Psychiatry By Ten Teachers by Brian Lunn, Nisha Dogra, and Stephen Cooper

4257cb538c2bb56.jpg Author Brian Lunn, Nisha Dogra, and Stephen Cooper
Isbn 9780340984260
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Year 2011
Pages 248
Language English
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Category psychology


PSYCHIATRY by Ten Teachers This page intentionally left blank PSYCHIATRY by Ten Teachers Edited By Nisha Dogra BM DCH FRCPsych MA PhD Senior Lecturer in Child and Adolescent Psychiatry, The Greenwood Institute of Child Health, University of Leicester Brian Lunn MB ChB FRCPsych Honorary Clinical Senior Lecturer, Newcastle University Stephen Cooper MD FRCPI FRCPsych Professor of Psychiatry, Queen’s University Belfast First published in Great Britain in 2011 by Hodder Arnold, an imprint of Hodder Education, an Hachette UK company, 338 Euston Road, London NW1 3BH © 2011 Hodder Arnold All rights reserved. Apart from any use permitted under UK copyright law, this publication may only be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency. 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For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN-13 978-0-340-98426-0 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Project Editor: Production Controller: Cover Design: Joanna Koster Sarah Penny Jonathan Williams Amina Dudhia Cover image © Sovereign, ISM/Science Photo Library Typeset in 9.5 on 12pt Minion by Phoenix Photosetting, Chatham, Kent Printed and bound in Italy What do you think about this book? Or any other Hodder Arnold title? Please visit our website: Contents The Ten Teachers vii Preface viii Acknowledgements ix Abbreviations x CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 CHAPTER 7 CHAPTER 8 Defining mental health and mental illness Nisha Dogra and Stephen Cooper Personality, predisposing and perpetuating factors in mental illness Nisha Dogra and Stephen Cooper Assessment and engagement with patients Brian Lunn and Nisha Dogra Making the most of your placement Nisha Dogra 1 10 25 40 Mental health legislation Brian Lunn Mood disorders John Eagles Anxiety disorders Ciaran Mulholland 45 Phobias Richard Day 85 CHAPTER 9 Schizophrenia Brian Lunn CHAPTER 10 Substance misuse Ilana Crome 53 71 95 104 CHAPTER 11 Eating disorders John Eagles 118 CHAPTER 12 Organic disorders Simon Budd CHAPTER 13 Psychiatric aspects of intellectual disability Howard Ring CHAPTER 14 Disorders of childhood and adolescence Nisha Dogra 132 CHAPTER 15 Disorders of personality Nisha Dogra and Stephen Cooper CHAPTER 16 Commonly used pyschological treatments Ian Collings and Nisha Dogra 182 156 168 188 CHAPTER 17 Psychopharmacology Stephen Cooper 197 CHAPTER 18 Psychiatric emergencies Brian Lunn and Richard Day 214 Index 225 The Ten Teachers Simon Budd MBChB MMedSc FHEA Ilana Crome MA MPhil MB ChB MD FRCPsych Honorary Senior Lecturer in Psychiatry, University of Leeds Professor of Addiction Psychiatry and Academic Director of Psychiatry, Keele University and Consultant Addiction Psychiatrist, North Staffordshire Combined Healthcare NHS Trust, Stoke-on-Trent Ian Collings MB BS DPM MRCPsych PGDME Specialist Registrar, Rehabilitation Psychiatry, Whitchurch Hospital, Cardiff Honorary Clinical Tutor, Cardiff University Richard Day MBChB BSc(MedSci) MRCPsych Clinical Senior Lecturer and Honorary Consultant Psychiatrist, Ninewells Hospital, University of Dundee John Eagles MB ChB MPhil FRCPsych Consultant Psychiatrist, Royal Cornhill Hospital, Aberdeen Brian Lunn MB ChB FRCPsych Honorary Clinical Senior Lecturer, Newcastle University Nisha Dogra BM DCH FRCPsych MA PhD Senior Lecturer in Child and Adolescent Psychiatry, The Greenwood Institute of Child Health, University of Leicester Ciaran Mulholland MB BCh BAO DMH MRCPsych MD Stephen Cooper MD FRCPI FRCPsych Howard Ring BSc MBBS MD FRCPsych Professor of Psychiatry, Queen’s University Belfast Lecturer, Department of Experimental Psychology, University of Cambridge Senior Lecturer and Consultant Psychiatrist, Queen’s University Belfast Preface Most of those students reading this textbook will not become psychiatrists. However, as doctors, all of you, whether in your Foundation posts or later, will encounter patients with significant mental health problems and symptoms of psychiatric illnesses. In order to carry out your role as a doctor effectively you will require the necessary knowledge and skills. This book has been written to try to address the needs of all students, whatever their career intentions. The book is largely based around the Core Curriculum devised as part of the editors’ work for the Royal College of Psychiatrists’ Scoping Group on Undergraduate Education. The ‘core curriculum’ arose from a consensus around this work. In each subject we have tried to be explicit about why the area covered is relevant to you as a medical student and each chapter gives clinical examples to illustrate the points made. We have sought to avoid overloading you with details but have instead focused on essential information to help you meet the mental health needs of all patients. In some chapters, for example 1, 3 and 4, you are asked to reflect on your own perspectives as we consider that many societal and professional attitudes towards those with mental illness need to be challenged. We hope you find that this book helps you to get as much as possible from your clinical placements and by the end feel confident that you could recognise and manage mental health problems when you qualify. It is worth emphasising that no clinical placement will be successful unless you practice your skills and no book can substitute for spending time with patients. However, it is helpful to have a framework around which to organise your experience. Whilst this textbook is focused on the needs of all medical students, we would be delighted if using it during your placements makes you consider becoming a psychiatrist. We would be happy to receive any feedback and sincerely hope the book works as it is intended to. Nisha Dogra Brian Lunn Stephen Cooper Acknowledgements We would like to thank all those that helped produce this text. Nisha would like to thank the following colleagues and medical students who reviewed various drafts at different stages: Nick Brindle Guy Brookes Dr Melanie Hobbs Akshay Kansagra Dr Khalid Karim Ruby Lekwauwa Professor James Lindesay Dr Pablo Ronzoni Dr Daniel Smith Dr Mark Steels Professor Scott Weich Thanks also to Jo Welch for her administrative support. Abbreviations BSE CAMHS CPN CSF CVD EEG FSH GABA-BDZ LH MMN MRI NMDA OCD PCP PET PRN SPET Bovine spongiform encephalopathy Child and Adolescent Mental Health Services Community psychiatric nurse Cerebrospinal fluid Cardiovascular disease Electroencephalography Follicle-stimulating hormone Gamma-aminobutyric acid/ benzodiazepine Luteinizing hormone Mismatch negativity Magnetic resonance imaging N-Methyl-D-aspartic acid Obsessive–compulsive disorder Phencyclidine Positron emission tomography Pro re nata – as needed Single photon emission computed tomography CHAP TE R 1 D E F I N I N G ME N T A L H E A L T H AND MENTAL ILLNESS Nisha Dogra and Stephen Cooper Introduction .................................................................... 1 Defining mental health, mental illness and mental health problems ....................................................... 1 The classification of mental illness .................................. 3 Anti-psychiatry ............................................................... 4 The scale of the problem ................................................ 5 Myths about mental illness ............................................. 6 Stigma and mental illness ............................................... 6 Children, mental illness and stigma ................................ 7 Media, mental illness and stigma .................................... 8 Interventions to reduce stigma ........................................ 8 Summary ........................................................................ 8 Further reading ............................................................... 9 K E Y C H A P T E R F E AT U RE S O Discussion of the terminology around mental health, mental health problems and mental illness O Outline of the scale of individual suffering from mental health problems and a public health dimension of the scale of the problems O Define stigma, how it is perpetuated and its consequences on individuals and practice O The evidence regarding which interventions may reduce stigma O The steps you may need to take to reflect on your views and their impact on your practice Exercise Introduction In this chapter we define mental health, mental health problems and mental illness. This is important because, although it sounds fairly straightforward, our discussion will demonstrate the difficulties that abound with the terminology. The scale of the problem and access to services at a public health level are outlined. We then discuss stigma generally, explore the reasons for it and possible sequelae. We also review the interventions to reduce stigma before asking you to reflect on your own perspective and their potential impact on your future practice. Defining mental health, mental illness and mental health problems It is important to state at the outset that there is no widely agreed consensus on the meaning of these terms and their use. Many outside the health arena challenge the terms, and mental illness as a concept is widely challenged by the anti-psychiatry movement (which does include doctors). However, the reality On your own or with some peers answer the following questions? (You will get more from the exercise if you answer as honestly as you can.) What is your own understanding of mental health, mental illness and mental health problems? What sorts of problems do people experience that could be described as mental health problems or mental illness? How can you tell if someone is experiencing mental health problems or mental illness? How often do you use words that reflect on patients with mental health in a less than complimentary way? How do you think you have formed your views on mental illness and what part might your cultural background have played in forming these views? remains that if an individual experiences difficulties which impact on their emotional and inner worlds, their functioning can be affected. Mental health and mental illness can be viewed as two separate, yet related, issues. 2 Defining mental health and mental illness ● face problems, resolve them and learn from them. Mental health The World Health Organization (WHO) definition of health is: ‘A state of complete physical, mental and social well-being, and not merely the absence of disease.’ ( This is supported by the Royal College of Psychiatrists, who have argued that there is no health without mental health. The WHO adds: Mental health is not just the absence of mental disorder. It is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. Another way of looking at this is that mental health includes how people look at themselves, their lives and the other people in their lives; how they feel about these different components, evaluate their challenges and problems; and how they explore choices. This includes handling stress, relating to other people and making decisions. However, even a cursory glance at the definition raises important questions as the concept is clearly rooted in societal norms and expectations. The way that the normal stresses of life are defined will vary from society to society and within subgroups. The contribution to the community is also societal and culturally based. Perhaps a useful way of viewing the definition in practice is that someone is considered as having mental health when they manage day-to-day living without too much difficulty in a way that satisfies them and fulfils familial and societal expectations of them without causing them undue stress. Immediately this alerts you to consider the plight of those who do not meet familial or societal expectations as they conflict with individual perspectives and the significant impact this can have on mental health (for example, consider being gay in countries in which homosexuality is illegal, or forced marriages). Culture and its influence on how mental health is understood are discussed later in this chapter. Definitions of mental health relating specifically to children have been provided by several bodies and emphasize the expectations of a healthy child. So, a mentally healthy child is one who can for example: ● develop emotionally, creatively, intellectually and spiritually; ● initiate, develop and sustain mutually satisfying personal relationships; This could easily apply to adults and in some ways is developmentally rather than culturally contextual, as these functions apply in whichever society the young person is living. Mental health problems The term ‘mental health problems’ is one that encompasses a range of experiences and situations. Mental health might usefully be viewed as a continuum of experience, from mental well-being through to a severe and enduring mental illness. Mental health problems cover a wide range of problems which affect someone’s ability to get on with their daily life. Mental health problems can affect anyone, of any age and background, as well as having an impact on the people around them such as their family, friends and carers. Mental health problems result from a complex interaction of biological, social and psychological factors. Major life events such as bereavement, relationship break-up or serious illness can impact significantly on how we feel about ourselves and subsequently on our mental state and health. A minority of people may experience mental health problems to such a degree that they may be diagnosed as having a mental illness. Common mental health problems include anxiety (including phobias), obsessive compulsive disorders, adjustment disorders and milder mood problems. Mental illness A mental illness is an illness that causes disturbances in thinking, perception and behaviour beyond those that might be experienced even in an acutely distressed state. They can be severe, seriously interfering with a person’s life, significantly impairing a person’s ability to cope with life’s ordinary demands and routines, and even causing a person to become disabled. The majority of people will not experience mental illness, but will undoubtedly experience mental health problems at different times in their lives. Another common term is mental disorder, and this is often used in the sense that a person who is mentally ill is suffering from a mental disorder – the use is usually in the context of legislation. In practice most clinicians tend to use mental health problems for less serious disorders and mental illness for more severe disorders. A complicating factor is that The classification of mental illness subjective components are also relevant. A clinician may feel that the anxiety symptoms their patient has are fairly mild but for the patient the impact on their life may be significant. Some patients who are seriously mentally ill (for example someone who is manic or acutely psychotic) cannot understand why others think they are ill because from their perspective all is well. In this book we use the term mental health problems as that is a widely used terminology, although specific disorders such as schizophrenia, depression and the like are defined as mental illness using the International Classification of Disease (WHO). Box 1.1: Multi-axial classification often used in child mental health services (ICD-10) Axis 1 – Mental health diagnosis Axis 2 – Developmental Axis 3 – Intellectual Axis 4 – Organic/physical Axis 5 – Psychosocial Mental and behavioural disorders (F00–F99) F00–09 Organic, including symptomatic, mental disorders F10–19 Mental and behavioural disorders due to psychoactive substance use The classification of mental illness The International Classification of Diseases (ICD) is the international standard diagnostic classification for all general epidemiological and many health management purposes, research and clinical use. It is used to classify diseases and other health problems recorded on many types of health and vital records such as death certificates. However the way that these diagnostic categories are used in practice varies across the world. The major categories for mental health and behavioural disorders are shown in Box 1.1. The ICD is revised periodically and is currently in its tenth edition with the eleventh edition being planned. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and provides diagnostic criteria for mental disorders. It is used in the USA and in varying degrees elsewhere. There is some consistency between the two classification systems, especially for mental health. However, the DSM tends to use broader categories and is considered by some too inclusive in some of the disorders it includes. The multi-axial format used by the DSM can be helpful as shown in Box 1.2. Both classification systems have their limitations but are useful in providing a common language for research and practice and both use the categorical approach as described below. F20–29 Schizophrenia, schizotypal and delusional disorders F30–39 Mood [affective] disorders F40–48 Neurotic, stress-related and somatoform disorders F50–59 Behavioural syndromes associated with physiological disturbances and physical factors F60–69 Disorders of adult personality and behaviour F70–79 Mental retardation F80–89 Disorders of psychological development F90–99 Behavioural and emotional disorders with onset usually occurring in childhood and adolescence Box 1.2: Multi-axial system used in DSM The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability. • Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disorders • Axis II: underlying pervasive or personality conditions, as well as mental retardation • Axis III: acute medical conditions and physical disorders • Axis IV: psychosocial and environmental factors contributing to the disorder • Axis V: Global Assessment of Functioning or Children’s Global Assessment Scale for children and teens under the age of 18 Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, phobias and schizophrenia. Entity or dimension? Kendall and Zealley (1988) present the relative merits of using categories and dimensions with respect Common Axis II disorders include personality disorders and mental retardation. 3 4 Defining mental health and mental illness to mental illness. Typically, medicine has used categories, given its roots in the biological sciences. Categorization allows for easier definitions. It enables recognition of someone’s symptoms conforming to a clinical concept. However, a dimensional approach allows for greater flexibility. They conclude that where psychotic illness is concerned then a categorical approach may be preferable, whereas in other conditions, the situation is more likely to be changeable, and perhaps benefit from a dimensional perspective. The categorical approach essentially allows the clinician to make a diagnosis based on the presence or absence of symptoms. There are two possibilities, either the patient has the disorder or not. The difficulties with the categorical approach are that disorders may not present with the whole range of symptoms needed for a diagnosis to be made. However, the presence of those symptoms may still be sufficient to cause significant impairment. The dimensional approach allows for context and specific factors to be accounted for such as developmental stage and gender, among others. With respect to emotions and behaviours it can be useful to ask when is a problem a problem, as people may have the same level of anxiety for example but be troubled by it to different extents. Pain is a common symptom in general medicine and may be a helpful analogy. So, we all experience some degree of anxiety but it is only likely to be viewed as a problem that needs help when it occurs frequently and/or is so severe that it interferes with everyday functioning. The symptom may also be identified as a problem when it begins to impact on those around the patient. One way of distinguishing between distress associated with adverse life events and more severe disorders, which involve physiological symptoms and underlying biological changes, is to distinguish between mental health problems and mental illness, using a multidimensional model. This has an additional advantage in enabling normal ‘distress’ (e.g. grief following bereavement) to be recognized as part of the ‘human condition’, rather than being medicalized and possibly classed as ‘depression’. It is suggested that a variety of normal human experiences have become medicalized through an ever increasing range of psychological disorders with virtually every type of behaviour eligible for a medical label (e.g. social phobia, over-eating disorder, dependent personality disorder). Mental health: one of many factors It is also important to recognize that neither physical nor mental health exists separately; mental, physical and social functioning are interdependent. Furthermore, all health issues need to be considered within a cultural and developmental context. The quality of a person’s mental health is influenced by idiosyncratic individual factors and experiences, their family relationships and circumstances and the wider community in which they live. Additionally, each culture influences people’s understanding of, and attitudes towards, mental health issues. However, a culture-specific approach to understanding and improving mental health can be unhelpful if it assumes homogeneity within cultures and ignores individual differences. Culture is only one, albeit an important, factor that influences individuals’ beliefs and actions. It can be argued that the above are rooted in Western perspectives. However, they provide a useful starting point from which to discuss mental health issues. Incongruence between personal values, familial and wider societal expectations can be a significant stressor especially for young people. People’s cultural backgrounds can affect: ● the way they think about mental health and mental health problems; ● the way they make sense of certain symptoms and behaviours; ● the services they choose to accept; ● the treatment and management strategies they find acceptable; ● the way in which those who have mental health problems are perceived. Some of these factors are mitigated by others, such as the level of education and personal experience. Anti-psychiatry This term was coined in the 1960s in response to a movement led by Laing and Szasz, who essentially questioned the validity of psychiatry and the use of diagnoses that they felt were subjective. Their perspective was that medical concepts were being inappropriately applied to normal human behaviour. There was also considerable opposition to the treatments applied. Since then, the ‘movement’ has The scale of the problem had periods of greater visibility than at other times. Whatever one’s perspectives about psychiatry, the suffering that many people experience cannot be dismissed. A major example of a criticism of psychiatry by the anti-psychiatry movement is that earlier versions of the classification systems included homosexuality as a disorder, which many now accept is not the case. However, psychiatry and indeed medicine are very much products of the various societal relationships, so it seems rather strange to single out some disorders over others and deny their existence. Just because we do not understand the aetiology of a disorder does not necessarily mean that the disorder does not exist. There is now a tendency to call anti-psychiatry critical psychiatry. The scale of the problem The prevalence of specific disorders will be covered in the chapters relating to those disorders. Here we will outline the scale of the problem in terms of broad figures and also the public health impact of mental illness. We use information provided by the WHO. The purpose is not to overwhelm you with figures but impress upon you that the scale of mental illnesses and the impact of these on individuals and society is not insignificant. Also, psychiatrists treat only a small proportion of those who have mental 0 % of total burden* 10 5 health problems, with some treated in primary care, but the vast majority receiving no treatment at all. WHO has consistently argued that the economic and personal costs of mental illness are huge. For example, estimates made by the WHO in 2002 showed that 154 million people globally suffer from depression and 25 million people from schizophrenia; 91 million people are affected by alcohol use disorders and 15 million by drug use disorders (Fig. 1.1). One in four patients visiting a health service has at least one mental, neurological or behavioural disorder, but most of these disorders are neither diagnosed nor treated. It is also important to note the high prevalence rates of mental illness in those suffering from chronic physical conditions such as cancer, heart and cardiovascular diseases, diabetes and HIV/AIDS. The mental illness can lead to noncompliance with prescribed medical regimens and poorer prognosis. Stress, depression and anxiety are common reasons for absenteeism from work but may often not be addressed as illness and may be hidden to prevent stigmatization. An often cited figure by the WHO is that one in four people in the world will be affected by mental or neurological disorders at some point in their lives. Unfortunately, this does not emphasize that only a small minority will go on to have enduring and disabling illness. It is well established that mental and behavioural disorders have a large impact on 15 20 Cardiovascular illness Mental illness Cancer Respiratory conditions Alcohol use Infectious and parasitic disease Drug use *Disability Adjusted Life Years (DALYs) Figure 1.1 The burden of disease: established market economies (1990). Murray, C.L., Lopez, A.D. (eds) (1996) The Global Burden of Disease. Harvard University Press. 5 6 Defining mental health and mental illness individuals, families and communities. Individuals suffer through the symptoms they experience but also because they may be unable to work when they are unwell and often suffer from discrimination even after they have recovered. There is an associated ‘loss of productivity’ with economic impact on individuals and society. Families also bear the burden of mental illness in that they often provide support and care to family members who are mentally ill and also manage the negative impact of stigma and discrimination. The nature of mental illness often means that family relationships are also affected in addition to the stress caused by disturbed behaviour and disruption to normal family life. In many parts of the world the cost of treatment is borne by families and not the state. Costs resulting from mental illness can be viewed as direct (that is the costs related to providing care and treatment for the disorder) and indirect (costs related to loss of productivity in work, school and home). A number of studies have reported on the quality of life of individuals with mental disorders, concluding that the negative impact is not only substantial but sustained. It has been shown that quality of life continues to be poor even after recovery from mental disorders as a result of social factors that include continued stigma and discrimination. The WHO considers that mental health provision was severely under-resourced in many countries because of stigma, apathy and neglect. Change may be happening but it is slow. Another cost for those suffering with mental health problems is the negative impact of stigma. Before we discuss this, we highlight some common myths. Box 1.3: Common myths about mental illness As you read through these myths, think about which statements you agree with and what basis you have made your decision on. • Young people and children don’t suffer from mental health problems • A person who has had a mental illness will not recover • Mentally ill people are violent and dangerous • Mental illness affects others and cannot affect me • Mental disorders are caused by a personal weakness in character • Mental illness is a single, rare disorder • Psychiatric disorders are not true medical illnesses like heart disease and diabetes • People who have a mental illness are just ‘crazy’ • Schizophrenia means split personality, and there is no way to control it It is the fear of the unknown that causes such myths about mental illness. The endurance of myths leads to stigma. The Royal College of Psychiatrists’ website provides further information on many of these issues ( Stigma and mental illness In this section the aim is to explore the concepts of, and the relationship between, stigma and mental illness. One possible reason for both conceptual confusion regarding mental illness and reluctance to seek help is that the stigmatization of mental illness continues to be a worldwide phenomenon. Myths about mental illness Myths about mental illness abound across the world in all societies. The myths often seek to explain the cause of the behaviours exhibited as part of mental illness but also demonstrate the ignorance there is about mental illness. While myths persist, individuals with mental illness often delay seeking treatment or families fail to access appropriate treatment. Box 1.3 highlights some common myths and Box 1.4 gives the facts about the myth. Before moving to Box 1.4, try the exercise in Box 1.3 and see how many myths form your knowledge base about mental health and illness. Definition of the concept of stigma The word stigma used to convey the negative views about those with mental illness originates from the Greek tradition of branding slaves with marks to identify them. Social stigma is a ‘mark of infamy or disgrace; sign of moral blemish; stain or reproach caused by dishonourable conduct; reproachful characterization’ (Webster’s Dictionary). Stigmatization is a social construct, and through this process those with mental illness are identified as being somehow different and having less worth. Children, mental illness and stigma Box 1.4: Common myths about mental illness and the facts Myth: Young people and children don’t suffer from mental health problems Fact: It is estimated that between 10 and 25% of young people under the age of 18 suffer from mental health problems impacting on their ability to function at home, in school or in their community (see Chapter 14) Myth: A person who has had a mental illness can never recover Fact: People with mental illnesses do recover and resume normal activities. Recovery depends on appropriate treatment and psychosocial factors and many people function well between episodes of illness Myth: Mentally ill people are violent and dangerous Fact: The vast majority of people with mental illnesses are not violent or dangerous but are often vulnerable. On average about 55 people a year are killed by someone with a psychiatric illness at the time of the homicide Myth: Mental illness affects others and cannot affect me Fact: Mental illnesses are surprisingly common and do not discriminate – they can affect anyone. One in four people will experience a mental illness at some point Myth: Mental disorders are caused by a personal weakness in character Fact: Mental disorders are caused by biological, psychological and social factors Myth: Mental illness is a single disorder Fact: Mental illness is not a single disease but a broad classification covering many disorders, as shown in this chapter Myth: Psychiatric disorders are not true medical illnesses like heart disease and diabetes. People who have a mental illness are just ‘crazy’ Fact: Brain disorders, like heart disease and diabetes, are legitimate medical illnesses. Research shows there are biological factors that can in combination with other factors cause psychiatric disorders, and they can be treated effectively (see Chapter 2) Much of the work about stigma has until quite recently been survey based and focused largely on schizophrenia. Stigma can be seen as an overarching term that contains three components that interlink: problems of knowledge (ignorance), problems of attitudes (prejudice) and problems of behaviour (discrimination). The extent and impact of stigmatization of adult mental illness It is difficult to be clear about why we as a society continue to have such negative views about those with mental illness. It may be a way of creating a sense that those with mental illness are different from us and thereby reducing our own fears of becoming like ‘them’. It is therefore perhaps not surprising that negative attitudes towards mental illness are largely culturally non-specific and commonplace across the world. Stigmatizing processes can affect multiple domains of people’s lives, having a dramatic bearing on the distribution of life chances in such areas as earnings, housing, criminal involvement, health and life itself. Health care staff attitudes generally tend to be similar to those of the lay public. Medical students have been shown to be critical of those whom they believe play a part in the development of their problems, for example self-harm, eating disorders and substance misuse. Patients are often very critical of general practitioner attitudes. However, they also complain about negativity from mental health professionals, especially those patients with personality disorders and substance misuse problems. It is worth adding that not only are there negative views about those who have mental health problems but also about staff who work with them. Exercise Just reflect on some of the stereotypes and attitudes towards mental illness and psychiatrists you have come across in your medical career Myth: Schizophrenia means split personality, and there is no way to control it Fact: Schizophrenia is often confused with multiple personality disorder. Actually, schizophrenia is a brain disorder that causes disordered thinking and perceptual abnormalities (see Chapter 9) Children, mental illness and stigma From the sparse literature available on stigma in relation to children and mental illness, it appears that adolescents’ attitudes towards mental illness 7 8 Defining mental health and mental illness tend to be negative and stigmatizing. Our work in Nigeria with young people shows that such attitudes transcend culture. Exercise Think about the last three times you have seen mental illness depicted on TV or in the newspaper. How did the media portray mental illness? Did the articles factor is that by its very nature, the media is highly visible and hard to ignore. Further, the tabloids’ use of derogatory language may legitimize its use in our everyday language. The media appear to give greater priority to their own needs to entertain and cause headlines. In the process, they may be drawn to using the short cuts that stereotypes provide without challenging the damage they might be causing. • stereotype people with mental illness (for example assuming they are all violent)? • minimize the difficulties faced by people with mental illness and/or the illness itself? • patronize people with mental illness? • assume that people with mental illness are somehow different from ‘normal people’? • perpetuate other myths? Media, mental illness and stigma Popular images of mental illness are both longstanding and stable. Two large-scale literature reviews have suggested that the media can be regarded as an important influence on community attitudes towards mental illness. It is considered that there is a complex and circular relationship between mass media representation of mental illness and public understanding. Negative media images promote negative attitudes and the resulting media coverage feeding off an already negative public perception. It is also thought that negative images will have a greater effect on public attitudes than positive portrayals. Thornicroft explored newspaper, television and film portrayal of mental illness and found it to be largely negative, although there were occasional exceptions. All media leaned heavily towards depicting those with mental illness as being dangerous. There was a tendency to use mental illness generically as opposed to referring to specific diagnoses. Disappointingly, children’s television programmes consistently linked violence to mental illness and use derogatory terms. This may suggest to young children that these are acceptable ways in which to refer to those who have mental health problems. There is an argument that media representations matter because they play an active part in shaping and sustaining what mental illness means as suggested above. Another relevant Interventions to reduce stigma There is generally limited evidence about effective interventions to reduce stigma. Large-scale interventions, such as high-profile campaigns, are often difficult to evaluate. In the UK there have been several such campaigns (e.g. The Royal College of Psychiatrists’ campaign, Every Family in the Land). There is little evidence to indicate that these have successfully changed public or personal attitudes. Although much of the work to date has focused on adults, there are increasing efforts to address the issue among younger populations, with some evidence that knowledge and attitudes can be improved. There is as yet little evidence that anti-stigma work takes place in many medical schools and, where it does, how well it works to reduce the negative views that medical students have about mental illness. We discuss this more in Chapter 4, ‘Making the most of your placement’. It has been argued that the best way forward to tackle stigma may be to focus on discrimination rather than merely knowledge. In a way this also makes sense from the medical student educational perspective. Good Medical Practice, published by the GMC, places on doctors a responsibility to provide equitable care irrespective of various patient characteristics, including any diagnosis they may have. So irrespective of your own views you need to ensure you provide good quality care to all patients including those that have mental health problems. Summary There is still considerable debate around the terminology used in psychiatry. We suggest it is important to understand the principles of when Further reading someone is ‘mentally healthy’ and when they may have mental health problems that may be severe enough to be defined as a disorder. It is clinically more useful to take a multidimensional approach rather than the traditional categorical approach used in medicine. The impact of mental illness in the broadest sense for individuals, their families and society is significant and cannot be ignored. Yet despite the fact that we are all vulnerable to developing mental health problems, the stigmatization about mental illness pervades all cultures and societies and continues to be a challenge. Efforts are being made to address some of the stigmatization but progress is slow. Perhaps, you might want to conclude this chapter by returning to the exercise at the beginning of the chapter and ask yourself, are you ready to challenge yourself? Further reading American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington DC: American Psychiatric Association. Crisp A (2004) The nature of stigmatisation. In A H Crisp (ed.) Every Family in the Land: Understanding Prejudice and Discrimination against People with Mental Illness. London: Royal Society of Medicine Press. Crisp AH, Gelder M, Rix S, et al. (2000) Stigmatisation of people with mental illnesses. British Journal of Psychiatry 177: 4–7. Edney DR (2004) Mass Media and Mental Illness: A Literature Review. (Accessed 14/01/10). Gureje O, Lasebikan VO, Ephraim-Oluwanuga O, et al. (2005) Community study of knowledge of and attitude to mental illness in Nigeria. The British Journal of Psychiatry 186: 436–441. Jorm AF, Korten AE, Jacomb PA, et al. (1997) ‘Mental health literacy’: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia 166: 182–186. Kendall R (1988) Diagnosis and classification. In R Kendall and A Zealley (eds) Companion to Psychiatric Studies. Edinburgh: Churchill Livingstone. Rose D, Thornicroft G, Pinfold V, Kassam A (2007) 250 labels used to stigmatise people with mental health. BMC Health Services Research 7: 97. Thornicroft G (2006) Shunned: Discrimination against People with Mental Illness. Oxford: Oxford University Press. World Health Organization (1992) International Statistical Classification of Diseases and Related Health Problems, 10th revision. Geneva: WHO Press. World Health Organization (2001) World Mental Health Day. Mental Health: Stop Exclusion – Dare to Care. (Accessed 30/10/10). 9

Author Brian Lunn, Nisha Dogra, and Stephen Cooper Isbn 9780340984260 File size 1.4 MB Year 2011 Pages 248 Language English File format PDF Category Psychology Book Description: FacebookTwitterGoogle+TumblrDiggMySpaceShare An essential purchase for every medical student and junior doctor, Psychiatry by Ten Teachersfollows the renowned Ten Teachers’ highly-praised and successful tradition of providing key information written by ten respected experts in the field. In addition, the work conforms to the core curriculum recommended to medical schools by the RCPsych Scoping Group on Undergraduate Psychiatry. Completely up to date, it encourages students to get the most out of their psychiatry attachment and helps them to pass their exams, as well as providing key advice on providing quality medical care, regardless of the field in which they decide to specialize. Useful tips and advice ensure that this is more than a standard introduction to the subject, encouraging additional reading, supporting critical thinking and bringing exam success.     Download (1.4 MB) Assessing Critical Thinking In Middle And High Schools: Meeting The Common Core Cognitive Behavioural Therapy Explained Psychiatry Mentor: Your Clerkship & Shelf Exam Companion, 2nd Edition Masquerading Symptoms Internationalizing the Undergraduate Psychology Curriculum : Practical Lessons Load more posts

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