Mental Health

&
Mental Illness

Romina Shrestha
B.N. (Psychiatric Nursing), M.A. (Clinical Psychology), M.N. (Child Health Nursing)

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Mental health
 “…… the successful adaptation to stressors
from the internal or external environment,
evidenced by thoughts, feelings and
behaviors that are age appropriate and
congruent with the local and cultural norms”

(Townsend, 1996)

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Mental illness

 “…..maladaptive responses to stressors from

the internal and external environment,
evidenced by thoughts, feelings and
behaviors that are incongruent with the local
and cultural norms and interfere with the
individual’s social, occupational and/or
physical functioning.”

(Townsend, 1996)
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Classification of mental disorders
 ICD (international classification of mental and
behavioral disorder): by world health
organization(WHO)
 Published dates: 1949, 1955, 1968, 1978, 1994,
ICD-11 was accepted by WHO's World Health
Assembly (WHA) on 25 May 2019 and will come
into effect on 1 January 2022.
 DSM (diagnostic and statistical manual of
mental disorders): by American psychiatric
association (APA)
 Published dates: 1952, 1968, 1980, 1994, 2013
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ICD Classification
 F00-09: Organic, including symptomatic, mental
disorders
 F10-19: Mental and behavioural disorders due to use
of psychoactive substances
 F20-29: Schizophrenia, schizotypal and delusional
disorders
 F30-39: Mood [affective] disorders
 F40-49: Neurotic, stress-related and somatoform
disorders
 F50-59: Behavioural syndromes associated with
physiological disturbances and physical factors
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ICD Classification Conti….
 F60-69: Disorders of personality and behaviour
in adult persons
 F70-79: Mental retardation
 F80-89: Disorders of psychological
development
 F90-98: Behavioural and emotional disorders
with onset usually occurring in childhood and
adolescence
 F99:In addition, a group of "unspecified mental
disorders".
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Multiaxial assessment system
 Multiaxial assessment is a system or method
of evaluation, grounded in the
biopsychosocial model of assessment that
considers multiple factors in mental health
diagnoses
 Multiaxial diagnosis is characterized by five
axes in the current version of the Diagnostic
and Statistical Manual of Mental Disorders
(DSM-IV TR; American Psychiatric
Association, 2000). 
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Types of Axes By Disorder

 Axis I provided information about clinical disorders.

Any mental health conditions
 Axis II provided information about personality
disorders and mental retardation.
 Axis III provided information about any medical
conditions 
 Axis IV was used to describe psychosocial and
environmental factors affecting the person
 Axis V was a rating scale called the Global
Assessment of Functioning

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Differences between Psychosis and
Neurosis
1. Definition
2. Epidemiology
3. Etiology
4. Sign and symptoms
 General Behavior
 Social significance of symptoms
 Personality
 Insight
5. Self management
6. Treatment procedures
7. Outcome of treatment

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Mental Status Examination
 A mental status examination (MSE) is an
assessment of a patient's level of cognitive
(knowledge-related) ability, appearance,
emotional mood, and speech and thought
patterns at the time of evaluation. It is one
part of a full neurological (nervous system)
examination and includes the examiner's
observations about the patient's attitude and
cooperativeness as well as the patient's
answers to specific questions.
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Purpose
 The MSE is an important part of the
differential diagnosis of psychiatric
symptoms or disorders.
 The MSE results may suggest specific areas
for further testing or specific types of
required tests.
 A mental status examination can also be
given repeatedly to monitor or document
changes in a patient's condition

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Precautions
 A MSE cannot be given to a patient who
cannot pay attention to the examiner, for
example as a result of being in a coma or
unconscious; or is completely unable to
speak (aphasic); or is not fluent in the
language of the examiner.

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Preparation

 Preparation for a mental status examination

includes a careful medical and psychiatric
history of the patient. The history helps the
examiner to interpret the patient's
appearance and answer with greater
accuracy.

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Description/ Components
1. General appearance and behavior
2. Talk or speech
3. Mood
4. Thought
5. Perception
6. Orientation
7. Concentration and attention
8. Memory
9. Intelligence
10. Judgment
11. General fund of knowledge
12. Insight
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General appearance and behavior
 a. Appearance
 person's age, race, sex, civil status, nutritional
status, personal hygiene or grooming
 b. Attitude toward the examiner
/Movement and behavior
 person's gait (manner of walking), posture,
psycho-motor coordination, eye contact, facial
expressions, and similar behavior

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General appearance and behavior
 Clinical implication
 Appearance
 Hygienic and well groomed look reflect
someone’s ability to care for himself.
 Unkempt appearance suggests schizophrenia.
 Flamboyant look suggests mania.
 A careless or indifferent look suggest
depression or substance abuse.

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General appearance and behavior
 Clinical implication:
 Behavior
 Agitation suggests mania, schizophrenia,
anxiety, stimulant use, alcohol or drug
withdrawl.
 Fine and coarse tremors can indicate anxiety,
alcohol withdrawl.
 Motor retardation suggests catatonia,
depression or parkinson’s disease.
 Extrapyramidal symptoms, Akathisia, Akinesia,
Dyskinesia etc all suggest antipsychotic side
effect.
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2. Talk or speech
 patient's speech, including quality, quantity,
rate, and volume of speech during the
interview
 Some things to keep in mind during the
interview are whether patients raise their
voice when responding, whether the replies
to questions are one-word answers or
elaborative, and how fast or slow they are
speaking

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Talk or speech
 Clinical implication:
 Mutism usually suggests schizophrenia, or
depression.
 Aphasia suggests dementia.
 Unusual use of words (eg. Echolalia,
perseveration, neologism, word salad etc)
suggests schizophrenia or organic mental
disorder.

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3. Mood
 a. Mood (subjective)
 "sustained emotion that the patient is
experiencing"
 b. Affect (objective)
 “person's outwardly observable emotional
reactions”
 is defined in the following terms: expansive
(contagious), euthymic (normal), constricted
(limited variation), blunted (minimal variation), and
flat (no variation)
Clinical implication: - Whether the subjective and
objective moods are congruent or not is noted.
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4. Thought
 Thought should be goal directed, coherent
and responsive to stimuli.
 a. Thought formation
 b. Thought process/ progression
 c. Thought content
 d. Abstract thought

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a. Thought formation
 Describe whether the formulated thought is
autistic (characterized by withdrawal of the
individual into the self and into the fantasy
world of his/her own creation) or realistic.

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b. Thought process/ progression
 refers to the logical connections between
thoughts and their relevance to the main
thread of conversation
 Clinical implication:
 Cicumstantiality suggests schizophrenia, or
organic psychosis.
 Tangentiality suggests schizophrenia.
 Flight of ideas suggests mania.
 Looseness of association suggests schizophrenia.

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c. Thought content
 assesses what the patient is saying for
indications of delusions, obsessions, or
thoughts of suicide etc

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 Clinical implications:
 Delusions
 Delusion of persecution/ grandeur suggest
schizophrenia, mania, stimulant intoxication etc.
 Delusion of guilt suggests psychotic depression.
 Delusion of partner’s infidelity suggests paranoid
disorder.
 Ideas of reference suggests schizophrenia or
chronic stimulant abuse.

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Clinical implications continue…
 Obsessions suggest obsessive disorders.
 Suicidal, as well as, homicidal thoughts
suggest depression, personality disorder,
alcoholism or psychosis.

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d. Abstract thought
 ability to determine similarities
 ability to understand proverbs

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5. Perception

 Document information on all aspects of the

patient's illusion (i.e. false perception),
hallucination (i.e. perception without
stimulation) and other perceptual
abnormalities

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Perception
 Clinical implications:
 Illusions suggest organic psychosis.
 Hallucinations
 Auditory is more common in schizophrenia and
alcohol withdrawl.
 Visual suggests delirium, alcohol/ drug withdrawl
or intoxication.
 Tactile suggests delirium or chronic stimulant
abuse.
 Olfactory and gustatory suggest epilepsy.

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6 Orientation
 (ability to locate himself or herself) with
regard to time, place, and personal identity
 Clinical implication:
 Defect in one or more suggest delirium,
dementia or drug intoxication.

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7. Attention and Concentration
 Attention
 Selective perception
 Concentration
 Sustained attention
 Clinical implication:
 Defect in one or more suggest delirium,
dementia or drug intoxication.

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8 Memory
 Immediate (5-10)mins
 Recent (24-72)hrs
 Remote (significant past)
 Clinical implication:
 Demented patients have trouble with recent
memory.
 Delirious patients have more global memory
deficit.

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9 Intelligence

 Global mental ability

 Based on the information provided by the
patient throughout the interview, estimate the
patient's intelligence quotient (i.e., below
average, average, above average)
 Clinical implication:
 Poor Intelligence is indicative in mental
retardation.

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10 Judgment

 Estimate the patient's judgment based on the

history or on an imaginary scenario
 Clinical implication:
 To test awareness of a psychological problem.

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11 General fund of knowledge
 higher number of correct answers is better
 interviewer always should take into
consideration the patient's educational
background and other training in evaluating
answers and assigning scores

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12 Insight
 Patient’s understanding of the illness
 Clinical implication:
 Missing insight suggest psychosis.

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Insight
 On mental status examination, patient expresses awareness
for being sick but blames others. His “insight” falls into
the following grade:
a. Grade 1(Complete denial)
b. Grade 2(Awareness of being sick but denying at the same
time)
c. Grade 3 (Awareness of being sick but blaming it on others,
external factors, or medical or unknown organic factors)
d. Grade 4 (Intellectual insight)
e. Grade 5 (True emotional insight)

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