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
• For communication – with patients and other doctors
• To guide prognosis (outcome)
• To guide treatment
• To carry out research and understand illness
Disadvantages
• Labelling, stigma
• Change in how person views themselves
• “Halo” effects: normal behaviour looks “abnormal”
• Ignoring other conditions that require treatment
• Continuum of disorder is reality, not distinct categories
• Can encourage overlooking subclinical symptoms
• Disability or impairment of functioning
• Distinct from disease
• Emphasises personal experience (can have disease but not be ill)
• Cannot be resolved by effort of will
• In most societies, implies that medical help will be forthcoming
May be represented in Disability Adjusted Life Years (DALYs) that
allow comparison of all illnesses.
DALY = value for quality of life 1 (perfect health) to 0 (death).
Depression, Alzheimer’s, and alcohol-related disorders are
comparable in DALYs to COPD, cerebrovascular disease, ischaemic
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
Concerned with impact of family, society, culture and spirituality
on the likelihood of developing a mental illness and on the ways
these factors impact on mental health and illness.
• Culture is “the ideas, customs, and social behaviour of a
particular people or society” – not the same as race / ethnicity
• Spirituality is "a transcendent dimension within human
experience...discovered in moments in which the individual
questions the meaning of personal existence and attempts to
place the self within a broader ontological context"
• Development, symptom expression, help-seeking and outcome
of mental illness are affected by family, spirituality, culture,
society.
• So cultures with different beliefs to host culture may present
differently, later, with apparently different needs.
How psychology relates to medicine
Amanda Williams
Key areas:
• Changes in behaviour associated with illness and disorder
• Psychological variables in aetiology of medical problems
• Patients’ responses to illness and to treatments
• Psychological treatments
• Doctor-patient relationship
• Doctors’ beliefs, behaviour, stress and burnout.
Psychology is not common sense, or intuition.
Psychology is a science, but often relies on soft data, has no direct
access to important variables, identifies associations but rarely
causal pathways.

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
can help to get a bigger context. What
contributes to this context?
A. Patient’s beliefs about illness and
health.
B. Patient’s culture of origin.
C. Patient’s beliefs about what doctor
wants to know.
D. Patient’s emotional state.
E. What patient’s family and friends
think.
F. What’s on the internet about the
symptoms.
Which of these is NOT true of risk appraisal?
A. Screening has costs in
unnecessary anxiety for false
positives
B. People overestimate
newsworthy risks and
underestimate everyday ones.
C. Many people don’t understand
probabilities such as 1 in 1000
D. People find it easy to
understand odds ratios for risk.
E. Framing information (risk of
dying vs chance of survival)
affects decisions.
F. Culture can affect the value
people put on risks.
Which of these does NOT increase take-up of
preventive behaviours against infection?
A. Greater perceived
susceptibility
B. Depression about
impact of illness
C. Higher anxiety about
threat of illness
D. Greater perceived
severity of illness
E. Greater belief in
preventive behaviours
working
F. More trust in authorities
(doctors) & their advice
All of these.
The least important is
probably the internet,
which patients tend to
consult after seeing a
doctor rather than
before.
Very few people find it
easy to understand or
explain odds ratios, even
doctors, who are familiar
with their use.
Conveying risk in ways
that people understand
easily and unambiguously
(such as visual
representations) is
becoming increasingly
important as patients are
more often involved in
their healthcare decisions.
01/05/2018
Which of these is NOT true of risk appraisal?
A. Screening has costs in
unnecessary anxiety for false
positives
B. People overestimate
newsworthy risks and
underestimate everyday ones.
C. Many people don’t understand
probabilities such as 1 in 1000
D. People find it easy to
understand odds ratios for risk.
E. Framing information (risk of
dying vs chance of survival)
affects decisions.
F. Culture can affect the value
people put on risks.
Psychology of health, illness and symptom
presentation Amanda Williams
… applying psychological theories, methods and research to
promotion of health, prevention and treatment of illness and
disability, analysis & improvement of health care system & policies.
• Changing health-related behaviours
• Symptom perception, interpretation, and action
• Hospitalisation
How do people understand their own health?
They judge by how they feel, whether they have symptoms (or in
older people, whether they have more than common symptoms),
and whether they can do everyday activities …
- but hard to decide how ‘bad’ a symptom is
- hard to decide if experience is ‘normal’
Which of these does NOT increase take-up of
preventive behaviours against infection?
A. Greater perceived
Depression about illness does not
susceptibility increase preventive behaviours (such as
B. Depression about getting vaccinations, washing hands,
impact of illness etc.). In general, people who are
C. Higher anxiety about depressed are less motivated and so
threat of illness less likely to do these, even if they are
well aware of the value.
D. Greater perceived
severity of illness People are more likely to use preventive
E. Greater belief in behaviours when they feel that they
preventive behaviours make sense (and/or are suggested by
working someone who knows), are personally
relevant (there is a genuine risk), and
F. More trust in authorities will work to reduce risk of infection.
(doctors) & their advice
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Behaviours that contribute to disease
In developed countries, major killers are cancer, heart disease and
stroke, lung disease and diabetes.
Major risk factors: blood pressure, cholesterol, BMI, blood sugar.
So why don’t people adopt healthier behaviours?
Knowledge is necessary but not sufficient for changing behaviour.
Knowledge is filtered through beliefs, mis/understanding of body,
values, etc.
Knowledge affects intentions to behave a particular way.
But intentions account for < ¼ of variance in behaviour.
What else accounts for behaviour?
• Consistency of intentions? Are there doubts about goal?
• Is there a clear plan, including when, where, how long, etc.?
• Is there a plan to deal with barriers?
• Are there long-established habits that need to change?
Symptom perception, interpretation, presentation
What influences reporting of symptoms?
• Characteristics of symptom: severity, novelty, etc.
• Cognitive characteristics: attention, expectation, beliefs, fears, etc.
Raising awareness of symptoms (bird flu?) increases reporting.
Misfit of symptoms with beliefs (no pain down arm?) decreases
reporting (of heart attack).
Meaning of symptoms – trivial? serious? – affects seeking opinion.
First opinions sought from friends, family, workmates (less if
embarrassing). That influences decision to consult doctor or not.
Patients present what they think is most relevant to doctor (so
personal and social problems not reported, or only if asked).
They also present what was treated before (cough – antibiotics?).
Behaviour change and adherence Rob Horne
Definition of adherence and impact of non-adherence
Methods to assess and improve adherence
Understanding some key drivers of adherence
WHO estimates 30-50% of medications are not taken as prescribed.
Non-adherence can be:
• Non-initation: collecting and starting treatment
• Non-implementation: timing, taking breaks, diet, dose, behaviour
• Persistence vs discontinuation
Non-adherence predicts morbidity and mortality in a range of
diseases including cancer, renal transplant, epilepsy
Non-adherence puts substantial extra burden on healthcare.
Patients tend not to disclose it; doctors tend not to suspect it.
Adhering, even to placebo (!), lowers risk of mortality
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Changing patients’ behaviours
1 Clear assessment of needs, involving patient in process.
2 Defining goals and the behaviours that are necessary to
increase or decrease to reach the goals;
and the key beliefs associated with those behaviours;
3 Identifying effective behaviour change techniques.
What are effective behaviour change techniques?
Self-monitoring characterises all effective change +
• prompting intentions and goal setting;
• and/or specifying goals in context;
• and/or feedback on performance;
• and/or reviewing earlier goals.
COM-B model: Capability + Opportunity + Motivation (mechanisms
to bring about change) = Behaviour
Procedures and hospitalisation
All stressful.
Procedures: people have preference for information or not.
Those who want it become less anxious; those who don’t, ignore it.
Staff are generally poor at judging patients’ anxiety and need for
information.
Information about what to expect during & after is most helpful
and may make procedure quicker and less likely to have problems.
High levels of anxiety about procedure/surgery are associated with
slower recovery, more pain, poorer sleep, more days in hospital.
Children are usually helped by having parent/s present, unless
parent is very anxious, in which case child better without.
Which of these will NOT improve adherence
to treatment?
A. Scare patient about effects
of non-adherence
B. Provide information in pack
with decision aids
C. Boost motivation by
exploring ambivalence
D. Show empathy for patient’s
problems in adhering
E. Use reminders on
packaging (days of week)
F. Use MEMS caps that record
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
thoughts and feelings or improve stress management.
Behavioural – to reduce behaviours that elevate risk
Social – reducing isolation and loneliness reduces CVD events
Pharmacotherapy – symptomatic e.g. antidepressants
Need to understand mechanisms better.
Need better measures of stress, mood, etc.
Brain receives input & generates output. But it evaluates input
against predictions –
- multisensory integration – from all senses, external and internal
worlds
- Integration helps us distinguish self from rest of world
- Match/mismatch of prediction and incoming signals enables
maintenance and updating of awareness
In some neurological conditions, proprioception and other senses
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!