COURSE OUTLINE OF

PSYCHIATRY
For Yekatit 12 HMC CI medical students
Rehana Abdurahman, md., psychiatrist
OBJECTIVE
 To enable you to know
 Course objective
 Learning outcome
 Course outline
 Lecture formatting
 Student responsibilities
 Grading
COURSE OBJECTIVES
This course is designed to Consolidate
the
Knowledge
Skills
Attitudes required in approaching and
managing common and important presenting
problems in psychiatry.
LEARNING OUTCOMES
 Aftercompleting this module you should have
the knowledge and confidence to:
Elicit a complete psychiatric history from
psychiatric patients and their relatives using
appropriate interview techniques
Perform a mental status examination and
physical examination emphasizing aspects
pertinent to psychiatric evaluation
LEARNING OUTCOMES
Recognize psychiatric emergencies and be
familiar with their management
Describe the clinical presentations, course,
differential diagnosis and prognosis of
common and severe mental disorders
Understand psychological and
pharmacological treatments, including
indications, contraindications, dosage and side
effects.
LEARNING OUTCOMES
 Apply knowledge of normal and abnormal structure and
function of the body in assessing and managing
psychiatric problem
 Apply knowledge of human life cycle and effect of
different psychological environmental and social factors
in assessing and managing psychiatric problems
 Apply knowledge of various causes(genetic,
developmental, metabolic, toxic, infectious, social,
psychological)of disease in assessing and managing
psychiatric problem
LEARNING OUTCOMES
 Analyze important determinants, risk factors in assessing
and managing cases
 Identify psychopathologies and abnormal physical
findings in a patient with psychiatric disorder
 Recognize psychiatric co morbidities in patient with
general medical condition
 Demonstrate the ability to communicate
appropriately, clearly, sensitively and effectively with
patients with psychiatric disorder
 Prerequisites
Internal medicine
Pediatrics
 Duration
5 weeks
COURSE OUTLINE
 It
has three parts
Introduction – General aspect
Specific disorders
Skills
Amanuel Specialized Hospital
Yekatit 12 hospital ?
COURSE OUTLINE
 Introduction & general issues
Introduction to psychiatry
 Psychological theories relevant to

psychiatry
 Sign and symptoms of psychiatric illness

Psychiatric interviewing and assessment

Classification in psychiatry
COURSE OUTLINE
 Specific disorders
Psychotic disorders
Mood disorders
Anxiety disorders
Personality disorders
Substance related disorders
Somatic symptoms and related disorders
Neuro-cognitive disorders
Trauma and stress related disorder
Emergency psychiatry
Common childhood and adolescent psychiatry
Psychiatric management
COURSE OUTLINE
 Skills
Learn basic interview skill
 Observe clinical evaluation of psychiatric patient.
 Take history starting from the third week

 More focus on psychotic disorder, mood disorder,

substance related disorder, and emergency

psychiatry
 Role play

 Videos

 Case presentation
COURSE OBJECTIVES
 Attitude
Traditional/Spiritual/Modern
Scientific/Unscientific
Medical/psychiatric
Others
Time Topic
Week one  Introduction  Dr. Rehana
 Psychological theories relevant to  Dr. Ashenafi
psychiatry
 Classification in psychiatry  Dr. Rehana
 Sign and symptoms in psychiatry  Dr Ashenafi
 Psychiatric clinical skill  Dr. Rehana
 Mood disorder  Dr. Rehana
 Anxiety disorders  Dr. Ashenafi
 Psychotic disorder

Week two • Cognitive disorder • Dr. Ashenafi

• Trauma and stress related disorders • Dr. Rehana
• Personality disorder • Dr. Ashenafi
• Substance related disorder • Dr. Ashenafi
• Somatic symptom disorders • Dr. Ashenafi
• Emergency psychiatry • Dr. Rehana
• Child psychiatry • Dr. Ashenafi
• Psychotherapy • Dr. Rehana
• Pharmacotherapy • Dr. Rehana
SCHEDULE
 Week three & Week four :- Practice in Amanuel
hospital, Presentation of seminars and case
presentation.
 Week five
 Case presentation/seminar
 Attachment
 Revision?
 Exam
SEMINAR TOPICS AND PROGRAM
 WeekII,III and week IV
Other mood disorders
Other psychotic disorders
Sleep disorder
Sexual disorder
Obsessive compulsive and related disorder
Communicating bad news
HIV Psychiatry
CASE PRESENTATION
 Starting from week two, two to three seminars
per week should be presented
 Everybody should participate in case
presentation and should participate actively in
every activity
 The rest of the topics should be covered by self
reading
ECT
LECTURE FORMATS
 Description of the condition
 Clinical presentation
 Epidemiology & etiology
 Differential diagnosis
 Treatment
 Prevention & promotion  
TEACHING METHODS
 Interactive Lectures
 Seminars

 Video show
 Role play

 Case vingettes, presentation & discussion

 Self reading

 Rounds

 Observation
 Logistics
Student booklet (will be discussed)
 Lecture materials (Soft copy)
STUDENT RESPONSIBILITIES
 Attendance(90%)
 Participation
 Professionalism – respecting ethical
principles of autonomy, beneficence and
justice
 PROFESSIONALISM
 Ethical
principles vital to mental health care:
Compassion

Respect for psychiatric patients’ dignity

Rights for privacy

Honesty

Altruism

Collaborative care with other health

professionals
Grouping
For teaching round and bed side
teaching –10 to 12
For seminars and case

presentation - 4 to 5
Grading
60 % written examination
20% Evaluation of presentations
20% Progressive clinical
assessment and attendance
REFERENCES
Kaplan & Sadock’s comprehensive
text book of psychiatry (2017,10th
edition)
Kaplan & Sadock’s Synopsis of
psychiatry (2015,11th edition)
Others
INTRODUCTION TO
PSYCHIATRY
By Rehana Abdurahman, MD,
Psychiatrist
LEARNING OBJECTIVES
 To help you to have a clear understanding of psychiatry,
mental health and mental disorder
 To help you understand history of psychiatry

 To help you understand the main causative factors

 To help you understand common misconceptions in

psychiatry
 To help you know the importance and prevalence of
mental disorders
PSYCHIATRY

What do you understand by

the word psychiatry?
PSYCHIATRY
 Psych : soul or mind
 Iatros : healer

 Psychiatry : is that branch of medicine

dealing with mental disorder and its
diagnosis, management and prevention
WHY PSYCHIATRY?

Who is mentally ill?/Has mental

disorder?

Which mental disorder?

 WHO IS MENTALLY HEALTHY/MENTALLY
ILL?
 A 40
year old man who dress in unusual
manner?

 A mother
who beats her son harshly whenever he
misbehave

 An18year old boy whose academic performance

decreased since grade 9
 A 20 year old boy who isolates him self since early
life

 A 4thyear University student who has problem in

focusing in his study

 A 2nd year male University student who spend 5hrs

per day chewing khat

 A man who drinks alcohol on daily basis

WHY PSYCHIATRY?
 Understand the gap
Need for more information/knowledge
Importance of evaluation by a professional
who knows the subject matter
Proper attitude
 HEALTH
 What is Health?

 What is mental health?

 Relationship between health and mental

health
HEALTH, MENTAL HEALTH AND
MENTAL DISORDER
Health is defined as a complete
Physical
Mental
Social well-being
 And not merely the absence of
disease and infirmity
 Health is not the absence of negatives
but the presence of positives
MENTAL HEALTH
 Difficult to define especially positive mental
health
 One can use several concepts to understand
normality
 Medical model(Normality as health):- absence of
psychiatric disorder or psychopathology.
 Alleviation of gross pathologic signs and symptoms of
illness
 NORMALITY
 Who is mentally ill and who is well?
 Takes several steps to define positive mental
health
First step – “average” is not healthy Mix
up of prevalent psychopathology
Second step – Depends on geography, culture
and historical moment.
Third step – Trait or state
Fourth step – “Contamination by value”
NORMALITY
 Finally what is it good for? The self/society, fitting
in/creativity, happiness/survival? Who is the judge?
 Thus, common sense, not post modernism, must
prevail
 Health is the activity of a living body in
accordance with its specific excellences
 The best way to enrich the current understanding of
what constitutes mental health is
to study a variety of healthy populations from
different perspectives, in different cultures and for a
long period of time
MODELS OF MENTAL HEALTH
 Seven different empirical approaches
1) Above normal, objectively desirable, capacity to work and
to love
2) Presence of multiple human strength
3) Maturity
4) Positive emotion
5) Emotional intelligence and successful object relations
6) Subjective well-being – happy, contented and desired.
7) Resilience- successful, adaptation and homeostasis
 ABOVE NORMAL
 Normality would encompass the major portion of adults
 Mental health is not normal; it is above average

 Positive mental health is above normal

 Based on an active, joyous, energetic engagement with the

world
 Action, cognition, and feeling are merged into one

 With “flow” the participant feels alive and in the world

 ” On the GAF, a score of 95 to 100 equaled “no

symptoms, superior functioning in a wide range of
activities; life’s problems never seem to get out of hand;
patient is sought out by others because of his warmth and
integrity.”
PRESENCE OF MULTIPLE HUMAN
STRENGTH
 Traits rather than category
 Optimistic cognition

 Four components in positive mental health

 Talents–e.g.. High IQ
 Enablers – e.g. strong family, good school system
 Strengths – e.g. kindness, forgiveness, honesty
 Outcome – e.g. improved social relationship and subjective
wellbeing
 “Loneliness kills. It’s as powerful as smoking or
alcoholism.”
- Robert Waldinger
 MATURITY
 Maturity is associated with increasing mental health
 In Erikson’s model the adult social radius expanded over
time through the mastery of certain tasks such as
 “Identity versus Identity Diffusion,”
 “Intimacy versus Isolation,”
 “Generativety versus Stagnation,”
 “Integrity versus Despair.
 POSITIVE EMOTION
 This model defines both mental and spiritual health as
the amalgam of the positive emotions that bind us to
other human beings.
 Love, hope, joy, forgiveness, compassion, faith, awe,
and gratitude comprise the important positive and
“moral” emotions included in this model.
 All involve human connection, helps to broaden and
built, make thought patterns more flexible, creative,
integrative, and efficient
 Negative emotions – fear and anger – about self, survival
and narrows attention
 EMOTIONAL INTELLIGENCE
 High socio-emotional intelligence reflects above-average
mental health
 Aristotle defined socio-emotional intelligence as
follows:
 “Anyone can become angry—that is easy. But to be angry
with the right person, to the right degree, at the right
time, for the right purpose, and in the right way—that is
not easy.”
 Closely linked with identifying, responding and managing
emotion in self and in others
 Anger, fear, excitement, interest, surprise, disgust, and
sadness is expressed through facial expression.
 SUBJECTIVE WELLBEING
 Positive mental health does not just
involve being a joy to others; one must
also experience subjective well-being.
 Subjective wellbeing is not just the
absence of misery, but the presence of
positive contentment
 RESILIENCE
 Ability to bounce back from adversity, trauma, and
stress-they remain focused, flexible, and productive in
bad times as well as good
 There are three broad classes of coping mechanisms
 To elicit help from appropriate others
 To use conscious cognitive strategies intentionally
 Adaptive involuntary coping mechanisms that distort our
perception of internal and external reality in order to reduce
subjective distress, anxiety, and depression. optimal
adaptation in the handling of stressors
 altruism, sublimation, suppression, anticipation, humor
MENTAL HEALTH
 Process model:-(Normality as a process) normality as a
dynamic and changing process. Rather than as a static
concept
 Continuum model:- describe normality and mental
disorder as falling at two ends of continuum, rather than
discrete event.
 Discrete model
CONTINUOUS OR DISCRETE?
 Continuous model:
Mental Health Mental Illness
+++++++++++++++++++++++++++++
Healthy>>>Adjustmentreaction>>>Neurosis>>>Psychosis

We all have differing degrees of mental

health at different times in our lives.
Most people aren’t at the extremes but
fall somewhere in the middle.
Anyone can become mentally ill, given
the right circumstances.
CONTINUOUS OR DISCRETE?
 Discrete model
Some people are mentally healthy; others have specific
mental disorders.
“Decision trees” can distinguish who has a specific mental
disease and who doesn’t.

 Mentally Healthy Mentally Ill


MENTAL HEALTH
 Mentalhealth is defined as a state of well-
being in which an individual
realizes his own potential
can cope with normal stresses of life
can work productively and fruitfully
is able to make a contribution to his/her
community
WHAT IS MENTAL HEALTH?
Additional features:
 Has self-awareness and self-knowledge
 Has self-esteem, self-acceptance
 Has a sense of psychological well-being
 Has sense of autonomy and voluntary control over
behavior
 Reality orientation
 Is able to maintain fulfilling relationships
 Has sense of competence, mastery, purpose
MENTAL HEALTH
 Has ability to enjoy life
 Has the ability to bounce back from adversity

 Has the ability to achieve balance (moderation)

 Has the ability to be flexible and adapt

 Has the ability to feel safe and secure

 Has the capacity to self-actualization (making the best of

what you have)
 Meets the responsibilities

 A balance between work and play, rest and activity

“The successful performance of
mental function, resulting in
productive activities, fulfilling
relationships, and the ability to adapt
to change and cope with adversity”
WHO HAS MENTAL HEALTH?
 We all fall short to some extent
 Therefore, advocates of mental health
believe that a broad range of mental health
services should be available to general
population, not just seriously mentally ill
 They believe that prevention and
education, as well as treatment, are
important
MENTAL DISORDER

What is mental disorder?

What sort of psychiatric disorders

do you know?
MENTAL DISORDER(DSM-5)
 Psychiatricdisorder is disturbance of
1. Cognition (thought)

2. Conation (action)

3. Affect (feeling)(emotion)

Or any disequilibrium between the three

MENTAL DISORDER ACCORDING TO
DSM - 5
 Dysfunction in the psychological, biological, or
developmental processes underlying mental functioning
 Significant distress or disability in social, occupational,
or other important activities
 An expectable or culturally approved response to a
common stressor or loss, such as the death of a loved
one, is not a mental disorder.
 Socially deviant behavior (e.g., political, religious, or
sexual) and conflicts that are primarily between the
individual and society are not mental disorders
MENTAL DISORDER
 Mental illness is
a state of psychological, social, spiritual
and or physical ill health
It interferes with individual’s thinking,
appropriate perception of the environment,
social relationship and the ability to adapt
to changing living conditions or function
optimally.
MENTAL DISORDER
 Mental disorder is specific diagnosis of a
condition or type of mental illness that is
made by a trained health/mental health
professional after formal psychiatric
assessment or interview
How prevalent is mental
disorder?
PREVALENCE OF MENTAL DISORDER
 Common to all countries
 25% of the world’s population will
develop mental illness at some stage in
their lives
 lifetime prevalence in USA : 28%
 lifetime prevalence in Iran : 10.5-21%
 450million people suffer from mental
disorder
PREVALENCE OF MENTAL DISORDER
 Estimatesmade by WHO in 2019
264 million people suffer from depression
45 million people from Bipolar disorder
25 million people suffer from schizophrenia
91 million people suffer from alcohol use
disorder
15 million people suffer from drug use
disorder
50 million people from Alzheimer and other
dementia
PREVALENCE OF MENTAL DISORDER
 Prevalence of mental disorders in Ethiopia
Common mental disorders ---- 12 to 17%
Schizophrenia ---------0.6 to o.7%
Mood disorders ------- 3.8 to 5%
Childhood disorders ----12 to 24%
Substance dependence --- 4%
Khat abuse -------------------- 22 to 64%
Suicide attempt -------------- 0.9 to 3.2%
Completed suicide ----- 7.7/100,000/year
WHY CONCERN ABOUT MENTAL
ILLNESS?
 Itaffects every body – estimated 1:5 person
 They are a major public health burden- 40% of
those attending general care service
 Because they are very disabling

 Because societies are rapidly changing

 In low- and middle-income countries, between 76% and
85% of people with mental disorders receive no
treatment for their disorder
 Poor quality of care for many of those who do receive
treatment
 Because mental illness leads to stigma

 Because mental illness can be treated with simple,

relatively inexpensive methods
What is the relationship between
mental health and physical health?
 Mental illness caused by GMC(Biologically)
 Genetically predisposed individuals precipitated by
GMC can develop mental illness
 Caused by GMC (Psychologically)

 No causal relationship

 Mentally ill Physical illness

WHY STUDY PSYCHIATRY ?
 Only 40% receive treatment during
lifetimes
 Depression is diagnosed in only 50%
of those with depression who present
to GPs
 Adequate treatment ensues in only
about 17% of depressed patients in
primary care settings
 Half the patients who commit suicide
sought treatment in a primary care
setting within 1 month of dying
 Two-thirds of patients with
undiagnosed depression have six visits
or more a year with GPs for somatic
complaints
BARRIERS TO DIAGNOSIS & TREATMENT IN
PRIMARY CARE SETTING (PATIENT
FACTORS)
 May present with a somatic complaint
 Concurrent medical illness often obscures
psychiatric symptoms
 Denial
 Stigma & shame
 The belief that psychiatric illness is
untreatable
 The belief that drugs are mind-altering
and/or addictive
BARRIERS TO DIAGNOSIS & TREATMENT IN
PRIMARY CARE SETTINGS (PHYSICIAN
FACTORS)
 Lack of time
 Fear of being embarrassed
 Uncertainty
 Fear that the patient will have an
illness that is unresponsive to
treatment
 Prior negative experience
 Lack of knowledge
BEGIN AT THE BEGINNING

As old as history of mankind

Cared for in the community
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
BEGINNING OF PSYCHIATRY: A
HISTORICAL PERSPECTIVE
 Ancient ages
Evidence of ancient Greece and Rome
contains evidence of the belief that spirits
or demons cause mental illness.
In the 5th century BC the Greece historian
Herodotus wrote an account of a king who
was driven mad by evil spirits
The Roman poets Virgil and Ovid
repeated these themes in their works
 Inthe Book of Kings, Saul, first king of
Israel, suffered from depressive episodes,
that he attributed to being possessed by an
evil spirit
 Saul asked David, his successor, to play
the harp to improve his condition
HISTORY OF PSYCHIATRY
 The early Babylonian, Chinese and
Egyptian civilization also
Viewed mental illness as possession
Used exorcism, which sometimes
involved beatings, restraints and
starvation to drive evil spirits from their
victim.
HIPPOCRATES
 Hippocrates (460-377 BC) believed that
epilepsy (known as "Sacred Disease") was
a condition with natural origins in the brain.
 He also believed that the human body was
filled with four basic substances, called
humors, which are in balance when a
person is healthy.
 To Hippocrates, diseases resulted from
an imbalance of these humors (Humorism)
 He described 4 basic constitutional types
of human beings, based on inherent
predominance's of humor and qualities of
disposition: Sanguine, Choleric,
Melancholic and Phlegmatic
 This classification followed the deficiency
or dominancy of the four humors: blood,
lymph, bile(melancholia) and
phlegm(dementia)
HISTORY OF PSYCHIATRY
 Hippocrates(400BC)
Natural origin
Associate it with body humors
Classified mental illness – mania,
melancholia and phrenitis
Suggested more human treatment – rest,
bathing, exercise and dieting.
“mentally ill are genuinely suffering and
should be treated like other sick person”
HIPPOCRATIC TRADITION
 Introduced the concept of disturbed
physiology, an early version of the idea
that blood chemistry might play a role in
development of mental illness.
 Believed to be influenced by the
environment and food
 Placed mental illness on the same footing
as other medical disorders
HISTORY OF PSYCHIATRY
 Middle age
5th century AD to 15th century
Possessed by devil or demons
Accused them to be witches and
infecting others with madness
Results in barbaric treatment
 Treatments: Bloodletting, purging,
blistering, whipping – to restore humours
and let out evil spirits. Inhalation of
mercury.
 Also rest, music, diet, exercise.
HISTORY OF PSYCHIATRY
 17th
century
Suffer from poor treatment
Left to wander the country side or
committed to institutions
London hospital – cruel treatment of
patients
BEDLAM
 Patients chained to the walls if violent
 Filthy living conditions

 Used for the violently psychotic, sometimes for

morally ‘unusual’ people
 Patients beaten, poor sanitation

 By Victorian times people used to pay to see the

patients – a penny a viewing on the first Tuesday
of the month
 Bedlam beggars would go out on the streets to
ask for money
HISTORY OF PSYCHIATRY
 14th
to 17th century
Bodily disease Vs divine punishment
Physicians replaced monks
Mentally ill was considered worthy of
human treatment
Philip Pinel(1745-1826) first
emphasized on humane approach and
unchained them
MORAL THERAPY
 Pineal in Paris took the chains off patients
 Nothing bad happened

 Pioneered asylums – peaceful places, treating

patients with care and compassion, with work to
do – typically on farms
 Replicated by William Tuke in UK
HISTORY OF PSYCHIATRY
 19th century
European neurologists began investigating
causes of mental illnesses
Sigmund Freud was the prominent one
Introduced the concept of unconsciousness
and ego and reintroduced the art of dream
interpretation
Introduced “talking cure”
HISTORY OF PSYCHIATRY
 Emil Kraepelin - 1856–1926
 Eugen Bleuler - 1857–1939

 Shock Treatments –
 In the 1920s & 1930s convulsions produced by metrazol
given by Ladislas Meduna (1896–1964) and by insulin by
Manfred Sakel (1900–1957)
 In 1938 two Italian psychiatrists, Ugo Cerletti (1877–1963)
and Lucio Bini (1908–1964) - convulsions by means of
electroshock(ECT)
HISTORY OF PSYCHIATRY
 20th century
 Disease classification and rebirth of biological
psychiatry
 Advance in discovery of medication
 Solution before cause
 Discovery of relationship between illness and
specific neurotransmitter. E.g. increase in NE and
serotonin seemed to help depressed patients and
medications that block the transmission of dopamine
provided relief from hallucination and paranoia
HISTORY OF PSYCHIATRY
 Lobotomies
 The destruction of the white matter of the frontal lobes of the
brain
 During the late 1940s and early 1950s, Egas Moniz and
Walter Freeman for intractable psychotic and obsessive-
compulsive patients
 Psychotropic drugs
 Chlorpromazine in 1952
 Imipramine in 1957
 SSRI’S since 1988

 Deinstitutionalization
 

SECOND HALF OF 20TH CENTURY

SECOND HALF 20TH CENTURY

 Discovery of the first neurotransmitter by Otto

Loewi: Acetilcholine 
 Radiology and image diagnosis was first used as
a psychiatric tool in 1980
 The discovery of the efficacy of chlorpromazine
in the treatment of Schizophrenia in 1952
revolutionized the theurapeutical approach of the
condition  
 Lithium carbonate for Bipolar Disorder, in
1948
 When psychosocial problems seemed to
be the cause, psychotherapy seemed to be
the "cure"
 In 1995 genes that contribute to
schizophrenia were found in chromossome
6 and genes related to bipolar disorder in
chromosomes 18 and 21
SUMMARY OF HISTORICAL
PROGRESSION
 Spiritual and religious views – e.g. abnormal behavior as
“demonic possession”
 Gradual movement to more “scientific” and humane
views of mental illness during the Renaissance and
Enlightment.
 Establishment of asylums – e.g. the monastery of st. Mary of
Bethlehem in London become the notorious “Bedlam”
 La Bicetre hospital in Paris – patients in chains and shackles,
poorly fed, in dark, in unclean and unheated cell.
 Pinel’s reforms in France in 1792, after the French revolution
– removing the chains and creating decent conditions for the
mentally ill.
SUMMARY OF HISTORICAL
PROGRESSION
 The development of modern psychotherapy and the
fragmentations of approaches to abnormal behavior in the late
19th and 20th centuries
 Freud, the psychoanalytic perspective and the development of
psychoanalysis
 The behavioral perspective on mental illness – abnormal behavior as
learned, maladaptive behavior.
 The genetic-biological perspective and the “diathesis-stress” model
 The humanistic /cultural/normative perspective: Mental illness as
culturally relative and non-normative behavior.
ETHIOPIAN PSYCHIATRIC HISTORY
 The Amanuel Mental Hospital
Built by the Italians to serve as a general
hospital
After independence it was converted to a mental
asylum - far from the centre and deemed
appropriate for the isolation of ‘insane’
The hospital is no longer on its outskirts but it is
still located in an impoverished neighborhood
Few beds for the incarceration of mentally ill
offenders
ETHIOPIAN PSYCHIATRIC HISTORY
In the 1960s
More patients than beds, many being

necked & chained, busy twice weekly

ECT
Lonely neuropsychiatrist from

Yugoslavia (Dr. Pavicevic), half the

staff assigned because they failed
elsewhere
IMPORTANT LANDMARKS
 1stlandmark – introduction of psychiatry
in the curriculum of the new medical
faculty of Haile Sellassie I University

 2nd landmark – the return of Dr. Fikre

Workineh in the early seventies, later
joined by Dr. Abdulreshid Abdulahi
IMPORTANT LANDMARKS
 3rd
landmark – blueprint of mental health care in Ethiopia
1985
Psychiatry nursing training
Training of psychiatrists abroad

 4thlandmark – the starting of psychiatric residency program

in 2003 in collaboration with the Toronto University
Drs. Abdulreshid, Ataly & Mesfin
Dr. Clare
 Masters program in psychiatry

 PHD program
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Misconceptions about mental illness are
pervasive, and the lack of understanding can
have serious consequences for millions of people
who have a psychiatric illness
 The most common myths about mental illness:-
Violent, aggressive, irrational, untreatable,
unreliable, dependent, chronic.
MISCONCEPTIONS
 The profession
Results in mental illness
Can read the mind
 Patients
Dangerous & feared
Are not treatable & can’t work
 Fools, untrainable, don’t feel pain or
suffering ,don’t remember theirs & others deed’s
Can’t possess a property, don’t have equal rights
TRADITIONAL BELIEFS & PRACTICES IN
PSYCHIATRY
 Causation  Treatment
Possession Holy water
Witchcraft Sheiks & priests
Evil eye Herbalists
Sin Exorcism
Poisoning
MISCONCEPTION ABOUT MENTAL
ILLNESS
 "Misconceptions about mental illness contribute
to the stigma, which leads many people to be
ashamed and prevents them from seeking help,"
 "Dispelling these myths is a powerful step
toward eradicating the stigma and allaying the
fears surrounding brain disorders."
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Top Ten Myths about Mental Illness
Myth #1: Psychiatric disorders are not
true medical illnesses like heart disease
and diabetes. People who have a mental
illness are just "crazy."
 Fact:
Brain disorders, like heart disease and
diabetes, are legitimate medical illnesses.
Research shows there are genetic and
biological causes for psychiatric disorders,
and they can be treated effectively
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Myth #2: People with a severe mental illness,
such as schizophrenia, are usually dangerous and
violent.
Fact:
 Statistics show that the incidence of violence in
people who have a brain disorder is not much
higher than it is in the general population.
 Those suffering from a psychosis such as
schizophrenia are more often frightened, confused
and despairing than violent.
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Myth #3: Mental illness is the result of
bad parenting.
Fact:
Most experts agree that a genetic
susceptibility, combined with other risk
factors, leads to a psychiatric disorder. In
other words, mental illnesses have a physical
cause.
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Myth #4: Depression results from a personality
weakness or character flaw, and people who are
depressed could just snap out of it if they tried
hard enough.
Fact:
 Depression has nothing to do with being lazy or
weak. It results from changes in brain chemistry or
brain function, and medication and/or
psychotherapy often help people to recover.
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Myth #5: Schizophrenia means split personality,
and there is no way to control it.
Fact: Schizophrenia is often confused with
multiple personality disorder.
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Myth #6: Depression is a normal part of the
aging process.
Fact:
 It is not normal for older adults to be depressed.
Signs of depression in older people include a loss of
interest in activities, sleep disturbances and
lethargy. Depression in the elderly is often
undiagnosed, and it is important for seniors and
their family members to recognize the problem and
seek professional help.
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Myth #7: Depression and other illnesses, such as anxiety
disorders, do not affect children or adolescents. Any
problems they have are just a part of growing up.
Fact:
 Children and adolescents can develop severe mental illnesses.
In the United States, one in ten children and adolescents has a
mental disorder severe enough to cause impairment.
However, only about 20 percent of these children receive
needed treatment. Left untreated, these problems can get
worse. Anyone talking about suicide should be taken very
seriously
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Myth #8: If you have a mental illness, you can
will it away. Being treated for a psychiatric
disorder means an individual has in some way
"failed" or is weak.
Fact:
 A serious mental illness cannot be willed away.
Ignoring the problem does not make it go away,
either. It takes courage to seek professional help.
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Myth #9: Addiction is a lifestyle choice and
shows a lack of willpower. People with a
substance abuse problem are morally weak or
"bad".
Fact:
 Addiction is a disease that generally results from
changes in brain chemistry. It has nothing to do
with being a "bad" person.
MISCONCEPTION ABOUT MENTAL
ILLNESS
 Myth #10: Electroconvulsive therapy (ECT), formerly
known as "shock treatment," is painful and barbaric.
Fact:
 ECT has given a new lease on life to many people who
suffer from severe and debilitating depression. It is used
when other treatments such as psychotherapy or
medication fail or cannot be used. Patients who receive
ECT are asleep and under anesthesia, so they do not feel
anything.
SOME FACTS ON MENTAL ILLNESS
h Has nothing to do with h Mentally ill are not all
intelligence dangerous
h Can happen to anyone h Difficult to diagnose and
h Chronic but not to treat
contagious h Treated but not cured
 "Thesemisconceptions can do irreparable harm
to people with legitimate illnesses who should
and can be treated,"

"Research in brain disorders is flourishing, and

we expect to see new and better treatments that
will have the power to change lives and bring
hope to many,"
“Every patient deserves a
clinician and a healer who is
not prejudiced”
ETIOLOGY OF MENTAL DISORDERS
 Unknown or incompletely understood.
 Caused by combination and interaction of
several factors.
 Causes are remote in time
 Single cause may lead to several effect.
 Complex and ambiguous
WHAT CAUSES MENTAL ILLNESS?
 No one really knows. Research so far is
inconclusive
 Research is being carried out from diverse
perspectives:
Psychological
Biological
Sociological
CONTEMPORARY VIEWS
The Bio-Psycho-social model is so
far the most plausible approach to the
problem.
All the three aspects need to be
explored in diagnosis and
management
Biologic influences Psychological influences Socioculturalinfluence

C.Family stability
A.Prenatal, perinatal B.interactions Ethnicity
and neonatal events Intelligence quotient Housing
Physical health status Self-concept Child-rearing patterns
Nutrition Skills Economic level
genetics Creativity Religion
History of injuries Emotional developmental Values and beliefs
Neuroanatomy level
physiology

Mental health
STRESS DIATHESIS MODEL
 Is an integration of concepts of genetic vulnerability and
environmental stressors.
 A diathesis is when genetics predisposes certain illness.

 An individual may continue to lead a normal life, but

when faced with environmental stressors abnormal
behavior results
 This supports that one inherits the vulnerability factors
but not the mental disorder
 Some disorders are expressed more in vulnerable
individuals than the others.
 Life Events

Personality/coping
skills

Filter

Genetic vulnerability factors

for depression
 divorce
Virus or toxin
Bad childhood

Even if you inherit the gene

for schizophrenia,the
chance of whether or not
you develop the disease
schizophrenia may be affected by outside
factors
Minor stressors Moderate stressors Major stressors

DNA with DNA with

predisposition for predisposition for Normal DNA
schizophrenia- depression –
highly biologically moderatly
determined biologically
determined

depression PTSD
schizophrenia
BIOLOGICAL MODELS OF CAUSATION
OF MENTAL ILLNESSES
 The formulation of psychiatric disorders involves the
integration of four key elements:
 Genetic vulnerability to the expression of a disease .
 Life event stressors that come to the individual’s way
(divorce , financial problem, etc)
 The individual’s personality ,coping skills and social support
available.
 Other environmental influences on the individual and his
genom, including viruses, toxins and other disease.
GENETIC VULNERABILITY
 Abnormal functioning of genes give rise to genetic
vulnerability
 If the rate of the illness is greater among monozygotic
than dizygotic, then heredity is an important factor
(bipolar & schizophrenia)
 Multiple sites in DNA within the genom must interact to
produce psychiatric illness.
 Such genes may act independently or synergistically.
RELATIVE RISK FOR 1ST DEGREE
RELATIVES
 Schizophrenia and bipolar disorder: 10x
 Substance use including alcoholism: 4-8x

 Generalized anxiety disorder : 5x

 Bulimia and anorexia nervosa : 5x

 Obsessive-compulsive disorder: 4x

 Unipolar depression: 3x

 Phobias ( simple and social): 3x

TWIN STUDIES: MZ VS. DZ RISK
 Autism: 6x
 Schizophrenia: 5x

 Bipolar disorder: 4x

 Major depressive disorder: 2x

 Alcoholism: 2x

 Alzheimer’s disease: 2x
GENETIC LINKAGE RESULTS
 Schizophrenia: loci on chromosomes 1, 2, 4, 5, 6, 7, 8, 9,
10, 13, 15, 18, 22 and x
 Bipolar disorder: 1, 4, 6, 10, 12, 13, 18, 21, 22 and x

 Depression: 1, 2, 5, 8, 10, 11, 15, 18, 19

 Alcoholism : 1, 4, 9, 15, 16, 19

 ADHD: 7, 10, 12, 15, 16, 17

NEUROCHEMISTRY
 Neurotransmitters
 Noradrenaline
 Serotonin
 Dopamine
 GABA
 Acethylcholine
OTHER ENVIRONMENTAL INFLUENCES
 Numerous biochemical products
 Different types of toxins (biological or
chemical)
 All these could have influences in either
contributing in changing genes or
inducing vulnerable genes for the
manifestation of psychiatric disorders.
MEDICAL CONDITIONS
 Bacterial and viral infections, metabolic
illnesses, medications and street drugs and
insults(injuries) to the brain can all lead to
mental disorder.
 The elderly are particularly vulnerable to
changes in mental status resulting from
apparently minor changes in body chemistry.
ETIOLOGY OF MENTAL DISORDERS
 A single
disease may result from several
causes and scheme for understanding the
illness
Predisposing, precipitating and perpetuating
factors.
Predisposing factors are those that render
the person susceptible or vulnerable and are
present over a long period of time.
ETIOLOGY OF MENTAL DISORDERS
 Precipitating factors are events that
precede clinical onset.
 Perpetuating factors are factors that
prolong the course of a disorder after it
has been provoked.
PREDISPOSING FACTORS
 Increase susceptibility to psychiatric disorder
 Established in utero or in childhood

 Operate throughout patient’s lifetime

 Genetics:-

E.g. schizophrenia, BPD, dementia

 Age:-

E.g. Adolescence, middle life, old age

 Gender:-

E.g. Alcohol (M>F)

 Physical,psychological and social factor early in life and pre-
morbid personality is important.
PRECIPITATING FACTORS
 Trigger an episode of illness
 Determine its time of onset
 Environment:- Emotional as well as physical milieu
 Family interactions (engagement, marriage, discord, separation,
death, becoming a parent).
 Other interpersonal relationship(difficulties with friends or

neighbors).
 Living circumstances (immigration)

 Financial affairs (inadequate finances)

 Legal affairs (being arrested or sued)

 Occupation – stress related to job.

 Physical
illness
Personal (pain, discomfort)
Financial (cost of treatment)
Emotional (feeling of depression)
Body image (breast amputation)
Endocrinal (hyperthyroidism)
PERPETUATING FACTORS
 Delayrecovery from illness
Secondary demoralization and
withdrawal from social activities.
Substance use/abuse
Lack of social support
Chronic physical illness
 THE SYMPTOMS OF MENTAL ILLNESS
 There are five major types of symptoms
Physical :- ‘Somatic’ symptoms. These affect
the body and physical functions, and include
aches, tiredness and sleep disturbance.
Feeling :- emotional symptoms. Typical
examples are feeling sad or scared.
THE SYMPTOMS OF MENTAL ILLNESS
Behaving:- Behavioral symptoms. Related to
what a person is doing .E.g. aggressiveness
and suicidal attempt.
Imagining:- Perceptual symptoms. These arise
from one of the sensory organs and include
hearing voices or seeing things that others can
not.
 In reality these symptoms are closely associated
with each other.
SERIOUS MENTAL ILLNESS
 Always Included in Definition
 Schizophrenia
 Major Depression
 Bipolar Disorder

 Sometimes Included
 Severe Anxiety Disorders
 Cognitive Disorders
 Some Personality Disorders
MANAGEMENT OF MENTAL DISORDER
 Mainlyof three types
Biological- mainly medication, ECT
Psychological
social
SUMMARY
 Rather than the absence of mental illness, mental health
refers to the presence of positive characteristics.
 Mental disorder is a very common condition but
under and misdiagnosis is very frequent
 Psychiatry has evolved a great deal and is still
moving foreward
 Has complex and multifactorial etiology

 It can be easily treated

“The Sun Still Shines Above The
Storm”

“Where there is help there is hope”

 REVISION
 Meaning of mental heath and mental disorder
 History of mental illness

 Prevalence of mental disorder

 Misconception in psychiatry

 Etiological explanation of mental disorder