Mental Disorder – Page 3 – Mental Health Matters

What is Neuropsychiatry?

Published on 05/28/2021 by Andrew Marshall8 Comments

Introduction

Neuropsychiatry or Organic Psychiatry is a branch of medicine that deals with mental disorders attributable to diseases of the nervous system.

It preceded the current disciplines of psychiatry and neurology, which had common training, however, psychiatry and neurology have subsequently split apart and are typically practiced separately. Nevertheless, neuropsychiatry has become a growing subspecialty of psychiatry and it is also closely related to the fields of neuropsychology and behavioural neurology.

The Case for the Rapprochement of Neurology and Psychiatry

Given the considerable overlap between these subspecialities, there has been a resurgence of interest and debate relating to neuropsychiatry in academia over the last decade. Most of this work argues for a rapprochement of neurology and psychiatry, forming a specialty above and beyond a subspecialty of psychiatry. For example, Professor Joseph B. Martin, former Dean of Harvard Medical School and a neurologist by training, has summarized the argument for reunion: “the separation of the two categories is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway.” These points and some of the other major arguments are detailed below.

Mind/brain Monism

Neurologists have focused objectively on organic nervous system pathology, especially of the brain, whereas psychiatrists have laid claim to illnesses of the mind. This antipodal distinction between brain and mind as two different entities has characterised many of the differences between the two specialties. However, it has been argued that this division is fictional; evidence from the last century of research has shown that our mental life has its roots in the brain. Brain and mind have been argued not to be discrete entities but just different ways of looking at the same system (Marr, 1982). It has been argued that embracing this mind/brain monism may be useful for several reasons. First, rejecting dualism implies that all mentation is biological, which provides a common research framework in which understanding and treatment of mental disorders can be advanced. Second, it mitigates widespread confusion about the legitimacy of mental illness by suggesting that all disorders should have a footprint in the brain.

In sum, a reason for the division between psychiatry and neurology was the distinction between mind or first-person experience and the brain. That this difference is taken to be artificial by proponents of mind/brain monism supports a merge between these specialties.

Causal Pluralism

One of the reasons for the divide is that neurology traditionally looks at the causes of disorders from an “inside-the-skin” perspective (neuropathology, genetics) whereas psychiatry looks at “outside-the-skin” causation (personal, interpersonal, cultural). This dichotomy is argued not to be instructive and authors have argued that it is better conceptualized as two ends of a causal continuum. The benefits of this position are: firstly, understanding of aetiology will be enriched, in particular between brain and environment. One example is eating disorders, which have been found to have some neuropathology (Uher and Treasure, 2005) but also show increased incidence in rural Fijian school girls after exposure to television (Becker, 2004). Another example is schizophrenia, the risk for which may be considerably reduced in a healthy family environment (Tienari et al., 2004).

It is also argued that this augmented understanding of aetiology will lead to better remediation and rehabilitation strategies through an understanding of the different levels in the causal process where one can intervene. It may be that non-organic interventions, like cognitive behavioural therapy (CBT), better attenuate disorders alone or in conjunction with drugs. Linden’s (2006) demonstration of how psychotherapy has neurobiological commonalities with pharmacotherapy is a pertinent example of this and is encouraging from a patient perspective as the potentiality for pernicious side effects is decreased while self-efficacy is increased.

In sum, the argument is that an understanding of the mental disorders must not only have a specific knowledge of brain constituents and genetics (inside-the-skin) but also the context (outside-the-skin) in which these parts operate (Koch and Laurent, 1999). Only by joining neurology and psychiatry, it is argued, can this nexus be used to reduce human suffering.

Organic Basis

To further sketch psychiatry’s history shows a departure from structural neuropathology, relying more upon ideology (Sabshin, 1990). A good example of this is Tourette syndrome, which Ferenczi (1921), although never having seen a patient with Tourette syndrome, suggested was the symbolic expression of masturbation caused by sexual repression. However, starting with the efficacy of neuroleptic drugs in attenuating symptoms (Shapiro, Shapiro and Wayne, 1973) the syndrome has gained pathophysiological support (e.g. Singer, 1997) and is hypothesized to have a genetic basis too, based on its high inheritability (Robertson, 2000). This trend can be seen for many hitherto traditionally psychiatric disorders (see table) and is argued to support reuniting neurology and psychiatry because both are dealing with disorders of the same system.

Table: Linking Traditional Psychiatric Symptoms or Disorders to Brain Structures and Genetic Abnormalities.

Psychiatric Symptoms	Psychodynamic Explanation	Neural Correlates	Source
Depression	Anger turned inward	Limbic-cortical dysregulation, monoamine imbalance	Mayberg (1997)
Bipolar Disorder (Mania)	Narcissistic	Prefrontal cortex and hippocampus, anterior cingulate, amygdala	Barrett et al. (2003), Vawter, Freed, & Kleinman (2000)
Schizophrenia	Narcissistic/escapism	NMDA receptor activation in the human prefrontal cortex	Ross et al. (2006)
Visual Hallucination	Projection, cold distant mother causing a weak ego	Retinogeniculocalcarine tract, ascending brainstem modulatory structures	Mocellin, Walterfang, Velakoulis, (2006)
Auditory Hallucination	Projection, cold distant mother causing a weak ego	Frontotemporal functional connectivity	Shergill et al., 2000
Obsessive Compulsive Disorder	Harsh parenting leading to love-hate conflict	Frontal-subcortical circuitry, right caudate activity	Saxena et al. (1998), Gamazo-Garran, Soutullo and Ortuno (2002)
Eating Disorder	Attempted control of internal anxiety	Atypical serotonin system, right frontal and temporal lobe dysfunction, changes to mesolimbic dopamine pathways	Kaye et al. (2005), Uher and Treasure (2005), Olsen (2011), Slochower (1987)

This table is in not exhaustive but provides some neurological bases to psychiatric symptoms.

Improved Patient Care

Further, it is argued that this nexus will allow a more refined nosology of mental illness to emerge thus helping to improve remediation and rehabilitation strategies beyond current ones that lump together ranges of symptoms. However, it cuts both ways: traditionally neurological disorders, like Parkinson’s disease, are being recognized for their high incidence of traditionally psychiatric symptoms, like psychosis and depression (Lerner and Whitehouse, 2002). These symptoms, which are largely ignored in neurology, can be addressed by neuropsychiatry and lead to improved patient care. In sum, it is argued that patients from both traditional psychiatry and neurology departments will see their care improved following a reuniting of the specialties.

Better Management Model

Schiffer et al. (2004) argue that there are good management and financial reasons for rapprochement.

US Institutions

Behavioural Neurology & Neuropsychiatry fellowships are accredited by the United Council for Neurologic Subspecialties (UCNS; http://www.ucns.org), in a manner analogous to the accreditation of psychiatry and neurology residencies in the United States by the American Board of Psychiatry and Neurology (ABPN).

The American Neuropsychiatric Association (ANPA) was established in 1988 and is the American medical subspecialty society for neuropsychiatrists. ANPA holds an annual meeting and offers other forums for education and professional networking amongst subspecialists in behavioural neurology & neuropsychiatry as well as clinicians, scientists, and educators in related fields. American Psychiatric Publishing, Inc. publishes the peer-reviewed Journal of Neuropsychiatry and Clinical Neurosciences, which is the official journal of ANPA.

International Organisations

The International Neuropsychiatric Association was established in 1996. INA holds congresses biennially in countries around the world and partners with regional neuropsychiatric associations around the world to support regional neuropsychiatric conferences and to facilitate the development of neuropsychiatry in the countries/regions where those conferences are held.

The British NeuroPsychiatry Association (BNPA) was founded in 1987 and is the leading academic and professional body for medical practitioners and professionals allied to medicine in the UK working at the interface of the clinical and cognitive neurosciences and psychiatry.

Recently, a new non-profit professional society named Neuropsychiatric Forum (NPF) was founded. NPF aims to support effective communication and interdisciplinary collaboration, develop education schemes and research projects, organise neuropsychiatric conferences and seminars.

What is Trichotillomania?

Published on 05/24/2021 by Andrew Marshall12 Comments

Introduction

Trichotillomania (TTM), also known as hair pulling disorder or compulsive hair pulling, is a mental disorder characterised by a long-term urge that results in the pulling out of one’s hair. This occurs to such a degree that hair loss can be seen. A brief positive feeling may occur as hair is removed. Efforts to stop pulling hair typically fail. Hair removal may occur anywhere; however, the head and around the eyes are most common. The hair pulling is to such a degree that it results in distress.

The disorder may run in families. It occurs more commonly in those with obsessive compulsive disorder. Episodes of pulling may be triggered by anxiety. People usually acknowledge that they pull their hair. On examination broken hairs may be seen. Other conditions that may present similarly include body dysmorphic disorder, however in that condition people remove hair to try to improve what they see as a problem in how they look.

Treatment is typically with cognitive behavioural therapy (CBT). The medication clomipramine may also be helpful, as will clipping fingernails. Trichotillomania is estimated to affect one to four percent of people. Trichotillomania most commonly begins in childhood or adolescence. Women are affected about 10 times more often than men. The name was created by François Henri Hallopeau in 1889, from the Greek θριξ/τριχ; thrix (meaning “hair”), along with τίλλειν; tíllein (meaning “to pull”), and μανία; mania (meaning “madness”).

Brief History

Hair pulling was first mentioned by Aristotle in the fourth century B.C., was first described in modern literature in 1885, and the term trichotillomania was coined by the French dermatologist François Henri Hallopeau in 1889.

In 1987, trichotillomania was recognised in the Diagnostic and Statistical Manual of the American Psychiatric Association, third edition-revised (DSM-III-R).

Epidemiology

Although no broad-based population epidemiologic studies had been conducted as of 2009, the lifetime prevalence of trichotillomania is estimated to be between 0.6% and 4.0% of the overall population. With a 1% prevalence rate, 2.5 million people in the US may have trichotillomania at some time during their lifetimes.

Trichotillomania is diagnosed in all age groups; onset is more common during preadolescence and young adulthood, with mean age of onset between 9 and 13 years of age, and a notable peak at 12-13. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female. Among adults, females typically outnumber males by 3 to 1.

“Automatic” pulling occurs in approximately three-quarters of adult patients with trichotillomania.

Signs and Symptoms

Trichotillomania is usually confined to one or two sites, but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, and legs. Some less common areas include the pubic area, underarms, beard, and chest. The classic presentation is the “Friar Tuck” form of vertex and crown alopecia. Children are less likely to pull from areas other than the scalp.

People who suffer from trichotillomania often pull only one hair at a time and these hair-pulling episodes can last for hours at a time. Trichotillomania can go into remission-like states where the individual may not experience the urge to “pull” for days, weeks, months, and even years.

Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape. Individuals with trichotillomania may be secretive or shameful of the hair pulling behaviour.

An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socialising, due to appearance and negative attention they may receive. Some people with trichotillomania wear hats, wigs, false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as “pulling”) whatsoever. This “pulling” often resumes upon leaving this environment. Some individuals with trichotillomania may feel they are the only person with this problem due to low rates of reporting.

For some people, trichotillomania is a mild problem, merely a frustration. But for many, shame and embarrassment about hair pulling causes painful isolation and results in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. Hair pulling can lead to great tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem.

Other medical complications include infection, permanent loss of hair, repetitive stress injury, carpal tunnel syndrome, and gastrointestinal obstruction as a result of trichophagia. In trichophagia, people with trichotillomania also ingest the hair that they pull; in extreme (and rare) cases this can lead to a hair ball (trichobezoar). Rapunzel syndrome, an extreme form of trichobezoar in which the “tail” of the hair ball extends into the intestines, can be fatal if misdiagnosed.

Environment is a large factor which affects hair pulling. Sedentary activities such as being in a relaxed environment are conducive to hair pulling. A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep. An extreme example of automatic trichotillomania is found when some patients have been observed to pull their hair out while asleep. This is called sleep-isolated trichotillomania.

Causes

Anxiety, depression and obsessive-compulsive disorder (OCD) are more frequently encountered in people with trichotillomania. Trichotillomania has a high overlap with post traumatic stress disorder, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hair pulling as addictive or negatively reinforcing, as it is associated with rising tension beforehand and relief afterward. A neurocognitive model – the notion that the basal ganglia plays a role in habit formation and that the frontal lobes are critical for normally suppressing or inhibiting such habits – sees trichotillomania as a habit disorder.

Abnormalities in the caudate nucleus are noted in OCD, but there is no evidence to support that these abnormalities can also be linked to trichotillomania. One study has shown that individuals with trichotillomania have decreased cerebellar volume. These findings suggest some differences between OCD and trichotillomania. There is a lack of structural MRI studies on trichotillomania. In several MRI studies that have been conducted, it has been found that people with trichotillomania have more gray matter in their brains than those who do not suffer from the disorder.

It is likely that multiple genes confer vulnerability to trichotillomania. One study identified mutations in the SLITRK1 gene.

Diagnosis

Patients may be ashamed or actively attempt to disguise their symptoms. This can make diagnosis difficult as symptoms are not always immediately obvious, or have been deliberately hidden to avoid disclosure. If the patient admits to hair pulling, diagnosis is not difficult; if patients deny hair pulling, a differential diagnosis must be pursued. The differential diagnosis will include evaluation for alopecia areata, iron deficiency, hypothyroidism, tinea capitis, traction alopecia, alopecia mucinosa, thallium poisoning, and loose anagen syndrome. In trichotillomania, a hair pull test is negative.

A biopsy can be performed and may be helpful; it reveals traumatised hair follicles with perifollicular haemorrhage, fragmented hair in the dermis, empty follicles, and deformed hair shafts. Multiple catagen hairs are typically seen. An alternative technique to biopsy, particularly for children, is to shave a part of the involved area and observe for regrowth of normal hairs.

Classification

Trichotillomania is defined as a self-induced and recurrent loss of hair. It includes the criterion of an increasing sense of tension before pulling the hair and gratification or relief when pulling the hair. However, some people with trichotillomania do not endorse the inclusion of “rising tension and subsequent pleasure, gratification, or relief” as part of the criteria because many individuals with trichotillomania may not realise they are pulling their hair, and patients presenting for diagnosis may deny the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled.

Trichotillomania may lie on the obsessive-compulsive spectrum, also encompassing OCD, body dysmorphic disorder (BDD), nail biting (onychophagia) and skin picking (dermatillomania), tic disorders and eating disorders. These conditions may share clinical features, genetic contributions, and possibly treatment response; however, differences between trichotillomania and OCD are present in symptoms, neural function and cognitive profile. In the sense that it is associated with irresistible urges to perform unwanted repetitive behaviour, trichotillomania is akin to some of these conditions, and rates of trichotillomania among relatives of OCD patients is higher than expected by chance. However, differences between the disorder and OCD have been noted, including: differing peak ages at onset, rates of comorbidity, gender differences, and neural dysfunction and cognitive profile. When it occurs in early childhood, it can be regarded as a distinct clinical entity.

Because trichotillomania can be present in multiple age groups, it is helpful in terms of prognosis and treatment to approach three distinct subgroups by age: preschool age children, preadolescents to young adults, and adults.

In preschool age children, trichotillomania is considered benign. For these children, hair-pulling is considered either a means of exploration or something done subconsciously, similar to nail-biting and thumb-sucking, and almost never continues into further ages.

The most common age of onset of trichotillomania is between ages 9 and 13. In this age range, trichotillomania is usually chronic, and continues into adulthood. Trichiotillomania that begins in adulthood most commonly arises from underlying psychiatric causes.

Trichotillomania is often not a focused act, but rather hair pulling occurs in a “trance-like” state; hence, trichotillomania is subdivided into “automatic” versus “focused” hair pulling. Children are more often in the automatic, or unconscious, subtype and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hair pulling, including seeking specific types of hairs to pull, pulling until the hair feels “just right”, or pulling in response to a specific sensation. Knowledge of the subtype is helpful in determining treatment strategies.

Treatment

Treatment is based on a person’s age. Most pre-school age children outgrow the condition if it is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including behaviour modification programmes, may be considered; referrals to psychologists or psychiatrists may be considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other mental disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated.

Psychotherapy

Habit reversal training (HRT) has the highest rate of success in treating trichotillomania. HRT has also been shown to be a successful adjunct to medication as a way to treat trichotillomania. With HRT, the individual is trained to learn to recognise their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioural versus pharmacologic treatment, cognitive behavioural therapy (CBT, including HRT) have shown significant improvement over medication alone. It has also proven effective in treating children. Biofeedback, cognitive-behavioural methods, and hypnosis may improve symptoms. Acceptance and commitment therapy (ACT) is also demonstrating promise in trichotillomania treatment. A systematic review from 2012 found tentative evidence for “movement decoupling”.

Medication

The United States Food and Drug Administration (FDA) has not approved any medications for trichotillomania treatment.

Medications can be used to treat trichotillomania. Treatment with clomipramine, a tricyclic antidepressant, was shown in a small double-blind study to improve symptoms, but results of other studies on clomipramine for treating trichotillomania have been inconsistent. Naltrexone may be a viable treatment. Fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) have limited usefulness in treating trichotillomania, and can often have significant side effects. Behavioural therapy has proven more effective when compared to fluoxetine. There is little research on the effectiveness of behavioural therapy combined with medication, and robust evidence from high-quality studies is lacking. Acetylcysteine treatment stemmed from an understanding of glutamate’s role in regulation of impulse control.

Different medications, depending on the individual, may increase hair pulling.

Devices

Technology can be used to augment habit reversal training or behavioural therapy. Several mobile apps exist to help log behaviour and focus on treatment strategies. There are also wearable devices that track the position of a user’s hands. They produce sound or vibrating notifications so that users can track rates of these events over time.

Prognosis

When it occurs in early childhood (before five years of age), the condition is typically self-limiting and intervention is not required. In adults, the onset of trichotillomania may be secondary to underlying psychiatric disturbances, and symptoms are generally more long-term.

Secondary infections may occur due to picking and scratching, but other complications are rare. Individuals with trichotillomania often find that support groups are helpful in living with and overcoming the disorder.

Society and Culture

Support groups and internet sites can provide recommended educational material and help persons with trichotillomania in maintaining a positive attitude and overcoming the fear of being alone with the disorder.

Media

A documentary film exploring trichotillomania, Bad Hair Life, was the 2003 winner of the International Health & Medical Media Award for best film in psychiatry and the winner of the 2004 Superfest Film Festival Merit Award.

Trichster is a 2016 documentary that follows seven individuals living with trichotillomania, as they navigate the complicated emotions surrounding the disorder, and the effect it has on their daily lives.

What is a Psychiatric Advance Directive?

Published on 05/21/2021 by Andrew MarshallLeave a comment

Introduction

A psychiatric advance directive (PAD), also known as a mental health advance directive, is a written document that describes what a person wants to happen if at some time in the future they are judged to be suffering from a mental disorder in such a way that they are deemed unable to decide for themselves or to communicate effectively.

It can inform others about what treatment they want or do not want from psychiatrists or other mental health professionals, and it can identify a person to whom they have given the authority to make decisions on their behalf. A mental health advance directive is one kind of advance health care directive.

Legal Foundations

Psychiatric advance directives are legal documents used by persons currently enjoying legal capacity to declare their preferences and instructions for future mental health treatment, or to appoint a surrogate decision maker through Health Care Power of Attorney (HCPA), in advance of being targeted by coercive mental health laws, during which they may be stripped of legal capacity to make decisions.

In the United States, although 25 states have now passed legislation in the past decade establishing authority for PADs, there is relatively little public information available to address growing interest in these legal documents. In addition in states without explicit PAD statutes, very similar mental health advance care planning can and does take place under generic HCPA statutes – expanding the audience for PADs to all 50 states (see National Resource Centre on Psychiatric Advance Directives).

In addition, states are beginning to recognise legal obligations under the federal Patient Self-Determination Act of 1991, which includes informing all hospital patients that they have a right to prepare advance directives and – with certain caveats – that clinicians are obliged to follow these directives.

Finally, the Joint Commission on the Accreditation of Healthcare Organisations (JCAHO) requires behavioural health facilities to ask patients if they have PADs. The Centres for Medicare and Medicaid Services announced that patients have the right to formulate advance directives and to have hospital staff and practitioners who provide coercive interventions in the hospital comply with these directives. Hospitals out of compliance risk loss of Medicare and Medicaid revenue.

Proponents of these directives believe thy of followed by treatment providers, crisis planning using PADs will help involuntary detainees retain control over their decision making – especially during times when they are labelled incompetent. Additionally, advocates argue that health care agents will be instrumental in providing inpatient clinicians with information that can be central to patients’ treatment, including history of side effects and relevant medical conditions.

Clinical Benefits

Recent data from a NIH-funded study conducted by researchers at Duke University has shown that creating a PAD with a trained facilitator increases therapeutic alliance with clinicians, enhances involuntary patients’ treatment satisfaction and perceived autonomy, and improves treatment decision-making capacity among people labelled with severe mental illness.

Moreover, PADs provide a transportable document – increasingly accessible through electronic directories – to convey information about a detainee’s treatment history, including medical disorders, emergency contact information, and medication side effects. Clinicians often have limited information about citizens detained and labelled as psychiatric patients who present or are coercively presented and labelled as in crisis. Nonetheless, these are the typical settings in which clinicians are called upon to make critical patient-management and treatment decisions, using whatever limited data may be available. With PADs, clinicians could gain immediate access to relevant information about individual cases and thus improve the quality of clinical decision-making – appropriately managing risk to patients and others’ safety while also enhancing patients’ long-term autonomy.

For these reasons, PADs are seen as an innovative and effective way of enhancing values of autonomy and social welfare for detainees labelled with mental illness. Since PADs are among the first laws that are specifically intended to promote autonomy among people detained under mental health laws, wider use of PADs would empower a traditionally disenfranchised group when targeted for coercive psychiatry.

Barriers

National surveys in the United States indicate that although approximately 70% of people targeted by coercive psychiatry laws would want a PAD if offered assistance in completing one, less than 10% have actually completed a PAD.

Some people detained and forcibly drugged under coercive psychiatry laws report difficulty in understanding advance directives, scepticism about their benefit, and lack of contact with a trusted individual who could serve as proxy decision maker. The sheer complexity of filling out these legal forms, obtaining witnesses, having the documents notarized, and filing the documents in a medical record or registry may pose a formidable barrier.

Recent studies of practitioners of coercive psychiatry’s attitudes about PADs suggest that they are generally supportive of these legal instruments, but have significant concerns about some features of PADs and the feasibility of implementing them in usual coercive intervention settings. Clinicians are concerned about lack of access to PAD documents in a commitment, lack of staff training on PADs, lack of communication between staff across different components of mental health systems, and lack of time to review the advance directive documents.

In a survey conducted of 600 psychiatrists, psychologists, and social workers showed that the vast majority thought advance care planning for crises would help improve patients’ overall mental health care. Further, the more clinicians knew about PAD laws, the more favourable were their attitudes toward these practices. For instance, while most psychiatrists, social workers, and psychologists surveyed believed PADs would be helpful to people detained and targeted for forced drugging and electroshock when labelled with severe mental illnesses, clinicians with more legal knowledge about PAD laws were more likely to endorse PADs as a beneficial part of patients’ treatment planning.

However, many clinicians reported NOT knowing enough about how PADs work and specifically indicated they lacked resources to readily help patients fill out PADs. Thus, if clinicians knew more about advance directives and had ready assistance for creating PADs, they said they would be much more likely to help their clients develop crisis plans.

Resources

It thus has become clear that the potential significance of PADs is becoming widely recognised among those targeted for coercive psychiatry, survivors of coercive psychiatry, influential policy makers, clinicians, family members, and patient advocacy groups but that significantly more concerted efforts at dissemination were needed. The community of stakeholders interested in PADs and the broader concept of self-directed care are in need of online resource and gathering place for exchange of views and information.

As a result, in the United States, a collaboration between the Bazelon Centre for Mental Health Law and Duke University has led to creation of the MacArthur Foundation-funded National Resource Centre on Psychiatric Advance Directives, the only web portal exclusively devoted to developing a learning community to help people targeted for coercive psychiatry, their families, and clinicians prepare for, and ultimately prevent, coercive psychiatry interventions. The NRC-PAD includes basic information, frequently asked questions, educational webcasts, web blog, most recent research, legal analyses, and state-by-state information on PADs and patient-centred crisis planning. The NRC-PAD website thus includes easy step-by-step information to help those targeted for forced drugging, family, and clinicians complete PADs that mirror the provisions in the PAD statutes.

Book: Mental Health Disorders: A Social Problem That Needs Help From Society, How To Provide Treatment, Mental Health Audiobook

Published on 03/29/202103/29/2021 by Andrew MarshallLeave a comment

Book Title:

Mental Health Disorders: A Social Problem That Needs Help From Society, How To Provide Treatment, Mental Health Audiobook.

Author(s): Scott Langanke.

Year: 2021.

Edition: First (1ed).

Publisher: Independently Published.

Type(s): Paperback.

Synopsis:

There are many different mental disorders, with different presentations. They are generally characterised by a combination of abnormal thoughts, perceptions, emotions, behaviour, and relationships with others. Mental disorders include depression, bipolar disorder, schizophrenia, and other psychoses, dementia, and developmental disorders including autism.

It is becoming an imperative social problem that needs our joined hands to tackle.

This audiobook is designed for mental health professionals who do not have much time to study and also for ordinary people who want to understand more about mental disorders in order to help themselves or others overcome difficulties. It comes in text & audio format so that you can listen to it while at the gym or stuck in traffic! Sections include:

Introduction.
Cautionary Statement for Forensic Use of DSM-5.
Personality Disorders.
Brief Psychotic Disorder.
Schizotypal Disorder.
Narcissistic Personality Disorder.
Diagnostic Criteria For Autism And Autism Spectrum Disorder (ASD).
Neurodevelopmental Disorders.
Communication Disorders.
Specific Learning Disorder.

And SO MUCH MORE!

What is Biological Psychiatry?

Published on 03/26/202107/08/2021 by Andrew Marshall1 Comment

Introduction

Biological psychiatry or biopsychiatry is an approach to psychiatry that aims to understand mental disorder in terms of the biological function of the nervous system. It is interdisciplinary in its approach and draws on sciences such as neuroscience, psychopharmacology, biochemistry, genetics, epigenetics and physiology to investigate the biological bases of behaviour and psychopathology. Biopsychiatry is the branch of medicine which deals with the study of the biological function of the nervous system in mental disorders.

There is some overlap with neurology, which focuses on disorders where gross or visible pathology of the nervous system is apparent, such as epilepsy, cerebral palsy, encephalitis, neuritis, Parkinson’s disease and multiple sclerosis. There is also some overlap with neuropsychiatry, which typically deals with behavioral disturbances in the context of apparent brain disorder. In contrast biological psychiatry describes the basic principles and then delves deeper into various disorders. It is structured to follow the organisation of the DSM-IV, psychiatry’s primary diagnostic and classification guide. The contributions of this field explore functional neuroanatomy, imaging, and neuropsychology and pharmacotherapeutic possibilities for depression, anxiety and mood disorders, substance abuse and eating disorders, schizophrenia and psychotic disorders, and cognitive and personality disorders.

Biological psychiatry and other approaches to mental illness are not mutually exclusive, but may simply attempt to deal with the phenomena at different levels of explanation. Because of the focus on the biological function of the nervous system, however, biological psychiatry has been particularly important in developing and prescribing drug-based treatments for mental disorders.

In practice, however, psychiatrists may advocate both medication and psychological therapies when treating mental illness. The therapy is more likely to be conducted by clinical psychologists, psychotherapists, occupational therapists or other mental health workers who are more specialised and trained in non-drug approaches.

The history of the field extends back to the ancient Greek physician Hippocrates, but the phrase biological psychiatry was first used in peer-reviewed scientific literature in 1953. The phrase is more commonly used in the United States than in some other countries such as the UK. However the term “biological psychiatry” is sometimes used as a phrase of disparagement in controversial dispute.

Brief History

Early 20th Century

Sigmund Freud was originally focused on the biological causes of mental illness. Freud’s professor and mentor, Ernst Wilhelm von Brücke, strongly believed that thought and behaviour were determined by purely biological factors. Freud initially accepted this and was convinced that certain drugs (particularly cocaine) functioned as antidepressants. He spent many years trying to “reduce” personality to neurology, a cause he later gave up on before developing his now well-known psychoanalytic theories.

Nearly 100 years ago, Harvey Cushing, the father of neurosurgery, noted that pituitary gland problems often cause mental health disorders. He wondered whether the depression and anxiety he observed in patients with pituitary disorders were caused by hormonal abnormalities, the physical tumour itself, or both.

Mid 20th Century

An important point in modern history of biological psychiatry was the discovery of modern antipsychotic and antidepressant drugs. Chlorpromazine (also known as Thorazine), an antipsychotic, was first synthesized in 1950. In 1952, iproniazid, a drug being trialled against tuberculosis, was serendipitously discovered to have anti-depressant effects, leading to the development of monoamine oxidase inhibitors (MAOIs) as the first class of antidepressants. In 1959 imipramine, the first tricyclic antidepressant, was developed. Research into the action of these drugs led to the first modern biological theory of mental health disorders called the catecholamine theory, later broadened to the monoamine theory, which included serotonin. These were popularly called the “chemical imbalance” theory of mental health disorders.

Late 20th Century

Starting with fluoxetine (marketed as Prozac) in 1988, a series of monoamine-based antidepressant medications belonging to the class of selective serotonin reuptake inhibitors were approved. These were no more effective than earlier antidepressants, but generally had fewer side effects. Most operate on the same principle, which is modulation of monoamines (neurotransmitters) in the neuronal synapse. Some drugs modulate a single neurotransmitter (typically serotonin). Others affect multiple neurotransmitters, called dual action or multiple action drugs. They are no more effective clinically than single action versions. That most antidepressants invoke the same biochemical method of action may explain why they are each similarly effective in rough terms. Recent research indicates antidepressants often work but are less effective than previously thought.

Problems with Catecholamine/Monoamine Hypotheses

The monoamine hypothesis was compelling, especially based on apparently successful clinical results with early antidepressant drugs, but even at the time there were discrepant findings. Only a minority of patients given the serotonin-depleting drug reserpine became depressed; in fact reserpine even acted as an antidepressant in many cases. This was inconsistent with the initial monoamine theory which said depression was caused by neurotransmitter deficiency.

Another problem was the time lag between antidepressant biological action and therapeutic benefit. Studies showed the neurotransmitter changes occurred within hours, yet therapeutic benefit took weeks.

To explain these behaviours, more recent modifications of the monoamine theory describe a synaptic adaptation process which takes place over several weeks. Yet this alone does not appear to explain all of the therapeutic effects.

Scope and Detailed Definition

Biological psychiatry is a branch of psychiatry where the focus is chiefly on researching and understanding the biological basis of major mental disorders such as unipolar and bipolar affective (mood) disorders, schizophrenia and organic mental disorders such as Alzheimer’s disease. This knowledge has been gained using imaging techniques, psychopharmacology, neuroimmunochemistry and so on. Discovering the detailed interplay between neurotransmitters and the understanding of the neurotransmitter fingerprint of psychiatric drugs such as clozapine has been a helpful result of the research.

On a research level, it includes all possible biological bases of behaviour – biochemical, genetic, physiological, neurological and anatomical. On a clinical level, it includes various therapies, such as drugs, diet, avoidance of environmental contaminants, exercise, and alleviation of the adverse effects of life stress, all of which can cause measurable biochemical changes. The biological psychiatrist views all of these as possible aetiologies of or remedies for mental health disorders.

However, the biological psychiatrist typically does not discount talk therapies. Medical psychiatric training generally includes psychotherapy and biological approaches. Accordingly, psychiatrists are usually comfortable with a dual approach: “psychotherapeutic methods […] are as indispensable as psychopharmacotherapy in a modern psychiatric clinic”.

Basis for Biological Psychiatry

Sigmund Freud developed psychotherapy in the early 1900s, and through the 1950s this technique was prominent in treating mental health disorders.

However, in the late 1950s, the first modern antipsychotic and antidepressant drugs were developed: chlorpromazine (also known as Thorazine), the first widely used antipsychotic, was synthesized in 1950, and iproniazid, one of the first antidepressants, was first synthesized in 1957. In 1959 imipramine, the first tricyclic antidepressant, was developed.

Based significantly on clinical observations of the above drug results, in 1965 the seminal paper “The catecholamine hypothesis of affective disorders” was published. It articulated the “chemical imbalance” hypothesis of mental health disorders, especially depression. It formed much of the conceptual basis for the modern era in biological psychiatry.

The hypothesis has been extensively revised since its advent in 1965. More recent research points to deeper underlying biological mechanisms as the possible basis for several mental health disorders.

Modern brain imaging techniques allow non-invasive examination of neural function in patients with mental health disorders, however this is currently experimental. With some disorders it appears the proper imaging equipment can reliably detect certain neurobiological problems associated with a specific disorder. If further studies corroborate these experimental results, future diagnosis of certain mental health disorders could be expedited using such methods.

Another source of data indicating a significant biological aspect of some mental health disorders is twin studies. Identical twins have the same nuclear DNA, so carefully constructed studies may indicate the relative importance of environmental and genetic factors on the development of a particular mental health disorder.

The results from this research and the associated hypotheses form the basis for biological psychiatry and the treatment approaches in a clinical setting.

Scope of Clinical Biological Psychiatric Treatment

Since various biological factors can affect mood and behaviour, psychiatrists often evaluate these before initiating further treatment. For example, dysfunction of the thyroid gland may mimic a major depressive episode, or hypoglycaemia (low blood sugar) may mimic psychosis.

While pharmacological treatments are used to treat many mental disorders, other non-drug biological treatments are used as well, ranging from changes in diet and exercise to transcranial magnetic stimulation and electroconvulsive therapy. Types of non-biological treatments such as cognitive therapy, behavioural therapy, and psychodynamic psychotherapy are often used in conjunction with biological therapies. Biopsychosocial models of mental illness are widely in use, and psychological and social factors play a large role in mental disorders, even those with an organic basis such as schizophrenia.

Diagnostic Process

Correct diagnosis is important for mental health disorders, otherwise the condition could worsen, resulting in a negative impact on both the patient and the healthcare system. Another problem with misdiagnosis is that a treatment for one condition might exacerbate other conditions. In other cases apparent mental health disorders could be a side effect of a serious biological problem such as concussion, brain tumour, or hormonal abnormality, which could require medical or surgical intervention.

Examples of Biologic Treatments

Seasonal affective disorder: light therapy, SSRIs (Like fluoxetine and paroxetine).
Clinical depression: SSRIs, serotonin-norepinephrine reuptake inhibitors (venlafaxine), dopamine reuptake inhibitors: (bupropion), tricyclic antidepressants, monoamine oxidase inhibitors, electroconvulsive therapy, transcranial magnetic stimulation, fish oil, St. John’s wort.
Bipolar disorder: lithium carbonate, antipsychotics (like olanzapine or quetiapine), anticonvulsants (like valproic acid, lamotrigine and topiramate).
Schizophrenia: antipsychotics such as haloperidol, clozapine, olanzapine, risperidone and quetiapine.
Generalized anxiety disorder: SSRIs, benzodiazepines, buspirone.
Obsessive-compulsive disorder: tricyclic antidepressants, SSRIs.
ADHD: clonidine, D-amphetamine, methamphetamine, and methylphenidate.

Latest Biological Hypotheses of Mental Health Disorders

New research indicates different biological mechanisms may underlie some mental health disorders, only indirectly related to neurotransmitters and the monoamine chemical imbalance hypothesis.

Recent research indicates a biological “final common pathway” may exist which both electroconvulsive therapy and most current antidepressant drugs have in common. These investigations show recurrent depression may be a neurodegenerative disorder, disrupting the structure and function of brain cells, destroying nerve cell connections, even killing certain brain cells, and precipitating a decline in overall cognitive function.

In this new biological psychiatry viewpoint, neuronal plasticity is a key element. Increasing evidence points to various mental health disorders as a neurophysiological problem which inhibits neuronal plasticity.

This is called the neurogenic hypothesis of depression. It promises to explain pharmacological antidepressant action, including the time lag from taking the drug to therapeutic onset, why downregulation (not just upregulation) of neurotransmitters can help depression, why stress often precipitates mood disorders, and why selective modulation of different neurotransmitters can help depression. It may also explain the neurobiological mechanism of other non-drug effects on mood, including exercise, diet and metabolism. By identifying the neurobiological “final common pathway” into which most antidepressants funnel, it may allow rational design of new medications which target only that pathway. This could yield drugs which have fewer side effects, are more effective and have quicker therapeutic onset.

There is significant evidence that oxidative stress plays a role in schizophrenia.

Criticism

A number of patients, activists, and psychiatrists dispute biological psychiatry as a scientific concept or as having a proper empirical basis, for example arguing that there are no known biomarkers for recognized psychiatric conditions. This position has been represented in academic journals such as The Journal of Mind and Behaviour and Ethical Human Psychology and Psychiatry, which publishes material specifically countering “the idea that emotional distress is due to an underlying organic disease.” Alternative theories and models instead view mental disorders as non-biomedical and might explain it in terms of, for example, emotional reactions to negative life circumstances or to acute trauma.

Fields such as social psychiatry, clinical psychology, and sociology may offer non-biomedical accounts of mental distress and disorder for certain ailments and are sometimes critical of biopsychiatry. Social critics believe biopsychiatry fails to satisfy the scientific method because they believe there is no testable biological evidence of mental disorders. Thus, these critics view biological psychiatry as a pseudoscience attempting to portray psychiatry as a biological science.

R.D. Laing argued that attributing mental disorders to biophysical factors was often flawed due to the diagnostic procedure. The “complaint” is often made by a family member, not the patient, the “history” provided by someone other than patient, and the “examination” consists of observing strange, incomprehensible behaviour. Ancillary tests (EEG, PET) are often done after diagnosis, when treatment has begun, which makes the tests non-blind and incurs possible confirmation bias. The psychiatrist Thomas Szasz commented frequently on the limitations of the medical approach to psychiatry and argued that mental illnesses are medicalised problems in living.

Silvano Arieti, while approving of the use of medication in some cases of schizophrenia, preferred intensive psychotherapy without medication if possible. He was also known for approving the use of electroconvulsive therapy on those with disorganised schizophrenia in order to make them reachable by psychotherapy. The views he expressed in Interpretation of Schizophrenia are nowadays known as the trauma model of mental disorders, an alternative to the biopsychiatric model.

Book: The Origins and Course of Common Mental Disorders

Published on 03/18/202103/18/2021 by Andrew MarshallLeave a comment

Book Title:

The Origins and Course of Common Mental Disorders.

Author(s): David Goldberg and Ian Goodyer.

Year: 2005.

Edition: First (1st).

Publisher: Routledge.

Type(s): Hardcover, Paperback, and Kindle.

Synopsis:

Why are some people more vulnerable to common mental disorders than others?

What effects do genes and environments exert on the development of mental disorders?

The Origins and Course of Common Mental Disorders describes the nature, characteristics and causes of common emotional and behavioural disorders as they develop across the lifespan, providing a clear and concise account of recent advances in our knowledge of the origins and history of anxious, depressive, anti-social, and substance related disorders.

Combining a lifespan approach with developments in neurobiology, this book describes the epidemiology of emotional and behavioural disorders in childhood, adolescence and adult life. David Goldberg and Ian Goodyer demonstrate how both genes and environments exert different but key effects on the development of these disorders and suggest a developmental model as the most appropriate for determining vulnerabilities for psychopathology. Divided into four sections, the book covers the:

Nature and distribution of common mental disorders.
Biological basis of common disorders.
Human life cycle relevant to common disorders.
Developmental model.

This highly readable account of the origins of emotional and behavioural disorders will be of interest to behavioural science students and all mental health professionals including psychiatrists, psychologists, social workers, nurses, and counsellors.

Book: Models for Mental Disorder: Conceptual Models in Psychiatry

Published on 03/18/2021 by Andrew MarshallLeave a comment

Book Title:

Models for Mental Disorder: Conceptual Models in Psychiatry.

Author(s): Peter Tyrer.

Year: 2013.

Edition: Fifth (5th).

Publisher: Wiley-Blackwell.

Type(s): Paperback and Kindle.

Synopsis:

Models for Mental Disorder, first published in 1987, anticipated the
move towards integration of psychiatric services into multidisciplinary teams (doctor, psychologist, nurse, social worker, etc) and the need to bring together the different philosophies of mental illness.

Peter Tyrer has identified four different models of mental disorder that are relevant to clinical practice: the disease, psychodynamic, cognitive-behavioural and social models.

Each model is described and reviewed, with reference to case studies and
illustrations, to show how it relates to mental health disorders and can be
used to interpret and manage these disorders.

The book has been widely read and is often used for training purposes so that
each professional can understand and appreciate that differences in viewpoint
are often a consequence of one or more models being used in a different way
rather than a fundamental schism in approach.

Since the fourth edition was published in 2005, the disciplines of mental health
have moved even closer together with the growth of assertive outreach and
more integrated community teams. This, combined with the greater awareness
of mental health among users of services, which leads to more penetrating and
informed questions at interviews with professionals, has emphasized the need
for a wider understanding of these models.

The only book to describe the models framing mental health diagnosis and management.
A great review for those wanting a better grasp of psychiatric disorders and for integration of concepts for treatment planning.
New information on formal classifications of mental disorder.
New information on mindfulness and mentalisation regarding the dynamic model.
Clearly written in a style which includes some humour and a conversational presentation – a joy to read for the beginner and more experienced practitioner alike.
Features a teaching exercise for use when training students in the various models.

Book: Mental Disorders Audio And Text Book: Complete Understanding, Ways To Treat And Easy To Follow

Published on 03/15/2021 by Andrew MarshallLeave a comment

Book Title:

Mental Disorders Audio And Text Book: Complete Understanding, Ways To Treat And Easy To Follow.

Author(s): Garfield Chrismom.

Year: 2021.

Edition: First (1st).

Publisher: Independently Published.

Type(s): Paperback and Kindle.

Synopsis:

It is becoming an imperative social problem that needs our joined hands to tackle.

Introduction.
Cautionary Statement for Forensic Use of DSM-5.
Personality Disorders.
Brief Psychotic Disorder.
Schizotypal Disorder.
Narcissistic Personality Disorder.
Diagnostic Criteria For Autism And Autism Spectrum Disorder (ASD).
Neurodevelopmental Disorders.
Communication Disorders.
Specific Learning Disorder.

And SO MUCH MORE!

Book: Management of Mental Disorders

Published on 03/15/2021 by Andrew MarshallLeave a comment

Book Title:

Management of Mental Disorders.

Author(s): Dr. Gavin Andrews, Dr. Kimberlie Dean, Dr. Margo Genderson, Dr. Caroline Hunt, Dr. Philip Mitchell, Dr. Perminder Sachdev, and Dr. Julian Trollor.

Year: 2014.

Edition: Fifth (5th).

Publisher: Createspace Independent Publishing Platform.

Type(s): Paperback.

Synopsis:

Management of Mental Disorders, 5th Edition (MMD5) is an innovative book that provides practical guidance in recognizing and treating mental disorders. The fifth edition has been revised by experts and is a compilation of the best practices in mental health circa 2013. MMD5 outlines the steps required for proper assessment and focuses on how to implement the many effective treatments that are now available. This book also includes resource materials, such as outcome measures, worksheets, and information pamphlets for individuals with mental disorders and their families. MMD5 is designed to complement the skills of busy clinicians and for use as a textbook for undergraduate and graduate students.

The design of the fifth edition – core assessment and clinical skills and sections on the internalising, externalising, psychotic, neurodevelopmental, and neurocognitive clusters of disorders – is based on papers prepared for the discussions of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, 11th Edition (ICD-11) working groups. These papers presume that disorders within each of these five clusters share genetic risk factors, familiarity, specific environmental risk factors, neural substrates, biomarkers, temperamental antecedents, abnormalities of cognitive or emotional processing, symptom similarity, high rates of comorbidity, course of illness, and treatment response that differ in important ways from disorders within the other four clusters. The clusters are not intended to replace existing diagnostic criteria but rather are used to facilitate the identification of possible relationships between disorders in terms of the risk and clinical factors.

The present edition is the first to make the five-cluster structure of mental disorders explicit. Management of Mental Disorders is a publication of the Clinical Research Unit for Anxiety and Depression (CRUfAD), University of New South Wales (UNSW) School of Psychiatry at St Vincent’s Hospital, Sydney, Australia.

CRUfAD has produced treatment protocols for 30 years, first for the Royal Australian and New Zealand College of Psychiatrists and then with the Division of Mental Health, World Health Organisation, Geneva. Country specific versions of previous editions of the Management of Mental Disorders were produced for New Zealand, Canada, the United Kingdom, China, and Italy.

What is Open Dialogue?

Published on 03/15/2021 by Andrew MarshallLeave a comment

Introduction

Open Dialogue is an alternative approach for treating psychosis as well as other mental health disorders developed in the 1980s in Finland by Yrjö Alanen and his collaborators.

Background

Open dialogue interventions are currently being trialed in several other countries including Australia, Austria, Denmark, Germany, Italy, Norway, Poland, the United Kingdom, and the United States.

Key principles of the open dialogue method include: the participation of friends and family, responding to the client’s utterances (which may seem nonsensical in the case of pyschosis), trying to make meaning of what a client has to say, and “tolerating uncertainty”.

Theoretical Basis

In a paper illustrating the Open dialogue method Seikkula, Alakar and Aaltonen postulate that “from the social constructionist point of view, psychosis can be seen as one way of dealing with terrifying experience in one’s life that do not have language other than the one of hallucinations and delusions” and that “psychotic reactions should be seen [as] attempts to make sense of one’s experiences that are so heavy that they have made it impossible to construct a rational spoken narrative” arguing that people may talk about such experiences in metaphor.

They offer a model that “psychotic reactions greatly resemble traumatic experiences” with experiences of victimisation “not being stored in the part of the memory system that promotes sense-making”. Postulating that “an open dialogue, without any pre-planned themes or forms seems to be important in enabling the construction of a new language in which to express difficult events in one’s life.”

This understanding differs radically from common psychiatric models of psychosis that view it as being caused by a biological process in the brain, such as the dopamine hypothesis of schizophrenia.

Effectiveness

A systematic review of academic publications on the topic in 2018 concluded that: “most studies were highly biased and of low quality” and that “further studies are needed in a real-world setting to explore how and why [open dialogue] works.”