01/05/2018

Introduction to psychiatry
Rob Howard
Revision: mental health year 1 Understand mental health as a continuum
2017-18 Consider how society views mental illness, and stigma
Identify how mental health problems can impact on anyone,
Amanda C de C Williams including doctors
Know when and where to seek help for yourself
Various terms: mental illness, psychiatric disorder, mental health
problem, etc.
Much stigma and discrimination, so may appear to be less
common than it actually is.
• Functional disorders e.g. psychosis, neurosis, substance abuse
• Organic disorders e.g. dementias, head injury, delirium
• Neurodevelopmental disorders e.g. intellectual disability,
Millais, Tate autistic spectrum disorders

Which is not a criterion for diagnosing depression, Which is not a criterion for diagnosing depression,
in addition to depressed mood most of day and/or in addition to depressed mood most of day and/or
diminished interest and pleasure? diminished interest and pleasure?
A. Weight loss or gain A. Weight loss or gain Social isolation is a common
B. Insomnia or hypersomnia B. Insomnia or hypersomnia occurrence in depression,
C. Psychomotor agitation or C. Psychomotor agitation or usually because of social
withdrawal by the depressed
retardation retardation person, but it is not a diagnostic
D. Fatigue D. Fatigue criterion.
E. Feelings of worthlessness E. Feelings of worthlessness It is an important thing to ask
or guilt or guilt about, though.
F. Social isolation F. Social isolation
And for the other criteria, 3 or
G. Reduced concentration or G. Reduced concentration or more are required.
indecisiveness indecisiveness
H. Thoughts of death or H. Thoughts of death or
suicidal thoughts suicidal thoughts

Diagnoses: advantages & disadvantages Illness ?

Advantages • Disability or impairment of functioning
• For communication – with patients and other doctors • Distinct from disease
• To guide prognosis (outcome) • Emphasises personal experience (can have disease but not be ill)
• To guide treatment • Cannot be resolved by effort of will
• To carry out research and understand illness • In most societies, implies that medical help will be forthcoming
Disadvantages May be represented in Disability Adjusted Life Years (DALYs) that
• Labelling, stigma allow comparison of all illnesses.
• Change in how person views themselves
DALY = value for quality of life 1 (perfect health) to 0 (death).
• “Halo” effects: normal behaviour looks “abnormal”
• Ignoring other conditions that require treatment Depression, Alzheimer’s, and alcohol-related disorders are
• Continuum of disorder is reality, not distinct categories comparable in DALYs to COPD, cerebrovascular disease, ischaemic
• Can encourage overlooking subclinical symptoms heart disease.
Depression is single most important contributor to burden of
disease in high income countries, particularly in work age people.

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Doctors have higher rates of mental disorder Doctors have higher rates of mental disorder
than general population. Which is NOT a risk? than general population. Which is NOT a risk?
A. They conceal problems, A. They conceal problems, They may identify with
go on working when ill go on working when ill patients, but this is not a
known risk factor.
B. They over-identify with B. They over-identify with
patients patients The others are all clearly
identified as risk factors,
C. They self-medicate and C. They self-medicate and and all of them, in principle,
don’t ask for help don’t ask for help offer routes to try to
improve the situation, and
D. Working conditions may D. Working conditions may get doctors prompt and
contribute to illness and contribute to illness and appropriate help as soon as
they need it, and advice
delay recovery delay recovery when they are not sure.
NB Fitness to practice requires awareness of NB Fitness to practice requires awareness of
risk to patients from own mental health risk to patients from own mental health
problems; duty to seek help problems; duty to seek help

Society, culture, mental health Andrew Sommerlad How psychology relates to medicine
Concerned with impact of family, society, culture and spirituality Amanda Williams
on the likelihood of developing a mental illness and on the ways Key areas:
these factors impact on mental health and illness. • Changes in behaviour associated with illness and disorder
• Culture is “the ideas, customs, and social behaviour of a • Psychological variables in aetiology of medical problems
particular people or society” – not the same as race / ethnicity • Patients’ responses to illness and to treatments
• Spirituality is "a transcendent dimension within human • Psychological treatments
experience...discovered in moments in which the individual
• Doctor-patient relationship
questions the meaning of personal existence and attempts to
place the self within a broader ontological context" • Doctors’ beliefs, behaviour, stress and burnout.
• Development, symptom expression, help-seeking and outcome Psychology is not common sense, or intuition.
of mental illness are affected by family, spirituality, culture, Psychology is a science, but often relies on soft data, has no direct
society. access to important variables, identifies associations but rarely
• So cultures with different beliefs to host culture may present causal pathways.
differently, later, with apparently different needs.

Integrating mind and body Patients’ presentation can be puzzling, but it

Behaviour is mostly what you have to work with at the start of a can help to get a bigger context. What
medical problem. contributes to this context?
You have to infer what it means about the patient – his or her
cognitive, emotional, and social state. A. Patient’s beliefs about illness and health.
There are some strong psychological principles to help inference – B. Patient’s culture of origin.
such as mechanisms of attention, memory, and learning; C. Patient’s beliefs about what doctor wants
development across the lifespan - and many that are weak or of
to know.
limited application.
Behaviour change can signal biological change – in developmental D. Patient’s emotions state.
delays, neurological lesions and pathology, dementias, etc. E. What patient’s family and friends think.
Behaviours can produce biological change – smoking and cancer, F. What’s on the internet about the
smoking & diet & inactivity and cardiovascular disease, etc.
symptoms.
Behaviours are important in how people cope with disease and
treatment, and may affect outcomes.

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Patients’ presentation can be puzzling, but it Which of these is NOT true of risk appraisal?
can help to get a bigger context. What A. Screening has costs in
unnecessary anxiety for false
contributes to this context? positives
A. Patient’s beliefs about illness and All of these. B. People overestimate
health. The least important is newsworthy risks and
underestimate everyday ones.
B. Patient’s culture of origin. probably the internet,
C. Many people don’t understand
C. Patient’s beliefs about what doctor which patients tend to probabilities such as 1 in 1000
wants to know. consult after seeing a D. People find it easy to
doctor rather than understand odds ratios for risk.
D. Patient’s emotional state. before. E. Framing information (risk of
E. What patient’s family and friends dying vs chance of survival)
think. affects decisions.
F. What’s on the internet about the F. Culture can affect the value
symptoms. people put on risks.

Which of these is NOT true of risk appraisal? Psychology of health, illness and symptom
A. Screening has costs in presentation Amanda Williams
unnecessary anxiety for false Very few people find it
positives easy to understand or … applying psychological theories, methods and research to
explain odds ratios, even promotion of health, prevention and treatment of illness and
B. People overestimate doctors, who are familiar
newsworthy risks and with their use.
disability, analysis & improvement of health care system & policies.
underestimate everyday ones. • Changing health-related behaviours
C. Many people don’t understand Conveying risk in ways
probabilities such as 1 in 1000 • Symptom perception, interpretation, and action
that people understand
D. People find it easy to easily and unambiguously • Hospitalisation
understand odds ratios for risk. (such as visual How do people understand their own health?
E. Framing information (risk of representations) is
becoming increasingly They judge by how they feel, whether they have symptoms (or in
dying vs chance of survival)
affects decisions. important as patients are older people, whether they have more than common symptoms),
F. Culture can affect the value
more often involved in and whether they can do everyday activities …
their healthcare decisions. - but hard to decide how ‘bad’ a symptom is
people put on risks.
- hard to decide if experience is ‘normal’

Which of these does NOT increase take-up of Which of these does NOT increase take-up of
preventive behaviours against infection? preventive behaviours against infection?
A. Greater perceived A. Greater perceived
Depression about illness does not
susceptibility susceptibility increase preventive behaviours (such as
B. Depression about B. Depression about getting vaccinations, washing hands,
impact of illness impact of illness etc.). In general, people who are
C. Higher anxiety about C. Higher anxiety about depressed are less motivated and so
threat of illness threat of illness less likely to do these, even if they are
well aware of the value.
D. Greater perceived D. Greater perceived
severity of illness severity of illness People are more likely to use preventive
E. Greater belief in E. Greater belief in behaviours when they feel that they
preventive behaviours preventive behaviours make sense (and/or are suggested by
working working someone who knows), are personally
relevant (there is a genuine risk), and
F. More trust in authorities F. More trust in authorities will work to reduce risk of infection.
(doctors) & their advice (doctors) & their advice

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Behaviours that contribute to disease Changing patients’ behaviours

In developed countries, major killers are cancer, heart disease and
1 Clear assessment of needs, involving patient in process.
stroke, lung disease and diabetes.
Major risk factors: blood pressure, cholesterol, BMI, blood sugar. 2 Defining goals and the behaviours that are necessary to
So why don’t people adopt healthier behaviours? increase or decrease to reach the goals;
Knowledge is necessary but not sufficient for changing behaviour. and the key beliefs associated with those behaviours;
Knowledge is filtered through beliefs, mis/understanding of body, 3 Identifying effective behaviour change techniques.
values, etc. What are effective behaviour change techniques?
Knowledge affects intentions to behave a particular way. Self-monitoring characterises all effective change +
But intentions account for < ¼ of variance in behaviour. • prompting intentions and goal setting;
What else accounts for behaviour? • and/or specifying goals in context;
• Consistency of intentions? Are there doubts about goal? • and/or feedback on performance;
• Is there a clear plan, including when, where, how long, etc.? • and/or reviewing earlier goals.
• Is there a plan to deal with barriers? COM-B model: Capability + Opportunity + Motivation (mechanisms
• Are there long-established habits that need to change? to bring about change) = Behaviour

Symptom perception, interpretation, presentation Procedures and hospitalisation

What influences reporting of symptoms? All stressful.
• Characteristics of symptom: severity, novelty, etc. Procedures: people have preference for information or not.
• Cognitive characteristics: attention, expectation, beliefs, fears, etc. Those who want it become less anxious; those who don’t, ignore it.
Raising awareness of symptoms (bird flu?) increases reporting. Staff are generally poor at judging patients’ anxiety and need for
Misfit of symptoms with beliefs (no pain down arm?) decreases information.
reporting (of heart attack). Information about what to expect during & after is most helpful
Meaning of symptoms – trivial? serious? – affects seeking opinion. and may make procedure quicker and less likely to have problems.
First opinions sought from friends, family, workmates (less if High levels of anxiety about procedure/surgery are associated with
embarrassing). That influences decision to consult doctor or not. slower recovery, more pain, poorer sleep, more days in hospital.
Patients present what they think is most relevant to doctor (so Children are usually helped by having parent/s present, unless
personal and social problems not reported, or only if asked). parent is very anxious, in which case child better without.
They also present what was treated before (cough – antibiotics?).

Behaviour change and adherence Rob Horne Which of these will NOT improve adherence
Definition of adherence and impact of non-adherence to treatment?
Methods to assess and improve adherence A. Scare patient about effects
Understanding some key drivers of adherence of non-adherence
WHO estimates 30-50% of medications are not taken as prescribed. B. Provide information in pack
Non-adherence can be: with decision aids
• Non-initation: collecting and starting treatment C. Boost motivation by
• Non-implementation: timing, taking breaks, diet, dose, behaviour exploring ambivalence
• Persistence vs discontinuation
D. Show empathy for patient’s
Non-adherence predicts morbidity and mortality in a range of problems in adhering
diseases including cancer, renal transplant, epilepsy
E. Use reminders on
Non-adherence puts substantial extra burden on healthcare. packaging (days of week)
Patients tend not to disclose it; doctors tend not to suspect it.
F. Use MEMS caps that record
Adhering, even to placebo (!), lowers risk of mortality opening, then discuss

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Which of these will NOT improve adherence Understanding non-adherence

to treatment? Different reasons need different interventions
Using scary messages may feel
A. Scare patient about effects intuitively like it should work, but in
• Intentional (motivation, beliefs, preferences, perceived barriers)
of non-adherence fact it tends to make people avoid • Unintentional (capacity, resources, practical barriers)
the images, the messages, and
B. Provide information in pack processing that message in terms of Can be summed up as patient’s understanding of
what it means for them. This has - necessity (doubts about necessity of treatment) vs
with decision aids been shown many times in public
C. Boost motivation by health campaigns, but does not - concerns (about adverse and long term effects)
seem to stop people using scary
exploring ambivalence messages in further campaigns. Face Concerns may be fed by
D. Show empathy for patient’s to face, there may be a place for it,
problems in adhering but it will not encourage the patient - Information about side-effects in medication pack
to explore with the healthcare
E. Use reminders on professional the barriers they
- Attribution of common symptoms (tiredness, nausea,
packaging (days of week) perceive, or other reasons why they headache, etc.) to medication
do not adhere. But those are the
Health scares (MMR, DVT from pill) can lead to non-adherence and
F. Use MEMS caps that record most useful aspects to discuss to
improve adherence. significantly worse health consequences.
opening, then discuss

Psychoneuroimmunology Samantha Lawes Stress

Stress is experienced when a person perceives that the ‘demands
Explore psychological aspect of modern day stress, using: exceed the personal and social resources the individual is able to mobilise’.
• Life events
• Stress as an appraisal of demands and resources
• Prolonged activation or stress response
Constellation of events = stimulus (stressor) that is perceived in brain as stress
Physiological stress response:
• SAM and HPA axes
and activates stress responses “fight/flight”
• Sympathetic Adrenal Medullary system is a fast reaction to sudden stress Stress pathways: HPA axis and sympathetic NS
• Hypothalmic pituitary Adrenal system which is slow acting and is seen as the body’s stress • stress hormones from adrenal: glucocorticoids and epinephrine
system by controlling the levels of cortisol and other hormones that are related to stress
• glucocorticoids (cortisol) and catecholamines (noradrenaline, adrenaline)
• Effects of cortisol – stress hormone
• Acute and chronic stress and immune function regulate immune function by binding to receptors on immune cells
Acute stress induces an evolved defensive response against infection (major
Stress shown to be an important independent factor associated with:
• Cardiovascular disease
health risk, after injury or without injury)
• Type 2 diabetes • improves healing & resistance to infection in healthy individual
• Cancer
Chronic stress: system struggles to restore homeostasis
• Common cold
• HIV • Increases susceptibility to disease – respiratory infections, chronic
• Vaccination inflammation, some cancers, slower healing
• Wound healing
Stress may be modifiable to reduce disease risk

Psychological aspects of cardiovascular disease Risk factors in CVD

Ruth Hackett
Demographic: e.g. family history, sex, age non-modifiable
• Psychological factors – which are important? Clinical: e.g. hypertension, high cholesterol, diabetes
– stress, esp chronic such as work, financial strain, being a treatable: partially modifiable
carer, social isolation & loneliness Behavioural: e.g. smoking, excess alcohol, obesity, physical
– mood and mood disorders, particularly with CHD inactivity largely modifiable
– disposition: anger, hostility vs optimism, wellbeing Psychological : e.g. stress, mood disorders,
• What mechanisms can account for relationships? personality/dispositional factors largely modifiable
• Can intervention reduce negative impact of
psychological factors? Protection from social support Psychosocial (i.e. psychological & behavioural) factors associated
and connectedness. with new-onset disease, triggering vulnerability, exacerbating
existing illness, undermining recovery.
This is over and above clinical risk factors; evidence mainly from
epidemiological studies.

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Which of the following is NOT true of ways Which of the following is NOT true of ways
that psychological factors may act on cardiac that psychological factors may act on cardiac
health? health?
A. Stress is associated with risk A. Behaviours affect risk of Higher self-esteem may
behaviours such as smoking CHD have some health benefits,
B. Behaviours affect B. Behaviours affect not least in response to
susceptibility to CHD when susceptibility to CHD when stress, but it is not a known
stressed stressed marker for cardiac health
C. Stress affects cortisol C. Depression affects cortisol where the important issues
regulation regulation are risk behaviours
D. Depression causes poorer D. Depression causes poorer (smoking, diet, exercise,
outcome once ill outcome once ill
alcohol), depression, and to
E. Depression increases E. Depression increases an extent, anger/hostility.
inflammatory activity inflammatory activity
F. High self-esteem protects F. High self-esteem protects
from stress-related illness from stress-related illness

Cardiovascular disease: interventions to modify The embodied self Brianna Beck

psychological factors
Psychological – such as cognitive therapy – to alleviate depressive Brain receives input & generates output. But it evaluates input
thoughts and feelings or improve stress management. against predictions –
Behavioural – to reduce behaviours that elevate risk - multisensory integration – from all senses, external and internal
Social – reducing isolation and loneliness reduces CVD events worlds
Pharmacotherapy – symptomatic e.g. antidepressants - Integration helps us distinguish self from rest of world
- Match/mismatch of prediction and incoming signals enables
maintenance and updating of awareness
Need to understand mechanisms better.
In some neurological conditions, proprioception and other senses
Need better measures of stress, mood, etc.
disrupted so no longer match.

Can induce illusions in healthy subjects using assumption of

integrations
- Rubber hand
- Virtual body

The sense of body ownership is lost in some The sense of body ownership is lost in some
neurological disorders. How is it studied in neurological disorders. How is it studied in
normal people in order to gain insight into normal people in order to gain insight into
these disorders? these disorders?
A. Vestibular stimulation A. Vestibular stimulation A, B, D, and E.
Virtual reality is experienced
B. Rubber hand illusion B. Rubber hand illusion as if one is in the virtual scene
C. Virtual reality in body. It needs stimulation to
C. Virtual reality create a full body illusion.
D. Full body illusion
D. Full body illusion Epileptic seizures can be
E. Enfacement illusion associated with
E. Enfacement illusion F. Epileptic seizure disembodiment experience,
F. Epileptic seizure but that’s clinical observation,
not experiment!