Understand Mental Health Problems

The optional unit ‘Understand Mental Health Problems’ examines the different types of mental health conditions and their classifications as well as the impact that mental illness has on individuals and others.

Learning Outcome 1: Understand the types of mental ill health

1.1 Describe the following types of mental ill health according to the psychiatric (DSM/ICD) classification system: • mood disorders, • personality disorders, • anxiety disorders, • psychotic disorders, • substance-related disorders, • eating disorders, • cognitive disorders

The two most common systems used to categorise mental health conditions are:

• The International Classification of Diseases (ICD) Chapter V produced by the World Health Organisation (WHO)
• The Diagnostic and Statistical Manual of Mental Disorders (DSM) produced by the American Psychiatric Association (ASA)

In recent years, these publications have converged so that they are generally (but not specifically) comparable.

At my service , I am the senior worker and carry the caseload for the boroughs individuals who have substance misuse problems with the more complex physical and / or mental health needs, including co-morbidity. I work in partnership with the local mental health teams, have specialised training. To inform my practice and aid joint-working I refer often to mental health practitioner literature such as the ‘International Statistical Classification of Diseases and Related Health Problems’ and the ‘Diagnostic and Statistical Manual of Mental Disorders’. Both of these texts I have used to answer some of the questions below, cited individually.

1.1 a mood disorders

Mood Disorders refers to a superordinate grouping of Bipolar and Depressive Disorders. Mood disorders are defined according to particular types of mood episodes and their pattern over time. The primary types of mood episodes are Depressive episode, Manic episode, Mixed episode, and Hypomanic episode. Mood episodes are not independently diagnosable entities, and therefore do not have their own diagnostic codes. Rather, mood episodes make up the primary components of most of the Depressive and Bipolar Disorders.
(Chapter 6 – International Classification Of Diseases – Mortality and Morbidity Statistics)

1.1 b personality disorders

Personality disorder is characterized by problems in functioning of aspects of the self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships) that have persisted over an extended period of time (e.g., 2 years or more). The disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive (e.g., inflexible or poorly regulated) and is manifest across a range of personal and social situations (i.e., is not limited to specific relationships or social roles). The patterns of behaviour characterizing the disturbance are not developmentally appropriate and cannot be explained primarily by social or cultural factors, including socio-political conflict. The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
(Chapter 6 – International Classification Of Diseases – Mortality and Morbidity Statistics)

1.1 c anxiety disorders

Anxiety and fear-related disorders are characterized by excessive fear and anxiety and related behavioural disturbances, with symptoms that are severe enough to result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Fear and anxiety are closely related phenomena; fear represents a reaction to perceived imminent threat in the present, whereas anxiety is more future-oriented, referring to perceived anticipated threat. A key differentiating feature among the Anxiety and fear-related disorders are disorder-specific foci of apprehension, that is, the stimulus or situation that triggers the fear or anxiety. The clinical presentation of Anxiety and fear-related disorders typically includes specific associated cognitions that can assist in differentiating among the disorders by clarifying the focus of apprehension.
(Chapter 6 – International Classification Of Diseases – Mortality and Morbidity Statistics)

1.1 d psychotic disorders

Schizophrenia and other primary psychotic disorders are characterized by significant impairments in reality testing and alterations in behavior manifest in positive symptoms such as persistent delusions, persistent hallucinations, disorganized thinking (typically manifest as disorganized speech), grossly disorganized behavior, and experiences of passivity and control, negative symptoms such as blunted or flat affect and avolition, and psychomotor disturbances. The symptoms occur with sufficient frequency and intensity to deviate from expected cultural or subcultural norms. These symptoms do not arise as a feature of another mental and behavioural disorder (e.g., a mood disorder, delirium, or a disorder due to substance use). The categories in this grouping should not be used to classify the expression of ideas, beliefs, or behaviours that are culturally sanctioned.
(Chapter 6 – International Classification Of Diseases – Mortality and Morbidity Statistics)

1.1 e substance‐related disorders

Substance-related disorders are disorders of intoxication, dependence, abuse, and withdrawal caused by various substances including: alcohol, caffeine, inhalants, nicotine, prescription medications that are supratherapeutically abused (such as sedatives or opioids), as well as illicitly attained drugs like amphetamines, opioids (opium, heroin), cannabis, cocaine (inc crack-cocaine), hallucinogens, and phencyclidine (PCP).

According to the ‘Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revised’ (DSMIV-TR) [EDITORS NOTE: The latest version of the DSM is DSM5 (2013)], all of the substances listed above, with the exceptions of nicotine and caffeine, have disorders of two types: substance use disorders and substance-induced disorders. Substance use disorders include abuse and dependence. Substance-induced disorders include intoxication, withdrawal, and various mental states (dementia, psychosis, anxiety, mood disorder, etc.) that the substance induces when it is used.

The DSM-IV-TR lists disorders in the following categories:
> alcohol-related disorders
> amphetamine-related disorders
> caffeine-related disorders
> cannabis-related disorders
> cocaine-related disorders
> hallucinogen-related disorders
> inhalant-related disorders
> nicotine-related disorders
> opioid-related disorders
> phencyclidine-related disorders
> sedative-, hypnotic-, or anxiolytic-related disorders
> polysubstance dependence

1.1f eating disorders

Eating Disorders such as Anorexia Nervosa or Bulimia Nervosa involve abnormal eating behaviours that are not explained by another health condition and are not developmentally appropriate or culturally sanctioned and include preoccupation with food as well as prominent body weight and shape concerns. They are different to feeding disorders like Pica which involve behavioural disturbances that are not related to body weight and shape concerns, such as eating of non-edible substances or voluntary regurgitation of foods.

1.1 g cognitive disorders

Neurodevelopmental disorders are behavioural and cognitive disorders that arise during the developmental period that involve significant difficulties in the acquisition and execution of specific intellectual, motor, or social functions. Although behavioural and cognitive deficits are present in many mental and behavioural disorders that can arise during the developmental period (e.g., Schizophrenia, Bipolar disorder), only disorders whose core features are neurodevelopmental are included in this grouping. The presumptive etiology for neurodevelopmental disorders is complex, and in many individual cases is unknown.

(Chapter 6 – International Classification Of Diseases – Mortality and Morbidity Statistics)

1.2 Explain the key strengths and limitations of the psychiatric classification system

The strengths of the psychiatric classification system are:-

• Inappropriate behaviours can be distinguished from functional ones.
• A range of mental disorders are arranged, organised and described in a particular manner and order – giving standardisation.
• It is universally accepted and recognised allowing practitioners to plan and do appropriate treatments & therapies so an individual can get the right diagnoses & treatment from hospital to hospital anywhere they may go.
• It has greatly assisted in raising awareness and increasing impact on research agendas around mental illness.

The limitations of the Psychiatric classification system are:

• It does not explain the causes of the various psychological disorders. It can lead to put individuals into the wrong classification, because they do not clearly follow by description. This can lead to a wrong decision about the treatment, so improper care.
• It can box people into one of the available categories, sometimes inappropriately and it doesn’t accommodate the unique nature of the human condition.
• The system does not account for individuals who have ‘atypical’ symptoms, which could lead to inconsistent interpretation by physicians.
• The system looks at an individual as a one-dimensional source of data rather than looking at them holistically.

1.3 Explain alternative frameworks for understanding mental distress

The medical framework views mental disorders as a result of physical causes such as substance abuse and brain defects or injury. This model has been adopted by psychiatrists rather than psychologists.

Supporters of this framework consequently consider symptoms to be outward signs of the inner physical disorder – behaviour or thoughts, such as hallucinations, delusions or suicidal ideas are symptoms of mental. They believe that if symptoms are grouped together and classified into a ‘syndrome’ – clusters of symptoms that go together – the true cause can eventually be discovered to make a ‘diagnosis’ and appropriate physical treatment administered.

• The implications of this perspective are:
• The individual cannot, from their own resources, do anything to ameliorate their “illness.”
• To effect any change in an individuals’ behaviour, they must take the psychiatric drugs which the psychiatrist prescribes.

The psychosocial / behavioural framework views mental disorders as a result of learned habits, which arise from interaction between external stressors and the individuals’ personality. These learnt habits have come about by a process of conditioning.  Though most learning is useful as it helps one to adapt to their environment, however some learning is maladaptive and behaviour therapy aims to reverse this learning (counter conditioning).

The implications of the this perspective are:

• The individual is the only person who can effect the behavioural change, though they might need some support, either from family, friends, colleagues, etc. or professionals such as counselors, social workers, psychologists, etc.

In those cases where professional assistance is needed, the blueprint for effective assistance is:

• a) To help the individual understand the factors/circumstances that brought about the problem in the first place.  This might include: a history of trauma; an impoverished learning environment during formative years, or absence of effective role models.
• b) To help the individual identify and define the problem in specific terms; perhaps dismantle the problem into component parts.
• c) To encourage a sense of competence and empowerment.
• d) To develop, with the individual, specific plans for replacing sub-optimal habits with habits that are more productive.

1.4 Explain indicators of mental ill health

The following factors in an individual’s history (or present) could potentially trigger (even latently) or aggravate poor mental health; and are indicators that I look for when working with clients:

• Drug and alcohol misuse
• Childhood abuse, trauma, or neglect
• Social isolation or loneliness
• Experiencing discrimination and stigma
• The death of someone close
• Severe or long-term stress
• Unemployment or losing employment
• Social disadvantage, poverty &/or debt
• Homelessness or unsuitable housing
• caring for a family member or friend
• A long-term physical health condition
• Domestic violence or other abuse as an adult Significant trauma as an adult, such as military combat, being involved in a serious accident or being the victim of a violent crime
• Physical causes –such as a head injury or conditions such as epilepsy can have an impact on behaviour and mood (it is important I rule out causes such as this before seeking further treatment for a mental health problem)
• Genetic factors – researchers are currently investigating whether there might be a genetic cause of various mental health problems but there is no clear proof yet.

Mental ill health presentation indicators include:

• Trouble understanding & relating to situations & people. Unable to concentrate, confused & unable to organise their thoughts. Exhibiting withdrawal from friends and activities.
• Uncontrolled crying laughing for seemingly no reason or at inappropriate time.
• Excessive / disproportionate low mood, fears, irritably, guilt, anger, &/or fear. Exhibiting excessive anger, hostility or violence.
• Moods fluctuating to extremes for seemingly no reason.
• Inability to cope with daily problems or stress.
• Paranoid and deluded. Exhibiting detachment from reality, paranoia or hallucinations.
• Suicidal.

Learning Outcome 2: Understand the impact of mental ill health on individuals and others in their social network

2.1 Explain how individuals experience discrimination

Individuals with mental ill health can experience stigma, discrimination, exclusion and face barriers to engaging fully in society which will often negatively affect their wellbeing. They are more likely (compared with the general population) to have spent longer periods in custody or in the care of a local authority, and be long term unemployed.
Thus they may become isolated through not participating in the community as much as they would like, e.g. in work, voluntary or recreational activities. The stigma and discrimination of mental health problems may also act as a barrier to people seeking help or becoming involved in community activities. Due to misinformation, assumptions and stereotypes about mental ill health; there can be difficulties getting employment because employers think that they might cause trouble or be off work too often or not be able to work to expectations, Neighbours may think they are a risk to others or social groups as fears that they are dangerous and unpredictable.
Social exclusion, or excluding particular groups from participating, is detrimental to mental health.

People from black and minority ethnic communities with mental ill health are adversely affected by institutional and individual racism. Racism and its effects are major contributing & aggravating factors to the prevalence of mental health problems and affect mental health in two distinct ways: as contributors to anxiety, stress and low self-esteem as well as to feelings of helplessness and hopelessness and lack of control over external forces. Racism can also act as a barrier to accessing and receiving appropriate services, e.g. through communication difficulties from language differences, staff attitudes or harassment.

Adults over 65 do not have the same access to specialist mental health services as those under 65. Old age services have been excluded from investment and have seen reduced resources in some areas.
In mental health the traditional configuration of services in relation to older people has been to define access by a specific age, usually age 65. Although having administrative benefits by creating clear accountability of services, this approach may also be considered discriminatory, for example, when a person attending any specialist mental health service is required to transfer to an older people’s service only because they have reached the age of 65. In doing so they may lose benefits of the relationships they have formed with those services and be disadvantaged. Defining older people’s services by any age will always be arbitrary and risks people attending services that are not best placed to meet their needs.

Discrimination exists when inequitable distribution of resources prevents services meeting needs, when older people are required to attend services not designed to meet their needs, or when older people are denied access to services available to younger people that could meet their needs.

Lesbian, gay and bisexual and transgender people mental ill health are adversely affected by harassment, stigma and discrimination. There is a heightened risk of mental health problems, which can be associated with increased risk taking in terms of health behaviours, and there is evidence of increased risk of suicide among younger people, linked to experiences of bullying and the process of coming out

2.2 Explain the effects mental ill health may have on an individual

As considered in 1.4 above, mental illness often impacts negatively on the emotions of its sufferers in forms such as experiencing excessive low mood, fears and worries, fluctuating mood, inability to cope with daily problems or stress etc.

Delusions are the psychological effect sometimes felt by individuals faced by the problem of mental illness.
Psychotic experiences or episodes (also called psychosis) are when an individual perceives or interprets events very differently from people around them. This could include:

• Hallucinations, such as hearing voices or having visions
• Delusions, such as paranoia or delusions of grandeur.

Emotional abilities are associated with prosocial behaviours such as stress management and physical health. Individuals with mental ill health often have poor emotional regulation and can move to suppress these negative emotions which lead to self-destructive acts such as anti-social behaviours &/or substance abuse.

Panic attacks can be often experienced by those suffering mental ill health and are an exaggeration of their body’s normal response to fear, stress or excitement. These are bouts of intense, often very frightening symptoms, usually lasting between 5 and 20 minutes. They may experience overwhelming physical sensations, such as a pounding heartbeat or chest pains, sweating and nausea, feeling faint and unable to breathe &/or shaky limbs.

Self-harm is a behaviour to express, or get relief from, very deep distress and often (but not exclusively) carried out by individuals with mental ill health due to poor emotional regulation, where they take actions to cause themselves physical pain. It but it can be a means of expressing feelings that they can’t articulate or think clearly about. After self-harming they may feel a short-term sense of release, but the cause of their distress is unlikely to have gone away.

Many people experience suicidal thoughts and feelings as part of a mental health problem. They can be unpleasant, intrusive and frightening, but having thoughts about suicide doesn’t necessarily mean that they intend to act on them.

Individuals with serious mental health problems face barriers to access to health services and have significantly poorer physical health outcomes. They have significantly higher risks of long term physical illness and dying early, particularly from cardiovascular diseases, and are more likely to have a range of lifestyle risk factors for physical ill health, including smoking, less healthy eating and physical activity, and heavier use of alcohol.

The most common type of treatment available is prescription medication. These don’t cure mental health problems, but they can ease many symptoms. Which type of drug offered will depend on the diagnosis, for example: antidepressants, minor tranquillisers or sleeping pills anti-anxiety medication, mood stabilisers, antipsychotics.
However, drugs can have unpleasant side effects that may make the individual feel worse rather than better. They can also be difficult to withdraw from, or cause physical harm if taken in too high a dose.

Sometimes a person with mental ill health cannot make sound decisions concerning their financial plans because they cannot make sound decisions as considered in 1.4 above. Practical and financial problems with budgeting due to mental health problems may lead to accumulation of debt as some ill health may cause periods of over spending and find it difficult to control, or not having the skills or confidence to find help in managing their money will result in further unhappiness and anxiety. Those experiencing anxiety or depression may feel tempted to ignore the problem and hope that it will go away. I have worked with many clients who become too afraid to open any official-looking envelopes (bills etc).

Many individuals suffering from mental illness have been getting help from mental health services, but some can still face barriers in accessing services for support, due to issues with transport (financial &/or availability). My Borough has its mental health services relatively geographically central in the borough meaning access from the outskirts (particular north and south) by public transport can take some time and require multiple changes.

Social exclusion can have a long lasting effect on individuals with poor mental health, unfortunately often marking the start of a downward trend into poor health, unemployment, debt and family breakdowns

Mental health services and agencies can to be of great help to their patients as treatments are normally (now) person-centred, inclusive and empowering. In my area there is a recovery college only for individuals who are engaged with the central mental health team, and local charities run multiple positive programmes and activities to support those with poor mental health and holistically improve their lives.

2.3 Explain the effects mental ill health may have on those in the individual’s familial, social or work network

Looking after a family member with mental ill health can be an extremely stressful time and coping this may rouse various reactions such as somatic problems (migraines, loss of appetite, fatigue, insomnia), cognitive and emotional problems (anxiety, depression, guilt, fear, anger, confusion) and behavioural troubles (changes in attitude, and social withdrawal).

Family life can become unsettled and unpredictable as the needs of the ill become paramount. Family members may have emotional or physical issues of their own they feel unable to deal with as supporting the individual takes priority, thus negatively impacting their own health.

There may be concerns about possible violence (see 1.4 above), embarrassing behaviours, and intra-family conflict.

If there are children in the family, they may be too young to fully grasp the consequences of mental illness and find it difficult to understand why their parent / relation isn’t well or is acting unusually. Therefore, many tend to blame themselves and grow up feeling different, lonely, and isolated. Ultimately this may lead to the child developing psychological, behavioural, and social problems of their own.

Family members will often want to ensure their loved ones are protected from any form of discrimination and the best possible care, so at a practical and financial cost, family and friends may have to take time off / give up work or recreational pursuits to care for the individual, offer financial assistance to the individual, pay for private treatment &/or provide assistance attending appointments, support with daily activities, transportation, housework, cleaning, money management, etc.

Sometimes family members will be required to segregate their loved once especially if there is the risk of violence. This can increase feelings of shame and guilt.

Additionally discrimination can appear in public opinion about how to treat people with mental illness which can lead to families not feeling confident in using services or speaking to their friends or colleagues about what is going on at home and how they feel, leading to social exclusion.

Effectively caring for and supporting mentally ill individuals will help in showing them that they are still important and valuable. This increase belonging and strengthen the familial relationships.

Families may also take on the role of day-to-day care. This often happens with little training or support, or acknowledgment of their own needs and mental health. When families are accepted as partners in care and do receive training and support, there is strong evidence that this leads to better outcomes for everyone involved and have a positive effects on the person with mental ill health, improving neighbourhood environments, developing health and social services which support mental health, anti-bullying strategies at school, workplace health, community safety, childcare and self-help networks.

2.4 Explain how to intervene to promote an individual’s mental health and well-being

I work using a person-centred approach which promotes an individual’s mental health and well‐being.

I work closely and regularly with the individual and with others involved in their lives, care or support. I use effective communication to get to know my clients wholly and not just around their substance misuse, which includes finding out about their history, preferences, needs and wishes.

• The individual remains in control of their care & support and that they are treated respectfully and as a whole person with their holistic needs taken into consideration so their well-being and emotional health is increased.
• I know what to watch out for with the individuals regarding the indicators of poor / declining mental health and well‐being.
• The individual trust me and is more likely to come to me with concerns around their mental health and well‐being.

Exercising my duty of care promotes an individual’s mental health and well‐being by working together with others ensuring that myself & my colleagues work in ways that empower individuals. Developing an open and honest environment in the service when working with individuals and others will mean that they will be more likely to approach me if they have concerns about their mental health. We have regular safeguarding training and review meetings to ensure that we keep up-to-date with current best practice. I work with mental health teams, taking the time to understand their roles and responsibilities, observing current best practice shared and by learning from any mistakes made.

I promote individuals’ mental health and well-being by taking their views, preferences, wishes, beliefs and feelings into account when supporting them in planning and taking risks: which I do by actively involving individuals and/or their representatives in decisions about their support and providing them with all the information they require to make their own decisions.

I encourage my clients to engage internally and externally to my service in:

• Arts therapies – music, painting, dance or drama – to express and understand themselves in a therapeutic environment with a trained therapist. Arts therapies can be especially helpful if individuals find it difficult to talk about their problems and how they are feeling.  We provide visual journaling, embroidery, creative writing, and craft groups.
• Complementary and alternative therapies, as some individuals find these helpful to manage stress and other common symptoms of well-being and mental health problems. We provide mindfulness, reflexology, acupuncture and yoga groups.
• Peer support Groups – bringing together people who’ve had similar experiences to support each other. This can offer many benefits, such as: feeling accepted for who they are, increase self-confidence, meeting new people and using their experiences to help others, finding out new information and places for support, challenging stigma and discrimination. Local charities run two Mental health specific groups.
• Physical health activities – as taking steps to look after their physical health can help manage well-being & mental health. We provide walking, body conditioning (keep-fit) and allotment groups.

I also advise my clients generally or suggest the attend specifically the weekly health and well-being group supports individuals around how to; get enough sleep, eat healthily, keep physically active and overall look after themselves.

If working with a client in my service and mental ill health indicators are identified (as considered in 1.4 above) I will discuss with the individual if they feel a referral for a mental health assessment or GP appointment might be useful and appropriate (depending on the presentation).

For common problems such as depression and anxiety, an individual’s GP may be able to give them a diagnosis after one or two appointments. For less common problems the individual would need to be referred to a mental health specialist (such as a psychiatrist) via the local Assessment Team (again depending on the presentation), and they may want to see them over a longer period of time before making a diagnosis.

The two most common forms of treatment offered though the NHS are medication and talking treatments.