1.

1 Concept of mental health

One of the most important aims of education is to help the individual in making adjustment with
the changing environment. It is the mental health which helps the person to adjust in the
environment. It is a state or condition on which an individual feels a sense of well-being. This
condition also provides an individual the capacity to be resilient to the stresses her / meets and to
respond to these challenges without having to compromise his well-being. This also makes him
productive and fruitful for himself and his community.

1.2 Meaning of mental health

• It is a state or condition on which an individual feels a sense of well-being.

• It is a condition and a level of social functioning which is socially and personally

satisfying in all aspects of life.(social. physical., spiritual, and emotional)

• How we feel about ourselves, how we feel about others and how we are able to meet the
demands of life.

• A mentally healthy person lives a “fuller, happier, harmonious and effective life”.

1.3 Definition
A state of emotional and psychological well-being in which an individual is able to use his or her
cognitive and emotional capabilities function in society, and meet the ordinary demands of
everyday life.

WHO defines health as – A state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity (2001).

• WHO: A state of well-being in which the individual realizes his or her own abilities, can
cope with the normal stresses of life, can work productively and fruitfully, and is able to make a
contribution to his or her community.

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• Hadfield: “mental health is the full and harmonious functioning of the whole
personality”.

1.4 CHARACTERISTICS OF MENTAL HEALTH

• Able to live happily and peacefully

• Is not disturbed by mental conflicts

• Has a true self-appraisal of his strength and weakness

• Is cooperative with others and has a feeling of security

• Has diverse and varied interest and lives constructively

• Is rational in approach

• Is emotionally stable and socially mature

• Has high degree of frustration tolerance

• Has good physical health

1.4.1 Importance of Mental Health

• Mental health has much wider scope than physical health as it aims for the development
of wholesome balanced and integrated personality.

• Mental health is very important because of following things:

• Helps in the development of desirable personality – Mental health helps in the

development of a wholesome, well-balanced and integrated personality.

• Helps in proper emotional development – The individual who enjoy good mental health
are supposed to demonstrate proper emotional maturity in their behaviours. On the other side,
those who are tense, disintegrated and mentally unhealthy demonstrate sudden emotional
outburst.

• Helps in proper social development- Ones mental health helps one in becoming sociable
and establishing proper social relationships in the society.

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• Helps in proper moral development – The individuals who enjoy sound mental health are
usually found to behave as a man of integrity and character by following the ethical standards of
the society.

• Helps in proper artistic development – Proper mental health helps the individual in the
development of appropriate aesthetic sense, artistic taste and refined temperament.

• Helps in seeking proper adjustment – A mentally healthy individual is an adjusted person.

He is able to adjust his needs as per the demands of the situation and well-being of the society.

• Helps in seeking goals of life – Optimum mental health always helps the individuals to
divert his energies in full capacity for the realization of the goals.

• Helps in progress of the society – Mental health helps the individual to develop as well
balanced useful citizens who are conscious not only of their rights but also of their
responsibilities.

• Helps in prevention of mental illness – A sound mental health and balanced personality
has enough resistance to fight against the odds of life and bear the accidental stresses and strains
of life in comparison to those with impaired mental health. We know that every individual is a
unique being. Along with the features and characteristics shared with over people, i.e. the
universal ones, each individual had many particular characteristics.

• The individual is born as a man, but only gradually with the help of adults and through
his own activity, becomes an individual. As for the adult’s influence, the decisive role in this
process is played by education which is purposeful, planned, professional and institutionalized.
However, the development of the individual is influenced both by internal and external
influences. In the process of education and development of personality, the pupil is not only the
object of education but also the subject of his own development. These subjective tendencies are
intelligence, attitude, aptitude, creativity and interest which are particularly the concern of
psychology.

1.4.2 Factors affecting mental health

• In the present Materialistic society- individual needs and wants have multiplied resulting
in dissatisfaction, alienation and frustration.

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• The conflict provoking and frustrating situations are further accentuated by general
atmosphere of insecurity.

• The competitive motive results in aspirations far beyond one’s abilities which has
resulted in excessive tension, anxiety, fear and guilt feeling.

• The hold of family and religion over men has become loose resulting in a life without
moorings and values

• Social prejudices and stereo types have precipitated social conflicts which in turn have
tended to disrupt the individual mental balance

(Changing Trends in Mental Health Care)

• Attention to life style: if we are doing too much or too little in our lives, mental health
can suffer. We need a good balance between work or study and leisure pursuits.

• Social contact: having contact with others whose company we enjoy, whether at school,
work, at home or as a member of a club, helps to develop social interaction.

• Reviewing our lives from time to time: This involves considering what our aims and
goals in life are and whether we are taking steps to achieve them. Problems can arise when we
feel life is not satisfying and fulfilling.

• Awareness of how mind and body interact: just as our state of mental health can affect
our physical health and mental health, the reverse is also true. If diet, sleep and exercise are
neglected and inadequate, not only our bodies will suffer but also our minds.

• Having people in our lives we trust: it is important to have someone to go to with our
problems and worries, such as friends, teachers or family members.

• Awareness of what can go wrong: just be conscious of what can go wrong. Realize that
tiredness and irritability, if ignored, might lead to more serious stress-related problems.

• Taking steps to resolve problems- be aware of problems and seek help if necessary.

1.4.5 Mental Health Problem Symptoms, Causes and Effects

Mental health problems can cover a broad range of disorders, but the common characteristic is
that they all affect the affected person’s personality, thought processes or social interactions.

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They can be difficult to clearly diagnose, unlike physical illnesses. Mental health disorders occur
in a variety of forms, and symptoms can overlap, making disorders hard to diagnoses. However,
there are some common disorders that affect people of all ages.

Attention Deficit Hyperactivity Disorder is characterized by an inability to remain focused on

task, impulsive behavior, and excessive activity or an inability to sit still. Although this disorder
is most commonly diagnosed in children, it can occur in adults as well.

Anxiety/Panic Disorder

Anxiety disorder is defined by intermittent and repeated attacks of intense fear of something bad
happening or a sense of impending doom.

Bipolar Disorder

Bipolar disorder causes a periodic cycling of emotional states between manic and depressive
phases. Manic phases contain periods of extreme activity and heightened emotions, whereas
depressive phases are characterized by lethargy and sadness. The cycles do not tend to occur
instantly.

Depression

Depression covers a wide range of conditions, typically defined by a persistent bad mood and
lack of interest in pursuing daily life, as well as bouts of lethargy and fatigue. Dysthymia is a
milder but longer-lasting form of depression.

Schizophrenia

Schizophrenia is not, as commonly thought, solely about hearing voices or having multiple
personalities. Instead, it is defined by a lack of ability to distinguish reality. Schizophrenia can
cause paranoia and belief in elaborate conspiracies.

Overview

Mental illness, also called mental health disorders, refers to a wide range of mental health
conditions disorders that affect your mood, thinking and behavior. Examples of mental illness
include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors.
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Many people have mental health concerns from time to time. But a mental health concern
becomes a mental illness when ongoing signs and symptoms cause frequent stress and affect
your ability to function. A mental illness can make you miserable and can cause problems in
your daily life, such as at school or work or in relationships. In most cases, symptoms can be
managed with a combination of medications and talk therapy (psychotherapy).

Symptoms
Signs and symptoms of mental illness can vary, depending on the disorder, circumstances and
other factors. Mental illness symptoms can affect emotions, thoughts and behaviors.

Examples of signs and symptoms include:

 Feeling sad or down

 Confused thinking or reduced ability to concentrate
 Excessive fears or worries, or extreme feelings of guilt
 Extreme mood changes of highs and lows
 Withdrawal from friends and activities
 Significant tiredness, low energy or problems sleeping
 Detachment from reality (delusions), paranoia or hallucinations
 Inability to cope with daily problems or stress
 Trouble understanding and relating to situations and to people
 Problems with alcohol or drug use
 Major changes in eating habits
 Sex drive changes
 Excessive anger, hostility or violence
 Suicidal thinking

Sometimes symptoms of a mental health disorder appear as physical problems, such as stomach
pain, back pain, headaches, or other unexplained aches and pains.

Causes
Mental illnesses, in general, are thought to be caused by a variety of genetic and environmental
factors:g

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Inherited traits. Mental illness is more common in people whose blood relatives also have a
mental illness. Certain genes may increase your risk of developing a mental illness, and your life
situation may trigger it.

Environmental exposures before birth. Exposure to environmental stressors, inflammatory

conditions, toxins, alcohol or drugs while in the womb can sometimes be linked to mental illness.

Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that carry signals to
other parts of your brain and body. When the neural networks involving these chemicals are
impaired, the function of nerve receptors and nerve systems change, leading to depression and
other emotional disorders.

Risk factors
Certain factors may increase your risk of developing a mental illness, including:

 A history of mental illness in a blood relative, such as a parent or sibling Stressful life
situations, such as financial problems, a loved one's death or a divorce
 An ongoing (chronic) medical condition, such as diabetes
 Brain damage as a result of a serious injury (traumatic brain injury), such as a violent
blow to the head
 Traumatic experiences, such as military combat or assault
 Use of alcohol or recreational drugs
 A childhood history of abuse or neglect
 Few friends or few healthy relationships

Mental illness is common. About 1 in 5 adults has a mental illness in any given year. Mental
illness can begin at any age, from childhood through later adult years, but most cases begin
earlier in life. The effects of mental illness can be temporary or long lasting. You also can have
more than one mental health disorder at the same time. For example, you may have depression
and a substance use disorder.

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Complications (mental problems)
Mental illness is a leading cause of disability. Untreated mental illness can cause severe
emotional, behavioral and physical health problems. Complications sometimes linked to mental
illness include:

 Unhappiness and decreased enjoyment of life

 Family conflicts
 Relationship difficulties
 Social isolation
 Problems with tobacco, alcohol and other drugs
 Missed work or school, or other problems related to work or school
 Legal and financial problems
 Poverty and homelessness
 Self-harm and harm to others, including suicide or homicide
 Weakened immune system, so your body has a hard time resisting infections
 Heart disease and other medical conditions

Prevention
There's no sure way to prevent mental illness. However, if you have a mental illness, taking steps
to control stress, to increase your resilience and to boost low self-esteem may help keep your
symptoms under control. Follow these steps:

Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger
your symptoms. Make a plan so that you know what to do if symptoms return. Contact your
doctor or therapist if you notice any changes in symptoms or how you feel. Consider involving
family members or friends to watch for warning signs.

Get routine medical care. Don't neglect checkups or skip visits to your primary care provider,
especially if you aren't feeling well. You may have a new health problem that needs to be treated,
or you may be experiencing side effects of medication.

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Get help when you need it. Mental health conditions can be harder to treat if you wait until
symptoms get bad. Long-term maintenance treatment also may help prevent a relapse of
symptoms.

Take good care of yourself. Sufficient sleep, healthy eating and regular physical activity are
important. Try to maintain a regular schedule. Talk to your primary care provider if you have
trouble sleeping or if you have questions about diet and physical activity.

Symptoms, Causes and Treatment

Organic mental disorder

An organic mental disorder is a previously used term to describe a dysfunction of the brain that
was meant to exclude psychiatric disorders. It is currently known under the category of
neurocognitive disorders. It describes reduced brain function due to illnesses that are not
psychiatric in nature. Sometimes the term organic mental disorder is used interchangeably with
the terms organic brain syndrome (OBS), chronic organic brain syndrome, or neurocognitive
disorder—this latter term is the one used more commonly now.

Causes
Organic mental disorders are disturbances that may be caused by injury or disease affecting brain
tissues as well as by chemical or hormonal abnormalities. Exposure to toxic materials,
neurological impairment, or abnormal changes associated with aging can also cause these
disorders. Alcohol, or metabolic disorders such as liver, kidney, or thyroid disease, or vitamin
deficiencies, may be factors too.

Concussions, blood clots, or bleeding in or around the brain from trauma may lead to organic
brain syndrome. Low oxygen in the blood, high amounts of carbon dioxide in the body, strokes,
brain infections, and heart infections can lead to an organic mental disorder as well.3

Degenerative disorders like Parkinson's disease, Alzheimer's disease, Huntington disease, and
multiple sclerosis may also be contributing factors.

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Symptoms
A person with an organic mental disorder may have difficulty concentrating for a long period of
time. Others may get confused while performing tasks that seem routine to others. Managing
relationships and collaborating and communicating with colleagues, friends, or family may also
prove difficult. Overall the severity of the symptoms and the type of symptoms a person has
varies, depending on the cause of their disorder.

Primary Symptoms

 Confusion
 Agitation
 Irritability

A change in behavior, impaired brain function, cognitive ability, or memory5

If you or your loved one is experiencing any of these symptoms, it's important to seek medical
care as soon as possible. A serious medical problem may have caused these symptoms to surface,
and early intervention may be key.

Treatment
Blood tests, spinal taps, or an electroencephalogram may be administered to diagnose organic
brain syndrome or an organic mental disorder. Imaging of the brain, like a CT scan or MRI, is
also useful, depending on a doctor's suspicion.

Treatments for organic mental disorders vary on what the underlying cause of the disorder is.
Medication may be prescribed or rehabilitation therapy may help patients recover function in the
parts of the brain affected by the organic mental disorder.

Schizoaffective Disorder
WHAT IS SCHIZOAFFECTIVE DISORDER?

What Is Schizoaffective Disorder?

Schizoaffective disorder is a chronic mental health condition that involves symptoms of both
schizophrenia and a mood disorder like major depressive disorder or bipolar disorder. In fact,
many people with schizophrenia are incorrectly diagnosed at first with depression or bipolar

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disorder. Scientists don’t know for sure if schizoaffective disorder is related mainly to
schizophrenia or a mood disorder. But it’s usually viewed and treated as a combination of both
conditions. Only a tiny number of people get schizoaffective disorder -- .03% of the population.
It’s equally likely to affect men and women, but men usually get it at a younger age. Doctors can
help manage it, but most people diagnosed with it have relapses. People who have it often have
problems with substance use as well.

Types of Schizoaffective Disorder

There are two types. Each has some schizophrenia symptoms:

Bipolar type: Episodes of mania and sometimes major depression

Depressive type: Only major depressive episodes

Symptoms of Schizoaffective Disorder

The symptoms may vary greatly from one person to the next and may be mild or severe. They
may include:

 Delusions (false, sometimes strange beliefs that the person refuses to give up, even when
they get the facts)
 Depression symptoms (feeling empty, sad, or worthless)
 Hallucinations (sensing things that aren't real, such as hearing voices)
 Lack of personal care (not staying clean or keeping up appearance)
 Mania or sudden, out-of-character jumps in energy levels or happiness, racing thoughts,
or risky behavior
 Problems with speech and communication, only giving partial answers to questions or
giving answers that are unrelated
 Problems with speech and communication, only giving partial answers to questions, or
giving answers that are unrelated. (The doctor may call this disorganized thinking.)
 Trouble at work, school, or in social settings

Causes of Schizoaffective Disorder

Scientists don’t know the exact cause. Risk factors for schizoaffective disorder include:

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  Genetics: You may inherit a tendency to get features linked to schizoaffective disorder
from your parents.
 Brain chemistry and structure: If you have schizophrenia and mood disorders, you might
have problems with brain circuits that manage mood and thinking. Schizophrenia is also
tied to lower levels of dopamine, a brain chemical that also helps manage these tasks.
 Environment: Some scientists think things like viral infections or highly stressful
situations could play a part in getting schizoaffective disorder if you’re at risk for it. How
that happens isn’t clear.
 Drug use: Taking mind-altering drugs. (Your doctor may call them psychoactive or
psychotropic drugs.)

Schizoaffective disorder usually begins in the late teen years or early adulthood, often between
ages 16 and 30. It seems to happen slightly more often in women than in men. It's rare in
children. Because schizoaffective disorder combines symptoms that reflect two mental illnesses,
it’s easily confused with other psychotic or mood disorders. Some doctors may diagnose
schizophrenia. Others may think it’s a mood disorder. As a result, it’s hard to know how many
people actually have schizoaffective disorder. It’s probably less common than either
schizophrenia or mood disorders alone.

Diagnosis of Schizoaffective Disorder

There are no laboratory tests to specifically diagnose schizoaffective disorder. So doctors rely on
your medical history and your answers to certain questions. (Doctors call this the clinical
interview.) They also use various tests such as brain imaging (like MRI scans) and blood tests to
make sure that another type of illness isn’t causing your symptoms. If the doctor finds no
physical cause, they may refer you to a psychiatrist or psychologist. These mental health
professionals are trained to diagnose and treat mental illnesses. They use specially designed
interview and assessment tools to evaluate a person for a psychotic disorder.

In order to get diagnosed with schizoaffective disorder, you must have:

 Periods of uninterrupted illness

 An episode of mania, major depression, or a mix of both

Symptoms of schizophrenia

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At least two periods of psychotic symptoms, each lasting 2 weeks. One of the episodes must
happen without depressive or manic symptoms.

Treatment of Schizoaffective Disorder

Treatment includes:

Medication: What you take depends on whether you have symptoms of depression or bipolar
disorder, along with symptoms that suggest schizophrenia. The main medications that doctors
prescribe for psychotic symptoms such as delusions, hallucinations, and disordered thinking are
called antipsychotics. All these drugs can probably help with schizoaffective disorder, but
paliperidone extended release (Invega) is the only drug that the FDA has approved to treat it. For
mood-related symptoms, you might take an antidepressant medication or a mood stabilizer.

Psychotherapy: The goal of this type of counseling is to help you learn about your illness, set
goals, and manage everyday problems related to the disorder. Family therapy can help families
get better at relating to and helping a loved one who has schizoaffective disorder.

Skills training: This generally focuses on work and social skills, grooming and self-care, and
other day-to-day activities, including money and home management.

Hospitalization: Psychotic episodes may require a hospital stay, especially if you’re suicidal or
threaten to hurt others.

Electroconvulsive therapy: This treatment may be an option for adults who don’t respond to
psychotherapy or medications. It involves sending a quick electric current through your brain.
(You’ll get a type of medicine called general anesthesia to help you sleep through it.) It causes a
brief seizure. Doctors use it because they think it changes your brain chemistry and may reverse
some conditions.

Complications of Schizoaffective Disorder

This condition may raise your risk of:

 Alcohol or other substance abuse problems

 Anxiety disorders
 Conflict with family, friends, co-workers and otherss

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  Poverty and homelessness
 Significant health problems
 Social isolation
 Suicide, suicide attempts, or suicidal thoughts
 Unemployment

Prevention of Schizoaffective Disorder

You can’t prevent the condition. But if you’re diagnosed and start treatment ASAP, it can help
you avoid or ease frequent relapses and hospitalizations, and help cut the disruptions in your life,
family, and friendships.

4.0 UNIT 4
4.1 Disorders of adult personality and Behavior
A personality disorder is a type of mental disorder in which you have a rigid and unhealthy
pattern of thinking, functioning and behaving. A person with a personality disorder has trouble
perceiving and relating to situations and people. This causes significant problems and limitations
in relationships, social activities, work and school. In some cases, you may not realize that you
have a personality disorder because your way of thinking and behaving seems natural to you.
And you may blame others for the challenges you face. Personality disorders usually begin in the
teenage years or early adulthood. There are many types of personality disorders. Some types may
become less obvious throughout middle age.

Symptoms
Types of personality disorders are grouped into three clusters, based on similar characteristics
and symptoms. Many people with one personality disorder also have signs and symptoms of at
least one additional personality disorder. It's not necessary to exhibit all the signs and symptoms
listed for a disorder to be diagnosed.

Cluster A personality disorders

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Cluster A personality disorders are characterized by odd, eccentric thinking or behavior. They
include paranoid personality disorder, schizoid personality disorder and schizotypal personality
disorder.

Paranoid personality disorder

 Pervasive distrust and suspicion of others and their motives

 Unjustified belief that others are trying to harm or deceive you
 Unjustified suspicion of the loyalty or trustworthiness of others
 Hesitancy to confide in others due to unreasonable fear that others will use the
information against you
 Perception of innocent remarks or nonthreatening situations as personal insults or attacks
 Angry or hostile reaction to perceived slights or insults
 Tendency to hold grudges
 Unjustified, recurrent suspicion that spouse or sexual partner is unfaithful

Schizoid personality disorder

 Lack of interest in social or personal relationships, preferring to be alone

 Limited range of emotional expression
 Inability to take pleasure in most activities
 Inability to pick up normal social cues
 Appearance of being cold or indifferent to others
 Little or no interest in having sex with another person

Schizotypal personality disorder

 Peculiar dress, thinking, beliefs, speech or behavior

 Odd perceptual experiences, such as hearing a voice whisper your name
 Flat emotions or inappropriate emotional responses
 Social anxiety and a lack of or discomfort with close relationships
 Indifferent, inappropriate or suspicious response to others
 "Magical thinking" — believing you can influence people and events with your thoughts
Belief that certain casual incidents or events have hidden messages meant only for you
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Cluster B personality disorders

Cluster B personality disorders are characterized by dramatic, overly emotional or unpredictable

thinking or behavior. They include antisocial personality disorder, borderline personality
disorder, histrionic personality disorder and narcissistic personality disorder.

Antisocial personality disorder

 Disregard for others' needs or feelings

 Persistent lying, stealing, using aliases, conning others
 Recurring problems with the law
 Repeated violation of the rights of others
 Aggressive, often violent behavior
 Disregard for the safety of self or others
 Impulsive behavior

Consistently irresponsible

Lack of remorse for behavior

Borderline personality disorder

Impulsive and risky behavior, such as having unsafe sex, gambling or binge eating

Unstable or fragile self-image

Unstable and intense relationships

Up and down moods, often as a reaction to interpersonal stress

Suicidal behavior or threats of self-injury

Intense fear of being alone or abandoned

Ongoing feelings of emptiness

Frequent, intense displays of anger

Stress-related paranoia that comes and goes

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Histrionic personality disorder

Constantly seeking attention

Excessively emotional, dramatic or sexually provocative to gain attention

Speaks dramatically with strong opinions, but few facts or details to back them up

Easily influenced by others

Shallow, rapidly changing emotions

Excessive concern with physical appearance

Thinks relationships with others are closer than they really are

Narcissistic personality disorder

Belief that you're special and more important than others

Fantasies about power, success and attractiveness

Failure to recognize others' needs and feelings

Exaggeration of achievements or talents

Expectation of constant praise and admiration

Arrogance

Unreasonable expectations of favors and advantages, often taking advantage of others

Envy of others or belief that others envy you

Cluster C personality disorders

Cluster C personality disorders are characterized by anxious, fearful thinking or behavior. They
include avoidant personality disorder, dependent personality disorder and obsessive-compulsive
personality disorder.

Avoidant personality disorder

Too sensitive to criticism or rejection

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Feeling inadequate, inferior or unattractive

Avoidance of work activities that require interpersonal contact

Socially inhibited, timid and isolated, avoiding new activities or meeting strangers

Extreme shyness in social situations and personal relationships

Fear of disapproval, embarrassment or ridicule

Dependent personality disorder

 Excessive dependence on others and feeling the need to be taken care of

 Submissive or clingy behavior toward others
 Fear of having to provide self-care or fend for yourself if left alone
 Lack of self-confidence, requiring excessive advice and reassurance from others to make
even small decisions
 Difficulty starting or doing projects on your own due to lack of self-confidence
 Difficulty disagreeing with others, fearing disapproval
 Tolerance of poor or abusive treatment, even when other options are available
 Urgent need to start a new relationship when a close one has ended

Obsessive-compulsive personality disorder

 Preoccupation with details, orderliness and rules

 Extreme perfectionism, resulting in dysfunction and distress when perfection is not
achieved, such as feeling unable to finish a project because you don't meet your own
strict standards
 Desire to be in control of people, tasks and situations, and inability to delegate tasks
 Neglect of friends and enjoyable activities because of excessive commitment to work or a
project
 Inability to discard broken or worthless objects
 Rigid and stubborn
 Inflexible about morality, ethics or values
 Tight, miserly control over budgeting and spending money

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Obsessive-compulsive personality disorder is not the same as obsessive-compulsive
disorder, a type of anxiety disorder.

When to see a doctor

If you have any signs or symptoms of a personality disorder, see your doctor or other primary
care professional or a mental health professional. Untreated, personality disorders can cause
significant problems in your life that may get worse without treatment.

Causes

Personality is the combination of thoughts, emotions and behaviors that makes you unique. It's
the way you view, understand and relate to the outside world, as well as how you see yourself.
Personality forms during childhood, shaped through an interaction of:

Your genes. Certain personality traits may be passed on to you by your parents through inherited
genes. These traits are sometimes called your temperament.

Your environment. This involves the surroundings you grew up in, events that occurred, and
relationships with family members and others.

Personality disorders are thought to be caused by a combination of these genetic and

environmental influences. Your genes may make you vulnerable to developing a personality
disorder, and a life situation may trigger the actual development.

Risk factors

Although the precise cause of personality disorders is not known, certain factors seem to increase
the risk of developing or triggering personality disorders, including:

 Family history of personality disorders or other mental illness

 Abusive, unstable or chaotic family life during childhood
 Being diagnosed with childhood conduct disorder
 Variations in brain chemistry and structure

Complications

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Personality disorders can significantly disrupt the lives of both the affected person and those who
care about that person. Personality disorders may cause problems with relationships, work or
school, and can lead to social isolation or alcohol or drug abuse.

MENTAL RETARDATION
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. There are varying degrees of intellectual disability, from
mild to profound.

What is intellectual disability?

Someone with intellectual disability has limitations in two areas. These areas are:

Intellectual functioning. Also known as IQ, this refers to a person’s ability to learn, reason,
make decisions, and solve problems.

Adaptive behaviors. These are skills necessary for day-to-day life, such as being able to
communicate effectively, interact with others, and take care of oneself.

IQ (intelligence quotient) is measured by an IQ test. The average IQ is 100, with the majority of
people scoring between 85 and 115. A person is considered intellectually disabled if he or she
has an IQ of less than 70 to 75.

To measure a child’s adaptive behaviors, a specialist will observe the child’s skills and compare
them to other children of the same age. Things that may be observed include how well the child
can feed or dress himself or herself; how well the child is able to communicate with and
understand others; and how the child interacts with family, friends, and other children of the
same age.

Intellectual disability is thought to affect about 1% of the population. Of those affected, 85%
have mild intellectual disability. This means they are just a little slower than average to learn
new information or skills. With the right support, most will be able to live independently as
adults.

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What are the signs of intellectual disability in children?
There are many different signs of intellectual disability in children. Signs may appear during
infancy, or they may not be noticeable until a child reaches school age. It often depends on the
severity of the disability. Some of the most common signs of intellectual disability are:

 Rolling over, sitting up, crawling, or walking late

 Talking late or having trouble with talking
 Slow to master things like potty training, dressing, and feeding himself or herself
 Difficulty remembering things
 Inability to connect actions with consequences
 Behavior problems such as explosive tantrums
 Difficulty with problem-solving or logical thinking

In children with severe or profound intellectual disability, there may be other health problems as
well. These problems may include seizures, mood disorders (anxiety, autism, etc.), motor skills
impairment, vision problems, or hearing problems.

What causes intellectual disability?

Anytime something interferes with normal brain development, intellectual disability can result.
However, a specific cause for intellectual disability can only be pinpointed about a third of the
time.

The most common causes of intellectual disability are:

Genetic conditions. These include things like Down syndrome and fragile X syndrome.

Problems during pregnancy. Things that can interfere with fetal brain development include
alcohol or drug use, malnutrition, certain infections, or preeclampsia.

Problems during childbirth. Intellectual disability may result if a baby is deprived of oxygen
during childbirth or born extremely premature.

Illness or injury. Infections like meningitis, whooping cough, or the measles can lead to
intellectual disability. Severe head injury, near-drowning, extreme malnutrition, infections in the
brain, exposure to toxic substances such as lead, and severe neglect or abuse can also cause it.

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None of the above. In two-thirds of all children who have intellectual disability, the cause
is unknown.

Can intellectual disability be prevented?

Certain causes of intellectual disability are preventable. The most common of these is fetal
alcohol syndrome. Pregnant women shouldn’t drink alcohol. Getting proper prenatal care, taking
a prenatal vitamin, and getting vaccinated against certain infectious diseases can also lower the
risk that your child will be born with intellectual disabilities.

In families with a history of genetic disorders, genetic testing may be recommended before
conception. Certain tests, such as ultrasound and amniocentesis, can also be performed during
pregnancy to look for problems associated with intellectual disability. Although these tests may
identify problems before birth, they cannot correct them.

How is intellectual disability diagnosed?

Intellectual disability may be suspected for many different reasons. If a baby has physical
abnormalities that suggest a genetic or metabolic disorder, a variety of tests may be done to
confirm the diagnosis. These include blood tests, urine tests, imaging tests to look for structural
problems in the brain, or electroencephalogram (EEG) to look for evidence of seizures. In
children with developmental delays, the doctor will perform tests to rule out other problems,
including hearing problems and certain neurological disorders. If no other cause can be found for
the delays, the child will be referred for formal testing.

Three things factor into the diagnosis of intellectual disability: interviews with the parents,
observation of the child, and testing of intelligence and adaptive behaviors. A child is considered
intellectually disabled if he or she has deficits in both IQ and adaptive behaviors. If only one or
the other is present, the child is not considered intellectually disabled.

After a diagnosis of intellectual disability is made, a team of professionals will assess the child’s
particular strengths and weaknesses. This helps them determine how much and what kind of
support the child will need to succeed at home, in school, and in the community.

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Childhood behavioural disorders
Keywords: Childhood behavioural disorders, Disruptive behaviour disorder, Conduct disorder,
Challenging behaviour, Emotional disorder, Anxiety, Depression, Autism, Pervasive
developmental disorders

Core tip: Mental health problems in children and young people (CYP) include several types of
emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive
developmental (autism) disorders, characterized as either “internalizing” or “externalizing”. The
routine Paediatric or General Practitioner clinic present with several desirable characteristics that
make them ideal for providing effective mental health services to CYP. Childhood mental health
disorders have significant negative impacts on the individual, the family and the society. It is
particularly important for all Paediatricians to be aware of the range of presentation, prevention
and management of the common mental health problems in CYP.

INTRODUCTION
Mental health disorders (MHD) are very common in childhood and they include emotional-
obsessive-compulsive disorder (OCD), anxiety, depression, disruptive (oppositional defiance
disorder (ODD), conduct disorder (CD), attention deficit hyperactive disorder (ADHD) or
developmental (speech/language delay, intellectual disability) disorders or pervasive (autistic
spectrum) disorders. Emotional and behavioural problems (EBP) or disorders (EBD) can also be
classified as either “internalizing” (emotional disorders such as depression and anxiety) or
“externalizing” (disruptive behaviours such as ADHD and CD).

While low-intensity naughty, defiant and impulsive behaviour from time to time, losing one’s
temper, destruction of property, and deceitfulness/stealing in the preschool children are regarded
as normal, extremely difficult and challenging behaviours outside the norm for the age and level
of development, such as unpredictable, prolonged, and/or destructive tantrums and severe
outbursts of temper loss are recognized as behavior disorders. Community studies have identified
that more than 80% of preschoolers have mild tantrums sometimes but a smaller proportion, less
than 10% will have daily tantrums, regarded as normative misbehaviors at this age. Challenging
behaviors and emotional difficulties are more likely to be recognized as “problems” rather than
“disorders” during the first 2 years of life.

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Emotional problems, such as anxiety, depression and post-traumatic stress disorder (PTSD) tend
to occur in later childhood. They are often difficult to be recognized early by the parents or other
careers as many children have not developed appropriate vocabulary and comprehension to
express their emotions intelligibly. Many clinicians and careers also find it difficult to distinguish
between developmentally normal emotions (e.g., fears, crying) from the severe and prolonged
emotional distresses that should be regarded as disorders. Emotional problems including
disordered eating behavior and low self-image are often associated with chronic medical
disorders such as atopic dermatitis, obesity, diabetes and asthma, which lead to poor quality of
life.

Identification and management of mental health problems in primary care settings such as
routine Pediatric clinic or Family Medicine/General Practitioner surgery are cost-effective
because of their several desirable characteristics that make it acceptable to children and young
people (CYP) (e.g., no stigma, in local setting, and familiar providers). Several models to
improve the delivery of mental health services in the Pediatric/Primary care settings have been
recommended and evaluated recently, including coordination with external specialists, joint
consultations, improved Mental Health training and more integrated on-site intervention with
specialist collaboration.

CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Challenging behaviours
Any abnormal pattern of behavior which is above the expected norm for age and level of
development can be described as “challenging behavior”. It has been defined as: “Culturally
abnormal behavior (s) of such an intensity, frequency or duration that the physical safety of the
person or others is likely to be placed in serious jeopardy or behavior which is likely to seriously
limit or deny access to and use of ordinary community facilities”. They can include self-injury,
physical or verbal aggression, non-compliance, and disruption of the environment, inappropriate
vocalizations, and various stereotypies. These behaviors can impede learning, restrict access to
normal activities and social opportunities, and require a considerable amount of both manpower
and financial resources to manage effectively.

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Many instances of challenging behavior can be interpreted as ineffective coping strategies for a
young person, with or without learning disability (LD) or impaired social and communication
skills, trying to control what is going on around them. Young people with various disabilities,
including LD, Autism, and other acquired neurobehavioral disorders such as brain damage and
post-infectious phenomena, may also use challenging behavior for specific purposes, for
example, for sensory stimulation, gaining attention of carers, avoiding demands or to express
their limited communication skills. People who have a diverse range of neurodevelopmental
disorders are more likely to develop challenging behaviors.

Some environmental factors have been identified which are likely to increase the risk of
challenging behavior, including places offering limited opportunities for making choices, social
interaction or meaningful occupation. Other adverse environments are characterized by limited
sensory input or excessive noise, unresponsive or unpredictable carers, predisposition to neglect
and abuse, and where physical health needs and pain are not promptly identified. For example,
the rates of challenging behavior in teenagers and people in their early 20s is 30%-40% in
hospital settings, compared to 5% to 15% among children attending schools for those with severe
LD.

Aggression is a common, yet complex, challenging behaviour, and a frequent indication for
referral to child and adolescent Psychiatrists. It commonly begins in childhood, with more than
58% of preschool children demonstrating some aggressive behaviour. Aggression has been
linked to several risk factors, including individual temperaments; the effects of disturbed family
dynamics; poor parenting practices; exposure to violence and the influence of attachment
disorders.

Disruptive behaviour problems

Disruptive behaviour problems (DBP) include attention deficit hyperactivity disorder (ADHD),
oppositional defiant disorder (ODD) and conduct disorder (CD). They constitute the commonest
EBPs among CYP. Recent evidence suggests that DBPs should be regarded as a
multidimensional phenotype rather than comprising distinct subgroups. ADHD is characterized
by levels of hyperactivity, impulsivity and inattention that are disproportionately excessive for
the child’s age and development.

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Subtypes of attention deficit hyperactivity disorder (based on DSM-5)

Details Fails to pay close attention to details or makes careless mistakes Squirms and fidgets

• Has difficulty sustaining attention

• Can’t stay seated

• Does not appear to listen

• Runs/climbs excessively

• Struggles to follow through on instructions

• Can’t play/work quietly

• Has difficulty with organization

• Avoids or dislikes tasks requiring a lot of thinking

• Blurts out answers

• Loses things

• Unable to wait for his turn

• Is easily distracted

• Intrudes/interrupts others

• Talks excessively

ADHD: Attention deficit hyperactivity disorder.

CD refers to severe behaviour problems , characterized by repetitive and persistent
manifestations of serious aggressive or non-aggressive behaviours against people, animals or
property such as being defiant, belligerent, destructive, threatening, physically cruel, deceitful,
disobedient or dishonest, excessive fighting or bullying, fire-setting, stealing, repeated lying,
intentional injury, forced sexual activity and frequent school truancy Children with CD often
have trouble understanding how other people think, sometimes described as being callous-
unemotional. They may falsely misinterpret the intentions of other people as being mean. They

26
may have immature language skills, lack the appropriate social skills to establish and maintain
friendships, which aggravates their feelings of sadness, frustration and anger.

Oppositional defiant disorder Conduct disorder

A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at

least 6 mo as evidenced by at least four out of 8 symptoms from any of the following categories,
and exhibited during interaction with at least one individual who is not a sibling A repetitive
and persistent pattern of behavior in which the basic rights of others or major age-appropriate
societal norms or rules are violated, as manifested by the presence of at least three of the
following 15 criteria in the past 12 mo from any of the categories below, with at least one
criterion present in the past 6 mo

Aggression to people and animals:

(1) Often bullies, threatens, or intimidates others;

(2) Often initiates physical fights;

(3) Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken
bottle, knife, gun);

(4) Has been physically cruel to people;

(5) Has been physically cruel to animals;

(6) Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed
robbery);

(7) Has forced someone into sexual activity

Angry/irritable mood:

(1) Often loses temper;

(2) Is often touchy or easily annoyed;

(3) Is often angry and resentful

Argumentative/defiant behavior:

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(4) Often argues with authority figures or, for children and adolescents, with adults;

(5) Often actively defies or refuses to comply with requests from authority figures or with rules;

(6) Often deliberately annoys others;

(7) Often blames others for his or her mistakes or misbehavior

Destruction of property:

(8) Has deliberately engaged in fire setting with the intention of causing serious damage;

(9) Has deliberately destroyed others’ property (other than by fire setting)

Deceitfulness or theft:

(10) Has broken into someone else’s house, building, or car;

(11) Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others);

(12) Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but
without breaking and entering; forgery)

Vindictiveness:

(13) Often stays out at night despite parental prohibitions, beginning before age 13 yr;

(14) Has run away from home overnight at least twice while living in the parental or parental
surrogate home, or once without returning for a lengthy period;

(15) Is often truant from school, beginning before age 13 yr

Note: The persistence and frequency of these behaviors should be used to distinguish a behavior
that is within normal limits from a behavior that is symptomatic and the behavior should occur at
least once per week for at least 6 mo

Disruptive mood dysregulation disorder (DMDD) is a childhood disorder characterized by a

pervasively irritable or angry mood recently added to DSM-5. The symptoms include frequent
episodes of severe temper tantrums or aggression (more than three episodes a week) in
combination with persistently negative mood between episodes, lasting for more than 12 mo in
multiple settings, beginning after 6 years of age but before the child is 10 years old.

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COMPLICATIONS OF CHILDHOOD BEHAVIOURAL AND
EMOTIONAL DISORDERS
EBDs in childhood, if left untreated, may have negative short-term and long-term effects on an
individual’s personal, educational, family and later professional life. CD has been linked to
failure to complete schooling, attaining poor school achievement, poor interpersonal
relationships, particularly family breakup and divorce, and experience of long-term
unemployment. DBPs in parents have been linked to the abuse of their offspring, thereby
increasing their risk of developing CD. Children presenting with hyperactivity-inattention
behaviors are more likely to have a more favorable educational outcome compared with those
with aggression or oppositional behaviors.

A high prevalence of sleep disturbances is associated with various childhood EBPs. Sleep
problems in early childhood is associated with increased prevalence of later Anxiety disorders .

Several studies have confirmed a strong relationship between early childhood EBPs and poor
future long-term physical and mental health outcomes. Chronic irritability in preschool children,
CD and ODD in older children each may be predictive of any current and lifetime Anxiety,
Depression and DBDs in later childhood, Mania, Schizophrenia, OCD, major depressive disorder
and panic disorder. Individuals on the adolescent-onset CP path often consume more tobacco and
illegal drugs and engage more often in risky sexual behaviour, self-harm, and have increased risk
of PTSD, than individuals without childhood conduct problems. They also frequently experience
parenting difficulties, including over-reactivity, lax and inconsistent discipline, child physical
punishment and lower levels of parental warmth and sensitivity

MANAGEMENT OF BEHAVIOURAL AND EMOTIONAL

DISORDERS IN CHILDREN
Identification of appropriate treatment strategies depend on careful assessment of the prevailing
symptoms, the family and caregiver’s influences, wider socio-economic environment, the child’s
developmental level and physical health. It requires multi-level and multi-disciplinarian
approaches that include professionals such as Psychologists, Psychiatrists, Behavioural Analysts,
Nurses, Social care staff, Speech and language Therapists, Educational staff, Occupational
Therapists, Physiotherapists, Paediatricians and Pharmacists. Use of pharmacotherapy is usually
considered only in combination with psychological and other environmental interventions.

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Holistic management strategies will include various combinations of several interventions such
as child- and family-focused psychological strategies including Cognitive Behavioural Therapy
(CBT), behavioural modification and social communication enhancement techniques, parenting
skills training and psychopharmacology. These strategies can play significant roles in the
management of children with a wide range of emotional, behavioural and social communication
disorders. Effective alternative educational procedures also need to be implemented for the
school age children and adolescents.

In early childhood, similar parenting strategies have been found useful to manage several
apparently dissimilar EBPs (e.g., infant feeding or sleeping problems, preschool tantrums,
disruptive and various emotional problems). This may suggest there is a common maintaining
mechanism, which is probably related to poor self-regulation skills, involving the ability to
control impulses and expressions of emotion.

Several studies have confirmed the effectiveness of various psychological and pharmacologic
therapies in the management of childhood EBDs. A meta-analysis of thirty-six controlled trials,
involving 3042 children (mean sample age, 4.7 years), evaluating the effect of psychosocial
treatments including parenting programmes on early DBPs, demonstrated large and sustained
effects (Hedges’g = 0.82), with the largest effects for general externalizing symptoms and
problems of oppositionality and non-compliance, and were weakest, relatively speaking, for
problems of impulsivity and hyperactivity.

The treatment of CD among CYP with callous-unemotional traits is still at early stages of
research. The mainstay of management for CDs includes individual behavioural or cognitive
therapy, psychotherapy, family therapy and medications.

Parental skills training

Any challenging behaviour from CYP is likely to elicit persistent negative reactions from many
parents, using ineffective controlling strategies and a decrease in positive responses. There is
evidence from published research that social-learning and behaviourally based parent training is
capable of producing lasting improvement in children

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5.0 UNIT 5
National Mental Health Programme – Mental Health Act, District
Mental Health Progrramme. Socio-cultural factors in Psychiatry –
Magico-religious practices – Cultural beliefs – Stigma.
Health services
There are very few doctors. Clinical officers, medical assistants and enrolled nurses comprise the
backbone of Malawian healthcare, but there are shortages of these health personnel, especially in
the rural areas, as people prefer to practise in urban areas. The smallest health unit in Malawi is
the ‘health post’, which is manned by ‘health surveillance assistants’ (who have 10 weeks’
orientation training). Each health post serves a small number of villages. Next in the referral
hierarchy is the health centre, which is usually staffed by medical assistants (who have 2 years’
training) and nurses. Patients who cannot be treated at the health centre are referred to the district
hospitals, which are present in all but 3 of the 28 districts. There are four general tertiary referral
hospitals, distributed in all three regions of Malawi, with two in the southern region, which is the
biggest.

Mental health resources and services

Zomba Mental Hospital, which is situated in the southern region, is the only government tertiary
psychiatric referral hospital in Malawi. It has 333 beds and on average admits 1500 patients per
year. There is a smaller psychiatric unit in the central region, in Lilongwe, with about 30 beds,
and this is run as part of Kamuzu Central Hospital, which is the tertiary referral hospital in the
central region. Psychiatric patients from the northern region are usually referred to a missionary
hospital, St John of God in the city of Mzuzu, which has 50 in-patient beds and which runs an
effective community programme. In total there are therefore just over 400 psychiatric beds for
the entire population.

The commonest reasons for admission to Zomba Mental Hospital are schizophrenia, bipolar
disorders, intellectual disability, epilepsy, and substance-related and HIV-related conditions
(according to hospital statistics for the year 2005). Nearly all patients admitted present with
severe forms of these conditions.

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Mental health services in all the districts fall under the office of the district health officer and the
associated expenditure is included in the district’s health budget. As with the other general
tertiary hospitals, Zomba Mental Hospital has its own budget.

Public psychiatric services fall under clinical services (curative) within the Ministry of Health.

Staffing
There is only one psychiatrist for the entire population of Malawi, but since he is based in
Zomba, the old capital city, the psychiatrist:population ratio is 0 for the rest of the country.

There are no professional social workers and only one occupational therapist, at Zomba Mental
Hospital. There are two clinical psychologists attached to the College of Medicine in Malawi,
who teach medical students; they do not do any clinical work in the psychiatric hospitals.

The district psychiatric nurses do weekly outreach clinics, visiting different health centres and
health posts within their districts; the management team from Zomba Mental Hospital visits each
district twice a year to monitor mental health activities throughout the country.

Mental health policy and legislation

The old 2000–04 policy is still being used while it is awaiting review. This policy includes the
integration of psychiatric services into the primary healthcare system, the appointment of a
national mental health coordinator at the Ministry of Health’s headquarters and a human
resources development plan.

The Mental Treatment Act was enacted in 1959 and amended in 1968. A Mental Health Bill is
awaiting review by stakeholders and later parliamentary amendment; it is anticipated that it will
be passed in 2007. It compares well with legislation in countries such as South Africa and
Kenya, and includes the formation of a mental health review board, which will monitor the care
and treatment of psychiatric patients in hospital. It covers areas such as admissions, the rights of
inpatients and the safekeeping of patients’ property.

Training

Undergraduate medical students

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There is one medical school, the Malawi College of Medicine, which is part of the University of
Malawi, in Blantyre. As part of their MBBS course, students in the third year have 2 weeks of
psychiatry theory and in the fourth year they undergo a 5-week rotation in theory and clinical
work.

Other health workers

The two main health sciences colleges offer training of paramedical staff – the clinical officers,
medical assistants and enrolled nurses. Clinical officers can go for further training in specific
areas and become psychiatric clinical officers, orthopaedic clinical officers and so on. Plans are
being finalised to train district primary health workers in the management of common psychiatric
disorders. Currently, most primary health workers lack skills in the assessment and management
of psychiatric patients and end up referring all those they come across.

Postgraduate specialisation

The College of Medicine at the University of Malawi has offered postgraduate training only
since 2005 in certain specialties, in conjunction with certain universities in South Africa. This
does not include psychiatry, so all psychiatric training at present has to be done outside Malawi.

Psychiatric nurses

The St John of God College of Health Sciences provides a degree in psychiatric nursing for
registered state nurses with a minimum of a university diploma in nursing, and the Malawi
College of Health Sciences provides a certificate course in psychiatry for enrolled nurses.

Research

Mental health in Malawi has been the subject of several research projects. These have included
studies in psychoactive substances, the teaching of psychiatry in the colleges and attributions for
admissions to Zomba Mental Hospital (MacLachlan et al, 1995). More studies are under way or
being developed by Zomba Mental Hospital on, for example:

 community attitudes to and knowledge of mental illness

 the prevalence of HIV and neurosyphilis among inpatients

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  district mental health activities in southern Malawi, including what proportions of the
district budgets are allocated to mental health

common causes of relapse and readmission in patients with schizophrenia

 Pathways to care for psychiatric patients

 neuropsychological sequalae of cerebral malaria.

At the St John of God Hospital a randomised controlled trial of carer education in schizophrenia
and bipolar disorders is under way.In general, there is not much information on mental health in
the Malawian context and this provides opportunities and challenges for research.

Professional organisations

In the past there was a Mental Health Association of Malawi, but it stopped functioning, for
unknown reasons, around 1999. At present, a ‘core group’ is being formed, comprising: the
psychiatrist at Zomba Mental Hospital; the clinical psychologist at the Malawi College of
Medicine; the chief nursing officer at Zomba Mental Hospital; and the psychiatric clinical officer
at the St John of God Hospital. The main goal of this core group is to develop the preliminary
constitution of a new professional association and to recruit members. Some of the functions of
the association will be:

 to deal with challenges in mental health

 to act as an advisory body to the Medical Council of Malawi on the registration of mental
health professionals
 to develop, review and conduct policy for mental health professionals.

There are at present no non-governmental organisations operating in the mental health field in
Malawi.

Challenges

Notable problems include a critical shortage of trained staff and frequent shortages of drugs
owing to procurement problems. The referral system is not very good; neither is follow-up care,
as most district psychiatric services seem to be insufficiently well developed.

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35