In this article, I will share some learnings related to mental health and mental disorders, taken from my masters course in mental health from which I graduated recently.
What is mental health
Mental health has a Bio — psycho — social basis = biological + psychological + social. It can be said to be an absence of mental disorders
Mental disorder: disorder or disability of the mind (1983 mental health act, UK)
Examples of mental disorders
affective disorders, such as depression and bipolar disorder;
schizophrenia and delusional disorders; neurotic disorders; organic mental disorders, such as dementia and delirium;
personality and behavioural changes caused by brain injury; importantly from a legal perspective, personality disorders;
mental and behavioural disorders caused by psychoactive substance use;
eating disorders;
learning disabilities; autistic spectrum disorders; and behavioural and emotional disorders of children and young people.
Positive psychology for mental health: Paying more attention to building on positive behaviors and traits already present in individuals. Positive psychology interventions aim to boost positive emotions and help clients find meaning in life
Five steps to mental wellbeing
Taken from the UK NHS toolkit — ‘Five steps to mental wellbeing.’ The five steps are as follows:
- ‘connect’ — connect with the people around you;
2. ‘give to others’ — such as volunteering at your local centre, can improve your mental wellbeing and help you build new social networks;
3. ‘be mindful / take notice’ — be more aware of the present moment, including your thoughts and feelings, your body, and the world around you.
4. ‘keep learning’ — learning new skills can give you a sense of achievement and new confidence. So start a cooking course, start learning to play a musical instrument
5. ‘be active’ — take a walk, go cycling, or play a game of football
Example of a mental disorder: Schizophrenia
Schizophrenia is a mental disorder characterized by two or more of the following symptoms during a one-month period as per DSM-5 (American Psychiatric Association, 2013):
- two or more symptoms among hallucinations, delusions, disorganized speech, disorganized or catatonic behavior,
- negative symptoms, and which are not attributable to any other condition.
- A form of psychosis
- Hears voices: cannot filter our irrelevant stimuli
- Feels others can read their mind
- Subject gets paranoid: cuts off social interaction
- Often occurs in more creative people (see film, a beautiful mind)
- Some people can have multiple episodes at various intervals
As per the ICD-10 definition (World Health Organization, 1983), psychosis can be diagnosed if the subject reports the presence of auditory hallucinations, delusions and abnormalities of behavior such as catatonia, overexcitement and retardation, within a short period of time.
Biology of schizophrenia
- Associated with increased dopamine (neurotransmitter) synthesis
- Dopamine hypothesis of schizophrenia: dopamine neurotransmitters disturbances in the mesolimbic pathway and prefrontal cortex of the brain could be a cause of the positive symptoms of schizophrenia
- Negative and cognitive symptoms are associated with the mesocortical pathway in the brain
- Decrease of grey matter in the brain: loss of brain tissue, cognitive difficulties
Environmental and developmental factors
- Associated with environmental factors and triggers such as stress
- Social anxiety and depression in childhood may be linked
- Being abused as a child can increase one’s risk of psychosis
- Social fragmentation in big cities, and being a member of migrant or minroty ethnic groups is associated with a higher risk
Genetic factors
- Ripke et al. (2014) identified 108 independently associated genetic loci that function as markers of schizophrenia
Treatment
- Treated by antipsychotic drugs: Block dopamine receptors
Example of a mental disorder: Addiction
- In addiction, the use of a drug of abuse is increased to maintain euphoria or avoid dysphoria or withdrawal.
- Example: addiction to drugs, alcohol
- The number of receptors increases, the number of neurotransmitters decreases, reinforcing properties of the drug gradually decrease (tolerance), and the body’s dependence on the drug increases. The subject has to take more of the drug to get the same pleasure.
- Genetic factors: Twin studies and adoption studies which suggest that transmission of alcoholism is determined more by genetics than the environment
- Social and developmental factors: include economic deprivation, drug use among peers, neighbourhood disorganization, family conflict and behavior problems in childhood. These increase the risk of addiction for those who are geneticvally already susceptible.
- Biology of addiction: Reward pathway of the brain (related to modulation of the dopamine system) is hijacked by addictive drugs. For example, nicotine and MDMA are associated with increase in the firing of dopamine neurons in the nucleus accumbens, that is associated with pleasure.
Example of a mental disorder: Depression
As per DSM-5, depresion is diagnosed if 5 or more of the following symptoms are diagnosed in the same 2-week period and at least one of the symptoims includes depressed mood or loss of interest or pleasure: depressed mood, diminished interest or pleasure, insomnia, psychomotor retardation, daily fatigue or loss of energy, feelings of worthlessness, diminished ability to think or concentrate, recurrent thoughts of death, impairment of social or occupational functioning
- Affects about one in five adults, median onset is about 25 years of age, leading cause of morbidity (DALYs — disability adjusted life year)
- One third genetic, two third environmental (social traumas, financial, health problems)
- Associated with change in inflammatory markers in immune system
- Monoamine hypothesis: depression due to deficiency of neurotransmitter levels in the brain
- Antidepressants can help to reduce the symptoms: increased number of new neurons
Cognitive behavioral therapy (CBT) for depression
CBT is based on the cognitive model, that postulates that negative thoughts and views about oneself, the world and future, affect one’s behavior.
CBT treatment for depression includes the following:
- Identifying negative thoughts, emotions and behaviors: The client is encouraged to monitor their automatic thoughts, emotions and behaviors that occur every day.
- Challenging negative thought patterns: Once the negative thoughts are identified, the client is encouraged to examine each thought and challenge the assumptions underlying such thoughts and emotions, sometimes with evidence of the opposite.
- Action plans and activities to strengthen positive behaviors: The client is encouraged to cultivate positive emotions and experiences. This can be done by encouraging them to bring to mind positive memories and positive incidents during the day. This enables them to focus more on the positive incidents rather than only the negative ones.
Example of a mental disorder: Stress
Stress is the subjective state of sensing potentially adverse changes in the environment that will lead to a response that enables the animal to adapt to the changing environment.
Stress is a process with the following steps:
- The adverse changes in the environment are perceived by the brain regions, leading to release of stress mediator molecules to deal with the changes
- This triggers the stress responses in the person, including physiological, cognitive and behavioral responses, that enable the person to adapt to the stressful changes in the environment
Biology of stress
- Associated with activation of the HPA axis (hypothalamic–pituitary–adrenal axis).
- This involves the activation of the region of the brain called hypothalamus, which then activates the pituitary glands and then affects the adrenal cortex activating the adrenal glands.
- The adrenal gland releases the hormone cortisol in the blood. This causes changes in the sympathetic nervous system, which governs the fight or flight response, causing changes such as pupil dilation, conversion of glycogen to glucose, secretion of adrenaline and noradrenaline, reduces the bladder constriction and digestive system, increases heart rate etc. It also causes changes in the immune system, cardiovascular system affecting blood pressure, and related changes, in such a way that one is better equipped to deal with the stressor.
- This normal adaptive response is termed as allostasis.
- Repeated, prolonged or chronic stress can reduce the effectiveness of the normal allostatic response of the body It can weaken our immune system, cause health conditions such as diabetes and significantly weaken our standard of life — allostatic load
- Cortisol is the stress hormone, which is secreted by the HPA axis, stimulated by the prefrontal cortex and limbic system. Increased cortisol in the body results in increased blood pressure and heart rate, diverts resources away from inflammatory areas, weakening the immune system, and improves the memory and thinking. In the short term this is beneficial but in the long term chronic stress can cause a toxic build up.
Mindfulness for stress reduction
- Mindfulness involves exercises such as sitting in a meditation posture and paying attention to the breath as it comes in an goes out through the nostrils.
- One pays gentle and sustained focused attention on the breath. If the mind wanders, such as a thought occurs or an itch or pain sensation occurs, one notices the sensation, and gently returns to noting the breath.
- Mechanism: training us to note our body sensations as they occur and thus increase our awareness of the stress response. It also trains us to accept our thoughts and feelings as they occur, without judging them as desirable or not.
- 8 week Structured program: Mindfulness based Stress Reduction (MBSR)
- Mindfulness helps to enhance the immune system and other mechanisms.
- Biological markers of stress such as the cortisol levels in saliva and blood, blood pressure, heart rate variability, cytokine levels, and so on have been measured in various studies to be improved by mindfulness meditation
Conclusion
In this article, we briefly discussed what is mental health and how common mental disorders such as addiction, depression and schizophrenia have a biological, genetic and social component. We also looked at some of the common treatments for mental disorders such as antipsychotic or antidepressant drugs, mindfulness meditation and CBT.
