Menatl Health - Training The Trainer Programme Sri Lanka

Mental Health:
Training the Trainer Programme

Sri-Lanka
Professor Rachel Jenkins

Director, WHO Collaborating Centre for Research & Training in Mental
Health & Section of Mental Health Policy
In collaboration with
National Institute of Mental Health Angoda
Sri Lanka College of Psychiatrists Learning Disability Fund
© WHO Collaborating Centre

Programme Funded by:
• The Learning Disability Fund
Individual Donations from:

• Dr. Marius Cooray
• Professor Chitramohan
• Dr Anthony Fernando

• Course Tutor:
• Professor Rachel Jenkins
• Special Advisors:
• Dr. Jayan Mendis
• Dr. Sherva Cooray
• Dr. Damani De Silva
• Assisted by:
• Dr. Thilak Ratnayake
• Dr. Anthony Fernando

Mental Health
Training the Trainer Programme Sri-Lanka
30th November – 4th December 2009
Unit 1
In collaboration with
National Institute of Mental Health Angoda
Sri Lanka College of Psychiatrists Learning Disability Fund

WELCOME
• Dr. Jayan Mendis/ Dr Sherva Cooray
• Introductions:
• Purpose of programme
– Increase mental health capacity in primary care
– Continuing professional development
– A booster, jump start, eye opener!

GROUND RULES
• What ground rules do we all suggest to

facilitate smooth running of the course?

EXPECTATIONS
• What do I want from this course?
• Please write answers on 1 sheet of paper
– One thing I hope will happen
is………………………………
– One thing I hope won’t happen
is……………………………
– I will know if the course has been successful
if…………………….

METHODS OF COURSE
• Participatory for all of us so that we can improve our
skills and competencies as well as our knowledge
– slides,
– role-plays,
– videos,
– small group discussions
– large group discussions

ROLE PLAYS 1
• When we do role plays
– Everyone takes part in each one
– We split into groups of 3 people
– And one person takes the role of the patient
– One the relative
– And one person is the health worker at the
health centre or dispensary

ROLE PLAYS 2
• After 5-10 mins acting the scenario in
separate groups,
• the teacher then selects one of the groups
to demonstrate to the others
• And then we have a general discussion
about what the demonstration did well
• And what could be improved

COURSE MATERIALS
Please check you have everything in your pack and
can recognise it
• Pre-training assessment
• Curriculum timetable for the week
• Role plays
• Unit 2 Slides –core skills
• WHO Primary care guidelines
• Manual for volunteer community health workers
• Mental Health Act
• Post- training assessment

USE OF COURSE MATERIALS
• This is a very intensive course
• We will make plenty of time for discussion
and role plays
• We are giving you the course materials so
that you can use them every day over the
next five years for
– Reference whenever it is helpful to look
something up
– Teaching to colleagues and other sectors

Activity: Pre-training assessment
• We would like to see whether our course

is effective or not
• So we would like you to fill in the
questionnaire
• We will be analysing it to see if the group
as a whole benefits from the course
• So you do not need to put your name on
the paper if you don’t want to.

UNIT 1: CONCEPTS OF
MENTAL HEALTH
•This unit comprises 57 Slides, interspersed
by questions and Discussion
•Please take a moment to orientate yourself

through pages 1-13 of the WHO primary care
guidelines-reading these is part of your
homework for tonight

1.1. mental health, mental illness,
causes, consequences,
interventions
– Mental health and healthy lifestyles
– Mental disorder,
• Prevalence and symptoms
• Biopsychosocial causes and consequences
– Myths and misconceptions
– Culture and mental illness
– Interventions

What is Mental Health?
• positive sense of well-being
• belief in own worth and the dignity and
worth of others
• ability to
– deal with the inner world of thinking, feeling,
managing life and taking risks
– initiate, develop and sustain mutually
satisfying personal relationships
– sustain a spiritual life

What are healthy lifestyles?
• Coping strategies
• Self –esteem
• Self-care
• Relationships with family members, friends, colleagues
• Utilising time, money, self
• Participation and cooperation
– Social clubs, religious groups, self-help groups
– work

What are mental disorders?
• Disturbances in perception, beliefs, thought
processes and mood (psychoses)
• Disturbances in mood, concentration, irritability,
fatigue (neuroses or common mental disorders)
• Progressive organic disease of the brain (dementias)
• Abnormal personality traits which are handicapping
to the individual and /or to others (Personality
disorders)
• Excess consumption and dependency on
alcohol, drugs and tobacco

Overall Prevalence Rates
• Common Mental Disorders 10-20%

• Psychoses 1%
• Personality disorders 3-5%
• Dementias 5% over 65 and 20% over 80
• Substance abuse –variable
• Childhood disorders-10%

Symptoms of common mental
disorders
• Excessive concern • Fatigue
about bodily • Poor concentration
symptoms • Impaired sleep
(headache,
• Impaired appetite
backache)
and weight loss
• Loss of enjoyment
• Irritability
• Low mood
• Low libido
• Crying • Obsessional
• Anxiety and panic thoughts and actions

Common Mental disorders
• Mixed anxiety-depression
• Depression
• Anxiety
• Panic disorder

Bio-psycho-social causes of
mental illness
• Social
– Life events e.g bereavement, unemployment
– Chronic adversity e.g poverty, domestic violence
– Lack of social supports
• Psychological
– Learned helplessness
– Pessimistic cognitive approaches
– Unhelpful learned patterns of behaviour
• Physical
– Genetic
– Endocrine
– Nutrition
– Infection

Bio-psycho-social
consequences of mental illness
• Suffering • marital breakdown
• Disability • Intellectual and
• Mortality emotional damage to
– Suicide children
– Physical illness
• Cycle of disadvantage
• Unemployment across generations
• Low productivity
• Reduced access to and
• Poverty success of physical
• Stress on carer health programmes
– burnout, compassion
fatigue, depression

Rationale for action on mental
health
• Positive mental health contributes to
the social, human and economic capital
of societies
• The burden of mental illness is high
• Effective interventions are available

Common myths and
misconceptions 1
• Mental disorders cannot be treated
• Mental disorders never get better
• Mental illness only happens to other people
• Mental illness is mostly caused by addictions-
therefore if we put all our resources into
prevention of drug trafficking and addiction we
won’t need to worry about mental illness

Common Myths and
Misconceptions 2
• Mental Disorders are not real illnesses, so it is
• not essential to put on the agenda of key health
committees
• not essential to make available essential medicines and
treatments
• not essential to have adequate recording and
monitoring systems
• not essential to have high organisational profile at
national, regional and local level
• not essential to have human resources strategy

Pathways to care
• Individual
• Family
• Community
• Dispensary and health centre
• District hospital
• Provincial hospital
• National hospital

Culture and mental health 1.
• Some erroneous assumptions

• Mental illness is rare in low/Middle income countries
• Schizophrenia is rare in low/Middle income countries
• Chronic Schizophrenia has a better outcome in low income
countries
• Depression in low income countries presents with somatic
symptoms rather than low mood, compared to western countries-
in fact it presents with somatic symptoms in both rich and poor
countries

Culture and mental health 2
• Culture influences
• Value placed by society on mental health
• Presentation of symptoms
• Illness behaviour
• Access to services
• Way individuals and families manage illness
• Way community responds to illness
• Degree of acceptance and support
• Degree of stigma and discrimination

Mental Health Interventions
• Health Promotion
• Primary Prevention
• Secondary Prevention
• Tertiary Prevention
• Prevention of mortality

Promotion-Enhancing healthy
functioning
• Nutrition
• Exercises
• Health education
• Problem-solving
• Communication skills
• Immunization
• Maternal and child health care
• Employment etc.

Primary Prevention-preventing
illness
• Support vulnerable groups

Secondary Prevention-early detection and
treatment to facilitate recovery
– Crisis interventions
– Counselling
– Medications
– Psychotherapy
– Psycho-education
– Psycho-social support etc.

Tertiary Prevention-Rehabilitation
• to prevent disability and

• improve healthy functioning

Prevention of mortality
• Suicide
• Premature physical mortality

1. 2. MENTAL HEALTH
AND PHYSICAL HEALTH
8 slides
Discussion

Relationship between mental and
physical health:
• Health is a state of mental, physical and
social well-being
• The components interact with each other
• Mental health influences susceptibility to, and
recovery from, physical disease
• Physical health influences susceptibility and
recovery from mental disorders

Mental health impacts on
physical health.
• By causing illness, worsening prognosis and by
exacerbating pain
– Continued stress and emotional disturbances can
cause physical illness.
– The presence of psychological symptoms may result
in poor prognosis of physical illness eg depression
worsens prognosis of heart attacks and cancer.
– Mental disorder may exacerbate the pain of a
physical disease (lower threshold to pain).

Physical health impacts on
mental health
• By causing illness,
– cancer, diabetes, heart diseases and cancer may
cause depression
– Side effects of some treatments for physical illness
(eg steroids ) include mental disorders such as
depression and psychosis

Diagnostic confusion between
mental and physical disorders
• Physical illness may present with mental

symptoms
• Mental illness may present with physical
symptoms which have no organic basis
• Patients with known mental illness are more
likely have their physical health ignored by
health professional

Mental symptoms of physical disease 1:
• Mental symptoms may in fact be the presenting symptoms of a physical
disease
– Thyrotoxicosis
– anxiety states
– Myxoedema
– depression
– Memory loss, somnolence and depressed mood
– Lethargy: feeling slowed up, disinclined to undertake even familiar tasks,
unable to concentrate.
– Hyperthyroidism
– over-arousal, distractibility and anxiety
– Diabetes Mellitus
• Listlessness, irritability, and confusion
• Late complications include some degree of chronic brain syndromes

Mental symptoms of physical
disease 2.
• Electrolyte imbalance eg from renal failure
• Alkalosis; dulling of perception, confusion, and tetany
• Acidosis; dulling mental functions, drowsiness, impaired
consciousness, eventual papillloedema
• Hypernatraemia; lassitude, weakness, irritability,
confusion
• Hypokalaemia; apathy, lethargy, confusion
• Hypomagnesaemia; depression, disorientation, delirium

Physical symptoms of depression
• Headache
• Backache
• Stomach ache
• Pains here and here and here
• Feeling generally unwell

What to do.
• Integration of mental and physical health
throughout health delivery system.
• Remember
• Bio-Psycho-Social causes, presentations,
consequences and management plans

1. 3. Mental and Neurological
Health, Gender and the
Millennium Development Goals
23 slides
Discussion
Prepare and give talk to CHWs

The UN Millennium Goals
• Eradicate extreme • Improve maternal health
poverty • Combat HIV/AIDS,
• Achieve universal primary malaria and other
education diseases
• Promote gender equality • Ensure environmental
and empower women sustainability
• Reduce child mortality • Develop a global
partnership for
development

Progress uneven and slow
• UN say we need the following to achieve MDGs
– Financial support
– Political will
– re-engage governments
– Re-orientate development priorities and policies
– Build capacity
– Reach out to partners
• But the UN didn’t mention mental health!!

Mental and Neurological Health
• Is key partner to achieve the MDGs

• Is relevant to generic inequities in poor
countries
– Poverty
– Gender
– Access to services
• Why is it key partner?

You will remember that
the mental disorder is common
• Psychosis 0.5-1%
• Common Mental Disorders 10-15%
• Neurological disorders 15%
• Substance abuse-culture specific, often
10%
• PTSD-common in post conflict situations

And that the burden is high
• Suffering
• Disability
• Mortality
• Loss of economic productivity
• Poverty

-indeed the consequences and
burden are far-reaching
• Family burden
• Intellectual, emotional and physical
consequences for children
• Intergenerational burden-cycles of
disadvantage
• Reduced access to and success of health
promotion, prevention and treatment
programmes

Measuring the Burden
• World Bank/WHO invented the DALY to
measure Global Burden of Disease
• Disability Adjusted Life Year
• DALY= prevalence x disability x years of
life lived with disability + years of life lost
through premature death

Mental illness is major cause of
global burden of disease
• Neuropsychiatric disorders
– 13% DALYS in 2001 and 14.6% in 2020
– 4 of 10 leading causes of disability
– 28% of years lived with disability
• one of the world's highest suicide rates—47 per
100,000 in 1991—with most victims under 30
years old’.

Additional global burden from
behavioural problems
– Unsafe sex 2.9%

– Alcohol 3.5%
– Tobacco 3.3%

Global burden from infectious
diseases
– TB 2.5%
– Measles 1.8 %
– Malaria 2.9%

DALYs are only estimates of total
burden
• No inclusion of family or social burden
• Estimates in many countries
• Co morbidity
– Double counting because of co morbidity within mental
disorder
– Undercounting because of co morbidity with physical
illness
• No inclusion of premature physical mortality of
people with mental illness

PREMATURE PHYSICAL
MORTALITY OF MENTAL
ILLNESS
• Greatly increased premature mortality in
people with mental illness from
– Infectious disease
– Respiratory disease
– Cardiovascular disease
– Malignancies

SUICIDE
• 15th leading cause of death
• Rates highest in
– EE (8 of top 10 countries)
– Sri Lanka:
one of the world's highest suicide rates—47 per
100,000 in 1991—with most victims under 30 years
old’.
– Finland

MNH AND POVERTY
• Poverty causes mental and neurological illness
• Mental and neurological illness causes poverty
• Cycle of poverty

Poverty leads to illness
• Poverty
– associated with malnutrition, inadequate shelter, no
control over sewage, unsafe water, overcrowding
– Leads to exposure to infectious agents and
environmental toxins
– Leads to developmental; disabilities and epilepsy
• Micronutrient deficiencies cause developmental
disabilities
– Folate and spina bifida
– Iodine and cognitive deficits
– Vitamin A deficiency and blindness
– Chronic hunger and anxiety and depression

Poverty leads to unhealthy
lifestyles
• Poor people have more
– Unsafe sex,
– Smoking and other substance abuse,
– domestic violence, destructive behaviour,
– poor diet,
– failure to use seat belts etc

Mental illness leads to poverty
• MN illness interferes with capacity for work and
other roles,
– leading to decreased social and economic productivity
of affected person and carer and children
– Vicious cycle

MNH AND EDUCATION
• Consistent relationship between mental
illness and education, unemployment
– Pakistan Patel et al 1998
– Burundi Baingana et al 2004
– Kenya Jenkins et al 2005

MNH causes educational
failure
• Children with MNH
– Repeat classes, drop out, perform poorly
• Vulnerable children
– E.g. orphans, child soldiers, street
children, child headed households heave
increased rates of MNH

Gender and rates of illness
• Men have higher • Women have higher
rates of rates of
– Suicide (except China) – Depression
– Schizophrenia in (sometimes)
young people – Post natal depression
– Substance abuse which results in
emotional, cognitive
and physical damage to
children

Gender and violence
impacting on mental health
• Men • Women
– Violence and injuries – More exposed to rape
– Leading to depression, and sexual violence
(25%)
PTSD, dissociation,
– Leading to depression,
somatisation, sexual injury, pregnancy,
dysfunction and self STDs and death
harm – FGM
– Forced prostitution
– Caregivers for AIDS etc

MNH and Child Mortality
• Prevention and treatment of depression
improves compliance with
– antenatal care
– Vaccination programmes
– Prevention and treatment of infectious
disease
– Rehydration therapy for diarrhoea

MNH and maternal health
• Depression and anxiety in mother
increase likelihood of
– Smoking, alcohol, drugs
– Poor antenatal care
– Lack of treated bed nets
– Unsafe sex
– Poor self assertion to combat violence and
abuse

WHY MENTAL AND
NEUROLOGICAL HEALTH ARE
IMPORTANT
• MN ill health causes a heavy burden
• MN ill health impedes the achievement
of other health and development targets
• MN illness contributes to poverty and
differentially affects the poor
• MNH has intrinsic value as does
physical health

DISCUSSION

ACTIVITY-TALK TO VOLUNTEER
COMMUNITY HEALTH WORKERS
• Prepare a 3 minute talk to your local volunteers on
mental health and mental illness.
• Add 2 minutes on symptoms of mental disorders and

psychosis.
• add 1 minute on mental health and MDGs.
• Teacher to select someone to present

Mental Health:
Sri-Lanka Unit 2

With collaboration from

National Institute of Mental Health Sari Lanka
Sri Lanka College of Psychiatrists
Learning Disability Fund

CORE SKILLS
ESSENTIAL FOR
MENTAL HEALTH
PRACTICE
UNIT 2

UNIT 2
• This unit will explore
– Communication skills
– Interviewing and assessments
– Mental state examination
– Diagnosis, investigations, case formulation
– Care planning
– Psychosocial support
– Breaking bad news
– Psychosocial rehabilitation
– Medication management
– Violence management

2.1.Communication
10 Slides
skills
Discussion
Role Play (2)

Interviews-general
• introduce yourself
• eye contact
• Do not read notes while patient speaking
• privacy
• Begin with a general subject
• Be empathic- imagine what it must feel like
• Show that you have time to listen to the person
• Give the person a chance to talk without relatives
• Try to speak to relatives as well
• Record key information for future reference
• Keep in mind the screening questions

Interviews-specific
• Pick up
– non verbal clues
– verbal clues

Clues to distress:
NON-VERBAL
• weeping, tremor, nervous manner
• quality of the patient’s voice
• restlessness, agitation
VERBAL
• Spoken words of distress

Open and closed questions
• Open question-does not suggest a reply
– eg How are you feeling?
• Directive question-suggests topic
– Eg can you describe the pain
• Closed questions-can be answered with a
simple yes or no
– Eg are you feeling like crying

Picking up clues
Use directive and probe questions
– e.g. “You mentioned that you have been feeling depressed. Could
you tell me more about that?
Reflection
– e.g. Mrs. M, I can see that you are still very upset about your
husbands’ death.
Closed question
E.g. Have you found yourself crying a lot?

Draw attention to non-verbal clues
DISTRESS
• You still seem very upset by your mother’s death
• You look quite sad
• You sound very upset
• You’ve got quite a tremor when you talk about this
ANGER
• You seem very angry about this-tell me about it
EMBARRASSMENT
• This is something that you find difficult to talk about

Dealing with over-talkative
patients:
• Pick up a verbal clue from the many offered
– E.g: could you first of all tell me about the pain you
mentioned?
• Promise to come back to it later:
– E.g: we’ll come back to that later, but first of all I need
to hear all about that pain
• Speak when they breathe in!

Empathy is supportive
“You’ve been going through a bad

time”
“Things have been very difficult for
you”
“That must have been really
frightening”

Enable expression of feelings
• Don’t tell patient to
– Relax
– Stop crying
– Calm down
• Better to say
– I can see this is making you anxious, upset, angry
• This, paradoxically, will be much more calming for the
patient

Interview stages
• Listen • Make links – between
• Enable expression of physical, psychological and
social
feelings
• Clarify with questions
• Negotiate the management
plan
• Provide
• Motivate change in
information/education behaviour
about symptoms, causes
• Problem solving
and consequences
• Conjoint interviewing

2.2 IDENTIFYING CLIENTS WITH
MENTAL HEALTH PROBLEMS
• 15 slides
• Discuss 4 case vignettes

Different ways in which person
with mental illness may present
1.• Direct complaints of
• many physical complaints (especially
more than three) that do not fit into a symptoms of mental illness,
pattern of any known physical illness eg depression or psychosis
• relationship problems, such as or alcohol problems
marital and sexual problems • personal or family history of
• life problems, such as mental illness
unemployment or the death of a • Obvious alcohol misuse or
close friend/relative family violence
• The person or relatives
suspect supernatural causes

Helpful Screening questions for
possible mental disorder
– problems sleeping at night?
– tired easily?
– lost interest in your usual activities?
– feeling sad or unhappy recently?
– feeling tense or anxious
– worrying a lot about things
– scared or frightened of anything?
– How much money and time have you been spending on
alcohol recently?
If any of the answers are “Yes”, ask more detailed questions
to explore and confirm the diagnosis.

Assessment -Identifying
Information
– Sex
– Age
– Address
– Occupation
– Marital status
– Next of kin

Assessment -History of current
complaint
• nature, duration, severity and impact on person’s life.
• When and how did it start?
• Is it getting worse?
• brief systematic review
– Changes in appetite, weight, sleep patterns, bowel and bladder
habits, sexual feelings
– Decreased ability to enjoy oneself
• Are medicines (or other treatments) being taken?
• The person’s belief about the illness-what the person feels the
illness is and why it has happened

Assessment –previous history
– history of mental illness (if so, ask for old
prescription or old clinic notes.
– Relevant medical history, such as recent head
injury, admission to hospital.

Assessment-social
– Recent major life events, such as separation, death in the family,
unemployment.
– Social circumstances-finance, housing , work , marriage, children
– Social support-,
• who does the person live with,
• who cares for the person,
• support from outside the home, such as religious or spiritual support and
friends?

Assessment-forensic
– Any truancy or running away

– Problems at school with teachers, other students
– Problems with police
– Problems with neighbours
– Violence in family
.

Assessment-personality
• Pre-morbid personality:
– The sort of person h/she was before became ill including
interests, hobbies, mood, friendship, habits- alcohol and drug
use etc.
Q: Mr. Abey, I want to ask you some questions now about the
sort of person you were before you became ill. Could you
remember how you were a year or so ago? Could you start
by telling me about your interests
Q: Mrs Abey I want to ask you what kind of person your
husband was before he became ill. Can you remember how
he was a year of so ago?

Life charts can be helpful
Draw a life chart to combine the information, and

indicate possible relationships between life
events, physical illnesses and psychiatric illness

Things to remember!!
• Give enough time to talk • A systematic assessment
to the person and listen interview is the first important
step in the treatment
• Most mentally ill people
• Mentally ill people may also
can give a clear and suffer from a physical illness;
complete history of their never dismiss a physical
problem. complaint just because a
• Relatives can also person has a mental illness.
provide useful information

Interviewing parents about
children 1.
• Start with open questions
• Then seek for clarity
Child’s recent health and behaviour
• Emotional symptoms e.g. fears, anxiety, suicidality
• Behaviour problems e.g. stealing, aggression, cheating
• Attention and concentration
• Motor skills (activity level)
• Fits or faints, abnormal movements

Interviewing parents about
children 2.
• School performance including attendance, bullying,
relationships with teachers)
• Peer and sibling relationships
• Bladder and bowel control
• Physical health (appetite, weight, sleep, major illness
• Recent adversity (bereavement, separations)
• family history
• child’s family life and relationships
• child’s personal history- temperamental characteristics

Discuss case vignettes
• Read the case vignettes, discuss in group
and decide what you think the diagnosis is
for each one.
– Anna
– James
– Nymabiti
– David

2.3. MENTAL STATE
EXAMINATION
An orderly and systematic procedure of

examining the client’s status of cognitive,
feeling and behaviour, making an accurate
interpretation of findings to assist in diagnosis.
35 slides

Appearance and behaviour
– Physique
– Grooming:
• clothing, cleanliness, make-up, hair etc.
• whether these are appropriate to age,
gender, social class.
– Level of consciousness

Reaction to Interviewer
– Is the client cooperative, friendly,

suspicious or critical?
– Can the behaviour be considered
• as reaction to unfamiliar and stressful
experience?
• a symptom of illness,
• an indication of personality problems.

Motor / Psychomotor activity
– Facial expression
– Posture
– Gait
– Retarded
– Over-activity
– Involuntary movements- tics

Talk and thoughts
• Talking and thinking are closely related
• Person’s thought is only available through
speech or some other forms of communication.
• Form versus Content
– Form is how we speak
– Content is what we speak

The speed of talk
• Retardation of speech- delay in starting to speak as well
as the rate of speech.
• Mutism- a total absence of speech
• Pressure of speech- a rapid outpouring of ideas which are
often difficult to interrupt
• Poverty of speech-restricted vocabulary and ideas
• Continuity of talk
– Hesitant with longer than usual interruptions for thought. E.g. in
anxious and depressed patients, indecisions or preoccupied with
worries, deafness

Coherence of talk 1
• Coherence and relevant to current conversation
• Does the patient use words of his or her own
(neologisms)
• Does talk follow a sequence in which
consecutive ideas follow logically, working
towards an identifiable goal, or is it
circumstantial, tangential, or over-inclusive?

Coherence of talk 2
• Is there lack of logical flow of
– paragraphs . – flight of ideas
– sentences - “knights move” thinking
– phrases - thought disorder
– words -, word salad
• Do patient’s thoughts get stuck-Thought block
• Repetition of a response when it is no longer appropriate-
perseveration.

Content of talk-pre-occupations
• brood on past unpleasant events eg in
depression, person may become
preoccupied with previous death in family
• worries and fears-anxiety
• experience and try to resist intrusive
repetitive ideas and themes usually with
unpleasant content, eg in obsessional
states

Thought Content –suicidal
ideas
• The patient needs to be given a chance to
talk freely and openly. Some of the questions
one may ask:
– Have you been feeling depressed for several
days at a time?
– When you feel this way, have you ever thought of
ending your life?
– When did these thoughts occur?
– Have you planned what you will do?
– Do you intend to carry it through?

Beliefs
• Abnormal beliefs: Ideas which are shared by
many people within a particular cultural or ethnic
group may seem strange to others; for instance,
particular religious beliefs and practices.
• Over-valued ideas- are beliefs which are
strongly held about matters which are of special
importance and preoccupy the subject (e.g..
Witchcraft in traditional societies)

When abnormal beliefs
become Delusions
• Delusions
– mistaken beliefs
– which are strongly held with conviction
– which are not shared by others of the same cultural or social
background and intellect, and
– which persist despite all the evidence to contrary. Common
in Schizophrenia.
E.g. Patient insists that there are men plotting to kill him, hidden in
the hospital grounds behind the shrubs and trees. The nurse
takes him round the grounds and they look carefully in potential
hiding places. Eventually they return to the ward, and the nurse
points out that there was no one there.
The patient responds “of course not, they knew we were going to
look for them and they left, but I know they are back in the
grounds now”

Delusions of persecution
• Beliefs that one is being deliberately wronged,
or conspired against, by another
person/agency.
Q: Do you think that others are trying to harm,
kill, poison or interfere with you?
Q: Do you ever feel uncomfortable as if
people are watching you?

Delusional mood
• The individual feels that his or her
environment has changed in some way which
is puzzling, and the individual may not be able
to describe this change clearly.
Q:Do you ever get the feeling that something
odd is going on that you can’t explain? Do
familiar surroundings seem strange?

Delusions of reference
• The belief that events or other people’s actions or
words refer specifically to the individual and have a
special meaning for the individual. Does not include
being overly self-conscious, as in social phobia.
Q: Do people seem to say things that have a double
meaning?
Q: Is there an experiment going on to test you out?
Q: Do people drop hints about you?

Delusions of control
• Delusions of control, influence or passivity- the belief
that one’s feelings, impulses, thoughts or actions are
not one’s own but are controlled an external force.
The individual must acknowledge that he or she no
longer has the will of his or her own but being
controlled by another force (other than God or fate).
Q: Do you feel that you are under the control of a person
or force other than yourself?
Q: Do you feel as if you are a robot or a zombie with no
will of your own?

Religious delusions:
• The individual believes he or she has a special
link with God/Christ. Exclude intense religious or
cultural beliefs.
Q:Do you think that you have been specially
chosen, or have special powers?

Nihilistic delusions
• The belief that the self or part of the self

does not exist. Often associated with
depressive episodes.
Q: Do you feel that part of your body has
died or been removed

Grandiose and fantastic
delusions
• Exaggerated belief of one’s importance,
power, knowledge or identity. Common in
manic and schizophrenic disorders.
• .Fantastic delusions- The belief that the
individual has had an amazing adventure or
experience. Common in manic disorders.

Delusions of jealousy
• Belief without good reason, that one’s
partner is unfaithful

Subjective Mood
• Expressed by the patient.
– How have you been feeling recently? Or
how have you been in your spirits?
– Have you been feeling mainly happy or
sad?
– How sad? Can you snap out of it?
.

Objective mood
– To what extent does the mood fluctuate,
are fluctuations appropriate, and in what
direction are these fluctuations?
– Sadness
– Weeping
– Cheerfulness and euphoria
– Irritability, blunting of affect

Abnormal Perception
• Illusions- Mistaken perception with a presence of
external stimuli.
• Hallucinations- False sensory perception in the
absence of appropriate external stimuli. The
individual sees, hears, smells, sense or tastes
something that other people don’t.
Types of hallucinations:

Auditory Hallucinations
• Hearing voices or sounds.
Q: Do you hear sounds such as muttering, whispering,
music, etc.
Q: Do you hear voices talking about you or to you? Do
these voices give orders? What do the voices say?
Q: Can you carry on a two-way conversation with the
voices?

Other types of hallucination
• Visual hallucinations- Being able to see objects,
people or images that others cannot see.
Common in delirium
• Olfactory and gustatory hallucinations common
in organic mental disorders.
• Tactile hallucinations (false perception of touch
or surface sensation (e.g. Crawling sensation)
• Somatic hallucinations- The false perception that
things are occurring in or to the body.

Derealisation
The world appears different and unfamiliar.

Q: Have you had the feeling that everything
around you is unreal?
Q: Have you felt that everything is an imitation
of reality, with people acting instead of being
themselves?

Depersonalisation
• The perception or experience of self seems
different and unfamiliar. Common in fatigue,
substance abuse and adolescence
Q: Have you felt as if you were outside yourself,
looking at yourself from the outside?
• Heightened perception. Common in substance

abuse
• Dulled perception

Level of consciousness
Impairment of consciousness indicates organic
brain disease.
– Clouding of consciousness- lack of clear-mindedness
with disturbance in perception and attitudes
– Coma- unconscious
– Delirium-Bewildered, confused, restless, disoriented
– Somnolence- abnormal drowsiness
– Stupor-lack of reaction to and awareness of
surroundings

Orientation
• Orientation to time, place and person.
Q: What day of the week is today?

Q: Where are we?
Q: Who are you
Q: Who am I?..

Intellectual ability
• Attention and concentration
• Memory- ability to register, store and retrieve/recall
information.
• Intelligence- use of vocabulary, complexity of
concepts expressed and memory.
• Abstraction- ability to deal with concepts; extract
common characteristics from group of objects; juggle
more than one idea at a time; and interpret
information.

Insight and Judgement
Insight
• individual’s awareness of his or her situation and illness.
• includes awareness and acknowledgement of the nature of
illness, causes of illness and appropriate treatment.
Q: Do you think you are ill?
Q: What sort of illness do you think you have?
Q: What do you think might have caused this illness?
Q: Has anything happened to upset you?
Q: What sort of help do you think you need now?
How realistic are the patient’s views?

Summary-1
• Appearance and behaviour
– Appearance
– Attitude to situation and examiner
– Motor behaviour
• Speech
– Rate/Speed
– Volume
– Quantity of information
• Mood and Affect
– Mood (e.g. depressed, euphoric, suspicious)
– Affect (e.g. restricted, flattened, inappropriate

Summary-2
• Form of thought
– Amount of thought and rate of production
– Continuity of ideas
– Disturbance in language or meaning
• Content of thought
– Preoccupations
– Morbid thoughts e.g. suicidal
– Abnormal beliefs e.g delusions

Summary-3
• Perception
– Illusions
– Hallucinations
– Depersonalisation
– De-realization etc.
• Intellectual function
– Orientation to time, place and person
– Attention and concentration

Summary-4
– Registration and short-term memory
– Intelligence
– Long-term memory
• Insight
– Nature of illness
• Causes of illness
– Appropriate treatment

2.4. DIAGNOSIS
•Multi-axial
•Physical, psychological, social

ICD-10 Primary Care
Categories of mental disorder
• F00 Dementia • F31 Bipolar disorder
• F05 Delirium
• F10 Alcohol use disorder
• F32 Depression
• F11 Drug use disorder • F40 Phobic Disorders
• F17.1 Tobacco use • F41.0 Panic disorder
disorder
• F20 Chronic Psychotic • F41.1 Generalized
disorder anxiety
• F23 Acute Psychotic
• F41.2 Mixed Anxiety
disorder
and depression

ICD-10 cont..
• F43.2 Adjustment • F51 Sleep problems
disorder • F52 Sexual disorders
• F70 Mental
• F44 Dissociative
Retardation
(Conversion) disorder
• F90 Hyperkinetic
• F45 Unexplained
(attention deficit)
Somatic complaints
disorder
• F48.0 Neurasthenia • F91 Conduct disorders
• F50 Eating Disorder

• F98.0 Enuresis
• Z63 Bereavement
disorder
• F99 Mental disorder
not otherwise
specified

2.5.DIFFERENTIAL
DIAGNOSIS
• What is it?
– Possible alternative diagnoses of the condition.
– Data collected from the history and Mental State
examination are used to formulate
hypotheses/predictions about the differential diagnosis
and aetiology.
• How to decide?
– carry out investigations.

Purpose of Investigations:
1. Confirm diagnosis and rule out
alternatives.
2. Confirm causes
3. Assess change and monitor progress in
response to treatment

Physical investigations
• Temperature
• Physical examination
• Urine tests
• Stool tests
• EEG
• ECG

Physical investigations-blood tests
– Haematology e.g. ESR, white cell count in
infections, Malaria Parasites
– Biochemistry e.g Liver function tests-
alcoholism, thyroid function tests-
hyperthyroidism, electrolytes-delirium or
anorexia nervosa.
– Bacteriology, Virology, Serology: for urinary
tract infection, herpes zoster, neurosyphilis

Social investigations
– Assessment of family members
– Home assessment
– Financial assessment
– Occupational assessment
– additional informant e.g.. Teacher,employer,
relative.

2.6.CASE FORMULATION
• Integration of diagnosis, aetiology,
treatment, and prognosis.
• The unique characteristics of each

patient’s case which are needed for the
process of management.

Components of case
formulation
• Description/statement of the problem
• Differential diagnosis
• Aetiology
• Further Investigations
• Plan of Treatment
• Prognosis

The problem statement.
• Demographic data
– Begin with name, age, occupation and marital status
• Descriptive formulation
– Describe the nature of onset e.g. acute or insidious,
the total duration of the present illness and the course
e.g. cyclic or deteriorating.
– List the main phenomena (symptoms and signs) that
characterize the disorder

The differential diagnosis
– List in order of probability all diagnoses that
should be considered
– Include any disorder that you may wish to
investigate
– Give the evidence for and against each
diagnosis that you consider
– Include any current physical disease that may
account for.

Aetiology and investigations
• Aetiology
– List the possible predisposing and precipitating
factors that may have contributed to the current
condition extracted from the history.
• Investigations
– List all investigations that are required to support
your preferred diagnosis and to rule out the
alternatives, any that you think are required to
improve your understanding of the aetiology.

Treatment
– Outline the treatment you wish to follow

– It should stem typically from your
discussion of the aetiology as well as
from the diagnosis
– Consider each stage of management in
turn

Prognosis
– Describe the expected outcome of the
management of this illness episode,
with regard to both symptoms and also
subsequent function eg. Self-care and
return to community
– Consider the risk of subsequent relapse
– Give your reasons for these predictions

DISCUSS Mrs Okoth
• Prepare a case formulation
– Description/statement of the problem
– Differential diagnosis
– Aetiology
– Further Investigations
– Plan of Treatment
– Prognosis

2.7. CARE PLANNING

Principles of care planning
• Mentally ill patients should be treated with
respect and dignity
• Whole person approach- Physical,
Psychological and social
• Part of overall cycle of
– Assessment, diagnosis, care planning,
implementation, review

Assessment and Diagnosis:
• Observation, interviewing, and

History taking
• Mental State Examination
• Investigations
• Preferred or most probable
diagnosis
• Differential diagnosis

Care Planning -components
– Medication
– Psychotherapy
– Psycho-education
– Family support
– Physical health care
– Social interventions

Review of care plan
• Review client regularly

• Adjust care plan to meet evolving needs

2.8. PSYCHOSOCIAL
SUPPORT

Components of psychosocial
support
• Empathise with feelings and difficulties
• Offer sustained support eg do come back and see
me when you need to
• Find out practical social problems
• Give practical useful information
• Boost self esteem
• Tell carer they are doing difficult job well
• Assess whether carer depressed and treat
• Mobilise family and other community social
networks

Mobilisation of community
• Set up self help groups
• Arrange for CHW to visit
• Mobilise other sectors
– Education, social welfare, child protection,
community leaders etc

Levels of support:
• Support the Individual
• Support the Family
• Support the Community

Health workers can give more
effective psychosocial support
– If they
• are familiar with catchment area and local resources
• have developed their knowledge, attitudes and skills
• have linkages with community, school and employment
agencies, justice system etc.

Information about illness is
supportive
– Nature , causes, management and prognosis.
– Side effects of medication .
– Early intervention to avoid relapse
– Problem solving- helping clients to realize their
problems and work through their problems.

2.9. Engagement with
people with severe
mental illness

Why some clients are reluctant
to seek help?
• Stigma from
– Society
– Health professionals
• Fear of unknown
• Lack of expected services
• Can you think of other reasons?

How will you engage your
clients?
• Improve accessibility of services
– Resources e.g. drugs, staff with appropriate knowledge and
skills.
– effective communication, staff time to spend with clients
– access to support when needed
• Involve clients in
– care planning and management
– Professional-patient-family triad
– Mental Health Education
• Case finding- e.g. neglected patients
• Outreach visits

DISCUSS HOME VISITS
• What is the value of home visits?
• What can be learned about
– Family resources
– Family dynamics
– Causes and consequences of illness and
relapses

2.10. BREAKING BAD
NEWS

Meaning
• Any news that drastically and negatively alters
the patients’ view of her or his future.
• Drastic changes either real or potential, in the
quality of life or the ending of hope of an
improvement (real or imagined) for the future.
– How the patient responds can be influenced by the
patients’ psychosocial context.

Breaking Bad News.
• The most difficult duty for health
professionals
– Stressful and anxiety provoking
– The way the news is broken has an impact on
the recipients
– Discomfort and uncertainty(on the deliverer
may lead to
– Emotional disengagement from clients

Breaking Bad News
But our patients need us to do it well because:
• The experience of a life threatening illness is
devastating for most patients and their families
• They have a need for information and emotional
support
• Information should be delivered in an optimal
manner so as to provide support for them

The ABCDE of Breaking Bad News:
• A- Advance Preparation
– Arrange adequate time and privacy
– Confirm medical facts
– Review relevant data
– Emotionally prepare for the encounter
• B- Building a therapeutic relationship
– Identify patient preference regarding the disclosure of bad news
• C- Communicating effectively
– Determine the patient’s knowledge and understanding of the
situation
– Proceed at patient’s pace, allow silence and tears, answer
questions
– Avoid medical jargon

The ABCDE cont.,
• D- Dealing with patient and family reactions
– Assess and respond to emotional reactions
– Empathise with the patient
• E- Encouraging/Validating emotions
– Offer realistic hope based on the patients goals
– Deal with your own needs

General Principles
• Who should tell patients?
• Preferably only one person should be
responsible for breaking bad news, and
usually this should be the most senior
health worker involved in case.
• Make sure that the patient knows your
name, role and designation.

What to tell?
• The patient has a legal and moral right to
accurate, reliable information
• Primary responsibility is to the individual patient
(& parents if patient is child.)
• Responsibility to spouse and relatives is
important but secondary.
• Ensure that the patient understands treatment
options and the reasons for any future
investigations.

Different ways of coping
• Some cope by learning as much as
possible about a situation so they can feel
more in control.
• Others prefer not to know and cope by
avoiding thinking about it.

When to tell?
• The patient should be prepared for the
possibility of bad news as early as possible
in the diagnostic process, by the doctor of
first contact.
• If a number of investigations are being
performed, do not give results of each test
individually: Plan a consultation when all
results are available.

Non Verbal Communication
• Use non verbal cues to convey warmth,
sympathy, encouragement or reassurance to
the patient.
• In most cultural groups, this involves making
eye contact, facing the patient, not
interrupting when the patient is speaking,
nodding encouragingly, and giving full
attention to the patient.

Non Verbal Communication 2
• It is critical that the patient feels that you have
time to talk and listen.
• Hence, avoid writing notes, reading the patient’s
files, or looking elsewhere when the patient is
talking to you.
• In some cases, touch can be very reassuring for
the patient, and in other cases it may not be
appreciated.

Dealing with language and cultural
differences
• Use an interpreter whenever there is a
language difference between the doctor and
patient.
• Be sensitive to the person’s culture, race,
religious beliefs and social background.
• Consult a health professional who has detailed
knowledge and experience of that culture.

Ensure privacy and adequate time
• Give the patient the bad news in a place which is
quiet and private.
• Allow enough uninterrupted time during the initial
meeting for the family to think about what you are
going to tell, so that they can discuss it with you and
ask you questions.
• Ensure that interruptions, such as beepers and
telephones, do not occur.
• Sit, not stand
• The patient should be clothed

Assess Understanding
• Assess the patient’s understanding of the
situation.
• The patient may already be quite aware that
the prognosis is likely to be bad, or they may
have very little awareness of this.
• Their response will provide an appropriate
starting point for you.

Assess Understanding
• E.g ‘I know the last few weeks of waiting
must have been quite difficult for you. How
much do you know about your condition?’

Provide information simply and
honestly
• Tell the patient the diagnosis and prognosis
honestly and in simple language, though not
bluntly.
• Avoid technical jargon, which obscure the
truth.
• If the patient has cancer, then use this word.
• Give the facts which are relevant to the
diagnosis and for management.

Encourage patients to express feelings
• Allow and encourage the family to express their feelings,

such as crying.
• Some immediate reactions may be dumbness, disbelief,
anger or acute distress.
• Accept these feelings and concerns by letting them know
that it is quite normal to feel this way.
• This helps the patient feel accepted and to discuss their
concerns.
• Have tissues available!
• Respond to the family’s feelings with empathy.

Give a broad time frame
• Avoid giving a prognosis with a definite time scale, but,
if possible, give the patient a broad, realistic time frame
which will allow them to arrange their life & personal
affairs.
• E.g ‘this obviously comes as a shock, but it is important
not to jump to the wrong conclusions. No one can tell
you exactly what will happen, but many patients with
this disease have survived for . . . . . . . (realistic time).’

Avoid the notion of ‘nothing more
can be done’
• Even if the disease is too far advanced for curative
treatment, try to reassure the patient that you will
provide support (medical and non medical) for as
long as is needed to make the patient’s remaining
life as comfortable as possible.
• Where the treatment is palliative, do not pretend
that it is likely to cure the disease.
• E.g ‘A lot of things can be done to make your life as
normal and comfortable as possible. We will do all
we can to help you through this difficult time.’

Arrange Review
• When in shock , people forget what they have
been told. They also think of key questions later.
Therefore., at the end of the consultation, arrange
a time in the immediate future (preferably within
the next 24 hours) to review the situation with the
family.
• In the interim period, either be personally available
or nominate someone else if the family has any
questions or concerns.
• Write this information down.

Arrange Review
• E.g ‘I know this is a lot to take in at this stage, so why
don’t we meet again tomorrow after you’ve had a
chance to think about it more clearly and to discus it
with your family / friends. You will probably think of a
lot of questions in the meantime. Just write them
down so you won’t forget them, and I will do my best
to answer them at our next meeting. In the meantime,
if you have any concerns, don’t hesitate to contact
either me on . . . . . . . or Dr Murali . . . ...’

Discuss treatment options
• Discuss the possible treatment options and their side
effects with the family at this stage.
• Make it clear to the patient that a treatment
recommendation will be made to them, but that they will
be involved in the final decision about it.
.’

Offer assistance: to tell others
• Ask the family who they would like to tell about the
situation, and then offer assistance and support in
telling these people.
• These may include children, other family members
or employers.
• Encourage family meetings to discuss issues which
arise over time and answer questions honestly.
• If there are children involved, then involve a health
professional used to dealing with children.

Offer assistance to tell others
• E.g ‘There are people who will want to
know what is happening to you. Are there
particular people you would like me to tell
specifically? Are there people you would
not wish to have the information? I would
be happy to talk with anyone, either on the
phone or in a general discussion with your
family or other special friends.’

Provide information about support
services
• Give the patient information about any
locally available support services, such as
religious groups, cancer support groups,
palliative care services, bereavement
counseling, internet groups & websites
• Suggest referral to these if desired
• Reinforce that the health worker will also be an
important support all the time

Support services
• E.g ‘there are a number of different people
and support groups who you and your
family may find it helpful to talk to.
• Talking about your situation with others
who have been through a similar
experience may help you to cope with it.
• Your health worker will also be there for
you.’

Document information given
• Document what the patient has been told, which
family/other members have been told, who is
permitted to know about the patient’s situation,
and the patient’s reaction to the news.
• Be concise and include this on their medical
record.

ROLE PLAY 4:
• Role play –Seetha
• Everyone to take part

2.11. COMMUNITY
BASED
REHABILITATION

What is Rehabilitation?
• The process of helping people find ways of
returning to the normal life they led before the
illness started.
– Re-learning
– Re-training
• The minimization of the disabilities and
impairments resulting from illnesses or
disorders.

Why rehabilitation cont..,
– Abnormal behaviour can make the person
isolated from others
– Stigma and discrimination make it harder for
people with mental illness to get jobs or
marry.

Aims of Psychosocial
Rehabilitation
To improve quality of life of person and family and
reduce both stress and stigma associated with mental
illness.
Specifically:
• To reduce and prevent disability, complications and
handicap
• To avoid/prevent acute relapses, and
• To enable people with mental illness to live
satisfactory lives in the community

Methods of Rehabilitation 1:
• Vocational assessment and training.
– E.g. carpentry, farming, gardening, knitting,
sewing, basketry, IT skills,
• Social skills and competence training
– Communication
– Assertiveness
– Medication management

Methods of Rehabilitation 2
• Assisting clients to learn or re-learn the
skills necessary for their daily living
– Washing clothes, dishes and other house
chores
– Gardening, knitting, basket making, carpentry
– Managing funds and other resources

Methods of rehabilitation 3:
• Monitor behaviour and medication adjustment:
– Patients should be monitored to identify any signs of relapse and
adjust medication accordingly
– follow-up regularly
• Teach people with mental illness and their care givers to recognize
signs of an impending relapse
• Support the Family
– Education about the illness and the management
– Problem-solving
– Support
– The family is crucial

How are we going to achieve
rehabilitation for those who
need it?
• Not possible to send everyone to
district/provincial/national level
• Each health centre of 10,000 people will have at least
– 100 with psychosis
– 100 with severe depression
– 100 with severe epilepsy
– 100 with mental retardation
• How are we going to achieve it??

Plan for it.
• Discussion at PHC level with key stakeholders
– Health workers, community health workers, religious leaders,
administrative officers, chiefs, assistant chiefs etc
– Brainstorm opportunities and possibilities
– Plan for groups of clients
– Plan for individuals
– Review progress and refine plans

GROUP ACTIVITY
• How can you set up rehabilitation in your
area?

2.12. MEDICATION
MANAGEMENT

Principles
• treat with respect and dignity
• Whole person approach
– Biological, Psychological and Sociological
aspects must be considered
• Proper diagnosis
• Comprehensive management

Medication in PHC
• Goal- to produce an overall reduction of illness

• But-Most drugs may produce unpleasant side
effects
• Therefore- improvement of symptoms and
functioning should justify the side effects
experienced
• Always- consider the short term and long term
benefits and disadvantages of medication.

The Phases of Treatment
• Acute Phase :
– Stabilise acute symptoms
– Relieve symptoms
– Restore previous function
• Continuation :
– Maintain stabilisation
– Prevent return of acute symptoms
– Continue treatment for the duration of the episode
• Maintenance :
– Ensure against relapse

Common drugs used:
1. For depression (antidepressants)
2. for anxiety (anti-anxiety medications- should
rarely be used, no more than 2 weeks)
3. For psychosis (anti-psychotic medications)
4. Drugs to control manic-depressive (bipolar)
disorders.-mood stabilisers (not available in
Gvnt sector)

Medication use
• Some medicines may need to be started in a
small dose and increased gradually until the
recommended dose is reached (to limit side
effects)
• Always keep a close watch for the side effects
• Never exceed the maximum dose
• Avoid using some drugs for too short or too long
a period.
• Review the patient as appropriate

Steps in using medications for
mental illness
• identify the type of mental illness.
• Decide whether a drug treatment is required.
• Decide on the appropriate type of medication
required
• Explain to the patient how to take the medicine
and for how long
• Explain the potential side effects of medications
• Explain to the patient and family on the
importance of adhering to drug regime

Common drugs
• Antidepressants: used in depressive disorders
– Tricyclic antidepressant e.g. Imipramine, amitriptyline.
(available in public system)
– Serotonin “boosters” e.g.. Fluoxetine, Sertraline and
Fluvoxamine (expensive and not available in public system)
– New drugs, such as Venlafaxine, paroxetine, bupropion and
citalopram
– (very expensive and not available in public system)

Points to remember in using
antidepressants
• Side effects start on day 1
• Antidepressants take 2 weeks to start to have
entidepressant effect, and 6 weeks to be fully effective
• Treatment must be continued for at least 6 months to
avoid relapse
• They act only if given in the right dose
• Can cause drowsiness- the patient should avoid alcohol
• Side-effects are often short lived. Encourage patients to
continue with medication.Avoid tricyclics in people with
prostate enlargement or glaucoma.
• Avoid tricyclics in patients known to have Myocardial
Infarction

Anti-anxiety medicines
• Also called sleeping pills or minor tranquillisers.
• Used in past to treat sleep problems and anxiety.
• Example: Benzodiazepines such as Diazepam
(Valium), Nitrazepam, Lorazepam.
• But it is better not to use them for more than 2-4
days because they are not curative and rapidly
cause addiction
• Proper use is for status epilepticus and pre-
eclampsia

Side effects of Anti-anxiety
medicines..
– Drowsiness
– Dizziness
– Ataxia
– Respiratory depression
– Disinhibition, especially in children, the elderly and
people who are brain damaged or affected by other
drugs
– Addiction

Points to remember
• The patient should avoid alcohol
• Avoid giving to a woman in the last
trimester
• Do not give them for more than a few
days as they may produce dependence

Anti-psychotic medications
• Major tranquillisers.
– The drugs have the ability to effect some psychotic symptoms
such as hallucinations, delusions and thought disorders.
– Used in treatment of acute psychotic states e.g. drug-induced
psychosis, acute schizophrenia, mania and psychotic
depression
– Used to treat severe mental disorders and to help calm people
who are aggressive or confused.
– Used as maintenance treatment in chronic and recurrent
psychotic states
• Examples: Chlorpromazine (Largactil), Trifluoperazine and
Haloperidal.

Anti-psychotic medication..
• Side-effects
Extra-pyramidal side effects include
– Acute dystonia
• The eyes roll up and the individual is unable to look down
(Oculogyric crisis or look-ups)
• Spasms of the neck muscles where the neck is flexed
backwards or to the side (Torticollis or retrocollis)
• Spasms of the jaw muscles, tongue and flow of the mouth
(Trismus or lock-jaw)
• Laryngeal spasms which may cause difficult in breathing

Side effects of Anti-psychotics…
• Akathisia- an intense feeling of restlessness in
legs. Tend to relentlessly and feel unable to sit still.
• Parkinsonism – muscle stiffness, rigidity of the
arms and legs, Tremors especially of hands, loss
of facial expression, slowed movement or akinesia,
stooped posture
• Tardive dyskinesia- abnormal involuntary
movements of the face, eyes, mouth, tongue, trunk
and /or limbs occurring after 6 months to 2 years
or more after commencing medication

Points to remember
• They can take several weeks to reach full effect
• In brief psychoses, treatment may be reduced
gradually after 2 weeks. If symptoms recur,
return to original dose, continue for 3 months
and then withdraw them again.
• Treat Schizophrenia for at least a year
• Treat mania until symptoms subside and for 3
months thereafter.

Monitoring, Recognizing and
Managing side effects
• Medication side effects can be extremely disabling and
distressing, and a major reason for lack of adherence.
• Some side effects can be eliminated, reduced in severity,
or made more tolerable using a range of simple strategies
– Decreasing the dose
– Taking divided doses
– Taking medication with appropriate food
– Taking extra medication to counteract side effects e.g.
Benzhexol (Artane) 2-15mg daily, Benztropine
(Cogentin) 0.5 –6mg daily

ROLE PLAYS
• 5. explain side effects of antidepressants
• 6. explain side effects of antipsychotics

2.13. MANAGING
AGGRESSIVE AND
VIOLENT PATIENT
INCLUDING DOMESTIC
VIOLENCE

What is violence and
aggression?
• Violence
– behaviour that intentionally inflicts, or attempt
to inflict physical harm.
• Aggression
– behaviour that is threatening, hostile, or
damaging in a non-physical way

Causes of violence/aggression
:
– Genetic
– Environment
• e.g long standing childhood victimization, violent
lifestyle
– Biological abnormalities

Mental disorders which may
occasionally be associated with
violence/aggression
• Personality disorders
• Substance abuse
• Schizophrenia
• Epilepsy
• Mental retardation
• Dementia
• Head injuries- personality changes
• Depression

What to do:
• Take a quick brief history from relatives or
friends to identify the cause and severity of
violence.
• Rate of onset
• Precipitating factors
• Mental state
• Maladjustment

Management 1:
• Get help, exercise caution, allow for
escape, identify yourself.
• Try to calm the patient; speak gently (‘I can
see that you are very upset’). Avoid any
sudden or threatening action.
• Listen to the patient
• Do not loosen any bonds
• Do not contradict or argue with the patient

Management 2;
• Give patient choices eg would you like to
discuss or would you like some medicine?
• Do not make false promises
• Attempt to negotiate treatment (medication to
calm you’).
• Try to persuade the patient to surrender any
weapon in his/her possession
• Do not attempt any heroics

Management 3;
• If the patient has to be restrained ensure
there is enough help to control each limb
without hurting the patient. (5 people)
• Approach from behind.( Try not to)

Drug treatment;
• Haloperidol 5-10mg Orally or i.m . If

struggling.
• Midazelam 5mg IM/ orally

Management 4
• Observe the patient- response to
treatment
– Vital signs BP, RR & PR every 15 mts
• Psycho-education on positive approach to
anger management
• Emphasise adherence to medication
(later)

2.14 DOMESTIC
VIOLENCE

What is it?
• Victimization of a person with whom the
abuser has or has had an intimate,
romantic, or spousal relationship.
• Encompasses both men and women.
• Victims are usually being controlled and
manipulated by the abuser while fearing
and loving him/her.

Factors associated with
Domestic Violence
• History of family violence
• Alcohol or drug use by the batterer, victim
or both
• A current relationship involving abuse
• Psychiatric history
• Being abused as a child

Types of Domestic Violence
• Verbal and emotional:
– Public humiliation, name calling
– Threats and intimidation
– Isolation (abuser being extremely jealous, and not
allowing the victim to see friends or family members)
– Child neglect and abuse
• Physical:
– Beating, kicking, punching
– Non-consensual or painful sexual behaviour

Dynamics of Domestic Violence
The cycle of Domestic Violence has 3 components:
• Tension building
– The victim tries to be compliant and kind in an attempt to avoid
violence.
– The abuser becomes angry with increasing frequency and
intensity.
• Acute battering
• Reconciliation or the ‘honey moon phase’
– The abuser expresses loving behaviour and apology and with
assurance that it won’t happen again.
– (the patient is much less likely to seek or receive help in this
phase)

Why people stay in violent
abusive relationships?
The complexity of the Domestic Violence environment.
• Love
• Hope: that there is room for change.
• Dependence
– Emotional, economic especially where children are involved
• Fear of deepening violence,
• Fear of losing the children or the home.
• Learned helplessness
– Self blame
– Chronic anxiety
– Re-directing anger inwardly

Presentation of the client/ victim
of Domestic Violence
• Injuries including bruises, scratches, swellings etc.
• Vague medical complaints
• Acute pain with no visible injuries
• Chronic pain
• Stress and/or depressive symptoms
• Poor eye contact
NB: The abuser may accompany the victim but
refuse to leave the patient alone, insist on
answering questions for the patient

Factors that may deter health
workers from intervening 1
• Social
– societal tolerance
• Personal
– Sex bias
– Personal history of abuse
– Concerns over privacy
– Perceived powerlessness

Factors that may deter health
workers from intervening 2
• Professional
– Time constraint
– Inadequate skills
– Professional detachment
– Professional relationship with the abuser
– Blaming the victim, disapproving of her/his
decision and circumstances

Management 1
• Provide a safe environment
• Inquire about domestic violence and/or recognise
abuse from information obtained
• Establish the diagnosis of domestic violence
• Acknowledge the abuse and reassure the patient that
he or she is not at fault
• Evaluate emotional status and treat the emotional
injury
• Diagnose and treat physical injuries and other
medical or surgical problems

Management 2
• Clearly document the history, physical findings and
interventions
• Determine the risks to the victim and any children
and assess safety and available options
• Counsel the patient
• Develop a follow-up plan
• Offer referral to shelter (where appropriate), legal
services and counselling with patients' consent

Management 3
• Support the children, whatever their age
• Ensure safety
• Support psychologically-see slides on
children

Myths about family violence 1
• Family violence is rare
– Many victims are abused by family members
and intimates
• Family violence is confined to the lower
classes
– Family violence is in all classes

Myths about family violence 2
Alcohol and drug abuse are real causes of violence in the
home
Fact: Some male batterers do not abuse alcohol or drugs.
Some do abuse alcohol and drugs, and these
substances can increase the lethality of the violence.
The use of alcohol and drugs is not an excuse to evade
responsibility for the violence
Battered wives like being hit, otherwise they would leave…
Fact: The economic and social realities enclosed in abusive
relationship is complex.

Help for the perpetrator
• Engage in discussion
• Clarify that violence is not acceptable and
is a criminal matter
• Assess and treat disorder and substance
abuse
• Refer for therapy if necessary

Discuss: The Violent Cycle

Sexual assault
• Define
– Sexual contact without consent in adults
– Any sexual contact with minors, whether with
or without consent
– Varying degrees of severity
– Associated with humiliation and control
– Crime

Sexual Assault-short term
effects
• acute stress reaction
– Panic, fear of danger, being alone, of repeat
– Sleep difficulties and nightmares
– Tense , trembling, shaking, diarrhoea/constipation, nausea, lack
of appetite, headache, sweating, tiredness
– Preoccupation with assault
– Easily startled
– Loss of interest
– Tearfulness
– Difficulty thinking, concentrating, remembering
– Shock, disbelief, feeling numb, unreal, isolated, detached
– Guilt and self-blame
– Anger and irritability

Sexual Assault-long term effects
• Self injury
• Alcohol misuse
• Drug misuse
• Clinical depression and suicidal ideation
• Anxiety, phobia or PTSD
• Behavioural disturbance
• sexual dysfunction e.g. loss of libido, erectile
dysfunction

Information for patient and family
• Psychological reactions
– are normal reaction to a very abnormal situation, and
will usually subside with support
– they are not a sign of weakness or madness
• Men as well as women can be victims of rape
• Most rapes of men are committed by
heterosexual men against heterosexual men in
order to hurt and humiliate

Advice and support for patient and
family
• Ensure patient safe from repeated assault
• Check physical and medical needs including
investigations and prophylaxis for STDs/ HIV and
Hepatitis B
• Support patient in reporting assault to police
• Listen sympathetically without judging or pushing
for details
• Gently challenge distorted beliefs of self-blame
• Encourage appropriate coping strategies
• Encourage social support
• Assess risk of suicide and violence to perpetrator

Medication
• Most acute stress reactions resolve without
medication
• If anxiety severe, consider benzodiazepine for 3
days only
• If depressed and does not resolve after 2-4
weeks, give antidepressants
• If symptoms persist after 6-8 weeks of
antidepressant, refer to district services for
additional advice and support
• If psychotic, give antipsychotic

2.15 Child Abuse
• Sexual contact
• Violence
• Psychological abuse
• Child neglect

Childhood Abuse
Potential Long Term Effects
• Helplessness, vulnerability, sensitivity to
shaming and humiliation, difficulty asking for
help
• Loss of confidence, assertiveness and trust
• Self harm, aggression, risk of abusing others
• Depression, despair and suicidal thoughts
• Substance abuse
• Relationship difficulties
• Eating disorders
• Problems with sexual identity

Childhood abuse-initial action
• Listen sympathetically
• Reduce self blame
• Ensure patient is safe
• Assess risk of suicide
• Mobilise support

Child Protection issues
• Arise if patient under 18 and claims abuse at
home, school or in a children’s home as, if
they return, they risk being abused again.
• If patient fears another child is being abused
• Health workers are responsible for protecting
children from significant harm
• Consult district child protection officer

UNIT 3
NEUROLOGICAL DISORDERS


National Institute of Mental Health ,Sri Lanka
260
UNIT 3
– Epilepsy-see page 48 in WHO PHC guidelines

– Dementia-see page 50
– Parkinsonism
– Headache
– Delirium-see page 51
NB the curriculum timetable is tight so it may be necessary to

skip the Parkinsonism slides and Headache slides
It is crucial to cover delirium-toxic confusional state
261
3.1 EPILEPSY
Please refer to page 48 in the WHO PHC guidelines
Epilepsy - repeated seizures which originate in the brain.
• Grand mal – sudden loss of consciousness followed by rhythmic

muscle spasms involving all parts of the body (‘fit’). Patient may
have prodromal symptoms (‘aura’) eg headache, nausea, in the
days before an attack
• Temporal lobe epilepsy-
• Petit mal – patient suddenly loses touch with his/her
surroundings but does not fall (‘absence’)
262
Causes
• Intrauterine or perinatal factors, birth injury
• Infections leading to brain damage
• Brain injury or disease eg tumours
• Metabolic disorders eg liver or kidney disease
• Hypoglycaemia (low blood sugar)
• Alcohol or drugs (illicit or prescribed) – intoxication or
withdrawal
• In most cases there is no obvious cause
• In children, commonly caused by high temperatures
due to infections – advise parents on how to reduce
temperature
263
Differential diagnosis:
• Epileptic seizures need to be
distinguished from other causes of loss of
consciousness eg fainting
264
What to do:
• For new cases of epilepsy, a full investigation by a doctor may be necessary
(if possible) in case there is a treatable cause
• Advise family:
– Educate care giver about illness, need to take medicine
consistently, attend regular clinics for follow up
– During a seizure, protect patient from harm but do not restrain or
put anything in patient’s mouth. Afterwards place patient in
recovery position until fully conscious.
– Keep a record of the number and type of seizures
• Medication may be required to control seizures eg phenobarbitone,
phenytoin, carbemazepine.
• Long term management crucial
265
What to do:
• Status Epilepticus (ongoing seizures one after
another) is a potentially dangerous situation and
admission to hospital may be necessary if possible.
• There may be particular problems for women of
child-bearing age who are also taking
phenobarbitone eg interference with oral
contraceptives; effects on unborn foetus.
• Most people with epilepsy do NOT have a mental illness,
but may be vulnerable to depression. Psychosis is rare.
266
TEMPORAL LOBE
EPILEPSY
267
Definition:
• A condition characterized by recurrent
unprovoked seizures originating from the
temporal lobe.
– Simple partial seizures without loss of
consciousness (aura)
– Complex partial seizures (with loss of
awareness
268
Causes:
• Past infections, e.g. encephalitis or bacterial
meningitis
• Trauma producing confusion or haemorrhage that
results in encephalomalacia
• Hematomas
• Vascular malformations (i.e. arteriovenous
malformation, cavernous angioma)
• Febrile seizures
• Hippocampal sclerosis
• Genetic
269
Presenting complaints:
Somato-sensory complaints
• Seizures without loss of awareness
• Olfactory and gustatory illusions and hallucinations
• Auditory hallucinations consist of a buzzing sound, a
voice or voices
• Distortions of shape, size, and distance of objects
• Things may appear shrunken (micropsia) or larger
(macropsia) than usual
• Tilting of structures
270
• Psychic complaints:
– Sense of familiarity (déjà vu) or unfamiliarity
(jamais vu)
– Depersonalization (feeling of detachment from
oneself, surroundings appear unreal)
– Fear or anxiety
– Dissociation
271
• Physical complaints;
– Following the aura, seizure begins with a
wide-eyed, pupils, and behavioural arrest.
– Oral alimentary automatism e.g. lip smacking
– Patients may continue their ongoing motor
activity or react to their surroundings (reactive
automatism).
– Repetitive stereotyped manual automatisms
– Period of confusion
272
Differential diagnosis:
• Panic disorder
• Psychogenic seizures
• Excessive daytime somnolence
273
What to do:
• Medication
– Anti-convulsants e.g. Phenobarbitone or phenytoin
– Educate the patient and family on importance of
adherence
– Follow-up at clinic
• Patient education
– Avoid driving or operating heavy machines
– Long-term medication
The goal is to help the patient lead as normal life as possible
274
Epilepsy
• Role play negotiating a management plan
with client and relative
275
3.2 DEMENTIA
Please refer to page 50 in the WHO PHC guidelines
Cause in young adults:
– HIV
– Heavy alcohol abuse
Cause in adults over 60
– Alzheimers disease
– Vascular dementia
– Lewy body dementia –Parkinson’s
.
276
What the patient may complain of:
• Forgetfulness, becoming muddled – but may not be

aware of problems
Relatives may complain that patient has:
• Failing memory; changes in personality or behaviour
eg deterioration in personal hygiene or social
interaction; disorientation
In later stages: distressing or dangerous behaviour eg
wandering, getting lost, (neighbours bring them
home) , incontinence, aggression
277
Diagnostic features:
• Poor memory for recent events
• Patient may have become apathetic or
disinterested, but could appear alert despite failing
memory
• Decline in day to day functioning eg dressing,
washing and cooking
• Changes in personality or emotional control –
patients may become easily upset, tearful or irritable
as well as apathetic. May have delusions of being
persecuted.
278
Diagnostic features (continued)
Note: because of difficulties in obtaining information
from a patient with dementia, it is important to talk to
a close relative or family member who knows them
well.
Formal memory tests can also be used, eg:
Ask patient:
• Give the names of 3 common objects and repeat
them after about 3 minutes
• Accurately identify the day of the week, month, year
etc (as appropriate)
• Give their full name and where they live
279
What to do:
• Examine for treatable causes : eg sudden increases in confusion

which may be due to acute infection, toxic reaction to medication ,
acute psychosis, misuse of alcohol or drugs (see Delirium or Acute
Psychosis slides)
• Investigate any other possible physical cause eg HIV, cancer
(Aids?), high BP, alcohol, vitamin deficiency
• Assess for depression which can cause confusion in elderly people
– treat depression (see Depression slides)
• If possible, avoid use of medication especially sleeping tablets as
they make confusion worse. Aspirin in low doses may slow down
vascular dementia.
280
Advice for family and friends:
• Explain that
– Loss of memory and confusion may cause
behaviour problems eg suspiciousness,
emotional outbursts
– Memory loss proceeds slowly but long term
outlook varies
– Confusion may be made worse by physical
illness or stress
– Learning new information will be difficult for
patient
281
How family and friends can help:
• Maintain patient’s physical health – good diet,

exercise
• Treat any physical illness promptly
• Encourage patient to use remaining abilities as
much as possible
• Use reminders and prompts to help memory
(Note: please add to this according to local cultural
norms and available support)
282
Dementia
• Role play giving support to a carer
283
3.3 PARKINSON’S DISEASE
A chronic, progressive neuro-degenerative movement
disorder characterised by:
– Tremors
– Rigidity
– Slow movement ,
– Poor balance
– Difficulty walking
284
Risk factors:
• ? Genetic predisposition
• Trauma or other illness
• Exposure to an environmental toxins e.g.
pesticide.
• Accelerated aging
285
• Based on clinical history and examination.
• The patient may present with:
– slowness of movement
– Tremors-typically at rest affecting the hands, arms, jaw
and face
– Rigidity- producing a resistance to passive movement-
increase in tone leading to lead pipe or cogwheel
phenomenon due to superimposed tremor.
– Postural instability
286
Other features:
• Cognitive problems including slowness of thought
and dementia in later stage
• Autonomic disturbances- constipation, urinary
incontinence, excessive sweating, greasy skin.
• Drooling of saliva due to failure to swallow
• Depression
• Pain and sensory symptoms
• Handwriting may become small
287
Differential Diagnosis:
• Essential tremor
• Drug-induced parkinsonism e.g..
Chlorpromazine, haloperidol and other
major tranquillisers
288
What to do 1:
• Accurate diagnosis
• Symptomatic therapy to reduce functional
disability and handicap
• Long-term individualized treatment
planning
• Remaining physically active to maintain
independence
289
What to do 2:
• Team approach is important
• Advice and support for patient and family.
• Educate the patient and family on disease
progression and advise accordingly e.g
depression, sleep disorders, personality
change.
• Psycho-social support
290
What to do 3:
• Medication
– Anticholinergics such as Benzhexol,
– Levodopa therapy e.g Sinemet for nocturnal akinesia and
rigidity
– Long acting dopamine agonists e.g. Pergolide can reduce
the frequency and duration of the fluctuations associated
with dyskinesia.
• Side-effects
– Nausea and vomiting
– Postural hypertension
291
Parkinsonism-Discuss
• Have you seen it in your practice?
• What did you do for the client?
• What problems did the family have?
292
3.4 HEADACHE
293
Introduction:
• Occasional headaches are regarded as
normal
• Problematic when:
– Are debilitating and disabling
– Impair quality of life
– Engender fears of serious pathology
294
Types:
1. Migraine
2. Tension-type headache
3. Cluster headache
4. Medication-overuse headache (rebound)
5. Secondary headaches
295
Diagnostic features 1:
• A thorough history is important
• Headache questions include:
– Type of pain
– Time
• Onset
• Frequency
• duration
– Character
• Intensity
• Nature and quality
• Site and spread
• Associated symptoms
296
Diagnostic features 2:
– Causes
• Predisposing and/or trigger factors
• Aggravating and/or relieving factors
• Family history of similar headache.
– Response
• What does the patient do during the headache?
• How much is activity (function) limited or prevented?
• What medication has been and is used and in what manner?
– State of health between attacks
• Completely well, or residual or persistent symptoms?
• Concerns, anxieties, fears about recurrent attacks, and/ or
their cause?
297
Migraine 1:
• Intense throbbing or pounding pain
• Involve one side of the head
• associated with
– nausea and vomiting
– Sensitivity to light, sounds and smells
– Sleep disruption and depression
• Attacks are recurrent and tend to become
less severe with age.
298
Migraine 2:
• The patient may present with aura (warning signs)

– Visual disturbances e.g. flashing, brightly coloured lights in zigzag
pattern,
– Unilateral paraesthesia of hand, arm, face (Pins and needles
sensation
– Irritability
– Sleeplessness
– Fatigue
– Depression or euphoria
– Yawning and craving for sweet or salty foods
– Abnormal tastes and smell
• After attack the patient feels drained of energy with low grade
headache
299
Migraine 3:
• Predisposing factors:
– Stress
– Depression/anxiety
– Menstruation
– Menopause
– Head or neck trauma
• Trigger factors: stress, anxiety and emotions may
induce other triggers like:
– Missed meals and poor sleep
– Bright lights
– Loud noise
– Strenuous unaccustomed exercise.
• Dietary sensitivity
300
Tension type headache.
• pain or discomfort in the head, scalp or neck,
usually associated with muscle tightness.
• Causes:
– Stress
– Depression
– Anxiety
– Bad posture- head in one position for a long time without
moving e.g. use of microscope, typing
301
Cluster headache
• Cyclical patterns of clusters- unilateral,
excruciating pain around the eye
• Bouts of frequent attacks
• May last from weeks to months (6-12
weeks)
• Extremely painful and causing marked
agitation.
302
Medication-overuse headache
• Chronic overuse of headache medication
can cause daily headache.
– Occurs daily or near daily
– Worst on awakening in the morning
– Oppressive
– Increases after physical exertion
– Confirmed only when symptoms improve
within two months of withdrawing the
overused medication
303
Differential diagnosis
• Each is in the differential diagnosis of each of the others.

• Transient Ischaemic Attack is DD of Migraine aura without
headache
• Secondary headaches:
– Intracranial tumours and abscesses
– Meningitis
– Sub-arachnoid haemorrhage
– Temporal arteritis
– Primary angle-closure glaucoma
– Idiopathic intracranial hypertension
– Carbon monoxide poisoning
304
What to do : general
• Headaches impact on others as well as the patient.

• Thorough history is important
• Reassurance and psychological support is important
• healthy lifestyle with
– good nutrition- do not skip meals, avoid prolonged fasting
– adequate water intake
– sufficient sleep
– exercises
• Relaxation
• Stress management
305
What to do : migraine
• Medication depends on diagnosis.
Migraine
• Step one:
– simple oral analgesics:
• Aspirin 900 mg (adults only),
• Paracetamol 1,000 mg,
• Ibuprofen 400-600mg in divided doses.
– If necessary- Ant emetics Phernegan
• Step two:
– Parental administration- diclofenac
– Rectal administration- diclofenac suppositories
306
What to do : tension headache
Tension type headache
• Symptomatic treatment with analgesics
• Anti-depressants for frequent episodic or
chronic TTH. Amitryptyline 10mg at night
and incrementing by 10-25mg each 1-2
weeks.
307
What to do : others types
headache
• Cluster headache
– Need specialist care (refer)
• Medication overuse headache

– Withdrawal of the suspected medication
– Psychological support
308
What to do : Referral
– Diagnostic uncertainty
– Suspicion of secondary headache
– Persistent management failure
– Presence of risk factors for coronary heart
disease
– Presence of serious pathology in the
differential diagnosis e.g. headache
associated with unexplained neurological
signs, motor weakness.
309
3.5. DELIRIUM
Mental disorders due to brain damage and
dysfunction caused by physical illness
• Family members may ask for help because a
patient becomes suddenly confused, much quieter
or agitated
• Patients may seem uncooperative, fearful or
tearful
• Delirium occurs in many older patients who are in
hospital for physical illness.
310
Common causes of delirium
• Malaria
• Respiratory Tract Infection
• Urinary Tract Infection
• Electrolyte imbalance
311
• Sudden onset ( hours or days) of:

– Confusion (disoriented in time and place, misunderstanding
situation). Dementia never comes on suddenly.
– If pre-existing dementia suddenly worsens, suspect delirium
– Impairment of memory
– Disturbed level of consciousness
312
Plus:
– Agitation or apathy
– Changes in mood (fearfulness, sadness)
– Being perplexed
– Illusions
– Suspicion
– Disturbed sleep
– Disturbed thinking (incoherent speech)
– Hallucinations-often visual. If psychotic person has visual
hallucinations, suspect delirium
– Sweating, rapid heart rate, rapid breathing
313
What to do:
• Delirium is a medical emergency which may need
hospital care
• If cause is obvious, eg infection, treat cause
• Make sure patient cannot harm him/herself or
others
• Contact with familiar people can reduce confusion;
keep light levels bright
• Maintain fluid and food intake
• Encourage patient to move about
• Encourage restful sleep at night
314
What to do (continued)
• Referral may be necessary if:
– The cause is unknown
– Drug or alcohol withdrawal or overdose is
suspected
– Other underlying condition requires medical
assistance
• Referral to a psychiatrist is not usually
necessary
315
Delirium
• Read case vignettes
• Discuss
316
Neurological disorders
• are covered in pages 48-51 of the WHO
Primary care guidelines
• Please read for your homework tonight
317
Mental Health

Unit 4

National Institute of Mental Health Sri Lanka

UNIT 4
COMMON MENTAL DISORDERS
This unit will cover

• general features of CMD
• specific disorders
319
UNIT 4
– Depression – Acute psychosis, bipolar
– Somatisation-hapa hapa
disorder, schizophrenia
syndrome
– Childhood emotional
– Anxiety, phobias and PTSD disorder
– Sleep disorders – Childhood conduct disorder
– Eating disorders – Dyslexia
– Sexual disorders – ADHD
– Autism
– Alcohol and substance
– Learning disability
abuse
– Child abuse
320
SYMPTOMS OF COMMON
MENTAL DISORDERS
• Excessive concern about • Fatigue
bodily symptoms • Poor concentration
(headache, backache) • Impaired sleep
• Loss of enjoyment • Impaired appetite and
• Low mood weight loss
• Crying • Irritability
• Anxiety and panic • Low libido
• Obsessional thoughts
and actions
321
Common Mental disorders
• Mixed anxiety-depression
• Depression
• Anxiety
• Panic disorder
• Obsessive compulsive disorder
322
Symptoms and Syndromes
• Some terms are used with two different meanings
• Eg depression (low mood)
– as a symptom, and
– as a syndrome (depressive illness) with persistent low
mood accompanied by many other symptoms
• Eg anxiety (worrying)
– as a symptom, and
– as a syndrome (anxiety state) with persistent anxiety
accompanied by other symptoms
323
Bio-psycho-social causes of
mental illness
• Social
– Life events e.g bereavement, unemployment
– Chronic adversity e.g poverty, domestic violence
– Lack of social supports
• Psychological
– Learned helplessness
– Pessimistic cognitive approaches
– Unhelpful learned patterns of behaviour
• Physical
– Genetic
– Endocrine
– Nutrition
– Infection
324
Bio-psycho-social
consequences of mental illness
• Suffering • marital breakdown
• Disability • Intellectual and
• Mortality emotional damage to
– Suicide children
– Physical illness • Cycle of disadvantage
• Unemployment across generations
• Low productivity • Reduced access to and
• Poverty success of physical
• Stress on carer health programmes
– burnout, compassion
fatigue, depression
325
4.1. DEPRESSIVE ILLNESS
• Please refer to pp 35-36 of WHOPHC guidelines

• Low mood most of time lasting more than two weeks
• A common illness which can be treated
• Not weakness or laziness
• Affects ability to cope
• Support from family and friends is very important
326
 Malaria although no fever and normal blood film

 Physical pain eg headache, backache
 Tiredness
 Irritability
 Anxiety
 Inability to sleep
 Worries about money or relationships
 Increased drug or alcohol use
 (in a new mother) constant worries about her baby
or fear of harming the baby
327
Depression Checklist:
Ask patient and also care giver about:
A. Low mood or sadness

B. Loss of interest or pleasure
C. Loss of energy/more tired than usual
If ‘yes’ to any of these, continue as next slide:

(if ‘no’ the patient is unlikely to be depressed)
328
Depression Checklist: continued
1. Disturbed sleep – difficulty falling asleep, waking early in the morning
2. Disturbed appetite – either more or less than usual
3. Poor concentration
4. Agitation or slowing of movement or speech
5. Loss of interest in sex
6. Loss of self-confidence or self-esteem
7. Thoughts of death or suicide
8. Feelings of guilt
Depression is likely if:

Positive to A, B or C and at least four positive from 1-8 occurring
most of the time for 2 weeks or more.
329
Who is at most risk?
People who have

• experienced adverse life events and social difficulties, for
example, unemployment, single parents, homeless
people, people who have no-one to confide in
• had depression or another psychiatric illness before
• chronic physical illness or disability
• recently given birth
• family history of depression, suicide attempts and
substance abuse
330
What to do: 1a
• Assess risk of suicide:
What do you think about life

Do you ever feel that life is not worth living?
Do you ever feel hopeless?
Do you ever feel you would rather be dead
Have you thought of killing yourself?
Have you thought how you would do it
Have you tried to kill yourself before?
Have you given away any of your possessions?
331
What to do: 1b
Is the patient likely to act on the plan?
If patient is making active plans to kill himself, this

patient is at high risk and will need close supervision,
from family, friends and health professionals. If
possible, refer to a specialist .
332
What to Do:
2. Explain ‘depression’ to the patient and their family stressing
that its treatable and not a weakness
3. Give advice on good health:
Eat a healthy diet
Take regular exercise (proven to help depression)
Cut down on alcohol; don’t take drugs; do not smoke
Cut down on caffeine (coffee, tea)
Depressed people may not think so clearly about personal
safety so reinforce Safe Sex message –use a condom
4. Encourage patient to talk to family
and friends
333
What to do:
5. Help the patient identify stresses or
problems in their life and make plans to
deal with them:
Set short term goals
Review regularly with patient
Avoid major decisions or life changes
6. Help patient plan short term activities
which will give pleasure
334
What to do:
7. If depression has lasted 4 weeks or more and is affecting
the patient’s ability to cope with daily life, medication may
be necessary.
• amitryptyline if patient is anxious or can’t sleep
• imipramine if patient is lethargic
• start with 25mg daily, and gradually build up to 50-
75 mg a day
• 50mg a day will work eventually
• 75mg a day will work quicker if can tolerate side
effects
335
What to do:
Tell patient and relative :
Take medicine every day, and supervise
It will take two or three weeks before he/she starts to feel
better and six weeks before recovery
Continue with medicine for at least four months
Do not stop taking the medicine suddenly
There will be side effects at first, but these will be
manageable if explained in advance
Take dose twice a day or all at night to manage sedative
effects
Sip water regularly to manage dry mouth
336
What to do:
NB Caution with antimalarials as tricyclic antidepressants

and chloroquine both prolong cardiac QT interval.
Do not give if known or suspected heart disease.

Consider new antimalarials, or discontinue
antidepressant while antimalarial taken.
337
What to do:
8. If available, some ‘talking treatments’ may be
helpful, for example:
Cognitive behavioural therapy
Interpersonal therapy
Structured Problem Solving
9. Referral to a specialist may be necessary if:
Significant risk of suicide or danger to others which cannot be
managed safely at home
If depression persists after a course of treatment in primary
care
338
Show video of depression
• The video demonstrates assessment and
management skills
• There may not be time to watch the whole

video
• Please allow enough time afterwards for
the role plays
339
Role play depression
• Role play 8a and 8b
• As always, everyone to take part
340
Role play
assessment of suicidal risk
• Divide into groups of three (patient,
relative, health worker)
• Make up a scenario
• Health worker to carefully establish degree
of suicidal risk, using the series of
questions on page 35
341
4. 2. UNEXPLAINED SOMATIC
SYMPTOMS
• See page 38 of WHO PHC guidelines
• Patient has
– physical symptoms which do not go away despite negative
investigations
– Frequent consultations
– may have underlying anxiety and/or depression
• Some patients may want relief from their symptoms
• Others may be convinced they have serious illness
in spite of negative investigations
342
What to do:
• Acknowledge that the physical symptoms are real to the patient

• Investigate physical symptoms
• If no physical illness, explain that stress can cause symptoms
• Explain link between physical symptoms and stress
• reassurance that no serious physical disease
• Encourage exercise and enjoyable activities
• Relaxation methods may help
• Encourage patient to deal with any problems in their life
• Structured problem solving
343
Avoid too many investigations
• Do not prescribe medication for each new symptom

• Advise patient not to drink alcohol or take other
drugs
• Treat depression if present (see Depression slides)
• Regular, scheduled short appointments may prevent
too many urgent visits
344
Show video of somatisation
• This video is on same CD as the
depression video but is a separate file
• It is very long, and it wont be possible to
watch it all
• Please allow time for role play afterwards!
345
Somatisation
• Feeling understood
• Broadening the agenda
– Feedback results
– Acknowledge reality of pain
• Making the link with stress

– “I wonder if…”
• Negotiating treatment
– Explore patients views
– Acknowledge roles and concerns
– Problem solving and coping strategies
– Relaxation
– antidepressants
346
Negotiating a treatment contract
• Reframe symptoms as depression

• Link to life events
• Ask for feedback from client
• Negotiate medication
• Provide information about antidepressants- side
effects, not addictive
• Work with patient on problems (self, life, practical)
• Set realistic time scales
• Meet each week to review until improvement
347
Role play of somatisation
• Role plays 9a and 9b
• As before, everyone to take part
• Please demonstrate some of the skills you
have watched on the video
348
4.3. DISSOCIATIVE
DISORDER
• See page 39 of WHO PHC
• A patient may have unusual or dramatic physical symptoms
– seizures;
– loss of memory;
– being in a trance;
– loss of feeling;
– visual disturbances;
– paralysis;
– inability to speak;
– confusion about who they are or appearing to be ‘possessed’.
• The patient does not produce the symptom(s) intentionally
349
• The physical symptoms are unusual and do
not fit any known disease
• They come on suddenly and are usually
related to stress or difficult personal
circumstances
• They may be:
• Dramatic
• Change from time to time
• Be related to getting attention from other people
350
What to do:
• If other unexplained symptoms are present, see
slides on ‘Unexplained somatic symptoms’
• Treat depression if present (see Depression slides)
• Give advice to patient and family:
– Physical symptoms often have no clear physical cause
– They may be brought about by stress
– They usually resolve quickly leaving no permanent
damage
351
What to do :
• Encourage patient to acknowledge recent stresses
• Advise patient to take a brief rest and relief from stress, then
return to usual activities
• Encourage problem-solving for difficulties; give positive
reinforcement for improvement; do not reinforce symptoms
• Advise against a long period of rest or withdrawal from activities
• Medication not usually needed unless patient is depressed
• If patient is having hysterical fits or hysterical paralysis which do
not settle spontaneously, then 10-20mg iv valium can terminate
the attack and enable the health worker to interview the client.
Do not continue the diazepam.
352
4.4. ANXIETY
See page 37 of WHOPHC
What is anxiety?
• may be a perfectly normal response to stressful life events or
circumstances.
• only an illness if no obvious stress or threat, or worse than the
situation warrants.
• Most anxiety is mixed with depression, and can then be treated
as for depression-see above
• If no depression present, proceed
353
Common Types of Anxiety
• Generalized Anxiety
• Panic Disorder
• Phobic Disorder
354
Anxiety
What the patient complains of:
– Symptoms of tension – headache, pounding heart, cannot sleep

– Stress
– Sudden unexplained physical symptoms eg chest pain, dizziness,
shortness of breath
– Intense fear of collapse, heart attack or stroke
– Symptoms of anxiety either in or when thinking about certain
situations which are not frightening to most people
355
Anxiety Checklist
• Ask if the patient is
A. Feeling tense or anxious
B. Worrying a lot about things
If YES to either of the above, continue:
356
Anxiety checklist, continued
1. Symptoms of arousal and anxiety

2. Experienced intense or sudden fear for no
apparent reason?
Fear of dying; Fear of losing control; Pounding
heart; Sweating; Trembling or shaking; Chest
pains or difficulty breathing; Feeling dizzy, light-
headed or faint, Numbness or tingling sensations;
Feelings of unreality; Nausea.
357
Anxiety checklist, continued
3. Experienced fear/anxiety in specific situations?
eg. Leaving familiar places; Travelling alone;
crowds/confined spaces or public places
4. Experienced fear/anxiety in social situations?
eg. Speaking in front of others; social events;
eating in front of others; worry a lot about what
others think; self-conscious
358
Anxiety checklist: summing up
If Positive to A, B and 1, happening regularly:
Generalized anxiety
If positive to 1 and 2:
possible Panic Disorder
If positive to 2 and 3
possible Agoraphobia
If positive to 3 and 4
possible Social Phobia
359
Note:
Some physical illnesses (such as

Thyrotoxicosis), some medication and
some street drugs can cause anxiety
symptoms e.g. coffee, and amphetamines
360
Generalised anxiety
What to do:
1. Explain anxiety to patient especially the link between physical and psychological
symptoms
2. Give good health advice:
Eat a healthy diet
Take regular exercise
Cut down on alcohol; do not take drugs; do not smoke
* Cut down on caffeine (coffee, tea, cola)
Safe sex – use a condom
* Especially important – too much caffeine causes anxiety symptoms
361
Generalised anxiety (continued):
3. Teach relaxation method

4. Advise patient not to use alcohol or
cigarettes to cope with worries (see
health advice)
5. Help patient learn new ways of dealing
with worries
6. Help patient work out ways of dealing
with problems in their life
(use books or leaflets if available)
362
Generalised anxiety (continued):
• Help patient plan things which give pleasure,

especially things which have reduced anxiety before
• Explain that medicine doesn’t usually help with
anxiety
• If patient has depression as well as anxiety – treat
the depression first
• Refer to a specialist only if anxiety is very severe
and interfering with daily life
363
Panic Disorder:
What to do:
Note: many medical conditions can cause

symptoms like panic, for example: heart
disease, asthma, thyrotoxicosis
Symptoms need to be investigated until sure
there is no physical cause
364
Panic disorder (continued):
1. Explain to patient that panics are
common and can be treated
2. Explain how anxiety causes physical
symptoms which may be frightening
3. Explain that symptoms and frightening
thoughts (eg going to die or going mad)
will go as the panic subsides
365
Panic Disorder (continued):
4. Give general health advice (see slide 20)

5. Teach patient how to deal with a panic attack:
At first sign of an attack:
Stay where you are, if possible
Tell yourself that the feelings will soon pass. Even
if it seems like a long time, it is usually only a few
minutes
Focus on thinking about something you can see
which isn’t threatening
366
Panic Disorder (continued):
Breathe slowly and deeply, counting to 3 on each

breath in and out
When the feelings subside, continue what you were
doing
Practice while in clinic

4. Most people do not need medication to deal with panic-
benzodiazepines are addictive. If medicine essential,
then consider 25mg amitryptyline a day or propranolol,
but avoid maintenance diazepam.
367
Phobic Disorders
A phobia is an unreasonably strong fear and/or avoidance of

people, places or events such as:
• Leaving home or being alone at home
• Crowds or public places
• Travelling by matatu, bus, train, plane or car
• Open spaces
• Speaking in public
• Social events
• Other things such as animals, darkness, heights, blood
368
Phobic disorders:
• What to do:
– Explain to patients that they can treat their phobia
successfully
– Avoiding the fear makes it worse
– Fears can be overcome by facing them

systematically
369
Phobic disorders (continued) :
• Ensure the patient understands the
problem and wants to deal with it.
• Help patient plan steps to overcome the
fear (‘exposure’)
1. Find a small first step to face the fear eg if
afraid to leave home, take a short walk away
from home with a relative or friend
2. Practice this step until it becomes boring not
frightening
370
Exposure (continued)
3. Explain that to succeed you have to experience panic and not
run away
4. Practice, slow, deep breathing
5. Do not leave the feared situation until the fear starts to go – at
first this may take 30 minutes or more
6. Once the first step feels comfortable, practice with a more
difficult step eg a longer time away from home, or go out
alone.
7. Do not take alcohol, anti-anxiety medication or street drugs for
at least four hours before practising these steps
8. Keep a diary to track progress
371
• If patient is also depressed -see
depression slides
• Most patients will not need medication,
except:
• If the feared situation happens rarely eg
fear of flying, short term medication may
be useful
372
• Consider establishing a patient group for
people with anxiety, panic and phobias
– Share experiences
– Teach and practice relaxation techniques
– Support each other
373
Video of anxiety
374
Role play of anxiety
• Role play 10a
• Anxiety management skills are crucial as
they are effective whereas
benzodiazepines are addictive and not
curative
375
4.5. ADJUSTMENT DISORDER
• Brief reaction to stress which resolves
quickly
376
• Feeling overwhelmed or not able to cope

• Stress-related physical symptoms eg: not sleeping,
headache, abdominal pain, chest pain, palpitations
• Symptoms of anxiety or depression
• Increased use of alcohol or drugs
An acute reaction to a recent stressful or traumatic
event
377
What to say to the patient:
• Stressful events often have physical and mental effects, physical
symptoms are real and caused by stress
• These effects usually last only a short time – a few days or
weeks
• Reinforce any positive steps the patient has taken to deal with
the stress
• Advise patient against the use of alcohol or drugs
• Identify relatives or friends who can provide support
• Do not prescribe medication unless symptoms are very severe –
and then only for a few days
378
4.6. POST TRAUMATIC STRESS
DISORDER
What the patient complains of:
Physical symptoms eg various pains, poor

sleep, tiredness), various anxiety and
depression symptoms linked to a
particular trauma and lasting more than
one month
379
Diagnostic Features:
• History of an extremely traumatic event
that would distress almost anyone
• Intrusive memories, flashbacks and
nightmares
• Patient avoids thoughts, activities and
situations which remind him/her of the
event
380
• Sense of numbness, emotional blunting,

detachment from other people
• Not responding to surroundings, no longer enjoys
anything
• Being over vigilant, easily startled, poor sleep,
irritability, excessive anger, poor concentration or
memory -
‘autonomic arousal’
381
What to do:
1. Explain that traumatic events often have
psychological effects. Most people get
better without any treatment.
If symptoms last more than a month
treatment may be needed
Explain to family that patient needs
support and understanding
382
What to do:
2. Advise patient to talk about the event
with sympathetic friends or family
member
3. Encourage patient to face avoided
activities and situations gradually (see
‘Phobic Disorders)
4. Ask about suicide risk (see Depression)
383
What to do:
5. Don’t use alcohol, smoking or street drugs to
cope with anxiety symptoms
6. Cognitive behaviour therapy may help if
available.
7. Medication is not usually needed, but anti-
depressants may help if patient is depressed
– they may take longer to work than usual.
384
Discuss PTSD
• Have you seen it and where?
• How can you distinguish between
depression, anxiety and PTSD?
• Role play 10c Mohamed H amed
385
4.7. SLEEP PROBLEMS
These include:
• Insomnia – not being able to sleep

• Sleeping too much during the day
• Other problems such as sleep talking,
sleep-walking, nightmares, night terrors
386
• Difficulty falling asleep

• Waking up in the night
• Waking early-see depression
• Not feeling refreshed by sleep
• Falling asleep during the day
• Exhaustion, tiredness
• Poor memory or concentration
• Irritability or depression
• Dependence on sleeping tablets
387
Sleep problems check list
Ask:
A. Have you had any problems with sleep?
• Difficulty falling asleep
• Restless or not being refreshed by sleep
• Early morning waking
• Frequent or long periods of being awake
If YES to any of the above questions,
continue:
388
Sleep checklist continued
1. Do you have any illnesses or pain
2. Are you taking any medicines
3. Do you
• Drink alcohol, coffee, tea, chew khat/mira before
you go to bed?
• Eat shortly before going to bed?
• Take naps in the daytime?
• Have you changed your routine (shiftwork?)
• Hear loud noises during the night?
389
Sleep checklist continued:
4. Do you have problems at least 3 times a week?

5. Has anyone said you snore very loudly?
6. Do you get sudden attacks of sleep during the day that
you can’t control?
7. Are you feeling low or losing interest or pleasure in
things?
8. Are you worried, anxious or tense?
9. How much alcohol do you drink in a typical week?
390
Sleep checklist: summing up
Positive to any of 1, 2 or 3 – give advice on underlying
problem
Positive to 4 – possible sleep problem
Positive to 5 – consider sleep apnoea
Positive to 6 – consider narcolepsy
Positive to 7 – consider depression
Positive to 8 – consider anxiety
If weekly drinking is more than 21 units for men or 14
units for women, consider alcohol use problems
391
What to do:
• Treat underlying physical illness, pain,
anxiety or depression as appropriate
• Advise patient:
• Most sleep problems do not last long, and do not
require treatment
• People vary in the amount of sleep they need
• Sleeping tablets are rarely needed
392
Advice for patient and family:
• Keep regular times for going to bed and getting up.
• Do not drink coffee, tea or alcohol in the evening; do
not eat meals late at night
• Do not take naps in the day time
• Daytime exercise can help, but exercise in the
evening may not be good.
• Make plans for dealing with problems and worries
before going to bed
• Avoid taking sleeping tablets, or take for very short
time.
393
Discuss sleep disorders
• How common are they in your clinics?
• What are the common causes?
• Discuss case scenarios
– 11a Mrs Hemalatha
394
4.8. EATING DISORDERS
Maladaptive eating patterns which endanger health
Patient may complain of:
• Various physical symptoms e.g abdominal pain, bloating,

constipation, intolerance to cold, light-headedness,
changes in skin, hair and nails.
• Lack of periods, fertility problems, gastro-intestinal or
throat problems
• Low mood, anxiety, irritability
395
Eating disorders:
Family may ask for help because of worries
about patient’s loss of weight, refusal to
eat, vomiting or lack of periods
Patient may severely restrict what they eat,
binge eat, make themselves vomit,
exercise excessively or misuse laxatives
396
Diagnostic features: (common)
• Unreasonable fear of being fat or gaining weight
• Thinking of themselves entirely in terms of body shape
and weight
• Great efforts to control or reduce weight
• Denial that weight or eating habits are a problem
(anorexia nervosa)
• Obsessional symptoms
• Increasing withdrawal
• School and work problems
397
Diagnostic features of anorexia nervosa:
• Severe dietary restriction despite very low

weight
• Morbid fear of being fat
• Unreasonable belief that he/she is
overweight
• Lack of periods
• Some patients binge and abuse laxatives
398
Diagnostic features of bulimia
nervosa:
• binge-eating (episodes of uncontrolled
overeating)
• Purging (attempting to get rid of food eaten by
vomiting or using laxatives or diuretics)
• Strict dieting and excessive exercise to
compensate
• Thinking of him/herself in terms of shape and
weight
399
Note:
People can show symptoms of both types of eating

disorder at different times
Medical consequences of severe weight loss include:

poor attention and concentration; poor memory; low
blood pressure, slow heart rate, other heart
problems; suppression of bone marrow;
osteoporosis; muscle weakness; gastro-intestinal
problems
400
What to do:
1. Help the patient recognise that they have a
problem:
– This can be very difficult! They are often almost
delusional about body image
– Explain the dangers of purging and severe weight loss
– Purging and severe dieting are not effective ways of
controlling weight
1. Gain support from a family member

2. Educate patient and family about good nutrition
401
What to do:
4. Set manageable goals for weight gain with the
patient and family member – use a food diary to
chart progress
5. Do not expect rapid progress
6. Encourage family to be supportive and consistent
7. If weight loss severe, low dose chlorpromazine at
night can be life saving
8. If no improvement in about 8 weeks, refer to a
specialist
402
Discuss eating disorders
• Have you seen any in your clinic?
• What kinds of problems have you
encountered in managing them
403
4.9a. SEXUAL DISORDERS
(Female)
Common problems:
• Lack or loss of sexual desire
• Not able to achieve or maintain response to sexual
excitement
• Sexual pain:
– Vaginismus – spasm of vaginal muscles on attempted
penetration with fear or phobia
– Dyspareunia – recurrent genital pain associated with
intercourse
• Delay or absence of orgasm or climax
404
• Patients may be reluctant to discuss sexual

problems – may complain instead of physical
symptoms, depression or relationship problems
• Patients may talk about sexual problems during a
routine smear test or when discussing contraception
NB: patients with sexual problems may have a history
of sexual abuse or assault.
405
Some possible causes:
• Depression – may cause, or be caused by, sexual
or relationship problems
• Side effects of medication or misuse of alcohol or
drugs
• Gynaecological problems eg pelvic or vulval
infections
• Other physical illnesses eg atherosclerosis, multiple
sclerosis, diabetes
Note: more than one form of sexual dysfunction may
be present
406
What to do:
• Treat physical causes where possible eg infections;
reduce alcohol or drug dependence
• Ask about previous traumatic experiences
• Discuss sexual beliefs and expectations with patient
and partner. Encourage patient and partner to
discuss their preferences.
• Encourage patient and partner to practice giving
each other pleasure without full intercourse; – it may
take some time to regain full sexual activity.
407
• Vaginismus
– Cause is usually psychological.
– Explore psychological issues and give support
– Vaginal dilators in graded sizes can help , but may not be generally
available.-this is a service lack at present.
– may be difficult to treat without specialist help
• Dyspareunia:
– Lack of foreplay, poor lubrication, anxiety and muscle tension.
– Relaxation, use of lubricants and prolonged foreplay may help.
• Lack of orgasm:
– Discuss couples’ beliefs and attitudes.
– Lack of foreplay common problem. Stimulation of the clitoris may help
– Women may experience sexual satisfaction without orgasm..
– Women may be encouraged to use vibrators if available and/or sexual fantasy to
give themselves pleasure.
408
Discuss female sexual problems
• What kinds of problems present in your
clinic?
• How do you manage them?
• What difficulties do you encounter?
409
4.9b. SEXUAL DISORDERS
(Male)
Common problems:
• Lack or loss of sexual desire
• Erectile dysfunction or impotence
• Premature ejaculation
• Retarded ejaculation or problems with orgasm
– intravaginal ejaculation may be absent, but
can occur normally during masturbation
410
Some possible causes:
• Depression and/or relationship problems with a partner may
cause, or be caused by, sexual dysfunction.
• Erectile dysfunction can be caused by physical factors eg alcohol
or drug misuse, smoking, high blood pressure, diabetes,
hydrocoele, multiple sclerosis, spinal injury, some medication eg
antipsychotics, antidepressants, diuretics, betablockers.
Ask: is it impossible to achieve erection at any time – morning, night or
during masturbation?
• Specific disease in sexual organs, rare
• Unreasonable expectations of sexual performance
Note: more than one sexual dysfunction may be present.
411
What to do:
1. Erectile Dysfunction:
Explain – often temporary; due to stress, loss of
confidence, fear of failure.
Advice to patient and partner-
• Do not have intercourse for several weeks
• Practice giving each other pleasure without full
intercourse
• Gradually return to full intercourse
Medication may help if available
412
What to do:
2. Premature Ejaculation:
Usually seen in young men from first attempts
at intercourse.
Advise: Can learn to delay ejaculation with
experience.
3. Retarded ejaculation or orgasmic problems:
More difficult to treat, but self-pleasuring and
penile stimulation may help.
413
What to do:
4. Lack or loss of sexual desire:
Explain: the level of sexual desire
varies between individuals – may be
different expectations between partners
Many causes: stress; illness;
bereavement; relationship problems;
Encourage cooperation between
partners, stress reduction.
414
Discuss male sexual problems
• What is your experience in your clinic?
• What difficulties have you encountered in
dealing with them?
415
masturbation
• Discuss
• Normal human activity in private to release
sexual desires without imposing
inappropriately on others
416
Homosexuality
• Discuss
• Not a mental disorder
• Normal variation of human sexuality in 5-
10% of adults
• Not a mental disorder in itself , but
difficulties of adjusting and living with
homosexuality may predispose to
depression and substance abuse
417
4.10. ALCOHOL MISUSE
• See page 40of WHOPHC guidelines
• Drinking above :
28 units per week for men
21 units per week for women
418
Alcohol misuse
The patient may present with:
• Low mood
• Nervousness
• Unable to sleep
• Physical consequences of drinking eg ulcer, gastritis,
liver disease or high blood pressure
• Accidents or injuries related to drinking
• Poor memory or concentration
• Self-neglect e.g poor hygiene
• Failed treatment for depression
419
Note:
There may also be
• legal and social problems due to drinking eg marital
problems, domestic violence, child abuse or neglect,
missed work
• Signs of alcohol withdrawal eg sweating, tremors,
sickness, hallucinations, fits
Patients may be unaware of, or deny, alcohol
problems. Family members may complain before
the patient does.
420
Alcohol Checklist:
A. Number of units of alcohol in a typical
day when drinking
B. Number of days per week having
alcoholic drinks
C. Total quantity =A x B
421
Alcohol Checklist - continued
If drinking is above limit, or if there is a
regular or hazardous pattern:
Ask:
1. Have you been unable to stop, reduce or
control your drinking?
2. Have you ever felt you cannot resist a
strong urge to drink?
422
Alcohol Checklist - Continued
Has stopping or cutting down drinking ever caused you
problems:
• the shakes
• being unable to sleep
• feeling nervous or restless
• sweating
• heart beating fast
• headaches
• fits.
423
Alcohol checklist - continued
4. Have you ever continued to drink
although you know it will make problems
worse?
5. Has anyone said they are worried about

your drinking eg your family or friends?
424
Alcohol Checklist: summing up
• If A x B is over the recommended limit, it
will lead to social and physical harm
• If A x B is over the recommended limit and
positive to 1-5, there is alcohol
dependence
425
What to tell the patient and family:
• Alcohol misuse is a serious illness

• There may be family history
• Do not get into argument about whether or not patient is
dependent-it is the sheer quantity which causes harm
• Dependence is only important in that it makes reduction difficult
• Stopping or cutting down on drinking will bring benefits and
enables some recovery of body organs
• Drinking whilst pregnant can harm the baby
• Giving up alcohol is not easy – success depends on the patient
wanting to give up
426
How to help the patient:
• Explain the dangers of drinking and the benefits
of giving up
For patients willing to stop:
1.Set a definite date to stop
2.Explain withdrawal symptoms
3.Plan how to avoid situations where he/she is likely
to drink
4.Identify friend or family member who will provide
support
427
How to help: (continued)
• Give advice on healthy eating
• Give encouragement, not blame
For patients who relapse:

• Give praise for success
• Identify cause of failure and plan to avoid this
next time
• Return to first steps and try again
428
For patients not willing to stop:
• Do not reject or blame
• Explain the problems caused by alcohol
• Agree a further assessment in the future
429
Note:
• Patients with serious alcohol dependence
and other severe health problems may
need specialist care if available
430
Alcohol role play
• Please make up a scenario
• Demonstrate assessment of
– quantity, frequency and type of alcohol
– psychological , physical and social problems
– Negotiating management
431
4.11 DRUG ABUSE
• See page 41 of WHOPHC guidelines
432
Presenting complaints
• Depression, nervousness, insomnia
• Request for drugs
• Request for help to with draw
• Intoxication
• Withdrawal
• Physical complications eg abscess,
thrombosis
433
Diagnostic features 1
• Physical harm-eg injuries while intoxicated
• Psychological harm-eg symptoms of
mental disorder
• Social harm-eg loss of job, family
problems, criminality
434
Diagnostic features 2
• Habitual/harmful/chaotic drug use
• Difficulty controlling drug use
• Strong desire to use drugs
• Tolerance (can use large quantities
without appearing intoxicated
• Withdrawal eg anxiety, tremors)
435
Diagnosis
• History
• Examination
• Investigations (HB, LFTs, urine drug
screen, hepatitis B and C
436
Essential information for patient and
family
• Drug misuse is a chronic , relapsing
problem. Often requires several attempts
to stop
• Abstinence is long term goal.
• harm reduction (stopping injection) is
important
• Stopping/reducing brings benefits
• Drugs in pregnancy harms the baby
437
Advice and support to patient and family
• Discuss costs and benefits

• Information about heath risks
• Personal responsibility to change
• Clear advice to change
• Assess and manage physical health
problems
• Problem solving
438
management
• Do not reject or blame
• Advise on harm reduction strategies
• Point out harm caused by drugs
• Negotiate goals for reduction /stopping
• Discuss strategies for avoiding high risk
social/stressful situations
• Self monitoring through diary
• Gradual withdrawal
439
Substance abuse role play
• Please make up a scenario
• Demonstrate assessment of
– quantity, frequency and type of substance
– psychological , physical and social problems
– Negotiating management
440
4.12. ACUTE PSYCHOSIS
See page 42 of WHOPHC guidelines
– Hallucinations (eg hearing voices when no-one is there,
seeing visions)
– Strange beliefs or fears
– Being afraid or confused
Family members may ask for help with changes in
behaviour which cannot be explained e.g
withdrawal, suspiciousness, self-neglect or threats.
441
• Hallucinations
• Delusions (firmly held beliefs not shared
by others in patient’s social, cultural or
ethnic group)
• Disorganised or strange speech
• Agitation or odd behaviour
• Extreme and very changeable emotions
442
Note:
Psychotic symptoms can sometimes be caused
by:
• Misuse of some drugs eg khat, amphetamines,
cocaine, cannabis
• Alcoholism
• Infectious illness causing very high
temperature
• Epilepsy, brain abscess, tumour or other brain
disease
443
What to tell patient and family:
• Agitation and strange behaviour can be

symptoms of mental illness
• People often get better from this
• No-one is to blame for the illness
444
What to do:
• Make sure that patient and whoever cares for them
are safe
• Make sure patient’s basic needs are met eg enough
to eat and drink, somewhere to live
• Do not cause the patient too much stress; do not
argue with the patient’s beliefs even if you think they
are wrong
• Do not criticise or confront the patient unless it is
necessary to prevent them doing something to hurt
themselves or others
445
• Provide support and encouragement to patient, family and local
community
• Mobilise community to give social support to people with severe and
long term illness
• Mobilise CHW and public health technicians to organise sustained
community support to patient and family
• Outreach and home visits
• Encourage patient to return to normal activities as soon as possible.
• Advise patient not to take drugs or drink alcohol
• Refer to specialist if
– Significant risk of suicide, violence or neglect
– Refuse to take medication
– Refuse to stop misuse of alcohol or drugs
446
If prescribing medication:
• Chlorpromazine available in PHC
– Use lowest dose possible to control
symptoms
– Provide support and supervision to ensure
patient takes medication
– Monitor side-effects – treat as necessary
– Continue medication for at least 6 months
after symptoms resolve
447
4.13. BIPOLAR DISORDER
See page 44 of WHOPHC guidelines

Patients may have episodes of depression, often
severe; and at other times episodes of extreme
excitement, called mania
Patients may not realise they are ill (“lack of insight”).

Relatives may be the first to complain.
448
What is Mania?
Mania is a period of very high or irritable
mood lasting at least a week and which is
severe enough to disrupt work and social
activities completely.
In hypomania, symptoms may be present,
but less severe and less disruptive
Plus at least three of the following:
449
What is Mania?
1. Increased activity or restlessness
2. Rapid speech which is difficult to interrupt
3. Increased speed of thinking
4. Increased self esteem or grandiose ideas
5. Need for less sleep
6. Easily distracted
7. Loss of inhibitions eg being unusually tactless or
rude; making inappropriate sexual advances to
strangers; buying expensive goods that are not
needed.
450
What to do:
For depressive episodes, use depression slides.
For episodes of mania:

For general advice, see slides on Acute Psychosis;
similar medication may be used to control over-
excitement
Note: some patients will have only one episode of
mania or depression and recover completely.
451
What to do:
For patients who have repeated episodes of
mania and/or depression, specialist
psychiatric help may be required.
Mood stabilizers to prevent relapses
452
4.14. SCHIZOPHRENIA
453
What is it?
• Common serious mental illness characterized by
distortion of thinking and perception and usually
accompanied by inappropriate or blunted emotions
– Thought disorders
– Lack of insight
– Detachment from reality
– Delusions
– Hallucinations
454
Presenting problems:
• Individuals may have problems with:
– Hearing voices when no-one is around
– Strange beliefs
– Disturbance with thinking or concentration
– Managing daily activities including meeting
own physical needs e.g washing.
– Managing social interactions, work or studies
455
Presenting problems:
• Families may ask for help with the
individuals’:
– Strange, frightened or annoying behaviour
(e.g. irritability, suspiciousness)
– Apathy, withdrawal or poor living skills
456
Diagnosis:
The client must show the signs and symptoms for at
least a month.
• Hallucinations
– seeing, hearing, sensing or tasting things that other people
do not see, hear, smell or taste
– Voices talking about patient
• Delusions
– e.g. a person may believe that he or she is Jesus or the,
Virgin Mary; or he or she is being followed, poisoned or
experimented upon or controlled.
457
Diagnosis Continued:
• Thought interference in which the person believes that
thoughts are being inserted into or withdrawn from the mind;
are being broadcast to others; or are being echoed in the
mind.
• Disordered thinking resulting in incoherent or irrelevant
speech.
• Negative symptoms include:
– Extreme apathy
– Blunted or inappropriate affect
– Loss of initiative and drive
– Social withdrawal
458
Differential diagnosis: What to
do
Thorough assessment to exclude organic factors.
• Substance abuse can present with delusions,
hallucinations and abnormal speech.
• Severe (psychotic) depression can presents with
delusions and auditory hallucinations (voices talking
to patient).
• Mania also present with delusions and
hallucinations.
459
Course of Schizophrenia
1. Prodromal stage
– A general loss of interest
– Avoidance of social interactions
– Avoidance of work or study (dropping out of school, work,
college etc.)
– Being irritable and oversensitive
– Odd beliefs (e.g. superstitiousness)
– Odd behaviour (e.g. talking to self in public)
460
Course of Schizophrenia 2.
active phase
– Psychotic symptoms such as delusions, odd

behaviour and hallucinations are prominent.
– Often accompanied by strong affect as
distress, anxiety, depression and fear
461
Course of schizophrenia
3. Residual phase
• similar to prodromal phase

– Blunted affect
– impairment of role functioning
462
Management of acute episode:
1. think Bio-Psycho-Social .
2. maximize the safety of the individual and others
3. reduce symptoms of psychosis and disturbed
behaviour
4. build a therapeutic relationship with the
individual and family (carers)
5.develop management plan to aid recovery from
acute episode
463
Maximizing safety:
• Work as a team
• Assess the risk of harm to self and others
• Remove dangerous objects that might be
used to either self harm or harm others
• The patient may need to be observed for
some time at the PHC premises.
464
Reduce symptoms and
disturbed behaviour :
• Anti-psychotic medications
– Risperidone 2-6 mg/ day (50-200mg three times a day
Or Haloperidol 3- 6 mg/day
Fluphenazine deaconate 12.5 – 25.50 mg monthly
465
Side effects of Anti-psychotics 1
• Akathisia- an intense feeling of restlessness in legs.
Tend to relentlessly and feel unable to sit still.
• Parkinsonism – muscle stiffness, rigidity of the arms
and legs, Tremors especially of hands, loss of facial
expression, slowed movement or akinesia, stooped
posture
• Tardive dyskinesia- abnormal involuntary
movements of the face, eyes, mouth, tongue, trunk
and /or limbs occurring after 6 months to 2 years or
more after commencing medication
466
Side effects of Anti-psychotics 2
• The eyes roll up and the individual is unable to look

down (Oculogyric crisis or look-ups)
• Spasms of the neck muscles where the neck is flexed
backwards or to the side (Torticollis or retrocollis)
• Spasms of the jaw muscles, tongue and flow of the
mouth (Trismus or lock-jaw)
• Laryngeal spasms which may cause difficult in
breathing
467
Monitoring, Recognizing and
Managing side effects
• Medication side effects can be extremely disabling and
distressing, and a major reason for lack of adherence.
• Some side effects can be eliminated, reduced in severity, or
made more tolerable using a range of simple strategies
– Decreasing the dose
– Taking divided doses
– Taking medication with appropriate food
– Taking extra medication to conteract side effects e.g. Benzhexol
(Artane, Broflex) 2-15mg daily, Benztropine (Cogentin) 0.5 –6mg daily
468
Points to remember
• Antipsychotics can take several weeks to reach full
effect
• In brief psychoses, treatment may be reduced
gradually after 2 weeks. If symptoms recur, return to
original dose, continue for 3 months and then
withdraw them again.
• Treat Schizophrenia for at least a year
• Treat mania until symptoms subside and for 3
months thereafter.
469
Reducing symptoms and
disturbed behaviour on long
term basis:
• Psychological intervention
– Low stimulation
– Low stress
• Minimize stressors
• Avoid arguing with the individual on delusional ideas
• Avoid confrontation or criticism unless necessary for
preventing harmful or disruptive behaviour
470
Reducing symptoms and
disturbed behaviour:
– High levels of support
• Show empathy and concern
• Develop trusting relationship with the client and
family
• Psycho-education to minimize anxiety and
confusion, to individual, family and community.
• Protecting social relationships
471
Building a therapeutic
relationship:
• Health worker-patient and family
relationship
• Social networks
• Engage community support worker/ social
worker
• Engage community
472
Building therapeutic
relationships:
Role of social relationships in recovery:
• Expressing emotions and receiving
reassurance
• Reality testing
• Practical feedback from others
• Constancy in relationships
• Support from family
473
Long-term management of
Schizophrenia:
Long term management crucial to improve the health
and social functioning.
• Structured Problem solving: to reduce, minimize and
help control stress and anxiety in daily living.
• Communication skills
• Physical health
• Lifestyles- dietary habits, smoking, alcohol
consumption
• Adherence to medication
474
Long-term management
• Follow-up including home visiting
• Rehabilitation- work skills
• Self-help groups
• Community support
475
Psychosis-prepare some management
plans
476
Psychosis
• Video
• Role plays
477
4.15 CHILDHOOD AND ADOLESCENT
DISORDERS - Overview:
• 10-20% of young people may have mental

or emotional disorder warranting treatment
at any one time
• Many psychiatric disorders have an onset
during childhood and adolescence, and so
impair education and vocational choices.
478
Developmental influences:
• Intelligence
• Temperament
• Family environment including relationships
• Maltreatment
• Parental ill-health
• Chronic and severe physical illness
479
Issues in assessing children
and adolescents
• Obtain information from several informants e.g.
Parents, school teachers
• Systematically assess all potential areas of
psychopathology
– Achievement of developmental milestones
– Fears, phobia, obsessions
– Depressive symptoms
– Inattention, impulsivity, excessive activity
– Aggressive, delinquent, and rule breaking conduct e.g.
stealing
– Problems with learning
480
Assessing children and
adolescents:
– Bizarre or strange ideas and behaviour
– Use of alcohol and drugs
– Relationships with parents, siblings and peers.
• Ask about abuse and suicidal behaviour
• Determine the significance of symptoms given the child’s
age
• Assess impairment in functioning
• Identify strengths and resources in the child and family
• Determine the quality of the family environment
• Conduct Mental State Examination
481
Common childhood and
adolescent disorders;
• Emotional disorders
– Depression
– Anxiety
• Conduct disorders
• ADHD- Attention Deficit and Hyperactivity
Disorder
• Truancy
• Dyslexia- Difficult with studies
482
4.16. EMOTIONAL
DISORDERS
• Depression- A common problem in adolescents
• Often presents with physical symptoms, frequently related to
school work.
Common features:
– Headache and other aches and pain
– Difficulty in concentration
– Poor sleep
– Loss of appetite
– Withdrawing from family and friends
483
Depression features continue;
• Feeling bad about oneself
• Becoming moody and irritable
• Seeing life is pointless
• Suicidal feelings and ideas
• irritability
484
Effects of Depression in
adolescents;
• Poor school performance
• Poor relationship with family and friends
• Increased risk of self harming (even
suicide)
• Drug or alcohol misuse
485
What to do;
• Assess the situation with parents and adolescent to
identify the problem and cause and meaning of the
problem.
– How has your health been recently? –sleep, concentration
and emotions.
– Have you been worried about anything recently?
– Have you shared these worries or concerns with anyone
else?
– Have you felt like ending your life? How often? Since when?
– Has anyone hurt you recently?
– Have you been drinking alcohol or taking drugs?
486
What to do;
• Listen to the adolescent’s account of
his/her feelings and concerns.
• Help the adolescent to make the link
between his/her feelings and stressful
situation is facing.
• Suggest that you could talk to his/her
parents (and teachers, if possible) and
share the concerns with them.
• Make practical suggestions
487
What to do;
• Teach the adolescent problem-solving
techniques to cope with stress
• Advise not to use alcohol or drugs
• Follow-up review
• If none of the above steps help, give anti-
depressants. E.g. Amitriptyline 25mg
Orally at night
488
Emotional disorders in children and
adolescents-Discuss
• Have you seen these problems?
• How have you intervened?
• What else do you think you can do?
489
4.17. CONDUCT
DISORDERS
See page 55 of WHOPHC
guidelines
490
Definition:
• Impaired functional behaviour
characterized by constant conflict with
adults and other children.
• Antisocial behaviour leading to exclusion
from school or trouble with the law.
491
Causes/Factors
• Traumatic life experience
– Rejection or emotional abuse
– Harsh punishments
– Hostility
– Broken relationships
• Genetic vulnerability
• Lack of positive joint activities with the child
• Insufficient praise
• Poor monitoring of the whereabouts of older children
• School failure
492
• Aggression to people and animals
– Bullies, threatens or intimidates others
– Often initiates physical fights
– Has used weapon that could cause serious
physical harm to others (e.g. knife, stick,
stone)
– Physically cruel to people or animals
– Steals from a victim while confronting them
(e.g. assault)
– May force someone into sexual activity.
493
• Destruction of property
– Deliberately destroys other’s property
– Deliberately engaged in fire setting with the intention to
cause damage
• Deceitfulness, lying or stealing
– Lies to obtain goods, or favor or to avoid obligations
– Steals items without confronting a victim (e.g. shoplifting
– Breaks into building, house or car
– Trespasses into someone else field and cause destruction
494
Presenting complaints.
• Serious violation of rules and regulations
– Often stays out at night despite parental
objections
– Often truant from school
– Runs away from school
– May be involved in gang groups; take drugs
495
• Repetitive, persistent and excessive antisocial,
aggressive or defiant behaviour lasting six months
or more.
• Oppositional-defiant disorder in young children:
– Angry outbursts
– Loss of temper
– Refusal to obey commands and rules
– Destructiveness
– hitting
496
• In older children and adolescents
– Vandalism
– Cruelty to people and animals
– Bullying
– Lying
– Stealing outside the home, sometimes in-house.
– Truancy
– Drug and alcohol misuse
– Criminal acts
– Oppositional-defiant behaviour.
497
Differential Diagnosis;
• Attention Deficit/hyperactivity disorder
• Hyperactivity
• Depressive disorder
• Specific reading retardation (dyslexia)
• Generalized learning disability
• Autism spectrum disorders
• Adjustment reaction
498
What to do:
• Remember: Antisocial behaviour is learnt and can be corrected by un-learning.
• Thorough history is essential
• Educate parents and the child on “effective communication” by:
– Promote positive joint activities between parents and child
– Encourage praise and rewards for specific agreed desired behaviours.
– Set clear house rules and give short specific commands about desired behaviour
– Provide consistent and calm consequences for misbehaviour
– Avoid arguments with the child
– Monitor the whereabouts of teenagers
• Get to know his/her friends and parents
• Check with parents
• Educate the child on:
– Anger management
– Goal setting, and self control
• Work with parents and teachers where appropriate.
• Treat any co-existing condition
499
Conduct disorders-discuss
• Have you seen these problems?
• How have you intervened?
• What else do you think you can do?
500
4.18. ADHD (Attention deficit
hyperactivity syndrome)
• Presentation (p57 of WHOPHC guidelines)
– Restless; unable to sit in a chair through a full lesson
– Fidgety, chattering and interrupting people
– Difficulty in concentration or paying attention e.g. unable to
complete homework
– Easily distracted and not finish what they have started
– Impulsive- suddenly doing things without thinking first
– Unable to wait their turn in games or in talking to others
– Extremely demanding
– Problems with learning and studies
– Disorganized and untidy
501
Effect of ADHD in child’s life:
• At home
– Difficulty to discipline
– Irritates parents with his impulsive behaviour and not
listening to them
• At school
– Poor performance in studies
– Irritate his teacher with his inability to sit quietly and
interrupting the class
• At play
– Irritates his peers
502
ADHD: What to do 1:
• A thorough history and assessment
• Educate and support parents on dealing
with the child
• Maintain consistency and structure:
routines, stated expectations of behaviour
family rules
• Set realistic expectations, short-term goals
and praise success
503
ADHD What to do 2;
• Promote positive interactions with the child
• Ensure adequate sleep
• Establish constructive communication with
school
• Keep confrontations to a minimum
• Refer for specialist care if no improvement
504
4.19. Dyslexia: Learning
difficulties
• Page 58 of WHOPHC guidelines
• Learning difficulty that affects ability to read or deal
with numbers , irrespective of intelligence.
• Problems with:
– Concentration, perception, and memory
– Verbal skills, abstract reasoning, hand-eye coordination
– Social adjustment (low self-esteem), poor grades,
underachievement.
505
4.19. Dyslexia: Learning difficulties
• The child may have difficulties with:

– Copying, spelling and writing
– Understanding instructions
– Numbers and mathematics
– Reading
– Behaviour problems
.
506
Causes
• Neuro-biological
• May be aggravated by
– Large class sizes
– Poorly trained teachers
– Language not commonly used at home
507
Other Causes:
– Intellectual Disability (Mental retardation)

– Depression
– Conduct disorder
– Difficulties with hearing or vision
– Drug misuse
– +++
508
What to do 1
Remember:
• A dyslexic child is not stupid, dumb or
thick.
• Teachers, parents and mental health
worker need to work together to help the
child.
509
What to do 2:
• Phonetic reading and writing
• Extra individual help with numeracy and literacy
• Extra time in exams
• Continued support
• Dyslexic children can be very intelligent, but get
frustrated by their difficulties
• Crucial to assist as much as possible as early as
possible to enable children to progress educationally
510
What to do;
• Liaison with school authority
– The child should be helped to learn at her /his own pace with
such help as:
• Extra tutoring-but not too much to exhaust the child
• Homework to be given early enough and left on the board
long enough to ensure every child got it right.
• Position the child in front seats.
– Helping the child to learn through more than one of the sense
(Multi-sensory teaching methods) including touch and
movement.
511
What to do;
• Parents should assist dyslexic children with
assignments
• Children should be helped to build self-confidence.
– Let the child identify his strengths and weakness
– Discuss objectively and build on strengths
– Promote positive thinking
– Praise the child for all achievements, both
non-academic and academic
NB: Dyslexic children are good at other things that are
valuable in their life- build on that as well.
512
Dyslexia-discuss
• Do you know anyone with dyslexia
• What do you think PHC can do to support
children and parents and teachers?
513
4.20. ASD (Autism Spectrum
Disorder) :
• Impairment in:
– Communication skills
– Social interactions
– Restricted, repetitive and stereotyped patterns
of behaviour
514
Causes:
• Genetic factors
– ?abnormal brain development in early life
515
• Parents may complain of obvious
developmental problems:
– Unresponsive to people, or focusing intently
on one item for long periods of time
– Outbursts of cry or screaming
516
Diagnostic features;
• Abnormal or impaired development before
the age of 3 in at least one of the
following:
– Selective social attachment or reciprocal
social interactions
– Receptive or expressive language, as used in
social communication
– Restricted, repetitive and stereotyped pattern
of behaviour- functional or symbolic play
517
• Social difficulties
– Avoids eye contact, seem indifferent to others & prefers
being alone
– Difficulties in interacting reciprocally with others-slower in
learning to interpret what others are thinking or feeling as
such may
• Ignore other people or be insensitive to their needs,
thoughts and feelings.
– Difficulties in seeing things from another perspective
– Difficulties in regulating emotions e.g. crying in class or
verbal outbursts that seem inappropriate to those around
them
518
• Communication difficulties
– Delayed language development with no effort do so.
– Use of language in unusual ways-repetition of phrases or
words over and over.
– Young children may show little interest in the speech of
others
– Difficulties in understanding body language, tone of voice,
or phrases of speech.
– Difficulties in expressing own body language- facial
expressions, movements and gestures rarely match what
they are saying.
– Difficult to let others know what they need.
– Some may remain mute throughout their lives.
519
• Behaviour difficulties
– Odd repetitive motions e.g. flapping arms or
walking on their toes. Some suddenly freeze
in position.
– Routinized behaviour, resistance to change- a
slight change in any routine can be extremely
disturbing.
– Unusual persistent, intense pre-occupation or
interests e.g. intellectual, art
520
Problems that may accompany ASD;
• Sensory problems
– Sensitivity to certain sounds, textures, tastes
and smell
• Seizures
521
Differential diagnosis;
• Attention-deficit/hyperactivity disorder
• Learning disability
• Epilepsy
522
What to do;
• Thorough history on behavioral characteristics
• Exclude other problems- thorough investigations
• Identify patients strengths and potentials and build
on the strengths.
• Family education and ongoing support
The goal is to help the child develop to the fullest

potential
523
What to do;
• Childs’ educational placement
– Special schools vs mainstream with extra
attention and assistance
• Behavioural management to reinforce
desirable behaviour and reduce
undesirable ones
524
What to do;
• An effective treatment program will build
on the child’s interest, predictable
schedule:
– Teach tasks as a series of simple steps
– Actively engage the child’s attention in highly
structured activities
– Provide regular reinforcement of behaviour
– Involve parents, teachers and other
professionals e.g. social workers
525
What to do;
• Physical activity to develop coordination and body
awareness:
– Children string beads, place puzzles together, paint, and
participate in other motor skills activities.
• Social interactions:
– How to use language
– Structured activities that will help children learn social skills
and functional communication
• Medication
– Limited role
– Treat co-existing problem e.g. epilepsy
526
4.21. Learning disability
This is slow or incomplete mental development

resulting in:
• Difficulties in learning
• Problems with social adjustment
527
Learning disability-range
There is a wide range of severity:
• Severe – the person will need help with daily tasks all
their life and will only ever have very simple speech
• Moderate – the person may be able to do simple work
with support and will need guidance and support in
daily tasks
• Mild – the person will be limited in school work, but
will be able to live alone and do some kind of paid
work as an adult.
528
Causes of learning disability 1:
• Genetic conditions such as Down’s syndrome
• Problems before the child is born e.g. poor
maternal nutrition, excess alcohol consumption
during pregnancy, mothers’ infections during
pregnancy
• Problems during childbirth- e.g. Prolonged
labour, birth trauma
529
Causes of learning disability 2.
• Problems in the first year of life- e.g.
infections of the brain, severe and prolonged
jaundice, uncontrolled convulsions, accidents
and severe malnutrition
• Problems in the way the child is being looked
after, e.g. poor stimulation, child abuse and
emotional neglect
530
Recognition of Learning
Disability
• At birth – unusual faces or failure to thrive eg
Down’s Syndrome. A few conditions are treatable eg
hypothyroidism
• As a child: delay in normal development; not able to
do school work as well as other children; difficult
behaviour; poor socialisation; may be the target of
bullying
531
Recognition of Learning
Disability
• In adolescence: difficulties with peers; social
isolation; inappropriate sexual behaviour; difficulties
forming relationships and developing independence
• In adulthood: difficulties in everyday tasks – needing
support; problems in establishing independent life –
marriage, work, child-rearing; inappropriate sexual
behaviour or other antisocial behaviour
532
What to do:
Explain to family:
– Early training can help towards self-care and
independence
– People with Learning disability are capable of
loving relationships and have the same basic
needs as other people
– Sudden changes in behaviour may mean the
person is ill and needs medical help
533
What to do:
Advise family:
– Reward effort
– Teach the same set of social rules as to other
children
– Learning and practising skills is helpful but the
‘miracle’ cures do not exist
Other advice will depend on what facilities
are available locally – please add as
necessary
534
Common problems in the child:
• Physical functions; ability to walk and using hands
• Self-care; ability to feed, bathe and use the toilet
independently
• Communication with others
• Social functioning:; e.g. playing with others, being
bullied
• Physical disability in severe cases
• Mental illness
535
When should you suspect
learning disability in a child?
• delayed in achieving key milestones
• difficulties in school work and playing with
others
• Not able to carry out instructions
• Children after cerebral malaria
536
When should you suspect learning disability
in an adolescent?
• Difficulties in social relationships with

other adolescents
• Shows inappropriate sexual behaviour
• Is not able to learn the same rate as other
students in class
537
When should you suspect
learning disability in an adult:
• Difficulties in everyday functioning e.g.
cooking, cleaning
• Has problems in social adjustment e.g.
making friends, finding work
538
Management of learning
disability:
• Thorough assessment: Physical, Cognitive,
psychological
• Maintain therapeutic working relationship with the
child and family
• Long term support from health, education and social
sectors
539
Management of learning disability
• Educate the parents on proper management

– Level of expectations of child
– Activities should be broken into smaller parts
– Stimulation
– Use of rewards and praise when the child succeeds in any
activity
– Parents should not overprotect the child
– Support and supervision
– Social activities
– Child can continue to learn through adulthood-continue
educational activities
540
Medical Management:
• Medicine has very little role in mental
retardation except in control of seizures.
– Anticonvulsants
541
Learning disability-discuss
• How many cases do you see?
• How do they present to you?
• How can you support families?
542
4.22. CHILD ABUSE AND
NEGLECT
543
Introduction:
• Challenge associated with social stigma,
that occurs frequently in the privacy of
family homes and that may result in
severe consequences if disclosed.
• Most victims suffer in silence
544
Definition:
• Any mistreatment or neglect of a child
• Resulting in non-coincidental harm or injury
that cannot be reasonably explained
• Includes:
– Physical abuse
– Emotional abuse
– Sexual abuse
– Neglect
545
Factors:
• Risk factors
– Poverty
– Violence
– Mental health
– Disability
• Other factors
– Poor parenting skills and lack of understanding about child
development
– Cycle of abuse & domestic violence
– Substance abuse in family
– Teen mothers
546
Consequences:
• Developmental delays
• Mental health problems
• Delinquency-drug misuse
• Runaway and living rough- street children
547
• Difficult to get information
• Skillful observation and assessment is
important
• Children may present with complaints of
the consequences of the abuse
548
• Signs of physical harm
– Multiple superficial injuries e.g. bruises, abrasions, cuts,
cigarette burns etc.
– Fractures
– Retinal & subdural haemorrages in non-ambulant children
– Failure to thrive and short stature
– Poisoning, asphyxiation
– Delayed immunization
– Untreated medical condition
– Sexually transmitted diseases
549
• Signs of psychological harm
– Depression
– Anxiety and fears
– Inability to trust or love others
– Low self-esteem
– Fear of entering into new relationships or activities
– Conduct or oppositional defiant behaviour
– Deliberate self-harm
– Sexualized behaviour inappropriate to age and stage of development
– Substance misuse
– Sleep problems
– Flashbacks, nightmares
– Educational under-achievement
– Social isolation
550
What to do;
• Remember:
– Child abuse and neglect is often disputed or
denied by parents and alleged abuser.
– There may be delays in seeking medical help.
– There may be inconsistencies in history/
explanation and not compatible with the injury
or child’s development (in trying to protect the
abuser or the child fearing further abuse).
551
What to do;
• Effective interviewing and observation skills
• Attend to immediate medical and psychological
needs
• Prepare a comprehensive treatment plan including
help for the child, the non-abusing care giver,
siblings and the abuser
• Follow-up the family
– Support the child and family
– Counseling
Treatment depends on the nature and sequale of
maltreatment
552
Child Protection issues
• Arise if patient under 18 and claims abuse at

home, school or in a children’s home as, if
they return, they risk being abused again.
• If patient fears another child is being abused
• Health workers are responsible for protecting
children from significant harm
• Consult district child protection officer
553
Childhood abuse-initial action
• Listen sympathetically
• Reduce self blame
• Ensure patient is safe
• Assess risk of suicide
• Mobilise support
554
Childhood Abuse
Potential Long Term Effects
• Helplessness, vulnerability, sensitivity to shaming
and humiliation, difficulty asking for help
• Loss of confidence, assertiveness and trust
• Self harm, aggression, risk of abusing others
• Depression, despair and suicidal thoughts
• Substance abuse
• Eating disorders
• Problems with sexual identity
555
Mental Health:


National Institute of Psychiatry, Sri Lanka

UNIT 5
TRAINING
THE
TRAINERS
SRI LANKA

UNIT 5
In this final unit, we are going to cover
• Mental Health within the context of
National health sector strategic plan
• Mental health policy
• Mental health legislation
• Role of community health workers
• Traditional health practitioners
• Health management information systems
• Roles and Responsibilities

5.1. GENERAL HEALTH POLICY
SRI LANKA’S NATIONAL HEALTH SECTOR

STRATEGIC PLAN
Discussion

VISION
• An efficient and high quality health

care system that is accessible
equitable and affordable for
every Sri Lankan

MISSION
(Road map)
• Promote and participate in the provision
of integrated and high quality
– promotive,
– preventive,
– curative and
– rehabilitative health care services to all Sri
Lankans.

POLICY OBJECTIVES
• increase access to health care services.
• improve the quality of health care services.
• improve efficiency and effectiveness of health service
delivery.
• foster performance by development of human
resources and other resources.
• mobilise financial resources to fund health care
services.

OVER ARCHING POLICY
– The Concept
There is no health without Mental Health
– State of complete physical, mental, emotional and

social well-being and not merely absence of
disease or infirmity, in all matters relating to the
reproductive health system and to its functions and
processes

DISCUSSION
• Any questions on the general health policy
or the disease specific health policies

2. NATIONAL MENTAL HEALTH
POLICY
• 10 Slides
• Discussion

WHO DEFINITIONS
HEALTH
• “A state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity”.
(WHO Constitution – 1948)
MENTAL HEALTH
• “A state of well-being in which the individual realises his or her
abilities, can cope with normal stresses of life, can work productively
and fruitfully, and is able to make contribution to his or her
community”
(WHO 2001 World Health Report).

VISION
(Dream)
• Make Sri Lanka the leading country in the
Region in provision of quality mental
health care services.

MISSION
(Road map)
• To provide quality
– promotive,
– preventive,
– curative and
– rehabilitative
mental health care services to
all Sri Lankans.

GOAL
• To improve the mental health status of all
Sri Lankans.

Mental Health Policy Objectives
• Promote mental health

• Prevent mental illness
• Rights & equity of access to appropriate Healthcare
• Consent
• Treat mental illness in the least restrictive environment
• Rehabilitate people with long term problems
• Prevent suicide
• Tackle stigma
• Provide health services for people with mental illness in
Sri Lanka an Essential Package of Health and social
services
• Confidentiality

How to achieve goal
• Policy and regulatory framework
• Strengthen collaboration
– multidisciplnary,
– all levels,
– intersectoral
• Decentralise and integrate with all levels of
health system
– Primary care
– Secondary care
– Tertiary care
• Integrate mental health with primary care

STRATEGIC IMPERATIVES
1. Demystification .
2. Destigmatisation
3. Decriminalisation
4. Deinstitutionalisation
5. Decentralisation

STRATEGIC IMPERATIVES 2.
6. Integration of mental health services within

general health services.
7. Rehabilitation of mentally-sick persons within

their families and communities.
8. Communalisation of mental illnesses.

USEFUL TOOLS
• Policy
• Legislation
• Plans
• Standards and guidelines
• Training and supervision
• Medicines, skills, education, support
• Collaboration

DISCUSSION
Any questions about the mental
health policy

5.3. SRI LANKA
A MENTAL HEALTH
LEGISLATION
• 12 Slides
• Discussion
• Activity-human rights
• Activity-effects of implementing policy

MENTAL HEALTH
LEGISLATION 1.
GUIDING PRINCIPLES
• Regulates mental health care environment in the best
interest of the patient/client/consumer/user.
• Safeguards the Human Rights of the patient as

guaranteed under International Human Rights
Instruments, Regional charters as well as National
Constitutions and Legislations.

MENTAL HEALTH
LEGISLATION 2.
• Sets obligations of
mental health care users and
mental health care providers.
• Regulates
access to mental health care
Provision of mental health care
treatment for voluntary and involuntary patients
statutory treatment through criminal justice system.
• Regulates the manner in which the property of mentally-

sick persons may be dealt by the Courts of Law.

THE MHA
encouragement of community treatment and
care for persons with mental illness; and
the
provision of quality care, treatment
continuing care, and rehabilitation of
persons with mental illness and accessible
mental health services for all

INSTRUMENTS SAFEGUARDING
RIGHTS OF PEOPLE WITH
MENTAL DISORDERS 2.
• UN Convention on the Rights of the Child.

• UN Principles for the protection of persons
with Mental Illness and Improvement of
Mental Health Care (MI Principles)

MENTAL HEALTH ACT
Sri Lanka
• developed its own legislation
“The Mental Health Act”

The Mental Health Act: DRAFT
•
“ TO PROVIDE FOR THE PROTECTION OF PERSONS
WITH MENTAL ILLNESS;
TO PROMOTE MENTAL HEALTH SERVICES;
FOR THE ESTABLISHMENT OF THE MENTAL HEALTH
BOARD AND THE PROVINCIAL MENTAL HEALTH
REVIEW COMMITTEES;
TO PROVIDE FOR THE REPEAL OF THE MENTAL

DISEASES ORDINANCE (CHAPTER 559)
AND TO PROVIDE FOR MATTERS CONNECTED
THEREWITH OR INCIDENTAL THERETO”

The Mental Health Act: Sri Lanka
• Recognising that health is a state of physical, mental and
social well being and that mental health services shall be
provided as part of primary, secondary and tertiary health
services;
•
• Recognising that the Constitution of the Democratic
Socialist Republic of Sri Lanka 1978 provides for freedom
from degrading treatment and discrimination, equality
before the law and protection of its citizens in Article 11 and
provides for the advancement of the welfare of the disabled
persons in its Article 12;

The objectives of the MHA:
• (i) to provide for the protection of persons with mental
illness; and
• (ii) to provide required services and programs for-
• (a) the promotion of mental health services;
• (b) the prevention of mental illnesses; and
• (c) the treatment, care, and rehabilitation of
persons with mental illness.

THE MENTAL HEALTH BOARD
• 3.(1) Establishes a Mental Health Board (hereinafter

referred to as “the Board”).
•
• (2) The Board shall by the name assigned to it by
subsection (1), be:
a body corporate and shall have perpetual succession and
a common seal and may sued and be sued by such name.
•
•

Functions of the Board.5.
• (i) issue licenses for health facilities prescribed by regulation for
the admission of involuntary patients;
• (ii) authorize Psychiatrists to admit involuntary patients to
Psychiatric Inpatient Units and authorised health facilities;
• (iii) authorize Psychiatrists to be in charge of the psychiatric Units
in Prisons
• (iv) appoint members to the Provincial Mental Health Review
Committees established under section 10 of this Act, on the
recommendation of the Provincial Secretary in charge of the
subject of Health in each Province

Functions of the Board.5
• (v) publish a code of practice to be followed by all the mental

health personnel, involved with the care of persons with
mental illness under this Act and ensure its implementation
• (vi) submit an administrative report annually of the work done
by Board to Parliament;
• (vii) appoint sub-committees to carry out functions specified
by the Board;
• (viii) maintain registers of patients, who are detained over
one year in any health facility and monitor their status
annually until they are discharged;

• (ix) conduct inquiries related to complaints submitted to the

Board by the Provincial Mental Health Committees or any
other person, including deficiencies in treatment, care and
services providing to the persons with mental illness;
• (x) take all such measurers as are necessary, in
consultation with the relevant Ministries, Provincial
Councils, local authorities, district and divisional
secretariats, public and private sector organisations, to
promote the furtherance of, and safeguarding,the interests
and rights of mentally ill persons; and
•

• (xi) provide for the implementation of

internationally accepted norms and best
practices relating to persons with mental
illnesses

OBJECTIVES OF THE
MHA
1. Demystify mental illness
2. Destigmatise mental illness
3. Decriminalise mental illness
4. make mental illness a community
issue
5. Decentralise services

PART III
ESTABLISHMENT OF PROVINCIAL MENTAL
HEALTH REVIEW COMMITTEES
Constitution of Committees
• (i) an Attorney-at-law nominated by the Board who

shall be the Chairman;
• (ii) a Psychiatrist nominated by the College of
Psychiatrists
• (iii)three fit and proper persons who have served in
recognized professions for a period not less than twenty
years other than medical practitioners, attorneys-at-law
and psychiatrists

Duties of Committees.
• (i) hear appeals of involuntary admission, and detention
under the provisions of this Act;
• (ii) inspect licensed mental health facilities within
their respective province annually to ensure their
compliance with prescribed licensing requirements;
• (iv) inspect mental health services and facilities in
prisons and forensic Psychiatric units; and
• (v) make recommendations to mental health
facilities for the improvement of conditions of such Units.

VOLUNTARY ADMISSIONS
• 15.(1) Any person who is desirous of submitting himself
for treatment for mental illness may be admitted to a
Mental health facility as a voluntary patient:
• BUT
Persons under the age of eighteen years
• shall be admitted as a voluntary patient at the request of
his nearest relative or guardian, and shall be admitted to
a child and adolescent psychiatric unit of a Mental
health facility.

Transfer from voluntary to involuntary
status.
•(1). If the Psychiatrist in charge of the Mental health

• facility is of the opinion that the mental state of the
voluntarily admitted mentally ill person is such as to render it
necessary for that mentally ill person to be detained remain
as an involuntary patient in a Mental health facility
•that Psychiatrist shall transfer that voluntarily admitted
mentally ill person under temporary admission as an
involuntary patient.

PART V
INVOLUNTARY ADMISSIONS:
Emergency
Reasonable cause for suspecting that a person is
• suffering from mental illness and that person is violent or
uncontrollable that person shall be admitted to a Mental
health facility under emergency admission as an
involuntary patient.
Provided
• Immediate admission of that person to a Mental health
facility is necessary,
• either for his own sake or that of the public,

Involuntary Admissions:Temporary
• a reasonable cause for suspecting that a person is

• suffering from mental illness and is likely to benefit by
temporary treatment
• in a Mental health facility but is for the time being unable
to give consent to
• receive such treatment may be admitted to any Mental
health facility under temporary admission as an
involuntary patient

PART VI
DETENTION FOR TREATMENT
Deals with:
• Period of detention.
• Further detention.
• Discharge of detained patients.
• Appeals.
• Seclusion.

TYPES OF ADMISSIONS
• Voluntary admission
• Involuntary admission
• Emergency admission
• Admission through criminal justice
system as special category patient or
mentally disordered offender.

PART XI
MENTALLY ILL SUSPECTED OFFENDERS
• apply to suspected offenders with mental illness

(hereinafter referred to as the “suspected offender’”
under this Part of this Act), in custody of the police, or in
remand prison, who are being charged with criminal
offences and held for investigation.
PART XII: MENTALLY ILL PRISONERS

“nearest relative”
• (i)father or mother;
• (ii)brother or sister;
• (iii)husband or wife;
• (iv)son or daughter;
• (v)grand-parent;
• (vi)grand-child;
• (vii)uncle or aunt; or
• (viii)nephew or niece.
• in that order;

Some Definitions in MHA
• “primary carer” means the family member or
other person who has the lead responsibility for
caring for a person with mental illness
• “Voluntary” means with informed consent;
• “Seclusion” means sole confinement in a room
that it is not within the control of the person
confined to leave;

Task of the primary care worker
• Identify if person needs admission
• Advise person and relatives
• If person agrees, arrange escort if required
• If person refuses to go for assessment, seek
family/community/administration/police
assistance as appropriate, depending on risk of
violence and absconding
• And take person to hospital for assessment

DISCUSSION

Activity: Human rights
• In groups of 3
• imagine you are a patient with mental
health problems.
• what human rights do you have the right
to expect?.

SUMMARY OF MENTAL
HEALTH POLICY
• Integrate mental health into primary care
• Develop specialist care in every district
• Effective links between primary and specialist care
• Good practice guidelines
• Liaison between health and other sectors
– (eg NGOs, police, prisons, education and social sectors)
• Liaison between public and private health sectors
• Dialogue with traditional health practitioners
• Mental health promotion in schools, workplaces,
community

Activity: Legislation and Mental
Health Policy
• In groups of 3 :
• Compile an imaginary story about
– a person with mental health problems
(symptoms, causes, consequences) , and the
world in which they live now ( risks, lack of
care and all the problems they face)
– The same person if policy, legislation and

delivery of services all came together;

ROLE PLAY
• 1. Involuntary admission

5.4. REPRODUCTIVE
HEALTH AND MENTAL
HEALTH

MOH policy on Reproductive
Health
• Family planning
• Safe motherhood and child survival
• Management of STDs/HIV/AIDS
• Promotion of adolescent and youth health
• Management of infertility
• Gender issues and reproductive rights
• Integration of services and quality of care

Reproductive health and
mental health 1
• Family planning
– Depressed women less likely to access
family planning services
– Aggressive and substance using men less
likely to agree to condoms

Reproductive health and mental
health 2
• Safe motherhood and child survival
– Depressed mothers less likely to
• access antenatal and postnatal care
• Avoid getting nutritional (folate and iron) deficiency
• Immunise infants
• Manage oral rehydration of infant diarrhoea
– Mothers get depressed after hysterectomies and abortion and
still births
– Psychoses related to pregnancy and childbirth affect care of
child

health 3
• Management of STD/HIV/AIDS
– Depressed adults
• have lower immunity
• Less likely to comply with treatments
• Less likely to attend clinics
– People with STDs need prompt treatment
to avoid social isolation, depression,
suicidal tendencies and psychosis

mental health 4
• Promotion of adolescent and youth health
– Depressed young people less able to be assertive and safe
– Unprotected sex leads to unwanted pregnancy, abortions,
complications and depression, and STDs
– Substance abuse in young people leads or predisposes to
unsafe sex, STDs, HIV/AIDS, and unwanted pregnancy

health 6
• Integration of services and quality of
care
– Mental health is intrinsic to reproductive
health, and services need to be integrated
at primary and secondary care levels
– Cancers in reproductive system can lead
to stress and depression
• Menopause/andropause can cause
stress and depression

health 7
• Management of infertility
– Depressed young women more vulnerable to chlamydia
because of lack of condom use and lower immunity
– Women who are unable to have children are considered
social misfits, isolated and discriminated against, leading to
stress, depression, suicide or promiscuity

health 8
• Gender issues and reproductive rights
– Men who abuse substances, personality disordered or
depressed are more likely to commit domestic violence,
psychological and sexual abuse
– Victims of FGM experience stress, depression, difficulty in
child birth, damage to child, still births and depression
– Rape leads to unwanted pregnancies, abortions and
depression
– Domestic violence precipitated by substance abuse leads to
depression

mental health 9
• Depression and anxiety increase likelihood of
– Smoking
– Poor antenatal care
– Impaired breastfeeding
– Lack of treated bednets
– Unsafe sex
– Poor self assertion to combat violence and abuse
• Complaints of vaginal discharge often clue to depression
or concern about sexual problems
• Menopausal symptoms not understood

5.5. CHILD HEALTH AND
MENTAL HEALTH

MOH Policy on Child health
• Integrated management of childhood
illnesses
• Strengthen health systems
• Promote adolescent and youth health

Contribution of mental health to
integrated management of
childhood illnesses
– Childhood emotional and conduct disorders are associated
with malnutrition, trauma, and physical illnesses
– Childhood physical illnesses have psychological, cognitive
and social consequences for child
• Management should therefore always be holistic (bio-psycho-
social)
– Physically ill children often have depressed mothers
• Assess and treat the mother as well as the child

Contribution of mental health to
promoting adolescent and youth
health
• Promote adolescent and youth health
– Children of depressed mothers less likely to
• Be immunised
• Be well nourished
• go to school

Consequences of childhood
mental illness and behavioural
problems
• Low academic achievement
• Adult psychiatric problems
• Unwanted pregnancy
• Criminal behaviour
• Personality traits which handicap in labour
market
• Lack of healthy lifestyles
• Impact on health of next generation

Therefore
• Support parents and children
• Treat depressed mothers
• Integrated holistic management of
childhood illlnesses
– Addressing emotional and conduct disorders,
dyslexia, etc

5.7. HIV/AIDS AND MENTAL HEALTH
relatively small number of HIV/AIDS cases, but high

risk behaviors that contribute to the spread of the
infection are prevalent, making the country highly
vulnerable to an AIDS epidemic.
Sri Lanka has a narrowing window of opportunity to
forestall a large scale epidemic
4,800 adults and children. as of the end of 2002

World Bank 2005

Consequences of HIV/AIDS
• Deteriorating quality of life of infected people
• Taxing the already strained health and social
care system
• Increased number of orphans
• Decreased productivity
• Reduced workforce
• Increased poverty
• Reduced life expectancy +++

Mental health influences sexual
behaviour, and prevention of HIV
• Sex is a human behaviour
• Mental health is a major influence on
human behaviour
• substance abuse, psychological
conditions, personality disorders can
influence risk behaviours for HIV/AIDS
infection.

Mental health influences
immunity
• Our emotions, beliefs, relationships with others
and behaviour habits can influence our immune
system:
– Making it stronger or weaker
– Towards sickness or health
• Long-term stress suppresses immune system to
fight viral as well as bacterial and parasitic
infections and thus creating fertile environment
for pathogens

Mental health influences
prognosis of HIV
• Beliefs- believing that you must die from
being HIV-infected can trigger fear,
decreases in immunity, avoidance of
health promoting behaviour leading to
shorter life span
• Grief- if is held and not expressed it can
trigger a decrease in immunity and speed
up the progression of disease

Mental health promotion
improves prognosis of HIV
• Self-disclosure to trusted support-
provides a boost to immunity system
functioning
• Self-assertiveness promotes the strength
and quantity of natural killer cells of the
immune system
• Body care:
– Regular sleep, good nutrition, physical
exercise, breathing

HIV damages mental health
-Psychological impact of having a fatal disease

– Problems that emerge from life circumstances
– Depression, substance abuse
– actual neurological changes in the physical and
chemical structures of the CNS occur as result of the
HIV virus, opportunistic infection or related treatment.

HIV damages the brain
– AIDS Dementia Complex

• Characterized by marked impairment in cognitive
functioning, involving the ability to observe,
concentrate, memorize, and quickly and flexibly
process information
• Can lead to irritability, poor coordination, apathy
and social withdrawal
– Cryptococcal meningitis, TB meningitis,
opportunistic disease
– Tumors

Management
• Life with HIV is no longer necessarily a shortened
life.
• Serious illness should motivate the individual to
assess his/her prior behaviour and create planned
goals and strategies for the near future.
• Thorough assessment and proper diagnosis
– Bio-psycho-social aspects

Medical Management
• HIV/AIDS- Antiretroviral regime: Triple therapy to
suppress virus growth and prevent mutant
– Niverapine
– AZT
– Lamivudine
• Treatment of psychosis
• Treatment of physical disease eg TB

Psychological issues at stage
of diagnosis
• Acute stress, suicidal ideation, substance
abuse
• Social isolation due to fear isolation, retreat
• Poor coping strategies that could suppress the
immune system
• Fear of stigma leading to secrecy, silence,
guilt, this inhibits ability to own their confusion,
anger & grief.
• Feeling of betrayal
.
Psychological issues after
diagnosis:
– anticipate or experience stigma
– changes in relationship patterns
– Isolation
– changes in productivity due to opportunistic infections
– Accessibility of drugs
– Helplessness
– Alienation +++

Psychological interventions:
• Pre & Post counseling for HIV-testing.
• Psycho-education
• Social skills development
• Assertiveness training- coping strategies
• Social support
– Self acceptance, acceptance by family/friends and co-
workers
– Patient’s ability to access help both the emotional and
problem-solving realms e.g. expression of feelings,
emotions, and thoughts, and accessing information
from others.
• Self-help groups

Treat the person as well as the
virus

Treat the person as well as the
virus
• Comprehensive care-team work
• Address biopsychosocial issues
• Reduce stigma
• Adherence to therapy
• Promote general well being

Advice for family and friends
• Personal safety
– HIV can only be transmitted by exchange of
blood, semen, saliva
– Safe sex
• Prognosis improved by
– Social support
– ARVs
– Healthy lifestyle

5.8. Role of Community Health
Workers
• Link between PHC and Community
• Create awareness
• Identify families caring for sick people
• Persuade families to bring relative to PHC
• Supervision of treatment by home visits
• Monitor side effects
• Early detection of relapse
• Social support to vulnerable and sick

Role of community health workers
• Immunisation
– Look for depressed mothers
• Antenatal and postnatal care
– Look for depression and psychosis
• Physical infections
– Look for depression
• Home based care for HIV and TB
– Look for depression

So
• Give your CHWs information about
– symptoms and signs of depression ,
psychosis etc
– medication and side effects
– early detection of relapse
– How to mobilise support

5.9. TRADITIONAL
HEALTH
PRACTITIONERS

Why Traditional Health
practitioners?
• Major health care resources
– A significant sector of the population consult TH or
RH at some time
– People often simultaneously consult both traditional
health practitioners and western medicine
– Accessibility
– Operate in the social context
– Interventions sometimes effective

Common types of Traditional
Health Practice
• Sri-Lankan
– Ayurveda
– Herbal
– Spiritual
– Combination of herbal and spiritual
– Traditional healing rituals (Thovil..)
– Yoga
– Homeopathy
– Chinese herbal medicine
– acupuncture

Advantages of THP
• Community oriented with strong social support and detailed
knowledge of client and family
• Understand psychosocial dynamics of family and community
• Use psychosocial interventions

Disadvantages of THP
• A rise of the corrupt THPs/quacks
– money oriented, various abuses
– Inadequate training/apprenticeship
• Overdose of herbs
• Herbs may interact with western medicines
• Introduction of infection including HIV
– Razor blades
• Safety??

Potential for Collaboration
• GOK is encouraging Professional accountability
through registration
• It would be possible to train THPs to :
– recognise and refer all cases of
• delirium, psychosis, severe depression, epilepsy
– promote safe practice
• Research THP methods

Collaboration cont..,
• Mutual dialogue
• Referral
• Research THP methods
• Sharing information

Working with Traditional Health
practitioners:
• Identify genuine THPs within your working area
• Visit them in their practice settings
• Create a dialogue with the good ones
• Invite them to your practice setting
• Develop a system whereby both sides can learn from
each other
• Set strategies for cooperation and collaboration
– Developing guidelines
– Holding meetings/Discussion
• Follow-up

5.10. HEALTH
MANAGEMENT
INFORMATION SYSTEM

What is HMIS?
• A system of collecting, recording, keeping
and reporting including dissemination of
health related information (mental Health)
• It has a clear flow of communication from
service point to decision/policy level and
vice versa

Structure and flow of HMIS:
Ministry
↑↓
Provincial
↑↓
District
↑↓
Primary care setting

USE:
• Planning for
– Drug supply
– Services required
– Space for accommodation of patients
• Evaluation of services
• Communication

What information is needed?
• New patients including:
– Identification information
– Diagnosis
– Management plan
• Follow-up patients:
– All of above plus progress report

Information needed on mental
health from PHC to District
– New cases
– Follow-up patients
– Home visits conducted
– Outreach activities conducted
– Medicines supply and use
– Problems encountered
– Strategies for improvement

Use these Diagnostic categories
in the patient register
• Depression
• Anxiety
• Post Traumatic Stress Disorder
• Schizophrenia
• Bipolar disorder
• Drug abuse
• Alcohol abuse

Diagnostic categories cont…
• Childhood emotional disorders
• Childhood conduct disorders
• Learning disabilities
• Dementia
• Toxic Confusional States/Delirium
• Epilepsy
• Child abuse
• others

Demographic Information
• Age
• Sex
• Occupation
• Marital status

Use of information at PHC:
• Health worker must be able to make simple
interpretation of information and use the
information to improve care.
– Identifying common mental health conditions in the
area. (What, Who, When, Why)
– Follow-up those who miss their appointments
– Psycho education to families and clients on
adherence to medication
– Ensure medicine supply

5.11. ROLES AND
RESPONSIBILITIES AT EACH
LEVEL

ROLES AND
RESPONSIBILITIES: PHC
• Clinical
• BUT YOUR ROLE DOES NOT END
THERE !
• Training and skills
• Administration
• Community education

IT IS DEMORALISING TO
JUST BE A
“NEXT, NEXT, NEXT”
HEALTH WORKER

Clinical roles
• Identification, diagnosis, treatment, follow up, referral
– Address physical, psychological and social axes
simultaneously
– Use good practice guidelines
– Use psychosocial skills
– Rational prescribing of psychotropics and
antimalarials
– Reduce use of benzodiazepines
– Conduct outreach and home visits
– LiaIse with community health workers
– LiaIse with families

Community mental health
education
• Liaise with and educate other sectors
– Schools, police, prisons, NGOs,
traditional healers, social welfare,
community leaders, religious groups

Skills
• Attend CPD programmes in house and
elsewhere
• Develop psychosocial skills
• Receive on job support, supervision
and training from district level

Administration
• Proper use of registration book and patient files
– Collect data on consultations using diagnostic categories
• Ensure availability of
– antidepressants, antipsychotics,anti-epileptics by auditing and
ordering on time
• Develop and maintain simple case registers of people with
severe mental illness
– For follow up, relapse prevention, outreach and planning for
medicines
• Access transport for outreach
• Communicate and liase with district
– mental health coordinator, medical officer, clinical officer and
nursing officer

Monitoring and evaluation
• Monitor and evaluate routine
consultations
• Undertake operational research into
locally relevant questions

5.12 ROLES AND
RESPONSIBILITIES:
DISTRICT MH COORDINATOR
• Administration
• Clinical
• Training and skills
• Support of district mental health team
• Monitoring and supervision of PHC

Reporting and Planning
• Prepare and submit reports to District Medical
Officer of Health, Provincial Medical Officer of
Health and the Director of Mental Health on all
issues which affect the delivery of mental health
services at PHC and District level
• Contribute to District health plans
• Contribute to inter-sectoral collaboration on mental
health in areas of jurisdiction

Support staff in District MH IP
and OP clinics
• ensure adequate functioning of key structural
issues: lights, fans, water, toilets, beds,
sheets, food supply.
• perform clinical duties
• liaise with the families of mentally ill people
• ensure adequate medicine supply
• Clinical roles as for PHC

CLINICAL AND LIAISON
• manage a programme of / or deliver psychosocial
treatments
• liaise with local police, prisons, child protection, schools
and other institutions of learning, religious bodies,
NGOs, CBOs and traditional health practitioners
• communicate with primary care about referrals, referral
criteria, shared care, information transfer, medicines,
guidelines
• support, supervise, monitor and evaluate district mental
health services

Monitoring and Supervision
• support, facilitate, supervise local PHC
clinics to enable them to undertake tasks
listed in section A
• monitor and evaluate their performance
and suggest service improvements and
developments

community mental health
education
– work with local media (radio, TV, electronic and print) to
produce mental health programmes for public airing and
viewing.
– contribute to school health education programmes on
positive mental health, life skills, depression, epilepsy,
substance abuse and other key and topical programmes
– prepare and distribute mental health educational
materials

ROLES AND RESPONSIBILITIES:
PROVINCIAL MH COORDINATOR

Leadership
• strategic leadership to Province on Mental
Health
• coordination, supervision, monitoring,
evaluation of mental health services in the
province
• liaison for specialist sector, primary care
sector and community sector

Administration issues
• liaise with provincial health management

team on issues below
• Assist/ provide data re: preparation of
reports about delivery of mental health
services

• contribute to
– provincial health plans
– inter-sectoral collaboration on mental
health in areas of jurisdiction

Support staff in provincial psychiatric
units and clinics
• Ensure adequate functioning of key

structural issues - lights, fans, water,
• toilets, beds, sheets, food supply.
• Clinical service delivery and Psychosocial
treatments
• liaise with the families of mentally ill people
• ensure adequate medicine supply

• liaise with local police, prisons, child
protection, schools and other institutions of
learning, religious bodies, NGOs, CBOs and
traditional health practitioners.
• communicate with primary care about
referrals, referral criteria, shared care,
information transfer, medicines, guidelines

Monitoring and Supervision
• Supporting PHCs to fulfil their roles and

responsibilities
• Offer support to district mental health
coordinators within the Province to enable
them to fulfil their roles and responsibilities
• Support, supervise, monitor and evaluate
district mental health services

Conduct community
education at Provincial level
• work with local media (radio, TV, electronic and print) to
produce mental health programmes for public airing and
viewing
• contribute to school health education programmes on
positive mental health, life skills, depression, epilepsy,
substance abuse
• prepare and distribute mental health educational materials
• work with local NGOs, schools, employers, community
and religious leaders and other organisations on mental
health education

ROLES AND
RESPONSIBILITES
National Level

National Hospitals
• train medical students, psychiatrists,

psychologists, psychiatric social workers
• deliver diploma, MD and other courses
• conduct research and development

Sri Lanka : Health Education
• train nurses, clinical officers, occupational
therapists
• deliver continuing education and in-
service training in primary care

Sri Lanka : The Mental Health
& Evidence Based Research
• Conduct research
• Conduct mental health research

Division of Mental Health,
Ministry of Health 1
• strategic leadership
• overall coordination of mental health services in
Sri Lanka, liaison with specialist sector, primary
care sector and community sector
• Development, implementation and oversight of
the National Mental Health Policy, strategic plan
and programmes

• Development, administration,
implementation, oversight and review of
mental health legislation
• development and review of national mental
health guidelines and standards for mental
health care services
• collaboration with other sectors in mental
health at national and international level

• monitoring and evaluation and supervision of
mental health services in the country
• overview of human resource development and
management
• technical assistance, facilitation and capacity
building for provinces and districts

• liaison within MOMH on mental health issues
– mental health information systems, statistics for planning
– essential package of health interventions
– medicine supply
– continuing education
– Guidelines
– integration into health sector reform
– research and development

Disaster preparedness
• These slides on disasters are approved by
WHO Geneva
• and are compatible with the IASC
Guidance on mental health and
psychosocial support in emergency
settings
• Please also read the IASC guidance which
is available on the web.

Key common issues
• Disasters are events
– affecting a social group
– which produce such material and human
losses
– that the resources of the community are
overwhelmed
– and therefore the usual social mechanisms to
cope with emergencies are insufficient

Levels of disasters
• Level 1
– Localised, few victims, local health resources
available
• Level 2
– Many deaths, considerable resources needed and
regional help necessary
• Level 3
– Massive losses , local and regional resources
insufficient, national and international help required

Disasters reveal
• Previous failures eg
– Socially vulnerable groups
– Buildings
– Dam construction
– Sanitation
– Food security
– Water supply
– Distribution and coordination of health services
– Training and supervision of health services
– Disaster preparedness

Some contextual issues in pre-
disaster populations
• Conflict and ethnic tension
• Poverty
• Rigours of way of life
• Scarce health care
• Previous studies showing high rates of
illness

Disaster is a major life stress of
extreme severity
• loss of
– Life (orphans, widows, widowers)
– Livelihood
– Physical functioning: Injuries and disability
– Shelter , food, livestock
– Access to health care
– Access to education
– Leaders and community structures

So, following a disaster
• We have to cope with
– The pre-existing mental disorders in the general
population and within any primary care and hospital
services in the area
– Normal psychological responses to the disaster,
– Additional mental disorders caused by the disaster
and its attendant physical and social effects
– Loss of pre-existing health, social and educational
infrastructure and human resource

Therefore the common mental
health problems in post disaster
populations include
• Universal normal response to the abnormal stress

(disaster)
• Grief and Bereavement
• Depression
• Anxiety
• PTSD
• Psychosis
• Substance abuse
• epilepsy

Rescue and relief workers,
and front line health workers
• Profound sadness, grief, anger are normal reactions
• Everyone is touched by it
• May not want to leave scene until work is finished
• Will try to override stress and fatigue with dedication and

commitment
• May deny need for rest and recovery time

So key immediate tasks for primary
care
• Plan, preferably before the disaster, and ensure every
worker reads the disaster plan
• Support front line health workers in their roles
• Ensure adequate rest and supervision
• Establish system of triage so that only most complex

cases are referred to specialists at district level.

Key immediate tasks continued.
• Assess and manage mental disorders according to the
WHO primary care guidelines adapted for Sri Lanka,
giving appropriate information to clients, families as
indicated, treat, and refer as necessary
• Work with other sectors to meet basic needs for food,

water, shelter, communication with relatives and friends,
• Mobilise community social and practical support and
group activities

Key immediate tasks continued
• Do NOT do psychological debriefing-this has been
shown to be psychologically damaging.
• Instead, offer listening and general psychosocial support
and ensure links to all practical assistance
• Liaise with local community leaders, teachers, social
welfare, child protection, police, prisons, NGOs and
traditional health practitioners
• Attend local training events
• Ensure sustained medicine supply by ordering well in
advance .
• Collect consultation data

When do we start to plan for the
long term?
• There are long term issues right from the
start of any disaster
• Need to incorporate them into our
planning from start
• They influence how we deliver the
emergency and post emergency care

Specialist roles in normal and
disaster situations
• Train
• Support and supervise
• Intersectoral coordination
• Public education
• NOT front line work because of logistic
reasons
• Clinical work at secondary and tertiary
levels

MENTAL HEALTH IS AN
INTERSECTORAL ISSUE
• Health, education, social welfare, criminal justice

, NGOs, traditional health practitioners
• Therefore mental health needs intersectoral
coordination at national, provincial, and local
levels
– Whether or not there is a disaster

Mental health is an intersectoral
issue
• And front line workers need awareness and
training in mental health
– Whether or not there is a disaster
• Primary care workers (nurses, clinical officers, communtiy
health workers)
• Social workers
• Child protection officers
• Teachers
• Volunteers
• Police officers
• Army coordinators
• NGO coordinators

National level tasks in disaster
• Establishment of emergency coordinating structure (s)
• Rapid situation appraisal
• Strategic action plan –regularly updated in light of experience
and changing circumstances
• Implementation plan and timetable
• Supervision systems on mental health from national level to
provincial to district to primary care level to community health
workers
• Intersectoral partnerships for mental health
• Partnership with other health areas eg child health,
reproductive health, HIV, malaria, NCDs
• Steer HMIS, human resources, media liaison
• Steer monitoring/audit and research agenda

Regional level tasks
• Train trainers for all front line health workers in mental
health, integrated as part of their routine work
– Promotion, prevention, treatment, rehabilitation

• Train trainers for other key front line workers eg
teachers
• Establish sustainable methods for supervision cascade

District level tasks
• Train front line workers and supervise them regularly over
long term
• Establish mental health inter-sectoral committees
• Community mobilisation
• Establish decentralised specialist services at district level,
who can support primary care, take small numbers of
referrals and lead community mobilisation

Mobilisation of community for mental
health in normal non-disaster situations
• Mobilise other sectors

– Education, social welfare, child protection,
community leaders etc
– Establish mental health coordinating
committees at village and municipal levels
• This is even more crucial in disaster
situations, and the community will be more
resilient if it has been done before

Government/UN/WHO country office
coordinating mechanism
• To prevent anarchy
• Obtain valid information
• Needs assessment and map
• Public health integrated plans
• Ensure no area neglected
• Remove bureaucratic barriers to speedy implementation

• evaluation

Disasters have the second disaster
• Lack of coordination!
• Need all outside help to be coordinated,
so does not duplicate or leave gaps, and
is consistent with overall plan
• Support local structures
• Build local capacity
• Work sustainably so does not collapse
when donor money withdrawn

127 wars since WWII
125 wars in low income countries
16 of 20 poorest countries have had major conflict in last 15 years
Nearly all low income countries are next to a country that has
experienced war
60% since 1999 have been in sub Saharan Africa
13M IDPs and 3.5 M refugees in Africa
Conflict causes as many deaths in Africa as epidemic diseases
Sri- Lanka?

SRI-LANKAN: STUDIES
• Only 6% of the study population had not experienced any war
stresses. (Somasundaram et al 2002)
• Psychosocial sequelae were seen in 64% of the population,

including somatization (41%), PTSD (27%), anxiety disorder
(26%), major depression (25%), alcohol and drug misuse
(15%), and functional disability (18%).
• The breakdown of the Tamil society led to women taking on
more responsibilities, hence more vulnerable to stress ( Steel
Z. Silove D. Bird K, et al ).
• Children and adolescents had higher mental health morbidity
(Somasunderam et al 1994).

GENDER ISSUES
• Child soldiers
– Boys-active combatants
– Girls-sexual slaves and combatants
• Women ex combatants
• Gender violence
• Cultural attitudes to widows
• Culturally appropriate ways of seeking
women’s views

PEACE AND DEVELOPMENT
• There can be no peace without
development
• There can be no development without
peace
• Classically, donors have insisted that
peace comes first, then economic
development
• But what works best is different

FOR LASTING PEACE
• Ex combatants, IDPs and refugees need
– Homes
– Jobs
– Education
– Health
– Justice

KEY GROUPS TO CONSIDER
WHEN BUILDING THE PEACE
• Combatants/ex-combatants
• Refugees
• Internally displaced persons
• Women
• Children
• General population
• Alcohol Abuses
• School children

REFUGEES and IDPs
• World’s refugee burden is carried
overwhelmingly by the poorest countries of
world
• 20 countries with the highest ratios of
refugees have an average annual per capita
income of 700 dollars (2003 Data)

CONCLUSIONS
• Conflict is crucial issue for MDGs
• No peace without development
• Strengthen basic systems of health and
education
• Stop and Reverse the brain drain
• Mental health an intrinsic issue for each of MDGs
• Mental health should be included in the PRSPs
• Donors should strengthen local health systems
and capacity rather than bypass

5.12. NEXT STEPS
• Group work
– Plan aims and strategies for next year
• Clinical
– Individual
– Client groups
• Administrative
• Intersectoral liaison
• Other

5.13. CONCLUSIONS
• Post test
• Certificates
• Reimbursements of travel
• Contact details for follow up
• We very much hope you have enjoyed the
course

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Mental Health:

Training the Trainer Programme

Professor Rachel Jenkins

© WHO Collaborating Centre

• The Learning Disability Fund

Individual Donations from:

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Training the Trainer Programme Sri-Lanka

30th November – 4th December 2009

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• What ground rules do we all suggest to

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• We would like to see whether our course

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•Please take a moment to orientate yourself

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• Common Mental Disorders 10-20%

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• Some erroneous assumptions

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• to prevent disability and

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• Physical illness may present with mental

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• Is key partner to achieve the MDGs