Clinical Assessment and Diagnosis of Psychiatric Disorders-1

Clinical Assessment and Diagnosis of Psychiatric Disorders
Module 3
Unit 7 : Neurotic, stress related and somatoform disorders – Phobia, Obsessive Compulsive
Disorder, Panic Disorder
INTRODUCTION
Neurotic stress related and somatoform disorders have a common historical origin with the concept of
neurosis and association of a substantial proportion of these disorders with psychological causation.
About one third of population in developed countries will suffer from neurotic neurotic disorders during
its lifetime course.
Mixed of symptoms, especially anxiety and depressive ones are common in these disorders
with the exception of social phobia their frequency is higher in women than in men.
PHOBIC DISORDER
Phobia is defined as an irrational fear of a specific object, situation or activity often leading to persistant
avoidance of feared object, situation or activity. The common types of phobias are;
Agoraphobia
Social phobia
Specific phobia
Some common features of phobia are;
Presence of feared object, situation or activity.
The fear is out of proportion to the dangerousness perceived.
Patient recognizes the fear as irrational and unjustified.
This leads to persistent avoidance of that particular object, situation or activity.
Gradually this results in marked distress and restriction in the freedom of mobility.
AGORAPHOBIA
Agoraphobia is an example of irrational fear of situations. It is the commonest type of phobia in clinical
practice. It is characterised by an irrational fear of being in places far away from familiar setting of
home. Although it was earlier thought to be a fear of open spaces only ,now it includes fear of open
spaces, public spaces, crowded spaces, and any other place from where there is no easy way to escape.
Dept. of Social Work, St. Gregorios College of Social Science, Parumala 1|Page
The patient is afraid of all the places or situations from where escape may be perceived to be difficult, if
he suddenly develops embrassing or incapacitating symptoms(classical symptoms of panic).A full-blown
panic attack may occur (agoraphobia with panic disorder), or a few symptoms only(eg; dizziness or
tachycardia)-(agoraphobia with panic disorder).
As agoraphobia increases, there is a gradual restriction in normal day-to-day activities. The activities
may restrict that the person becomes self imprisoned in his home.
SOCIAL PHOBIA
This is an example of irrational fear of activities or social interactions, characterised by an irrational fear
of performing activities in the presence of other people or interacting with others. There is a marked
distress and disturbance in routine daily functioning.
Some examples are, fear of blushing(erythrophobia), eating in company

of others, public performance, participating in groups, writing in public, speaking to strangers, dating,
speaking to authority figures and urinating in public lavatory. Sometimes alcohol and other drugs are
used to overcome the anxiety occurring in social situations.
SPECIFIC PHOBIA
Specific phobia is an example of irrational fear of objects or situations. It is characterised by an irrational

fear of a specific object or situation. Anticipatory anxiety leads to persistent avoidant behavior.
The disorder is diagnosed only if there is marked distress or/and avoidance in daily functioning, in
addition to the specified object or situation. Some examples includes acrophobia(fear of
height),xenophobia(fear of strangers),claustrophobia(fear of closed places)algophobia(fear of
pain),zoophobia(fear of animals).
PREVALENCE
Studies indicate that the lifetime prevalence of phobia around the world ranges from 3-5%,with fears
and phobias.
ETIOLOGY
Psychodynamic theory
In phobia secondary defense mechanism is displacement . By using displacement , anxiety is transferred

from a really dangerous or frightening object to a neutral object. The neutral object chosen
unconsciously is the one which can be easily avoided in day-to-day life, in contrast to the frightening
object.
In agoraphobia, loss of parents in childhood and separation anxiety have been theorised to contribute to
causation. From a psychobiological percepective,the traumatic experiences of childhood may affect the
child's developing brain in such a manner the child becomes suceptable to anxiety and fear.
The behavioural theory explain phobia as a conditioned reflex. Initially the anxiety provoked by a
naturally frightening or dangerous object occurs in contiguity with a second neutral object. If this
happens enough, the neutral object becomes a conditioned stimulus for causing anxiety.
Biological theories
All phobias, especially agoraphobia are closely linked to panic disorders. It has-been suggested that
probably the biological models of panic disorders apply to phobias too.
COURSE
Phobias are generally common in women with an onset in late second decade. The course is usually
chronic with gradually increase restrictions in daily activities. Sometimes phobias are spontaneously
remitting.
TREATMENT
Most patients with phobic disorder rely on avoidance to manage their fears and anxieties.
The treatment model is usually multi-model. The patient with more than one phobia and presence of
panic symptoms often seek treatment earlier.
PSYCHOTHERAPY
Psychodynamically oriented psychotherapy is not usually helpful in treatment of phobias. This
approach is however indicated when there are characterological or personality difficulties as
well. Supportive psychotherapy is helpful adjust to behaviours therapy and drug treatment. CBT
can be used to break the anxiety patterns in phobic disorder. It is usual in combine CBT with
behavioural techniques.
BEHAVIOURAL THERAPY
Important techniques like flooding,systamatic desensistation,explosure and response
prevention, Relaxation techniques are useful
DRUG TREATMENT
Benzodiazepines are useful in reducing the anticipatory anxiety. Alprazolam is stated to have
antiphonic ,anti-panic and anti-anxiety properties. The other drugs used include clonazepam and
diazepam. However long-term use of benzodiazepines is fraught with the dangers of tolerance
and dependence.
Other antidepressants such as imipramine(TCA) and phenelzine (MA01) are useful in treating panic
attacks associated with phobias, there by decreasing distress.
OBSESSIVE-COMPULSIVE DISORDER
An obsession is defined as:
An idea, impulse or image which intrudes into the conscious awareness repeatedly.
It is recognised as one's own idea, impulse or image but is perceived as ego-alien.
It is recognised as irrational and absurd (insight is present).
Patient tries to resist against but it is unable.
Failure to resist, leads to marked distress.
An obsession is usually associated with compulsion. A compulsion is defined as:
A form of behavior which is usually follows obsessions.
It is aimed at either preventing or neutralising the distress or fear arising out of obsession.
The behaviour is not realistic and is either irrational or excessive.
Insight is present, so the patient realises the irrationality of compulsion.
The behaviour is performed with a sense of subjective compulsion.
Compulsions may diminish the anxiety associated with obsessions.
PREVALENCE
The worldwide prevalence of OCD is approximately 2% og the general population. Females are affected
at a slightly higher rates than male adulthood, although male are commonly affected in childhood.
EPIDEMOLOGY,COURSE AND OUTCOME
In India, OCD is more common in unmarried males, while in other countries, no gender differences are
reported. This disorder is commoner in persons from upper social strata and with high intelligence.
Recent studies shows the lifetime prevalence of OCD to be as high as 2-3%

through the Indian date shows a lower prevalence rate. Although OCD have a steady chronic cause, the
longitudinal profile of this disorder can also be episodic.
A summary of long term follow-up studies shows about 25% remained unimproved over time ,
50% had moderate to marked improvement while 25% has recovered completely.
ETIOLOGY
Several caustic factors have been explored in the past but no clear etiology of obsessive compulsive
disorder is known yet. Some important theories include ;
Psychodynamic theory
Sigmund Freud found obsessions and phobias to be psychogenitically related.
Undoing: This defense mechanism leads to compulsions which prevent consequences of obsessions.
Reaction formation results in the formation of obsessive compulsive personality traits rather than
contributing symptom, while displacement leads to formation of phobic symptoms.
Behavioural theory
This theory explains obsessions as conditioned stimuli to anxiety. Compulsions have been described with
obsessions.
Biological theories
OCD is found in 5-7% of first degree relatives of the patients with OCD. Psychosurgery has been
successfully used for treatment of OCD.
CLINICAL SYNDROMES
ICD-10 classifies OCD into three subtypes:
Predominantly obsessive thoughts or ruminations.
Predominantly compulsive acts
Mixed obsessional thoughts and acts.
Depression is very commonly associated with OCD. It is estimated that at least half the patients of OCD
have major depressive episodes while many others have mild depression. Premorbidly obsesssional or
anankastic personality disorder or traits may be commoner than in rest of population. Four
clinical syndromes have been described in literature, such as
Washers
This is commonest type. Here the obsession is of contamination with dirt, germs, body
excretions and the like. The compulsion is washing of hands or the whole body, repeatedly many times a
day. It is usually spreads on to washing of clothes, washing of bathroom,bedroom,door knobs, and
personal articles, gradually.
The person tries to avoid contamination but is unable to, so washing becomes a ritual.
Checkers
In this type, the person has multiple doubts, eg: the door has not been locked, kitchen gas has been left
open, counting of money was not exact,etc. The compulsion ,of course, is checking repeatedly to
'remove' the doubt'.
Any attempt to stop the checking leads to mounting anxiety. Before one doubt has been cleared,
other doubts may creep in.
Pure obsessions
This syndrome is characterised by repeatative intrustive thoughts, impulses or images which are not
associated with compulsive acts. The content is usually sexual or aggressive in nature. The distress
associated with these obsessions is dealt bt counter-thoughts(counting thoughts) and not by
behavioural rituals. A varient is obsessive rumination,which is a pre-occupation with thoughts.
Primary obsessive slowness

A relatively rare syndrome, it is characterised by severe obsessive ideas and/or compulsive ritual in the
relative absence of manifested anxiety. This leads to marked slowness in daily activities.
This subtype is quite difficult to diagnose in the routine clinical practice, unless the possibility of this
subtype is kept in mind. The Y-BOCS(Yale-Brown Obsessive compulsive Scale) classifies the symptoms
and signs of OCD as follows.
Aggresive obsessions
Contamination obsessions
Sexual obsessions
Saving obsessions
Religious obsessions
Obsession with need for symmetry or exactness
Somatic obsessions
Miscellaneous obsessions
Cleaning/washing compulsions
Counting compulsions
Ordering /arranging compulsions
Hoarding /collecting compulsions
Miscellaneous compulsions.
TREATMENT
PSYCHOTHERAPY
Psychoanalytic psychotherapy is used in certain selected patients, who are psychologically oriented.
Supportive psychotherapy is an important adjunct to other modes of treatment. It is also needed by

the family members.
Behaviour therapy and cognitive behavioural therapy
Behaviour modification is an effective mode of therapy. , with a success rate as high as 80%, especially
for the compulsive acts. It is costmary these days to combine CBT with BT agt most centers. The
techniques are listed below;
Thought-stopping
Response prevention
Systematic desensitisation
Modelling
Drug Treatment
Benzodiazepines: have a limited role in controlling anxiety as adjuncts and should be used very
sparingly.
Antidepressants: Some patients may improve dramatically with specific serotonin reuptake
inhibitors9(SSRIs).Clomipramine , a non specific serotonin reuptake inhibitor was the first drug
used effectively in the treatment of OCD. Fluoxetine a is good alternative to clomipramine and
often preferred for these days for its better side-effect profile.
Antipsychotics: These are occasionally used in low doses(eg; haloperidol,risperidol,

olazapine,aripiprazole,pimozide) in the treatment of severe, disabling anxiety.
Buspirone has also been used beneficially as an adjunct for argumentation of SSRIs , in some patients.
Electrocompulsive therapy
In presence of severe depression with OCD, ECT may be needed. ECT is particularly
indicated when there is a risk of suicide and/or when there is a poor response to the modes of
treatment. However ECT is not the treatment of first choice in OCD.
Psychosurgery
It can be used in treatment of OCD that has become intractable ,and is not responding to
other modes of treatment. The best responders are usually those who have significant associated
depression, although pure obsessions also do respond. It is usually followed by intensive behaviour
therapy aimed at rehabilitation.
CONCLUSION
Panic Disorder
People with OCD can develop elaborate rituals, known as compulsions, that they feel they must
complete in order to minimize anxiety. People with a phobia, on the other hand, typically do not think
much about the feared object or situation unless exposed to it some way.
Panic Disorder: Panic disorder is a type of anxiety disorder. It causes panic attacks, which are sudden
feelings of terror when there is no real danger. If a person has panic disorder, he may feel as losing control.
He/she may also have physical symptoms, such as fast heartbeat, chest or stomach pain, breathing
difficulty, weakness, sweating, feeling hot or a cold chill and tingly or numb hands.
Anxiety disorder due to a medical condition includes symptoms of intense anxiety or panic that are
directly caused by a physical health problem. Generalized anxiety disorder includes persistent and
excessive anxiety and worry about activities or events — even ordinary, routine issues. GAD includes
persistent and excessive anxiety and worry about activities or events — even ordinary, routine issues. The
worry is out of proportion to the actual circumstance, is difficult to control and affects how you feel
physically. It often occurs along with other anxiety disorders or depression.
PANIC DISORDER
Panic disorder occurs when a person experience recurring unexpected panic attacks. The DSM-5 defines
panic attacks as abrupt surges of intense fear or discomfort that peak within minutes. People with the disorder
live in fear of having panic attack. Panic attacks are sudden periods of intense fear that may include
palpitations, sweating, shortness of breath, numbness or a feeling that something terrible is going to happen.
The maximum degree of symptoms occurs within minutes.
The DSM-5 lists two types of panic attacks:
Expected panic attack- These are anticipated when a person is subjected to specific cues or panic triggers.
Unexpected panic attack- These panic attacks occur suddenly without any obvious cause or indication. When
an unexpected panic attack occurs, a person can be completely relaxed before symptoms develop.
Prevalence of panic disorder

Lifetime prevalence estimates for panic disorder in US adults range from 2.0% to 6.0%. the 12-month
prevalence in adults is 2.7%, of which 44.8% are classified as severe cases. Lifetime prevalence rates of major
depression in panic disorder may be as high as 50-60%. Patients with panic disorder can also have migraine
headaches (12.7%), tension headaches (5.5%), and combined migraine and tension headaches (14.2%). The
lifetime prevalence of panic disorder in people with epilepsy is 6.6%.
Etiology of panic disorder

Panic disorder appears to be a genetically inherited neurochemical dysfunction that may involve autonomic
imbalance; decreased GABA-ergic tone; allelic polymorphism of the catechol-O-methyltransferase (COMT)
gene; increased adenosine receptor function; increased cortisol; diminished benzodiazepine receptor function;
and disturbances in serotonin, serotonin transporter (5-HTTLPR) and promoter (SLC6A4) genes,
norepinephrine, dopamine, cholecystokinin, and interleukin-1-beta. Some theorize that panic disorder may
represent a state of chronic hyperventilation and carbon dioxide receptor hypersensitivity. Some epileptic
patients have panic as a manifestation of their seizures. Genetic studies suggest that the chromosomal regions
13q, 14q, 22q, 4q31-q34, and probably 9q31 may be associated with the heritability of panic disorder
phenotype.
Clinical Manifestation
DSM-5 criteria for panic disorder include the experiencing of recurrent panic attacks, with 1 or more attacks
followed by at least 1 month of fear of another panic attacks or significant maladaptive behavior related to
the attacks. A panic disorder is the abrupt onset of intense fear or discomfort that reaches a peak within
minutes and includes at least four of the following symptoms:
• Palpitations, pounding heart or accelerated heart rate

• Sweating
• Trembling or shaking
• Sensations of shortness of breath or something
• Feelings of chocking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light-headed or faint
• Chills or heat sensations
• Paresthesia (numbness or tingling sensations)
• Derealization (feeling of unreality) or depersonalization (being detached from oneself)
• Fear of losing control or going crazy
• Fear of dying
Course and Outcome

Course
The frequency and severity of panic attacks vary widely between individuals. Panic disorder can continue for
months or years, depending on how and when treatment is pursued. If left untreated, symptoms may become
so severe that a person has significant problems with their friends, family, or job. Some people may
experience several months or years of frequent symptoms, then many symptom-free years. In others,
symptoms persist at the same level indefinitely. There is some evidence that many people, particularly those
whose symptoms begin at an early age, may naturally experience a partial or even complete reduction in
symptoms after middle age.
Outcome
Adults with panic disorder will often change their behavior to feel safer and try to prevent future panic attacks.
• Social isolation
• Physical health problems
• Abuse of alcohol or other things
• Financial distress
• Unemployment
• Damaged personal relationship
• Failure in education
• Onset or worsening of co-occurring disorders
• Pervasive sense of hopelessness or helplessness
Treatments
The aims of treatment for panic disorder are:
• To help cope with and stop panic attacks
• To become aware of and stop fear-driven avoidance
• To reduce the vulnerability to future panics.
The major treatments for panic disorder are:
• Cognitive Behavioral Therapy

• Antidepressant medication
• Benzodiazepine medication.
Research suggests that Cognitive Behavioral Therapy (CBT) is the preferred treatment but Selective
Serotonin Reuptake Inhibitor (SSRI) antidepressants are also commonly used. However, effective treatment
should include behavioural treatment to limit avoidance.
Psychological treatments
• Cognitive Behavioural Therapy

CBT for panic disorder involves treatments that change the behaviour (exposure and anxiety management
such as slow-breathing) and those that change anxiety-provoking and worrying thoughts (i.e. cognitive
therapy). The goal is to help to develop a less upsetting understanding of physical changes that occur when a
person is anxious.
There is evidence that CBT is more effective than medication in both the short and long term. One advantage
of CBT over medication is that it has been shown to be helpful in the long-term, i.e. several months to several
years after short-term treatment has finished.
• Education about the disorder

Following assessment, a therapist will teach about anxiety in general, and panic disorder specifically. This
will involve talking about the 'fight or flight' response and details of how this affects the body. Education will
involve dispelling fears that people commonly have about this disorder such as that they are going crazy or
will die as a result of the symptoms.
• Cognitive therapy
This part of treatment involves identifying triggers for panic attacks and understanding the fears about the
symptoms of panic. Triggers might be a thought or situation or a slight physical change such as faster
heartbeat. People are taught to be more realistic in their interpretation of panic symptoms and feared
situations.
• Interoceptive and in vivo exposure

Interoceptive exposure involves becoming less frightened of the symptoms of panic in a controlled manner.
For those who avoid situations for fear of having a panic attack it will be important to face feared places. In
Dept. of Social Work, St. Gregorios College of Social Science, Parumala 10 | P a g e

vivo exposure involves breaking a fearful situation down into achievable steps and doing them one at a time
until the most difficult step is achieved.
• Relaxation and breathing techniques

Panic can be made worse by over breathing. Slowing one's breathing rate can be effective for some people to
help deal with a panic attack and also to prevent a full-blown attack from occurring. Relaxation is probably
more useful as a general strategy for dealing with anxiety but has been shown to be helpful for some people
with panic disorder. Relaxation and slow-breathing alone have not generally been shown to effectively treat
panic disorder, although there is some evidence that a form of relaxation called 'applied relaxation' can be
helpful.
Medications for panic disorder
• Antidepressants
There are many different types of antidepressant medications that have been found to be effective in treating
panic disorder. Most medications will be started at a low dose and increased to an effective level.
• Tricyclic antidepressants
Tricyclic antidepressants (TCAs) are an older class of drugs known for helping depression. They are also
effective in treating anxiety. Imipramine has been shown in many good studies to be an effective treatment
for panic disorder.
• Selective Serotonin Re-uptake Inhibitors

In recent years, there has been a lot of talk about drugs in this class of antidepressants as they are as effective
as the older types of antidepressants but are associated with fewer side effects. The most well-known is
probably Prozac (fluoxetine) but now there are a range of other SSRIs, many which have been shown to help
people with panic disorder (i.e. Cipramil / citalopram, Aropax / paroxetine, Zoloft / sertraline and Luvox /
fluvoxamine).
• Benzodiazepines
These drugs are designed to reduce tension and increase relaxation without causing sleep. Benzodiazepines
such as alprazolam (Xanax) have been found to be effective in treating panic disorder. Long-term use is
associated with dependence, increased risk of motor accidents and memory problems.

Unit : 8 GENERALIZED ANXIETY DISORDER
Generalized Anxiety
Generalized anxiety disorder is not unusual for anyone to occasionally worry about things such as
family problems, health or money, people with generalized anxiety disorder (GAD) find
themselves extremely worried about these sorts of things, as well as many other issues, even when
there may be little or no reason to worry. Patients with GAD may be anxious just trying to get
through an average day, always believing that things will go badly. The constant worrying, can at
times, keep patients with GAD from being able to perform everyday tasks. Patients with GAD may
make statements such as: “I was always a worrier: I’d feel keyed up and unable to relax. It could
go on for days and days at a time, sometimes constantly.” Others report trouble sleeping, waking
in the middle of the night, unable to fall back asleep. Concentration can be a problem, making
reading almost impossible. Patients with GAD often imagine the worst, handicapping many
aspects of their lives.
1.1. Prevalence of GAD
Surveys of the general population suggest that during a person’s lifetime, somewhere
between 4 to 6% of people will experience GAD. Women seem to be more susceptible to GAD
then men, occurring approximately twice as frequently in females. The most common age range
for the symptoms of GAD to appear is 45-59 years with a decline in diagnosis after age 60. If GAD
is left untreated, it becomes chronic and usually remains, with most patients still suffering from
the disease years after the diagnosis. Unfortunately, statistics suggest that only about 40% of
patients with GAD are able to receive appropriate treatment (Bandelow, et al 2013).
1.2. Etiology of GAD
There is no singular cause of generalized anxiety disorder (GAD) that has been identified.
Evidence has shown that multiple factors are usually at play, influencing the development of GAD.
Some of the common factors include things like genetic predisposition, brain chemistry, family
background, social influence, and life experiences.
1.2.1. Genetics
Genetics may play a role in determining whether or not to develop GAD. As with many other
mental and medical health conditions, we can be genetically predisposed for developing certain
symptoms. This is the same with generalized anxiety disorder. Technological and methodological
advances have allowed researchers to examine the role genes play in the development of GAD in
more detail, but the research is still in preliminary stages. Despite this, it has significant
implications for anyone who faces anxiety disorders. We know, for example, that we can have a
genetic vulnerability to developing GAD if certain genetic markers have been passed on to us.
Vulnerability, in combination with certain environmental factors, can trigger the development
symptoms.

1.2.2. Brain Structure
The limbic system is a collection of brain structures that, among other functions, is involved in the
regulation of many of our basic emotional reactions. Although it is generally under the control of
the "thinking" part of our brain, it can respond to stimuli on its own as well.
1.2.3. Life Experiences
Although genetic and biologic factors clearly contribute to the development of GAD, a greater
percentage of the risk for GAD lies in complex psychological, environmental, and social factors.
Mental health researchers have found that trauma in childhood can increase our risk of
developing GAD. Difficult experiences such as physical and mental abuse, neglect, the death of a
loved one, abandonment, divorce, or isolation can all be contributing factors. Research has shown
that life events that result in specific feelings of loss, humiliation, entrapment, and danger are
reliable predictors of the development and onset of generalized anxiety disorder. It is important
for medical and mental health practitioners to gather family and social history, information that
can help lead to an accurate diagnosis.
Some behavioral scientists believe that anxiety is a learned behavior, suggesting that if we
have a parent or caregiver who demonstrates anxious behavior, we may tend to mirror that same
anxious behavior. We are learning from caregivers and other important people close to us how to
handle challenging, stressful situations. When they model less effective methods of stressful
management, we tend to do the same. These early social learning experiences can influence our
development of long-lasting anxiety.
1.2.4. Societal Factors
Of people who are on social media, it has been shown that approximately 30% are plugged
into social media for 15 hours or more per week. Researchers are finding that the use of social
media, particularly in excess, can greatly impact our mental health, sometimes resulting in
anxiety and depression. People with GAD are less effective in accurately interpreting social
cues and interactions, leaving them to potentially feel a heightened sense of danger or rejection,
even when there is no observable threat present. Interactions through social media can be
interpreted in these same inaccurate ways, possibly even more so when we are, at times,
missing essential non-verbal cues in communication such as facial expressions, body language,
and tone and exacerbating GAD.
1.2.5. Lifestyle Factors
Caffeine;

Using everyday addictive substances like caffeine can heighten feelings of worry or
nervousness, contributing to the development of anxiety.5 Our culture tends to ask more and more
of us, pushing us to perform, and leaving us to fear feeling left behind, socially, financially,
physically, or otherwise. Relying on caffeine sources such as coffee, tea, soda, and energy drinks
can cause some people to feel restless and anxious, especially when used in large quantities.
Relationships;
Our relationships can be a source of great comfort, but also pain. Relationships can be a
significant source of anxiety for women, in particular. Women are twice as likely as men to develop
GAD. Because women are more likely to experience anxiety disorders, experts recommend that
women and girls aged 13 and older should be screened for anxiety during routine health exams.
Research has shown that two main factors of anxiety, specifically related to women, were being
afraid of and/or humiliated by a current partner or ex-partner. dangerous and fearful experience
within intimate relationships can influence the development of anxiety.
Job Stress;
Work can be a great source of stress and become a trigger in the development of anxiety. Some
employers expect extraordinarily high levels of performance and productivity that can threaten our
sense of employment security. When looking for work, we can find ourselves competing with
many others who are highly qualified and experienced, causing stress related to the ability to
provide for ourselves and our families. Career and work-related stress, particularly the loss of a
job, can be a significant source of heightened anxiety.
1.3.Clinical Manifestation
GAD is manifested by the following signs of motor tension, autonomic hyperactivity,

apprehension and vigilance, which should last for at least 6 months in order to make a diagnosis:
Psychological: - fearful anticipation, irritability, sensitivity to noise, restlessness, poor

concentration, worrying thoughts and apprehension.
Physical: -
• Gastrointestinal: dry mouth, difficulty in swallowing, epigastric discomfort, frequent

or loose motions.
• Respiratory: constriction in the chest, difficulty inhaling, over breathing.
• Cardiovascular: palpitations, discomfort in chest.
• Genitourinary: frequency or urgent micturition, failure of erection, menstrual
discomfort, amenorrhea.

• Neuromuscular system: tremor, prickling sensations, tinnitus, dizziness, headache,
aching muscles.
• Sleep disturbances: insomnia, night terror.
• Other symptoms: depression, obsessions, depersonalisation, derealisation.
1.4.Course And Outcome Of GAD
Although generalized anxiety disorder (GAD) is a common disorder associated with significant
levels of morbidity, little is known of its long-term course and outcomes. During the first 5 years,
GAD follows a chronic course with low rates of remission and moderate rates of relapse/recurrence
following remission. Retrospective studies suggest that this chronic pattern may last up to 20 years.
It is hoped that, as with depression, long-term prospective studies in GAD will provide insight into
the course, nature, and outcomes of the disorder over time. The studies will also identify any
changes in the duration and severity of episodes of GAD over time, enabling treatments to
effectively reflect the course of the disorder. Studies of other anxiety disorders and depression
suggest that the course and outcome of the disorder may be influenced by certain factors such as
stressful life events, anxiety sensitivity/negative affect, gender, subsyndromal symptoms, and
comorbid disorders. Currently, studies are underway to determine the effects of these factors on
the risk of relapse/recurrence, maintenance of full symptoms, and development of subsyndromal
symptoms in GAD. GAD is currently under recognized and undertreated, but it is hoped that this
will change with the ever-increasing awareness of anxiety disorders. As treatment for GAD
becomes more common, future prospective studies will identify the effect of therapy on the course
and nature of the disorder, leading to increased understanding of GAD and the development of
effective treatment strategies tailored for individual patients.
1.5. Treatment Modalities

Treatment decisions are based on how significantly generalized anxiety disorder is affecting
the patitent’s ability to function in his/her daily life. The two main treatments for generalized
anxiety disorder are psychotherapy and medications. Also it may benefit most from a combination
of the two. It may take some trial and error to discover which treatments work best for.
1.5.1. Psychotherapy
Also known as talk therapy or psychological counselling, psychotherapy involves working

with a therapist to reduce the anxiety symptoms. Cognitive behavioral therapy is the most effective
form of psychotherapy for generalized anxiety disorder. Generally a short-term treatment,
cognitive behavioral therapy focuses on teaching patients specific skills to directly manage their

worries and help them gradually return to the activities they've avoided because of anxiety.
Through this process, their symptoms improve as them build on their initial success.
1.5.2. Medications
Several types of medications are used to treat generalized anxiety disorder, including those
below;
• Antidepressants. Antidepressants, including medications in the selective serotonin reuptake

inhibitor (SSRI) and serotonin and norepinephrine reuptake inhibitor (SNRI) classes, are the
first line medication treatments. Examples of antidepressants used to treat generalized
anxiety disorder include escitalopram (Lexapro), duloxetine (Cymbalta), venlafaxine
(Effexor XR) and paroxetine (Paxil, Pexeva).
• Buspirone. An anti-anxiety medication called buspirone may be used on an ongoing basis.

As with most antidepressants, it typically takes up to several weeks to become fully effective.
• Benzodiazepines. In limited circumstances, doctor may prescribe a benzodiazepine for relief

of anxiety symptoms. These sedatives are generally used only for relieving acute anxiety on
a short-term basis. Because they can be habit-forming, these medications aren't a good choice
if the patient have or had problems with alcohol or drug abuse.
1.5.3. Lifestyle and home remedies
While most people with anxiety disorders need psychotherapy or medications to get anxiety
under control, lifestyle changes also can make a difference. Here's what we can do:
• Keep physically active. Develop a routine so that we're physically active most days of the
week. Exercise is a powerful stress reducer. It may improve our mood and help us stay
healthy. Start out slowly and gradually increase the amount and intensity of our activities.
• Make sleep a priority. Do what we can to make sure we're getting enough sleep to feel
rested. If we aren't sleeping well, see our doctor.
• Use relaxation techniques. Visualization techniques, meditation and yoga are examples of
relaxation techniques that can ease anxiety.
• Eat healthy. Healthy eating — such as focusing on vegetables, fruits, whole grains and fish
— may be linked to reduced anxiety, but more research is needed.
• Avoid alcohol and recreational drugs. These substances can worsen anxiety.

• Quit smoking and cut back or quit drinking coffee. Both nicotine and caffeine can worsen
anxiety.
Dissociative Disorder
Introduction
Dissociation is a phenomenon in which there is lack of connection in a person's thoughts,
memories, feelings, actions or sense of identity. During the period of dissociation, certain
information is split off from other information with which it is normally connected. Dissociative
experience is probably a Continuum, from complete absorption in a task with their total
unawareness of surroundings, to fugue states to total amnesia.
Dissociation can be interpreted as an “emergency defence” or a “shut of mechanism.”
Dissociation is closely related to conversion syndrome ( hysteria, hysterical dissociation) and
some consider the latter to be a subset of dissociation syndrome. Hypnosis is a widely used
technique to induce dissociation. There is evidence that identical functional brain changes occur
in conversion paralysis and hypnotically induced paralysis of the lower limb (Halligan et al
2000) Dissociation is an important symptom in post traumatic stress disorder (PTSD), as well as
in the borderline personality. Conversion, PTSD, and borderline personality disorder, however,
are not classified under the rubric of dissociative disorders in DSM 5. Syndromes included in the
DSM-5 as dissociative disorders are dissociative identity disorder (multiple personality).
Dissociative Amnesia, Dissociative Amnesia with dissociative fugue, depersonalization
disorder, and other specified or unspecified dissociative disorder.
Symptoms
• Memory loss (amnesia) of certain time periods, events, people and personal information
• A sense of being detached from yourself and your emotions
• A perception of the people and things around you as distorted and unreal
• A blurred sense of identity
• Significant stress or problems in your relationships, work or other important areas of your
life
• Inability to cope well with emotional or professional stress
• Mental health problems, such as depression, anxiety, and suicidal thoughts and behaviors
There are three major dissociative disorders defined in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5), published by the American Psychiatric Association:

• Dissociative amnesia. The main symptom is memory loss that's more severe than normal
forgetfulness and that can't be explained by a medical condition. You can't recall
information about yourself or events and people in your life, especially from a traumatic
time. Dissociative amnesia can be specific to events in a certain time, such as intense
combat, or more rarely, can involve complete loss of memory about yourself. It may
sometimes involve travel or confused wandering away from your life (dissociative fugue).
An episode of amnesia usually occurs suddenly and may last minutes, hours, or rarely,
months or years.
Types of Dissociative Amnesia
1. Localized Amnesia – is present in an individual who has no memory of specific

events that took place, usually traumatic. The loss of memory is localized with a
specific window of time.
2. Selective amnesia – happens when a person can recall only small parts of events that
took place in a defined period of time. For example, an abuse victim may recall only
some parts of the series of events around the abuse.
3. Generalized Amnesia – occurs when patients cannot remember anything in their
lifetime, including their own identity.
4. Continuous Amnesia – occurs when patients have no memory of events up to and
including the present time. This means that patients are alert and aware of their
surroundings but are not able to remember anything.
• Dissociative identity disorder. Formerly known as multiple personality disorder, this

disorder is characterized by "switching" to alternate identities. You may feel the presence
of two or more people talking or living inside your head, and you may feel as though you're
possessed by other identities. Each identity may have a unique name, personal history and
characteristics, including obvious differences in voice, gender, mannerisms and even such
physical qualities as the need for eyeglasses. There also are differences in how familiar
each identity is with the others. People with dissociative identity disorder typically also
have dissociative amnesia and often have dissociative fugue.
• Depersonalization-derealization disorder. This involves an ongoing or episodic sense of

detachment or being outside yourself — observing your actions, feelings, thoughts and self
from a distance as though watching a movie (depersonalization). Other people and things
around you may feel detached and foggy or dreamlike, time may be slowed down or sped
up, and the world may seem unreal (derealization). You may experience depersonalization,
derealization or both. Symptoms, which can be profoundly distressing, may last only a few
moments or come and go over many years.

Causes
Dissociative disorders usually develop as a way to cope with trauma. The disorders most often
form in children subjected to long-term physical, sexual or emotional abuse or, less often, a
home environment that's frightening or highly unpredictable. The stress of war or natural
disasters also can bring on dissociative disorders.
Personal identity is still forming during childhood. So a child is more able than an adult to step
outside of himself or herself and observe trauma as though it's happening to a different person. A
child who learns to dissociate in order to endure a traumatic experience may use this coping
mechanism in response to stressful situations throughout life.
Risk factors
People who experience long-term physical, sexual or emotional abuse during childhood are at
greatest risk of developing dissociative disorders.
Children and adults who experience other traumatic events, such as war, natural disasters,
kidnapping, torture, or extended, traumatic, early-life medical procedures, also may develop
these conditions.
Complications
People with dissociative disorders are at increased risk of complications and associated
disorders, such as:
• Self-harm or mutilation
• Suicidal thoughts and behavior
• Sexual dysfunction
• Alcoholism and drug use disorders
• Depression and anxiety disorders
• Post-traumatic stress disorder
• Personality disorders
• Sleep disorders, including nightmares, insomnia and sleepwalking
• Eating disorders
• Physical symptoms such as lightheadedness or non-epileptic seizures
• Major difficulties in personal relationships and at work

Treatment
With appropriate treatment, many people are successful in addressing the major symptoms of
dissociative identity disorder and improving their ability to function and live a productive,
fulfilling life.
Treatment typically involves psychotherapy. Therapy can help people gain control over the
dissociative process and symptoms. The goal of therapy is to help integrate the different
elements of identity. Therapy may be intense and difficult as it involves remembering and coping
with past traumatic experiences. Cognitive behavioral therapy and dialectical behavioral therapy
are two commonly used types of therapy. Hypnosis has also been found to be helpful in
treatment of dissociative identity disorder.
There are no medications to directly treat the symptoms of dissociative identity disorder.
However, medication may be helpful in treating related conditions or symptoms, such as the use
of antidepressants to treat symptoms of depression.
➢ Module 3
➢ Social cultural factors in psychiatric disorders with special reference to India.
➢ Culture’ is an abstraction, reflecting the total way of life of a society. It is a precipitate of the group’s
history and an expression of its adaptation to the physical environment. It refers to the shared
patterns of beliefs, feeling and behavior and the basic values and concepts that members of the group
carry in their minds as guides for the conduct. Besides social relationships, economics, religion,
philosophy, mythology, scriptures, technology and other aspects of living contribute to the culture.
Culture is constantly in the process of change and it is transmitted from one generation to the next.
All societies have it though their styles vary from one group to another.
➢ The term “culture”, which is a keystone in psychiatry, is plagued by confusion because of a lack of
concise, universally acceptable definition. In fact at least one hundred and sixty different definitions
exist. Culture is thus best conceptualized as a totality, composed of a complex system of symbols
possessing subjective dimensions such as values, feelings, and ideals and objective dimensions
including beliefs, traditions, and behavioral prescriptions, articulated into laws and rituals. This
unique capacity of culture to bind the objective world of perceived reality to the subjective world of
the personal and intimate, lends it, its powerful role as expressor, mediator, and moderator of
psychological processes and, ultimately, emotional disorders.
➢ Culture uniquely influences mental health of people living in a given society. Mental health problems,
from presentation of illness to course and outcome, at every stage are influenced by cultural issues.
Large numbers of patients get referred to the physician or psychiatrist of their cultural milieu as
he/she can understand the patient and his psyche due to the understanding of cultural factors which
influence the disease and healing process.
➢ No culture confers absolute immunity against psychological vicissitudes. The forms of psychiatric
disorders are identical in all cultures though the content of symptoms differ. For example, an Indian
peasant when deluded complains of being possessed by a demon, while his western counterpart
believes that his mind is being manipulated by electronics. It was believed a few decades ago, that
people from oriental cultures experienced little or no stress. Mental illness and stress-related
disorders like heart disease, high blood pressure, diabetes, cancer and suicide behavior were
considered to be less frequent amongst them. This really is not so. Transcultural studies indicate that

populations, exposed to a rapid onslaught from other cultures experience a cultural shock resulting
in a high degree of mental and social stress.
➢ Understanding of mental health in different cultures
➢ Conceptually, if we look at the ancient culture, there are four cultural streams that are prominently
seen. The Indian, Egyptian, Roman and Chinese culture. One similar phenomenon observed
regarding mental health problems in all of them is the impact of supernatural on the human mind.
The understanding of illness also in different cultures interestingly has been perceived as an
imbalance of humors leading to problems of mind and body. For example, the personality traits sat,
raj and tam and the three humors, vat, pitt and kaph conceptualized in Indian subcontinent also
correspond to theories of Chinese and Roman culture. All cultures developed independently,
thousands of miles apart with very little communication. The similar thinking about mental health
issues shows the similarity of human thoughts across cultures.
➢ In India, mental health and psyche has been an area of exploration for centuries together, right from
the vedic period, there has been a description of human mind, its functioning, consciousness and
dynamics of human behavior.
➢ There have been a sizeable number of studies which relate to the demographic factors, cultural
factors influencing presentation of illness, diagnosis of the illness-culture bound syndromes and
influence of the cultural factors and the belief system on psychopathology, stigma and discrimination
towards the patient. An attempt has been made to critically look at the research on culture and
psychiatry in different areas and their influence on the patient, his diagnosis and treatment.
Demographics
➢ In a study “Rapid urbanization - Its impact on mental health: A South Asian perspective” suggested that
urbanization is affecting the entire gamut of population especially the vulnerable sections of society. Rapid
urbanization has also led to creation of “fringe population” mostly living from hand to mouth which further
adds to poverty. Urban population is heavily influenced by changing cultural dynamics leading to particular
psychiatric problems like depression, alcoholism, and delinquency. Judicious use of resources, balanced
approach to development, and sound government policies are advocated for appropriate growth of
advancing economies of South-Asian region.
➢ Presentation of symptoms in different cultures
➢ In a study of psychiatric patients presenting with somatic complaints reported that more patients
from Muslim ethnic group presented with somatic symptoms in South Indian population. Headache
followed by nauseating sensation and vomiting were the prominent somatic complaints of the
neurotic disorders. In a repeated the study in north Indian population and found that the
predominant somatic complaint was constipation and feeling of gas in the abdomen.
➢ Culture-bound syndromes
➢ In a study “Culture-bound syndromes: The story of dhat syndrome.” explored the possibility of the
presence of similar symptoms and syndromes in different cultures and historical settings. And
concluded that the presence of similar symptoms and syndromes in different cultures and historical
settings. “ Dissociative disorders in a psychiatry institute in India - A selected review and patterns
over a decade” emphasized that unlike in the West, dissociative identity disorders were rarely
diagnosed; instead, possession states were commonly seen in the Indian population, indicating cross-
cultural disparity.

➢ Implications in psychotherapeutic process
➢ In Indian thought, human behavior has been explored at length. In post-vedic period, in Upanishads,
Bhagwad Gita, Yogic and ayurvedic literature abnormalities of human behavior have been described
and the treatise has been emphasized mainly through psychic changes.[29] In India psychotherapy also
needs to be based on cultural concepts and the prevailing belief system through centuries from
generation to generation, which becomes more acceptable to the patient. If we accept psychotherapy
as a interpersonal method of mitigating suffering, the process of change occurs in an individual through
a psychotherapeutic relationship which has been described as the ‘guru- chela relationship’ in India,
where in the wise offers advice to the pupil and helps him in relieving the suffering. This has been
observed in Buddhist and Jain traditions too
Unit : 10 TRANSCULTURAL PSYCHIATRY -CULTURE BOUND SYNDROME
INTRODUCTION
Culture refers to the meanings, values and behavioral norms that are learned and transmitted in the
dominant society and within its social groups. Culture powerfully influences cognition, feelings
and self-concept as well as the diagnostic process and treatment decisions.
Culture has six essential components
• Culture is learned
• Culture can be passed on from one generation to the next.
• Culture involves a set of meanings in which words, behaviors, events, and symbols have
agreed upon by the cultural group.
• Culture act as a template to shape and orient future behaviors and perspectives within and
between generations and to take account of naval situations encountered by the group.
• Culture exists in constant stage of change.
• Culture includes a pattern of both subjective and objective components of human behavior.
Culture and psychiatry
• Culture shapes how and what psychiatric symptoms are expressed.
• Culture influences the meanings that are given to symptoms.
• Culture also impacts the interaction between the patient and the health care system.
TRANSCULTURAL PSYCHIATRY
Transcultural psychiatry, cross-cultural psychiatry or cultural psychiatry is a branch of psychiatry

concerned with the cultural context of mental disorders and the challenges of addressing ethnic

diversity in psychiatric services. It emerged as a coherent field from several strands of work,
including surveys of the prevalence and form of disorders in different cultures or countries; the
study of migrant populations and ethnic diversity within countries; and analysis of psychiatry itself
as a cultural product.
Transcultural psychiatry is the discipline that deals with the description, assessment and
management of all psychiatric conditions as they reflect and are subjected to the influence of
cultural factors in a biopsychosocial context while using concepts and instruments from social and
biological sciences to advance a full understanding of psychopathology and its treatment.
HISTORY OF TRANSCULTURAL PSYCHIATRY
It is almost 100 years ago that the founder of modern psychiatry Emile Kraepelin, envisaged a new
discipline of comparative psychiatry, focussed on ethnic and cultural aspects of mental health and
illness.
Study of cultural differences in psychopathology has progressed under a number of names within
psychiatry (e.g. Transcultural psychiatry, cultural psychiatry, ethno psychiatry, cross-cultural
psychiatry)
The term transcultural psychiatry was introduced by Eric Wittkower of McGill University,
Montreal. (1950)
Henry Murphy defined the principal objectives of the discipline; to identify, verify and explain the
links between mental disorders and the broad psychosocial characteristics which differentiate
nations, peoples and cultures (1982)
WHY TRANSCULTURAL PSYCHIATRY IMPORTANT?
• Boundaries between normality and pathology vary across cultures.
• Thresholds of tolerance for specific symptoms or behaviours differ across culture.
• A given behaviour is abnormal or not and whether it requires clinical attention depends on
cultural norms.
• Awareness of the significance of culture may correct mistaken interpretations of

psychopathol0gy.
• Cultural meanings, habits, and traditions contribute to either stigma or support.

• It provides coping strategies and suggest help seeking options.
• Influences acceptance or rejection of a diagnosis and adherence to treatments.
• Cultural differences between the clinician and patient have implications for the accuracy
and acceptance of diagnosis as well as for treatment decisions and clinical outcomes.
CULTURE BOUND SYNDROMES

▪ Culture bound syndromes are also known as culture related specific disorders, culture
specific disorders/syndromes.
▪ In the American handbook of psychiatry, Exotic psychiatric syndromes or Rare atypical

unclassifiable disorders.
▪ They all refer to certain illnesses or disorders which occur exclusively in certain
cultures and not in others.
▪ The term culture -bound syndrome denotes a set of behavioral and experiential
phenomena that is present in a particular socio-cultural context and are readily
recognized as illness behavior by most participants in that culture.
▪ The syndrome is commonly assigned culturally sanctioned explanations, that, in turn,

generate culturally congruent remedies, usually in the form of hearing rituals.
ACCULTURATION AND ASSIMILATION
Adults, such as migrants or refugees, who only in part adopt the culture of a host society are said
to be assimilated, whereas those who assume a new cultural identity consonant with the host
culture are said to be acculturated.
Persons who abandon their native culture but fail to be assimilated or acculturated usually lose
their sense of identity or purpose in life and are at high risk for suicide, substance abuse, and
alcoholism.
THE CONCEPT OF CULTURE BOUND SYNDROMES
The DSM&ICD are not universally applicable; psychopathological syndromes exist, especially in
non-Western cultures that do not fit the scientific nomenclature unless they are placed into the
atypical category. These syndromes are perceived to be more influenced by culture and, therefore,
have been labeled culture -bound. Some syndromes are found in distinct cultural groups, whereas
others are found in large cultural regions.
HISTORY OF CBS
Conditions now been referred to as CBS were first described in Kraepelin textbook of psychiatry,

the 8th edition in 1909.
The Chinese psychiatrist Pow Meng Yap, a pioneer in cultural psychiatry (1962) introduced
‘atypical cultural bound psychogenic psychosis’ which he later abbreviated to culture bound
syndrome (1969).
In 1985 in the book ‘The Culture Bound Syndromes’, Ronald Simons & Charles Huges used the
taxonomic principles to group the syndromes based on their phenomenological similarity across
diverse cultural settings.
Ruth Levin & Albert Gaw suggested the term ‘folk diagnostic categories. They proposed a
criterion for culture specific syndromes-
• Must be a discreet, well defined syndrome
• Recognized as a specific illness in the culture
• Disorder must be recognized and sanctioned as a response to certain precipitants in the

culture.
• Higher incidence or prevalence in the society where it is culturally recognized.
CBS were first described outside the west and so were thought to be only non-western conditions
NOSOLOGY
❖ The term culture -bound syndrome was included in DSM IV (1994) and ICD 10(1992)
❖ According to DSM IV culture -bound syndrome denotes
▪ Recurrent,
▪ Locality -specific patterns of aberrant behavior and troubling experience that may or
may not be linked to a particular DSM-IV diagnostic category
▪ Indigenously considers to be ‘illnesses’, or at least afflictions
▪ Generally limited to specific societies or culture areas.
DSM IV describes about 25 CBS
1. Amok 14. pibloktoq
2. Ataques de nervios 15. Qi-gong psychotic reaction
3. Bilis and colera 16. rootwork
4. Boufe delirante 17. Sangue dormido

5. Dhat 18. Shenjing shuairuo
6. Falling out or blacking out 19. Shenjing shenkui
7. Ghost sickness 20. Shenjing dormido
8. Hwa-byung 21. Shin-byung
9. Koro 22. Spell
10. Latah 23. Susto
11. Locura 24. Taijin kyofusho
12. Mal de ojo 25. Zar
13. Nevios
❖ ICD 10
➢ ICD 10 categorizes culture bound syndrome in the Annex 2 and lists 12 culture bound
syndromes
➢ It lacks any diagnostic and cultural explanatory guidelines.
➢ ICD 10 describes about 12 CBS
1. Amok 7. Pibloktoq
2. Dhat 8. Susto
3. Koro 9. Taijin Kyofoshu
4. Latah 10. Ufufuyane
5. Nervios 11. Uqamairineq
6. Frigophobia 12. Windigo
❖ DSM 5
➢ The DSM 5 includes them in the appendix under the heading ‘Glossary of Cultural
Concepts of Distress’-refers to ways that cultural groups experience, understand, and
communicate suffering, behavioral problems, or troubling thoughts and emotions.
➢ Three concepts-syndromes, idioms, and explanations.

▪ Syndromes-clusters of symptoms and attributions that tend to co-occur among
individuals in specific cultural groups, communities, or contexts and they are
recognized locally as coherent patterns of experience.
▪ Idioms-are ways of expressing distress that may not involve specific symptoms or
syndromes, but that provide collective, shared ways of experiencing and talking about
personal or social concerns.
▪ Explanations-are labels, attributions, or features of an explanatory model that indicate

culturally recognized meaning or etiology for symptoms, illness or distress.
EXAMPLES OF CULTURE BOUND SYNDROMES
IN INDIA
• Dhat syndrome
• Possession syndrome
• Koro
• Bhanmati sorcery
• Suudu
• Gilhari syndrome
• Ascetic syndrome
• Mass hysteria
• Culture -bound suicide (sati, santhra)
1.DHAT SYNDROME
➢ ‘Dhat’ gets its origin from the Sanskrit word ‘Dhatus’. In Susruta Samhita, it means ‘elixir
that constitute the body’. In Charka Samhita, disorder of Dhatus have been described as
‘Shukrameha’ in which there is passage of semen in the urine.
➢ First described in western literature by NN Wig. It is more prevalent in the India. It showed
global presence, China (Shen K’uei), Sri Lanka (Prameha), other parts of South East Asia
(Jiryan). Malhota and Wig called ‘DHAT’ ‘a sexual neurosis of the Orient’
➢ Notion of semen loss Frightens the individual Series of somatic symptoms

Symptoms
• Vague somatic symptoms due to semen loss
• Semen loss via nocturnal emissions, urine and masturbation
• Weakness, fatigue, palpitations, sleeplessness,anxiety,loss of appetite, and guilt.
➢ Treatment -Wig suggested
Empathetic listening, non-confrontational approach, reassurance, use of anti-anxiety and

antidepressant drugs, wherever required.
2. POSSESSION SYNDROME
➢ Diagnosable under Dissociative disorders.
➢ Person is possessed usually by spirit/soul of deceased relative local deity.
➢ Speaks in changed tone, sometimes in opposite sex tone.
➢ Usually seen in rural areas or in migrants from rural areas.
➢ In religious shrines during special annual festivals where people get possessed
simultaneously
➢ Majority are females who otherwise don’t have any outlet to express their emotions.
➢ Treatment-careful exploration of underlying stress which precipitated the possession

attack.
3.KORO
➢ Koro-Malay word meaning ‘the head of the turtle’
➢ Reported primarily among the Chinese of southern coastal china
➢ In India it is seen in Northeast states like Assam. More common in Males.
➢ There is a fear of retraction of genital organs
➢ Psychosexual problems
Lack of masculine relations, Lack of heterosexual relations, Misconceptions about

sexual practices, Existence of castration anxiety Sudden and intense anxiety that
penis or vulva or nipples will retract into the body This belief will lead to panic
reaction

➢ It occurs as an epidemic in a particular group. Strong belief that ghosts are involved and
driving away of ghosts would lead to removal of the disease.
➢ Therapy: Assurance, educational counselling
4.BHANMATI SORCERY
➢ Seen in South India
➢ Belief in magical spells that produce evil spirits to cause psychiatric illness like
conversation disorders, somatization disorders, anxiety disorders, dysthymia,
schizophrenia
➢ Nosological status unclear
5.SUUDU
➢ Syndrome of painful urination and pelvic heat familiar in south India.
➢ Occurs both in males and females
➢ Attributed to an increase in the ‘inner heat’ of the body often due to dehydration
➢ Treated by local practices like applying sesame oil, having oil massage and intake of
fenugreek.
6.GILHARI SYNDROME
➢ This population believed that it starts as feeling of Gilhari(squirrel)running on back of body

associated with intense pain and anxiety and finally Gilhari reaching the throat causing
stoppage of breathing.
➢ Gilhari Syndrome is prevalent in Bikaner region.
➢ People believed that Gilhari must be crushed to death or it will kill patients and the
treatment is mainly received from local expert or faith healers.
7.ASCETIC SYNDROME
➢ First described in Nelki (1972)
➢ Appears in adolescents and young adults.
➢ Characterized by social withdrawal, severe sexual abstinence, practice of religious

austerities, lack of concern with physical appearance and considerable loss of weight.
8.MASS HYSTERIA

➢ Short lasting epidemics where hundreds to thousands of people believe and behave in a
manner in which ordinarily, they won’t.
➢ Choudhary et al (1993) reported an epidemic of atypical hysteria in a tribal village of the

State of Tripura India.
➢ Twelve persons were affected in a chain reaction within a span of ten days.
➢ Cardinal feature was an episodic trance state of 5 to 15 min.
➢ It was associated with restlessness, attempts at self-injury, running away, inappropriate

behavior, inability to identify family members, refusal of food and intermittent mimicking
of animal sounds.
➢ Self -limiting and showed an individual course of one to three days duration.
9. CULTURE BOUND SUICIDE
➢ Sati: self-immolation by a widow on her husband’s pyre. Named based on Hindu

mythology.
➢ Jouhar: suicide committed by a woman even before the death of her husband when faced
by prospect of dishonor from another man.
➢ Santhara/Sallekhana: voluntarily giving up life by fasting unto death over a period of time
for religious reasons to attain God/Moksha.
Other examples
• NEURASTHENIA
It denotes a condition with symptoms of fatigue, anxiety, headache, impotence, neuralgia and
depressed mood. It was explained as being a result of exhaustion of the central nervous system's
energy reserves', which was attributed to the stresses of civilization and urbanization and the
pressures placed on the intellectual class by the increasingly competitive business environment.
Typically, it was associated with upper class individuals. In China a similar syndrome is known as
shenjing shuairuo. In Japan the condition is known as shinkeisuijaku.
• AMOK
Amok is from the Malay/Indonesian/Filipino meaning ‘mad with rage’ The phrase is particularly
associated with a specific sociopathic syndrome in Malaysian culture. In a typical case of running
amok, a male who has shown no previous inclination to violence will acquire a weapon and, in a
sudden frenzy, attempt to kill or seriously injure anyone he encounters. Norse ‘Berserkers’ and the
Zulu battle trance are other examples of the tendency of certain groups to work themselves up into
a killing frenzy.
• SUSTO
Susto, a ‘fright sickness’, is indigenously attributed to ‘soul loss’ resulting from traumatic
experiences. Among Native Indian populations of Latin America, susto may be conceptualized as
a case of spirit attacks. The onset of the disease generally follows a sudden frightening experience
such as an accident, witnessing a relative's sudden death, or other potentially dangerous events.
Symptoms of susto are thought to include nervousness, anorexia, insomnia, listlessness,
despondency, involuntary muscle tics and diarrhea.
• GHOST SICKNESS
Ghost sickness is native to American Indian tribes and believed to be caused by association with
the dead or dying and is sometimes associated with witchcraft. It is considered to be a psychotic
disorder of Navajo origin. Its symptoms include general weakness, loss of appetite, a feeling of
suffocation, recurring nightmares and a pervasive feeling of terror. The sickness is attributed to
ghosts (chindi) or, occasionally, to witches.
• WENDIGO PSYCHOIS
Wendigo psychosis is a culture-bound disorder which involves a craving for human flesh and the
fear that one will turn into a cannibal. This once occurred frequently among Algonquian Indian
cultures, though has declined with the Native American urbanization.
• LATAH
It is a condition of hyper startling found in the Middle East and South-East Asia and is found
mainly in adult women. The afflicted have a severe reaction to being surprised in which they lose
control of their behavior, mimic the speech and actions of those around them and sometimes obey
any commands given them. Similar conditions have been recorded within other cultures and
locations, such as among French-Canadian lumberjacks in Maine (Jumping Frenchmen of Maine)
and the Ainu of Japan.
• BILIS
Underlying cause: strongly experienced anger or rage
Latino groups view anger as a particularly powerful emotion that can have direct effect on the
body and exacerbate existing symptoms. Major effects are disturbing core body balance (balance
between hot & cold valences in the body and between material and spiritual aspects of the body)
Symptoms: headache, trembling, screaming, stomach disturbances, loss of consciousness.
TREATMENT OF CBS
 Determining whether the symptomatology represents a culturally appropriate

adaptive response to a situation.
 Clinicians are well advised to
1.Know or search out the demographics of the local population or catchment

area being served
2.Recognize that always a local pattern exists of conceptualization, naming,

vocabulary, explanation and treatment of patterns of distress that afflicts a
community, including mental disorders.
3.Talk with the family and learn about local customs or search out other modes
of documentation.
 Implies acceptance of, and respect for, the patient’s cultural frame of reference
and opens the possibility of direct intervention in the lives of patients, who may
be willing to cooperate when they feel understood.
Unit 10: Behavioural syndrome associated with physiological disturbances and factors.
Eating Disorder and Sleeping Disorder
EATING DISORDER
Eating disorder are serious health conditions related to persistent eating behaviors that negatively
impact a person’s health and his or her ability to function in important area of life. Obsessions with food,
body weight and shape may also signal an eating disorder. Report suggest that at least 20 million
woman and 10 million men in the United States suffer from an eating disorder.
Eating disorder describe illnesses that are characterized by irregular eating habits and
severe distress or concern about body weight or shape.
Types of Eating Disorder

1. Anorexia Nervosa :
Anorexia Nervosa is a psychological and potentially life threatening eating disorder. Those
suffering from this eating disorder are typically suffering from an extremely new body weight
relative to their height and body type. Major types of Anorexia Nervosa
A. Binge/ Purge type ; The person struggling with this type of eating disorder will often purge after
eating.
B. Restrictive type ; The individual suffering from restrictive anorexia is often perceived as highly self
disciplined.

2. Bulimia Nervosa :
Bulimia Nervosa commonly called Bulimia, is a serious potentially life threatening eating
disorder. People with Bulimia may secretly binge eating large amounts of food with a loss of control
over the eating and then purge, trying to get rid of the extra calories in an unhealthy way.
3. Binge Eating Disorder :

Binge Eating Disorder is characterized by repeated episodes of uncontrolled intake of
unusually large amounts of food in a short period of time. Binge Eating Disorder is commonly known
by compulsive overeating or consuming abnormal amounts of food while feeling unable to stop and
a loss of control.
4. Obesity ( Overeating Associated with Other psychological Disturbances) :

Obesity caused by a reaction to distressing events is included here. Obesity is a medical
condition in which excess body fat has accumulated to an extent that it may have a negative effect
on health.
5. Psychogenic Vomiting :
This is a clinical syndrome in which biopsychosocial factors interact to produce symptoms in
which are often mistaken for upper gastrointestinal tract disease.
Signs and Symptoms of an Eating Disorder

• Constant weight fluctuations
• Obsession with calories and fat contents of food
• Continued fixation with food, recipes or cooking
• Depression or lethargic stage
• Avoidance of social functions, family and friends
• Switching between periods of overeating and fasting
Causes of Eating Disorder

An eating disorders may often be associated with biological, genetic or environmental factors
combined with a particular event that triggers the condition.
 Biological factors include :

• Irregular hormone functions
• Genetics

• Nutritional deficiencies
 Psychological factors include:
• Negative body image
• Poor self esteem
 Environmental factors include :
• Dysfunctional family dynamic
• Professional and careers that promote being thin and weight loss.
• Family and childhood traumas
• Stressful transitions or life change
Treatment for Eating Disorder

 Medical care and monitoring
The highest concern in the treatment of eating disorder is addressing any health issues that
may have been a consequence of eating disordered behaviours.
 Nutrition
This would involve weight restoration and stabilization guidance for normal eating
and the integration of an individualized meal plan.  Therapy
Different forms of psychotherapy such as individual, family and group therapy can be helpful
in addressing the underlying causes of eating disorders.
 Medications
Antidepressants are the most common medications used to treat eating disorders that
involve binge eating or purging behaviour but depending on the situations other medications
are sometimes prescribed.
SLEEP DISORDER
Sleep disorders are a group of conditions that affect the ability to sleep well on a regular basis.
Whether they are caused by a health problem or by too much stress, sleep disorders are becoming
increasingly common in the United States.
Types of Sleep Disorder

1. Dyssomnias :
Dyssomnias are sleep disorders that are characterized by disturbances in the amount,
quality or timing of sleep. Which can lead to excessive sleepiness during the day.

A. Insomnia ;
Insomnia is also known as the Disorder of Initiation and/ or Maintenance of Sleep.
A person with insomnia has difficulty falling asleep or staying asleep. They may
consistently wake up too early.
B. Hypersomnia ;
Hypersomnia means one or more of the excessive day time sleepiness, sleep
attacks during the day time or sleep drunkenness.
C. Disorders of Sleep wake Schedule ;

These are characterized by a disturbances in the timing of sleep.
2. Parasomnias :
Parasomnias are a class of sleep disorders that cause abnormal movements and
behaviours during sleep. The behavior can occur during any stage of sleep.
A. Sleepwalking ( Somnambulism) ;
The patient carries out automatic motor activities that range from simple to
complex.
B. Sleep terrors or Night terrors ;
A night terrors or Sleep terror, causes you to suddenly wake up in a terrified

state. The terror can last from 30 seconds to 5 minutes.
C. Bedwetting ;
Bedwetting is involuntarily urinating during sleep.
D. Bruxism ( Teeth grinding) ;

The patient has an involuntarily and forceful grinding of teeth during sleep.
E. Sleep talking ;
It happens when you talk while asleep.
Signs and Symptoms of Sleep Disorder
• Difficulty falling or staying asleep

• Daytime fatigue
• Unusual breathing patterns
• Unusual movement
• Irritability or anxiety
• Lack of Concentration

• Depression
• Weight gain
Causes of Sleep Disorder
• Allergies and respiratory problems

• Frequent urination
• Chronic pain
• Stress and anxiety
Treatment for Sleep Disorder

1. Medical treatments ;
• Sleeping pills
• Melatonin supplements
• Medications for any underlying health issues
• Breathing device or surgery
• A dental guard
2. Life style changes ;
• Reducing stress and anxiety by exercising and stretching
• Drinking less water before bedtime

• Decreasing tobacco and alcohol use
• Maintaining a healthy weight
3. Therapies ;
• Cognitive Behavioral Therapy

• Sleep restriction therapy
• Stimulus control therapy
SEXUAL DYSFUNCTIONS
INTRODUCTION : Sexual dysfunction occurs when you have a problem that prevents you from wanting or enjoying
sexual activity. It can happen anytime. Men and women of all ages experience sexual dysfunction, although the

chances increase as you age. The sexual response cycle traditionally includes excitement, orgasm, and resolution.
Desire and arousal are both part of the excitement phase of the sexual response. Treatment options are available, it
is important to share your concerns with your partner and healthcare provider.
DEFINITION
Sexual dysfunction refers to a problem occurring during any phase of the sexual response cycle that prevents the
individual or couple from experiencing satisfaction from the sexual activity. According to the DSM-5, sexual
dysfunction requires a person to feel extreme distress and interpersonal strain for a minimum of six months
(excluding substance or medication-induced sexual dysfunction).
CAUSES
Physical causes
➢ Heart and vascular (blood vessel) disease

➢ Neurological disorders
➢ Hormonal imbalances
➢ Chronic diseases such as kidney or liver failure.
➢ Alcoholism and drug abuse.
➢ Side effects of some medications, including some antidepressant drugs.
Psychological causes
➢ Work-related stress
➢ Anxiety
➢ Concern about sexual performance
➢ Marital or relationship problem
➢ Depression
➢ Feelings of guilt
➢ Concerns about body image
➢ Effects of a past sexual trauma.
SYMPTOMS
Men and women

• Lack of interest in or desire for sex
• Inability to become aroused
• Pain with intercourse
Men
• Inability to achieve or maintain an erection suitable for intercourse (erectile dysfunction).

• Absent or delayed ejaculation despite adequate sexual stimulation (retarded ejaculation)
• Inability to control the timing of ejaculation (early or premature ejaculation)
Women
• Inability to achieve orgasm

• Inadequate vaginal lubrication before and during intercourse
• Inability to relax the vaginal muscles enough to allow intercourse
TYPES
Sexual disorders affect both men and women and are classified into 4 main categories:
1. Sexual desire disorders

2. Sexual arousal disorders
3. Sexual orgasmic disorders
4. Sexual pain disorders
Sexual aversion disorder is an intense dislike of genital contact with a sexual partner and the person feels disgust
and revulsion towards sexual activity. The main feature is avoidance, which is similar to what happens when a
person has a phobia or fear.
Hypoactive sexual desire disorder, or HSDD, is having little or no sexual fantasies and desire for sexual activity. This
lack of desire is beyond what normally happens in a relationship’s duration and life cycle. The clinical diagnosis of
HSDD is subjective and takes into account the person’s age, physical health, and personal life circumstances.
In combined arousal disorder, the woman does not experience physiologic or subjective (mental) arousal. In
missed arousal disorder, women have physiologic arousal but not subjective arousal. With genital arousal disorder
there is subjective arousal, when the woman is mentally aroused and feels sexual arousal from non-genital
stimulation, but she lacks physiologic arousal or vaginal congestion, that is, no pleasurable sexual sensations in her
clitoris or vagina.

Male erectile disorder, or ED, is the inability of a man to reach, or maintain an adequate erection until completion
of sexual activity. This is a common problem that may be due to many factors, including physical, psychological,
medical conditions, or medications.
Men with male orgasmic disorder have a delay in, or absence of, orgasm following a normal sexual excitement
phase with sexual activity.
With premature ejaculation, a man ejaculates with minimal sexual stimulation before, on, or shortly after
penetration. This can be distressing for both the man and his partner.
Male dyspareunia, or male sexual pain, is very uncommon, and is usually due to a medical condition. There are 4
categories of male sexual pain:
o Ejaculatory pain that occurs occasionally.
o Pain associated with sexual activity as part of a chronic pelvic pain syndrome.
o Painful genital conditions that interfere with sexual activity or are associated with sexual dysfunction, such
as chronic testicular pain.
o Other causes of sexual pain that include conditions of the penis, such as phimosis or a tight frenulum.
Women with female sexual arousal disorder have little or no genital responsiveness to stimulation and they don’t
produce adequate lubrication to engage in sexual intercourse.
Female orgasmic disorder is a delay or lack of orgasm following a normal excitement phase. It’s important to note
that many women are able to achieve orgasm with specific forms of stimulation, but not with intercourse, so this is
considered within the normal range sexual function.
Female dyspareunia is pain in the vaginal area that occurs before, during, or after sexual intercourse. Pain may
occur with entry into the vagina or as deep pain. Both psychological and physical factors can contribute to the
condition.
Vaginismus is the involuntary tightening of the outer part of the vaginal muscles that makes vaginal penetration
difficult, even when a woman wants sexual penetration. Women with this condition can still achieve orgasm and
enjoy sexual activity, just not penetration.
DIAGNOSIS
In most cases, the individual recognizes that there is a problem interfering with his or her enjoyment (or the
partner's enjoyment) of a sexual relationship. He or she may order diagnostic tests to rule out any medical

problems that may be contributing to the dysfunction, if needed. Typically, lab testing plays a very limited role in
the diagnosis of sexual dysfunction
An evaluation of the person's attitudes about sex, as well as other possible contributing factors (fear, anxiety, past
sexual trauma/abuse, relationship concerns, medications, alcohol or drug abuse, etc.) will help the clinician
understand the underlying cause of the problem, and will help him or her make recommendations for appropriate
treatment.
TREATMENT
Most types of sexual dysfunction can be corrected by treating the underlying physical or psychological problems.
Other treatment strategies include:
Medication — When a medication is the cause of the dysfunction, a change in the medication may help. Men and
women with hormone deficiencies may benefit from hormone shots, pills, or creams.
Sex therapy — Sex therapists can be very helpful to couples experiencing a sexual problem that cannot be addressed
by their primary clinician. Therapists are often good marital counsellors, as well. For the couple who wants to begin
enjoying their sexual relationship, it is well worth the time and effort to work with a trained professional.
Behavioural treatments — These involve various techniques, including insights into harmful behaviours in the
relationship, or techniques such as self-stimulation for treatment of problems with arousal and/or orgasm.
Psychotherapy — Therapy with a trained counsellor can help a person address sexual trauma from the past, feelings
of anxiety, fear, or guilt, and poor body image, all of which may have an impact on current sexual function.
Education and communication — Education about sex and sexual behaviours and responses may help an individual
overcome his or her anxieties about sexual function. Open dialogue with your partner about your needs and
concerns also helps to overcome many barriers to a healthy sex life.
CONCLUSION
Disorders of sexual dysfunction can be lifelong or they may begin at any stage of life. They can also be situational,
meaning they occur only under certain circumstances or with a certain partner, or, they can occur all the time. The
success of treatment for sexual dysfunction depends on the underlying cause of the problem. The outlook is good
for dysfunction that is related to a condition that can be treated or reversed. Mild dysfunction that is related to

stress, fear, or anxiety often can be successfully treated with counselling, education, and improved communication
with partners.
Module 4 Unit 11
TOPIC : ORGANIC DISORDERS, DELIRIUM AND DEMENTIA
INTRODUCTION
An organic mental disorder also known as organic brain syndrome is a form of decreased mental function
due to a medical or physical diseases rather than a psychiatric illness while mental or behavioural
abnormalities related to the dysfunction can be the permanent, treating the diseases early may prevent
permanent damage in addition to fully restoring mental function.
Organic mental disorders are psychiatric disturbances relating from transient or permanent central
nervous system dysfunctions. According to brain pathology there are two types of organic mental
disorders. The main is acute organic mental disorders ( delirium) and chronic mental disorders (
dementia).
DEMENTIA
Dementia is progress decline in cognitive function due to change or diseases in the brain. Dementia causes
problem with thinking,memory, and reasoning. It happens when the parts of the brain used for learning,
memory, decision making and language are damaged or diseased .Alzheirmer's diseases the most
common cause of dementia.
Dementia is a general loss of cognitive abilities, including impairment of memory as well as one or
more of the following aphasia, apraxia, agnosia, or disturbed planning organizing, and abstract thinking
abilities.
PREVELENCE
The prevalence of dementia in various geriatric psychiatry setting has previously been investigated and
lbeen found to lie between 15.2% and 6.1 %. The present study investigated the percentage of patients
with organic brain disorder.Dementia acquired brain injury or other brain diseases. In one geriatric
psychiatric department in copenhagen, denmark. The journals of all patients admitted to the geriatric
psychiatric department in 2002 were studied in order to find evidence of psychiatric discharge diagnosis
of OBD 2002.
ETIOLOGY
1. Significant loss of neurons and volume in brain regions devoted to memory and higher
mental functioning.
2. Neurofibrillary angels ( twisted nerve cell fibers that are the damaged remains of
microtubules.)
3. Environmental factors : infection, metals,toxins

4. Excessive amount of metal ions, such as zinc and copper in brain.
5. Deficiencies of vitamin B6 and B12 and folate possible risk factors due to increased level
of Homocysteine.
6. Early depression : common genetic factors seen in those with early depression and
Alzheimer's diseases.
COURSE OF DEMENTIA
No two people with dementia experience the disease exactly the same way, and the rate of progression
will vary by person and type of dementia.In addition, it is not uncommon for individuals to have mixed
dementia, meaning they have more than one type.That said, there is a natural course of the diseases, and
over time the capabilities of all person with dementia
Will worsen.
Eventually, the ability to function goes away keep in mind that changes in the brain from dementia
begin years before diagnosis, when there are no outward symptoms. This makes it difficult to know how
much time a person has left though there are ways to come close to knowing life expectancy.
OUTCOME OF DEMENTIA
Suspecting you or a loved one has dementia can be extremely distressing.But the more you understand
about the condition, the more you can do to improve the outcome with dementia, there will likely be
noticeable decline in communication,learning, remembering, and problem solving.These changes may
occur quickly or very slowly over time. The progression and outcome vary, but are largely determined by
the type of dementia and which area of the brain is affected.
Facing up to the possibility of dementia inevitably shifts your perceptions, relationships, and priorities.But
experiencing symptoms doesn't have to mean the end of your normal life.
CLINICAL MANIFESTATIONS
● forgetfulness
● Confusion with performing simple task
● Poor concentration
● Confusion about month amd season
● Problems in learning new skills and ideas
● Disorientation in time
● Amnesia
● Suspiciousness
● Inappropriate sexual behaviour
● Wondering
● misplacing things

● Changes in personality
● Hallucinations
● Delusion
● Memory and impairment.
TYPE OF DEMETIA
1) Cortical dementia
Dementia where the brain damage primarily affects the brain's cortex or outer layer.
Subcortical dementia
Dementia that affects part of the brain below the cortex. Subcortical dementia tends to cause
changes in emotions and emotions and movement in addition to problems with memory.
Progressive dementia
Dementia that gets worse over time gradually interfering with more and more cognitive
abidementil
Primary dementia
Dementia such as Alzheimer's disease, in which the dementia it self is the major signs the some
organic brain syndrome not directed related to any other organic illness.
Secondary dementia
Dementia that occurs as a result of a physical disease or injury. Such as HIV diseases or cerebral
trauma.
STAGES OF DEMENTIA
1)mild cognitive impairment
Characterized by general forgetfulness, this affects many people as they age but it only
progresaive to dementia for some.
2) mild dementia
People with mild dementia will experience cognitive impairment the occasionally impact their daily life.
Symptoms include memory loss,confusion, personality changes, getting lost, and difficulty in planning and
carrying out tasks.
3) moderate dementia
Daily life becomes more challenging and the individual may need more help. Symptoms are similar to mild
dementia but increased. Individuals may need help getting dressed and combing their hair.
4) severe dementia

At this stage, symptoms have worsened considerably. There may be a loss of ability to communicate and
the individual might need full time care.
TREATMENT
Treatment of dementia will largely depend on the etiology. Insomnia and psychotic or mood symptoms
need appropriate care.
Dementia is a chronic and devastating illeness which takes away the identity of the person. By the terminal
stage, patients often become empty shells of their former selves realizing this can be fatal to them.
Following non pharmacological approaches are of great help insight oriented psychotherapy. Assistance
in greving maximizing any areas of intact functioning, activity scheduling and day structuring,cognitive
skills training, family psycho education, care giver stress and burn out management.
ETIOLOGY
Delirium is an abrupt change in the brain that causes mental confusion and emotional disruption. It makes
it difficult to think, remember, sleep, pay, attention and more. Delirium is also referred to as " acute
confusion state or acute brain syndrome ".Delirium is an acute organic mental disorder characterized by
impairment of consciousness, disorientation, and disturbances in perception and restlessness.
PREVALENCE
● Delirium may occur at any age but is more common among the elderly
● At least 10% of elderly patients who are admitted to the hospital have delirium 15 % 50%
experience delirium at some time during hospitalization.
● Delirium is also common after surgery amd among nursing home residents and ICU patients.
● When delirium occurs in younger people, it is usually due to drug use or life threatening
systematic disorder.
ETIOLOGY
Vascular
Infections
Neoplastic
Intoxication
Traumatic
Vitamin deficiency
Endocrine and metabolic
Metals
CLINICAL FEATURES
Impairment of consciousness
Clouding of consciousness ranging from drowsiness to stupor and coma.

Impairment of attention
Difficulty in shifting focusing and sustaining attention
Appearance and behaviour
The patients looks unwell and behaviour may be marked by agitation or hypoactivity.
Mood
Mood is frequently labile, with perplexity, intermittent periods of anxiety or depression.
Speech
The patient may mumble and he incoherent.
Perception
Visual perception is the modality most often affected. Illusions and misinterpretations are frequent.
Cognition
There are abnormalities in all areas of cognitive function memory registration, retention, and recall are all
affected
Orientation
In obvious cases, orientation in person, time, and place will be disturbed.
Concentration
Concentration is impaired
Memory
Disturbance are seen, with impaired registration short term recall and long term recall.
Insight
Insight is usually impaired
Disturbances of the sleep wake cycle
Insomnia or in severe cases total sleep loss or reversal of sleep wake cycle.
Psychomotor disturbances
Hypoactivity or hyperacInsigh
COURSE OF DELIRIUM
1) By the third hospitals day, approximately one. Half the patients who are diagnosed with delirium
have been diagnosed.
2) Symptoms of delirium usually last 3 to 5 days, but there is slow resolution symptoms contributing
to persistent symptoms of delirium at 6 to 8 Weeks for severely ill patients

3) Symptoms resolution is frequently incomplete by hospital discharge with as many as 15 percent
of patients remaining symptomatic of delirium at 6 months.
4) In general, studies suggest that the increased mortality risk associated With delirium was main
tained at 12,24 and 36 months with a risk of at all time points.
OUTCOME OF DELIRIUM
Delirium has been associated with various important adverse outcomes, including increased mortality,
longer hospital stays and increased dependency, leading to discharge from hospital toba care home.
Results are inconsistent however.
SYMPTOMES OF DELIRIUM
● Disrupted or wondering attention

● Inability to think or behave with purpose
● Disorganized thinking
● Speech that doesn' t make sense
● Inability to stop speech patterns or behaviours.
● Changes in feeling
● Decrease in short term memory
● Change in alertness
● Change in movement
● Changes in level of consciousness
● Changes in sleep patterns.
TREATMENT
Delirium is usually caused by other medical conditions, so important to threat those conditions in order
to threat delirium the doctor will careful review the patient.
● Medical history
● Physical exam results
● Lab results
● Drug use
Some ways to treat delirium include focusing on the patients environment. The person with delirium will
do best in a quiet setting.The following are tips for caregivers people:-
● Help promote sleep and rest by reducing noise and distraction

● Reassure the patient amd help them understand the environment
● Explain to the patient what is happening
● Bring familiar objects from home to help make the patient more comfortable in an unfamiliar
environment
● Feed the patient and give him or her drinks, it appropriate throughout the day
● Encourage the patient to get out bed if its safe to do so
● Keep the patient oriented
● Make sure the patient has nutritional foods and stays hydrated
● Keep the patient awake during the day and exposed to sunlight avoid naps

● Try to ensure that the patient gets maximum uninterrupted sleep at night
The patient should do as much as possible on his or her own.these actions include:
● Using an interpreter to help understand care plans if there are language barriers.
● Being involved in their treatment and asking the doctor any questions they may have
● Using eyeglasses and hearing aids to promote good vision and hearing
● Getting out of bed during the daytime.This include sitting in a chair during mealtimes or walking
when possible.
Epilepsy
is a chronic non communicable disease of the brain that affects around 50 million people
worldwide. It is characterized by recurrent seizures, which are brief episodes of involuntary
movement that may involve a part of the body (partial) or the entire body (generalized) and are
sometimes accompanied by loss of consciousness and control of bowel or bladder function.
Seizure episodes are a result of excessive electrical discharges in a group of brain cells.
Different parts of the brain can be the site of such discharges. Seizures can vary from the briefest
lapses of attention or muscle jerks to severe and prolonged convulsions. Seizures can also vary in
frequency, from less than 1 per year to several per day.
One seizure does not signify epilepsy (up to 10% of people worldwide have one seizure
during their lifetime). Epilepsy is defined as having two or more unprovoked seizures. Epilepsy
is one of the world’s oldest recognized conditions, with written records dating back to 4000 BC.
Fear, misunderstanding, discrimination and social stigma have surrounded epilepsy for centuries.
This stigma continues in many countries today and can impact on the quality of life for people
with the disease and their families.
Signs and symptoms
Characteristics of seizures vary and depend on where in the brain the disturbance first
starts, and how far it spreads. Temporary symptoms occur, such as loss of awareness or
consciousness, and disturbances of movement, sensation (including vision, hearing and taste),
mood, or other cognitive functions.
People with epilepsy tend to have more physical problems (such as fractures and bruising
from injuries related to seizures), as well as higher rates of psychological conditions, including
anxiety and depression.

Similarly, the risk of premature death in people with epilepsy is up to three times higher
than in the general population, with the highest rates of premature mortality found in low- and
middle-income countries and in rural areas.
A great proportion of the causes of death related to epilepsy, especially in low- and
middle-income countries are potentially preventable, such as falls, drowning, burns and
prolonged seizures.
Rates of disease
Epilepsy accounts for a significant proportion of the world’s disease burden, affecting
around 50 million people worldwide. The estimated proportion of the general population with
active epilepsy (i.e. continuing seizures or with the need for treatment) at a given time is between
4 and 10 per 1000 people.
Globally, an estimated five million people are diagnosed with epilepsy each year. In
high-income countries, there are estimated to be 49 per 100 000 people diagnosed with epilepsy
each year. In low- and middle-income countries, this figure can be as high as 139 per 100 000.
This is likely due to the increased risk of endemic conditions such as malaria or
neurocysticercosis; the higher incidence of road traffic injuries; birth-related injuries; and
variations in medical infrastructure, the availability of preventive health programmes and
accessible care. Close to 80% of people with epilepsy live in low- and middle-income countries.
Causes
Epilepsy is not contagious. Although many underlying disease mechanisms can lead to
epilepsy, the cause of the disease is still unknown in about 50% of cases globally. The causes of
epilepsy are divided into the following categories: structural, genetic, infectious, metabolic,
immune and unknown. Examples include:
• brain damage from prenatal or perinatal causes (e.g. a loss of oxygen or trauma during
birth, low birth weight);
• congenital abnormalities or genetic conditions with associated brain malformations;
• a severe head injury;
• a stroke that restricts the amount of oxygen to the brain;
• an infection of the brain such as meningitis, encephalitis or neurocysticercosis,
• certain genetic syndromes; and
• a brain tumour.

Treatment
Seizures can be controlled. Up to 70% of people living with epilepsy could become seizure free
with appropriate use of antiseizure medicines. Low-cost treatment is available, with daily
medication that costs as little as US$ 5 per year. Discontinuing anti-seizure medicine can be
considered after 2 years without seizures and should take into account relevant clinical, social
and personal factors. A documented etiology of the seizure and an abnormal
electroencephalography (EEG) pattern are the two most consistent predictors of seizure
recurrence.
• In low-income countries, about three quarters of people with epilepsy may not receive the
treatment they need. This is called the “treatment gap”.
• In many low- and middle-income countries, there is low availability of antiseizure
medication. A recent study found the average availability of generic antiseizure
medicines in the public sector of low- and middle-income countries to be less than 50%.
This may act as a barrier to accessing treatment.
• It is possible to diagnose and treat most people with epilepsy at the primary health-care
level without the use of sophisticated equipment.
• WHO pilot projects have indicated that training primary health-care providers to
diagnose and treat epilepsy can effectively reduce the epilepsy treatment gap.
• Surgery might be beneficial to patients who respond poorly to drug treatments.
Prevention
An estimated 25% of epilepsy cases are preventable.
• Preventing head injury is the most effective way to prevent post-traumatic epilepsy.
• Adequate perinatal care can reduce new cases of epilepsy caused by birth injury.
• The use of drugs and other methods to lower the body temperature of a feverish child can
reduce the chance of febrile seizures.
• The prevention of epilepsy associated with stroke is focused on cardiovascular risk factor
reduction, e.g. measures to prevent or control high blood pressure, diabetes and obesity,
and the avoidance of tobacco and excessive alcohol use.
• Central nervous system infections are common causes of epilepsy in tropical areas, where
many low- and middle-income countries are concentrated. Elimination of parasites in
these environments and education on how to avoid infections can be effective ways to
reduce epilepsy worldwide, for example those cases due to neurocysticercosis.
Social and economic impacts
Epilepsy accounts for 0.5% of the global burden of disease, a time-based measure that
combines years of life lost due to premature mortality and time lived in less than full health.

Epilepsy has significant economic implications in terms of health-care needs, premature death
and lost work productivity.
The economic impact of epilepsy varies significantly depending on the duration and
severity of the condition, response to treatment, and the health-care setting. Out-of-pocket costs
and productivity losses create substantial burdens on households. An economic study from India
estimated that public financing for both first- and second-line therapy and other medical costs
alleviates the financial burden from epilepsy and is cost-effective (1).
Although the social effects vary from country to country, the stigma and discrimination
that surround epilepsy worldwide are often more difficult to overcome than the seizures
themselves. People living with epilepsy can be targets of prejudice. The stigma of the disease can
discourage people from seeking treatment for symptoms, so as to avoid becoming identified with
the disease.
Human rights
People with epilepsy can experience reduced access to educational opportunities, a

withholding of the opportunity to obtain a driving license, barriers to enter particular
occupations, and reduced access to health and life insurance. In many countries legislation
reflects centuries of misunderstanding about epilepsy. For example:
• In both China and India, epilepsy is commonly viewed as a reason for prohibiting or
annulling marriages.
• In the United Kingdom of Great Britain and Northern Ireland, laws which permitted the
annulment of a marriage on the grounds of epilepsy were not amended until 1971.
• In the United States of America, until the 1970s, it was legal to deny people with seizures
access to restaurants, theatres, recreational centres and other public buildings.
Legislation based on internationally-accepted human rights standards can prevent discrimination

and rights violations, improve access to health-care services, and raise the quality of life for
people with epilepsy.
How is epilepsy diagnosed?
If you suspect you’ve had a seizure, see your doctor as soon as possible. A
seizure can be a symptom of a serious medical issue.

Your medical history and symptoms will help your doctor decide which tests will
be helpful. You’ll probably have a neurological examination to test your motor
abilities and mental functioning.
In order to diagnose epilepsy, other conditions that cause seizures should be ruled
out. Your doctor will probably order a complete blood count and chemistry of the
blood.
Blood tests may be used to look for:
• signs of infectious diseases

• liver and kidney function
• blood glucose levels
Electroencephalogram (EEG) is the most common test used in diagnosing

epilepsy. First, electrodes are attached to your scalp with a paste. It’s a
noninvasive, painless test. You may be asked to perform a specific task. In some
cases, the test is performed during sleep. The electrodes will record the electrical
activity of your brain. Whether you’re having a seizure or not, changes in normal
brain wave patterns are common in epilepsy.
Imaging tests can reveal tumors and other abnormalities that can cause seizures.
These tests might include:
• CT scan
• MRI
• positron emission tomography (PET)
• single-photon emission computerized tomography
Epilepsy is usually diagnosed if you have seizures for no apparent or reversible

reason.

Conclusion
The burden of epilepsy manifests itself at a number of different levels.

Taking a population-level approach, both epidemiological and economic studies
have revealed the extent of the negative impact of epilepsy on existing levels of
health and health care. It is an unfortunate truth that the current burden, often
couched in terms of the “treatment gap” in epilepsy, is concentrated in regions with
the greatest health challenges and the least resources with which to respond to
them. More positively, however, one can conclude that it is in these very regions
that there exists the greatest opportunity to reduce current levels of epilepsyrelated
deaths and disability, employing efficacious treatments which have been shown to
be a highly cost-effective use of scarce resources.
Alcohol and Substance abuse

Alcohol is a depressant , which in low doses causes euphoria , reduces anxiety and increases sociability . In
higher doses , it causes drunkenness , stupor , unconsciousness or death .Long term use can lead to alcohol
abuses , cancer , physical dependence and alcoholism . Substance abuse refers to the harmful or hazardous use
of psycho active substance, including Alcohol and illicit drugs . Psycho active substance use can lead to
dependence syndrome a cluster of behavioural , cognitive and physiological phenomena that developed after
repeated substance use and that typically include a strong desire to take the drug , difficulties its use , increased
tolerance and sometimes physical state .
EFFECTS OF ALCOHOL
Alcohol is one of the most widely used recreational drugs in the world about 33 % of people being current
drinkers . Drinking too much on a single occasion or over time can take a serious toll on health . Here’s how
alcohol can affect body
BRAIN : Alcohol interferes with the brains communication pathways and can affect the way the brain looks and
works . These disruption can change mood and behaviour and make it harder to think clearly and move with
coordination .
HEART : Drinking a lot over a long time or too much causing problems including
• Cardiomyopathy
• Arrhythmias
• Stroke
• High blood pressure
LIVER : Heavy drinking takes a toll on the liver and can lead to variety of problems including
• Fatty liver
• Fibrosis
• Cirrhosis

PANCREAS : Alcohol causes the pancreas to produce toxic substances that can eventually lead to pancreatitis , a
dangerous inflammation and swelling of the blood vessels in the pancreas that prevent proper digestion .
IMMUNE SYSTEM : Chronic drinkers are more liable to contract diseases like pneumonia & tuberculosis than
people who do not drink too much and also make your body a much target for disease .
Depending on how much is taken and the physical condition of the individual alcohol can cause .
• Slurred speech
• Vomiting
• Breathing difficulty
• Distorted vision and hearing
• Impaired judgement
• Anaemia
• Blackouts
LONG TERM EFFECTS

• Unintentional injuries such as car crash , falls, burns
• Intentional injuries such as sexual assault , domestic violence
• Increased family problems
• Ulcers
• Sexual problems etc
CAUSES OF SUBSTANCE USE
SOCIAL FACTORS
• Peer pressure
• Imitation
• Cultural and religious reason
• Celebrations
• Conflicts (usually intra familial )
PSYCHOLOGICAL FACTORS
• Curiosity
• To escape reality
• Low self esteem
• Childhood loss or trauma
• Poor stress management
• As a relief from fatigue or boredom
• Psychological distress
BIOLOGICAL FACTORS
• Family history
• Genetic predispotion
• Pre existing psychiatric or personality disorder or medical disorder.

SYMPTOMS AND SIGNS OF SUBSTANCE ABUSE
Family and Friends may be among the first to recognize the signs of substance abuse .Early recognition
increases the chance for successful treatment .
• Declining grades
• A significant change in mood or behaviour
• Aggressiveness and irritability
• Forgetfulness
• Hopeless
• Depressed or even suicided
• Feeling rundown
COMMONLY ABUSED DRUGS
Both legal and illegal drugs have chemicals that can change how your body and mind work .
MARIJUANA
Which comes from the plant cannabis sativa is the most commonly used illegal drug . The drug is
usually smoked but it can also be eaten .It smoke irritate your lungs more and contains more cancer
causing chemicals than tobacco smoke . Common effects of Marijuana includes pleasure , relaxation
and memory
COCAINE
Derived from the coco plant of South America. Cocaine can be smoked , injected and swallowed
.The intensity and duration of the drugs effects depends on how you take it. Short term effects also
include paranoia , constriction of blood , stroke , irregular heart and death .
HEROIN
It is also known as dope , smoke , horse . Effects of heroin intoxication includes drowsiness , pleassure
and slowed breathing . Overdose may result in decreased breathing to the point of stopped breathing
and death .
METHAMPHETAMINES
It is a powerful stimulant that increases alertness , decreased appetite and gives a sensation of
pleasure
LSD
Lsd and hallugemogenic mushrooms can cause hallucination , numbness , nausea , and increased
heartrate . Long term effects include unwanted flashbacks , hallucination , delusion , paranoia .
KETAMINE
This is an anaesthetic that can be taken orally or injected .ketamine can impair memory and
attention .High doses can cause amnesia , paranoia etc.

ANABOLIC STERIODS
Steroids are often abused by body builders or athletes to increase muscle mass or improve
performance . It leads to mood problem and developing other kind of drug abuse .
CONCLUSION
We can conclude that consequences of substance abuse and alcohol in the society in general and on
youths in particularly are extremely negative on every aspects of life which needs immediate
intervention .Collaborative efforts of all stakeholders is needed no one alone can control it .
Unit : 12
Topic : PARANOID PERSONALITY DISORDER, ANTI SOCIAL PERSONALITY DISORDER.

INTRODUCTION
Personality Disorders are mental health conditions that affect how someone think, perceive, feel or
relate to others. A personality disorder is characterized by inflexible patterns of thinking,feeling or
relating to others that cause problems in personal, social and work situations. Personality Disorders tend
to emerge during the late childhood or adolescence and usually continue throughout adulthood.
The personality traits that make up personality disorders are common. It create a bit of problem for
diagnosis. They are a group of mental illness involve long term pattern of thoughts and behaviors that
are unhealthy and flexible.
Paranoid Personality Disorders (PPD)

Paranoid Personality Disorders ( PPD) is one of a group of conditions called eccentric personality
disorders. People with PPD suffer from Paranoia , an unrelenting mistrust and suspicion on others, even
when there is no reason for suspicious.
People with these disorders often appear odd or peculiar. This disorder often begins in childhood or
early adolescence and appears to be more common in men than in women. Studies estimate that PPD
affects between 2.3% and 4.4% of general population.
Causes
The exact cause of PPD is not known but it likely involves a combination of biological and psychological
factors. The fact that PPD is more common in people who have close relatives with schizophrenia and
delusional disorder suggests a genetic link between the two disorders ( may run in the family). It is also
believed that early childhood experience, including physical or emotional trauma, play a role in the
development of Paranoid Personality Disorder.
Symptoms

People with PPD are always on guard, believing that others are constantly trying to de-mean, harm or
threaten them. These generally unfounded beliefs,as well as their habits of blame and distrust, interfere
with their ability to form close or even workable relationships. People with this disorder
● Doubt the commitment, loyalty or trustworthiness of others, believing that others are exploiting
or deceiving them.
● They are reluctant to confide others or reveal personal information because they are of afraid
the information will be used against them.
● They are unforgiving to others and also holding grudges.
● They are hypertensive and take criticism poorly
● They are the type of reading hidden meanings in the innocent remarks or casual looks of others
● They are having difficulty relaxing cannot see their role in problems or conflicts, believing they
are always right
● They are hostile, stubborn and argumentative
Psychotherapy and medications from prescribed medical practitioner is the treatment method
of Paranoid Personality Disorder ( PPD).
Anti-Social Personality Disorder

Anti-Social Personality Disorder is a particularly challenging type of personality disorder charectrized by
impulsive, irresponsible and often criminal behavior. Someone with Anti-Social Personality Disorder will
typically be manipulative, deceitful and reckless,and won't care for other people's feeling. Like other
types of personality disorders, Anti-Social Personality Disorder is on a spectrum, which means it can
range in severeity from occasional bad behavior to repeatedly breaking the law and committing serious
crimes.
SIGNS
● Exploit, manipulate or violate the rights of others

● Lack concerns, regret or remorse about other people's distress.
● Behave irresponsibly and show disregard for normal social behavior
● Have difficulty in sustaining long term relationship
● Be unable to control their anger
● Lack guilt or not learn from their mistakes
● Blame others for problems in their lives
● Repeatedly break the law
How it develop
Anti-Social Personality Disorders affect more in men than women. It is not known why some people
develop anti social personality disorder,but both genetics and traumatic childhood experiences such as
child abuse, neglects etc.. A person with anti social personality disorder will have often grown up in
difficult family circumstances. One or both parents may misuse alcohol, parental conflict and harsh,
inconsistent parenting are common.

These types of difficulties in childhood will often lead to behavioral problems during adolescence
and adulthood.
Effects
Criminal behavior is a key feature of anti social personality disorder and there is a high risk that
someone with the disorder will commit crimes and can be imprisoned at some point in their life. Men
with anti social personality disorder have been found to be 3 to 5 times more likely to misuse alcohol
and drugs than others. Increased risk of dying pre maturely as a result of the reckless behavior or
attempting suicide.
Treatment
Evidence suggest behavior can improve over time with therapy even if core charectristics such as lack of
empathy remain. But the anti social personality disorder is one of the most difficult type of personality
disorders to treat. Patient may reluctant to seek treatment and may only start therapy when ordered by
a Court.
Emotionally unstable
INTRODUCTION
Behaviors that are considered maladaptive and cause significant personal distress and interrupt daily functioning
are more likely to be labeled as disorders.
Today, many mental health professionals agree that psychological disorders are characterized by both personal
distress and impairment in multiple areas of life.
A psychological disorder is a designation often used interchangeably with the terms mental disorder, psychiatric
disorder, or mental illness. The “official” term is mental disorder, defined in the latest edition of the American
Psychiatric Association's diagnostic manual, the DSM-5. It defines a mental disorder as:1
"...a syndrome characterized by a clinically significant disturbance in an individual's cognitive, emotion regulation,
or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental
functioning. Mental disorders are usually associated with significant distress in social, occupational, or other
important activities."
The DSM-5 also notes that expected responses to a common stressor such as the death of a loved one are not
considered mental disorders. The diagnostic manual also suggests that behaviors that are often considered at odds
with social norms are not considered disorders unless these actions are the result of some dysfunction.
The classification and diagnosis is an important concern for both mental health providers and mental health clients.
Clinicians utilize the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric
Association, to determine whether a set of symptoms or behaviors meets the criteria for diagnosis as a mental
disorder. The International Classification of Diseases, published by the World Health Organization, is also frequently
used.
Relatively recent research has revealed that psychological disorders are far more widespread than previously
believed.
PREVALENCE :-

EMOTIONALLY UNSTABLE PERSONALITY DISORDER :- ( Impulsive and Borderline )
Emotionally unstable personality disorder (EUPD), which is also known as 'borderline personality disorder, is the
most common type of personality disorder. This condition typically cause individuals to experiences intense and
fluctuating emotions, which can last anywhere from a few hours to several days at a time. These emotions can range
from extreme happiness, euphoria and self-belief, to crushing feelings of sadness and worthlessness later the same
day. In addition, it is not uncommon for individuals with EUPD to also experience suicidal thoughts and engage in
self- harming behaviours. The rapid and extreme fluctuations in mood that are associated with EUPD can often make
it difficult for sufferers to maintain stable personal relationship. The prevalence of emotionally unstable personality
disorder in the general population is 1%. Although, overall personality disorders are distributed equally between
males and females, emotionally unstable personality disorder is more common amongst females. One study
reported a prevalence of 30.1% in males and 52.8% in females.
HISTRONIC:-
Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder
characterized by a pattern of excessive attention-seeking behaviors, usually beginning in early adulthood, including
inappropriate seduction and an excessive need for approval. People diagnosed with the disorder are said to be lively,
dramatic, vivacious, enthusiastic, and flirtatious.
It affects 2–3% of the general population and 10–15% in inpatient and outpatient mental health institutions. The
survey data from the National epidemiological survey from 2001–2002 suggests a prevalence of HPD of 1.84 percent.
Approximately 65% of HPD diagnoses are women while 35% are men. Although two thirds of HPD diagnoses are
female, there have been a few exceptions.
ETIOLOGY
1. Emotionally unstable personality disorder:

• Genetics :-
Genes you inherit from your parents may make you more vulnerable to developing emotionally unstable personality
disorder. A study found that if 1 identical twin had EUPD, there was a 2-in-3 chance that the other identical twin
would also have EUPD. However, these results have to be treated with caution and there's no evidence of a gene for
EUPD.
• Problem with brain chemicals :-

It's thought that many people with EUPD have something wrong with the neurotransmitters in their brain,
particularly serotonin.
Neurotransmitters are "messenger chemicals" used by your brain to transmit signals between brain cells. Altered
levels of serotonin have been linked to depression, aggression and difficulty controlling destructive urges.
• Problem with brain development :-

Researchers have used MRI to study the brains of people with EUPD. MRI scans use strong magnetic fields and radio
waves to produce a detailed image of the inside of the body.
The scans revealed that in many people with EUPD, 3 parts of the brain were either smaller than expected or had
unusual levels of activity. These parts were:

The amygdala – which plays an important role in regulating emotions, especially the more "negative" emotions, such
as fear, aggression and anxiety
The hippocampus – which helps regulate behaviour and self-control
The orbitofrontal cortex – which is involved in planning and decision making
Problems with these parts of the brain may well contribute to symptoms of EUPD.
The development of these parts of the brain is affected by your early upbringing. These parts of your brain are also
responsible for mood regulation, which may account for some of the problems people with EUPD have in close
relationships.
• Environmental factors :-
A number of environmental factors seem to be common and widespread among people with EUPD. These include:
*being a victim of emotional, physical or sexual abuse

*being exposed to long-term fear or distress as a child
*being neglected by 1 or both parents
*growing up with another family member who had a serious mental health condition, such as bipolar disorder or a
drink or drug misuse problem
2. Histronic : -
Although it is said that the history of histrionic personality disorder stems from the word hysteria, actually it comes
from Etruscan histrio which means an actor. Hysteria can be described as an exaggerated or uncontrollable emotion
that people, especially in groups, experience. Beliefs about hysteria have varied throughout time. It wasn’t until
Sigmund Freud who studied histrionic personality disorder in a psychological manner. “The roots of histrionic
personality can be traced to cases of hysterical neurosis described by Freud.” He developed the psychoanalytic
theory in the late 19th century and the results from his development led to split concepts of hysteria. One concept
labeled as hysterical neurosis (also known as conversion disorder) and the other concept labeled as hysterical
character (currently known as histrionic personality disorder). These two concepts must not be confused with each
other, as they are two separate and different ideas.
Histrionic personality disorder is also known as hysterical personality. Hysterical personality has evolved in the past
400 years and it first appeared in the DSM II (Diagnostic and Statistical Manual of Mental Disorders, 2nd edition)
under the name hysterical personality disorder. The name we know today as histrionic personality disorder is due
to the name change in DSM III, third edition. Renaming hysterical personality to histrionic personality disorder is
believed to be because of possible negative connotations to the roots of hysteria, such as intense sexual expressions,
demon possessions, etc.
People with histrionic personality disorder are prone to emotional overreaction in a wide variety of situations, and
from the viewpoint of others they may seem constantly on edge. When they do react, it is usually from a self-
centered perspective, and the needs of others are seldom their priority. Mental health experts believe that
personality disorders like HPD usually develop as a result of stress, anxiety, and trauma experienced during
childhood. Young people who are subjected to neglect or abuse must rely on limited resources and life experiences
to cope with haunting memories and the feelings of shame, inadequacy, or weakness that accompany them, and
personality disorders may develop as a form of adaptation or compensation.
Overindulgent or inconsistent parenting can also lead to HPD later in life. This type of neglectful caregiving doesn’t
set boundaries and can therefore interfere with a child’s healthy emotional and psychological development.

Having a family history of personality disorders, and other mental health conditions, is a risk factor for histrionic
personality disorder. There are genetic factors involved that help explain the connection, but negative role modeling
by parents with mental health issues can undoubtedly play a part in the development of HPD as well.
There are neurochemical, genetic, psychoanalytical, and environmental causes contributing to histrionic personality
disorder. Traits such as extravagance, vanity, and seductiveness of hysteria have similar qualities to women
diagnosed with HPD. HPD symptoms do not fully develop until the age of 15 with treatment only beginning at
approximately 40 years of age.
• Neurochemical/physiological
Studies have shown that there is a strong correlation between the function of neurotransmitters and the Cluster B
personality disorders such as HPD. Individuals diagnosed with HPD have highly responsive noradrenergic systems
which is responsible for the synthesis, storage, and release of the neurotransmitter, norepinephrine. High levels of
norepinephrine leads to anxiety-proneness, dependency, and high sociability.
• Genetic
Twin studies have aided in breaking down the genetic vs. environment debate. A twin study conducted by the
Department of Psychology at Oslo University attempted to establish a correlation between genetic and Cluster B
personality disorders. With a test sample of 221 twins, 92 monozygotic and 129 dizygotic, researchers interviewed
the subjects using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and concluded that
there was a correlation of 0.67 that histrionic personality disorder is hereditary.
• Psychoanalytic theory
Though criticised as being unsupported by scientific evidence, psychoanalytic theories incriminate authoritarian or
distant attitudes by one (mainly the mother) or both parents, along with conditional love based on expectations the
child can never fully meet. He believed the reason for being unable to love could have resulted from a traumatic
experience, such as the death of a close relative during childhood or divorce of one's parents, which gave the wrong
impression of committed relationships. Exposure to one or multiple traumatic occurrences of a close friend or family
member's leaving (via abandonment or mortality) would make the person unable to form true and affectionate
attachments towards other people.
• HPD and antisocial personality disorder
Another theory suggests a possible relationship between histrionic personality disorder and antisocial personality
disorder. Research has found 2/3 of patients diagnosed with histrionic personality disorder also meet criteria similar
to those of the antisocial personality disorder.
Some family history studies have found that histrionic personality disorder, as well as borderline and antisocial
personality disorders, tend to run in families, but it is unclear if this is due to genetic or environmental factors.
CLINICAL MANIFESTATION
1. EUPD :-

 Impulsivity
 Mood swings.
 An overwhelming fear of abandonment.
 Extreme anxiety and irritability.
 Anger.
 Paranoia and being suspicious of other people.
 Feeling empty, hopeless and worthless.
 Suicidal thoughts.
 Self- harm
 Having a pattern of unstable or shallow relationships.
 Rapidly changing your opinions of other people.
 Dissociation - feeling as though you have lost touch with reality.
2. HISTRONICS
According to ICD - 10, the diagnostic guidelines for Histronic personality disorder include clinical features like self
dramatisation and exaggerated expression of emotions, suggestibility, shallow and labile affectivity, continual
attention-seeking attitude, inappropriate seductiveness and over-concern with physical attractiveness. Associated
features may include egocentricity, self-indulgence, continuous longing for appreciation, feelings that are easily hurt
and persistent manipulative behaviour to achieve own needs.
Tantrums or anger outbursts are common. People with HPD are usually high-functioning, both socially and
professionally. They usually have good social skills, despite tending to use them to manipulate others into making
them the center of attention.
Individuals with HPD often fail to see their own personal situation realistically, instead dramatizing and exaggerating
their difficulties. They may go through frequent job changes, as they become easily bored and may prefer
withdrawing from frustration (instead of facing it). Because they tend to crave novelty and excitement, they may
place themselves in risky situations. All of these factors may lead to greater risk of developing clinical depression.
Additional characteristics may include:
1. Exhibitionist behavior.
2. Constant seeking of reassurance or approval.
3. Excessive sensitivity to criticism or disapproval.
4. Pride of own personality and unwillingness to change, viewing any change as a threat.
5. Inappropriately seductive appearance or behavior of a sexual nature.
6. Using factitious somatic symptoms (of physical illness) or psychological disorders to garner attention.
7. A need to be the center of attention.
8. Low tolerance for frustration or delayed gratification.
9. Rapidly shifting emotional states that may appear superficial or exaggerated to others.
10. Tendency to believe that relationships are more intimate than they actually are.
11. Making rash decisions.
12. Blaming personal failures or disappointments on others.
13. Being easily influenced by others, especially those who treat them approvingly.
14. Being overly dramatic and emotional.

15. Influenced by the suggestions of others.
Some people with histrionic traits or personality disorder change their seduction technique into a more maternal or
paternal style as they age.
A mnemonic that can be used to remember the characteristics of histrionic personality disorder is shortened as
"PRAISE ME":
 Provocative (or seductive) behavior.
 Relationships are considered more intimate than they actually are.
 Attention-seeking.
 Influenced easily by others or circumstances.
 Speech (style) wants to impress; lacks detail.
 Emotional lability; shallowness.
 Make-up; physical appearance is used to draw attention to self.
 Exaggerated emotions; theatrical.
COURSE AND OUTCOME AND DIFFERENT TREATMENT MODALITIES :-

1. EUPD :-
Research during the past two decades has clearly demonstrated that EUPD has a positive trajectory over time.
Although it is a disorder associated with many psychiatric and medical comorbidities, many of the most troubling
symptoms remit during the first few years. Unfortunately, several of the underlying personality traits remain for
longer periods, and these are the elements of the disorder that may not be fully addressed by current treatments.
• Treatments in the form of group or individual psychotherapy.
• Dialectial behaviour therapy (DBT)
• Mentalisation based therapy (MBT)
• Schema therapy.
• Cognitive behavioral therapy ( CBT)
• Transference focused psychotherapy.
• Talk therapy.
• Anger management.
• Medication-
*effective mood stabilizers - Topiramate( topamax), lamotrigine (lamictal).
*Anti depressants - celexa ( citalopram), Lexapro( escitalopram), prozac( fluoxetine) etc.
10. Hospitalization helps in some cases if symptoms are severe.
This condition cannot be cured, but symptoms can be managed effectively, monitored and ultimately reduced in
intensity or entirely eliminated.
2. HISTRONIC :-
If signs of this personality disorder are present, the doctor will begin an evaluation by performing a
complete medical and psychiatric history. If physical symptoms are present, a physical exam and laboratory
tests (such as neuroimaging studies or blood tests) may also be recommended to assure that a physical
illness is not causing any symptoms that may be present.
If the doctor finds no physical reason for the symptoms, he or she might refer the person to a psychiatrist
or psychologist, health care professionals who are specially trained to diagnose and treat mental illnesses.
Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person
for a personality disorder. In general, people with histrionic personality disorder do not believe they need

therapy. They also tend to exaggerate their feelings and to dislike routine, which makes following a
treatment plan difficult.
Psychotherapy (a type of counseling) is generally the treatment of choice for histrionic personality disorder.
The goal of treatment is to help the individual uncover the motivations and fears associated with his or her
thoughts and behavior, and to help the person learn to relate to others in a more positive way.
Medication might sometimes be used as treatment for other conditions that might also be present with
this disorder, such as depression and anxiety, which are co occuring conditions.
Many people with this disorder are able to function well socially and at work. Those with severe cases,
however, might experience significant problems in their daily lives. Although prevention of the histrionic
personality disorder might not be possible, treatment can allow a person who is prone to this disorder to
learn more productive ways of dealing with situations.
Module : 4, Unit :13
Obsessive–compulsive personality disorder (OCPD)
Obsessive–compulsive personality disorder (Anankastic Disorders) (OCPD) is a cluster

C personality disorder marked by an excessive need for orderliness, neatness,
and perfectionism. Symptoms are usually present by the time a person reaches adulthood, and
are visible in a variety of situations.
The cause of OCPD is thought to involve a combination of genetic and environmental factors,
namely problems with attachment.
Some of OCPD's symptoms are persistent and stable, whilst others are unstable. The obsession
with perfectionism, reluctance to delegate tasks to others, and rigidity and stubbornness are
stable symptoms.
Characteristics of OCPD
OCPD is a personality disorder defined by strict adherence to orderliness and control over one's
environment at the expense of flexibility and the openness to new experiences.4 OCPD is
characterized by personality traits such as:
• Excessive need for perfection and relentless control over one's environment and
interpersonal relationships
• Preoccupation with details, rules, lists, and order that can result in missing the major
objective of an activity
• Excessive devotion to work at the expense of family or friends
• Rigidity and inflexibility with regards to morals, ethics, values, and/or the adherence to
rules
• Inability to get rid of items that no longer have value (hoarding)
• Inability to be generous to others

Symptoms of Obsessive-Compulsive Personality Disorder
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and
interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early
adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
▪ Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the
major point of the activity is lost
▪ Shows perfectionism that interferes with task completion (e.g., is unable to complete a project
because his or her own overly strict standards are not met)
▪ Is excessively devoted to work and productivity to the exclusion of leisure activities and
friendships (not accounted for by obvious economic necessity)
▪ Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not
accounted for by cultural or religious identification)
▪ Is unable to discard worn-out or worthless objects even when they have no sentimental value
▪ Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way
of doing things
▪ Adopts a miserly spending style toward both self and others; money is viewed as something to
be hoarded for future catastrophes
▪ Shows significant rigidity and stubbornness
Causes of Obsessive-Compulsive Personality Disorder
Researchers today don’t know what causes obsessive-compulsive personality disorder,

however, there are many theories about the possible causes. Most professionals subscribe to a
biopsychosocial model of causation — that is, the causes are likely due to biological and genetic
factors, social factors (such as how a person interacts in their early development with their
family and friends and other children), and psychological factors (the individual’s personality
and temperament, shaped by their environment and learned coping skills to deal with stress).
This suggests that no single factor is responsible — rather, it is the complex and likely
intertwined nature of all three factors that are important. If a person has this personality
disorder, research suggests that there is a slightly increased risk for this disorder to be “passed
down” to their children.
Treatment of Obsessive-Compulsive Personality Disorder
Treatment of obsessive-compulsive personality disorder typically involves long-term

psychotherapy with a therapist that has experience in treating this kind of personality
disorder. Medications may also be prescribed to help with specific troubling and debilitating
symptoms.
ANXIOUS-AVOIDANT PERSONALITY DIS ORDER

Avoidant Personality Disorder
Avoidant personality disorder is characterized by feelings of extreme social inhibition,

inadequacy, and sensitivity to negative criticism and rejection. Yet the symptoms involve more
than simply being shy or socially awkward. Avoidant personality disorder causes significant
problems that affect the ability to interact with others and maintain relationships in day-to-day
life. About 1% of the general population has avoidant personality disorder.
Avoidant Personality Disorder Symptoms
Avoidant personality disorder symptoms include a variety of behaviours, such as:
• Avoiding work, social, or school activities for fear of criticism or rejection. It may feel as if
you are frequently unwelcome in social situations, even when that is not the case. This is
because people with avoidant personality disorder have a low threshold for criticism and
often imagine themselves to be inferior to others.
• Low self-esteem
• Self-isolation
• When in social situations, a person with avoidant personality disorder may be afraid to
speak up for fear of saying the wrong thing, blushing, stammering, or otherwise getting
embarrassed. You may also spend a great deal of time anxiously studying those around you
for signs of approval or rejection.
• A person who has an avoidant personality disorder is aware of being uncomfortable in social
situations and often feels socially inept. Despite this self-awareness, comments by others
about your shyness or nervousness in social settings may feel like criticism or rejection. This
is especially true if you are teased, even in a good-natured way, about your avoidance of
social situation.
Social Impact of Avoidant Personality Disorder
Avoidant personality disorder causes a fear of rejection that often makes it difficult to connect with
other people.
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), a person diagnosed with avoidant personality disorder needs to show at least
four of the following criteria:
• Avoids occupational activities that involve significant interpersonal contact, because of

fears of criticism, disapproval, or rejection.
• Is unwilling to get involved with people unless they are certain of being liked.
• Shows restraint within intimate relationships because of the fear of being shamed or
ridiculed.
• Is preoccupied with being criticized or rejected in social situations.
• Is inhibited in new interpersonal situations because of feelings of inadequacy.

• Views self as socially inept, personally unappealing, or inferior to others.
• Is unusually reluctant to take personal risks or to engage in any new activities because
they may prove embarrassing.
Avoidant Personality Disorder Treatments
As with other personality disorders, a mental health professional will design a treatment plan
that is appropriate for you. Avoidant personality disorder treatments vary, but they will likely
include talk therapy. If a co-existing condition, such as depression or anxiety disorder, is also
diagnosed, appropriate medications may also be used.
Avoidant Personality Disorder and Other Conditions
Other mental health disorders can occur along with avoidant personality disorder. Treatments
in these cases will be designed to help with the symptoms of each disorder. A few of the
conditions that most frequently occur with avoidant personality disorder include:
• Social phobia, in which a person experiences overwhelming anxiety and self-

consciousness in common social situations.
• Dependent personality disorder, in which people rely excessively on others for advice or
to make decisions for them.
• Borderline personality disorder, in which people have difficulties in many areas including
social relationships, behaviour, mood, and self-image.
Many avoidant personality disorder symptoms are commonly shared among these other
conditions, particularly in the case of generalized social phobia. Because of this, the disorders
can be easily confused. It may take some time for a mental health professional to make a clear
diagnosis and choose the appropriate treatments for you.
tDependent Personality Disorder
Dependent personality disorder (DPD) is one of a group of conditions called anxious personality
disorders and is defined by helplessness, submissiveness, a need to be taken care of and for
constant reassurance, and an inability to make decisions.
What is dependent personality disorder (DPD)?
Dependent personality disorder (DPD) is described as the need to be cared for by others. This
condition results in submissive and clingy behaviour, a fear of separation, and difficulty making
decisions without reassurance from others.DPD appears to occur equally among males and
females, and usually first appears in early-to-middle adulthood.

What causes dependent personality disorder (DPD)?
Dependent personality disorder may be caused by a combination of biological and

developmental factors. People exposed to authoritarian or overprotective parenting styles,
chronic physical illness, or separation anxiety during childhood may be more likely to develop
dependent personality traits.
What are the symptoms of dependent personality disorder (DPD)?
Symptoms of dependent personality disorder include:
• An inability to make common, everyday decisions without the reassurance of others

• Avoidance of personal responsibility, including tasks requiring independent functioning
• An intense fear of abandonment and a sense of devastation or helplessness when
relationships end, and a tendency to quickly seek out and begin new relationships
• Difficulty being alone
• Avoidance of disagreement with others out of fear of losing support or approval
• Willingness to tolerate mistreatment and abuse from others
• Placing the needs of their caregivers above their own
• Over-sensitivity to criticism
• Pessimism and lack of self-confidence, including a belief that they are unable to care for
themselves
• Difficulty beginning projects
What are the risk factors?
Some risk factors that might contribute to the development of this disorder include:
• having a history of neglect
• having an abusive upbringing
• being in a long-term, abusive relationship
• having overprotective or authoritarian parents
• having a family history of anxiety disorders
Diagnosis
Clinicians and clinical researchers conceptualize dependent personality disorder in terms of four
related components:

• Cognitive: a perception of oneself as powerless and ineffectual, coupled with the belief that other
people are comparatively powerful and potent.
• Motivational: a desire to obtain and maintain relationships with protectors and caregivers.
• Behavioral: a pattern of relationship-facilitating behavior designed to strengthen interpersonal ties and
minimize the possibility of abandonment and rejection.
• Emotional: fear of abandonment, fear of rejection, and anxiety regarding evaluation by figures of
authority
Treatment
People who have DPD are generally treated with psychotherapy. The main goal of this therapy
is to make the individual more independent and help them form healthy relationships with the
people around them. This is done by improving their self-esteem and confidence.[16]
Medication can be used to treat patients who suffer from depression or anxiety because of
their DPD, but this does not treat the core problems caused by DPD. Individuals who take these
prescription drugs are susceptible to addiction and substance abuse and therefore may require
monitoring.
SPECIFIC LEARNING DISABILITY

Specific learning disability is a disorder that interferes with a student’s ability to listen, think, speak, write,
spell, or do mathematical calculations. Students with a specific learning disability may struggle with
reading, writing, or math. The term “specific learning disability” is commonly used in federal and state law,
the Diagnostic and Statistical Manual of Mental Disorders (DSM), and by many private and public schools.
63% of people know someone who has a learning disability
43% of people wrongly think that learning disabilities are correlated with IQ
10-15% of school-aged children have a learning disability
“Specific learning disability” is an umbrella term that can describe many different types of learning issues.
An educational evaluation may show that your child has a specific learning disability in a certain subject
area
TYPES OF SPECFIC LEARNING DISABILITIES
Dyslexia: It is also called as developmental reading disorder. The child presents with a serious delay
in learning to read which is evident from the early years. The problems may include omissions,
distortions, or substitutions of words, long hesitations, reversal of words, or simply slow reading.
Writing and spelling are also impaired. It is important to differentiate the disorder from scholastic
backwardness; therefore a proper assessment is mandatory.
Dyscalculia: It is also called as developmental arithmetic disorder or developmental mathematic
disorder. The child presents with arithmetic abilities well below the level expected for the mental age
(below par). The problems may include failure to understand simple mathematical concepts, failure

to recognise mathematical signs or numerical symbols, difficulty in carrying out mathematical
manipulations, and difficulty in learning mathematical tables.
Dysphasia: It is also called as developmental language disorder, developmental communication
disorder. There are three main types:
i. Phonological disorder: Also called as dyslalia, it is characterised by below par accuracy in
the use of speech sounds despite normal language skills. The problems include severe
articulation errors that make it difficult for others to understand the speech. Speech sounds or
phonemes are omitted, distorted or substituted (e.g. wabbit for rabbit, ca for car, bu for blue).
ii. Expressive language disorder: It is characterised by a below par ability of using expressive
speech. The problems include restricted vocabulary, difficulty in selecting appropriate
words, and immature grammatical usage. Cluttering of speech may also be present.
iii. Receptive language disorder: The disorder often presents as a receptive-expressive language
disorder and both receptive and expressive impairments are present together. The disorder is
characterised by a below par understanding of language. Problems include failure to respond
to simple instructions; it is obviously important to rule out deafness and pervasive
developmental disorder.
Motor Dyspraxia: It is also called as motor skills disorder, developmental coordination disorder,
clumsy child syndrome. It is characterised by poor coordination in daily activities of life, e.g. in
dressing, walking, feeding, and playing. There is an inability to perform fi ne or gross motor tasks.
SIGNS OF SPECIFIC LEARNING DISABILITIES

Persistent difficulties in reading, writing, arithmetic, or mathematical reasoning
Inaccurate or slow and effortful reading or writing
Poor written expression that lacks clarity
Difficulties remembering number facts
Inaccurate mathematical reasoning
TREATEMENT
While there is no cure for specific learning disorder, there are many ways to improve reading, writing, and
math skills for a child. Treatment usually includes both strengthening the skills and developing a learning
strategy tailored to take advantage of a child’s strengths. For example, repetition and mnemonic devices
might make it easier to memorize a math formula, and drawing a picture to illustrate a word problem might
help a child visualize what is being asked. Treatment for specific learning disorder often also involves
multimodal teaching. If a child has trouble comprehending a subject with his or her eyes and ears alone,
other senses such as touch, taste, and even smell can play a role in the learning process. Similarly, learning
to convert one sort of problem into another format may help. A learning specialist can help determine the
services or accommodations a child might benefit from at school. Psychotherapy, cognitive behaviour
therapy in particular, may also be helpful in treating the emotional and behavioural problems that can
accompany specific learning disorder.

CAUSES
No one really knows what causes a learning disability. Often, learning problems can run in families
(genetic), but environmental factors can play a role too. Mostly, learning disabilities occur because
there is an enormous range of variation that occurs normally in people’s cognitive strengths and
weaknesses. If we think about our physical development, nearly everyone has two eyes, a nose and a mouth,
yet each of our faces has its own distinctive features. The same is true of brain development. Whereas most
children’s cognitive profiles are adequate to the tasks we expect children to accomplish in school, there are
many children for whom that is not true. Those children encounter difficulty meeting age and grade level
expectations, and the problem can become identified as a “learning disability.”
PERVASIVE DEVELOPMENTAL DISORDERS

Infantile autism was described for the first time by Leo Kanner in 1943 as ‘autistic disturbance of
affective contact’. This syndrome has variously been described as autistic disorder, pervasive
developmental disorder, childhood autism, childhood psychosis and pseudo-defective psychosis. This
syndrome is more common (3-4 times) in males and has a prevalence rate of 0.4-0.5 per 1000 population.
Although earlier it was thought to be commoner in upper socio-economic classes, recent studies have
failed to confirm this finding. Typically, the onset occurs before the age of 2½ years though in some
cases, the onset may occur later in childhood. Such cases are called as childhood onset autism or
childhood onset pervasive developmental disorder. Autism occur ring before or after 2½ years of age is
not clinically very different.
CLINICAL FEATURES
The characteristic features are:
1. Marked impairment in reciprocal social and interpersonal interaction):

a. Absent social smile.
b. Lack of eye-to-eye-contact.
c. Lack of awareness of others’ existence or feelings; treats people as furniture.
d. Lack of attachment to parents and absence of separation anxiety.
e. No or abnormal social play; prefers solitary games.
f. Marked impairment in making friends.
g. Lack of imitative behaviour.
h. Absence of fear in presence of danger.
2. Marked impairment in language and non-verbal communication

a. Lack of verbal or facial response to sounds or voices; might be thought as deaf initially.
b. In infancy, absence of communicative sounds like babbling.
c. Absent or delayed speech (about half of autistic children never develop useful speech).
d. Abnormal speech patterns and content. Presence of echolalia, perseveration, poor articulation and
pronominal reversal (I-You) is common.

e. Rote memory is usually good. (learning by repetition)
f. Abstract thinking is impaired.
3. Abnormal
a. Mannerisms. (way of speaking or behaving)
b. Stereotyped behaviours such as head-banging, body-spinning, hand-flicking, lining-up objects, rocking,
clapping, twirling, etc.
c. Ritualistic and compulsive behaviour. (follow a similar pattern in every time)
d. Resistance to even the slightest change in the environment.
e. Attachment may develop to inanimate objects. .Hyperkinesia is commonly associated.
4. Mental retardation only about 25% of all children with autism have an IQ of more than 70. A large
majority (more than 50%) of these children have moderate to profound mental retardation. There appears
to be a correlation between severity of mental retardation, absence of speech and epilepsy in autism.
5. Other features
a. Many children with autism particularly enjoy music.
b. In spite of the pervasive impairment of functions, certain islets of precocity or splinter functions may
remain (called as Idiot savant syndrome). Examples of such splinter functions are prodigious rote memory
or calculating ability, and musical abilities.
c. Epilepsy is common in children with an IQ of less than 50. The course of infantile autism is usually
chronic and only 1-2% become near normal in marital, social and occupational functioning. A large
majority (about 70%) lead dependent lives.
OTHER PERVASIVE DEVELOPMENTAL DISORDERS

Childhood psychosis is a vague term which includes all psychotic illnesses occurring in childhood, such
as infantile and childhood onset autism, childhood schizophrenia, mood disorders, and organic psychiatric
disorders. This term has frequently been misused in the past, also meaning at times infantile autism alone.
This is a term which is probably best dispensed with.
Schizophrenia, mood disorders and organic psychiatric disorders have a nearly similar picture in children
as in adulthood. Sometimes, childhood onset schizophrenia may be mistaken for autism. The most
important differentiating features are:
1. Delusions, formal thought disorder and hallucinations may be present in childhood-onset
schizophrenia while they are always absent in infantile autism.
2. Typical age of onset of symptoms is before 2½ years in infantile autism while it is after 5-6 years in
childhood onset schizophrenia.
3. Moderate to severe mental retardation and epilepsy are common in infantile autism while they are
rare in childhood-onset schizophrenia. Mental retardation, if ever present, is usually of mild type.
Another type of childhood psychosis, called Heller’s syndrome or disintegrative psychosis, has often
been described in literature. Typically, the age of onset is between 3 to 5 years and the syndrome is

characterised by a rapid downhill course, leading to deterioration and development of neurological
deficits.
CAUSES
The causes of these disorders were unknown. While genetics is believed to play a primary role, some
children in families with a history of pervasive developmental disorders do not have a disorder. Medical
researchers believe that genetic susceptibility plus additional factors contribute to the development of one
of these disorders. Factors under investigation as a cause of these disorders include immune system
problems, allergies, drugs, environmental pollution, and infections. Autopsy studies of individuals with
pervasive developmental disorders have shown that brain cell structure is different, particularly in the
brain stem area. In addition, because many individuals with pervasive developmental disorders are also
affected by seizures, "electrical miswriting" of the brain may also contribute to these disorders.
Researchers have used magnetic resonance imaging (MRI) and positron emission tomography (PET) to
find subtle differences in the brain structure and function of children with these disorders.
Symptoms of pervasive developmental disorders may be visible as early as infancy; however, the
typical age of onset is age three. Although each of the five types has some distinctive symptoms, in
general, early symptoms of a pervasive developmental disorder include the following:
Impaired language skills
Difficulties relating to people, objects, or activities
Unusual play
Repetitive body movements or behaviour patterns
Difficulties handling changes in routine or surroundings
Unusual responses to sensory stimuli, like loud noises and lights
TREATEMENT
No cure existed for these disorders, and no specific therapy works for all individuals. Treatment depends
on the severity of the disorder and consists of specialized therapy, special education, and medication to
address specific behavioural problems. Medications that may be prescribed to treat specific symptoms
include anti-depressants, anti-anxiety medications, anti-spasmodic and anti-seizure medications, and
stimulants. Therapeutic interventions include applied behaviour analysis (the Lovaas method), auditory
integration training, behaviour modification programs, play therapy, occupational and physical therapy,
animal-assisted therapy, art/music/dance therapy, sensory integration, and speech therapy.
Alternative treatment
Alternative treatments for pervasive developmental disorders focus on nutrition. Some evidence has
shown that vitamin therapy with vitamin B6 and magnesium supplementation can help children with
autism. Because some children with pervasive developmental disorders have food sensitivities or food
allergies, allergy testing and subsequent dietary modification may help. In food-allergic children, certain
foods have been shown to increase hyperactivity and autistic behaviour. Anti-yeast therapy has also been
proposed because children with autism sometimes have higher yeast levels in their bodies. Administering
anti-yeast medications has decreased negative behaviours in some children. Before parents turn to

alternative therapy, they should consult a physician to make sure it does not interfere or interact with any
other medications.
Hyperkinetic, conduct disorder
Introduction
Hyperkinetic disorder is a chronic condition including attention difficulty, hyperactivity and impulsiveness.
The exact cause of conduct disorder is not known, but it is believed that a combination of biological, genetic,
environmental, psychological, and social factors play a role. Biological: Some studies suggest that defects or
injuries to certain areas of the brain can lead to behaviour disorders.
Conduct disorders
Conduct disorder" refers to a group of repetitive and persistent behavioural and emotional problems in
youngsters. Children and adolescents with this disorder have great difficulty following rules, respecting the rights
of others, showing empathy, and behaving in a socially acceptable way.
Prevalence
Conduct disorder
3-16% under 16s
Cd diagnosed from 10-15 years
Etiology
Individual- your child is temperament
Genetic-its more common In children of adults who had conduct problems when they were young
Physical-problems in processing social information and brain damage
Environmental-family problems and social pressures
SYMPTOMS
Aggressive behaviour: These are behaviours that threaten or cause physical harm and may include
fighting, bullying, being cruel to others or animals, using weapons, and forcing another into sexual activity.
Destructive behaviour: This involves intentional destruction of property such as arson (deliberate fire-setting) and
vandalism (harming another person's property).
Deceitful behaviour: This may include repeated lying, shoplifting, or breaking into homes or cars in order to steal.
violation of rules: This involves going against accepted rules of society or engaging in behaviour that is not
appropriate for the person's age. These behaviours may include running away, skipping school, playing pranks, or
being sexually active at a very young age.
CAUSES

Biological: Some studies suggest that defects or injuries to certain areas of the brain can lead to behaviour
disorders. Conduct disorder has been linked to particular brain regions involved in regulating behaviour, impulse
control, and emotion. Conduct disorder symptoms may occur if nerve cell circuits along these brain regions do not
work properly. Further, many children and teens with conduct disorder also have other mental illnesses, such
as attention-deficit/hyperactivity disorder (ADHD), learning disorders, depression, substance abuse, or an anxiety
disorder, which may contribute to the symptoms of conduct disorder.
Genetics: Many children and teens with conduct disorder have close family members with mental illnesses,
including mood disorders, anxiety disorders, substance use disorders and personality disorders. This suggests that
a vulnerability to conduct disorder may be at least partially inherited.
Environmental: Factors such as a dysfunctional family life, childhood abuse, traumatic experiences, a family history
of substance abuse, and inconsistent discipline by parents may contribute to the development of conduct disorder.
Psychological: Some experts believe that conduct disorders can reflect problems with moral awareness (notably,
lack of guilt and remorse) and deficits in cognitive processing.
Social: Low socioeconomic status and not being accepted by their peers appear to be risk factors for the
development of conduct disorder.
Treatment
psychotherapy : Psychotherapy (a type of counselling) is aimed at helping the child learn to express and control
anger in more appropriate ways. A type of therapy called cognitive-behavioural therapy aims to reshape the child's
thinking (cognition) to improve problem solving skills, anger management, moral reasoning skills, and impulse
control. Family therapy may be used to help improve family interactions and communication among family
members. A specialized therapy technique called parent management training (PMT) teaches parents ways to
positively alter their child's behaviour in the home.
Medication : Although there is no medication formally approved to treat conduct disorder, various drugs may be
used (off label) to treat some of its distressing symptoms (impulsivity, aggression, deregulated mood), as well as
any other mental illnesses that may be present, such as ADHD or major depression.
Hyperkinetic disorder
Attention deficit hyperactivity disorder(ADHD) is a neurodevelopmental disorder characterized by inattention,
or excessive activity and impulsivity, which are otherwise not appropriate for a person's age. Some individuals with
ADHD also display difficulty regulating emotions or problems with executive function
Prevalence
ADHD prevalence rates may vary depending on several factors:
Age – ADHD can affect people of all ages, and ADHD prevalence rates are known to vary between children,
adolescents and adults.1-4
Gender – a higher prevalence of ADHD is often reported in males compared with females.5,6
Presentation of ADHD – symptoms of ADHD can vary between patients in terms of severity and the combination
of inattention, hyperactive and impulsive symptoms. ADHD, its symptoms and its impact may also vary throughout
a patient’s lifespan.7-10

The majority of adults with ADHD have diagnosed or undiagnosed psychiatric comorbidities, which can complicate
diagnosis and treatment of ADHD.11-13
ETIOLOGY
ADHD is a disorder with multiple etiologies. Combinations of genetic, neurological, and environmental factors
contribute to pathogenesis and its heterogeneous phenotype .
Evidence from family, twin, and adoption studies has suggested strongly that ADHD is a highly hereditary,
polygenic disorder .Gene variants predicting risk for ADHD are important for brain development, cell migration,
and encoding for catecholamine receptor and transporter genes . The identification of gene sets affecting
neurotransmitter pathways in the brain has suggested that rare copy number variants or the accumulation of
larger deletions and duplications influencing gene transcription are more commonly found in individuals with
ADHD . (For more information, see the companion statement on special populations in this issue.) Ongoing
pharmacokinetics research aims to identify genes involved in medication response with ADHD .
No inherited neurological factors affecting brain development or resulting in brain injury have been implicated in
ADHD pathogenesis. The contribution of pregnancy and birth complications is mixed, but strong evidence supports
greater ADHD risk following in utero exposure to alcohol or tobacco and low birth weight (<2,500 g) . Hypoxic–
anoxic brain injury , epilepsy disorders , and traumatic brain injury also contribute to ADHD risk.
Exposure to environmental toxins (specifically lead, organophosphate pesticides, and polychlorinated biphenyls)
has been linked to ADHD symptoms . Except for children experiencing exceptional early deprivation , a causal
relationship between family environment and psychosocial adversity and ADHD is unclear .
Neuroimaging studies point to ADHD as a disorder of early brain development. Based on volumetric and functional
MRI studies , differences are found in the structural development and functional activation in the prefrontal
cortex, basal ganglia, anterior cingulate cortex, and cerebellum . Activity among these areas depends on
catecholamine brain circuitry. Despite weak evidence for deficits in these neurotransmitters, their role is
substantiated by their distribution in those areas of the brain involved in ADHD and the positive response of ADHD
patients to medications that modulate the neurotransmission of catecholamine’s . A delay in cortical maturation
has been documented, with peak cortical thickness attained in the cerebrum at 7 years in typically developing
children and at 10 years in those with ADHD .
Symptoms in children and teenagers
The symptoms of ADHD in children and teenagers are well defined, and they're usually noticeable before the age
of 6. They occur in more than 1 situation, such as at home and at school.
Inattentiveness
The main signs of inattentiveness are:
❖ having a short attention span and being easily distracted
❖ Making careless mistakes – for example, in schoolwork
❖ Appearing forgetful or losing things

❖ Being unable to stick to tasks that are tedious or time-consuming
❖ Appearing to be unable to listen to or carry out instructions
❖ Constantly changing activity or task
❖ Having difficulty organising tasks
❖ Hyperactivity and impulsiveness
❖ The main signs of hyperactivity and impulsiveness are:
❖ Being unable to sit still, especially in calm or quiet surroundings
❖ Constantly fidgeting
❖ Being unable to concentrate on tasks
❖ Excessive physical movement
❖ Excessive talking
❖ Being unable to wait their turn
❖ Acting without thinking
❖ Interrupting conversations
❖ Little or no sense of danger

These symptoms can cause significant problems in a child's life, such as underachievement at school, poor social
interaction with other children and adults, and problems with discipline.
Treatment
Psychoeducation
Psychoeducation means you or your child will be encouraged to discuss ADHD and its effects. It can help children,
teenagers and adults make sense of being diagnosed with ADHD, and can help you to cope and live with the
condition.
Behaviour therapy
Behaviour therapy provides support for carers of children with ADHD and may involve teachers as well as parents.
Behaviour therapy usually involves behaviour management, which uses a system of rewards to encourage your
child to try to control their ADHD.
Cognitive behavioural therapy (CBT)
CBT is a talking therapy that can help you manage your problems by changing the way you think and behave. A
therapist would try to change how your child feels about a situation, which would in turn potentially change their
behaviour.
Emotional disorder , Mental retardation

An emotional and disorder is an emotional disability characterized by the following: (i) An
inability to build or maintain satisfactory interpersonal relationships with peers and/or teachers.
Emotional disorders
Emotional disorders generally have a good prognosis, often because they arise in
response to some identifiable but remedial stress. Consequently, emotional disorder
persisting into adolescence implies a more serious underlying cause. The school refusal
syndrome is the most likely condition to show continuity from early childhood. It may
reappear at the transfer from primary to secondary school, or early on during secondary
schooling. A previous history of separation difficulties in, for instance at the start of
nursery or primary school and/or an overdependent relationship between the child and
parent(s), is common. The increased necessity for independence, autonomy and
assertiveness at secondary school may prove too much for the vulnerable adolescent
• Feeling sad
• 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 it
• Difficulty learning that cannot be explained by intellectual challenges or any other
health issue
• An inability to develop healthy, interpersonal relationships with teachers and peers
• Inappropriate thoughts, emotions, or actions under normal circumstances
• Frequent unhappiness, depression, fear, or anxiety about life or school
•
BIOLOGICAL FACTORS:-
•
• renatal exposure to drugs or alcohol
• A physical illness or disability
• An undernourished or malnourished lifestyle
• Brain damage
•• Hereditary factors.
•
LIST OF EMOTIONAL DISORDERS

Emotional disorders list would typically cover various types of emotional disorders in
various stages – from childhood to adulthood. Several such emotional disorders in
children are broadly categorized into conduct disorders, emotional disturbances,
personality disorders, anxiety disorders, and so on. Though the list of overly
emotional disorders in children is endless, the following are the frequently exhibited
disorders.
CONDUCT DISORDERS
Children suffering from conduct disorders are mostly diagnosed with anti-social
behaviors, namely aggressiveness, throwing tantrums, stealing, lying, and hostility,
destructive and manipulative attitude. Their noncompliance to rules and indifference
towards others poses a great challenge to teachers, leading to frustration and
annoyance.

AFFECTIVE DISORDERS
Emotional disorders list include improper eating habits, depression, and extreme
stress; most of these lead to negative behavior in the individual’s personality. In
children, the most commonly encountered psychiatric emotional disorder is the
change of mood. It includes depression and bipolar disorder.
PERSONALITY DISORDERS
The rigid and pervasive behavior pattern exhibited is totally different from the cultural
expectations, and results in distress. The disorder may be schizotypal, showing
uneasiness in close relationships or borderline, marked by uncertainty in interpersonal
relationship or dependent, exhibiting a highly clinging attitude with the need to be
cared for.
ANXIETY DISORDERS
The most prevalent types of emotional disorders in children are anxiety disorder. The
suffering children exhibit fear, shyness and nervousness. It includes phobia, panic,
obsessive-compulsive disorders, separation anxiety, and post-traumatic stress
disorder.
ATTENTION DEFICIT HYPERACTIVITY DISORDER

Children exhibiting over activity and short span of attention are easily diverted and are
unable to consolidate their schedules.
OPPOSITIONAL DEFIANT DISORDER

Children easily lose their temper and argue a lot with others. They are quickly irritated
by others and express anger often.
PERVASIVE DEVELOPMENT DISORDER

Distortions in the thought process of a child and delay in development is caused when
the brain is incapable of processing the information. It includes autism and Asperger’s
syndrome.
SCHIZOPHRENIA
Schizophrenia includes poor reasoning and judgment, hallucinations, delusions, lack
of motivation and concentration.
• PREVENTIVE MEASURES:-

••
•
Create consistency in your teen’s life and maintain a positive environment
• Provide clear expectations and direct instructions to your teen for home and school
life
• Correct factors in your teen’s environment that are negative and encourage
undesirable behavior
• Punish undesirable behavior while rewarding desirable behavior
• Have a plan for conflict resolution
• Invest in your teen’s life and encourage their participation and belonging at home
and at school
Mental retardation :-
Mental retardation refers to substantial limitations in present functioning. It starts before age 18 and
is characterized by significantly subaverage intellectual functioning, existing concurrently with related
limitations in two or more of the following applicable adaptive skill areas: social skills..
4 Levels::-
The condition is further divided into four levels of retardation based on IQ, which include mild mental
retardation (IQ between 50-55 and 70), moderate mental retardation (IQ between 35-40 and 50-55),
severe mental retardation (IQ between 20-25 and 35-40), and profound mental retardation (IQ below
20 or 25.
Causes:-
This trauma before birth, such as an infection or exposure to alcohol, drugs, or other toxins. trauma
during birth, such as oxygen deprivation or premature delivery. inherited disorders, such as
phenylketonuria (PKU) or Tay-Sachs disease. chromosome abnormalities, such as Down
syndrome.
Mild mental retardation is defined as significantly sub average intellectual ability, which ranges
between 50–55 and 70, and concurrent delays in adaptive functioning that present prior to the age of
• Mild Mental retardation:- More than 85% of kids with the disability fall in this
category and have no trouble until shortly before high school. With an IQ of around
5069, they are sometimes unable to grasp abstract concepts but can, by and large, learn
at a considerably fast rate and function independently.
• Moderate Mental retardation:-: Falling under the IQ range of 36-49, they constitute
about 10% of the children that are afflicted with intellectual disability. These children can
be integrated into society as they can pick up speech and essential life skills; however,
their academic performance is likely to be dismal, and they would perform poorly in
school. These children can have some amount of autonomy but cannot remain
independent for a long duration.
• Severe Mental retardation:-: With an IQ of 20-35, these kids are in a minority of
34%. Through extensive training, kids with severe intellectual disability may be able to
learn necessary life skills, but because they have an abnormal development, they would
need frequent assistance.
• Profound Mental retardation:-: This is the most severe form of disability and is also
the rarest, with only 1-2% of mentally challenged children constituting this group. They
have IQ less that 20. They are severely handicapped and require extensive supervision

due to poor life skills. However, with regular training and setting a routine, they may be
able to pick up some essential skills.
Causes
Mental retardation (MR) refers to substantial limitations in present functioning. It starts before age 18
and is characterized by significantly subaverage intellectual functioning, existing concurrently with
related limitations in two or more of the following applicable adaptive skill areas:
Communication
Self-care
Home living
Social skills
Community use
Self-direction
Health and safety
Functional academics
Leisure
Work
Traditionally, MR has been classified into 5 categories:
Mild MR – IQ from (50-55) to 70
Moderate MR – IQ from (35-40) to (50-55)
Severe MR – IQ from (20-25) to (35-40)
There are various known causes of mental retardation, including genetic disorders, maternal infections,
psychosocial conditions, drug exposure, and environmental chemical exposure. The established risk factors
for MR include: [3]
• Various genetic disorders (e.g. Down’s Syndrome, phenylketonuria)
• Certain maternal infections during pregnancy (e.g. rubella)
• Mother who abuses substances such as alcohol during pregnancy
• Certain psychosocial conditions (e.g. problems with caregiving, low socioeconomic status, low parental
education)
• Maternal exposure to various drugs (e.g. thalidomide, valproic acid)
• Maternal exposure to environmental chemicals (discussed in detail later)
Prevention of mental retardation:-
Mental retardation could be prevented through counseling to determine the risk of a couple
having a retarded baby. Other prenatal preventative measures include ensuring that a pregnant
mother has adequate nutrition and immunization against infectious diseases; monitoring to

screen for foetal abnormalities that are associated with mental retardation; and reduced use of
drugs and alcohol by women during pregnancy. The birth of a child, the chances of retardation
can be reduced by maintaining good nutrition for both the nursing mother and the young child;
avoiding environmental hazards such as lead; and providing the child with emotional,
intellectual, and social stimulation.
Another important preventative measure is early detection of certain metabolic and nutritional
conditions that result in mental retardation following a period of degeneration. Screening for
certain disorders is mandatory in most states.
MODULE 5: UNIT15
SCHIZOPHRENIA:
PREVALENCE, ETIOLOGY, CLINICAL MANIFESTATIONS, COURSE AND OUTCOMES AND TREATMENT.
The term schizophrenia was introduced into the medical language by the Swiss psychiatrist Eugen
Bleuler. Schizophrenia refers to a major mental disorder, or a group of disorders, whose causes are still
largely complicated and which involves a complex set of disturbances of thinking, perceiving and social
disturbances. So far, no society or culture anywhere in has been found free from schizophrenia and
there is evidence that this illness represents a serious public health problem.
Schizophrenia literally means “fragmented mind”. It represents a heterogeneous syndrome of

disorganized thoughts, delusions, hallucinations and impaired psychosocial functioning.
HISTORY
In 1896, Emil Kraeplin differentiated the major psychiatric illnesses into two clinical types: Dementia
praecox, and manic depressive illness. Under dementia praecox, he bought together the various
psychiatric illnesses (such as paranoia, catatonia and hebephrenic), which were earlier thought to be
distinct illnesses. He recognised the characteristic features of dementia praecox such as delusions,
hallucinations, disturbances of affect and motor disturbances.
Eugen Bleuler (1911), while renaming dementia praecox as schizophrenia, recognised that this disorder
did not always have a poor prognosis as described by Kraeplin. Bleuler described the fundamental
symptoms of schizophrenia which were then thought to be diagnostic of schizophrenia. He also
described accessory symptoms which included delusions, hallucinations and negativism.
*Eugen Bleuler’s fundamental symptoms of schizophrenia also called 4A’s of Bleuler.

▪Ambivalence: Marked inability to decide for or against.
▪Autism: Withdrawal into self.
▪Affect disturbances: Disturbances of affect such as inappropriate affect.
▪Association disturbances: Loosening of associations, thought disorder.
*Kurt Schneider (1959) described symptoms which thought not specific of schizophrenia, were of great
help in making a clinical diagnosis of schizophrenia. These are known as Schneider’s first rank
symptoms of schizophrenia.
▪Audible thoughts: Voices speaking out through aloud or ‘thought echo’.
▪Voice heard arguing: Two or more hallucinatory voices discussing the subject in third person.
▪Thought withdrawal: Thoughts cease and subject experiences them as removed by an external force.
▪ Thought insertion: Experience of thoughts imposed by some external force on person’s passive mind.
▪Thought diffusion or broadcasting: Experience of thoughts escaping the confines of self and as being
experienced by others around.
▪Made feelings or affect, impulses and acts: The person experiences feelings, impulses and acts which
are imposed by some external force.
▪Somatic passivity: Bodily sensations, especially sensory symptoms are experienced as imposed on body
by some external force.
▪Delusional perceptions: Normal perceptions but it has a private and illogical meaning.
PREVALENCE
Prevalence refers to the proportion of existing cases, both old and new. Point prevalence on adult
ranges between 1 and 17 per 1000 population. National Mental Health survey 2015-2016) shows that
prevalence of schizophrenia is 0.5%.
Sociodemographic characteristics:
▪Affects men and women equally.

▪Men tends to experience symptoms a little bit earlier than women. Most of the people do not get
schizophrenia after age 45.
▪Schizophrenia rarely occurs in children.
▪Most cases of schizophrenia appear in late teens or early adulthood.
▪Schizophrenia also teens to be more severe in men than in women.
ETIOLOGY
While many factors have been associated with developing schizophrenia, including genetics, early
environment, psychological and social processes, but the exact cause of the disease is unknown.
•Genetic causes: Individuals with a first degree relative (parent or sibling) who has schizophrenia have a
10% chance of developing the disorder, as opposed to the 1% chance of the general population.
•Environmental causes: Inherited genes make a person vulnerable to schizophrenia and then
environmental factors act on this vulnerability to trigger the disorder. High levels of stress are believed
to trigger schizophrenia by increasing the body’s production of the hormone cortisol.
•Abnormal brain structure and chemistry:
▪Enlarged brain ventricles are seen in some schizophrenic, indicating a deficit in the volume of brain
tissue.
▪Abnormally low activity in the frontal lobe, the area of the brain responsible for planning, reasoning
and decision making.
▪Abnormalities in the temporal lobes, hippocampus and amygdala are connected to schizophrenias
positive symptoms.
•Other factors:
▪Prenatal exposure to viral infection
▪Low oxygen levels during birth
▪Physical or sexual abuse in childhood
▪Alcoholism and drug abuse

CLINICAL MANIFESTATIONS
There are 3 broad categories of symptoms of schizophrenia: positive symptoms, negative symptoms and
cognitive symptoms. Signs and symptoms of schizophrenia vary dramatically from person to person,
both in pattern and severity. Not every person with schizophrenia will have all symptoms, and the
symptoms of schizophrenia may also change over time.
(a) Positive symptoms: People with positive symptoms often lose touch with reality.
•Hallucinations: A sensory perception without an external stimuli. Voices are the most common type of
hallucinations in schizophrenia.
•Delusions: This are false beliefs that are not part of the person’s culture and do not change. They may
have paranoid delusions and believe that others are trying to harm them, such as cheating, harassing,
spying on, or plotting against them or the people they care about. These beliefs are called delusion of
persecution.
•Thought disorders: These are unusual or dysfunctional ways of thinking. It is called disorganised speech
and thinking. Effective communication can be impaired and answer to questions may be partially or
completely unrelated.
•Catatonia: Purposeless abnormal motor activity or aggressive behaviour.
(b)Negative symptoms: People with negative symptoms need help with everyday tasks. They often
neglect basic personal hygiene. This may make them seem lazy or unwilling to help themselves.
•Flat affect: Reduced expression of emotions via facial expression or voice tone.
•Alogia: Reduced speech
• Avolition: Inability to begin and sustain activities
•Anhedonia: Inability to experience pleasure
•Asociality: Withdrawal from social contacts.
© Cognitive symptoms:
•Poor executive functioning: Inability to understand information to make decisions.
•Poor working memory: Inability to see information immediately after learning.

TYPES OF SHIZOPHRENIA
①PARANOID SCHIZOPHRENIA: The most common type of schizophrenia. Patients are usually
preoccupied with paranoid delusions or auditory hallucinations. Cognitive function is usually preserved.
If thought disorder is present, it does not prevent description of delusions or hallucinations.
②RESIDUAL SCHIZOPHRENIA: The patient does not have acute psychosis, but some symptoms of
schizophrenia remain. Largely negative symptoms are seen, such as flat affect, social withdrawal and
loose associations. Prominent delusions or hallucinations are not present.
③CATATONIC SCHIZOPHRENIA: Motor symptoms are most notable. The patient may either
demonstrate rigid immobility or excessive purposeless movement. The patient may be silent and
withdrawn or may become loud and shout. Bizarre voluntary movements such as posturing may also
occur. The patient may fluctuate between the two extremes.
④DISORGANISED SCHIZOPHRENIA: The patient tends to have disorganised speech and behaviour with
a flat affect. Hallucinations and delusions are not well formed and fragmented.
⑤UNDIFFERENTIATED SCHIZOPHRENIA: The patient meets the criteria for a diagnosis of schizophrenia
but does not meet the criteria for a specific type, or the patient may meet the criteria for multiple types
of schizophrenia. No one type appears to be dominant.
COURSE AND OUTCOME
Since the time of Kraeplin, when the disorder was conceptualised as dementia praecox, schizophrenia
has been associated with a progressive downhill course, with a large number of patients hospitalised in
mental asylums. However the longitudinal studies of schizophrenia suggest that this pattern occurs in
only a minority of patients.
*ICD 10 suggest the course of schizophrenia as:
▪Continuous
▪Episodic with progressive deficit
▪Episodic with stable deficit
▪Episodic remittent
▪Incomplete remission

▪Complete remission
*ICMR reports shows:
▪Very favourable outcome- 27%
▪favourable outcome- 40%
▪Intermediate outcome- 31%
▪unfavourable outcome- 2%
Since studies have suggested that longer the duration of untreated psychosis, worse is the outcome,
underlining the importance of early diagnosis and treatment of schizophrenia. The most important
cause of death in schizophrenia is suicide.
TREATMENT
There is no known cure for schizophrenia, fortunately there are effective treatments that can reduce
symptoms, decrease the likelihood that new episodes of psychosis will occur, short term the duration of
psychotic episodes and in general offer the majority of people the possibility of living more productive
and satisfying lives.
The treatment of schizophrenia can be discussed under the following:-
(1) Somatic treatment

(a) Pharmacological treatment
(b) Electro convulsive therapy (ECT)
(a) Pharmacological treatment:
The first drug to be used with beneficial effect was reserpine (Rauwolfia serpentine extract), in India by
Sen and Bose (1931). Reserpine is no longer used for the treatment of schizophrenia for variety of
reasons, including its propensity to cause severe and suicidal depression.
Atypical (or the second generation) antipsychotic drugs such as, risperidone, quetiapine, aripiprazole
and ziprasidone are more commonly used than the older typical (or first generation) antipsychotics such
as trifluperazine and haloperidol, in acute stages. Atypical antipsychotics are more useful when negative
symptoms are prominent.

Clozapine another atypical antipsychotic, the clinical trials have shown that clozapine is effective in
about 30% of patients who had no beneficial response to traditional (typical and atypical) antipsychotics.
(b) Electro convulsive therapy: For adults with schizophrenia who do not respond to drug therapy, ECT
may be considered. ECT may be helpful for someone who also has depression.
The indications for ECT in schizophrenia are:-
•Catatonic stupor or uncontrolled catatonic excitement.
•Acute exacerbation not controlled with drugs.
•Risk of suicide, homicide or danger of physical assault.
(c) Cognitive behavioural therapy: CBT aims to identify the thinking patterns that are causing to have
unwanted feelings and behaviour and learn to replace this thinking with more realistic and useful
thoughts. Most people require 8 – 10 sessions of CBT over 6 – 12 months. CBT sessions usually last
for about an hour.
(2)Psychosocial treatments
Psychosocial treatment is an extremely important component of comprehensive management of

schizophrenia. It includes:-
(a)Psychoeducation: psychoeducation for the patients and family regarding the nature of illness, and its
course and treatment. It helps in establishing a good therapeutic relationship with the patients and the
family.
(b)Individual psychotherapy: It may help to normalize though patterns, learning to cope with stress and
identify early warning signs of relapse can help people to manage their illness.
(c)Social skills training: This focuses on improving communication, social interaction and improving the
ability to participate in daily activities.
(d)Family therapy: This provides support and education to patient families.
(e)Vocational rehabilitation and supported employment: This focuses on helping people with
schizophrenia prepare for, find and keep jobs

Module 5, unit 15
Schizotypal and Delusional disorders
Schizotypal disorders
Schizotypal disorder is a disorder categorized on the axis ll in the DSM 4.
It is a disorder characterized by eccentric behaviour and anomalies of thinking and affect., These include
inappropriate or constructed rapport with others and social withdrawal, odd beliefs or magical thinking,
suspiciousness or paranoid ideas, obsessive ruminations without inner resistance, unusual perceptual experiences,
stereotyped thinking etc.....
Characteristics
• Characterised by a need for social isolation , anxiety in social situations, odd behaviour and thinking and
often unconventional belief
• People with this disorder feel extreme discomfort with maintaining close relationships with people , and
therefore they often do not
• People who have this disorder may display peculiar manners of talking and dressing often have difficulty
in framing relationship
Problems associated to schizotypal disorder

1.Axis I
Schizotypal disorder usually co occurs with major depressive disorder, dysthymia, and generalised
social phobia. Furthermore, sometime schizotypal disorder co- occur with obsessive compulsive disorder
and it’s presence appears to affect treatment outcome adversely.
Some persons with schizotypal disorder go on to develop schizophrenia. However most of them do not.
Although STPD symptomatology has been studied longitudinally in a number of community samples, the
results receives do not suggest any significant likelihood of the development of schizophrenia.
2. Axis ll
In most instances, schizotypal disorders co – occurs with the schizoid , paranoid, avoidant and borderline
personality disorders
Signs and symptoms
• Schizotypal disorder is characterized by a pattern of social and interpersonal deficits marked by acute
discomfort with , and reduces capacity for close relationships as well as by cognitive or perceptual
distortions and eccentricities of behaviour, beginning by early adulthood and present in a variety of
contexts as indicated by five or more of the following
1. Ideas of reference( excluding delusions of reference)
2. Odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural
norms
Eg. Superstitioners
3. Unusual perceptual experience including bodily illusions
4. Odd thinking and speech
5. Suspiciousness or paranoid ideation
6. Inappropriate affect

7. Lack of close friends
8. Excessive social anxiety.
Causes of schizotypal disorders
1.Biological and genetic factors

2. Social factors( such as how a person interacts
In their family and friends and other
Children)
3. Psychological factors ( The individual’s personality shaped by their environment and learned coping skills to deal
with stress)
Treatment
1 . Psychotherapy
While individual therapy is the preferred modality at the onset of therapy, it may be appropriate to
consider group therapy as the client progresses. Such a group should be for this specific disorders, through which
may be difficult to form or find smaller communities
There is no simple solution to this problem. Social skills training and other behavioural approaches which
emphasis the learning of the basis of social relationships and social interactions may be beneficial
2. Medications
Medications can be used for treatment of this disorders more acute phases of psychosis. Psychosis is
usually transitory, though, and should effectively resolve with the prescription of an appropriate anti-psychotic
Delusional Disorders
Delusional Disorders are psychiatric disorders in which the predominant symptoms are delusions.
Formerly called Paranoia or paranoid disorder.
Types
1. Erotomanic type
Delusions that another person, usually of higher status, is in love with the individual
2. Grandiose type
Delusions of inflated worth, power, knowledge, identify , or special relationship to a famous person
a) Jealous type – delusions that individual’s sexual partner is unfaithful
b) Persecutory type – delusions that the person ( or someone to whom the person is close) is being
malevolently treated in some way
3. Somatic type – delusions that the person has some physical defect or general medical condition.
4. Persecutory – patients believe that they are being persecuted and harmed. Patients often experience
some degree of emotional distress such as irritability, anger and resentment
5. Nihilistic – delusions of nothing less.
The sufferer may believe that they or the world has ceased to exist, that they are dead or that parts of
the body or mind have vanished.
6. Mixed type – delusions characteristic of more than one of the above type but no one them predominates

7. Unspecified type – persecutory and jealous types are most common, and Erotomanic
and somatic types are the most unusual
Clinical features
Mental status
1. General description – mental status examination is usually remarkably normal except for the
presence of markedly abnormal delusional system.
2. Mood , feeling and affect - patient's moods are consistent with the content of other delusions
3. Perceptual disturbances – patients with delusional disorder do not have prominent or sustained
hallucinations. Tactile or olfactory hallucinations may be present if they are consistent with the
delusions.
4. Thought – Disorders of thought content in the form of delusions is the key symptom of the disorder
Eg. Delusions of being persecuted , of being infected with a virus
5. Impulse control – clinicians must evaluate patients with delusional disorder for ideation or plants to
act on their delusional material by suicide, homicide or other violence. If patients are unable to
control their impulses , hospitalization is probably necessary.
Causes
1.Genetic
The fact that delusional disorder is more common in people who have family members with
delusional disorder or schizophrenia suggests genes may be involved. It is believed that , as with
other mental disorders, a tendency to have delusional disorder might be passed on from parents to
their children.
2. Biological
Abnormal brain regions that control perception and thinking may be linked to the delusional
symptoms
3. Environmental or psychological
Evidence suggests that stress can trigger delusional disorder. Alcohol and drug abuse also
might contribute to it. People who tend to be isolated, such as immigrants or those with poor sight
and hearing, appear to be more likely to have delusional disorder.
Treatment
1.Hospitalization
Often needed because patients may need a complete medical and neurological evaluation to determine
whether a non psychiatric, medical condition is causing the delusional symptoms. Patients may need an
assessment of their ability to control , violent impulses, such as to commit suicide and homicide
2. Pharmacotherapy
In an emergency, severely, agitated patients should be given an antipsychotic drugs intramuscularly
3. Psychotherapy
Eg. Insight oriented supportive , cognitive and behavioural therapies are often effective.
Unit 16 : Mood Affective Disorder / Mania and Depression

Mania is a period of extreme high energy or mood associated with bipolar disorder. Everyone’s moods
and energy levels changethroughout the day and over time. But mania is a serious change from the way
a person normally thinks or behaves, and it can last for weeks or even months. It makes sense that this
could cause serious problems in a person’s relationships, work, and school.
Mania looks different for everyone, but it generally includes some of the following:
• having lots of energy

• feeling “euphoric” (extremely excited and happy, or even “high”)
• feeling unstoppable or invincible
• mind racing
• speaking very quickly (mental health professionals call this “pressured speech”)
• strange or unusual behavior
• easily distracted or annoyed
• not sleeping
• impulsive behavior
• intense anxiety
• feeling detached from reality (psychosis)
People with bipolar disorder often have mixed feelings about their mania.
Sudden increases in drug use, unprotected sex, or spending too much money are common. Even though
mania usually feels really good in the moment, it still causes problems for people’s lives. Sometimes,
mania can even lead to hospitalization. It’s important to note that these are drastic changes from what a
person is typically like. If someone alwaysspeaks quickly, makes impulsive decisions, and doesn’t sleep
much, those probably aren’t signs of a manic episode.
Mania can also include psychotic symptoms. Someone experiencing psychosis might:
• see or hear things that other people can’t (hallucinations)

• speak or in a way that seems disorganized or bizarre to others
• be fearful or suspicious of friends or family members, strangers, or organizations
(paranoia)
• feel like they’re being watched.
Hypomania
Hypomania is a less intense form of mania. The symptoms are similar, but its impact on people’s daily
lives is not as severe. It does not involve psychotic symptoms and rarely leads to hospitalization. Because
it is less disruptive, it often goes unnoticed or unreported. Hypomania is most common in bipolar II and
cyclothymia.
causes of hypomania or mania include:
• high levels of stress

• changes in sleep patterns or lack of sleep
• using recreational drugs or alcohol
• seasonal changes – for example, some people are more likely to experience hypomania and mania in
spring
• a significant change in your life – moving house or going through a divorce, for example
• childbirth

Ages affected
• Toddlers (3-5yrs) – very rare

• Children (6-13yrs) – rare
• Teenagers(14-18yrs) – very common
• Young adults(19-40yrs) – very common
• Adults(41-60yrs) – very common
• Seniors(66+yrs) – common
Treatment of mania
Certain drugs include Chlorpromazine,Haloperidol,Clozapine,Risperidone,Olanzapine etc...
The neurotransmitters like Norepinephrine, dopamine and serotonin have been studied since the
1960s as factors in mania and depression.
For eg.,during a manic episode, clients with bipolar disorder have a significantly higher
Norepinephrine and epinephrine levels than a depressed or normal mood person.
DEPRESSION
By WHO, depression is a common mental disorder that presents with depressed mood, loss of
interest or pleasure, feeling of guilt or low self worth, disturbed sleep or appetite,low energy and poor
concentration.
SIGNS AND SYMPTOMS OF DEPRESSION
• Fatigue
• Thoughts of death and suicide
• Feeling guilty
• Difficulty in concentrating, remembering
• Sleeping too much or too little
• Reduced or increased appetite which results to weight gain or loss
• Irritability or restlessness
Scientists have also found evidence which makes some people with a genetic predisposition
to major depression vulnerable to the disorder.some life event that may trigger causes of depression like:
❖ Death of a loved one

❖ Major loss
❖ Chronic stress
❖ Alcohol and drug abuse
TYPES OF DEPRESSION
❖ Major depression: symptoms of depression that last for more than two weeks.
❖ Dysthymia: experiences episodes of depression that alternate with periods of feeling normal
❖ Bipolar disorder: recurrent episodes of depression and extreme mania.
❖ Seasonal affective disorder(SAD): depression during the winter months when daylength is
short.
ETIOLOGY

❖ Genetic cause
❖ Environmental factors
❖ Biochemical factors: biochemical theory of depression postulates a deficiency of
neurotransmitters in certain areas of the brain(noradrenaline,dopamine).
❖ Dopaminergic activity: reduced in the case of depression,over activity in mania
❖ Endocrine factors: hypothyroidism,hormone level changes,alcohol abuse
❖ Physical illness: neurological disorder,thyroid disease,diabetes, carcinoma
TREATMENT
ANTIDEPRESSANTS
1. MAO inhibitors (Monoamine oxidase)
Irreversible: Isocarboxazid,phenelzine
Reversible: clorgyline,moclobemide
2. Tricyclic antidepressants (TCAs): NA and 5HT reuptake inhibitors –
Doxepin,dothiepin,clomipramine.
3. NA reuptake inhibitors: Amoxapine,desimipramine.
NON PHARMACOLOGIC THERAPY
❖ Lifestyle changes
❖ Stress reduction,social support,sleep
PSYCHOTHERAPY
❖ Cognitive behavioural therapy

❖ Interpersonal therapy
❖ Psychodynamic therapy
Unit 18: Substance induced psychotic disorders
Introduction
Substance-induced psychotic disorder is a condition that causes symptoms like hallucinations and delusions and that
is triggered by misuse of drugs or alcohol. In most cases the psychosis is short-term, but in rare cases, heavy and long-
term use of a drug can cause psychosis that lasts for months or year
Drug induced psychosis, also known as stimulant psychosis, refers to any psychotic episode which has been
caused by abuse of stimulants, an adverse reaction to prescription drugs, or excessive use of alcohol which has directly
triggered by a psychotic reaction.
Psychosis is a collection of symptoms characterised by losing touch with reality. Losing touch with reality means
believing, thinking, seeing, hearing or feeling things that aren't really there. The person who is experiencing psychosis
believes these things are real. Psychosis may also include delusions and paranoia. Psychosis can also include feelings
of being depersonalized or detached and dissociated from one's own body.
Drug induced psychotic disorder also known as Substance induced psychotic disorder is a condition that is
characterized by psychotic symptoms, like hallucinations and delusions caused by the use of a drug or substance or
by withdrawal from a substance. The disorder may be acute and last only as long as the drug is in the body, as is often

the case with hallucinogenic drugs like LSD. In some cases, however, the psychosis can persist for longer periods of
times, in rare instances even for years.
To actually be diagnosed with substance-induced psychotic disorder, the symptoms must persist beyond the typical
symptoms that are commonly caused by a drug. The symptoms must be in excess of what is normally expected from
a specific substance or persist after the person has detoxed from the drug or substance.
Drug induced psychotic symptoms and signs
The symptoms of drug induced psychotic disorder may vary by individual or by the type of drug causing the psychosis,
and they may vary in intensity depending on how much substance was used and whether use has been long-term. The
symptoms are essentially the same as those caused by other factors, like mental illness or brain diseases:
• Delusions. False unshakable beliefs, Delusions may be paranoid.
• Hallucinations. Hallucinations are sensory perception without an external stimuli. Seeing, hearing, or
otherwise sensing things that are not really there, but that the hallucinating person believes are real. For
instance, this may involve hearing voices and believing they are real.
• Disordered thinking. Psychosis may include disorganized, confused thinking, as well as disturbing and
persistent thoughts. This can cause someone to speak in a way that is difficult to understand.
• Dissociation. Someone experiencing psychosis may feel detached from reality, from their own body, and
from their own sense of self. They may feel as if the world around them isn’t real or that they are not
connected to reality.
People who are experiencing drug induced psychosis may also show certain signs that are not obviously related,
but that may be caused by the psychotic state. These include depression, anxiety, trouble concentrating, changes in
sleep patterns, social withdrawal, inappropriate behaviours or unusual changes in behaviour, and declines in self-care.
Substance Implicated in Drug Induced Psychotic Disorder
Any mind-altering substance has the potential to trigger psychosis, although it is more common with some substances
than others. Very large quantities of any drug taken over a long period of time can cause psychotic symptoms. Drug
induced psychosis is generally rare, but some of the substances that are more likely to cause it include:
• Amphetamine and methamphetamine. These stimulant drugs can cause psychotic symptoms after long
periods of heavy use. The symptoms often include paranoia and delusions. These are usually temporary, but
in some exceptional cases of very heavy and long-term use, the psychotic symptoms can last for months or
even years.
• Cocaine. Another stimulant, cocaine also has the potential to cause psychosis, most often paranoid delusions.
• Hallucinogens. These drugs cause hallucinations, but they generally cease after stopping use of the drug. In
some people they may cause other temporary psychotic symptoms, including paranoia, delusions, and a sense
of depersonalization or dissociation. It is also possible that hallucinogen use will cause chronic psychotic
symptoms or even flashbacks.
• Alcohol. Withdrawal from alcohol can very dangerous for people who have been long-term heavy drinkers.
One potential complication from withdrawal is alcoholic hallucinosis, which causes hallucinations.
Withdrawal may also cause delirium tremens, which can have symptoms of psychosis. Heavy and prolonged
alcohol use may trigger psychotic symptoms and a psychotic condition called Korsakoff’s syndrome, which
is related to vitamin B1 deficiency.
• Cannabis. Marijuana is known to induce psychosis in some people. The mind-altering compounds found
naturally in the cannabis plant. These products may be even more likely to trigger psychosis. Cannabis-
related psychosis is more common in younger users.
Substance use and co-occurring Psychotic Disorder
Some people who experience substance-induced psychosis also have a co-occurring psychotic disorder, such as
schizophrenia or bipolar disorder with psychosis. These people are typically more sensitive to the effects of drugs.
Another connection between psychotic disorders and substance use is that people with psychosis and related mental
illnesses are more likely to misuse substances as an attempt to self-medicate. Substance use may also trigger psychotic
episodes in someone with a psychotic condition, whether diagnosed or undiagnosed.

Substance use Disorders
1. Amphetamine use disorders
Though synthesized by Edleano in 1887, it was introduced in Medicine in 1932 as benzedrine inhaler, for the treatment
of Coryza, rhinitis and asthma. One of the commonest patterns of ‘use’ is seen amongst the students and sports persons
to overcome the need for sleep and fatigue. Tolerance usually develops to the central as well as cardiovascular effects
of amphetamines.
Intoxication and Complications
The signs and symptoms of acute amphetamine intoxication are primarily cardiovascular (tachycardia, hypertension,
haemorrhage, cardiac failure and cardiovascular shock) and central ( seizures, hyperpyrexia, tremors, ataxia, euphoria,
papillary dilatation, tetany and coma). The neuropsychiatric manifestations include anxiety, panic, insomnia,
restlessness, irritability, hostility and bruxism.
Acute intoxication may present a paranoid hallucinatory syndrome which closely mimics paranoid schizophrenia.
Chronic amphetamine intoxication leads to severe and compulsive craving for the drug.
Treatment of Intoxication
Acute intoxication is treated by symptomatic measures, e.g. hyperpyrexia (cold sponging, parenteral antipyretics),
seizures ( parenteral diazepam), psychotic symptoms (antipsychotics), and hypertension (antihypertensives).
Acidification of urine (with oral NH4CL; 500 mg every 4 hours) facilitates the elimination of amphetamines.
Withdrawal syndrome
The withdrawal syndrome is typically seen on an abrupt discontinuation of amphetamines after a period of chronic
use. The syndrome is characterised by depression (may present with suicidal ideation), marked asthenia, apathy,
fatigue, hypersomnia alternating with insomnia, agitation and hyperphagia.
Treatment of withdrawal symptoms
The presence of severe suicidal depression may necessitate hospitalisation. The treatment include symptomatic
management, use of antidepressants and supportive psychotherapy.
2. Cocaine use disorders
Cocaine is an alkaloid derived from the coca bush, Erythroxylum coca, found in Bolivia and Peru. It was isolated by
Alert Neimann in 1860.
Cocaine (common street name: crack) can be administrated orally, intranasally, by smoking or parenterally,
depending on the preparation available. It gives a ‘ rush’ of pleasurable sensations.
Acute Intoxication
Acute cocaine intoxication is characterised by papillary dilatation, tachycardia, hypertension, sweating, and nausea or
vomiting. A hypomanic picture with increased psychomotor activity, grandiosity, elation of mood, hypervigilance and
increased speech output may be present. Later, judgement is impaired and there is impairment of social or occupational
functioning.
Withdrawal Syndrome
Cocaine use produces a very mild physical, but a very strong psychological, dependence. A triphasic withdrawal
syndrome usually follows an abrupt discontinuation of chronic cocaine use
Complications

The complications of chronic cocaine use include acute anxiety reaction, uncontrolled compulsive behaviour,
psychotic episodes ( with persecutors delusions, and tactile and other hallucinations), delirium and delusional disorder.
High doses of cocaine can often lead to seizures, respiratory depression, cardiac arrhythmias, coronary artery
occlusion, lung damage, gastrointestinal necrosis, foetal anoxia and perforation of nasal septum.
Treatment
Cocaine use disorder is commonly associated with mood disorder, particularly major depression and cyclothymia.
The treatment of overdose consists of oxygenation, muscle relaxants and IV thiopentone and /or IV diazepam (for
seizures and severe anxiety).
3. LSD use disorders
Lysergic acid diethylamide, first synthesized by Albert Hoffman in 1938 and popularly known as ‘acid’, is a powerful
hallucinogen.
Intoxication
The characteristic features of acute LSD intoxication are perceptual changes occurring in a clear consciousness. These
perceptual changes include depersonalization, derealisation, intensification of perceptions, synaesthesia (merging of
senses that are not normally connected), illusions and hallucinations.
In addition, features suggestive of autonomic hyperactivity, such as papillary dilatation, tachycardia, sweating,
tremors, incoordination, palpitations, raised temperature, piloerection and giddiness, can also be present.
These changes are usually associated with marked anxiety and /or depression, though euphoria is more common
in all small doses. Persecutory and referential ideation may also occur.
Sometimes, acute LSD intoxication presents with an acute panic reaction, known as a bad trip, in which the
individual experiences a loss of control over his self. The recovery usually occurs within 8-12 hours of the last dose.
Rarely, the intoxication is severe enough to produce an acute psychotic episode resembling a schizophreniform
psychosis.
Withdrawal Syndrome
No withdrawal syndrome has been described with LSD use.
However, sometimes, there is a spontaneous recurrence of the LSD use experience in a drug free state. Described
as flashback, it usually occurs weeks to months after the last experience. Such episodes are often induced by stress,
fatigue, alcohol intake, severe physical illness or marihuana intoxication.
Complications
It includes psychiatric symptoms (anxiety, depression, psychosis or visual hallucinosis)
Treatment
The treatment of acute LSD intoxication consists of symptomatic management with antianxiety, antidepressant or
antipsychotic medication, along with supportive psychotherapy.
4. Cannabis use disorders
Cannabis is derived form the hemp plant, Cannabis sativa. Cannabis (street names : grass, hash or hashish, marihuana)
Cannabis produces a very mild physical dependence, with a relatively mild withdrawal syndrome, which is
characterised by fine tremors, irritability, restlessness, nervousness, insomnia, decreased appetite and craving. This
syndrome begins within few hours of stopping Cannabis use and lasts for 4 to 5 days.

On the other hand, psychological dependence ranges from mild (occasional ‘trips’) to marked (compulsive use).
All the active ingredients are called as marijuana or marihuana. Cannabis can be detected in urine for up to 3 weeks
after chronic heavy use.
Acute Intoxication
Mild cannabis intoxication is characterised by mild impairment of consciousness and orientation, light headedness,
tachycardia, a sense of floating in the air, a euphoric dream like state, alternation(either increased or decreased) in
psychomotor activity and tremors, in addition to photo phobia, lacrimation, tachycardia, reddening of conjunctiva, dry
mouth and increased appetite.
Perceptual disturbances are common and can include depersonalization, derealisation, synaesthesia ( sensation in
one sensory modality caused by a sensation in another sensory modality, e.g. ‘seeing’ the music) and increased
sensitivity to sound. Hallucinations are seen only in marked to severe intoxication.
Complications
a. Transient or short-lasting psychiatric disorders

Acute anxiety, paranoid psychosis, suicidal ideation, hypomania, schizophrenia- like state ( which is
characterised by persecutory delusions, hallucinations and at times catatonic symptoms), very rarely,
depression.
b. Amotivational syndrome
Chronic cannabis use is postulated to cause lethargy, apathy, loss of interest, anergia, reduced drive and
lack of ambition.
c. Hemp insanity or cannabis psychosis
It was first described by Dhunjibhoy in 1930. It was described as being similar to an acute
schizophreniform disorder with disorientation and confusion, and with a good prognosis.
d. Other complications
Chronic cannabis use sometimes leads to memory impairment, worsening or relapse in schizophrenia
or mood disorder, chronic obstructive airway disease (lung disease that block airflow and make it difficult to
breathe), pulmonary malignancies (lung cancer), alteration in immunity, decreased testosterone levels,
anovulatory cycles (menstruation) reversible inhibition of spermatogenesis, if taken during pregnancy, there
is increased risk for the developing foetus.
Treatment
Psychotherapy and psycho education
Module 6
Unit: 19 Mental Health Policies and programmes
INTRODUCTION
The govt. of India launch the national health programme in1982. Keeping in view the heavy burden of
mental illness in the community and inadequate of mental health care infrastructure in the country to
deal with it. Public education in the mental health to increase awareness and reduce stigma. For early
detection and treatment, the OPD and indoor services are provided. Providing valueable data and
experience at the level of community to the state and centre for future planning, improvement in
service and research.

DEFINITION
Mental Health (WHO): Mental Health is a state of wellbeing in which an individual realize his/her own
abilities can cope with the normal stresses of life, can work productively and is able to make a
contribution to his/her community.
LEVEL OF N.M.H.P
This program include 3 sub program
1. Treatment sub prog

a. Village level
b. Primary health level
c. At district level
2. Rehabilitation sub prog
3. Prevention sub prog
AIM OF N.M.H.P
• Prevent and treatment of mental neurological disorder and there associated disability.
• Use of mental health technology is improve general health services.
• Application of mental health principles in total national development to improve quality of life.
OBJECTIVES
• Introduction about the National Mental Health Programme.

• Definition of Mental Health and Mental illness.
• Aim of N.M.H.P
• Objective of N.M.H.P
• Level of N.M.H.P
• Knowledge about the organization
• Warming sign of mentally ill person
• Nurse’s role in N.M.H.P or mental health services. Birth of the NMHP
• The experience and knowledge acquired from the above pilot studies became the basis of
drafting of the National Health Programme (NMHP)

• It was written by an expert drafting committee which consisted of some of the leading, senior
psychiatrists in India and was reviewed and revised in two national workshops attended by a
large number of mental health professionals and other stakeholders during 1981-82.
• It was finally adopted for implementation by the Central Council of Health and Family Welfare
(CCHFW), Government of India in August 1982.
• India thus became one of the first countries in the developing world to formulate a national
mental health programme.
MERITS
• Improvement of nutritional and health status of girls.

• Training and equipment of adolescent girls to upgrade home based vocational skills.
• 6 kg of free food grains (rice) per month per beneficiary.
• Promotion of health, hygiene, nutrition, family welfare, home management and childcare.
• Better understanding of their environment related social issues and its impact on their lives.
DEMERITS
• Limited undergraduate training in psychiatry.

• Inadequate mental health human resources.
• Lack of policy driven epidemiological data and research driven mental healthcare policies.
• Limited number of models and their evaluation.
• Uneven distribution of resources across states. Non-implementation of the MHA, 1987
Privatization of healthcare in tha 1990s.
CONCLUSION
• In the IXth five year plans, NMHP got specific budgetary allocation of 28crores and the major
focus during these five years was on DMHP.
• The Xth five year plans were introduced in 2003 after in-depth analysis and consultations with
the stakeholders.
• There was several folds increase in the budgetary allocation for the program.
• XIth five year plan focused on centres of excellence in mental health and the manpower
development in the fields of mental health.
• Over the years it has been observed that the focus on community mental health is of utmost
importance and DMHP needs to be strengthened in view of its coverage and utilization of its
service components.
National Mental health policy
The vision of the National Mental Health Policy is to promote
mental health, prevent mental illness, enable recovery from mental illness, promote
destigmatization and desegregation, and ensure socio-economic inclusion of persons affected
by mental illness by providing accessible, affordable and quality health and social care to all
persons through their life-span within a rights-based frame work.
Goals of the policy

16. To reduce distress, disability, exclusion morbidity and premature mortality associated
with mental health problems across life span of the person.
17. To enhance understanding of the mental health in the country.
18.To strengthen the leadership in the mental health sector at the national, state and
district levels.
Objectives of the Policy

 To provide universal access to mental health care.
 To increase access to and utilisation of comprehensive mental health services by
persons with mental health problems.
 To increase access to mental health care especially to vulnerable groups including
homeless persons, persons in remote areas, educationally, socially and deprived
sections.
 To reduce prevalence and impact of risk factors associated with mental health
problems.
 To reduce risk and incidence of suicide and attempted suicide.
 To ensure respect for rights and protection from harm of persons with mental health
problems.
 To reduce stigma associated with mental health problems.
 To enhance availability and equitable distribution of skilled human resources for mental
health.
 To progressively enhance financial allocation and improve utilisation for mental health
promotion and care.
 To identify and address the social, biological and psychological determinants of mental
health problems and to provide appropriate interventions.
Conclusion : A National Mental Health Policy should be developed and implemented
to provide minimum mental health care -which should be an essential component of
Primary Health Care. To date the Primary Health Care Planning has not been able to
address adequately the psycho-social aspects of health care, despite a wealth of
evidence regarding the significance of this aspect. This policy proposal aims to fill this
void, which has been felt by many in the health field, in a way that maximises existing
health care resources; thus minimizing the additional financial burden to the country.
Such additional financial burden occure needs to be met by mobilising resources both
within and outside the country.
Unit : 20 Mental Health Act, 1987

INTRODUCTION
According to WHO, mental health is “ a state of well-being in which the individual realizes his
or her own abilities, can cope with the normal stresses of life, can work productively and
fruitfully, and is able to make a contribution to his or her community. The Mental Health Act is
the main piece of legislation that covers the assessment, treatment and rights of people with a
mental health disorder. People detained under the Mental Health Act need urgent treatment for a
mental health disorder and are at risk of harm to themselves or others. In India, the Mental
Health Act was passed on 22nd May 1987. This act came into effect in all the states and union
territories of India in April 1993. This act replaces the Indian Lunacy Act of 1912.
MENTAL HEALTH ACT,1987
“An act to consolidate and amend the law relating to the treatment and care of mentally ill
persons, to make better provision with respect to their property and affairs and for matters
connected therewith or incidental thereto”.
OBJECTIVES OF THE ACT
▪ To establish central and state authorities for licensing and supervising the psychiatric
hospitals.
▪ To establish such psychiatric hospitals and nursing homes.
▪ To provide a check on working of these hospitals.
▪ To provide for the custody of mentally ill persons who are unable to look after
themselves and are dangerous for themselves and for others.
▪ To protect the society from dangerous and manifestations of mentally ill.
▪ To regulate procedure of admission and discharge of mentally ill persons.
▪ To safeguard the rights of these detained individuals.
▪ To protect citizens from being detained unnecessarily.
▪ To provide the maintenance charges of mentally ill.
▪ To provide legal aid to poor mentally ill criminals at state expenses.
▪ To change offensive terminologies of Indian Lunacy Act to new soother ones.
SAILENT FEATURES OF THE ACT

Mental Health Act is divided into 10 chapters consisting of 98 sections.
CHAPTER 1: Deals with preliminaries of the act
➢ Cost of maintenance: In relation to a mentally ill person admitted in a psychiatric hospital
or nursing home, shall mean the cost of such items as the state government may , by
general or special order, specify in this behalf.
➢ District Court: The court competent to deal with all or any of the matters specified in this
act.
➢ Inspecting Officer: A person authorised by the state government to inspect any

psychiatric hospital or nursing home.
➢ Licence: Granted licence.
➢ Licensee: The holder of a licence.
➢ Licensed psychiatric hospital: A psychiatric hospital, on this case may be licensed or

deemed to be licensed under this act.
➢ Licensing authority: An officer or authority specified by the state government for the
purposes of this act.
➢ Medical practitioner: A person who possesses a recognised medical qualification.
➢ Mentally ill person: A person who is in need of treatment by reason of any mental
disorder other than mental retardation.
➢ Psychiatrist: A medical practitioner possessing a post-graduate degree or diploma in

psychiatry.
➢ Reception order: An order made under the provisions of this act for the admission and
detention of a mentally ill person in a psychiatric hospital.
CHAPTER 2: Deals with establishment of mental health authorities at central and state levels.
➢ Central Authority for mental health services: The Central government shall establish an
Authority for mental health. The Authority established shall be in charge of regulation,
development, direction and co-ordination with respect to mental health services under the
central government. They supervise the psychiatric hospitals and nursing homes under
the control of the Central government.
➢ State Authority for mental health services: The State government shall establish an
Authority for mental health and holds the responsibilities of central government
authorities as mentioned above.
CHAPTER 3: Deals with establishment and maintenance of psychiatric hospitals and nursing
homes.
➢ Establishment or maintenance of psychiatric hospitals and nursing homes: The Central
government or the State government may establish or maintain psychiatric hospitals or
nursing homes for the admission, treatment and care of mentally ill persons.
Separate psychiatric hospitals and nursing homes may be established or maintained for;
❖ Those who are under the age of 16 years.
❖ Those who are addicted to alcohol or other drugs which lead to behavioural changes
in a person.
❖ Those who have been convicted of any offence.
➢ Establishment of psychiatric hospitals or nursing homes only with license: A psychiatric

hospital or nursing home should be licensed by the central or state government. The
license provided should be for a period of 3 months.
➢ Application for license: If a person intends to establish or continue the maintenance of

such hospital or nursing home after the expiry of the period of 3 months, he must make
an application to the licensing authority for the grant of a fresh license for at least one
month before the expiry of such period.
➢ Grant or refusal of license: The licensing authority shall make such inquiries where it is
satisfied that;
❖ The establishment of the psychiatric hospital or nursing home before the

commencement of this act is necessary.
❖ The applicant is in a position to provide the minimum facilities prescribed for the
admission, treatment and care of mentally ill persons.
❖ The psychiatric hospital or nursing home will be under the charge of a medical officer
who is a psychiatrist.
➢ Duration and renewal of license: Every license has a duration of 3 months, and if you
want to grant a fresh license again, you must give an application form to the licensing
authority before one month of the expiry date.
➢ Inspection of psychiatric hospitals or nursing homes: An Inspecting officer, at any time,

enter and inspect any psychiatric hospital or nursing home and require the production of
any records, which are required to be kept in accordance with the rules made in this
behalf, for inspection. The inspecting officer may interview the inpatients privately for
ensuring if any inpatient is not receiving proper treatment and care if he gets any
complaint related to the treatment and care, he may report the matter to the licensing
authority.
CHAPTER 4: Deals with the procedures of admission and detention of mentally ill in a
psychiatric hospitals.
➢ ADMISSION ON VOLUNTARY BASIS
• Request by major for admission as voluntary patient
• Request by guardian for admission of a ward
• Discharge of voluntary patients
➢ ADMISSION UNDER SPECIAL CIRCUMSTANCES
• Any mentally ill person who does not, or is unable to express his willingness
for admission as a voluntary patient, may be admitted and kept as an inpatient
in a psychiatric hospital or nursing home on an application made in that behalf
by a relative or a friend of the mentally ill person.
➢ RECEPTION ORDERS
• Application for reception orders: An application for a reception order may be
made by the medical officer or by the husband, wife or any other relative of
the mentally ill person.
• Form and contents of medical certificates: Every medical certificate shall
contain a statement that each of the medical practitioners independently
examined the alleged mentally ill person and has formed his opinion on the
basis of his own observations and from the particulars communicated to him.
CHAPTER 5: Deals with the inspection, discharge, leave of absence and removal of mentally ill
persons.
➢ INSPECTION
• Appointment of visitors: Appoint for every psychiatric hospital or nursing
home, not less than 5 visitors, of whom at least one shall be a medical officer,
a psychiatrist and 3 social workers.
• Monthly inspection by visitors: Three visitors shall, at least once in every
month make a joint inspection to the psychiatric hospital or nursing home.
• Inspection of mentally ill prisoners: Three visitors including at least one social
worker, visit such person at the place where he is detained, in order to assess
the state of mind of such persons.
➢ DISCHARGE
• Order of discharge by medical officer in charge
• Discharge of mentally ill persons on application
• Discharge of person on his request
➢ LEAVE OF ABSENCE
• Grant of leave of absence by magistrate
➢ REMOVAL
• Removal of mentally ill persons from one psychiatric hospital or nursing
home to another
• Admission, detention and retaking in certain cases
CHAPTER 6: Deals with the judicial inquisition regarding alleged mentally ill persons
possessing property and its management.
➢ It consists of legal customary actions towards the property possess by mentally ill
persons. A guardian may be appointed by court of law on behalf of an alleged
mentally ill person incapable of looking after self and property.
CHAPTER 7: Deals with the maintenance of mentally ill persons in a psychiatric hospital or
nursing home
➢ Deals with ways and means to meet the lost of maintenance of mentally ill persons
detained in psychiatric hospital or nursing home. If a mentally ill patient is detained
as an inpatient and does not have property to bear the cost of treatment, in such cases
the expenses shall be borne by state government.
CHAPTER 8: Deals with the protection of human rights of mentally ill persons
➢ No letter or communication sent by or to a mentally ill person shall be interpreted,
detained or destroyed.
➢ No mentally ill person shall be subjected during treatment to any indignity or cruelty
CHAPTER 9: Deals with penalties and procedures for infringement of guidelines of the act.
➢ Any person who violates the procedures shall be punishable. Either imprisonment for 2
years of fine of 1000 rupees or both.
➢ Any manager who contravenes the provisions shall be punishable with fine of 2000
rupees and may be detained in a civil prison till he complies with the said provisions.
CHAPTER 10: Deals with miscellaneous matters.
➢ Report by medical officer: The medical officer should make a report about the mental and
physical condition of the discharged person to the authority.
Mental Health care Act 2017
Introduction
Mental health is an integral part of health and is more than the absence of mental illnesses. Mental
Health needs to be discussed in India. Mental Health is a pervasive problem in India . There has been a
remarkable surge in the mental illness in India where there endures a lack of recognition of it. While
there are many reasons for this, one such is insufficiency in the lack of awareness about the importance
of psychologists and therapies. According to a survey by the Indian Council of Medical Research (ICMR)
that claimed that 7.5% of the total country’s population is hit by mental illness . Because of the recent
pandemic that has taken over the world which resulted in lockdowns there was a rapid growth in the
numbers arising because of fear of Job Loss, Anxiety & Domestic Violence, Panic Attacks, raising the
number to 20% . This would account at least one in seven Indians suffering from the mental illness.
The Mental Healthcare Act (MHCA) passed by the government in 2017 was seen as an appreciated
step in the area of catering to the millions of Indians wanting help. It looks to guard, advance and fulfil
the rights of persons with mental illness and establish the onus on the state to grant affordable mental
healthcare to its citizens.
"An Act to provide for mental healthcare and services for persons with mental llness and to protect,
promote and fulfil the rights of such persons during delivery of mental healthcare and services and for
matters connected therewith or incidental thereto". WHEREAS the Convention on Rights of Persons with
Disabilities and its Optional. It ensures that these persons have a right to live life with dignity by not
being discriminated against or harassed.
Protocol was adopted on the 13th December, 2006 at United Nations Headquarters in New York and
came into force on the 3rd May, 2008; And whereas India has signed and ratified the said Convention
on the 1st day of October, 2007; AND WHEREAS it is necessary to align and harmonise the existing laws
with the said Convention.
The Mental Healthcare Act, 2017 abolishes the existing Mental Healthcare Act, 1987 which had
been extensively criticized for not acknowledging the rights of a mentally ill person and flooring the way
for isolating such dangerous patients & contained many such drawbacks as mentioned below:
* Limited the definition of “mental illness to “mental disorder”.
* No attention to WHO guidelines.
* Much stress is laid on licensing the authorities.
The term “Mental illness” in this act is defined in Act in Section 2 which consists of Definitions.
According to this act mental illness indicates a substantial disorder of thinking, mood, perception,
orientation or thought that grossly damages judgment, behaviour, capacity to recognise reality or ability
to meet the usual requirements of life, mental conditions associated with the degradation of alcohol and
drugs, but does not constitute mental barrier which is a condition of arrested or inadequate
development of mind of a person, particularly characterised by subnormality of knowledge.
Mental illness shall be defined in the same style as nationwide or overseas held medical criteria.
Additionally, mental illness cannot be decided by a person’s political, economic or social status,
association in cultural society, racial or religious group, or non-conformity with a community’s moral,
social, cultural, work or political interpretations and religious opinions.
The MHA 2017 provides a wide & elaborative definition of “mental illness” which was lacked by the
previous act 1987.
List of chapters
The Mental Health Care Act 2017 is split into 16 chapters which are further elaborated as below.
# Chapter I
1.It comprises the definitions & terms that are asserted in the Act.
2.Mental Illness gets a brand new & elaborative definition.
3.It involves post-graduate Ayush doctors as Mental Health Professionals.
#Chapter II
1.This chapter covers mental illness and the capacity to make mental health care and treatment
decisions without any prejudice.
2.How mental health should be determined.
3.Capacity to make mental health care and treatment decisions.
#Chapter III
1.This chapter deals with the Advance directives.
2.Manner of making Advance Directives & maintaining it & its power, review & liability allocated to it.
#Chapter IV
1.It lies down the guidelines of determining a nominated representative.
2.Appointment & Revocation of NR & his Duties.
#Chapter V
1. It consists of Various Rights that are conferred to a mentally ill person.
Section 18 – Right to access mental healthcare.
Section 19 – Right to community living.
Section 20 – Right to protection from cruel, inhuman and degrading treatment.
Section 21 – Right to equality and non-discrimination.
Section 22 – Right to information.
Section 23 – Right to confidentiality.
Section 24 – Restriction on the release of information in respect of Right to access medical records.
Section 25 – Right to personal contacts and communication.
Section 26 – Right to legal aid.
#.Chapter VI
1.It gives direction to the government to execute the programme.
2.It also promotes mental health & preventive programs.
#Chapter VII
1.Gives provisions for creating the Central Mental Health Authority.
2.Includes Establishment, Composition & Duties of CMHA.
#Chapter VIII
1.Gives provisions of creating the State Mental Health Authority.
2.Cover Establishment, Composition & Duties of SMHA.
#Chapter IX
1.It comprises finance, accounts and audit.
2.Accounts, Audits & Annual Reports by Central & State Authority.
#Chapter X
1.This includes Mental Health Care establishments.
#Chapter XI
1.Development of Mental Health Review Boards.
2.Registration, Audit, Inspection & Inquiry of mental health.
#Chapter XII
1.Admission, treatment and discharge of mentally ill.
#Chapter XIII
1.This Chapter guarantees guidelines in terms of Duties of police officers concerning a mentally ill
person.
#Chapter XIV
1.It restricts unauthorized duty and medication.
#Chapter XV
1.It deals with penalty and punishment.
#Chapter XVI
1.This chapter talks about the Power of the Central Government to issue regulations.
Major provisions
1) New definition of mental illness
Earlier, Mental illness was defined as any mental disorder and seldom as mental retardation but the
new act provides a broader definition which is stated below:
2) Various rights for persons with mental illness
*Every person has a right to obtain mental health care and its treatment from mental health services
run or financed by the appropriate government.
* Right to live with dignity is provided for every person with mental illness.
* No discrimination of any basis including gender, sex, religion, culture, sexual orientation, caste, social,
class, disability and political beliefs should be done against mentally ill people.
* Rights of confidentiality as for mental health, treatment, mental health care, and physical health care
to mentally ill people.
* Forbid the usage of the release of a photograph or any such matter related to a mentally ill person in
the media without the acquiescence of the person.
* Right of picking the person who would be answerable for making decisions with the view to the
treatment, his admission into a hospital, etc.
* Persons with mental illness will also have the right to protection from barbaric and demeaning
treatment.
* Free treatment is provided for the person with mental illness if they are homeless & fall in Below
Poverty Line, even if they don’t own a BPL card.
3) Advance directive
A person with mental illness shall have the right to make an advance directive that states how he/she
wants to be treated for the illness and who his/her nominated representative shall be. The advance
directive should be certified by a medical practitioner or registered with the Mental Health Board.
4) Mental health authority
The Bill provides power to the government to set-up the Central Mental Health Authority at
national-level and State Mental Health Authority in each State.
Every mental health practitioner and mental health institute including nurses, clinical psychologists,
also psychiatric social workers will be compelled to be registered with this Authority.
These bodies command to:
1.Register, supervise and manage a register of mental health professionals & establishments,
2.Generate quality and service provision norms for such establishments,
3.Train law enforcement administrators and mental health experts on the outlines of the Act,
4.Receive complaints about deficiencies in the provision of services, and
5.Advise the government upon matters representing mental health.
5) Mental health treatment
The Bill also specifies the process and procedure to be followed for admission, treatment and
discharge of mentally-ill individuals. A medical practitioner or a mental health professional shall not be
held liable for any unforeseen outcomes on following a valid advance directive.
6) Decriminalization of suicide
As provided in Section 115;
*.Notwithstanding anything contained in Section 309 of the Indian Penal Code any person who
attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress and shall
not be tried and punished under the said code.
*.The Appropriate Government shall have a duty to provide care, treatment and rehabilitation to a
person, having severe stress and who attempted to commit suicide, to reduce the risk of recurrence of
attempt to commit suicide”.
*.This is a milestone judgement which annulled Section 309 IPC which stated that ‘Any person
attempting to perform suicide shall be punished with simple imprisonment which may prolong to one
year.
7) Abolishment the barbarous treatments
*.It also affirms that a person with mental illness shall not be subjected to electroconvulsive therapy
(ECT) therapy without the application of muscle relaxants and anaesthesia.
*.Electro-convulsive therapy for minors is prohibited.
*.Chaining in any manner or method whatsoever is banned.
Criticisms of the Act
The Act does not provide for the advance directive to minors, as per Section 5 of the said Act. All the
services are to be ensured by both Central and State governments. The expenditures estimated will not
meet the obligations under the bill. The Centre and State, both have responsibilities as per the Act; it
does not provide sharing of funds between them. All the States have different financial conditions; the
Central government has to assure funds for meeting the legal obligations.
If a person no longer demands an order of supported admission to the Mental Health
establishment, the Act provides that they may continue to remain in the mental health establishment as
an independent patient and does not clarify for how long and what procedure is to be adopted to give
the person an effective chance to live in the community. Discussions should be started with the Central
and state governments to recognise the lack of resources and ensure their availability with proper
budgeting to perform the provisions of the MHCB. The MHCA does propose some timelines, but detailed
and precise response plans are required to prepare the system before the action is executed. Emphasis
should be laid on training for skill development. In the chapter, I of the Act – ‘mental health
professional’ is limited to clinical psychiatrists and specialists containing a postgraduate degree in
Ayurveda, Homeopathy, Siddha, and Unani. Despite the main worry is psychotherapists and
psychoanalysts are omitted from the act as the current definition. Although the law to punish the
person committing suicide has been prohibited, a lot still needs to be done for the mentally ill people.
Conclusion
The Mental Healthcare Act of 2017 looks alien in nature but impractical in scope. There is no doubt
that in the scope the act is a big leap from its predecessor 1987 Act. However the present healthcare
system seems to be incompetent and we suffer from lack of infrastructure and specialists in the field,
resultant of this causes the degraded quality of living and healthcare of the mentally ill. The Act has
taken a standard shift of rendering “mental healthcare” essentially as “justiciable rights.”
The new act has set outcome principles that mental health professionals will embrace and embed in
practice. The decriminalization of attempt to suicide is one of the major highlights of the act, along with
the concept of Advance Directive and ban on all those treatment procedures that gave these mentally ill
person nightmares, also trying to fix the system of institutions by engaging them and making sure they
work at standards which are prescribed by the authorities in the act. Breaching its stated policies of
equality, the act ends up discriminating against the mentally ill. There is a lack of comprehensive rules
and regulations to include all the settings. The resolve to implement the principles holding the act
appears weak, given the delay of ring‐fenced resources beyond inflationary arrangements. However,
more promotive programs & campaigns should be promoted on mental health. The government should
press more on allocating more funds in Mental Health Organisations.
Unit 21: Recommendations of WHO

INTRODUCTION
The World Health Report 2001 provides a new understanding of mental disorders that offers new hope to the
mentally ill and their families in all countries and all societies. It is a comprehensive review of what is known about
the current and future burden of disorders, and the principal contributing factors. It examines the scope of
prevention and the availability of, and obstacles to, treatment. It deals in detail with service provision and
planning; and it concludes with a set of far-reaching recommendations that can be adapted by every country
according to its needs and its resources
Up6. ESTABLISH NATIONAL POLICIES, PROGRAMMES AND LEGISLATION
Mental health policy, programmes and legislation are necessary steps for significant and sustained action. These
should be based on current knowledge and human rights considerations. Most countries need to increase their
budgets for mental health programmes from existing low levels. Some countries that have recently developed or
revised their policy and legislation have made progress in implementing their mental health care
programmes.Mental health reforms should be part of the larger health system reforms. Health insurance schemes
should not discriminate against persons with mental disorders, in order to give wider access to treatment and to
reduce burdens of care.
7. DEVELOP HUMAN RESOURCES
Most developing countries need to increase and improve training of mental health pro-
fessionals, who will provide specialized care as well as support the primary health care
programmes. Most developing countries lack an adequate number of such specialists to
staff mental health services. Once trained, these professionals should be encouraged to
remain in their country in positions that make the best use of their skills. This human
resource development is especially necessary for countries with few resources at present.
Though primary care provides the most useful setting for initial care, specialists are needed
to provide a wider range of services. Specialist mental health care teams ideally should include medical and non-
medical professionals, such as psychiatrists, clinical psycholo-
gists, psychiatric nurses, psychiatric social workers and occupational therapists, who can
work together towards the total care and integration of patients in the community
8. LINK WITH OTHER SECTORS
Sectors other than health, such as education, labour, welfare, and law, and nongovernmental organizations should
be involved in improving the mental health of communities. Nongovernmental organizations should be much more
proactive, with betterdefined roles, and should be encouraged to give greater support to local initiatives.
9. MONITOR COMMUNITY MENTAL HEALTH
The mental health of communities should be monitored by including mental health indicators in health
information and reporting systems. The indices should include both the numbers of individuals with mental
disorders and the quality of their care, as well as some more general measures of the mental health of
communities. Such monitoring helps to determine trends and to detect mental health changes resulting from
external events, such as disasters. Monitoring is necessary to assess the effectiveness of mental health pre-vention
and treatment programmes, and it also strengthens arguments for the provision of more resources. New
indicators for the mental health of communities are necessary.
10. SUPPORT MORE RESEARCH
More research into biological and psychosocial aspects of mental health is needed in order to increase the
understanding of mental disorders and to develop more effective interventions. Such research should be carried
out on a wide international basis to understand variations across communities and to learn more about factors
that influence the cause, course and outcome of mental disorders. Building research capacity in developing
countries is an urgent need.
WORLD HEALTH REPORT – 2001
The title of the World Health Report 2001 is: Mental Health: New Understanding, New Hope
(World Health Organization, 2001a) This title was chosen because the World Health Report
summarizes a new understanding of mental disorders, based on science and sensibility, and by
doing so, offers new hope that from the sum of our new understanding, people with mental
disorders will hope to live full and productive lives in their own communities. To realize this
hope, governments have a central role to bring about positive change in the acceptance and
treatment of mental disorders. The Report was written by a small group of WHO staff from the
Department of Mental Health and Substance Dependence led by Srinavasa Murthy from the
Indian National Institute of Mental Health, Bangalore and Derek Yach from WHO coordinated
the group. Contributions to the Report were received by 21 outstanding scientists from all over
the world (among them: Gavin Andrews, Leon Eisenberg, David Goldberg, Steve Hyman, Arthur
Kleinman and Norman Sartorius). More than 150 experts have provided inputs, comments and
advice at different stages of the preparation of the Report.
In focusing 2001 upon mental health, the message from WHO has been clear
and unequivocal: mental health - neglected for far too long - is crucial to the overall well-being
of individuals, societies and countries and must be universally regarded by governments and
health systems in a new light.
OVERVIEW OF TREATMENT APPROACHES TO MENTAL HEATHL PROBLEMS

1. PROVIDE TREATMENT IN PRIMARY CARE- The management and treatment of
mental disorders in primary care is a fundamental step which enables the largest
number of people to get easier and faster access to services – it needs to be recognized
that many are already seeking help at this level. This not only gives better care; it cuts
wastage resulting from unnecessary investigations and inappropriate and non-specific
treatments. For this to happen, however, general health personnel need to be trained in
the essential skills of mental health care. Such training ensures the best use of available
knowledge for the largest number of people and makes possible the immediate
application of interventions.
2. MAKE PSYCHOTROPIC DRUGS AVAILABLE- Essential psychotropic drugs should be
provided and made constantly available at all levels of health care. These medicines should be
included in every country’s essential drugs list, and the best drugs to treat conditions should be
made available whenever possible. In some countries, this may require enabling legislation
changes. These drugs can ameliorate symptoms, reduce disability, shorten the course of many
disorders, and prevent relapse. They often provide the first-line treatment, especially in
situations where psychosocial interventions and highly skilled professionals are unavailable.
3. GIVE CARE IN THE COMMUNITY- Community care has a better effect than institutional
treatment on the outcome and quality of life of individuals with chronic mental disorders.
Shifting patients from mental hospitals to care in the community is also cost-effective and
respects human rights. Mental. Health services should therefore be provided in the
community, with the use of all available resources. Community-based services can lead
to early intervention and limit the stigma of taking treatment. Large custodial mental
hospitals should be replaced by community care facilities, backed by general hospital
psychiatric beds and home care support, which meet all the needs of the ill that were
the responsibility of those hospitals.
4. EDUCATE THE PUBLIC -Public education and awareness campaigns on mental health
should be launched in all countries. The main goal is to reduce barriers to treatment and
care by increasing awareness of the frequency of mental disorders, their treatability, the
recovery process and the human rights of people with mental disorders. The care
choices available and their benefits should be widely disseminated so that responses
from the general population, professionals, media, policy-makers and politicians reflect
the best available knowledge. From the general population, professionals, media, policy-
makers and politicians reflect the best available knowledge.
5. INVOLVE COMMUNITIES, FAMILIES AND CONSUMERS- Communities, families
and consumers should be included in the development and decision-making of policies,
programmes and services. This should lead to services being better tailored to people’s
needs and better used. In addition, interventions should take account of age, sex,
culture and social conditions, so as to meet the needs of people with mental disorders
and their families.
CONCLUSION
The World Health Report 2001 is a unique collection of science, public health and ethics
which provides Member States with useful recommendations to translate science into
action and which, ultimately, will result in heightened awareness of mental health,
decreased stigma attached to mental disorders and a substantial reduction in the gap
existing today between those who receive treatment and those who do not.
Module 6,Unit 22: Perspectives on prevention, Biological and Psychosocial

Interventions, Rehabilitation
Perspectives on Prevention
Mental and behavioural disorders are not exclusive to any special group they are found in people of all
regions, all countries and all societies. About 15 million people suffer from mental disorders according to
estimate given in WHO's World Health report 2001. One person in four will develop one or more mental
or behavioral disorders during their lifetime. To reduce the health,social and economic burdens of mental
disorders it is essential that countries and regions pay greater attention to promotion and prevention in
mental health at the level of policy formulation, legislation, decision making and resource allocation within
the overall healthcare system. Mental ill health refers to mental health problems symptoms and disorders
including mental health strain and symptoms related to temporary or persistent distress. Preventive
interventions focus on ;
• Reducing risk factors

• Enhancing protective factors
Mental disorder prevention aims at “reducing incidence, prevalence, recurrence of mental disorders; the
time spent with the symptoms are the risk condition for a mental illness, preventing or delaying recurrences
and also decreasing the impact of illness in the affected person their families and the society”
There are three categories of prevention :-
• Primary prevention
• Secondary prevention
• Tertiary prevention
Primary prevention
Primary prevention focuses on various determinants in the whole population or in the high risk group. It
can be also told as a specific protection. This comprises measures applicable to a particular disease or group
of diseases in order to intercept their causes before they involve the individual in other words, to avoid the
occurrence of the condition Anti stigma campaigns such as mental health awareness week or mental health
literacy programmes. Within primary prevention there is three major prevention methods are included and
they are ;
1. Universal prevention
It is defined as those interventions that are targeted at the general public or to a whole population group that
has not been identified on the basis of increased risk.
2. Selective prevention
This targets individuals or subgroups of the population whose risk of developing a mental disorder is
significantly higher than average as evidence by biological, psychological or social risk factors.
3. Indicated prevention
This method targets high risk people who are identified as having minimal but detectable signs or symptoms
foreshadowing mental disorder or biological markers indicating predisposition for mental disorder but who
do not meet diagnostic criteria for disorder at that time.
Secondary prevention
Secondary prevention seeks to lower the rate of established cases of disorder or illness in the population
through early detection and treatment of diagnosable diseases. This provide a targeted help and support.
This type of prevention is often called selective or targeted prevention. In some cases disease may be
affected because of biological characteristics they are born with or experiences they have had. This supports
those who have experienced trauma or been victim of hate crime.
Tertiary prevention
Tertiary prevention supports those with mental health problems to stay well and have a good quality of life.
It includes interventions that reduce disability and enhance rehabilitation and prevent relapses and
recurrences of the illness. It aims to reduce symptoms that can be disabling, limit complications and
empower people experiencing problems to manage their own symptoms as much as possible. Tertiary
prevention is seen as distinct, but complementary to treatment for mental health problems. And is often
carried out in community rather than clinical settings. This tries to restore their previous situation or
maximizing the use of their remaining capacities. It comprises both interventions at the level of the
individual and modifications of the environment.
Some major preventive methods that improve mental health and reduce the risks for mental health disorders
• Parenting
• Meditation
• Internet and mobile based intervention
• Strengthening community networks
• Reducing economic insecurity
• Improving access to education
• Improving housing
• Improving nutrition
Biological and Psychosocial interventions
Biological Interventions
In biological interventions of mental health the interventions are took against the organic or physical cause
of a disorder. The focus of this method is on genetics, neurotransmitters, neurophysiology, neuroanatomy
etc. The treatments or the steps are done to cure the underlying problems in the brain and nervous system
in order to help alleviate symptoms of the disorder.
For example:- In cases of depression which is caused by chemical imbalance in brain and prescribe
antidepressant medications to help bring healthy balance of brain back.
In biological interventions biological tests and curative pharmacological treatments have prior importance.
Various biological factors can affect a mood and behaviour. These things have to be evaluated before
initiating further treatments. Dysfunction of the thyroid gland may lead to a major depressive episode, or
hyperglycemia or psychosis. While pharmacological treatments are used to treat many mental disorder,
other non drug biological treatments are used as well ranging from changes in diet and exercise to
transcranial magnetic stimulation and electroconvulsive therapy.
In cases of some mental health disorders it could be a side effect of a serious biological problem such as
Brain Tumor,hormonal abnormality which can be cured by medical or surgical interventions.
Psychosocial Interventions
Psychosocial interventions broadly defined as non pharmacological interventions focused on psychological
or social factors can improve symptoms ,functioning ,quality of life and social inclusion when used in the
treatment of people with mental health conditions. It can be also called as a therapeutic intervention which
address the psychological ,social ,personal ,relational and vocational problems associated with mental
health disorders. This deals with both primary and secondary symptoms.
There are different therapeutic models and techniques under psychosocial interventions including cognitive
behavioral therapy (CBT), Peer Support etc. This method is offered to a person who is experiencing mental
health difficulties and it will depend on a type of problem they are experiencing. It take an overview on a
person’s unique situation. The choice of selecting a therapy is supported through the evidence and findings
which support efficacy of the interventions.
The aim of psychosocial intervention is to promote support and maintain recovery by providing;
• Comprehensive and meaningful assessment and ensuring all elements of experience to promoting
and maintaining recovery
• Support which is meaningful and psychotherapeutic
• Psychological interventions which reduce distress
• Support to regain or develop skills which assist in self care and activities of daily life
• Support to consider educational and employment opportunities
• Psychological therapy to explore personal psychological vulnerabilities which leave a person open
to ongoing mental health problems.
Rehabilitation
Rehabilitation is the action of restoring someone to health or normal life through training and therapy after
addiction or illness.
Rehabilitation activities that involved targeted interventions to;
• Acquire and apply new skills

• Utilise supports in community
• Access resources required to live meaningful life in a community
Psychiatric rehabilitation is an aspect of treatment that focuses on helping the person return to an optimal
level of functioning and achieve their life goals. This is brought about by providing medical psychological
and social input. There is no strict boundary between treatment and rehabilitation.
People with severe and chronic psychiatric illness such as bipolar disorder and schizophrenia may be
mentally disabled by their condition and require rehabilitation to pick up basic skills.
In the case of disorder such as mental retardation a process of habilitation is followed to help patients learn
skills necessary for daily functioning.
The process of rehabilitation aims to help the patient develop the social and intellectual skills that they will
need to integrate with mainstream society. This helps person to find a meaningful role for themselves at
home and work. This supports the patient by providing opportunities preventing stigma and discrimination.
The rehabilitation process focus on:-
• Assessing what the person is capable of (their skills, strengths and abilities)
• Accepting the limitations caused by illness
With a thorough understanding of these aspects a trained professional is able to identify what
support the patient needs in order to get back to a

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Clinical Assessment and Diagnosis of Psychiatric Disorders

Some common features of phobia are;

Presence of feared object, situation or activity.

The fear is out of proportion to the dangerousness perceived.

Patient recognizes the fear as irrational and unjustified.

This leads to persistent avoidance of that particular object, situation or activity.

Some examples are, fear of blushing(erythrophobia), eating in company

Specific phobia is an example of irrational fear of objects or situations. It is characterised by an irrational

In phobia secondary defense mechanism is displacement . By using displacement , anxiety is transferred

attacks associated with phobias, there by decreasing distress.

It is recognised as one's own idea, impulse or image but is perceived as ego-alien.

It is recognised as irrational and absurd (insight is present).

Patient tries to resist against but it is unable.

An obsession is usually associated with compulsion. A compulsion is defined as:

A form of behavior which is usually follows obsessions.

The behaviour is not realistic and is either irrational or excessive.

Insight is present, so the patient realises the irrationality of compulsion.

The behaviour is performed with a sense of subjective compulsion.

Compulsions may diminish the anxiety associated with obsessions.

EPIDEMOLOGY,COURSE AND OUTCOME

Recent studies shows the lifetime prevalence of OCD to be as high as 2-3%

Predominantly obsessive thoughts or ruminations.

Predominantly compulsive acts

Mixed obsessional thoughts and acts.

Primary obsessive slowness

Obsession with need for symmetry or exactness

Ordering /arranging compulsions

Hoarding /collecting compulsions

Supportive psychotherapy is an important adjunct to other modes of treatment. It is also needed by

Behaviour therapy and cognitive behavioural therapy

Antipsychotics: These are occasionally used in low doses(eg; haloperidol,risperidol,

Prevalence of panic disorder

Etiology of panic disorder

• Palpitations, pounding heart or accelerated heart rate

Course and Outcome

• To help cope with and stop panic attacks

• Cognitive Behavioral Therapy

• Cognitive Behavioural Therapy

• Education about the disorder

• Interoceptive and in vivo exposure

Dept. of Social Work, St. Gregorios College of Social Science, Parumala 10 | P a g e

• Relaxation and breathing techniques

• Selective Serotonin Re-uptake Inhibitors

Dept. of Social Work, St. Gregorios College of Social Science, Parumala 11 | P a g e

1.2. Etiology of GAD

Dept. of Social Work, St. Gregorios College of Social Science, Parumala 12 | P a g e

1.2.3. Life Experiences

1.2.4. Societal Factors

1.2.5. Lifestyle Factors

Dept. of Social Work, St. Gregorios College of Social Science, Parumala 13 | P a g e

GAD is manifested by the following signs of motor tension, autonomic hyperactivity,

Psychological: - fearful anticipation, irritability, sensitivity to noise, restlessness, poor

• Gastrointestinal: dry mouth, difficulty in swallowing, epigastric discomfort, frequent

Dept. of Social Work, St. Gregorios College of Social Science, Parumala 14 | P a g e

1.4.Course And Outcome Of GAD

1.5. Treatment Modalities

Also known as talk therapy or psychological counselling, psychotherapy involves working

Dept. of Social Work, St. Gregorios College of Social Science, Parumala 15 | P a g e

• Antidepressants. Antidepressants, including medications in the selective serotonin reuptake

• Buspirone. An anti-anxiety medication called buspirone may be used on an ongoing basis.

• Benzodiazepines. In limited circumstances, doctor may prescribe a benzodiazepine for relief

1.5.3. Lifestyle and home remedies

Dept. of Social Work, St. Gregorios College of Social Science, Parumala 16 | P a g e

• A sense of being detached from yourself and your emotions