Week 12 - Mental Illness - Part 1.pdf

WEEK 12: MENTAL ILLNESS – PART 1 EHR522: EXERCISE FOR METABOLIC AND MENTAL HEALTH CONDITIONS Subject Coordinator: Tim Miller [email protected] 02 6338 4442 Clinical Exercise Physiology, 5th Edition - Chapter 34 MENTAL ILLNESS - INT...

WEEK 12: MENTAL ILLNESS – PART 1 EHR522: EXERCISE FOR METABOLIC AND MENTAL HEALTH CONDITIONS Subject Coordinator: Tim Miller [email protected] 02 6338 4442 Clinical Exercise Physiology, 5th Edition - Chapter 34 MENTAL ILLNESS - INTRODUCTION  1 in 5 adults, and 1 in 7 young people, experienced a mental illness in the past 12 months  In Australia, approximately $11.6 billion was spent on health services in 2020-21. This represents 7.3% of the total government health expenditure  Mental illness has an extensive impact on individuals, families and the community more broadly TERMINOLOGY  Mental Illness – A health problem that significantly affects how a person feels, thinks, behaves and interacts with others  Mental illness is diagnosed in accordance with the criteria set out in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)  Mental Health Problem  Does not meet the diagnostic criteria for a mental illness  Is often experienced temporarily as a reaction to life stress  Can progress to mental illness if it is not managed effectively TERMINOLOGY  Mental Health Consumer – A person who lives with, or is in the process of recovering from, a mental illness or mental health problem  Recovery-Oriented Approach  An approach to mental health care includes principles of self-determination and personalised / individualised care  Emphasises hope, social inclusion, goal-setting and self-management  Focuses on achievement of an optimal state of personal, social and emotional wellbeing, as defined by each individual, whilst living with or recovering from a mental health condition  A change in language is a key component of the recovery and mental health model AETIOLOGY OF MENTAL ILLNESS  Aetiology of mental illness is believed to be related to a combination of three factors:  Biology  Psychology  Environment  Mental illness is associated with personal distress and/or problems functioning in social, work or family activities TREATMENT PROVISION  Psychologist – A registered allied health professional who specialises in human behaviour and who can assist with managing how an individual thinks, feels, behaves and reacts  Psychiatrist – A medical doctor who has completed specialised training in psychiatry.They are responsible for diagnosing, treating and preventing mental, emotional and behavioural disorders  A Psychiatrist has trained as a medical doctor and can prescribe medication. A psychologist is not a medical doctor and can’t prescribe medication MENTAL HEALTH AND PHYSICAL ACTIVITY CYCLE TYPES OF MENTAL ILLNESS  Psychotic Disorders (Schizophrenia and Schizoaffective Disorder)  Mood Disorders (Major Depressive Disorder and Bipolar Disorder)  Trauma- and Stressor-Related Disorders (PTSD and Acute Stress Disorder)  Anxiety Disorders (Generalised Anxiety Disorder, Panic Disorder and Phobias)  Feeding and Eating Disorders (Anorexia Nervosa and Binge-Eating Disorder) PSYCHOTIC DISORDERS  Psychotic disorders are a group of mental illnesses characterised by abnormal thinking and perceptions  Schizophrenia – A mental illness in which there is an abnormal interpretation of reality. It is characterised by two or more of the following  Delusions  Hallucinations  Disorganised speech (e.g. frequent derailment or incoherence)  Grossly disorganised or catatonic behaviour  Negative symptoms (ie. diminished emotional expression or avolition)  Schizoaffective Disorder – The concurrent presence of schizophrenia and a mood disorder MOOD DISORDERS  Mood disorders are a group of mental illnesses where a disturbance in a person’s emotional state is the main underlying feature  Major Depressive Disorder (MDD) – Characterised by discrete episodes of at least 2 weeks’ duration involving clear-cut changes in affect, cognition, and neurocognitive functions and inter-episode remissions (the diagnostic criteria is long and somewhat complex)  Bipolar Disorder – Characterised by periods of mania followed by periods of depression  Bipolar I Disorder – More severe mania and less severe, or absent, depressive episodes  Bipolar II Disorder – Less severe mania (hypomania), but more severe depressive episodes MANIC EPISODES  Mania is a distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased activity or energy  Mania is characterised by  Inflated self-esteem or grandiosity  Decreased need for sleep  More talkative than usual  Racing thoughts  Easily distracted by external stimuli  Increased goal-directed activity  Excessive involvement in activities that have a high potential for painful consequences TRAUMA- AND STRESSOR-RELATED DISORDERS  A form of anxiety that develops after experiencing a traumatic or stressful event  Associated with intense feelings of fear, horror, anger, sadness and hopelessness  Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder are two examples  Symptoms include  Flashbacks, intrusive memories and nightmares with physical symptoms  Heightened vigilance  Irritability and lack of focus / concentration  Avoidance, detachment and dissociation ANXIETY DISORDERS  Anxiety disorders are a group of mental illnesses characterised by feelings of excessive worry and fear  Can cause physical symptoms such as a fast heart rate, sweating, shakiness and so on  There are many anxiety disorders. Among them  Generalised Anxiety Disorder  Social Anxiety Disorder  Separation Anxiety Disorder  Panic Disorder  Selective Mutism ANXIETY DISORDERS  Generalised Anxiety Disorder (GAD) is characterised by excessive worry about actual circumstances, events or conflicts that occur in everyday life  GAD occurs in 3 – 8% of the Australian population  GAD is somewhat more common in females than in males  Family history is the most important risk factor for GAD development. It affects 25% of first-degree relatives with GAD  GAD typically begins in childhood  GAD is a long-term condition, and symptoms tend to decrease with advancing age  MDD is more likely to develop the longer GAD exists, particularly if it’s untreated  GAD is treated with psychotherapy, medications. There may also be a role for exercise FEEDING AND EATING DISORDERS  Feeding and eating disorders create a persistent disturbance of eating or eating- related behaviour  They result in the altered consumption of food  Can significantly impair physical health or psychosocial functioning  Anorexia Nervosa – Characterised by restriction of energy intake relative to requirements, leading to a significantly low body weight. There is intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain. There are different types (restricting or binge-eating / purging) FEEDING AND EATING DISORDERS  Binge-Eating Disorder – Characterised by eating a very large amount of food in a discrete time window, and by having little to no control of eating behaviour during that episode. There is marked distress regarding the episodes, and they are not associated with the use of inappropriate compensatory strategies (as is the case in bulimia nervosa)  Binge-eating episodes are associated with  Eating much more rapidly than normal  Eating until feeling uncomfortably full  Eating large amounts of food when not physically hungry  Eating alone because of embarrassment regarding volume of food consumed  Feeling disgusted with oneself, depressed, or very guilty afterwards SCHIZOPHRENIA SCHIZOPHRENIA  Schizophrenia is a severe mental illness that affects how a person thinks, acts, expresses emotions, perceives reality and relates to others  Characterised by disruptions in thinking which affect language, perception and one’s sense of self  Affects about 1% of the Australian population  Usual onset is at 15 – 25 years of age  It affects slightly more males than females AETIOLOGY OF SCHIZOPHRENIA  Development of Schizophrenia is multi-factorial and can include contributions from genetic susceptibility and environmental influences  Genetic Susceptibility  Risk is approximately 10% for a first-degree relative  Risk is approximately 3% for a second-degree relative  Environmental and Social Influences  Childhood trauma  Social isolation  Discrimination  Economic diversity DIAGNOSIS OF SCHIZOPHRENIA  Diagnosis takes a minimum of six months and is based on the criteria below  Two or more of the following must be present for at least one month or longer  Delusions  Hallucinations  Disorganised thinking (speech)  Disorganised or abnormal motor behaviour  Negative symptoms  Symptoms must have had a significant impact on one’s ability to work, study or perform daily tasks  All other possible causes for symptoms have been excluded SCHIZOPHRENIA  Behaviours and presentation of persons with Schizophrenia fall into four domains  Positive Symptoms – Refer to the added thoughts or actions that aren’t based in reality  Negative Symptoms – Refer to the absence of normal thinking or behaviours  Cognitive Symptoms – Refer to the impairment of executive and cognitive function  Mood Symptoms – Refer to abnormal emotional states POSITIVE SYMPTOMS  Delusions – False, mixed or other unusual beliefs that aren’t based in reality or fact that the person refuses to give up (e.g. believing that other people can hear their thoughts)  Hallucinations – Perceiving sensations without an external stimuli (e.g. hearing voices, seeing things that aren’t there, smelling odours that don’t exist or feeling something touch you that is not there)  Disorganised Thinking (Speech) – Disorganised speech that impairs effective communication  Disorganised or Abnormal Motor Behaviour – Unpredictable agitation or catatonia (a lack of movement and communication or unresponsiveness) NEGATIVE SYMPTOMS  Negative symptoms of Schizophrenia include  A lack of interest in the world  Social withdrawal  Diminished emotional expression  Inability to act spontaneously  Reduced sense of purpose  Avolition COGNITIVE SYMPTOMS  Cognitive symptoms of Schizophrenia include  Confusion, with difficulty understanding information and using it to make decisions  Difficulty focusing or paying attention to relevant stimuli  Poor short- and long-term memory  Reduced capacity to use information correctly  Inability to recognise one’s own cognitive limitations MOOD SYMPTOMS  Mood symptoms of Schizophrenia include  Loss of motivation  Loss of interest or pleasure in things  Excessive mood behaviours, including excessive fluctuation in mood  Periods of time doing very little followed by periods of time being extremely active PATHOPHYSIOLOGY OF SCHIZOPHRENIA  Results in structural brain abnormalities  Cerebral atrophy (5% of brain volume)  Smaller medial temporal lobes  Increased size of the third and lateral ventricles PATHOPHYSIOLOGY OF SCHIZOPHRENIA  Results in functional brain abnormalities  Abnormalities in neurotransmission due to excess or deficient amounts of dopamine, serotonin and/or glutamate MANAGEMENT OF SCHIZOPHRENIA  The goal of treatment is to ease the symptoms and reduce the risk of relapse  Treatments include  Medications – Antipsychotics to relieve or assist with symptoms  Psychotherapy – To address behavioural, psychological, social and occupational problems  Hospitalisation – For people with severe symptoms who might harm themselves or others, or who can’t care for themselves at home  Electroconvulsive Therapy – May be used when medications no longer work, or if severe depression and/or catatonia makes treatment difficult ANTIPSYCHOTIC MEDICATIONS  Antipsychotics, particularly second-generation antipsychotics, increase the risk of diabetes, hypertension and hyperlipidaemia  First generation antipsychotics (D2 receptor antagonists)  Chlorpromazine  Fluphenazine  First generation antipsychotics are associated with a higher risk of extrapyramidal symptoms such as  Dystonia  Parkinsonism  Tardive dyskinesia ANTIPSYCHOTIC MEDICATIONS  Second generation antipsychotics (5-HT2A / D2 receptor antagonists)  Olanzapine  Clozapine  Second generation antipsychotics are associated with a lower risk of extrapyramidal symptoms, but a higher risk of metabolic side effects such as  Diabetes  Hypertension  Hyperlipidaemia MAJOR DEPRESSIVE DISORDER (MDD) MAJOR DEPRESSIVE DISORDER (MDD)  MDD is characterised by a presence of sad, empty or irritable moods  MDD is accompanied by related changes that significantly affect an individual’s capacity to function  Affects about 10% of the Australian population  Lifetime incidence is slightly higher in females than in males MDD – BEHAVIOUR AND PRESENTATION  MDD symptoms occur most of the day, almost every day and may include  Feelings of sadness, tearfulness, emptiness or hopelessness  Loss of interest or pleasure in most or all normal activities, such as hobbies or sports  Tiredness and lack of energy  Sleep disturbances  Angry outbursts, irritability or frustration  Changes to appetite (increased or decreased)  Anxiety, agitation and restlessness  Slowed thinking, speaking or body movements  Feelings of worthlessness or guilt  Trouble thinking, concentrating, making decisions and remembering things  Frequent or recurrent thoughts of death, suicidal thoughts or suicide attempts DIAGNOSIS OF MDD  The person must be experiencing five or more of the following symptoms during the same 2-week period and at least one of the symptoms must be either (i) depressed mood or (ii) loss of interest or pleasure  Depressed mood most of the day, nearly every day  Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day  Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day  Insomnia or hypersomnia nearly every day  Psychomotor agitation or retardation nearly every day  Fatigue or loss of energy nearly every day  Feelings of worthlessness or excessive or inappropriate guilt nearly every day  Diminished ability to think or concentrate, or indecisiveness, nearly every day  Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide AETIOLOGY OF MDD  MDD is a complex mental illness that involves a combination of genetic, environmental and psychosocial factors that appear to influence both brain structure and brain chemistry  MDD risk factors include  Abuse  Age  Chronic disease or illness  Conflict  Death or loss  Gender  Family history  Major events  Stress  Substance misuse PATHOPHYSIOLOGY OF MDD  A number of pathophysiological mechanistic theories have been developed to explain MDD  Neurochemical imbalances (noradrenaline, serotonin and dopamine)  Neuroendocrine function (HPA-axis)  Neuroanatomical changes (brain volume changes) MANAGEMENT OF MDD  There are a range of management strategies available for MDD, including  Pharmacological interventions  SSRIs  SNRIs  Exercise interventions  Psychotherapy  Transcranial magnetic stimulation  Electroconvulsive therapy MANAGEMENT OF MDD POST-TRAUMATIC STRESS DISORDER (PTSD) POST-TRAUMATIC STRESS DISORDER (PTSD)  PTSD is a mental illness that involves intense and disturbing thoughts and feelings  PTSD is typically caused by an exposure to an actual or threatened death, serious injury or sexual violence  Symptoms usually occur within three months of exposure, but may appear later  Symptoms usually persist for months and sometimes years  PTSD affects and estimated 12% of the Australian population  Women are twice as likely as men to be diagnosed with PTSD PTSD – BEHAVIOURS AND PRESENTATIONS  Intrusive thoughts – For example, re-living the event, distressing memories and nightmares that cause severe emotional or physical reactions  Avoidance – Avoiding thinking or talking about the event, places, activities or people that remind the individual of the event  Cognitive and mood changes – Memory problems, concentration difficulties, negative thoughts about self and others, hopelessness, emotional numbness and detachment  Physical and emotional reactions – Easily startled or frightened, feeling tense or ‘on edge’, self-destructive behaviour, sleeping problems, irritability, angry outbursts, aggressive behaviour, shame or guilt DIAGNOSIS OF PTSD  For a person to be diagnosed with PTSD they must experience all of the following symptoms for one month or longer  At least one intrusive symptom  At least one avoidance symptom  At least two arousal and reactivity symptoms  At least two cognition and mood symptoms  Symptoms must be serious enough to significantly interfere with daily function, such as work, school or relationships with friends and family  PTSD often occurs with other related conditions, such as depression, substance use, memory problems and other physical and mental health issues AETIOLOGY OF PTSD  There is no precise explanation for why some people develop PTSD while others do not, following exposure to the same or similar events  PTSD is multifactorial, like most mental illnesses  Personality traits may provide a predisposition to symptoms  Individual differences in the regulation of brain chemistry and hormone responses to traumatic and stressful experiences may, in part, explain why some people develop PTSD while others do not RISK FACTORS FOR PTSD  Risk factors for the development of PTSD include  Exposure to intense or long-lasting trauma or stress  Experiencing trauma earlier in life  Occupations related to traumatic and stressful events  Pre-existing mental illnesses or a family history of mental illness  Substance misuse / abuse  Limited support systems  Family history of PTSD PATHOPHYSIOLOGY OF PTSD PATHOPHYSIOLOGY OF PTSD MANAGEMENT OF PTSD  Psychological treatments for PTSD include  Trauma-focused therapy  Cognitive processing therapy (CPT)  Prolonged exposure (PE) therapy  Second generation SSRIs and SNRIs are most frequently used in the management of PTSD  Sertraline  Paroxetine  Fluoxetine  Venlafaxine EVIDENCE FOR EXERCISE IN MDD EVIDENCE FOR EXERCISE IN MDD  There is a bi-directional relationship between physical health behaviours and psychological well-being  MDD is associated with more than a doubling of the risk for mortality and non- fatal CVD events  Even sub-clinical elevations in depressive symptoms are associated with a worse prognosis in patients with established CAD PHYSICAL ACTIVITY / EXERCISE IN MDD DEVELOPMENT  Those who are less physically active are more likely to have MDD and are also more likely to develop MDD in the future  Those who are physically active but become sedentary are also more likely to develop MDD  People who are more active and are genetically predisposed to MDD are less likely to develop MDD compared to people of equal genetic risk for MDD who have low levels of physical activity EXERCISE IN MDD TREATMENT  Whilst not all RCTs are in agreeance, overall, meta-analyses indicate that exercise reduces symptoms in people with MDD. This tends to be more successful when exercise programs are supervised by appropriate exercise professionals  Some RCTs have shown exercise to be as effective as an SSRI for the treatment of MDD  In fact, over the long-term (6 months), exercise was shown to be more effective at achieving MDD remission than SSRI treatment  Most studies on exercise and MDD focus on aerobic exercise  Whilst more studies investigating the impact of resistance training on MDD are needed, the studies that do exist show that resistance training improves MDD symptoms EXERCISE IN MDD TREATMENT  There is also some evidence that other lifestyle factors can act additively or synergistically with exercise to improve MDD symptoms  Dietary modification  Smoking cessation  Sleep hygiene  A growing body of evidence suggests that exercise can reduce depression through both biological and psychological mechanisms  There is evidence that exercise can retard a number of the mechanistic pathways suggested to be responsible for the development of MDD EXERCISE IN MDD TREATMENT EXERCISE IN MDD TREATMENT  There appears to be a dose-response relationship between exercise volume and reduction in MDD risk / symptoms  The greatest differences in risk for MDD have been observed among those who were completely sedentary versus those engaging in low doses of physical activity  We really don’t have an ‘optimal’ dose at this stage EXERCISE IN MDD TREATMENT EXERCISE IN MDD TREATMENT  One of the problems is that exercise participation and adherence is lower in patients with MDD  Need to use the strategies at your disposal to try to optimise adherence  Motivational interviewing techniques  Action planning concepts  Transtheoretical model of behaviour change  Modest goal setting strategies EVIDENCE FOR EXERCISE IN ANXIETY DISORDERS EXERCISE IN ANXIETY TREATMENT  Less RCTs have been performed to investigate the effect of exercise on anxiety when compared to MDD  Research in anxiety has heavily favoured aerobic exercise.Very little exists regarding resistance training and anxiety  Aerobic exercise has been shown to be effective at reducing symptoms in those with diagnosed anxiety disorders (mostly GAD) and those with raised anxiety (but no diagnosed condition) on validated rating scales  Higher intensity aerobic exercise has been shown to be more effective than lower intensity aerobic exercise EXERCISE IN ANXIETY TREATMENT  Physiological mechanisms hypothesised to be responsible for the benefits of exercise for anxiety have some overlap with those proposed for MDD  Alterations in serotonergic and noradrenergic pathways  Increased 5-hydroxytriptamine turnover  Increased atrial natriuretic peptide levels EXERCISE IN ANXIETY TREATMENT  Exposure to the physiological effects of exercise provokes anxious feelings in some individuals and is a reason why many people with anxiety are reluctant to undertake exercise (anxiety sensitivity)  It has been proposed that exposure to physical training increases tolerance to these symptoms and decreases anxiety sensitivity  Engagement with exercise may lead to an increased sense of self-efficacy as patients see an increase in their ability to cope with the physiological challenges of exercise  Patients with anxiety disorders tend to withdraw from social situations and engaging in exercise represents a change in social behaviour (emotion action tendencies)  Distraction Theory – Exercise may provide “time out” from daily activities and decrease anxious rumination, allowing the patient to think anxiolytic thoughts instead