Mental health ha
-First mental health service started NEPAL in BIR HOSPITAL as a OPD basis -1961 A.D
-In 1965- BIR hospital arranged 5 bedded wards.
-In 1971-BIR hospital again increases bed from 5 to 12 bedded ward.
-In 1985 A.D First mental hospital established in Lagan Khel (Patan mental hospital)
-First mental health policy established at 2052 B.S
-New mental health policy established-2073B.S
-World Mental health day-10th October
Mental Health
Mental health is defined as an adjustment of human beings to the world and to each other with a maximum of effectiveness and happiness.
Characteristics of a mentally healthy person:
o Ability to make adjustments.
o Sense of personal worth, feels worthwhile and important.
o Solves problems largely by own effort and makes own decision.
o Sense of personal security and feels secure in a group, shows understanding of other people’s problems and motives.
o Sense of responsibility.
o Give and accept love.
o Lives in a world of reality rather than fantasy.
o Shows emotional maturity in his behavior, according to their age development
o Have a philosophy of life means person have aim in life.
o Have variety of interest
o Normal ADL (activity of daily living)
SYMPTOM OF MENTAL ILL PERSON:
o Feeling anxious or worried.
o Feeling depressed or unhappy
o Emotional outbursts
o Sleep problems
o Weight or appetite changes
o Quiet or withdrawn
o Feeling guilty or worthless
o Confused thinking or reduced ability to concentrate
o Excessive fears or worries, or extreme feelings of guilt
o Extreme mood changes of highs and lows
o Withdrawal from friends and activities
o Significant tiredness, low energy or problems sleeping
o Detachment from reality (delusions), paranoia or hallucinations
o Inability to cope with daily problems or stress
o Trouble understanding and relating to situations and to people
o Problems with alcohol or drug use
o Major changes in eating habits
o Sex drive changes
o Suicidal thinking
PSYCHOLOGY:
-In ancient period psychology is derived from Greek word; psyche(soul) and logos(study). Aristotle and Rudolph Gackle defined psychology is a study of soul.
-Later it was changed by Wilhelm Wundt and William James, they defined
Psychology is a study of human behavior.
-Father of psychology is -Wilhelm Wundt
-Father of psychoanalysis is- Sigmund Freud.
CLASSIFICATION OF MENTAL DISORDERS
ICD10 (International Statistical Classification of Disease and Related
Health Problems) – 1992:
F00-F09 Organic, including symptomatic, mental disorders
F10-F19 Mental and behavior disorders due to psychoactive substance use
F20-F29 Schizophrenia, schizotypal and delusional disorders
F30-F39 Mood [affective] disorders
F40-F49 Neurotic, stress-related and somatoform disorders
F50-F59 Behavioral syndromes associated with physiological disturbances and physical factors
F60-F69 Disorders of personality and behavior in adult persons
F70-F79 Mental retardation
F80-F89 Disorders of psychological development
F90-F98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence
F99 Unspecified mental disorders".
2.According to DSMIV (Diagnostic and statistical manual)
It has 5 axis:
Axis
I: Clinical Disorders (all mental disorders except Personality Disorders and Mental Retardation)
Axis II: Personality Disorders and Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and environmental problem
Axis V: Global Assessment of Functioning (Psychological, social and job-related functions are evaluated on a continuum between mental health and extreme mental disorder)
Difference between Psychosis and neurosis:
Psychosis: a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality.
Treated with Antipsychotic, antidepressant and ant manic drug with ECT and other therapy
Neurosis: a relatively mild mental illness that is not caused by organic disease, involving symptoms of stress (depression, anxiety, obsessive behavior, hypochondria) but not a radical loss of touch with reality.
Treated by Therapies sometime they need Anti-anxiety drug.
Psychosis
This is a symptom of a disorder
A person has lost touch with reality
Hallucinations and delusions illusion are common
There is no insight and empathy (feeling for other)
Causes severe impairment of everyday functioning
Higher risk of self-harm, always affect personality
Example-schizophrenia, bipolar disorder, Mania, depression
It changes the anatomical structure and functionalities of the neuro-cerebral substance.
Is treated with antipsychotic medications, antimanic anti depressive
Drug and ECT (Electroconvulsive therapy) and psychotherapy.
Neurosis
This is a group of disorders
A person has not lost touch with reality
Hallucinations and delusions are not present/only fear, anxiety, stress is common
Present empathy and insight
Causes mild impairment of everyday functioning
Lower risk of self-harm, no affect in personality
Example-anxiety, panic disorder, phobia, conversion disorder, obsessive compulsive disorder
Not any changes brain function and structure.
Treated by anti-anxiety drug and psychotherapy (behavior therapy, cognitive therapy, group therapy, Counseling, social support.
DISEASE CONDITION:
•SCHIZOPRENIA:
Skhizo-splitted
Phren-Mind/personality
Schizophrenia is a chronic and severe psychotic mental disorder that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality.
Cause:
-Genetics (heredity)
-Neurotransmitters-increase dopamine, serotonin level
-Environment: Things like viral infections, exposure to toxins like marijuana, or highly stressful situations
-screenful childhood period
-child birth from consanguineous marriage
TYPES:
1.Paranoid- Delusional suspicious
2.Hebephrenic-Disorganized type means person cannot organize himself as an accepted manner like Cannot able to do ADL
3.Catatonic-Motor disturbances mostly
2 types:
a. over active
b. stupor-not able to stand
4.Undiffrentiated: Unable to diagnose
5.Residual: At least one symptom presents in the past
6.Simple-Early
Sign and symptom:
• Delusion
• Hallucination
• Illusion
• Thought block
• Echolalia or echopraxia
• Loss of insight, judgement, ego boundaries
• Anhedonia
• Suicidal attempts
• Increase or decrease activity
• Neologism
• Verbigeration (repetition of senseless word or phrases)
Management
-Antipsychotic drug
Chlorpromazine
Triflupromazine
Fluphenazine
Haloperidol
Clozapine
Risperidone
Olanzapine
Adverse effect: Main
EPS (Extra pyramidal syndrome): It cause psychomotor problem that is:
a. akathisia-feeling of muscular discomfort
b. dystonia-slow sustained muscular movement
c. dyskinesis-abnormal irregular chorionic movement
d. neuroleptic induced parkinsonism-rigidity, tremors, bradykinesia, stooped posture, ataxia.
It treated by Anti-Parkinson drug: Carbidopa, Levodopa, Trihexyphenidyl Selegiline
-ECT
-Other therapies according to situation (Mostly Cognitive therapy)
MOOD DISORDER:
MANIA
-Mental illness marked by periods of great excitement or euphoria, delusions, and overactivity.
Cause
-neurotransmitter- increase serotonin, dopamine
-high levels of stress.
-changes in sleep patterns or lack of sleep.
-using recreational drugs or alcohol.
-Family history
Sign and symptom
• Grandiose beliefs.
• Inappropriate elation or euphoria.
• Inappropriate irritability.
• Flight of ideas
• Pressure of speech
• Inappropriate social behavior.
• Increased sexual desire.
• Increased talking speed or volume.
• Markedly increased energy.
• Decrease need for sleep (less than 3 hour)
• Weight loss
Management:
Antimanic or mood stabilizing drug
-Lithium
-Carbamazepine
-Sodium Valproate(antiepileptic drug)
Note: Lithium toxic level in blood-more than 2 mEq/L
ECT
Other therapy according to situation
DEPRESSION
-It is a state of low mood activity that can affect a person’s thoughts, behavior, feeling and sense of well-being which lead helplessness, hopelessness, worthlessness.
-mostly seen in Female
-main reason for Suicide
Main cause
-Disfunction of Hypothalamic-Pituitary-Adrenal Axis
-Loss of loved object
-Repeated losses in past
-Fixation in oral sadistic phase
Sign and Symptom
• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness, or pessimism
• Irritability
• Feelings of guilt, worthlessness, or helplessness, hopelessness
• Loss of interest or pleasure in hobbies and activities
• Decreased energy or fatigue
• Moving or talking more slowly
• Feeling restless or having trouble sitting still
• Difficulty concentrating, remembering, or making decisions
• Difficulty sleeping, early-morning awakening, or oversleeping
• Appetite and/or weight changes
• Thoughts of death or suicide, or suicide attempts
• Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment
Management:
-Antidepressant Drug
A) Tricyclic antidepressant:
• Imipramine
• Clomipramine
• Amitriptyline
B) SSRIs (Selective Serotonin Reuptake Inhibitor):
• Sertraline
• Fluoxetine
C) Atypical Antidepressant:
• Amineptine
D) MAOIs (Monoamine Oxidase Inhibitors):
• Trazodone
• Isocarboxazid
-ECT
-Therapies according to situation
Neurotic Stress related Disorders
PHOBIA:
-It is an unreasonable fear of a specific object, activity or situation.
-Phobia is a reaction but anxiety is response.
Types:
Acrophobia – The fear of heights.
Agoraphobia – The fear of open or crowded spaces, or fear of being in places away from familiar setting which result confinement to home or avoidance of public places.
Social phobia-Fear of performing activities in familiar setting or interacting with people
Cynophobia – The fear of dogs.
Claustrophobia – The fear of small or closed spaces.
Hemophobia – The fear of blood. Even the sight of blood can cause fainting.
Pyrophobia – The fear of fire. A natural/primal fear that can be debilitating.
Iatrophobia – The fear of doctors.
Algophobia-Fear of pain
Zoophobia-Fear of animals
Thalassa phobia-Fear of Sea
Management of PHOBIA-
1.Antianxiety drugs
Ethanol
Midazolam
Alprazolam
Diazepam
Lorazepam
2.Behaviour therapy: Behavioral therapy is a term that describes a broad range of techniques used to change maladaptive behaviors. The goal is to reinforce desirable behaviors and eliminate unwanted ones.
a. Desensitization-
This is done by progressively or gradually exposing you to your fears in a safe setting.
b. Flooding-exposed directly to a maximum-intensity anxiety-producing situation or stimulus,
c- Positive reinforcement-providing positive things to change behavior like reward.
PTSD: Post Traumatic Stress Disorder
Posttraumatic stress disorder
(PTSD) is a mental disorder
that can develop after a person is exposed to a traumatic event, such as sexual assault, warfare, traffic collisions, earthquake, floods or other threats on a person's life that lead re-experiences of imaged of stressful event and avoidance of reminder.
OCD (obsessive compulsive disorder)
-Obsessive-Compulsive Disorder (OCD) is a common, chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that he or she feels the urge to repeat over and over.
Obsessions are repeated thoughts, urges, or mental images that cause anxiety. Common symptoms include:
• Fear of germs or contamination
• Unwanted forbidden or taboo thoughts involving sex, religion, and harm
• Aggressive thoughts towards others or self
• Having things symmetrical or in a perfect order
Compulsions are repetitive behaviors that a person with OCD feels the urge to do in response to an obsessive thought. Common compulsions include:
• Excessive cleaning and/or handwashing
• Ordering and arranging things in a particular, precise way
• Repeatedly checking on things, such as repeatedly checking to see if the door is locked or that the oven is off
• Compulsive counting
HYPOCHONDRIASIS
Hypochondriasis or hypochondria (illness anxiety disorder) is a condition in which a person is excessively and unduly worried about having a serious illness.
Also called Doctor shopping disease.
SLEEPING DISORDER
• Somnambulism-sleep walking
• Somniloquy-sleep talking
• Narcolepsy-excessive day time sleepiness
• Bruxism-teeth grinding during sleep
EATING DISORDER
Pica –eating nonnutritive substance
Bulimia nervosa-binge(excess)eating with compensatory measure (self-inducing vomiting, use of laxative and diuretic) to having weight phobia. Major sign and symptom are sore throat, heartburn, tooth staining.
Anorexia nervosa-fasting or dieting for beauty consciousness.
SEXUAL DISORDER
Fetishism-Sexual arousal and satisfaction occur with a non-living object.
Transvestism-occurs by wearing clothes of opposite sex
Sadism-aroused by physically or psychologically humiliation, injury of the sexual partner
Masochism-aroused by physically or psychologically humiliation injury inflicted own self by others
Voyeurism-arousal and satisfaction occur by seeing naked person and images.
Frotteurism-aroused by act of touching and rubbing against opposite sex organ
Zoophilia-involve sexual activity with animal
Pedophilia-involve sexual activity with child
CHILDHOOD AND ADOLESCENT DISORDER
MENTAL RETARDATION:
-Intellectual disability (ID), once called mental retardation, is characterized by below-average intelligence or mental ability and a lack of skills necessary for day-to-day living. People with intellectual disabilities can and do learn new skills, but they learn them more slowly.
Normal IQ (Intelligence quotient) =90-110
THE MAJOR LEADING CAUSE OF MR:
-Trauma before birth, such as an infection or exposure to alcohol, drugs, or other toxins.
Hydrocephalus
-Trauma during birth, such as oxygen deprivation or premature delivery.
-Inherited disorders, such as phenylketonuria (PKU) or Tay-Sachs disease.
-Chromosome abnormalities, such as Down syndrome
Classification of MR-
Mild- 50-70
Moderate-35-50)
Severe-20-35
Profound-below 20
(Border line MR-70-90)
CHILDHOOD AUTISM:
Autism is a complex neurobehavioral condition that includes impairments in social interaction and developmental language and communication skills combined with rigid, repetitive behaviors. Because of the range of symptoms, this condition is now called autism spectrum disorder (ASD).
ADHD (ATTEINTION DEFICIT HYPERACTIVE DISORDER)
ADHD
is a chronic condition marked by persistent inattention, hyperactivity, and sometimes impulsivity. ADHD begins in childhood and often lasts into adulthood.
TERMINOLOGY:
-Echolalia-Repetitive repeating of words or phrases just spoken by someone else
-Echopraxia- Repetitive imitative of behavior
-Paralalia- continuous repetition of one word
-Extrapyramidal Symptoms (EPS)- Physical symptoms including tremors, slurred speech, dystonia, and anxiety that are side effects to neuroleptic drugs caused by effects on the basal ganglia and associated structures within the brain.
-Hallucination- It is false perception in absence of a stimulus, or It is the perception of a non-existent object.
Types:
a.Visual-vision
b.Auditory-hearing
c.Gustatory-taste
d.Tactile-touch
e.Olfactory-smell
-Illusions: A misconception, incorrect perception or misinterpretation of real environment.
Example: Seeing Snake for a Rope.
-Delusion: It is thought disorder. It is a false belief or thinking.
Types:
a. Persecutory delusion-Client have false belief of: Cheated, poisoned, drugged, followed, harassed.
b. Jealousy-person think that his or her sexual partner is unfaithful
c. Grandiosity-person have irrational ideas regarding his own talent, worth, knowledge and power
-
Paranoia: A state of guarded emotion and suspiciousness.
-Somatic symptoms: Symptoms that are experience as a physical feeling or sensation.
-Anhedonia: Lack of ability to feel pleasure.
-Apathy-Lack of emotion
-Aphasia-Impairment of communication
-Apraxia-Inability to carry out normal activity
-Ambivalence-Conflict
-Euphoria-Excessive feeling of happiness or elation
SUBSTANCE ABUSE DISORDER:
1.ALCOHOL:
-80-100mg of alcohol per 100ml blood –Intoxication (mood change, inappropriate sexual behavior
-Impaired judgement, speech, incoordination, unsteady gait, impaired attention etc.)
200-250mg of alcohol per 100ml blood-Toxic, sleepy, confused, altered thought process
-300mg/100ml of blood –unconscious
-500mg/100ml of blood –Fatal
A) Withdrawal symptom of alcohol: Nausea, vomiting, insomnia,
Late withdrawal symptom is Delirium tremors.
B) Amnesia
C)Dementia
D)Visual hallucination
E) Anxiety disorder
F) Suicidal behavior
TREATMENT-
: Detoxication-Benzo diazepam, Vitamin B1
: Alcohol deterrent therapy: Disulfiram (250 and 500mg; initial dose starts by500mg by orally for first 2 weeks, followed by maintenance dosage of 250mg)
2.OPOIDS:
Morphine,
Codeine
Heroin
Synthetic drugs- Methadone and Pethidine, Another painkiller
Adverse effect: Bradycardia, hypotension, respiratory depression, subnormal temperature, pinpoint pupil.
Withdrawal symptom: Watery eyes, runny nose, yawing, loss of appetite, sweating, raised body temperature
Antidote-Naloxone, Naltrexone
3.COCAINE: Crack
Acute intoxication: Tachycardia, hypertension, hypomanic, pupillary dilatation, sweating
Withdrawal symptom: Anorexia, agitation, depression, fatigue, sleepiness
Antidote: Amyl Nitrate
4.CANNABIS:
Bhang, dhaturo, Marijuana
Acute intoxication-impairment of consciousness and orientation, dream like state, flashback phenomenon, dry mouth, increased appetite.
Withdrawal symptom: mostly found in first 72-96 hour –increased salivation, hyperthermia, insomnia, decreased appetite,
5.LSD-LYSERGIC ACID DIETHYL AMIDE
. Powerful hallucinogen
Withdrawal symptom: flashback
ORGANICE MENTAL DISORDER: Cognitive disorder
DEMENTIA
Dementia is not a disease, it is impaired, ability to remember, think ability to remember or make decisions that interferes with doing everyday activities.
-It is chronic progressive irreversible disease, treated by Cholinesterase inhibitor like DONAZEPIL(ARECEPT), GALANTAMINE.
-mostly seen in elderly
-oriented and conscious.
DELIRIUM
Confused, disoriented, not able to think or remember clearly seen in anyone anytime.
Reversible, occur due to certain drugs, alcohol, stroke injury from fall.
Acute, treat underlying causes.
Loss of consciousness, Tremor present
AMNESIA
Amnesia is total or partial loss of ability to recall experience and events. Seen in anyone anytime.
Memory loss which mostly occur by Vitamin B1 deficiency, long term alcohol user, infection in brain, tumor in memory area.
Short term, no specific treatment
Oriented and conscious
Notes:
Senile dementia or Alzheimer’s seen in Elderly (over 60 yr) person
Dementia mostly occurs due to accumulation of Beta Amyloid protein in brain
Tacrine and Aricept are drug of choice for dementia
PSYCHOTHERAPY USE IN MENTAL PROBLEM
INDIVIDUAL THERAPY
GROUP THERAPY-Alcoholic
RELAXATION THERAPY-All
SUPPORTIVE THERAPY-Depression
FAMILY THERAPY-Depression
COGNITIVE THERAPY-Schizophrenia
BEHAVIOUR THERAPY-Phobia
PHYSICAL THERAPY-ECT AND LIGHT THERAPY (for depressive patient)
ELECTRO-CONVULSIVE THERAPY:
-Artificial induction of Grand mal seizure through the application of electrical current to the brain.
Indication-Major psychotic condition like: Schizophrenia, Mania, Depression
Contraindication-Absolute (MAIN)-Increased ICP (Intracranial pressure)
Others-Cerebral hemorrhage, Cerebral aneurysm, Brain tumor, Congestive heart failure, Retinal detachment
Drug used during ECT:
A.PRE ECT:0.6mg Atropine IM 30min before or IV just before ECT
B. INTRA ECT:
Anesthetic agent-Thiopental sodium
Muscle Relaxant-Succinylcholine
100% Oxygen
C)After ECT: Diazepam if there is post-ictal confusion
VOLTAGE:70-120Volts
DURATION:0.7-1.5 Second
FREQUENCY-3 times per week
TOTAL NUMBER:6-10
APPLICATION OF ELCETRODES:
a. Bilateral-Each electrode is placed 2.5-4cm above the midpoint, on a line joining the tragus of ear and lateral canthus of eye
unilateral-one side of head (right side of head in a right-handed person)