OverviewofPsychiatricDisorders

DrLisaLampe
SeniorLecturer,Psychiatry
StaffSpecialistPsychiatristNSLHD

Psychiatry
Thatbranchofmedicineconcernedwith
understandingandmanaging
abnormalitiesofthewaywethink,feel
andbehave.

PsychiatricDisorders
Illnessesordiseasestates,manifestby
abnormalitiesofthinking,feelingand
behaving,thatcausetheindividual
significantdistress orsignificantlyimpair
theirabilitytowork,playandlove.

Whyarethesedisordersimportant?
Common:
20%ofthecommunityin12months
40%overalifetime
Bothincommunityandhospitalpractice
Startearlyinlife
Frequentlypersist
Causehighlevelsofdisabilityanddistress

Importance:MentalDisordersareCommon
% of sample
1997

2007

Any anxiety disorder

9.7

14.4

Substance use disorder

7.7

5.1

Any affective disorder

5.8

6.2

Neurasthenia

1.5

N/A

Psychosis

0.4

N/A

Personality disorder

6.5

N/A

Any disorder

20.3

20.0

7.1

12-month Prevalence of DSM-IV Disorders in Australia

AndrewsG,HendersonS,HallW.Prevalence,comorbidity,disabilityandserviceutilisation:Overview
oftheAustralianNationalMentalHealthSurvey:BritishJournalofPsychiatry,2001.
ABSNationalSurveyofMentalHealthandWellbeing:SummaryofResults.4326.0.2007

Importance:mentaldisorderscarryahighburdenofdisease

I. Hickie, G. Groom and T. Davenport. Investing in Australia's future: Summary, December 2004, p. 9.
http://www.aph.gov.au/senate/committee/mentalhealth_ctte/report/c04.htm

Theburdenofmentaldisordersvariesbygenderandover
thelifespan

Victorian Burden of Disease Study: Incident YLD rates

per 1000 population by mental disorder

Theburdenofmentaldisordersvariesbygenderandover
thelifespan

Victorian Burden of Disease Study: Incident YLD rates

per 1000 population by mental disorder

MentalDisordershaveamajoreconomicimpact
8%ofhealthbudget(but19%oftotalburdenofdiseasedueto
illness)
$4.7bspentannually
20millionmentalhealthrelatedPBSsubsidisedprescriptions
worth$700m
90%ofscriptsforantidepressantsandantipsychotics
Directandindirectcostsperperson:
Bipolardisorder$16000
Schizophrenia$50000
Carersandthepersonwiththeillnessincurmostofthecosts
http://www.aph.gov.au/senate/committee/mentalhealth_ctte/report/c04.htm ; SANE Mental
Health Report, 2004

Organic
disorders

Delirium, dementia, acquired brain

injury, medical illness presenting as
psych.

Psychotic
disorders

Schizophrenia, schizoaffective
disorder, delusional
disorders.

Mood
disorders

Major depression, bipolar

disorder (may also be psychotic),
dysthymia

Anxiety
disorders

Panic, phobias, obsessive compulsive

disorder, posttraumatic stress

Personality
disorders

Lifelong maladaptive patterns

of interacting with the world and
others & in view of self

Somatoform
disorders

Psychiatric disorders that present

as physical illness (eg conversion
disorder, hypochondriasis)

Substance
disorders

Abuse, dependence, withdrawal

intoxication

Other
disorders

Sleep disorders, eating disorders,

paraphilias, Munchausens,
childhood disorders

Intense
reactions

Adjustment disorders,
pathological bereavement

Role
problems

Abnormal illness behaviour,

abnormal treatment behaviour

TheSickRole:TalcottParsons
Sociologicalview,firstpresentedin1951
Illnessnotjustasaconditionbutasocialrole
Fourmainfeaturesofsickrole:
Exemptionofsickpersonfromcertainnormalsocial
responsibilities
Exemptedfromresponsibilityforhisownconditioni.e.
victimofforcesbeyondhiscontrol(Parsons,1975)
Priceofexemptionisexclusionfromfullparticipationin
society,deemedtobeinundesirablestate
Obligationtocooperatewithtreatmentandtrytogetwell
Towhatextentdoesthisapplyinpsychiatry?
Parsons T. Illness and the role of the physician: A sociological perspective. Based on address to Harvard presented in
1951. Copy available in Am. J. Orthopsychiatry, 21: 452-460, 2010; Parsons T. The sick role and the role of the
physician reconsidered. The Milbank Memorial Fund Quarterly. Health and Society, 53: 257-278, 1975.

SymptomsandSignsofPsychiatricIllness
Behaviour
Observed
Reportedbehaviouralchanges
Needforcorroborativehx
Impulsecontrol

Self/otherharm/suicide

Relationships
Emotion(moodandaffect)

Depression
Elation
Anxiety
Irritability

Thinking
Content
Delusions
Overvaluedideas
Obsessions

Form

Perception
Hallucinations
Illusions

Cognition
InsightandJudgment

Psychiatricillness
Whatconstitutestheabnormalitycanbedifficultto
determineandcaninvolvedifficultclinicaljudgments
Relatestodistressandfunctionalimpairment
Thisintroducessubjectivitytosomediagnoses
Culturalandsocial
e.g.homosexuality,slavesdesiringfreedom
Lackofscientificknowledge
e.g.epilepsyaspsychiatricillness

ClassificatorySystems
DSMIV
ICD10
Botharecategorical

Whichdiseasemodel?

NormalityDisorder
Depression
Grief
Pathological
grief

Shyness

Normal social
anxiety

Social
phobia

NormalityDisorder

Suspiciousness

Mood
swings

Delusions

Bipolar
disorder

Biopsychosocial(cultural)model

Patho
physiological
effects

Individual
genetic
vulnerability
Individual

Environ
mental
stressors

Biologicalcontext
Brainstructurechangesoverthelifetime

T2weightedaxialimageshowing
lateralventriclesratedasnormal

T2weightedaxialimagedemonstrating
enlargedlateralventricles

Biopsychosocial(cultural)model

Patho
physiological
effects

Family

Individual
genetic
vulnerability

Environ
mental
stressors

ThisBeTheVerse
Theyfuckyouup,yourmumanddad.
Theymaynotmeanto,buttheydo.
Theyfillyouwithfaultstheyhad
Andaddsomeextrajustforyou
Buttheywerefuckedupintheirturn
Byfoolsinoldstylehatsandcoats,
Whohalfthetimeweresoppystern
Andhalfatoneanothersthroats.
Manhandsonmiserytoman.
Itdeepenslikeacoastalshelf.
Getoutasearlyasyoucan,
Anddonthaveanykidsyourself.
PhillipLarkin

Familyinteractionasastressor

Brownetal,Brit.J.prev.soc.Med.1962

Levelsofemotionandhostilityexpressedbyfamily
memberstoeachotherwasfoundtorelateto
deteriorationinschizophrenia
Thiswasmediatedbythedegreeofemotional
involvement,aproxyforhoursofcontact
Nowconsideredintermsofcommunicationstyle risk
factorforrelapse

Biopsychosocial(cultural)model

Environmentalcontext
Stressinteractswithgeneticfactors
Effectofviolenceinchildhoodupontheindividualis
moderatedbyafunctionalpolymorphismoftheMAOA
gene(Caspi etal,2002,Science)
Individualswiththeshortformofthe5HTTLPRgene
maybemorevulnerabletodepressioninthecontextof
environmentalstress

Comorbidityiscommon
Withotherpsychiatricdisorders
Anxietyanddepression
Personalitydisorder
Withsubstanceabuse
Withothermedicalconditions

Comorbidity:
Males

Substance
Use 8.3%

1.4%

Comorbidity:
Females

Anxiety
3.6%

0.8%
0.6%
0.3%
Affective
1.4%

Anxiety
7.3%

3.1%

Affective
3.2%

0.8%
0.3%
0.9%
2.4%
Substance
Use

Data from first National Survey of Mental Health and Wellbeing, Australia

Comorbiditywithothermedicalconditions

Formulation
PsychiatricDisorder
Thesesymptoms
Undergoingthesestressors
Personality
Medicalillnesses
Havingcertainpredisposingfactors
Livinginthesecircumstances

Formulation
Biological

Psychological

Social

Predisposing

Familyhistoryof
depression

Lossoffatheratage12

Frequentmovesmade
itdifficulttoestablish
friendships

Precipitating

Workstresswith
Partnerasked fortrial
Increaseduseof
alcoholinpast2/12 increasedhoursandnew separation2/52ago
bosspast3/12

Perpetuating
Pattern

Poorproblemsolving
skills
Recurrentepisodes
ofdepression

Protective

Prognosis

Recoverylikely

Fewclosefriends;
familyinterstate

Typicallyprecipitatedbypsychosocial stress
Insightful,hopeful,
intelligent

Doeshaveone
confidant;capableof
goodrelationships

Better copingskills
wouldriskrelapse

Increased socialisation
mayriskrelapse

Mr Joe Bloggs is a 36 year old married account manager with 3

children who presents with
a six week history of persistent
Formulation
low mood, worse in the mornings; initial and middle insomnia,
loss of appetite and 3kg weight loss; poor energy and
concentration consistent with a major depressive episode. It
occurs in a context of recurrent episodes of depression
usually triggered by psychosocial stress.
He has a likely biological predisposition given the family
history of depression, and other predisposing factors include
early loss of a parent (his father) and frequent moves as a
child which likely made it difficult for him to establish
friendships and grow in social confidence. This may well have
also predisposed to stress in intimate relationships, and
recent marital dysfunction represents an immediate precipitant
for the current episode. Other contributing factors include
increased work stress over the past 3 months and increase use
of alcohol as a maladaptive coping strategy.
Protective factors are evident including a supportive
friendship, hopefulness, insight and a pattern of good
recovery, suggesting a good prognosis for the current episode.

Treatments arealsoBiopsychosocial
Biological
Pharmacological
ECT

Psychological

Cognitive
Behavioural
Depth
Counselling

Social

CBT

Recoveryrequiressocial/vocationalinputaswell

Bond,2004.PsychiatricRehabilitationJ.27,345359.

More
consumers
enrolled in
supported
employment
subsequently
obtain
competitive
employment
than
consumers
without a
period of
supported
employment

Recoveryisthegoal

Emphasisonhopeandempowerment
Morethanjustsymptomcontrol:
Reintegrationintodesiredculture&community
Satisfyingrelationships
Meaningfulworkandleisureactivity
Spiritualdimension
Goalsidentifiedbytheindividual

Ethicalandlegaldimension
The Mental Health Act 2007
The objects of this Act
include:
a)
to provide for the
care, treatment and control
of persons who are mentally
ill or mentally disordered
b)
while protecting
the civil rights of those
persons, to give an
opportunity for those
persons to have access to
appropriate care
c)
to facilitate the
involvement of those
persons, and persons caring
for them, in decisions
involving appropriate care,
treatment and control.

Individualrights
Freedom
Treatment
Accesstoservices

Safety
Self
harm
exploitation

Others
Staff

Mentalhealthact

Definition of mental illness under the Act

> mental illness means a condition that
seriously impairs, either temporarily or
permanently, the mental functioning of a
person and is characterised by the presence in
the person of any one or more of the following
symptoms:
(a) delusions,
(b) hallucinations,
(c) serious disorder of thought form,
(d) a severe disturbance of mood,
(e) sustained or repeated irrational
behaviour indicating the presence of any one
or more of the symptoms referred to in
paragraphs (aHd).

Mentally ill person (s. 14)

1.
A person is a mentally ill person if the person is
suffering from mental illness and, owing to that illness,
there are reasonable grounds for believing that care,
treatment or control of the person is necessary:
a)
for the persons own protection from serious harm, or
b)
for the protection of others from serious harm.
2.
In considering whether a person is a mentally ill
person, the continuing condition of the person, including
any likely deterioration in the person's condition and the
likely effects of any such deterioration, are to be taken into
account.

Mentally disordered person (s. 15)

A person (whether or not the person is suffering from
mental illness) is a mentally disordered person if the
persons behaviour for the time being is so irrational as to
justify a conclusion on reasonable grounds that temporary
care, treatment or control of the person is necessary:
(a) for the persons own protection from serious physical
harm, or
(b) for the protection of others from serious physical
harm.

Involuntary admission (s. 12-13

1) A patient or other person must not be involuntarily admitted to
... a mental health facility unless an authorised medical officer* is
of the opinion that:
a)
the person is a mentally ill person or a mentally disordered
person, and
b)
no other care of a less restrictive kind, that is consistent
with safe and effective care, is appropriate and reasonably
available to the person

The Mental Health Review Tribunal

> Specialist quasi-judicial body constituted under
the Mental Health Act 2007
Lawyer alone (Mental Health Inquiry)
Panel consisting of Lawyer, Psychiatrist and
suitably qualified community member for most other
matters.
> Wide range of powers concerned with treatment and care of people
with a mental illness, including:
Involuntary patient orders
Community treatment orders
Make and revoke orders for financial management by NSW
Trustee for detained patients
Approve use of ECT for involuntary patients
Approve surgery on detained patients

Commonthemes
1. PsychologicalDisordersarecommon
2. Aetiologyismultifactorial
3. Comorbidityistherule:withmedicaland
otherpsychiatricillness
4. Disorderscommonlystartearlyinlife
5. Treatmentmustconsiderbiopsychosocial
domains
6. Recoveryshouldbethegoalofintervention