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

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

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.

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

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

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.

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

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

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.

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

Mental illnesses Somatoform Disorder Dissociate states/Conversion disorder

Mental illnesses Schizophrenia Bipolar affective disorder Dementia

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.

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

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.

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.

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

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

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

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

Management of depression –SSRI Citalopram : 20-40mg/day Escitalopram : 10-20mg/ day Fluoxetine : 20-60mg/day Fluvoxamine : 100-300mg/day(given b.d.) Paroxetine : 20-60mg day Sertraline : 50-200mg/day

Management of depression Amitriptyline : 50-200mg/day Clomipramine : 50-250mg/day Imipramine : 50-200mg/day Dothiepin : 75-225mg/day Venlafaxine : 75- 225mg/day Mirtazapine : 15-45mg/day

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

Anxiety disorders Phobias Panic disorders Generalized anxiety disorder Obsessive compulsive disorder

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

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

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

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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

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

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.

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.

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

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

Treatment of obsessive compulsive disorder Response may take 10-12 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.

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

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

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

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

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.

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

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.

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.

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

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

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.

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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

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

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

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%.

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.

Dementia 20% of our population will be over 65 years by the year 2020. 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

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.

References 1.The Maudsley Prescribing Guidelines in Psychiatry.11th Edition. Anxiety spectrum disorders. Chapter 4 pages 197-252 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)

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