3rd Sem Psychopathology For Social Work

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Master of Social Work - III Semester

Psychopathology for Social Work
Module 1 Psychiatry & Psychiatric Assessment
Psychiatry - Definition, History and Growth of Psychiatry, Traditional; and

Modern attitude towards psychiatric illness.
Assessment in psychiatry: Psychiatric interviewing - Content, types,

techniques & skills, Case history recording and mental status examination.
Module 2 Overview of Clinical Psychopathology
Disorders of perception, thought, speech, memory, emotion, experience of

the self, consciousness & Motor disorders.
Classification in psychiatry - Need, types –
ICD & DSM- ICD 10- Categories of classification – Overview of
Diagnostic Guidelines
Module 3 : Neurotic and Behavioural Syndromes
Prevalence, etiology, clinical manifestation, course and outcome and

different treatment modalities of:
Neurotic, stress-related and somatoform disorders – Phobia, Obsessive
Compulsive Disorder, Panic Disorder, Generalized Anxiety Disorder,
Dissociative Disorder, Somatoform Disorder
Social - Cultural factors in psychiatric disorders with special reference to

India.
Transcultural psychiatry - culture bound syndromes.
Behavioural syndrome associated with physiological disturbances and

factors- Eating Disorders, Sleep Disorders, Sexual Dysfunction
Module 4 : Psychological Disorders

Deleena Francis (11TH Batch)

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Organic Disorders – Dementia, Delirium

Epilepsy
Alcohol and Substance Abuse
Personality Disorders: Paranoid, Dissocial (Anti-social), Emotionally
unstable (Impulsive &Borderline), Histrionic, Anankastic, Anxious-
avoidant, Dependent
Childhood Disorders: Specific Learning Disability, Pervasive
Developmental Disorder, Hyperkinetic Disorders, Conduct Disorder,
Emotional Disorders
Mental retardation
Module 5 : Schizophrenia & Mood Disorders

Schizophrenia, schizotypal and delusional disorders
Mood [affective] disorders – Mania & Depression
Module 6 : Mental Health Policies & Treatment Approaches
Mental Health Policies and Programmes: Merits and demerits - National

Mental Health Programme (NMHP – 1982) -Mental Health Act, 1987,
Mental Health Care Act 2010.
Recommendations of WHO - World Health Report 2001
Overview of Treatment Approaches to Mental Health Problems:
Perspectives on Prevention, Biological and Psychosocial Interventions,
Rehabilitation

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Module 1 Psychiatry & Psychiatric Assessment
HISTORY OF PSYCHIATRY
Begin at the beginning
• For the most part, through the ages, most people with mental health problems were
simply cared for in the community.
• Much like modern day developing world, they probably did better than most
clients do today.
Not all good
• However, people with active psychosis could well have lived in the wilderness, or
become beggars.
• Could have been labelled witches, possessed, or imprisoned or executed for

violence.
What was it like then?
• Different presentations of mental illness – less learning disability, no

schizophrenia, more delirium and organic mental illness – esp syphillis
• No asylums until 8th century. None in Britain until 1300‘s.
Hippocrates
• Pre medicine illness, including mental illness thought to be related to spiritual

phenomena requiring prayer, sacrifice, and exorcism.
• Hippocrates thought that mental illness based in the brain. Described mania,
delirium, melancholia, anxieties, phobias and puerperal psychosis and paranoia.
Mania in Greece
• Some patients with mania are cheerful – they laugh, play, dance day and night,
and stroll through the market, sometimes with a garland on their head, as if they
had won a game: these patients do not worry their relatives. But others fly into a

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rage . . . The manifestations of mania are countless. Some maniacs, who are
intelligent and well educated, deal with astronomy, although they never studied it,
with philosophy, but auto didactically, they consider poetry a gift of muses
(Kappadokien),
Humors
Mental illness thought due to disturbances of humors – black bile, yellow bile, blood
and phlegm
• Black bile: earth, cold and dry, associated with melancholia.
• Yellow bile: fire, hot and dry, associated with mania.
• Needed to rebalance the humors to cure people – warm, cold, purging,

bloodletting, diet, activity, rest and exercise etc. Persisted until 17th century. Many
people died.
Weird and wonderful
• Socrates – hysteria – the womb wandered around the body causing problems.
Therefore have babies to make it stay in the proper place – the womb as a cause of
problems for women persisted as a belief right until the 20th Century.
Persian times
• Both physical and spiritual causes proposed.
• Many advances in medicine, including in mental illness.
• First psychiatric hospitals, which used baths, drugs, music and activities and
counselling.
Middle ages in Britain
• Mental illness mixture of spiritual and medical causes – most understanding from
‗humors‘.
• Also the first asylums started here – Bethlehem hospital, later changed to Bedlam.
The first place to use incarceration as a treatment for mad people.
Recent developments
• Outpatient work and community care developed

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• Psychiatry split into subspecialties – adult, old age, LD, forensic and child.
• New treatments developed, others diminished (ECT, psychosurgery, sterilisation).
Today
o Community care developed.
o Person centred approaches
o Increased rights in law
o Reduced hospital admissions
o Debate on formulation vs. diagnostics
o Holistic care.
o Nurse practitioners.
Psychiatry definition
� The medical specialty concerned with the prevention, diagnosis, and treatment of
mental illness.
� The branch of medicine that deals with the diagnosis, treatment, and prevention of
mental and emotional disorders.
Early Age- Era of superstitions

 History- Overview
� Mental illness- caused by devils, evil spirits, supernatural beings
� Archaeological findings of skulls with holes
� Treatment by priests and ‗tantriks‘
Bright period of middle age- era of naturalism
� Hippocrates – naturalism
� mental illness caused due to natural causes – needs treatment
� Role of heredity and environment
� Asclepiads – discriminate between acute and chronic
Dark period of middle age- return of supersitionAge – Return

� Re-emergence of superstitious beliefs
� 15-16 century -Mass hysteria – dancing mania in Italy (tarantism)

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� mentally ill tortured –burning alive, cutting of tongue etc.

� Arabs had a positive outlook to mentally ill
Reappearance of scientific approach- era of reason
� Evil - ill
� Paracelsus – dancing mania as a disease – advocated bodily magnetism (hypnosis)
� Johann Meyer(16th Century)- book on witchcraft- many killed as witches were really
ill
� St Vincentale Paul – mental illness like other diseases –need humane treatment
� Henry VIII, converted monastery to mental hospital in 1547 – asylums – inhumane
treatments
� Philippe Pinel 19th century – raised voice against inhumane treatment in asylums and
introduced humane treatment in La Bicette mental hospital in Paris
� York Treatment – William Tuke
Emergence of modern thought-era of modern medicine Emergence of modern Th

� Emergence of Organic view
� William Griesinger (19th Century)- discussed brain pathology
� Emil Kraepelin – classification of mental illness – syndromes
� More humane treatment – Mental Hygiene Movement after Clifford Beers, The mind
that Found Itself
� Psychological and socio-psychological views
� Anton Mesmer – Mesmerism
� Joseph Breur – Catharsis
� Sigmund Freud- free association
� Behavioral theories
� Family Theories
ASSESSMENT IN PSYCHIATRY
Ő Psychiatric interviewing
Functions
 Determine the nature of the problem
 Developing and maintaining a therapeutic relationship
 communicating information and implementing a treatment plan
Four Dimensions

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� Establishing rapport
� Assessing patient‘s mental status
� Using specific techniques
� Diagnosing
Styles of interview:
� Insight oriented interview: emphasize eliciting and interpreting unconscious
conflicts, anxieties and defenses
� Symptom oriented approach:
Classification of patient‘s complaints and dysfunctions as defined by specific
Diagnostic
Three Phases
� Beginning of the Interview
� Interview Proper
� Ending of Interview
o Beginning of Interview
Introducing the interviewer
Ensuring Privacy
Non-threatening questions
o Interview Proper
� Exploration of detailed understanding of patients problems
� Focus on content and process
� Use of techniques
Techniques
� Open-ended vs. closed ended questions
� Reflection: repeating the patient in a supportive way
� Facilitation
� Silence
� Confrontation – helping clients to face things, which are to be faced in
respectful way
� Clarification
� Interpretation – helping the client to see interrelationships that patient
may not see
� Summation: summarizing information revealed by the client
� Explanation: explaining treatment strategies in an understandable
language
� Transition: shifting to new areas of exploration if adequate information
obtained on the previous area

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� Self-revelation: limited, discreet self disclosure may be useful to keep the

client at ease
� Positive reinforcement
� Reassurance: truthful reassurance can increase trust and compliance of
clients
� Advice:
o Ending of Interview
 Help the client to leave the interview feeling understood and respected
 Thanking clients for sharing information
 Clear description of treatment
 Details of appointment and referral if required
Case History and Mental Status Examination

Name, age, marital status, sex, Occupation, domicile, socioeconomic Status
(upper/lower/middle)
� Informant:
� Information:
� Whether reliable and adequate?
� Precipitating factor if any:
Chief complaint: exactly why the patient came to the hospital preferably in the patient's
own words and information from informants
� Complaints with duration to be recorded chronologically
History of present illness
� Onset: insidious/ sub acute/acute
� Course of illness: episodic/continuous
� Deteriorating/improving/fluctuating
� a) Description of the complaints recorded (like a story)
� If episodic record history of last episode
� If continuous record history of whole period
� b) Associated disturbances: personal, social, occupational functioning
� Biological functioning: sleep appetite, bowel and bladder functioning, libido
� Negative history: ruling out other disorders
� Past history of physical or psychiatric illness:
In episodic illness record history of all past episodes
Family history
� Genogram of family of origin- description of each family member,
� Brief family assessment

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� Family history of any psychiatric illness

Personal history
History of the client's life from infancy to the present
� Birth and early development
� Behavior during childhood
� Physical illness during childhood
� Schooling
� Occupational history
� menstrual history
� Sexual history
� marital history
� Habits (alcohol, drugs etc.)
Premorbid personality
� Attitude towards others,
� Attitude to self,
� Moral and religious attitudes and standards,
� Mood,
� Leisure activities and interests,
� Fantasy life,
� Reaction to stress,
� Habits (sleep, eating etc.)
Mental Status Examination
� General appearance and behavior: Well kempt/ill kempt, cooperative or not

cooperative, ETEC maintained or not, rapport could be established or not
� Psychomotor activity: increased, decreased or normal
� Talk: relevant/irrelevant, coherent, spontaneous/limited (monosyllabic), volume and
tone: appropriate/increased or decreased
Thought:
� Form: presence of formal thought disorder
� Stream: flight of ideas, retardation of thinking, circumstantialities/ tangentiality,
perseveration
� Possession: obsessions, thought alienation
� Content: delusion
Perception: Hallucination (all senses), illusion (sensory distortion)

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Mood: subjective mood and objective mood Appropriate or not, Congruent or not,
Lability
Cognitive functions
� Attention and concentration:
� Orientation: place/person/time
� Memory: immediate/recent/past (mention impaired or intact)
� General information and intelligence
� Abs tractability: proverb test
� Judgments: personal judgment/ social judgment/ test judgment
� Insight: present/absent
� Summary
� Diagnostic formulation
� Diagnosis:
Personal history: history of the client's life from infancy to the present
� Birth and early development
� Behavior during childhood
� Physical illness during childhood
� Schooling
� Occupational history
� Menstrual history
� Sexual history
� Marital history
� Habits (alcohol, drugs etc.)
� Premorbid personality:
� Attitude towards others,
� Attitude to self,
� Moral and religious attitudes and standards,
� Mood,
� Leisure activities and interests,
� Fantasy life,
� Reaction to stress,
� Habits (sleep, eating etc.)

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Module 2 Overview of Clinical Psychopathology
DISORDERS OF THOUGHT & SPEECH
Intelligence
 Ability to think and act rationally and logically
 IQ= 100 X Mental Age/Chronological Age
Thinking
 Undirected fantasy thinking
 Imaginative thinking
 Rational or conceptual thinking – attempts to solve a problem
 Autistic thinking
Disorders of thinking – classification
 Disorders of stream of thought
 Disorders of possession of thought
 Disorders of the content of thinking
 Disorders of form of thinking
Disorders of stream of thought
 Disorders of tempo
 Flight of ideas
 Inhibition or retardation of thinking
 Circumstantiality
 Disorders of continuity of thinking

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 Perseveration
 Thought blocking
Flight of ideas
 Thought follows one another rapidly, there is no general direction of thinking and
the connections between successive thoughts appear to be due to chance factor
 Speech diverted to external stimuli and by internal superficial association
 Prolixity- mild form – losses thread of thought for few moments and finally reach
the goal
Inhibition or retardation of thinking
 The train of thought is slowed down and the number of ideas and mental images
which present themselves is decreased
 Typical of retarded depression
Circumstantiality
 Thinking proceeds with many unnecessary trivial details but finally the point is
reached
 Found in epileptic personality change
Perseveration
 Mental operations tend to persist beyond the point at which they are relevant and
thus prevent progress of thinking
 May be verbal or ideational
Thought Blocking
 Sudden arrest of the train of thought leaving a blank. An entirely new thought may
then begin
Disorders of possession of thought
 Obsessions
 Thought alienation

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 Thought insertion
 Thought deprivation/thought withdrawal
 Thought broadcasting
Obsessions
Schneider
 An obsession occurs when someone cannot get rid of a content of consciousness,

although when it occurs he realizes that it is senseless or at least that it is
dominating and persisting without cause
 identified as own thought
 Appears against patient‘s will
 Understands as senseless
 Unable to control
 The thoughts and efforts to control results in anxiety
 Occurs mostly in depression, schizophrenia
Thought alienation
 Patient experiences the thought under control of an outside agency or that others
are participating in his thinking
 Thought insertion – thoughts being inserted into the mind- recognizes as foreign –
comes form without
 Thought withdrawal/ deprivation- thoughts suddenly disappear and withdrawn

from the mind by a foreign influence
 Thought broadcasting- as the person thinks others also think unison with him
Disorders of content of thinking
 Delusions

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 A false unshakable belief which is out of keeping with the patients social and
cultural background
 Delusion and overvalued idea
 Primary delusion
 Secondary delusion
Primary delusions- new meaning arises in connection with some other psychological
event
o Schneider – delusional mood, delusional perception, sudden delusional idea
o Delusional mood- patient has the idea that something going on around and
concerns and does not know what it is
o Delusional perception- attribution of a new meaning usually in the sense of self

reference to a normally perceived object
o Sudden delusional idea- fully formed delusion in patients mind
Secondary delusions- arise from some other morbid experience
o Freud – delusion of persecution, erotomania, jealousy as a result of latent

homosexuality
o Systematized delusions- one basic and the remainder of the system is logically
built on it
Content of delusions
 Delusion of persecution
 Delusions of jealousy- delusion of marital infidelity
 Delusion of love
 Grandiose delusions-
 Delusions of ill health /hypocondriacal delusions
 Delusions of guilt
 Nihilistic delusions

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 Delusions of poverty
Disorders of form of thinking
 Formal thought disorder - connections between associations are lost – results from
condensation, displacement and misuse of symbols
 Condensation- two ideas with something in common are blended into a false
concept

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Module 3 : Neurotic and Behavioural Syndromes
SOMATOFORM AND DISSOCIATIVE DISORDERS
 Definition
Somatoform disorders are a group of conditions, involving physical complaints

or disabilities that occur without any evidence of physical pathology, to account for them.
 Types of DSM-IV Somatoform Disorders
◦ Hypochondriasis
◦ Somatization disorder
◦ Conversion disorder
◦ Pain disorder
◦ Body dysmorphic disorder
 Hypocondriasis
o Pre occupation with fears of contracting or the idea that one has a serious
disease based on misinterpretation of bodily symptoms.
o Pre occupation persist clinically significant distress or impairment duration
of at least six month.
Aetiology
 Faulty interpretation of physical signs and sensations
Treatment
 Cognitive behavioural therapy
 Behavioural techniques

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 Supportive psychotherapy
 Somatization disorder
o somatization disorder is characterized by multiple complaints of physical
ailments over a long period, beginning before age 30.that are inadequately
explained by independent finding of physical illness or injury and that lead
to medical treatment or to significant life impairment.
o Somatization disorder is commonly among women that among men.
Diagnostic criteria
 four pain symptoms
The patient must report a history of pain with respect to atleast 4 different
functions.
Eg; head, abdomen, back joints or during sexual intercourse or urination.
 two gastro intestinal symptoms
The patient must report a history of at least two symptoms other than pain,
pertaining to the gastro intestinal system such as nausea, boating, diarrhea or vomiting
when not pregnant.
 One sexual symptom
In a patient must report at least one reproductive symptom other than pain eg;
sexual indifference or dysfunction, menstrual irregularity or vomiting throughout
pregnancy.
 One pseudo neurological symptom
the patient must report a history of at least one symptom not limited to pain,
suggestive of a neurological condition eg; various symptoms that mimic sensory or motor
impairment such as loss of sensation or involuntary muscle contraction in a hand.
Treatment
 Supportive psychotherapy

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 Behaviour modification
 Relaxation therapy
 Drug therapy
 Conversion disorder
Conversion disorder involves a pattern in which symptoms affecting sensory or

voluntary motor function lead one to think a patient as a medical or neurological
condition however upon medical examination it becomes apparent that the pattern of
symptoms cannot be fully explained by any known medical condition.
Symptoms
Conversion disorder involves a pattern in which symptoms or deficit affecting

sensory or voluntary from the motor function lead one to think that a patient has a
medical or neurological condition
Treatment
1. Re Inforcement
2. Problem solving therapies
3. Behaviour modification
 Pain disorder
The symptoms of pain disorder resemble the pain symptoms seen in somatization
disorder, but with pain disorder, the other kinds of symptoms of somatization are not
present. Pain disorder is characterized by the experience of persistent and severe pain in
one or more areas of the body.
Treatment
 Positive reinforcement
 Relaxation training
 Changing the consultant doctor
 A supportive relationship with a physician
 Body dysmorphic disorder

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most people fantasies about improving some aspect of their physical appearance
, but some relatively normal looking people imagine they are so ugly that they are unable
to interact with people or otherwise function normally for fear that people will laugh at
their ugliness. This disorder is called bdd.
Treatment
 Plastic surgery
Types of ICD-10 somatoform disorder
1. Hyperventilation syndrome
2. Irritable bowel syndrome
3. Pre menstrual syndrome
 Hyper ventilation syndrome (hvs)
The syndrome becomes particularly marked in the presence of psycho social

stress or any emotional up even.
Mild form – excessive fatigue, headache, chest pain, palpitation, sweating, light head
deadness
Severe form – tetany, loss of consciousness
Treatment
I. Relaxation technique
II. Teaching relaxed breathing technique
III. Breathing-in-bag technique
 Irritable bowel syndrome (ibs)
This is a common syndrome, often known by a large verity of names, such as

spastic colitis, irritable colon syndrome, nervous diarrhea, mucus colitis, and colon
neurosis.
Symptoms
 Abdominal pain, discomfort or cramps

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 Alteration of bowel habits(diarrhea, constipation)
 A sensation of incomplete evacuation
 Hypotility- painless diarrhea
Treatment
o A stable and trustful doctor patient relationship
o Supportive psychotherapy
o Anti- anxiety and anti-depressants medication
 Premenstrual syndrome(pre menstrual tension)
It is characterized by variety of physical & psychological & behavioural

syndrome occurring in the 2nd half of menstrual cycle the symptom start after a few days
of ovulation reach a peak about 4-5 days before, menstruation and disappear usually
around menstruation.
Aetiology
 Biological factors –excess of estrogens and progesterone deficiency.
 Psychological factors – encompass education, expectation and attitude towards

menstruation and feminality.
 Dissociative disorder
Individuals feel detached from themselves or their surroundings, and reality,

experience, and identity may disintegrate.
5 types
◦ Depersonalization disorder
◦ Dissociative amnesia
◦ Dissociative fugue
◦ Dissociative trance disorder
◦ Dissociative identity disorder

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 Depersonalization disorder
◦ Severe feelings of depersonalization dominate the individual‘s life and

prevent normal functioning
◦ It is chronic
◦ 50% suffer from additional mood and anxiety disorders
 Dissociative Amnesia
◦ Inability to recall personal information, usually of a stressful or traumatic

nature
◦ Generalized vs. selective amnesia
 Dissociative Fugue
◦ Sudden, unexpected travel away from home, along with an inability to

recall one‘s past (new identity)
◦ Occur in adulthood and usually end abruptly
 Dissociative trance disorder
◦ Altered state of consciousness in which the person believes firmly that he

or she is possessed by spirits; considered a disorder only where there is
distress and dysfunction
◦ Trance and possession are a common part of some traditional religious and
cultural practices and are not considered abnormal in that context
 Dissociative Identity Disorder
◦ Formerly multiple personality disorder
◦ Many personalities (alters) or fragments of personalities coexist within one

body
◦ The personalities or fragments are dissociated
◦ Switch (transition from one personality to another, includes physical

changes)

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Aetiology
 psychodynamic theory
 Behavioural theory
Treatment
 Behaviour therapy
 Psychotherapy
 Supportive psychotherapy
 Psycho analysis
 Drug therapy
Phobia and obsessive compulsive disorder
Phobia
A phobia is a persistent and disproportionate fear of some object or situation that presents
little or no actual danger and yet leads to a great deal of avoidance of these feared
situations.
Some characteristic features;
• Presence of the fear of an object, situation or activity
• The fear is out of proportions to the dangerousness perceived.
• The patient recognises the fear as irrational and unjustified.
• Patient is unable to control the fear and is very distressed by it.
• This leads to persistent avoidance of the particular object, situation or activity.
• The phobia and phobic object become a preoccupation with the patient, resulting
in marked distress and restriction of the freedom of mobility.
According to DSM-IV-TR, there are three main categories of phobias are specific phobia,
social phobia, agoraphobia
Specific phobia

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Specific phobia is characterised by an irrational fear of a specified object or situation.

1. E.g.: acrophobia
2. Zoophobia
3. Xenophobia
4. Algophobia
5. Claustrophobia
Criteria
 Individual experiences excessive and persistent fear of a specific object or

situation and has feelings of anxiety, fear, or panic right when encountering it
 The person knows that their reaction of fear is unreasonable
 Individual‘s fear, anxiety, or avoidance causes significant distress or it interferes

with the person‘s day to day life
 In children younger than 18 years old, the problem must be present for at least six
months before diagnosing a specific phobia
 The person‘s fear, panic, and avoidance aren‘t better explained by another disorder
Social phobia
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
E.g.: erythrophobia
Agoraphobia
It is an irrational fear of situations.

In agoraphobia the most commonly feared and avoided situations include streets and
crowded places such as shopping malls etc…
Aetiology
• Psychodynamic theory; anxiety is usually dealt with defence mechanism of
repression. In phobia the secondary defence mechanism is displacement
• Behavioural theories; explain phobia as conditioned reflex.
Treatment

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Psychotherapy; cognitive behaviour therapy can be used to break the anxiety patterns
in phobic disorder.
• Behaviour therapy; the behaviour therapies are systematic desensitisation, relaxation
techniques, flooding.
• Drug treatment:
Benzodiazepines: reducing the anticipatory anxiety.
Alprazolam: is stated as anti- phobic.
OCD –obsessive compulsive disorders:
OCD is defined by the occurrence of unwanted and intrusive obsessive thoughts or

distressing images, these are usually accompanied by compulsive behaviours performed
to neutralize the obsessive thoughts or images or to prevent some dreaded event or
situations.
History
 14th & 15th century thought people were possessed by the devil and treated by
exorcism
 17th century thought people were cleansing their guilt
 18th century finally considered medical issue
 20th century began treating with behavioral techniques
Obsessions
Recurrent and persistent thoughts, impulses or images that are experienced, at some time
during the disturbance, as intrusive and inappropriate and that cause marked distress or
anxiety
Compulsions
The behaviours or mental acts are aimed at preventing or reducing distress or preventing
some dreaded event or situations.
Clinical syndromes
1. Predominant obsessive thoughts or ruminations

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2. Predominantly compulsive acts

3. Mixed obsessional thoughts and acts.
Types
 Washers- the obsession is of contamination with dirt, germs etc…
 Checkers- the person have multiple doubts.
 Doubters and sinners are afraid that if everything isn‘t perfect or done just
right something terrible will happen or they will be punished.
 Counters and arrangers are obsessed with order and symmetry. They may
have superstitions about certain numbers, colours, or arrangements.
 Hoarders fear that something bad will happen if they throw anything away.
They compulsively hoard things that they don‘t need or use.
Characteristics
• Affects almost 3% of world‘s population

• Start anytime from preschool to adulthood
• Typically between 20-24
• Many different forms of ocd – differ from person to person
• Cause of ocd is still unknown
• Better when diagnosed early
Aetiology
• Psychodynamic theory: Sigmund Freud found obsessions and phobias to be
psycho genetically related.
Isolation of affect; by this defence mechanism ego removes the affect.
• Behavioural theory: the behavioural theory explains obsessions as conditioned
stimulus to anxiety.
Causes
 Serotonin is involved in regulating anxiety

 Abnormality in the neurotransmitter serotonin
 In order to send chemical messages serotonin must bind to the receptor sites
located on the neighboring nerve cells
 Ocd suffers may have blocked or damaged receptor sites preventing serotonin
from functioning to full potential
 Possible genetic mutation

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 Some people suffering have mutation in the human serotonin transporter gene
Ocd and the brain
 Pet scans show people with ocd have different brain activity from others
 Another theory: miscommunication between the orbital frontal cortex, the caudate
nucleus, and the thalamus
 Caudate nucleus doesn‘t function properly and causes thalamus to become

hyperactive and sends ―never-ending‖ worry signals between ofc and thalamus 
ofc responds by increasing anxiety
Co morbidity
 Has excessive co morbidity with other diseases
 Common diseases: depression, schizophrenia, Tourette‘s syndrome
 Depression is the most common
 Many people with ocd suffered from depression first
 2/3 of ocd patients develop depression  makes ocd symptoms worse and more
difficult to treat
 People with ocd common diagnosed as schizophrenic  hard to separate

obsessions from delusions
Who is at risk?
 For many people, ocd starts during childhood or the teen years. Most people are
diagnosed by about age 19. Symptoms of ocd may come and go and be better or
worse at different times.
 Ocd affects about 2.2 million American adults. It strikes men and women in
roughly equal numbers and usually appears in childhood, adolescence, or early
adulthood. One-third of adults with ocd develop symptoms as children, and
research indicates that ocd might run in families.
Treatments:
 Only completely curable in rare cases

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 Most people have some symptom relief with treatment
 Treatment choices depend on the problem and patients preferences
 Psychotherapy:
 Psychoanalytic psychotherapy is used in certain selected patients.
 Behavioural therapy and cbt:
 Thought stopping
 Response prevention
 Systematic desensitization
 Drug treatment:
 Antidepressants like saris, fluoxetine, clomipramine etc…
Conclusion
 Ocd is a complicated issue
 Most cases are incurable
 Best form of treatment is cbt in combination with medication
 Most important thing that can be done to discover more about ocd and its
treatments is to research the brain
GENERALIZED ANXIETY DISORDER

GAD is an anxiety disorder characterized by chronic anxiety, exaggerated worry and
tension, even when there is little or nothing to provoke it.
Signs & Symptoms

 • People with generalized anxiety disorder can't seem to shake their concerns.
 • worries are accompanied by physical symptoms, especially fatigue, headaches,
muscle tension, muscle aches, difficulty swallowing, trembling, twitching,
irritability,
 Sweating, and hot flashes.
PANIC DISORDER

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an anxiety disorder and is characterized by unexpected and repeated episodes of intense

fear accompanied by physical symptoms that may include chest pain, heart palpitations,
shortness of breath, dizziness, or abdominal distress.
Signs & Symptoms

 • People with panic disorder have feelings of terror that strike suddenly and
repeatedly with no warning.
 During a panic attack, most likely your heart will pound and you may feel sweaty,
weak, faint, or dizzy.
 Hands may tingle or feel numb, and you might feel flushed or chilled.
 May have nausea, chest pain or smothering sensations, a sense of unreality, or fear
of impending doom or loss of control.
TRANSCULTURAL PSYCHIATRY
• Discipline of comparative psychiatry, focused on ethnic and cultural aspects of

mental health and illness
• Introduced by Eric wittkower of McGill university
• Henry Murphy defined the principal objectives of the discipline:
– To identify, verify and explain the links between mental disorder and the
broad psychosocial characteristics which differentiate nations, peoples, and
cultures
• Socio-cultural factors exert influence on all psychiatric disorders. Cultural
variation is most pronounced in reactive and neurotic disorders but the influence
of culture is also significant in the major psychoses and can even be recognized in
organic brain syndromes.
• The discipline that deals with the description, definition, assessment, and
management of all psychiatric conditions as they reflect and are subjected to the
influence of cultural factors in a bio psychosocial context while using concepts
and instruments from social and biological sciences to advance a full
understanding of psychopathology and its treatment
BEHAVIOURAL SYNDROME ASSOCIATED WITH PHYSIOLOGICAL

DISTURBANCES AND FACTORS-
EATING DISORDERS, SLEEP DISORDERS, SEXUAL DYSFUNCTION

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The Sexual Response Cycle
 Desire (also called libido).
This stage, in which a man or woman begins to want or "desire" sexual intimacy or
gratification, may last anywhere from a moment to many years.
 Excitement (also called arousal).
This stage, which is characterized by the body‘s initial response to feelings of sexual
desire, may last from minutes to several hours.
 Plateau.
This stage, the highest point of sexual excitement, generally lasts between 30 seconds
and three minutes.
 Orgasm.
This stage, the peak of the plateau stage and the point at which sexual tension is
released, generally lasts for less than a minute.
 Resolution.
The duration of this stage—the period during which the body returns to its pre
excitement state—varies greatly and generally increases with age.

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Sexual dysfunction
 Is the persistent or recurrent inability to react emotionally or physically to sexual

stimulation in a way expected of the average healthy person or according to one‘s
own standards of acceptable sexual response.
 Sexual dysfunction can occur during the desire, excitement, plateau, or orgasm
stage of the sexual response cycle.
Psychological/emotional factors,
Including stress, negative body image, performance anxiety, expectation of failure, fear
of pregnancy, memory of negative sexual experiences, and fear of acquiring or
transmitting a sexually transmitted disease
Biological/physiological factors,
Including changes related to aging, certain medical conditions (arthritis, reproductive

cancers, diabetes, cardiac disease, and hypertension), physical injury (such as spinal cord
injuries), and the effects of hormonal contraceptive methods, pregnancy, and substance
abuse
Interpersonal/social factors,
Including peer pressure, poor communication with a partner, sexual abuse, attitudes
toward sexual orientation, uncertainty of how to behave, and conflicts with one‘s partner
Environmental factors,
Including cultural influences, gender dynamics, availability of partners (partner ratio),

and physical setting (lack of privacy)
Types
 Inhibited sexual desire (ISD)
 Female sexual arousal disorder (FSAD)
 Dyspareunia
 Vaginismus
 Anorgasmia
 Premature ejaculation (PE)

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 Male orgasmic disorder
 Erectile dysfunction (ED)
Paraphilias/Sexual Deviations
 Paraphilias are impulse control disorders (mental illnesses) that are characterized
by recurrent and intense sexual fantasies, urges, and behaviors
 outside of acceptable patterns of behavior—because they involve unusual objects,

activities, or situations not considered sexually arousing to others
 Paraphilias include sexual urges or fantasies involving inanimate objects, sexual

behaviors with non-human objects, sexual behaviors involving humiliation or
suffering of oneself or another person, or sexual behavior that involves children or
non-consenting adults.
Paraphilias include:
o Exhibitionism
o Fetishism
o Frotteurism
o Pedophilia
o Masochism
o Sadism
o Transvestitism
o Voyeurism
 Exhibitionism("Flashing")
Exhibitionism is characterized by intense, sexually arousing fantasies, urges, or
behaviors involving exposure of the individual's genitals to an unsuspecting stranger
 Fetishism
People with this disorder have sexual urges associated with non-living objects. The
person becomes sexually aroused by wearing or touching the object

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 Frotteurism
With this disorder, the focus of the person‘s sexual urges is related to touching or
rubbing his genitals against the body of a non-consenting, unfamiliar person
 Pedophilia
People with this disorder have fantasies, urges, or behaviors that involve illegal sexual
activity with a prepubescent child or children (generally age 13 years or younger).
 Sexual masochism
Individuals with this disorder use sexual fantasies, urges, or behaviors involving the
act (real, not simulated) of being humiliated, beaten, or otherwise made to suffer in
order to achieve sexual excitement and climax.
 Sexual sadism
Individuals with this disorder have persistent fantasies in which sexual excitement
results from inflicting psychological or physical suffering (including humiliation and
terror) on a sexual partner.
 Transvestitism
Transvestitism, or transvestic fetishism, refers to the practice by heterosexual males of
dressing in female clothes to produce or enhance sexual arousal.
 Voyeurism ("Peeping Tom")

This disorder involves achieving sexual arousal by observing an unsuspecting and
non-consenting person who is undressing or unclothed, and/or engaged in sexual
activity. This behavior might conclude with masturbation by the voyeur
 Kleptophilia: A condition wherein a person gets sexual feelings by stealing things.
 Necrophilia: A condition wherein a person gets sexually aroused at the sight of a dead
body and gets sexual pleasure by ‗having sex‘ with the dead body.
 Zoophilia: A condition wherein a person has sex with animals for fulfilling his sexual
urges. This is also known as bestiality.
Causes
 childhood trauma, such as sexual abuse
 objects or situations can become sexually arousing if they are frequently and
repeatedly associated with a pleasurable sexual activity

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 an overly intimate relationship with parents, or rejection, hostile treatment, and

social deprivation during childhood
Module 4 : Psychological Disorders
ORGANIC DISORDERS (DEMENTIA & DELIRIUM)
There are three types of psychiatric disorders.
1. Those due to a known organic cause
2. Those in whose causation an organic factor has not yet been found or proven.
3. Those primarily due to psychosocial factors.
Organic mental disorders
Only disorders with a known organic cause are called “organic mental disorders”
In ICD 10: F00-F09
Classification
1. Delirium
2. Dementia

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3. Organic amnestic syndrome
4. Other organic mental disorders
DELIRIUM
 One of the common organic mental disorders.
 Earlier known by different names.
- Acute Confuisional States
- Acute Brain Syndrome
- Toxic Psychosis
- Metabolic Encephalopathies
Clinical features of delirium
 It is a relatively acute onset.
 Clouding of consciousness. 'Decreased awareness of surroundings and a

decreased ability to respond to environmental stimuli‟.
 Disorientation. „Decreased attention span and distractibility‟.
 Marked perceptual disturbances.
- Illusions
- Hallucination
- Misinterpretation
 Disturbance in sleep-wake cycle.
 Impairment of registration & retention of new memories.
Motor Symptoms in delirium
 Asterixis. (Flapping tremor)
 Multifocal myoclonus.
 Carphologia or floccillation.

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(Picking movements at cover - sheets and clothes)
 Tone and reflex abnormalities
 Motor and verbal preservation
 Dysnomia
 Agraphia
 Impaired comprehension can also been seen
Diagnosis
 Often it has an underlying etiology which may be correctable.
 Any delay in diagnosis, and thus starting the treatment, may lead to permanent
deficits.
 Diagnosis of delirium is mainly clinical.
 But tests may help to find out the etiology.
According to ICD 10, to diagnose the delirium, symptoms should be present in each of
the five areas described below.
1. Impairment of consciousness and attention
2. Global disturbance of cognition.
3. Psychomotor disturbances.
4. Disturbances of sleep wake cycle.
5. Emotional disturbances.
6. A history of underlying physical or brain disease.
7. Evidence of cerebral dysfunction.
(An abnormal EEG)
These also help to reach the diagnosis of delirium.
Predisposing factors

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1. Pre-existing brain damage or dementia.
2. Extremes of age. (very old/very young)
3. Previous history of delirium.
4. Alcohol or drug dependence.
5. Generalized or focal cerebral lesion.
6. Chronic medical illness.
7. Surgical procedure and postoperative period
8. Severe psychological symptoms. (such as fear)
9. Treatment with psychotropic medicines.
10. Present or past history of head injury.
11. Individual susceptibility to delirium.
Etiology
‗Any factor which disturbs the metabolism of brain sufficiently can cause delirium.‘
Management
In some cases where a cause is not obvious some investigations should be done.
 Complete blood count.
 Urinalysis.
 Blood glucose.
 Blood urea.
 Serum electrolytes.
 Liver and renal function tests.
 Thyroid function tests.
 X-ray chest.

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 ECG
 CSF examination.
 VDRL
 EEG
 Identification of the cause and its immediate correction will helpful for
management.
 Symptomatic measures: Small doses of benzodiazepines or antipsychotics may be

given either orally or parenterally.
 Supportive medical care and nursing care.
DEMENTIA
Definition
ICD-10
―Syndrome due to the disease of the brain, usually of a chronic or progressive nature, in
which there is disturbance of multiple higher cortical function, including memory,
thinking, orientation, comprehension, calculation, learning capacity, language and
judgment‖ Consciousness is not clouded.
What is Dementia?
Dementia is a term used to describe a cluster of symptoms including:
 Forgetfulness (progressive)
 Difficulty doing familiar tasks
 Confusion
 Poor judgment
 Decline in intellectual functioning
 Dementia is not the name of an actual disease
 Dementia is not a part of normal aging

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Clinical features of dementia
 Impairment of intellectual functions.
 Impairment of memory.
 Deterioration of personality with lack of personal care.
 Impairment of judgment and impulse control.
 Consciousness - Usually normal
 Orientation - Usually normal. Grossly disturbed in late stages
 Memory - Immediate retention and recall normal. Recent memory disturbed.

Remote memory disturbed in late stages.
 Comprehension - Impaired only in late stages.
 Sleep wake cycle - Usually normal.
 Attention and concentration - Usually normal.
 Diurnal variation – Usually absent.
 Perception – Hallucinations may occur.
 Other features – Catastrophic reaction; preservation
Diagnosis
Diagnosis of dementia is clinical.
According to ICD 10, the following features are required for diagnosis.
 Evidence of decline in both memory and thinking.
 Sufficient enough to impair personal activities of daily living.
 Memory impairment.
 Duration of at least 6 months.
Stages of Dementia
Stage 1 (Early stage, 2 to 4 years)

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 Forgetfulness.
 Declining interest in environment.
 Hesitancy in initiating actions.
 Poor performance at work.
Stage 2 (middle stage, 2 to 12 years)
 Progressive memory loss.
 Hesitates in response to questions.
 Has difficulty in following simple instructions.
 Irritable, anxious.
 Wandering.
 Neglects personal hygiene.
 Social isolation
Stage 3 (Up to a year)
 Marked loss of weight.
 Unable to communicate.
 Does not recognize family.
 Incontinence of urine and feces.
 Loses the ability to stand and walk.
 Death is usually caused by aspiration pneumonia.
Types of dementia
1) Alzheimer‘s Dementia.
2) Multi-infarct Dementia.
3) Hypothyroid Dementia.
4) AIDS Dementia complex.

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5) Lewy body Dementia.
Alzheimer’s Dementia.
 Most commonly seen in women.

 Seen in about 70% of all cases of dementia in USA.
 Earlier this was differentiated in two forms
- Presenile form.
- Senile form.
 Diagnosis of Alzheimer's dementia is by excluding all other causes of dementia.
Treatment
 Cholinesterase inhibitors are used for the treatment of Alzheimer's dementia.

(Eg: - Rivastigmine
- Donepezil and
- Galantamine)
 Also using drugs for the treatment of Alzheimer's dementia.
(Eg: - Ginkgo biloba
- Piracetam)
Multi-infarct Dementia.
 Second commonest cause of dementia.
 It is more common in India.
 Treatable causes of dementia.
Features
- An Abrupt onset.
- Acute exacerbations.
- Stepwise clinical deterioration.
- Fluctuating course.
- Presence of hypertension.
- History of previous stroke.

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- Emotional Lability is common.
Hypothyroid Dementia.
 Most important and treatable causes of dementia.
 It accounts for less than 1% of dementias.
 Hypothyroidism should be suspected in every patient of dementia.
 Laboratory tests are used for diagnosis.
 If the treatment is started within two years of the onset of dementia, complete
recovery is possible.
AIDS Dementia complex.
 About 50-70% of patients suffering from AIDS exhibit a triad of cognitive,

behavioral and motoric deficits of subcortical dementia type and this is known as
the ‗AIDS Dementia complex.‘ (ADC).
 Diagnosis is established by two type of tests
- ELIZA test
- Western Blot Test
Lewy body Dementia.
 Second most common cause of the degenerative dementia.
 Clinical features include;
-Fluctuating cognitive impairment over weeks or months, with involvement of

memory and higher cortical functions.
-Recurrent and detailed visual hallucinations.
-Spontaneous Extra pyramidal or parkinsonian symptoms such as rigidity and tremors.
- Neuroleptic sensitivity Syndrome.
Management of dementia
 Basic investigations.

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-Blood count.
-Urinalysis.
-Blood glucose.
-CT scan and MRI scan. Etc…
 Treatment of the underlying cause, if treatable.
Eg:
- Treatment of hypertension in multi-infarct dementia.
- Thyroxin replacement in hypothyroid dementia. Etc…
 Symptomatic management.
-Environmental manipulation and focus on coping skills. (Reduce stress).
-Treatment of medical complications, if any.
-Care of food and hygiene.
-Supportive care for the patient and Family/Careers.
-Depression can be treated with low dose of SSRIs. (Citalopram or Certraline).
-Psychotic symptoms can be treated with low doses of antipsychotics. (Haloperidol).
EPILEPSY
Organic disorder
Disorder with a known organic cause are called organic disorder
Eg: Brain damage
CNS problem (central nervous system)
What is Epilepsy?

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 Epilepsy is a disorder characterized by recurring seizures(also known as seizures

disorder)
 A seizure is a brief, temporary disturbance in the electrical activity of the brain.
 When nerve cell in the brain fire electrical impulses at a rate of up to four times
higher than normal, this cause a sort of electrical storm in the brain
 A pattern of repeated seizures is referred to as epilepsy
Prevalence
 65 million number of people around the world who have epilepsy
 50% of people with epilepsy develop seizures by the age of 25, however, anyone
can get epilepsy at any time
 1 in 26 people in USA will develop epilepsy at some point in their lifetime
 Between 4 and 10 out of 10,000 number of people on earth who live with active
seizure at any one time
 Roughly 20,0000 new cause of seizures and epilepsy occur each year
Etiology (causes of epilepsy)
 In about 70% of people with epilepsy, the cause is not known, remaining 30%, the
most cause are…
 Head trauma
 Brain tumor and stroke
 Lead poisoning
 Infection of brain tissue
 Heredity
 Prenatal disturbance of brain development
Groups at increased risk for epilepsy
 About 1% of the general population develops epilepsy.
 The risk in higher in people with certain medical condition.

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 Mental retardation
 Cerebral palsy
 Alzheimer's disease
 Stroke
 Autism
Types
1. Primary Epilepsy
2. Secondary epilepsy
Primary Epilepsy
 Birth injuries
 During delivery- so need more care- adequate monitoring- 52% mothers are
anemic
 Injuries occurred in childhood

 Infections- high fever, typhoid
Secondary epilepsy
1. Brain Tumor
2. Tuberculmia: Tubet
3. Cysticercoids: Worms
4. Cerebral syphilis
5. Alcohol
6. After head injury
7. During pregnancy and delivery
8. After stroke
Classification
1. Generalized seizure Disorders

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a. Grand mal ( Major)
b. Petit mal ( Minor)
2. Partial Epilepsy
a. Simple partial
b. Complex partial
Clinical manifestation (symptoms
 Periods of blackout or confused memory
 Occasional ―fainting spells‖
 Episodes of blank staring in children
 Sudden falls for no apparent reason
 Episodes of blinking or chewing at inappropriate times
 A convulsion, with or without fever
 Cluster of swift jerking movements in babies
First aid
 Stay calm and track time
 Do not restrain the person, but help them avoid hazards
 Protect neck, remove glasses, loosen tight neck wear
 Move anything hard or sharp out of the way
 Turn person on one side position mouth to ground
 Understand that verbal instructions may not obeyed
 Stay until person if fully aware and help reorient them
 Call ambulance if seizures last more than 5 minutes
Dangerous response to seizures
Do not.

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• Put anything in the person mouth
• Try to hold down or restrain the person
• Attempt to give oral anti-seizures medication
• Keep the person on the back face up throughout convulsion
How is epilepsy diagnosed?
 Clinical assessment
 Patient history
 Tests (Blood, EEG, CT, MRI or PET scan)
 Neurologic exam
 Clinical evaluation to look for causes
Type of Treatment
• Medication
• Surgery
• Non-pharmacologic treatment
• Ketogenic diet
• Vagus nerve stimulation(VNS)
• Lifestyle modification
ALCOHOL AND SUBSTANCE ABUSE
o includes disorders in which behavioral changes are caused by taking substances that
affect the central nervous system, and which are viewed as extremely undesirable in
almost all subcultures
Substance abuse (drug abuse)

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• A pattern of pathological use; e.g. inability to reduce or stop use, intoxication

almost throughout the day or nearly every day for at least a month, and episodes of
overdose.
• Impairment in social or occupational functioning; e.g. fights, loss of friends,

absence from work, loss of job, legal difficulties
Substance dependence (drug dependence)
• Tolerance: the need for increased amount of drug to achieve the desired effect.
or
• Withdrawal: physical symptoms after cessation or reduction in the use of a

particular substance
Types of substances abused
 Alcohol – Ethyl Alcohol
 Barbiturates and similarly acting sedatives and hypnotics
 Cannabinoids- (Marijuana, Hashish, charas, bhang
 Cocaine
 Hallucinogens like Lysergic acid diethylamide (LSD)
 Opioids – Morphine, heroin, pethdine,bupernorphine
 Phencyclidine (PCP)
 Tobacco
 Others - Volatile liquids, snake venom etc.
Aetiology
Biological factors
• Biological factors – 20-25%inherit genetic predisposition to drinking
• Children of alcoholics 3-4 times more vulnerable
• Higher concordance in monozygotic twins

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Psychosocial Factors
– Easy accessibility of drugs
– Sociocultural patterns
– Fast societal changes
Learning Theories – certain drugs positively reinforce addictive behaviors – people learn
from modeling
• Psychodynamic Factors: addiction as a form of substitution for a regressive

infantile autoeroticism
• Personality- substance use co occur with certain personality types – antisocial,

borderline, narcistic personality types
• Prevalence of PDs 4 times higher in addicted persons
Clinical Presentations
• Pathological patterns of Consumption
– Compulsive use
– Intoxication
– Tolerance
– Dependence
– Withdrawal symptoms
– Multiple drug use
Treatments
• Behaviour therapy
• Group therapy
• Psychotherapy
• Deterrent agents [alcohol sensiting drugs]
• Psychological treatment approaches

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• Medications
Alcohol
• Intoxication- central nervous system depressant – effect depend on blood alcohol

concentration
• Withdrawal symptoms
– Uncomplicated/simple – tremors, insomnia, anxiety, increased blood

pressure, increased sweating
– Occurs 8-12 hours of last consumption of alcohol
– lasts for 10-15 days
• Complicated –
– Delirium Tremens – disorientation, auditory or visual hallucination,

agitation,
– Convulsions
– Hypotension, coma
Management
Multimodal in nature
– Immediate intervention – acute intoxication, overdose, detoxification
– Short term management- brief counseling, motivation enhancement,

general rehabilitation
– Long term management – after care
Treatment
• Detoxification –
• Deterrent therapy –
• Psychosocial interventions –
– Individual therapy – motivation enhancement, cognitive behavior,

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– Behavior therapy- aversion,
– Group Psychotherapy
– Family oriented therapy
– Self help groups
• Sociocultural – environment modification, yoga, meditation
• Relapse prevention
PERSONALITY DISORDERS
An enduring pattern of inner experience and behaviour that deviates markedly from the
expectations of the culture of the individual who exhibits it
- American Psychiatric Association
Personality disorders are grouped into 3 clusters on Axis II of the Diagnostic and
statistical Manual of Mental Disorders. In ICD-10, it is coded in F60-F69
Classification
 Cluster A: Odd or Eccentric
 Cluster B: Dramatic, Emotional, or Erratic
 Cluster C: Anxious or Fearful
DSM-IV-TR Personality Disorders
 Paranoid Personality Disorder
 Schizoid Personality Disorder
 Schizotypal Personality Disorder
 Antisocial Personality Disorder
 Borderline Personality Disorder
 Histrionic Personality Disorder
 Narcissistic Personality Disorder
 Avoidant Personality Disorder

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 Dependent Personality Disorder
 Obsessive-Compulsive Personality Disorder
Paranoid Personality Disorder
 suspicious of other‘s motives
 interprets actions of others as deliberately demeaning/threatening
 expectation of being exploited
 see hidden messages in benign comments
 easily insulted/ bears grudges
 appear cold and serious
Treatment
 Individual psychotherapy
 Supportive psychotherapy
The response to treatment is very poor. Drug treatment has a very limited role.
Antisocial Personality Disorder
 Irresponsible and antisocial behavior
 Self-centered, inability to maintain relationships, irritability, unreliable
 Poor sexual adjustment/inability to delay gratification
 Aggressive, impulsive, manipulative
 Poor judgment
 Conflict with authority
 Poor work history
 Failure to handle responsibility
Treatment
 Individual psychotherapy

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 Psycho analysis or psychoanalytical psychotherapy.
 Group psychotherapy and self-help groups.
 Drug therapy.
Borderline Personality Disorder
 uncertainty about sexuality
 chronic feeling of ―emptiness‖
 recurrent threats of self-harm
 unstable interpersonal relationships
 Impulsive/unpredictable behaviors
 Extreme shifts in mood/depression
 Easily bored/argumentative
 Self-destructive behaviors
 Splitting, manipulative
 Inability to tolerate anxiety
Treatment
 Psycho analysis
 Psychoanalytical psychotherapy.
 Supportive psychotherapy
 Cognitive behaviour therapy
 Drug therapy
(Not a first choice for treatment)
Histrionic Personality Disorder
 Overly dramatic, intensively expressive
 Enjoys being the center of attention

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 Poor interpersonal relationships
 Romantic fantasies and control of partners
 Easily bored
 Displays dependency
Treatment
 Psycho analysis
 Psychoanalytical psychotherapy.
Avoidant Personality Disorder {Anxious P.D}
 Social inhibition,
 feelings of inadequacy,
 Hyper sensitivity
 Beginning by early adulthood
 The patient avoids occupational activities with significant interpersonal contact

use to fear of criticism disapproval or rejection.
 Unwilling to get involved with people unless certain of being liked
 Restrained in intimates relationships due to fear of being shamed or ridiculed
 Preoccupied with being criticized or rejected in social situations
 The patient views himself as socially inept unappealing or inferior to others
 Unusually reluctant to take personal risks or to engage in new activities because

they may be embarrassing
Clinical features-signs & symptoms
 The patient is usually shy and quiet and prefers to be alone
 The patient usually anticipates unwarranted rejection before it happens
 Opportunities to supervise others at work are usually avoided by the patient
 These patients are often devastated by minor comments they perceive to be critical

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 Despite self-imposed restrictions, avoidant personality disorder patients usually

long to be accepted and be more social
Aetiology
 Parental rejection
 Adverse early life experience
Treatment
o Individual psychotherapy, group psychotherapy , behavioral techniques
o Beta – blockers medicine
o Antidepressants
o Anxiolytic
Dependent personality disorder
DSM - DIAGNOSTIC CRITERIA
o Dependent behaviour
o Clinging behaviour
o Separation fear
o Difficulty making everyday decisions without excessive advise and reassurance
o Needs others to assume responsibility for major areas of his life
o Difficulty expressing disagreement with others and unrealistically fears loss of

support or approval if he disagrees
o Difficulty initiating projects or doing things on his or her own , due to be a lack of
self confidence in Judgment or abilities
o Goes to excessive lengths to obtain nurturance and support to the point of

volunteering to do things that are unpleasant
o Uncomfortable or helpless when alone due to exaggerated fears of being unable to

care for himself

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o Urgently seeks another source of care and support when a close relationship ends
o Unrealistically preoccupied with fears of being left to take care of himself
Clinical features
 Patients will endure great discomfort in order to perpetuate the care taking
relationship
 Social interaction is usually limited to the caretaker network
Etiology
1. Oral stage fixation
2. Cultural factors and social factors
Treatment
 Psychotherapy
 Group therapy
 Behavioral therapy
 Family therapy
 Antidepressants
 Anxiolytic
Obsessive –compulsive P.D
 Neat ,perfection, open, efficient
 Pre occupied with details, rules, lists organization or schedules, to the extent that
the major point of the activity is lost
 Perfectionism interferes with task completion
 Excessively devoted to work and productivity to the exclusion of leisure activities

and friendships

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 Unable to discord worn out or worthless objects, even if they have no sentimental
value
 Reluctant to delegate tasks to others
 Rigidity and stubbornness
Clinical features
 Obsession with detail can paralyze decision making
 These patients are often very frugal with regard to financial matters, time
management
Etiology
Anal stage –difficulties
Insecurity feeling -perfectionism
Treatment
 Long term individual therapy
CHILDHOOD DISORDERS: LEARNING DISABILITY
LEARNING DISABILITY
Learning disability (LD) is a neurological disorder that affects the brain‘s ability to
receive process, store and respond to information. LD is not a single disorder, but is
manifested by a group of disorders.
 The unknown factor is the disorder that affects the brain's ability to receive and
process information.
 This disorder can make it problematic for a person to learn as quickly or in the
same way as someone who is not affected by a learning disability.
 People with a learning disability have trouble performing specific types of skills or
completing tasks if left to figure things out by themselves or if taught in
conventional ways.
Types of L D

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 Learning disabilities can be categorized either by the type of information

processing that is affected or by the specific difficulties caused by a processing
deficit.
 Four stages of information processing used in learning:
 Input,
 Integration,
 Storage,
 Output.
Common Types of Learning Disabilities
Dyslexia Difficulty processing Problems reading, writing, spelling,

language speaking
Dyscalculia Difficulty with math Problems doing math problems,

understanding time, using money
Dysgraphia Difficulty with writing Problems with handwriting, spelling,

organizing ideas
Dyspraxia Difficulty with fine motor Problems with hand–eye

(Sensory skills coordination, balance, manual
Integration handiness
Disorder)
Auditory Difficulty hearing Problems with reading,

Processing differences between comprehension, language
Disorder sounds
Visual Processing Difficulty interpreting Problems with reading, math, maps,

Disorder visual information charts, symbols, pictures
Causes
 Heredity - Learning disabilities often run in the family.

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 Problems during pregnancy and birth - Learning disabilities can result from
anomalies in the developing brain, illness or injury, fetal exposure to alcohol or
drugs, low birth weight, oxygen deprivation, or by premature or prolonged labor.
 Accidents after birth - Learning disabilities can also be caused by head injuries,
malnutrition, or by toxic exposure.
Early detection:
 Paying attention to normal developmental milestones for toddlers and preschoolers

is very important.
 Early detection of developmental differences may be an early signal of a learning

disability and problems that are spotted early can be easier to correct.
 A developmental lag might not be considered a symptom of a learning disability

until the child is older.
 Try not to get caught up in trying to determine the label or type of disorder and
focus instead on figuring out how best to support the child.
 Types of learning disabilities are often grouped by school–area skill set or

cognitive weakness.(he or she is struggling with reading, writing, or math, and
narrowing down the Signs that your child might have a motor coordination
disability include problems with physical abilities that require hand–eye
coordination, like holding a pencil or buttoning a shirt.
 A child with a math–based learning disorder may struggle with memorization and
organization of numbers, operation signs, and number ―facts‖ (like 5+5=10 or
5x5=25) or have difficulty telling time.
Attention deficit disorder (hyperkinetic disorder)
 This is a syndrome first described by Heinrich Hoff in 1854.
 Also known as Minimal Brain Dysfunction(MBD), Hyper kinetic syndrome,

Strauss syndrome, organic drivenness and minimal brain damage.
 Occurs in about 3% of school age children.
 Males are 6-8 times more often affected.
The onset occurs before the age of 7 years.

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 ADD is of four clinical types:
1. With hyperactivity
2. Without hyperactivity
3. Residual type
4. With conduct disorder
1. ADD WITH HYPERACTIVITY (HYPERKINETIC DISORDER)
The characteristic clinical features are:
 Poor attention span with distractibility
 Hyperactivity
 Impulsivity
2. ADD without hyperactivity
 It is a rare disorder with similar clinical features, except hyperactivity.
3. Residual type
 It is usually diagnosed in a patient in adulthood, with a past history of ADD and

presence of a few residual features in adult life.
4. Hyperkinetic disorder with conduct disorder(Hyperkinetic conduct disorder) \
Aetiology & course
 Factors such as minimal brain damage, maturational lag, genetics,

neurotransmitters (nor epinephrine and dopamine) and early developmental
psychodynamic factors.
 The cause is not yet known but it is more likely to be a biological factor than
purely psychosocial one.
 A large majority (about 80%) of patients improve on their own by the time of
puberty, though a few (15-20%) may have persistent symptoms even in adulthood.

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Treatment
1. Pharmacotherapy
 Stimulant medication: Dextro-amphetamine or dexamphetamine(2.5-20 mg/day)

and methylphenidate(5-60 mg/day).
o These drugs decreases hyperactivity and/or distractibility.
2. Behaviour Modification
 Counselling and supportive psychotherapy
CONDUCT DISORDERS
 Conduct disorders are characterized by a persistent and significant pattern of

conduct in which the basic rights of others are violated or rules of society are not
followed.
 The onset occurs much before 18 years of age usually even before puberty.
 This disorder is much more (about 5 to 10 times) common in boys.
Main characteristics of conduct disorder are:
1. Aggressive behavior is the hallmark.
2. A child with conduct disorder rarely performs at the level of predicated by IQ or

age, causing academic, social and developmental problems.
3. Child with conduct disorder also at risk for STDs, rape, teenage pregnancy,
injuries, substance abuse and suicide attempts.
Prevalence
 The prevalence of this disorder has increasing over the last 50 years, at least in
industrialized countries.
 It occurs in almost all cultures, its level of occurrence may vary from one culture
to another.
 Not only are boys but also girls are diagnosed with this disorder but the age
pattern is different.

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 For boys aged 10 to 20, the rate is highest at age 10 and decreases thereafter.
 For girls, the mid teens represent a peak for this behavior.
Aetiology
1. Genetic Factors
 Alcoholism and personality disorder in father is reported to be strongly

associated with conduct disorders.
2. Biochemical Factors
 Correlation between elevated plasma levels of testosterone and aggressive

behaviors.
3. Organic Factors
 Children with brain damage and epilepsy are more prone to conduct disorder.
4. Psychosocial Factors
 Parental rejection.
 Inconsistent management with harsh discipline.
 Frequent shifting of parental figures.
 Absent father.
 Marital conflict and divorce in parents.
 Associations with delinquent subgroups.
 Parents with antisocial personality disorder or alcoholic dependence.
Symptoms
 Fighting with family members and peers.
 Frequent lying.
 Stealing or Robbery.
 Running away from home and school.
 Deliberate fire-setting.

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 Breaking someone else‘s house articles, car etc.
 Deliberately destroying other‘s property.
 Cruelty towards other people and animals.
 Physical violence like rape, assaultive behavior and use of weapons etc.
Treatment modalities
 The treatment is difficult. The most common mode of management is placement in

a corrective institution.
 Behavioral, educational and psychotherapeutic measures are employed for

changing the behavior.
 Drug treatment may be indicated in the presence of epilepsy, hyperactivity,

impulse control disorder and episodic aggressive behavior(lithium,
carbamazepine) and psychotic symptoms.
 Parental instruction to teach how to deal with the mild‘s demands.
 Juvenile Justice System, if needed, to provide structured rules and means for
monitoring and controlling the child‘s behavior.
MENTAL RETARDATION
 ―Mental Retardation refers to significantly sub-average general intellectual

functioning resulting in or associated with concurrent impairments in adaptive
behavior and manifested during the developmental period‖.(American Association
on Mental Deficiency, 1983)
 About 3% of the world population is estimated to be mentally retarded.
 In India, 5.3 out of 1000 children are mentally retarded(The Indian Express,13th
March 2001)
 Mental Retardation is more common in boys than girls.
 With severe and profound mental retardation mortality is high due to associated
physical diseases.
Classification

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 Based on IQ Mental Retardation is classified into four. They are:
Type Intelligence Quotient (IQ)
1. Mild (Educable) 50-70
2. Moderate (Trainable) 35-50
3. Severe (Dependent retarded) 20-35
4. Profound (Life support) <20
 IQ is the ratio between Mental Age (MA) and Chronological Age (CA).
 Chronological Age is determined from the date of birth.
 Mental Age is determined by Intelligence tests.
Signs and symptoms
1. Failure to achieve developmental milestones.
2. Deficiencies in cognitive functioning such as inability to follow commands or

directions.
3. Reduced ability to learn or to meet academic demands.
4. Excessive or receptive language problems.
5. Psychomotor skill deficits.
6. Difficulty in performing self-care activities.
7. Low self-esteem, depression and labile moods.
8. Neurologic impairments.
Etiology
1. Genetic Factors
 Chromosomal abnormalities
 Down‘s syndrome
 Fragile x syndrome

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 Turner‘s syndrome
 Metabolic disorders
 Cranial malformation
 Gross diseases of brain
2. Prenatal Factors
 Infections
 Endocrine disorders
 Physical damage and disorders
 Intoxication
 Placental dysfunction
3. Perinatal Factors
4. Postnatal Factors
 Infections
 Accidents
 Lead poisoning
5. Environmental and socio-cultural factors
 Cultural deprivation
 Low socio-economic status
 Inadequate caretakers
 Child abuse
Treatment modalities
1. Behavior management.
2. Environmental supervision.

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3. Monitoring the child‘s developmental needs and problems.
4. Programs that maximize speech, language, cognitive, psychomotor, social, self-

care, and occupational skills.
5. Family therapy to help parents develop coping skills and deal with guilt or anger.
Prevention
1. Primary prevention
 Preconception
 During gestation
 At delivery
 Childhood
2. Secondary prevention
3. Tertiary prevention
PERVASIVE DEVELOPMENTAL DISORDERS
 The term Pervasive Developmental Disorder(PDD) refers to a group of disorders

characterized by abnormalities in communication and social interaction and by
restricted repetitive activities and interests.
 Usually development is abnormal from infancy and most cases are manifest before
the age of 5 years.
PDD includes:
1. Childhood autism
2. Atypical autism
3. Rett‘s syndrome
4. Asperger‘s syndrome
5. Childhood disintegrative disorder and other PDD‘s
Prevalence

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 Prevalence is 4-5/10,000 in children under 16 years of age.
 Male to female ratio is 4 or 5 to 1.
 This disorder is evenly distributed across all socio-economic classes.
1. Childhood Autism or Autistic Disorder
Characteristics of Autistic disorder are:
 In appropriate responses to environment.
 Pronounced impairments in language, communication, and social interaction.
 Repetitive interest and behaviors.
 Difficulty understanding feelings of others and world around them.
 Disordered thinking.
 Repetitive, self-injuries, or other abnormal behaviors.
Etiology
 Genetic factors
 Siblings of autistic children show a prevalence of autistic disorder of 2 percent.
 Biochemical factors
 At least 1/3rd of patients with autistic disorder have elevated plasma serotonin
 Medical factors
 Early developmental problems such as postnatal neurological infections(meningitis,

encephalitis), congenital rubella.
 Perinatal factors
 Maternal bleeding after the first trimester
 High medication usage during pregnancy in mothers of autistic children.
Symptoms

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1. Behavioral characteristics
2. Communication and language
3. Activities
Course and treatment
Long course.
 About 10-20% autistic children begin to improve between 4 and 6 years of age and
attend on ordinary school and obtain work.
 10-20% can live at home, but need to attend a special school or training center.
 60% improve little and unable to lead an independent life.
Treatment
 Pharmacotherapy
 Behavioral methods
 Special schooling
2. Atypical Autism
 A pervasive developmental disorder that differs from autism in terms of either age
of onset or failure to fulfill criteria, i.e. disturbances in reciprocal social
interactions, communication.
 Atypical autism is seen in profoundly retarded individuals.
3. Rett’s Syndrome
 A condition of unknown cause, reported only in girls.
 Characterized by apparently normal or near normal early development which is

followed by partial or complete loss of acquired hand skills and of speech,
together with deceleration in head growth .

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 Onset between 7 and 24 months of age.
4. Asperger’s Syndrome
 Characterized by severe and sustained abnormalities of social behavior similar to

those of childhood autism.
 Stereotyped and repetitive activities and motor mannerisms such as hand and
finger-twisting or whole body movements.
 It differs from autism in that there is no general delay or retardation of cognitive

development or language.
5. Childhood disintegrative Disorder
 Behavioral symptoms such as anxiety, anger, or outbursts.
EMOTIONAL DISORDERS
 When a child is described as having an emotional disorder this means that he/she
has a diagnose /diagnosable disorder of mood or anxiety.
 Characterized by Emotional distress that last, either continually or intermittently,

for a period of months/years.
Emotional disorders include:
ADHD
Autism
Bipolar Mood Disorder
Anxiety Disorder
1. Attention-Deficit/Hyperactivity Disorder
 Children or adults with ADHD show the behavioral characteristics of

impulsivity(or motor hyperactivity), the cognitive characteristics of inattention or
both.
Symptoms
 Motoric hyperactivity

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 Impulsivity
 Inattention
Etiology
 Genetic factors
◦ The family transmission of ADHD is prominent in males.
 General medical factors

◦ Streptococcal infection, resistance to thyroid hormone, hyperthyroidism
occasionally constipation.
 Neuromedical factors
◦ Brain damage (often frontal cortex), neurological disorders, low birth weight.
Treatment
 Behavioral therapy
 Relaxation training
2. Bipolar Mood Disorder
 Characterized by recurrent episodes of mania and depression in the same patient at

different times.
 Onset occurs between ages 20 and 30.
 Symptoms sometimes appear in late childhood or early adolescence.
Symptoms
Manic phase Depressive phase
 Grandiose or hyperirritable mood Low self-esteem
 Increased psychomotor activity Feelings of hopelessness
 Rapid speech with frequent topic changes Suicidal ideation
 Decreased need for sleep and food Anhedonia

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 Impulsivity Psychomotor retardation
Etiology
o Precise cause unknown
o Genetic, biochemical and psychological factors may play a role.
o Triggered by stressful events, antidepressant use
o Sleep deprivation and hypothyroidism
Course
 An average manic episode lasts for 3-4 months, while depressive episode lasts for
4-9 months.
Treatment
 Lithium
 Valporic acid
 Carbamazepine
 Antidepressants
 Antipsychotics
3. Anxiety disorder
 Normal anxiety becomes pathological when it causes significant subjective

distress and/or impairment in functioning of an individual.
Two types of anxiety:
1. Trait anxiety
 This is a habitual tendency to be anxious in general.
 Exemplified by ‗I often feel anxious‘.
2. State anxiety
 This is the anxiety felt at the present, cross-sectional moment.

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 Exemplified by ‗I feel anxious now‘.
Symptoms
Physical symptoms
A. Motoric symptoms
B. Autonomic and Visceral symptoms
Psychological symptoms
A. Cognitive symptoms
B. Perceptual symptoms
C. Affective symptoms
D. Other symptoms
Treatment
1. Psychotherapy
2. Relaxation techniques
3. Other behavior therapies
4. Drug treatment

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Module 5 : Schizophrenia & Mood Disorders
SCHIZOPHRENIA
Major psychotic disorder
Definition
A biologically-based, psychosocially influenced disorder of unclear pathogenesis and
heterogeneous presentation, usually with a chronic, relapsing and remitting course, and
Profound bio psychosocial complications requiring a comprehensive treatment approach
History
�Emil Kraeplein:
Classified mental illness into three groups
 Dementia praecox
 Manic- depressive psychosis
 Paranoia
�Eugene Bleuler- Swiss psychiatrist
• Coined the term schizophrenia – no association with thought, feelings and
behaviour
Suggested primary symptoms
4 A‘s of Bleuler
Disturbance in
 Association
 Affect
 Autism
 Ambivalence
• Kurt Schneider – First rank symptoms of schizophrenia
 Audible thoughts
 Voices heard arguing
 Voices commenting on one‘s action
 Thought withdrawal
 Thought insertion
 Thought diffusion or broadcasting

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FRS
• Made feelings or affect
• Made impulses
• Made volition or acts
• Delusional perception
• Somatic passivity
Clinical features
 Thought & speech disorders
o Autistic thinking
o Loosening associations
o Thought blocking
o Thought alienation – thought insertion, withdrawal etc.
o Neologisms
o Perseveration, echolalia,
o Poverty of speech, poverty of thought
 Delusions
o Delusions of persecution, reference, grandeur, delusion of control, somatic
delusions etc
 Disorders of perception
o Hallucinations, illusions
 Disorders of affect:
o apathy, emotional blunting , Anhedonia,
 Disorders of motor behaviour
o Decreased or increased psychomotor activity
o Mannerisms, stereotypes
o Catatonic features
 Negative symptoms
o Affective blunting
o Apathy- lack of initiative

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o Anhedonia
o Social withdrawal
Other features
o Impaired social, occupational functioning
– Absent insight
– No disturbance of consciousness, orientation, memory and intelligence
– Suicide can occur during illness
Signs and Symptoms
 Positive
 Negative
 Cognitive
Positive Symptoms:
Hallucinations
• Auditory
• Visual
• Tactile
• Olfactory
• Gustatory
Delusions
• Fixed, false belief held despite negative evidence, and not consistent with
cultural norms
 Thought
 Conviction
 Over-valued
 Idea
 Delusion
• Bizarre vs. non-bizarre

• Mood congruent vs. mood incongruent
• Systematic vs. non-systematic

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 Paranoid/persecutory - nihilistic
 Grandiose `- somatic
 Jealous - referential
 Erotomanic - control
- thought interference
Disorganized Thought
• Circumstantialities - incoherence
• Illogic - blocking
• Tangentiality - neologisms
• Loose associations - clanging
• Flight of ideas
We see the stately dimension of godly bliss that Marlowe‘s dOctOr fAUstUs dies and
Lives. Lucifer—oh Lucy, luck, lackluster, lazy Lucifer—devilishly adorns all
sanctifarious, all beauty, all evil. Our world dissolves into SACRED nihilism.
• Circumstantiality
• Tangentiality
• Loose Associations
Disorganized Behavior
• Catatonia
– Motoric immobility
– Repetitive, purposeless movements
– Extreme negativism or mutism
– Abnormal voluntary movements
– Echolalia/echopraxia

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Negative Symptoms
 Amotivation
 Alogia
 Flat affect
 Social isolation
Cognitive Symptoms
 Poor attention
 Poor working memory
Epidemiology
• 1% of general population estimated to have schizophrenia
• Age of onset
20- 25 – males
25-35 for females
• Male and female equally vulnerable 50% commit suicide

Familial
– Twin concordance
(MZ45%:DZ20%)
– 10% if first degree relative
– 3% if second degree relative
Classification:
 Paranoid schizophrenia
 Hebephrenic schizophrenia
 Catatonic schizophrenia
 Residual schizophrenia
 Simple schizophrenia
 Post schizophrenic depression
 Schizophrenia unspecified

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Paranoid schizophrenia
 Delusions of persecution, reference, exalted birth, special mission etc(
suspiciousness)
 Hallucinatory voices that threaten the patient or give commands or auditory
hallucinations without verbal form
 Hallucinations of smell, taste sexual or other bodily sensations
Catatonic schizophrenia
 Prominent psychomotor disturbances
 Stupor
 Excitement
 Negativism
 Rigidity
 Waxy flexibility
 Command automatism
Hebephrenic schizophrenia
 Affective changes prominent
 Delusions and hallucinations fleeting and fragmentary
 Behaviour unpredictable and mannerisms common
 Disorganized thought
 Tendency to remain solitary
 starts in adolescence
 Negative symptoms prominent
Simple schizophrenia
 Uncommon category
 Delusions and hallucinations not marked
 Withdrawn
 Gradual decline of performance
 Aimless activities
 Closely related to residual type

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Post schizophrenic depression

 Patient has had schizophrenic illness within the last 12 months
 Some shiz. Symptoms still present
 Depressive symptoms are prominent , fulfills criteria for depressive episode
Residual schizophrenia
 Prominent negative schizophrenic symptoms
 Clear evidence of one episode of schizophrenia in the past
 A period of at least one year were florid positive symptoms were absent
Etiology
 Biologically-based
 Psychosocially-influenced
 Heterogeneous
 Multifactorial
 Genetics Environment
 Predisposition Precipitant
Family theories
 Downward drift hypothesis
 Double bind communication
 Scizophrenogenic mother
 Marital schism –conflict
 Marital skew – conflict , seek support of child making one partner isolated
 Scapegoating
 Expressed emotions- hostility, emotional over involvement, criticality
 Pseudo mutuality and pseudo hostility
Biological
• Genetic: 10% of first degree relatives, 3% of second degree relatives Concordance

rate of monozygotic twins- 46%

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• Neuro chemical : increased dopamine discharge in the brain

Treatment Principles
 Disease management
 Rehabilitation/recovery
 Continuum of care
 Integration/coordination
 Pharmacotherapy: essential but insufficient
Management
• Chemotherapy/psychopharmacological:
� Antipsychotic medicines:
Atypical :eg.respiridone, olanzapine, clozapine
traditional: haloperidol, chlorpromazine
� ECT- indicated for catatonic stupor, severe side effects with drugs, uncontrolled with
drugs etc.
Psychosocial
– Psycho education
– Group psychotherapy – social skills training
– Family therapy
– Individual psychotherapy ( sometimes cognitive)
– Psychosocial rehabilitation
Relapse Triggers
• Non-adherence to treatment
• Inadequate life support
• Inadequate socialization/recreation
• Substance abuse
• High expressed emotion

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Favorable Prognostic Signs

• Acute onset
• Precipitant
• Female
• Good premorbid functioning
• Few negative/cognitive symptoms
• Developing country
• Supportive family with low expressed emotion
• Catatonia
Complications
• Socioeconomic
• Educational
• Occupational
• Legal/violence
• Medical
• Family/interpersonal
Conclusions
SCHIZOPHRENIA is… a biologically-based, psychosocially influenced disorder of
unclear pathogenesis and heterogeneous presentation, usually with a chronic, relapsing
and remitting course, and profound bio psychosocial complications requiring a
comprehensive treatment approach
Delusional disorder
 Persistent delusions of persecution, grandeur, infidelity, somatic delusions,
erotomanic delusions
 Absence of significant or persistent hallucinations
 Absence of schizophrenia, organic disorders and mood disorders
 Personality disturbed in delusional area near normal in other areas

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 Delusions are no bizarre and well systematized

 Appropriate affect
MOOD (Affective) DISORDERS

Includes mania and depression
MANIA- Clinical features
Elevated, expansive, irritable mood
o Euphoria – mild elevation of mood – increased sense of well being and
happiness not in keeping with the ongoing events- seen in hypomania
o Elation – moderate elevation of mood – feeling of confidence and enjoyment
along with increased psychomotor activity – seen in mania
o Exaltation – severe elevation of mod- intense elation with delusions of
grandeur – severe mania
o Ecstasy – very severe elevation of mood – intense sense of rapture or
blissfulness- seen in mania with psychotic symptoms.
 Psychomotor activity
– Increased psychomotor activity ranging from overactiveness and restlessness to manic
excitement (involved in ceaseless activity)
 Speech and Thought – more talkative, thoughts racing in mind, pressure of speech,
uses playful language with punning, rhyming etc., flight of ideas, delusions of
grandeur with inflated self esteem
 Distractibility common
o Goal directed activity: tries to do many things at one time, plans and executes
multiple activities
o Increased sociability even with unknown people
o Impulsive and shows disinhibition
Biological functioning
• Sleep reduced with decreased need for sleep
• Appetite increased and decreased food intake due to over activity later

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• Increased libido
Hypomania
 Lesser degree of mania
 Euphoric mood
 Inflated self-esteem or grandiosity
 Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
 More talkative than usual or pressure to keep talking
 Flight of ideas or subjective experience that thoughts are racing
 Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli)
 Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation
 Excessive involvement in pleasurable activities that have a high potential for
painful consequences (e.g., the person engages in unrestrained buying sprees,
sexual indiscretions, or foolish business investments).
 The disturbance in mood and the change in functioning are observable by others.
 The episode is not severe enough to cause marked impairment in social or
occupational functioning, or to necessitate hospitalization, and there are no
psychotic features.
Mania without psychotic symptoms
o Mood elevated to the extent that it does not keep the person in touch with reality-
elated mood
o Inflated self-esteem or grandiosity
o Often accompanied by increased energy level, over activity, and pressure of
speech-flight of ideas
o Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli)
o Lavish spending, increased religiosity
o Sometimes becomes aggressive

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o The episode is severe enough to cause marked impairment in social or

occupational functioning, or necessitate hospitalization, and there are no psychotic
features
o Exalted or ecstasy mood
o Grandeur idea comes to delusional stage
o Irritability and suspiciousness
o Pressure of speech and flight of ideas lead to incoherent speech
o Excitement results in aggression
o Incongruent mood – Lability present
DEPRESSION
Clinical Features
Depressed Mood
• Sadness of mood
• Loss of interest and/or pleasure in almost all activities
• Easy fatigability
Depressive ideation
 Hopelessness, helplessness, worthlessness
 Difficulty in thinking, concentration, indecisiveness, slowed thinking, subjective
poor memory, lack of initiative and energy
 Suicidal ideas/death wishes
Psychomotor activity:
o slow thinking and activity, decreased energy and monotonous voice
o Agitation common in older patients
o Somatic symptoms: ( ICD 10)
Biological functioning:
o Decreased sleep, early morning awakening sometimes hypersomnia
o Significant decrease in appetite or weight
o Diurnal variation with depression worst in the morning time

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Psychotic features:
o 15-20% depressed patients have delusions(nihilistic, delusion of guilt, delusion of
poverty etc.) hallucinations
• Bipolar affective disorder

 Recurrent episodes of mania and depression in the same patient at different times
(can occur in any sequence)
 Patients with recurrent episodes of mania
• Recurrent depressive disorder
 At least two episodes of depression (Unipolar depression)
Etiology
Genetic:
 Lifetime risk of first degree relatives with BPAD is 25%
 Children with one parent having disorder – life time risk is 27%
 Children with both parents with mood disorders – life time risk 74%
 Concordance rate of monozygotic twins – 65%
Neuro chemical:
 Functional increase or decrease of amines
 Endocrine function disturbed in depression
Psychosocial factors:
 Exposure to Life events can trigger affective disorders
 Children who lose their mothers at young age
 People with Histrionic and obsessive compulsive personality at risk of developing
affective disorders
Treatment:
o Chemotherapy:
o Mood stabilizers: eg. Lithium carbonate, carbamazepine, sodium valproate
o Antidepressants: eg. Imipramine, amitriplin, sertralin, fluoxetine
o Antipsychotics: eg. Respiridone, olanzapine

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o Electro Convulsive Therapy; indicated for depression with suicidal risk,

delusional depression, mania with severe excitement
o Psychosocial interventions:
• cognitive therapy
• behavior therapy
• group therapy
• psycho education

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Module 6 : Mental Health Policies & Treatment Approaches
NATIONAL MENTAL HEALTH PROGRAMME
Aims of mental health services

• Prevention and treatment of mental and neurological disorders
• Use of mental health technology to improve general health services
• Application of mental health principles in total national development to improve
Quality of life
Present situations of mental health services

• 10-20 per 1000 affected with serious mental disorder at any point of time
• 20,000 beds in 42 mental hospitals
• 2000-3000 beds in general and teaching hospitals
• Half of these beds are occupied by chronic long term patients
• Not more than 10% of those requiring urgent help are receiving services of existing
facilities
• 900 qualified psychiatrists
• 400-500 cps
• 200-300 psws
• 600 psy. Nurses
• Majority located in urban areas
Objectives
• To ensure availability and accessibility of minimum mental health care for all in the
Foreseeable future, particularly to the most vulnerable and underprivileged sections of the
society
• To encourage application of mental health knowledge in general health care and in
social development
• To promote community participation in the mental health service development and to
Stimulate efforts towards self help in the community
Approaches
• Diffusion of mental health skills to the periphery of the health service system
• Appropriate appointment of tasks in mental health care
– chv – liaison between care system and community – identification and referral
• supervise follow up of patients
– mpw – first aid and follow up
– hi – early recognition and management of priority psychiatric conditions
– mo – overall supervision
• Equitable and balanced territorial distribution of resources
• Integration of basic mental health care into general health services
– focus on psychosocial factors contributing to ill health

87
• Linkage to community development

– Involvement of district, block and local leadership to mental health care
Mental health care

– Three sub programmes
• Treatment
• Rehabilitation
• Prevention
• Mental health training
• Mental retardation and drug dependence
Outline plan of action

• needs for cooperation and coordination
– Social welfare
– Schools
– ICMR
Objectives
1. To ensure availability and accessibility of minimum mental health care for all in the
foreseeable future, particularly to the most vulnerable and underprivileged sections of
population.
2. To encourage application of mental health knowledge in general health care and in
social development.
3. To promote community participation in the mental health services development and to
stimulate efforts towards self-help in the community.
Strategies
1. Integration mental health with primary health care through the NMHP;
2. Provision of tertiary care institutions for treatment of mental disorders;
3. Eradicating stigmatisation of mentally ill patients and protecting their rights through
regulatory institutions like the Central Mental Health Authority, and State Mental health
Authority.

88
Advantages
 Help national development on a broader perspective
 Incorporates multidimensional concept of mental health
 Efficient & effective delivery through inter-sectoral collaboration
 capacity to accommodate extra work
 Responds to community needs
 Cost effective in long run of programmes
 Holistic approach to mental health
Disadvantages
 Sometimes fail to target priority effectively
 Complex programming may lead to more failure
 Lack of expertise in integrated programme management
MENTAL HEALTH ACT 1987
Aim
 To consolidate and amend the law relating to the treatment
 And care of mentally ill person.
 To make better provisions with respect to their property and
 Affairs and for matters connected herewith or incidental
 There too.
 It has 10 chapters

89
Chapters of the Act
Preliminary
Mental Health Authorities
Psychiatric Hospitals and Psychiatric Nursing Homes
Admission and detention in psychiatric hospital or psychiatric nursing home
Inspection, Discharge, leave of absence and removal of mentally ill persons
Judicial inquisition regarding alleged mentally ill person possessing property,

custody of his person and management of his property
Liability to meet cost of maintenance of mentally ill persons detained in

psychiatric hospital or psychiatric nursing home
Protection of Human Rights of mentally ill persons
Penalties and Procedures
Miscellaneous
Objectives of the Act
To regulate admission to Psychiatric Hospitals and Psychiatric Nursing Homes
To protect society from the presence of mentally ill persons
To protect citizens being detained in psychiatric hospitals without sufficient cause
To regulate responsibility for maintenance charges of mentally ill persons
To provide facilities for establishing guardianship or custody of mentally ill

persons
To provide for the establishment of Central State Authorities for Mental Health
Services
To regulate the powers of Government for establishing, licensing and controlling

psychiatric hospitals and nursing homes
To provide legal aid to mentally ill persons

90
Mentally ill person means:
― A person who is in need of treatment by reason of any mental disorder other than
mental retardation‖ (Section 2(l)
Important sections of the Act
State Mental Health Authority under subsection 1 of section 4
Establishment and maintenance of psychiatric hospitals under section 5
License for psychiatric hospitals and nursing homes (sec 6 –sec 12)
Inspection of psychiatric hospitals, sec 13
Treatment of outpatient, sec 14
Reception order, sec 20
Medical certifications, sec 21
Powers and duties of a police officer in respect of certain mentally ill persons, sec
23
Order of discharge, sec 40-44
Application for judicial inquisition, sec 50
Provision for appointing guardian or manager, sec 52-69
Cost of maintenance to be borne by Government in certain cases, sec 78
Persons legally bound to maintain mentally ill person not absolved from such
liability, sec 80
Protection of Human Rights of mentally ill persons, sec 81
Penalty for psychiatric hospitals and nursing homes functioning in contravention

of chapter III
Pension etc. of mentally ill person payable by Government, sec 90
Legal Aid to mentally ill persons at state expense, sec 91
Protection of Action taken in good faith, sec 92

91
Power of central Government to make Rules
MENTAL HEALTH CARE ACT 2010
27 December 2010
The Act seeks to bring in a comprehensive law to safeguard the rights and interests of
persons with mental illnesses. Provisions include medical insurance cover, RTI with
regards to treatment and ability to take action against inhuman treatment.
• In a first in the country, the treatment of the mentally ill may soon come under the
health insurance cover. This is part of the comprehensive legislation the Union
health ministry is planning to protect the rights of persons suffering from mental
illness.
• At present, the health insurance schemes do not cover any mental illness,
psychosomatic dysfunction or problems connected to psychiatric conditions,
disorganisation of personality or mind even if it is caused or aggravated by
accident.
• Under Section 10 — right to equality and non-discrimination — of the proposed
Mental Health Care Act (MHCA) 2010 prepared by the health ministry, persons
with mental illness will have to be treated as equal to persons with physical illness
in the provision of all healthcare. Accordingly, the public and private insurance
providers shall make provisions for medical insurance for treatment of mental
illness on the same basis as is available for treatment of physical illness, failing
which will be seen as discrimination.
• ―Families get wiped away under financial burden and debt while taking care of
treatment of persons with mental illness. Mental health has to be treated like any
other illness, hence, it has to be covered under insurance,‖ said Dinesh Trivedi,
minister of state for health and family welfare.
• The draft of the MHCA says the proposed legislation aims to regulate and improve
accessibility to mental healthcare by mandating sufficient provision of quality
public mental health services. Besides banning certain acts like chaining or giving
electric shocks without anaesthesia, the proposed act also encourages people to
come forward and report inhuman treatment of such persons in the neighbourhood.
• The ambit of Right to Information will be extended to persons with mental illness
and their families to seek information with regard to their treatment etc and they
can make complaints against care givers.
The government has acknowledged that the previous law, Mental Health Act
(MHA) 1987, failed to protect the rights of mentally ill persons. The updated,
amended and comprehensive law is more rights based. It prohibits discrimination

92
of persons with mental illness and aims to ensure the environment around such
persons is conducive to facilitate recovery, rehabilitation and full participation in
society.
• Accordingly, such persons need to be provided treatment in a manner which helps
them live in the community and with their families. Long-term hospital-based
mental health treatment shall be used only in exceptional circumstances, for as
short a duration as possible, and only as a last resort when other means have
failed.
No person with mental illness can be kept in a mental health facility merely
because he/she does not have a family, is not accepted by them, or is homeless. In
such cases, the government will provide for halfway homes, group homes, etc, for
persons who no longer require treatment in a more restrictive mental health
facility, the draft act prescribes.
• Similarly, they cannot be subjected to any cruel, inhuman or degrading treatment
in a mental health facility, including the compulsory tonsuring. Patients can be
allowed to wear own personal clothes too.
• Besides, electro-convulsive therapy without the use of muscle relaxants and
anaesthesia, electro-convulsive therapy for minors, sterilisation of men or women,
and chaining will be prohibited treatments. In fact, physical restraint or seclusion
can only be used when it is the only means to prevent imminent and immediate
harm to person concerned or to others, that too if it is authorised by the
psychiatrist in charge of the person‘s treatment.
Every mentally ill person will have a right to make an ‗advance directive‘ in
writing, specifying the way he/she wishes to be cared for and treated for a mental
illness. This directive can be made by a person irrespective of their mental illness
history. However, it shall not apply to any emergency treatment.
• Mental illness shall be determined in accordance with nationally and
internationally accepted medical standards of the World Health Organisation.

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1

Master of Social Work - III Semester

Module 1 Psychiatry & Psychiatric Assessment

Psychiatry - Definition, History and Growth of Psychiatry, Traditional; and

Assessment in psychiatry: Psychiatric interviewing - Content, types,

Module 2 Overview of Clinical Psychopathology

Disorders of perception, thought, speech, memory, emotion, experience of

Module 3 : Neurotic and Behavioural Syndromes

Prevalence, etiology, clinical manifestation, course and outcome and

Social - Cultural factors in psychiatric disorders with special reference to

Behavioural syndrome associated with physiological disturbances and

Module 4 : Psychological Disorders

Prevalence, etiology, clinical manifestation, course and outcome and

Deleena Francis (11TH Batch)

Organic Disorders – Dementia, Delirium

Module 5 : Schizophrenia & Mood Disorders

Prevalence, etiology, clinical manifestation, course and outcome and

Schizophrenia, schizotypal and delusional disorders

Mood [affective] disorders – Mania & Depression

Module 6 : Mental Health Policies & Treatment Approaches

Mental Health Policies and Programmes: Merits and demerits - National

Deleena Francis (11TH Batch)

Module 1 Psychiatry & Psychiatric Assessment

Begin at the beginning

Not all good

• Could have been labelled witches, possessed, or imprisoned or executed for

What was it like then?

• Different presentations of mental illness – less learning disability, no

• No asylums until 8th century. None in Britain until 1300‘s.

• Pre medicine illness, including mental illness thought to be related to spiritual

Deleena Francis (11TH Batch)

• Black bile: earth, cold and dry, associated with melancholia.

• Yellow bile: fire, hot and dry, associated with mania.

• Needed to rebalance the humors to cure people – warm, cold, purging,

Weird and wonderful

• Both physical and spiritual causes proposed.

• Many advances in medicine, including in mental illness.

Middle ages in Britain

• Outpatient work and community care developed

Deleena Francis (11TH Batch)

• New treatments developed, others diminished (ECT, psychosurgery, sterilisation).

o Community care developed.

o Person centred approaches

o Increased rights in law

o Reduced hospital admissions

o Debate on formulation vs. diagnostics

Early Age- Era of superstitions

Dark period of middle age- return of supersitionAge – Return

Deleena Francis (11TH Batch)

� mentally ill tortured –burning alive, cutting of tongue etc.

Emergence of modern thought-era of modern medicine Emergence of modern Th

Deleena Francis (11TH Batch)

Deleena Francis (11TH Batch)

� Self-revelation: limited, discreet self disclosure may be useful to keep the

Case History and Mental Status Examination

Deleena Francis (11TH Batch)

� Family history of any psychiatric illness

Mental Status Examination

� General appearance and behavior: Well kempt/ill kempt, cooperative or not