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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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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 on [email protected]  

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 not  do 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 that  in 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 understood due to a lack of awareness of this.

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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 directly into 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 reinforcement  is 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 person’s 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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OBSESSIVE-COMPULSIVE DISORDER

The term “OCD” is oft en 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:

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 it  and 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 anyone’s 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 don’t want it to (see Anxiety).

  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 knows these are just their own thoughts, and that it is not rational to 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

person’s 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 patient’s actual character. 

   w   w   w .   o   c    d   u    k .   o   r   g

   w   w   w .    k   e   e   p   c   a    l   m  -   o  -   m   a   t   i   c .   c   o

 .   u    k

   w   w   w .   s   e   r   i   o   u   s    l   y   m   e   n .   c   o   m 

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Given this persistent state of distress caused 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 checking the house for fire-

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

unrelated, such as counting or arranging things 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 10th most debilitating illness of any kind (WHO GBD 1998), so it’s

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? Isn’t a compulsive eater just another overweight

person who needs to get some self-control? Why can’t 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, it’s what everyone sees, and we’re persistently told 

by popular culture that it’s 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 guilty for eating it, it is a sin/“syn”, a weakness, an indulgence

o  People who are overweight  have overindulged, they are disgusting, they are a burden 

o  Thinness means 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 reassurance from 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 don’t

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 don’t look  like 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-

loathing entailed in the binge/purge cycle. The act of purging is at the centre of this.

  Sufferers of BN purge because the knowledge that they have eaten fills them with panic – it means

they have lost control of themselves, they have failed, they can’t even lose weight properly, and now

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

o  Needless to say, this thinking is distorted – that’s a 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).

  Binging occurs for several reasons:

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 I’ve failed to restrict properly

like someone with a “real” eating disorder, I’ve eaten large quantities of food because I can’t even control

myself, and I’ve 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.

   s    h   e   t   a    k   e   s    f    l   i   g    h   t .   t   u   m    b    l   r

 .   c   o

 

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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 don’t they

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

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

enough and feeling unsafe/out of control – for 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 don’t 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 here’s something (they may think) that I’m not a failure at .

  As discussed, this diet restriction is thus negatively reinforced and 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 triggering for 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 loss itself 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 imaginable as 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 manipulative – lying, 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 sufferer’s every waking thought  and 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 you’re 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 don’t understand the basic psychology of compulsive eating you may not get very far. This isn’t 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-worth – which, as

discussed previously and below, distorts people’s thinking. 

 

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

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

o  They are widely used as treats or 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 distress and 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 don’t care 4 – it’s all about how you respond to them

and enable them to reach a healthy weight.

As I’m sure you can imagine, but just in case it’s 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 we’ve 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 cycle gradually 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 that  – very often it has no suicidal intent  behind it, and is a

means of coping. But why would people injure themselves to cope? Doesn’t that just cause more pain? 

I’m just going to tell you now to get it over with –  the answer is compulsion driven by negative

reinforcement  plus 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 escalates and 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-hatred – and 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 of  relief , 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 “good” – just less shit).

 

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

right , or jolts them back to reality from 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-injuries are often a sign of severe distress 

and warrant full investigation. Also keep in mind that this behaviour is a compulsion and 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 binary – people may self-harm without

specifically intending to die, but at the same time feel that they wouldn’t mind  if they accidentally did.

The psychological distortion of self-hatred creates ambiguous feelings about dying – not caring aboutyourself, combined with a lack of motivation to take suicidal action (we will discuss in Depression how

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 biolo gical 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 it’s basically

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

the totally misguided impression that it’s 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 don’t believe it’s possible to fully

appreciate what it’s 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 complex and 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 you’re 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 you’ve ever experienced, and all the time.

  Depression is also often experienced as emptiness – where 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-worth and hopelessness about the future develop

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

 

Cognitive bias develops – this 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 assumptions about the

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

simplified models to 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.

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 develop from 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 body’s 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

isn’t working).

BE VIGILANT FOR DEPRESSION AT ALL TIMES

We’re all taught the Red Flags for cancer – we constantly have it in the back of our minds in any history,

because of course it’s 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 don’t

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. 

    S   y    l   v   i   e    R   e   u   t   e   r

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ANXIETY

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

Anxiety… meh. Everyone gets stressed. It’s not really like the proper 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 costly to the economy, and most importantly, suffering from them is

truly grim.

So what is Anxiety? Firstly, it’s a misnomer in my opinion – “anxiety” is worrying I’ve 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,8 people 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 all9 remember 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 thing leads 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 you’ve 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

Essentially anything related to the threat of something bad happening, be it physical harm orsocial 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

dangerous the 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 deep12 in the primitive midbrain, so the learned fear is much more difficult to overcome

than this.13 It 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 something makes us no less afraid of it  – if we are avoiding something which is

actually harmless, we never un-learn our erroneous fear of 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 reinforced and 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 disorder can develop from more singular beginnings.

While people can choose not to engage in rumination and avoidance behaviours, this is usually not one’s 

instinctual inclination. Also, remember these things creep in very gradually and insidiously – nobody

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 person’s daily life away. 

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

slightly more anxious personality – perhaps the sort of person who is inclined to worry and play it safe.The mechanisms described will be more likely to take hold under these conditions.

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

be simply unable to just do the thing they’re afraid of  – the overriding motivating force of fear renders this

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

    b   o   g   g    l   e   t    h   e   o   w    l .   t   u

   m    b    l   r .   c   o

 

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PSYCHOSIS AND SCHIZOPHRENIA

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

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

psychosis along with the “negative symptoms”14 which 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 hallucinations and 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

  Everyone’s 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 the same neural circuits which are firing when you actually experience those things. In terms of brain activity, thinking about something is similar to re-experiencing it.

  “Source Monitoring” is the brain’s 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, inserted or 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, threatening stimuli 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 motivation – things 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 one’s 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.

  Delusions are the result of an unconscious cognitive effort by the sufferer to make sense of 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, hallucinations can 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; they’re hearing and seeing people that aren’t there, they’re believing all these far-

fetched paranoid things, they’re saying things that make no sense.

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

response to the things they perceive around 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 it’s like to have auditory hallucinations of voices constantly talking

about what you’re 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 don’t 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 person’s normal thinking and

behaviour – and they are usually what is called “ego-dystonic”, that is, sufferers are aware they have a

problem and are distressed by 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 it’s 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 17 if you’re 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 responses to 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 manipulating people 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 twisted into 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 attenders at

A&E or primary care, and are perceived to be “difficult” and “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 conscience for 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 fault  that 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 conditioning – that is, the

learning process we discussed in  Anxiety Disorders is 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 can learn antisocial 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 categories – in truth it’s 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&E than 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.21 I believe this is because we feel we understand the 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 bias exactly like those discussed in Anxiety Disorders.23 In 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 violent  – we’ve 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 you’re 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 don’t understand why the above is 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 that’s another manifestation of feeling threatened25

   JEALOUSY, HATRED, PERSONAL GAIN – the same reasons ordinary people do crime, which may

happen with or without  mental illness and are usually not really relevant to it .26 

The fact is we’re 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 someone’s

feelings of threat – don’t 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 dimensions rather 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 individual’s illness.

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 not  lying 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” alternatives which 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 phobic anxiety 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 behaviour such 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

rationalise their 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 work  – especially 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 uncertainty is 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 don’t even get me started on

paracetamol).

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

thinking. They don’t 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 explain that 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 curable28 than mental illness).

  The meds are like  ACE inhibitors –  they don’t 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 they’re 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 patient’s

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 it’s obvious and it’s not real science), you literally need to do

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

the cranial nerves or the Sepsis Six.

Yup. I went there.

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A VERY ABRIDGED SUMMARY

  This handout only contains an overview to give you a general grasp of what’s 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 don’t 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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FOOTNOTES

1 There was a fascinating and terrifying experiment conducted some time ago (back when there weren’t 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 cocaine – so 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.

2 Actually 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-hatred and reduces treatment-seeking in BN, thus worsening the illness.

3 Another 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.

4 Actually 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.

5 These 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.

6 And 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 don’t believe give you any more than a

list of symptoms, some epidemiology and smatterings of neuroscience.

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

8 Marked “Extremely poor”  – 2/30. #nailedit

9 But 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.

10 Unless you’re Little Albert, in which case an experimental psychologis t who should probably be reported to social

services has control over it.

11 In 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.

12 Like the Balrog of Morgoth

13 A 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.

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

having too much blood”. Not entirely  wrong, but largely missing the true complexity of what’s actually going on –  it’s

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.

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

17 What is illness? Helpfully it’s defined as “a prolonged state of disease or sickness” and those two are then often

defined as “a state of being ill”. Helpful. So I’d 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 doesn’t have to be something which a previously healthy person develops (see all congenital

illnesses).

-  The person doesn’t 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 doesn’t 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 are just like having no legs is a part of who you

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

Also bear in mind the impact  of 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

bad are “illnesses”. That seems like quite a stretch, especially considering that PDs tend to conform to fairly

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

everyone else, but the traits of the disorder itself  seem 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 what’s 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.

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

18 On 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.

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

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 one’s 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).

21 When I did the psych block even the introductory lectures began with telling you to make sure the patient isn’t

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.

22 Short opinion piece (do take with a pinch of salt). I’m 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 unrepresentative of almost all people with psychiatric conditions.

Even stories where mental illness isn’t 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.

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

24 Remember, for a person with paranoid delusions, they don’t think  there are people trying to harm them: there

are people trying to harm them. Fact.

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

didn’t make that shit up – it’s actually an ancient Buddhist proverb (minus the bit about the dark side) and is well

enshrined in modern psychological theory.

26 Except to ASPD, of course

27 Patients are very often hit by the side-effects straight away, and haven’t 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.

28 And much better taught… 


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