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Severe Mental Disorders
Etheldreda Nakimuli-Mpungu, MMed (Psych), MBChB
Johns Hopkins University
Dr. Etheldreda Nakimuli-Mpungu

Psychiatrist

Uganda

Mania (HIV)
3
Class Objectives

Be able to ...
-  Define the primary characteristics of severe mental disorders
and how they differ from the common disorders already
discussed
-  Recognize the impact of culture on various aspects of
presentation and treatment
-
Discuss the place of severe mental disorders in the realm of
global mental health issues
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Definitions

Mental disorders: behavioral or psychological pattern that causes
significant distress and functional impairment

Severe mental disorders: chronic affective or non-affective
psychoses with extensive hospitalization

Psychosis: delusions, hallucinations, disorganized speech, grossly
disorganized or catatonic behavior
5
Section A
Psychotic Disorders
Photo by vanessa_hutd. Creative Commons BY-SA. Retrieved from
http://www.flickr.com/photos/svenjajan/3444006054/sizes/m/
Schizophrenia (SZ) DSM-IV
A.  Psychotic symptoms
B.  Poor functioning
C.  Duration of six months
D.  Not due to a mood disorder
E.  Not due to substances or other disease
F.  Not due to pervasive developmental disorder
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Other Psychotic Disorders I

Schizoaffective disorder: mood episodes and psychosis occur
together

Delusional disorder: at least one month of non-bizarre delusions
without other active symptoms of SZ

Brief psychotic disorder: psychosis lasts more than one day and
remits by one month
8
Other Psychotic Disorders II

Shared psychotic disorder: delusions in an individual who is
influenced by someone else who has a longer-standing delusion with
similar content

Psychotic disorder due to a general medical condition

Substance-induced psychotic disorder

Psychotic disorder not otherwise specified
9
Schizophrenia: Clinical Presentation

Socially unacceptable behaviors

Isolation

Poor academic achievement

Neglect of body hygiene
10
Schizophrenia: Clinical Presentation

Hallucinations and delusions result in
-  Unusual behaviors
-
-
-
Hyperactivity
Suspicion—refusal of food
Aggression
11
A Psychiatric Hospital in Uganda
Photo by Etheldreda Nakimuli-Mpungu
12
Mental Health Unit
Photo by Etheldreda Nakimuli-Mpungu
13
Associated Symptoms

Avolition

Anhedonia

Alogia

Blunt affect

Dysphoric mood—depression, anxiety, or anger

Disturbances in sleep pattern

Abnormalities of psychomotor activity

Difficulty in concentration, attention, and memory

Poor insight
14
Laboratory Findings

Neuro-imaging studies

Enlarged lateral ventricles in the brain
15
Prevalence and Incidence

Prevalence: 0.5% to 1.5%

Incidence: 0.5 to 5.0 per 10,000

Rates vary in different populations
16
Place Annual Incidence per 1000
Annual incidence per 1000
Aarhus, Denmark
0.18
Chandigarh, India (rural)
0.42
Chandigarh, India (urban)
0.35
Dublin, Ireland
0.22
Honolulu, Hawaii
0.16
Moscow, Russia
0.28
Nagasaki, Japan
0.21
Nottingham, England
0.22
Source: Eaton and Chen. (2008).
17
Etiology

The first-degree biological relatives of schizophrenics have a risk for
SZ that is about 10 times greater than that of the general
population

Concordance rates for schizophrenia are higher in monozygotic
twins (49%) than in dizygotic twins 25%

Adoption studies—biological relatives of schizophrenics have a
substantially increased risk for SZ, whereas adoptive relatives have
no increased risk

Stress—diathesis model
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Course and Prognosis

Heterogeneity as to onset, course, and outcome

Considerable chronicity—long-term course is mostly stable, not
progressive

Extended prodrome and insidious onset

Outcome: 33% – 33% – 33%?

Negative—volatile positive symptoms

More benign course in non-modern settings?
Sources: Verghese et al. (1989); Srinivasan et al. (2005).
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Acute Admission Wards for SMD
Photo by Etheldreda Nakimuli-Mpungu
20
A Convalescent Ward
Photo by Etheldreda Nakimuli-Mpungu
21