Table of Contents
Introduction to BMH module .................................................................................................................. 2
Evolution of consciousness ...................................................................................................................... 3
Communication in the brain .................................................................................................................. 17
Regulation of Brain function ................................................................................................................. 35
Current conceptualisations of mental health ......................................................................................... 47
Clinical Assessment: Understanding Psychopathology ........................................................................... 76
Psychological models of formulation ................................................................................................... 106
Depression: Neurobiology and Treatment ........................................................................................... 113
Bipolar disorder .................................................................................................................................. 133
Anxiety disorders ................................................................................................................................ 151
Eating disorders.................................................................................................................................. 182
Psychosis: Diagnosis and Epidemiology ............................................................................................... 192
Psychosis: Neurobiology and treatment .............................................................................................. 196
Personality disorders .......................................................................................................................... 212
Substance misuse ............................................................................................................................... 218
The Neurobiology of Cognition............................................................................................................ 232
The Neuropsychology of Cognition ...................................................................................................... 246
BASIC MENTAL HEALTH
KCL
PATRYCJA_KUSACZUK@ICLOUD.COM
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,Introduction to BMH module
Aims of the module
- To provide students with an overview of key aspects of mental illness, including aetiology, classification,
assessment and treatment
- To enable students to develop their knowledge and understanding of different theoretical approaches in the field
of mental health
- To strengthen students’ ability to critically appraise different approaches to treatment and care
Learning outcomes
- Have an enhanced knowledge of theoretical perspectives on the aetiology of mental illness
- Have an enhanced knowledge of psychiatric classification and the main psychiatric disorders
- Have a systematic understanding of assessment and formulation
- Be able to critically evaluate the respective roles of pharmacological, psychological and social approaches to
treatment and care
Assessment
- Written exam (1.5 hours, 40% of assessment - 5 essay questions, choose 1)
- Formulation exam (2 hours, 40% of assessment)
- MCQ exam (1.5 hours, 20% of assessment - 30 questions)
Students will be presented a short video (about 10mins) and will have to complete systematically and clearly five sections:
1.HISTORY: information about the individual and his/her current and past clinical history
2.MENTAL STATE EXAMINATION: includes appearance and behaviour, affect, speech, insight and risk.
3.DIAGNOSIS: analyse and interpret information in the light of psychiatric classification (either ICD-10 or DSM-V); suggest a
diagnosis, well supported by the analysis of the presenting symptoms
4.EXPLANATION: suggest a possible explanation (using a model where appropriate, i.e. the Biopsychosocial Explanatory
Model).
5.PROGNOSIS: drawing on your knowledge of the relevant disorder(s) and the history and presentation of the presented
patient, state which factors may influence the prognosis.
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,Evolution of consciousness
Outcomes:
By the end of these first three weeks you will be able to:
- Understand the evolution of the human brain, and its functional anatomy
- Appreciate a biological model wherein dysfunction can lead, for some, to symptoms of mental ill-health
- Understand the rationale for the pharmacological management of some disorders, including psychosis.
- Understand the principles of the evolution of the human nervous system, including a logical, sequential overview of
the roles of the brainstem, hypothalamus, thalamus, limbic systemic, hippocampal formation, and cortical lobes
with regional functions. The mechanism of fast, ionotropic (glutamate and GABA) neurotransmission will be
discussed
- Recognise that numerous other neurotransmitter pathways and systems feed into this model, helping to regulate
brain functioning. These include dopamine, serotonin, noradrenaline (norepinephrine), acetylcholine, and opioid
systems, recognising this list is not exhaustive
- Be able to logically link major neurotransmitter classes with mental illnesses
Building a brain
1. Overview of brain anatomy
a. Neuroanatomy – orientate ourselves with major structure
2. Primal activity
a. Evolutionary perspectives of the nervous system
3. Evolutionary psychology
a. Prefrontal cortex – how it evolved
The brain: a staggering communication device
- The most complicated machine in the known universe
- We often think about neurons - we think of brain function, about one neuron talking to another - and textbooks
and so forth often illustrate two neurons communicating. However, it’s important to think about the scale of the
brain.
o The brain has 100 billion neurons
o A typical neuron will have 30,000 other neurons communicating with it
o When two neurons talk, they can transmit 5,000 pieces of information - that’s a neurotransmitter - in
milliseconds
o A brain typically has 1,000 trillion connections
- Communication example:
o If you move your toes, if you wiggle your feet, that involves two neurons: the neuron that goes from your
motor cortex to your spinal cord, that will sign up to the second neuron, and will travel all the way down to
your toes. So, each neuron, depending on your size, can be two and a half to three foot long. Neurons, as
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, we’ll discuss later on, only account for 10 per cent of the brain. The other 90 per cent is accounted for by
glial cells. These are support cells of the brain.
Brain divisions and terminology
- The brain is sometimes divided into hindbrain, midbrain, and forebrain
o These are just different ways of looking at different parts of it.
o The hindbrain and midbrain are sometimes called the ‘brainstem’ together, and they contain very basic
parts for our functioning, so they help automate heart function and lung function.
o For example, we don’t have to think to breathe. We don’t have to think to make our heart race.
- The cerebellum is also part of the hindbrain
o The cerebellum is important in terms of movement and balance. And increasingly, we’re understanding its
importance terms of learning.
o From our point of view, one of the reasons we’re interested in the brain stem is it contains the basis of
some neurotransmitters - so in particular, serotonin, noradrenaline, and dopamine.
o So they start their lives here; they project toward the parts of the brain, but they begin here.
- The forebrain, which is sometimes called a telencephalon, is perhaps the part of the brain people are most familiar
with.
o This is the higher part of the brain. It’s literally higher. It’s on top of the other parts, but it also contains
more complex functions.
o But of course, the brain is a very interconnected device, so for the forebrain to work, it needs that input
from the brainstem.
The forebrain
- The diencephalon is the bit of the brain that isn’t the lobes or the cerebellum or the brainstem.
o It’s a part in the middle. It contains two important pieces - the thalamus and the hypothalamus.
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, o Drive very important basic functions for humans (sleep, appetite, thirst, motivational drive)
- Cerebrum
o It involves the occipital, the frontal, temporal, and parietal lobes.
o It’s the vast bulk of the brain - so if one looks at the brain, that’s what you see. We know that the cell
bodies are in the top part of this.
- Grey matter
o The top half centimetre contains the grey matter - it’s called the grey matter because it looks grey, that’s
where all the cell bodies are.
o From those cell bodies, they project wiring underneath. They project their axons. So they communicate
underneath it.
- White matter
o It’s called white matter because it looks white - it’s surrounded by fat.
- Brain
o The brain is highly convolved. That means it’s folded. It’s not a sphere.
o The reason it’s folded is to increase the surface area; so, if you imagine a smooth surface and you put cells
underneath it, there’d be a limit to how many you could put in. If you can fold it, you can increase the
surface area.
The cerebrum
- Occipital
o Back of the brain
o Involved in: vision, not just the arrival of the stimuli from the eye onto the cortex, it involves processes
such as motion perception and integrating all this information to make sense of it
o This is why machines and computers find it difficult to see. They can take in a visual image, but it’s a
complex process to make sense of what an image means.
o So, a lot of the work of the occipital lobes is not just receiving information, it’s trying to make sense of
visual information, for example, in three dimensions.
- Temporal
o Side of the brain, one on each side
o The primary auditory cortex is there, and that’s involved in the perception of speech.
o MH application
▪ That will become important in terms of mental health when we think of hallucinations or hearing
voices.
▪ Hallucinations or voices are the perception of speech when there isn’t an external source, and
that’s due to hyperactivity of this normal function.
o Memory production - declarative
▪ There are different types of memory; the temporal lobes are primarily involved in what are known
as declarative memories.
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, ▪ A nondeclarative memory is a motor memory. For example, walking or playing the piano or typing,
that is a nondeclarative memory. You don’t have to think about how to do it. You just do it. It’s a
motor process. That is not primarily a temporal lobe function. Temporal lobe is involved in
declarative types.
o Declarative memory
▪ Episodic – autobiographical, e.g., what you did today or yesterday
▪ Semantic – facts you have learned e.g., capital of France
o MH application
▪ The classic example is Alzheimer’s dementia, but it’s a more complex process, and it also occurs in
issues such as cognitive problems in schizophrenia
- Parietal
o Function
▪ Contain the primary sensory cortex - Where all sensory information from the body goes, and the
brain makes sense of it
▪ Their functions are not as straightforward as some of the other lobes, because the parietal lobes
tend to integrate information from other parts of the brain.
o MH application
▪ Problems with the parietal lobes lead to what are known as apraxis or agnosis
▪ The parietal lobe is critical for pulling information together and making an overarching decision
without us having to think it through. So parietal lobe function is often best seen when it
dysfunctions, but its main role is an integration of material.
The frontal lobe
- The frontal lobe can be divided in two: into the prefrontal cortex, or PFC, and the primary motor cortex
- The frontal lobe is divided in two:
o the part of the brain that controls motion - the primary motor cortex
o and everything else – PFC (all off the frontal lobe apart from movement)
- The PFC itself, of course, can be divided into lots of other parts
o PFC is involved in the higher parts that make us human-- personality expression, social awareness, goal
setting, paying attention, task-switching, executive functioning - the bit that makes you human.
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,Evolution of the nervous system
- Initial nervous responses in very simple organisms were towards or away from basic stimuli.
o So light, heat, smell, sound, vibration, touch. And of course, basic animals do that now.
o So if you shine a light on a pond at night, or if you clap your hands, or make a movement, animals respond
towards it or away from it, and over many millions of years, animals would move towards positive stimuli
and away from negative ones.
- As animals became more complex, they began to integrate this into spinal cord, where they have more
complicated reflexes.
o At the top of the spinal cord, a brain stem occurred, and a brain stem is an outgrowth of the spinal cord
where reflexes became a bit more sophisticated.
o The reason this is helpful is it began to allow the also automation of organs. The great examples in the
human body are our hearts and our lungs.
o So brain stem controls this. We don’t think to breathe. We don’t think for our heart to beat. Our brain
stem will do this for us. So at this point, we have organisms that are alive and are allowed to have some
complexity. They can have organs.
- The next stage of complexity is to overlay this with basic, primal behaviour, allowing an organism to do more
complex behaviour.
o The critical part of the brain that does this is the hypothalamus.
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,The hypothalamus
- Structure
o In humans, it’s only about the size of an almond, but it regulates huge amounts of really important
behaviour, and they’re very primal behaviours, and if we’re thinking on an evolutionary perspective, this
makes sense. So after a spinal cord and a brain stem, the next thing we want to do is control basic
behaviour.
- Function – appetite, motivation, reproduction
o Behaviours the hypothalamus controls are appetites of food and thirst, basic motivational drives, and
reproduction.
- Importance using animal studies
o People would get cats or dogs and they would take away the entire brain except for the hypothalamus,
and the animal would remain alive and would eat, would drink, would reproduce. It is that critical to our
behaviour.
- Inputs - Primal
o Sensory input from taste, smell, from our genital, things that are giving very basic behaviours information
to the animal about its wellbeing
o From our eyes about light - light acts as a zeitgeber so it tells the animal if its day or night
o Hippocampus and the amygdalae – involved in memory production, hypothalamus gets input from
serotonin and noradrenaline. If it doesn’t get appropriate input from those neurotransmitters, it doesn’t
function well, and the parts that the hypothalamus is in control of - appetite, libido, motivational drive -
don’t function.
- Functions - primal
o Sexual behaviour
▪ Core function of the hypothalamus, it’s involved in the hypothalamic pituitary axis.
▪ In women, this is involved in menstruation, lactation (which is production of breast milk).
▪ In men, it’s involved in spermatogenesis, which is production of sperm, and in controlling
testosterone levels.
▪ The sexual functioning that the hypothalamus controls is what’s known as basic sexual functioning
- so male mounting, female lordosis, behaviour such as hip elevation - and it’s also involved in the
interpretation of pheromones, although the strength of that in humans is debated
▪ The deeper, earlier, more ancient parts of the brain are very strong drivers of human behaviour,
but our prefrontal cortex can overlay them or can control and nuance them, and that’s, of course,
true in terms of functions such as sexual behaviour.
o Food and fluid intake – drives appetite
▪ It tells us when we’re hungry. It makes us seek out food. This, naturally, is a very ancient and basic
behaviour for all animals.
▪ Traditionally, the hypothalamus was seen as having two centres: a satiety centre that told us when
we were full, and a hunger centre which told us when we needed food.
o Motivational behaviour – very primal
▪ So, seeking out food, water, sexual reproduction.
▪ It’s what’s called appetitive or consummatory motivational behaviour. It drives us to undertake
these.
▪ It is not involved in what might be called higher motivational process, such as, for example,
completing an MSC course.
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,Limbic system and hippocampal system
- Our evolutionary story is now progressing over many millions of years
at this point.
- So, we’ve established that we have a brain stem, and this helps
regulate organ functioning, and makes organisms more complex.
- We’ve now added a hypothalamus on top of this, and now we have
interesting animals that can undertake complex behaviour.
- The next evolutionary development was development of what’s
known as the limbic system and hippocampal formation.
Phylogenetically ancient system
- ‘Phylogenetically ancient’ means that we’ve had this in our brain a very, very long time on an evolutionary
timescale. So very basic animals still have this. We’ve had this over hundreds of millions years, from when we were
swimming in the sea to when we evolved into animals that crawled onto land.
- The limbic system/hippocampal formation helped us feel motion and remember things, and this is critical for
development. With the evolution of the nervous system, each time a new part evolved, it built on top of the earlier
parts. This is why deep parts of the brain, parts that are under the surface the cortex, are more ancient.
- Limbic system
o The limbic system is involved in emotions - very pure, raw emotions. So primal things we feel: anger, fear,
happiness, and so forth.
o Not the thinking that occurs with it - the thinking of emotions, that’s a later process. That’ll be our frontal
lobes. But the pure emotion is the limbic system.
o And we’re aware that other animals feel emotions. So if we see cats, or dogs, or other animals around us,
they feel as well. They don’t think about the emotion the same way we do, but they feel it, and this is a
very ancient development. Of course, although this is quite ancient, these are still very primal drivers of us.
We feel emotions every day, and they control our actions.
- Hippocampi and amygdalae
o Related structures. They’re involved in memory -
o Hippocampi
▪ they’re involved in memory formation, remembering things
o Amygdalae
▪ Involved in memory and are involved in fearful memories
▪ Really important that organisms remember particularly aversive events
▪ This helps to avoid negative experiences in the future
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, Limbic system reminder
- One of the brains ancient systems
- Involved in emotional processing
- Confusing, ill-defined set of structures
o if one were to cut open a brain, it’s hard to point out exactly which parts are the limbic system and which
parts aren’t.
- Sits in the ‘deep’ subcortical part of the brain
- Amygdalae
o So on the one hand, it’s a very important evolutionary process, the remembering of fearful experiences.
But in an extreme example where an individual has a very severe stress or trauma, this can become
pathological. The memory won’t go away. The memory keeps coming back to them.
o That’s what we call PTSD, post-traumatic stress disorder. PTSD is, in part, a problematic pathological
dysfunction of this pathway - this pathway that’s really important on an evolutionary viewpoint, but which
has gone awry and which causes problems where an individual cannot forget.
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