Mental Health and psychiatric Disorders UNIT-I 1. Psychiatry It is a branch of medicine that deals with the diagnosis, treatment and prevention mental illness. Development of psychiatry • Pythagoras (580-510 BC) : developed the concept that the brain is the seat of intellectual activity • Hippocrates (460-370 BC) : described mental illness as hysteria, mania and depression • Plato (427-370 BC) identified the relationship between mind and body. • Asciepiades, who is referred to as the father of psychiatry, made use of simple hygienic measures, diet bath, massage in place of mechanical restraints • Aristotle, a Greek philosopher, emphasized on the release of repressed emotions for the effective treatment of mental illness. He suggested catharsis and music therapy for the patient with melancholia. • St. Augustine who believed that although God acted directly in human affairs, people were responsible for their own actions Ancient Ages: Mantel illness thought to be due to magical forces of the deities, the therapists were priests who used magigo religious treatment. Greek and Roman Psychiatry : Mental illness were viewed as mainly psychological mainly somatic or a combination of both, Responsibility for the insane was not taken , most insane patients were restrained home, insanity was evaluated by judges , not physicians . 1773: The first mental hospital in the US was built in Williamsburg, Virginia 1793: Philip Pinel removed the chains from mentally ill patients confined in Bicetre, a hospital outside Paris i.e. the first revolution in psychiatry 1812: The first American text book in psychiatry was written by Benjamin Rush, who is referred to as the father of American Psychiatry 1812: Clifford Beers, an ex- patient of mental hospital wrote the book, ―The Mind That found itself‖ based on his bitter experiences in the hospital 1912: Eugene Bleuler, a Swiss psychiatrist coined the term Schizophrenia 1927: Insulin shock treatment was introduced for schizophrenia 1936: frontal lobotomy was advocated for the management of psychiatric disorders 1938: Electro Convulsive Therapy (ECT) was used for the treatment of psychoses 1939: development of psychoanalytical theory by Sigmund Freud led to new concepts in the treatment of mental illness. 1946: The Bhore committee presented the situation with regard to mental health services. Based on the recommendations 5 hospitals were set up at Amirtsar, Hyderabad, Srinagar, Jamnagar and New Delhi 1949: Lithium was first used for the treatment of mania 1952: Chlorpromazine was introduced which brought about a revolution in psycho-pharmacology 1963: The community Mental Health centers Act was passed Psychiatry got its name as a medical specialty in the early 1800s. For the first century of its existence, the field concerned itself with severely disordered individuals confined to asylums or hospitals. These patients were generally psychotic, severely depressed or manic, or suffered conditions we would now recognize as medical: dementia, brain tumors, seizures, hypothyroidism, etc. As was true of much of medicine at the time, treatment was rudimentary, often harsh, and generally ineffective. Psychiatrists did not treat outpatients, i.e., anyone who functioned even minimally in everyday society. Instead, neurologists treated "nervous" conditions, named for their presumed origin in disordered nerves. Around the turn of the 20th century, the neurologist Sigmund Freud published theories on the unconscious roots of some of these less severe disorders, which he termed psycho-neuroses. These disorders impaired relationships and work, or produced odd symptoms such as paralysis or mutism that could not be explained medically. Freud developed psychoanalysis to treat these "neurotic" patients. However, psychiatry, not neurology, soon became the specialty known for providing this treatment. Psychoanalysis thus became the first treatment for psychiatric outpatients. It also created a split in the field, which continues to this day, between biological psychiatry and psychotherapy. 1.1 Psychiatry in Zambia There are various factors that contribute to mental health in Zambia. It is clear from the Zambian perspective that social, demographic, economic, political, environmental, cultural and religious influences affect the mental health of the people. With a population of 10.3 million and annual growth rate of 2.9%, Zambia is one of the most urbanized countries in sub-Saharan Africa. Poverty levels stood at 72.9% in 1998. In terms of unemployment, the most urbanized provinces, Lusaka (the capital city), and the copper-belt are the most affected. The gross domestic product (GDP) is US$3.09 billion dollars while per capita income is US$300. The total budget allocation for health in the year 2002 was 15% while the proportion of the GDP per capita expenditure for health was 5.6%. The HIV/AIDS prevalence rates stand at 20% among the reproductive age group 15–49 years. Political instability and wars in neighbouring states has resulted in an influx of refugees. Environmental factors affecting the country include natural and man-made disasters such as floods and drought, mine accidents, and deforestation. To a large extent in Zambia, people who are mentally ill are stigmatized, feared, scorned at, humiliated and condemned. However, caring for mental ill health in old age is positively perceived. It is traditionally the duty and responsibility of the extended family to look after the aged. Gender based violence (GBV) is another issue. Women, who are totally dependent on their spouses economically, are forced by circumstances to continue living in abusive relationships to the detriment of their mental well-being. In Zambia, the family is considered sacrosanct and the affairs of the family members, private. It is within this context that GBV is regarded as a family affair and therefore a private affair, yet spouse beating has led to depression and in some cases death. In terms of psychiatric services, there are close to 560 beds for psychiatric patients across the country. Common mental disorders found in Zambia are acute psychotic episodes, schizophrenia, affective disorders, alcohol related problems and organic brain syndromes. About 70–80% of people with mental health problems consult traditional health practitioners before they seek help from conventional health practitioners. Over time the number of frontline mental health workers and professional staff has been declining. This is due to the ‗brain drain‘, retirement, death and low output from training institutions. For practicing psychiatrists, only one is available for the whole country. Other key mental health workers such as psychologists, social workers and occupational therapists are also in short supply. All in all, the mental health services situation in Zambia could be described as critical, requiring urgent attention. 1.2 Mental Health Mental health refers to our cognitive, behavioral, and emotional wellbeing - it is all about how we think, feel, and behave. The term 'mental health' is sometimes used to mean an absence of a mental disorder. Mental health can affect daily life, relationships, and even physical health. Mental health also includes a person's ability to enjoy life - to attain a balance between life activities and efforts to achieve psychological resilience. According to Medilexicon's medical dictionary, mental health is: "Emotional, behavioral, and social maturity or normality; the absence of a mental or behavioral disorder; a state of psychological well-being in which one has achieved a satisfactory integration of one's instinctual drives acceptable to both oneself and one's social milieu; an appropriate balance of love, work, and leisure pursuits." According to the WHO (World Health Organization), mental health is; "... a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community." The WHO stresses that mental health "is not just the absence of mental disorder. ―The most common types of mental illness are anxiety disorders, mood disorders, and schizophrenia disorders; below we explain each in turn: 1.2.1 The global burden of mental disorders Numbers cannot do justice to the pain and suffering caused by mental disorders. Worldwide, 121 million people suffer with depression, 70 million with alcohol-related problems, 24 million with schizophrenia and 37 million with dementia. Until the last decade, however, other health priorities and a lack of sophisticated measures for estimating the burden of mental disorders resulted in the distress of millions of people, their families and cares all over the world going unnoticed. Several developments have brought the substantial underestimation of the burden of mental disorders to greater public awareness. These include the publication of the World Development Report: investing in health (World Bank, 1993) and the development of the disability-adjusted life-year for estimating the global burden of disease, including years lost because of disability (Murray & Lopez, 1996, 2000). According to 2000 estimates, mental and neurological disorders accounted for 12.3% of disability-adjusted life-years, 31% of years lived with disability and 6 of the 20 leading causes of disability worldwide. It is estimated that the burden of mental disorders will grow in the coming decades. By2020 mental disorders are likely to account for 15% of disability-adjusted life-years lost. Depression is expected to become the second most important cause of disability in the world. Developing countries with poorly developed mental health care systems are likely to see the most substantial increases in the burden attributable to mental disorders. The impressive reductions in rates of infant mortality and infectious diseases, especially in developing countries, will result in greater numbers of people reaching the age of vulnerability to mental disorders. The life expectancies of people with mental disorders can be expected to increase, and gradual gains in life expectancy can be expected to result in increasing numbers of older people suffering from depression and dementia. Other possible reasons for the increase in the burden of mental disorders include rapid urbanization, conflicts, disasters and macroeconomic changes. Urbanization is accompanied by increased homelessness, poverty, and overcrowding, higher levels of pollution, disruption in family structures and loss of social support, all of which are risk factors for mental disorders . Rising numbers of people all over the world are exposed to armed conflicts, civil unrest and disasters, leading to displacement, homelessness and poverty. People exposed to violence are more likely than others to suffer from mental disorders such as post-traumatic stress disorder and depression, possibly leading to drug and alcohol abuse and increased rates of suicide. In many developing countries the rush for economic development has had multiple consequences. Economic restructuring has led to changes in employment policies and sudden and massive rises in unemployment, a significant risk factor for mental disorders such as depression and for suicide. This highlights the way in which policy changes in one sector (economic policy) create unanticipated or unintended problems in another, i.e. the health sector. Some authors have presented a scenario of increasing mental ill-health that is associated with urbanization, particularly in developing countries. In addition to the obvious suffering caused by mental disorders there is a hidden burden of stigma and discrimination. In both low-income and high-income countries the stigmatization of people with mental disorders has persisted throughout history. It is manifested as bias, stereotyping, fear, embarrassment, anger, rejection or avoidance. For people suffering from mental disorders there have been violations of basic human rights and freedoms, as well as denials of civil, political, economic and social rights, in both institutions and communities. Physical, sexual and psychological abuses are everyday experiences for many people with mental disorders. They face rejection, unfair denial of employment opportunities and discrimination in access to services, health insurance and housing. Much of this goes unreported and therefore the burden remains un quantified. Vulnerable groups The burden of mental disorders does not uniformly affect all sections of society. Groups with adverse circumstances and the least resources face the highest burden of vulnerability to such disorders. These groups include: women, especially abused women; people living in extreme poverty, e.g. slum dwellers; people traumatized by conflicts and wars; migrants, especially refugees and displaced persons; children and adolescents with disrupted nurturing; and indigenous populations in many parts of the world. Members of each of these groups face an increased risk for mental disorders. Moreover, it is not uncommon for many of the vulnerabilities to be present simultaneously in the same individuals. Different vulnerable groups may be affected by the same problems. Members of these groups are more likely than other people to be unemployed, to face stigmatization and to suffer violations of their human rights. They also face significant access barriers, e.g. with regard to the availability and cost of treatment of satisfactory quality for their mental disorders. Negative stereotyping and bias among health providers further reduces the likelihood of receiving appropriate attention for their mental health needs. World Health Organization presents 10 facts about mental health problem in the world Fact 1 Around 20% of the world's children and adolescents have mental disorders or problems About half of mental disorders begin before the age of 14. Similar types of disorders are being reported across cultures. Neuropsychiatric disorders are among the leading causes of worldwide disability in young people. Yet, regions of the world with the highest percentage of population under the age of 19 have the poorest level of mental health resources. Most low- and middle-income countries have only one child psychiatrist for every 1 to 4 million people. Fact-2Mental and substance use disorders are the leading cause of disability worldwide: About 23% of all years lost because of disability is caused by mental and substance use disorders. Fact-3: About 800 000 people commit suicide every year: Over 800 000 people die due to suicide every year and suicide is the second leading cause of death in 15-29-year-olds. There are indications that for each adult who died of suicide there may have been more than 20 others attempting suicide. 75% of suicides occur in low- and middle-income countries. Mental disorders and harmful use of alcohol contribute to many suicides around the world. Early identification and effective management are key to ensuring that people receive the care they need. Fact-4: War and disasters have a large impact on mental health and psychosocial well-being Rates of mental disorder tend to double after emergencies. Fact-5 Mental disorders are important risk factors for other diseases, as well as unintentional and intentional injury, mental disorders increase the risk of getting ill from other diseases such as HIV, cardiovascular disease, diabetes, and vice-versa. Fact-6 Stigma and discrimination against patients and families prevent people from seeking mental health care. This stigma can lead to abuse, rejection and isolation and exclude people from health care or support. Within the health system, people are too often treated in institutions which resemble human warehouses rather than places of healing. Fact-7 Human rights violations of people with mental and psychosocial disability are routinely reported in most countries Fact-8: Globally, there is huge inequity in the distribution of skilled human resources for mental health Shortages of psychiatrists, psychiatric nurses, psychologists and social workers are among the main barriers to providing treatment and care in low- and middle-income countries. Low-income countries have 0.05 psychiatrists and 0.42 nurses per 100 000 people. The rate of psychiatrists in high income countries is 170 times greater and for nurses is 70 times greater. Fact: 9: There are 5 key barriers to increasing mental health services availability in order to increase the availability of mental health services, there are 5 key barriers that need to be overcome: the absence of mental health from the public health agenda and the implications for funding; the current organization of mental health services; lack of integration within primary care; inadequate human resources for mental health; and lack of public mental health leadership. Fact-10: Financial resources to increase services are relatively modest: Governments, donors and groups representing mental health service users and their families need to work together to increase mental health services, especially in low- and middle-income countries. The financial resources needed are relatively modest: US$ 2 per capita per year in low-income countries and US$ 3-4 in lower middle-income countries. Mental Health Problem Symptoms, Causes and Effects Mental illness is a disease or condition that affects the way a person thinks, feels, behaves, and relates to others and to his or her surroundings and impairs their ability to function on a daily basis. Mental illnesses can be treated using any or a combination of the following methods: 1. Counseling 2. Psychotherapy 3. Medication 4. Brain-stimulation treatments 5. Alcohol and substance use treatments Mental health problems can cover a broad range of disorders, but the common characteristic is that they all affect the affected person‘s personality, thought processes or social interactions. They can be difficult to clearly diagnose, unlike physical illnesses. Mental health disorders occur in a variety of forms, and symptoms can overlap, making disorders hard to diagnoses. However, there are some common disorders that affect people of all ages. Attention Deficit Hyperactivity Disorder (ADHD) Attention Deficit Hyperactivity Disorder is characterized by an inability to remain focused on task, impulsive behavior, and excessive activity or an inability to sit still. Although this disorder is most commonly diagnosed in children, it can occur in adults as well. Anxiety/Panic Disorder Anxiety disorder is defined by intermittent and repeated attacks of intense fear of something bad happening or a sense of impending doom. Bipolar Disorder Bipolar disorder causes a periodic cycling of emotional states between manic and depressive phases. Manic phases contain periods of extreme activity and heightened emotions, whereas depressive phases are characterized by lethargy and sadness. The cycles do not tend to occur instantly. Depression Depression covers a wide range of conditions, typically defined by a persistent bad mood and lack of interest in pursuing daily life, as well as bouts of lethargy and fatigue. Dysthymia is a milder but longer-lasting form of depression. Schizophrenia Schizophrenia is not, as commonly thought, solely about hearing voices or having multiple personalities. Instead, it is defined by a lack of ability to distinguish reality. Schizophrenia can cause paranoia and belief in elaborate conspiracies. What Causes a Mental Health Disorder? There is no single cause for mental health disorders; instead, they can be caused by a mixture of biological, psychological and environmental factors. People who have a family history of mental health disorders may be more prone to developing one at some point. Changes in brain chemistry from substance abuse or changes in diet can also cause mental disorders. Psychological factors and environmental factors such as upbringing and social exposure can form the foundations for harmful thought patterns associated with mental disorders. Only a certified mental health professional can provide an accurate diagnosis of the causes of a given disorder. What Are the Signs of a Mental Health Disorder? Mental health disorders exist in broad categories: anxiety disorders, mood disorders, psychotic disorders, personality disorders and impulse control disorders. If someone you know experiences erratic thought patterns, unexplained changes in mood, lack of interest in socializing, lack of empathy, inability to tell the difference between reality and fantasy, or a seeming lack of control, that person may have a mental health disorder. This is, by no means, a complete list of symptoms. Emotional Symptoms of Mental Health Problems Mental health problems can cause a wide variety of emotional symptoms, some of which include: Changes in mood Exaggerated sense of self Erratic thinking worth Chronic anxiety Impulsive actions Physical Symptoms of Mental Health Problems Mental health problems typically do not cause physical symptoms in and of themselves. Depression, however, can indirectly cause weight loss, fatigue and loss of libido, among others. Eating disorders, a separate class of mental health disorders, can cause malnutrition, weight loss, amenorrhea in women, or electrolyte imbalances caused by self-induced vomiting. This makes eating disorders among the most deadly of mental health disorders. Short-Term and Long-Term Effects of Mental Health Instability In the short-term, mental health problems can cause people to be alienated from their peers because of perceived unattractive personality traits or behaviors. They can also cause anger, fear, sadness and feelings of helplessness if the person does not know or understand what is happening. In the long-term, mental health disorders can drive a person to commit suicide. According to the National Institute for Mental Health, over 90 percent of suicides have depression or another mental disorder as factors. 1.3. Mental health problems in Africa: Depression is the leading cause of disability throughout the world and is especially prevalent among lowincome African countries, where 75 percent of the people who suffer from mental illness do not have easy access to the mental health care they need. The United Nation's Millennium Development Goals (MDGs) seek to act as a catalyst to end poverty and accelerate development in low- and middleincome countries. Although the MDGs set out specific targets for defeating diseases like HIV and malaria, they failed to call for similar measures to improve mental health outcomes. Yet there is an urgent need to set up initiatives that address mental health needs in the post-2015 development agenda, which will succeed the MDGs at the end of 2015. Many mental health problems among African populations have been tied to poverty, warfare and natural disasters — problems that have displaced 10.5 million sub-Saharan Africans. The increasing number of refugees with mental health problems will likely create even greater burdens for the already underresourced and underfunded health care services of African nations who host refugees. Development programs that respond to the mental health needs of their target population are more likely to be successful with meeting their objectives. Therefore, governments and donor countries can no longer ignore the immense need for better mental health care in Africa — or the need to better fund it. 1.4 Mental health in Zambia Since 1992, the country has five national development plans; the latest was the Fifth National Development Plan (FNDP) in 2006. In the ﬁrst four plans, there was no mention of mental health. There is only a casual mention in the FNDP, in which the health agenda is dominated by infectious diseases (HIV, tuberculosis, malaria and diarrhoeal diseases) followed by child health and reproductive health. The strategy for mental health is less than coherent. Zambia still uses the 1951 Mental Disorders Act in which patients are referred to as idiots, imbeciles and invalids. Since the early 2000s, there has been some effort to reform the Act and this reached the stage of a parliamentary draft bill in 2006. However, the draft bill is far from perfect as it is not based on the United Nations human rights charter, which is the bedrock of most current mental health legislation. The limited availability of mental health professionals to spearhead this agenda has contributed to the lack of progress. It has to be said, however, that there is almost no recourse to the Act in clinical practice, as most people are too ignorant to challenge their detention for treatment against their will. Zambia has only three psychiatrists for a population of 12 million. Two of these are not in clinical practice but are attached to the local university. There are no graduate psychologists, occupational therapists or mental health social workers. The bulk of the work in mental health is carried out by clinical officers, who are specially trained medical assistants. 1.4.1 Infrastructure and services Zambia has only one psychiatric hospital, Chainama Hills Hospital, which is based in the capital city of Lusaka. It was opened in 1962 as a national referral center. It has a capacity of 500 beds, divided into 380 general adult and 120 forensic. It is modeled after the asylums that characterised English mental healthcare more than 50 years ago. The wards are large halls with many patients in each. The beds are usually just mattresses placed on the ﬂoor. Apart from Chainama, there are smaller units, called annexes, in seven provincial headquarters: Ndola, Mansa, Kasama, Kabwe, Chipata, Mongu and Livingstone. These provide a few extra beds and are staffed by clinical officers and psychiatric nurses. In Zambia, therapy almost exclusively comprises the use of psychotropics; talking therapies are non-existent. However, this is not as problematic as it might be, given that almost all admissions are for psychotic illness (mostly acute psychotic episode, followed by schizophrenia and bipolar disorders). It is rare to see patients with depression unless they have psychotic symptoms as well. The country has no speciﬁc forensic, drug and alcohol or children‘s services. Challenges Government policy and legislation While some progress has been made in putting forward the mental health agenda for government policy, much remains to be done to convince not only government but also parliament of the importance of a robust mental health policy and infrastructure. Successful lobbying cannot be achieved by locals alone but requires the help of international partners such as the World Health Organization and the World Psychiatric Association. Human resources there is a serious deﬁcit of trained personnel in the medical ﬁeld. This is even more pronounced in mental health. Zambia needs more psychiatrists just to help build capacity in the mental health services, let alone to run such services. There is also a need for other mental health professionals, including psychologists and occupational therapists. To address this deﬁcit, local training must be developed. Training people overseas, as has been proved over the years, is not a viable the establishment of training facilities will be expensive, nonetheless. Infrastructure: There is a need to have mental health beds in every district. Every district has a general hospital and, to keep costs down, some of these could be allocated to psychiatry. Stigma: High levels of stigma exist not only against those who are mentally ill but also against their families and those working in the mental health services. Many patients are disowned by their families. Most long-stay patients in Chainama Hospital have no contact with their family members. The ‗out of sight out of mind‘ mentality is prevalent. Public awareness campaigns are needed. These could be targeted at schools, colleges, workplaces and other public areas. One or two charities are trying but, with limited capacity, little is being achieved. The government may decide to make this one of the priorities for mental health. It is certainly an achievable goal which, unlike the above, does not require massive funding. 1.5 Changing Trends in Mental Health Care- View of Mental Health and well- being. Mental disorders account for a significant burden of disease in all societies. Effective interventions are available but are not accessible to the majority of those who need them. These interventions can be made accessible through changes in policy and legislation, service development, adequate financing and the training of appropriate personnel. With this message the World health report 2001makes a compelling case for addressing the mental health needs of populations. WHO is striving to shift mental health from the periphery of health policies and practice to a more prominent position in the field of global public health? Policy-makers and governments are becoming increasingly aware of the burden of mental disorders and the need for immediate action to address it. The Mental Health Policy and Service Guidance Package has been developed by WHO as a component of the Mental Health Global Action Project in order to assist policy-makers and service planners in addressing mental health and to help Member States with the implementation of the policy recommendations in The World Health Report 2001. 1.5.1 The global burden of mental disorders Mental disorders account for nearly 12% of the global burden of disease. By 2020 they will account for nearly 15% of disability-adjusted lifeyears lost to illness. The burden of mental disorders is maximal in young adults, the most productive section of the population. Developing countries are likely to see a disproportionately large increase in the burden attributable to mental disorders in the coming decades. People with mental disorders face stigma and discrimination in all parts of the world. Economic and social costs of mental disorders: The total economic costs of mental disorders are substantial. In the USA, the annual direct treatment costs were estimated to be US$ 148 billion, accounting for 2.5% of the gross national product. The indirect costs attributable to mental disorders outweigh the direct treatment costs by two to six times in developed market economies, and are likely to account for an even larger proportion of the total treatment costs in developing countries, where the direct treatment costs tend to be low. In most countries, families bear a significant proportion of these economic costs because of the absence of publicly funded comprehensive mental health service networks. Families also incur social costs, such as the emotional burden of looking after disabled family members, diminished quality of life for careers, social exclusion, stigmatization and loss of future opportunities for self-improvement. Resources and funding for mental health Mental health services are widely underfunded, especially in developing countries. Nearly 28% of countries do not have a separate budget for mental health. Of the countries with separate mental health budgets, 37% spend less than 1% of their total health budgets on mental health. Less than 1% of total health budgets is spent on mental health by 62% of developing countries and 16% of developed counties. 1.6 Recent developments in the understanding, treatment and care of persons with mental disorders During the last five decades there have been significant changes in our understanding of mental disorders. This is attributable to a combination of scientific advances in treatment and an increasing awareness of the need to protect the human rights of people with mental disorders in institutional care settings and in the community. Interface between physical and mental disorders It is now widely acknowledged that the relationship between mental disorders and physical disorders is complex and reciprocal and that it acts through multiple pathways. This is a key development. Mental disorders lead to poor physical outcomes, as illustrated by the significantly reduced life expectancies of persons with schizophrenia. Persons with mental disorders are less likely than other people to pay attention to symptoms of physical illness. Consequently, they delay seeking treatment for comorbid conditions such as diabetes and hypertension. They face significant barriers to receiving treatment for physical disorders because of stigma and discrimination. Mental disorders also increase the likelihood of non-adherence to treatment regimens for physical conditions, and this leads to poorer outcomes. Among people with mental disorders there is an increased biological vulnerability to suffering from physical disorders. Depression, for example, is associated with reduced levels of functioning of the immune system and consequently with an increased risk of other physical disorders. The reverse relationship also holds true: people suffering from chronic physical conditions have a heightened probability of developing mental disorders such as depression. Rates of suicide are higher among people with physical disorders than among other people; this is especially marked in elderly people. Increased vulnerability is frequently attributable to the social consequences of physical disability. Limitations imposed by physical illness lead to reduced employment opportunities and reductions in the quality and quantity of social networks and family life. The drugs that are used to treat many physical conditions have direct deleterious effects on psychological functioning and indirect effects on mental health through increased physical side-effects. The effects include depression, anxiety and other mental disorders in already vulnerable individuals. Mental disorders also impose a range of consequences on the course and outcome of comorbid chronic conditions, such as cancer (Spiegel et al., 1989), heart disease, diabetes and HIV/AIDS. A Numerous studies have demonstrated that patients with untreated mental disorders are at heightened risk for diminished immune functioning, poor health behavior, non-compliance with prescribed medical regimens, and unfavorable disease outcomes. For example, it has been shown that depressed patients are three times more likely not to comply with medical regimens than non-depressed patients, and that depression predicts the incidence of heart disease. During the last five decades there have been significant changes in our understanding of mental disorders. Mental disorders are associated with poor physical outcomes. Mental disorders have a negative effect on the outcome of comorbid physical conditions Physical disorders increase vulnerability to mental disorders. Key points: Relationship between physical and mental disorders - There is a complex two-way interplay between mental and physical disorders. - Untreated mental disorders result in poor outcomes for comorbid physical illness. - Persons with mental disorders have a heightened risk of suffering from physical illness because of diminished immune function, poor health behavior, non-compliance with prescribed medical regimens and barriers to obtaining treatment for physical disorders. -Persons with chronic physical illness are significantly more likely than other people to suffer from mental disorders. Effective treatments for mental disorders There are effective treatments for many mental disorders. The World health report 2001presents the evidence for the effectiveness of various treatments for such disorders. Some of these treatments are summarized here. Depression of varying severity can be effectively treated by antidepressant medications. Psychotherapy is as effective as antidepressants in mild to moderate depression. Depression can be effectively treated by primary care personnel using a combination of medications and psychotherapy or counseling. In the treatment of schizophrenia, antipsychotic medication can help to reduce symptoms and prevent relapse. Psychosocial rehabilitation and family therapy in combination with medication can reduce relapse rates from 50% to 10%. In the case of alcohol-related problems, brief interventions directed at people who are hazardous drinkers have been shown to reduce alcohol consumption by 30% and to reduce heavy drinking over a period of 6 to 12 months or longer. It has been shown that these interventions are cost-effective. For patients with more severe alcohol dependence, both outpatient and inpatient treatment options have proved effective, although outpatient treatment is substantially less costly. Several psychological treatments, including cognitive behavioral treatment, motivational interviewing and the ―twelve steps‖ approaches associated with professional treatment, have proved equally effective (World health report 2001). Treatment for drug dependence is cost-effective in reducing drug use by between 40% and 60% and in diminishing the associated health and social consequences, e.g. criminal activity and the risk of HIV infection For a more detailed examination of the evidence for the effectiveness of various treatments against mental disorders. There are effective treatments for many mental disorders, including depression, schizophrenia and alcohol- and drug-related problems. Key points: Effective treatments for mental disorders - There are effective treatments for many mental disorders. - Depression can be successfully treated with antidepressant medication and psychological interventions. -Psychosocial rehabilitation and family therapy in combination with medication can reduce the relapse rates for schizophrenia from 50% to 10%. - Brief interventions directed at people who are hazardous drinkers have been shown to reduce alcohol consumption by 30%. - Treatment for drug dependence is cost-effective in reducing drug use by 40-60%. Global health reform trends and implications for mental health: The last 30 years have seen major reforms in the general health sector and the mental health sector. Decentralization and health financing reforms are the two key changes that have affected general health care systems. These issues are important for mental health because there is an increasing awareness of the need for adequate funding of mental health services and an emphasis on integrating these services into general health care systems. 1.5.2 Decentralization Decentralization is the transfer of responsibility for health service provision from central to local government structures. Before the implementation of this process, health systems were largely public structures administered directly by central government health departments. Central government was therefore responsible for the financing, policy implementation, regulation, and operation of services at the tertiary, secondary and primary levels of health systems. Decentralization began in the industrialized countries and has proceeded to influence the shape of systems in developing nations. The decentralization of public health services to the local government level has been rapidly adopted by developing countries for a number of reasons. These include: changes in internal economic and political systems in response to the pressures of economic globalization; the perception that services planned in accordance with local needs can more appropriately address them; disruptions of systems caused by civil disturbances and population displacements. 1.5.3 Health finance reforms Health finance reforms have largely been driven by a desire to improve access to health care, advance equity in health service provision and promote the use of cost-effective technologies in order to obtain the best possible health outcomes for populations. However, such reforms have also been seen by governments as a means of controlling the costs of health care and of spreading them to other players, especially the users of services. Health finance reforms include changes in revenue collection, involving the concept of pooling, and reforms in the purchasing of health services. 1.5.4 Revenue collection Health systems are financed from a variety of sources, including general taxation, compulsory or voluntary health insurance contributions, out-of-pocket payments, and donations. Most high-income countries rely on either general taxation or compulsory social health insurance contributions, whereas in low-income countries out-of-pocket financing is more common. There is widespread agreement that prepayment systems of all kinds, including general taxation and compulsory or voluntary health insurance schemes, are fairer than out-of-pocket payment. Decentralization in health service provision is part of a global trend of decentralization growing out of economic reforms. Health finance reforms have been driven by a desire to improve health outcomes and control the cost of health care. Prepayment systems are fairer than other forms of payment for health services. Health systems are therefore encouraged to adopt prepayment and to reduce the proportion of out-of-pocket payments. Some low-income countries or settings where prepayment capacities are inadequate could consider an element of direct contribution at the time of utilization in the form of copayment for specific interventions, so as to reduce demand. Copayment has the effect of rationing the use of specific interventions but does not necessarily reduce the demand for them. 1.5.5 Pooling Pooling is a way of spreading risks among the users of health systems. Prepayment systems of all kinds provide opportunities for pooling but the exact nature of pooling arrangements determine whether they increase access for those most in need of mental health services. Pooling is based on the principles that the healthy should subsidize the sick and that the rich should subsidize the poor. Pooling that is based purely on health risk can result in regressive subsidies from the low-risk poor to the high-risk rich, and for this reason most health systems combine risk and income cross-subsidization in order to redistribute risk and ensure equity. 1.5.6 Purchasing There is a worldwide trend towards separating the purchase and provision of health services. In the past these functions were integrated into a single organization with central control. Purchaser-provider splits have accompanied the decentralization process. Furthermore, there is a move from passive purchasing, i.e. following a predetermined budget or simply paying bills when they are presented, to active or strategic purchasing strategies. This is happening in many countries, among them Chile, Hungary, New Zealand, and the United Kingdom. The aim of strategic purchasing is to maximize the performance of health systems for individuals and populations by actively choosing to purchase specific effective interventions from the most cost-effective providers. Implications of reforms for mental health: opportunities and risks Health sector reforms provide a number of opportunities for mental health services but also carry significant risks. In a rational decision-making process the obvious burden of mental health and the availability of effective interventions should lead to an increased provision of financial and human resources for promotion, prevention, treatment and rehabilitation in the field of mental health. A reforming health system provides the opportunity to redirect available resources towards mental health even in circumstances where the total health resources are constant. Health sector reforms also provide an opportunity to integrate mental health services into general health care, especially at the primary care level. Integration with primary care increases the possibility of universal coverage (including mental health) without a substantial increase in financial and administrative inputs. Integrated care helps to reduce the stigma associated with seeking help from stand-alone mental health services. In low-income countries with acute shortages of mental health professionals the delivery of mental health services through general health care is the most viable strategy for increasing access to mental health care in underserved populations. As noted above, mental disorders and physical health problems are very closely associated. People with common mental disorders such as depression and anxiety often present with somatic symptoms to general primary care services. An integrated service encourages the early identification and treatment of such disorders and thus reduces disability. Among other possible benefits is the provision of care in the community and opportunities for community involvement in care. It is a prerequisite for this strategy that general health staff acquire knowledge and skills in the field of mental health. Pooling is based on the principle of subsidy from the better-off financially or in health status to people who are worse off in these respects. There is a trend towards separating the purchase and provision of health services. Health sector reforms create both opportunities and risks for mental health services. Health sector reforms provide an opportunity to integrate mental health services into general health care. However, there are risks associated with health sector reform. Mental health services may become marginalized as reconfigured health systems move further away from the provision of such services. How does this happen? Mental health may fall off the agenda of local health planning because decentralization leads to the transfer of managerial and administrative responsibilities to the local level. In developing countries with an acute shortage of trained mental health professionals, local managers and administrators are unlikely to have an understanding of mental health in relation to local populations. In these circumstances, local decentralized services run the risk of ignoring or inadequately addressing mental health issues. Decentralization may therefore defeat the goal of integration of mental health services into general health services because mental health is not given the importance it deserves. A concerted effort is therefore required to include mental health on the agenda of health sector reform. Decentralization also carries a risk of fragmentation and duplication of services, with the result that resources are used inefficiently because of a lack of economies of scale. A further risk is that the transfer of responsibility (devolution) may lead to significant differences in the provision of mental health services between decentralized regions. Democratic societies tend to be majoritarian rather than egalitarian because of the nature of the political and decision-making processes. Decentralized regions take decision-making closer to the population and are consequently highly vulnerable to capture, i.e. the decision-making process can become driven by considerations other than those of health, responsiveness to beneficiaries and financial fairness. Persons with mental disorders suffer multiple social disadvantages, including effective disenfranchisement in many societies. Devolution may therefore lead to the exclusion of people with mental disorders from the decision-making process and to the neglect of their needs for physical and mental health services. Payment at the point of service delivery (out-of-pocket payment, copayment) leads to restricted access to services and is likely to exclude the poorest members of society, who, paradoxically, are the most likely to require mental health services . Furthermore, people with mental disorders, especially people with chronic severe conditions such as schizophrenia, are unlikely to have the personal financial resources with which to pay for services. Such people depend on their careers and families to make the required payments. Difficult choices have to be made by families in developing countries with respect to the allocation of limited resources for the treatment of family members with severe mental disorders. Strategic purchasing also involves substantial risks for the provision of mental health services. The use of strategic purchasing requires information to be available on the effectiveness of alternative interventions for a particular health problem. In many countries, however, especially developing countries, such data are rarely available. Moreover, strategic purchasing requires that there is a possibility of choosing from various providers. This is unsustainable in developing countries where there is an absolute shortage of mental health professionals. Because of these problems the decision may be taken not to purchase any mental health services. For this reason, resources should be made available for collating information and conducting cost-effectiveness research on mental health interventions. Substantial investment is also necessary in order to increase the number of mental health professionals, especially in developing countries. Health sector reforms also carry significant risks for mental health services. Mental health can easily fall off the health planning agenda in decentralized health services. Payment at the point of service delivery leads to restricted access to services and is likely to exclude the poorest members of society. Risks can arise as a consequence of financing reforms. These risks should therefore be taken into account in connection with the process of decentralization. Countries should carefully consider whether it is feasible for them to implement a decentralization strategy in the presence of the risks. Physical and human resources for mental health should be available in the regions concerned if decentralization is to succeed. One way of ensuring this at the national level is to specify both the minimum level of services for mental health to be provided by local decentralized regions and the pro-portion of the total health budget to be dedicated to mental health. Investment should also be made in the training of personnel in order to enable planning, management and budgeting for mental health services. Key points: Health sector reforms - opportunities for mental health - Integration of mental health services into general health services. - Increasing the share of health resources for mental health in line with the burden imposed by mental disorders. Key points: Health sector reforms - risks for mental health - Marginalization of mental health services. - Decentralization can lead to the fragmentation and exclusion of services for people with mental disorders. -A move towards out-of-pocket payments harms the interests of people with mental disorders as they are unlikely to have the resources to pay for services. -Pooling systems such as public and private insurance schemes may exclude treatment for mental disorders and thus disadvantage people with such disorders. UNIT II PSYCHIATRIC INTERVIEWING Psychiatric Interviewing - Case History Recording and Mental State Examination- Psychiatric Assessment - Psycho-Social and Multidimensional Use of Mental Health Scales in assessment and intervention. 2.1 The psychiatric interview refers to the set of tools that a mental health worker (most times a psychiatrist or a psychologist but at times social workers or nurses) uses to complete a psychiatric assessment. The goals of the psychiatric interview are: Build rapport. Collect data about the patient's current difficulties, past psychiatric history and medical history, as well as relevant developmental, interpersonal and social history. Diagnose the mental health issue(s). Understand the patient's personality structure, use of defense mechanisms and coping strategies. Improve the patient's insight. Create a foundation for a therapeutic alliance. Foster healing. The data collected through the psychiatric interview is mostly subjective, based on the patient's report, and many times cannot be corroborated by objective measurements. As such, one the interview's goals is to collect data that is both valid and reliable. The psychiatric interview is undertaken primarily in order to establish a diagnosis. It includes historytaking and the clinical examination of the mental state. However, the psychiatric interview is much more than a diagnostic process. It also helps to establish rapport between patient and doctor and to educate and motivate the patient. Interviewing patients also serves an important therapeutic purpose. This is the goal for patients during psychotherapeutic consultations, but it also applies to all other patients for whom the opportunity to discuss problems with a sympathetic listener is often helpful. The diagnostic process in psychiatry differs from that in other medical disciplines in that: It relies almost exclusively on history-taking and clinical examination. The account obtained from the patient must be corroborated by information from the patient's partner, children or other relatives, or from the family doctor, social worker or teacher, as appropriate. Interviewing such third parties should only be undertaken with the patient's fully informed consent. However, such corroborative interviews should be the rule rather than the exception because psychiatric patients may, consciously or unwittingly, conceal important information. Verbal accounts from patients and third parties should be supplemented by written records from family doctors, hospitals or schools when appropriate. This is especially the case for events that occurred many years ago or for which the patient has only a second-hand account from parents or others. Psychiatric interviews should be conducted in macroscopic settings that facilitate the patient's privacy and comfort and ensure the doctor's safety. These goals are relatively easy to achieve in psychiatric outpatient clinics but present challenges when patients are interviewed in their home (privacy and safety) or in general medical hospital departments (comfort, privacy and safety), and may be impossible to achieve in some settings, for example police stations or prisons. The microscopic setting of the interview also warrants attention. Patients feel more at ease if seated at the same level as, and to one side of, rather than opposite, the doctor. One tried and trusted arrangement is for the doctor to sit at a fixed desk with the patient seated in a heavy or fixed chair to the doctor's left. The door should be to the doctor's right and should open outwards. This arrangement facilitates writing (for a right-handed doctor), eye contact between patient and doctor and safety (the desk and patient's chair are virtually immobile, the door can be reached and opened quickly and, given that it opens outwards, cannot be barricaded from within the room). Safety is enhanced by ensuring that there are no potential weapons such as lamps, electrical cables or coat hangers in the interview room, and by telling a receptionist, nurse or other colleague that the interview is taking place. The primary aims of the first psychiatric interview to make an initial differential diagnosis and to formulate a treatment plan. These goals are achieved by Gathering information Chief complaint History of current and past suicidal and homicidal ideation History of presenting Current and past history of victimization problem(s) (e.g. domestic violence, child abuse) Precipitating factors History of psychiatric problems, including treatment and response Symptoms Social and developmental history Affective Family psychiatric and social history Cognitive Mental history Physical Medical history Substance use and abuse Changes in role and social functioning Arriving at an empathic understanding of how the patient feels. This understanding is a critical base for establishing rapport with the patient. When the clinician listens carefully and then communicates an appreciation of the patient‘s worries and concerns, the patient gains a sense of being understood. This sense of being understood is the bedrock of all subsequent treatment, and allows the clinician to initiate a relationship in which an alliance for treatment can be established. 2.1 Case History: A case history is defined as a planned professional conversation that enables the patient to communicate his/her symptoms, feelings and fears to the clinician so as to obtain an insight into the nature of patient‘s illness & his/her attitude towards them. A case study method is one of the old and widely used methods in clinical psychology and psychiatry to gather the information from the patient. In this regard it is important to say that, although taking history of the patient is important. Collection of information through case history method is still more popular among the researchers, especially for the researchers working in qualitative research. Different case history forms have been used in different organizational sector for collection of information accordingly. In this regard it is important to say that the uses of case history forms in clinical settings are quite important especially for clinical psychologists and psychiatrists. In this regard, researchers stated that a ‗case study’ is a research method that involves an up-close, in-depth, and detailed examination of a subject of study (the case), in relation to the contextual conditions. Many people in the history of clinical psychology used case history for the collection of information and completed their study successfully. For example, Freud, in his first research in clinical psychology collected information from 80 cases and analyzed to find out different psycho dynamic and psychoanalytic principles related to different mental disorders. Similarly, Watson, and Rayner, the experiment of little Alberta is one of the best examples of case study as an effective method of technique for data collection. From the history and till date case study method is one of the most effective techniques for the collection of information especially in clinical psychology and psychiatry. Besides the field of clinical psychology and psychiatry, now days case study is one of the commonly used qualitative technique in most of the field of social sciences. Therefore it is called that case study as a method of diagnosis of the positive relationship of any past event with the present behavior. As a case history is based on retrospective information, Goffman affirmed that, the development and origin of many psychological problems can be analyzed by ordering the historical information according to its development systematically. Therefore, it can be said that Case History supposed literal presentation of the historical facts that serves to legitimate official explanations, as it appears to have the authority of an authentic life history. Further Lofland, stated that the method of data collection using case history functions as a special history related to the present problem behavior of the patient. In other words, it can be said that it's one of the methods of data collection using biography of the Client to the present malevolence characteristics related to the past threats. Objectives: To establish a positive professional relationship. To provide the clinician with information concerning the patient‘s past dental, medical& personal history. To provide the clinician with the information that may be necessary for making a diagnosis. To provide information that aids the clinician in making decisions concerning the treatment of the patient. Steps in case history takings 1. Assemble all the available facts gathered from statistics, chief complaint, medical history, dental history and diagnostic tests. 2. Analyze and interpret the assembled clues to reach the diagnosis. provisional 3. Make a differential diagnosis of all possible complications. 4. Select a closest possible choice-final diagnosis. 5. Plan an effective treatment accordingly. Methods of obtaining the patient history There are 3 methods: 1) Interview 2) Health questionnaire 3) Combination of these 1) Interview In this the patient is asked about his or her health in an organized fashion. The patient is allowed to discuss any problem fully. The disadvantage include :a) Method depends on the dentist skill as an interviewer. b) The interviewer may skip some important topics. c) The interviewer requires time to be done well. 2) Health questionnaire The health questionnaire is a printed list of heath related questions that the patient is requested to answer at the first appointment S.NO Advantage Disadvantage 1 It Takes little of the dentist‘s Little time to build rapport with the patient time 2 It offers a standardized The questions or their format may be approach for each patient. interpreted inaccurately by some patient. Combination 1. The combined method is considered by the authors to be the best appropriate technique for history taking in the routine practice of Dentistry. 2. This approach uses the advantages of both techniques and reduces the disadvantages after reviewing a completed health questionnaires, the dentist discusses the response with the patient. Components of Case History Statistics Provisional Diagnosis Chief complaint investigations History of present illness Final diagnosis Medical history treatment plan Past dental history Personal history General examination Extraoral examination Intraoral examination Psychiatric assessment A psychiatric assessment, or psychological screening, is the process of gathering information about a person within a psychiatric service, with the purpose of making a diagnosis. ... The assessment includes social and biographical information, direct observations, and data from specific psychological tests. A psychiatric assessment is most commonly carried out for clinical and therapeutic purposes, to establish a diagnosis and formulation of the individual's problems, and to plan their care and treatment. This may be done in a hospital, in an out-patient setting, or as a home-based assessment. Psychiatric assessment of depression patients is usually based on doctor–patient interviews carried out within the health services, for example, hospital- or home-based sitting assessments. The majority of mental diagnostic criteria for most psychiatric conditions are based on observation data rather than biological data. General Principles of Assessment Psychiatric assessment follows the same structure as any medical assessment, with systematic exploration of signs and symptoms of disorder. Unlike other fields of medicine, assessment of mental disorder relies more heavily upon the person's report of their experiences, collateral history from those in a good position to observe the development of disorder in the person, and the observations of the health worker during the interview. The health worker's observations are collected systematically in a ‗mental state examination‘, which looks at abnormalities of general appearance and behaviour, speech, mood, thoughts, perceptions, cognition and the patient's level of awareness about their condition (insight). The health worker's communication and observational skills are, therefore, of paramount importance in order to make a correct diagnosis. Psychosocial interventions: Psycho-Social and Multidimensional - Use of Mental Health Scales in assessment and intervention. What is in a mental health assessment? The mental health test assesses your emotional wellbeing via a series of questions and also includes a physical examination. ... A mental health assessment is designed to: diagnose mental health conditions such as anxiety, depression, schizophrenia, postnatal depression, eating disorders and psychotic illnesses. Intelligence Cognitive Functioning Mood Mental Status Medical Evals History of Treatment Relationships/ Social Skills Lifestyle Commonly used the tests are 1. Minnesota Multiphasic Personality Inventory 2. Bender Gestalt 3. Beck Depression Inventory 4. WechslerAdult Intelligence Scale-R 5. Wechsler Intelligence Scales 6. Sentence Completion 7. Rorschach Inkblot Test 8. Thematic Apperception Test 9. Millon Clinical Multiaxial Inventory (I & II) 10. Mac Andrew Alcoholism Scale 11. Children‘s Depression Inventory 12. Symptom Checklist-90 Addiction Alcohol Use Disorders Identification Test Bergen Shopping Addiction Scale CAGE Questionnaire CRAFFT Screening Test ADHD: Attention deficit hyperactivity disorder ADHD Rating Scale Adult ADHD Self-Report Scale (ASRS v1.1) Brown Attention-Deficit Disorder Scales Disruptive Behavior Disorders Rating Scale Swanson, Nolan and Pelham Teacher and Parent Rating Scale Vanderbilt ADHD Diagnostic Rating Scale Autism spectrum ASAS (Australian scale for Asperger's syndrome) Autism Spectrum Quotient (AQ) Childhood Autism Rating Scale (CARS) Childhood Autism Spectrum Test (CAST) Q-CHAT (Quantitative Checklist for Autism in Toddlers) Autism Diagnostic Observation Schedule (ADOS) Anxiety: Anxiety disorder and Posttraumatic stress disorder Beck Anxiety Inventory Child PTSD Symptom Scale Clinician Administered PTSD Scale (CAPS) Daily Assessment of Symptoms – Anxiety Generalized Anxiety Disorder 7 (GAD-7) Hamilton Anxiety Scale (HAM-A) Hospital Anxiety and Depression Scale Panic and Agoraphobia Scale (PAS) Panic Disorder Severity Scale (PDSS) PTSD Symptom Scale – SelfReport Version Screen for child anxiety related disorders Social Phobia and Anxiety Inventory-Brief form Social Phobia Inventory (SPIN) o Taylor Manifest Anxiety Scale Trauma Screening Questionnaire o UCLA PTSD Index o Yale–Brown Obsessive Compulsive Scale (Y-BOCS) Zung SelfRating Anxiety Scale Dementia and cognitive impairment Abbreviated mental test score Addenbrooke's Cognitive Examination Clinical Dementia Rating General Practitioner Assessment Of Cognition Informant Questionnaire on Cognitive Decline in the Elderly Mini-mental state examination Montreal Cognitive Assessment Dissociation: Dissociation (psychology) and Dissociative disorder Dissociative Experiences Scale (DES) Depression: Major depressive disorder and Rating scales for depression Beck Depression Inventory (BDI) Beck Hopelessness Scale Centre for Epidemiological Studies - Depression Scale (CES-D) Center for Epidemiological Studies Depression Scale for Children (CES-DC) Edinburgh Postnatal Depression Scale (EPDS) Geriatric Depression Scale (GDS) Hamilton Rating Scale for Depression (HAM-D) Hospital Anxiety and Depression Scale Kutcher Adolescent Depression Scale (KADS) Major Depression Inventory (MDI) Montgomery-Åsberg Depression Rating Scale (MADRS) PHQ-9 Mood and Feelings Questionnaire (MFQ) Weinberg Screen Affective Scale (WSAS) Zung Self-Rating Depression Scale Eating disorders: Eating disorder Anorectic Behavior Observation Scale Eating Attitudes Test (EAT-26) Eating Disorder Inventory (EDI) Binge Eating Scale (BES) Mania and bipolar disorder Bipolar Spectrum Diagnostic Scale Child Mania Rating Scale General Behavior Inventory Hypomania Checklist Mood Disorder Questionnaire (MDQ) Young Mania Rating Scale (YMRS) Personality and personality disorder Buss-Perry Aggression Questionnaire (AGQ) Minnesota Multiphase Personality Inventory Hare Psychopathic Checklist Narcissistic Personality Inventory Schizophrenia and psychos Positive and Negative Syndrome Scale (PANSS) Scale for the Assessment of Positive Symptoms (SAPS) Scale for the Assessment of Negative Symptoms (SANS) Psychosocial Interventions: There is no widely accepted categorization of psychosocial interventions. The term is generally applied to a broad range of types of interventions, which include psychotherapies (e.g., psychodynamic therapy, cognitive-behavioral therapy, interpersonal psychotherapy, problem solving therapy), community-based treatment (e.g., assertive community treatment; first episode psychosis interventions]); vocational rehabilitation; peer support services; and integrated care interventions.. The full list, which is too long to reproduce here, consists of interventions from a wide range of theoretical orientations (e.g., psychodynamic, behavioral, social justice, attachment, recovery, and strength-based theories). Each theoretical orientation encompasses a variety of interventions (e.g., within psychodynamic orientations are relational versus ego psychological approaches; within behavioral orientations are cognitive and contingency management approaches). UNIT-III MENTAL DISORDERS Study of the Clinical Signs, Symptoms, Causes and Treatment of the following Common Mental Disorders: Organic Mental Disorders- Mental and Behavioural Disorders due to psychoactive substance use- SchizophreniaMood (Affective Disorders) - Neurotic stress related and somatoform disorders. A mental disorder, also called a mental Illnesses psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitting, or occur as a single episode. Many disorders have been described, with signs and symptoms that vary widely between specific disorders. Such disorders may be diagnosed by a mental health professional. The most common psychiatric disorders Common Disorders Alcohol/Substance Abuse. Alcohol/Substance Dependence. Anxiety Disorders. Adult Attention Deficit/Hyperactivity Disorder (ADHD/ADD) Bipolar Disorder. Major Depressive Episode. Hypomanic Episode. Manic Episode. Mixed Specifier (Formerly Mixed Episode) Depression. Eating Disorders. Generalized Anxiety Disorder The most common mental disorders Anxiety disorders, next to depression, are among the most common mental health disorders in young people. This can include phobias, panic disorder, and social anxiety, post-traumatic stress disorder (PTSD) or obsessive-compulsive disorder (OCD). Mental health disorders Common mental health problems covered in this information include depression and anxiety disorders such as generalized anxiety disorder, panic disorder, obsessive-compulsive disorder (called OCD for short) and posttraumatic stress disorder (called PTSD for short). There are five major categories of mental illnesses: Anxiety disorders. Mood disorders. Schizophrenia and psychotic disorders. Dementia. Eating disorders. Mental illness refers to a wide range of mental health conditions — disorders that affect your mood, thinking and behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors. Many people have mental health concerns from time to time. But a mental health concern becomes a mental illness when ongoing signs and symptoms cause frequent stress and affect your ability to function. A mental illness can make you miserable and can cause problems in your daily life, such as at school or work or in relationships. In most cases, symptoms can be managed with a combination of medications and talk therapy (psychotherapy). The following common mental health disorders in adults (18 years and older): Depression (including sub threshold disorders) Anxiety disorders (including GAD, panic disorder, phobias, social anxiety disorder, OCD and PTSD). Symptoms and presentation Depression Depression refers to a wide range of mental health problems characterized by the absence of a positive affect (a loss of interest and enjoyment in ordinary things and experiences), low mood and a range of associated emotional, cognitive, physical and behavioral symptoms. Distinguishing the mood changes between clinically significant degrees of depression (for example, major depression) and those occurring ‗normally‘ remains problematic and it is best to consider the symptoms of depression as occurring on a continuum of severity. Commonly, mood and affect in a major depressive illness are un reactive to circumstance remaining low throughout the course of each day, although for some people mood varies diurnally, with gradual improvement throughout the day only to return to a low mood on waking. In other cases a person's mood may be reactive to positive experiences and events, although these elevations in mood are not sustained with depressive feelings often quickly re-emerging. Behavioral and physical symptoms typically include tearfulness, irritability, social withdrawal, an exacerbation of pre-existing pains, and pains secondary to increased muscle tension. A lack of libido, fatigue and diminished activity are also common, although agitation and marked anxiety can frequently occur. Typically there is reduced sleep and lowered appetite (sometimes leading to significant weight loss), but some people sleep more than usual and have an increase in appetite. A loss of interest and enjoyment in everyday life, and feelings of guilt, worthlessness and deserved punishment are common, as are lowered self-esteem, loss of confidence, feelings of helplessness, suicidal ideation and attempts at self-harm or suicide. Cognitive changes include poor concentration and reduced attention, pessimistic and recurrently negative thoughts about oneself, one's past and the future, mental slowing and rumination The essential feature of GAD is excessive anxiety and worry (apprehensive expectation), occurring on more days than not for a period of at least 6 months, about a number of events or activities. The person with GAD finds it difficult to control the anxiety and worry, which is often accompanied by restlessness, being easily fatigued, having difficulty concentrating, irritability, muscle tension and disturbed sleep . The focus of the anxiety and worry in GAD is not confined to features of another disorder, for example having panic attacks (as in panic disorder) or being embarrassed in public (as in social anxiety disorder). Some people with GAD may become excessively apprehensive about the outcome of routine activities, in particular those associated with the health of or separation from loved ones. Some people often anticipate a catastrophic outcome from a mild physical symptom or a side effect of medication. Demoralization is said to be a common consequence, with many individuals becoming discouraged, ashamed and unhappy about the difficulties of carrying out their normal routines. GAD is often comorbid with depression and this can make accurate diagnosis problematic. Panic disorder People with panic disorder report intermittent apprehension, and panic attacks (attacks of sudden short-lived anxiety) in relation to particular situations or spontaneous panic attacks, with no apparent cause. They often take action to avoid being in particular situations in order to prevent those feelings, which may develop into agoraphobia .The frequency and severity of panic attacks varies widely. Situational triggers for panic attacks can be external (for example, a phobic object or situation) or internal (physiological arousal). A panic attack may be unexpected (spontaneous or uncured), that is, one that an individual does not immediately associate with a situational trigger. The essential feature of agoraphobia is anxiety about being in places or situations from which escape might be difficult, embarrassing or in which help may not be available in the event of having a panic attack. This anxiety is said to typically lead to a pervasive avoidance of a variety of situations that may include: being alone outside the home or being home alone; being in a crowd of people; travelling by car or bus; being in a particular place, such as on a bridge or in a lift. Obsessive-compulsive disorder OCD is characterized by the presence of either obsessions or compulsions, but commonly both. An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person's mind. Obsessions are distressing, but are acknowledged as originating in the person's mind and not imposed by an external agency. They are usually regarded by the individual as unreasonable or excessive. Common obsessions in OCD include contamination from dirt, germs, viruses, body fluids and so on, fear of harm (for example, that door locks are not safe), excessive concern with order or symmetry, obsessions with the body or physical symptoms, religious, sacrilegious or blasphemous thoughts, sexual thoughts (for example, of being a pedophile or a homosexual), an urge to hoard useless or worn out possessions, or thoughts of violence or aggression (for example, stabbing one's baby). Compulsions are repetitive behaviors or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, or a covert mental act that cannot be observed. Covert compulsions are generally more difficult to resist or monitor than overt ones because they can be performed anywhere without others knowing and are easier to perform. Common compulsions include checking (for example, gas taps), cleaning, washing, repeating acts, mental compulsions (for example, repeating special words or prayers in a set manner), ordering, symmetry or exactness, hoarding/collecting and counting . The most frequent presentations are checking and cleaning and these are the most easily recognized because they are on a continuum with everyday behavior. A compulsion is not in itself pleasurable, which differentiates it from impulsive acts such as shopping or gambling, which are associated with immediate gratification. Post-traumatic stress disorder PTSD often develops in response to one or more traumatic events such as deliberate acts of interpersonal violence, severe accidents, disasters or military action. Those at risk of PTSD include survivors of war and torture, of accidents and disasters, and of violent crime (for example, physical and sexual assaults, sexual abuse, bombings and riots), refugees, women who have experienced traumatic childbirth, people diagnosed with a life-threatening illness, and members of the armed forces, police and other emergency personnel. The most characteristic symptoms of PTSD are re-experiencing symptoms. People with PTSD involuntarily re-experience aspects of the traumatic event in a vivid and distressing way. Symptoms include flashbacks in which the person acts or feels as if the event is recurring; nightmares; and repetitive and distressing intrusive images or other sensory impressions from the event. Reminders of the traumatic event arouse intense distress and/or physiological reactions. As a result, hyper vigilance for threat, exaggerated startle responses, irritability and difficulty in concentrating, sleep problems and avoidance of trauma reminders are other core symptoms. However, people with PTSD also describe symptoms of emotional numbing. These include inability to have any feelings, feeling detached from other people, giving up previously significant activities and amnesia for significant parts of the event. Two further common mental health disorders, social anxiety disorder and specific phobias, are briefly described below. However, because no NICE guidelines currently exist for these disorders they will not be discussed in detail in the remainder of this chapter. Social anxiety disorder Social anxiety disorder, also referred to as social phobia, is characterized by an intense fear in social situations that results in considerable distress and in turn impacts on a person's ability to function effectively in aspects of their daily life. Central to the disorder is a fear of being judged by others and of being embarrassed or humiliated. This leads to the avoidance of a number of social situations and often impacts significantly on educational and vocational performance. The fears can be triggered by the actual or imagined scrutiny from others. The disorder often begins in early adolescence, and although an individual may recognize the problem as outside of normal experience, many do not seek help. Social anxiety disorder is characterized by a range of physical symptoms including excessive blushing, sweating, trembling, palpitations and nausea. Panic attacks are common, as is the development of depressive symptoms as the problem becomes chronic. Alcohol or drug misuse can develop because people use these substances in an attempt to cope with the disturbing and disabling symptoms. It is also often comorbid with other disorders such as depression. Specific phobias A specific phobia is an unwarranted, extreme and persistent fear of a specific object or situation that is out of proportion to the actual danger or threat. The fear and anxiety occur immediately upon encountering the feared object or situation and tend to lead to avoidance or extreme discomfort. The person with a specific phobia recognizes that the fear is excessive, unwarranted or out of proportion to the actual risk. Specific phobias result in significant interference with the activities of daily life; they are usually grouped under a number of subtypes including animal, natural environment, blood-injection-injury and situational. Symptoms Signs and symptoms of mental illness can vary, depending on the disorder, circumstances and other factors. Mental illness symptoms can affect emotions, thoughts and behaviors. Examples of signs and symptoms include: Feeling sad or down Confused thinking or reduced ability to concentrate Excessive fears or worries, or extreme feelings of guilt Extreme mood changes of highs and lows Withdrawal from friends and activities Significant tiredness, low energy or problems sleeping Detachment from reality (delusions), paranoia or hallucinations Inability to cope with daily problems or stress Trouble understanding and relating to situations and to people Alcohol or drug abuse Major changes in eating habits Sex drive changes Excessive anger, hostility or violence Suicidal thinking Sometimes symptoms of a mental health disorder appear as physical problems, such as stomach pain, back pain, headache, or other unexplained aches and pains. Causes: Mental illnesses, in general, are thought to be caused by a variety of genetic and environmental factors: Inherited traits: Mental illness is more common in people whose blood relatives also have a mental illness. Certain genes may increase your risk of developing a mental illness, and your life situation may trigger it. Environmental exposures before birth: Exposure to environmental stressors, inflammatory conditions, toxins, alcohol or drugs while in the womb can sometimes be linked to mental illness. Brain chemistry: Neurotransmitters are naturally occurring brain chemicals that carry signals to other parts of your brain and body. When the neural networks involving these chemicals are impaired, the function of nerve receptors and nerve systems change, leading to depression. Risk factors Certain factors may increase your risk of developing mental health problems, including: Having a blood relative, such as a parent or sibling, with a mental illness Stressful life situations, such as financial problems, a loved one's death or a divorce An ongoing (chronic) medical condition, such as diabetes Brain damage as a result of a serious injury (traumatic brain injury), such as a violent blow to the head Traumatic experiences, such as military combat or being assaulted Use of alcohol or recreational drugs Being abused or neglected as a child Having few friends or few healthy relationships A previous mental illness Mental illness is common. About 1 in 5 adults has a mental illness in any given year. Mental illness can begin at any age, from childhood through later adult years, but most begin earlier in life. The effects of mental illness can be temporary or long lasting. You also can have more than one mental health disorder at the same time. For example, you may have depression and a substance use disorder. Complications Mental illness is a leading cause of disability. Untreated mental illness can cause severe emotional, behavioral and physical health problems. Complications sometimes linked to mental illness include: Unhappiness and decreased enjoyment of life Family conflicts Relationship difficulties Social isolation Problems with tobacco, alcohol and other drugs Missed work or school, or other problems related to work or school Legal and financial problems Poverty and homelessness Self-harm and harm to others, including suicide or homicide Weakened immune system, so your body has a hard time resisting infections Heart disease and other medical conditions Prevention There's no sure way to prevent mental illness. However, if you have a mental illness, taking steps to control stress, to increase your resilience and to boost low self-esteem may help keep your symptoms under control. Follow these steps: Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your symptoms. Make a plan so that you know what to do if symptoms return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Consider involving family members or friends to watch for warning signs. Get routine medical care. Don't neglect checkups or skip visits to your health care provider, especially if you aren't feeling well. You may have a new health problem that needs to be treated, or you may be experiencing side effects of medication. Get help when you need it. Mental health conditions can be harder to treat if you wait until symptoms get bad. Long-term maintenance treatment also may help prevent a relapse of symptoms. Take good care of yourself. Sufficient sleep, healthy eating and regular physical activity are important. Try to maintain a regular schedule. Talk to your health care provider if you have trouble sleeping or if you have questions about diet and physical activity. 2. Organic Mental Disorders An organic mental disorder is a permanent or temporary dysfunction in the brain that is caused by physiological problems with the brain. The causes range from heredity to an injury of the brain to a disease that affects brain tissue or changes the chemical or hormonal levels of the brain. The symptoms of organic mental disorders vary depending on the underlying issue of what caused the imbalance or malfunction of the brain, but they can be difficult to deal with. While there may or may not be a cure for the disorder depending on the exact physiological cause, therapy and counseling may be options that can be helpful for dealing with the symptoms that accompany organic mental disorders. From hallucinations to delusions to personality problems, there is a wide range of problems that may develop because of a physical problem with the brain. Organic mental disorders affect the brain's chemistry and hormonal balance in a negative way, causing mild to serious problems for those afflicted. From social problems to internal emotional problems, the effects of organic mental disorders can be difficult to overcome. Getting help with any of the many organic mental disorders is possible, with therapy being a popular way for people to deal with the root cause of the problem. Symptoms of / Reasons for Organic Mental Disorders Hallucinations Depression Inability to perform in social situations Confusion Changes in personality Types of Organic Mental Disorders Organic Hallucinosis - People suffering from this may experience many different types of hallucinations that can hamper their ability to lead a normal life. Organic Catatonic Disorder These are characterized by problems dealing with motor skills or malfunctioning muscles. Organic Delusional Disorder Someone who insists that something is true even when it's not may be suffering from organic delusional disorder. Organic Mood Disorder Deep emotional problems may be caused by organic mood disorder, which can cause depression or mania. Organic Anxiety Disorder Those who have problems with anxiety in public places Organic Dissociative Disorder This is characterized by problems with awareness, identity, memory, perception, or a combination thereof. Organic Emotionally Labile Disorder Those who suffer from wild mood swings in both directions Organic Personality Disorder Organic personality disorders deal with problems that cause people to not fit in well with the majority of society in an extreme fashion. Post encephalitic Syndrome This is brought on during the late stages of Parkinson's disease as the nerves break down. Post concessional Syndrome These are problems that may occur after a concussion due to a blow to the head. Unspecified Organic Disorder- Those organic disorders that are not mentioned above may be classified as unspecified, but they are just as serious. Treatment for Organic Mental Disorders The treatment methods are going to vary depending on what type of mental disorder you are dealing with, but for the most part, a professionally guided therapy program and counseling are recommended for long term success with treating organic mental disorders even though there may be no cure. For many, pursuing online therapy allows them to get the help they need while still being able to function in their day to day life. All young children can be naughty, defiant and impulsive from time to time, which is perfectly normal. However, some children have extremely difficult and challenging behaviours that are outside the norm for their age. The most common disruptive behaviour disorders include oppositional defiant disorder (ODD), conduct disorder (CD) and attention deficit hyperactivity disorder (ADHD). These three behavioural disorders share some common symptoms, so diagnosis can be difficult and time consuming. A child or adolescent may have two disorders at the same time. Other exacerbating factors can include emotional problems, mood disorders, family difficulties and substance abuse. Behavioral disorders in children All young children can be naughty, defiant and impulsive from time to time, which is perfectly normal. However, some children have extremely difficult and challenging behaviors that are outside the norm for their age. The most common disruptive behavior disorders include oppositional defiant disorder (ODD), conduct disorder (CD) and attention deficit hyperactivity disorder (ADHD). These three behavioral disorders share some common symptoms, so diagnosis can be difficult and time consuming. A child or adolescent may have two disorders at the same time. Other exacerbating factors can include emotional problems, mood disorders, family difficulties and substance abuse. Oppositional defiant disorder Around one in ten children under the age of 12 years are thought to have oppositional defiant disorder (ODD), with boys outnumbering girls by two to one. Some of the typical behaviors of a child with ODD include: Easily angered, annoyed or irritated Frequent temper tantrums Argues frequently with adults, particularly the most familiar adults in their lives, such as parents Refuses to obey rules Seems to deliberately try to annoy or aggravate others Low self-esteem Low frustration threshold Seeks to blame others for any misfortunes or misdeeds. Conduct disorder Children with conduct disorder (CD) are often judged as ‗bad kids‘ because of their delinquent behavior and refusal to accept rules. Around five per cent of 10 year olds are thought to have CD, with boys outnumbering girls by four to one. Around one-third of children with CD also have attention deficit hyperactivity disorder (ADHD). Some of the typical behaviors of a child with CD may include: Frequent refusal to obey parents or other authority figures Repeated truancy Tendency to use drugs, including cigarettes and alcohol, at a very early age Lack of empathy for others Being aggressive to animals and other people or showing sadistic behaviors including bullying and physical or sexual abuse Keenness to start physical fights Using weapons in physical fights Frequent lying Criminal behavior such as stealing, deliberately lighting fires, breaking into houses and vandalism A tendency to run away from home Suicidal tendencies – although these are more rare. Attention deficit hyperactivity disorder Around two to five per cent of children are thought to have attention deficit hyperactivity disorder (ADHD), with boys outnumbering girls by three to one. The characteristics of ADHD can include: Inattention – difficulty concentrating, forgetting instructions, moving from one task to another without completing anything. Impulsivity – talking over the top of others, having a ‗short fuse‘, being accident-prone. Over activity – constant restlessness and fidgeting. Risk factors in children’s behavioral disorders The causes of ODD, CD and ADHD are unknown but some of the risk factors include: Gender – boys are much more likely than girls to suffer from behavioral disorders. It is unclear if the cause is genetic or linked to socialization experiences. Gestation and birth – difficult pregnancies, premature birth and low birth weight may contribute in some cases to the child‘s problem behavior later in life. Temperament – children who are difficult to manage, temperamental or aggressive from an early age are more likely to develop behavioral disorders later in life. Family life – behavioral disorders are more likely in dysfunctional families. For example, a child is at increased risk in families where domestic violence, poverty, poor parenting skills or substance abuse are a problem. Learning difficulties –problems with reading and writing are often associated with behavior problems. Intellectual disabilities – children with intellectual disabilities are twice as likely to have behavioral disorders. Brain development – studies have shown that areas of the brain that control attention appear to be less active in children with ADHD. Diagnosis of children‘s behavioral disorders: Disruptive behavioral disorders are complicated and may include many different factors working in combination. For example, a child who exhibits the delinquent behaviors‘ of CD may also have ADHD, anxiety, depression, and a difficult home life. Diagnosis methods may include: Diagnosis by a specialist service, which may include a pediatrician, psychologist or child psychiatrist In-depth interviews with the parents, child and teachers Behaviour check lists or standardized questionnaires. A diagnosis is made if the child‘s behavior meets the criteria for disruptive behaviour disorders in the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association. It is important to rule out acute stressors that might be disrupting the child‘s behavior. For example, a sick parent or victimizing by other children might be responsible for sudden changes in a child‘s typical behaviour and these factors have to be considered initially Treatment of behavioral disorders in children Untreated children with behavioral disorders may grow up to be dysfunctional adults. Generally, the earlier the intervention, the better the outcome is likely to be. A large study in the United States, conducted for the National Institute of Mental Health and the Office of School Education Programs, showed that carefully designed medication management and behavioral treatment for ADHD improved all measures of behavior in school and at home. Treatment is usually multifaceted and depends on the particular disorder and factors contributing to it, but may include: Parental education – for example, teaching parents how to communicate with and manage their children. Family therapy – the entire family is helped to improve communication and problem-solving skills. Cognitive behavioural therapy – to help the child to control their thoughts and behaviour. Social training – the child is taught important social skills, such as how to have a conversation or play cooperatively with others. Anger management – the child is taught how to recognise the signs of their growing frustration and given a range of coping skills designed to defuse their anger and aggressive behaviour. Relaxation techniques and stress management skills are also taught. Support for associated problems – for example, a child with a learning difficulty will benefit from professional support. Encouragement – many children with behavioural disorders experience repeated failures at school and in their interactions with others. Encouraging the child to excel in their particular talents (such as sport) can help to build self-esteem. Medication – to help control impulsive behaviours. 3. Schizoaffective disorder It describes a condition that includes aspects of both schizophrenia and a mood disorder (either major depressive disorder or bipolar disorder). Scientists are not entirely certain whether schizoaffective disorder is a condition related mainly to schizophrenia or a mood disorder. However, it is usually viewed and treated as a hybrid or combination of both condition. Schizoaffective disorder can be managed, but most people diagnosed with the condition have relapses. Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression. Schizophrenia and bipolar disorder will offer many overlapping resources for schizoaffective disorder. Many people with schizoaffective disorder are often incorrectly diagnosed at first with bipolar disorder or schizophrenia because it shares symptoms of multiple mental health conditions. Schizoaffective disorder is seen in about 0.3% of the population. Men and women experience schizoaffective disorder at the same rate, but men often develop the illness at an earlier age. Schizoaffective disorder can be managed effectively with medication and therapy. Cooccurring substance use disorders are a serious risk and require integrated treatment. A few definitions: Schizophrenia is a brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others. Depression is an illness that is marked by feelings of sadness, worthlessness, or hopelessness, as well as problems concentrating and remembering details. Bipolar disorder includes cycling mood changes, such as severe highs (mania) and lows (depression). Symptoms The symptoms of schizoaffective disorder may vary greatly from one person to the next and may be mild or severe. They may include: Depression Poor appetite Weight loss or gain Changes in sleeping patterns (sleeping very little or a lot) Agitation (being very restless) Lack of energy Loss of interest in usual activities Feelings of worthlessness or hopelessness Guilt or self-blame Trouble with thinking or concentration Thoughts of death or suicide Being more active than usual, including at work, in your social life, or sexually Talking more or faster Rapid or racing thoughts Little need for sleep Agitation Being full of yourself Being easily distracted Self-destructive or dangerous behavior (such as going on spending sprees, driving recklessly, or having risky sex) Schizophrenia Delusions (strange beliefs that the person refuses to give up, even when they get the facts) Hallucinations (sensing things that aren't real, such as hearing voices) Disorganized thinking Odd or unusual behavior Slow movements or not moving at all Lack of emotion in facial expression and speech Poor motivation Problems with speech and communication Symptoms The symptoms of schizoaffective disorder can be severe and need to be monitored closely. Depending on the type of mood disorder diagnosed, depression or bipolar disorder, people will experience different symptoms: Hallucinations, which are seeing or hearing things that aren‘t there. Delusions, which are false, fixed beliefs that are held regardless of contradictory evidence. Disorganized thinking. A person may switch very quickly from one topic to another or provide answers that are completely unrelated. Depressed mood. If a person has been diagnosed with schizoaffective disorder depressive type they will experience feelings of sadness, emptiness and feelings of worthlessness or other symptoms of depression. Manic behavior. If a person has been diagnosed with schizoaffective disorder: bipolar type they will experience feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania. Causes The exact cause of schizoaffective disorder is unknown. A combination of causes may contribute to the development of schizoaffective disorder. Genetics. Schizoaffective disorder tends to run in families. This does not mean that if a relative has an illness, you will absolutely get it. But it does mean that there is a greater chance of you developing the illness. Brain chemistry and structure. Brain function and structure may be different in ways that science is only beginning to understand. Brain scans are helping to advance research in this area. Stress. Stressful events such as a death in the family, end of a marriage or loss of a job can trigger symptoms or an onset of the illness. Drug use. Psychoactive drugs such as LSD have been linked to the development of schizoaffective disorder. Diagnosis Schizoaffective disorder can be difficult to diagnose because it has symptoms of both schizophrenia and either depression or bipolar disorder. There are two major types of schizoaffective disorder: bipolar type and depressive type. To be diagnosed with schizoaffective disorder a person must have the following symptoms. A period during which there is a major mood disorder, either depression or mania that occurs at the same time that symptoms of schizophrenia are present. Delusions or hallucinations for two or more weeks in the absence of a major mood episode. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the illness. The abuse of drugs or a medication is not responsible for the symptoms. Treatment Schizoaffective disorder is treated and managed in several ways: Medications, including mood stabilizers, antipsychotic medications and antidepressants, Psychotherapy, such as cognitive behavioral therapy or family-focused therapy and self-management strategies and education Neurotic and Stress-Related Disorders are classified into the following types: Neurotic refers to Neurosis, plural neuroses, also called psychoneurosis or plural psychoneuroses, mental disorder that causes a sense of distress and deficit in functioning. Neuroses are characterized by anxiety, depression, or other feelings of unhappiness or distress that are out of proportion to the circumstances of a person‘s life. They may impair a person‘s functioning in virtually any area of his life, relationships, or external affairs, but they are not severe enough to incapacitate the person. Affected patients generally do not suffer from the loss of the sense of reality seen in persons with psychoses. A certain aspects of Neurosis 1. The presence of a symptom or group of symptoms which cause subjective distress to the patient 2. The symptom is recognized as undesirable (i.e. insight is present). 3. The personality and behaviour are relatively persevered and not usually grossly disturbed. 4. The contact with reality is preserved. 5. There is an absence of organic causative factors. Stress-related disorders can include mental health disorders that are a result of an atypical response to both short and long-term anxiety due to physical, mental, or emotional stress. These disorders can include, but are not limited to obsessive-compulsive disorder and post-traumatic stress disorder. Stress is a conscious or unconscious psychological feeling or physical condition resulting from physical or mental 'positive or negative pressure' that overwhelms adaptive capacities. 1. Phobic anxiety disorder 2. Obsessive compulsive disorder 3. Reaction to severe stress and adjustment disorders 4. Dissociative and conversion disorders 5. Somatoform disorders 1. Anxiety disorder Anxiety disorders are a group of mental disorders characterized by significant feelings of anxiety and fear. Anxiety is a worry about future events, and fear is a reaction to current events. These feelings may cause physical symptoms, such as a fast heart rate and shakiness. Anxiety is a normal phenomenon, it is characterized by a state of apprehension or unease arising out of anticipation, Anxiety from fear, as fear is an apprehension in response to an external danger while in anxiety the danger is largely unknown. 2. Obsessive compulsive disorder Obsessive-Compulsive Disorder (OCD) is a common, chronic and longlasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that he or she feels the urge to repeat over and over. Signs and Symptoms People with OCD may have symptoms of obsessions, compulsions, or both. These symptoms can interfere with all aspects of life, such as work, school, and personal relationships. Obsessions are repeated thoughts, urges, or mental images that cause anxiety. Common symptoms include: Fear of germs or contamination Unwanted forbidden or taboo thoughts involving sex, religion, and harm Aggressive thoughts towards others or self Having things symmetrical or in a perfect order Compulsions are repetitive behaviors that a person with OCD feels the urge to do in response to an obsessive thought. Common compulsions include: Excessive cleaning and/or hand washing Ordering and arranging things in a particular, precise way Repeatedly checking on things, such as repeatedly checking to see if the door is locked or that the oven is off Compulsive counting 3. Reaction to severe stress, and adjustment disorders Adjustment disorders are stress-related conditions. You experience more stress than would normally be expected in response to a stressful or unexpected event, and the stress causes significant problems in your relationships, at work or at school. Work problems, going away to school, an illness, death of a close family member or any number of life changes can cause stress. Most of the time, people adjust to such changes within a few months. But if you have an adjustment disorder, you continue to have emotional or behavioral reactions that can contribute to feeling anxious or depressed. You don't have to tough it out on your own, though. Treatment can be brief and it's likely to help you regain your emotional footing. Symptoms Signs and symptoms depend on the type of adjustment disorder and can vary from person to person. You experience more stress than would normally be expected in response to a stressful event, and the stress causes significant problems in your life. Adjustment disorders affect how you feel and think about yourself and the world and may also affect your actions or behavior. Some examples include: Feeling sad, hopeless or not enjoying things you used to enjoy Frequent crying Worrying or feeling anxious, nervous, jittery or stressed out Trouble sleeping Lack of appetite Difficulty concentrating Feeling overwhelmed Difficulty functioning in daily activities Withdrawing from social supports Avoiding important things such as going to work or paying bills Suicidal thoughts or behavior 4. Dissociative disorders (DD) are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception. People with dissociative disorders use dissociation, as a defence mechanism, pathologically and involuntarily. Some dissociative disorders are triggered by psychological trauma, but dissociative disorders such depersonalization/derealization disorder may be preceded only by stress, psychoactive substances, or no identifiable trigger at all. Conversion disorder (CD) is a diagnostic category used in some psychiatric classification systems. It is sometimes applied to patients who present with neurological symptoms, such as numbness, blindness, paralysis, or fits, which are not consistent with a well-established organic cause, which cause significant distress, and can be traced back to a psychological trigger. It is thought that these symptoms arise in response to stressful situations affecting a patient's mental health or an ongoing mental health condition such as depression. Conversion disorder was retained in , but given the subtitle functional neurological symptom disorder. The new criteria cover the same range of symptoms, but remove the requirements for a psychological stressor to be present and for feigning to be disproved. 5. A somatic symptom disorder formerly known as a somatoform disorder is any mental disorder which manifests as physical symptoms that suggest illness or injury, but which cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder (e.g., panic disorder). Somatic symptom disorders, as a group, are included in a number of diagnostic schemes of mental illness, including the Diagnostic and Statistical Manual of Mental Disorders. Unit-IV Study of the Clinical Signs, Symptoms, Causes and Treatment of: Behavioural syndromes associated with physiological disturbances and physical factorsdisorders of adult personality and behaviour- Mental Retardation- Disorders of Psychological Development Behavioural and emotional disorders with onset in childhood and adolescence- suicide In behavioral ecology, a behavioral syndrome is a correlated suite of behavioral traits, often (but not always) measured across multiple contexts. The suite of traits that are correlated at the population or species level is considered the behavioral syndrome, while the phenotype of the behavioral syndrome an individual shows is their behavioral type. A behavioral syndrome is a suite of correlated behaviors expressed either within a given behavioral context (e.g., correlations between foraging behaviors in different habitats) or across different contexts (e.g., correlations among feeding, antipredator, mating, aggressive, and dispersal behaviors). A physiological disorder is a condition in which the organs in the body malfunction causes illness. Examples are Asthma, Glaucoma and Diabetes. Physiological Disorders is normally caused when the normal or proper functioning of the body is affected because the body organs have malfunctioned, not working or the actual cellular structures have changed over a period of time causing illness. Therefore the majority of diseases and ailments you will be able to name as they fall under the physiological category Physiological psychology studies the ways in which physical problems can influence our mental health. Specifically, much of physiological psychology is focused on figuring out what causes brain abnormalities that lead to mental illness. Three possible explanations are infection, malnutrition, and metal poisoning. The examples of physiological diseases Tuberculosis. Tuberculosis (TB), infectious disease that is caused by the tubercle bacillus, Mycobacterium tuberculosis. ... Lyme disease. Cancer. Cocaine. Down syndrome. AIDS. Alzheimer disease. Diabetes mellitus Behaviors are commonly correlated between individuals in so-called ―behavioral syndromes.‖ Between-individual correlations of phenotypic traits can change the trajectories of evolutionary responses available to populations and even prevent evolutionary change if underpinned by genetic correlations. Whether behavioral syndromes also influence the course of evolution in this manner remains unknown. Here, we provide the first test of the degree to which evolutionary responses might be affected by behavioral syndrome structure. This test, based on a meta-analysis of additive genetic variance–covariance matrices, shows that behavioral syndromes constrain potential evolutionary responses by an average of 33%. For comparison, correlations between life-history or between morphological traits suggest constraints of 13–18%. This finding demonstrates that behavioral syndromes might substantially constrain the evolutionary trajectories available to populations, prompts novel future directions for the study of behavioral syndromes, emphasizes the importance of viewing syndrome research from an evolutionary perspective, and provides a bridge between syndrome research and theoretical quantitative genetics. Personality disorder A personality disorder is a type of mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving. A person with a personality disorder has trouble perceiving and relating to situations and people. This causes significant problems and limitations in relationships, social activities, work and school. In some cases, you may not realize that you have a personality disorder because A way of thinking and behaving seems natural to you. And you may blame others for the challenges you face. Personality disorders usually begin in the adolescence age years or early adulthood. There are many types of personality disorders. Some types may become less obvious throughout middle age. A personality disorder is a type of mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving. A person with a personality disorder has trouble perceiving and relating to situations and people. Symptoms of a personality disorder Types of personality disorders are grouped into three clusters, based on similar characteristics and symptoms. Many people with one personality disorder also have signs and symptoms of at least one additional personality disorder. It's not necessary to exhibit all the signs and symptoms listed for a disorder to be diagnosed. Symptoms vary depending on the type of personality disorder. A person with borderline personality disorder (one of the most common types) tends to have disturbed ways of thinking, impulsive behaviour and problems controlling their emotions. They may have intense but unstable relationships and worry about people abandoning them. A person with antisocial personality disorder will typically get easily frustrated and have difficulty controlling their anger. They may blame other people for problems in their life, and be aggressive and violent, upsetting others with their behaviour. The types are grouped into three categories: Suspicious – paranoid, schizoid, schizotypal and antisocial. Emotional and impulsive – borderline, histrionic and narcissistic. Anxious – avoidant, dependent and obsessive compulsive. Cluster A personality disorders Cluster A personality disorders are characterized by odd, eccentric thinking or behavior. They include paranoid personality disorder, schizoid personality disorder and schizotypal personality disorder. Paranoid personality disorder Pervasive distrust and suspicion of others and their motives Unjustified belief that others are trying to harm or deceive you Unjustified suspicion of the loyalty or trustworthiness of others Hesitancy to confide in others due to unreasonable fear that others will use the information against you Perception of innocent remarks or nonthreatening situations as personal insults or attacks Angry or hostile reaction to perceived slights or insults Tendency to hold grudges Unjustified, recurrent suspicion that spouse or sexual partner is unfaithful Schizoid personality disorder Lack of interest in social or personal relationships, preferring to be alone Limited range of emotional expression Inability to take pleasure in most activities Inability to pick up normal social cues Appearance of being cold or indifferent to others Little or no interest in having sex with another person. Schizotypal personality disorder Peculiar dress, thinking, beliefs, speech or behavior Odd perceptual experiences, such as hearing a voice whisper A name Flat emotions or inappropriate emotional responses Social anxiety and a lack of or discomfort with close relationships Indifferent, inappropriate or suspicious response to others "Magical thinking" — believing you can influence people and events with A thoughts Belief that certain casual incidents or events have hidden messages meant only for you Cluster B personality disorders Cluster B personality disorders are characterized by dramatic, overly emotional or unpredictable thinking or behavior. They include antisocial personality disorder, borderline personality disorder, histrionic personality disorder and narcissistic personality disorder. Antisocial personality disorder Disregard for others' needs or feelings Persistent lying, stealing, using aliases, conning others Recurring problems with the law Repeated violation of the rights of others Aggressive, often violent behavior Disregard for the safety of self or others Impulsive behavior Consistently irresponsible Lack of remorse for behavior Borderline personality disorder Impulsive and risky behavior, such as having unsafe sex, gambling or binge eating Unstable or fragile self-image Unstable and intense relationships Up and down moods, often as a reaction to interpersonal stress Suicidal behavior or threats of self-injury Intense fear of being alone or abandoned Ongoing feelings of emptiness Frequent, intense displays of anger Stress-related paranoia that comes and goes Histrionic personality disorder Constantly seeking attention Excessively emotional, dramatic or sexually provocative to gain attention Speaks dramatically with strong opinions, but few facts or details to back them up Easily influenced by others Shallow, rapidly changing emotions Excessive concern with physical appearance Thinks relationships with others are closer than they really are Narcissistic personality disorder Belief that you're special and more important than others Fantasies about power, success and attractiveness Failure to recognize others' needs and feelings Exaggeration of achievements or talents Expectation of constant praise and admiration Arrogance Unreasonable expectations of favors and advantages, often taking advantage of others Envy of others or belief that others envy you Cluster C personality disorders Cluster C personality disorders are characterized by anxious, fearful thinking or behavior. They include avoidant personality disorder, dependent personality disorder and obsessive-compulsive personality disorder. Avoidant personality disorder Too sensitive to criticism or rejection Feeling inadequate, inferior or unattractive Avoidance of work activities that require interpersonal contact Socially inhibited, timid and isolated, avoiding new activities or meeting strangers Extreme shyness in social situations and personal relationships Fear of disapproval, embarrassment or ridicule Dependent personality disorder Excessive dependence on others and feeling the need to be taken care of Submissive or clingy behavior toward others Fear of having to provide self-care or fend for a self if left alone Lack of self-confidence, requiring excessive advice and reassurance from others to make even small decisions Difficulty starting or doing projects on A own due to lack of selfconfidence Difficulty disagreeing with others, fearing disapproval Tolerance of poor or abusive treatment, even when other options are available Urgent need to start a new relationship when a close one has ended Obsessive-compulsive personality disorder Preoccupation with details, orderliness and rules Extreme perfectionism, resulting in dysfunction and distress when perfection is not achieved, such as feeling unable to finish a project because you don't meet A own strict standards Desire to be in control of people, tasks and situations, and inability to delegate tasks Neglect of friends and enjoyable activities because of excessive commitment to work or a project Inability to discard broken or worthless objects Rigid and stubborn Inflexible about morality, ethics or values Tight, miserly control over budgeting and spending money Treatment for a personality disorder: Treatment for a personality disorder usually involves a talking therapy. This is where the person talks to a therapist to get a better understanding of their own thoughts, feelings and behaviours. It will last for at least 3 months, but can often last longer depending on the severity of the condition and other problems the person may have. As well as listening and discussing important issues with the person, the therapist may identify strategies to resolve problems and, if necessary, help them change their attitudes and behaviour. Therapeutic communities: Therapeutic communities (TCs) are an intensive form of group therapy in which the experience of having a personality disorder is explored in depth. The person attends at least 1 day a week and sometimes even 5 full days a week. TCs have been shown to be effective for mild to moderate personality disorders, but require a high level of commitment. Medication: Medication may be prescribed to treat problems associated with a personality disorder, such as depression, anxiety or psychotic symptoms. For example, moderate to severe symptoms of depression might be treated with a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). Recovery: Many people with a personality disorder recover over time. Psychological or medical treatment is often helpful, but support is sometimes all that's needed. There's no single approach that suits everyone – treatment should be tailored to the individual. Causes: It's not clear exactly what causes personality disorders, but they're thought to result from a combination of the genes a person inherits and early environmental influences – for example, a distressing childhood experience (such as abuse or neglect). Intellectual disability (ID): once called mental retardation, is characterized by below-average intelligence or mental ability and a lack of skills necessary for day-to-day living. People with intellectual disabilities can and do learn new skills, but they learn them more slowly. There are varying degrees of intellectual disability, from mild to profound. Mental Retardation or intellectual disability: Someone with intellectual disability has limitations in two areas. These areas are: Intellectual functioning. Also known as IQ, this refers to a person‘s ability to learn reason, make decisions, and solve problems. Adaptive behaviors. These are skills necessary for day-to-day life, such as being able to communicate effectively, interact with others, and take care of oneself. IQ (intelligence quotient) is measured by an IQ test. The average IQ is 100, with the majority of people scoring between 85 and 115. A person is considered intellectually disabled if he or she has an IQ of less than 70 to 75. To measure a child‘s adaptive behaviors, a specialist will observe the child‘s skills and compare them to other children of the same age. Things that may be observed include how well the child can feed or dress himself or herself; how well the child is able to communicate with and understand others; and how the child interacts with family, friends, and other children of the same age. Intellectual disability is thought to affect about 1% of the population. Of those affected, 85% have mild intellectual disability. This means they are just a little slower than average to learn new information or skills. With the right support, most will be able to live independently as adults. Signs of intellectual disability in children are; There are many different signs of intellectual disability in children. Signs may appear during infancy, or they may not be noticeable until a child reaches school age. It often depends on the severity of the disability. Some of the most common signs of intellectual disability are: Rolling over, sitting up, crawling, or walking late Talking late or having trouble with talking Slow to master things like potty training, dressing, and feeding himself or herself Difficulty remembering things Inability to connect actions with consequences Behavior problems such as explosive tantrums Difficulty with problem-solving or logical thinking In children with severe or profound intellectual disability, there may be other health problems as well. These problems may include seizures, mood disorders (anxiety, autism, etc.), motor skills impairment, vision problems, or hearing problems. What Causes Mental Retardation? If a child has an intellectual disability (ID), their brain doesn‘t develop properly. Their brain may also not function within the normal range of both intellectual and adaptive functioning. In the past, medical professionals called this condition ―mental retardation.‖ There are four levels of ID: mild, moderate, severe, and profound. Sometimes ID may be classified as ―other‖ or ―unspecified.‖ ID involves both a low IQ and problems adjusting to everyday life. There may also be learning, speech, social, and physical disabilities. Severe cases of ID are diagnosed at birth. However, you might not realize A child has a milder form of ID until they fail to meet common developmental goals. Almost all cases of ID are diagnosed by the time a child reaches 18 years of age. Mental Retardation Mental retardation is a condition in which people have significantly below average mental functioning (an intelligence quotient or IQ of 70-75 or less compared to the normal average of 100), causing problems with everyday living. People who are mentally retarded may have problems with communication, taking care of themselves, daily living, social skills, community interactions, directing themselves, health and safety, school, leisure activities, and work. The condition, which is more common in boys than girls, begins at birth or in childhood. If a person with normal intelligence becomes impaired as an adult, such as in severe mental illness or brain injury, the condition is not called mental retardation. Mental Retardation Classification: There are four levels of mental retardation: mild, moderate, severe, and profound. These levels are determined by performance on standardized IQ tests and by the potential to learn adaptive skills such as communication and social interaction. Mild retardation: The vast majority of people with mental retardation has IQ levels of 55 to 69 and is considered mildly retarded. Mildly retarded children often go undiagnosed until they are well into their school years. They are often slower to walk, talk, and feed themselves than most other children. They can learn practical skills, including reading and math, up to about the fourth to sixth grade level. Mildly retarded adults usually build social and job skills and can live on their own. Mild intellectual disability Some of the following symptoms of mild intellectual disability include: • Taking longer to learn to talk, but communicating well once they know how • Being fully independent in self-care when they get older • Having problems with reading and writing • Social immaturity • Inability to deal with the responsibilities of marriage or parenting • Benefiting from specialized education plans • Having an IQ range of 50 to 69 Moderate retardation: A much smaller number of people with mental retardation have IQ ranging from 40 to 54 and are considered moderately retarded. Children who are moderately retarded show noticeable delays in developing speech and motor skills. Although they are unlikely to acquire useful academic skills, they can learn basic communication, some health and safety habits, and other simple skills. They cannot learn to read or do math. Moderately retarded adults usually cannot live alone, but they can do some simple tasks and travel alone in familiar places. Moderate intellectual disability If a child has moderate ID, they may exhibit some of the following symptoms: Are slow in understanding and using language May have some difficulties with communication Can learn basic reading, writing, and counting skills Are generally unable to live alone Can often get around on their own to familiar places Can take part in various types of social activities Generally have an IQ range of 35 to 49 Severe retardation: An even smaller parentage of people with mental retardation has IQs ranging from 20 to 39 and is considered severely mentally retarded. Their condition is likely to be diagnosed at birth or soon after. By preschool, they show delays in motor development and little or no ability to communicate. With training, they may learn some self-help skills, such as how to fed and bathe themselves. They usually learn to walk and gain a basic understanding of speech as get older. Adults who are severely mentally retarded may be able to follow daily routines and perform simple tasks, but they need to be directed and live in a protected environment. Symptoms of severe ID include: Noticeable motor impairment Severe damage to, or abnormal development of, their central nervous system Generally have an iq range of 20 to 34 Profound retardation Only a very few people with mental retardation have IQs of 0 to 24 and are considered severely mentally retarded. Their condition is usually diagnosed at birth, and they may have other medical problems and need nursing are. Children who are profoundly retarded need to be continuously supervised. These children show delays in all aspects of development. With training, they may learn to use their legs, hands, and jaws. Adults who are profoundly retarded usually learn some speech and may learn to walk. They cannot take care of themselves and need complete support in daily living. Symptoms of profound ID include: Inability to understand or comply with requests or instructions Possible immobility Incontinence Very basic nonverbal communication Inability to care for their own needs independently The need of constant help and supervision Having an IQ of less than 20 Symptoms of intellectual disability Symptoms of ID will vary based on A child‘s level of disability and may include: Failure to meet intellectual standards Sitting, crawling, or walking later than other children Problems learning to talk or trouble speaking clearly Memory problems Inability to understand the consequences of actions Inability to think logically Childish behavior inconsistent with the child‘s age Lack of curiosity Learning difficulties Iq below 70 Inability to lead a normal life due to challenges communicating, taking care of themselves, or interacting with others If a child has ID, they will probably experience some of the following behavioral issues: Aggression Dependency Withdrawal from social activities Attention-seeking behavior Depression during adolescent and adolescence years Lack of impulse control Passivity Tendency toward self-injury Stubbornness Low self-esteem Low tolerance for frustration Psychotic disorders Difficulties paying attention Some people with ID may also have specific physical characteristics. These can include having a short stature or facial abnormalities. Causes of intellectual disability According to the Merck Manual, doctors can only identify a specific cause of ID in about a third of mild cases and two-thirds of moderate to profound cases. Causes of ID can include: Trauma before birth, such as an infection or exposure to alcohol, drugs, or other toxins. Trauma during birth, such as oxygen deprivation or premature delivery. Inherited disorders, such as phenylketonuria (PKU) or Tay - Sachs disease. Chromosome abnormalities, such as down syndrome. Lead or mercury poisoning. Severe malnutrition or other dietary issues. Early childhood illness, such as whooping cough, measles, or meningitis. Severe brain injury. How is intellectual disability diagnosed? To be diagnosed with ID, A child must have below average intellectual and adaptive skills. A child‘s doctor will perform a three-part evaluation: Interviews with you Observations of a child Standard tests A child will be given standard intelligence tests, such as the StanfordBinet Intelligence Test. This will help the doctor determine A child‘s IQ. The doctor may also administer other tests such as the Vineland Adaptive Behavior Scales. This test provides an assessment of a child‘s daily living skills and social abilities, compared to other children in the same age group. It‘s important to remember that children from different cultures and socioeconomic statuses may perform differently on these tests. To form a diagnosis, a child‘s doctor will consider the test results, interviews with you, and observations of a child. A child‘s evaluation process might include visits to specialists, who may include: Psychologist Speech pathologist Social worker Pediatric neurologist Developmental pediatrician Physical therapist Laboratory and imaging tests may also be performed. These can help A child‘s doctor detect metabolic and genetic disorders, as well as structural problems with A child‘s brain. Other conditions, such as hearing loss, learning disorders, neurological disorders, and emotional problems can also cause delayed development. A child‘s doctor should rule these conditions out before diagnosing a child with ID. Treatment options for intellectual disability: A child will probably need ongoing counseling to help them cope with their disability; will get a family service plan that describes A child‘s needs. The plan will also detail the services that a child will need to help them with normal development. A family needs will also be addressed in the plan. When a child is ready to attend school, an Individualized Education Program (IEP) will be put in place to help them with their educational needs. All children with ID benefit from special education. The federal Individuals with Disabilities Act (IDEA) requires that public schools provide free and appropriate education to children with ID and other developmental disabilities. The main goal of treatment is to help A child reach their full potential in terms of education, social skills, and life skills. Treatment may include behavior therapy, occupational therapy, counseling, and in some cases, medication. The long-term outlook When ID occurs with other serious physical problems, A child may have a below average life expectancy. However, if a child has mild to moderate ID, they will probably have a fairly normal life expectancy. When a child grows up, they may be able to work a job that requires basic intellectual skills. They may be able to live independently and support themselves. Support services are also available to help adults with ID live independent and fulfilling lives. In the Republic of Zambia, an estimated 256,000 persons have some form of disability, and of these, 5.4% have intellectual disabilities. Even now, traditional beliefs about the etiology of intellectual disabilities persist and considerable stigma is attached to the presence of persons with intellectual disabilities who are often excluded from community life. Recently, antidiscrimination legislation has been enacted and there is a policy related to pupils with special educational needs. Although a range of Zambian and international nongovernmental organizations and church groups have developed services for children and their families, their impact is impeded by widespread poverty. Adults remain vulnerable, with no entitlement to social welfare benefits and very limited access either to government‐led trust funds for persons with disabilities or to employment. The most striking issue is poverty (Zambia is one of the world's poorest nations) and an absence of even basic support for people with intellectual disabilities outside of families. Other key issues include a lack of useful data, no specific policy related to persons with intellectual disabilities, and limited progress in achieving education for all. Disorders of Psychological Development There are several ways of using this term. The narrowest concept is used in the category "Specific Disorders of Psychological Development" in the ICD-10. These disorders comprise language disorders, learning disorders, motor disorders and autism spectrum disorders. ... Developmental disorders are present from early life. The term is sometimes used to refer to what are more frequently known as mental disorders or psychiatric disorders. Mental disorders are patterns of behavioral or psychological symptoms that impact multiple areas of life. These disorders create distress for the person experiencing these symptoms. While not a comprehensive list of every mental disorder, the following list includes some of the major categories of disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The latest edition of the diagnostic manual is the DSM-5 and was released in May of 2013. The DSM is one of the most widely used systems for classifying mental disorders and provides standardized diagnostic criteria. 1. Neuro developmental Disorders : Neuro developmental disorders are those that are typically diagnosed during infancy, childhood, or adolescence. These psychological disorders include: Intellectual disability (or Intellectual Developmental Disorder) was formerly referred to as mental retardation. This type of developmental disorder originates prior to the age of 18 and is characterized by limitations in both intellectual functioning and adaptive behaviors. Limitations to intellectual functioning are often identified through the use of IQ tests, with an IQ score between 70 and 75 often indicating the presence of a limitation. Adaptive behaviors are involved practical, everyday skills such as self-care, social interaction, and living skills. Global developmental delay is a diagnosis for developmental disabilities in children who are under the age of five. Such delays relate to cognition, social functioning, speech, language, and motor skills. It is generally seen as a temporary diagnosis applying to kids who are still too young to take standardized IQ tests. Once children reach the age where they are able to take a standardized intelligence test, they may be diagnosed with intellectual disability. Communication disorders are those that impact the ability to use, understand, or detect language and speech.. The DSM-5 identifies four different subtypes of communication disorders: language disorder, speech sound disorder, childhood onset fluency disorder (stuttering), and social (pragmatic) communication disorder. Autism spectrum disorder is characterized by persistent deficits in social interaction and communication in multiple life areas as well as restricted and repetitive patterns of behaviors. The DSM specifies that symptoms of autism spectrum disorder must be present during the early developmental period and that these symptoms must cause significant impairment in important areas of life including social and occupational functioning. Attention-deficit hyperactivity disorder is characterized by a persistent pattern of hyperactivity-impulsivity and/or inattention that interferes with functioning and presents itself in two or more settings such as at home, work, school, and social situations. The DSM-5 specifies that several of the symptoms must have been present prior to the age of 12 and that these symptoms must have a negative impact on social, occupational, or academic functioning. 2 Bipolar and Related Disorders Bipolar disorder is characterized by shifts in mood as well as changes in activity and energy levels. The disorder often involves experiencing shifts between elevated moods and periods of depression. Such elevated moods can be pronounced and are referred to either as mania or hypomania. Compared to the previous edition of the DSM, in the DSM-5 the criteria for manic and hypomanic episodes include an increased focus on changes in energy levels and activity as well as changes in mood. Mania is characterized by feeling overly excited and even hyper. Periods of mania are sometimes marked by feelings of distraction, irritability, and excessive confidence. People experiencing mania are also more prone to engage in activities that might have negative long-term consequences such as gambling and shopping sprees. Depressive episodes are characterized by feelings of intense sadness, guilt, fatigue, and irritability. During a depressive period, people with bipolar disorder may lose interest in activities that they previously enjoyed, experience sleeping difficulties, and even have thoughts of suicide. Both manic and depressive episodes can be frightening for both the person experiencing these symptoms as well as family, friends, and other loved ones who observe these behaviors and mood shifts. Fortunately, appropriate and effective treatments, which often include both medications and psychotherapy, can help people with bipolar disorder successfully manage their symptoms. 3 Anxiety Disorders Anxiety disorders are those that are characterized by excessive and persistent fear, worry, anxiety and related behavioral disturbances. Fear involves an emotional response to a threat, whether that threat is real or perceived. Anxiety involves the anticipation that a future threat may arise. In one survey published in the Archives of General Psychiatry, it was estimated that as many as 18 percent of American adults suffer from at least one anxiety disorder. Types of anxiety disorders include: Generalized anxiety disorder which is marked by excessive worry about everyday events. While some stress and worry are a normal and even common part of life, GAD involves worry that is so excessive that it interferes with a person's well-being and functioning. Agoraphobia is characterized by a pronounced fear a wide range of public places. People who experience this disorder often fear that they will suffer a panic attack in a setting where escape might be difficult. Because of this fear, those with agoraphobia often avoid situations that might trigger an anxiety attack. In some cases, this avoidance behavior can reach a point where the individual is unable to even leave their own home. Social anxiety disorder is a fairly common psychological disorder that involves an irrational fear of being watched or judged. The anxiety caused by this disorder can have a major impact on an individual's life and make it difficult to function at school, work, and other social settings. Specific phobias involve an extreme fear of a specific object or situation in the environment. Some examples of common specific phobias include the fear of spiders, fear of heights, or fear of snakes. The four main types of specific phobias involve natural events (thunder, lightning, tornadoes), medical (medical procedures, dental procedures, medical equipment), animals (dogs, snakes, bugs), and situational (small spaces, leaving home, driving). When confronted by a phobic object or situation, people may experience nausea, trembling, rapid heart rate, and even a fear of dying. Panic disorder is a psychiatric disorder characterized by panic attacks that often seem to strike out of the blue and for no reason at all. Because of this, people with panic disorder often experience anxiety and preoccupation over the possibility of having another panic attack. People may begin to avoid situations and settings where attacks have occurred in the past or where they might occur in the future. This can create significant impairments in many areas of everyday life and make it difficult to carry out normal routines. Separation anxiety disorder is a type of anxiety disorder involving an excessive amount of fear or anxiety related to being separated from attachment figures. People are often familiar with the idea of separation anxiety as it relates to young children's fear of being apart from their parents, but older children and adults can experience it as well. When symptoms become so severe that they interfere with normal functioning, the individual may be diagnosed with separation anxiety disorder. Symptoms involve an extreme fear of being away from the caregiver or attachment figure. The person suffering these symptoms may avoid moving away from home, going to school, or getting married in order to remain in close proximity to the attachment figure. 4 Trauma and Stressor-Related Disorders Trauma- and stressor-related disorders involve the exposure to a stressful or traumatic event. These were previously grouped with the anxiety disorders but are now considered a distinct category of disorders. Disorders included in this category include: Acute stress disorder, which is characterized by the emergence of severe anxiety within a one month period after exposure to a traumatic event such as natural disasters, war, accidents, and witnessing a death. As a result, the individual may experience dissociative symptoms such as a sense of altered reality, an inability to remember important aspects of the event, and vivid flashbacks as if the event were reoccurring. Other symptoms can include reduced emotional responsiveness, distressing memories of the trauma, and difficulty experiencing positive emotions. Adjustment disorders can occur as a response to a sudden change such as divorce, job loss, end of a close relationship, a move, or some other loss or disappointment. This type of psychological disorder can affect both children and adults and is characterized by symptoms such as anxiety, irritability, depressed mood, worry, anger, hopelessness, and feelings of isolation. Post-traumatic stress disorder can develop after an individual has experienced a stressful life event. Symptoms of PTSD include episodes of reliving or re-experiencing the event, avoiding things that remind the individual about the event, feeling on edge, and having negative thoughts. Nightmares, flashbacks, bursts of anger, difficulty concentrating, exaggerated startle response, and difficulty remembering aspects of the event are just a few possible symptoms that people with PTSD might experience. Reactive attachment disorder can result when children do not form normal healthy relationships and attachments with adult caregivers during the first few years of childhood. Symptoms of the disorder include being withdrawn from adult caregivers and social and emotional disturbances that result from patterns of insufficient care and neglect. 5 Dissociative Disorders Dissociative disorders are psychological disorders that involve a dissociation or interruption in aspects of consciousness, including identity and memory. Dissociative disorders include: Dissociative amnesia involves a temporary loss of memory as a result of disassociation. In many cases, this memory loss, which may last for just a brief period or for many years, is a result of some type of psychological trauma. Dissociative amnesia is much more than simple forgetfulness. Those who experience this disorder may remember some details about events, but may have no recall of other details around a circumscribed period of time. Dissociative identity disorder, formerly known as multiple personality disorder, involves the presence of two or more different identities or personalities. Each of these personalities has its own way of perceiving and interacting with the environment. People with this disorder experience changes in behavior, memory, perception, emotional response, and consciousness. Depersonalization / de-realization disorder is characterized by experiencing a sense of being outside of one's own body (depersonalization) and being disconnected from reality (derealization). People who have this disorder often feel a sense of unreality and an involuntary disconnect from their own memories, feelings, and consciousness. 6 Somatic Symptom and Related Disorders Formerly referred to under the heading of somatoform disorders, this category is now known as somatic symptom and related disorders. Somatic symptom disorders are a class of psychological disorders that involve prominent physical symptoms that may not have a diagnosable physical cause. In contrast to previous ways of conceptualizing these disorders based on the absence of a medical explanation for the physical symptoms, the current diagnosis emphasizes the abnormal thoughts, feelings, and behaviors that occur in response to these symptoms. Disorders included in this category: Somatic symptom disorder involves a preoccupation with physical symptoms that makes it difficult to function normally. This preoccupation with symptoms results in emotional distress and difficulty coping with daily life. Suicide in Children and Adolescences Suicides among young people continue to be a serious problem. Suicide is the second leading cause of death for children, adolescents, and young adults age 5-to-24-year-olds. The majority of children and adolescents who attempt suicide have a significant mental health disorder, usually depression. The tragedy of a young person dying because of overwhelming hopelessness or frustration is devastating to family, friends, and community. Parents, siblings, classmates, coaches, and neighbors might be left wondering if they could have done something to prevent that young person from turning to suicide. Adult suicide is when a young person, generally categorized as someone below age 21, deliberately ends their own life. Rates of attempted and completed youth suicide in Western societies and other countries are high. Among younger children, suicide attempts are often impulsive. They may be associated with feelings of sadness, confusion, anger, or problems with attention and hyperactivity. Among adolescence agers, suicide attempts may be associated with feelings of stress, self-doubt, pressure to succeed, financial uncertainty, disappointment, and loss. For some adolescence s, suicide may appear to be a solution to their problems. Depression and suicidal feelings are treatable mental disorders. The child or adolescent needs to have his or her illness recognized and diagnosed, and appropriately treated with a comprehensive treatment plan. Thoughts about suicide and suicide attempts are often associated with depression. In addition to depression, other risk factors include: Family history of suicide attempts Exposure to violence Impulsivity Aggressive or disruptive behavior Access to firearms Bullying Feelings of hopelessness or helplessness Acute loss or rejection About Adolescence Suicide The reasons behind a adolescence‘s suicide or attempted suicide can be complex. Although suicide is relatively rare among children, the rate of suicides and suicide attempts increases greatly during adolescence. Suicide is the third-leading cause of death for 15- to 24-year-olds, according to the Centers for Disease Control and Prevention (CDC), after accidents and homicide. It's also thought that at least 25 attempts are made for every completed adolescence suicide. The risk of suicide increases dramatically when kids and adolescence s have access to firearms at home, and nearly 60% of all suicides in the United States are committed with a gun. That's why any gun in a home should be unloaded, locked, and kept out of the reach of children and adolescence. Overdose using over-the-counter, prescription, and non-prescription medicine is also a very common method for both attempting and completing suicide. It's important to monitor carefully all medications in A home. Also be aware that adolescence s will "trade" different prescription medications at school and carry them (or store them) in their locker or backpack. Suicide rates differ between boys and girls. Girls think about and attempt suicide about twice as often as boys, and tend to attempt suicide by overdosing on drugs or cutting themselves. Yet boys die by suicide about four times as often girls, perhaps because they tend to use more lethal methods, such as firearms, hanging, or jumping from heights. Children and adolescents thinking about suicide may make openly suicidal statements or comments such as, "I wish I was dead," or "I won't be a problem for you much longer." Other warning signs associated with suicide can include: Changes in eating or sleeping habits Frequent or pervasive sadness Withdrawal from friends, family, and regular activities Decline in the quality of schoolwork Preoccupation with death and dying Frequent complaints about physical symptoms often related to emotions, such as stomachaches, headaches, fatigue, etc. Young people who are thinking about suicide may also stop planning for or talking about the future. They may begin to give away important possessions. People often feel uncomfortable talking about suicide. However, asking A child or adolescent whether he or she is depressed or thinking about suicide can be helpful. Specific examples of such questions include: Are you feeling sad or depressed? Are you thinking about hurting or killing a self? Have you ever thought about hurting or killing a self? Rather than putting thoughts in A child's head, these questions can provide assurance that somebody cares and will give A child the chance to talk about problems. Parents, teachers, and friends should always err on the side of caution and safety. Any child or adolescent with suicidal thoughts or plans should be evaluated immediately by a trained and qualified mental health professional. Which Adolescence is at Risk for Suicide? It can be hard to remember how it felt to be a adolescence, caught in that gray area between childhood and adulthood. Sure, it's a time of tremendous possibility, but it also can be a period of stress and worry. There's pressure to fit in socially, to perform academically, and to act responsibly. Adolescence is also a time of sexual identity and relationships and a need for independence that often conflicts with the rules and expectations set by others. Young people with mental health problems — such as anxiety, depression, bipolar disorder, or insomnia — are at higher risk for suicidal thoughts. Adolescences going through major life changes (parents' divorce, moving, a parent leaving home due to military service or parental separation, financial changes) and those who are victims of bullying are at greater risk of suicidal thoughts. Factors that increase the risk of suicide among adolescence s include: A psychological disorder, especially depression, bipolar disorder, and alcohol and drug use (in fact, about 95% of people who die by suicide have a psychological disorder at the time of death) Feelings of distress, irritability, or agitation Feelings of hopelessness and worthlessness that often accompany depression A previous suicide attempt A family history of depression or suicide Emotional, physical, or sexual abuse Lack of a support network, poor relationships with parents or peers, and feelings of social isolation Dealing with bisexuality or homosexuality in an unsupportive family or community or hostile school environment Warning Signs Suicide among adolescence s often happens after a stressful life event, such as problems at school, a breakup with a boyfriend or girlfriend, the death of a loved one, a divorce, or a major family conflict. Adolescence s who is thinking about suicide might: Talk about suicide or death in general Give hints that they might not be around anymore Talk about feeling hopeless or feeling guilty Pull away from friends or family Write songs, poems, or letters about death, separation, and loss Start giving away treasured possessions to siblings or friends Lose the desire to take part in favorite things or activities Have trouble concentrating or thinking clearly Experience changes in eating or sleeping habits Engage in risk-taking behaviors Lose interest in school or sports What Can Parents Do? Many adolescence s who commit or attempt suicide have given some type of warning to loved ones ahead of time. So it's important for parents to know the warning signs so adolescence s who might be suicidal can get the help they need. Some adults feel that kids who say they are going to hurt or kill themselves are "just doing it for attention." It's important to realize that if adolescence s are ignored when seeking attention, it may increase the chance of them harming themselves (or worse). Getting attention in the form of ER visits, doctor's appointments, and residential treatment generally is not something adolescence wants — unless they're seriously depressed and thinking about suicide or at least wishing they were dead. It's important to see warning signs as serious, not as "attention-seeking" to be ignored. Watch and Listen Keep a close eye on a adolescence who is depressed and withdrawn. Understanding depression in adolescence s is very important since it can look different from commonly held beliefs about depression. For example, it may take the form of problems with friends, grades, sleep, or being cranky and irritable rather than chronic sadness or crying. It's important to try to keep the lines of communication open and express A concern, support, and love. If A adolescence confides in you, show that you take those concerns seriously. A fight with a friend might not seem like a big deal to you in the larger scheme of things, but for a adolescence it can feel immense and consuming. It's important not to minimize or discount what A adolescence is going through, as this can increase his or her sense of hopelessness. If a adolescence doesn't feel comfortable talking with you, suggest a more neutral person, such as another relative, a clergy member, a coach, a school counselor, or A child's doctor. Ask Questions Some parents are reluctant to ask adolescence s if they have been thinking about suicide or hurting themselves. Some fear that by asking, they will plant the idea of suicide in their adolescence‘s head. It's always a good idea to ask, even though doing so can be difficult. Sometimes it helps to explain why you're asking. For instance, you might say: "I've noticed that you've been talking a lot about wanting to be dead. Have you been having thoughts about trying to kill a self?" Get Help If you learn that A child is thinking about suicide, get help immediately. A doctor can refer you to a psychologist or psychiatrist, or A local hospital's department of psychiatry can provide a list of doctors in A area. If adolescence is in a crisis situation, A local emergency room can conduct a comprehensive psychiatric evaluation and refer you to the appropriate resources. If you've scheduled an appointment with a mental health professional, make sure to keep the appointment, even if A adolescence says he or she is feeling better or doesn't want to go. Suicidal thoughts do tend to come and go; however, it is important that A adolescence get help developing the skills needed to decrease the likelihood that suicidal thoughts and behaviors will emerge again if a crisis arises. If A adolescence refuses to go to the appointment, discuss this with the mental health professional — and consider attending the session and working with the clinician to make sure A adolescence has access to the help needed. The clinician also might be able to help you devise strategies so that A adolescence will want to get help. Remember that ongoing conflicts between a parent and child can fuel the fire for a adolescence who is feeling isolated, misunderstood, devalued, or suicidal. Get help to air family problems and resolve them in a constructive way. Also let the mental health professional know if there is a history of depression, substance abuse, family violence, or other stresses at home, such as an ongoing environment of criticism. Helping Adolescence s Cope with Loss What should you do if someone adolescence knows, perhaps a family member, friend, or a classmate, has attempted or committed suicide? First, acknowledge a child's many emotions. Some adolescence s say they feel guilty — especially those who felt they could have interpreted their friend's actions and words better. Others say they feel angry with the person who committed or attempted suicide for having done something so selfish. Still others say they feel no strong emotions or don't know how to express how they feel. Reassure A child that there is no right or wrong way to feel, and that it's OK to talk about it when he or she feels ready. When someone attempts suicide and survives, people might be afraid of or uncomfortable talking with him or her about it. Tell an adolescence to resist this urge; this is a time when a person absolutely needs to feel connected to others. Many schools address a student's suicide by calling in special counselors to talk with the students and help them cope. If adolescence is dealing with a friend or classmate's suicide, encourage him or her to make use of these resources or to talk to you or another trusted adult. If you’ve lost a Child to Suicide For parents, the death of a child is the most painful loss imaginable. For parents who've lost a child to suicide, the pain and grief can be intensified. Although these feelings may never completely go away, survivors of suicide can take steps to begin the healing process: Maintain contact with others. Suicide can be a very isolating experience for surviving family members because friends often don't know what to say or how to help. Seek out supportive people to talk with about a child and feelings. If those around you seem uncomfortable about reaching out, initiate the conversation and ask for their help. Remember that A other family members are grieving, too, and that everyone expresses grief in their own way. A other children, in particular, may try to deal with their pain alone so as not to burden you with additional worries. Be there for each other through the tears, anger, and silences — and, if necessary, seek help and support together. Expect that anniversaries, birthdays, and holidays may be difficult. Important days and holidays often reawaken a sense of loss and anxiety. On those days, do what's best for An emotional needs, whether that means surrounding a self with family and friends or planning a quiet day of reflection. Understand that it's normal to feel guilty and to question how this could have happened, but it's also important to realize that you might never get the answers you seek. The healing that takes place over time comes from reaching a point of forgiveness — for both A child and a self. Counseling and support groups can play a tremendous role in helping you to realize you are not alone. Some bereaved family members become part of the suicide prevention network that helps parents, adolescence agers, and schools learn how to help prevent future tragedies. The records of all suicides and of all open verdicts in Lusaka (Zambia) over a 5-year period (1967-71) were found: 7.4 for all races; 11.3 for men of all races; 3.0 for women of all races; 6.9 for all African residents; 11.2 for African males; 2.2 for African females; 12.8 for all Africans above the age of 14 years; 20.9 for all European residents; 20.7 for all European males; 21.0 for all European females. The male: female ratio among Africans was 5:1. There was a tendency for the suicide rate among Africans to rise with age. Differences in suicide rates between African and European residents were found not to be statistically significant. Though hanging was by far the most commonly used method of suicide by Africans, Europeans and 'doubtful suicides' among Africans preferred other methods to a statistically significant degree. It is suggested that the role of other methods in African suicides may well have been underestimated in the past. No definite seasonal variation in suicide rates was found. Domestic quarrels, mental illness and physical diseases would appear to be some of the important precipitating factors of suicide in Lusaka. It is also suggested that the question of whether or not suicide is rare in Africans cannot be answered until such time as when reliable figures are available in Africa. UNIT-V MENTAL HEALTH PROGRAMME National Mental Health Programme – Mental Health Act, District Mental Health Programme Socio-cultural factors in Psychiatry – Magico-religious practices – Cultural beliefs – Stigma. Mental health policy, plans and programmes WHO‘s mental health policy and service guidance package - An explicit mental health policy is an essential and powerful tool for a mental health section in a ministry of health. When properly formulated and implemented through plans and programmes, policy can have a significant impact on the mental health of populations. This module sets out practical steps for the development of policies, plans and programmes and for their implementation. Specific examples from countries are used to illustrate the process of developing policy, plans and programmes throughout the module. Comprehensive mental health action plan 2013–2020 WHO comprehensive mental health action plan 2013-2020 was adopted by the 66th World Health Assembly. Dr Margaret Chan, the WHO Director-General, described the new Comprehensive Mental Health Action Plan 2013–2020 as a landmark achievement: it focuses international attention on a long-neglected problem and is firmly rooted in the principles of human rights. The action plan calls for changes. It calls for a change in the attitudes that perpetuate stigma and discrimination that have isolated people since ancient times, and it calls for an expansion of services in order to promote greater efficiency in the use of resources. The 66th World Health Assembly, consisting of Ministers of Health of 194 Member States, adopted the WHO‘s Comprehensive Mental Health Action Plan 2013-2020 in May 2013. The action plan recognizes the essential role of mental health in achieving health for all people. It is based on a life-course approach, aims to achieve equity through universal health coverage and stresses the importance of prevention. The four major objectives of the action plan are to: Strengthen effective leadership and governance for mental health. Provide comprehensive, integrated and responsive mental health and social care services in community-based settings. Implement strategies for promotion and prevention in mental health. Strengthen information systems, evidence and research for mental health. Each of the four objectives is accompanied by one or two specific targets, which provide the basis for measurable collective action and achievement by Member States towards global goals. A set of core indicators relating to these targets as well as other actions have been developed and are being collected via the Mental Health Atlas project on a periodic basis. Mental health in Zambia There are no official estimates of the number of people with mental health issues in Zambia, and nor is there a system for the routine collection of data. This hampers the development of services and breaches Article 31 of the Convention on the Rights of Persons with Disabilities, in which Zambia has undertaken to ―collect appropriate information, including statistical and research data, to enable them to formulate and implement policies‖. It is not only statistics which are lacking; academia and media have also shown little interest in people with mental health issues too. People with mental health issues in Zambia are more likely than others to be denied education and be unemployed or in a low income job. Gender-based violence for women with mental health issues is prevalent, as women are economically dependent on their spouses and can be forced to live in abusive relationships. Sexual abuse of girls is also a problem: over 6,000 girls were reportedly victims of sexual abuse (―defilement‖) in the period 2010–2013. The World Health Organization (WHO) estimates that 80% of people with epilepsy live in developing regions, but there are no recent statistics on numbers of people with epilepsy in Zambia. Chainama Hills Hospital estimates that it provided services to 1,500 people with epilepsy in 2013. Similarly there is a lack of data on substance abuse; with Chainama Hills Hospital reporting that it provided services to 1,800 people for alcohol-related abuse and 500 for other substances in 2013.In many aspects, the Persons with Disabilities Act (PWDA) passed in September 2012 meets Zambia‘s obligations under the UN Convention on the Rights of Persons with Disabilities (CRPD). In the Zambian health system, issues of mental health are guided by the Mental Health Policy of 2005; the Mental Health Policy‘s vision is a society in which the government creates an environment Advantageous to utilisation of mental health services. Early detection of mental illness requires more investment in awareness strategies and spending on mental health at all levels, especially the primary health care level. Mental illness constitutes a large proportion of the burden of disease in Zambia. Although data regarding the burden of mental disorders in the country are lacking, there are some indicators of the magnitude of the problem. For example, Mayeya et al (2004) found a prevalence of 36 and 18 per 100 000 for acute psychotic states and schizophrenia respectively, based on hospital figures. Acute psychotic states refer to mental illnesses which present in an acute state and do not normally exceed a period two weeks for resolution while schizophrenia refers to a chronic state of psychotic illness. Further, according to the Mental Health and Poverty Project (MHaPP) Country Report of 2008, about 2667 patients per 100,000 populations are admitted annually to the only tertiary referral psychiatric hospital and units around the country. It is expected that metal health problems in general will increase, taking into account the extent of predisposing factors like HIV/AIDS, poverty and unemployment. It is recognised that this is a very high incidence when compared to expected prevalence of about 3 percent for severe mental disorders and 19 percent for mild to moderate disorders. This observation would support the proposition that there is lack of provision for mental health at the primary and secondary level and that mental health services mostly accessed at tertiary level. By contrast, mental health care services have continued to receive inadequate attention: mental health was not among the twelve priority areas in the National Health development plan; mental health was not provided for in the basic package of services defined by the ministry of Health; and only 0.38% of health care funding was directed towards mental illness in 2008. Moreover, legislation related to mental health care, not updated since 1951, fails to mention basic human rights related to the mentally ill. The current system of metal health care is based largely on secondary and tertiary health institutions. Metal health services at the primary health care level are either inadequate or lacking due to several factors, the main one being the low level and misplacement of mental health professionals. Considering the way forward the government was confronted with two options for improving mental health services. The first is strengthening of the status quo by making the ―vertical‖ system work more efficiently. This would imply investment in secondary and tertiary institutions to increase the number and competencies of human resources as well as the physical structures and logistics. Secondly, there was the option of investing in integrating mental health in primary health care services. The government decided on the latter. Although mental illness constitutes a large proportion of the burden of disease in Zambia, it receives inadequate attention. Mental health was not among the twelve priority areas in the National Health development plan and was not provided for in the basic package of services defined by the Ministry of Health. Only 0.38% of health care funding was directed towards mental illness in2008. Metal health services are lacking in general in general health care, including secondary and primary care levels. Policy options: An incremental versus a comprehensive option for integrating mental health into primary care An increment adoption: This option would start with a pilot project introducing mental health services into primary care with a well-designed evaluation prior to scaling up. Key advantages of this option are: It is possible to make improvements in the plan, if needed, prior to scaling up. The pilot would help ensure that full implementation of the plan achieves its intended objectives and could provide better data for estimating the costs of scaling up. It may be more feasible than rapidly scaling up throughout the country. A comprehensive option This option would entail implementation of a comprehensive plan to introduce mental health services into primary care in all nine provinces of Zambia. Key advantages of this option are: Scaling up could occur more rapidly. Monitoring and evaluation could be used to ensure that the implementation of the plan is working as intended. It may be less likely to stall and then an incremental approach. Implementation strategies: Strategies to implement either option must address a number of barriers, including: Insufficient funding for mental health services due to inadequate advocacy, inadequate mental health indicators, inadequate public awareness of mental illnesses, social stigma attached to mental illnesses, mental health care not being perceived as cost-effective or affordable, and resources that are allocated to mental health at the district level not being earmarked A lack collaborative effort between mental health workers in the tertiary care hospital and provincial units, primary care workers and community health workers and organizations Primary care workers already being overburdened due to low numbers and limited types of health workers trained and supervised in mental health care, poor working Conditions in the public health service, lack of incentives to work in rural areas, and inadequate training of the general health workforce in mental health Insufficient funding for mental health services due to inadequate advocacy, inadequate mental health indicators, inadequate public awareness of mental illnesses, social stigma attached to mental illnesses, mental health care not being perceived Integrating mental health into primary health care: strategic options The two strategic options that are considered here focus on integration of mental health into primary health care using (1) an incremental approach or (2) a comprehensive approach. In the incremental system, it is envisaged that a few centers will be selected for implementation with a view to scaling up at a later stage. In the comprehensive system an effort is made to initiate a process widely across the country without a need for extending to other centers at a later date. The important distinction between these two options is the implication for resource allocation in specific context of Zambia. It is important to take into account the country‘s ability to fulfill the resource allocation implications of these options before adopting one or the other or both. The two options, how they would differ and their advantages and disadvantages are summarized in Table 1 in relation to the ten WHO/WONCA principles for integrating mental health into primary care Key characteristics of two options for integrating mental health into primary care Principles The statuesque 1. Policy and plans need to incorporate primary care for mental health The Ministry of Health is committed to integrating mental health in primary care. Implementation of this policy has been slow, nonsystematic and uncoordinated Option 1 Option 2 Incremental A comprehensive plan implementation for scaling up starting with a pilot project A systematic and coordinated plan for integrating mental health in primary care The plan will initially be implemented in a small number of districts A comprehensive plan for scaling up the integration of mental health in primary care will be implemented throughout the country 2. Advocacy Several independent is required to organizations (e.g. shift MUHNZA, MHAZ)are attitudes and Working largely behaviour independently A voluntary coalition of organizations will collaborate in advocating for change A mental health advisory board will be established to ensure input into the plan and its implementation and to help monitor and coordinate implementation of the plan, as well as to advocate for change 3. Adequate training of primary care workers is required Limited training for specialized skills at the only tertiary care mental health hospital, limited mental health training in the curricula for general health workers, and limited efforts and resources for in service training A pilot project in a small number of districts including systematically planned and coordinated training and supportive supervision for primary care workers A cascade approach for training relevant cadre of primary care workers throughout the country 4. Primary care tasks must be limited and doable Treatable mental health problems commonly go un recognised, minimal mental health services provided in primary care, lack of follow-up for discharged psychiatric patients Improved recognition of high priority mental illnesses, diagnosing and treating high priority conditions that are optimally managed in primary care, improving referrals and communication with specialized mental health workers, and follow-up of discharged psychiatric patients Implemented initially in a small number of districts focusing on a minimal number of high priority Implemented throughout the country and the prioritised conditions and tasks may be expanded to include all conditions and tasks 5. Specialist mental health professionals and facilities must be available to support primary care Inadequate specialist mental health professionals, they do not have responsibility or time to provide adequate support, and the referral process is ineffective and inefficient Principles 6. Patients must have access to essential psychotropic and other mental health medications in primary care The status quo No psychotropic drugs included in the primary health care kit or available in private pharmacies, and inappropriate drugs are being used priorities that are best provided in primary care Increased supply of mental health professionals, posts providing support as a key component of the job description, and an effective and efficient referral process Implemented initially in a small number of districts with a minimal sufficient increase in capacity Implemented throughout the country and may include additional expansion of the specialist mental health service to increase its capacity to handle referrals as well as to provide outreach, supervision and support for primary care workers Option 1 Option 2 Include appropriate psychotropic and other drugs for mental health problems (e.g. depression) in the primary health care drug kit Implemented Implemented initially in a small throughout the number of districts country and the for a minimal prioritised conditions number of high may be expanded to priority conditions include all priorities for which drugs are needed in primary care 7. Integration is a process, not an event The process of integrating mental health into primary care does not have a timeline and is uncoordinated Stage by stage changes building on experience, beginning with a pilot project, including rigorous evaluation of both impacts and processes A plan for achieving comprehensive mental health care over a defined period of time with ongoing monitoring, evaluation and adaptation 8. A mental health service coordinator is crucial Currently there is a National Mental Health Services Unit with a small number of staff Strengthen the National Mental Health Services Unit and ensure that it has a clear mandate and capacity for coordinating the integration of mental health into primary care Initially focusing on ensuring a clear mandate and capacity for coordinating the pilot project 9. Collaboration with key stakeholders is required Not currently coordinated In addition establishing establish coordinators at the provincial level and focal point persons at the district level The National Mental An advisory board Health Services Unit with key will be responsible for stakeholders will identifying key be established stakeholders and (see 2 above) working with them 10. Financial resources are needed No earmarked funds allocated to integrating mental health in primary care Earmarked funds for Earmarked funds the pilot project and for mental health other elements of this professionals to option outlined above, support an including for training, advisory board, drugs, mental health training, additional professionals to tasks undertaken support primary care by primary care workers, evaluation, workers, drugs, and strengthening mental health coordination professionals to support primary care workers and to manage increases in referrals, and coordination The Mental Disorders Act, enacted in Zambia during the colonial era, refers to people with mental and psycho-social disabilities in derogatory language and enforces a system of indiscriminate arrest, indefinite detention (including in prisons) and forcible treatment without procedural protections Mental Disorders Act An Act to provide for the care of persons suffering from mental disorder or mental defect; To provide for the custody of their persons and the administration of their estates; To provide for matters incidental to or connected with the foregoing. Current status of mental Health laws in Africa In 2005, 79.5% of African countries had mental health legis- lation, but 70% of these hadn‘t been changed for fifteen or more years. Many of these legislations also fail to adequately promote the rights of people with mental health conditions. In Ghana, the current mental health legislation is the 1972 Mental Health Decree, which is a revision of the 1888 Lunatic Asylum Ordinance. In Zambia, the Mental Health Disorders Act of 1951, which was inherited from the colonial era, has remained unchanged. The current state of mental health Law in Zambia • Zambia‘s Mental Health Disorders Act of 1951, which was inherited from the colonial era, is outdated. The law is inadequate and does not promote the dignity, respect and autonomy of people who have a mental or intellectual disability. The law also fails to safeguard against abuses related to involuntary admission and treatment, seclusion and restraints, Special treatments or clinical and experimental research amongst people with mental disorders The law uses derogatory and stigmatizing language such as ―imbecile,‖idot,‖ to describe those with mental disorders. The law neglects the critical need to promote community based care. It thus perpetuated an outdated model of care often associated with human rights violations and poor quality of care It is essential that this mental health law is repeated according to national and the international human rights frameworks, such as the newly adopted the UN convention on the Rights of Persons with Disabilities (2007), which supports the rights of people with mental health disorders on an equal basis with others in all aspects of life. WHO 10 Basic principles of mental Health Law Promotion of mental health and prevention of mental disorders Access to basic mental health care Mental health assessments in accordance with internationally accepted principles Provision of the least restrictive type of mental health care Self-determination Right to be assisted in the exercise of self-determination Availability of review procedure Automatic periodical review mechanism Qualified decision-maker Respect of the rule Socio-cultural factors in Psychiatry The socio cultural factors that affect health relate to society (socio) and culture (cultural). Within society and culture, the syllabus list five (5) socio cultural factors that determine health. Every human being needs to acquire by interacting with peers, learning and gradually adapted to their socio-cultural environment, attitudes, group, class, gender, provide it fits the circumstances of the environment, personal values to their reference system which is considered to be ―culture‖. We cannot assess psychiatric disorders in isolation, so it is essential to study the socio-cultural context in which it occurs. It is dynamic, its historic time and not everyone psychiatric pathology. Specifically, in this patient it is evident that we are beings bio-psycho-social. it is a continuation and must integrate these three areas when assessing a patient. Family: Family is by far the greatest influence on health from the socio cultural factors. Family will determine your culture and often have a huge impact on your choice of religion, friends and may even decide what and how much media exposure you have (particularly at a young age).Your family are your most intimate relationships and have a huge influence on your attitude towards health, the value you place on health, and influence your behaviour choices relating to protective and risk behaviors‘. For example, if you grew up in a house where your parents eat fast food frequently (say 3 times a week) you are more likely to think this is normal and even if you know it is not healthy, you‘re more likely to eat it, because this is what your family are eating. You may also think that cutting back on eating this sort of food means only eating it once a week, rather than 3 times a week. Conversely, if your family is health practitioners, such as a nutritionist and an exercise sport scientist, then you are more likely to priorities healthy eating and exercise. However, you may have an overemphasis on physical health and neglect the other dimensions of health. Peers Peer pressure is often the first thing that people think about when it comes to peer influences, however, there is little evidence to say that you are more likely to smoke because your friends tell you to. Instead, your peers influence you by creating environments where you seek to fit into the group by adapting their behaviours. This can be positive, if your group have lots of protective behaviours that they engage in, or negative, if the behaviours increase risk. This pressure to fit into your peer groups is most sharply felt during adolescence. During the teenage year, many young people select behaviours that place them within a particular peer group that they wish to belong to. This may be developing sporting skills to fit in to the group that love sport, or picking up binge drinking if your peers regularly participate in such activities on the weekend. Media The media is another of the socio cultural factors that determine health. The media plays a large role in shaping health. This can be done through marketing campaigns such as ―Quit‖, ―Coco-pops‖, or McDonalds advertising. It can be direct through news articles that focus on pink ribbon day or TV shows such as ―The Biggest Loser‖. However, most of the influence from the media is not so obvious. It is done through regular shows and subtle phrases that promote particular aspects. When a series shows the cool kids smoking, or drinking, or engaging in sexual activity, it makes the viewer start to think that these are behaviours associated with those particular groups. People then begin to seek to live out the character displayed on their screens. For example, many of our current images used in advertising depict women in sexually seductive or available poses. These are chosen deliberately to get your attention in order to advertise their products, but it also communicates that women are objects to be used sexually and exploited in such ways. The rise in sexual images and videos that are considered normal today cannot be underestimated. What you now see on billboards advertising perfume used to be centre page fold out posters in pornography magazines. Our society is becoming increasingly desensitized to these graphic images leading to increases in sexual assault, harassment, and higher risk sexual activity at younger ages. As we start to think that these things are normal, we begin to act on it which leads to risk behaviours. Religion: Your religion is another of the socio cultural factors that influence your health. This can often be in a positive manner, providing a purpose for life and promoting self-worth. Given that Spirituality is an entire dimension of health, it is no surprise that your religion will influence your health. Often regions also have rules, such as not getting drunk, no sex before marriage, that promote protective behaviours in individuals and promote health. However, religion can also be limiting. Some regions place restrictions on clothes and social interactions, which can have negative effects on the health of the individual. For example, a monk who takes a vow of silence and lives in isolation will lack social interaction. Other religions limit the social interaction between sexes or prevent contact between those belonging to the religion and ―outsiders‖. Religion can also limit your choices in relation to health care. For example, the Seventh Day Adventists will refuse a blood transfusion as it is against their beliefs. Culture The last of the socio cultural factors mentioned in the syllabus is culture. Culture is all the traditions, values, and a number of other behaviours, including traditional foods or social activities. Culture is passed down by the immediate and wider family. A sense of connection and belonging to your culture can have a positive influence on health, especially improving the social dimension of health. Many cultures have traditional meals which can affect health. The Mediterranean cultures have a diet high in healthy fats and vegetables leading to lower rates of cardiovascular disease. They also have a high value for family, and community increasing social health. The Japanese have very low intakes of meat and high intake of fresh vegetables, which both positively impact health. Each culture also has their preferred method of treating illness and fixing the body. Traditional Chinese Medicine for example uses herbs, and acupuncture as their main medicinal treatments, while many western countries such as Australia and America utilise the pharmacological (drug) method. It often expects people with mental health problems to accept themselves. We underestimate the effects of our broader culture on the process of acceptance of a mental health problem Acceptance of Mental Illness: Promoting Recovery Among Culturally Diverse Groups. Here, you will see that culture offers a number of challenges and resources to the acceptance process. 1. Cultural stigma: Most of us are familiar with the exacting toll that a culture can take with regard to stigma. One Jewish American woman I interviewed described this phenomenon in the U.S. She stated, ―In America you're not supposed to be depressed, and, if you are, you're supposed to snap out of it, and pull yourself up by your bootstraps.‖ While some empowerment can be found in Western cultural values of autonomy and self-reliance, these expectations can also make it difficult to accept a mental health problem and seek help. 2. Explanatory models: The medical anthropologist and psychiatrist Arthur Kleinman went around the world listening to people‘s stories about their medical and mental health problems. He learned of the explanatory models that their health narratives revealed—cultural explanations for the origin of a mental health problem. It‘s not surprising that these explanatory models would have an effect on acceptance, posing risk and/or resilience. Risk could result from a cultural view of mental illness as the effect of demon possession requiring banishment from the group. In turn, resilience could result from a cultural view of mental illness as a connection to a higher power, elevating the person‘s social status. 3. Cultural isolation versus cultural supports: As a result of stigma, people may feel a sense of isolation within their cultural group. One interviewee in my book spoke of feeling that members of his cultural group ―don‘t accept people who have mental illnesses. A lot of cultures understand it, but they…don‘t want to understand it.‖ He identified this lack of support as a key barrier to accepting his mental health problem. On the other hand, another woman described her depression advocacy group for women of color as a source of cultural support that was central to her acceptance process. 4. Cultural pride: Some research has found that cultural and ethnic identity pride can buffer against the mental health effects of racism and prejudice. One African American woman spoke to the centrality of cultural pride to her acceptance process. She stated, ―When you meet people that are doing good in your cultural identity, it makes you want to do good, too. It makes you want to say, ‗Well, they can do it, I can do it.‘ It gives you a broader outlook than the stereotypes that people have about people.‖ Cultural pride can buffer against not only racism and prejudice, but also foster acceptance of a mental health problem. Magico-religious practices Definition of magico-religious: of, belonging to, or having the character of a body of magical practices intended to cause a supernatural being to produce or prevent a specific result (as an increase of the crops) A magico-religious practice combines elements of religion, as in propitiating a divine entity while engaging in ceremonial acts to bring about a desired result. A magico-religious belief system combines elements of religion and magical practice into a single whole- drawing upon the assistance of the Gods for magical practices and/or performing magic as part of religious ceremonies / worship. Magical thinking in various forms is a cultural universal and an important aspect of religion. Magic is prevalent in all societies, regardless of whether they have organized religion or more general systems of animism or shamanism. Religion and magic became conceptually separated with the development of western monotheism, where the distinction arose between supernatural events sanctioned by mainstream religious doctrine (miracles) and magic rooted in folk belief or occult speculation. In pre-monotheistic religious traditions, there is no fundamental distinction between religious practice and magic; tutelary deities concerned with magic are sometimes called hermetic deities or spirit guides. Functional differences between religion and magic Early sociological interpretations of magic by Marcel Mauss and Henri Hubert emphasized the social conditions in which the phenomenon of magic develops. According to them, religion is the expression of a social structure and serves to maintain the cohesion of a community (religion is therefore public) and magic is an individualistic action (and therefore private). Ralph Merrifield, the British archaeologist credited as producing the first full-length volume dedicated to a material approach to magic, defined the differences between religion and magic: "'Religion' is used to indicate the belief in supernatural or spiritual beings; 'magic', the use of practices intended to bring occult forces under control and so to influence events; 'ritual', prescribed or customary behaviour that may be religious, if it is intended to placate or win favour of supernatural beings, magical if it is intended to operate through impersonal forces of sympathy or by controlling supernatural beings, or social if its purpose is to reinforce a social organisation or facilitate social intercourse". In 1991 HenkVersnel argued that magic and religion function in different ways and that these can be broadly defined in four areas: Intention magic is employed to achieve clear and immediate goals for an individual, whereas religion is less purpose-motivated and has its sights set on longerterm goals; Attitude – magic is manipulative as the process is in the hands of the user, ―instrumental coercive manipulation‖, opposed to the religious attitude of ―personal and supplicative negotiation‖; Action – magic is a technical exercise that often requires professional skills to fulfil an action, whereas religion is not dependent upon these factors but the will and sentiment of the gods; Social – the goals of magic run counter to the interests of a society (in that personal gain for an individual gives them an unfair advantage over peers), whereas religion has more benevolent and positive social functions .This separation of the terms 'religion' and 'magic' in a functional sense is disputed. It has been argued that abandoning the term magic in favour of discussing "belief in spiritual beings" will help to create a more meaningful understanding of all associated ritual practices. However using the word 'magic' alongside 'religion' is one method of trying to understand the supernatural world, even if some other term can eventually take its place. Religious practices and magic Both magic and religion contain rituals. Most cultures have or have had in their past some form of magical tradition that recognizes a shamanistic interconnectedness of spirit. This may have been long ago, as a folk tradition that died out with the establishment of a major world religion, such as Judaism, Christianity, Islam or Buddhism, or it may still co-exist with that world religion. Names of the gods There is a long-standing belief in the power of true names, this often descends from the magical belief that knowing a being's true name grants power over it. If names have power, then knowing the name of a god regarded as supreme in a religion should grant the greatest power of all. This belief is reflected in traditional Wicca, where the names of the Goddess and the Horned God - the two supreme deities in Wicca - are usually held as a secret to be revealed only to initiates. This belief is also reflected in ancient Judaism, which used the Tetragrammaton (YHWH, usually translated as "LORD" in small caps) to refer to God in the Tanakh. The same belief is seen in Hinduism, but with different conclusions; rather, attaining transcendence and the power of God is seen as a good thing. Thus, some Hindus chant the name of their favorite deities as often as possible, the most common being Krishna. Stigma, Discrimination, and Mental Health Mental illness stigma is defined as the ―devaluing, disgracing, and disfavoring by the general public of individuals with mental illnesses‖. (1) Stigma often leads to discrimination, or the inequitable treatment of individuals and the denial of the ―rights and responsibilities that accompany full citizenship‖. (2) Stigmatization can cause individual discrimination, which occurs when a stigmatized person is directly denied a resource (e.g. access to housing or a job), and structural discrimination, which describes disadvantages stigmatized people experience at the economic, social, legal, and institutional levels. (3) In addition, stigma can prevent mentally ill individuals from seeking treatment, adhering to treatment regimens, finding employment, and living successfully in community settings. In 2001, the World Health Organization (WHO) identified stigma and discrimination towards mentally ill individuals as ―the single most important barrier to overcome in the community‖, and the WHO‘s Mental Health Global Action Programme (mhGAP) cited advocacy against stigma and discrimination as one of its four core strategies for improving the state of global mental health. Cultural Perspectives on Mental Illness Attitudes toward mental illness vary among individuals, families, ethnicities, cultures, and countries. Cultural and religious teachings often influence beliefs about the origins and nature of mental illness, and shape attitudes towards the mentally ill. In addition to influencing whether mentally ill individuals experience social stigma, beliefs about mental illness can affect patients‘ readiness and willingness to seek and adhere to treatment.(6) Therefore, understanding individual and cultural beliefs about mental illness is essential for the implementation of effective approaches to mental health care. Although each individual‘s experience with mental illness is unique, the following studies offer a sample of cultural perspectives on mental illness. A review of ethnocultural beliefs and mental illness stigma by Abdullah et al. (2011) highlights the wide range of cultural beliefs surrounding mental health. For instance, while some American Indian tribes do not stigmatize mental illness, others stigmatize only some mental illnesses, and other tribes stigmatize all mental illnesses. In Asia, where many cultures value ―conformity to norms, emotional self-control, [and] family recognition through achievement‖, mental illnesses are often stigmatized and seen as a source of shame.(7) However, the stigmatization of mental illness can be influenced by other factors, such as the perceived cause of the illness. In a 2003 study, Chinese Americans and European Americans were presented with a vignette in which an individual was diagnosed with schizophrenia or a major depressive disorder. Participants were then told that experts had concluded that the individual‘s illness was ―genetic‖, ―partly genetic‖, or ―not genetic‖ in origin, and participants were asked to rate how they would feel if one of their children dated, married, or reproduced with the subject of the vignette. Genetic attribution of mental illness significantly reduced unwillingness to marry and reproduce among Chinese Americans, but it increased the same measures among European Americans, supporting previous findings of cultural variations in patterns of mental illness stigmatization Culture, Beliefs, Attitudes, and Stigmatized Illnesses Cultural Awareness, Sensitivity, and Safety Culture can be defined in terms of the shared knowledge, beliefs, and values that characterize a social group. Humans have a strong drive to maintain the sense of identity that comes from membership in an identifiable group. In primeval and nomadic times, a person‘s survival likely benefited from establishing strong bonds with an in-group of trusted relatives or clanmates with whom one co-operated and shared, versus an out-group against which there was competition for scarce resources. Within the intermixing of modern society, many of us seek to retain a sense of cultural identity and may often refer to our cultural roots, or use double-barreled descriptions such as Asian-American. It is important that we are all aware of our own cultural influences and how these may affect our perceptions of others, especially in the doctor-patient encounter. In many subtle ways, the cultural identities of both doctor and patient affect their interaction, and in a diverse country this can form an exciting challenge. Culture and individual We all perceive others through the filter or perspective of our own cultural upbringing, often without being aware of it: communication can go wrong without our understanding why. The clinician must become culturally aware and sensitive, then culturally competent so that she or he can practice in a manner that is culturally safe. Cultural awareness: Cultural competency in medical practice requires that the clinician respects and appreciates diversity in society. Culturally competent clinicians acknowledge differences but do not feel threatened by them. ―Culturally competent communication leaves our patients feeling that their concerns were understood, a trusting relationship was formed and, above all, that they were treated with respect.‖ While a clinician will often be unfamiliar with the culture of a particular patient, the direct approach is often the best: ask the patient what you need to understand about her culture and background in order to be able to help her. A direct approach helps establish mutual respect and tailor the best and most appropriate care for each patient. Awareness of one‘s own culture is an important step towards awareness of, and sensitivity to, the culture and ethnicity of other people. Clinicians who are not aware of their own cultural biases may unconsciously impose their cultural values on other people. ―As physicians, we must make multiple communication adjustments each day when interacting with our patients to provide care that is responsive to the diverse cultural backgrounds of patients in our highly multicultural nation.‖ Cultural safety refers to a doctor-patient encounter in which the patient feels respected and empowered, and that their culture and knowledge has been acknowledged. Cultural safety refers to the patient‘s feelings in the health care encounter, while cultural competence refers to the skills required by a practitioner to ensure that the patient feels safe. To practice in a manner that is culturally safe, practitioners should reflect on the power differentials inherent in health service delivery. Taking a culturally safe approach also implies acting as a health advocate: working to improve access to care; exposing the social, political, and historical context of health care; and interrupting unequal power relations. Given that the patient exists simultaneously within several caring systems, influenced by their family, community, and traditions, the culturally safe practitioner allows the patient to define what is culturally safe for them. Our culture influences the way we perceive virtually everything around us, often unconsciously. Several useful concepts describe issues that can arise: Ethnocentrism. The sense that one‘s own beliefs, values, and ways of life are superior to, and more desirable than, those of others. For example, you may be trained in Western medicine, but your patient insists on taking a herbal remedy. You may be tempted to say ―So, why are you consulting me, then?‖ Ethnocentrism is often unconscious and implicit in a person‘s behavior. Personal reflection is a valuable tool for physicians to critically examine their own ethnocentric views and behaviors. Cultural blindness. This refers to attempts (often well-intentioned) to be unbiased by ignoring the fact of a person‘s race. It is illustrated in phrases such as ‗being color blind‘, or ‗not seeing race‘. However, ignoring cultural differences may make people from another culture feel discounted or ignored; what may be transmitted is the impression that race or culture are unimportant, and that values of the dominant culture are universally applicable. Meanwhile, the person who is culturally blind may feel they are being fair and unprejudiced, unaware of how they are making others feel. Cultural blindness becomes, in effect, the opposite of cultural sensitivity. Culture shock. Most physicians come from middle-class families and have not experienced poverty, homelessness or addictions. Exposure to such realities in their patients therefore requires great adaptations and can be distressing. This is a common experience in those who have visited a slum in a developing country, but may also arise at home in confronting abortion, infanticide, or female circumcision. Cultural conflict. Conflict generated when the rules of one‘s own culture are contradicted by the rules of another. Cultural imposition (or cultural assimilation or colonialism).The imposition of the views and values of your own culture without consideration of the beliefs of others. Stereotyping and generalization. What may be true of a group need not apply to each individual. Hence, talking about cultures can lead to dangerously prejudicial generalizations. Prejudice is the tendency to use preconceived notions about a group in pre-judging one of the group‘s members, so applying cultural awareness to individuals can be hazardous. Yet, on the other hand, ignoring culture (cultural blindness) can be equally detrimental. The key is to acknowledge and be respectful of differences, and to ask patients to explain their perspective when in doubt. The Relevance of Culture for Health Culture influences health through many channels: 1.Positive or negative lifestyle behaviors. While we often focus on the negative influences of lifestyle behavior—such as drug cultures, or the poor diet of some teen cultures, for example—we should not neglect the positive cultural influences on behaviors and practices. For example, Mormons and Seventh Day Adventists have been found to live longer than the general population, in part because of their lifestyle including the avoidance of alcohol and smoking, but also because of enhanced social support. 2. Health beliefs and attitudes. These include what a person views as illness that requires treatment, and which treatments and preventive measures he or she will accept, as with the Jehovah‘s Witness prohibition on using whole blood products. 3. Reactions to being sick. A person‘s adoption of the sick role (and, hence, how he or she or he reacts to being sick) is often guided by his or her cultural roots. For instance, ―machismo‖ may discourage a man from seeking prompt medical attention, and culture may also influence from whom a person will accept advice. 4. Communication patterns, including language and modes of thinking. Beyond these, however, culture may constrain some patients from expressing an opinion to the doctor, or may discourage a wife from speaking freely in front of her husband, for example. Such influences can complicate efforts to establish a therapeutic relationship and, thereby, to help the patient. 5. Status. The way in which one culture views another may affect the status of entire groups of people, placing them at a disadvantage. The resulting social inequality or even exclusion forms a health determinant. For example, women in some societies have little power to insist on condom use. What elements of a patient’s culture should a health care provider consider when deciding how best to manage a case? Cultural influences may affect a patient‘s reaction to the disease, to suggested therapy, and to efforts to help them prevent recurrences by changing risk factors. Therefore, it may be important for health care providers to find out about such possibilities; they can explain that they need them to tell about their family‘s and community‘s feelings about health recommendations. Health care providers should explain that they are not familiar with their community and want them to tell if they may have beliefs or obligations that the health care provider should be aware of, such as any restrictions on diet, medications, etc., if these could be relevant. Difference between cultural competence and cultural safety Cultural competence is included within cultural safety, but safety goes beyond competence to advocate actively for the patient‘s perspective, to protect their right to hold the views they do. When a patient knows that you will honor and uphold their perspective and not try to change it, they will be more likely to accept your recommendations. A physician who practices culturally safe care has reflected on her own cultural biases recognizes them and ensures that her biases do not impact the care that the patient receives. This pattern of self-reflection, education and advocacy is also practiced at the organizational level.