Mental Health Notes Units-1

252SW013 MENTAL HEALTH & PSYCHIATRIC DISORDER
DMI-ST. JOHN THE BAPTIST UNIVERSITY
LILONGWE, MALAWI
Module Code: 252SW013
Subject Name: Mental Health & Psychiatric Disorder
Detail Notes
School of Social Work
Module Teacher: Joy Wanozga Chione
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Unit I
History of Psychiatry - Concept of Mental Health - Mental Health in Malawi - Mental Health
Problems - Changing Trends in Mental Health Care - View of Mental Health and well- being.
Unit II
Psychiatric Interviewing - Case History Recording and Mental State Examination - Psychiatric
Assessment - Psycho-Social and Multidimensional - Use of Mental Health Scales in assessment
and intervention.
Unit III
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 – Schizophrenia - Mood (Affective Disorders) - Neurotic stress related and
somatoform disorders.
Unit IV
Study of the Clinical Signs, Symptoms, Causes and Treatment of: Behavioural syndromes
associated with physiological disturbances and physical factors - disorders of adult personality
and behaviour - Mental Retardation - Disorders of Psychological Development Behavioural and
emotional disorders with onset in childhood and adolescence- suicide
Unit V
National Mental Health Programme – Mental Health Act, District Mental Health Progrramme.
Socio-cultural factors in Psychiatry – Magico-religious practices – Cultural beliefs – Stigma.
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Contents
1.0 Unit 1.....................................................................................................................................................4
1.1 Concept of mental health......................................................................................................................4
1.2 Meaning of mental health.....................................................................................................................4
1.3 Definition...............................................................................................................................................4
1.4 CHARACTERISTICS OF MENTAL HEALTH................................................................................................5
1.4.1 Importance of Mental Health.............................................................................................................5
1.4.2 Factors affecting mental health......................................................................................................6
1.4.5 Mental Health Problem Symptoms, Causes and Effects.................................................................7
Symptoms....................................................................................................................................................9
Examples of signs and symptoms include....................................................................................................9
Causes.........................................................................................................................................................9
Risk factors................................................................................................................................................10
Complications (mental problems).............................................................................................................11
Prevention.................................................................................................................................................11
2.0 UNIT 2..................................................................................................................................................12
Introduction...............................................................................................................................................12
AIM OF HISTORY TAKING...........................................................................................................................12
SETTING OF THE INTERVIEW.....................................................................................................................12
DURATION OF THE INTERVIEW..................................................................................................................13
GENERAL PRINCIPLES OF INTERVIEWING..................................................................................................13
Consent for the Interview..........................................................................................................................13
History of Present Illness...........................................................................................................................17
Past Psychiatric History.............................................................................................................................18
Past Medical History..................................................................................................................................19
Past Medical History..................................................................................................................................20
Family History............................................................................................................................................20
Personal History........................................................................................................................................21
Family History............................................................................................................................................21
TECHNIQUES OF HISTORY TAKING.............................................................................................................23
CLOSING OF INTERVIEW............................................................................................................................24
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INTERVIEWING THE DIFFICULT PATIENTS..................................................................................................25

MEDICAL RECORDS....................................................................................................................................25
SUM UP.....................................................................................................................................................27
3.0 UNIT 3..................................................................................................................................................27
3.1 Symptoms, Causes and Treatment......................................................................................................27
Causes.......................................................................................................................................................28
Symptoms..................................................................................................................................................28
Treatment..................................................................................................................................................29
Schizoaffective Disorder............................................................................................................................29
Causes of Schizoaffective Disorder............................................................................................................30
Diagnosis of Schizoaffective Disorder........................................................................................................31
4.0 UNIT 4..................................................................................................................................................33
4.1 Disorders of adult personality and Behavior.......................................................................................33
Symptoms..................................................................................................................................................33
MENTAL RETARDATION.............................................................................................................................38
What is intellectual disability?...................................................................................................................38
What are the signs of intellectual disability in children?...........................................................................39
What causes intellectual disability?...........................................................................................................39
The most common causes of intellectual disability are:............................................................................40
Childhood behavioural disorders...............................................................................................................41
INTRODUCTION.........................................................................................................................................41
CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS.......................................................................42
Challenging behaviours.............................................................................................................................42
Disruptive behaviour problems.................................................................................................................43
ADHD: Attention deficit hyperactivity disorder.........................................................................................44
COMPLICATIONS OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS......................................47
MANAGEMENT OF BEHAVIOURAL AND EMOTIONAL DISORDERS IN CHILDREN.......................................47
Parental skills training...............................................................................................................................49
5.0 UNIT 5..................................................................................................................................................49
National Mental Health Programme – Mental Health Act, District Mental Health Progrramme. Socio-
cultural factors in Psychiatry – Magico-religious practices – Cultural beliefs – Stigma..............................49
Health services..........................................................................................................................................49
Mental health resources and services.......................................................................................................49
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Staffing......................................................................................................................................................50
Mental health policy and legislation..........................................................................................................50
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1.0 Unit 1
1.1 Concept of mental health
One of the most important aims of education is to help the individual in making adjustment with
the changing environment. It is the mental health which helps the person to adjust in the
environment. It is a state or condition on which an individual feels a sense of well-being. This
condition also provides an individual the capacity to be resilient to the stresses her / meets and to
respond to these challenges without having to compromise his well-being. This also makes him
productive and fruitful for himself and his community.
1.2 Meaning of mental health

• It is a state or condition on which an individual feels a sense of well-being.
• It is a condition and a level of social functioning which is socially and personally

satisfying in all aspects of life.(social. physical., spiritual, and emotional)
• How we feel about ourselves, how we feel about others and how we are able to meet the
demands of life.
• A mentally healthy person lives a “fuller, happier, harmonious and effective life”.
1.3 Definition
A state of emotional and psychological well-being in which an individual is able to use his or her
cognitive and emotional capabilities function in society, and meet the ordinary demands of
everyday life.
WHO defines health as – A state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity (2001).
• WHO: 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.
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• Hadfield: “mental health is the full and harmonious functioning of the whole
personality”.
1.4 CHARACTERISTICS OF MENTAL HEALTH

• Able to live happily and peacefully
• Is not disturbed by mental conflicts
• Has a true self-appraisal of his strength and weakness
• Is cooperative with others and has a feeling of security
• Has diverse and varied interest and lives constructively
• Is rational in approach
• Is emotionally stable and socially mature
• Has high degree of frustration tolerance
• Has good physical health
1.4.1 Importance of Mental Health

• Mental health has much wider scope than physical health as it aims for the development
of wholesome balanced and integrated personality.
• Mental health is very important because of following things:
• Helps in the development of desirable personality – Mental health helps in the

development of a wholesome, well-balanced and integrated personality.
• Helps in proper emotional development – The individual who enjoy good mental health
are supposed to demonstrate proper emotional maturity in their behaviours. On the other side,
those who are tense, disintegrated and mentally unhealthy demonstrate sudden emotional
outburst.
• Helps in proper social development- Ones mental health helps one in becoming sociable
and establishing proper social relationships in the society.
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• Helps in proper moral development – The individuals who enjoy sound mental health are
usually found to behave as a man of integrity and character by following the ethical standards of
the society.
• Helps in proper artistic development – Proper mental health helps the individual in the
development of appropriate aesthetic sense, artistic taste and refined temperament.
• Helps in seeking proper adjustment – A mentally healthy individual is an adjusted person.

He is able to adjust his needs as per the demands of the situation and well-being of the society.
• Helps in seeking goals of life – Optimum mental health always helps the individuals to
divert his energies in full capacity for the realization of the goals.
• Helps in progress of the society – Mental health helps the individual to develop as well
balanced useful citizens who are conscious not only of their rights but also of their
responsibilities.
• Helps in prevention of mental illness – A sound mental health and balanced personality
has enough resistance to fight against the odds of life and bear the accidental stresses and strains
of life in comparison to those with impaired mental health. We know that every individual is a
unique being. Along with the features and characteristics shared with over people, i.e. the
universal ones, each individual had many particular characteristics.
• The individual is born as a man, but only gradually with the help of adults and through
his own activity, becomes an individual. As for the adult’s influence, the decisive role in this
process is played by education which is purposeful, planned, professional and institutionalized.
However, the development of the individual is influenced both by internal and external
influences. In the process of education and development of personality, the pupil is not only the
object of education but also the subject of his own development. These subjective tendencies are
intelligence, attitude, aptitude, creativity and interest which are particularly the concern of
psychology.
1.4.2 Factors affecting mental health

• In the present Materialistic society- individual needs and wants have multiplied resulting
in dissatisfaction, alienation and frustration.
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• The conflict provoking and frustrating situations are further accentuated by general
atmosphere of insecurity.
• The competitive motive results in aspirations far beyond one’s abilities which has
resulted in excessive tension, anxiety, fear and guilt feeling.
• The hold of family and religion over men has become loose resulting in a life without
moorings and values
• Social prejudices and stereo types have precipitated social conflicts which in turn have
tended to disrupt the individual mental balance
(Changing Trends in Mental Health Care)
• Attention to life style: if we are doing too much or too little in our lives, mental health
can suffer. We need a good balance between work or study and leisure pursuits.
• Social contact: having contact with others whose company we enjoy, whether at school,
work, at home or as a member of a club, helps to develop social interaction.
• Reviewing our lives from time to time: This involves considering what our aims and
goals in life are and whether we are taking steps to achieve them. Problems can arise when we
feel life is not satisfying and fulfilling.
• Awareness of how mind and body interact: just as our state of mental health can affect
our physical health and mental health, the reverse is also true. If diet, sleep and exercise are
neglected and inadequate, not only our bodies will suffer but also our minds.
• Having people in our lives we trust: it is important to have someone to go to with our
problems and worries, such as friends, teachers or family members.
• Awareness of what can go wrong: just be conscious of what can go wrong. Realize that
tiredness and irritability, if ignored, might lead to more serious stress-related problems.
• Taking steps to resolve problems- be aware of problems and seek help if necessary.
1.4.5 Mental Health Problem Symptoms, Causes and Effects

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.
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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 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.
Overview
Mental illness, also called mental health disorders, 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.
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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).
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
 Problems with alcohol or drug use
 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, headaches, or other unexplained aches and pains.
Causes
Mental illnesses, in general, are thought to be caused by a variety of genetic and environmental
factors:
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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 and
other emotional disorders.
Risk factors
Certain factors may increase your risk of developing a mental illness, including:
 A history of mental illness in a blood relative, such as a parent or sibling 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 assault
 Use of alcohol or recreational drugs
 A childhood history of abuse or neglect
 Few friends or few healthy relationships
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 cases 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.
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Complications (mental problems)

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 primary 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.
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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 primary care provider if you have
trouble sleeping or if you have questions about diet and physical activity.
2.0 UNIT 2
Introduction
Psychiatric interview is the most essential and also the most important aspect in the evaluation
and care of persons with mental illness. All mental health professionals, regardless of theoretical
orientation, must struggle to learn and master this skill of listening and constructing both, the
patient’s symptomatology and his/her life history. While the biological or phenomenological
oriented professional try to identify patient’s symptomatology; cognitive–behaviorally oriented
professional look for distortions, assumptions or inferences; psycho-dynamically oriented
professional look for hints at unconscious conflicts; behaviorists search for covert patterns of
anxiety and stimulus associations. Therapeutic listening requires sensitivity to the storyteller and
an ability to integrate a patient orientation with a disease focus. Listening to someone requires
time, concentration, imagination, a sense of humor, and an attitude that places the patient as the
central focus of his or her own life story
AIM OF HISTORY TAKING

The major purpose of the initial interview is to obtain information that will help to establish a
criteria-based diagnosis. This diagnosis is useful not only in identifying and labeling the patients
problems but also in predicting the course of the illness, the prognosis and the ensuing treatment
decisions. A well-conducted psychiatric interview results in the understanding of the bio-
psychosocial aspects of the disorder and provides the information necessary to develop an
individualized treatment plan.
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SETTING OF THE INTERVIEW

The setting in which the psychiatric interview takes place include psychiatric inpatient units,
medical/ surgical inpatient units, emergency rooms, outpatient offices, etc. For having a proper
interview, the atmosphere in which interview is held is of paramount importance. The interview
room should be relatively sound proof. The furnishings and the decor should be pleasant and not
distracting. It is suggested that the interviewer’s chair and the patient’s chair be of relatively
equal height so that the interviewer does not tower over the patient (or vice versa) and the two
should be seated approximately 4 to 6 feet apart. The mental health professional should not be
seated behind a desk. The therapist should dress professionally and be well groomed.
Distractions should be kept to a minimum. Unless there is an urgent matter, there should be no
telephone or beeper interruptions during the interview. The patient should feel that the time has
been set aside just for him or her and that for this designated time he is the exclusive focus of the
mental health professionals attention.
DURATION OF THE INTERVIEW

The length of time for the interview and its focus vary, depending on the setting, the specific
purpose of interview, and other factors (including availability of professional services). For an
initial interview, 45 to 90 minutes is generally required. Despite this, more than one session may
be necessary to complete an evaluation. For medically ill patients or in acutely disturbed or
violent patients, the time duration of one sitting may be 20 to 30 minutes or less. In these
situations, a number of brief sessions may be necessary. The clinician must accept the reality that
the history obtained is never complete or fully accurate. An interview is continuous process and
some aspects of the evaluation are ongoing, as the patient learns to trust the therapist, he/she will
possibly reveal more information that will guide further exploration and treatment.
Nevertheless, there are basic principles and techniques that are important for all psychiatric
interviews and these will be discussed in the next section. There are special issues in the
evaluation of children that will not be addressed. This section focuses on the psychiatric
interview of adult patients only.
GENERAL PRINCIPLES OF INTERVIEWING
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Consent for the Interview

Prior to the interview, the professionals should introduce her/him self and, depending on the
circumstances, may need to identify why they are speaking with the patient. Unless implicit (the
patient coming to the office), consent to proceed with the interview should be obtained and the
nature of the interaction and the approximate amount of time for the interview should be stated.
A crucial issue is whether the patient is, directly or indirectly, seeking the evaluation on a
voluntary basis or has been brought involuntarily for the assessment. This should be established
before the interview begins, as this information will guide the interviewer especially in the early
stages of the interview process.
Privacy and Confidentiality
Confidentiality is the most important component of the patient–therapist relationship. The

interviewer should make every attempt to ensure that the content of the interview cannot be
overheard by others. Sometimes, in a hospital unit or other institutional setting, this may be
difficult. If the patient is sharing a room with others, an attempt should be made to use a different
room for the interview. If this is not feasible, the interviewer may need to avoid certain topics or
indicate that these issues can be discussed later when privacy can be assured. Generally, at the
beginning, the interviewer should indicate that the content of the session(s) will remain
confidential except for what needs to be shared with the referring physician or treatment team.
Some evaluations, including forensic and disability evaluations, are less confidential and what is
discussed may be shared with others. In those cases, the interviewer should be explicit in stating
that the session is not confidential and identify who will receive a report of the evaluation. This
information should be carefully and fully documented in the patient’s record.
A special issue concerning confidentiality is when the patient indicates that he intends to harm
another person. When the evaluation suggests that this might indeed happen, the mental health
professional has a legal obligation to warn the potential victim and must inform the appropriate
authorities depending on the law of the state (the law concerning notification of potential victim
varies from place to place).
Often members of the patient’s family, including spouse, adult children, or parents come with the
patient to the first session or are present in the hospital or other institutional setting when the
mental health professional first sees the patient. If a family member wishes to talk to the mental
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health professional, it is generally preferable to meet with the family member(s) and the patient
together at the conclusion
patient before the mental health professional speaks to the relative. While interviewing the
relatives, the mental health professional should not bring up material that the patient has shared
but listen to the input from the family member.
In educational and occasionally forensic settings, there may be occasions when the session is
recorded. The patient must be fully informed about the recording and how the recording will be
used. Occasionally in educational settings, one-way mirrors may be used as a tool to allow
trainees to benefit from the observation of an interview. The patient should be informed of the
use of the one-way mirror and the category of the observers and be reassured that the observers
are also bound by the rules of confidentiality. These devices will have an impact on the interview
that the mental health professional should be open to discussing as the session unfolds. Issues
concerning confidentiality are crucial in the evaluation/treatment process and may need to be
discussed on multiple occasions.
Respect and Consideration
As should happen in all clinical settings, the patient must be treated with respect, and the
interviewer should be considerate of the circumstances of the patient’s condition. The patient is
often may be experiencing considerable pain or other distress and frequently have the feeling of
vulnerability and uncertainty of what may happen. Because of the stigma of mental illness and
misconceptions about mental health disorders, the patient may not be comfortable about seeing a
mental health professional. The professional should be aware of these issues and attempt to
decrease the distress.
Rapport/Empathy
Respect for and consideration of the patient will contribute to the development of rapport. In the
clinical setting, rapport can be defined as the harmonious responsiveness of the physician to the
patient and the patient to the physician. It is important that the patient increasingly feels that the
evaluation is a joint effort and that the professional is truly interested in his story. Empathic
interventions (“that must have been very hard for you”) or even a nonverbal response (with
appropriate facial gestures) further increase the rapport. Empathy is understanding what the
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patient is thinking and feeling and occurs when the professional is able to put oneself in the
patient’s place while at the same time maintaining objectivity. Head nodding, putting down one’s
pen, leaning towards the patient, or a brief comment, “I see,” can accomplish this objective and
simultaneously indicate that this is important material. In fact, the large majority of empathic
responses in an interview are nonverbal. While empathy is essential, the professional should not
forget to retain his/her objectivity. Maintaining objectivity is crucial in a therapeutic relationship
and differentiates empathy from identification. With identification, the professional not only
understands the emotion but also experiences it to the extent that he or she loses the ability to be
objective. This is especially important in those patients who as part of their illness already have
significant boundary problems (e.g., individuals with borderline personality disorder).
Patient–Physician Relationship
The patient–physician relationship is the core of the practice of medicine. While the relationship
between any one patient and physician will vary depending on each of their personalities and
past experiences as well as the setting and purpose of the encounter, there are general principles
that, when followed, help to ensure that the relationship established is helpful. The patient comes
to the interview seeking help. This desire for help motivates the patient to share information and
feelings that are upsetting and often private. The patient is willing, to varying degrees, to do so
because of a belief that the professional has the expertise, by virtue of training and experience, to
be been very hard for you”) or even a nonverbal response (with appropriate facial gestures)
further increase the rapport. Empathy is understanding what the patient is thinking and feeling
and occurs when the professional is able to put oneself in the patient’s place while at the same
time maintaining objectivity. Head nodding, putting down one’s pen, leaning towards the patient,
or a brief comment, “I see,” can accomplish this objective and simultaneously indicate that this is
important material. In fact, the large majority of empathic responses in an interview are
nonverbal. While empathy is essential, the professional should not forget to retain his/her
objectivity. Maintaining objectivity is crucial in a therapeutic relationship and differentiates
empathy from identification. With identification, the professional not only understands the
emotion but also experiences it to the extent that he or she loses the ability to be objective. This
is especially important in those patients who as part of their illness already have significant
boundary problems (e.g., individuals with borderline personality disorder).
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There are two additional essential ingredients in a helpful patient–physician relationship. One is
the demonstration by the physician that he or she understands what the patient is stating and
emoting. The other essential ingredient in a helpful patient–physician relationship is the
recognition by the patient that the physician cares. The patient–physician relationship is
reinforced by the genuineness of the physician.
Patient-Centered
A psychiatric interview should be patient-centered. That is, the focus should be on understanding
the patient and his/her life story. The patient’s early life experiences, family, education,
occupation(s), religious beliefs and practices, hobbies, relationships, and losses are some of the
areas that, in concert with genetic and biological variables, contribute to the development of the
personality. An appreciation of these experiences and their impact on the person is necessary in
forming an understanding of the patient. It is especially important that the resulting treatment
plan be based on the patient’s goals and not on the professional’s goals. Numerous studies have
demonstrated that often the patient’s goals for treatment (e.g., continuing education) are not the
same as the professional’s (e.g., decrease in psychotic symptoms). Traditionally, medicine has
focused on illness and deficits rather than strengths and assets. A patient-centered approach
focuses on strengths and assets as well as deficits.
Safety and Comfort
Both the patient and the interviewer must feel physically safe. On occasions, especially in
hospital or emergency room settings, this may require other staff being present or the door to the
room where the interview is conducted left ajar. In emergency room settings, it is generally
advisable for the interviewer to have a clear, obstacle free exit path. Patients, especially if
psychotic or confused, may feel threatened and need to be reassured that they are safe and the
staff will do everything possible to ensure their safety. The interview may need to be shortened
or quickly terminated if the patient becomes more agitated and threatening. Once issues of safety
have been assessed .
History of Present Illness

The present illness is a description of the evolution of the symptoms of the current episode. In
addition, the account should also include any other changes that have occurred during this same
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time period in the patient’s interests, interpersonal relationships, behaviours, personal habits,
physical health, biofunctions and the extent of sociooccupational dysfunction. The chronology of
patient’s symptoms must be maintained. The presence or absence of stressors should be
established, and these may include situations at home, work, school, legal issues, medical
comorbidities, and interpersonal difficulties. Also important are factors that alleviate or
exacerbate symptoms such as medications, support, coping skills, or time of day. The essential
questions to be answered in the history of the present illness include what (symptoms), how
much ( severity), how long, and associated factors. It is also important to identify why the patient
is seeking help now, and also what were the ‘precipitating’ and ‘maintaining’ factors. If any
treatment has been received for the current episode, it should be defined in terms of what was
done (e.g., psychotherapy or medication), and the specifics of the modality used (e.g., doses of
medication), adequacy of the treatment and the effect of these interventions. Often it can be
helpful to include a psychiatric review of systems in conjunction with the history of the present
illness to help rule in or out other psychiatric diagnoses with pertinent positive and negative
history. This may help to identify whether there are comorbid disorders or disorders that are
actually more bothersome to the patient but are not initially identified for a variety of reasons.
It is also advisable to record a negative history of what all symptoms were not present during the
course of the present illness, as this is often useful in differential diagnosis.
Past Psychiatric History

In the past psychiatric history, the clinician should obtain information about all psychiatric
illnesses and their course over the patient’s lifetime, including symptoms and treatment. Because
comorbidity is the rule rather than the exception, in addition to prior episodes of the same illness
(e.g., past episodes of depression in an individual who has a major depressive disorder) the
professionals should also be alert for the signs and symptoms of other psychiatric disorders.
Description of past symptoms should include when they occurred, how long they lasted, and the
frequency and severity of episodes.
Past treatment should also be reviewed in detail. These include outpatient treatment such as
psychotherapy (individual, group, couple, or family), inpatient treatment, including voluntary or
involuntary and what precipitated the need for the higher level of care, support groups, or other
forms of treatment such as vocational training. Medications and other modalities such as
20
electroconvulsive therapy or alternative treatments should be carefully reviewed. One should

explore what was tried, how long and at what doses these were used (to establish adequacy of the
trials), and why these were stopped. Important questions must include what was the response to
the medication/modality and whether there were any side effects. It is also helpful to establish
whether there was reasonable compliance with the recommended treatment.
Special consideration should be given to establishing a lethality history that is important in the
assessment of current risk. Past suicidal ideation, intent, plan, and attempts should be reviewed
including the nature of attempts, perceived lethality of the attempts or other death preparations.
Because many patients will withhold specific information about recent suicidal behaviours or
suicidal ideation, several specific behavioural questions may be used to determine how close the
patient was to a lethal attempt. Violence and homicidal history should include any violent actions
or intent. History of nonsuicidal self-injurious behaviour should also be recorded.
Past Medical History

The past medical history includes an account of major medical and surgical illnesses and
conditions as well as treatments, both past and present. The patient’s reaction to these illnesses
and coping skills employed are important to understand. The past medical history is an important
the same illness (e.g., past episodes of depression in an individual who has a major depressive
disorder) the professionals should also be alert for the signs and symptoms of other psychiatric
disorders. Description of past symptoms should include when they occurred, how long they
lasted, and the frequency and severity of episodes.
Past treatment should also be reviewed in detail. These include outpatient treatment such as
psychotherapy (individual, group, couple, or family), inpatient treatment, including voluntary or
involuntary and what precipitated the need for the higher level of care, support groups, or other
forms of treatment such as vocational training. Medications and other modalities such as
electroconvulsive therapy or alternative treatments should be carefully reviewed. One should
explore what was tried, how long and at what doses these were used (to establish adequacy of the
trials), and why these were stopped. Important questions must include what was the response to
the medication/modality and whether there were any side effects. It is also helpful to establish
whether there was reasonable compliance with the recommended treatment.
21
Special consideration should be given to establishing a lethality history that is important in the
assessment of current risk. Past suicidal ideation, intent, plan, and attempts should be reviewed
including the nature of attempts, perceived lethality of the attempts or other death preparations.
Because many patients will withhold specific information about recent suicidal behaviours or
suicidal ideation, several specific behavioural questions may be used to determine how close the
patient was to a lethal attempt. Violence and homicidal history should include any violent actions
or intent. History of nonsuicidal self-injurious behaviour should also be recorded.
Past Medical History

The past medical history includes an account of major medical and surgical illnesses and
conditions as well as treatments, both past and present. The patient’s reaction to these illnesses
and coping skills employed are important to understand. The past medical history is an important
consideration when determining potential causes of mental illness as well as comorbid or
confounding factors and may dictate potential treatment options or limitations. Medical illnesses
can precipitate a psychiatric disorder (e.g., depression in an individual recently diagnosed with
HIV), imitate a psychiatric disorder ( hyperthyroidism resembling an anxiety disorder), be
precipitated by a psychiatric disorder or its treatment (metabolic syndrome in a patient on a
second-generation antipsychotic medication), or influence the choice of treatment of a
psychiatric disorder ( hepatic dysfunction disorder and the use of disulfuram). It is important to
pay special attention to neurological issues including seizures, head injury and pain disorder.
Nonpsychotropic medications, over-the-counter medications, sleep aids, herbal, and alternative
medications should also be reviewed. These can all potentially have psychiatric implications
including side effects or producing symptoms as well as potential medication interactions.
Family History
Because many psychiatric illnesses are familial, a careful review of family history is an essential
part of the psychiatric assessment. Furthermore, an accurate family history helps not only in
defining a patient’s potential risk factors for specific illnesses but also the formative
psychosocial background of the patient. Psychiatric diagnoses, medications, hospitalizations,
substance use disorders and lethality history should all be covered. The importance of these
issues is highlighted, for example, by the evidence that, at times, there appears to be a familial
response to medications and a family history of suicide is a significant risk factor for suicidal
22
behaviours in the patient. Proper understanding of medical illnesses present in family members
may also be important in both the diagnosis and the treatment of the patient. Family traditions,
beliefs, and expectations may also play a significant role in the development, expression, or
course of the illness. Also the family history is important in identifying potential support as well
as stresses for the patient.
Personal History
The personal history reviews the stages of the patient’s life. It is an important tool in determining
the context of psychiatric symptoms and potential treatment options or limitations. Medical
illnesses can precipitate a psychiatric disorder (e.g., depression in an individual recently
diagnosed with HIV), imitate a psychiatric disorder ( hyperthyroidism resembling an anxiety
disorder), be precipitated by a psychiatric disorder or its treatment (metabolic syndrome in a
patient on a second-generation antipsychotic medication), or influence the choice of treatment of
a psychiatric disorder ( hepatic dysfunction disorder and the use of disulfuram). It is important to
pay special attention to neurological issues including seizures, head injury and pain disorder.
Nonpsychotropic medications, over-the-counter medications, sleep aids, herbal, and alternative
medications should also be reviewed. These can all potentially have psychiatric implications
including side effects or producing symptoms as well as potential medication interactions.
Family History
Because many psychiatric illnesses are familial, a careful review of family history is an essential
part of the psychiatric assessment. Furthermore, an accurate family history helps not only in
defining a patient’s potential risk factors for specific illnesses but also the formative
psychosocial background of the patient. Psychiatric diagnoses, medications, hospitalizations,
substance use disorders and lethality history should all be covered. The importance of these
issues is highlighted, for example, by the evidence that, at times, there appears to be a familial
response to medications and a family history of suicide is a significant risk factor for suicidal
behaviours in the patient. Proper understanding of medical illnesses present in family members
may also be important in both the diagnosis and the treatment of the patient. Family traditions,
beliefs, and expectations may also play a significant role in the development, expression, or
course of the illness. Also the family history is important in identifying potential support as well
as stresses for the patient.
23
Personal History
The personal history reviews the stages of the patient’s life. It is an important tool in determining
the context of psychiatric symptoms and illnesses and may, in fact, identify some of the major
factors in the evolution of the disorder. Frequently, current psychosocial stressors will be
revealed in the course of obtaining a social history. It can often be helpful to review the social
history chronologically to ensure all information is covered.
Any available information concerning prenatal or birth history and developmental milestones
should be noted. For the large majority of adult patients such information is not readily available
and when it is, it may not be fully accurate. Any known history of prenatal or birth problems or
issues with developmental milestones should be noted. Childhood history should include
childhood home environment including members of the family and social environment including
the number and quality of friendships. A detailed school history including how far the patient
went in school and how old they were at that level, any special education circumstances or
learning disorders, behavioural problems at school, academic performance, and extracurricular
activities should be obtained. Childhood physical and sexual abuse should be carefully queried.
Work history must cover the types of jobs, performance at jobs, reasons for changing jobs, and
current work status. The nature of the patient’s relationships with supervisors and co-workers
should be reviewed. The patient’s income, financial issues, and insurance coverage including
pharmacy benefits are often important issues.
Marriage and relationship history including sexual preferences and current family structure
should be explored. This should include the patient’s capacity to develop and maintain stable and
mutually satisfying relationships as well as issues of intimacy and sexual behaviours. In women,
a reproductive and menstrual history is important as well as a careful assessment of potential for
current or future pregnancy. Current relationships with parents, grandparents, children, and
grandchildren are an important part of the social history. It is important to identify cultural and
religious influences on the patient’s life and current religious beliefs and practices. Premorbid
Personality
The premorbid personality of the patient often gives valuable insights into his/her
symptomatology, diagnosis and management. Ideally, the premorbid personality of an individual
24
should be assessed in the interview with corroborative evidence. Patients who are unwell often
give a false reporting of their premorbid personality, and in cases where there is no available
informant, a reassessment may be warranted once patient’s symptoms have improved.
Substance Use/Abuse and Addictions
A careful review of substance use, abuse, and addictions is essential to the psychiatric interview.
The clinician should keep in mind that this information may be difficult for the patient to discuss,
and a nonjudgmental style will elicit more accurate information. If the patient seems reluctant to
share such information specific questions may be helpful (e.g., “Have you ever used intravenous
drugs?” or “Do you drink alcohol every day?”). History of use should include what substances
have been used including alcohol, drugs, medications (prescribed or not prescribed to the
patient), and routes of use (oral or intravenous). The frequency and amount of use should be
determined keeping in mind the tendency for patients to minimize or deny use that may be
perceived as socially unacceptable.
Other important substances and addictions that should be covered in this section include tobacco
and caffeine use.
TECHNIQUES OF HISTORY TAKING

General principles of the psychiatric interview such as the doctor-patient relationship and
confidentiality are described in the earlier section. In addition to the general principles, there are
a number of specific techniques that can be effective in obtaining information in a manner
consistent with the general principles. These helpful techniques can be described as facilitating
and expanding interventions.
There are also some interventions that are generally counterproductive and interfere with the
goals of helping the patient tell their story and reinforcing the therapeutic alliance.
Effective Listening
The first and foremost skill in eliciting a good history is the art of patient and receptive listening.
The professionals must not only listen to what has been said by the patient but also focus on to
the non-verbal gestures and observe the behaviour through different phases of the history. At
times, despite their best attempts, professionals often hit road blocks and are unable to obtain
25
valuable information from the patient. It is best to learn to be aware of such situations and to
assess the possible reasons that may be causing the same
Questioning
While trying to various areas of the history the therapist should start with open ended broad
questions and then should gradually narrow down the focus. For example, the opening question
can be “what brings you here?”. Whenever possible, questions which can elicit only a “yes” or
“no” answer must be avoided.
Facilitating Information Gathering
These are some of the techniques (see Text Box-3) that are effective in enabling the patient to
continue sharing their story and also are helpful in promoting a positive doctor patient
relationship.
Expanding the scope of information: There are a number of techniques (see Text Box-4) that can
be used to expand the focus of the interview. These techniques are helpful when the line of
discussion has been sufficiently mined, at least for the time being, and the interviewer wants to
encourage the patient to talk about other issues. These techniques are most successful when a
degree of trust has been established in the interview and the patient feels that the professional is
nonjudgmental about what is being shared.
Techniques which can impede the Information Collection
While supportive and expanding techniques facilitate the gathering of information and the
development of a positive doctor-patient relationship, it is important to note that certain
techniques can actually hamper the interview and collection of information (see Text Box-5) .
Some of these activities are from the same categories as the more useful interventions but are
unclear, unconnected, poorly timed, and not responsive to the patient's issues or concerns.
CLOSING OF INTERVIEW
The last 5 to 10 minutes of the interview are very important and often sufficient attention is not
given to the same by an inexperienced interviewer. Patients often keep important issues or
questions until the end of the interview and having at least a brief time to identify the issue is
helpful. If there is to be another session, then the psychiatrist can indicate that this issue will be
26
addressed at the beginning of the next session or ask the patient to bring it up at that time. It can
also be useful to give the patient an opportunity to ask a question. “I’ve asked you a lot of
questions today. Are there any other questions you’d like to ask me at this point?” or asking the
patient if he has any other additional information to share which therapist has not asked.
will feel that the record is more important than what they are saying. Also, the interviewer may
miss nonverbal communications that can be more important than the words being recorded.
INTERVIEWING THE DIFFICULT PATIENTS

Hostile, Agitated and Potentially Violent Patients
Safety for the patient and the therapist is the priority when interviewing agitated patients. Hostile
patients are often interviewed in emergency settings, but angry and agitated patients can present
in any setting. The chairs should ideally be placed in a way in which both the interviewer and
patient could exit if necessary and not be obstructed. The professional should be aware of any
available safety features and should be familiar with the facility’s security plan. If the
professional is aware in advance that the patient is agitated, then they can take additional
preparatory steps such as having security closely available if necessary. The professional should
be aware of their own body position and avoid postures that could be seen as threatening
including clenched hands or hands behind the back. The therapist must avoid having things like
stethoscope around the neck, nor should have other things hanging around here and there.
Therapist attitude should never convey a violent patient that he may be deceived or punished.
Adequate distance must be maintained from the patient.
The professional should approach the interview in a calm, direct manner and take care not to
bargain or promise to elicit cooperation in the interview. As stated above, the priority must be
safety. However, a professional who is fearful regarding their own physical safety will be unable
to perform an adequate assessment. Similarly, a patient who feels threatened will be unable to
focus on the interview and may begin to escalate thinking that he or she needs to defend
him/herself. An interview may need to be terminated early if the patient's
If this interview was to be a single evaluative session, then a summary of the diagnosis and
options for treatment should generally be shared with the patient. If this was not to be a single
27
session and the patient will be seen again, then the professional may indicate that they can work
further on the treatment plan in the next session.
MEDICAL RECORDS
Throughout the interview, most professionals take notes. Generally, these are not verbatim
recordings, except for the chief complaint or other key statements. Occasionally, patients may
have questions or concerns about the note-taking. These concerns, which often have to do with
confidentiality, should be discussed (and during this discussion notes should not be taken). Too
much attention to the record keeping can be distracting. It is important that eye contact be
maintained as much as possible during the note-taking. Otherwise, patients
Generally, unpremeditated violence is preceded by a period of gradually escalating psychomotor

activity, professional should consider whether other measures are necessary including assistance
from security personnel or need for medication and/or restraint.
If the patient makes threats or gives some indication that they may become violent outside the
interview setting, then further assessment is necessary. Because past history of violence is the
best predictor of future violence, past episodes of violence should be explored as to setting, what
precipitated the episode, and what was the outcome or potential outcome (if the act was
interrupted). Also, what has helped in the past in preventing violent episodes (medication, time-
out, physical activity, or talking to a particular person) should be explored. Is there an identified
victim and is there a plan for the violent behaviour? Has the patient taken steps to fulfill the
plan? Depending on the answers to these questions the professional may decide to prescribe or
increase antipsychotic medication, recommend hospitalization, and perhaps, depending on the
jurisdiction, notify the victim.
Deceptive Patients
Mental health professionals are trained to diagnose and treat psychiatric illness. Although
professionals are well trained in eliciting information and maintaining awareness for deception,
these abilities are not foolproof. Patients lie or deceive their doctors for many different reasons.
Some are motivated by secondary gain (e.g., for financial resources, absence from work, or for a
supply of medication). Some patients may deceive, not for an external advantage, but for
assuming a sick role. There are no current biological markers to definitively validate a patient's
28
symptoms. Hence, professionals are dependent on the patient’s self report. Given these
limitations, it may be useful, especially when there is question about the patient’s reliability (may
be related to inconsistencies in the patient's report), to gather collateral information regarding the
patient. This allows having a more broad understanding of the patient outside of the interview
setting, and discrepancies in symptom severity between self report and collateral information
may suggest deception.
Suicidal Patient
There is a false notion that patients should not be questioned about suicidal behaviour directly as
talking about suicide may actually provoke such acts. However, in reality, most of the patients
who commit suicide do communicate about the same either verbally, non-verbally or both. It is
always better to ask the patient directly about wish to die, any suicidal thoughts, suicidal plans,
or suicidal attempts, etc. In fact, this may be the first opportunity given to the patient to discuss
about the same and may be therapeutic on its own.
SUM UP
History taking is an art. A good interviewer is one who shows concern for the patient, has
adequate time to listen to the patient, is able to convey empathy and build a strong doctor-patient
relationship, and does not lose the focus. For good history taking, the professional should be
properly dressed and groomed and should spare at least 45-90 minutes. At the beginning of the
interview, consent of the patient should be sought and they should be ensured about the privacy
and confidentiality. The therapist should respect the patient’s needs and these should be given
the upmost consideration. The data must be obtained in the form of identification data, chief
complaints, elaboration of the same in a chronological order as part of history of present illness,
effect of various biopsycho-social factors on the development, progression, continuation/
persistence or amelioration of symptoms must also be understood. Besides focusing on the
current symptomatology, history taking should also include past psychiatric and medical history,
family history of medical and psychiatric disorders, personal history including history of birth,
early development, education, occupation, present living situation, premorbid personality, history
of substance abuse, treatment history should be evaluated. Wherever possible, the therapist
should use open ended questions and should avoid closed ended or compound questions and
should refrain from giving premature advice.
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3.0 UNIT 3
3.1 Symptoms, Causes and Treatment
Organic mental disorder
An organic mental disorder is a previously used term to describe a dysfunction of the brain that
was meant to exclude psychiatric disorders. It is currently known under the category of
neurocognitive disorders. It describes reduced brain function due to illnesses that are not
psychiatric in nature. Sometimes the term organic mental disorder is used interchangeably with
the terms organic brain syndrome (OBS), chronic organic brain syndrome, or neurocognitive
disorder—this latter term is the one used more commonly now.
Causes
Organic mental disorders are disturbances that may be caused by injury or disease affecting brain
tissues as well as by chemical or hormonal abnormalities. Exposure to toxic materials,
neurological impairment, or abnormal changes associated with aging can also cause these
disorders. Alcohol, or metabolic disorders such as liver, kidney, or thyroid disease, or vitamin
deficiencies, may be factors too.
Concussions, blood clots, or bleeding in or around the brain from trauma may lead to organic
brain syndrome. Low oxygen in the blood, high amounts of carbon dioxide in the body, strokes,
brain infections, and heart infections can lead to an organic mental disorder as well.3
Degenerative disorders like Parkinson's disease, Alzheimer's disease, Huntington disease, and
multiple sclerosis may also be contributing factors.
Symptoms
A person with an organic mental disorder may have difficulty concentrating for a long period of
time. Others may get confused while performing tasks that seem routine to others. Managing
relationships and collaborating and communicating with colleagues, friends, or family may also
prove difficult. Overall the severity of the symptoms and the type of symptoms a person has
varies, depending on the cause of their disorder.
30
Primary Symptoms
 Confusion
 Agitation
 Irritability
A change in behavior, impaired brain function, cognitive ability, or memory5
If you or your loved one is experiencing any of these symptoms, it's important to seek medical
care as soon as possible. A serious medical problem may have caused these symptoms to surface,
and early intervention may be key.
Treatment
Blood tests, spinal taps, or an electroencephalogram may be administered to diagnose organic
brain syndrome or an organic mental disorder. Imaging of the brain, like a CT scan or MRI, is
also useful, depending on a doctor's suspicion.
Treatments for organic mental disorders vary on what the underlying cause of the disorder is.
Medication may be prescribed or rehabilitation therapy may help patients recover function in the
parts of the brain affected by the organic mental disorder.
Schizoaffective Disorder
WHAT IS SCHIZOAFFECTIVE DISORDER?
What Is Schizoaffective Disorder?
Schizoaffective disorder is a chronic mental health condition that involves symptoms of both
schizophrenia and a mood disorder like major depressive disorder or bipolar disorder. In fact,
many people with schizophrenia are incorrectly diagnosed at first with depression or bipolar
disorder. Scientists don’t know for sure if schizoaffective disorder is related mainly to
schizophrenia or a mood disorder. But it’s usually viewed and treated as a combination of both
conditions. Only a tiny number of people get schizoaffective disorder -- .03% of the population.
It’s equally likely to affect men and women, but men usually get it at a younger age. Doctors can
help manage it, but most people diagnosed with it have relapses. People who have it often have
problems with substance use as well.
31
Types of Schizoaffective Disorder
There are two types. Each has some schizophrenia symptoms:
Bipolar type: Episodes of mania and sometimes major depression
Depressive type: Only major depressive episodes
Symptoms of Schizoaffective Disorder
The symptoms may vary greatly from one person to the next and may be mild or severe. They
may include:
 Delusions (false, sometimes strange beliefs that the person refuses to give up, even when
they get the facts)
 Depression symptoms (feeling empty, sad, or worthless)
 Hallucinations (sensing things that aren't real, such as hearing voices)
 Lack of personal care (not staying clean or keeping up appearance)
 Mania or sudden, out-of-character jumps in energy levels or happiness, racing thoughts,
or risky behavior
 Problems with speech and communication, only giving partial answers to questions or
giving answers that are unrelated
 Problems with speech and communication, only giving partial answers to questions, or
giving answers that are unrelated. (The doctor may call this disorganized thinking.)
 Trouble at work, school, or in social settings
Causes of Schizoaffective Disorder

Scientists don’t know the exact cause. Risk factors for schizoaffective disorder include:
 Genetics: You may inherit a tendency to get features linked to schizoaffective disorder
from your parents.
 Brain chemistry and structure: If you have schizophrenia and mood disorders, you might
have problems with brain circuits that manage mood and thinking. Schizophrenia is also
tied to lower levels of dopamine, a brain chemical that also helps manage these tasks.
32
 Environment: Some scientists think things like viral infections or highly stressful
situations could play a part in getting schizoaffective disorder if you’re at risk for it. How
that happens isn’t clear.
 Drug use: Taking mind-altering drugs. (Your doctor may call them psychoactive or
psychotropic drugs.)
Schizoaffective disorder usually begins in the late teen years or early adulthood, often between
ages 16 and 30. It seems to happen slightly more often in women than in men. It's rare in
children. Because schizoaffective disorder combines symptoms that reflect two mental illnesses,
it’s easily confused with other psychotic or mood disorders. Some doctors may diagnose
schizophrenia. Others may think it’s a mood disorder. As a result, it’s hard to know how many
people actually have schizoaffective disorder. It’s probably less common than either
schizophrenia or mood disorders alone.
Diagnosis of Schizoaffective Disorder

There are no laboratory tests to specifically diagnose schizoaffective disorder. So doctors rely on
your medical history and your answers to certain questions. (Doctors call this the clinical
interview.) They also use various tests such as brain imaging (like MRI scans) and blood tests to
make sure that another type of illness isn’t causing your symptoms. If the doctor finds no
physical cause, they may refer you to a psychiatrist or psychologist. These mental health
professionals are trained to diagnose and treat mental illnesses. They use specially designed
interview and assessment tools to evaluate a person for a psychotic disorder.
In order to get diagnosed with schizoaffective disorder, you must have:
 Periods of uninterrupted illness

 An episode of mania, major depression, or a mix of both
Symptoms of schizophrenia
At least two periods of psychotic symptoms, each lasting 2 weeks. One of the episodes must
happen without depressive or manic symptoms.
Treatment of Schizoaffective Disorder
Treatment includes:
33
Medication: What you take depends on whether you have symptoms of depression or bipolar
disorder, along with symptoms that suggest schizophrenia. The main medications that doctors
prescribe for psychotic symptoms such as delusions, hallucinations, and disordered thinking are
called antipsychotics. All these drugs can probably help with schizoaffective disorder, but
paliperidone extended release (Invega) is the only drug that the FDA has approved to treat it. For
mood-related symptoms, you might take an antidepressant medication or a mood stabilizer.
Psychotherapy: The goal of this type of counseling is to help you learn about your illness, set
goals, and manage everyday problems related to the disorder. Family therapy can help families
get better at relating to and helping a loved one who has schizoaffective disorder.
Skills training: This generally focuses on work and social skills, grooming and self-care, and
other day-to-day activities, including money and home management.
Hospitalization: Psychotic episodes may require a hospital stay, especially if you’re suicidal or
threaten to hurt others.
Electroconvulsive therapy: This treatment may be an option for adults who don’t respond to
psychotherapy or medications. It involves sending a quick electric current through your brain.
(You’ll get a type of medicine called general anesthesia to help you sleep through it.) It causes a
brief seizure. Doctors use it because they think it changes your brain chemistry and may reverse
some conditions.
Complications of Schizoaffective Disorder
This condition may raise your risk of:
 Alcohol or other substance abuse problems

 Anxiety disorders
 Conflict with family, friends, co-workers and otherss
 Poverty and homelessness
 Significant health problems
 Social isolation
 Suicide, suicide attempts, or suicidal thoughts
 Unemployment
34
Prevention of Schizoaffective Disorder
You can’t prevent the condition. But if you’re diagnosed and start treatment ASAP, it can help
you avoid or ease frequent relapses and hospitalizations, and help cut the disruptions in your life,
family, and friendships.
4.0 UNIT 4
4.1 Disorders of adult personality and Behavior
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 your 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
teenage years or early adulthood. There are many types of personality disorders. Some types may
become less obvious throughout middle age.
Symptoms
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.
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
35
 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 your 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 your 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
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 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
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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
38
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 yourself 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 your own due to lack of self-confidence
 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 your 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
Obsessive-compulsive personality disorder is not the same as obsessive-compulsive

disorder, a type of anxiety disorder.
When to see a doctor
If you have any signs or symptoms of a personality disorder, see your doctor or other primary
care professional or a mental health professional. Untreated, personality disorders can cause
significant problems in your life that may get worse without treatment.
39
Causes
Personality is the combination of thoughts, emotions and behaviors that makes you unique. It's
the way you view, understand and relate to the outside world, as well as how you see yourself.
Personality forms during childhood, shaped through an interaction of:
Your genes. Certain personality traits may be passed on to you by your parents through inherited
genes. These traits are sometimes called your temperament.
Your environment. This involves the surroundings you grew up in, events that occurred, and
relationships with family members and others.
Personality disorders are thought to be caused by a combination of these genetic and

environmental influences. Your genes may make you vulnerable to developing a personality
disorder, and a life situation may trigger the actual development.
Risk factors
Although the precise cause of personality disorders is not known, certain factors seem to increase
the risk of developing or triggering personality disorders, including:
 Family history of personality disorders or other mental illness

 Abusive, unstable or chaotic family life during childhood
 Being diagnosed with childhood conduct disorder
 Variations in brain chemistry and structure
Complications
Personality disorders can significantly disrupt the lives of both the affected person and those who
care about that person. Personality disorders may cause problems with relationships, work or
school, and can lead to social isolation or alcohol or drug abuse.
MENTAL RETARDATION
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.
40
What is 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.
What are the signs of intellectual disability in children?

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
41
 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 intellectual disability?

Anytime something interferes with normal brain development, intellectual disability can result.
However, a specific cause for intellectual disability can only be pinpointed about a third of the
time.
The most common causes of intellectual disability are:

Genetic conditions. These include things like Down syndrome and fragile X syndrome.
Problems during pregnancy. Things that can interfere with fetal brain development include
alcohol or drug use, malnutrition, certain infections, or preeclampsia.
Problems during childbirth. Intellectual disability may result if a baby is deprived of oxygen
during childbirth or born extremely premature.
Illness or injury. Infections like meningitis, whooping cough, or the measles can lead to
intellectual disability. Severe head injury, near-drowning, extreme malnutrition, infections in the
brain, exposure to toxic substances such as lead, and severe neglect or abuse can also cause it.
None of the above. In two-thirds of all children who have intellectual disability, the cause
is unknown.
Can intellectual disability be prevented?
Certain causes of intellectual disability are preventable. The most common of these is fetal
alcohol syndrome. Pregnant women shouldn’t drink alcohol. Getting proper prenatal care, taking
a prenatal vitamin, and getting vaccinated against certain infectious diseases can also lower the
risk that your child will be born with intellectual disabilities.
In families with a history of genetic disorders, genetic testing may be recommended before
conception. Certain tests, such as ultrasound and amniocentesis, can also be performed during
42
pregnancy to look for problems associated with intellectual disability. Although these tests may
identify problems before birth, they cannot correct them.
How is intellectual disability diagnosed?
Intellectual disability may be suspected for many different reasons. If a baby has physical
abnormalities that suggest a genetic or metabolic disorder, a variety of tests may be done to
confirm the diagnosis. These include blood tests, urine tests, imaging tests to look for structural
problems in the brain, or electroencephalogram (EEG) to look for evidence of seizures. In
children with developmental delays, the doctor will perform tests to rule out other problems,
including hearing problems and certain neurological disorders. If no other cause can be found for
the delays, the child will be referred for formal testing.
Three things factor into the diagnosis of intellectual disability: interviews with the parents,
observation of the child, and testing of intelligence and adaptive behaviors. A child is considered
intellectually disabled if he or she has deficits in both IQ and adaptive behaviors. If only one or
the other is present, the child is not considered intellectually disabled.
After a diagnosis of intellectual disability is made, a team of professionals will assess the child’s
particular strengths and weaknesses. This helps them determine how much and what kind of
support the child will need to succeed at home, in school, and in the community.
Childhood behavioural disorders

Keywords: Childhood behavioural disorders, Disruptive behaviour disorder, Conduct disorder,
Challenging behaviour, Emotional disorder, Anxiety, Depression, Autism, Pervasive
developmental disorders
Core tip: Mental health problems in children and young people (CYP) include several types of
emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive
developmental (autism) disorders, characterized as either “internalizing” or “externalizing”. The
routine Paediatric or General Practitioner clinic present with several desirable characteristics that
make them ideal for providing effective mental health services to CYP. Childhood mental health
disorders have significant negative impacts on the individual, the family and the society. It is
particularly important for all Paediatricians to be aware of the range of presentation, prevention
and management of the common mental health problems in CYP.
43
INTRODUCTION
Mental health disorders (MHD) are very common in childhood and they include emotional-
obsessive-compulsive disorder (OCD), anxiety, depression, disruptive (oppositional defiance
disorder (ODD), conduct disorder (CD), attention deficit hyperactive disorder (ADHD) or
developmental (speech/language delay, intellectual disability) disorders or pervasive (autistic
spectrum) disorders. Emotional and behavioural problems (EBP) or disorders (EBD) can also be
classified as either “internalizing” (emotional disorders such as depression and anxiety) or
“externalizing” (disruptive behaviours such as ADHD and CD).
While low-intensity naughty, defiant and impulsive behaviour from time to time, losing one’s
temper, destruction of property, and deceitfulness/stealing in the preschool children are regarded
as normal, extremely difficult and challenging behaviours outside the norm for the age and level
of development, such as unpredictable, prolonged, and/or destructive tantrums and severe
outbursts of temper loss are recognized as behavior disorders. Community studies have identified
that more than 80% of preschoolers have mild tantrums sometimes but a smaller proportion, less
than 10% will have daily tantrums, regarded as normative misbehaviors at this age. Challenging
behaviors and emotional difficulties are more likely to be recognized as “problems” rather than
“disorders” during the first 2 years of life.
Emotional problems, such as anxiety, depression and post-traumatic stress disorder (PTSD) tend
to occur in later childhood. They are often difficult to be recognized early by the parents or other
careers as many children have not developed appropriate vocabulary and comprehension to
express their emotions intelligibly. Many clinicians and careers also find it difficult to distinguish
between developmentally normal emotions (e.g., fears, crying) from the severe and prolonged
emotional distresses that should be regarded as disorders. Emotional problems including
disordered eating behavior and low self-image are often associated with chronic medical
disorders such as atopic dermatitis, obesity, diabetes and asthma, which lead to poor quality of
life.
Identification and management of mental health problems in primary care settings such as
routine Pediatric clinic or Family Medicine/General Practitioner surgery are cost-effective
because of their several desirable characteristics that make it acceptable to children and young
people (CYP) (e.g., no stigma, in local setting, and familiar providers). Several models to
44
improve the delivery of mental health services in the Pediatric/Primary care settings have been
recommended and evaluated recently, including coordination with external specialists, joint
consultations, improved Mental Health training and more integrated on-site intervention with
specialist collaboration.
CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Challenging behaviours
Any abnormal pattern of behavior which is above the expected norm for age and level of
development can be described as “challenging behavior”. It has been defined as: “Culturally
abnormal behavior (s) of such an intensity, frequency or duration that the physical safety of the
person or others is likely to be placed in serious jeopardy or behavior which is likely to seriously
limit or deny access to and use of ordinary community facilities”. They can include self-injury,
physical or verbal aggression, non-compliance, and disruption of the environment, inappropriate
vocalizations, and various stereotypies. These behaviors can impede learning, restrict access to
normal activities and social opportunities, and require a considerable amount of both manpower
and financial resources to manage effectively.
Many instances of challenging behavior can be interpreted as ineffective coping strategies for a
young person, with or without learning disability (LD) or impaired social and communication
skills, trying to control what is going on around them. Young people with various disabilities,
including LD, Autism, and other acquired neurobehavioral disorders such as brain damage and
post-infectious phenomena, may also use challenging behavior for specific purposes, for
example, for sensory stimulation, gaining attention of carers, avoiding demands or to express
their limited communication skills. People who have a diverse range of neurodevelopmental
disorders are more likely to develop challenging behaviors.
Some environmental factors have been identified which are likely to increase the risk of
challenging behavior, including places offering limited opportunities for making choices, social
interaction or meaningful occupation. Other adverse environments are characterized by limited
sensory input or excessive noise, unresponsive or unpredictable carers, predisposition to neglect
and abuse, and where physical health needs and pain are not promptly identified. For example,
the rates of challenging behavior in teenagers and people in their early 20s is 30%-40% in
45
hospital settings, compared to 5% to 15% among children attending schools for those with severe
LD.
Aggression is a common, yet complex, challenging behaviour, and a frequent indication for
referral to child and adolescent Psychiatrists. It commonly begins in childhood, with more than
58% of preschool children demonstrating some aggressive behaviour. Aggression has been
linked to several risk factors, including individual temperaments; the effects of disturbed family
dynamics; poor parenting practices; exposure to violence and the influence of attachment
disorders.
Disruptive behaviour problems

Disruptive behaviour problems (DBP) include attention deficit hyperactivity disorder (ADHD),
oppositional defiant disorder (ODD) and conduct disorder (CD). They constitute the commonest
EBPs among CYP. Recent evidence suggests that DBPs should be regarded as a
multidimensional phenotype rather than comprising distinct subgroups. ADHD is characterized
by levels of hyperactivity, impulsivity and inattention that are disproportionately excessive for
the child’s age and development.
Subtypes of attention deficit hyperactivity disorder (based on DSM-5)
Details Fails to pay close attention to details or makes careless mistakes Squirms and fidgets
• Has difficulty sustaining attention
• Can’t stay seated
• Does not appear to listen
• Runs/climbs excessively
• Struggles to follow through on instructions
• Can’t play/work quietly
• Has difficulty with organization
• Avoids or dislikes tasks requiring a lot of thinking
• Blurts out answers
46
• Loses things
• Unable to wait for his turn
• Is easily distracted
• Intrudes/interrupts others
• Talks excessively
ADHD: Attention deficit hyperactivity disorder.

CD refers to severe behaviour problems , characterized by repetitive and persistent
manifestations of serious aggressive or non-aggressive behaviours against people, animals or
property such as being defiant, belligerent, destructive, threatening, physically cruel, deceitful,
disobedient or dishonest, excessive fighting or bullying, fire-setting, stealing, repeated lying,
intentional injury, forced sexual activity and frequent school truancy Children with CD often
have trouble understanding how other people think, sometimes described as being callous-
unemotional. They may falsely misinterpret the intentions of other people as being mean. They
may have immature language skills, lack the appropriate social skills to establish and maintain
friendships, which aggravates their feelings of sadness, frustration and anger.
Oppositional defiant disorder Conduct disorder
A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at

least 6 mo as evidenced by at least four out of 8 symptoms from any of the following categories,
and exhibited during interaction with at least one individual who is not a sibling A repetitive
and persistent pattern of behavior in which the basic rights of others or major age-appropriate
societal norms or rules are violated, as manifested by the presence of at least three of the
following 15 criteria in the past 12 mo from any of the categories below, with at least one
criterion present in the past 6 mo
Aggression to people and animals:
(1) Often bullies, threatens, or intimidates others;
(2) Often initiates physical fights;
47
(3) Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken
bottle, knife, gun);
(4) Has been physically cruel to people;
(5) Has been physically cruel to animals;
(6) Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed
robbery);
(7) Has forced someone into sexual activity
Angry/irritable mood:
(1) Often loses temper;
(2) Is often touchy or easily annoyed;
(3) Is often angry and resentful
Argumentative/defiant behavior:
(4) Often argues with authority figures or, for children and adolescents, with adults;
(5) Often actively defies or refuses to comply with requests from authority figures or with rules;
(6) Often deliberately annoys others;
(7) Often blames others for his or her mistakes or misbehavior
Destruction of property:
(8) Has deliberately engaged in fire setting with the intention of causing serious damage;
(9) Has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or theft:
(10) Has broken into someone else’s house, building, or car;
(11) Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others);
48
(12) Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but
without breaking and entering; forgery)
Vindictiveness:
(13) Often stays out at night despite parental prohibitions, beginning before age 13 yr;
(14) Has run away from home overnight at least twice while living in the parental or parental
surrogate home, or once without returning for a lengthy period;
(15) Is often truant from school, beginning before age 13 yr
Note: The persistence and frequency of these behaviors should be used to distinguish a behavior
that is within normal limits from a behavior that is symptomatic and the behavior should occur at
least once per week for at least 6 mo
Disruptive mood dysregulation disorder (DMDD) is a childhood disorder characterized by a

pervasively irritable or angry mood recently added to DSM-5. The symptoms include frequent
episodes of severe temper tantrums or aggression (more than three episodes a week) in
combination with persistently negative mood between episodes, lasting for more than 12 mo in
multiple settings, beginning after 6 years of age but before the child is 10 years old.
COMPLICATIONS OF CHILDHOOD BEHAVIOURAL AND

EMOTIONAL DISORDERS
EBDs in childhood, if left untreated, may have negative short-term and long-term effects on an
individual’s personal, educational, family and later professional life. CD has been linked to
failure to complete schooling, attaining poor school achievement, poor interpersonal
relationships, particularly family breakup and divorce, and experience of long-term
unemployment. DBPs in parents have been linked to the abuse of their offspring, thereby
increasing their risk of developing CD. Children presenting with hyperactivity-inattention
behaviors are more likely to have a more favorable educational outcome compared with those
with aggression or oppositional behaviors.
A high prevalence of sleep disturbances is associated with various childhood EBPs. Sleep
problems in early childhood is associated with increased prevalence of later Anxiety disorders .
49
Several studies have confirmed a strong relationship between early childhood EBPs and poor
future long-term physical and mental health outcomes. Chronic irritability in preschool children,
CD and ODD in older children each may be predictive of any current and lifetime Anxiety,
Depression and DBDs in later childhood, Mania, Schizophrenia, OCD, major depressive disorder
and panic disorder. Individuals on the adolescent-onset CP path often consume more tobacco and
illegal drugs and engage more often in risky sexual behaviour, self-harm, and have increased risk
of PTSD, than individuals without childhood conduct problems. They also frequently experience
parenting difficulties, including over-reactivity, lax and inconsistent discipline, child physical
punishment and lower levels of parental warmth and sensitivity
MANAGEMENT OF BEHAVIOURAL AND EMOTIONAL

DISORDERS IN CHILDREN
Identification of appropriate treatment strategies depend on careful assessment of the prevailing
symptoms, the family and caregiver’s influences, wider socio-economic environment, the child’s
developmental level and physical health. It requires multi-level and multi-disciplinarian
approaches that include professionals such as Psychologists, Psychiatrists, Behavioural Analysts,
Nurses, Social care staff, Speech and language Therapists, Educational staff, Occupational
Therapists, Physiotherapists, Paediatricians and Pharmacists. Use of pharmacotherapy is usually
considered only in combination with psychological and other environmental interventions.
Holistic management strategies will include various combinations of several interventions such
as child- and family-focused psychological strategies including Cognitive Behavioural Therapy
(CBT), behavioural modification and social communication enhancement techniques, parenting
skills training and psychopharmacology. These strategies can play significant roles in the
management of children with a wide range of emotional, behavioural and social communication
disorders. Effective alternative educational procedures also need to be implemented for the
school age children and adolescents.
In early childhood, similar parenting strategies have been found useful to manage several
apparently dissimilar EBPs (e.g., infant feeding or sleeping problems, preschool tantrums,
disruptive and various emotional problems). This may suggest there is a common maintaining
mechanism, which is probably related to poor self-regulation skills, involving the ability to
control impulses and expressions of emotion.
50
Several studies have confirmed the effectiveness of various psychological and pharmacologic
therapies in the management of childhood EBDs. A meta-analysis of thirty-six controlled trials,
involving 3042 children (mean sample age, 4.7 years), evaluating the effect of psychosocial
treatments including parenting programmes on early DBPs, demonstrated large and sustained
effects (Hedges’g = 0.82), with the largest effects for general externalizing symptoms and
problems of oppositionality and non-compliance, and were weakest, relatively speaking, for
problems of impulsivity and hyperactivity.
The treatment of CD among CYP with callous-unemotional traits is still at early stages of
research. The mainstay of management for CDs includes individual behavioural or cognitive
therapy, psychotherapy, family therapy and medications.
Parental skills training

Any challenging behaviour from CYP is likely to elicit persistent negative reactions from many
parents, using ineffective controlling strategies and a decrease in positive responses. There is
evidence from published research that social-learning and behaviourally based parent training is
capable of producing lasting improvement in children
5.0 UNIT 5
National Mental Health Programme – Mental Health Act, District
Mental Health Progrramme. Socio-cultural factors in Psychiatry –
Magico-religious practices – Cultural beliefs – Stigma.
Health services
There are very few doctors. Clinical officers, medical assistants and enrolled nurses comprise the
backbone of Malawian healthcare, but there are shortages of these health personnel, especially in
the rural areas, as people prefer to practise in urban areas. The smallest health unit in Malawi is
the ‘health post’, which is manned by ‘health surveillance assistants’ (who have 10 weeks’
orientation training). Each health post serves a small number of villages. Next in the referral
hierarchy is the health centre, which is usually staffed by medical assistants (who have 2 years’
51
training) and nurses. Patients who cannot be treated at the health centre are referred to the district
hospitals, which are present in all but 3 of the 28 districts. There are four general tertiary referral
hospitals, distributed in all three regions of Malawi, with two in the southern region, which is the
biggest.
Mental health resources and services

Zomba Mental Hospital, which is situated in the southern region, is the only government tertiary
psychiatric referral hospital in Malawi. It has 333 beds and on average admits 1500 patients per
year. There is a smaller psychiatric unit in the central region, in Lilongwe, with about 30 beds,
and this is run as part of Kamuzu Central Hospital, which is the tertiary referral hospital in the
central region. Psychiatric patients from the northern region are usually referred to a missionary
hospital, St John of God in the city of Mzuzu, which has 50 in-patient beds and which runs an
effective community programme. In total there are therefore just over 400 psychiatric beds for
the entire population.
The commonest reasons for admission to Zomba Mental Hospital are schizophrenia, bipolar
disorders, intellectual disability, epilepsy, and substance-related and HIV-related conditions
(according to hospital statistics for the year 2005). Nearly all patients admitted present with
severe forms of these conditions.
Mental health services in all the districts fall under the office of the district health officer and the
associated expenditure is included in the district’s health budget. As with the other general
tertiary hospitals, Zomba Mental Hospital has its own budget.
Public psychiatric services fall under clinical services (curative) within the Ministry of Health.
Staffing
There is only one psychiatrist for the entire population of Malawi, but since he is based in
Zomba, the old capital city, the psychiatrist:population ratio is 0 for the rest of the country.
There are no professional social workers and only one occupational therapist, at Zomba Mental
Hospital. There are two clinical psychologists attached to the College of Medicine in Malawi,
who teach medical students; they do not do any clinical work in the psychiatric hospitals.
52
The district psychiatric nurses do weekly outreach clinics, visiting different health centres and
health posts within their districts; the management team from Zomba Mental Hospital visits each
district twice a year to monitor mental health activities throughout the country.
Mental health policy and legislation

The old 2000–04 policy is still being used while it is awaiting review. This policy includes the
integration of psychiatric services into the primary healthcare system, the appointment of a
national mental health coordinator at the Ministry of Health’s headquarters and a human
resources development plan.
The Mental Treatment Act was enacted in 1959 and amended in 1968. A Mental Health Bill is
awaiting review by stakeholders and later parliamentary amendment; it is anticipated that it will
be passed in 2007. It compares well with legislation in countries such as South Africa and
Kenya, and includes the formation of a mental health review board, which will monitor the care
and treatment of psychiatric patients in hospital. It covers areas such as admissions, the rights of
inpatients and the safekeeping of patients’ property.
Training
Undergraduate medical students
There is one medical school, the Malawi College of Medicine, which is part of the University of
Malawi, in Blantyre. As part of their MBBS course, students in the third year have 2 weeks of
psychiatry theory and in the fourth year they undergo a 5-week rotation in theory and clinical
work.
Other health workers
The two main health sciences colleges offer training of paramedical staff – the clinical officers,
medical assistants and enrolled nurses. Clinical officers can go for further training in specific
areas and become psychiatric clinical officers, orthopaedic clinical officers and so on. Plans are
being finalised to train district primary health workers in the management of common psychiatric
disorders. Currently, most primary health workers lack skills in the assessment and management
of psychiatric patients and end up referring all those they come across.
53
Postgraduate specialisation
The College of Medicine at the University of Malawi has offered postgraduate training only
since 2005 in certain specialties, in conjunction with certain universities in South Africa. This
does not include psychiatry, so all psychiatric training at present has to be done outside Malawi.
Psychiatric nurses
The St John of God College of Health Sciences provides a degree in psychiatric nursing for
registered state nurses with a minimum of a university diploma in nursing, and the Malawi
College of Health Sciences provides a certificate course in psychiatry for enrolled nurses.
Research
Mental health in Malawi has been the subject of several research projects. These have included
studies in psychoactive substances, the teaching of psychiatry in the colleges and attributions for
admissions to Zomba Mental Hospital (MacLachlan et al, 1995). More studies are under way or
being developed by Zomba Mental Hospital on, for example:
 community attitudes to and knowledge of mental illness

 the prevalence of HIV and neurosyphilis among inpatients
 district mental health activities in southern Malawi, including what proportions of the
district budgets are allocated to mental health
common causes of relapse and readmission in patients with schizophrenia
 Pathways to care for psychiatric patients

 neuropsychological sequalae of cerebral malaria.
At the St John of God Hospital a randomised controlled trial of carer education in schizophrenia
and bipolar disorders is under way.In general, there is not much information on mental health in
the Malawian context and this provides opportunities and challenges for research.
Professional organisations
In the past there was a Mental Health Association of Malawi, but it stopped functioning, for
unknown reasons, around 1999. At present, a ‘core group’ is being formed, comprising: the
psychiatrist at Zomba Mental Hospital; the clinical psychologist at the Malawi College of
54
Medicine; the chief nursing officer at Zomba Mental Hospital; and the psychiatric clinical officer
at the St John of God Hospital. The main goal of this core group is to develop the preliminary
constitution of a new professional association and to recruit members. Some of the functions of
the association will be:
 to deal with challenges in mental health

 to act as an advisory body to the Medical Council of Malawi on the registration of mental
health professionals
 to develop, review and conduct policy for mental health professionals.
There are at present no non-governmental organisations operating in the mental health field in
Malawi.
Challenges
Notable problems include a critical shortage of trained staff and frequent shortages of drugs
owing to procurement problems. The referral system is not very good; neither is follow-up care,
as most district psychiatric services seem to be insufficiently well developed.
55

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252SW013 MENTAL HEALTH & PSYCHIATRIC DISORDER

DMI-ST. JOHN THE BAPTIST UNIVERSITY

Module Code: 252SW013

Subject Name: Mental Health & Psychiatric Disorder

School of Social Work

Module Teacher: Joy Wanozga Chione

252SW013 MENTAL HEALTH & PSYCHIATRIC DISORDER

INTERVIEWING THE DIFFICULT PATIENTS..................................................................................................25

1.2 Meaning of mental health

• It is a condition and a level of social functioning which is socially and personally

1.4 CHARACTERISTICS OF MENTAL HEALTH

• Is not disturbed by mental conflicts

• Has a true self-appraisal of his strength and weakness

• Is cooperative with others and has a feeling of security

• Has diverse and varied interest and lives constructively

• Is emotionally stable and socially mature

• Has high degree of frustration tolerance

• Has good physical health

1.4.1 Importance of Mental Health

• Mental health is very important because of following things:

• Helps in the development of desirable personality – Mental health helps in the

• Helps in seeking proper adjustment – A mentally healthy individual is an adjusted person.

1.4.2 Factors affecting mental health

(Changing Trends in Mental Health Care)

1.4.5 Mental Health Problem Symptoms, Causes and Effects

Attention Deficit Hyperactivity Disorder is characterized by an inability to remain focused on

Examples of signs and symptoms include:

 Feeling sad or down

Environmental exposures before birth. Exposure to environmental stressors, inflammatory

Complications (mental problems)

 Unhappiness and decreased enjoyment of life

AIM OF HISTORY TAKING

SETTING OF THE INTERVIEW

DURATION OF THE INTERVIEW

GENERAL PRINCIPLES OF INTERVIEWING

Consent for the Interview

Privacy and Confidentiality

Confidentiality is the most important component of the patient–therapist relationship. The

Respect and Consideration

Safety and Comfort

History of Present Illness

Past Psychiatric History

electroconvulsive therapy or alternative treatments should be carefully reviewed. One should

Past Medical History

Past Medical History

Substance Use/Abuse and Addictions

TECHNIQUES OF HISTORY TAKING

Facilitating Information Gathering

Techniques which can impede the Information Collection

INTERVIEWING THE DIFFICULT PATIENTS

Generally, unpremeditated violence is preceded by a period of gradually escalating psychomotor

A change in behavior, impaired brain function, cognitive ability, or memory5

What Is Schizoaffective Disorder?

Types of Schizoaffective Disorder

There are two types. Each has some schizophrenia symptoms:

Bipolar type: Episodes of mania and sometimes major depression

Depressive type: Only major depressive episodes

Symptoms of Schizoaffective Disorder

Causes of Schizoaffective Disorder

Diagnosis of Schizoaffective Disorder

In order to get diagnosed with schizoaffective disorder, you must have:

 Periods of uninterrupted illness

Treatment of Schizoaffective Disorder

Complications of Schizoaffective Disorder