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Contents

Overview

  • What is (and isn’t) a mental disorder?
  • What are the major groups of mental disorders?
  • How do we know when someone has a mental disorder?
  • How are mental disorders classified around the world?
  • Who gets mental disorders?
  • Epidemiology of mental disorders

Definition of mental health

What is mental health

Never defined, probably means being able:

  • to work
    • (that is, you can be productive)
  • and to love
    • (that is, you can get along with others)

Burden of a Disease

  • Add together
    • Years of life lost – YLL
      • =(Life expectancy of the longest living culture in the world) - (Age at death)
        • this is just an arbitrary zero
      • Life expectancy in Japan is 82.5, Switzerland is 82, Australia is 82
      • Choose the life expectancy of the longest-living culture because otherwise it's unfair for countries with a higher mortality rate
    • Years lived with disability – YLD
      • Years lived with disability is based on ADLs and the level of impairment
      • You rank disorders based on how much of an impact they have on your life, and weight each disease based on its severity (marginal utility)
      • General notion: looking at the notion of how much a disease impairs functioning
  • To get
    • Disability Adjusted Life Years lost -DALY
    • DALY = YLL + YLD

Burden of Disease: Australia 1996

  • Mental disorders – 3rd overall
    • CVD and Cancer make their money by killing you (YLL), not through YLD
    • Mental disorders - YLL is small, YLD is large
  • MSK is high on disability but not great
    • But in the new iteration, it has come in second

Years Lived with Disability/100,000 Global Burden of Disease 2012

  • Mental Disorders 2,564,000 YLDs
  • Musculoskeletal disorders 2,409,000 YLDs
    • Some glitch means this is actually incorrect
  • Cardiovascular 319,000 YLDs
  • Neoplasms 65,000 YLDs

Burden of mental disorders YLDs/100,000; World 2012

  • Internalising (e.g. depression, anxiety) is the most significant for burden

Illnesses

  • are they categories or dimensions?
    • they are dimensions - they start off with mild symptoms where it doesn't meet criteria, and then it hits some artificial threshold where it becomes a "disorder"
      • the only exception is the rare single-gene specific disorders. Even broken legs come in varying levels
  • People take complaints to doctors, they don’t take disorders. What determines that they decide to go?
    • Abnormality
    • Severity
    • Chronicity
    • Disability
    • Utility - the perception that the doctor will do something useful
      • e.g. word of mouth recommendations
  • So people certainly think in dimensions

Mental disorders are dimensional

  • Recognition is based on
    • Symptoms [things the patient complains of] – Signs [things the doctor notices]
  • Diagnosis depends on the symptoms and signs satisfying the criteria (threshold) of the DSM-IV (USA) or the ICD-10 (WHO).
  • There are no critical lab tests
  • “Don’t have the required symptoms, don’t get the diagnosis” – doctors think in categories
  • Despite the diagnostic threshold the disorders are dimensions; subclinical to severe categories
    • E.g. for depression we need 5 of the symptoms; but what if they have 4 very severe symptoms
    • Threshold is the point at which it is incompetent not to offer treatment, and wrong for the health services not to provide it

Normal Mood Variation (Normal Mood)

  • Happiness = k.sin(Time)

Abnormal mood variation (depression)

  • Drop in mood is:
    • Severe (symptom severity)
    • Long duration
    • Functional impairment

Problems in Identifying When Someone Has a Mental Disorder

  • How do we distinguish between mental disorders and normal reactions to stressful situations?
  • We using explicit diagnostic criteria
    • International Classification of Diseases 10ed – Diagnostic and Statistical Manual IVed
  • And Dx critical symptoms are seldom seen as responses to stress

Characteristics of Diagnostic Systems

  • DSM-IV and ICD-10 are changing to be:
    • Based on etiological assumptions about mental disorders
    • Conceptualize mental disorders as dimensions
    • Not set in stone

Classifying

5 clusters of mental disorders

  1. Neuro-cognitive disorders (I forgot)
  2. Neuro-developmental disorders (Thick)
  3. Psychotic disorders (Mad)
  4. Internalizing disorders (Sad)
  5. Externalising disorders (Bad)
  6. Disorders within each clustersharegenes, information processing biases, comorbidities, treatments and service provisions.
    • While between clusters these would be different

Neuro-cognitive disorders: delirium, dementias, amnestic disorders;

  • The neuro-cognitive cluster share neural substrate deficits expressed in increases in deficits in basic mental functions.
  • Neuro-developmental disorders: mental retardation; autism spectrum disorders; learning, motor skill and communication disorders; pervasive developmental disorders
    • People don't grow out of them: IQ stays at the same percentile (same applies for autism and emotional relationship levels, and same applies for dyslexia. You can be trained to compensate but the defect stays)
    • The developmental cluster share a common course related to cognitive and emotional processing delays.
  • Psychotic cluster: Schizophrenia, bipolar disorder, other psychotic disorders, cluster A personality disorders.
    • The psychotic cluster share biomarkers for stimulus processing deficits.
    • Have difficulty working out the meanings of what you say etc
  • Internalizing disorders: depressive; panic, phobias, GAD; OCD/BDD/hypochondriasis; PTSD, eating disorders, dissociative disorders, adjustment disorders; somatoform disorders; cluster C personality disorders
    • The emotional cluster share temperamental antecedents of negative affectivity.
    • Vulnerability: get anxious/sad fast with environment (due to genetics)
  • Externalising disorders: substance use disorders, cluster B personality disorders, impulse control disorders, conduct disorder, ADHD
    • The externalising cluster share temperamental antecedents of disinhibition.
    • Temperament = structure of brain, inherited
    • Criminal; don't look at consequences

Example: DSM-IV-TR Schizophrenia

  • A. Characteristic symptoms: two or more of the following, each present for a significant portion of the time during a 1-month period:
    • delusions
    • hallucinations
    • disorganised speech
    • grossly disorganised or catatonic behaviour
    • negative symptoms ie apathy, affective flattening
  • B.Social/occupational dysfunction:For a significant portion of the time since the onset
  • C. Duration: Continuous signs of the disturbance persist for at least 6 months.
  • D.Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out
    • Schizoaffective: symptoms of schizophrenia and symptoms of bipolar disorder
  • E.Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance or a general medical condition

Schizophrenia is not a very common disorder . . .[NISAD]

. . . but the costs of treatment are enormous. .[NISAD]

And in addition to monetary costs . . . .[NISAD]

  • Patients carry a life-time heavy burden of psychological ill-health, personal distress and socio-economic disadvantage.
  • Many lose their essential roles in life and are severely impaired in their daily functioning.
  • Social isolation, unemployment, poverty and living in substandard accommodation are widespread.
  • In contrast to the availability of medications, there is a serious lack of access to evidence-based psychosocial treatments and rehabilitation.

The three characteristic features of schizophrenia

  • Stimulus Processing Deficits lead to Reality Distortion
  • Negative Symptoms
  • Intellectual Impairment
  • It is a Brain Disorder

Summary

  • Mental disorders are the largest cause of disability in the world and in Australia
  • No simple laboratory tests for mental illness exist
  • Mental disorders are defined on the basis of changes (severity and duration) in feelings, thoughts and behaviours. These are operationalised through diagnostic criteria
    • Problems exist with the current definitions:
    • Confusion between categories and dimensions
    • Difficulty in defining what is meant by “normal”
    • Emergence of etiology and epidemiology to define Clusters
  • Culture was an important aspect of classification systems but the influence is waning

Epidemiology of Mental Disorders

Overview

  • How do we get epidemiological data
  • Standard survey tools; answer a whole lot of questions to make a reliable diagnosis of mental disorders
  • How many people in Australia have a mental disorder over a 12 month period?
    • See chart on next slide
  • Data about comorbidity, disability, treatment seeking, and age of onset.
  • Prevalence rates around the world.
    • Mental disorders are much more frequent in the young and much less frequent in the old

NSMHWB: how many this year?

  • Mood 7%
  • Anxiety 14%
  • Substance use 8%
  • Schizophrenia 0.3%
  • Any of the above 20%: THEREFORE COMORBIDITY IS COMMON

NSMHWB: Comorbidity

  • Some people met criteria for more than one mental disorder.
  • High intracluster comorbidity
  • Comorbidity is associated with disability and treatment seeking

NSMHWB: Who Seeks Treatment?

Condition n in Australia in treatment
Schizophrenia 40 000 95%
Depression 650 000 60%
Any anxiety disorder 1 100 000 35%
  • People go to doctors depending on the severity, chronicity, disability that the symptoms cause
  • And, on whether they think the doctor can do anything
  • Only 30% of depressed patients get evidenced based treatment
  • Anxious patients - don't seek treatment because "it's part of my nature" or "doctor didn't help"

==NSMHWB: What Services?

  • General practitioner only 13%
  • Mental health only 2%
  • Other health professionals only 4%
  • Combination health professionals 15%
  • Seeing any health professional 34%
  • No mental health consultation 66%
  • Treatment seeking for a physical disorder 80%
  • Patients much more likely to get treatment that is evidenced based if physical not mental ailment


Age of Onset (NZ Survey)

Disorder Median age
Depression 32
Any anxiety 14

Within anxiety:

  • Specific phobia - 7%
  • Social phobia - 12%
  • OCD - 18%
  • PTSD - 24%
  • Panic disorder - 24%
  • GAD - 32%

World Mental Health Surveys 12 Month Prevalence any mental disorder

  • Within a country: Poorer, less educated have a higher rate of mental disorder
    • But between countries, it's around the other way


Summary

  • Epidemiology of mental health is usually derived from structured diagnostic interviews.
  • The 12 month prevalence of mental disorders in western countries ranges from 15 – 30%.
  • 2.4 million Australian adults met criteria for a mental disorder in 1997.
  • <40% of adults with a mental disorder seek treatment.
  • Mental disorders produce considerable disability.
  • The age of onset is often in youth, suggesting prevention and early intervention services should be developed.
  • Counselors are
  • NNTs:
    • CBT: 2 in mild depression, 3 in severe depression
    • SSRIs: 16 in mild depression, 4 in severe depression

Correlates and Causes of Mental Disorders

Overview

  • Who gets mental disorders?
  • What causes the different mental disorders?

Gender

  • Prevalence of anxiety and depression is consistently higher in females
  • Prevalence of substance use disorders is higher in males
  • Added together the overall rates are comparable
  • Women will weep, men will drink

Age

  • Prevalence of mental disorders in general is higher in the young and lower in older age groups (>65 years)
  • Prevalence of substance use disorders is higher in younger age groups (18-24 years)
  • Prevalence of dementia is higher in the elderly
  • As you become older, you get accustomed to your state of life until you become physically disabled

Marital status

  • Prevalence of all groups of mental disorders is consistently lower in those who are married or living in a de facto relationship
  • Prevalence of all groups of mental disorders is higher in those who never married; or who are widowed, separated or divorced, even after controlling for gender
  • Hard to make causal inferences
    • Mental disorder --> less likely to have a partner

Employment status

  • Prevalence of most groups of mental disorders are lower in the employed,
  • Prevalence of most disorders is higher in those who are not currently in the workforce (don't know which way causation runs)
  • Prevalence of mental disorders among the employed is equal across occupational groups (e.g. managers, professionals, clerical workers and labourers)
  • Hard to make causal inferences

Educational status

  • Prevalence of mood and anxiety disorders higher in people who stopped their education at high school
  • These disorders are less prevalent in those who continue with higher education (e.g. university and TAFE)
  • Again causation could go both ways

Country of birth

  • Examined in the Australian National Survey of Mental Health and Well-Being
  • Prevalence of mental disorder lowest in those born in non English speaking countries, mainly due to substance use disorders being lower

What causes mental disorders?

  • Contribution of genes?
    • Schizophrenia 70%
    • Bipolar disorder 70%
    • Alcoholism 60%
    • Anxiety disorders 40%
    • Major depression 30%
  • The majority of studies have been carried out in Western societies

What causes mental disorders?

  • The impact of the environment is important
  • WHO Comparative Risk Assessment Project. Forty environmental preventable causes of illness. CSA:
    • prevalence of broadly defined child sexual abuse is 6% in males and 21% in females
    • prevalence varies around the world
    • those who experience CSA are twice as likely to develop mental disorders as those who do not, controlling for other childhood adversity
    • CSA accounts for 15% of depression
  • Depression: Munich study, cohort identified at 18 years followed till 28, first onset depression 18-28
    • 1. No familiality, no stressors prior to 18: 2.5%
    • 2. No familiality, stressors prior to 18: 2.5%
    • 3. Familiality, no stressors prior to 18: 5%
    • 4. Familiality, stressors prior to 18: 7.5%

*Conclusion: environmental stressors are hypothesised to have a particularly deleterious effect only on those individuals with a genetic diathesis or predisposition to a particular psychopathology (Plomin et al, 2000). Cf Schizophrenia: where it is also true.

Genetics of mental disorders

  • There is no single “mental disorder gene”
  • Genes are probably necessary but not always sufficient to cause mental disorders.
  • The environment is a trigger for the development of a mental disorder
  • Interaction between genes and environment:
    • Role of temperament in externalizing/internalising disorders


  • 1. Caspi, A. et al. 2002. Role of the genotype in the cycle of violence in maltreated children. Science 297, 851-854.
  • 2. Caspi, A. et al. 2003. Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science 301, 386-389.
  • 3. Caspi, A. et al. 2005. Moderation of the effect of adolescent-onset cannabis use on adult psychosis by a functional polymorphism in the COMT gene: Longitudinal evidence of a gene X environment interaction. Biological Psychiatry.
  • Chased up babies who were born in Dunedin NZ.
    1. Abnormality in MAO --> experience of violence as a child --> this group carried out 40% of the violence in the population. Without experiencing violence, you have no particular risk of being
    2. Serotonin transporter gene abnormality --> vulnerability to environmental stressors --> depression
    3. COMT abnormality and smoke dope before 21 --> increase in risk of psychosis as an adult

Prevention of Mental Disorders

  • Be kind to children
  • Teach infants, children & adolescents mental health skills

Common internalising mental disorders

  • Healthy migrant phenomenon: the healthy, bright, courageous people escape wartorn places
  • Criminals have higher rates of mental disorders (depression, schizophrenia)
    • Causality or not? Going to gaol also drives you mad

This course outline

  • Lectures on 1) depression, 2) GAD & PTSD; 3) phobias; 4) pharmacology of medication for these disorders; 5) management in primary care.
  • Tutorials on 1) communication and assessment in these disorders, 2) suicide prevention.
  • From Schools of Psychiatry, Community Medicine, Pharmacology,

One year prevalence of common mental disorders

Burden of mental disorders YLDs/100,000; World 2012

Features of internalizing disorders

  • Shared neural substrates
  • Shared temperamental antecedents
  • Shared cognitive and emotional processing
  • Shared genetic risk factors
  • Causal environmental risk factors
  • Symptom similarity
  • Within group comorbidity
  • Similar course of illness
  • Similar treatment response
  • Similar treatment services (SSRIs and CBT)


  • List of the internalising disorders
    1. Major depressive
    2. Dysthymia
    3. GAD
    4. Panic disorder
    5. Social phobia
    6. OCD
    7. PTSD
    8. Specific phobia
    9. Bulimia
    10. Anorexia (?)
    11. Somatophorm disorders
    12. Neurosthemia
  • These people are hyperattentive to images of threat or harm

Stress, anxiety and the Yerkes Dodson Curve

  • Need to be able to draw this for patients
  • When relaxed, your performance is at best average
  • When you get a little anxious, performance rises to good
  • When you get very anxious, your performance falls as you freeze

Symptoms of arousal

  • flight or fight changes + anxious anticipation
  • Flight or Fight changes vs symptoms (everyone has it when threatened):
    • Respiration increases
    • Blood from gut to muscles
    • Sweating increases
    • Heart rate increases
    • Muscle tension
    • Pupils dilate
    • Mental arousal
    • shortness of breath
    • nausea
    • cold sweat
    • palpitations
    • shaking, trembling
    • things look unreal
    • selective attention

Hierarchical 3-factor model of common mental disorders. Depression is an internalising disorder.

The burden of any disease continues when:

  1. Cause is overwhelming
  2. Prevention is ineffective
    1. Treatment is difficult
    2. not effective
    3. too expensive
    4. unavailable
    5. unacceptable
      • e.g. ECT is very effective for severe depression, but needs to have several bad episodes before it's accepted
  3. The disease is difficult to detect or diagnose
  4. The condition remits and recurs
  5. People do not come for treatment

Common Internalising Mental Disorders: 1. Depression

  1. Recognition: Definition of depression, clinical vignettes, epidemiology and natural history. Assessment.
  2. Treatment: Drugs & CBT; proactive collaborative care.
  3. Problem: Why does the burden persist?

Depression DSM-IV criterion

More than two weeks of persistently *‘sad or blue’ and/or

  • loss of interest or pleasure

Plus 3 or more of the following

  • Loss of energy
  • Change in sleep
  • Change in eating, weight
  • Change in ability to concentrate (*)
  • Change in ability to think or move quickly
  • Feelings of worthlessness, guilt (*)
  • Thoughts of death (*)

NB: the 5* symptoms are as good as the 9 (Zimmerman et al 2006, Andrews et al 2007)

  • Physical symptoms are nonspecific to depression so they're less important than psychological symptoms
    • So in the ICE, say psychological first; physical symptoms are not pathognomonic of depression
    • And with schizophrenia, don't start with "it lasts 6 months or more"

Disability due to depression

  • ‘Depression had the largest effect on worsening health scores’ when compared to angina, arthritis, asthma or diabetes; n=250,000, 60 countries
  • When comorbid, more disabling than any other pair of disorders

Dimensionality

  • of DSM-IV Major Depressive Episode

The relationship between the number of symptoms and impairment is linear.

Video clip: depression

  • Chronic episode 12 minutes
    • Ruminate on failures
    • Sympathetic signs, panicky, dry mouth
    • Feelings of worthlessness, guilt
    • Agitated
    • Sleep changes, appetite changes, slow movement
    • Social withdrawal
    • Loss of interests, enjoyment
    • Feeling down, never felt truly happy
  • See also the depression recovery stories on www.thiswayup.org.au/clinic

Symptom mnemonic

just a mnemonic.

  • Anhedonia
  • Sleep changes
  • Appetite/weight changes
  • Dysphoria (low mood)
  • Fatigue
  • Agitation (psychomotor) -- restlessness
  • Concentration loss
  • Esteem loss
  • Suicidal ideations
  • Anxious people worry about the future.
  • Depressed people ruminate about the past.

Questions to ask someone you suspect is depressed

  • Define depression
  • Work with ASADFACES
  • Establish chronicity
  • Discuss risk factors if relevant
  • Has this impacted on your:
    • Work
    • Relationships
    • Hobbies etc
  • Risk factors: women, 55 years old peak, etc

Symptoms in the vignette

  1. Persistent depression
  2. Loss of interest or pleasure
  3. Loss of energy
  4. Change in sleep
  5. Change in eating, weight
  6. Change in ability to concentrate
  7. Change in ability to think or move quickly
  8. Feelings of worthlessness, guilt
  9. Thoughts of death

Epidemiology - demography

  • Prevalence – point 3%; lifetime~50%
  • Age of first episode –
    • peaks in teenage and the very old
    • peak prevalence in middle age
  • Gender ratio F/M = 2/1
  • Associations: poor education, work history, marital history [cause goes both ways]

Epidemiology – natural history

  • Depression is episodic
  • Remits after a median of 8 weeks, mean of 26.

But 5% of episodes last for > 1 year

    • Remission = free of symptoms for > 2 months
  • Recurs again and again: average person reports 7 previous episodes. Cumulative duration 3-4 years.
  • Depression is often chronic (subclinical - not diagnostic but still bad)
  • PHH/POWH 15 year follow-up of severe cases
    • Only 1/5 recovered and had no recurrence
    • 3/5 had recurrences, 1/10 were chronically ill, 1/10 suicided [UK replication]
  • US study of patients in specialist clinics
    • 12 year follow-up of ‘severe’ cases
    • They met criteria [ie had >4 symptoms] for 2yrs
    • were sub-threshold for 5yrs of the time (big disability hit is here - being seriously below par)
    • were symptom free for 5yrs of the time

Cause: Family history + Adversity

[NB if lifetime risk is 50%, causes will be multiple, some causes may relate to transitions from sub-threshold to threshold cases]

  • Genetics (35%) both direct and via relation to temperament (neuroticism)
  • Adversity
    • Adverse life events, PTSD, IPV, CSA 20%
  • Genetics more important than adversity
  • New cases can be prevented
    • Seven studies: relative risk reduced from 1.00 to 0.72 [Cuijpers et al 2005]
  • Universal prevention programs in Australia
    • No data: beyondblue, Mind Matters, Data: www.thiswayup.org.au/schools

Diagnosis difficult – can be easy

[PHQ-9: Kroenke et al 2001]

  • No lab tests
  • PHQ9 is a self completion questionnaire, the 9 items reflect the 9 DSM-IV criteria
    • Can be filled in by a patient in waiting room, scored by the receptionist.
    • It is free and accurate
    • Should be a routine in all primary care
    • Practice nurse can phone to check patient’s progress
  • NB: suicidal thoughts = "belief that you're better off dead or of harming myself" is heading in that trajectory
    • Means and a plan, history of attempt or intention. Clinician makes this decision

PHQ-9 Symptom Checklist

  • Find them on the net
  • Score > 20 is major depression
  • Look at the other cutoffs

Treatment - Medications are effective

‘Treatments that Work’ Nathan & Gorman 2007

  • Anti-depressant drugs are effective
    • Only in very severe cases? JAMA Jan 10 2010
    • NICE guidelines: citalopram, fluoxetine [superiority over placebo ES = 0.55]
  • Advantages: easy to use, safe
  • Disadvantages: NNT=16 for mild, NNT=4 for severe cases
  • Depression that is mild is not better treated by medication than by placebo
    • On the other hand, it is negligent not to give people with schizophrenia medication

Treatment – CBT is effective

‘Treatments that Work’ Nathan & Gorman-2002

  • Cognitive behaviour therapy for depression, effect size superiority over placebo = 0.68, 17 studies [Haby et al 2006]
  • Usual content: education about disorder, activity scheduling/exercise, problem solving, cognitive restructuring, relapse prevention [see www.crufad.org]
  • Severe depression needs CBT + drugs or ECT + maintenance medication.
  • Patients seduce you away from your roster of treating the actual problem
    • Internet CBT --> WYSIWYG; they only get what has been put in by the researchers; not distracted by garble.

Treatment is affordable, available and acceptable

  • Direct treatment costs for depression
    • Optimal treatment costs $10,000/YLD
  • SSRIs are widely available, CBT is widely available face to face or via the internet
  • Half the population approve of SSRIs or CBT for depression

People don’t come so what should we do?

  • beyondblue is the national depression initiative,
    • pushes stories about seriousness of depression and the need to treat,
    • facilitates money and training for treatment
  • clinicians need to be proactive,
    • as if they had tuberculosis; follow them up
  • Or use internet CBT

Web based treatment for Depression

  • www.thiswayup.org.au/clinic
  • Two trials of clinician-guided internet CBT vs waitlist (n = 175)
    • Completion rates ~ 80%
    • Mean ITT Effect Size~1.0 at F-U, NNT=2. – Cost effectiveness $900/YLD
  • Decline in negative affectivity scores
  • More cost effective than f2f treatment

Depression: Web people are chronic (n=100 starters, 66 completers)

On the web; 50% who start recover, 72% who complete all lessons recover

  • Also their suicidal ideation decreased and their participation in work went up

iCBT works in research trials

  • iCBT also works when prescribed by General Practitioners.


Depression by severity (N=420)

  • NNT << 2

PHQ9; "Better off dead days"

  • Woman who moved from mild to severe was saved from suicide because of the iCBT treatment alerting the GP of the patient worsening (Prozac doesn't email, but the system does).
    • SEEING A PSYCHOLOGIST WHO ISN'T TRAINED IN CBT IS A WASTE OF GOVERNMENT MONEY. Counselors and therapists are a waste of money. iCBT is the way to go.
      • GPs love to transfer to the local counselor because it transfers responsibility, but it is not evidence based.

Indications for Treatment

  • use PHQ-9 scores
  • 0-4 normal
  • 5-9 sub-threshold: watchful waiting; prior history iCBT
  • 10-14 mild: iCBT
  • 15-19 moderate: iCBT
  • 21-27 severe: iCBT+SSRIs+ proactive care + specialist advice

The burden of depression need not continue because

  1. Known causes do not overwhelm
  2. Prevention can be effective
  3. Depression is not difficult to diagnose
  4. Treatment is not difficult
    1. Drugs, CBT & iCBT are effective
    2. Not expensive
    3. Available and acceptable
  5. People need proactive management, and encouragement to come for treatment
  6. See NICE guideline #23
  7. Just do it! Be assertive, proactive.
    • All libraries in Australia have free internet.

Common Internalising Mental Disorders: 2. Phobias

Phobias: Course Outline

  1. Recognition: Definition of a phobia, clinical vignettes, epidemiology and natural history. Assessment.
  2. Treatment: Drugs, CBT; proactive ideal care.
  • Irrational because you have some fear that reasonable people don't have

DSM-IV Phobia

  • An irrational fear of situations
    • Leads to avoidance of the situation
    • Anticipatory anxiety at prospect of entering situations
    • Anxiety when in the situation, often with fears of specific consequences

Types of phobias

  • Specific Phobias
    • Heights, closed spaces, snakes, spiders and other insects, dogs

and other carnivores, still water

    • Blood/injury phobias
  • Phobias that follow trauma
  • Panic Disorder/Agoraphobia
  • Social Phobia
  • Phobias in obsessive compulsive disorder

Bold are our focuses

Panic Disorder/Agoraphobia

  • Panic attack
    • Sudden attack of fear in situations in which others would not be afraid
    • Brief duration
    • Panic attacks are normal given the circumstances
    • At least 4 symptoms of flight or fight response
  • Panic disorder
    • Recurrent panic attacks, some unexpected
    • Anticipatory anxiety about panic consequences
    • Avoidance and other changes in behaviour
  • Agoraphobia
    • Avoidance of situations for fear of panic or panic like symptoms

Panic attacks are sudden, brief

  • Nervous, heart starts beating fast, can't get breath, start to feel dizzy, start shaking, feel like you're going to collapse/die, nauseous
    • Takes a few minutes but feels like hours
    • Feel like the anxiety will damage their body (they are their own risk)
    • Afterwards, feels shaken and exhausted
  • Afraid of having panic attacks - agoraphobia

Definition of Agoraphobia

  • Situations are avoided for fear of panic
  • Especially situations from which escape would not be possible or help not available
    • It's not the situation, it's what you THINK will happen to you - i.e. you're scared of something that is VERY unlikely. It's about your reaction to the situation, which is not in itself threatening.
  • Common situations are public transport, traveling alone, crowded places, lonely places
  • Common panic outcome fear - the panic will result in physical or mental collapse. Hence the need to be able to escape from the situation or to get medical help.


Diagnostic Measure

  • GHQ7 is the new industry standard

DVD - Recognition of Panic/agoraphobia

  • See www.thiswayup.org.au/clinic

Epidemiology - demography

  • Prevalence – point 1.7%; lifetime 5%
  • Age of first episode – median 20
    • Gender ratio F/M = 3/1
  • Associations: poor education, work history, marital history [cause goes both ways]
  • Vulnerability: anxious temperament

Epidemiology – natural history

  • Panic is often chronic, 1/3 do not remit after 10 years
  • Panic is significantly comorbid with social phobia, GAD and Cluster A personality disorders
  • Disability 1⁄2 cases are significantly disabled
  • 85% seek help, usually from a GP.

Treatment of Panic/Agoraphobia

UNDO THE RISK FACTORS - same as for CVD. You want to lower their neuroticism. Maintain control over arousal when it is appropriate.

  • Education about the disorder
    • It’s not your heart, it’s the ordinary flight or fight response occurring inappropriately. You should read “Don’t Panic” or visit www.thiswayup.org.au
  • Reduce the intensity of panics
    • Hyperventilation control during panic
    • Medication with TCAs or SSRIs (Citalopram, Fluoxetine) never with Benzodiazepines
      • Only ignorant doctors prescribe benzos for anyone
  • Reduce the anticipatory anxiety
    • Cognitive therapy – “I’ve had panics before and I’m still alive. I can manage with the slow breathing technique”
  • Reduce avoidance of feared situations
    • Graded exposure: from presently tolerated situations – being home alone - to those from which escape would not be possible or help available should panic occur – Centrepoint tower
    • Interoceptive exposure to symptoms of panic by deliberate hyperventilation in feared situation


  • People overprescribe benzos because they're "lovely". Anxiety disorder is different to being anxious. If someone with panic is put on benzo, you just sever the connection between them and their anxiety, but don't cure disorder. They get 1) desensitise 2) withdrawal symptoms 3) dependent 4) block new learning (so won't learn about panic disorders) 5) they block peripheral vision (unsafe in driving)
    • Hopeless doctors prescribe Xanax (benzos) to addicts to earn money from prescriptions (but Xanax + heroin produces respiratory depression and death).

Social phobia

Note that it's normal to hate being on display in front a lot of people. But people with social phobia believe that if people see they're anxious, then they'll think less of them as a person permanently.

  • Severe anxiety in social or performance situations or when under scrutiny.
  • Recognised as excessive or unreasonable
  • Situations are avoided or endured with intense anxiety & distress.
  • Underlying fear is of negative evaluation.
  • Anxiety or avoidance interferes with social, occupational or role functioning or causes significant distress.

Typical Fears and Cognitions

  • Situations: interviews, eating or drinking, parties, crowds and public transport
  • Thoughts:
    • “They’ll see I’m anxious and think I’m odd”
    • “What if I ... ? ”shake, vomit, have nothing to say, have to leave the room?”
      • “They’ll think less of me”
      • “They’ll think I’m incompetent”
      • “They won’t like me”
    • See www.thiswayup.org.au

Cognitive Model

  • Positive feedback loop that gets out of control quickly
  • Can have panics. It's not the symptom that defines it, it's what the person thinks
    • "What are you avoiding?" "Public places" "In case what?"
      • Get to the core issue to distinguish between panic disorder and social phobia
      • Panic disorder = fear of panic attacks. Social phobia = fear of being judged by others

Epidemiology - demography

  • Prevalence – point 1.5%; lifetime 10%
  • Age of first episode – peaks in teenage
  • Gender ratio F/M = 1/1
  • Associations: poor education, work history, marital history [cause goes both ways]
  • Vulnerability: introversion + neuroticism

Epidemiology – natural history

  • Chronicity- 1/3 still have symptoms 10 years later
  • Comorbidity with panic disorder, depression, substance dependence and avoidant personality disorder
    • Equivalent to getting drunk before you go out
  • Disability: 2/3 are moderate or severely disabled
  • Help seeking: only 20% seek help; only 7% got an effective treatment
    • Do it online so it's self-help (social phobia means they can't sit in the doctor's office)

Diagnostic measure

  • GAD-7 is the industry standard measure

Treatment

  • Patient education
    • They should read Rapee “Overcoming shyness”
    • Or read www.thiswayup.org.au
    • Or do course at www.thiswayup.org.au/clinic (NNT=2.1)
    • MUST realise so much of cognitions caught up in internal and external monitoring there is no capacity left for processing, mind blanks, feel confused, can’t keep up; and don’t notice that people like them.
      • Actually people DO like you - your fears are unjustified! YAY!

Cognitive Restructuring

  • Identify thoughts
  • Challenge thoughts ‘what evidence is there’
  • Rephrase unhelpful or unreasonable thoughts to better reflect reality
  • Base behaviour on more helpful/realistic premise
  • Review outcome and hence validity of challenges (behavioural experiments)
  • Repeat ...

Cognitive Behaviour Therapy

  • People grow into their increased assurance - it's like learning to ride a bike

Web based treatment of Social Phobia

  • Sydney trials (n=731)
    • ~ 80% adherence,
    • ITT Effect Size = 1 - 1.5.
    • Better than face-to-face treatment
    • Improvement is stable at 6 months
    • Comorbid depression and anxiety improves



Comorbid conditions improve

  • Comorbidity isn't a bar to treatment of social phobia. Internalising disorders are all one, you teach the same techniques (with different language) and they improve.

Psychopharmacology

  • Case reports, open trials and double-blind trials all show that SSRIs are effective.
  • There are reports of the use of:
    • Citalopram**
    • Fluoxetine*
  • Never benzodiazepines

Why does the burden of phobias continue?

  • Pan/Ags see doctors in case they have a physical disorder but are reluctant to engage in confronting their fears: Once well treated they stay well. “Anxiety won’t harm me”
  • Socials don’t see doctors: are reluctant to engage in confronting their fears: Once well treated they stay well. “Others don’t despise me”
    • Conga line in the park, others see and laugh: "they saw me and don't despise me".

Patient education in Phobias

  • Making certain patients understand critical information
  • Talk about the temptation to avoid
  • Stress the advantages of medication, graded exposure, problem solving, cognitive challenging
  • Need to identify early warning signs of relapse and confront don’t avoid

The burden of phobias need not continue because

  1. Known causes do not overwhelm
  2. Prevention can be effective
  3. Treatment is not difficult
    1. Both drugs and CBT are effective (NOT BENZODIAZAPENES)
    2. Neither are expensive
    3. Both are available
    4. Both are acceptable
  4. Phobias are not difficult to detect or diagnose
  5. People need proactive management, and encouragement to come for treatment
  6. Just do it! Be assertive until cured

Common Internalising Mental Disorders: GAD & PTSD

GAD - Clinical Features

  • Excessive WORRY is the core feature of GAD
  • Months of intrusive worries about day-to-day concerns
  • Accompanied by behaviour change
  • If people keep coming in about trivial questions, you should ask "do you think you're a worrier?", then they'll say "of course, that is why I'm here"

GAD - Epidemiology

  • Point prevalence
    • 3%, F>M
  • Onset
    • Median age of onset 30
  • Course
    • chronic, constant or waxing/waning WORRY
    • only 25% describe periods of > 3 months symptom free
    • Vulnerability - Neuroticism

GAD – Disability and help seeking

  • Has been underestimated until recent studies
  • Equivalent to major depression
  • Work impaired days equivalent to peptic ulcer and greater than arthritis, asthma, diabetes (Andrews et al., 1998; Kessler et al., 2001).
  • 60% seek help, two thirds get medication, few get CBT

Assessment measure

  • GAD-7 is the new industry standard measure.

Treatment

  • Patient education
    • See Lampe L, Overcoming Worry, Sydney, Simon and Schuster, 2004
    • Info: www.thiswayup.org.au

Psychopharmacology of GAD

Antidepressants

  • anxiolytic or symptom control action is independent of sedative action
  • tricyclics, SSRIs shown to be effective: probably all work; use Citalopram or Fluoxetine.
  • delay in onset of action
  • with SSRIs must start slow to minimise increase in agitation
  • About as good as CBT, but need to keep taking pills
  • Broken sleep, concerned, pains, headaches
    • They wear out quickly

CBT Treatment Programs

Components of treatment in most CBT programs:

  • Education
  • Dearousal training
  • Cognitive challenging of content of worry
  • Structured problem solving
  • Exposure to avoided situations

www.thiswayup.org.au/clinic for GAD

  • Two trials of clinician-guided internet CBT vs waitlist (n=198)
    • Outcome measures – GAD7 and PSWQ
    • Completion rates ~ 80%
    • Mean ITT Effect Size ~ 1.0 post Rx (NNT=1.8)
    • 13 times more cost effective than face to face treatment

*Example: "I haven't made their lunch tomorrow" --various logical steps--> "their career is doomed"

    • What? The start and the end are not sensibly connected. All this thought wears people out. Each thing is conceivable but low probability event. Then the product of all the small probabilities is very small.
    • Helping the current problem is irrelevant. Look at the behaviour pattern and ask them "are you a worrier?".
    • Intolerance of uncertainty; catastrophising and seeking help from wise people

GAD in primary care (n=195)

  • NNT(CBT) = 1.4. NNT(Meds) = 2.

Post Traumatic Stress Disorder

  • Exposed to a traumatic event (traumatic from anyone's viewpoint; i.e. feared you might be harmed or die)
    • Then recurrent distressing recollections of the event when awake or asleep; as though it's now happening
      • Awake = flashbacks; real and incredibly distressing
      • Asleep = dreams/nightmares
    • Avoidance of stimuli associated with the trauma that could trigger recollections
    • Persistent arousal (in case the memories return)

E.g. guy who had reconstructed bodies at Mt Erebus and later saw their faces at butcher shop as carcasses.

Epidemiology – natural history

  • More than half the adults in Australia report a traumatic event (i.e. thought they might die)
    • So the issue isn't the trauma, it's the fact that you can't put it behind you. Don't sympathise with the trauma.
  • Only one in ten trauma survivors report ever meeting criteria for PTSD, one in 40 for current PTSD.
  • Developing PTSD depends on the severity of the trauma and on vulnerability to anxiety and depression “I couldn’t put the memories behind me”


Epidemiology - demography

  • Prevalence – point 1.7%; lifetime 2.6-7.8%
  • Age of first episode – median = 22
  • Gender ratio F/M = 1/1
  • Associations: poor education, work history, marital history, [cause goes both ways], neuroticism, previous psychopathology, type/severity of trauma, support/functioning at time

Diagnostic measures

  • GAD-7 is the standard measure

Cognitions

  • I am a weak person
  • People cannot be trusted, generally
  • The world is a dangerous place
  • Somebody else would have stopped the event from happening
  • I have to be on guard all the time

These are not reasonable ways to think about your life, but might be reasonable in certain dangerous situations

Treatment

  • Patient education
    • Andrews et al , Treatment of Anxiety Disorders (2004)
    • www.thiswayup.org.au/clinic
  • Aim of Treatment (McFarlane and Yehuda,2000)
    • Patient must recollect the trauma
    • Manage the reactions to the memories – Habituate to the memories
  • Get them to tell you about what happened, and record it; at 35 minutes they choke up. Then they go away for a week and come back after listening to it again
    • Then in a week they come back, try again and they'll finish at around 35 minutes and they'll give you more detail
    • Repeat and repeat until they get a lot of detail and get bored of it, the nightmares, flashbacks and the avoidance of situations that trigger recall disappear.
  • Debrief the therapist so that staff survive

CBT

  • Patient recounts the trauma
    • Spends the next week listening to a tape recording of that session
  • Patient recounts the trauma
    • Spends the next week listening to a tape recording of that session
  • Repeats this process until intrusive thoughts, avoidance and arousal cease
  • Key is the safe and supportive therapeutic environment

Psychopharmacology

  • Case reports, open trials and double-blind trials all show that SSRIs help, don’t cure.
  • There are reports of the use of:
    • Citalopram**
    • Fluoxetine*

Why does the burden of GAD & PTSD continue?

  • GAD:
    • people defer seeking help; think that the excessive worry is ‘just them’.
    • Doctors do not understand the power of specialist or web based treatment
  • PTSD:
    • Society wants people to be compensated (and to get compensation you must not recover).
    • Patients want to avoid the memories. With specialist treatment people can stay well.

The burden of GAD & PTSD need not continue because

  1. Known causes do not overwhelm
  2. Treatment is not difficult (NO BENZOs)
    1. Both drugs and CBT are effective
    2. Neither are expensive
    3. Both are available
    4. Both are acceptable
  3. Neither GAD or PTSD are difficult to detect or diagnose
  4. People need proactive management, and encouragement to come for treatment
  5. Just do it!

Summary of the day

  • The Nature of Mental Disorders
  • The Internalizing Disorders – Depression
    • Panic/agoraphobia
    • Social phobia
    • Generalized Anxiety Disorder
    • Post Traumatic Stress Disorder
    • [OCD; Specific Phobias]
  • NB: Do you have a fear? (Most people say yes). And does the fear stop you do something? (Most people say no). People become bored of the heights and are cured.
    • The biggest risk for a depressive disorder is to take a specific phobia to high school (because of bullies).