Understanding Mental Illness: Causes, Diagnosis, and Effects on Behavior

1. Introduction to Mental Illness

2. Why do people with mental illness behave the way they do?

3. What Is Mental Illness?

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

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

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

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

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

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

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

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

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

13. Wisconsin Criminal Responsibility • In Wisconsin law: "A person is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect he lacked substantial capacity either to appreciate the wrongfulness of his conduct, or conform his conduct to the requirements of the law."

14. Four Kinds of Impulsivity • 1) Urgency: the tendency to give in to strong impulses in the face of intense negative emotions. • 2) Lack of perseverance: individuals are not able to persist in a task when they get frustrated, bored, or tired. • 3) Lack of premeditation: the inability to think through the consequences of behavior before acting. • 4) Sensation seeking: preference for excitement and stimulation.

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

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

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

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

19. Natural History of Schizophrenia • The illness begins with genetic vulnerability, and lies dormant until the premorbid phase in elementary school. These are too non-specific to be of diagnostic value. • The prodromal phase begins in puberty: anxiety, depression, irritability, poor sleep, social withdrawal, cognitive decline. 30-50% progress to schizophrenia within a year.

20. Natural History of Schizophrenia • With the onset of the illness, around 18-20, the disease enters the progressive phase. If treated 86% will recover, but the vast majority will relapse within 3 years. • In the chronic/residual phase, people with schizophrenia experience repeated episodes and relapses. The illness often becomes resistant to medication.

21. Frequency of Symptoms • Lack of insight 97% • Auditory hallucinations 74% • Ideas of reference 70% • Suspiciousness 65% • Flat affect 65% • Paranoid state 64% • Thought alienation 52% • Thoughts spoken aloud 50%

22. Course of the Illness • The three major groups of symptoms of schizophrenia are: • psychotic symptoms • deficit symptoms • cognitive symptoms.

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

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

25. Cognitive Symptoms • Disorganized thinking • Loss of attention, memory, verbal skills, • Generalizations are incorrect, trouble with abstraction • May be the most disabling aspect of the illness

26. Schizophrenia and Violence - Risk Factors • Past history of violence • Substance abuse • Non-adherence with treatment

27. Other Issues • Medical problems • 40% are obese (vs. 27% in general population) • 75% smoke (vs. 25% in general population) • Drug abuse • Diabetes twice the rate • Sudden death 3x higher • Cardiovascular death twice as high • Increased death rates from infectious disease and respiratory illness.

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

29. Antipsychotics • Antipsychotics are used to treat disorganized thinking and hallucinations in people who are psychotic. They don’t cure schizophrenia. • Antipsychotics are powerful medications that usually cause sedation, cloudy thinking, weight gain, and sometimes muscle stiffness. • Sometimes a patient can miss taking his antipsychotic medication for months with no effects. Sometimes the illness will worsen in a day.

30. A Few Principles About Medications • In spite of what some patients may tell you, nobody does worse when they are taking their medication. All people with serious mental illnesses are easier to work with when they are taking their medication. • Stopping medication is virtually always a setback for recovery. • Most medications require a period of time before they work (days to weeks to months.)

31. Medication Non-Compliance Rates • Arthritis 55-71% • Bipolar Disorder 20-57% • Diabetes 19-80% • Hypertension 50% drop out at 1 year • Schizophrenia 24-88% • Seizure Disorder 54-82% • Any long term illness 54%

32. Medication Adherence • Family members and people with regular contact with the patient have an enormous influence on medication adherence.

33. Psychosocial Treatments • Assertive community treatment (ACT) reduces frequency of hospitalization and increases housing stability. • Supported employment • Family psychoeducation • Social skills training

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

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

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

37. Natural History • Mean age of onset is 19. • 60% relapse within 4 years • Episodes become more treatment resistant.

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

39. Natural History - Deterioration • Medical problems include heart disease, diabetes, obesity, thyroid, and sexually transmitted diseases. Risk factors include nicotine, alcohol, and drug use, anxiety and eating disorders. • Occupational status will deteriorate in 50-66% • Social functioning will deteriorate in 50% with divorce 2.5x more likely • 23% will have a lack of awareness that they have an illness.

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

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

42. Bipolar Depression • Very difficult to treat and prevent. • Subsequent depression may be the worst part of mania. • This is a very high risk condition for suicide.

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

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

45. Mood Stabilizers - Anticonvulsants • Carbamazepine (Tegretol) • Divalproex sodium (Depakote) • Lamotrigene (Lamictal)

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

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

48. Impairment • In 2020, major depression will be second only to heart disease in the amount of disability suffered. • Cardiac clients have 4x greater risk of depression and depression is the best predictor of MI in next year. The risk of having and dying from an MI is the same as being a smoker. • 45.5% of people with depression want to die, 36.4% have considered suicide, 8.8% have made an attempt. Lifetime risk of death 14.6% (20x general population).

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

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