Major Mental Illness Overview

1. Major Mental Illness Overview David Mays, MD, PhD dvmays@wisc.edu

2. The Million Dollar Question • We believe that mental illness is a brain disorder, although there is evidence that our immune systems, our hormone levels, inflammation, heart disease, cancer, and even the bacteria in our gut can affect our moods and our ability to concentrate. • And because the brain is so difficult to study, scientists haven’t figured out what the brain problem is with any of our mental illnesses. • Researchers are looking at brain cells (neurons), brain “wiring”, and genetics to try to find out what’s wrong.

3. Where Does Mental Illness Come From? • Mental illnesses run in families, but that does not explain who gets a mental illness in the community. • A “bad childhood” is sometimes linked to mental illness, but not always. • We currently believe that mental illnesses, like physical illnesses, come from a combination of genes and environmental exposure.

4. Estimated Heritability of Mental Illnesses • Autism 90% • Schizophrenia 80% • Bipolar Disorder 80% • Attention Deficit 77% • Alcohol Dependence 55% • Major Depression 42% • Anxiety Disorders 30-45%

5. So How Do We Diagnose a Mental Disorder? • Since we don’t know what is wrong with the brain in the first place, we don’t have any blood tests or brain scans to show someone has a mental illness. This is very different than diabetes or heart disease. • All we can do is observe someone’s behavior and look for patterns (syndromes). These patterns are what we call mental illnesses – depression, schizophrenia, anxiety.

6. How Do Mental Illnesses Affect Behavior? • Human behavior is a mixture of instinct, reactivity, emotions, and planned behavior. Different people have different temperaments, and in different situations, we may be more emotional or more thoughtful. • A brain disease can affect all of these processes. Typically, mental illnesses affect our perceptions, our self-control, and how we understand what is happening.

7. Seeing Patterns is the Default Mode • Humans see patterns in the world. • Humans also want the world to make sense. So we create stories/reasons about why everything happens. • Which sentence do you prefer ?: • The king died and then the queen died. • The king died and then the queen died of grief.

8. Delusions • Mental illness may cause some people have “false beliefs” (delusions). They may think they are being watched or that they have special powers or knowledge. Everything will fit into this pattern. There is no way to convince them they are wrong. You will certainly not convince them they have a mental illness. • Perceptions may also be abnormal because people will hear “hallucinations.” Sometimes people have “command hallucinations” which tell them what to do.

9. Delusions • When you are dealing with someone who is delusional, arguing with them usually just creates frustration for everybody. • “Playing along” with someone’s delusions usually backfires, because people with mental illness aren’t stupid and will figure out you are just humoring them. Now you have lost credibility. • Instead, be honest, and try to find something in the person’s story that you can genuinely understand and agree with. (“It must be hard when nobody believes you.”)

10. Impulses and Self-Control • Just like intoxication, some mental illnesses make people more impulsive and less able to exert self-control.

11. Reasoning • Mental illness can also impair peoples’ ability to think logically and reach reasonable conclusions. They may • blame others for their behavior • have unreasonable expectations of other people • believe that their families would be better off without them • come up with outlandish schemes to make money or solve problems.

12. In Summary • We don’t know what’s wrong with the brain when people have a mental illness, so we diagnose illnesses by behavior. • One thing we do know is that mental illnesses affect behavior in different ways, changing people’s perceptions, impulse control, and ability to reason. • But remember, there is a spectrum of mental illness, from very mild to very severe. Different people will present differently, and everyone has good and bad days.

13. Schizophrenia • Schizophrenia is a brain disorder that interferes with thinking, reality testing, and activities of daily living. • The cause of schizophrenia is not known, but it appears to result from a combination of genetic factors and other stresses. • Medications relieve some symptoms, but they don’t cure the illness. Nevertheless, many people can get somewhat better over time.

14. Variability • We think that there are different causes, even different types of schizophrenia, in the same way that individuals with heart failure will have different causes for their condition. • The symptoms of schizophrenia span a wide range of severity. Some people function quite well. Others are totally disabled.

15. Course of the Illness • Schizophrenia has a chronic course of remissions and exacerbations. • The three major problems in schizophrenia are • psychotic symptoms • deficit symptoms • cognitive symptoms.

16. Psychotic Symptoms • Hallucinations, delusions (most frequently of prosecution, or of being controlled by outside forces, x-rays, outer space), mutism, word salad, thought blocking • Less a cause of disability than negative symptoms

17. Deficit Symptoms • Restricted emotional expression, reduced initiative, poor rapport, poor hygiene. • These symptoms appear earlier, are harder to treat, and worsen over time, unlike positive symptoms.

18. Cognitive Symptoms • Disorganized and dissociative thinking • Loss of attention, memory, executive function, verbal skills, motor skills • Generalizations are incorrect • Trouble with abstraction • Difficulty with understanding the main idea • May be the most disabling aspect of the illness

19. Schizophrenia and Substance Abuse • Substance abuse and schizophrenia commonly appear together. 50% are substance dependent, >70% are nicotine dependent. • It is not clear why there is so much co-occurrence of substance use and mental illness. • Patients report that substance abuse helps with symptoms, boredom, anxiety, sadness, friends.

20. Schizophrenia and Substance Abuse • Smoking may reduce auditory hallucinations, improve concentration, decrease EPSE’s, and be an antidepressant.

21. So What Does This Mean For You? • People with schizophrenia are not stupid. Don’t talk down to them or humor them. They will probably know if you are lying to them. Be tactful, but honest. • People with schizophrenia suffer because of their thoughts, which they cannot control. It is not a problem of “character.” It is an incurable brain disease. Be respectful and compassionate. • As with all interactions with people, listen well and develop a rapport around those things that you can understand – like how it feels to not be listened to.

22. So What Does This Mean For You? • Medication effects and side effects are complicated and individual. They need to be sorted out by the doctor. • Medication overdose can sometimes look like intoxication. Anyone who takes medication and shows confusion and slurred speech needs to go to an ER. • Medications are not cures, but nearly everyone does better when they take their medications. You can encourage medication compliance by a positive attitude.

23. Bipolar Disorder • A medical condition in which people have mood swings out of proportion, or totally unrelated to things going on in their lives • These swings affect thoughts, feelings, physical health, behavior, and functioning • Depression is the most frequent episode.

24. Natural History • Depression is the most frequent episode. • Depressive episodes last longer (25.4 weeks) than manic episodes (5.5 weeks). • The time between episodes is usually 12-14 months.

25. Bipolar Disorder and Substance Abuse • Bipolar disorder is commonly associated with substance abuse. 23.6% have an alcohol disorder, 12.9% have a drug abuse disorder, 37% have nicotine dependence. • Treatment of one does not resolve the other, but controlled bipolar disease usually leads to diminished substance abuse.

26. The Manic Phase • Hypomania • Energetic, extroverted, assertive, hypersexual, self-confident, rapid speech • Mania • Poor judgment, euphoric, grandiose, paranoid, irritable, hyperactive, manipulative, demanding, pressured speech • Psychosis • Delusional, labile, distractible, confused, combative

27. Mood Stabilizers • Lithium • Effective for mania, depression and maintenance, and suicide reduction • Requires blood work and high levels can be fatal • Side effects include frequent urination (35%), memory problems (28%), tremor (27%), weight gain (19%).

28. Lithium Can Be a Dangerous Drug • A very high blood level of lithium may be fatal. This can happen if the person is dehydrated from illness or heat, or took an overdose. If a lithium overdose is suspected the person should be taken to an emergency room. • What you would observe is slurred speech, clumsiness, confusion.

29. So What Does This Mean For You? • Although patients with bipolar disorder may appear to be fairly normal, they are often unpredictable and may be very irritable. • Having bipolar disorder is very unpleasant and uncomfortable. Our treatment with medication is often inadequate, but it is better than no treatment at all. • Depressed patients are at risk for suicide. Manic patients have very poor judgment and often abuse substances.

30. Depression • Depression is a commonly experienced mood, but the illness of depression is more than just being sad. Depressed people are usually not able to relate to others and may be able to express only a limited range of emotions.

31. Symptoms • Mood • Depressed mood • Vegetative • Weight loss or gain • Insomnia or sleeping too much • Decreased sex drive • Behavioral • Slowness or agitation • Fatigue • Diminished interest or pleasure in most activities

32. Symptoms • Cognitive • Feelings of worthlessness or guilt • Diminished ability to think and concentrate • Poor frustration tolerance • Negative distortions • Impulse Control • Recurrent thoughts of suicide, homicide, or death • Somatic • Headaches, stomach aches, muscle tension • Chronic Painful Physical Conditions

33. Antidepressants • Antidepressants help about 2/3 of the people who take them regularly. • There are different types of antidepressants. All of them have some side effects. • They are not addicting or abusable.

34. Other Treatments for Depression • Electroconvulsive therapy (ECT) • Light therapy • Physical activity (30 min aerobic/day) • Omega-3 Fatty Acids, St. John’s Wort, SAMe

35. Anxiety • We are all familiar with anxiety. Anxiety can be a constant, low grade background nuisance that interferes with concentration, appetite, and sleep. Or it can be a raging brain storm that impairs our perceptions, judgment, and self-control. • People who are never anxious are at great risk from harm in their environment. People who are too anxious all the time, have health problems related to their cardiovascular system, immune system, memory, and mood.

36. Anxiety and Substance Abuse • 70% of alcoholics have anxiety problems, mostly caused by the alcoholism. 15% of anxiety disorder clients have substance abuse problems. The relationship is bidirectional and complex. • Alcohol relieves anxiety in the short term, but chronic drinking makes anxiety.

37. Anxiety and Substance Abuse • It is difficult to detect substance dependence in the presence of an anxiety disorder. • Anxiety can be precipitated by caffeine, diet pills, androgenic steroids, etc.

38. Panic Attack • A panic attack is a discrete episode of unexpected terror accompanied by a variety of physical symptoms including fear, anxiety, catastrophic thinking with a sense of impending doom, or the belief that loss of control, death, or insanity is imminent. • Physical symptoms can be neurological, gastrointestinal, cardiac, or pulmonary.

39. Panic Attack • A panic attack lasts from 5 to 30 minutes, with symptoms usually peaking at 10 minutes. They may occur during sleep. • Many psychiatric disorders have panic attacks associated with them. • Panic attacks can be triggered by certain situations - driving in the rain, crossing a bridge, being crowded, waiting in line.

40. Panic Disorder • Panic disorder is the presence of recurrent, unexpected panic attacks followed by at least a month of persistent anxiety or concern. • 10% of the population report having a panic attack. • 4.7% of the population develop panic disorder.

41. Symptoms of PTSD: 4 Groups • Re-experiencing: common and reflect normal responses to trauma • Hyperarousal: common and reflect normal responses to trauma. • Avoidance • Negative cognitions and mood

42. Psychological First Aid • PFA consists of 8 core components: • Contact and engagement • Safety and comfort • Stabilization • Information gathering • Practical assistance • Connection with social supports • Information on coping support • Linkage with collaborative service

43. What is Personality? • A complex pattern of deeply embedded characteristics that are largely unconscious, cannot be eradicated easily, and express themselves automatically in almost every facet of functioning. They comprise an individual’s distinctive pattern of perceiving, feeling, thinking, and coping. • These traits are ego-syntonic - they feel familiar and personal.

44. Why Are We the Way We Are? • There are three shapers of human personality: • Genes • Environment • Chance

45. DSM-5 • Cluster A: odd and eccentric (cognitive) • Paranoid • Schizoid • Schizotypal • Cluster B: dramatic, emotional (externalizing) • Antisocial • Borderline • Histrionic • Narcissistic • Cluster C: anxious, fearful (internalizing) • Avoidant • Dependent • Obsessive

46. Borderline Personality Description • Interpersonal problems • Turbulence, fear of abandonment, self-esteem dependent on important others • Affective instability • Reactivity, intense negative emotions, pervasive dysphoria • Behavioral difficulties • Impulsive, self-destructive, addictions, recklessness • Cognitive problems • Lack of stable sense of self, psychosis and dissociation • Comorbidity • Substance abuse, impulse control disorders, mood disorders, eating disorders, anxiety disorders, PTSD, ADHD

47. Interpersonal Agenda of the Borderline Personality • The person’s primary concern is to find someone who can understand them perfectly enough so that their sense of isolation will abate and their misery will stop. It is a kind of “Golden Fantasy” – by finding the one person who can help them, all of their needs will be met. • A strong fear of abandonment arises when something seems to disrupt the developing relationship. Abandonment fear is expressed with “rage” as a kind of hostile dependence.

48. Self-Injury • There are many reasons why people do things to their bodies that may seem deviant to mainstream observers. Not everyone is manifesting psychiatric pathology. • Causes for concern: • Injury to face or genitals • Carving words or messages on the body • Indifference or odd affect • Severe injury

49. Some Reasons for SIB • Affect regulation • Reconnection with the body • Calming the body during periods of arousal • Validating inner pain • Avoiding suicide • Communication • Express things which cannot be said out loud • Control/punishment • Trauma re-enactment • Bargaining and magical thinking • Self-control/manipulation

50. Hospitalization • Borderline personality disorder is the predominant personality disorder on inpatient services. Hospitalization is useful for clients who are acutely suicidal or destabilized, but hospitalization should rarely be used for SIB, and does not decrease the risk for future suicide attempts in chronically suicidal people. • Hospitalization usually results in regression in borderline clients (e.g. renewed and intransigent focus on their internal life and misery.)