Health

• A condition in which all functions of the body and mind are normally active

• In other words health involves finding balance in all aspects of your life

Physically

Mentally

Emotionally and

Spiritually

• The World Health Organization defines health as a state of complete physical, mental, or

social well-being and not merely the absence of disease or infirmity.

Mental Health

• 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.

• Psychological adjustment to one’s circumstances or environment.

• The ability to cope with or make the best of changing stresses and stimuli.

Mental Illness

• Any of various conditions characterized by impairment of an individual's normal

cognitive, emotional, or behavioural functioning, and caused by social, psychological,

biochemical, genetic, or other factors, such as infection or head trauma.

Introduction to Mental Health (Psychiatry), Classification and General

Causes of Mental Illness

Introduction

• Psychiatry is the branch of medicine that deals with the cause, diagnosis, treatment and

prevention of mental illness; as well as promotion of mental health.

• Mental illness abnormalities can be seen in a number of ways

Significant deviation from normal thoughts and feelings

Significant deviation from normal behaviors

Perceived subjective distress

 

Classifications

• The classification of mental disorders (also known as psychiatric nosology or taxonomy)

is a key aspect of psychiatry.

• It is an important issue for consumers and providers of mental health services.

• There are currently two widely established systems for classifying mental illness.

• Chapter V of the International Classification Of Diseases (ICD-10) produced by the

World Health Organization (WHO) and the

• Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the

American Psychiatric Association (APA)

• Both list categories of disorders thought to be distinct types, and have deliberately

converged their codes in recent revisions so that the manuals are often broadly

comparable, although significant differences remain.

• The International Classification of Diseases (ICD) is an international standard diagnostic

classification for a wide variety of health conditions. Chapter V focuses on ‘mental and

behavioural disorders’ and consists of 10 main groups:

F0: Organic, including symptomatic, mental disorders

F1: Mental and behavioural disorders due to use of psychoactive substances

F2: Schizophrenia, schizotypal and delusional disorders

F3: Mood [affective] disorders

F4: Neurotic, stress-related and somatoform disorders

F5: Behavioural syndromes associated with physiological disturbances and physical

factors

F6: Disorders of personality and behaviour in adult persons

F7: Mental retardation

F8: Disorders of psychological development

F9: Behavioural and emotional disorders with onset usually occurring in childhood

and adolescence

In addition, a group of ‘unspecified mental disorders’.

• Within each group there are more specific subcategories. The ICD includes personality

disorders on the same domain as other mental disorders, unlike the DSM.

• The ICD-10 state that mental disorder is ‘not an exact term’, although is generally used

‘to imply the existence of a clinically recognizable set of symptoms or behaviours

associated in most cases with distress and with interference with personal functions.

• The DSM-IV characterizes mental disorder as a clinically significant behavioral or

psychological syndrome or pattern that occurs in an individual and that

Is associated with present distress, or disability, or with a significant increased risk of

suffering.

No definition adequately specifies precise boundaries for the concept of 'mental

disorder'.

Different situations call for different definitions.

• The DSM also states that ‘there is no assumption that each category of mental disorder is

a completely discrete entity with absolute boundaries dividing it from other mental

disorders or from no mental disorder.’

• The DSM-IV consists of five axis (domains) on which disorder can be assessed. The five

axis are:

Axis I: Clinical Disorders (all mental disorders except Personality Disorders and

Mental Retardation)

Axis II: Personality Disorders and Mental Retardation

Axis III: General Medical Conditions (must be connected to a Mental Disorder)

Axis IV: Psychosocial and Environmental Problems (for example limited social

support network)

Axis V: Global assessment of functioning (psychological, social and job-related

functions are evaluated on a continuum between mental health and extreme mental

disorder)

General Causes of Mental Illness

• Predisposing factors

Genetics

Teratogenic effects

• Precipitating factors

Childhood abuse

Family disputes

Orphanage

Cannabis or other illicit drug use

Alcohol

Bad social influence

• Perpetuating factors

Family disharmony

Poverty

Chronic illness

Cannabis use

Bad social influence

History Taking in Psychiatric

Particulars of the Patients and Rapport Building

• Identification Data

Name, age, sex, marital status, education, occupation, religion socio-economic

background

Read the following example:

• Mr. Jones is a 74-year-old man seen at outpatient clinic with his wife because of memory

loss

• It is important to take history primarily from the patient and not from relative or next of

kin unless if the patient is uncooperative or is mute secondary to his illness.

• But in case of memory loss the history from the family member is also very important. As

patients with memory loss do not remember what happened

• Confidentiality must be observed.

History of the Presenting Chief Complaints

• Onset of symptoms chronologically

• Duration

• Course/progression

• Complication or problems the symptoms has caused

• Then cover any associated symptoms like problem with sleep, appetite and energy

• Ask about their mood and motivation for activities they normally enjoy

• Try to use the patient’s own words

• Include important negatives here as well

• This has to cover everything that is of relevance to the presentation and diagnosis

Past Psychiatric History

• Very often linked to the history of the presenting complaints which include

Diagnosis

Previous admissions

Previous contact with psychiatrist

Previous contact with other professionals

Previous antipsychotic treatment

Previous response to treatments

Past Medical History

• Ask about surgical operations

• Ask about medical conditions such as endocrine disease, cardiovascular, and infectious

• Ask about other conditions like head injuries, effects of post anaesthesia and spinal cord

injuries.

• Ask about obstetric conditions such as puerperal psychosis, eclampsia.

• Review of Other Systems Chronologically

Start with the affected systems

Drug History

Prescribed medications

Over the counter use

Herbal medicines

Liquids and injections

Illicit drug use-including indigenous substances

Family History

family structure (inheritable diseases)

Deaths in the family and their causes

Psychiatric illness in the family

Social economic status in the family

Education and employment within the family members

Family harmony prescribed

Alcohol use problems

Sub-clinical traits (personality traits)

Personal History

• A narrative from birth to recent

• Start with

Pregnancy (normal, complicated, unintended)

Birth

Childhood

Relationships with family/friends

Schooling and age at leaving

Menstrual and obstetric (in females)

Sexual and marital issues

Jobs performed

Social History

What sort of place they live at

Who are they living with

Any help

Drug and alcohol (if not done already)

Smoking

Premorbid Personality

People can have many different reactions to different situations.

Ask what they use to engage in for activities and what are they able to do now.

Ask about what gives them support, such as family, friends and spiritual/religion.

Forensic History

Violence /anger

Trouble with police

Arrests

Convictions

Times in prison

Current situation e.g. probation

Physical Examination

Mental Status Examination

• Psychiatric examination is covered systematically as follows

General Appearance and Behavior

• May be uncooperative or mute patients

Terms might include

Tidy, unkempt, anxious, agitated, threatening, tearful, eye contact (good/poor)

pacing, gestures, restless.

Gait and posture

Motor activity (excitement, stupor, catatonic, restlessness)

Speech

Need to include descriptions of

Rate of speech

Volume

Content of speech

Mood/Affect

• Rate as low/high

• Anxious

• Talks about subjective patient experiences

• Might also want to include associated features of mood disturbance include sociality

• Changes minute to minute

• Rate as blunted or

• Reduced or

• Flat (absence of emotional expression) or

• Inappropriate or

• Labile

• Apathy, ambivalence, euphoria

Thought

• Progression or sequence of thoughts

Flight of ideas

Retardation of thought

Preservation of thoughts

Circumstaciality

Thought block

• Content of thoughts

Obsessions

Delusions – these are false, fixed and unbreakable beliefs that falls outside the

person’s social, cultural or religious background) e.g.

Delusions of grandeur – a person believes that she/he is some one of great

importance

Delusions of persecution - a person believes that he has been selected for attack or

is being plotted against

Nihilist Delusions – a person believes that either he does not exist or that some

portions of himself are not existing

Delusions of self accusation- A person believes that he/she has sinned that is why

she/he is diseased

Erotomanic delusions - a person believes that he/she is loved intensely by ‘the

loved object’ who is usually married , of high socioeconomic status (public figure)

Perception

+T+ypes include

Hallucinations and Illusions

 Illusion

A misperception of an object

Occurs in

Normal people

Delirium

Dementia

Hallucinations

A perception without an object

Obvious ones include

Auditory

Visual and tactile

Cognition

• Consciousness (rate as normal, clouded, stupor or coma)

• Orientation (time, place, person)

• Attention (digit span test, give 5 digit not all even and not all odd and let him repeat

immediately)

• Concentration (count serial 7 from 100 or serial 3 from 20 backward)

• Judgment (ability to distinguish or to decide bad from good and vise verse)

Rate as good/ intact/ normal or poor/ impaired/ abnormal

• Reasoning (ability to distinguish between two identical items)

• Memory (short and long term )

• Intelligence (use simple arithmetic test)

Insight

• Complete denial of illness

• Slight awareness

• Intellectual insight

• After a detailed history and examination, investigations are carried out based on the

diagnostic and etiological formulations

• Psychiatric assessment and descriptive formulation is made before listing differential

diagnosis.                                                                                                           

REFFERNCES;

•      Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed.  Oxford: McGraw Hill

•      Davidson, S (2006). Principles and practice of medicine 20th Ed.  Churchill: Livingstone.

Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.

•      Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1st Ed. Hodder Arnold

•      Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford

•      Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.

•      Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF

•      Stuart and Saunders (2004): Mental health Nursing principles and practice. 1st Ed. Mosby

•      Swash, M., & Glynn, M. (2011). Hutchison's clinical methods: An integrated approach to clinical practice.