Mental Health Manual Final

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Module on
Mental Health, Tobacco, Alcohol & Substances abuse
Target Group: Doctors, Nurses and other Health Professionals

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Table of Contents
 Contributors and Reviewers

 Technical advisory panel
 Acknowledgements
 Abbreviations
 Preface
 Objectives
 Structure of the manual
 Overview of sessions and timetable
 Modules:
 Pre & Post training evaluation-Annex
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1. Module 1: Introduction To Mental Health And Mental Disorders

i) Introduce yourself (ice breaking)
ii) What is mental health
iii) What is mental disorders
iv) Causes of mental disorders
v) Types of mental disorders
vi) Bangladesh perspective
2. Module 2: Common phenomenology of mental disorders

i) Symptoms of mental disorders
ii) Phenomenology
3. Module 3: Minor mental Disorders

i) Generalized Anxiety disorders
ii) Phobic disorders
iii) Panic disorders
iv) Obsessive compulsive disorders
v) Conversion Disorder
4. Module 4: Major mental Disorders (1)

i) Schizophrenia
5. Module 5: Major mental Disorders (2)

i)Major depressive disorders
ii)Bipolar mood disorders
6. Module 6: Childhood mental disorders

i)Common childhood mental disorders
ii)Attention deficit hyperactivity disorders
iii)Conduct disorders
iv)Autism Spectrum disorders
7. Module 7: Mental health in special situation:

i) In pregnancy
ii) In elderly
iii)In chronic diseases
iv) Disaster and mental health
V) Occupational Stress
8. Module 8: Prevention of tobacco consumption

i) Current scenario
ii)Type of tobacco Consumption ,
iii)Exposure and Health effects.
iv) How to stop tobacco consumptions
iv) Role of physicians to prevent tobacco consumptions
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9. Module 9: Alcohol & Substances abuse (1)

i) Substances
ii) Terminology
iii) Bangladesh Perspective
iv) Prevention Plan
v) Substance related disorders
vi) Intoxication & Withdrawal of different substances
vii) Specific treatment plan
viii) Detoxification, rehabilitation
ix)Motivational interviewing and relapse prevention
10. Module 10: Treatment approach in mental disorders and substance abuse
i)Common medications
ii)Non pharmacological management
Annexure:
Case Reports
Pre & Post training evaluation
 Contributors and Reviewers

 Technical advisory panel
 Acknowledgements
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Abbreviations
ASD: Autism Spectrum Disorder

BMD: Bipolar Mood Disorder
BSMMU: Bangabandhu Sheikh Mujib Medical University
CDC: Center for Disease Control
CHCP: Community Health Care Provider
DGHS: Directorate General of Health Services
DM: Diabetes Mellitus
DSM 5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
ECT: Electro Convulsive Therapy
GAD: Generalized Anxiety Disorder
GI: Gastro Intestinal
GPs: general Practitioners
ICD 10: International Classification of Diseases
ID: Intellectual Disabilities
MDD: Major Depressive Disorder
MR: Mental Retardation
MoHFW: Ministry of Health & Family Welfare
NCDC: Non Communicable Disease Control
NIMH: National Institute of Mental Health
OCD: Obsessive-Compulsive Disorder
PDEI: Phosphodiesterase inhibitor
PFA: Psychological First Aid
PHC: Primary Health Care
PTSD: Post Traumatic Stress Disorder
SNRIs: Selective Noradrenergic Reuptake Inhibitors
SSRIs: Selective Serotonin Reuptake Inhibitors
TCAs: Tri Cyclic Antidepressants
THC: Tetra Hydro Cannabinol
UHC: Upazila Health Complex
USA: United State of America
USC: Union Sub Center
WHO: World Health Organization
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Preface
Mental health is a component of Health. It is vital for individuals, families and communities, and
is more than simply the absence of a mental disorder. A mental disorder is any illness that affects
people‘s emotions, thoughts or behavior, which is out of keeping with their cultural beliefs and
personality, and is producing a negative effect on their lives or the lives of their families.
There are many different types of mental disorders and effective treatments are available for
people with mental disorders, and many types of mental disorder can be managed initially at the
primary health care level. Improved knowledge of mental disorders may assist affected people to
access treatment and Improve the quality of the care they receive. The ability to work is
compromised in the people with mental disorders. Ignorance and fear of mental disorders across
the community contributes to the stigma and shame for affected people and their families, and
consequent discrimination those results in social exclusion, which has a negative effect on
recovery from mental disorders. The training program outlined in this manual is designed to help
general physicians and nurses with their day to day work. The training manual provides a step by
step guide to facilitating each training session and contains information on teaching methods,
training tips and the aims and objectives of each session.
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Objectives
The prime objective of this training manual is to build the capacity of health
professionals in the field of mental health so that they are able to effectively
respond to the mental health needs of their communities.
By the conclusion of the training, participants will be able to:
 Recognize symptoms and early identification of mental disorders

 Respond appropriately to people with mental disorders.
 Refer people experiencing possible mental disorders to appropriate services.
 Provide basic management to the people with mental disorders and support
their families.
 Early identification, diagnosis and primary management of substance related
disorders and problematic use of alcohol.
 Increase the ability to train the health professionals working at the primary
health care level.
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Structure of the manual
This manual outlines a training program that provides an introduction to mental

health, substance abuse, alcohol and tobacco control for community level health
professionals (doctors and nurses). It includes relevant background information for
both the facilitator and participants, and a range of associated participatory
activities. It consists of 10 sessions, each session has its own objective and consists
of presentations that are given by the facilitator and activities that involve the
whole group. A proposed timetable for the training is provided, but this can be
adjusted if necessary. It is important that the facilitator carefully monitor the timing
of each session as it is easy for sessions to extend beyond the allocated time.
The sessions will be interactive and use multimedia, handout, role play ,case
discussions and pre /post evaluation .
Module 1: Introduction to Mental Health and Mental Disorders
Objective: To provide information about mental disorders, causes and types.

Contents : Definition, causes and types of mental disorders and short description of World and
Bangladesh perspective .
Materials: Training module, multimedia, handout
Duration: 1 hour
Schedule: Interactive presentation: 50 minutes
Individual feedback and open discussion: 10 minutes
i) Introduce yourself (ice breaking)

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What is mental health:
Mental health is defined by the World Health Organization as 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 fully; and
– is able to make a contribution to his or her community.
– A healthy person has a healthy mind and is able to:
– think clearly;
– solve problems in life;
– work productively;
– enjoy good relationships with other people;
– feel spiritually at ease; and
– make a contribution to the community.
It is these aspects of functioning that can be considered as mental health.
Mental health is vital for individuals, families and communities, and is more than just the
absence of mental disorder.
What is mental disorders

Mental disorders can affect both men and women, and can affect people from different age
groups including the young and the elderly.
Mental disorders are common - about one in five adults experience a mental disorder at
some stage in their life.
Most people suffering from a mental disorder look the same as everyone else. It‘s not
always possible to tell that someone is experiencing a mental disorder just by looking
at the person.
Mental disorders include a variety of different conditions ranging from more common
problems such as excessive fear and worry (anxiety) or unusually sad mood (depression), to
more severe behavioral problems that can involve suspiciousness, violence, agitation and
other unusual behaviors (psychosis).
A mental disorder can be a brief episode or it may be a long-term persistent condition.
When a family member has a mental disorder, that family is often socially and economically
disadvantaged.
Communities often have many false beliefs about mental disorders, including what they
are, what causes them, and how to respond to a person experiencing a mental disorder.
Consequently, many people with mental disorders experience stigma and discrimination
that results in:
– delays in seeking appropriate help for the problem
– distress for the affected person and their family
– ongoing social and economic exclusion for the affected person and their family.
There are effective and affordable treatments for most mental disorders.
Appropriate treatment can help improve the quality of life for most people experiencing
mental disorders and also their families.
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Health professionals have an important role to play in relation to mental health.
They can:
 Recognize symptoms and early identification of mental disorders
 Respond appropriately to people with mental disorders.
 Refer people experiencing possible mental disorders to appropriate services.
 Provide basic management to the people with mental disorders and support their
families.
 Early identification, diagnosis and primary management of substance related disorders
and problematic use of alcohol
 Increase the ability to train the other healthcare providers working at the primary health
care level .
Causes of mental disorders

There is rarely one single cause of a mental disorder. Most mental disorders are caused by a
combination of factors, which includes :
 Biological factors
 Stressful life events
 Individual psychological factors e.g. poor self-esteem, negative thinking
 Adverse life experiences during childhood e.g. abuse, neglect, death of parents or other
traumatic experiences.
 Socio economic factors.
Some people may be more vulnerable to mental disorders than others but may not develop
an illness until they are exposed to stressful life events.
Mental disorders are NOT the result of possession by evil spirits, curses, astrological
influences or black magic.
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Multiple factors for Mental Disorders:
v) Types of mental disorders
Mental disorders can be divided into two main categories:

1. Minor Mental Disorders (previously known as Neurosis) : which include symptoms that
we all experience from time to time, for example, feelings of fear, worry or sadness. In
most of the cases the person with minor mental disorders have intact their insight
(perceive that they have some sort of mental illness)
2. Major Mental Disorders (Previously known as Psychosis) : which are often difficult for
the general community to understand, for example, hearing voices or expressing strange
or unusual beliefs. In most of the cases the person with major mental disorders have no
insight (cannot perceive that they have some sort of mental illness) e.g. Schizophrenia,
Bipolar Mood Disorder etc.
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Some common mental disorders:
vi) Mental Health: Bangladesh Perspective

Magnitude of the problems (Prevalence)
Nationwide survey on mental health in Bangladesh in 2003-2005 among people aged 18 years
and above revealed that 16.0% of adult population are suffering from mental disorders with
19.0% in female and 12.9% in male. Neoroses (8.4%), major depressive disorders (4.6%), and
psychoses including schizophrenia (1.1%%) were found in this survey.
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Another community study among children 5 years to 15 years in the Dhaka division showed that
about 18 % of the population was suffering from Mental Disorders, 2% from epilepsy, 0.8 from
substance abuse and 3.8 from Mental Retardation. In this survey Autism Spectrum disorder was
found 0.8%.
Current scenario : infrastructures & Human resources

• Human resources working in mental health: 0.50/100000
• Total number of Psychiatrist: 210 for 160 million people (0.13/100000)
• Clinical Psychologist: 10 for 160 million people
• Psychiatrist Social Workers: 3
• General physicians trained in mental health: 7000
• Nurses trained in mental health: 7200
• General Physician trained in disaster management: 60
• National Institute: 1 (200 beds)
• Mental hospital : 1 (500 beds)
• Department in Medical University : 1 (40 beds)
• Departments in medical colleges : 64 (0-60 beds)
• Total beds for mental health: 828 (0.58/100000)
• Treatment center for Drug Addiction: 4 (Govt.); 32 (Private)
• Budget Allocation in mental health: 0.44% of total Health Budget [2005 data]
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Future prospects
• Decrease Stigma regarding mental disorders
• Incorporate mental health services to primary health care system
• Develop mental health unit in secondary health care system (district hospital)
• Offer training on mental health to GPs, Health Workers and opinion leaders
• Adoption of mental health policy
• Enactment of Mental health Act, Bangladesh
• Incorporation of mental health in national health policy
• Inclusion of mental health & substance abuse in high school curriculum
• Development of approaches to disaster mental health services
• E-Mental health
• Public private partnership in capacity building for mental health services
• National guidelines for the management of common mental disorders and substance
abuse
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Module 2: Common phenomenology of mental disorders
Objective: To provide information about the signs and symptoms of mental disorders.
Contents : Common terminology describing signs symptoms of mental disorders.
Duration: 1 hour
i) Phenomenology
Affect: Emotion felt at the moment of time which can be observed.

Anxiety : Apprehension, tension or uneasiness that stems from the anticipation of danger which
may be internal or external.
Amnesia : Loss of memory.
Attention : Ability to focus on the matter in hand.
Behavior : Any activity that can be observed, recorded and measured.
Compulsion : Repetitive and seemingly purposeful behavior in response to an obsession and
person feels compelled to carry out. Compulsions are characteristic of obsessive compulsive
disorder.
Consciousness : A state of awareness of self and the environment.
Concentration : Ability to sustain the focus on the matter in hand.
Delusion : A delusion is a firm unshakable belief held by a person which cannot be corrected by
giving evidence against that belief and also cannot be explained considering the person's social,
educational or cultural background. e.g. : Delusion of control (passivity phenomenon),
Persecutory delusion
Delusion of Grandiosity: Believing himself or herself something special/big or having special
power.
Disorientation : Confusion about the date, place, person or time of day. Disorientation is
characteristic of delirium and dementia.
Emotional liability : Repeated, rapid and abrupt change of emotion
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Euphoria: exaggerated feelings of well being.

Flight of ideas: It is a continuous flow of accelerated speech with abrupt changes from topic to
topic but has some logical connection between them. Flight of ideas is most frequently seen in
manic episode.
Hallucination : Perception of stimulus in absence of sensory stimulus which is equal to the real
perceptual quality. e.g. Auditory hallucination, Visual hallucination, Olfactory hallucination,
Somatic hallucination .
Ideas of references: Ideas of talking about himself/herself by others or talking something
referring to him or her.
Insight : Understanding and judgment of one‘s condition in the present circumstances and its
effect towards himself, others and environment.
Intelligence : Capacity to act purposefully, to think rationally and to deal effectively with the
environment.
Memory : It is the ability to store information so that it can be recalled at a later time.
Mood: Sustained emotional state elicited by asking the person
Obsession : Recurrent, persistent senseless ideas, thoughts, images or impulses that enter the
mind despite the person‘s efforts to exclude them. Obsession is recognized by the person as his
own and not implanted from elsewhere. Obsessions are characteristic of obsessive-compulsive
disorder and may also be seen in schizophrenia, depression.
Perception : It is the process of selection, organization and interpretation of sensation.
Personality : Unique pattern of behavior and mental process that characterizes an individual and
the individual‘s interactions with the environment.
Phobia : Persistent, irrational fear of a specific object, activity or situation that results in a
compelling desire to avoid the phobic stimulus.
Pressure of speech: Speech that is increased in amount, accelerated and difficult or impossible
to interrupt.
Stress : A particular pattern of disturbing psychological and physiological reactions that occurs
when an environmental event threatens important motives and taxes one‘s ability to cope.
Thought insertion : It is the experience that thoughts are being inserted into the mind and is
recognized as being foreign and coming from outside.
Thought broadcasting : Experience of person‘s unspoken thoughts are known to other people
through mass media, telepathy or in some way. Thought insertion, thought withdrawal and
thought broadcasting are characteristics of schizophrenia.
Thought withdrawal: Experience of disappearance and withdrawal of thoughts from the mind
by external influence
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ii) Symptoms of mental disorders
The symptoms of mental disorders can produce a negative effect on the lives of individuals,
families and society as a whole.
The symptoms of mental disorders can be physical or psychological.
1. Physical symptoms are those that involve the physical functioning of the body e.g.
aches and pains, weakness, tiredness, sleep disturbance, and increased or decreased
appetite.
2. Psychological symptoms are those that involve the mental functioning of the body.
a. Feeling symptoms are those that involve our emotions or feelings e.g. sadness, fear
and worry.
b. Thinking symptoms are those that affect the way a person thinks e.g. problems in
understanding, concentrating, memory, and judgment (decision-making). Thinking
about ending your life (suicide) or thinking that someone else is going to harm you are
examples of thinking symptoms.
c. Behavioural symptoms are those that affect the way people act or what they do.
Behaviours are what we actually see others doing e.g. being aggressive, increased or
decreased talking, withdrawal from family and friends, self-harm e.g. cutting the skin,
and attempting suicide.
d. Imagining symptoms are those that involve the person perceiving or experiencing
things that are not actually real (although they seem very real to the person experiencing
them). For example, the person may be hearing voices or seeing things that are not
actually present.
The different types of symptoms are closely related to each other, for example, hearing
voices saying that others are going to harm you can lead to aggression due to fear.
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Module 3: Minor mental Disorders
Objective: Primary diagnosis and preliminary treatment Anxiety disorders

Contents: Brief introduction, clinical features and management procedure
Methods: Lecture, discussion, case presentation, brain storming
Duration: 1 hour
Schedule: 1 Interactive presentation: 50 minute
Individual feedback and open discussion: 10 minute
i) Generalized Anxiety Disorder (GAD)

The free floating anxiety, worries or physical symptoms cause clinically significant distress or
impairment in social, occupational or other important areas of functioning of the person.
1. Psychological symptoms of GAD
Fearful anticipation, irritability,

Sensitivity to noise, restlessness,
Poor attention and concentration,
Worrying thoughts.
2. Physical symptoms of GAD
Gastrointestinal system -
Dry mouth, difficulties in swallowing, epigastric discomfort, flatulent, constipation,
frequent loose motion.
Respiratory system - Constriction in the chest, inspiratory difficulties, over breathing.
Cardiovascular system -Palpitation, discomfort in the chest, awareness of missed beats.
Genitourinary system -Frequent / urgent micturition, failure of erection, menstrual
disturbance, amenorrhea.
Neuromuscular system -Tremor, prickling sensation, tinnitus, dizziness, headache, muscle
ache.
3. Sleep disturbance : Insomnia - early insomnia or through out disturbances, night terror.
4. Others : Depression, obsession, depersonalization.
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ii) Obsessive Compulsive Disorder

Obsession
In obsession, the patient has recurrent and persistent thought, impulses or images- that are
intrusive and inappropriate. The person attempts to suppress such things but fails.
Compulsion
There are repetitive behavior (like washing, ordering, checking), or mental acts (like praying,
counting, repeating words silently). The person feels driven to perform in response to an
obsession and resists the obsession.
These are usually associated with certain degrees of anxiety and depression.
iii) Phobic Anxiety Disorders

Here anxiety happens in presence to a specific objects or situations, which is irrational and
disproportionately high in comparison to the stimulus. The person avoids the situation or
stimulus and also experiences anticipatory anxiety.
There are three types of phobia - Specific or simple phobia ( e. g spider phobia, height phobia,
phobia of flying, phobia of dental chair, phobia of illness, phobia of animals, storms, height,
water, injections, blood, elevators, driving etc).
Social phobia (e.g. phobia in restaurants, canteen, dinner parties, seminars, board meetings
Agoraphobia (e.g. being on a bridge, traveling in bus or train or automobiles or planes)
This is an emergency medical situation to the patient where there is an episodic period of intense
fear or discomfort, in which 4 out of 13 following symptoms have to be present. The symptoms
develop abruptly and reach a peak within 10 minutes.
i) Palpitation, pounding heart or increased heart rate

ii) Sweating
iii) Trembling / shaking
iv) Sensation of shortness of breath or smothering
v) Choking feeling
vi) Chest pain / discomfort
vii) Nausea / abdominal distress
viii) Feeling dizzy, unsteady, lightened / faint
ix) De realization / de personalization
x) Fear of loosing control / going crazy
xi) Fear of dying
xii) Numbness / tingling
xiii) Chills / hot flash
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The panic attack patients urgently rush to emergency services / cardiologist or physicians and
often get admitted in hospital. But after 15-30 min they feel normal & seek discharge. Most of
the patients apprehend next attack and become fearful Panic attack and agoraphobia are
frequently co-exist.
Panic disorder is usually defined as 4 or more panic attacks in a month or apprehension of

another attack in the following month.
v) Conversion Disorder (dissociative disorder)
It is a neurotic disorder in which a wide variety of somatic and mental symptoms develop for
some real or imagined gain without being fully aware of the underlying motive.
Three characteristics of the symptoms :
1. They occur in the absence of physical pathology
2. They are produced unconsciously
3. They are not caused by over activity of the sympathetic nervous system
There is usually an emotional conflict and the hysterical symptom may have primary gain (e.g.
reduction of anxiety, avoidance of social responsibility) and secondary gain (e.g. care and
attention from others and ultimate solution of the problem)
Clinical syndromes of conversion disorder

A. Conversion symptoms ( Physical symptoms)
a. Motor symptoms - These may consist of paralysis, paresis, fits, tremors, rigidity,
abnormal gait, ataxia, fits.
b. Sensory symptom - Anesthesia, paraesthesia, hyperalgesia and pains, blindness,
deafness, aphonia, loss of smell, loss of taste.
c. Visceral - Vomiting, pain, retention of urine.
B. Dissociative symptoms ( Mental symptoms)

a. Amnesia - Forgetting a specific or traumatic episode in a clear consciousness and
complains that she or he knows nothing of his earlier life.
b. Fuge state - It is a state of wandering away from the environment and usually to escape
from a disagreeable or threatening situation. Emotional conflict or stress is expressed by
dissociation of the mind.
Common characteristics of conversion disorder

1. Age - Usually seen among teen age group
2. Sex - Female sexes predominate more than male
3. Education - Commonly seen among the less educated group
4. Culture - The symptoms are usually culturally backward
5. Conflict - An obvious or hidden conflict usually come into surface
6. Gain - a. Primary
b. Secondary
7. Symptomatic anomaly - The symptoms produced by the conversion disorder usually do

not follow the anatomical or physical rules
8. La-belle indifference - Unawareness about the distress or consequence of the conflict
9. Suggestibility - On suggestion the symptoms may either exacerbate or can be changed
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Difference between epileptic fit and fit from conversion disorder

Epilepsy/True Seizure Conversion
disorder/Pseudoseizure
Consciousness Real loss No real loss
Fits alone / during sleep Yes No
Every fit same as the other Same in each situation Different in each situation
Movement of the limbs Yes, in typical fashion Yes, but variable
Tongue bite Present Absent
Incontinence of urine and faeces Present Absent
History of fall and injury Present & genuine May be present due to
constant friction over the
ground
Management of anxiety disorders:

Assessment and Diagnosis:
History taking, Investigations, Diagnosis
Plan of treatment: Community/Outpatient department/Indoor admission/Refer to

higher centers
General management:
Nutrition/Safety security of patients
Specific management:
Pharmacological treatment: Anxiolytic drugs, Antidepressants in low dose
Nonpharmacological treatment: Psycho education, brief individual psychotherapy,

relaxation therapy, Cognitive therapy, behavior
therapy, rehabilitation etc
Follow up: Drug Compliance, Assessment of the symptoms, functional improvement

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Module 4: Major mental Disorders (1)
Objective: To diagnose and preliminary treatment of Schizophrenia

Contents: Introduction, prevalence, etiology, clinical features, management and prognosis
Methods: Lecture, case presentation, discussion
Materials: Training module, handouts, multimedia, patients
Duration: 1 hours
i) Schizophrenia
Schizophrenia is a major mental disorder of multifactorial (heterogeneous) etiologies
characterized by disturbance of thinking, emotion, perception and behavior.
Prevalence
The lifetime prevalence of schizophrenia around the world about 1%.
Etiology:
The exact cause of schizophrenia is unknown.
Researchers found that the most possible causes are genetic, biological and psychosocial or
environmental factors.
Clinical Features:
There is no single pathognomic sign or symptom for diagnosis of schizophrenia.
 There are positive & negative symptoms of schizophrenia

 Positive symptoms: Usually found in acute schizophrenia.
These are – hallucinations, delusions, disorganized or irrelevant speech, disorganized or
catatonic behaviors etc.
 Negative symptoms: Usually found in chronic schizophrenia.
These are – alogia (Decreased mental ability to think), affective flattening, apathy, social
isolation or withdrawal, avolition ( lack of drive to do anything), self neglect, decreased
speech etc.
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Schneider’s first rank symptoms
Kurt Schneider (1887 – 1967): He was a German Psychiatrist who first classified the symptoms
of schizophrenia in 1938.
Presence of at least one first rank symptom in absence of organic illness is usually
diagnostic of schizophrenia
• Auditory hallucination : 3rd person type, running commentary type

• Primary delusion : Delusional perception
• Thought insertion
• Thought withdrawal
• Thought broadcasting
• Delusion of control- action and feelings are experienced as controlled by external
force or agency
• Hearing of one‘s own thought (thought echo)
• Somatic hallucination
Diagnostic guideline:
DSM 5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
ICD 10: International Classification of Diseases . According ICD 10 the code of Schizophrenia
F-20
Management:
History taking, examination (general examination, systemic examination & mental state
examination), relevant investigations.
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Treatment:
Pharmacological treatment:
 Anti-psychotics medications
 Typical or 1st generation anti-psychotics eg. Haloperidol, Chlorpromazine,

Trifluoperazine etc.
 Atypical or 2nd generation anti-psychotics eg . Olanzapine, Risperidone, Aripriprazole,

Quetiapine, Clozapine ete.
Other Treatment: ECT ( Electroconvulsive therapy)
Non-pharmacological treatment:
Psychosocial management – Psycho education, family psychotherapy, cognitive behavior

therapy, social skill training, group therapy, vocational therapy and rehabilitation.
Hospitalization:
Indications for hospitalization are as follows –
1) For safety ( because of violent behavior, suicidal and homicidal ideation)
2) Non-compliance to treatment
3) For diagnostic purpose
Prognosis:
25% - complete remission of symptoms
35% - remission and relapse
25% - residual features
15% - debilitating course.
Follow up:
To assess the drug compliance, side effects of drugs, reduction of symptoms with rise of new
symptoms.
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Module 5: Major mental Disorders (2)
Objective: To diagnose and preliminary treatment of Mood Disorder (Major

Depressive disorders & Bipolar mood disorder)
Contents: Introduction, epidemiology, etiology, clinical features, management & prognosis
Materials: Training module, multimedia, patients, handout
Duration: 1 hour
Schedule: Interactive presentation: 50minutes
Mood is defined as a sustained and pervasive emotional state of mind. Mood disorders are
common episodic and treatable disorder.
Classification
1. Major depressive disorder

a. Unipolar depressive disorder
b. Bipolar depressive disorder
c. Psychotic depression
2. Bipolar mood disorders
a. Bipolar I disorder
b. Bipolar II disorder
c. Cyclothymia
d. Dysthymia
3. Mood disorder due to general medical condition.
Epidemiology of major depressive disorder and bipolar mood disorder
Major depressive disorder
The life time prevalence of

major depression is 5% -
17%.
Worldwide Prevalence 2% - 3% men
5% - 10% women
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Bangladesh Prevalence: 4.6%
Sex 2 : 1 women : men

Age 40 mean age
Bipolar mood disorder
The life time prevalence of

bipolar disorder is 0.3% -
1.5%.
Worldwide Prevalence 1% in both sex
Bangladesh prevalence: 0.4%
Sex Almost equal in both sexes
Age 30 mean age in both sexes
Causes
There have been many different approaches to the etiology of Mood disorders.
The genetic, biochemical, psychological and social factors that may contribute to the aetiology of
mood disorders.
i) Major Depressive Disorder
Common presenting complaints

 Depressed mood or persistent sadness
 Lack of initiatives and drive (avolition)
 Easy fatigability
 Change in appetite ( mostly reduced appetite)
 Early morning awakening (sleep disturbances)
 Inability to enjoy the pleasurable activities ( anhedonia)
 Irritability
 Suicidal idea or suicidal attempt
 Decreased libido.
Major depressive disorder (unipolar depression)
One or more major depressive episodes without a history of manic or hypomanic episode.
Depression Depression Depression

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Major depressive disorder (Bipolar depression)
One or more manic or hypomanic episodes with a history of major depressive episode.
Depression
Psychotic depression:
Severe depression having psychotic features like delusions, hallucination.
Management:
History taking, Mental State Examination, Investigations
Treatment:
 Anti-depressant drugs
 SSRIs (Selective Serotonin Reuptake Inhibitors) - eg. Sertraline, Fluoxetine,

Paroxetine, Fluvoxamine, Citalopram, Escitalopram etc.
 TCAs (Tricyclic anti-depressants) - eg . Amitriptyline, Nortriptyline, Clomipramine,
Imipramine ete.
 SNRIs (Serotonine Noradrenaline Reuptake Inhibitors) – Venlafaxine, Duloxetine .
 Others: ECT ( Electroconvulsive therapy)
Psychosocial management – Family psychotherapy, cognitive behavior therapy, graded

activities, interpersonal psychotherapy and rehabilitation.
Prognosis:
About 25% recur in the first 6 month of release from hospital.
30% - 50% recur in the following 2 years

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50 % - 75% recur in the following 5 years
Follow up
symptoms.
ii) Bipolar Mood Disorder

Presence of two distinct phases of mood in the patient, one is manic phase and another is
depressive phase with good inter-episodic functioning.
Manic Phase
Depressive Phase
Common presenting complaints
 Elated mood
 Self important ideas
 Talkativeness
 Over activity
 Excessive expenditure
 Irritability
 Aggressive behavior occasionally
 Reduced need for sleep
Management:
History taking, Mental State Examination, Investigations Diagnosis
Treatment:
A. Acute phase
1. Anti-psychotics drugs: Typical or atypical anti-psychotic drugs to reduce the

hyperactivity, violent behavior and delusion of patients.
29
2. Mood stabilizers: Lithium carbonate, Sodium valproate, Carbamazepine,

Lamotrigine etc.
3. Benzodiazepine: Lorazepam, Clonazepam, Diazepam etc for sedation initially.
B. Maintenance phase
Mood stabilizers only.
Psychosocial management – Family psychotherapy, interpersonal psychotherapy and
rehabilitation.
Hospitalization:
Indications for hospitalization are as follows –
1) For safety ( because of violent behavior, suicidal and homicidal ideation)
2) Non-compliance to treatment
Follow Up
symptoms.
Mood disorder due to general medical condition
Mood disorders which have a known physical cause are called mood disorders due to general
medical condition.
Eg.
Depression may occur in – Cushing‘s disease, Addision‘s dis, Hypothyroidism, Carcinoma,

Diabetes Mellitus.
Mania may occur in- Steroid, L-dopa, Anti-depressants etc.

30
Module 6: Childhood mental disorder
Objective: Primary diagnosis and preliminary treatment of common childhood mental

disorders
Materials: Training module, multimedia
Duration: 1 hour
i) Common childhood mental disorders

31
ii)Attention deficit hyperactivity disorders (ADHD)
Clinical features
Hyperactivity the accompanying sense of restlessness, which is not task-related and has an
irritating, disruptive quality that is annoying to other people.
Impulsivity
Impulsivity, that is the inability to delay a response or more overtly intrusive behavior, is
irritating to peers and adults whether it occurs at school, at home or in the community.
Distractibility
Inability to focus attention to study or anything.
Secondary problems
Learning disorders :Many children with hyperkinetic syndrome or ADHD show evidence of
generalized or specific learning disabilities.
Management:
Medications
Methylphenidate
Clonidine,
Atomoxetine
Risperidone
Haloperidol
Dietary measures
Advice to parents for additive-free and artificial coloring-free products diet for the child.
Parental counseling
32
Though no detailed control trials have been carried out, clinical evidence indicates that many
parents find this approach useful. Common topics for discussion include :
● counseling about the basis of the child‘s behavior

● discussion about the management of behavior
● the opportunity to talk about parents‘ own anxieties and concerns
Behavior modification
Rewarding expected behavior and overlooking unwanted behavior at home or school.
Environmental manipulation
Advice to teachers or parents about changes in the child‘s routine or overall environment at
home or at school can be useful. Examples include:
● placement of the child in a small, stable teaching group

● time limitation for individual activities
● alterations to classroom layout
● careful control of the number of activities or friends the child has at home after school.
Remedial education
Individual remedial programmers for general and specific learning difficulties are necessary for
many children.
iii)Conduct disorders
Conduct disorder is usually defined as persistent, antisocial or socially disapproved behavior that
often involves damage to property and / or aggression towards other people and is unresponsive
to normal control or authority. Boys are three times more likely to be affected than girls.
• "Conduct disorder" refers to a group of behavioral and emotional problems in youngsters.

• Children and adolescents with this disorder have great difficulty following rules and
behaving in a socially acceptable way.
• They are often viewed by other children, adults and social agencies as "bad" or
delinquent, rather than mentally ill.
Prevalence:
• Worldwide prevalence 4%-5.5%.
• Boys> Girls
33
• In Bangladesh :
Conduct Disorder-1.01%
• Onset: >7 Years of age
Symptoms of Conduct Disorder
• Aggression to people and animals
– bullies, threatens or intimidates others
– often initiates physical fights
– has used a weapon that could cause serious physical harm to others (e.g. a bat,
brick, broken bottle, knife or gun)
– is physically cruel to people or animals
– steals from a victim while confronting them (e.g. assault)
– forces someone into sexual activity
• Destruction of Property
– deliberately engaged in fire setting with the intention to cause damage
– deliberately destroys other's property
• Deceitfulness, lying, or stealing
– has broken into someone else's building, house, or car
– lies to obtain goods, or favors or to avoid obligations
– steals items without confronting a victim (e.g. shoplifting, but without breaking
and entering)
• Serious violations of rules
– often stays out at night despite parental objections
– runs away from home
– often truant from school
Management:
History taking, investigations (EEG, serum lead), diagnosis
Plan of treatment: Community/Outpatient department/ Refer to
higher centers/special school/mainstream school
General management:
Nutrition, safety
No pharmacological treatment:
Approaches
● Psycho education
● Work with the family/Family therapy for the whole group
● Behavior modification : reward for expected behavior
● Symptom management, for instance aggression
● Remedial education ( special coaching for specific subject)
● Treatment of physical problems
● Help with socio-economic disadvantage
● Support for re-housing
● Removal from home including reception into care and / or residential
schooling when necessary
34
● Ensure consistent, contingent response to behavior, i.e. rewards for

good behavior, sanctions for bad
Pharmacological treatment
If needed use antidepressant in low dose, mood stabilizers
Follow Up: To assess the drug compliance, side effects of drugs, reduction of symptoms with
rise of new symptoms.
iv)Enuresis
Definition
Enuresis is the involuntary passage of urine, in the absence of physical abnormality, after the age
of 5 years in a child of normal ability. Physical investigation is usually confined to the exclusion
of renal disease, diabetes or occasionally, when appropriate, nocturnal epilepsy.
Management:
History taking,
Examination:
Back and lower limb reflexes
Urine specimen to exclude renal failure and diabetes
Mental state of child
Investigations
Diagnosis
Plan of treatment: Community/Outpatient department/inpatient department/ Reffer to

higher centers
General management:
Nutrition, care of bed cleaning,
Pharmacological treatment: Antidepressants ( Imipramine )

35
No pharmacological treatment:
Psycho education
Star chart: Diary pattern of night-time dryness / wetness. with a star
placed on the sheet for each dry night. A common practice is to use a
single blue star for each dry night with three consecutive dry nights
meriting a gold star. Then a positive reinforcement for the desired
behavior that is a dry bed is given.
Enuresis alarm
Bladder training: It involves the child gradually extending the time
between micturition in a graded sequence from half an hour up to 4 hours
during the course of the training.
v)Autism Spectrum disorders

Autism spectrum disorder (ASD) and autism are both general terms for a group of complex
disorders of brain development. These disorders are characterized by difficulties in social
interaction, verbal and nonverbal communication and repetitive behaviors. It is one of the
neurodevelopmental disorders. The most obvious signs and symptoms of autism tend to emerge
between 2 and 3 years of age.
Prevalence of Autism: Worldwide
Centers for Disease Control and Prevention (CDC), USA identify around 1 in 68 American
children as on the autism spectrum–a ten-fold increase in prevalence in 40 years. Autism is four
to five times more common among boys than girls. An estimated 1 out of 42 boys and 1 in 189
girls are diagnosed with autism in the United States. Autism affects over 3 million individuals in
the USA and tens of millions worldwide.
Autism in Bangladesh
36
There are few studies on autism prevalence in Bangladesh and the brief summary of those
studies as follows:
Year Types of study Investigators Prevalence Conducted by
Mullick MSI &

2005 Epidemiological 2/1000 Investigators
Goodman R
World Health
Community Based, Sub Rabbani MG,
Organizations &
2009 National level-38 Upazila in Alam F , Ahmed 8.4/1000
National Institute
Dhaka Division HU et al
of Mental Health
Non
Communicable
Disease Control
program,
Directorate
general of health
NailaZaman et 1.55/1000 (Overall) Services ,
Epidemiological, 7 divisions al, 0.68/1000 (Rural
2013 Revitalization of
and Dhaka city area Area) 30/1000
Community
(Dhaka city)
Health Care
Initiatives in
Bangladesh,
Bangladesh
Medical
Research Council
Causes of Autism
The exact causes of autism spectrum disorder (ASD) are unknown, although it is thought
that several complex genetic and environmental factors are involved.
Risk factors
Factors thought to increase the risk of developing ASD, known as ‗risk factors‘, can usually be
divided into five main categories:
 Genetic factors – certain genetic mutations may make a child more likely to develop
ASD.
 Environmental factors – during pregnancy, a child may be exposed to certain
environmental factors (alcohol consumption, lead poisoning, and certain medications like
sodium valproate) that could increase the risk of developing ASD.
37
 Psychological factors – people with ASD may think in certain ways (‗theory of mind‘)
that contribute towards their symptoms. This is a person's ability to understand other
people's mental states, recognizing that each person they meet has their own set of
intentions, beliefs, emotions, likes and dislikes. To put it simply, it's seeing the world
through another person's eyes.
 Neurological factors – connections between parts of the brain (cerebral cortex, the
amygdala and the limbic system) may have become scrambled or ‗over connected‘
 Other health conditions – certain health conditions like fragile X syndrome, tuberous
sclerosis, and neurofibromatosis are associated with higher rates of ASD.
Moreover it has been postulated that low birth weight, advanced parental age during
conception, oxygen deprivation during birth, malnutrition of pregnant mother and
newborn also other risk factors for autism.
Sign-Symptoms:
Early Signs:
By 6 months: No big smiles or other warm, joyful expressions
By 9 months: No back-and-forth sharing of sounds, smiles, or other facial expressions.
By 12 months: Lack of response to name.
By 12 months: No babbling or ―baby talk.‖
By 12 months: No back-and-forth gestures, such as pointing, showing, reaching, or waving.

By 16 months: No spoken words.
By 24 months: No meaningful two-word phrases that don‘t involve imitating or repeating
Red Flags:
The following red flags may indicate a child is at risk for an autism spectrum disorder, and is in
need of an immediate evaluation
Impairment in Social Interaction:
 Lack of appropriate eye gaze

 Lack of warm, joyful expressions
 Lack of sharing interest or enjoyment
 Lack of response to name
Impairment in Communication:
 Lack of showing gestures

 Lack of coordination of nonverbal communication
 Unusual prosody (little variation in pitch, odd intonation, irregular rhythm,
unusual voice quality)
Repetitive Behaviors & Restricted Interests:

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 Repetitive movements with objects

 Repetitive movements or posturing of body, arms, hands, or fingers
Comorbid Symptoms or Conditions-

High rates of co-morbidity
• Tic disorders (9%)
• Seizures (to 25%)
• ADHD (30-75%)
• Affective Disorders (25-40%)
– e.g., depression or anxiety
– Higher in HFA/ Asperger‘s
• GI Problems (10-60%)
• Sleep Disturbance (50-75%)
• Challenging Behaviors (10-35%)
Management:
Management of autism is intensive and comprehensive that involves child‘s entire family and a
team of professionals. Some programs may be based at home with the help of professional. Some
programs are delivered in a specialized center, classroom or preschool. It is not unusual for a
family to choose to combine more than one treatment method. An experienced specialist or team
should design the program for the individual child
History taking, Examination, investigations, Diagnosis
Plan of treatment: Community/Out patient department/ Refer to

higher centers/special school/mainstream school
General management:
Nutrition, education
Nonpharmacological treatment: Psycho education, Analytic behavior therapy (ABA), special

school, speech therapy, occupational therapy, sensory stimulation, physiotherapy
Pharmacological treatment: If needed then use antipsychotics (Risperidone or Aripriprazole)

or others
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Module 7: Mental health in special situation:
Objective: To diagnose and preliminary treatment of mental disorders related with sexual
dysfunction, pregnancy, child birth, elderly people, in chronic illnesses and in
disasters
Materials: Training module, multimedia, case presentation, handout
Duration: 1 hour
Schedule: 1 Interactive presentation and case presentation: 50 minutes
i)Sexual dysfunctions
Sexual dysfunctions refers to a person‘s inability ―to participate in a sexual relationship as he or

she would wish‖.
Common sexual dysfunctions found are –
In Male - Premature ejaculation, Erectile disorder, Hypoactive sexual desire disorder, Dhat
syndrome
In Female – Female sexual arousal disorder, Orgasmic disorder, Vaginismus, Dyspareunia
Premature ejaculation
Habitual ejaculation before penetration or so soon afterwards that the woman has not
experienced pleasure.
It is usually occurs in young male persons.
Causes: performance anxiety, lack of sex knowledge, cultural factors, relational problems,
stressful marriage etc.
Treatment:
 Advice & reassurance
 Sex education
 Couple psychotherapy to improve relational problem.
 Behavioural approaches – Start- stop method, Squeeze technique
 Pharmacological approach - SSRIs .
Erectile disorder
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Inability to achieve an erection or to sustain it for long enough for satisfactory coitus.
Common causes- Anxiety about sexual performance, relational problem between partners, DM,
Vascular disease, alcohol, adverse effects of medicines etc.
Treatment:
Psychological treatment – Reassurance, sex therapy
Pharmacological treatment – PDE inhibitors ( eg. Sildenafil, Tedalafil)
Dhat syndrome:
Undue concern about the debilitating effects of the loss of semen is called Dhat syndrome.
This is cultured bound syndrome of this Indian subcontinent.
The patient is usually young, unmarried, less educated, from rural background and holding
strong traditional beliefs.
Most commonly the patient presents with vague and multiple somatic and psychological
symptoms like weakness, fatigue, aches and pains in the body, poor appetite, poor sleep, poor
concentration etc. He appears anxious, tense, depressed and preoccupied with the thought that he
has got a serious disease due to passage of semen in the urine.
Treatment
a) Reassurance and support
b) Psycho education – about physiology of seminal fluid, prostatic fluid, semen.
c) If anxiety prominent – anxiolytic drugs (eg. Alprazolam) in short duration.
d) If depression prominent – antidepressants ( Fluoxetine or Imipramine or Amitriptyline )
in 2 to 4 weeks.
Vaginismus
An involuntary muscle constriction of the outer third of the vagina that interferes with penile
insertion and intercourse.
Often afflicts highly educated women and those in high socioeconomic groups.
Causes are - sexual trauma such as rape,
-Women with psychosexual conflicts
-Pain or the anticipation of pain at the first coital experience
-Negative conditioning to sex (as being sinful, dirty, shameful esp during childhood and
adolescence)
Treatment –
Education, Psychotherapy and gradual vaginal desensitization (Kegel‘s exercise).
41
ii) In pregnancy
These are 3 groups of disorders/problems related with pregnancy and child birth
(a) Postpartum blue (b) Post natal depression (c) Puerperal psychosis.
Postpartum blue
About 50-70% women experience it within first few days of delivery usually within 10 days. The
condition is self limiting and lasts for 2-3 days.
Clinical features
● Anxiety about the baby
● Irritability
● Transient mood disturbance- unpredictable mood swing with tearfulness, mild depression,
profuse weeping over minor upset, liability of mood
● Poor concentration, forgetfulness
Treatment
● Understanding and support of the professionals, family and friends
● Reassurance
● Antenatal education by the professionals
Postnatal Depression
Postnatal depression is a less severe depressive disorder. It begins slowly within 6 weeks of
delivery with low mood, loss of interest and pleasure in usual activities. The patient gradually
develops irritability, aggressiveness, hopelessness, guilt feelings, fear to harm their children, loss
of appetite, reduced sleep, loss of libido, poor concentration, and suicidal ideation.
Treatment
● Mild cases can be treated by counseling and support with involving the partner.
● More severe cases are treated as that of depression.
Puerperal psychosis
Most cases present with clinical features of bipolar mood disorder with manic episode, unipolar
depressive disorder, schizoaffective disorder and schizophrenia.
Management:
History taking, Examinations, Investigations, Diagnosis
Plan of treatment: Community/Out patient department/inpatient department/ Refer to
higher centers
42
General management:
Nutrition, safety, care of mother and baby to prevent suicide and infanticide, urgent
hospitalization if required
Pharmacological treatment: Antidepressants, antipsychotics, anxiolytics, mood
stabilizers, ECT
Nonpharmacological treatment: Psycho education,
Follow Up; To assess the drug compliance, side effects of drugs, reduction of symptoms with
iii) Mental health in elderly people

Multiple social, psychological, and biological factors determine the level of mental health of
elder population. Many older adults lose their ability to live independently because of limited
mobility, chronic pain, frailty or other mental or physical problems, and require some form of
long-term care. In addition, older people are more likely to experience events such as
bereavement, a drop in socioeconomic status with retirement, or a disability. All of these factors
can result in isolation, loss of independence, loneliness and psychological distress in older
people. Common mental health problems in elderly are
a) Depression
b)Dementia
c) Organic psychosis
Dementia:
Dementia is a chronic organic mental disorder characterized by impairment of memory, intellect
and personality usually in elderly people. There is no impairment of consciousness.
Some important causes of dementia

A. Degenerative : Alzheimer‘s disease, Pick‘s disease, Parkinson‘s disease, Huntington‘s
disease
B. Vascular : Multi-infract dementia
C. Metabolic : Chronic hepatic or uremic encephalopathy, dialysis dementia,
D. Endocrine : Thyroid, pituitary
E. Deficiency : Pernicious anemia, pellagra, folic acid and thiamine deficiency
F. Infections : Creutzfeldt-Jacob disease, neurosyphilis, chronic meningitis, viral
encephalitis, AIDS dementia
G. Neoplastic : Neoplasm and other intracranial space occupying lesions.
H. Traumatic : Chronic subdural hematoma, head injury
43
Clinical features of dementia
A. Behavior
Often muddled, distractible, inappropriate and restless, sexual disinhibition, nonverbal
disinhibition, shop lifting, aimless and stereotyped behavior, mannerisms
B. Thinking
Slows and impoverished thinking. concrete thinking, reduced flexibility and
perseveration, incoherent thinking , persecutory ideas and belief
C. Judgment
Judgment is impaired..
D. Speech
Incoherent and nonsense talk, nominal dysphasia, meaningless noises and eventually the
patient may become mute.
utter
E. Mood
Anxiety, depression and irritability, sudden mood changes
Disorder of cognitive functions
i. Forgetfulness.
ii. Difficulties in new learning.
iii. Memory loss is more obvious for recent than remote.
iv. Impairment of attention and concentration.
F. Orientation
Disorientation for time and at the later stage, for place and person
Insight
Insight is lacking into the degree and nature of the disorder.
iv) In chronic diseases
In chronic physical illness the depression and anxiety disorders are more common. Special
attention is needed in case of person with:
a) Diabetes
b)Bronchial Asthma
c)Chronic Obstructive Pulmonary diseases
d)Hypertension
e) Ischemic heart disease
f)Other cardiac complications
g)Malignancy
h)Chronic Arthritis
i)Systemic Lupus Erythematas
j)Parkinson's disease
k)Psoriasis
l)Obesity
44
v) Disaster and mental health
The effects of a disaster, (both natural and manmade) can be long-lasting, and the resulting
trauma can reverberate even with those not directly affected by the disaster. Few mental
disorders are related with disaster effects. Affected individuals may have various stress reactions
that present psychological as well as physical symptoms.
Disasters leave a psychological impact on affected peoples varying from transient reactions to
the incident among the survivors, to lifelong emotional problems. The need for emotional
support is crucial in order to enable people to begin the process of recovery, and to help them
cope with the hardships imposed upon them due to the disaster.
Depending on the time that has elapsed since the disaster, psychological reactions seen among
the victims vary.
The emotional reactions generally observed in the affected population after a disaster include:
Immediate reactions (within 24 hours)
(1) Tension, anxiety, panic
(2) Stunned, dazed, shocked, disbelief
(3) Elation or euphoria among survivors / or people suffering lesser losses
(4) Restlessness, confusion (5) Agitation, crying and withdrawal
(6) Survivor‘s guilt These reactions are seen in nearly everybody in the affected region and can
be considered ‗NORMAL REACTIONS TO AN ABNORMAL SITUATION‘, and need not
necessarily require specific psychological interventions.
Within days to weeks after the disaster

(1) Being fearful, vigilant, hyper-alert (irritable, angry, unable to sleep)
(2) Worried, despondent
(3) Repeated ‗flashbacks‘
(4) Weeping, guilt feeling (including survivor‘s guilt)
(5) Sadness
(6) Positive reactions including: hoping / thinking of future, getting involved in relief and rescue
work
(7) Acceptance of disaster as nature‘s doing All these are normal responses and may need
minimal psychosocial intervention.
After about three weeks of disaster The previously noted reactions may persist and manifest as:
(1) Restlessness
(2) Feeling panicky
(3) Continued intense sadness, unrealistic pessimistic thoughts
(4) Outward inactivity, isolated and withdrawn behavior
(5) Anxiety manifested as physical symptoms such as palpitations, dizziness, restlessness,
nausea, headache, etc.
45
Mental disorders after a disaster
Some disaster survivors may develop full blown mental disorders which become apparent
usually a few weeks to months after the disaster.
Acute stress reaction:

The symptoms show a typically mixed and changing picture and include an initial state of "daze"
with some constriction of the field of consciousness and narrowing of attention, inability to
comprehend stimuli, and disorientation. This state may be followed either by further withdrawal
from the surrounding situation (to the extent of a stupor), or by agitation and over-activity.
Bereavement and grief Grief:

refers to ―the feelings and behaviours such as sadness, distress, anger, crying, etc.,
accompanying the awareness of irrevocable loss (not necessarily but including loss through
death)‖. The term bereavement is used when the loss is because of death. Following disasters
there may be grief for the loss of loved ones, home, valued possessions, livelihood, etc.
Diagnosable mental disorders:

These include Anxiety and Depressive disorders. These are the most common disorders but
others like Adjustment disorders (with anxiety and/or depressive symptoms), Somatoform
disorders (physical symptoms due to stress) can also be seen.
Alcohol and drug abuse :

There may be increased use of alcohol and/or other addictive substances resulting in substance
use related problems.
Post-traumatic stress disorder :

Post-traumatic stress disorder (PTSD) is characterized by symptoms similar to acute stress
disorder but lasting for more than 1 month. The symptoms of PTSD can be categorized in three
dimensions: (i) re-experiencing the trauma, (ii) avoiding stimuli associated with the trauma and
(iii) experiencing symptoms of increased autonomic arousal such as difficulty in falling or
staying asleep, irritability or outbursts of anger, difficulty in concentrating, hyper vigilance and
exaggerated startle response.
Pre-existing mental disorders :

Persons who are suffering from established mental disorders, may be more vulnerable to
developing psychosocial problems following disasters.
46
Physical symptoms :
Some people undergoing psychosocial trauma may complain of physical symptoms such as
headache, tiredness, palpitations, loss of appetite, pain in the abdomen, nausea or unidentifiable
pain all over the body.
Psychological First Aid (PFA) and Psycho social care is very important for the survivors of
disaster.
V) Occupational Stress
Occupational stress or Work-related stress occurs when there is a mismatch between the
demands of the job and the resources and capabilities of the individual worker to meet those
demands
According to WHO, occupational or work-related stress "is the response people may have when
presented with work demands and pressures that are not matched to their knowledge and abilities
and which challenge their ability to cope
Occupational stress can occur when there is a discrepancy between the demands of the
environment/workplace and an individual‘s ability to carry out and complete these demands
Stress is a person‘s physical and emotional response to the stressors.
Factors which are identified as potential causes of occupational stress:

 demands- relating to tasks and roles
 control- abusive supervision
 relationships- poor interpersonal relationships between manager and subordinate
 working conditions- poor management and unsatisfactory working conditions
 role- lack of participations in decision making, no clearly defined role
 support- lack of workplace support
Manifestations of Occupational Stress
PSYCHOLOGICAL BEHAVIORAL
 Fatigue  Drug use
 Anxiety  Alcohol intake
 Tension  Heavy smoking
 Irritability  Impulsive emotional
 Depression  behavior
 Boredom  Poor work & family
 Inability to concentrate  relationship
 Low esteem  Social isolation
PHYSIOLOGICAL  Family abandonment
47
 Increased heart rate  Sleep problems

 Increased blood pressure
 Indigestion
Module 8: Prevention of tobacco consumption
Objective: To have primary assessment and preliminary management for tobacco

consumptions
Contents: Brief introduction, clinical features of complications and management
procedure
Duration: 1 hour
Schedule: 1 Interactive presentation: 50 minute
i. Current scenario
Tobacco is a stimulant that is highly addictive due to its nicotine content.
According to the World Health Organization (WHO) 21% of the global population aged
15years and above smoked tobacco in 2012. Men smoked at five times the rate of women; the
average rates were 36% and 7% respectively.
Smoking among men was highest in the WHO Western Pacific Region, with 48% of men
smoke some form of tobacco. Smoking among women was highest in the WHO European
Region at 19%.
Bangladesh is one of the largest tobacco consuming countries in the world. Over 58% of men
and 29% of women use some form of tobacco, whether smoked (both cigarettes and bidis) or
smokeless. In 2012, an estimated 46.3 million adults used some form of tobacco product,
smoked or smokeless (WHO report).
For Prevention of new incidence :
Awareness program through--- a) Academic training for health professionals b)Motivational
program c) Involved media d) Family education and awareness e) Focusing risk groups for
smoking
48
ii. Tobacco related problems
iii. Tobacco and mental disorders

49
iv. How to stop tobacco consumptions
Start your stop smoking plan with START
S = Set a quit date.
Choose a date within the next 2 weeks, so you have enough time to prepare without losing your
motivation to quit. If you mainly smoke at work, quit on the weekend, so you have a few days to
adjust to the change.
T = Tell family, friends, and co-workers that you plan to quit.
Let your friends and family in on your plan to quit smoking and tell them you need their support
and encouragement to stop. Look for a quit buddy who wants to stop smoking as well. You can
help each other get through the rough times.
A = Anticipate and plan for the challenges you'll face while quitting.
Most people who begin smoking again do so within the first 3 months. You can help yourself
make it through by preparing ahead for common challenges, such as nicotine withdrawal and
cigarette cravings.
R = Remove cigarettes and other tobacco products from your home, car, and work.
Throw away all of your cigarettes (no emergency pack!), lighters, ashtrays, and matches. Wash
your clothes and freshen up anything that smells like smoke.
T = Talk to your doctor about getting help to quit.
Your doctor can prescribe medication to help with withdrawal and suggest other alternatives. If
you can't see a doctor, you can get many products over the counter at your local pharmacy or
grocery store, including the nicotine patch, nicotine lozenges, and nicotine gum.
iii) Role of physicians to prevent tobacco consumption
 Identify a smoker (tobacco users)

 Briefly describe about the complications of smoking (tobacco use)
 Special attention to female with child bearing age group
 Describe the complications of passive smoking
 Set a plan
 Psychoeducation, counseling
 Nicotine replacement Therapy (when needed)
 Refer to higher center
 Stimulus control
 Skill Training for concern person
50
Toxic Substance in Cigarrete:

51
Module 9: Alcohol & Substance abuse
Objective: To understand about substance abuse in Bangladesh perspective and

prevention plan
Contents: Brief introduction and prevention plan
Materials: Training module, multimedia, case presentation, handout
Duration: 1 hour
Schedule: 1 Interactive presentation and case presentation: 50 minutes
Substance abuse is also known as drug abuse or more scientifically substance use disorder.
The term is popularly known as ‗drug addiction‘.
Terminology
Drug Addiction:
Addiction is defined as a chronic, relapsing brain disease that is characterized by
compulsive drug seeking and use, despite harmful consequences. It is considered a brain
disease because drugs change the brain—they change its structure and how it works. These brain
changes can be long-lasting, and can lead to the harmful behaviors seen in people who abuse
drugs
Substance use disorder is a patterned use of drugs or substance in which users consume the
substance in amount or with methods which are harmful to them or others.
Substance dependence may be defined as a state of certain physiological and psychological

phenomena induced by the periodic or persistent taking of a physical substance, detrimental to
the individual or to society or both and characterized by the following features:
i. A strong drive, need or compulsion to continue taking the drug on a continuous or

periodic basis in order to experience its psychic effect and sometimes to avoid the
discomfort of its absence (withdrawal state).
ii. The development of tolerance, with a tendency to increase the dose to produce desired
effects.
iii. Periodic or persistent use despite evidence of harmful consequences.

52
Common causes
 Availability of drugs:
i. Taking drugs prescribed by doctors.

ii. Taking drugs that can be bought legally without prescription.
iii. Taking drugs that can be obtained only from illicit sources (street drugs).
 Social pressures / peer pressures: Within the immediate social groups or friends group,
there may be pressures for a young person to take drugs.
 Inability to cope with stressful situation: Failure to academic good grade, relationship
breakup, separation, divorce, extra marital relationship etc.
 Curiosity: Young people may be curious to have taste or explore the secret meaning of
drugs.
 Frustration: Maladjustment, unemployment, repeated failures and chronic illness may

create frustration leading to substance dependence.
 Vulnerable personality: Many drug users, particularly younger people taking drugs,
appear to have some degree of personality vulnerability. Delinquency and antisocial
personality are common history among drug abusers. Low self esteem, lack of
confidence, lack of efficacy and optimization.
The clinical course
Drug abusers lie and steal in order to get their regular supply and deteriorate socially. Chronic
dependence may affect behavior adversely leading to unemployment, motoring offenses and
family problems including neglect of children. As illicit drugs are generally expensive, the
abusers may cheat or steal to obtain money. Drug abusers often keep company with one another
and they may do antisocial or criminal activity like mugging under pressure. Liver, brain and
nervous system disorders are common among substance abusers. Hepatitis-B infection, AIDS
and sexual dysfunction are also common happenings among drug abusers. A significant
percentage of substance dependents commit suicide.
 Substance Intoxication (Substance induced disorder):
Substance Intoxication occurs when a person develops a reversible set of symptoms due to the
recent use of (or exposure to) a substance. Symptoms of substance intoxication will vary
according the substance.
53
 Withdrawal syndrome:
Substance withdrawal is diagnosed based upon the behavioral, physical, and cognitive symptoms
that occur due to the abrupt reduction or cessation of substance use. Like substance intoxication,
these symptoms vary according to each specific substance.
 Relapse:
Relapse is resuming the use of a drug or a chemical substance after one or more periods
of abstinence. The term is a landmark feature of both substance dependence and substance abuse,
which are learned behaviors, and is maintained by neuronal adaptations that mediate learning and
processing of various motivational stimuli. Relapse is associated with Trigger on- which may
sudden drive a person to take drug. There is conditioning time, place and person.
Four 'D' is important in relapse prevention, these are :
-- Drinking Water
-- Deep Breath
-- Delay
-- Divert mind
 Rehabilitation: Reintegration to the society.
Bangladesh Perspective
Recently conducted national survey on mental health in Bangladesh demonstrated that 0.63% of
the adult population were suffering from substance dependence with male suffering more
(96.4%) and female (3.6%). Another survey showed 0.8% children having substance use
problem (Rabbinate al 2009).
Common abusing substances in Bangladesh
 Cannabis- Marijuana, gaja, chaurosh, hashish

 Stimulants : Amphetamine (Yaba)
 Opioids- Phensidyl, heroin, morphine, pethedine, tidigesic
 Benodiazipines- Diazepam, nitrazepam, clonazepam etc.
 Alcohol
 Volatile substances
Prevention Plan
 Supply reduction
 Demand reduction
 Harm reduction
54
Substance related disorders
The DSM-5 category called Substance-Related and Addictive Disorders includes two sub-
categories:
 Substance use disorders and
 Substance-induced disorders.
Substance-induced disorders
Substance-induced disorders include medical conditions that can be directly attributed to the use
of a substance. These conditions include intoxication, withdrawal, substance-induced
delirium, substance-induced psychosis, and substance-induced mood disorders , Substance
induced anxiety disorder, Substance induced sleep disorder.
Substance use disorders

Substance use disorders include substance abuse and substance dependence. In DSM-IV, the
conditions are formally diagnosed as one or the other, but it has been proposed that DSM-
5 combine the two into a single condition called "Substance-use disorder
Intoxication &withdrawal of different substances

Heroin / Pethidine/ Phensedyl(Codeine)/ Tidigesic (Buprenorphine)
Withdrawal symptoms of opioids (Heroin / Pethidine / Phensedyl/ Tidigesic)
Common Presentation
dilated pupils coughing, Sleep disturbance
rhinorrhoea sneezing Restlessness
lacrimation yawning
bodyache gooseflesh
Followed by
Profuse sweating, fever, vomiting and dehydration.
These symptoms usually appear within 12-14 hours of the last dose. They are at their worst at
48-72 hours after the initial withdrawal and thereafter the symptoms gradually subside and may
eventually disappear in about a week.
55
Marijuana, charosh, hashish (cannabis sativa)
The active constituents are tetrahydrocannabinols (THC). The drug produces a dreamy state of
consciousness in which ideas seem disconnected, uncontrollable and freely flowing. Perception
of time, color and space is distorted and enhanced. There is also an extreme feeling of well-being
and excitement which is referred to as ―high‖. Chronic use of cannabis can lead to a state of
apathy called amotivational syndrome.
Amphetamine
Amphetamine is a psychostimulant, which is now frequently used in Bangladesh. The drug

stimulates the mental condition of the individual and increases the quantity of the activity but
quality decreases. On withdrawal, depression like symptoms appear and long term use may give
rise to schizophrenia like symptoms.
Alcohol
 Delirium tremens
is a withdrawal phenomenon of alcohol dependence. The drugs producing physical dependence

usually have strong withdrawal symptoms. Cannabis and benzodiazipines usually have
psychological dependence and withdrawal symptoms are not prominent. Restlessness, sleep
disturbance and uneasiness may be the common withdrawal symptoms in their cases.
Specific treatment plan

56
Management:

History taking, Investigations, Diagnosis
Plan of treatment: Community/Outpatient department/inpatient department/ Refer to
higher centers
General management:
Nutrition, safety
Pharmacological treatment: According to substance used
Nonpharmacological treatment: Motivational intervention, behavior modification, life
style change, rehabilitation, Psychotherapy and life style change--> Social skill training,
anger management, stress management, improving coping mechanism, Family therapy.
iv. Detoxification, rehabilitation (Any drug must be prescribed by specialists only)

Assessment Detoxification Rehabilitation & after care
Observation Drug withdrawal Psychotherapy to maintain

motivation
History I.V. Fluid
Social help
Diazepam Social activities : Clubs,
Psychiatric examination engagement with recreational
Antipsychotics, activities
Physical examination
Antidepressants
Religious works
S/S of drug intake and
withdrawal syndrome Antihistamines Vocational guidance
Social examination : Whether Mood stabilizers Suitable employment

any social etiological
Family support
factorpresent Clonidine
H2 Blocker
Motivational interviewing and relapse prevention
Motivational interviewing:
57
The spirit of Motivational Interviewing is based on three key concepts:
 collaboration between the therapist and the person with the addiction, rather than
confrontation by the therapist;
 drawing out the individual's ideas, rather the therapist imposing their ideas; and
 autonomy of the person with the addiction, rather than the therapist having authority over
them.
Relapse prevention:
Different triggers have been identified as possible precursors for relapse. By identifying these
triggers, it has become possible to develop prevention techniques which can be used to combat
each of them. The most common relapse triggers include:
* The individual can experience overconfidence. This can mean that they are not prepared when
things get hard.
* Life in recovery can take a bit of getting used and some people may experience periods of self-
pity. This is a dangerous emotion because it can sap motivation.
* Those people who have unrealistic expectations can become disappointed.
* If the individual_ behaves dishonestly_, it can lead them right back to addiction.
* Occasionally, people in recovery will experience periods of depression. This can take a lot of
the satisfaction out of sobriety.
* Those who continue other types of substance abuse will be increasing their chances of relapse.
* Taking recovery for granted leads to complacency. This then means that the individual is no
longer doing those things they need to do in order to remain sober.
58
Module 10: Treatment approach in mental disorders and substance abuse
Objective: To provide preliminary orientation regarding pharmacological and psychological

treatment
Contents: Brief introduction about psychotropic and non-pharmacological management
Methods: Lecture, discussion, brain storming
Materials: Training module, multimedia
Duration: 1 hour
Schedule: Interactive presentation and case presentation: 50 minutes each
Individual feedback and open discussion: 10] minute
i)Common medications
Classification of psychotropic drugs (drugs used in psychiatry)
Group of drugs
 Antipsychotic
 Antidepressant
 Mood stabilizer
 Anxiolytic
 Hypnotic
 Psycho stimulant
 Cognitive enhancers
Other drugs used in psychiatry
Drug group Name of drugs Clinical use

Anti-parkinsonian Procyclidine Drug induced extra pyramidal syndrome
Anti-epileptic Carbamazepine, valproate, Bipolar mood disorder, schizophrenia, schizo
phenytoin, topiramate, affective disorder, impulse control disorder
phenobarbiton
Pharmacotherapy Clonidine, Disulfiram Withdrawal from opioid, alcohol,
of chemical Methadone, Naltrexone, benzodiazepine
dependence and Alcohol dependence
abuse Detoxification in opioid dependence
59
Thyroid hormones Levothyroxine Adjuvant to antidepressant
Antipsychotic agents
Common Indications
 schizophrenia,
 schizoaffective disorder,
 delusional disorder,
 brief psychotic disorder,
 manic episode of bipolar mood disorder,
 major depressive disorder with psychotic features and
 anxiety disorders : in low dosages.
Dose schedule for common antipsychotic drugs

Drug Minimum(mg/day) Maximum(mg/day)
first episode relapse
Haloperidol 2 5 30
Chlorpromazine 200 300 1000
Aripiprazole 15 15 30
Risperidone 2 4 16
Olanzapine 5 10 20
Quetiapine 150 300 750
Fluphenazine depot 6.25/week 50/week
Common unwanted effects of antipsychotic drugs

Antidopaminergic Acute dystonia, akathisia, parkinsonism, tardive dyskinesia
effects
Antiadrenegiceffec Sedation, postural hypotension, inhibition of ejaculation
ts
Anticholinergic Dry mouth, reduced sweating, urinary hesitancy and retention,
effects constipation, blurred vision
Others Cardiac arrhythmias, weight gain, amenorrhea, galactorrhoea,
hypothermia, sensitivity reactions
Some common antidepressants
 Amitriptyline, imipramine, clomipramine (TCAs)

 Maprotyline
 Fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram
60
(SSRIs)
 Venlafaxine
 Mirtazapine
Indications of antidepressants
 major depression,
 anxiety disorders,
 panic disorder ( imipramine, SSRIs)
 childhood enuresis (imipramine),
 insomnia (amitriptyline),
 agoraphobia with panic attacks (imipramine and clomipramine),
 chronic pain syndromes (amitryptyline,maprotline), and
 bulimia (imipramine).
 obsessive-compulsive disorder (clomipramine, SSRIs).
Dosing
With any of the TCA drugs, it is best to start with a relatively low dose (e.g. 25 mg) which can
then be increased slowly. The response to all antidepressants usually takes 2 weeks and patients
who are going to respond will show some positive effects by 4-6 weeks. To prevent early
relapse, longer-term maintenance treatment of at least 6-12 months is to be practiced. It can be
increased upto maximum recommended dosage of 150 mg
The SSRIs have easy dosing schedule. Fluoxetine is usually initiated at 20 mg/day, and the
maximum recommended dosage is 80 mg/day. The initial and maintenance dosage of paroxetine
should be 20 mg/day for 2-3 weeks. If no response is seen, the dose may be increased weekly by
10 to 20 mg/day until a maximum dosage of 50 mg/day is achieved.
Sertraline is usually initiated at 50 mg/day, may be continued for 3-4 weeks, and, if no response
is seen, the dose may then be increased weekly by 50 mg/day until a maximum of 200 mg/day is
achieved.
Mood stabilizers
Lithium, carbamazepine, valproic acid, lamotrigine, gabapentin etc.
Indication:
1. Prophylactic treatment of bipolar mood disorder
2. To control mania
3. To enhance the effect of antidepressants in major depressive episode
Anxiolytics
Anxiolytic agents are the most commonly used psychotropic drugs. They are divided into many
subclasses, of which the benzodiazepines are the most frequently prescribed.
61
Benzodiazepines
Benzodiazepines are the drug of choice in anxiety. When treating a patient with generalized
anxiety disorder, the clinician should begin at 2 mg diazepam three times a day, with increases to
a maximum daily dose of 40 mg. A modal dosage of diazepam for generalized anxiety disorder
is 15-20 mg/day.
Diazepam, clonazepam, and lorazepam may all be effective in ameliorating or preventing panic
symptoms. Clonazepam is used in doses of 1-3 mg/day. Alprazolam is indicated for anxiety
associated with depression and panic disorder. The starting dosage of alprazolam in generalized
anxiety and panic disorder should be 1.5 mg/day or less, given in divided doses, with a gradual
increase in dosage as tolerated by the patient. The use of alprazolam in panic patients may
require doses up to 10 mg/day, but generally, 4-5 mg/day is used.
Beta-adrenoceptor antagonists
Clinicians should use propranolol in patients with peripheral symptoms of anxiety such as
tachycardia or with lithium-induced tremor, at 10 mg bid and increase to approximately 60-160
mg/day. Side effects of the β-blockers include bradycardia, hypotension, weakness, fatigue, ,
impotence, and bronchospasm.
Anti-depressants
Antidepressants in low dosages are usually anxiolytics.
Common Hypnotics: Dosages and action
Drug Therapeutic dose Time of onset Duration of

mg/day (Adult) (minutes) action
Diazepam 5-10 30-60 Long
Nitrazepam 5-10 20-50 Long
Flurazepam 15-30 30-60 Long
Zopiclone 3.75-7.5 15-30 Medium
Psycho-stimulants (e.g.: Methylphenidate)are currently approved for ADHD
Essential drugs required at the Primary Health Care ( PHC) level
 Amitryptyline
 Sertraline
 Haloperidol
 Sodium Valproate
 Phenobarbitone
 Procyclidine
62
ii. Physical treatment

Electroconvulsive therapy (ECT) is indicated for severe depressive disorders with risk of
suicide, depressive stupor, depression with food refusal, depressive psychosis, puerperal
psychoses, catatonic schizophrenia, schizophrenia and mania not responding to drug treatment.
Contrary to common belief, ECT is relatively safe without any hazardous effects.
iii) Nonpharmacological management
Counseling
Counseling is a process of communication which involves two persons, a counselor and a client,
denotes a wider procedure concerned as much with emotion as with knowledge. There are many
counseling for variety of problems, and in a variety of settings (general medical practice,
psychiatric care and in a student health service).
Approaches to counseling
 Identify and list problems that are causing distress
 Consider courses of action that might solve or reduce each a problem
 Select a problem and course of action that appear feasible and likely to succeed
 Review the results and then either select another problem if the first course of action has
succeed or another course of action if the first one has not succeeded.
Psychotherapy
Psychotherapy is the main treatment for patients with hysteria, anxiety disorder, phobic
disorders, obsessive-compulsive disorder, sexual disorder and other forms of minor mental
disorders. Even it is helpful in headache, migraine, hypertension, ischemic heart disease and
other chronic physical illness. Now a days it is part and parcel of general practice.
Behavior therapy
Behavior therapy may be defined as an attempt to alter human behavior by the process of
specific psychological techniques of overcoming maladaptive behavior. This type of therapy
emphasizes on behavior and its analysis followed by changing or correction of behavior.
Behavior therapy is usually used for the treatment of anxiety disorder, phobic disorder, obsessive
compulsive disorder or any neurotic symptoms which in the context we defined as any persistent
habit of maladaptive behavior acquired by learning.
Rehabilitation
Rehabilitation is the employment of the someone according to his/her potentiality through
training. eg: computer works, handicrafts, tailoring.
63
References:
1. Herrman H, Saxena S, Moodie R, editors. Promoting Mental Health: concepts, emerging

evidence, practice: report of the World Health Organization, Department of Mental Health and
Substance Abuse in collaboration with the Victorian Health Promotion Foundation and the
University of Melbourne. Geneva: World Health Organization; 2005.
2. Patel V. Where there is no psychiatrist. A mental health care manual. London: Royal
Collage of Psychiatrists; 2003.
3. Kitchener BA, Jorm AF. Mental Health First Aid Manual. Canberra: Centre for Mental Health
Research; 2003

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1

Target Group: Doctors, Nurses and other Health Professionals

 Contributors and Reviewers

1. Module 1: Introduction To Mental Health And Mental Disorders

2. Module 2: Common phenomenology of mental disorders

3. Module 3: Minor mental Disorders

4. Module 4: Major mental Disorders (1)

5. Module 5: Major mental Disorders (2)

6. Module 6: Childhood mental disorders

7. Module 7: Mental health in special situation:

8. Module 8: Prevention of tobacco consumption

9. Module 9: Alcohol & Substances abuse (1)

 Contributors and Reviewers

ASD: Autism Spectrum Disorder

 Recognize symptoms and early identification of mental disorders

Structure of the manual

This manual outlines a training program that provides an introduction to mental

Module 1: Introduction to Mental Health and Mental Disorders

Objective: To provide information about mental disorders, causes and types.

i) Introduce yourself (ice breaking)

What is mental health:

What is mental disorders

Health professionals have an important role to play in relation to mental health.

Causes of mental disorders

Multiple factors for Mental Disorders:

v) Types of mental disorders

Mental disorders can be divided into two main categories:

Some common mental disorders:

vi) Mental Health: Bangladesh Perspective

Current scenario : infrastructures & Human resources

Module 2: Common phenomenology of mental disorders

Affect: Emotion felt at the moment of time which can be observed.

Euphoria: exaggerated feelings of well being.

ii) Symptoms of mental disorders

Module 3: Minor mental Disorders

Objective: Primary diagnosis and preliminary treatment Anxiety disorders

i) Generalized Anxiety Disorder (GAD)

1. Psychological symptoms of GAD

Fearful anticipation, irritability,

ii) Obsessive Compulsive Disorder

iii) Phobic Anxiety Disorders

Agoraphobia (e.g. being on a bridge, traveling in bus or train or automobiles or planes)

i) Palpitation, pounding heart or increased heart rate

Panic disorder is usually defined as 4 or more panic attacks in a month or apprehension of

v) Conversion Disorder (dissociative disorder)

Clinical syndromes of conversion disorder

B. Dissociative symptoms ( Mental symptoms)

Common characteristics of conversion disorder

7. Symptomatic anomaly - The symptoms produced by the conversion disorder usually do

Difference between epileptic fit and fit from conversion disorder

Management of anxiety disorders:

History taking, Investigations, Diagnosis

Plan of treatment: Community/Outpatient department/Indoor admission/Refer to

Nutrition/Safety security of patients

Pharmacological treatment: Anxiolytic drugs, Antidepressants in low dose

Nonpharmacological treatment: Psycho education, brief individual psychotherapy,

Follow up: Drug Compliance, Assessment of the symptoms, functional improvement

Module 4: Major mental Disorders (1)

Objective: To diagnose and preliminary treatment of Schizophrenia

The lifetime prevalence of schizophrenia around the world about 1%.

The exact cause of schizophrenia is unknown.

There is no single pathognomic sign or symptom for diagnosis of schizophrenia.

 There are positive & negative symptoms of schizophrenia

Schneider’s first rank symptoms