.7

    For every one of the sick people you see, you absolutely have to be vigilant for depression, because it

    worsens pretty much all the outcomes, for everything, ever. And more importantly it directly dropsquality of life, which is basically the end goal of all of Medicine. Yet it is perfectly treatable with

    appropriate support, and even more so if you catch it early on. Do. Not. Miss. Depression.

    SylvieReuter

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    ANXIETY

    Schizophrenia grabs the headlines with wacky behaviour. Depression grabs headlines with suicide.

    Anxiety meh. Everyonegets stressed. Its not really liketheproper mental illnesses, right?

    Wrong in fact anxiety is almost as big a deal as depression. It comprises a spectrum of disorders which

    are debilitating, extraordinarily costlyto the economy, and most importantly, suffering from them is

    truly grim.

    So what is Anxiety? Firstly, its a misnomer in my opinion anxiety is worrying Ive forgotten something,or that I should be doing more revision. When describing actual Anxiety Disorders, persistent

    terror/panic/fear is probably a little more accurate. We are talking about intense states of mind

    which are hard to imagine.

    WHAT IS ACTUALLY GOING ON

    In a nutshell, anxiety is learned. However, unlike my Grade 5 Piano sight-reading,8people practise it

    repeatedly every day without even trying, so the brain becomes better and better at it, and before long an

    incapacitating disorder has become established.

    We all9remember Little Albert and the white rabbits from MIS Anxiety is often learned by

    association, much like negative reinforcement. Being very frightened while experiencing a

    given situation or thingleads to conditioned fear, which recurs when you experience that thing

    again.

    This can happen in a number of different ways, none of which anyone really has much control

    over:10

    o Obviously a traumatic experience with something (spiders, trains, swans, whatever) as a

    child can sometimes lead to a phobia of that thing

    o Associations are often formed in more subtle and complex ways than that, however. For

    instance, ruminating on a frightening thing youve heard about can cause you to associate fear

    with anything that might be related to it; the idea that something bad may happen when you

    are in a certain type of situation (i.e. a crowd) may cause you to fear that type of situation

    o

    Essentially anything related to the threat of something bad happening, be it physical harmorsocial rejection11(i.e. embarrassing yourself, being hated, failing to fulfil your role and

    disappointing others).

    Everyone learns fears such as these, as part of normal development.

    The process of practising them (which is obviously not deliberate) occurs through several

    mechanisms which make sense in the context of how our brains are evolutionarily programmed to

    help us survive by keeping us safe:

    RUMINATION

    We are naturally inclined to pay attention to salient thoughts (see PSYCHOSIS), i.e. those relating

    to things which threaten us, such as the learned fears of Anxiety.

    When we think about something repeatedly, we essentially practise thinking about it, and

    become more inclined to think about it over time it occupies more of our thoughts and

    becomes more salient to us.

    The cycle continues, and our internal representation of the threat grows.

    We start to develop cognitive bias (see DEPRESSION) our estimation of how likely or how

    dangerousthe subject of our rumination is becomes distorted.

    An objective observer may helpfully point out that the sufferer is worrying about nothing. However,

    although the rational frontal lobes may acknowledge this, the neural fear circuitry is powerful, and

    buried deep12in the primitive midbrain, so thelearned fear is much more difficult to overcome

    than this.13It is not to our evolutionary advantage to easily forget or dismiss fear learning.

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    AVOIDANCE

    We are naturally inclined to avoid things we are afraid of.

    This tendency is usually harmless and sometimes beneficial, but can cause problems

    because avoiding somethingmakes us no less afraid of itif we are avoiding something which is

    actually harmless, we never un-learn our erroneous fearof it.

    In terms of our primitive subconscious fear beliefs, we are only safe because we are avoiding it.

    Our internal representation of the threat remains just as dangerous.

    SAFETY BEHAVIOURS are another form of avoidance instead of avoiding the street we were

    mugged in, we may carry something that makes us feel safer, like an alarm.

    Again, we believe we are only safe because of that behaviour, so the threat is still there in our mind.

    The result of these two instinctual mechanisms is that the conditioned fear is not un-learned, and

    meanwhile it becomes reinforcedand is brought to mind increasingly frequently, which in turn leads

    to more avoidance, and gradually layers and layers of fear are laid down in the primitive self-

    preservation circuits of the midbrain (where they hold a considerable sway over rational decision-

    making, and are particularly hard to shift), to the point where a crippling disorder has developed.

    Because of our natural tendency to imagine possible dangers when we are in a threatening situation, the

    persistent state of high anxiety is fertile ground for all sorts of new fears to develop, and this is how a

    generalised anxiety disordercan develop from more singular beginnings.

    While people canchoose not to engage in rumination and avoidance behaviours, this is usually not ones

    instinctual inclination. Also, remember these things creep in very gradually and insidiouslynobody

    suddenly chooses to avoid leaving the house, but they may slowly become less and less inclined to go out

    for less important errands, and all the while the anxiety reinforces itself and quietly takes more and more

    of a persons daily life away.

    Clearly, this process does not happen to everyonewho is scared of anything. It also usually requires a

    slightly more anxious personalityperhaps the sort of person who is inclined to worry and play it safe.The mechanisms described will be more likely to take holdunder these conditions.

    Importantly, once this anxiety has become established, it is monstrously hard to overcome. Sufferers will

    be simply unable tojust do the thing theyre afraid ofthe overriding motivating force of fear renders this

    impossible. The anxiety must be gradually un-learnedbit by bit (see CBT).

    boggletheowl.tu

    mblr.co

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    PSYCHOSIS AND SCHIZOPHRENIA

    As you will have learned, psychosis is a mental state characterised by hallucinationsand/or delusions

    which has a number of possible causes, and Schizophrenia is a complex and chronic illness featuring

    psychosis along with the negative symptoms14which include social withdrawal and lack of

    motivation. The key feature is a loss of contact with reality the reality the sufferer is living in is

    disjointed (to a lesser or greater extent) from the one we all live in. It is reasonably well-taught so I will

    just say a few important things.

    WHAT IS ACTUALLY GOING ON

    We are taught that too much dopamine therefore hallucinationsand delusions.15

    However, it is possible to make more sense of the disease process than that. Psychosis involves a dis-

    integration of various mental functions, and I have outlined some of these below to give a rough

    picture of how the symptoms happen:

    SOURCE MONITORING

    Everyones ordinary mental activity features a constant stream of thoughts in words, images,

    sensations or voices a combination of memories and imagination.

    This involves activity in thesame neural circuitswhich are firing when you actually experiencethose things. In terms of brain activity, thinking about something is similar to re-experiencing it.

    Source Monitoring is the brains natural ability to discern the source of these mental experiences

    which ones are sensory input from real stimuli, and which are just internally generated as part of

    the constant chatter of consciousness.

    As you can imagine, if this process breaks down, then internally generated experiences may be

    perceived as real, external stimuli. That is basically what a hallucination is, and it is

    hypothesised that source monitoring is impaired in psychosis.

    This makes sense when you consider that hallucinations are most commonly voices a large

    proportion of ordinary thought is our internal monologue, which is usually like a voice.

    This also helps to explain thought disorder (another hallmark of psychosis) where you believe

    your own thoughts are being stolen, insertedor broadcasted.

    SALIENCE

    This is how important we perceive a given thing to be to us. We are naturally programmed to

    automatically identify things which are relevant or important to us and pay attention to them for

    instance, dramatic events, threateningstimuli or things we recognise.

    As far as we can tell, salience is mediated by dopamine. This makes sense in light of our

    understanding that dopamine is heavily involved in motivationthings which are important to us

    generally motivate us to do something about them.

    It is proposed that too much dopamine leads to an aberrant assignment of salience to the

    elements of ones experience. Things which are irrelevant an unimportant (a car going past, a bird

    landing on the windowsill) suddenly have a sense of great importance and relevance.

    Delusionsare the result of an unconscious cognitive effort by the sufferer to make senseof these

    aberrantly salient experiences the car must be people searching for me to kill me; the bird must be a

    messenger from God to tell me something important. Those are examples of delusory perceptions,

    which may come to form the evidence for delusory beliefs.

    In this theoretical framework, hallucinationscan be thought to be caused partly by the assignment

    of reality-like salience to

    internally generated experiences.

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    PEOPLE WITH PSYCHOSIS ARE COMPLETELY SANE AND RATIONAL

    This is something to always bear in mind with psychosis. You will be confronted with people who appear

    to be textbook crazy; theyre hearing and seeing people that arent there, theyre believingall these far-

    fetched paranoid things, theyre saying things that make no sense.

    However, they are in fact perfectly sane people, making perfectly reasonable decisions in

    response to the things they perceivearound them and the beliefs they have rationally drawn

    from their experience, just like anyone else.

    The difference, of course, is that not all of their experience has come from the external reality

    which everyone else is living in, and the process of making sense of what they perceive (by

    formulating it into ideas and beliefs) is corrupted by the disease.

    Suffering from psychosis is therefore in some ways simpler to imagine than the other conditions

    discussed. To imagine what its like to have auditory hallucinations of voices constantly talking

    about what youre doing, simply imagine actually hearing those voices. That is precisely what it is

    like for the sufferer the voices are 100% real and they feel and behave accordingly.

    The end result is that the sufferer is responding to their surroundings as anyone would, but the process

    is interrupted and based on flawed data, so the end result looks very unlike how someone would

    normally behave.

    Of course, another key symptom domain of schizophrenia is disorganisation thinking and speech

    appears to become fragmented and jumbled, without a logical flow from one topic to the next. This is

    related to a disruption of normal cognition, and also to deficits in focusing attention such that the suffer

    does not remain focused on one train of thought but jumps to the next, seemingly at random. This is

    harder to imagine, but I believe the following analogy (provided by the carer of a schizophrenia patient)

    can help:

    PSYCHOSIS IS LIKE DREAMING WHILE YOU ARE AWAKE

    When you are dreaming, your brain generates a whole stream of experiences from random fragments of

    memory or imagination. The narrative of the dream is chaotic and jumbled, and you perceive andinterpret the experiences quite differently to how you would in real life, but at the time it makes sense.

    I dont know how much similarity dreaming actually has to psychosis, but it provides a simple way of

    imagining something fairly close to the experience, and goes to show that many of the far-fetched

    phenomena of psychotic disorders are surprisingly close to perfectly ordinary brain function.

    Remember, realising you cannot trust your own perceptions or the solidity of the reality you live in is

    utterly, utterly terrifying. Watch out for extreme low mood and suicide when insight is gained.

    Paintings by artist Bryan Charnley,

    who had controlled schizophrenia

    but embarked on an experiment

    whereby he stopped his

    medication and painted a series of

    17 self-portraits over the weeks as

    he began to relapse.

    Tragically the illness eventually

    became out of control, and he

    committed suicide. His paintings

    provide a vivid insight into the

    mental state of psychosis.

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    PERSONALITY DISORDER

    Personality disorder is a topic as vast as it is fascinating it affects all of society (not to mention all of

    Medicine16) and, I think, really challenges our ideas about people (see the next footnote).

    The illnesses we have discussed so far are largely superimposed onto a persons normal thinking and

    behaviour and they are usually what is called ego-dystonic, that is, sufferers are awarethey have a

    problemand are distressedby their symptoms.

    Personality disorders are trickier than that they are psychological disorders marked by inflexible,disruptive and enduring behaviour patterns that impair social and other functioning, whether the

    sufferer recognises that or not. In this way they are usually ego-syntonic (in-line with the self)

    because the disorder is beneath the level of self-awareness from the point-of-view of the sufferer, it is

    just how they are, and its not a problem.

    The disorders can be thought of as extremes of ordinary personality traits which we all have. For

    example, everyone may feel emotional, get jealous or want to be liked at times, but a combination of

    genetic and environmental factors during childhood can lead to excessive degrees of such traits, and

    this often causes considerable disruption.

    There is a trap here is a PD actually an illness, or is it simply what the person is like? I would say that

    the former is more accurate and helpful, and I have explained why in this footnote 17if youre interested.

    Personality Disorders are learned, like anxiety, but the crucial difference is that they are learned very

    early on in life and so are inherently more ingrained, and because they have formed a part of how the

    person thinks for so long, it is harder to tease apart the disorder from the person. Below is an overview of

    two of the most common PDs which you are likely to encounter.

    EMOTIONALLY UNSTABLE PERSONALITY DISORDER Borderline Type

    Also known simply as Borderline Personality Disorder, EUPD is a complex set of learned behaviours

    and emotional responsesto traumatic or neglectful environments.

    During childhood, most people learn how to interact and form relationships with people in the

    normal, functional ways that we take for granted.

    In EUPD, an absence or disruption of normal parental attachment and early relationships

    causes some degree of abnormality in this learning process.

    Sufferers will have often learned to use dysfunctional ways to get their basic psychological needs18

    met, such as outbursts of rage, or manipulatingpeople around them, perhaps using self-harm.19

    o During such behaviours, sufferers often feel completely justified in their actions

    o However, afterwards they often become acutely aware of the hurt they have caused ,

    leading to a cycle of guilt and self-hatred

    As the name would suggest, a common feature is difficulty regulating emotion sufferers of

    EUPD will find their emotions are often out of their control, and swing rapidly from one extreme to

    another.

    Another common feature is a constant and pervasive fear of abandonment

    o EUPD sufferers may place excessive demands(for time or support) on those they interact

    with, as if relying on them completely for their basic psychological needs

    o When these impossible demands are not met, they feel abandoned, and this can manifest as

    uncontrollable anger

    o This anger is (paradoxically) a defence mechanism an attempt to gain a sense of strength

    o Others actions are often misinterpreted or twistedinto signifying abandonment

    An overriding theme is a lack of insight into the dysfunctionality of their own thoughts and emotions.These thought patterns will sustain and reinforce other psychiatric illnesses (commonly anxiety and

    depression), and the person will therefore struggle to get better with the usual treatments for these, and

    will not understand why.

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    The above traits paint quite an extreme and unpleasant picture, but bear in mind that people with EUPD

    are often just as kind and pleasant as anyone else . The disorder can vary widely in severity, the

    behaviours and thinking described can emerge in times of distress (or at random) but be less evident the

    rest of the time. Furthermore many patients actually defy the PD stereotype and gain reasonable insight

    into their condition (viewing it as ego-dystonic).

    Also, EUPD almost never exists without comorbid depression and/or anxiety. The problems forming

    and maintaining fulfilling relationships, the maladaptive coping mechanisms and negative self-image it is

    associated with, are a perfect recipe for psychiatric comorbidity.

    People with EUPD are widely maligned by healthcare staff, because they are often frequent attendersat

    A&E or primary care, and are perceived to be difficultand time-wasters these pejorative attitudes

    demonstrate a disregard for the pathology behind the behaviour.

    ANTISOCIAL PERSONALITY DISORDER

    This is a little more difficult. One of the most severe and disturbing personality disorders, people with

    Antisocial PD (usually men) exhibit a lack of consciencefor wrongdoing, even towards friends or family

    members. Their destructive behaviour, which tends to begin in childhood as Conduct Disorder, can

    include excessive lying, stealing, violence, manipulation, hurting animals you may be familiar with the

    terms previously used for ASPD: Psychopathy or Sociopathy. In this PD, the failure of fundamentalsocial learning (as described above) has been a partial or complete failure to learn empathy,

    conscience or concern for others.20

    Are people with ASPD essentially bad people? In a way, yes. Is it their faultthat they are like this? No

    again, the disorder is brought about by a combination of genetics and environmental factors

    Early signs which have been identified include an impairment in fear conditioningthat is, the

    learning process we discussed in Anxiety Disordersis impaired; this could be thought to cause a

    failure to learn the consequences of actions.

    If a young child is deprived of normal emotional attachments(i.e. in foster care), this is thought

    to impair their ability to form trusting relationships and lead to indifference towards others.

    Children canlearnantisocial behaviour from antisocial parents (and ASPD traits are also heritable

    to some extent).

    People with ASPD are thought to have reduced activity in the frontal lobes, leading to impulsivity.

    Traumatic experiences in childhood can precipitate ASPD (especially combined with other factors).

    Perhaps unsurprisingly, people with ASPD often fall into unemployment and crime a disproportionate

    percentage of people in prisons have the condition. Having said that, some people with ASPD become

    successful businessmen.

    There are a great many other personality disorders (Narcissistic, Histrionic, Anankastic, Schizotypal,

    Avoidant)which you may learn about. A couple of important things to remember:

    People will often have multiple traits from different categoriesin truth its not really accurate

    or possible to divide PD into separate diagnostic boxes (see A Note On Psychiatric Diagnosis).

    As I said in footnote 20, you cannot lump all people with PD in together any more than you can

    homogenise all of mental illness.

    BIPOLAR DISORDER

    Bipolar Disorder is reasonably well-taught, so I have very little more to say on it that has not already been

    covered in Depression. Mania (as you would expect) is in many ways the opposite of depression thecognitive biases run the other way, and positively skew your estimation of your importance, your

    abilities and the future, leading to excessive optimism and risky behaviours. Instead of low motivation,

    sufferers have abnormally high energy, enthusiasm and restlessness.

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    Part 3 Some Other Important Things

    ARE PSYCH PATIENTS DANGEROUS?

    No. Statistically, the rate of violent crime among people with mental illness is no higher than the

    general population, unless you include substance abuse. As a doctor, you are far more likely to be

    attacked by drunken people in A&Ethan by a patient with a psychiatric condition.

    However, despite this most medical students (along with society at large) have a fear of the crazy violent

    psych patient.21I believe this is because we feel we understandthe violence of non-mentally-ill people,

    whereas the dangerous madman (a stereotype established by popular culture and selective news

    coverage of mental illness22) is unpredictable could attack anyone for no reason and is therefore

    much more frightening.

    This is a cognitive biasexactly like those discussed in Anxiety Disorders.23In reality, people with mental

    illness are no more violent than the next person, but our own ideas about this frightening unpredictability

    distort our estimation of the threat.

    But needless to say, people with mental illness are sometimes violentweve not just been making that

    whole idea up. Why might they become violent? Surprise surprise: exactly the same reasons as you or I:

    FEELING THREATENED. This is pretty much the only reason. Anyone gets violent whenthreatened. And understandably youre more likely to feel threatened if:

    o You are being restrained

    o You have been forcibly taken to unfamiliar surroundings

    o People are trying to control your behaviour

    o You dont understand why the aboveis happening

    o You are generally in a state of high anxiety

    o There are people watching you all the time and plotting to kill you24

    o The above only really applies to psychosis and other impairments of cognition and perception.

    Clearly someone with OCD, for instance, is no particular harm to anyone.

    FEELING ANGRY. No actually thats another manifestation of feeling threatened25

    JEALOUSY, HATRED, PERSONAL GAINthe same reasons ordinary people do crime, which may

    happen with or withoutmental illness and are usually not really relevant to it.26

    The fact is were talking about risk and the actual risk of encountering a patient who has a specific

    delusion involving attacking the doctor is vanishingly small. By all means take precautionary measures if

    you have actual evidence that this individual may attack you, but them simply being a psychiatric

    patient is not evidence.

    And weigh up the fact that precautionary measures taken insensitively might well increase someones

    feelings of threat dont let the idea that your patients are dangerous become a self-fulfilling prophecy.

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    A NOTE ABOUT PSYCHIATRIC DIAGNOSIS

    The disorders we have considered so far are labelled as discrete

    conditions, but you will have noticed a series of common disease

    mechanisms underlying many of them (compulsion, low self-

    worth, cognitive bias, impulsivity). Indeed, they can often look

    very similar to one another, and it can be difficult to tease apart

    exactly which diagnoses apply. Also, we know that many feature

    high rates of comorbidity for instance, depression or anxiety isoften the starting point, or a consequence, of other conditions.

    For this reason it is helpful to conceptualise psychiatric diagnoses

    as dimensionsrather than separate boxes after all, they are all

    diseases in the same organ.

    This can more accurately represent the fact that multiple disease processes are often present in the same

    patient, which tie in together to create the overall shape of that individualsillness.

    ANTIDEPRESSANTS AND CBT

    The classic one-size-fits-all treatment for most psychiatric conditions managed in primary care, according

    to NICE. But what do they actually do?

    CBT

    Just to be clear, CBT is notlying on a couch talking about your feelings/mother.

    CBT is a structured method of un-learning the learned maladaptive coping patterns which we

    have discussed the cognitions (C) and behaviours (B) which have become habits (and are thus

    constantly sustaining the disorder) are identified, and specific exercises set out in order to

    practise alternativeswhich are less damaging.

    If recovering from a psychiatric condition is like crossing a deep river, CBT can be thought of as aboat:

    o You might be able to cross without it, but it will be very difficult and you might not. The boat

    is a good way of crossing, but most importantly you have to row. As we have seen, the habits

    of the illness are often instinctual steps to avoid distress taking opposite steps involves

    exposing yourself to the distress, repeatedly and at a low level. Some brief examples:

    To tackle phobicanxiety disorders, or those where certain situations are consistently

    avoided, the person would gradually expose themselves to the feared thing (and when

    nothing bad happens, the learned fear gradually extinguishes).

    In disorders of compulsive behavioursuch as OCD, the person tries to delay enacting

    the compulsion for as long as possible (while unbearable anxiety builds up). Eventually

    they are able to delay for longer and longer and finally stop them.

    To confront the cognitive biases of low self-worth, patients are required to try and

    catch themselves engaging in distorted thinking, and attempt to challenge and

    rationalisetheir negative beliefs. Through repeated attempts the beliefs can gradually

    start to dispel.

    The thing to bear in mind is that these exercises are tremendously hard workespecially when

    suffering from illnesses which directly attack motivation. They require a consistent, high level of

    mental effort, and are by no means a passive process of just talking to someone about the issues.

    Also, the exercises are usually not something the person can just figure out on their own theobjective input of a trained and experienced healthcare practitioner is instrumental in identifying

    the patterns of disease and devising appropriate interventions.

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    ANTIDEPRESSANTS

    Ho ho, nobody knows how psychiatric medications work, what a silly speciality.

    Bollocks. Just as a degree of diagnostic uncertaintyis ubiquitous in most medical specialities

    and yet the criticism of relying too heavily on subjective factors is levelled disproportionately at

    Psychiatry, so too is the above an example of something which is actually true for many areas of

    Medicine.

    We know the receptor modifying activity of psychotropic medications, but the overall mechanismby which they take effect remains largely unclear or theoretical (but then, the same is true of

    anaesthetic induction agents and countless other treatments and dont even get me started on

    paracetamol).

    What antidepressants/anxiolytics aim to achieve is reducing the pressureof the fear or negative

    thinking. They dont change how you think merely subdue the forces of low mood and anxiety.

    As you will hopefully be taught, an important thing you can do to improve compliance(a major problem

    with psychotropic medications) is to ensure that you explainthat the mood/anxiety modulating effects

    of the medication tend not to start for several weeks, whereas the unpleasant side effects usually start

    within the first few days, and then remit a week or so later27.

    I think the most helpful way to conceptualise how medications and CBT can lead to recovery is to think of

    common psychiatric illnesses like ischaemic heart disease(which happens to be similarly debilitating

    and painful, though less curable28than mental illness).

    The meds are like ACE inhibitors they dont really address the root of the problem, but they

    take the pressure off, improve symptoms and reduce risk of serious complications. They are used

    preferentially by many doctors because theyre easy.

    CBT is like lifestyle interventions (diet, exercise) it is proven to effectively tackles the

    underlying disease, but is difficult, and compliance is low.

    Crucially for either illness, I cannot understate the importance of winning the patients

    compliance by demonstrating that you are genuinely invested in their recovery, giving them hope

    and motivation, and explaining clearly what to expect from treatments. Tired though you may be

    of Comm Skills teaching (cos most of its obvious and its not real science), you literally need to do

    this to stand a decent chance of making people better. Its probably more important than learning

    the cranial nerves or the Sepsis Six.

    Yup. I went there.

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    22

    A VERY ABRIDGED SUMMARY

    This handout only contains an overview to give you a general grasp of whats going on

    Part 1

    Compulsion develops gradually and can reach a point where the person cannot control it

    Addiction is an illness where the ability to choose to abstain is impaired

    OCD is a disorder of being unable to control your own thoughts, and can be extremely debilitating

    Eating disorders are dangerous coping mechanisms which develop insidiously from low self-

    worth and terrifying feelings of being out of control. Anyone, male or female, of any size, can have

    an ED.

    Self-harm is predominantly a secretive, compulsive behaviour, the purpose of which is to decrease

    states of distress (subjectively this is experienced as craving followed by relief)

    Garfield likes coffee

    Part 2

    Depression is a pathological state of subjective suffering, involving cognitive distortion which

    reinforces negative beliefs and resists treatment. DO NOT MISS DEPRESSION.

    Anxiety disorders are learned and practised involuntarily, and gradually become states of intense

    and constant fear

    It can be assumed that people with psychosis are making sane and rational decisions, but theseare based on a disjointed reality which is a bit like a dream

    Personality disorders are a complex set of learned behaviours and emotional processing which

    are usually ego-syntonic, and cause tremendous dysfunction and psychiatric morbidity

    Seems I dont know very much about bipolar disorder

    Part 3

    People with mental illness are not especially dangerous be mindful of your own preconceptions

    It is difficult, and probably not helpful, to try and put psychiatric illnesses in separate categories

    Psychotropic medications take the pressure off, and CBT is difficult but it effectively addresses the

    problems driving the disease. For either to be effective you have to work with your patient

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    23

    FOOTNOTES

    1There was a fascinating and terrifying experiment conducted some time ago (back when there werent any Ethics,

    like all the best experiments), where cocaine addicts were connected to two drips. One delivered a small shot of

    saline, and the other delivered an extremely dilute shot of cocaineso dilute, that its effects were not noticeable

    by the subjects. They were then presented with two levers, which respectively delivered a small bolus of either drip.

    They were not told which lever was which, and instructed to repeatedly press them over a period of time, in a

    random order, trying to press both a roughly equal number of times.

    At the end of the experiment, when asked, the subjects had not been able to tell which lever was which,and believed they had pressed each lever roughly the same amount. However, without them even being aware of it,

    they had all pressed the cocaine lever far more frequently. They had not consciously perceived the shot of

    cocaine, but their subcortical reward and motivation circuits had picked it up and influenced their behaviour,

    without them controlling or even knowing about it. I think this gives some insight into how compulsion in

    addiction works, and how much of it is beneath awareness and beyond control.

    2Actually there is we all think of AN first, because it receives most of the media attention. People think of it as a

    crazy diet gone wrong, so is considered bizarre and also strangely glamorous; also for those who understand that it

    is an illness, it can look outwardly horrendous, so elicits a great deal of pity and intrigue.

    Sufferers of BN, on the other hand, often look totally normal. And they gorge themselves on great quantities of food,

    then make themselves sick. Nobody wants to think about that it elicits more disgust than pity. This general opinion

    drives further self-hatredand reduces treatment-seekingin BN, thus worsening the illness.

    3Another interesting study from before there were Ethics, the Minnesota Starvation Experiment, found that if you

    take people without EDs and restrict their diet, they begin to develop some of the same psychological symptoms as

    those observed in EDs namely an obsessional preoccupation with food and eating, as well as depression among

    other things. One can therefore suppose that in low-weight AN, the restricted diet directly worsens the

    psychological symptoms.

    4Actually I do because even if you try to conceal judgemental attitudes they will be perceived. I would urge you to

    try to assume that your overweight patients are deserving of kindness and help, because this will help enormously

    in the process of motivating them to make lifestyle changes.

    5These are mental states which are a challenge to understand or imagine they tend to involve a trance-like period

    of acting unusually and having no memory of it afterwards, and they are often an automatic psychological defencemechanism against past trauma which is too severe for the brain to process normally.

    6And to think, you get an entire module on Cancer (most of which you will never need unless you become an

    oncologist), and you get approximately 3 lectures about Depression, which I dont believe give you any more than a

    list of symptoms, some epidemiology and smatterings of neuroscience.

    7Unfortunately these three things often occur in tandem, and make each other considerably worse.

    8Marked Extremely poor2/30. #nailedit

    9But in case you were asleep or hungover another experiment from the Good Old Days, where they cruelly

    subjected a small child to frightening noises while showing him white rabbits, and surprise surprise he became

    terrified of all white fluffy things. And was probably reasonably messed up in later life.

    10Unless youre Little Albert, in which case an experimental psychologis t who should probably be reported to social

    services has control over it.

    11In terms of evolutionary psychology, social rejection can almost be equated to physical harm we are

    programmed to need the approval and cohesion of the social group, because humans cannot exist alone.

    12Like the Balrog of Morgoth

    13A key aim of CBT is becoming Gandalf.

    On a related, serious note though, JRR Tolkein actually experienced some extremely traumatic events (fighting in

    WW1, including the Battle of the Somme), and turned to creating the rich fantasy world of Middle Earth partly as a

    means of processing these terrifying experiences.

    14So called because they subtract something from the experience of the sufferer, as opposed to the positive

    symptoms (i.e. hallucinations or delusions) which add things.

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    24

    15Bear in mind that schizophrenia is caused by having too much dopamine is similar to heart failure is caused by

    having too much blood. Not entirelywrong, but largely missing the true complexity of whats actually going on its

    more accurate to say there are a variety of abnormalities in the system which uses dopamine, and treatments which

    can be (simplistically) thought of as reducing dopamine activity seem to help.

    16And were not really taught anything about in the MBChB course, it so I suppose I had better make this good.

    17What is illness? Helpfully its defined as a prolonged state of disease or sickness and those two are then often

    defined as a state of being ill. Helpful. So Id say that a ny sort of physical or mental dysfunction (relative to the

    norm) which causes suffering is a reasonable definition of illness. Essentially, something has gone wrong

    somewhere in a person(and by wrong we just mean different, in a bad way).

    - An illness doesnt have to be something which a previously healthyperson develops (see all congenital

    illnesses).

    - The person doesnt have to be aware that they have an illness, or perceive that there is something wrong

    with them in Medicine we hold that illness is objectively present, whether it has been diagnosed or not,

    so it being ego-syntonic does mean it is not an illness.

    - An illness doesnt have to be curable often it is only managed or adapted to.

    I would say PD fits this definition just fine. It is a part of who you arejust like having no legs is a part of who you

    are in other words, it sort of is, but not really, and its clearly also an illness.

    Also bear in mind the impactof telling someone their personality disorder is a part of who they are. You aresaying that they are disordered. Not their body, not just an aspect of their mind them. There is inevitably a

    judgemental, pejorative undertone in that statement, and a finality, a lack of scope for change. Treating PD is already

    tricky enough, but what is guaranteed to make it harder is disrespect and hopelessness.

    Of course this raises the fascinating question of whether or not all personality traits which we consider

    badare illnesses. That seems like quite a stretch, especially considering that PDs tend to conform to fairly

    standard patterns of diseaseyou can meet a hundred patients with EUPD, and they are all individual people like

    everyone else, but the traits of the disorder itselfseem to be quite replicable (in this way it looks very much like a

    disease). But on the other hand, PD lies on a spectrum with whats considered normal the cut-off point for

    defining disorder is purely arbitrary (like for hypertension). Also, we are not really in control of the personality

    traits we develop in this regard they look a bit like illnesses, in that they more or less just happen to us.

    Its a great question, which I will happily discuss over a cup of tea, but this footnote is already way too long.

    18On a basic level, every person needs certain things from the people in their lives validation (respect, and a senseof purpose), support when necessary, a sense of security, relationships, love. These needs can be seen to motivate a

    lot of what we do in terms of making friends, working, and generally interacting.

    19As discussed, society has a preconception that self-harm is a means of attention seeking. This is totally untruein

    the vast majority of cases, but can apply to some degree in EUPD, because sufferers have not learned more normal,

    functional means of communicating this need. Bear in mind that this may not be as blatant as showing the injuries to

    everyone and saying how damaged you are simply allowing some people to see it could be a mixture of genuinely

    seeking help and also trying to communicate a need for validation of ones feelings, without even realising.

    However, EUPD sufferers very often self-harm for the more common reasons (coping with states of

    distress), and in these cases may keep it hidden.

    20

    Bear in mind, you cannot lump all PDs in together . The only similarity between EUPD and ASPD is that theyboth involve deeply ingrained psychological characteristics of one sort or another while ASPD is invariably pretty

    unpleasant, people with EUPD are perfectly capable of empathy and are not sociopaths (unless they also have ASPD

    traits, which is possible).

    21When I did the psych block even the introductory lectures began with telling you to make sure the patient isnt

    between you and the door, and check there are no objects in the room which could be used as weapons. This may still

    be the case, although hopefully it has been approached more sensitively in light of some strongly-worded feedback.

    22Short opinion piece (do take with a pinch of salt). Im just gonna put this out there media coverage of mental

    illness is usually abysmal, and has a lot to account for. The media focus on the extraordinarily uncommon

    instances of dramatic violent crime by mentally disturbed people (be it using knives, guns or planes), which are

    totally unrepresentativeof almost all people with psychiatric conditions.

    Even stories where mental illness isnt the real issue are made to be about mental illness. Take the coverageof the recent Charleston shooting a bona fide terrorist by any definition, and an end-product of endemic societal

    racism and stupid gun-laws, but the first conclusion by reporters is that he must have been mentally disturbed. That

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    says rather more about the deeply prejudiced way we view terrorists of different ethnic backgrounds, but also

    reinforces the false stereotype that the psychiatrically unwell are a danger to society.

    23Shit, you mean normal people do it too?? Maybe the crazies are just like you and I after all.

    24Remember, for a person with paranoid delusions, they dont thinkthere are people trying to harm them: there

    are people trying to harm them. Fact.

    25Fear is the path to the Dark Side. Fear leads to anger, anger leads to hate, hate leads to suffering. George Lucas

    didnt make that shit up its actually an ancient Buddhist proverb (minus the bit about the dark side) and is well

    enshrined in modern psychological theory.

    26Except to ASPD, of course

    27Patients are very often hit by the side-effects straight away, and havent yet experienced any benefits, so stop

    taking them. Warn them about this likely scenario, and really encourage them to persist for long enough for the SEs

    to wear off and their mood/anxiety to improve.

    28And much better taught