MENTAL HEALTH

BY
TALEMWA AUSI
 Introduction
 Mental health: “Is the successful adaptation to stressors
from the internal or external environment, evidenced by
thoughts, feelings, and behaviors that are age-appropriate
and congruent with local and cultural norms.”
 Mental illness: “Maladaptive responses to stressors from
the internal or external environment, evidenced by
thoughts, feelings, and behaviors that are incongruent
with the local and cultural norms, and that interfere with
the individual’s social, occupational, and/or physical
functioning.”
 Magnitude of Mental Illness
• Mental health problems affect society as a whole,
and not just a small, isolated segment.
• They are therefore a major challenge to global
development.
• No group is immune to mental disorders, but the
risk is higher among the poor, homeless, the
unemployed, persons with low education, victims of
violence, migrants and refugees, indigenous
populations, children and adolescents, abused
women and the neglected elderly
 Magnitude cont’d
• WHO estimates about 450 million people world wide
have mental illness
• One in four people in the world will be affected by
mental or neurological disorders at some point in their
lives
• Placing mental disorders among the leading causes of ill-
health and disability worldwide
• In Uganda, Statistics show that close to 20% (6.8
million) out of the 34 million people in Uganda have
some degree of mental illness, ranging from anxiety and
depression to severe madness May 12, 2012
Classification of Mental illnesses
• Psychoses: Severe mental illnesses
characterized by loss of touch with reality,
disruption of relationships with other people.
• Neuroses: Neurosis refers to a mild mental
disorder where a patient maintains touch with
reality.
Organic Vs Functional Psychoses
 Organic psychoses are characterized by
abnormal brain function that is caused by a
known physical abnormality, which in most
cases is some organic disease of the brain.
Functional psychoses were believed to have
no physical brain disease evident upon clinical
examination.
• Much research suggests that this distinction
between organic and functional is probably
inaccurate.
 Causes of Mental Illness
 Not much is known about the actual cause of
mental illnesses
 There are factors that are thought to

contribute to the development of mental illness

divided into:
 Pre disposing (intrinsic / in born) factors
 Precipitating / environmental / extrinsic

factors
 Pre disposing factors
 These operate within the individual making him/her
vulnerable to developing mental illness
 Genetic factors
 Life in utero e.g. infections and drugs that cross the

placenta
 Biochemical factors e.g. neurotransmitters (dopamine,

serotonin etc)
 Personality: Sum total of physical, mental and social

characteristics of an individual that make him unique from

others
 Age and sex: Some mental illnesses are common in a

particular age and sex of an individual

 Precipitating factors
 These occur before development of mental
illness e.g.
 Faulty child upbringing
 Physical stresses on the body
 Psychological stresses
 Marriage and its problems
 Prevention of Mental illness
• Primary level
 Aims at reducing the incidence of mental disorders in individuals, families
and communities by:
 Reducing infections

 Ensuring proper maternal and child health services

 Proper nutrition

 Avoid alcohol and drug abuse

 Support of people with chronic illnesses

 Good health seeking behaviors

 Genetic counseling

 Focus on vulnerable groups

 Monitoring child growth and development

 The tool of primary prevention is health education
 Secondary level
 Aims at reducing the duration of mental illness
by:
 Early recognition of symptoms and signs of

mental illness, diagnosis and treatment

 Periodic screening of vulnerable populations
 Monitor patients already identified and on

treatment
 Appropriate referral of identified cases
 Counseling of identified patients
 Tertiary level
 Aims at reducing occurrence of disability due to mental
illness through rehabilitation by:
 Identify and link patients to supportive groups such as S/Z

groups, AA and Epilepsy support groups

 Foster a realistic attitude to wards the mentally ill
 Psychiatric patients should continue taking medications as

prescribed
 Follow up visits for patients either in the hospital or in their

homes
 Discourage use of alcohol and other substances
 Prevent institutionalisation
 General Symptomatology
 Study of signs and symptoms of mental illness
• General appearance and behavioor
o Motor disturbance / will power / volition: description
of patient’s movements which include:
 Tics: irregular repeated movements involving a group of
muscles
 Stereotypes: repeated regular movements without
significance
 Negativism: doing opposite of what is expected
 Echopraxia: imitation of movements of the interviewer
 Cont’d
• Posturing: voluntary assumption of abnormal posture
• Mannerism: repeated movements or actions that seem to
have significance to the patient.
o Disorders of mood / affect and emotion:
• Mood is inner feeling as expressed by the individual
• Affect is facial expression of a person / patient.
 Apathy: reduced emotional feelings
 Depression: abnormal degree of unhappiness
 Anxiety: feelings of tension, worry and fear
 Incongruity of affect: emotions opposite of the stimuli
 Disorders of thinking
• Thinking of mental patients is disturbed in three ways:
1. Stream of thought: this refers to how ideas flow:
• Pressure of thought: patient has abundant ideas
manifested through talking rapidly
• Flight of ideas: patient rapidly shifts from one idea to
another or from topic to topic
• Poverty of thought: patient has scarcity of thoughts
and ideas
• Thought block: patient suddenly gets blank and looses
truck in thinking
2. Form of thought: how ideas are connected and related to
one another.
• Neologisms: patient uses words only known to him / her
• Circumstantiality: client eventually answers a question but only
after giving excessive unnecessary detail
• Loosening of association: there is lack of connection
between ideas
• Perseveration: repetitive utterances of same words
irrespective of the question
• Word salad: mixing word that do not bring a clear
meaning
3. Thought content (delusions): false belief firmly held by the patient,
cannot be corrected by rational means and it is not in keeping with the
patient’s educational and cultural back ground. Examples:
• Grandiosity: patient believes s/he is of great importance
• Nihilistic delusions: false belief that there is a non existence of his
body, part of his body is not his etc.
• Unworthiness: belief that s/he is not worth to live.
• Hypochondriasis: patient believes that s/he has an incurable
disease despite evidence to the contrary.
• Paranoid: having trust in no body
• Depersonalization: belief that the body has changed
• De-realization: belief that world has changed
 Other delusions
• Thought broadcasting: this is a belief that the
patients thoughts are known before being
spoken.
• Thought withdraw: a belief that thoughts are
removed from the patient.
• Thought insertion: thoughts / ideas are put in
the patient to be spoken.
 Disorders of perception
• Perception is the process of becoming aware
of the environment.
• Two types of disorders of perception
1. Illusions: misinterpretation of the external
stimuli
2. Hallucinations: perception without external
stimuli
 Examples of hallucinations
• Auditory hallucinations: patient hears voices that
do not exist
• Visual hallucinations: patient sees objects that are
not there
• Gustatory hallucinations: patient tastes something
abnormal like poison
• Olfactory hallucinations: abnormal smell probably
in food, drinks, environment
• Tactile / somatic hallucination: patient feels insects
crawling over their bodies.
 Disorders of Speech
• Mutism: absence of speech
• Neologisns: words spoken but only
understood by the patient
• Echolalia: repetition of words of the
interviewer
• Incoherent speech: lack of logical order and
relationship in what the patient says.
 Disorders of Sleep (Insomnia,
Sleeplessness)
• Initial insomnia: Patient fails to sleep during the early
hours of the night
• Total / absolute / complete insomnia: no sleep all night
• Interrupted sleep: sleep disturbed by dreams or night
mares
• Inverted rhythm of sleep: patient remains awake at
night and sleeps during the day
• Terminal insomnia: pt sleeps early and wakes up early
• Narcolepsy: irresistible urge to sleep
• Somnambulism: sleep walking
 ORIENTATION

• Orientation refers to the client’s recognition of person,

place, and time; that is, knowing who and where he or she
is and the correct day, date, and year.
• Absence of correct information about person, place, and
time is referred to as disorientation
• The order of person, place, and time is significant.
• When a person is disoriented, he or she first loses track of
time, then place, and lastly person.
• Orientation returns in the reverse order: first, the person
knows who he or she is, then realizes place, and finally
time.
 Abstract thinking and Intellectual
abilities
• When assessing intellectual functioning, consider the client’s
level of formal education
• Assesses the client’s ability to use abstract thinking, which is to
make associations or interpretations about a situation or comment
• Ask the client to interpret a common proverb such as “a stitch in
time saves nine.”
• If the client can explain the proverb correctly, his or her abstract
thinking abilities are intact.
• Ask him or her to identify the similarities between pairs of
objects: for example, “What is similar about an apple and an
orange?” or “What do the newspaper and the television have in
common?”
 Judgment and Insight
• Judgment refers to the ability to interpret one’s environment
and situation correctly and to adapt one’s behavior and
decisions accordingly
• Assess a client’s judgment by asking the client hypothetical
questions such as, “If you found a stamped, addressed envelope
on the ground, what would you do?”
• Insight is the ability to understand the true nature of one’s
situation and accept some personal responsibility for that
situation.
• Can the client his strengths and weaknesses for his behaviours?
• Poor insight would be a client who places blame on others for
his / her behaviors
 Psychiatric Diagnoses

• Diagnostic and Statistical Manual of Mental Disorders,

Text Revision, fourth edition (DSM-IV-TR).
• This taxonomy is universally used by psychiatrists and
some therapists in the diagnosis of psychiatric illnesses.
• The DSM-IV-TR classifies mental disorders into
categories.
• It describes each disorder and provides diagnostic
criteria to distinguish one from another
• The DSM-IV-TR uses a multi-axial system to provide
the format for a complete psychiatric diagnosis:
• Axis I:clinical disorders, other conditions that may be
a focus of clinical attention
• Axis II: personality disorders, mental retardation
• Axis III: general medical conditions
• Axis IV: psychosocial and environmental problems
• Axis V: global assessment of functioning (GAF)
 Eating Disorders
• Anorexia nervosa is a life-threatening eating disorder
characterized by the client’s refusal or inability to
maintain a minimally normal body weight, intense
fear of gaining weight or becoming fat, significantly
disturbed perception of the shape or size of the body,
and steadfast inability or refusal to acknowledge the
seriousness of the problem or even that one exists.
• More than 90% of cases of anorexia nervosa and
bulimia occur in females (American Psychiatric
Association [APA], 2000).
 Eating disorders cont’d
• Clients with anorexia have a body weight that is 85% less than
expected for their age and height, have experienced amenorrhea
for at least three consecutive cycles, and have a preoccupation
with food and food-related activities.
• Anorexia nervosa can be classified into two subgroups depending
on how clients control their weight:
 Clients with the restricting subtype lose weight primarily
through dieting, fasting, or excessively exercising
 Those with binge eating sub type followed by purging through
vomiting, use of laxatives etc
• Clients with anorexia become totally absorbed in their quest for
weight loss and thinness.
 Eating disorders cont’d
• Bulimia Nervosa often simply called bulimia, is an
eating disorder characterized by recurrent episodes (at
least twice a week for 3 months) of binge eating followed
by inappropriate compensatory behaviors to avoid weight
gain such as purging.
• The amount of food consumed during a binge episode is
much larger than a person would normally eat.
• The client often engages in binge eating secretly
• Bulimia nervosa usually begins in late adolescence or
early adulthood; 18 or 19 years is the typical age of onset
• A specific cause for eating disorders is unknown.
• Studies of anorexia nervosa and bulimia nervosa have
shown that these disorders tend to run in families.
 Sexual / Paraphilic Disorders
• The term paraphilia is used to identify repetitive or
preferred sexual fantasies or behaviors that involve
• Non human objects,
• Suffering or humiliation of oneself or one’s partner,
or
• Non consenting persons (Black & Andreasen, 2011).
 Epidemiological Statistics

• Relatively limited data exist on the prevalence or course of

paraphilic disorders.
• Most available information has been obtained from studies
of incarcerated sex offenders.
• Another source of information has been from outpatient
psychiatric services for individuals with paraphilic
disorders outside the criminal justice system.
• Data suggest that most people with paraphilic disorders
who seek outpatient treatment do so for pedophilic disorder
(45 percent), exhibitionistic disorder (25 percent), or
voyeuristic disorder (12 percent).
 Types of Paraphilic Disorders

• The following types of paraphilic disorders are identified

by the DSM-5:
 Exhibitionistic disorder is characterized by recurrent and
intense sexual arousal of one’s genitals to an unsuspecting
individual (APA, 2013).
 Fetishistic disorder involves recurrent and intense sexual
arousal from the use of either non-living objects or
specific non-genital body part(s) (APA, 2013).
• A common sexual focus is on objects intimately
associated with the human body (e.g., shoes, gloves,
stockings)
 Frotteuristic disorder is the recurrent and intense
sexual arousal involving touching or rubbing against a
non consenting person (APA, 2013).
 Pedophilic disorder is sexual arousal from
prepubescent or early pubescent children equal to or
greater than that derived from physically mature
persons.
 Sexual masochism disorder is recurrent and intense
sexual arousal from the act of being humiliated, beaten,
bound, or otherwise made to suffer (APA, 2013)
 Sexual sadism disorder is recurrent and intense sexual
arousal from the physical or psychological suffering of
another individual (APA, 2013).
 Transvestic disorder involves recurrent and intense
sexual arousal from dressing in the clothes of the
opposite gender
 Voyeuristic disorder is identified by recurrent and
intense sexual arousal involving the act of observing an
unsuspecting individual who is naked, in the process of
disrobing, or engaging in sexual activity (APA, 2013).
 Personality disorders
• Black and Andreasen (2011) define personality as “the
characteristic way in which a person thinks, feels, and behaves;
the ingrained pattern of behavior that each person evolves, both
consciously and unconsciously, as his or her style of life or way
of being”.
• Personality: The combination of character, behavioral,
temperamental, emotional, and mental traits that are unique to
each specific individual.
• Personality disorders are diagnosed when personality traits
become inflexible and maladaptive and significantly interfere
with how a person functions in society or cause the person
emotional distress.
 Diagnosis of PDs
• Diagnosis is made when the person exhibits enduring behavioral
patterns that deviate from cultural expectations in two or more of
the following areas:
 Ways of perceiving and interpreting self, other people, and
events (cognition)
 Range, intensity, lability, and appropriateness of emotional
response (affect)
 Interpersonal functioning
 Ability to control impulses or express behavior at the appropriate
time and place (impulse control)
• Personality disorders are relatively common occurring in 10% to
13% of the general population.
 Cluster A personality disorders
 Paranoid personality disorder is characterized by pervasive
mistrust and suspiciousness of others.
• Clients with this disorder interpret others’ actions as potentially
harmful.
• Incidence is estimated to be 0.5% to 2.5% of the general
population; the disorder is more common in men than in
women.
 Schizoid personality disorder is characterized by a pervasive
pattern of detachment from social relationships and a restricted
range of emotional expression in interpersonal settings.
• It occurs in approximately 0.5% to 7% of the general
population and is more common in men than in women.
 Schizotypal personality disorder is characterized by
a pervasive pattern of social and interpersonal deficits
marked by acute discomfort with and reduced
capacity for close relationships as well as by
cognitive or perceptual distortions and behavioral
eccentricities.
• Incidence is about 3% to 5% of the population; the
disorder is slightly more common in men than in
women.
 Cluster B PDs
• Antisocial personality disorder is characterized by a
pervasive pattern of disregard for and violation of the
rights of others and with the central characteristics of
deceit and manipulation.
• This pattern also has been referred to as psychopathy,
sociopathy, or dyssocial personality disorder.
• It occurs in about 3% of the general population and is
three to four times more common in men than in
women.
• Borderline personality disorder is characterized by a
pervasive pattern of unstable interpersonal relationships,
self-image, and affect as well as marked impulsivity.
• About 2% to 3% of the general population has borderline
personality disorder; it is five times more common in those
with a first-degree relative with the diagnosis.
• Borderline personality disorder is the most common
personality disorder found in clinical settings.
• It is three times more common in women than in men.
• Histrionic personality disorder is characterized by a
pervasive pattern of excessive emotionality and
attention-seeking. It occurs in 2% to 3% of the
general population and 10% to 15% of the clinical
population.
• It is seen more often in women than in men. Clients
usually seek treatment for depression, unexplained
physical problems, and difficulties in relationships
• Narcissistic personality disorder is characterized by
a pervasive pattern of grandiosity (in fantasy or
behavior), need for admiration, and lack of empathy.
• It occurs in 1% to 2% of the general population and
2% to 16% of the clinical population.
• Fifty percent to 75% of people with this diagnosis are
men.
 Class C PDs
• Avoidant personality disorder is characterized by a
pervasive pattern of social discomfort and reticence,
low self-esteem, and hypersensitivity to negative
evaluation.
• It occurs in 0.5% to 1% of the general population and
10% of the clinical population.
• It is equally common in men and women.
• Dependent personality disorder is characterized by
a pervasive and excessive need to be taken care of,
which leads to submissive and clinging behavior and
fears of separation.
• These behaviors are designed to elicit caretaking
from others.
• The disorder occurs in as much as 15% of the
population and is seen three times more often in
women than in men.
• Obsessive-compulsive personality disorder is
characterized by a pervasive pattern of preoccupation
with perfectionism, mental and interpersonal control,
and orderliness at the expense of flexibility, openness,
and efficiency.
• It occurs in about 1% to 2% of the population,
affecting twice as many men as women.
 Others
• Depressive personality disorder is characterized by
a pervasive pattern of depressive cognitions and
behaviors in various contexts.
• It occurs equally in men and women and more often
in people with relatives who have major depressive
disorders.
• People with depressive personality disorders often
seek treatment for their distress and generally have a
favorable response to antidepressant medications
• Passive-aggressive personality disorder is
characterized by a negative attitude and a pervasive
pattern of passive resistance to demands for adequate
social and occupational performance.
• It occurs in 1% to 3% of the general population and
in 2% to 8% of the clinical population.
• It is thought to be slightly more prevalent in women
than in men
 Assessing a Mental Patient
• Assessment is the first involves the collection,
organization, and analysis of information about the
client’s health.
• In psychiatric mental health setting, this process is often
referred to as a psychosocial assessment, which includes a
mental status examination.
• The purpose of the psychosocial assessment is to
construct a picture of the client’s current emotional state,
mental capacity, and behavioral function.
• This assessment serves as the basis for developing a plan
of care to meet the client’s needs.
 Content of Assessment
• History
• General appearance and motor behavior
• Mood and affect
• Thought process and content
• Sensorium and intellectual processes
• Judgment and insight
• Self-concept
• Roles and relationships
• Physiologic and self-care concerns
 Common Mental Disorders
 Schizophrenia
• The psychotic illness later known as schizophrenia was
first described by Kraepelin late 19th century
• He utilized the existing term dementia praecox
• In 1911, Bleuler coined the term schizophrenia to
better describe the patients Kraepelin had been treating
• Schizophrenia comes from two Greek words that mean
‘‘split mind’’ and describes the splitting apart of mental
functions that Bleuler regarded as the central
characteristic of schizophrenia
• Schizophrenia, or ‘‘schizophrenic’’ in lay usage,
denotes a split personality or ‘‘one who has
simultaneously opposing thoughts.’’
• Bleuler did intend to emphasize that the ‘‘schiz’’ in
schizophrenia was a split, but not one in personality,
rather ‘‘a split in the meaning and emotion of one’s
thoughts and behaviors’’
• Bleuler also described the ‘‘Four As’’ (autism,
attention, affect, and association) as abnormalities that
are observed in many patients with schizophrenia.
• Bleuler’s Four As are now combined to describe the
negative symptoms of schizophrenia
• Positive symptoms mainly describe psychotic
symptoms and originally were not a prominent part of
either Kraepelin’s or Bleuler’s descriptions of the
illness
• Later in the 1950s, the German psychiatrist Schneider
(1959) published his ‘‘First Rank Symptoms’’ of
schizophrenia, emphasizing ‘‘positive’’ symptoms
that he considered pathognomonic for the illness
 Epidemiology of S/Z
• Schizophrenia is a relatively common illness.
• It affects approximately 1% of the worldwide population
at any given time.
• Owing to the chronic nature of the illness, those afflicted
stay afflicted, leading to an ever-growing population.
• Schizophrenia can theoretically manifest itself at any
age, with the most common time of presentation in late
adolescence or early adulthood.
• Men and women are considered to be equally affected,
but women tend to be diagnosed at a slightly older age.
 Types of S/Z
• The following are the types of schizophrenia
according to the DSM-IV-TR (APA, 2000).
• The diagnosis is made according to the client’s
predominant symptoms:
• Schizophrenia, paranoid type: characterized by
persecutory (feeling victimized or spied on) or
grandiose delusions, hallucinations, and, occasionally,
excessive religiosity (delusional religious focus) or
hostile and aggressive behavior
• Schizophrenia, disorganized type: characterized by grossly
inappropriate or flat affect, incoherence, loose associations, and
extremely disorganized behavior
• Schizophrenia, catatonic type: characterized by marked
psychomotor disturbance, either motionless or excessive motor
activity.
• Motor immobility may be manifested by catalepsy (waxy
flexibility) or stupor.
• Excessive motor activity is apparently purposeless and is not
influenced by external stimuli.
• Other features include extreme negativism, mutism, peculiarities
of voluntary movement, echolalia, and echopraxia.
• Schizophrenia, undifferentiated type: characterized by
mixed schizophrenic symptoms (of other types) along
with disturbances of thought, affect, and behavior
• Schizophrenia, residual type: characterized by at least
one previous, though not a current, episode; social
withdrawal; flat affect; and looseness of associations
• Schizoaffective disorder is diagnosed when the client
has the psychotic symptoms of schizophrenia and meets
the criteria for a major affective or mood disorder.
• The mood disorder can be mania, depression, or mixed
moods.
 Etiology of S/Z
• Whether schizophrenia is an organic disease with underlying physical
brain pathology has been an important question for researchers and
clinicians for as long as they have studied the illness.
• Newer scientific studies began to demonstrate that schizophrenia results
from a type of brain dysfunction.
• In the 1970s, studies began to focus on possible neurochemical causes,
which remain the primary focus of research and theory today.
• These neurochemical/neurologic theories are supported by the effects of
antipsychotic medications, which help to control psychotic symptoms,
and neuroimaging tools such as computed tomography, which have
shown that the brain of people with schizophrenia differs in structure
and function from the brain of control subjects.
 Biologic Theories
 Genetic Factors
• Most genetic studies have focused on immediate families (i.e.,
parents, siblings, and offspring) to examine whether
schizophrenia is genetically transmitted or inherited.
• Few have focused on more distant relatives.
• The most important studies have centered on twins; these
findings have demonstrated that identical twins have a 50% risk
for schizophrenia; that is, if one twin has schizophrenia, the
other has a 50% chance of developing it as well.
• Fraternal twins have only a 15% risk
• This finding indicates that schizophrenia is at least partially
inherited.
 Neuroanatomic and Neurochemical Factors
• With the development of noninvasive imaging techniques
such as computed tomography, magnetic resonance
imaging, and positron emission tomography in the past 25
years, scientists have been able to study the brain structure
(neuroanatomy) and activity (neurochemistry) of people
with schizophrenia.
• Findings have demonstrated that people with schizophrenia
have relatively less brain tissue and cerebrospinal fluid than
those who do not have schizophrenia this could represent a
failure in the development or a subsequent loss of tissue.
 TREATMENT
• Psychopharmacology
• The primary medical treatment for schizophrenia is
psychopharmacology.
• In the past, electroconvulsive therapy, insulin shock therapy,
and psychosurgery were used, but since the creation of
chlorpromazine (Thorazine) in 1952, other treatment modalities
have become all but obsolete.
• Antipsychotic medications, also known as neuroleptics, are
prescribed primarily for their efficacy in decreasing psychotic
symptoms.
• They do not cure schizophrenia; rather, they are used to manage
the symptoms of the disease.
 MOOD DISORDERS
• Mood disorders, also called affective disorders, are
pervasive alterations in emotions that are manifested by
depression, mania, or both.
• They interfere with a person’s life, plaguing him or her
with drastic and long-term sadness, agitation, or elation.
• Accompanying self-doubt, guilt, and anger alter life
activities especially those that involve self-esteem,
occupation, and relationships.
• Mood disorders are the most common psychiatric
diagnoses associated with suicide; depression is one of the
most important risk factors for it
 CATEGORIES OF MOOD
DISORDERS
• The primary mood disorders are major depressive
disorder and bipolar disorder (formerly called
manic depressive illness).
 A major depressive episode lasts at least 2 weeks,
during which the person experiences a depressed
mood or loss of pleasure in nearly all activities.
• In addition, four of the following symptoms are present:
changes in appetite or weight, sleep, or psychomotor activity;
decreased energy; feelings of worthlessness or guilt; difficulty
thinking, concentrating, or making decisions; or recurrent
thoughts of death or suicidal ideation, plans, or attempts.
• These symptoms must be present every day for 2 weeks and
result in significant distress or impair social, occupational, or
other important areas of functioning (American Psychiatric
Association [APA], 2000).
• Some people also have delusions and hallucinations; the
combination is referred to as psychotic depression
 Bipolar disorder is diagnosed when a person’s mood
cycles between extremes of mania and depression (as
described above).
• Mania is a distinct period during which mood is
abnormally and persistently elevated, expansive, or
irritable.
• The period lasts 1 week (unless the person is
hospitalized and treated sooner).
• At least three of the following symptoms accompany
the manic episode: inflated self-esteem or
grandiosity; decreased need for sleep; pressured
speech (unrelenting, rapid, often loud talking without
pauses); flight of ideas (racing thoughts, often
unconnected); distractibility; increased involvement
in goal-directed activity or psychomotor agitation;
and excessive involvement in pleasure-seeking
activities with a high potential for painful
consequences (APA, 2000).
 Etiology
• Chemical biologic imbalances triggered by
stressors serotonin and norepinephrine as the two
major biogenic amines implicated in mood disorders
• Genetic vulnerability in first degree relatives
• Hormonal fluctuations are being studied in relation to
depression. Mood disturbances have been
documented in people with endocrine disorders such
as those of the thyroid, adrenal, parathyroid, and
pituitary
 MAJOR DEPRESSIVE DISORDER

• Major depressive disorder typically involves 2 or more

weeks of a sad mood or lack of interest in life activities
with at least four other symptoms of depression such as
anhedonia and changes in weight, sleep, energy,
concentration, decision-making, self-esteem, and goals.
• Major depression is twice as common in women and
has a 1.5 to 3 times greater incidence in first-degree
relatives than in the general population.
• Incidence of depression decreases with age in women
and increases with age in men
 Onset and Clinical Course

• An untreated episode of depression can last 6 to 24

months before remitting.
• Fifty to sixty percent of people who have one episode
of depression will have another.
• After a second episode of depression, there is a 70%
chance of recurrence.
• Depressive symptoms can vary from mild to severe.
 Treatment and Prognosis

• PSYCHOPHARMACOLOGY
• Major categories of antidepressants include cyclic
antidepressants, monoamine oxidase inhibitors
(MAOIs), selective serotonin reuptake inhibitors
(SSRIs), and atypical anti-depressants
 BIPOLAR DISORDER

• Bipolar disorder involves extreme mood swings from

episodes of mania to episodes of depression
• During manic phases, clients are euphoric grandiose,
energetic, and sleepless.
• They have poor judgment and rapid thoughts, actions, and
speech.
• During depressed phases, mood, behavior, and thoughts
are the same as in people diagnosed with major depression
• Bipolar disorder occurs almost equally among men and
women
 Onset and Clinical Course

• The mean age for a first manic episode is the early

20s, but some people experience onset in adolescence
while others start older than 50 years
• Manic episodes typically begin suddenly with rapid
escalation of symptoms over a few days and they last
from a few weeks to several months.
• They tend to be briefer and to end more suddenly
than depressive episodes.
• The diagnosis of a manic episode or mania requires at
least 1 week of unusual and incessantly heightened,
grandiose, or agitated mood in addition to three or
more of the following symptoms: exaggerated self-
esteem; sleeplessness; pressured speech; flight of
ideas; reduced ability to filter extraneous stimuli;
distractibility; increased activities with increased
energy; and multiple, grandiose high-risk activities
involving poor judgment and severe consequences
such as spending sprees, sex with strangers, and
impulsive investments
 Treatment

• PSYCHOPHARMACOLOGY
• Treatment for bipolar disorder involves a lifetime
regimen of medications: either an anti manic agent
called lithium or anticonvulsant medications used as
mood stabilizers
• PSYCHOTHERAPY
• Psychotherapy can be useful in the mildly depressive or
normal portion of the bipolar cycle.
• It is not useful during acute manic stages because the
person’s attention span is brief and he or she can gain
little insight during times of accelerated psychomotor
activity
• Psychotherapy combined with medication can reduce the
risk of suicide and injury, provide support to the client
and family, and help the client to accept the diagnosis and
treatment plan
 DELIRIUM
• Delirium is an abrupt-onset type of confusional state
marked by the following:
1. Fluctuations in level of confusion
2. Inability to pay attention during interactions
3. Disorganized thinking
4. Changes in consciousness
5. Agitation or quiet and hypoactive behavior (such as
quickly falling back to sleep)
• Hallucinations and illusions are common.
Etiology
 Signs of Delirium

• Detecting delirium involves examining how the

person thinks (cognition), as well as the ability to
pay attention, degree of wakefulness, and
psychomotor behavior.
 Cognition
• The three components of cognition: perception, thinking,
and memory are all disrupted in delirium:
• Perception. The person shows a reduced ability to distinguish
and integrate sensory information and to differentiate it from
hallucinations, dreams, illusions, and imagery.
• Thinking. The thinking process is fragmented and
disorganized to the extent that the person is unable to reason,
judge, abstract, or solve problems.
• Memory. Memory is impaired in all three aspects; the person
is unable to form memories or store and retrieve (register,
retain, or recall) information.
 Attention and Wakefulness

• Attention is impaired in all three areas. The person has

difficulty with the following:
 Alertness, or maintaining vigilance
 Selectiveness, or the ability to focus and filter out or
selectively attend to stimuli at will
 Directiveness, or the ability to pull oneself back to a task or
direct and focus one’s mental processes
• Wakefulness is usually reduced during the day, leading to
drowsiness and naps.
• The person often experiences sleeplessness, restlessness,
and agitation at night.
 Psychomotor Behavior

• The delirious client is either hyperactive or

hypoactive, often alternating between the two
extremes.
• Speech may be slurred and disjointed, with aimless
vocalizations and repetitions.
• Tremors and irregular spasmodic (choreiform)
movements may be present
 DEMENTIA
• Dementia is defined by a loss of previous levels of
cognitive, executive, and memory function in a state of
full alertness
• In dementia, impairment is evident in abstract thinking,
judgment, and impulse control.
• The conventional rules of social conduct are often
disregarded.
• Behavior may be uninhibited and inappropriate.
Personal appearance and hygiene are often neglected.
• Cognitive disturbances in dementia:
 Aphasia, which is deterioration of language function
 Apraxia, which is impaired ability to execute motor
functions despite intact motor abilities
 Agnosia, which is inability to recognize or name objects
despite intact sensory abilities
 Disturbance in executive functioning, which is the
ability to think abstractly and to plan, initiate, sequence,
monitor, and stop complex behavior.
DSM-IV-TR DIAGNOSTIC CRITERIA:

• Symptoms of dementia
 Loss of memory (initial stages, recent memory loss such as

forgetting food cooking on the stove; later stages, remote

memory loss such as forgetting names of children, occupation)
 Deterioration of language function (forgetting names of

common objects such as chair or table, palilalia (echoing

sounds), and echoing words that are heard [echolalia])
 Loss of ability to think abstractly and to plan, initiate,

sequence, monitor, or stop complex behaviors (loss of

executive function): the client loses the ability to perform self-
care activities
 Onset and Clinical Course
 When an underlying, treatable cause is not present,
the course of dementia is usually progressive.
Dementia often is described in stages:
 Mild
 Moderate
 Severe
 Mild dementia
 Forgetfulness is the hallmark of beginning, mild
dementia.
 It exceeds the normal, occasional forgetfulness

experienced as part of the aging process.

 The person has difficulty finding words, frequently loses

objects, and begins to experience anxiety about these

losses.
 Occupational and social settings are less enjoyable, and

the person may avoid them.

 Most people remain in the community during this stage.
 Moderate dementia
 Confusion is apparent along with progressive memory loss.
 The person no longer can perform complex tasks but
remains oriented to person and place.
 He or she still recognizes familiar people.
 Toward the end of this stage, the person loses the ability to
live independently and requires assistance because of
disorientation to time and loss of information such as
address and telephone number.
 The person may remain in the community if adequate
caregiver support is available, but some people move to a
supervised living situation.
 Severe dementia
 Personality and emotional changes occur.
 The person may be delusional, wonder at night,

forget the names of his or her spouse and children,

and require assistance in activities of daily living
(ADLs).
 Most people live in a nursing facility when they reach

this stage unless extraordinary community support is

available.
 Categories of dementia
• Dementia of the Alzheimer’s type
• Vascular dementia
• Dementia due to HIV disease
• Dementia due to head trauma
• Dementia due to Parkinson’s disease
• Dementia due to Huntington’s disease
• Dementia due to Pick’s disease
• Dementia due to Creutzfeldt-Jakob disease
• Dementia due to other general medical conditions
• Substance-induced persisting dementia
• Dementia due to multiple etiologies
 Suicide
• The willful act of ending one’s own life
• Suicide is a fatal, self-inflicted, destructive act with
explicit or inferred intent to die.
• Suicide attempt occurs when the act is nonfatal, and
suicidal ideation involves thoughts of harming or
killing oneself
• Para-suicide involves acts of self-harm with
nonlethal intent, such as superficial cutting or
ingestion
 Epidemiology
• Suicide is a major preventable public health problem
globally
• Suicide affects all age groups, both genders, and all
cultures, religions, and socioeconomic classes.
• Be aware that any client in a health care, occupational, or
community setting may, given the right circumstances,
contemplate suicide.
• Men commit suicide more than four times as often as
women.
• However, women attempt suicide three to four times as
often as men.
 Risk Factors
• Past attempt/s approximately 10% of people who make a suicide
attempt will eventually die by suicide.
• Male gender
• Age. There is a significant increase in risk from childhood to
adolescence/early adulthood
• Family history of suicide increases risk to roughly two to six times that of
the general population
• Life situation and stressful life events have a significant association with
completed suicides.
• Mental disorders especially mood disorders
• Substance abuse
• Chronic illnesses
• Serotonin abnormalities (low)
 Assessment for Suicide
• Assessment of suicide potential involves a complete
psychiatric history, thorough examination of mental
state, and direct inquiry about suicidal thoughts,
behaviors/attempts, intents, and plans.
• In a suicide risk assessment, the clinician approaches
the patient in an empathic, objective, nonjudgmental,
and concerned manner and spends the necessary time
to listen to the patient.
• The clinician can ask directly about suicidality;
asking does not increase risk.
Suicide prevention
Post Traumatic Stress Disorder (PTSD)
• Posttraumatic stress
disorder (PTSD): Is a
disturbing pattern of behavior
demonstrated by someone who
has experienced a traumatic
event-for example, a natural
disaster, combat, or an assault.
• Trauma: An extremely
distressing experience that
causes severe emotional shock
and may have long-lasting
psychological effects.
• About 60% of men and 50% of women (Americans)are exposed
to a traumatic event in their lifetime.
• Women are more likely to experience sexual assault and
childhood sexual abuse.
• Men are more likely to experience accidents, physical assaults,
combat, or to witness death or injury.
• Although the exposure to trauma is high, less than 10 percent of
trauma victims develop PTSD.
• The disorder appears to be more common in women than in
men.
• PTSD symptoms are not related to common experiences such as
uncomplicated bereavement, marital conflict, or chronic illness,
but are associated with events that would be markedly distressing
to almost anyone.
• The individual may experience the trauma alone or in the
presence of others
• Three clusters of symptoms are present: reliving the event;
avoiding reminders of the event; and being on guard, or
hyperarousal.
• The person persistently re-experiences the trauma through
memories, dreams, flashbacks, or reactions to external cues about
the event and, therefore, avoids stimuli associated with the trauma
• The victim feels a numbing of general responsiveness and
shows persistent signs of increased arousal such as insomnia,
hyperarousal or hypervigilance, irritability, or angry outbursts.
• He or she reports losing a sense of connection and control over
his or her life.
• PTSD can occur at any age including childhood
• Symptoms of depression are common with this disorder and
may be severe enough to warrant a diagnosis of a depressive
disorder
• In the case of a life threatening trauma shared with others, survivors
often describe painful guilt feelings about surviving when others did not
or about the things they had to do to survive.
• Substance abuse, anger and aggressive behavior, and relationship
problems are common.
• In PTSD, Symptoms may begin within the first 3 months after the
trauma, or delay for several months or even years.
• DSM-5 describes another disorder that is similar to PTSD called acute
stress disorder (ASD).
• There are similarities between the two disorders in terms of precipitating
traumatic events and symptomatology, but in ASD, the symptoms are
time limited, up to 1 month following the trauma.
• By definition, if the symptoms last longer than 1 month, the diagnosis
would be PTSD.
 Predisposing Factors to Trauma-Related
Disorders
Psychosocial Theory: One psychosocial model that has
become widely accepted seeks to explain why certain persons
exposed to massive trauma develop trauma-related disorders
and others do not.
• Variables include characteristics that relate to:
(1) the traumatic experience,
(2) the individual, and
(3) the recovery environment.
 The Traumatic Experience
Specific characteristics relating to the trauma
• Severity and duration of the stressor
• Extent of anticipatory preparation for the event
• Exposure to death
• Numbers affected by life threat
• Amount of control over recurrence
• Location where the trauma was experienced (e.g., familiar
surroundings, at home, in a foreign country)
 The Individual
• Degree of ego-strength
• Effectiveness of coping resources
• Presence of preexisting psychopathology
• Outcomes of previous experiences with stress/trauma
• Behavioral tendencies (temperament)
• Current psychosocial developmental stage
• Demographic factors (e.g., age, socioeconomic status,
education)
 The Recovery Environment
• Availability of social supports
• The cohesiveness and protectiveness of family and friends
• The attitudes of society regarding the experience
• Cultural and subcultural influences
Other theories include:
1. Learning theory
2. Cognitive theory
3. Biological aspects
Diagnostic Criteria for Posttraumatic Stress
Disorder