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.[7] 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.