1. Common Mental Health Disorders
Dr. I.R.Medagama
Consultant Psychiatrist,
BH Panadura

2. Health
Health is a state of complete physical, mental and social well being
Mental health is an integral aspect of overall health and well-being

3. Good Mental Health A state of well-being in which:
The individual realizes his or her own abilities
Can cope with the normal stressors of life
Can work productively and fruitfully
Is able to make a useful contribution to his or her community.

4. Situation Worldwide
Approximately 450 million people worldwide have a mental illness
1 in 5 people have a mental illness
About 150 million people worldwide have depression
One million people die due to suicide each year

5. Sri Lanka About 10% of our population have a mental illness.
About 2,000,000 have mental illnesses
About 2% have major mental illnesses
About 384,000 have major mental illnesses

6. Mental illnesses Major public health burden.
Disability caused by Mental Illnesses is significant
Depression and alcohol abuse are the mental disorders mostly associated with suicides.

7. Symptoms of mental illnesses
Physical/somatic – sleep and appetite disturbances.
Deterioration in functioning
Behaviour- Symptoms such as aggressive behaviour, suicidal attempts.
Feelings –emotional symptoms such as fear, irritability and sadness

8. Symptoms of mental illnesses
Thoughts – abnormal beliefs such as thinking someone is going to harm him/her
Perceptual- Symptoms which are not real such as hearing voices, seeing things (hallucinations).
Memory problems

9. Causes of mental illnesses
Stressful life events –Bereavement relationship, family or marital problems, financial/ work related problems Social isolation, poverty Domestic violence trauma/ war/displacement Natural disasters such as floods, tsunami.
Genetic factors.
Physical disorders
Substance abuse.

10. Mental illnesses Depression Generalized anxiety disorder
Panic Disorder
Phobias
Obsessive compulsive disorder
Post traumatic stress disorder

11. Mental illnesses Somatoform Disorder
Dissociate states/Conversion disorder

12. Mental illnesses
Schizophrenia
Bipolar affective disorder
Dementia

13. Depression
Depression is a leading cause of disability across the world.
According to the WHO, depression will rank second only to Heart Disease by 2020 in terms of global disability
Lie time risk of suicide is about 6%-15%
1 in 10 people have Depression at some point in their lives
Can present as mild, moderate or severe depression.
Early detection and treatment important.

14. Depression - Essential features
Persistent low mood
Lack of energy
Lack of interest and enjoyment

15. Depression – Other features
Sleep and appetite problems
Pessimistic and negative thoughts
Suicidal ideation and attempts
Ideas of guilt and unworthiness
educed self-esteem and confidence
Reduced concentration _ Symptoms of two weeks duration.

16. Case history 1
32 year old housewife, mother of 2 presented with a history of early morning awakening, reduced appetite, loss of weight and feeling low of two months duration She admitted feeling lethargic and not enjoying things she enjoyed earlier. She was unable to cope with the daily activities. She cried often and expressed suicidal ideation Her husband was taking alcohol regularly and verbally abused her and assaulted her frequently.

17. Case History 2
7 year old girl presented with a H/O Change of behaviour of two months.
Father gone abroad three months back. Was very attached to the father
Stopped playing. Did not watch TV. Cried frequently. School work deteriorated.
Later, did not come out of her room, did not eat, poor sleep, school refusal

18. Case History 3
60 year old male, retired from work recently. Daughter left home 3/12 back.
Lack of interest and energy, hopelessness and sadness, low mood, somatic complaints, daily functioning affected Pessimistic and negative thoughts Suicidal ideation and plans

19. Depression in adolescents
Irritability
Aggression
Intolerance, being argumentative
Deterioration in school performance and level of functioning
Anti-social behaviour and loss of control
Anxiety
Difficulties with peers

20. Management of depression
Drug treatment – SSRI, Tricyclics, SNRI( Venlafaxine)
Moderate and severe disorders- drug treatment and psychological treatment can be combined.
Psychological treatment : Cognitive behaviour therapy/ Interpersonal therapy
ECT : Severe disorders with high suicidal risk or very poor oral intake Depressive stupor Where response to other forms of treatment are poor

21. Management of depression –SSRI
Citalopram : 20-40mg/day
Escitalopram : 10-20mg/ day
Fluoxetine : mg/day
Fluvoxamine : mg/day(given b.d.)
Paroxetine : 20-60mg day
Sertraline : mg/day

22. Management of depression
Amitriptyline : mg/day
Clomipramine : mg/day
Imipramine : mg/day
Dothiepin : mg/day
Venlafaxine : mg/day
Mirtazapine : 15-45mg/day

23. Anxiety Feeling apprehensive, fearful and worried.
Autonomic symptoms-palpitations, sweating, shortness of breath, chest pain, dizziness, tremors, headache.
Poor sleep, irritability, reduced concentration.
Muscle tension-tremors, restlessness, headache
Panic attacks and phobic symptoms Symptoms are persistent

24. Anxiety disorders Phobias Panic disorders Generalized anxiety disorder
Obsessive compulsive disorder

25. Phobic anxiety disorders
Persistent irrational fear with avoidance Anxiety occurs only in specific situations orin the presence of specific objects
The person is well at other times.
Types of phobias: Simple phobia Social phobia Agoraphobia

26. Specific phobias
Restricted to highly specific situations such as fears occurring in the presence of certain animals, insects, heights, thunder, going in lifts, fear of closed spaces, sight of blood or injury
Start in childhood

27. Social phobia Starts in adolescence
Anxiety related to criticism by others in social situations. Fear of being judged by others and of being embarrassed and humiliated.
Avoidance of social situations

28. Case history 4
A 22 year old university student presented symptoms of anxiety such as palpitations, sweating, dry mouth, and tremors whenever he had to talk in front of a crowd. He had severe difficulties in carrying out presentations which were required as a part of his academic work. This lead to him avoiding such situations. Even thinking about facing such situations made him severely anxious. He avoided facing oral examinations when he was compelled to go for such exams performed very poorly.

29. Treatment of social phobia
Responds well to CBT and exposure therapy
CBT is more effective than pharmacotherapy
1st Line pharmacological treatment is SSRI’s.
Venlafaxine can be used as second-line treatment
Treatment should be continued for at least six months.

30. Agoraphobia
Characterized by fear of open spaces and the presence of crowds
Anxiety related to leaving home, going to shops, being in crowded places and public places and when travelling alone in trains, buses.

31. Case history 5
A 35 year old housewife presented with symptoms of anxiety in crowded places. She especially found it difficult when she went to the market. She started trembling and had features of anxiety and developed palpitations and fears that she might die. This led to avoiding such situations gradually. Ultimately she avoided leaving her home as far as possible.

32. Panic Disorder Recurrent attacks of severe, unpredictable anxiety
Sudden onset of palpitations, chest pain, choking sensation, dizziness are common.
There is secondary fear of dying, losing control or going mad

33. Case history 6
A 19 year old boy presented with episodes of palpitations, shortness of breath, and chest pain of one months duration. During these episodes, he felt fearful that he might develop a heart attack or he might die. The episodes lasted a few minutes. He was well in between episodes. There was no triggering factor related to the episodes.

34. Management of panic disorder
CBT and drug treatment effective.
CBT is the treatment of choice
SSRI’s, SNRI’s, tricylics are effective SSRI’s considered 1st line of treatment.
Starting doses of SSRI,SNRI and tricyclics are lower that the doses used for depression as they can initially exacerbate anxiety.
The dose has to be adjusted according to the response.

35. Management of panic disorder
Therapeutic effect could be delayed and may take up to 6 weeks. Treatment should be continued at least for 8 months. Antidepressants should be tailed off over several weeks.
Little evidence to support the use of benzodiazepines
Little evidence to support the use of pharmacological and psychological interventions in combination.

36. Generalized anxiety disorder
Persistent and excessive anxiety and worrying about everyday life situations.
Chronic disorder associated with somatic complaints, high rates of comorbid depression and other anxiety disorders.

37. Treatment of generalized anxiety disorder
Cognitive therapy is as effective a pharmacotherapy in GAD. Combined therapy effective
SSRI’s, SNRI, tricyclics are effective as pharmacological treatment. Buspirone is another drug which can be used
SSRI’s are the first line of treatment
Treatment is with low initial doses. Dose has to be titrated gradually.
If there is no improvement with 12 weeks of optimal treatment, switching to another drug from a different class is recommended. Treatment should be continued for 18 months.

38. Obsessive Compulsive Disorder
Recurrent intrusive thoughts (obsessions) or compulsive acts
Distressing, arising from their own minds
Realizes they are senseless, tries to resist.
Obsessional thoughts are ideas, doubts, images, impulses
Common themes –contamination, doubts, sexual and blasphemous thoughts
Repeated acts/rituals (compulsions) are carried out to reduce anxiety- hand washing, bathing, counting, checking rituals.

39. Obsessive Compulsive Disorder
Interference with daily activities.
Can develop depressive episodes.

40. Case History 7
A 18 year old girl presented with recurring intrusive thoughts of dirt and contamination. She engaged in repeated hand washing, bathing, and complicated cleaning rituals. She had repeated checking behaviours due to doubts. Daily functioning affected

41. Case History 8
A 65 year old widow presented with a history of repeatedly occurring distressing ‘bad’ thoughts related to her religion. To counter-act the ‘sin’ which she felt she was doing, she repeated various ‘gathas” for long periods of time. This interfered with her daily functioning.

42. Case History 9
10 year old boy presented with excessive slowness when doing school work. He was very careful about how he wrote each letter and took a long time to write a sentence. When he made a mistake, he cut it off and started writing from the beginning. This affected his school performance significantly. He also, had rituals about how he kept his clothes prior to dressing and took a long time to arrange his school books.

43. Treatment of obsessive compulsive disorder
Cognitive behaviour therapy and SSRI’s are the first line of treatment
Combining CBT with SSRI is more effective than monotherapy
Main CBT interventions: exposure and response prevention

44. Treatment of obsessive compulsive disorder
Clomipramine is effective as SSRI. Can be used in patients not responding to SSRI
Tricyclics other than clomipramine and benzodiazepines are not recommended for the treatment of OCD
Fluoxetine is started at a doseof 20mg/day and gradually increased up to a dose of 80mg/day according to the response

45. Treatment of obsessive compulsive disorder
Response may take weeks
Treatment should be taken for 1-2 years and tailed off over several months.
If a patient has not responded adequately to a trial of 8-12 weeks of treatment which included 4-6 weeks at maximum tolerated dose, change of medication should be considered. CBT can be added if not already provided.
Switching to another SSRI, or to clomipramine or velafaxine and augmenting with an atypical anti-psychotic can be done.

46. Reactions to stress In response to life events: Adjustment reaction
In response to exceptionally severe stress: Acute stress reaction Post traumatic stress disorder

47. Post traumatic stress disorder
Prolonged and abnormal response to exceptionally intense stressful circumstances
Re-experiencing the stressful event-Intrusive thoughts, imagery, flash backs, nightmares
Hyper arousal
Avoidance

48. Treatment of PTSD
Psychological treatment: trauma focused psychological management. Consists of trauma based CBT and EMDR
Drug treatment : SSRI

49. Case History 10
10 year old boy who had been sexually abused presented with recurrent, intrusive thoughts regarding the event, flashbacks, nightmares and poor sleep. He had a fear of going out of the house. The features were of one month’s duration

50. Medically unexplained symptoms (Somatoform disorders)
Persisting physical symptoms
No evidence of organic aeitiology
Constantly preoccupied with thoughts related to the symptoms
Frequent medical consultations and negative investigations.
Precipitated by underlying psychosocial distress.
Underlying depression has to be looked for.

51. Case history 11
A 36 year old mother of two, was preoccupied with the thought that she was having a heart disease. She visited several physicians seeking treatment. However, all the investigations were normal. She was reluctant to accept that nothing was wrong with her and constantly talked of her complaints. Daily functioning was affected

52. Case history 12
A 8 year old girl presented with a history of recurring abdominal pain of four months duration. Investigations were normal She was found to be a victim of bullying in school.

53. Dissociative disorders
Isolated neurological symptoms that cannot be explained in terms of known pathology related to a physical illness.
Can present as seizures, paralysis, blindness, aphonia, sensory changes, amnesia, fugue, trance and possession states
Aeitiology- Psychological distress due to an underlying psychosocial problem.

54. Case History 13
15 year old boy presented with a history of hearing loss of one month’s duration. It started after he was put into a very strict religious school. All investigations were normal. Symptoms improved after he was removed from the school.
Dissociative deafness

55. Case history 14
A 16 year old girl presented with dysphonia. She had been returning home from school the previous day, when a man had tried to molest her. She escaped but was unable to speak afterwards.
Diagnosis: Dissociative dysphonia

56. Dissociative amnesia
Inability to recall important personal memories, usually stressful.
Usually partial and selective
Alone/with other disorders such as other dissociative disorders, ASR, PTSD
Must be differentiated from amnesia due to medical causes esp.in the elderly.

57. Case History 15
52 year old mother of one daughter presented with loss of memory of ten days duration Physical examination was normal Mental state examination revealed disorientation; other cognitive functions were normal MRI was normal

58. Case History 15 Her only daughter had got married ten days ago.
Diagnosis: Dissociative amnesia

59. Trance and possession state
Characterized by a temporary loss of sense of personal identity and full awareness of the surroundings
The person behaves as if taken over by another personality/being for a brief period
The person’s focus of attention is narrowed to a few aspects of the environment.
Causes such as psychotic disorders, organic disorders such as TLE ,Head Injury and substance abuse should be excluded.

60. Case History 16
A 23 year old young man started getting possessed by a goddess for three months duration. During these episodes he appeared to be under ‘external control’.
Prior to the onset of these episodes, there had been a land dispute with his neighbours. He was a quiet, timid person. He expressed feelings of utter helplessness due to his inability to help his family with this problem.

61. Case history 17
8 girls who were inmates of a children’s home developed sudden onset changes in behaviour which were indicative of possession states.
Some girls developed pseudoseizures
Initially, these episodes started in a girl who had a past history of such episodes.
She and two others had been scared byan incident in the home.

62. Epidemic hysteria Occur in closed groups of young women
Onset due to some threat to the group.
Due to effects of shared anxiety and suggestion
Usually the epidemic starts in some one who is very suggestible or the focus of attention.

63. Management-Acute dissociative/conversion disorders
Reassurance
Sympathetic, positive attitude.
Acceptable opportunity for rapid return to normality (e.g. physiotherapy etc.)
Any personal issues should be addressed.

64. Management of persisting symptoms
Remove any factors which are reinforcing the symptoms and encourage normal behaviour.
Explain symptoms are not due to physical disease but due to inability to convert willed intention into action, provoked by psychological factors.
Offer help through physiotherapy if necessary.

65. Management of persisting symptoms
Supportive, sympathetic consistent approach by all staff.
Self-help should be encouraged.
Undue concessions should not be made to the disabilities.
Medication not indicated (Unless secondary to a primary psychiatric disorder).
Attention should be directed away from the symptoms and towards the problem that provoked the disorder.

66. Management of persisting symptoms
Address issues related to personal and social difficulties.
Those who do not improve should be reviewed for undiscovered physical illness.
All patients should be followed up to detect unrecognized organic disease which would have not been identified at the onset. Address issues related to personal and social difficulties.

67. Treatment
Abreaction- the patient is encouraged to reveal the underlying stressful events and express emotions.
Hypnosis- A trance state is induced. The unconscious emotional conflicts are more accessible.

68. Anorexia Nervosa Body weight less than 85% of the expected weight
BMI < 17.5
Weight loss induced by excessive dieting, self-induced vomiting
Body image distortion- over valued ideas about being fat and out of shape
Amenorroea

69. Case History 18
A 14 year old girl presented with ankle oedema of one month’s duration amenorrhoea of nine month’s duration excessive loss of weight within a few months

70. Case History 10 She had a history of severe dieting
Exercised excessively-mainly sweeping the garden
Morbid fear of being fat in spite of her emaciated appearance

71. Schizophrenia
Delusions of control, thought insertion, thought withdrawal, thought broadcasting, delusional perception also persecutory delusions, delusions of reference
Hallucinations_ 3rd person AH, running commentary , thought echo, somatic hallucinations –also 2nd person AH
Poor self care, sleep problems, talking to self and smiling to self
Aggressive behaviour

72. Schizophrenia
Social withdrawal, blunt mood, poverty of speech, lack of initiative and drive.
Can present in different ways.
Can have depressive symptoms.
Risk of suicide is 10%.

73. Bipolar Affective Disorder
Different phases of the illness.
Depressive episodes
Manic Episodes- main features: over activity, increased energy disinhibited behaviour, over familiarity, irritability, grandiose delusions, auditory hallucinations, poor insight.

74. Dementia
20% of our population will be over 65 years by the year A large proportion of them will face mental health issues, especially dementia.
Usually in the elderly.
Incidence increases with age.
The prevalence in the over 65 age group is about 5%. It becomes as high as 20% in those over 80 years

75. Dementia Memory impairment _ usually early.
Deterioration of personality, apathetic.
Gradual progression
Global impairment of memory, intellect and personality and there is no impairment of consciousness
50-60% of cases of dementia are due to Alzheimer’s disease. Vascular dementia accounts for 20-25% of patients.

76. References
1.The Maudsley Prescribing Guidelines in Psychiatry.11th Edition. Anxiety spectrum disorders. Chapter 4 pages
National clinical guideline No:123 Common Mental Health Disorders. National Institute for Health and clinical excellence. May 2011
4.ICD 10 classification of mental and behavioural disorders WHO 1992
5. Gelder M, Harrison P and Cowen P. Shorter Oxford Textbook of Psychiatry (Fifth Edition)

77. Thank you