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THE AFRICAN TEXTBOOK OF

CLINICAL PSYCHIATRY AND


MENTAL HEALTH

The African Textbook of Clinical Psychiatry and Mental Health

ii

THE AFRICAN TEXTBOOK OF


CLINICAL PSYCHIATRY AND
MENTAL HEALTH
Professor David Musyimi Ndetei
Assisted by
Prof. Christopher P. Szabo
Prof. Tarek Okasha
Dr. John Mburu

Together with
Dr. Benson Gakinya, Prof. Gad Kilonzo, Prof. Duncan Ngare, Dr. Anne Obondo, Dr. Francisca
Ongecha-Owuor, Prof. Ruthie Rono, Prof. Mohamedi Boy Sebit, Dr. Musisi Seggane

THE AFRICAN MEDICAL AND RESEARCH FOUNDATION


Nairobi, 2006

iii

The African Textbook of Clinical Psychiatry and Mental Health

The African Medical and Research Foundation (AMREF)


P. O. Box 27691 00506, Nairobi, Kenya
Tel: +254 20 6993000
Fax: +254 20 609518
Website: www.amref.org

2006 The African Medical and Research Foundation


All rights reserved.

AMREF would like to acknowledge the generous contribution of Vronestein, Netherlands towards the
production of this publication

ISBN-10: 9966-874-71-2
ISBN-13: 978-9966-874-71-9

The publishers will consider any request for permission to reproduce sections of this publication with the
intention of increasing its availability for study purposes. AMREF would be grateful to learn how you are
using this book, and welcomes constructive comments and suggestions. Please address any correspondence
to:
Publications Editor
Directorate of Learning Systems
AMREF Headquarters
PO Box 27691 00506, Nairobi, Kenya
Email: amrefhlm@amrefhq.org

Illustrations and cover design by Elijah Njoroge


Layout and book design by Joy Muthoni Mita
Printed by:

iv

DEDICATION
This book is dedicated to those individuals and their families who toil with mental health related issues but have
no voice and suer silently, without hope. Indeed, there is hope for them.
It is my expectation that the students and professionals who read through these pages will be inspired to become
vehicles and instruments of change in clinical practice and policy, and in the process bring hope to these
people.
The book is also dedicated to my mother, Kalekye and my family.
David Musyimi Ndetei

The African Textbook of Clinical Psychiatry and Mental Health

In memory of my late father, John Ndetei Nzuki

vi

It is my dream that all citizens of this continent will have access to qualied and trained personnel, and
appropriate management that is aordable, eective, and without discrimination or stigmatisation.
The Walk towards the Promise
Inaugural lecture by David Musyimi Ndetei,
Professor of Psychiatry, University of Nairobi,
Kenya, 13th September 2001

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The African Textbook of Clinical Psychiatry and Mental Health

Table of Contents
Foreword ................................................................................................................................................xi
Preface ....................................................................................................................................................xiii
Acknowledgements ...............................................................................................................................xv

Section I: Psychiatry and Mental Health in Context


1.
2.
3.
4.
5.
6.
7.

Introduction to Mental Health and Clinical Psychiatry ...............................................................3


History of Psychiatry ..................................................................................................................6
Psychiatric and Mental Health Training .......................................................................................11
The Burden of Mental Illness........................................................................................................14
The Economic Burden of Mental Disorders in Africa ..................................................................18
Stigma and Mental Disorders2 ......................................................................................................20
Mental Health: From the Perspective of a Paediatrician and Surgeon .........................................24

Section II Part A: Clinical Psychology


8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Human Development and Life Cycle............................................................................................31


Personality and Personality Traits .................................................................................................48
Human Learning ...........................................................................................................................55
Human Motivation and Emotions .................................................................................................59
Memory and Forgetting.................................................................................................................62
Communication and Communication Skills .................................................................................66
Psychological Testing....................................................................................................................69
Stress and Stress Management ......................................................................................................73
Crisis and Crisis Management ......................................................................................................80
Critical Incident Stress Debrieng (Psychological Debrieng) ....................................................85

Section II Part B: Medical Sociology and Anthropology


18.
19.
20.
21.
22.
23.

Introduction to Medical Sociology and the Family .....................................................................91


Health and Illness Behaviours.......................................................................................................96
Culture, Health and Illness ............................................................................................................101
Culture and Mental Health ............................................................................................................107
Mental Health, Spirituality and Religion ......................................................................................115
Culture, Spirituality and Management ..........................................................................................119

Section III: Behavioural Neurosciences


24.
25.
26.
27.
28.

Neuroanatomy and Psychiatry ......................................................................................................125


Psycho-neurochemistry .................................................................................................................134
Psychoendocrinology ....................................................................................................................142
Psycho-neurological Investigations ..............................................................................................144
Genetics of Mental Disorders .......................................................................................................147

viii

Section IV: Clinical Adult Psychiatry


29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.

Aetiology in Psychiatry .................................................................................................................153


Psychopathology ...........................................................................................................................156
Psychiatric Interview, Assessment and Classication ...................................................................162
Somatoform and Dissociative Disorders.......................................................................................174
Mood Disorders.............................................................................................................................190
Anxiety and Adjustment Disorders ...............................................................................................214
Alcohol and other Substance Related Disorders ...........................................................................228
Sexual Disorders, Paraphilias and Gender Issues .........................................................................254
Personality Disorders ....................................................................................................................277
Schizophrenia and other Psychotic Disorders ...............................................................................287
Suicide and Suicidal Behaviour ....................................................................................................304
Liaison Psychiatry .........................................................................................................................311
HIV/AIDS and Mental Health ......................................................................................................320
Organic Psychiatry ........................................................................................................................329
Epilepsy .........................................................................................................................................348
Old Age and Mental Health ..........................................................................................................360
Forensic Psychiatry .......................................................................................................................367
Psychiatric Emergencies ...............................................................................................................381
Sleep Disorders .............................................................................................................................389

Section V: Child and Adolescence Psychiatry


48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.

Child Psychiatry: An Overview ...................................................................................................404


Adolescent Psychiatry: An Overview ..........................................................................................410
Mental Retardation ........................................................................................................................413
Pervasive Developmental Disorders .............................................................................................417
Disruptive Behaviour Disorders....................................................................................................423
Anxiety Disorders of Childhood and Adolescence .......................................................................431
Mood Disorders in Children and Adolescents ..............................................................................437
Psychotic Disorders in Childhood and Adolescence.....................................................................441
Tic Disorders .................................................................................................................................446
Sexual and other Types of Child Abuse ........................................................................................450
Eating Disorders ............................................................................................................................454
Other Disorders and Presentations ................................................................................................460

Section VI Part A: Physical Treatments


60.
61.
62.

Ethno-Psychopharmacology and its Implications in the African Context ....................................470


Psychopharmacotherapy ...............................................................................................................478
Electroconvulsive Therapy (ECT) ................................................................................................489

Section VI Part B: Non-Biological Treatments


63.
64.
65.
66.

Psychotherapy ...............................................................................................................................495
Cognitive Behaviour Therapy (CBT)............................................................................................504
Counselling ...................................................................................................................................507
Group, Marital and Family Therapies ...........................................................................................510

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The African Textbook of Clinical Psychiatry and Mental Health

67.
68.

Loss and Bereavement Therapies..................................................................................................516


Occupational Therapy, Rehabilitation, Community Psychiatry and Social Support Networks ....522

Section VI Part C: Emerging Trends


69.
70.

Complementary and Alternative Medicine in Psychiatry .............................................................531


Nursing in Mental Health ..............................................................................................................535

Section VII: Research and Ethics


71.
72.
73.

Research and Bio Statistics in Mental Health ...............................................................................549


Ethics in Psychiatric Research ......................................................................................................559
Ethics in the Practice of Psychiatry and Mental Health ................................................................567

Section VIII: Postscript


74.

The Practice of Psychiatry in Africa - A Personal Experience ......................................................577

Appendices
Appendix 1: WMA Declaration of Helinski 2000 .................................................................................582
Appendix 2: International Ethical Guidelines for Biomedical Research ...............................................586
List of Contributors .................................................................................................................................591
Index .......................................................................................................................................................595

Foreword
When Professor David Ndetei invited me to write a foreword for the book The African Textbook of Psychiatry
and Mental Health, I accepted to do so with much pleasurewithout even seeing the manuscriptfor several
partly independent reasons.
First, of all continents, Africa is undoubtedly most in need of qualied people who can competently deal
with mental health problems problems that are becoming even more frequent than before and have even
more serious consequences than they had in the past. There are many reasons for this epidemic of mental ill
health, including extreme poverty, the growing prevalence of infections and other diseases aecting the brain,
still decient perinatal care leading to injuries of the newborn, and nutritional deciencies that are reducing
the capacity to withstand physical or mental disorders. The situation is made worse by the reduction and even
disappearance of the traditional social structures that have helped people in need, particularly in urban areas.
Unfortunately, however, it seems that the same ominous trend is also be ing extended to the rural areas where,
already today, the traditional social networks are no longer as strong as they had been and can no longer buer
the multitude of problems that face people in Africa. There is thus an urgent need to bring together knowledge
that will be useful in dealing with mental disorders, in training health care workers and in activities that might
promote mental health and help to prevent mental illness.
Second, the knowledge needed must be assembled and presented by experts who are steeped in the cultures
in which it will be used. Recent years have seen the development of a multitude of psychiatric textbooks and
mental health care manuals: most of them have however been written by psychiatrists living in developed
countries with little or no experience or information about the situation in the developing countries. These texts
are useful as a source of facts that, however, need to be embedded in the doctrine of care developed for other
settings. The decision by a group of experts in Africa to jointly produce a textbook of psychiatry in Africa is
therefore an important step towards an agreement on ways of providing mental health care in Africa. It is my
fervent hope that the work of this group and the work of others in the area of education and other domains will
mark the beginning of the renaissance of African psychiatry that had been in the eyes of the world when Lambo,
Assuni, Tigani el Mahi, Raman, German, Smith and others in the early 1960s made through their achievements
and spirit. They made everybody feel that psychiatry in Africa might become the model for psychiatry in the
developing and in the industrialised world.
Third, the stigma of mental illness does not only aect the person who suers from it: it spreads to the family of
the patient and to all that has to do with mental illness. It marks mental health institutions and services many
of which are in a poor state because the resources for their improvement are lacking and for other reasons
and it has marked the discipline of psychiatry. It is therefore important to produce materials that will present
the huge advances of mental health knowledge to the medical students and to other health professionals and
convince them of the fact that mental health care can be based on solid evidence and therefore requires just as
much attention and resources as do services provided by other disciplines and services.
Fourth, we live in a period of intensied brain drain with an exodus of trained personnel. This is particularly
painful and harmful because it involves a high proportion of qualied sta in the less developed countries. Brain
drain is not a novelty in the eld of medicine: there were always young doctors who left their country to gain
additional experience and knowledge, to see the world or to make more money. What is new, however, is that
at present governments in several countries in the industrialised world actively recruit people from developing
countries and oer them very attractive conditions. What is also new is that the recruitment of experts from the
developing countries has become easier because the conditions in their home countries have worsened. What
is also new is that those who left for training or short-term employment are less likely to come back than was
the case before. I believe that the ight of academic sta to richer countries has, at least in part, to do with the
diculties of doing research, providing service and training thus making it very dicult to be proud of ones
department or programme. To change this situation and improve the working atmosphere the departments of
psychiatry in the developing countries will have to make an enormous eort: the production of locally written
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The African Textbook of Clinical Psychiatry and Mental Health

textbooks and the reform of teaching that can go hand in hand with the production of training materials is part
of this striving and will help to augment the prestige of the departments and make those who are working in
them feel proud and motivated to do even more.
For these reasons and because I believe that psychiatrists in Africa can make a major contribution, not only
to improve mental health care in their continent, but also to develop psychiatry worldwide, I welcome this
book and hope that others will follow thus helping to make psychiatry in Africa a winning proposition for all
concerned for the mental health professionals, for the society and, last but certainly not least, for people with
mental disorders, their families and those who are close to them.

Norman Sartorius, M.D., Ph.D.


Professor of Psychiatry, University of Geneva, Switzerland and former Director of the Division of Mental Health of
the World Health Organisation

xii

Preface
The concept for this book was rst mooted by the editor in the early 1990s. Various academic psychiatrists,
nurses, psychologists, rehabilitation specialists and psychiatric social workers embraced the idea, and started
writing enthusiastically, only to be confronted by insurmountable logistical, technical and geo-political barriers.
In many ways the manuscript was completed but remained on the shelf, only to be overtaken by events, such as
new concepts and practices and curriculums, thus requiring a fresh start.
The Department of Psychiatry, University of Nairobi, Kenya, in consultation with the WHO Mental Health
Division Geneva, embarked on the process of revising its undergraduate curriculum in the mid 1990s. This
revised curriculum put emphasis on the holistic concept of mental health, and therefore increased recognition
of the critical place of behavioural sciences. The approach recognised that mental health was bigger than clinical
psychiatry and that clinical psychiatry could not be complete unless practised in the bigger context of mental
health. Other medical schools in the region were moving in the same direction a multi-disciplinary approach.
The need for teaching materials thus increasingly became a priority.
No doubt one of the greatest curse of medical and related human resource in developing countries is brain
drain (Ndetei et al 2004, International Psychiatry 6: 15-18). The meagre resources in these countries are used
to train for the rich western countries. Further, even if we were not loaded with this burden, the gap between
demand for Appropriate, Aordable, Available and Accessible (the 4As) mental health and psychiatric services
continues to widen in developing countries due to social, economic, political and stigma reasons. Even within
a given country, the gap highly varies between urban and rural areas, so that number of personnel per countrys
population can be totally misleading. Many countries in Africa have less than one psychiatrist for every 2
million people.
There is, therefore, need to allocate more resources, energy and eort to the training of non-specialist personnel
who will be deployed at the levels where services are most needed. In this regard, eorts and resources should
focus on equipping medical students with adequate skills in mental health and psychiatry that will enable them
to function eectively at primary health care level. The students are equipped with similar skills to function this
way in relation to physical medical problems. Thus, there is no reason why they cannot be similarly equipped in
managing mental health and psychiatric problems.
Even where fully trained psychiatrists are available they cannot work in isolation and will need the inputs of
psychologists, psychiatric social workers, psychiatric nurses, occupational therapists and even the clergy, who
should have a working knowledge on mental health issues and management. They all complement each other
on strengths and limitations, to minimise the latter and enhance the former. To the extent possible, they should
share some common scripts and the more of this the better for the consumers of the services i.e. people with
mental health problems, their families and other support systems. It is hoped that this book will provide the
forum that addresses all the above challenges and required linkages.
The target groups for this book include medical students, psychology students, nurses, clinical ocers,
occupational psychiatric therapists, clergy, and any other related professionals. The book will also be useful for
the general practitioner and other health care professionals who interact with patients. Although the primary
focus is undergraduates, graduate and post-graduate students, other professionals will nd sections relevant to
their needs. Students or other specialists will nd sections of this book very handy, especially the chapters that
cover an integrative approach in medicine.
The title of this book captures a series of statements: the Pan-African collective eort in authorship and editorship
by active and current academicians on the Continent; a philosophy on the approach, minimum standards on
teaching, practice and delivery of psychiatry and mental health; and the interdependence of all the stakeholders
in the African context. It is also a statement that while Africa recognizes specialists, their role has limitations
that make them relatively unavailable at the level of service delivery. But, also, there are viable alternatives. It is a
statement that psychiatry and mental health has a place and a future in Africa. This book is part of that future.
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The African Textbook of Clinical Psychiatry and Mental Health

This book is not about psychiatry that is uniquely African only found in Africa. But it is about psychiatry
and mental health in Africa. I would like to agree with Africas pioneering psychiatrist, the late Prof. Lambo
that all people are mentally the same. What dierentiates them is culture. Paraphrased, there are no unique
African psychiatric disorders, but socio-cultural and economic factors may inuence the way the same disorders
present, help is sought, and services are availed. It is also a contribution to the practice of psychiatry in a wider
global perspective, for Africa is part and parcel of the global community and what happens here can no longer
be viewed as of peripheral signicance.
The writing of this book was a collective eort of various scholars. This eort has been facilitated by several
factors, some of them almost incidental. Over the years medical schools invited me either as an external
examiner, visiting professor or as a speaker, or I called on them if I happened to be in town for other reasons.
This exposure helped me to see both individual strengths and weaknesses, of all Departments I visited out of
which I focused only on the collective strengths. Then the sta were quick to agree with me on the principle of
collective strength and to suggest other areas I had not quite seen. Together we had a collective vision and dream
on how to realise them. In this book, we are pooling together our strengths in expertise and then re-distributing
them equitably.
One of my most inuential mentors, Professor Norman Sartorius was at his best, once again, mentoring me
through this process. Students, patients, their relatives, and their support systems have also been a source of
very unique mentoring. I have been most impressed by the way the students whether medical, psychology or
other related disciplines, have greatly appreciated and embraced the concepts of this book even before they were
put together in this form. The patients, their families and support systems have, by far, been my best practicaloriented, non-theoretical teachers. They taught me, not by word of mouth, (although some did), but through
experience on what they needed, what worked, what produced desired changes and not just what I thought.
That patients with mental illnesses are indispensable partners in their health care team. This is best illustrated
by a patient who wrote a section in this book (From the other side of the doctors desk). It is also graphically
illustrated by the story of Suzanne Johnston (British Medical Journal 2006, Vol. 332 pp.30-32) who even
allowed use of her photograph. These two stories, told from dierent contexts are strikingly similar in content.
In this book I want to make a statement that I totally agree with what they taught me and which my colleagues
and I give back to them. This we do through our students in psychiatry and mental health.
The two most important and basic considerations on the nal product and design of this edition were reasonable
adequacy of the contents and the minimum possible and reasonable cost to the student so that the book met all
the 4As described above. The contents were made possible by the contributors and the cost by grants from Africa
Mental Health Foundation, a grant to the publisher (AMREF), the ex-gratia permission from the American
Psychiatric Association to reproduce from DSM-IV-TR, the time and expertise donated by all contributors and
a modest design of the book.
I appreciate all the invaluable support, mentoring and teaching by all concerned persons and the contributors.
I attribute all that is good in and about this book to them.
However I take full responsibility for any shortcomings. With so many contributors, all from dierent backgrounds
and writing styles, it was not a realistic task to eliminate all repetitions and to completely synchronize the styles,
or even notice all important omissions. I desperately need to have all these pointed out to me, by both students,
teachers and where possible patients, their families and any support systems. These should be sent to me through
my email or physical address. Any suggestions on improvements are also most welcome. All of these will be taken
into account as we prepare for the next edition, in the not too distant future. The reader is politely reminded
that this edition is just but a beginning, with all the attendant teething problems of any new venture.

Prof. David M. Ndetei


P.O. Box 48423 00100, Nairobi, Kenya
E-mail: dmndetei@uonbi.ac.ke or dmndetei@mentalhealthafrica.com
Website: http://www.africamentalhealthfoundation.org

xiv

Acknowledgements
Very many people were involved in and facilitated the process of the production of this publication. The
University of Nairobi, Department of Psychiatrys undergraduate curriculum formed the seed for the contents
of this book, upon which many individuals provided useful additions and critique. Prof. Norman Sartorius gave
useful guides, the Editor of the South African Psychiatry Review, Prof. Christopher P. Szabo provided space for
a write-up on the concept of the book and the African Mental Health Foundation, through a grant, supported
all the logistics and compilation of the initial material.
I would also like to acknowledge the African Medical and Research Foundation (AMREF) who supported
the nal review process, by bringing together a small group of psychiatrists, psychologists and sociologists
who compiled a second draft of the manuscript. They met in Nairobi from 16th to 19th January 2006. The
group comprised the following: Prof. Ruthie Rono, Prof. Duncan Ngare, Dr. Anne Obondo, Dr. John Mburu,
Dr. Francisca Ongecha-Owuor, Dr. Benson Gakinya, Prof. Christopher Szabo, Prof. Gad Kilonzo, Dr. Musisi
Seggane and Prof. Mohamedi Boy Sebit.
Many other people provided inputs on the contents of the publication. These include amongst others, Prof.
Ahmed Okasha, past President of World Psychiatric Association, Prof. Mario Maj, President elect World
Psychiatric Association, Prof. Rachel Jenkins, Prof. Tuviah Zabow, Prof. Oye Gureje and Nhlanhla Mkhize.
I am also grateful to the American Psychiatric Association for granting us the permission to reprint materials
from DSM-IV TR.
I am especially grateful to the following postgraduate students from the Department of Psychiatry, University
of Nairobi, for very useful inputs:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Dr. Lukoye Atwoli, MBchB, Registrar in Psychiatry


Dr Joseph Thuo N. MBchB, Registrar in Psychiatry
Gideon Odhiambo B.A (Social work), Student in MSc in Clinical Psychology
Mr. Chrispinus Marumbu (BSc. Nursing), Student in MSc in Clinical Psychology
Elizabeth Mbatha B.A (Sociology) Student in MSc. in Clinical Psychology
Dr. Ian Kanyanya M. MBchB, Registrar in Psychiatry
Dr. Irungu Muthukia, MBchB, Registrar in Psychiatry
Dr. Mburu Mbugua J. MBchB, Registrar in Psychiatry
Dr. Moses R. Mwenda MBchB, Registrar in Psychiatry
Dr. W.D.C. Kinyanjui MBchB, Registrar in Psychiatry
Dr. Lillian Bunyasia-Asuga MBchB, Registrar in Psychiatry.

I am also grateful to the following from Africa Mental Health Foundation (AMHF): Norah Mutheu, Dinah
Nduleve, Christine Wayua, Solomon Stallone Akanga, and Ruth Wangu Walioli.
Serah Wadom Mwanyiky helped in editing the initial draft.
Finally, I would like to acknowledge the contribution of Grace Ndunge Mutevu, my personal assistant who coordinated most of the activities during compilation of the book.
My family was most supportive during the long hours taken up by this book.

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The African Textbook of Clinical Psychiatry and Mental Health

xvi

Section I:

Psychiatry and Mental


Health in Context

The African Textbook of Clinical Psychiatry and Mental Health

1
Introduction to Mental Health and
Clinical Psychiatry
David M. Ndetei, Ruthie Rono, Fred Kigozi

The dictionary denes mental as of the mind.


The mind is in turn dened as the seat of
consciousness, thought and feeling. Mental health
therefore would mean a state of well being of the
mind.

MENTAL HEALTH

According to the World Health Organisation


(WHO) mental health is dened as an essential and
integral part of health as a whole. Just as health
is not merely the absence of disease, so mental
health is not simply the absence of mental disorder
or illness, but also includes a positive state of
mental wellbeing. To many of us, mental health
is intricately associated with behaviour, discipline
and psychosocial wellbeing. Several factors affect
mental states of health. These factors include the
individual, family, friends and the community at
large.
Mental health is a priority area globally.
According to WHO:
450 million people worldwide are affected
by mental, neurological or behavioural
problems.
There are about 873,000 suicide cases every
year.
Mental illnesses cause immense suffering.
People with these disorders are often subjected

to social isolation, poor quality of life and


increased mortality. These disorders are the
cause of staggering economic and social
costs.
At least one in every four patients visiting a
health service has a mental, neurological or
behavioural disorder, but most of these are
neither diagnosed nor treated.
Mental illnesses affect and are affected by
chronic conditions such as cancer, heart
and cardiovascular diseases, diabetes and HIV/
AIDS. Untreated, they result in unhealthy
behaviour, non-compliance with prescribed
medical regimens and diminished immune
functioning. Cost-effective treatments exist
for most disorders and, if correctly applied,
could enable most of those affected to become
functioning members of society.
Barriers to effective treatment of mental illness
include lack of recognition of the seriousness
of mental illness and lack of understanding
about the benets of the services. Policy
makers, insurance companies, health and
labour policies, and the public discriminate
between physical and mental problems.
Most middle and low income countries devote
less than 1% of their health expenditure to
mental health. Consequently, mental health
policies, legislation, community care and
health facilities are not given the priority they

The African Textbook of Clinical Psychiatry and Mental Health

language, thoughts and emotions. Psychology


also seeks to understand how these processes
work. Branches of psychology include human
development,
social
psychology,
clinical
psychology, industrial psychology and counselling
psychology. Clinical psychology is closely related
to psychiatry in that clinical psychologists are
involved in the assessment of a wide range of
psychiatric problems, for example, phobias and
obsessive-compulsive disorders. They are also
involved in treatments, for example, cognitive
behavioural therapy and group therapy.

deserve. (Source: http//www.who.int/mentalhealth/en/ retrieved 16/1/06)

PSYCHIATRY
Psychiatry is an art as well as a medical science
concerned with mental processes of the individual,
the interaction between the doctor, the patients
and their relatives and workmates, in the process
of identifying the problem and carrying out
appropriate action. Psychiatrys generalised
approach stresses the unity of the body and mind.
The skill is acquired through observational data
and consequent development of principles based
on such data, thus making psychiatry the practice
of medicine and a scientic discipline.

Relationship with anthropology


Anthropology is derived from the Greek language
meaning the study of man. Anthropology aims
at holistic study of mankind including its origin,
development, social and political organisations,
religion, languages, art and artifacts. Branches
of anthropology include medical anthropology,
physical
anthropology
and
socio-cultural
anthropology. Physical anthropology is the study
of evolution of the human species and explanation
of the causes for the present diversity of human
populations. It includes studies of the arts,
musical instruments, weapons, clothes, tools and
agricultural implements of different populations
and all other aspects of technology which human
beings use to control shape, exploit and enhance
their social and natural environments.
Medical anthropology is a branch of anthropology
concerned with a wide range of biological
phenomena especially in connection with health
and diseases. Socio-cultural anthropology deals
with comparative study of present day human
societies and their cultural systems.

RELATIONSHIP BETWEEN
PSYCHIATRY AND
BEHAVIOURAL SCIENCES
There is a close relationship between psychiatry
and the social sciences professions in the provision
of holistic mental health services. Below is a
description of the relationship between psychiatry
and each of the disciplines involved in mental
health service provision.

Relationship with sociology


Sociology is the discipline which studies and
analyses human behaviour, the patterns of
interactions and relations in a social context.
Branches of sociology include rural sociology,
medical sociology, political sociology, sociology
of education, sociology of religion, sociology of
philosophy, law and society. All these branches
are important because they make important
contributions in sociological inquiry thereby
helping in the solution of sociological problems.
However, the focus here is on medical sociology
which is directly linked to psychiatry.
Medical sociology focuses on social interaction
between the patient and the doctor, and between
groups of people in hospitals or medical school
and among laymen in the community. It examines
the relationship between culture, personality traits,
values and norms.

ABOUT THE BOOK


This publication is multi-disciplinary in approach
and is written by a team of experts who are actively
involved in the teaching of behavioural sciences
and medicine.
Over the years it has become increasingly
evident that psychiatric illnesses form a major
part of the day-to-day problems. Many patients
are presenting with conditions which directly or
indirectly arise from stressful conditions. With
increasing demands on life, a highly competitive
lifestyle and a desire to succeed many people need
psychological help and counselling. It is therefore

Relationship with psychology


Psychology is the study of basic psychological
processes such as perception, learning, memory,
4

Introduction to Mental Health and Clinical Psychiatry in Africa

Section IV deals with the major aspects of clinical


psychiatry in adults. These include the various
causes of mental illness, signs and symptoms of
mental illness and how one should document and
classify mental disorders. The other chapters deal
with various types of disorders and behaviours,
such as suicide and suicidal behaviour.
Section V deals with child and adolescent
psychiatry.
Section VI covers the various treatments. The rst
part deals with biological and physical treatments,
while the second part describes the non-biological
or non-physical treatments. The third part covers
complementary and alternative medicine and the
nal section examines the area of nursing.
Section VII is on research and ethics. Mental
health has a great future in Africa, but this can only
be realised through evidence-based policies. Indeed
this applies to all medical problems in Africa. The
solutions must not only be evidenced-based but
must be economical and realistic. It is therefore
considered important that the future medical
professionals in Africa be exposed to principles of
research as early as possible.
Experience is the best teacher. Section VIII
contains a post-script from one of the longest
serving psychiatrists in Africa, Professor Allan
Haworth (University of Zambia). He has experience
spanning over 4 decades and was still active at
the time of writing this publication. It combines
his experiences from pre-independence to postindependence Zambia.
Although the primary targets for this book are
medical and paramedical students in mental health
and psychiatry, it will have an appeal to other
professionals and specialists.

imperative that health workers are equipped with


adequate knowledge and skills to be able to obtain
a psychiatric diagnosis. Therefore, mental health
needs to be emphasised as a key component in
the curriculum in order to improve the quality of
medical training in Africa.
This book has been divided into eight sections:
Section I takes a brief look at the development
of psychiatry and mental health. It also looks at the
various disciplines that constitute the mental health
discipline. The theme advanced is that mental
health is bigger than clinical psychiatry and clinical
psychiatry practised on its own is incomplete. The
economic burden of mental health and stigma in
the African context has also been discussed. This
section on stigma was reproduced with permission
from the World Psychiatry Association.
Section II is divided into three parts. The rst
one deals with clinical psychology. This section
also covers stress and its management. With the
increase of disasters, both man-made and natural,
crisis management has become a primary need at
primary health care level. The second part looks
at how social factors and structures, especially the
family, are critical to mental health and the practice
of clinical psychiatry. This chapter also explores the
relationship between health and illness behaviour.
The nal section is on medical anthropology and
looks at the relationship between culture and
health, illness, mental health and the increasingly
important area of spirituality.
Section III deals with behavioural neurosciences
that are relevant to mental disorders. It covers
anatomy, endocrinology and neurochemistry.
It also discusses the neurological investigation
relevant to psychiatry and the genetics of mental
disorders.

The African Textbook of Clinical Psychiatry and Mental Health

2
History of Psychiatry
David M. Ndetei, John Mburu

was classied into four temperaments sanguine, c


holeric, melancholic and phlegmatic.
Others prominent scholars such as Plato and
Aristotle contributed a lot in understanding mental
illness during their times. Plato (428-348 BC)
described the concepts of health, as harmony
between body and mind and disharmony between
the two was the cause of mental disorders. Plato
also alienated four types of mental illnesses,
prophetic, telestic or ritual, poetic, and erotic.

During the pre-literate cultures and Biblical times,


early medicine was intertwined with religion;
priests served as physicians and therefore illnesses
were perceived as mental and reecting a spiritual
disturbance. The mentally ill were regarded as
possessing supernatural powers and thought of as
sacred and in some situations, were treated with
respect.

THE CONTRIBUTION
OF HIPPOCRATES AND
CONTEMPORARIES

MIDDLE AGES
The early religions and middle ages were
characterised by the fall of the Roman Empire,
epidemics and decline of scientic thinking. The
study of the mentally ill reverted to religion and
superstition (demonology). Mental illnesses were
regarded as punishment for sin, hence torture was
prescribed to exorcise demons. In 1487 AD two
Dominican monks published a book, Malleus
Malecarum (The Witches Hammer), outlining
various methods of torture for witches and mental
patients. Abnormal thought processes like hearing
voices, and odd beliefs were attributed to the
devil.
It was the era of emergence of humanism in
which the burning of witches and mental patients
continued alongside a return to creative scientic

The Hippocratic School of Medicine approached


the study of medicine in a holistic way where
social, spiritual, physical and psychological factors
were held responsible for the cause of mental
disorders. The school proposed that the capacity
to feel, dream and think was located in the brain.
Medical concepts of mental disorders were well
documented by Hippocrates (460-370 BC) in
the 4th century where interaction of four body
humours namely; blood, black and yellow bile, and
phlegm were considered the aetiology of mental
disorders. According to the Hippocratic hypothesis
these humours were due to the combination of
four basic qualities of nature; namely heat, cold,
moisture and dryness. During this era personality

History of Psychiatry

psychiatric literature. His earlier attempt in the


analysis of symptoms resulted in categories such
as melancholia, mania, dementia and idiocy.
Melancholia was a disturbance of intelligence,
mania was excessive nervous excitement without
delirium, and dementia was disturbances in the
thought process, while idiocy was obliteration of
intellectual faculties and affects. He taught through
his writing and character, thus the birth of academic
psychiatry.
Jean Etienne Dominique Esquirol, Pinels most
distinguished pupil, was appointed to Salpetriere
in 1812. He instituted lectures in psychiatry and
attracted students from beyond France. He also
set up ten psychiatric hospitals and wrote a lot on
psychopathology.
Vincenzo Chiarugi worked at the Hospital
Bondicis in Italy and advocated, It is a supreme
moral duty and medical obligation to respect the
insane individual as a person. No physical force
or restraints were applied save for strait jackets for
violent patients.
William Tuke and Lindley Murray opened the
York Retreat in England in 1796, where patients were
treated as guests with kindness and understanding.
They encouraged a friendly atmosphere, free from
mechanical and medical restraints or manual work.
Four years earlier Dr. Andrew Duncan in 1792, then
Professor of Medicine at Edinburgh University
and President of the Royal College of Physicians,
Edinburgh, had sponsored an appeal, leading to
the establishment of the Royal Edinburgh Mental
Hospital in 1813.
The reforms which were pioneered in England
by Tuke were followed by the introduction of a bill
in Parliament for the better treatment of the insane
known as the Wynns Act of 1808, for providing
better care and maintenance of lunatics being
paupers or criminals of England.
Thomas Laycock, a professor of Medicine at
Edinburgh University and Lecturer in Medical
Psychology and Mental Diseases published a
book entitled, Mind and Brain in 1860. As an
example of his imaginative foresight he stressed
the reciprocal action of body and mind and stated
that a practical knowledge of mental science
is essential to parents, jurists and legislators,
governors of jails, schoolmasters, and teachers,
ministers of the gospel, naval and military ofcers
and employers of labour. In his view, psychiatry
was not a narrow specialty but a discipline for
general application in studying the conduct of
Man.

thinking. In 1405 AD, the rst mental hospital


was opened at Valencia in Spain. Patients lived in
deplorable conditions and inhumane treatments like
blood-letting, inducing vomiting and purgatives
continued but on a smaller scale.
The rights of mentally ill persons received
recognition when the father of legal medicine Paolo
Zacchia (1584-1659) wrote, Only a physician
was condent to judge the mental condition of a
person. Thomas Sydenham (1624-1689) initiated
the clinical approach in modern medicine by
describing in detail symptoms of mild mental
illness.

MODERN (MORAL) ERA OF


THE TREATMENT OF MENTAL
ILLNESS
This era dates from the end of the 18th century and
may be divided into four periods:
The period of humane reform,
The introduction of no-restraint,
The hospital period,
The social and community period.
The Moral Treatment Era was characterised by
restoration of dignity of mental patients through
abolition of restraints and establishment of large
mental hospitals with better clinical care. There
was increased realisation that mental illnesses were
not restricted to any particular group in society.
Pioneers of moral treatment included Phillipe
Pinel from France (1745-1826), Vincenzo Chiarugi
from Italy (1759-1820) and William Tuke from
Britain (1732-1822). Advocacy groups pressurised
governments to improve mental health services.

Humane reform
One of the most outstanding players in the period
of humane reform was Dr. Phillipe Pinel who
worked at the Bicetre Hospital, in Paris which
accommodated about 200 male patients. In 1794,
instead of blows and chains, he introduced light and
fresh air, cleanliness, workshops and promenades,
but above all kindness and understanding. The
results were outstanding. His prescriptions were
later transferred to the female mental hospital,
Salpetriere.
Pinel was not only an excellent hospital
administrator and physician, but also set very high
standards of medical care and practice. He insisted
on good case taking and made contributions to

The African Textbook of Clinical Psychiatry and Mental Health

to all specialties, and also has the advantage of


removing stigma so traditionally associated with
mental illness. Several landmarks examples can be
cited:
1. Jean Martin Charcot (1825-1893) claried the
role of psychological factors in the production
of physical symptoms by studying hysteria.
2. Sigmund Freud (1856-1939), amongst
other things, highlighted stages of normal
psychological development and their relevance
to personality disturbances and mental illness.
3. Emil Kraeplin (1856-1926) classied mental
illness and hypothesized they could be due to
coarse brain disease.
Examples of landmarks in development of
treatments:
1. Community-based approaches to mental health
were introduced in the early 20th century.
Mental hygiene, child guidance clinics and
mental hospitals were brought closer to the
people.
2. Manfred Sakel introduced insulin-coma therapy
for schizophrenia in 1933.
3. In 1917 Julius von Wagner Jauregg introduced
malaria therapy for syphillis.
4. Psycho-surgery (removing parts of the brain
thought to cause mental disorder) was practised
in 1936 by Egas Moniz.
5. In 1938 Ugo Cerletti and Lucio Bini discovered
electroshock therapy (passage of small currents
through brain to induce a convulsion).
6. Effective chemotherapy was introduced in the
early 1950s and had a great impact in reducing
mental hospital population In 1952 Delay
and Deniker who pioneered the synthesis of
chlorpromazine (Largactil) introduced it for
treating psychosis.
7. Roland Kuhn discovered an antidepressant drug
called Imipramine in 1957.

The Hospital Period: Seclusion vs Isolation


The modernisation of psychiatric hospitals has
resulted in numerous benecial changes in the
following areas: administration, infrastructure,
medical and nursing staff, psychiatric social
workers, occupational therapists, psychologists,
chiropodists and hairdressers.
The transition to modern hospital care of mental
patients was bridged by a short-lived concept.
This involved seclusion, but not isolation, for
dangerous, impulsive patients who could not be
trusted. It comprised single and padded rooms
which were locked, and in which the patients were
conned. This arrangement had several advantages:
it prevented struggling with the patient, it prevented
serious accidents, there was much less necessity to
use powerful sedatives and it eased the burden and
responsibility of the medical and nursing staff.
As the medical and nursing staff increased, it
became evident that the vast majority of the socalled single room cases responded more positively
when cared for and nursed in open wards where
they could be adequately supervised.

The Hospital and the Community


The mental hospital today has established outside
contacts and interests which previously did not
exist. In addition to in-patients, administrative
and clinical duties, they also involve themselves
in activities such as: out-patient clinics, child
guidance clinics, domiciliary consultations, and
medical-legal work. Instead of closed high wall
hospitals there has been a move towards open-door
systems where the wards are unlocked, patients are
given the freedom of the grounds and adjoining city
or country side and day and night hospital visits.
There are determined efforts to treat patients in
their homes through home visits, family practice
units, clinical psychologists, psychiatric social
workers and health visitors. The aim is to reduce
mental hospital admission rates and to maintain
patients at work so long as it is compatible with
their well-being.

HISTORICAL DEVELOPMENT
OF PSYCHIATRY IN AFRICA

THE EVOLUTION OF LIAISON


PSYCHIATRY

The history of psychiatry in Africa seems to have


followed the same pattern found in the western
culture, that is, primitive non-scientic, humanistic,
and lastly scientic stages. As Asuni observed,
in Nigeria the changes have taken place over a
relatively shorter period of time and therefore
overlap is more evident.

Liaison psychiatry has also evolved. It involves


the establishment of closer liaison with general
practitioners, medical, surgical and other
specialists. This relationship is of mutual benet

History of Psychiatry

to England to treat an eminent Nigerian who had


become psychotic there
Although the presumed psychopathology bears
many similarities found in western culture at
various stages of psychiatry, it is noteworthy that
extreme physical therapeutic approaches such
as ogging, binding and starving were hardly
practised in Africa. Tradition demanded that the
mentally ill be looked after like any other sick
person. They were taken to traditional healers for
diagnosis and treatment. This practice was also
found in Nigeria (Asuni (1972)). Lambo (1966),
a pioneer psychiatrist in Africa trained in modern
western psychiatry, used the same model in the
design of the Afro Psychiatric Hospital in Nigeria
where the sick person and his family would be
admitted together for sometime. In Tanzania,
Rappaport & Dent (1979) observed the extended
family group approach to psychotherapeutic
treatment and remarked, nothing we had seen
in a western clinic could compete with the deep
power of this ritual. The development period of
the rst and second stages of psychiatry cannot be
historically pinpointed, and unfortunately, recorded
Kenyan history makes little reference to medicine
and still less to mental illness.

The primitive/non-scientic and


humanistic stages
These seem to have developed concurrently. In the
primitive non-scientic stage, psychiatric illnesses
were attributed to supernatural powers and the
spirits of dead ancestors who were punishing the
sick person or the relatives of the sick (Prince
(1960), Asuni (1972)). The illnesses were also
attributed to sorcery and witchcraft invoked by
neighbours, relatives and distant clans as revenge,
punishment or simply because of jealousy. It is
important to note also that psychiatric illness
due to physical conditions was well appreciated.
Malaria (cerebral malaria), cannabis intoxication,
trypanosomiasis and head trauma were recognised
as causes of madness.
There are no documented detailed descriptions
of mental illness in most African societies
equivalent to the classical work by Prince (1964)
on the Yoruba of Nigeria, in which he described
local terminologies and theories of causation for
what was clearly schizophrenic illnesses, mania,
depression, hysteria, anxiety, delirium tremens,
epilepsy and psychosis associated with epilepsy
and organic brain syndromes. This was impressive
phenomenology considering that it was not stored
in written form, but was passed on verbally through
successive generations of traditional healers. What
can be adduced is that such psychiatric diagnostic
equivalents were well known in most societies
although they were not documented. The closest
Carothers (1953), then working in Kenya, came to
forming such an impression was when he observed
the African has greater difculty recognising
the strangeness of psychotics than the European
layman, implying that some of the psychotic
phenomena were acceptable within the societies
Some of the treatments were similar to those
found in western culture at the equivalent stages
and took such forms as offerings to appease the
ancestral spirits, rituals in atonements for wrongs
done, craniotomy to release the evil spirits (among
the Turkana in Kenya), and herbs to treat the primary
physical causes of the madness (e.g. malaria) or the
psychiatric illness. The success rate, according to
folklore was satisfactory in the majority of cases.
The chemical nature of these herbs was not studied
by scientic means but an idea of their nature may
be obtained from Princes studies (Prince (1960,
1964)) who in 1960 wrote, it is interesting that in
1925, long before tranquilisers or shock therapies
were known to European psychiatry, Chief
Adetona, with his Rauwola medicine, travelled

The scientic stages


Western psychiatric services in most African
countries have evolved at different paces and
very few countries have satisfactory and adequate
services. The gradual transference of psychiatric
management from the African traditional style
to that of western culture was in one sense a
regrettable step in that the care of the mentally ill
was taken from the relatives, which, was a move
away from a benecial therapeutic climate to a
sterile custodial one. New psychiatric units were
introduced in hospitals. This was a time when
the western inuence was inltrating into Africa
and there was outright condemnation of the local
cultural methods and beliefs.
Nevertheless it marked the start of the scientic
approach, for although we know little of the
early developments, it was one of the bases from
which Carothers, Asuni and Prince wrote so
much on psychiatry in Africa. Carothers (1947,
1953)) provided some of the early detailed
records of psychiatry in Kenya. He described a
whole spectrum of psychiatric diagnoses. Though
his methodological designs are suspect (he
used non-medical civil administrators to collect
epidemiological psychiatric data) he quotes a

The African Textbook of Clinical Psychiatry and Mental Health

psychiatric morbidity prevalence of 0.1 per 1,000


in the population and compares it with 4 per 1,000
found in England and Wales in1938, thus implying
that psychiatric morbidity in England and Wales was
at least 40 times more than in Kenya. Interestingly,
Gower (1938), working in West Africa, held the
opposite but extreme view for he wrote and was
quoted by Carothers (1953) if we are sane
all primitive Negroes are raving mad. Ndetei
& Muhangi (1979) from Kenya have since then
corrected the impression created by Carothers.
Lambo (1954) has succinctly criticised some of
Carothers prejudicial, impressionistic writings.

Further reading
1. Asuni, T. (1972): Psychiatry in Nigeria over the years.
Nigeria medical journal 2, 54-58.
2. Carothers, J.C. (1953): The African mind in health and
disease. A study of ethnopsychiatry. WHO Monogr.
Ser. Geneva.
3. Lambo, T.A. (1966): The village of Aro. In King, A.
(ed.): Medical care in developing countries. Oxford
University Press, Nairobi, Chapter 20.
4. Ndetei D.M. (1980): Psychiatry in Kenya yesterday,
today and tomorrow an overview. Act Psychatrica
Scandinavia 62: 201-211.
5. Ndetei D.M. (2001): The walk toward the promise: A
view of mental health in global, Kenyan and individual
perspectives. Inaugural lecture, University of Nairobi,
13th September 2001. University of Nairobi Press.
6. Prince R. (1960): The use of Rauwola for the
treatment of psychoses by Nigerian traditional doctors,
American Journal of Psychiatry, 117, 147-149.
7. Prince R. (1964): Indigenous Yoruba psychiatry.
In Kiev, A. (ed.): Magic, faith and healing. Studies
in primitive psychiatry. Collier-MacMillan Ltd.,
London, pp. 84-120.
8. Rappaport, H. and P.L. Dent (1979): An analysis
of contemporary East African folk psychotherapy.
British Journal of Medical Psychology, 52,49-54.

The present and the future


Mental health issues are as urgent in Africa as
they are in the West. However, Africa remains
considerably constrained by lack of resources, and
in particular human resources, most of whom are
lost to the West. There is need to come up with the
most cost-effective ways to address mental health
issues in Africa, ranging from research to human
resource development.
Mental health will continue to be a challenge
in Africa. How we meet that challenge tomorrow
depends on what we do today. This book is part of
that tomorrow.

10

3
Psychiatric and Mental Health Training
David M. Ndetei, Godfrey Lule, Ahmed Mohit, John Mburu, Lukoye Atwoli, Monique Mucheru

a holistic approach to management of disease,


incorporating the biological, psychological and
social factors. They provide the foundation for
understanding and practice of psychology and
psychiatry just like the basic sciences are to the
practice of internal medicine.
Behavioural sciences prepare the students to
understand their own personalities and also to
manage patients with different personality needs.
It also helps in the students own development as
a person; appreciating oneself and achieving the
status of self-actualisation.
Behavioural sciences impart skills that enhance
doctor-patient relationship. It expounds on
the phenomena of transference and countertransference, which facilitate in diagnosis and the
creation of a therapeutic alliance during treatment of
complex psychosocial disorders. Being conversant
with behavioural sciences improves work relations
that include how best to relate with colleagues at the
workplace. Medical and paramedical practitioners
work for long hours and sometimes under pressure,
hence are prone to developing burn-out syndrome.
Behavioural science provides skills that they can
utilise for stress management.
Most diseases, for example, hypertension,
bronchial asthma and peptic ulcers have been
proven to have a psychological origin and are
referred to as psychosomatic disorders. These
are best understood and managed by studying
behavioural sciences. There are some disease
states, especially chronic or terminal illnesses
which present with both physical and psychological

Psychiatric and mental health training in most parts


of Africa is a relatively new and developing eld.
Over the years, it has become increasingly evident
that mental illnesses form a major part of the dayto-day problems that present to a non-specialist
medical or clinical ofcer. Many patients present
with conditions, which directly or indirectly arise
from stressful situations. With increasing demands
on life, a highly competitive lifestyle and a desire
to succeed, many people need psychological help
and counselling as opposed to drug prescriptions.
The number of trained mental health
professionals in many African countries is far
below the demand. The few that are available
mainly deal with psychotic illnesses. This leaves
out, by far, the largest number of people needing
mental health care. It is not unusual not to have a
single psychiatrist in some countries. It is therefore
necessary that the non-specialist clinician be
equipped with adequate skills to be able to obtain a
psychiatric diagnosis or a mental health formulation
and manage such cases and also recognise at what
stage to refer. The common and universal practice
of referring any confused patient to the nearest
psychiatric institution without making any effort to
make a diagnosis should be abandoned.
Medical science usually focuses on the causes,
pathogenesis, diagnosis, management and control
of diseases affecting humanity. Behavioural
sciences focus on the psychological and social
determinants of health. It is that aspect of social
science that incorporates sociology, psychology
and anthropology. Behavioural sciences encourage

11

The African Textbook of Clinical Psychiatry and Mental Health

are interrelated and intertwined. He described a


relationship between biological, psychological and
social factors in relation to disease, in causation,
vulnerability,
precipitation,
manifestation,
management, prognosis and outcome, and more
importantly in the sustenance of health.

symptoms. It is important therefore for the medical


practitioner to not only treat the physical, but also
to provide counselling and other therapies to take
care of the patients psychological needs. Thus the
training of medical students should put emphasis
on this approach that has been popularly referred
to as the biopsychosocial model.

Biological system
This comprises the anatomic, structural,
biochemical and genetic determinants of disease
and their impact on the patients biological,
psychological and social functions.

THE BIOPSYCHOSOCIAL
MODEL
George Engel described the biopsychosocial model
of disease and divided it into 3 major parts, which
Figure 3.1: Towards an Integrated Bio-Psycho-Social (BPS) Model

BP

BPS
PS

BS

BP

BPS
PS

BS
S
Illustration by Prof. D. M. Ndetei

12

Psychiatric and Mental Health Training

serves the same purpose as with other interventions


including a psychotropic.
The biopsychosocial model highlights the
need for doctors and all medical and paramedical
professions, whatever their specialisation, to be
thoroughly familiar with patients and clients
psychology and social or cultural milieu, emotional
response and their interaction with health care
providers, rather than just making a diagnosis and
prescribing medicine.
The future of the practice of medicine will be
in the integration and not compartmentalisation of
biological, psychological, social and even spiritual
factors. Inclusion of behavioural sciences in the
medical training curriculum is the only way to
achieve this goal.
This holistic approach should be employed,
regardless of the primary nature of the ill-health.
Each system may affect and be affected by any of
the other systemsa fact that health professionals
should take into account.

Psychological system
The past, present, and anticipated factors together
with motivation and personalities have a bearing
on disease, both in its impact on the individual
and his reaction to it. Attitudes to safe or unsafe
environments, use of prescribed medicines,
substances such as alcohol, nicotine, sexual
behaviour and dietary habits may affect and
in turn be affected by physical conditions and
socio-cultural factors. Indeed, quite often most
psychological disorders have very clearly
demonstrated biochemical basis not much different
from diabetes (lack of insulin), for example.
Thus psychiatric disorders have physical and
psychological components.

Social system
The emphasis here is on cultural, environmental and
familial and societal inuence on the expression and
experience of illness. It should be noted that each
of these systems may affect or be affected by the
other systems. The role of religion, faith and belief
systems in health is important. People are attached
to their beliefs through the heart and mind. The
mind is the seat of emotions, with all the possible
consequences physical and psychological. If
religion gives mental relief in adversity, then it

Further Reading
1. Desjarlais, R., Eisenberg, L., Good, B., and Kleinman,
A. World mental health, problems and priorities in
low-income countries, (1995). Oxford University
Press, New York.

13

The African Textbook of Clinical Psychiatry and Mental Health

4
The Burden of Mental Illness
From the other side of the doctors desk: A true life story of a patient1

Healing from illness is a journey of discovery. So


is accurate diagnosis and treatment. The response
observed from the rst step of diagnosis, or the
treatment undertaken by the physician, opens
up new ways of understanding the cause of the
illness, as well as the most appropriate responses.
Should the response be encouraging, treatment
along existing lines with appropriate adjustments
becomes the most advisable option. Should the
initial action prove inadequate, then it becomes
imperative to abandon the initial path and return to
the diagnostic drawing board. Either way, the results
of action taken determine the course of action in
the next phase. To the extent that this is true, no
completely denitive response to an illnessor for
that matter any human problemcan be divined
from the word go.
This is the case, no matter what textbooks tell
you about absolute certainties in medical science.
Karl Popper, a philosopher of science, argues
that scientic discovery progresses in the same
manner, through a series of assumptions and
their refutation via the experimental method. Any
truly professional world is one in which accepted
hypotheses, or beliefs in cause-effect relationships,
are subjected to constant real-life experiments and
the chance that original diagnoses could be proved
wrong or partly true, by hard-nosed empirical
evidence. Intuition in discovering new ground in
that manner is the essence of scientic progress.

It is for that reason, I believe Albert Einstein when


he wrote that, Imagination is more important than
knowledge.
This essay, however, is not about the philosophy
of scientic discovery or the sociology of medical
practice. Rather, it is a plea by a social scientist
who has suffered from depression, to the readers
of this volume to be more open-minded in their
treatment of mental illness. There is a lot we still
do not know and need to explore. If the most
effective progress is made by constant change in
the light of evidence, then we must be open to new
experiences that become available to us on our own
initiative, from our peers or from journal articles.
There is another source of new evidence that we
often ignorethe patient.
I write this chapter to advance the case of the
patient as one of the most reliable sources of
healing. It is not intended, in any way, to demean the
signicance of routine scientic and professional
diagnosis, and treatment. It seeks to add value to
the professional skills learnt in medical school in
a manner that could help to reduce the margin of
error that is inevitable in all human decisions. This
chapter draws from two major sources: one is my
personal experience as an out-patient; the second is
my encounter with mental illness in my professional
life as a professor in the social sciences.

This is a life story of an eminent professor of economics who has taught in Africa and America, and is a worldwide consultant on
economic issues. It is a story of how he struggled with depression.

14

The Burden of Mental Illness

professionally arrogant in some cases. By failing to


discuss the diagnosis with me, however, I lost the
benet of their knowledge that would have helped
me and the doctors I subsequently consulted.

Diagnosis and self-diagnosis


One of the most important elements in healing
from disease has to be a two-way communication
between doctor and patient, in which the latter
is given the full benet of the doctors diagnosis
and treatment. We should never underestimate
the intelligence of the sick. Granted, the patient
may not always understand the full complexity
of medical science. As literacy spreads in Africa,
more patients will become inquisitive enough to
read what they can on their own, to monitor the
signs and trends of the illness, all of which makes
for better treatment by the doctor.
It was not until adulthood that I understood
what I was suffering from. Thanks to doctors in
Kenya and outside who were willing to engage
me about my self-diagnosis, and to discuss their
diagnosis with me. After each visit with them I felt
more condent. Through this process of patientdoctor interaction I have learnt more about what
triggers depression in my case, and which remedies
work best. As I move from one country to the next,
I bring the accumulated baggage of experience to
the doctor I see, and that makes treatment and my
life easier. After four decades of consultation, I
now have a diagnosis of my mental condition that
I feel is most consistent with how I feel. I have
a continuing low-order depression that becomes
accentuated by anxiety due to pressures at work or
in my social life. Fortunately, I have never had to
be hospitalised for the illness. Sometimes I go for
as many as 10 years before it strikes, but when it
returns, it weighs me down. I experience feelings of
despair and loss of self-condence, a sense of being
overwhelmed by the problems of the world, loss of
interest in simple things of life, continuous anxiety,
insomnia and palpitations. Over time I have learnt
to monitor the signs and to take remedial action. I
have learnt a great deal about the illness and the
successive drugs and modes of therapy that have
been used to treat it. With medicine, exercise and
by spacing out my work schedule, I have been able
to manage the illness.
I experienced severe disappointment with some
medical professionals along the way. No doubt
some of the doctors I consulted were some of the
most intelligent people I have ever met and nearly
all of them meant well. But communication with
patients was not their strength. In a patronizing
manner, they took patient history, asked some
questions, took time to examine me, even sent
me for laboratory tests, and then handed out
prescriptions. They were detached and aloof, even

The dangers of diagnosis without


communication
In 1961, at age 15, and in colonial Kenya, I sat the
Kenya Preliminary Examination, the national endof-primary school examination. It was not unusual
in those days for an entire class of 40 or so, to
send one or two students to the few high schools
reserved for Africans. Anyone in our situation who
felt anxious could therefore have been excused.
There were hardly any opportunities left for those
who failed the examination.
I desperately wanted to go to high school. I spent
time reading ction. H. Rider Haggards novel
based on the Zulu kingdom is one that I distinctly
recall, but I was also helping out with duties at
home on my fathers farm, and visiting friends.
Then I began to notice the slow, but sure creep of
insomnia. At rst it was just a nuisance that I could
ignore. But then it got worse, allowing me only a
few hours of sleep followed by empty gazes on the
roof punctuated by tossing and turning in bed. The
novels now took longer to nish.
Luckily, when I explained this to my parents
they were neither cynical nor inclined to mystical
or magical explanations. I was taken to one of the
few African physicians then practising in Nairobi.
The doctor wanted to know if I had ever suffered
from epilepsy, the answer to which was no. This
question gave me an early clue as to the direction
he was heading: he suspected something was not
right in the mind. I thought then that he was wrong,
but there was no conversation to be had between a
15-year old and such a reputable physician. In the
end he put me on treatment without saying what he
thought the problem wasa series of injections of
what I suspect was valium (diazepam). There was
no attempt to communicate with me. Had he cared
to inform my parents or me what his diagnosis
was, it might have saved us all a lot of subsequent
difculties.
The prescription worked and I had a restful
period. Results of the examinations were announced
and the outcome reinforced the sense of personal
comfort that I was already feeling. I had scored
the highest grades possible and been admitted to
the high school of my dreams. The anxiety had
subsided, giving way to optimism. At the time, I
could not relate anxiety to stress and insomnia.

15

The African Textbook of Clinical Psychiatry and Mental Health

the results were out. Again, it was a dream come


true, emerging from a severe bout of anxiety and
depression.
As a postgraduate student, I nally found a doctor
ready to engage me in a conversation about his
diagnosis. It was during the nal months before my
comprehensive doctoral examinationsa terror for
all students who had graduated from my department.
Unlike what had happened a few years earlier in
Nairobi, the doctor brought me face-to-face with
the connection between examination anxiety and
the illness. We went over the limited benets I had
obtained from valiumor a variant thereofthat
he had prescribed for me. He was persuasive. You
are a very educated person, he told me, do not
let the stigma of consulting psychiatrists deter you
from consulting doctor-so-and so. The rest was
easy. He guided me to the people who would really
help meclinical psychologists and psychiatrists.
Finally correct diagnosis and good communication
had met, and my health and anxiety took a turn
for the better. I peeped deep into my psyche and
for the rst time I began to see who I really was.
Recalling incident after incident since I was 15, I
wondered what had led to this. Now I read more
about affective disorders and their cure than I ever
had. I felt like someone who had conquered an
enemy by studying its real nature.

That experience was to come to me the hard way


much later. In the meantime I passed my national
examinations after Forms Four and Six with
ying colours. I was not worried about anxiety or
depression for a while.
That moment ceased at the end of my second
year at university. I had then made up my mind
to pursue scholarship as a career, which meant
that I needed to pass well enough to enrol for
postgraduate studies to a prestigious university
abroad. I was also required to graduate at the top
of my class. I knew that the few postgraduate
scholarships available went to the best of the best.
As the nal examinations of the second year drew
near, anxiety crept in. Looking back at this, it was
quite irrational. Overall, my work was among the
best in class. At least one lecturer had promised to
support my application for postgraduate studies.
Still unaware of what the previous diagnoses had
been, I could not relate the tell-tale signs provoked
by the oncoming examinations.
I knew that I was feeling sick, had lost appetite
and insomnia had struck. I had learnt on my own
that a lot of exercise helped me rest and study,
even though I was not sure why. I exercised, but
never got full respite from the illness. The full
happiness one would have expected on my personal
achievements eluded me. So I went to the general
practitioner at the university clinic. There was little
communication between us.
In desperation, I visited another physician
in Nairobi. At the then princely sum of Ksh 20
(equivalent to 0.25 US dollar) I was shown to the
examination room and soon I was reciting my
experience to him. I recall that palpitations were a
particular nuisance to me. He listened intently and
took a reading of my vitals. I recall that he asked
me to do a number of sit-ups before taking my
heartbeat again. He took out his prescription pad
and without a word, scribbled the prescription: two
weeks of a pale yellow tablet that many years later I
came to know as Valium (diazepam). The medicine
worked but it was not yet clear to me what I was
suffering from.
I did well in my exams. The dean of my faculty
told me that the marks I had received were truly
outstanding. I proceeded for my holidays feeling
elated. The palpitations and insomnia were gone.
When the nal examinations for the third year were
announced I was at the top. I had already received
admission for post-graduate studies to two of the
most prestigious universities in North America. I had
also been nominated and awarded a distinguished
international postgraduate scholarship long before

The dangers of wrong diagnoses


But that is only part of the story. I have narrated
the episode that preceded my entry to high school,
a correct diagnosis that was not explained to me
and was thus lost to all subsequent doctors I saw.
In the middle of my high school the anxiety struck
again. I was doing well at school. Even at the worst
of times I was passing my exams. But somehow I
began to feel I was not doing well enough. It was
the age of puberty. Again insomnia and a sense
of despondency set in. What followed was an
experience no patient ought to experience.
My rst stop was King George VI Hospital, as
Kenyatta National Hospital in Nairobi was known
at the time. The results were disastrous. The
attending nurse took my temperature, and did a
few other things I do not recall. The doctor who
was supposed to help me, a serious glum looking,
young moustached gentleman, with a stethoscope
hanging from his neck asked me what was wrong.
I went into the details of insomnia, palpitations,
indecisiveness and anxiety that I had rehearsed
so well. What he did thereafter actually worsened
my case. He took the hospital record card with
my name and the nurses observations on it, and

16

The Burden of Mental Illness

in turn determined ones career choice in university.


I do not know for sure, but my days of gloom, as
was to happen so often afterwards, may have had
something to do with an approaching, decisive
deadline and the mortal terror of failing, even when
by most rational analysis that eventuality seemed
quite remote.
My last encounter with misery-producing
diagnosis came towards the end of my undergraduate
education. The university clinic doctor listened
to my case with patience. He never gave me a
prescription. What I remember is his impatience,
and read cursorily through the le. Do you realize
that you seem to feel this way always before the
examinations? I do not know how I answered him
but whether I said yes or no was surely not going
to help me. I needed a professional reason for why
this was the case and something to help me deal
with it. But even without any treatment, the bit of
communication about the panicking syndrome by
the university doctor was of immense importance
to me. Henceforth, I included it in my repertoire of
symptoms. This helped all the caregivers I was to
see subsequently. It also helped me to understand
myself better.

proceeded to tear it bit by bit, throwing the shreds


into the dustbin, as I watched. All the time he was
staring straight at me with mirth written all over
his face. Go to your local dispensary and get
some medicine there, he said. I was devastated.
Probably it was my fault, I thought, may be I am a
hypochondriac.
I went to the dispensary at the time staffed by
a clinical ofcer. He did his best, prescribing a
large dose of pain relievers. I took them for a few
days and felt even worse, so I gave up. All this
heightened my anxiety. The thought kept recurring
that I may have done something to induce this
illness. Probably the doctor at King George VI
had seen through this young man with no medical
problem who was wasting his and the hospitals
time. I began to internalise the guilt, to look for the
cause of the problem within me. The more I did,
the worse I felt. The physicians guiding motto is
above all do no harm. That principle was violated
in a particularly vicious manner that morning. It
was a while before I went to see another doctor.
He too was a general practitioner, another one
of the few African doctors with a medical degree
from India. He was then and always in a serious
mood, not one given to discussion, least of all with
a high school youngster. Still in school uniform, I
explained my problems to him the best I could. He
drew a blood sample from my arm. I was asked
to wait for the results, then he made his diagnosis,
sharing none of it with me of course. I was curious
all the time and when he stepped outside, I looked
at the card and saw what he was about to treat me
for. He had written tachycardia. He gave me a
prescription, red coated tablets in a small khaki
envelope, and gave me another appointment. That
evening I went to my high school library and read
all I could about tachycardia. I read still more in the
days that followed to nd any clues that sounded
familiar with what I felt, but I found none. I took
the red pills, but did not get any better. Tachycardia,
I thought, what an elusive disease.
The remission from this round of illness did not
come from the red pills, which I soon abandoned.
Rather, it came from a change in circumstances
that had little to do with the doctors or me. I can
say this now with the benet of hindsight. It was
not so clear then, but halfway through my rst four
years of high school, I began agonising about what
I was going to do after the Form four examinations.
It was not an idle worry. By the time one entered
Forms ve and six, they would have already chosen
between the science and the arts stream. This

Effective patient-doctor communication


My epiphany came from the general physician
who handled my crisis in the run-up to my doctoral
examinations. He treated me as an equal. He told
me his treatment had reached its limits. I needed to
see someone more qualied than he was in mental
health. I went on to pass my examinations and my
examiners judged my proposal among the best they
had seen. The cloud over my mind gave way to
the freshness of a beautiful spring. It was to be ten
years before I had to see a doctor with anxiety. My
career prospered, as did my young family.
Even when circumstances changed after those
ten years, I knew what to do and what to avoid.
My encounters with primary care physicians and
psychiatrists in different countries are richer and
more fullling than the rough handling I had in
my earlier life. We can discuss prescriptions and
non-prescription treatment. Over the years, the
devastation caused by anxiety and depression
has subsided. I get remission going on for one or
several years, and I can predict the causes better
when panic strikes. When it strikes, a two-way
communication channel between psychiatrists and
I helps me nd a way out.

17

The African Textbook of Clinical Psychiatry and Mental Health

5
The Economic Burden of Mental Disorders in Africa
Ababi Zergaw, Atalay Alem, Damen Hailemariam

of their high prevalence, chronicity and early age


of onset. Often, they have a devastating effect on
functioning and quality of life. In todays world,
5 of the 10 leading causes of disability are mental
health problems. Furthermore, because of their
early age of onset, mental disorders have powerful
adverse effects on life course transition such as
educational attainment, teenage, child bearing and
cause marital instability and violence.
Unless attention is paid to the design, development
and evaluation of alternative low-cost methods for
the delivery of mental health care, the burden that
society and health services will experience will
continue to rise. This is so, in light of demographic
changes and epidemiological transitions, as well
as social factors that include changing family
structure and rising rates of urbanisation, migration
and mobility, and alcohol and drug use.
Compared to other economic studies in
the continent conducted on other diseases
like tuberculosis, malaria and HIV/AIDS,
economic studies on mental health are rare.
Therefore, availability of economic burden
studies on mental health to inform policy and
decision-making is minimal. Nevertheless, the
few available studies have demonstrated that the
burden of mental disorders on individuals and
their families are substantial. Studies conducted
in Nigeria compared costs of out-patient treatment
of schizophrenia with those of diabetes mellitus.
Patients with schizophrenia and their relatives lost
more working days than patients with diabetes and
their relatives. This study has also shown that the

Mental disorders cause extensive morbidity and


human suffering in many societies. In Africa,
where human suffering is exacerbated by many
other socio-economic and political factors, the
problem caused by mental disorders is grave. In the
continent, neuro-psychiatric conditions constitute
about 4 percent of the total burden of disease.
Moreover, the relationship between disease burden
and allocated health resource is disproportionate.
Eighty percent of countries in Africa spend less
than 1 percent of their total health budget on mental
health. This is further worsened by a shortage of
trained health personnel.
Economic evaluation studies which can help in
health policy and decision-making are rare, despite
the fact that resources are scarce. Economic
evaluation is about choice, which is concerned
with the best alternative use of limited resources.
It is a tool to identify the most efcient way of
meeting a stated objective. Its main function is to
allow policy-makers, managers and clinicians to
make choices by assessing the cost and benets
of achieving the stated objectives by different
alternative methods.

ECONOMIC BURDEN
EVALUATION
Mental disorders are among the most burdensome
of all classes of diseases. They may not in
themselves be fatal, but are burdensome because

18

The Economic Burden of Mental Disorders in Africa

result in distress, disability, reduced productivity


and lowered quality of life. They have devastating
effects on sufferers, their families, health systems
and the wider society. These disorders impose
a range of costs on individuals, families and
communities as a whole that include direct, indirect
and intangible costs. Direct costs are actual money
expenditures and in-kind contributions incurred
by patients, their families, and third parties, to
purchase medical goods and services. Costs of
non-medical goods and services ordinarily incurred
to obtain medical services such as transport to
medical facilities, are additional direct costs.
In-kind contributions are donations of goods or
services that would otherwise have to be purchased
through actual cash outlays. These include shelter,
food and utilities. Indirect costs are losses in
productivity associated with symptoms, disability
and premature death. Indirect costs include the
value of lost opportunities to work in the general
economy because of sick leave, disability leave
and unemployment associated with illness or in the
household. Relatives who divert time from work
to provide care or assistance with household work
also incur opportunity costs.
Intangible costs entail pain and suffering as well
as changes in quality of life. Intangible costs, which
are central to complete understanding of the impact
of illness, are not ordinarily considered in assessing
the economic burden of illness, because they cannot
be successfully quantied in a monetary sense, but
are nevertheless signicant. They include effects
on the patient (e.g., despair and the side effects
associated with medication) and on the carer (e.g.,
isolation, uncertainty, stress). Collectively, these
may be treated as intangible costs or as important
facets of patient or carer quality of life.
In the continent there is an urgent need to conduct
economic burden studies due to mental disorders
where loss of productivity is substantial. It is also
essential to understand that not treating mental
illnesses is more expensive than treating them.

cost of drugs was a signicant predictor of cost of


illness for both schizophrenia and diabetes.
Another study conducted on 44 schizophrenic
subjects on rst admission or in out-patient followup care at the state psychiatric hospital at Port
Harcourt, Rivers State of Nigeria, has investigated
and revealed that rural familes experienced more
nancial burden compared to those living in urban
areas. One South African study pointed out that
the introduction of follow-up by a psychiatric
nurse after discharge reduced the number of readmissions and the duration of stay in the hospital.
This was coupled with increased attendance at the
out-patient clinic.
A Kenyan study has shown that in the scal year
1998/99, Kenya lost approximately US$13,350,840
due to mental and behavioural disorders. This
study reported that the total economic cost of
mental and behavioural disorders per admission
was US$2,351. The study has also shown that the
unit cost of operating and organising psychiatric
services per admission is US$1,848, the out-ofpocket expenses borne by patients and their families
per admission US$51, and the productivity loss per
admission, US$453.
In a rural area of Ethiopia the burden due to
mental disorders has been shown to be signicant
such that depression and schizophrenia ranked 7th
and 8th among the 10 leading causes of burden of
disease in the area; contributing to about 11 percent
of the total disability adjusted life years lost. This
means that about 591 healthy life years were lost
for every 1000 people in the study area.
Most of the economic burden studies were
hospital-based, and on self-selected population
groups. However, there is a need to have populationbased studies since many people may not seek
treatment for mental health problems on time. In
addition, the small sample size of the economic
burden studies may not enable an estimate of the
extent of the burden, making their generalisation
for larger population groups questionable.

Further Reading
1. Kirigia, JM., and Sambo, LG., Cost of mental and
behavioural disorders in Kenya, (2003) Annals of
General Hospital Psychiatry, vol. 2: 2-7.

Categorisation of economic costs


Mental disorders such as schizophrenia, because
of the early onset, severe and persistent nature,

19

The African Textbook of Clinical Psychiatry and Mental Health

6
Stigma and Mental Disorders2
David M. Ndetei, Norman Sartorius, Lincoln Khasakhala,
Francisca Ongecha-Owuor

Mental illnesses cause severe disability and


suffering to patients, their relatives and the
society. Living with a mentally ill person leads to
restrictions of social and leisure activities not only
for the mentally ill, but the whole family. Mentally
ill people and their relatives are usually rejected
and stigmatised by the society. Stigma is dened
as feelings of disapproval that people have about
particular illnesses or ways of behaving. The
family members are looked upon as people who
are responsible for the illness. Thus, supporting
someone with a mental illness is a difcult life long
effort that is very stressful. The other problem faced
by these families includes nancial difculties. The
nancial loss arises due to the patients inability to
work and the expenditure incurred on management
of the illness. The relatives may be compelled to
work less hours or give up their jobs because of
their care-giving responsibilities.
Stigma associated with mental illness is a chief
obstacle to successful treatment and management.
It often leads to discrimination that needlessly
exacerbates the problems of individuals with
mental disorders. Such discrimination limits the
amount of resources for the treatment, availability
of housing, employment opportunities and social
interaction; problems that in turn further increase
the stigma associated with mental illness. Stigma
related to mental illness is in three forms:

The patient may be stigmatised by health care


providers, relatives and society.
The relatives also experience stigma from
the society, given that some communities
associate mental illness with a curse or taboo.
The mental health workers are also stigmatised
by other medical professionals as well as
society; hence, this compounds the success in
treatment of mental disorders.
Popular attitudes towards the mentally ill are
deep-seated and can be seen in the stigmatising
language that is often used to describe people
who are mentally illnuts or psycho.
Some people still refer to psychiatric hospitals
as nuthouses or loony bins. Using these
insensitive words when referring to people
with mental illness or their treatment centres
reinforce the stigma that already surrounds the
mentally ill.
The care-giver is an important ally in ensuring that
the mentally ill person follows the treatment that
has been prescribed, provides nancial assistance
and housing, assists the ill person with daily
activities, such as shopping, cooking and washing
clothes; monitors their symptoms, negotiates
with employers and social agencies and provides
emotional support. People with mental illness and
their families also have an important role to play in
planning and delivering treatment services.

Most of the material in this chapter is adopted from the World Psychiatric Association section on Stigma, with the kind permission
of its Chairman, Professor Norman Sartorius

20

Stigma and Mental Disorders

The risk of violence in persons with mental


illnesses appears to be very similar to that in
the healthy population, when substance abuse
is factored out.
The risk of sexual offences associated with
mental illness is low.
Only a small percentage of those with mental
disorders are responsible for the violent
behaviour that occurs in association with the
disorder.

MYTHS ON MENTAL ILLNESSES


Many myths about mental illness persist. Most
people do not accept mentally ill persons even if
they have been treated and are feeling better. Some
of the myths about mental illness are described
below.

People with mental illness cannot work


Fact: people with mental illness work, even if
they have symptoms. Several studies have shown
that people with major mental illnesses fare better
if they work. The ability to hold a job is not
necessarily related to the severity of the persons
illness. British and American studies have shown
that people with schizophrenia are more likely to
stay out of hospital, if they are employed. Work is a
vital part of rehabilitation; it increases self-esteem,
reconnects the ill person to the community and
provides a meaningful way to ll time.

All people with mental illnesses are


mentally retarded

People with mental illness are violent

Jail is an appropriate place for people with


mental illnesses

Fact: mental illness and mental retardation are


entirely different conditions. Most mental illnesses
occur in people of all levels of intelligence, and
often in talented and creative people. Some mental
illnesses like schizophrenia may cause cognitive
problems such as poor concentration and difculty
with abstract thinking. However, it does not affect
overall intelligence.

Fact: mental disorders and violence are closely


linked in the public mind. Sensationalised
reporting by the media may be responsible for
this. Other contributing factors are the popular
misuse of psychiatric terms like psychotic and
psychopathic. The stereotype of the violent
mental patient causes public fear and avoidance
of the mentally ill. People with mental illnesses
in general are no more dangerous than healthy
individuals from the same population. Individuals
with schizophrenia do show a slightly elevated
rate of crimes of violence, but such acts are almost
always committed by those who are not receiving
proper treatment. People with schizophrenia are
far more violent toward themselves than others.
Eight things to keep in mind about the stereotype
of violence:
Treatment dramatically reduces the risk of
violence.
The risk of violence is not necessarily due
to illness, but rather to a combination of
disorders.
The contribution of those with mental illness
to the overall incidence of crime is relatively
small.
The violence associated with mental illness is
most often directed at a family member.
People with mental illness do not pose a risk to
children.

Fact: jails and prisons typically have very


inadequate psychiatric services. Mentally ill
prisoners receive little or no treatment. Moreover,
they are subjected to double punishment. If they
are housed with the general prison population,
their abnormal behaviour leads to beatings and
abuse by other prisoners. If they are segregated for
their protection, they lose all social contact and the
isolation often worsens their symptoms.

People never recover from a psychotic


illness
Fact: this misconception leads to hopelessness
and despair. It may also cause families to neglect
or abandon ill relatives. The disorder takes many
different courses, with varying outcomes. Some
people have episodes of illness lasting weeks or
months with full remission of their symptoms
between each episode; others have a uctuating
course in which symptoms are continuous, but rise
and fall in intensity; others have very little variation
in the symptoms of their illness over time. At one
end of the spectrum, some people with psychosis
recover completely from the illnessall
their psychotic symptoms disappear and they
return to their previous level of functioning. Others
continue to have some symptoms, but are able to
lead satisfying and productive lives, while at the
other end of the spectrum is a course in which the

21

The African Textbook of Clinical Psychiatry and Mental Health

treatment. During the onset of the illness or during


periods of relapse, people may have some difculty
with decision-making. A persons ability to make
these decisions may change during the course of
the illness. Research shows that patient and family
involvement improves outcomes and increases the
likelihood of the patient adhering to the treatment
plan.
Negative portrayals of people who experience
mental illness in television, movies and other
media outlets, continue to perpetuate the stigma
and further activate discrimination. As one woman
observed,

illness never abates. Only about one-third of people


with schizophrenia do not recover signicantly and
may have to be institutionalised.

Mental illness is contagious


Fact: fear of contagion results in people avoiding
those who have a mental disorder. Fear of
contagion also lead to the stigmatisation of family
members, mental health professionals and places
of treatment.

Mental illness is caused by evil spirits


or witchcraft

When you go into the hospital for a broken leg,


people send owers or they visit you. If you go to
the hospital for a mental illness, people do not send
owers or visit.

Fact: there is a multitude of misconceptions about


the cause of mental illness, but mental disorder
is not caused by a curse or an evil eye, Gods
punishment for family sins or lack of faith in God or
reading too many books. It is not a form of demonic
possession. The genetic hypothesis has shown that
relatives of people with mental illness have a greater
risk of developing the illness than others. This risk
is progressively greater in relatives who are more
genetically similar to the person with the mental
illness. Genetic factors appear to be important in the
development of the mental illness, but they are not
sufcient to explain the entire pattern of occurrence.
Mental illness is not a simple, inherited disease,
but rather a complex genetic disease, which may
have a variety of triggers. Researchers believe
that a predisposition to develop mental disorder is
inherited, but an environmental trigger must also
be present to bring on the disease. Possible triggers
are:
complications during the mothers pregnancy
or labour.
prenatal exposure to a virus, specically during
the fth month of the mothers pregnancy,
when most brain development occurs.
complications during pregnancy and delivery
increase the risk, probably because of damage
to the developing brain.
a pregnant woman who contracts a viral
illness may have a child with a greater risk
of developing schizophrenia. However,
maternal viral infections probably account for
only a small fraction of the increased risk of
schizophrenia.
stress, particularly the stress of adolescence.

Many patients report that consistent support from


parents, friends, medical professionals or teachers
was a major factor in their rehabilitation. Here
is a quote from Elizabeth who had experienced
discrimination:
One night the police pulled me over for expired
plates on my car. It was dark. The lights were ashing.
I was terried and shaking. When the policeman
approached my car, I was so scared I couldnt speak.
He accused me of being uncooperative. I managed
to say that I had schizophrenia. What does that
have to do with anything? he said, crazy, loony,
schizo, and laughed out loudly.

Another mentioned that:


We are simply labelled Mathari (national referral
mental hospital in Kenya) cases. If we laugh, we
laugh like Mathari cases. If we weep, we weep like
Mathari cases. If we have wonderful ideas they are
from Mathari cases. There is nothing we can do
good or bad without it being dismissed as coming
from a Mathari case. (Source: D.M. Ndetei, The
Walk, Towards the Promise. Inaugural Lecture,
University of Nairobi, 2001).

REDUCING STIGMA AND


DISCRIMINATION
In order to reduce stigma and discrimination, it
is necessary to change peoples attitudes through
education and outreach programmes, change
public policy and laws to reduce discrimination
and increase legal protection for those with mental
illness.
Strategies to reduce stigma and improve the
quality of life for individuals with mental illness
include:

People with mental illness are not able to


make decisions about their own treatment
Fact: most people with mental illness are able and
eager to participate in decision-making about their
22

Stigma and Mental Disorders

Cultural and religious issues are very important.


They inuence the value placed by society on
mental health, the presentation of symptoms,
illness behaviour, access to services, pathways
through care, the way individuals and families
manage illness and the way communities respond
to illness.

Increase use of treatment strategies that control


symptoms, while avoiding side effects.
Initiate community educational activities
aimed at changing attitudes toward people
with mental illness.
Include anti-stigma education in the training
of teachers and health care providers.
Improve psycho-education of patients and
families about ways of living with the
disease.
Involve patients and families in identifying
the discriminatory practices.
Put emphasis on development of medications
that improve quality of life and minimise
stigmatising side effects.

Further Reading
1. www.antipsychiatry.org/stigma
2. Norman Sartorius (1997). Fighting schizophrenia
and its stigma. A New World Psychiatric Association
Educational Programme. British Journal of Psychiatry,
April 170:297.

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The African Textbook of Clinical Psychiatry and Mental Health

7
Mental Health: From the Perspective of
a Paediatrician and Surgeon
Rachel Musoke, Josephat Mulimba

and reading remains a good way of spending time


with children. When they are older then playing
games with them is another useful activity. Mothers
are often the ones in more contact with young
children presumably because of breastfeeding.
However, fathers have an emotional role to play in
ensuring the mental wellbeing of their children and
they should participate in childcare activities.
Working parents are usually under pressure to
nd time for their children. They may do so by
planning their work schedules, coming home as
soon as working hours are over or taking leave
when children are on holiday. Child minders are
valuable but they cannot replace parental love. The
responsibility of demonstrating love lies with the
parents and guardians.
One factor that plagues children of single parents
is the fate of the absent parent. Some children are
not told who their fathers are, while others are
forbidden to make contact. A lot of conicts go on
through the minds of these children. Consequently
such children become maladjusted. However,
some single parents have brought up well-adjusted
children depending on various factors including
parenting competence.

THE PAEDIATRICIANS
PERSPECTIVE
Children undergo numerous changes as they
develop from a totally dependent infant to a
partially independent adolescent. These changes
occur in phases at different ages during which
they need love, discipline and some independence,
within safe limits, in order to achieve good mental
health.
Children may be accepted, but not necessarily
loved. On the other hand, the parents may love a
child, but the child may be unaware that it is loved.
Parents must practically demonstrate love to their
children since a loved child is likely to be stable,
well behaved and condent. Many people have the
misconceived notion that loving a child too much
spoils it. On the contrary, unloved children are
spoilt, unruly and usually selsh. They are likely to
become irresponsible adults. Child should be loved
for who they are and not because of what they have
achieved. Some parents may only show love when
children excel and therefore they will always strive
to please. However, when they fail they show a lot
of anxiety. The stress that results may even make
the performance worse, leading to a vicious cycle.
Giving materially is not the same as giving
love. Loving a child means being there for it. In
these days of media entertainment there is little
interaction between family members. Story telling

Siblings sharing love


A single child has all the love and attention a
parent can give, but when there is more than one
child, rivalry, jealousy and anger may develop
in the older sibling. Young children have some

24

Mental Health: From the Perspective of a Paediatrician and Surgeon

difculty accepting additions to the family. The


responsibility of looking after younger siblings puts
a tremendous strain on the older child who loses
out on play that is important for healthy emotional
and physical development. Some parents obviously
favour one child leading to resentment by others.
The favoured child may also feel uncomfortable
about the situation. Another problem parents
create is comparison in terms of achievements or
appearance, usually through lack of realisation that
each child is different.

them wherever parents go to work, the daily childparent contact is completely cut off except during
scheduled parental visiting days.
Factors that affect children in school include
unrealistic expectations in academic performance,
too much homework at the expense of extra
curricular activities, excessive or unfair punishment
and bullying. When children are unhappy in school,
they may be too scared to tell their parents and
may present with falling sick often with atypical
illnesses.

Role reversal

The child

Where children assume adult roles prematurely,


such as when parents are sick, missing or dead they
experience enormous emotional turmoil. The worry
of permanently losing a sick parent or a divorce
puts the children under a lot of pressure that may
manifest as behavioural and emotional instability.

Broadly, children fall into two categories: the


easy and difcult child. A childs personality is
predetermined genetically. Easy children tend to be
quiet and undemanding. They usually want to please
and get approval of everyone they are in contact
with. They receive little attention and possibly love
because people around them assume that they are
happy even when they are hurting. People may not
notice when these children are angry, because anger
is not outwardly expressed. This group of children
are easily controlled or manipulated by others.
Difcult children are demanding, always arguing,
stubborn and most often want to solve their own
problems. They are natural leaders, but tend to be
anti-authority.

Extended family, friends and the


community
Africa is evolving from a situation where children
belonged to the community to the so-called nuclear
family, especially in urban areas. Fortunately in
rural communities there is still a lot of shared care
of children. That sense of belonging makes most
children happy and content. Friends tend to take
the place of relatives for the urban children.
Some children get to live partially or permanently
with a relative sometimes from an early age.
The child can interpret this as lack of love and
abandonment by its own parents. In this case it
may be difcult for the child and parents to really
bond resulting in total detachment.

The older child and adolescent


Adolescents want to be recognised in their own
right. During adolescence one is oscillating
between being a child and an adult and the
transitional time is beset by turmoil. How children
go through this period partly depend on their earlier
life experiences, as well as how they are guided.
If parents did not establish dialogue and trust they
may have problems dealing with their children.
Allowing the child to be independent is important
for personality development. With parental
guidance, a child goes through stages where they
are totally dependent to almost total independence
as adolescents. They gradually become responsible
for their actions at the same time knowing that there
is somebody to guide them through difculties.
Making mistakes is part of the game as long as
the mistake is not detrimental to their life. Instead
of punishment, they should be encouraged to
improve where they are failing. If a child is doing
right, but is not in conformity with his peers, he
should be supported by his parents. Closeness and
love by parents and other adults greatly helps the
child to learn to be a responsible person. When

School
Upon joining school, children are partially
separated from their parents and put under the
care of strangers. Initially it could be traumatising,
especially for the preschool child who feels
abandoned and reacts by crying.
In schools the child has to follow new sets of
rules, interact with strange adults, children and
learn to share with them. There may be a change of
language so that the child is unable to follow what
is going on. In the long run some children settle
and are happy in their new environment while
some show persistent behavioural aberrations.
Frequent change of schools for whatever reason,
affects the child in similar ways as joining school
for the rst time. Although putting children in
boarding schools is a better option to dragging

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The African Textbook of Clinical Psychiatry and Mental Health

including mental health can be addressed and


ensure adequate nutrition throughout childhood.
This will help prevent or reduce incidences of
childhood psychiatric complications and disorders
such as mental retardation.
Parents are usually worried about the survival
of a child suffering from an acute illness. The
paediatrician should counsel the parents and ensure
the illness is not discussed in the presence of the
child since this may cause them psychological
helplessness. Chronically ill children often ask
why they are different, why are they not able to
play like other children, and why they have to
take medication everyday. Paediatricians should
concentrate on counselling them depending on
their ages.
There is a lot that is not being addressed in
childrens mental health. There is an urgent need
to reconsider paediatric training and practice in
order to enhance the mental heath component of
children.

independence is denied the child may become


angry, frustrated and rebellious.

Discipline
The whole idea of discipline is to teach or educate.
It does not mean control and can be either positive
or negative. Positive discipline is loving discipline
which is rm, reasonable and exible, but not
permissive. Children are complimented when they
have done something good. When mistakes occur
in positive discipline the child is listened to before
being punished and the punishment chosen is not
excessive. Children who are positively disciplined
are happy and resourceful individuals. They will
try to excel in most of their activities.
Negative discipline seeks to control the child
who is forced to comply with whatever the parents
want. It is deceptive and promises are unmet.
The child eventually learns that these are empty
promises and rebels. Negative discipline makes
children angry, resentful and rebellious. Sometimes
this anger is suppressed, which is dangerous as it
leads to depression. The anger may be vented on
somebody else who was not originally the cause
of the problem. Their achievements are often
below their capabilities, because of their negative
attitudes to work.

MENTAL HEALTH AND


SURGERY
When a patient visits a surgeon, it is usually
assumed that after history taking, examination and
investigations, an organic problem will be identied,
excised and the patient cured. This, unfortunately,
is not always the case. A patient may, after the
most exhaustive history taking, examination and
investigation, be found to have no organic problem.
The patient may have a psychosomatic problem.
There are patients with organic problems whose
conditions are worsened by their psychological set
up. It should be remembered that any patient going
for any type of surgery may experience anxiety.
Patients with psychiatric problems who also have
surgical problems may require modications to
their treatment. An example is a patient with a
fracture who also has schizophrenia; operation and
mobilisation on crutches, which may be a logical
treatment for another patient, may not do. Trauma
that leads to injuries requiring compensation often
trigger a series of psychological problems, which
may be incurable unless the issue of compensation
is acted upon. The expected compensation or
denite lack of it rapidly brings about a cure.
Chronic ailments including surgical ones
lead to chronic anxiety which if not recognised
may jeopardise the patients recovery. In major
catastrophic disasters in which injuries occur,
survivors require psychological support as part

The paediatricians role in mental health


Mental health is rarely considered in child health
programmes though it is very important. It is
ignored because it seems to be subtle, difcult
to dene, and is not emphasised during medical
training. In the developing world, most of the
paediatricians time is spent caring for very sick
children, leaving little time to interact with well
children. Early childhood programmes focus on
the child up to 5 years largely because of the high
morbidity and mortality in this period. Even in
these programmes other health care workers rather
than the paediatricians do the bulk of the work.
It is not often that the paediatrician comes into
contact with expectant parents though it would be
the best time to start preparing the parents for their
new roles, especially if they are expecting their
rst child.
In most African countries there are more
paediatricians than psychiatrists, therefore
paediatricians should take more interest in
childrens mental health issues. At medical level,
paediatricians should prevent problems that lead to
brain injury, advocate improved maternal nutrition,
encourage women to utilise health care facilities
during pregnancy where child health issues
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Mental Health: From the Perspective of a Paediatrician and Surgeon

stopping in the middle of the head, may point to a


possible mental disorder. In locomotor problems,
where a patient is not responding as expected by
the surgeon, it is good at times to watch the patient
when he is not aware. Many a story has been told
where the patient was seen walking quite well, but
on reaching the clinic was unable to walk. Expected
compensation is a common cause of this.
Some patients continuously assign themselves
diseases, which have been found absent in them.
A patient, for example, will insist that he has a
tumour and that the surgeon is just not telling him
the truth. Such patients on enquiry have seen many
doctors before with similar complaints.

of overall management apart from surgical


interventions.
Preparing patients for surgery involves several
aspects and depends on whether it is emergency
or elective. The diagnosis, procedure and possible
complications should be carefully explained to the
patient and the family. Asking the patient to sign
on the dotted line without an explanation is wrong.
Fear in patients arises from being in hospital, which
is a strange place. Theatres usually instill fear in
patients and many of them wonder, as they are
led like a lamb to the slaughter, whether they are
making a one-way trip. Appropriate counselling by
the surgeon and other counsellors including nurses
does a lot to allay this fear.
The counselling process in a surgical set-up
includes responding to some questions the patients
often ask: What are the chances that I will be
normal after this surgery? This is particularly
common. What the patient really wants to know is
whether there will be any complications following
the surgery. For example, with back surgery,
there are prophets of doom, who preach that any
operation close to the spinal cord is incompatible
with normal postoperative sexual intercourse and
walking. The risks of either occurring are pretty
small, but it serves well to assure the patient. Other
questions that patients may pose include, Have
you seen or done operations of this kind before?
and How much will this operation cost? It is not
possible to enumerate all the questions that patients
ask; sufce it to say that it is good to answer them
as reassuringly as possible.

Some organic disorders of surgical and


psychiatric interest
There are various organic disorders that may cause
changes in a patient and mimic psychological
problems. Trauma to the brain causes subdural
haematoma and presents with delirium.
Infections resulting in space-occupying lesions
like tuberculoma or septic abscess can lead to
changes very difcult to distinguish from a
psychiatric illness. Endocrinological disorders such
as goitre may cause changes akin to psychiatric
disorders such as depression. Orthopaedic factors
such as low back pain are common and the majority
of low back pains have no obvious causes even
after exhaustive investigations.
Further Reading
1. Richard H. Granger and Elsa L. Stone, Collaboration
Between Child Psychiatrists and Paediatricians in
Practice, (2002). In Child and Adolescent Psychiatry
Ed. Melulin Lewis, Lippincott Williams & Wilkins,
pp 1116-1118.

Pointers to mental problems


A patient complaining of low back pain with
migration to both upper limbs, the skull and

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The African Textbook of Clinical Psychiatry and Mental Health

28

Section II Part A:

Clinical Psychology

29

The African Textbook of Clinical Psychiatry and Mental Health

30

8
Human Development and Life Cycle
Anne Obondo, Duncan Ngare, David M. Ndetei, Eddie Mbewe,
O. Morakinyo, Ruthie Rono, Ama S. Addo

of the mind or physical body must be treated if


both are affected. This branch of psychology is
concerned with the application of psychological
principles to the practice of medicine.

WHAT IS CLINICAL
PSYCHOLOGY?

Nature of clinical psychology

Denition of psychology

Clinical psychology determines the personality


types of coping and examines the attitudes of
an individual in response to subjective and
objective stressors. Clinical psychologists
help to determine the genetic, biochemical and
physiological factors and reactions in illnesses.
Behavioural methods are applied to help the
person match the coping and management skills
to the persons abilities, character, and personality
style. This is done after a detailed assessment of
the patient to ensure that appropriate care is given.
They then coordinate and provide psychological
care, and order for the assessment and treatment
procedures. These include the behavioural, biobehavioural, psycho-physical, neuropsychological,
intellectual, forensic, vocational and psychosocial
assessments and mental status examination.
The clinical treatment approaches used include:
individual, group, family psychotherapy, behaviour
modication, hypnosis, bio-feedback, crisis
intervention, pain management and rehabilitation
services.

Psychology is the science of behaviour. Psychologists


study a large variety of behaviours in humans and
animals and try to explain these behaviours by
studying the events that cause them. Psychology
is both a profession and a scientic discipline.
Psychology as an academic discipline has twelve
major branches which include: physiological
psychology, psycho-physiology, comparative
psychology, social psychology, behaviour
analysis, behaviour genetics, cognitive psychology,
experimental neuropsychology, developmental
psychology, personality psychology, cross-cultural
psychology and clinical psychology.
Clinical psychology is the branch of psychology
that focuses on psychological testing, assessment,
diagnosis of mental disorders and provision of
psychotherapy in the management of mental
disorders. Clinical psychology also involves
teaching and planning of services in mental
health.
It is based on the fact that the body and mind
are one indivisible structure. All diseases whether

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The African Textbook of Clinical Psychiatry and Mental Health

During the 7th and 8th weeks the embryos


sexual development begins with the appearance
of a genital ridge called the indifferent gonad.
The rst prenatal month has got the most rapid
growth in the life cycle.

HUMAN DEVELOPMENT AND


THE LIFE CYCLE
Conception to birth

The period of the foetus

Life begins with the fusion of two cells, a sperm and


an egg (ovum) in the fallopian tube of a woman.
The sperm penetrates through the wall of an ovum,
forming a zygote. From the moment of conception,
it will take approximately 266 days for this tiny
one-celled zygote to become a foetus ready to be
born.
Prenatal development is often divided into 3
major phases:

This begins from the 9th week to birth.


All organ systems become integrated in
preparation for birth. It is a period of renement
of all organ systems.
The foetus attains the age of viability at the
beginning of the 3rd trimester, usually between
22-28 weeks.
Third month

First Trimester

The foetus begins to perform many interesting


manoeuvres like kicking its legs, making sts
and twisting its body.
The digestive and excretory systems are
working.
Sexual differentiation is progressing rapidly
and the sex of the foetus can be detected by
the end of the 3rd month by ultrasound.

Germinal period (period of the zygote)


Lasts from conception through implantation,
when the developing zygote becomes rmly
attached to the wall of the uterus.
Normally lasts about 14 days.
The inner layer of the blastocysts will become
the embryo
The outer layer forms the amnion chorion,
placenta
and
umbilical cordsupport
structures that help sustain the developing
prenatal organism.

Second trimester
This is the 4th-6th months of pregnancy.
By the 4th month, the foetus is 8-10 inches
long and weighs about 6 ounces. Motor activity
includes rened actions like thumb suckling or
kicking (can be felt by mother), heartbeat and
hardening of the skeleton. The foetus assumes
a distinctly human appearance, but stands no
chance of survival outside the womb.
During the 5th and 6th months, the nails harden,
skin thickens, eyebrows and eyelashes and
scalp hair appear. Sweat glands are functioning
and heartbeat is audible. The foetus visual and
auditory senses are functional.

The period of the embryo


Lasts from the beginning of the 3rd week
through the 8th week of pregnancy.
It is the period when all major organs are
formed and begin to function.
By the 3rd week the embryonic disk is rapidly
differentiating into 3 cell layers: the outer
(ectoderm) becomes the nervous system,
skin and hair; the middle layer (mesoderm)
becomes the muscles, bones and circulatory
system and the inner layer (endoderm)
becomes the digestive system, lungs, urinary
tract and other vital organs like the pancreas
and liver.
In the 3rd week a portion of the ectoderm folds
into a neural tube that soon becomes the brain
and spinal cord.
By the end of the 4th week, the heart has
formed and begins to beat. The eyes, ears, nose
and mouth are beginning to form and buds that
will become arms and legs suddenly appear.

Third trimester
These are the 7th to 9th months of pregnancy.
Growth continues and all organ systems mature
in preparation for birth. The foetus reaches the
age of viability.
It becomes more regular and predictable in its
sleep cycles and motor activity.
A layer of fat develops under the skin.
Activity becomes less frequent during the last
2 weeks before birth.

32

Human Development and Life Cycle

do so subconsciously. Replacement of children


decreases grief in parents and these children are
usually over-protected.

Psychological aspects of pregnancy


Pregnancy is accompanied by biological,
physiological and psychological changes.
Depending on various factors, most females regard
pregnancy with a positive attitude if:
The pregnancy is well planned.
The partner is present.
There is maternal competence.
There is a role model, especially ones own
mother.
There are no conicts concerning the
mothering role.
However, a few females may present with emotional
disturbance and cognitive dysfunction. Whatever
the case, there are some common psychological
issues that occur during pregnancy.

Effects of medication on pregnancy


Upto about one-third of pregnant females
use psychotropics whose teratogenic effects remain
unclear. One should avoid these drugs unless it is
extremely necessary. They also produce symptoms
in infants such as sedation and hypotonia.
The wish in most mothers to nurse their babies
has increased and it is the most ideal situation, but
this does not always happen. Guilt feelings develop
if a mother is unable to nurse and breastfeed due to
effect of medicines or other medical reasons.
Culture-bound syndromes
Madonna complex: a psychological set of
mind, in which males view pregnant females
as sacred and not to be deled by sexual acts.
Couvade syndrome: a culture-bound syndrome
in which the father rests in bed as though he is
the one who gave birth to the child.

Pregnancy and marriage


Pregnancy is an expression of a sense of selfrealisation and identity of a female. It is a very
satisfying condition and for most females lack of
it is a cause of self-doubt regarding their gender
and sexual role. Pregnancy redenes the role of the
couple and means dealing with new responsibilities
as parents.

Infertility, mental health and pseudocyesis


Infertility may occur due to various reasons. In
situations where such diagnosis has been conrmed,
the female presents with several psychological
responses including denial, anger, frustration and
depression. The process of acceptance may be dealt
with by developing a condition called pseudocyesis.
This is false pregnancy with classic symptoms
of pregnancy and was rst described in 300 BC
by Hippocrates. The female has classic symptoms
of pregnancy except that she does not deliver
even after the expected gestation period. These
symptoms are amenorrhoea, nausea, enlargement
of breasts and abdominal distension (may be due
to broids). Cause of pseudocyesis include:
Somatic delusion not subject to reality testing
such as pregnancy test or psychotherapy.
Pathological wish to get pregnant or in some
cases the fear of getting pregnant.
Complication of hysterectomy or sterilisation.

Pregnancy and sexual behaviour


The effects of pregnancy on sexual behaviour vary
in couples:
Sexual drive may increase or decrease.
Fear of pregnancy is associated with reduced
drive.
Discomfort associated with pregnancy reduces
sexual drive.
Psychological set of mind, in which pregnant
females are viewed as sacred and not to
be deled by sexual acts, called Madonna
complex.
Some males view pregnant women as ugly,
thus avoiding sexual activity.
Intercourse is erroneously regarded as harmful
to the foetus.
Extra-marital relations in males usually occur
during the third trimester.

Mental disorders associated with child


birth

Effects of pregnancy loss (including abortions)

There are two such disorders that include


postpartum blues and psychosis. They present
as typical disorders and can mimic most of the
classied psychiatric disorders. However, they
only occur in association with childbirth and that is
why they are not classied as separate disorders.

When abortion takes place within the rst 12 weeks,


it may be a relief to the female. However, abortions
that occur later are associated with emotional
turmoil. If abortion is denied, the suicide risk tends
to increase in some females. Couples may wish to
replace such pregnancy losses and at times they
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The African Textbook of Clinical Psychiatry and Mental Health

Primitive reexes

Postpartum blues
Postpartum blues are characterised by the following
symptoms: state of sadness, dysphoria, frequent
tearfulness and clinging dependency. The course
of postpartum blues takes several days and may be
caused by rapid rise in hormonal levels, stress of
childbirth and responsibility of motherhood.

Babinskifanning and then curling the toes


when the bottom of the foot is stroked.
Palmer graspingcurling of the ngers around
objects that touch the babys palm.
Moroloud noise or sudden change in the
position of babys head will cause the baby
to throw his arms outward, arch the back and
then bring the arms towards each other as if to
hold onto something.
Swimmingan infant immersed in water will
display certain movements of the arms and
legs and involuntarily hold its breath.
Steppinginfants held upright so that their
feet touch a at surface will step as if to walk.

Postpartum psychosis
Basically these are severe symptoms compared
to postpartum blues and they may include severe
anxiety, hallucinations, delusions, depression and
thoughts to harm baby or self. Postpartum psychosis
occurs in approximately 1 to 2 per 1000 deliveries
and is predominantly a female disorder though in
some cultures it may occur in the husbands. The
risk factors for postpartum psychosis include family
history of mood disorder and previous history of
mood disorder in the patient.

Congenitally organised behaviour


These are early behaviours of newborns that do not
require specic external stimulation and that show
more adaptability than simple reexes. These are
looking, suckingnot always reexive, e.g. during
sleep and crying.

The newborn
Babies are born equipped with a range of abilities
and capabilities:
Sensory capacities

Infancy and toddlerhood

Babies are born sensitive to a range of frequencies


of womens voices and sense of smell. Two-dayold infants can learn to pair information coming
from different sensory modalities associated to a
particular voice with a particular face.

Physical development
In the rst 2 years most babies gain about 9 kg and
grow about 38 cm in height. Growth and maturation
in infancy for the most part proceed in a denite
order although individual differences exist. The
sequence of development is to a great extent due to
gradual maturation of cells in the brain. Hence the
brain plays a critical role in physical development.

Reexes
Infants also come equipped with a wide range of
reexes. A reex is an automatic response to an
event; an action that does not require thought.
The reexes may be survival reexes (have
adaptive value) or primitive reexes (not useful)
as follows:

Development of the nervous system


At birth the brain contains over 100 billion nerve
cells or neurons, but the networks of nerve bres
that interconnect them are relatively rudimentary.
During the rst few years of an infants life there
are major spurts of growth in this network, enabling
the emergence of new capabilities, including selfregulation and certain cognitive skills. Over the
course of the early years, neural pathways in the
brain that are used become strengthened and further
developed and those that are not used atrophy.
Brain maturation alters the infants physiological
states, bringing deeper sleep, more denitive
wakefulness, greater self-regulation of alertness
and increasingly regular sleep patterns. The nervous
system grows rapidly during the early years. At
birth the human brain weighs 350 g and by the end
of rst year, it weighs 1000 g.

Survival reexes
Breathingrepetitive
inhalation
and
expiration.
Eye blinkclosing and blinking the eyes.
Papillary reexconstriction of pupils to
bright light, dilation to dark surroundings.
Rooting turning the head in the direction of
touch.
Suckingsucking on objects placed into the
mouth.
Swallowing.

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Human Development and Life Cycle

Co-ordination of secondary schemes (8-12


months): object permanence is acquired, the
realisation that objects exist even when they
cannot be seen.
Tertiary circular reaction (12-18 months):
infants heightened interest in creating changes
in their environment fuels primitive reasoning
skills. Beginning of simple trial and error
behaviour.
Invention of new means through mental
combinations (18-24 months): they create
mental images that enable them to devise new
ways of dealing with their environment. They
think before they act.

The different parts of the brain develop at different


rates and follow a unique timetable. The hind brain
is responsible for bodily functions necessary for
survival. Its maturation is based on the development
of brain parts as well as the muscle and skeletal
system. The development of motor abilities during
the rst two years allows the infant to discover the
world. Gross motor skills involve large movements
such as running and jumping; ne motor skills
involve small, precise movements, such as picking
up a coin.
Locomotion is the ability to move from one
location to another. At 2 months, infants can raise
their chest by means of arms support. By 5 months
they can sit upright when supported, forward
mobility is evident at 6 months, at 8 months
crawling begins and they take their rst step at 1315 months.
Prehension is the ability to grasp objects
between the ngers and opposable thumb. The
neonate is born with a grasp reex, which subsides
at approximately 4 months, and prehension
occurs between 5-6 months. Prehension follows
a sequential pattern of development, particularly
those involving neuromuscular control and coordinated hand and eye movement. Childrens
artwork illustrates their increasing neuromuscular
ability. Handedness (the preference for and
subsequent predominant use of one hand) develops
at approximately 2 years of age.

Concept development
Advancement in cognitive functioning relies heavily
on the establishment and renement of concepts. A
concept is a mental image that represents an object
or event. At this time there are changes in shape,
size, spatial, class and time concepts of particular
importance as follows:
Shape and size: accurate shape and size
concept rely considerably on perceptual
constancythe tendency of objects to appear
the same under different viewing conditions.
Spatial concepts: youngsters do not realise
that an object can take a different spatial
appearance. Hence, they may have difculty
telling whether an object has been placed to
the left or right, behind or in front of another.
Class concept: they may have problems in
grouping objects.
Time concept: they have a limited concept of
time. Their understanding of it revolves around
their daily activities. They almost exclusively
use present tense when talking.

Mental development
Cognition refers to thinking, perceiving and
understanding. Jean Piagets theory of cognitive
development gives insight into how mature
thinking unfolds. He calls the rst stage of
cognitive development the sensorimotor stage that
occurs during the rst 2 years of life. Six sub-stages
comprise the sensorimotor period, each of which
facilitates overall mental development as follows:
Reex activities (0-1 month): during their rst
month, infants are limited to only primitive
reex activities such as crying or sucking.
Later the infant can discriminate between
objects that can be sucked and those that
cannot.
Primary circular reactions (1-4 months): should
an infant discover a pleasurable behaviour
pattern, chances are it will be repeated for its
own sake, e.g. thumb sucking.
Secondary circular reactions (4-8 months):
infants attempt to reproduce interesting events
in the external environment that might have
been rst caused by accident.

Cognition and memory


Children are capable of holding only a few words or
ideas in their minds. They frequently have difculty
remembering events that happened weeks, days or
even only hours before. This is due to the small
amount of information in their long-term memory
store. This improves with age due to metacognition
and metamemory abilities. Metacogniton is ones
awareness of how a cognitive process can be applied
to a given mental task, e.g. rehearsal of events so
that they can be remembered. Metamemory refers
to how ones own memory abilities can be used to
prevent forgetting.

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The African Textbook of Clinical Psychiatry and Mental Health

a fairly stable sequence. From crying, cooing,


babbling, holophrase and early sentences.
Crying: represents the earliest infants
vocalisations. There are many different
varieties of criesfrom whimpering, fussy,
to colicky cry. Each cry usually has meaning,
and is differentiated by pitch. Crying is not a
language, but a type of communication. During
the rst 6-8 weeks of life, crying is the main
vocalisation.
Cooing and babbling: between the second and
third month cooing emerges. It includes such
sounds as gurgling and mewing and generally
indicates the infant is pleased, happy or even
excited. It is a form of communication, though
not a language and follows no grammatical
rules. It diminishes in all children at
approximately 8 months. It also consists of
vowel sounds.
Babbling: emerges at about 6 months. It
consists of vowels and consonants. Children
from a variety of linguistic backgrounds babble
in a similar fashion. Language stimulation by
adults is benecial.
Holophase stage: occurs on average between
12 to 18 months. Children appear to learn
words that relate to important people, food,
toys, body parts and animals. The early words
are primarily concrete nouns and verbs.
Early sentence: by approximately 18 months,
children start using two-word expressions.
Usually these utterances consisting of single
words that exist as separate entities e.g. toy go.
Telegraphic sentences follow the development
of two words expressions. They are short and
simple and consist mainly of nouns and verbs.
They are called telegraphic because they lack
some words.

Development of sensory organs


Vision
The visual system develops rapidly. By 4 months
infants visual accommodation and focusing
abilities are close to those of mature adults.
Brightness sensitivity matures by approximately 3
months. Ability to see small objects with increasing
clarity is also evident during early infancy. Colour
perception is also evident at an early age. By
approximately 4 months the visual spectrum of the
primary colour categories of red, blue, and yellow
can be perceived. Depth perception allows a person
to distinguish downward slopes, descending steps
or edges of precipices. Infants are able to perceive
depth as early as the crawling stage.
Auditory
The auditory system also matures rapidly as
children learn the associative value of sounds. At
about 4 months, infants are aware of the sound
of a familiar voice and will turn their heads in
the direction of the sound. At 5 months they can
discriminate vocal expressions of emotions when
those expressions are presented in conjunction
with a face. Infants can distinguish different sound
frequencies at approximately 6-8 months.
Taste and smell
During the rst few months of life, infants are able
to discriminate between sweet, sour, bitter and
salty tastes.
Touch
During toddlerhood, touch is one of the most
pleasurable of the childs sensations. The sense
of touch adds a great deal of cognitive awareness
during these years, especially when exploring the
sensations of hardness and softness, roughness and
smoothness and warmth and cold, which are at
their peak.

Personality and social development


During the early years, personality and social
growth are largely shaped by the family. From
early interactions with parents, children get a
better understanding of themselves and their
social surroundings. This awareness of oneself and
society is called social cognition, and is gained
through primary socialisation process.

Language development
The study of language development is known as
psycholinguistics. The brain and the vocal cords
enable humans to match symbolic representations
with comparable meaningful vocalisations. The left
hemisphere is the part of the brain most directly
associated with languages. No one theory fully
explains language development although three
theories have been proposed; behavioural, social
learning and innate theories. Innate theory is
considered the most inuential of the three.
The development patterns of language follow

Attachment
This is the bond between the caregiver and the
infant. It shapes early personality and social
development of the infant. Children at this time
develop a strong attachment to both parents or

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Human Development and Life Cycle

researchers are not able to record infant feelings.


The most common emotional expression during
this stage includes: crying, laughter and humour,
fear and anxiety, and anger and aggression.
With age, emotions become more complex and
differentiated.
Personality and social growth are inuenced by
play. During these years, play is often exploratory,
manipulative or destructive. Playful interactions
with the environment help foster an early sense
of competence. Moreover, children will be
able to observe the effects of their action on the
environment.

caregivers. Attachment starts to form during the


rst year of a childs life. Behaviours that promote
parent-child attachment include holding, touching,
smiling and making eye contact. Four theories try
to explain how attachment occurs:
Behavioural theorystresses that attachment
is learnt.
Cognitive developmental theoryviews the
attachment process as a reection of the infant
developing mental abilities.
Ethological theoryproposes that an infants
social response develops largely through
innate tendencies.
Psychoanalytical theoryputs emphasis
on instincts. That attachment is shaped by
instinctive psychic energy, which at this stage
is directed towards the mother, because she is
perceived as a source of pleasure.
Possible clues to the development of the attachment
are:
The selective social smilesmile directed
only to familiar social stimuli (5-6 months).
Stranger anxietyafter 6 months. A child is
able to distinguish a stranger.
Separation anxietyby 12 months. A child
shows distress when separated from the
caregiver.

Personality development
Freud and Erikson devised theories of personality
development that cover the years of infancy
and toddlerhood. Freud in his psychosexual theory
denes the rst 18 months of life as the oral stage
of development and suggests that the mouth is
the primary source of pleasure and satisfaction to
the developing child. Hence, much of the childs
interaction with the environment is through contact
with the mouth. If there is satisfaction during
the oral stage, there will be normal personality
development and if not, xation will occur.
According to Erickson the two psychosocial
stages of importance during infancy and toddlerhood
are basic trust versus basic mistrust and autonomy
versus shame and doubt. Basic trust versus basic
mistrust occurs during the rst year of life. The
infant learns to deal with the environment through
the emergence of trustfulness or mistrust. Trust
is a feeling that some aspects of the environment
are dependable. It arises if the infants physical
and psychological needs are met. The opposite
is true of mistrust. Autonomy versus shame and
doubt occurs by the age of 1 to 3 years. Infants
become increasingly aware of their environment.
They realise the self is an entity separate from
the environment, hence, their need to exercise
autonomy.

Gender role development


This begins during the years of infancy and
toddlerhood and often reect parental gender
expectation.
Cognitive development theory suggests
that gender role emerges through the childs
growing cognitive awareness of his or her
sexual identity.
Behavioural theory proposes that the
environment conditions stimulate gender
role behaviour through the mechanisms of
reinforcement and punishment.
Social learning theory suggests that the
environment shapes individuals through
modelling and imitation.
Psychoanalytic theory proposes that a child
develops gender roles by interacting closely
with a parent and imitating the parents
behaviour.

Early childhood (2 to 6 years)


Physical development
Physical growth and development during early
childhood are quite rapid though not as in infancy.
The body proportions continue to change and motor
skills become more rened. By age 5 an average
child is 3.5 feet tall and weighs about 43 pounds.
There is no difference in height between the sexes.
By the end of the sixth year, the head has attained

Emotional development
Emotions are described as changes in arousal
levels. They are difcult to measure because

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The African Textbook of Clinical Psychiatry and Mental Health

Piaget referred to the second stage of cognitive


development as pre-conceptual thought. This stage
occurs between 2 to 4 years and is part of the much
longer pre-operational thought stage. Several
cognitive developments occur during this stage
including:
Symbolic functioning: the ability to
differentiate signiers (words and images)
from signicates (the objects or events to
which signiers refer), i.e. an act of reference
where a mental image is created to represent
what is not present. This is commonly
manifested in their new play behaviour.
Egocentrism: a style of thinking that inhibits a
person from seeing another persons point of
view (self-orientation). This is evidenced in
communication (collective monologue) where
they talk to one another, than with one another.
Also in their playparallel play (appearing to
play together, but each in their own play).
Animism: this refers to attributing life to
inanimate objects. They see all objects as
having properties like those of people.
Articialism: the belief that everything in the
world including natural objects and events has
been created by humanity.
Immanent justice: refers to the notion that
the world is equipped with a built-in code or
system of law and order. They try to explain
why something went wrong.

about 90 percent of its adult size and most of its


adult weight. The postural patterns also become
quite evident during the early years. Physical and
psychological factors responsible for this include:
Force of gravitywith age, body proportions
change and the centre of gravity drops lower
at the trunk making it easier for the child to
maintain balance equilibrium.
Type of body buildwhether heavy or light,
and the strength of bones and rmness of the
muscles.
Interaction with the environmentfactors like
nutrition, rest and activity.
Proper nutrition is essential. It enhances cognitive
and quantitative development. Lack of it may cause
retardation.
Motor skill development
The development of motor skills is accelerated
rapidly by such activities as jumping, climbing,
running and riding. Both gross and ne motor
skills advance during early childhood. Gross
motor skills require the co-ordination of large
body parts including such activities as tumbling
and rope skipping. Fine motor skills require the coordination of small body parts, mainly the hand.
Activities include, learning to write, turning pages
of a book and using scissors. Stages of motor skill
development follow the sequence:
Cognitive phasethe child seeks to understand
the motor skill and what it requires.
Associative phaseis characterised by trial
and error learning.
Autonomous
phaseperformance
is
characterised by efcient responses and fewer
errors.
Motor skill development is the product of maturation
and experience. Artwork greatly contributes to ne
motor skill development. By the end of the preschool period, children can produce recognisable
pictures that provide valuable insight into their
development and the perception of surroundings.

Concept development
The development of advanced cognitive skills
relies on the ability to acquire and categorise
new concepts from the environment, including
modications and variations of shape, size, space,
quality and time. Perceptual advances aid concept
development, although the pre-schoolers are
hindered by limited attention and attending skills.
Accurate shape and size discrimination during
childhood results from learning experiences and
is affected by a number of perceptual conditions,
including distance and the relationship between
one object and another. Perceptual discrimination
improves during early childhood, but the accurate
perception of shape and size still remains elusive.
Advancement in understanding spatial relationships
are limited during early childhood, they nd it
difcult to comprehend such spatial discrimination
as near or far. Children are not able to discriminate
quantities logically, independent of misleading
perceptual cues, for instance, more, less, few and
many.

Mental development
Progression of higher order facility is inuenced
heavily by pre-school childrens continuing
mastering of spoken languages. Hence, language
and thought are closely related developmental
processes and reect the youngsters general
cognitive activity. Cognitive advances enable
language development to accelerate, and also
enables the pre-schoolers to think qualitatively. Jean

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Human Development and Life Cycle

Young children refer almost exclusively to the


present before they do the future or the past. Preschoolers also have difculties distinguishing
morning from afternoon and the day of the week.
Usually childrens understanding of time is bound
by the recency of situations. In most cases, they
learn hours, followed by the half hours and then
quarter hours. They are able to name the days
of the beginning and end of the week before the
middle ones.

widespread among them. The amount of anger and


aggression seems to remain stable, but its mode
of expression changes. Undirected physical anger
outbursts begin to decline after the second year.
The use of threats and insults increases. Children
mostly express instrumental aggression (directed
at acquiring objects, territory or privileges).
Factors inuencing anger and aggression include
gender, home environment, imitation, modelling
and reinforcement.

Language development

Family inuences on the developing child

Pre-schoolers are able to fabricate multi-word


sentences, complete with fairly complex syntactical
constructions. They also advance in pragmatic (use
of language in social context) skills during early
childhood. Several factors contribute to their
overall language acquisition:
Familial settings in which a child is reared,
particularly its socio-economic level, is
believed to inuence language development.
Upper and middle class parents are able
to provide proper language instructions,
stimulating environment like reading material
and reinforcements. In the African context
the extended family provides an extensive
opportunity for interaction which accelerates
the learning process.
The course of language development appears
to be related to childrens general intelligence
levels. Children with above average intelligence
begin to talk at an early stage, acquire words
at a rapid pace and use grammatically correct
sentences.
Bilingualism promotes cognitive exibility
and creative expression.
Twins frequently have slower overall rates of
language development compared to singletons.
This could be due to the fact that they may not
have initiative to make their behaviour known
to others and lack of stimulation from parents
who may divide their time between them,
among other factors.

The family transmits appropriate behaviours,


values and knowledge to children and also provides
an emotional setting in which the youngsters can
experience love and acceptance. Certain factors
related to the childs interactions with the family
include:
Sibling relations: represent an intimate
connection, one that teaches the importance
of reciprocity and mutuality, as well as the
sharing of privileges and affection. Unsettled
feelings between siblings may result in sibling
rivalrya form of competition between
children of the same family for the attention of
the parents.
Child discipline: is dened as the teaching
of acceptable form of conduct or behaviour.
Parental discipline can either be authoritarian,
authoritative, permissive or neglecting.
Parents who employ authoritarian control
attempt to shape and control their children
by enforcing a set standard of conduct. The
emphasis is on obedience and use of punitive,
forceful measures. Authoritative control is
characterised by attempts to direct childrens
activities but in a more rational fashion. Firm
control is used, but verbal give and take is
also stressed. Reasons for discipline are also
communicated to the child. Permissive control
is usually non-punitive and parents behave in an
accepting and a formative manner towards the
child without placing any demands. The child
is consulted about policy decision and given
explanation for family rules. The authoritative
method of control appears to produce the most
favourable home climate.
Child maltreatment: can take the form of
physical, sexual and emotional abuse and
neglect or abandonment. Parents may abuse
their children due to pressures from work,
home, nancial difculties, or a history of
maltreatment in the parents background

Emotional development
Emotional reactions and expressions become
highly differentiated during early childhood.
This is due to increasing cognitive awareness,
expanding social horizons and new developmental
challenges. Pre-schoolers exhibit many new
fears, owing to their emotional susceptibility and
because they cannot understand many objects and
events. Fear of darkness and imaginary creatures is

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The African Textbook of Clinical Psychiatry and Mental Health

and low levels of self-esteem. All forms of


maltreatment impact negatively on the child.

elimination and retention of faeces. Adult reaction


during this stage will determine the childs later
behaviour. Parents who force early toilet training
may produce children who are obsessively clean
and neat. On the other hand, parents who neglect
toilet training may produce children who will
later exhibit slovenliness and indifference. Many
children at this age (the terrible twos) resent adult
authority and learn that they can retaliate through
retention of faeces and violent expulsion of them at
inappropriate times.
During the phallic stage (4 to 6 years) children
derive pleasure by manipulating and fondling the
genitals. The Oedipus complex is at work in boys
while girls experience the Electra complex. Boys
start competing unconsciously with their fathers
for their mothers, but due to castration anxiety,
they end up identifying with their fathers. Girls, on
the other hand, compete with their mothers for the
fathers attention. Fixation at this stage can produce
behaviour such as being unable to reach the level
of independence needed to function in society.
Erikson called this stage the initiative versus
guilt (ages 36). Children during this stage set
out to prove they have a will of their own. They
explore their environment and try to satisfy their
curiosity. Accompanying this high energy level are
rapidly developing physical skills, an increased
vocabulary, and the general ability to get around
and do new and different things. All this produces
an active child in pursuit of a variety of goals. If
adults give children an opportunity to exercise
their physical skills, answer their questions and
encourage fantasy, initiative is likely to result.
On the other hand, if children feel their questions
are annoying or a nuisance and that indulgence
in fantasy is a waste of time, guilt is likely to
surface.

School inuences
Early childhood education programmes provide
constructive learning experiences to young
children. They stress the importance of promoting
social, self-help and image skills. They also provide
a healthy learning environment and positive
guidance, discipline and emotional climate that
foster trust and security.
Peer group inuences
Moving from the family and being able to
interact with others is an important criterion of
social maturity. Peer group interaction provides
opportunities for children to further understand
their behaviour and the effect it will have on others.
Early group relations give children an opportunity
to increase their independence, competence and
emotional support. Peer relations may also provide
more complex and arousing sensory stimulations
than those available at home, offer new models of
identication, inuence self-concept development
and alter the character of childrens play. The peer
group during early childhood is quite selective,
usually consisting of individuals of approximately
the same age, who share a common play interest.
Peer groups also discriminate on the basis of
gender. Preference is on same sex playmates. Prosocial behaviour such as co-operation, comforting,
sympathising, sharing, altruism, and helping others
is present.
Play inuences
Play is an important social activity throughout
childhood. Through it children can better understand
themselves and how to relate to others. The
playgroup at this stage is usually small, restrictive
and short-lived. Many groups stop playing after 10
to 15 minutes. There are varieties of play and most
of them give the children the opportunity to develop
muscular coordination. The commonest forms are:
make believe or pretend plays, which encompass
imaginative skills and the socio-dramatic play.
Children play grown-up roles like parents, doctors
and teachers, all which may prepare them for later
life.
According to Sigmund Freud, children pass
through two psychosexual stages at this time: anal
and phallic stages.
During the anal stage (1 to 3 years) children
become aware of their bodys process of
elimination. Pleasure is derived from both the

Middle childhood (6 to 12 years)


Physical development
Physical development on the whole is slow, but
steady. Children gain control and perfect motor
skills. As a result, overall co-ordination, balance
and renement in physical activities increase at
this time. Boys are taller than girls between the
ages of 6 and 8. By age 9, differences in height are
negligible and past the age of 9, the average girl
is taller than the average boy until the adolescent
growth spurt when boys catch up and surpass girls.
The same applies to weight.
There is change in physical appearance as the
rounded, chubby physiques give way to leaner

40

Human Development and Life Cycle

appearances as fat layers decrease in thickness and


change in overall distribution. There are no marked
gender differences in body proportion. Boys have
considerably more muscle tissue than girls who
have more fat than boys. The skeleton continues
to produce centres of ossication. The bones
harden and become more rigid. The circulatory
system grows at a slow pace, although by the
school years, the weight of the heart has increased
to approximately 5 times its birth weight. The
brain nears its mature size and weight. The head
circumference also increases. The weight of the
lungs increases almost 10 times by the end of middle
childhood. Breathing becomes slower and deeper
as the respiratory system works more economically
and shows greater elasticity. The digestive system
matures as reected by fewer stomach upsets. They
can digest a wide range of foods.

o Centringconcentrating on a single
outstanding feature of an object and
excluding its other characteristics.
o Transductive reasoningreasoning from
particular to particular without seeking
generalisation to connect them.
o Transformational reasoningobserving
an event having a sequence of changes to
understand how one state is transformed
into another.
o Reversibilitythe ability to trace one line
of thinking back to where it originated.
Concrete operation (7 to 11 years): The stage
of concrete operation is characterised primarily
by the ability to comprehend as follows:
o Conservationthe amount, quantity or
matter remains the same despite changes
made in its outward physical appearance.
o Classicationthe ability to understand
the concepts of sub-classes, classes and
class inclusion.
o Serialisationability to order objects
according to size.
Children can understand concrete characteristics
of objects, but still cannot understand abstractions.
Their thinking is restricted to the immediate and
physical.

Motor skill development


Both gross and ne motor skills advance at this
period, although the latter proceed at slower rates.
Numerous factors inuence the course of motor skill
attainment: rates of physical maturity, opportunities
to engage in physical activities and levels of selfcondence. Boys typically surpass girls in many
motor skill areas, but such accomplishments must
be placed in proper perspective.
Mental development

Concept development

Children advance in their mental abilities. They


become more systematic and objective, but are still
limited in abstract thinking

Children continue to rene and elaborate their


concepts, particularly those related to:
Shape and size concepts: they show greater
awareness of shape and size concepts and how
they relate to the environment and distance.
Spatial concepts: they have a fairly good
understanding.
Relational concepts: they can reason about
relational concepts such as left or right.
Quantity concepts: by age 8 most children can
add, subtract, multiply, divide and deal with
simple fractions.
Time concepts: they demonstrate an
understanding of clock time, days of the week,
months and seasons.
Concept of death: by pre-school year, ideas
about death become numerous and detailed.
Death-related thoughts and experiences are
expressed in songs, play and questions. Many
pre-school children conceive death as partial,
reversible and avoidable and because of their

Piagets stage of cognitive development


Intuitive thought and concrete operation stages
span the school years.
Intuitive thought stage (ages 4 to 7): This is a
sub-stage of the pre-operational thought stage.
Childrens thinking at this time is characterised
by immediate perception and experience
rather than mental operations. Egocentrism
still exists, but it often changes because of
the childrens cognitive advances. As a result,
these new mental structures release children
from a lower form of egocentrism, but trap
them in a higher form, namely an egocentric
orientation to symbols and the objects they
represent. Symbolic functioning represents an
important cognitive advancement, but other
modes of thought, particularly intellectual
advancement is restricted:

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The African Textbook of Clinical Psychiatry and Mental Health

is greater use of gestures, pauses and facial


expressions.

egocentricity many view themselves as living


forever.
Development of problem-solving abilities

Personality and social development

There is overall improvement in problem-solving


abilities. This is due to cognitive advancement,
developing memory abilities and intrinsic moti
vation. Metacognition (the application of some
cognitive processes to a selected cognitive task)
is also rened at this time. Cognitive styles and
conceptual tempos differ from child to child.

Interactions between the child and society expand


and become more complex in peer group relations,
school activities, sports and family.
Emotional development
There
is
greater
emotional
maturity:
more independence, exibility and emotional
differentiation. The most common emotions
include:
Fear and anxiety: there is a decline in some
fears like darkness. At the same time new fears
emerge most of which relate to family and
school, e.g. test anxiety, and fear of ridicule,
rejection and disapproval.
Anger and aggression continue to be expressed
physically: outbursts like kicking and hitting
are common. Verbal expression of anger is
also common. Generally at this stage children
express greater amounts of hostile aggression
(aggression intended to hurt another person).
Happiness and humour: children express
happiness as a result of acceptance or
accomplishments. They also enjoy listening to
jokes and understand them.
Love is expressed not only through hugging
and kissing, but also through sharing and
talking. This love is extended to animals too.

Learning disabilities
This is the difculty in processing, remembering
or expressing information, which hinder cognitive
development. Some common learning disabilities
include:
Dyslexia: functional limitation in reading.
Dysgraphia: difculty with the physical act of
writing.
Dyscalculia: difculty with calculations.
Language decit: difculty in expressing
oneself verbally.
Auditory decit: difculty in processing
information through the sense of hearing.
Spatial organisation decit: difculty in
perceiving dimensions of space.
Memory decit: trouble remembering facts or
what has transpired during learning episodes.
Attention decit disorder: difculty in
concentrating for extended periods of time.
Attention decit hyperactive disorder:
difculty in concentrating for extended periods
of time together with high levels of excitability
and impulsivity.
Social skills decit: difculty in understanding
elements of social interaction.

Moral development
Moral development advances at this stage. Piaget
emphasises the importance of cognitive
development to morality and identied the premoral, moral realism and relativism stages.
Pre-moral stage (before 5 years): children have
a limited awareness of rules and the reasons
for them.
Moral realism (5-10 years): this is where
some moral judgment begins. Children learn
rules from parents, but do not yet understand
the reasons for them. Instead the rules are
regarded as sacred and untouchable. Children
also feel that punishment compensates for
their transgressions.
Moral relativism (from age 10): children
become aware of both the meaning of rules
and the reasons for them. Rules are regarded
as a product of mutual consent and respect.

Language development
Overall psycholinguistic development continues
and it is especially noticeable in:
Vocabulary and semantic development: word
acquisition rates are rapid, but comprehension
of word meaning and relationships among
words is slow to develop.
Syntactic development: the use of compound
and complex sentences increases, while use of
incomplete syntactic structures decline.
Pragmatics: when speaking, school-age
children became increasingly more adept
at taking their listeners into account. There

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Human Development and Life Cycle

They are also understood in relation to the


principles they uphold.

can comprehend more about their surroundings.


They seek to understand and make things that are
practical to them. Play intermingles with work
and becomes productive and the product is allimportant to childrens self-esteem. Children who
fail to be productive may feel inferior.

Family inuences
Children still need and rely on their parents, but
their boundaries with the outside world expand.
There is need for social independence, as children
want to spend more time outside the family. Many
also want to spend more time doing things on their
own. Children need to experience a favourable
home climate throughout this period. Shared
responsibility is part of this. The television plays
an important role in inuencing the children.
Televised violence may promote aggression in
children. However, controlled television viewing
can be useful for instruction and for enhancing and
enriching lives.

Adolescence
The word adolescence is from the Latin word
adolescere meaning to grow up in maturity.
Physical development
Puberty and sexual responsiveness
Puberty is derived from a Latin word pubertas,
which means age of adulthood. This is the stage
of physical development during which primary
and secondary characteristics mature and people
become capable of having children. It is a gradual
process, which transforms the internal and external
childs body into that of an adult.
Primary sex characteristics are the sexual and
reproductive organs, genitals and internal organs,
e.g. penis, testis, ovaries, fallopian tubes, uterus
and vagina. Secondary sex characteristics: are
the non-genital features, e.g. breast, pubic and
facial hair, broadening of shoulders and waistline,
distribution of fat and voice break. Both primary
and secondary characteristics develop notably
during adolescence.
Hormones account for many changes that occur
at this time. Other factors that may be responsible
for puberty, apart from the hormones include the
brain. As a result of these hormonal changes, limb
lengthening is a signal of growth spurt, which is
also inuenced by sex hormones like testosterone,
oestrogen and progesterone. Both testosterone and
oestrogen direct the development of genital growth
and the reproductive system growth. Sex hormonal
development causes adolescents to be more aware
of sexual feelings, desires, and arousals, which
may lead to dating, mate selection or sexual
intercourse.
Growth spurt is an accelerated rate of physical
growth that occurs just before puberty. It continues
at a lesser rate throughout adolescence. It is one
of the most apparent physical changes of teenage
years, e.g. girls reach physical maturity earlier than
boys. They are superior in height between ages 11
and 13. By age 15 however, boys begin to develop
rapidly and surpass girls both in height and weight.
The skeletal structure of both sexes increases in
height, weight, proportion and composition. Girls
may reach their mature size by age 17, while boys
do so at age 19.

School inuences
Teachers exert a lot of inuence on the child.
They serve as role models. The examples they
set, the tone they establish for peer relations and
the feedback they give to children are important
inuences. The methods of classroom control,
whether democratic, authoritarian or laissez-faire
affect children differently.
Peer group inuences
Interactions intensify at this time. Peer groups are
very selectivesimilar sex; age, social status and
race are criteria for acceptance. Peer groups often
meet certain needs at this time, such as desiring
to be away from adults or in the company of likeminded individuals. Friendships are closer and
more meaningful. Boys are more oriented to groups
while girls are drawn to one-one friendships. Robert
Selman (1981) proposes four stages of friendship:
the playmateship stage (pre-school years), one way
assistance stage (early school years), fair weather
co-operation (latter school years) and intimate and
mutually shared relationships.
Personality development
Freud calls this the latency period (6-11 years).
It is marked by the diminishing of the biological
and sexual drives and is a relatively quiet period
of transition. There are no prominent instinct
urges developing within the child. However,
Freud acknowledges that new skills do emerge.
Paramount among them are skills promoting ego
renement, particularly those that strengthen and
protect the ego from frustrations and failure. These
he called defence mechanisms.
Erickson refers to this stage as the industry
versus inferiority stage (6-11 years). Children
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The African Textbook of Clinical Psychiatry and Mental Health

social appearance, and are attention seekers. The


general problem of early maturation is the need to
adjust to the rapid growth. They tend to feel internal
disharmony and this may have an implication
on their sexual behaviour (begin physical sexual
relationship before they are psychologically
ready).

In females, ovaries increase in size and weight.


Menarche ranges from 10 to 15 years with majority
starting between 13 and 14. Menarche does not
necessarily mean attainment of reproductive
capacity. The subsequent monthly periods may
be irregular and occur without ovulation. Breast
development starts at ages 11 to 12, but can also
start at 14 years. The maturity may take another 3
years or longer. Female pubic hair starts to appear
after the breasts begin to develop. Sex hormones
are mainly responsible for the transformation of
the childs body to an adult shape.
Growth of testis and hormones for most boys,
start to accelerate by age 12. By 18 years, testicular
development is almost complete. Penile erections
are experienced and they increase in frequency and
can happen at any time and anywhere. Production
of seminal uid and rst ejaculation (spermache)
occurs by age 15. Initially, ejaculation has very few
sperms, hence cannot impregnate. Ejaculation of
semen that occurs at night sleep is called nocturnal
emissions (wet dreams). Development of male
pubic hair begins between ages 13 to 14. It starts
at the base of the penis and extend towards the
abdomen. Facial hair develops in a systematic
sequence. Starting from the corners of the upper
lip, then extending on the entire upper lip hence
acquisition of moustache. It starts smooth, but
becomes coarse with age. Later, hair appears on
the upper part of cheek and the middle line below
the lower lip. Finally it develops on the sides and
the borders of the chin. Much later it grows in front
of the ears. Other developments in males include:
increased activity of the sweat glands and marked
voice change. There is deepening of the voice as
a result of the lengthening of the vocal cords and
growth of the voice box (larynx).
Pronounced puberty changes affect adolescents
psychologically in the way they perceive
themselves and their pre-occupation with the
changes, especially on primary and secondary
sex characteristics. They must adjust to growth
spurt changes (therefore need help). The positivity
or negativity with which the adolescents view
themselves will greatly affect how they ultimately
evaluate themselves, e.g. menstruation, wet dreams,
erection, body size and organ size.
Generally, adolescents report higher levels of
personal satisfaction when they mature early than
late. Early maturers are more independent, self
condent, reliant and popular. This gives them a
positive body image. Late maturers have a poor
self-concept, are overly concerned about their

Motor development
There is an exhibition of steady increase in
strength, reactions and co-ordination abilities.
Males continue to surpass females in overall motor
skill development. Men have larger muscles and
are able to develop more force per gram of muscle
tissue. Hence, men are good in accuracy, speed and
overall body control, especially in activities that
call for endurance.
Mental development
Piagets formal operations cover the period from
11 to 15 years. It is a stage characterised by
new ways to understand and explore the world.
Entry into this stage is gradual and sometimes
unpredictable. Individuals may reach peak levels
of cognitive functioning in certain areas but not in
others. Childhood mental processes and operations
diminish, e.g. concrete operation.
Formal operation signies crystallisation and
integration of all previous cognitive stages.
Thinking becomes extremely rational and continues
to be rened in adulthood. Individuals can deal with
abstraction and hypothesis; can solve a problem by
providing alternatives, i.e. cognitive development
is exible. They can think about identity and their
future, because of the abstract reasoning power.
They, therefore, can think about occupational and
social roles. They are capable of generating new
ideas about themselves and life in general. Debates
are possible about a variety of issues, such as
politics, relationships, morals, legal issues, human
rights and ideal society. Important is the problem
solving strategy of adolescents through deductive
and inductive reasoning. Deductive is drawing
conclusions from sets of premises, syllogism (a
deductive inference consisting of two premises and
a conclusion), e.g. Tom is a man. Man is a mortal.
So Tom is mortal. Inductive means generalising
from specic, e.g. morality being generalised to a
harmonious society.
Language development
Language development improves. They ascend into
heights of language understanding and use, e.g.

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Human Development and Life Cycle

understand symbols, metaphors, word meanings,


similes, idioms, and characterisation.

development in early adulthood is both qualitative


and quantitative.

Adolescence egocentrism

Qualitative mental dimension

This is a form of self-centeredness characterised


by what people are thinking about them and hence,
conceptualising own thoughts and at the same time
concern with other peoples thoughts resulting
in self-consciousness. Two types of thinking
(consequences) result: imaginary audience and
personal fable.

This can be referred to as post-formal


reasoning. Dialectical thought is a kind of
thinking that allows an individual to appreciate
contradictions and opposites. Adolescents have
tendencies of thinking that there is only one correct
answer to every problem, hence very subjective.
Adults see things as relative and non-absolute.
They begin to accept and respect the diversity of
opinion and the rights of others. Hence, they are
said to have a relativistic perspective. Young adults
also start deep reasoning, i.e. can deal well with
myths, metaphors and paradox (pragmatics).

Imaginary audience
It is a delusion that other people are concerned
about how adolescents behave and look. They feel
as though they are the centre of focus. They may
talk loudly, show off, walk in individualistic styles
and dress prominently. Imaginary audience can
make them feel elated or deated depending on the
situation and audiences. They are self-critical, but
also self-admiring.

Quantitative mental dimensions


Longitudinal studies show that there is a quantitative
mental change during adulthood. A study done to
test the hypothesis whether intelligence changes
with age found that:
Crystallised intelligence and visualisation test
scores improved with age.
No age-related change was found in cognitive
exibility.
Visual motor exibility demonstrated
signicant decrease with age (Baltes).
The ndings dispel the myth of intellectual decline
during middle and old age. Therefore, intellectual
functioning is characterised more by stability than
change and discontinuity in adult life. Therefore,
people with above average intelligence can improve
or maintain their ability until latter adulthood,
whereas adults with average intelligence may
experience a decline in some mental capacities.
Adulthood marks a time when individuals can
sustain or increase their qualitative and quantitative
mental capacities, because with advancement of
age, adults have acquired practical insight into life,
considerable real world learning, good judgment,
discretion and wisdom.

Personal fable
These are stories that adolescents fabricate and
tell about themselves. It reects their conviction
of personal uniqueness and immunity. They feel
invulnerable (nothing bad can happen to them),
e.g. cannot die, get pregnant or contract a disease.
Egocentrism diminishes by the end of adolescence,
because experience makes them realistic.

Early adulthood (20-40 years)


Physical development
Quality and quantity increment in early childhood
is noticeable during this stage. The child gives
way to the appearance of a young adult and has
a lot of vitality. They are very attractive. Muscle
growth is complete and increases in strength up to
approximately 30 years. The heart and its blood
network (circulation) mature.
Motor development
From age 30, there tends to be an increase of fatty
tissue as compared to muscle tissue. Young adults
can participate in all sorts of activities, especially
between 20 and 30 years. These activities can take
place for a decade if they do not smoke or drink
and if they feed properly and exercise.

Personality and social development


Adult maturity
Gordon Allport postulates that maturity is an
on-going process characterised by a series of
attainments:
Extension of the self (to encompass multiple
facets of the environment).
Relative
warmth
to
others
(social
development).
Emotional security.

Cognitive development
Cognitive development is a systematic and
complicated problem-solving activity. New
levels of creative thoughts are achieved. Mental

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The African Textbook of Clinical Psychiatry and Mental Health

Realistic perception (the mature mind is able


to perceive the surroundings accurately).
Knowledge of self (self-insight). This can be
explained as knowing what one can and cannot
do.
Possession of skills and competences (all
facets of behaviour, i.e. physical, cognitive,
emotional, social and moral).
Establishing a unifying philosophy of life
(which embodies concepts over-guiding
purpose, ideals, needs, values and goals.
Erikson called this stage the intimacy versus
isolation stage. This means that early adulthood
is a time of intimate relationships. This will only
be achieved after solving the identity crisis of
adolescence. Individuals who know themselves
stand better opportunities of having intimate
relationships.
According to Daniel Levinsons theory (1978)
people are divided into eras, i.e. young and middle.
Each era consists of developmental periods marked
by distinct biopsychosocial tenets. He says there
is a transition period between these eras. The
transitions sometimes overlap. He describes 8 eras:
pre-adulthood. (0-22 years), early adulthood (1725), early adulthood transition (17-22), entry life
structure for early adulthood (22-28), transition
to middle adulthood (28-38), culminating life
structure for early adulthood (33-40), middle life
transition (40-45) and middle adulthood (40-45).
These transitions overlap and prepare an individual
to end one era and enter into the other.

The skin starts thinning, because of the sun,


age, cosmetics and less efcient blood circulation.
The face exhibits a lot of change, e.g. wrinkling
becomes the inevitable sign of aging; complexion
also changes and skin cancer is common; hair
becomes grey, begins to thin and replacement
becomes very slow. Hair loss is more pronounced
among men.
The cardiovascular system slows down by about
20 percent by age 50. There is general increase in
blood pressure and hardening of arteries; nervous
system decrease is negligible; respiratory system
decreases (75 percent at middle age compared to
100 percent at age 30), because of loss of lung
elasticity, the thorax becomes shorter, and chest
muscles become stiff and weaker. Inactivity makes
this worse. Vision starts to change; hearing starts
declining by age 40; health disorders are common;
obesity, hypertension, arteriosclerosis, cholesterol,
coronary artery diseases, cancer, osteoporosis and
arthritis. Menopause occurs at this stage and is
associated with decrease in oestrogen.

Middle adulthood (40-65 years)

Social and personality development

It is the longest life cycle and has numerous


challenges including old parents, rebellious
adolescents, politics, divorce and retirement.

In love and marriage, if all is well, marriages will


be stable. This stability comes from few nancial
worries, less household chores, more time with
each other, and adjustment to each others needs.
If not, divorce, and diverse marriage problems are
experienced.
Sherman indicates that empty nest syndrome
is experienced by those parents who lived a life
centred around the children. Parents are advised
to let go quite early. The opposite is true in the
western world where marital partners have more
time even to pursue academics and travel.
Research shows that sibling relationships persist
over the entire life cycle for most adults. There are
three types of sibling relations: extremely close
siblings, apathetic (indifferent) siblings and highly
revolting siblings. Most siblings are very close.
Close siblings were also the same in childhood.
Personality characteristics such as attitudes and

Mental development
Fluid intelligence is mental organisation and
re-organisation of information like in problemsolving. While this decreases with time, crystallised
intelligence increases over time. Sensory motor
change little with time. Short-term memory
declines slightly, especially when new information
is added, but there is signicant decline in longterm memory. This is because encoding and
retrieval processes become less efcient with age.

Physical development
Physical growth and development for the majority
ends by early adulthood. Some individuals are
able, however, to improve on or sustain muscle
strength during middle adulthood. Most individuals
experience a slight loss due to decrease of body
muscle bres and gradual loss of the lean body
mass, and increase of subcutaneous fat. A slight
decrease in stature begins to occur, because there
is compression of the spinal column and disc
changes. Continued vitality is possible in this stage
by keeping physically t, proper nutrition and
lifestyle, medical care, good sleep, and avoiding
stress, drinking and smoking. This slows down the
aging process.

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Human Development and Life Cycle

values seem to be replicated, i.e. carried on to


the next generation. Relationships are transmitted
across generations. Elder shows that children
whose parents had a high degree of marital conict
and who were unaffectionate subsequently had
tension in their own marriage and were ineffective
in disciplining their own children.
Middle-aged individuals play an important
role in intergenerational relationships, e.g. while
they are parents to a very demanding groupthe
adolescents and young adults, they are also sons
and daughters to another demanding group, their
aged parents. Stress can result in couples if they do
not realise this.

Death and dying


Death can and does occur at any stage. However,
old people are more aware of its eminence. Old
people are less afraid of death than others. Cultural
beliefs inuence the way people perceive and react
to dying and death. In the African culture there is a
lot of fear of the spirit world and death is also seen
as a taboo.
The dying patient
Elizabeth Kubler-Ross (1969) organised her theory
after interviewing dying patients. According to
her the dying process consists of ve interrelated
stages. She also says individual differences occur
where some may skip a stage, others may not go
through the stages in the given order, others may
get stuck in a particular stage. For others, the ve
stages may overlap:
Denial: this is where people may react with
shock, disbelief and denial.
Anger: when denial is no longer successful,
the patient experiences feelings of anger, rage,
envy or resentment.
Bargaining: the patient hopes that death can
be delayed and may promise God to do many
things if allowed to live.
Depression: as patients continue to experience
physical deterioration, they are engulfed
with a sense of great loss, hence, experience
depression. Two forms of depression may
surface: reactive depression (reacting to a loss
that has already occurred e.g. amputation) and
preparatory depression (depression in response
to impending loss or death).
Acceptance: this stage allows the dying to
express their feelings, settle and wait for their
death with quiet expectations. It is a period
almost devoid of feelings and patients may
request to be left alone most of the time.
Communication becomes more non-verbal
than verbal.
These stages may also apply to the bereaved.

Late adulthood (ages 65 years and above)


This is a new concept in psychology, because
people used to die early (before 65 years).
Physical development
There is great decline in body functions, i.e.
cardiovascular, vision, and hearing. Illnesses are
common and sexuality declines.
Cognitive development
Crystallised intelligence (based on cumulative
learning) increases throughout life, while uid
intelligence (ability to perceive and manipulate
information) starts to decline. Cognitive skills can
be kept alive through mnemonics (use of imagery).
Old people who are prepared to retire adjust better.
Such are healthy, have saved, are active and have a
healthy social network of friends and family.
Social and personality development
Erikson views this as a time of looking back at what
one has achieved in life. Through many different
routes, this person may have developed a positive
outlook in each of the preceding periods.
Mental health
Many old people may suffer from depression and
diseases that may affect their mental health, causing
brain cells to deteriorate.

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The African Textbook of Clinical Psychiatry and Mental Health

9
Personality and Personality Traits
Ruthie Rono, Lincoln Khasakhala, David M. Ndetei

Sanguine: individuals who had an abundance


of blood; they tended to be cheerful, optimistic
and active.
Phlegmatic: people who were listless, sluggish
and tired, because they had less phlegm.
Melancholic: people who were always sad,
brooding with melancholic temperaments
resulting from too much bile.
Choleric: people who were easy to excite and
also easy to anger, because of excess yellow
bile

DEFINITIONS
Personality may be dened as a distinctive and
relatively consistent way of thinking, feeling and
behaving that characterise a persons responses
to life situations. An individuals personality
comprises three components:
Components of identity that distinguish that
person from other people.
The behaviour is caused primarily by internal
rather than environmental factors.
The persons behaviour patterns seem to t
together in a meaningful fashion, suggesting
an inner personality that guides and directs
behaviour.
Distinctive behaviour pattern helps dene the
persons identity. People seem to behave somewhat
consistently over time and across different
situations.

These terminologies are still used as descriptive


adjectives by typologists, psychologists and
psychiatrists.

Trait theories
Allports cardinal, central and secondary trait
theory
Personality characteristics are unique attributes
of the individuals personal dispositions which
account for the consistency in pattern of behaviour
among individuals. Personality traits are thus
enduring patterns of perceiving, relating to and
thinking about the environment and oneself that
are exhibited in a wider range of contexts. The
traits unite a persons unique pattern of response
to a variety of environmental events. When
personality traits are inexible and maladaptive,
they will cause signicant functional impairment
or subjective distress to the characteristics of the
individual. There are three types of traits that

PERSONALITY THEORIES
What makes one person different from another? The
ancient Greeks thought the answer had something
to do with the four body uids, humours; blood,
phlegm or black and yellow bile. According to the
Greek physician Hippocrates (460-371 BC), there
are four possible personality types:

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Personality and Personality Traits

Personality traits characterise individuals


customary ways of responding to their world.
Our personalities are also exible due to
learning from experience and trying out various
responses to see which ones are more effective
(as we interact with our surroundings). People
who suffer from a personality disorder usually
do not have this exibility.

operate in individuals to provide a persons own


unique personality structure:

A cardinal trait: a powerful dominating


behaviour predisposition that provides the
pivot point in a persons entire life; such as
competitiveness, hatred, cruelty, loss and
reverence for life.
Central trait: this is present among all people,
forming major characteristics of personality,
such as sensitivity, honesty and generosity,
versus insensitivity, dishonesty and mean.
These are enduring and forming the building
blocks of personality.
Secondary traits: these are less generalised
and enduring; they affect individual behaviour
only in specic circumstances, such as the
dressing style, preferences or patterns of
exercises. They are changeable according to
environmental events.

THE DIFFERENT PERSONALITY


THEORIES
The psychodynamic perspective
Freuds psychoanalytic theory
According to Freud, the personality is divided
into three structures the Id, the Ego and
the Superego.

Cattells sixteen personality factor theory

The Id

According to this theory, individuals have different


dimensions of personality which are obvious,
called source traits, such as integrity, friendliness
and tidiness. These dimensions can be measured
in every day situation (life records) using a 16
personality factor (16PF) questionnaire to obtain
data of personality characteristics. After analysis,
the results are clustered, probably each cluster
indicating the operation of a single underlying
trait.
Trait theories offer the distinct advantage of
providing specic methods for measuring or
addressing basic characteristics that can be used
in comparing individuals. These theories share
the common assumption that traits may be used
to explain consistencies in behaviour and explain
why different people tend to react differently to the
same situation.

The Id exists within the unconscious mind. It is


the innermost core of personality and the only
structure present at birth. The Id is the source of all
psychic energy. It has no direct contact with reality
and functions in a totally irrational manner.
It operates according to the pleasure principle
(seeks immediate gratication or release regardless
of rational considerations and environmental
realities) and cannot directly satisfy itself by
obtaining what it needs from the environment (no
contact with the outer world).
In the course of development, a new structure
develops out of the Id (that has direct contact with
reality).
The Ego
The Ego functions primarily at a conscious level. It
operates on the reality principle, by testing reality
to decide when and under what conditions the Id
can safely discharge its impulses and satisfy its
needs. Sexual gratication within a consenting
relationship, for example, rather than allowing the
pleasure principle to dictate an impulsive sexual
assault.

Components
Temperament is the how of behaviour
and a biologically-based general style of
reacting emotionally and behaviourally to the
environment. Examples are: calm and happy,
irritable and fussy, outgoing and active, and
shy and inactive.
Character is the what of behaviour.
People tend to react in their own predictable
and consistent way. These consistencies
(personality traits) may be the result of
inherited characteristics, learned responses or
a combination of the two.

The Superego
This is the last personality structure to develop (age
4 or 5). It is the moral arm of the personality and
contains traditional values and ideals of society.
Ideals are internalised by the child through
identication with parents, who also use

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The African Textbook of Clinical Psychiatry and Mental Health

important ways by stressing social and cultural


factors in personality development. Modern
object relations theorists focus on the mental
representation that people form of themselves,
others and relationships.

reinforcement and punishment to teach the child


what is right and what is wrong. Like the Ego,
the Superego strives to control the instincts of
the Id (especially sexual and aggressive impulses
that are condemned by society).
The dynamics of personality involve a continuous
conict between impulses of the Id and counter
forces of the Ego and Superego. When dangerous
Id impulses threaten to get out of control or when
danger from the environment threatens, the result
is anxiety. To deal with the threat, the Ego may
develop defence mechanisms, which are used to
ward off anxiety and permit instinctual gratication
in disguised forms.
Defence mechanisms deny or distort reality.
Some defence mechanisms permit the release of
impulses from the Id in disguised forms that will
not conict with forces in the external world or
with prohibitions of the Superego. The major
defence mechanisms are:
Repression: pushing into the unconscious
mind.
Denial: refusing to acknowledge anxietyarousing aspects of the environment.
Displacement: repressing an undesirable
impulse and then directing it at a safer
substitute target.
Intellectualisation: repressing an upsetting
event and treating the situation as an
intellectually interesting event.
Projection: repressing unacceptable impulse,
then attributing to and projecting onto other
people.
Rationalisation: constructing a false, but
plausible explanation for an anxiety-arousing
behaviour.
Reaction formation: repressing an anxietyarousing impulse, then releasing an exaggerated
expression of the opposite behaviour.
Sublimation: releasing a repressed impulse in
the form of a socially acceptable behaviour.

The humanistic perspective


This puts emphasis on the subjective experiences
of the individual and thus deals with perceptual
and cognitive processes. Self actualisation is
viewed as an innate positive force that leads people
to realise their positive potential if not thwarted by
the environment.
Carl Rogers Self Theory
This theory attaches central importance to the
role of the self (an organised, consistent set of
perceptions and beliefs about oneself). The self
plays a powerful role in guiding our perceptions
and directing our behaviour. At the beginning of
their lives, children cannot distinguish between
themselves and their environment. They begin to
distinguish between the me and the not me as
they interact with their world.
There is need for self-consistency (an absence of
conict among self-perceptions) once self concept
is established and for congruence (consistency
between self-perceptions and experience). Experiences that are incongruous with the established
self-concept are a threat and may result in denial or
distortion of reality.
People are born with an innate need for positive
self-regard (acceptance, sympathy and love from
others). Positive regard is essential for healthy
development. Unconditional positive regard
implies that the child is inherently worthy of love.
Conditional positive regard is dependent on how
the child behaves.
Rogers described a number of characteristics
of the fully functioning person, such as feeling a
sense of inner freedom, self-determination, choice
in the direction of growth and no fear of behaving
spontaneously, freely and creatively. Rogerss
theory helped stimulate a great deal of research on
the self-concept including studies on the origins and
effects of differences in self-esteem, enhancement
and verication motives, and cultural and gender
contributions to the self concept.

Criticism of the psychoanalytic theory


A major shortcoming of the psychoanalytic theory
is that many of its concepts are ambiguous and
difcult to operationally dene and measure. How
can we measure the strength of an individuals Id
impulses, unconscious Ego defences and study
processes that are unconscious and inaccessible to
the person? However, inaccessibility to something
does not imply that it is non-existent. Neoanalytic
theorists modied and extended Freuds ideas in

Criticism of the Self Theory


Humanistic view relies too much on individuals
reports of their personal experiences. It is
impossible to dene an individuals actualising

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Personality and Personality Traits

unstable and emotionally reactive behaviour pattern


that involves moodiness, anxiety and depression.
Prediction studies indicate that the larger
number of more specic traits may be superior for
prediction of behaviour in specic situations.
However, traits have not proved to be highly
consistent across situations. They vary in stability
over time. Individuals differ in their self-monitoring
tendencies, and this variable inuences the amount
of cross-situational consistency they exhibit in
social situations.
Traits interact not only with situations,
but also with one another, thereby producing
inconsistency.

tendency, except in terms of the behaviour that it


supposedly produces.

Trait and biological perspective


Trait theorists
Trait theorists try to identify and measure the
basic dimensions of personality. They disagree
concerning the number of traits needed to
adequately describe personality. Cattell suggested
16 basic traits (personality dimensions).
Reserved
versus
Outgoing
Less intelligent
versus
More
intelligent
Affected by feelings versus
Emotionally
stable
Submissive
versus
Dominant
Serious
versus
Happy-golucky
Expedient
versus
Conscientious
Timid
versus
Venturesome
Tough minded
versus
Sensitive
Trusting
versus
Suspicious
Practical
versus
Imaginative
Forthright
versus
Shrewd
Self-assured
versus
Apprehensive
Conservative
versus
Experimenting
Group-dependent
versus
Self-sufcient
Uncontrolled
versus
Controlled
Relaxed
versus
Tense
Other theorists insist that as few as ve may
be adequate: openness, conscientiousness,
extraversion, agreeableness and neuroticism.
Eysenck suggests two major dimensions:
introversion-extraversion, sociable, active and
willing to take risks versus a tendency towards
social inhibition, passivity and caution.

Biological perspectives on traits


These state that there are differences in the
nervous system. Introversion-extraversion and
stability-instability are linked to the differences in
individuals normal pattern of arousal within the
brain (Hans Eysenck).
The biological perspective supports the possible
role of evolution in the development of universal
human traits and ways of perceiving behaviour. In
addition, studies comparing identical and fraternal
twins reared together or apart indicate that genetic
factors may account for as much as half of the
variance in personality test scores. Individual
experiences account for the rest.
Researchers are exploring relations between
personality factors and health. Evidence exists for
a Type A personality that is a risk factor in coronary
heart disease, a Type C cancer-prone pattern, and
the roles of optimism and conscientiousness in
promoting health and longevity.

Social cognitive theories


These are concerned with how social relationships,
learning mechanisms and cognitive processes
jointly contribute to behaviour. A key concept
is reciprocal determinism, relating to two-way
causal relations between personal characteristics,
behaviour and the environment.

Table 9.1
Introversion

Extraversion

Retiring
Reserved
Likes solitary activities
Does not attend parties

Outgoing and talkative


Wants many friends
Dislikes solitary
activities
Enjoys parties
Dominates social
situations

Reciprocal determinism
Person: personality characteristics, cognitive
processes and self-regulation skills.
Environment: stimuli from social or
physical environment and reinforcement
contingencies.
Behaviour: nature, frequency and intensity.

Stability-instability (neuroticism): represents a


continuum from high emotional stability to an

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The African Textbook of Clinical Psychiatry and Mental Health

live under great pressure


demanding of themselves and others
have an exaggerated sense of time urgency
become very irritated at delays or failures to
meet their deadlines
tend to schedule more and more activities in
less and less time
try to do several things at once.
Type A men and women have about double the risk
of coronary heart disease (even when other physical
risk factors, e.g. obesity and smoking are taken into
account). However, not all components of the type
A pattern increase vulnerability to CVD.
The crucial component here seems to be negative
emotions. In addition, a cynical hostility marked
by suspiciousness, resentment, frequent anger,
distrust and antagonism seems to be particularly
important. They over-react physiologically to
events that arouse anger.

Rotters theory
Rotters theory views behaviour as inuenced
by expectancies and the reinforcement value of
potential outcomes as follows:
Expectancies: our perception of how likely
it is that certain consequences will occur if
we engage in a particular behaviour within a
specic situation.
Reinforcement value: basically how much we
desire or dread the outcome that we expect the
behaviour to produce.
Rotters concept of locus of control is a generalised
belief in the extent to which we can control the
outcomes in our life as follows:
Internal locus of control: people with an internal
locus of control believe that life outcomes are
largely under personal control and depend
on their personal behaviour. Internal locus of
control is positively related to self-esteem,
feelings of personal effectiveness, coping with
stress in a more active and problem-focused
manner versus externals, and less likelihood
to experience psychological maladjustment
(depression, anxiety).
External locus of control: people with an
external locus of control believe that their fate
has less to do with their own efforts than with
the inuence of external factors (chance, luck,
powerful others).

Type B personality
These individuals tend to be coronary-disease
resistant. They are:
more relaxed
more agreeable
have far less sense of time urgency.

Type C personality
These have a cancer-prone personality. They are:
highly sociable and nice people
very inhibited in expressing negative emotions.
Bottling up such emotions (anger or anxiety)
seems to get in the way of active coping
tend to feel helpless and hopeless in the face of
severe stress
passive, uncomplaining and compliant.

Banduras concept of self-efcacy


This is considered a key factor in how people
regulate their lives. It relates to our self-perceived
ability to carry out the behaviour necessary to
achieve goals in a particular situation and believes
that people whose self-efcacy is high have
condence in their ability to do what it takes to
overcome obstacles and achieve their goals.

PERSONALITY TYPES
(FRIEDMAN AND ROSENMAN)

PERSONALITY DEVELOPMENT
Personality develops through the interaction
of hereditary dispositions and environmental
inuences. Children grow physically, mentally,
socially, emotionally and form attachments and
relationships.

Type A personality
These are at risk of developing cardiovascular
disease (CVD). They are:
aggressive
usually in a hurry
have high levels of competitiveness and
ambition

Ericksons psychosocial theory


Personality develops through confronting a series
of 8 major psychosocial stages. Each stage involves

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Personality and Personality Traits

Integrity versus despair

a different crisis or conict over how we view


ourselves in relation to other people and the world.
Each crisis is present throughout life, but takes on
special importance during a particular age period.

This marks the nal crisis and usually occurs


during late adulthood (over 60). Older adults review
their life and evaluate its meaning. The person
experiences integrity (a sense of completeness and
fullment), if the major crises of earlier stages have
been successfully resolved. Older adults who have
not achieved positive outcomes at earlier stages
may experience despair, regretting that they cannot
relive their lives in a more fullling way.

Psychosocial stages of personality development


Basic trust versus basic mistrust
During the rst year of life we depend totally on
parents or other caretakers. Whether we develop
basic trust or mistrust depends on how adequately
our needs are met and how much love and attention
we receive.

Freuds psychosexual theory of personality


development

Autonomy versus shame and doubt

It states that personality is powerfully moulded


by experiences in the rst years of life. Children
pass through a series of psychosexual stages during
which the Ids pleasure-seeking tendencies are
focused on specic pleasure-sensitive areas of the
body (erogenous zones). Potential deprivations
or overindulgences can arise during any of these
stages, resulting in xation (a state of arrested
psychosexual development).
The adult personality is basically moulded by
how children deal with instinctual urges and social
reality during the oral, anal and phallic stages as
follows:

During the next two years, children become


ready to separate themselves from their parents
and exercise their individuality. If parents unduly
restrict children, or make harsh demands during
toilet training, children develop shame and doubt
about their abilities and later lack the courage to be
independent.
Initiative versus guilt
Ages 3-5 display great curiosity about the world.
Children develop a sense of initiative if allowed
freedom to explore and receive answers to their
questions. They can develop guilt about their
desires and suppress their curiosity if they are held
back or punished.

The oral stage: during infancy


Infants gain primary satisfaction from taking in
food and from sucking on a breast, thumb or some
other object. Excessive gratication or frustration
of oral needs can result in xation on oral themes
of self indulgence or dependency as an adult.

Industry versus inferiority


At ages 6-12 life expands into school and peer
activities. Children who experience pride and
encouragement in mastering tasks develop industry
(a determination to achieve). Repeated failure
and lack of praise for trying leads to a sense of
inferiority.

The anal stage: second and third years of life


Pleasure becomes focused on the process of
elimination. The child is faced with societys
rst attempt to control a biological urge (during
toilet training). Harsh toilet training can produce
compulsions, overemphasis on cleanliness, and
insistence on rigid rules and rituals. Extremely
lax toilet training results in a messy, negative and
dominant adult.

Intimacy versus isolation


Young adults (20-40) develop intimacy, that is, the
ability to open oneself to another person and to
form close relationships. Many people form close
adult friendships, fall in love and marry.
Generativity versus stagnation

The phallic stage: 4 or 5 years

One achieves generativity by doing things for


others, exercising leadership and making the world
a better place (through their careers, volunteer
work, raising children, or involvement in religious
and political activities). Many young adults also
make such contributions to society, but generativity
typically becomes a more central issue later in
adulthood (40-60).

At this stage, children begin to derive pleasure from


their sexual organs. The male child experiences
erotic feelings towards his mother, desires to
possess her sexually and views his father as a rival.
These feelings arouse strong guilt and a fear that
the father might castrate him (castration anxiety).
This conicting situation is the Oedipus complex.

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Girls discover that they lack a penis and blame


the mother for their lack of the more desirable sex
organ. The female version of the Oedipus complex
is the Electra complex.
The phallic stage is a major milestone in the
development of gender identity as children normally
resolve these conicts by repressing their sexual
impulses and they move from a sexual attachment
to the opposite-sex parent to identication with the

same sex parent, boys taking on the traits of fathers


and girls those of their mothers.
The latency stage: about 6 years of age
Here, sexuality becomes dormant for about 6 years
and will re-emerge in adolescence as the beginning
of a life-long genital stage. Erotic impulses nd
direct expression in sexual relationships.

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10
Human Learning
Caleb Othieno, Ruthie Rono, David M. Ndetei

changes, but also to develop teaching and treatment


methods in schools and clinical settings. Behaviour
therapy is developed as a result of these theories.
The main theories of learning are:
Classical conditioning (Pavlovian)
Operant learning (Skinnerian)
Social learning
Cognitive learning
Biologic learning.

DEFINITION
Learning refers to the relatively permanent change
in a persons behaviour brought about by repeated
experiences. The laymans view of learning may
be narrowthat of only learning of facts by
heart, or the acquisition of skills such as typing
and driving. However, in this denition, any
change is includedchanges in social behaviour,
language and other communication skills and
feelings of emotional expression, attitudes and
beliefs. Learning is not always intentional nor
is the learner even always aware that it is taking
place. Experience refers to the events in the
social and the physical environment of the learner
and is specied in order to exclude changes due to
maturation, senility, injury or illness. Relatively
permanent distinguishes between learning and the
performance of what is learned. Learning can only
be measured by observing behaviour. It cannot be
measured directly. Note that performance can be
inuenced by factors such as motivation, anxiety
and fatigue.

Classical conditioning (Pavlovian)


Ivan Pavlov, a Russian physiologist in the earlier part
of the 20th century demonstrated that dogs could be
conditioned to salivate in response to new stimulus,
such as a ringing bell or light, if this had been paired
or presented together with food several times. The
food is the unconditioned stimulus (US) and the bell
the conditioned stimulus (CS).

LEARNING THEORIES
The main learning theories are the classical
and operant conditioning. Some argue that classical
conditioning may be a variant of operant conditioning.
The learning theories have not only been used to
understand and explain normal human behaviour

Food
(unconditioned
stimulus)

salivation
(unconditioned
response)

Bell or light
paired with food

salivation

Bell (conditioned
stimulus, CS)

salivation
(conditioned
response, CR)

Laws of classical conditioning


The main effect of classical conditioning is to
increase the number of different stimuli that can

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The African Textbook of Clinical Psychiatry and Mental Health

elicit a given reex or response. The CS must


precede the US by a very short period of time for
this type of learning to occur. The optimal length
varies with different CS-US combinations and with
different responses, but is often approximately
0.5 seconds. If the US-CS interval is too long, no
conditioning will occur and if the US precedes the
CS, conditioning does not usually occur. Classical
conditioning is a very simple form of learning and
has been demonstrated in atworms and decorticate
specimens. Therefore, conditioning can occur
without the learner being aware of the connections
between the CS, UR and US. In humans, however,
awareness may increase the effectiveness of
the conditioning procedure. Built-in or innate
characteristics of the animal also determine the
type of behaviour that can be conditioned.

to a red light. Alternatively, a circle and a square


drawing may evoke similar responses in an
organism.
Second order conditioning
When an organism has been conditioned, the
CS can act as an US and in turn be paired with
another new US to elicit similar responses in the
organism.
Discrimination
This refers to the process where one recognises the
difference between similar stimuli. Conditioned
discrimination is brought about through selective
reinforcement and extinction. A child, for example,
gradually learns that not all four-legged animals
are dogs. Experimental neurosis was described
as arising when an animal nds it increasingly
difcult to distinguish or discriminate between two
stimuli.

Acquisition
Each paired presentation of the CS and the US
is called a trial. The period when the organism is
learning the association between the CS and the
US is called the acquisition stage.

Operant conditioning (Skinnerian or


instrumental learning)
Thorndike in 1898 demonstrated that a cat
placed in a cage could be conditioned through
trial and error to learn how to deliberately press
a lever that delivers food pellets outside its cage.
The American psychologist, Burrhus Frederic
Skinner, later comprehensively studied this type
of associative learning. The learning in this case is
under the control of the individual, who operates or
inuences the environment, hence, the term operant
conditioning. The effect of operant conditioning is
to change the frequency with which an aspect of
behaviour occurs in a given setting. The frequency is
inuenced by the consequences of the behaviour. A
rat placed in a box with levers, accidentally presses
one that delivers food (the reward). Thereafter,
it will learn to do so when hungry. It might
continue doing so even in the absence of a reward.
Alternatively, a desired response may be made to
occur as best as possible and then the behaviour is
rewarded. The behaviour will eventually fade off if
it is not rewarded, every now and then. In real life
situations, a reward might be in the form of money,
praise, approval or certain privileges. In substance
use and addiction the reward is brain stimulation.
Various schedules may be used in reinforcing the
desired behaviour:
Fixed ratio, where reinforcement occurs after
a xed number of non-reinforced responses,
e.g. 20:1.

Reinforcer
Repeated pairing of the CS and the US strengthens
or reinforces the association between the two.
Varying time intervals
In simultaneous conditioning the CS begins a
fraction of a second or so before the onset of
the US and continues with it until the response
occurs. Hence, it is necessary to omit the US in
some trials to see if the conditioning has occurred.
Experiments show that learning is fastest when the
CS is presented about 0.5 seconds before the US
(delayed conditioning). In trace conditioning the
CS is presented rst and then removed before the
US starts (only a neural trace of the CS remains
to be conditioned).
Extinction or internal inhibition
If the conditioned stimulus is presented repeatedly
without being paired with food, the strength of the
response will gradually decline. This is known
as extinction.
Stimulus generalisation
An organism conditioned to respond to a certain
stimulus will respond to other similar stimuli in
the same way; a dog that has learned to respond
to yellow light will also respond in the same way

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Human Learning

Fixed interval, where reinforcement is done at


xed intervals of time.
Variable ratio, where reinforcement ratio is
varied constantly.
Variable interval, where the time between
reinforcements is varied.
Schedules of reinforcement have a powerful
effect on the strength of the learned behaviour.
Other factors include characteristics of the learner
and the n ature of the reinforcer. Behaviour that
is learned under intermittent reinforcement is
more resistant to change and better learned than
continuous reinforcement schedule conditions.
Fixed ratio schedules usually produce a stable rate
of response. By gradually increasing the number of
responses per reinforcement it is possible to obtain
very high ratios; the learner performing hundreds
of responses. When the reinforcement is presented
there may be a pause followed by a return to the
high rate of response. Variable ratio schedules
also result in very high response rates, but are not
characterised by high post-reinforcement pauses.

resembles that elicited by the unconditioned


(reinforcing) stimulus. Salivation is a dogs normal
response to food. In operant training the reinforced
behaviour bears no resemblance to the behaviour
normally elicited by the reinforcing stimulus.
Respondent (classical conditioning behaviour) is
directly under the control of a stimulus. Operant
conditioning, on the other hand, just seems to
happen. The operant behaviour operates on the
environment to produce some effect.

Social learning theory


This theory combines principles of both operant
and classical conditioning, and puts emphasis on
human interactions. It refers to learning inuenced
by otherslearning by imitating the behaviour of
other people. Other terms used are role modelling
and identication. In clinical situations: watching
one perform a dreaded task, for example, a child
playing fearlessly with dogs may modify phobic
behaviour. Commercial advertisers are well aware
of this form of learning and use models that they
think target populations can identify with. In
health promotion campaigns such as campaigns
against drug use, the educators may decide to use
individuals from the same culture and age group to
enhance the change. Note that although the person
learns by imitating others, personal factors are also
involved. The behaviours have to be rewarded if
they are to become part of the persons repertoire.
Behaviour occurs as a result of the interplay
between cognitive and environmental factorsa
concept known as reciprocal determination.

Types of operant conditioning


Reward training, where a rat presses a lever
more often, because it obtains a reward of
food.
Aversive conditioning, where painful events
such as noise or elec
Punishment training, involves administering
an aversive stimulus after an undesirable
behaviour. That particular response would
then be weakened or eliminated. It is not much
favoured, because although it eliminates one
type of behaviour, one cannot predict what the
organism will use to substitute it.
Avoidance training refers to a situation where
behaviour is learned, because it enables the
learner to avoid something unpleasant. If a
bell is rung a few seconds before a shock is
delivered the rat might learn to run away at the
sound of the bell, hence, avoiding the shock.
Escape learning, where the animal learns
to escape from a painful event, such as a
rat jumping from a chamber in which it is
subjected to an electric shock into a shock free
zone.
Shaping behaviour involves gradually
adjusting the behaviour by rewards until the
desired behaviour is reached.
There are differences between classical and operant
conditioning. In classical conditioning the response

Cognitive learning theory


The proponents of this theory argue that the human
being is not a passive organism, but is capable
of processing information and comprehending
the relationship between cause and effect. The
processed information is stored and may be
retrieved later when required. If the process
is faulty or it distorts real life situations, then
maladaptive behaviour may result. Aaron Beck
postulated that depressed patients have a negative
view of themselves, as they tend to focus only on
their failures. This leads to negative expectations
and low mood. A negative view of oneself leads to
negative interpretation of experiences and negative
expectations of the future.

Biological theories
Neurophysiologists have been able to demonstrate
certain changes in the nervous system of organisms

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The African Textbook of Clinical Psychiatry and Mental Health

so. The laws of classical conditioning require that


the exposure be repeated, but in the case of a phobia
developing following a single event such as a bomb
blast, the maintaining factors are thought to play a
big role. Thus in the example just cited, the blast
and the injuries or frightening sights are associated
with the place and as in classical conditioning this
leads to conditioned fear. Since the person fears
the place and is rewarded (by not experiencing
any anxiety), each time he avoids the place the
behaviour is reinforced. Fear of that particular
place may become generalised, the person may
fear going into town and eventually even getting
out of the house.
Inaccurate health beliefs and misinterpretation
of bodily sensations are thought to be responsible
for the development of somatoform disorders.
Restructuring the cognitive set is an important
therapeutic intervention. The application of similar
theories in depressive states has already been
described.

associated with learning. Broca and Wernicke


identied certain areas involved in language and
memory. By critically stimulating certain brain
sites, they were able to evoke certain memories.
In animals whose amygdala have been ablated,
learning is usually defective. Hypertrophy of
certain brain areas has also been associated with
learning. This is due to an increase in the number
of nerve connections between synapses. As new
pathways are created the chances of recall increase.
Other evidence for the biologic theories include the
experiments that show that if planarians (atworms)
that have been trained are ground up and fed to
untrained planarians, then the latter could be more
easily trained compared to controls. It is possible
then that in learning, some stable material, possibly
new ribonucleic acid (RNA) is formed in the brain
cells. Drugs that alter this process may enhance or
inhibit learning.

MALADAPTIVE LEARNING
HABITS AND HEALTH
PROBLEMS

Behavioural methods, approaches and


techniques in the management of health
problems
From the learning theories the methods of behaviour
therapy have developed. Behaviour therapy and
lately cognitive therapy techniques have been
applied in a wide range of medical and psychiatric
conditions. These include anxiety, depressive,
somatoform and addiction disorders, and even the
major psychoses.

The theories of learning have been used to explain


the development of certain psychiatric disorders.
These include anxiety disorders, depression
and somatoform disorders. It is easy to see how
one can be conditioned to fear certain objects or
situations if exposure to the event is paired with
a noxious stimulus, but in real life this is not always

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11
Human Motivation and Emotions
Caleb Othieno, Ruthie Rono, David M. Ndetei

of expressing emotions. Motivation and emotion


are closely related; strong emotions may lead to
certain actions: anger may lead to aggression.

DEFINITION
A motive is something that has the power to initiate
action. In psychology, it refers to the underlying
factors that energise and direct behaviour. Motives
seek to explain why people do what they do when
they do them.
Motivation is usually divided into needs and
drives. Needs refer to the physiological aspects
of emotion, while psychological factors are
considered drives. Thus, one may talk of the
physiological need for food in a hungry animal and
the hunger drive that leads it to seek the food. In
human beings, the following types of motivation
are recognised: survival and social needs, and
curiosity motives. The motives that are aimed at
preserving life such as the need for food and water
comprise the survival needs. Examples of social
needs include sexual and maternal behaviour.
The curiosity motives, for example, explorative
behaviour cannot usually be directly related to the
survival needs of the organism.
Emotion is the feeling, tone or response to
sensory input from the external environment or
mental images. The outward component of emotion
manifests itself as smiles or gestures. Accompanying
emotions are the physiological responses. These
are expressed through the nervous system the
limbic system and the autonomic nervous systems.
Moods are states of emotional reaction that last for
only a limited period, while temperament (a part of
personality) refers to an individuals habitual way

PHYSIOLOGICAL BASIS OF
MOTIVATION
Hunger
The hypothalamus has been identied as the centre
that regulates feeding behaviour. In animals that
have parts of their hypothalamus removed or
damaged, feeding disorders are observed. It was
initially thought that the lateral hypothalamus (LH)
housed the feeding centre, while the ventromedial
hypothalamus (VMH), was the satiety centre.
Later experiments, however, have shown that
they may be more concerned with regulating the
set body weights rather than feeding per se. Thus,
in animals with lateral hypothalamus lesions
the normal body weight is set at a lower point
resulting in an emaciated animal. The converse is
true for ventromedial lesionsthe animal becomes
obese. The disturbances in feeding are therefore
geared to maintaining the new body weights and
after the initial adjustment period when the animal
underfeeds (LH lesions) or overfeeds (VMH
lesions) eating resumes, but in a modied pattern to
maintain the new body weights. In regard to body
uids, the antidiuretic hormone (ADH) is released
by the osmoreceptors in the hypothalamus in
response to dehydration. The hormone acts on the

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The African Textbook of Clinical Psychiatry and Mental Health

seek to drink water. Furthermore, the kidneys will


conserve waterthus forming urine that is more
concentrated.

kidneys to increase the amount of water reabsorbed


from the tubules, thus preserving the body uids.

Social needs
Psychoanalytic Theories

Sexual and maternal needs are strong motivators


in all animals, including human beings. In human
beings, however, the innate instincts are modied
by social controls and needs. Thus, the basic
behaviour of seeking a partner, marriage and childbearing are tinted with cultural factors.

Sigmund Freud stated that human behaviour is


determined by two basic forces: the life instincts
(eros) and the death instincts (thanatos). The former
explains this behaviour that is directed towards
the preservation of life, such as sexual behaviour.
The latter leads to destruction, for example, the
aggressive nature of man.

Curiosity motives
Curiosity refers to the in-born drive or need to
manipulate and explore the environment. It seems
to be innate in that it is observed in children
from quite an early age. Children play with toys
and react to stimulation and novel situations
with pleasure. As they mature, they engage in
games that are more complex. It seems that the
exploration and stimulation provide the organism
with new and changing sensory input that are
essential for the integrated functioning of the
nervous system. Individuals that are deprived of
or placed in a situation where the sensory input is
severely diminished, begin to hallucinate and have
other sensory distortions.

Incentive (Behavioural) Theory


This theory is derived from the learning theories.
It holds that an organism is likely to engage in
a certain type of behaviour if it were rewarded
following food-seeking behaviour. Exploratory
behaviour or sensation seeking behaviour with no
tangible reward does not make sense using this
theory, although the survival needs and the sex
needs can be explained in this way.

Drive Reduction Theory


It is thought that tension builds up in an organism in
response to certain needs. As the goals are achieved,
for example obtaining food, the tension is reduced
and this is accompanied by a pleasurable feeling.
Like the incentive theory, the drive reduction theory
does not offer a satisfactory explanation for all the
human motives, in particular the tendency by some
individuals to seek tension-producing states.

Instincts
These innate biological forces predispose an
organism to act in certain ways. Some psychologists
postulate that all human thought and behaviour
are the result of instincts. Several instincts are
identied such as ight, repulsion and curiosity.

Humanistic Theory
This approach was proposed by Abraham Maslow.
He reasoned that human motivations were
organised in a hierarchy of needs. These are listed
below starting with the most complex or advanced
needs:
Self-actualisation needs: self-fullment and
realisation of ones potential.
Aesthetic needs: concerns about beauty, order
and symmetry.
Cognitive needs: the need for exploration and
to understand things.
Esteem needs: the need for competence and
achievement; and to gain approval and fame.
Love and need to belong: acceptance and
afliation to others.
Safety needs: security and freedom from
danger.

THEORIES OF MOTIVATION
Homeostasis and the Drive Theory
It is essential that the body maintain a constant
internal environment for its optimum functioning.
Corrective measures are in place to ensure that the
bodys temperature, body uids and the various
chemicals and hormones are maintained within a
certain range. In explaining the hunger drive, the
level of blood glucose acts as the main determinant.
When the levels fall below a certain limit the
organism feels hungry and will then seek food
in order to rectify the anomaly. In addition, food
stored in the body in the form of fat will be broken
down to boost the blood glucose levels. Likewise,
when the body uids are depleted, the animal will

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Human Motivation and Emotions

Physiological needs: these are basic and


include hunger, thirst and sexual gratication.
He stated that the lower needs in the hierarchy
must be partly fullled before those at the next
level can assume importance. If they are not, then
the organism remains preoccupied with them until
the needs are met. Beauty and environmental
conservation may not mean much to a person
whose needs for food are not met.

EMOTIONAL STATES IN
DIFFERENT SITUATIONS
Theories of Emotion
James-Lange theory
It states that bodily changes are the primary
cause of emotions. Thus, a subject perceives a
situation followed by bodily changes, which lead
to the subjective experience of emotions. The
type of emotion elicited, such as anger or fear, is
determined by the pattern of physiological changes
that precede it.

MOTIVATION AND HEALTH


BEHAVIOUR

Cannons theory

Individuals do not always act in a way that is


benecial to their health, for example, smoking,
drinking, and eating unhealthy foods. Theories
of motivation have been used to understand
why such seemingly irrational behaviour occurs
and to formulate behaviour change. In alcohol
and substance abuse, motivating the individual to
change forms an important part of the therapy.

Cannon thought that after the subject perceives


a particular situation, the bodily changes occur
simultaneously with the cortical reactions.
The cognitive theory of Schachter and Singer
It includes elements of the rst two theories. After
a subject perceives a situation, no specic bodily
changes follow. This is accompanied by a better
understanding of the situation, which in turn elicits
more emotions and bodily changes that are more
specic.

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The African Textbook of Clinical Psychiatry and Mental Health

12
Memory and Forgetting
Caleb Othieno, Ruthie Rono, Mohamedi Boy Sebit, David M. Ndetei

Semantic memory is the memory for automatic


skills that are acquired during life. It is also
necessary for the use of language.
Implicit memory for acquired skills such as
typing, riding a bicycle or driving a car.
Both the semantic and implicit types of memory
do not decline with age. Instead, one accumulates
information throughout life. In contrast, the
episodic type of memory declines with age.

MEMORY
Memory refers to those processes involved in the
acquisition of information, its subsequent retrieval
and use. The memory process can be divided into
three main components: registration, retention,
and recall and recognition.
Memory plays an important part in learning.
Learning implies retaining facts. If nothing is stored
from previous experience then no learning can take
place. Thinking and reasoning are also done with
remembered facts. Other phenomena that depend
on the continuity of memory are self-perception,
concepts about time: past, present and future. The
opposite of recall and recognition is forgetting.

Physiological basis of memory


Neurobiological basis of memory
The brain areas involved in memory are located in t
he hippocampus, amygdala, cortex and cerebellum.
Approximately 100 billion neurons are involved in
forming memories, including a layer of 4.6 million
in the hippocampus. Patients in whom the temporal
lobes, hippocampus have been removed are unable
to retain any material, although short-term memory
is not interfered with. In memory formation, it is
thought that an environmental stimulus forms
an electrical or chemical impulse, which passes
through the neurons to the brain. This triggers
the formation of connections between synapses.
An increase in synaptic connections occurs when
learning takes place. Long-term memories are
retained longer than short-term ones, because of
the longer duration of time that such memories
have had to link up with a number of locations in
the cortex. The more the connections, the better the
chances of contacting a neural pathway leading to
it.

Short and long-term memory


The following types of memory are recognised:
Immediate or short-term memory: for events
that have occurred within the past 30 seconds.
Recent memory: for events over the past few
hours or days.
Recent past memory: this refers to information
retained over the past few months.
Remote memory: refers to the ability to
remember events that have occurred in the
distant past.
Memory can also be classied according to
function as follows:
Episodic memory for discrete events.

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Memory and Forgetting

Storage may be the critical factor in good memory.


Relating material to something already known
creates more pathways. Information processed
at the semantic level decays at a slower rate than
that of rote learning (learning without meaning or
comprehension). Short-term memory is adversely
affected by chronic emotional states and lack of
effort caused by psychological exhaustion or too
much input. Note that the same factors adversely
affect learning. The capacity of the short-term
memory is 5-9 bits.
Smell and emotions are linked to long-term
memories. Scent conveys information through
the olfactory nerve to the hippocampus, which
plays a role in the control of emotions. Increased
adrenaline from stress may enhance learning, but
if it is too much the learning is inhibited. Mood
also affects learning and recall of material. A happy
mood enhances memory.

The two process theory of memory


This theory proposes a short-term memory
(STM) with a limited capacity and the long-term
memory (LTM) with an unlimited capacity. It is
noted that the retrieval system of the latter is not
always successful. The long-term or secondary
memory includes recent, recent past and remote
memories. The STM or the primary memory is
also referred to as the immediate, working or
buffer memory. The physiological support for the
two-process theory, as noted earlier, is that patients
with damage to the temporal lobes hippocampus
have impaired LTM, but the STM is unaffected.
The problem therefore seems to be the inability
to transfer new material from STM to LTM. The
consolidation theory proposes that the memory
trace needs to undergo consolidation to become
stable. If there is interference before that happens,
then the material is forgotten. This may explain
the retrograde amnesia that occurs following head
injury, electroconvulsive therapy (ECT) and
alcoholic blackouts.

Varieties of memory processes


Re-integrative (Recollection): Refers to
the process where earlier experiences are
reintegrated or re-established based on partial
cues. Studies under hypnosis show that
memories from ages 7-10 can be recalled more
accurately under hypnosis than in the waking
state. It is thought that memory depends on the
development of language, so experiences that
occur much earlier may not be remembered.
Alternatively, the child may perceive the
world differently from an adult so attempts

to remember what was registered earlier fails.


Sometimes in recollection, the subject may be
quite convinced that what he remembers is the
truth, while the facts are different.
Recall: Giving the subject something to
learn then after a time lapse asking them to
remember the material is used to test recall.
Recall is affected by rationalisation to make
the material understandable; conventionalism
(common
place
limits);
omissions,
displacements, telescopy and confabulation.
Pleasant experiences are more likely to be
remembered than unpleasant ones.
Recognition: In recognition one acknowledges
that a fact is familiar although one may not
remember all the details. One may remember a
face, but cannot recall the circumstances under
which it was seen. A similar experience is the
dj vu (previously seen) phenomenon a
sense of familiarity that is sometimes aroused
in strange surroundings. This may be due to a
single recognition followed by generalisation
of the situation from experience.
Relearning: Even when something may seem
to be completely forgotten, it may be easier to
learn it the second time round. This is because
of the learning that occurred in the past,
although the subject does not recall. Hermann
Ebbinghauss studied this using nonsense
syllables. He learned 7 lists of unrelated items
until he could make 2 errorless repetitions.
After learning the rst list, he waited 20
minutes then relearned the list again to 2
errorless repetitions. After learning other lists
he waited for longer intervals 1 hour, 1 day,
2 days, 6 days and 31 days before relearning
each list. The amount of learned material
retained plotted as a function of time is called
the retention curve.
Eidetic images: These refer to the
photographic memory visual impressions
that persist after the actual visual stimulus has
been removed. It occurs in about 5 percent of
children and declines with age.

Retrieval processes
The retrieval is an active process supported by the
occurrence of the tip of the tongue phenomenon.
One may feel certain that he knows something,
but may not be able to recall it immediately. One
may also suddenly remember something without
being aware that it was being processed by the
mind. This implies that an active search goes on
involuntarily.

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The African Textbook of Clinical Psychiatry and Mental Health

dependent). Other theories concerning forgetting


are: decay through disuse, interference effects and
motivated forgetting. Recent theories concerning
the neurobiological basis of learning including
RNA and the memory trace, lend support to the
earlier theories.

Clinical conditions or situations in which memory


needs to be assessed include:
Organic diseases: Low intelligence, acute brain
syndromes (delirious states) due to infections
such as encephalitis and head injury.
Anoxic brain damage following systemic
diseases, myocardial infarction, respiratory
embarrassment and carbon monoxide
poisoning.
Temporal lobe surgery and cerebral tumours.
Alcohol-related disorders: alcoholic blackouts,
alcohol-induced dementia.
Wernicke-Korsakoff psychosis.
Cerebral vascular disorders: subarachnoid
haemorrhage due to trauma or aneurysms and
transient global amnesia caused by decreased
blood ow to the parietal temporal region of
the left hemisphere.
Degenerative disorders causing dementia
such as Alzheimers disease and Huntingtons
chorea.
Benign forgetting of old age.
Anterograde amnesia due to electroconvulsive
therapy: this resolves invariably within weeks
and in most cases, within a few days.
Depression and anxiety.
Dissociative disorders.
Malingering/ctitious
disorders:
these
are characterised by inconsistent ndings
and retention of personal details. The
precipitants are usually stressful events related
to money, legal or disturbed relationships.
Psychoanalysis: involves the recollection of
earlier experiences, some of which may be
subconsciously blocked or forgotten.
Free recall.

Decay through disuse


It is assumed that with the passage of time, memory
traces in the brain fade. This, however, may not
necessarily be true. Motor skills such as riding a
bicycle or driving a car are retained for long. It is
also known that old people may vividly remember
their childhood experiences, but are unable to recall
what they had for breakfast.

Interference effects
New learning may interfere with material that had
previously been learnt. This is known as retroactive
inhibition. Prior learning may also interfere with
the learning and recall of new material proactive
inhibition. These effects have been demonstrated
using the nonsense syllables. However, learning
beyond bare mastery makes the person less
susceptible to interferences of either the proactive
or retroactive types.

Motivation and repression


Inaccessibility of learned material is sometimes due
to repression. In these cases, the retrieval would be
unacceptable to the individual, possibly because of
the anxiety or guilt that might be activated.

MOTIVATION, MEMORY AND


COMPLIANCE TO MEDICAL
ADVICE AND INSTRUCTIONS
Memory involves three separate, but related events
as follows:
Encoding and storing the information.
Retaining it over a period of disuse.
Retrieving it at the time of recall.
It is possible to intervene at all these stages in
improving memory. One can improve in encoding
and storage by the following techniques:
Mental imagery and recallmethod of loci.
Dual encoding systems: non-verbal imagery
and verbal symbolic processes.
Organisation of memory and hierarchical
organisations.

NATURE OF FORGETTING
It is thought that memories are never actually
completely erased under normal circumstances.
The fact that electrical stimulation of parts of
the brain may elicit memories long forgotten or
those that the subject was unaware of, support the
permanency of memories. Forgetting may be due
to loss of information or inability to retrieve the
information. The latter case occurs when critical
cues to retrieve the information is lacking (tip of the
tongue phenomenon). In the former case, an actual
decay of the memory trace is said to occur (trace

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Memory and Forgetting

Chunking: since the capacity of the STM


cannot be increased beyond its capacity of
7 2 if one has to retain larger amounts of
information in the STM, it has to be chunked
together.
Self-recitation,
practice
or
rehearsal,
and elaborative rehearsalworking out
associations.

Relearning and repetition.


Over-learning.
Drugs
that
enhance
storage
include
strychnine, nicotine, caffeine and amphetamines.

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The African Textbook of Clinical Psychiatry and Mental Health

13
Communication and Communication Skills
Anne Obondo, Lincoln Khasakhala, David M. Ndetei,
Victoria Mutiso, Francisca Ongecha-Owuor

begins the session by nding out what the problem


is.

INTRODUCTION

Ability to be honest and compassionate

Communication is an important tool in health care


through which signs and symptoms are expressed
and understood. The process of communication
helps resolve the mystery of the people we meet.
It is used to bridge some differences that exist
between people and can bring much satisfaction
and joy in our relationships.

Medical workers need to communicate bad news


gently and honestly, and with compassion. For
example, it is important to say I am sorry to say
this but yes the diagnosis is one of cancer.

Ability to empathise
The health professional has to be very familiar
with the case because this will provide him
with the ability to respond to certain situations
appropriately.

GUIDELINES TO GOOD
COMMUNICATION SKILLS

Ability to listen
Time

The health professional should set the ball rolling


and let the patient or relatives determine the
direction of the communication. However, the
health worker should be able to answer questions
raised by the patient and relatives.

Adequate time for the patient or client to tell


their own story, and to feel they have been
adequately heard and understood. Health workers
need adequate time to respond and explain their
decisions.

Ability to understand
Preparation

A health worker should be able to understand the


question asked by the patient or by the relative by
probing. This will help the health worker discover
why the question was asked in the rst place.
Only by determining the real reason behind the
question will the health worker be able to address

For appropriate intervention, the medical worker


needs to study the case carefully and in consultation
with other colleagues. During consultation, a
quiet room or area where distractions are minimal
should be used. The therapist or medical worker

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Communication and Communication Skills

Observation of posture and gait provides information


about the individuals perception of himself and
about physical problems or limitations. Postures
that are stooped, relaxed, awkward or always
erect provide evidence of how a person expresses
himself generally. It also suggests an individuals
self-concept by indicating his emotional status
at the time of observation. Clothing signies
authority, social position, nancial status, religious
persuasion, cultural inuence and self-concept,
whereas physical characteristics also denote the
level of health.
Eye contact or no eye contact are both vital
parts of ones facial expression either expressing
willingness to maintain social contact or social
withdrawal. Dominance can also be communicated
through eye contact or mutual glances. Hands
are expressive parts of our bodies that convey
messages such as feelings, attitudes and ideas
that may be positive, negative or even neutral
depending on the pattern of communication.
Messages conveyed may vary with culture and
environment.

the issues to the full satisfaction of the patient and


family.

Ability to care
Sometimes when dealing with patients, health
workers tend to leave them with no alternative
arrangement for follow up. It is important that
such alternative arrangements are made so that
the patient and relatives are helped to come to
terms with the situation and perhaps reinforce or
clarify what had already been said.

Consistency
Consistency in information given to the patient
and his relatives is very important. The health
worker should appraise all the other health care
workers involved e.g. family doctor, specialist,
nurse so that the patient or relatives are not given
conicting information which may confuse them.

CHANNELS OF
COMMUNICATION

Listening
Listening is a highly specialised perceptual process
used to absorb and attach meaning to patients
ideas. The health worker is able to assess beliefs,
feelings and ideas of patients which is useful in
setting goals for management of such patients.
Listening is the primary sensory skill used to
effect therapeutic communication with a patient
and his relatives. Listening involves paying
attention to what the patient has to say or showing
interest in his needs, problems and expectations.
Interest and sincerity is determined by the ability
to maintain eye contact. The more we listen to the
patient the more effort he is willing to make in
expressing ideas and perceptions clearly.
When the patient is talking, the following
should be considered:
Tone of voice: this is the channel through
which to detect the incongruency between
what a patient says and what he means.
Rhythm of words: for example, monotonous.
Rapidity of his speech: is it usual or unusual
for him? This needs verication by those
who know him well.
Relevance of patients verbal communication:
a patient may verbally communicate some
message which may be inappropriate in an
interpersonal situation yet it may express a

Non-verbal communication
Observation
Observation is important because it is used to
elicit additional information from patients by
observing non-verbal behaviours. It is important
to observe what a patient does, what happens to
him, and how he moves and looks. It is also a
primary source of data when patients are unable
or unwilling to provide information. An accurate
description of what is seen or observed is basic to
care of the patient.
The non-verbal clues given by the patient
or their relatives are very important. Through
observation, the health worker will detect the
many ways the patient reinforces and contradicts
verbal messages. It is important to observe the
harmony and disharmony of all the signals.
The home environment and family interactions
are clues to the socio-economic status, safety, age
and cultural make up. The design of a home and
its furnishings e.g. the general look of the home
(neat, casual, disarranged) its size, suitability
for those who live in it, utilisation of space for
privacy, work or play and reception given to the
visitors should be noted. Studying the styles of
living people adopt provide a more complete
picture of a family and its lifestyle.

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The African Textbook of Clinical Psychiatry and Mental Health

problem appropriate to his need that he cannot


deal with directly.
Use of phrases: such as I expect, I hope,
There is no point, What is the use?,
Dont bother may suggest expectations or
non-expectations.
Assessment of themes: for example, listening
to theme of wellness, loneliness, loss and
humour.

also the natural smell of the environment in which


people live. Families living in the slums become
desensitised to odours that directly affect their
health.

Verbal communication
Talking
Communicating verbally is a skill that most
people have developed and is sometimes used
by individuals to succeed. Failure of certain
individuals may be due to poor communication.
For a person to be able to communicate effectively,
he needs to have knowledge of the subject and
should be willing to explore the topic with another
person and to listen to points of view different from
his own.

Wellness:
The reason for their hospital attendance
this may help identify the patients areas of
wellness.
The period he considered himself well or what
he might do when he gets well
Loneliness:

Language used

I dont care
Nobody cares,
Even God has deserted me.
Withdrawal from interpersonal relationships.

Misunderstanding in communication can occur


when the terms and words used and their meanings
are not mutually understood.
Interpretation of message conveyed and received
In communication, there is a communicator and
a receiver. There is no communication unless the
message is conveyed, received and acted upon.
The communicator must be clear about what he
wants to communicate and how he communicates
it. Interpretation and reception of messages will
depend on the receivers state of mind, his needs
at the moment and the impact of the speakers
effectiveness in communicating with him.

Loss:
For example, I was quite active before this pain
on my back started. The threat of loss is inherent
in anything that someone feels is personally
signicant. As loss is expressed, listening becomes
a means of lending ego until a patient nds resources
within himself to function adequately again.
Touch, taste and smell
These are symbols of communication often
utilised particularly in nursing care and
community rehabilitation and management.

FEEDBACK IN
COMMUNICATION

Touch
The act of touching is an instance of non-verbal
communication which is culturally determined.
There are certain uses of touch that are accepted
within territorial limits that otherwise may not
be tolerated by patients. Using touch effectively,
appropriately and comfortably is a dilemma often
faced in an attempt to provide total patient care.

Feedback is the process of correction and


evaluation of what is being said and understood by
the parties involved in a communication exercise.
There are two types of feedback: internal (by self)
and external (by others). External feedback can be
either positive or negative.
Feedback is the last and most important link
in communication. It is a process of correction
and evaluation through which communication is
modied. From it, the patient learns what areas
of strength they should maintain and which ones
they should improve on. There is therefore need
to be skilled in giving and receiving feedback.

Taste
This sense provides sensory data on which
impressions of patients and their families are
based.
Smell
This refers to the smell of perfumes or deodorants
that people wear, the natural smell of people and

68

14
Psychological Testing
Ruthie Rono

THE NATURE OF
PSYCHOLOGICAL TESTS

TYPES OF PSYCHOLOGICAL
TESTS

A psychological test is an objective and standardised


measure of a sample of behaviour. They are tools
used by psychologists and psychiatrists to obtain
objective measures of a patients psychological
status. Psychological tests vary in the behaviours
they cover and in the way they are administered.
They could be administered individually, in a group
or by computer.
The tests can be grouped into four categories:
cognitive/developmental; academic/achievement;
neuropsychological/perceptual and emotional/
personality.
Psychological tests are traditionally used to:
Measure individual differences
Identify mentally handicapped persons
Examine and diagnose persons with severe
psychological or psychiatric problems
Classify children according to ability e.g. slow
learners
Select personnel in the job industry
Select or classify military personnel for
proper task assignment
Determine the appropriate therapeutic
approach for clients
Carry out basic research such as in the case
of monitoring and documenting the course of
mental health treatment and recovery.

These include:
Achievement and aptitude tests
Intelligence tests
Neuropsychological tests
Personality tests.

Achievement and aptitude tests


These are usually used within educational and
employment settings. They are used to measure
how much a person knows about a certain topic or
the capacity the person has to master material in a
specic area, such as mechanical work.

Intelligence tests
These are used to measure the intelligence or the
basic ability to understand ones world, assimilate
its functioning and apply this knowledge to
enhance the quality of life. It measures ones
potential. Intelligence tests are not a measure of
achievement.
Intelligence testing resulted from the work
of Alfred Binet and Theodore Simon who developed
the Binet-Simon scale in 1905 to differentiate
between normal and mentally handicapped
children. The concept of IQ was introduced by
Lewis Terman in 1916 when he translated and
revised the Binet-Simon scales and created the

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The African Textbook of Clinical Psychiatry and Mental Health

Stanford Binet Intelligence Scales. Terman used the


ratio of mental age to chronological age to obtain
an individuals IQ. In this concept, for example, a
child of ten years with a mental age of ten would
have an IQ of 100 which is the average IQ score.
The mental age-chronological age concept works
only for children.
The concept of IQ is no longer used by
psychologists. They use the term intelligence which
is measured based on an individuals deviation from
standardised norms, with 100 being the average.
Intelligence tests are frequently employed as
preliminary screening instruments to be followed
by tests of special aptitudes. They are used
clinically for identication and classication of
mentally retarded persons. Examples of this group
of tests are:
The Stanford-Binet and Wechsler Scales
Standard-Binet Intelligence Scale
Stanford-Binet (4th edition) cover qualitative,
spatial, and short memory tasks.
The test batteries are used for ages 2 years to adult
level.

The Basal level is reached when four items on two


consecutive levels are passed. The Ceiling level is
reached when three out of four or all four items
on two consecutive levels are failed. The Wechsler
scales include:
1. The Wechsler Preschool and Primary Scales
WPPSI-R (1989) for 3 to 7 years olds
2. The Wechsler Intelligence Scale for Children
(WISC III,1991) for 6 to 16 year olds
3. Wechsler Adult Intelligence Scales (WAIS R)
for 16 to 74 years.
Other tests in this category include:
(a) The Kaufman Scales designed for the same
uses as the Wechsler and Stanford-Binet
scales. The main focus of these scales is the
information processing assessment. They
include the:
Kaufman Assessment Battery for
Children (K-ABC). The test comprises
7 subtests that measure simultaneous
processing requiring synthesis and
organisation of spatial and visuoperceptual content and 3 subtests that
assess sequential processing requiring
serial or temporal arrangement and utilise
verbal, numerical and visuo-perceptual
content as well as short-term memory.
The battery also includes an achievement
scale of six subtests designed to measure
factual knowledge taught in school.
The Kaufman Adolescent and Adult
Intelligence Test (KAIT) (Kaufman &
Kaufman, 1993) was designed to measure
intelligence for 11 to 85 year olds. It
attempts to measure uid and crystallised
intelligence.
The Kaufman Brief Intelligence Test
(K-BIT) 1990 was designed as a quick
screening instrument to estimate the
level of intellectual functioning for 4 to
90 year old clients.
(b) The Differential Ability Scales (DAS) by
C.D Elliot (1990)
(c) The DAS-NAGLIER Cognitive Assessment
System measure basic cognitive functions
that are involved in learning presumed to be
independent from schooling.
(d) Other scales for infants and children include
the Bayley Scales of Infant Development
(1993), McCarthy Scales of Childrens
Abilities (MSCA- McCarthy, 1972) and the
Piagetian Scales.

Administration and scoring


The administration of the Stanford-Binet involves
the following:
Four booklets of printed cards for ip-over
presentation of test items
Test objects e.g. blocks, form board, multicoloured or different shaped beads, a large
picture of unisex and multi-ethnic dolls, record
booklets, guide for admission and scoring.
One needs to be highly trained in administering,
scoring and interpreting it. The examiner is also
expected to observe respondents work method
and problem solving approaches, and to judge
the emotional or motivational characteristics, e.g.
ability to concentrate, activity level, self condence
and persistence. There are 15 tests covering four
major cognitive areas. These are:
verbal reasoning
abstract or visual reasoning
quantitative reasoning
short-term memory.
These are administered in a mixed sequence to
maintain interest and attention. The administration
is a two-stage process. Stage 1 involves a vocabulary
test for routing to determine entry level. In stage 2
the examiner determines a basal level and ceiling
level for each test in terms of the individuals actual
performance.

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Psychological Testing

are unlikely to be truthfully answered in the


favourable direction. Infrequency score (F) is
determined from a set of 60 items. A high F score
may be indicative of scoring errors, carelessness in
responding, gross eccentricity, psychotic processes
or deliberate malingering. Correction score (K)
provides a measure of test taking attitude which
is believed to be more subtle. A high K score is
indicative of defensiveness or the attempt to fake
good. A low K score may represent excessive
frankness or self criticism or the attempt to fake
bad.
The MMPI-A was specically developed for use
with adolescents. It incorporates the same features
as the MMPI-2. It includes all the 13 basic scales
but accommodates younger test takers through the
reduction of the overall length of the test to 478
items.
Other tests in this category include the Millon
Clinical Multiaxial Inventory (MCMI-III) by
Millon, Millon & Davis, 1999. This inventory is
grounded in the biopsychosocial view of personality
functioning and psychopathology and its scales are
consistent with the DSM- IV classication system.
It contains 175 brief, self-descriptive statements
to be marked True or False by the client. The
score prole consist of 24 clinical scales each
based on 12 to 24 overlapping items. The scales
are classied as shown below.

Neuropsychological tests
These measure decits in cognitive functioning
such as the ability to think, speak and reason.
These deciencies may result from some brain
damage that may occur due to strokes or brain
injury. Neuropsychological tests are mainly used
to assess or diagnose brain damage and require
the application of knowledge about cognitive,
personality, neural and general physiological
functioning in both normal and pathological ranges.
Tests in this category include:
The Bender Visual Motor Gestalt Test
Benton Visual Retention Test
The use of electro-encephalography
Neuro-imaging techniques such as Magnetic
Resonance Imaging (MRI).

Personality tests
Personality tests measure the basic personality
types. These tests are mainly used for diagnosis
of psychopathology. One of the most common is
the Minnesota Multiphasic Personality Inventories
(MMPI) series. The MMPI has been revised and
reconstituted into two separate versions: the
MMPI-2 and the MMPI-Adolescent (MMPI-A).
The MMPI-2 consists of 567 items of afrmative
statements to which the test taker gives a True or
False response. The items range widely in content
and cover areas such as affective, neurological and
motor symptoms; general health; sexual, political
and social attitudes; educational, occupational,
family and marital questions. It also covers many
well known neurotic or psychotic behaviour
manifestations such as obsessive-compulsive
disorders, delusions and hallucinations, ideas of
reference, phobias, and sadistic and masochistic
trends. The MMPI-2 yields 10 basic clinical
scales. These are:
1. HS: Hypochandriasis
2. D: Depression
3. HY: Hysteria
4. PD: Psychopathic deviate
5. Mf: Masculinity-femininity
6. Pa: Paranoia
7. Pt: Psychasthenia
8. Sc: Schizophrenia
9. Ma: Mania
10. Si: Social introversion
The MMPI-2 also has validity scales. Lie Score
(L) is based on a group of items that may make
the respondent appear in favourable light but

Clinical personality patterns

Schizoid
Avoidant
Depressive
Dependent
Histrionic
Narcissistic
Antisocial
Aggressive (sadistic)
Compulsive
or
passive
(negativistic)
Self-defeating.
Clinical syndromes

71

Anxiety
Somatoform
Bipolar manic
Dysthymia
Alcohol dependence
Drug dependence
Post traumatic stress disorder.

aggressive

The African Textbook of Clinical Psychiatry and Mental Health

Unusual verbalisations are tallied and used to


detect severe psychopathology according to a
standardised scoring guide. Whole responses
are associated with conceptual thinking, colour
responses are associated with emotionality and
human movement responses are associated with
imagination and fantasy life. Information from
others sources such as interviews and case history
records are used. Other types of inkblot tests are
the Exners comprehensive system and Holtman
inkblot technique. The inkblot technique can be
used for children and adults.
The pictorial technique include the Thematic
Apperception Test (TAT) and the Rosenzweig
pictureFrustration Study. The verbal techniques
use word association tests.
The performance techniques include the Drawing
Techniques such as the Draw- A- Person (D-A-P)
technique and Play techniques and Toy tests used
with children.
Psychological tests assess a wide range of human
characteristics and require professional expertise to
administer. In the use of psychological tests, mental
health professionals need to adhere to professional
ethical standards so as to protect their clients. Of
particular importance are the ethical considerations
concerning user qualications and professional
competence, protection of privacy, condentiality,
and appropriate procedures for communicating test
results to clients.

The severe syndromes are thought disorder, major


depression and delusional disorder. The severe
pathology pattern includes schizotypal, borderline
and paranoid. The scale also has modifying indices
which are disclosure, desirability and debasement.
It also has a validity index (Anastasi & Urbina
1997).
Projective
Techniques
are
personality
assessment tools that use disguised, unstructured
testing procedures. They originated from Freudian
psychoanalysis theory and clinical settings.
It focuses on the whole or global approach to
personality as opposed to specic traits. It has been
found to be effective in revealing covert, latent or
unconscious aspects of personality. The test stimuli
are ambiguous and only brief instructions are given.
It is expected that the test materials will serve as
a screen on which respondents project thought
processes, needs, anxiety and conicts. The types
of projective techniques include:
1. the Inkblot
2. pictorial
3. verbal
4. performance techniques.
The Rorschach Inkblot technique utilises 10
stimulus cards about the size of a regular sheet of
paper, each with symmetrical inkblots. Six of the
blots are black with various shades of grey while
four are in colour. A client is shown each card at
a time and asked to say what it represents. The
examiner notes the responses, reaction time and
duration of response; positions in which the cards are
held; spontaneous remarks; emotional expressions
and other accidental behaviour during the test. The
psychometrician questions the client systematically
regarding the parts and aspects of each of the blots
to which associations were given hence the client
gets the opportunity to clarify earlier responses or
their formal characteristics such as human gures,
human details, animal gures, art objects, sexual
perceptions or landscape.

Further Reading for Chapters 8-14


1. Neil R. Carlson and William Buskit: Psychology: The
Study of Behaviour. 5th Ed. Allyn and Bacon. (1997)
Dodge Fernald: Psychology. Prentice-Hall.
2. Anastasi, Anne & Urbina, Susana (1997).
Psychological Testing. New Jersey. Prentice Hall.
3. Linda Brannon and Jess Feist (eds) (1992). Health
Psychology. An introduction to behaviour and health.
2nd Ed. Wadworth Inc.
4. Child and Adolescence Psychiatry. A Comprehensive
Textbook Edited by Melvin Lewis (2002). Published
by Lippincott Williams & Wilkins.

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15
Stress and Stress Management
Abdulreshid Abdullahi Bekry, David M. Ndetei, John Mburu,
Anne Obondo, Donald Kokonya

DEFINITION

CAUSES OF STRESS

Stress is a physical and psychological response to


harmful or potentially harmful circumstances. It is
a state of severe physiological and psychological
tension. It can also be dened as a non-specic
response of the body to any demand.

Stressors can be sudden, overwhelming or


cumulative. Some examples include:
Life crises e.g. accidents, death of spouse or
divorce.
Transitions e.g. divorce, bereavement and
retirement.
Catastrophesnatural and otherwise, e.g.
earthquakes and oods.
Daily hassles, little things in life that go
wrong.
Frustration and conicts.
Uncertainty, doubt and inability to predict the
future.
Physical and social environment such as lack
of a clean, tidy environment or lack of space.
Self, for example, Type A personality which
is associated with high levels of arousal, guilt
and irrational feelings.
Interpersonal relationships can be a source of
satisfaction or stress.

WHAT ARE STRESSORS?


A stressor is a stimulus which causes stress,
e.g. bereavement, divorce or a critical event such
as robbery or the demands of life. Our responses to
stress are inuenced by:
Personality (our strength)
The burden (type) of the stressor. Traumatic
stress is so intense that it overwhelms normal
psychological defences.
Ones subjective interpretation of the stressors.
Interpretation of the stressor takes two forms:
primary appraisalwhether the event is
positive, neutral or negative, and secondary
appraisalare the coping strategies sufcient
to deal with the challenge?

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The African Textbook of Clinical Psychiatry and Mental Health

STRESS AND OUTPUT

Figure 15.1: The relationship between pressure/stressors and stress


PRESSURE/STRESSORS

THE INDIVIDUAL

OUTCOME/STRESS

To achieve ordinary or
extraordinary pursuits in life

Genetic,
biological,
personality,
physical, psychological and social
status, environment, past and present life
experiences, future expectations, coping
styles, culture immunity factors.

Achievements in life pursuits,


physical, psychological and social
health status and related symptoms,
behaviours,
etc.
Adjustments
Disorders (see text) clinical
syndromes/disorders.

INDIVIDUALISED MEANING

is stressed? Usually not. They tend to see


him as merely sickly or abnormal.
(iii) Do health care professionals recognise
when their clients are stressed? Usually
not. They tend to over-investigate along
physical lines.
4. The Solution: Health Education to both the
client and support system, including the
professionals on how to recognise and manage
stress.
5. Prognosis: Most people can be helped to cope
with or minimise normal life stresses while
leading relatively normal and productive
lives.
Figure 15.2 demonstrates the Pressure/Stressor/
Stress and output curve. Different people take
different curve patterns but within the same general
principle.

For the same results of output for different people,


it would require different contributory factors.
1. Normal to mild stress: When pressure to
achieve is positively correlated with output.
Symptoms of stress, if present are not
disabling.
2. Moderate to severe stress: When pressure to
achieve does not lead to an increase in output.
Symptoms of stress become increasingly more
and severe and achieve clinical proportions.
The stress symptoms take a more predominant
position.
3. Pathological Stress: When increase in
pressure is negatively correlated with output,
is accompanied by debilitating symptoms
and the output declines. The stress symptoms
become the primary focus. There are usually
clinical syndromes and disorders which require
attention on their own.

RESPONSES TO STRESS

Other Considerations
1. Pressure and stressors and to some extent
stress are normal and at times are necessary
drives for people to achieve certain goals in
life.
2. There is no normal life without pressure
to achieve. It becomes abnormal when the
pressure to achieve produces signs and
symptoms that become the problem.
3. The Challenges:
(i) Does the stressed individual know the
sign and symptoms of stress? Most
people do not know and just think they
are suffering merely from a physical or
unexplained illness.
(ii) Do family members, friends and
workmates know when one of their own

Psychological responses
In the behavioural area, the individual may
display self-destructive life styles and risk-taking
behaviour, such as excess drug intake, suicidal
gestures and self neglect. They may start stuttering.
They may also experience frustration and become
aggressive.
Anxiety can be the most dangerous psychological
symptom of stress. It may manifest with physical
symptoms of autonomic hyperarousal and activity.
Depression can also be a sign of stress, but if it
persists to the stage of resistance and exhaustion, it
can be a real danger. One may also suffer inhibited
sexual desire.

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Stress and Stress Management

OUTPUT

Figure 15.2: The pressure/stressors/stress and output curve


Maximum

0 to Minimum

PRESSURE/STRESSORS/STRESS

Maximum/innite

A B = Increase in pressure leads to increase in out-put with no or minimal stress-related symptoms


BC = Increase in pressure does not lead to a corresponding increase in outcome. There are mild to moderate stress related
symptoms
CD = Increase in pressure leads to a decline in output and increasing more stress-related symptoms
Note: The curve varies greatly for different people with different AB, BC and CD intervals. There may be a shift to the left
or to the extreme right, with a very short AB for some people and for others may remain on AB phase even under extreme
pressure.

Spiritual signs and symptoms of excessive stress


may include doubts about ones faith, loss of self
condence or loss of purpose. At times there is
renewed faith in God.

ability to ght invading bacterial and viruses. One


may develop allergies, cancers and autoimmune
disorders such as rheumatoid arthritis.

Physiological responses

CONTROLLING THE CAUSES OF


STRESS

The body prepares itself either to ght or for


ight. After the escape from dangerous situations
the animal relaxes. However, in situations where
the individual is subjected to chronic stress some
physical symptoms may appear.

Controlling the environment


Avoid noisy surroundings.
Try to live in a space which is reasonably
large.
Keep your surrounding clean and neat.
Take time to enjoy nature, often through
picnics.
Save free time for relaxation and recreation.
Dedicate enough time to your partner and
family.
Try to create, where you can, a good working
environment.

HEALTH AND STRESS


All the bodys reactions to stress affect health. The
target systems include:
Cardiovascular system
Neurological system
Gastro-intestinal system
Immune system
Musculo-skeletal system
Endocrine system.
Prolonged exposure to stressors produce a number of
bodily symptoms. Chronic stress can lead to ulcers,
high blood pressure and heart disease. It can also
impair the immune system decreasing the bodys

Bodily control

75

Choose the healthy way to eat and drink.


Rest.
Drink a lot of water.
Do moderate, regular exercises.

The African Textbook of Clinical Psychiatry and Mental Health

Avoidance-avoidance conict

Avoid all types of drugs and toxic stimulants.


Do not use any type of tranquilising drug
unless it is prescribed by a physician.
Breathe properly (breathing as relaxation
technique).

Both alternatives are unpleasant and yet one has to


choose either. A patient has an abdominal tumour,
which causes unbearable discomfort. Alternatively,
surgery, which has very little success rate, is the
only available remedy and yet the patient needs to
be relieved of the pain. It becomes naturally very
difcult to choose either of these two alternatives.

Mental control
Plan your activities without becoming a slave
to your own plans, objectives or to those of
others.
Think positively.
Maintain a positive mental attitude.
Worry constructively and free yourself from
worry.
Share your talents.
Choose to be assertive.
Accept your mistakes and change them as
much as possible into challenges.
Free yourself from guilt.
Practise relaxationcan be taught by a clinical
psychologist or psychiatrist.

Approach-avoidance conict
This occurs when fullling a motive which will
have both pleasant and unpleasant consequences. A
young male doctor is torn between getting married
or not. Being married is attractive and socially
fullling, but it also means added responsibilities
and restrictions.
Double-approach-avoidance conict
The individual is torn between goals, which have
both pleasant and unpleasant consequences. A
young female doctor wants to obtain a masters
degree that is only available in a foreign country,
which she is afraid of going to. At the same time, she
is in love with a young man from a different tribe.
Her family does not approve of the relationship,
but she does not want to lose him. Which way does
she go?

CONFLICT AND ADJUSTMENT


Frustration

Adjustment to conicts

Frustration is the blocking of a motive by some


kind of obstacle. It is universal. An obstacle could
be a trafc jam, personal shortcoming, conicting
motives or conicts. The frustrated individual
becomes intolerant and physically aggressive,
more prone to misunderstanding others and more
likely to speak hurtful words.

Reactions to frustrations and conicts are sources


of stress that can cause physical and psychological
symptoms, just giving up, displaying self-pity, or
optimism and heroism in a few individuals. Stress
is not necessarily bad. At times, it helps the person
reach desired goals. General adaptation syndrome
is a sequence of responses that individuals go
through during stressful circumstances as follows:

Conict
Phase 1 (alarm phase)

Conict is the simultaneous arousal of more


incompatible motives, resulting in unpleasant
emotions, such as anxiety or anger. It is a pair of
goals that cannot be attained.

The body mobilises its resources to meet the


threats. There is a clear warning that a stress agent is
present, e.g. too much work, difculty completing
or avoiding a complex task. This often happens in
students when examinations are just about to be
done.

Types of conicts
Approach-approach conict

Phase 2 (resistance phase)

There are two goals, and to attain one means that the
other goal must be given up. For example, a nal
year medical student cannot often afford to be in
late night parties and expect to excel academically.
Therefore parties are given up although the student
misses them a lot.

There is an attempt to resolve the stress due to


fear of failure and frustration. Intially one does not
know what to do, but later makes some adjustments
and appears to be doing well. One may use defence

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Stress and Stress Management

mechanisms to cope. Students may arrange to


study in groups, use the library more often and
associate more often with their lecturers. Majority
of individuals overcome this phase and minimise
the stress.

DEFENCE MECHANISMS
Defence mechanisms are the unconscious
strategies that people use to deal with negative
emotions. They limit awareness so that lifethreatening and anxiety cues can be excluded.
They are invoked automatically as psychological
measures, which allow stressful situations to be
coped with by distorting reality. Inadequate use of
defence mechanisms can lead to overt anxiety or
depression. The defence mechanisms:
do not alter the stressful situation.
have an element of self deviation.
help during rough times, but delay the solutionseeking behaviour.
are unconscious processes as opposed to other
methods of coping with problems.
If it is the dominant mode of responding, it may
become a personality maladjustment.

Phase 3 (exhaustion)
This occurs when one cannot withstand the threat
any more and fails to resist the stress. Signs of
stress start appearing. They may be physical or
psychological, for example, fatigue, anxiety or
depression. Poor adjustment to stress is associated
with aggression, risk-taking, wishful thinking,
denial and dangerous escapism.

Coping strategies
Problem-focused
Dening the problem.
Coming up with alternatives.
Weighing the alternatives costs and
benets.
Choosing among alternatives.
Implementing the chosen alternatives.

Common Defence Mechanisms


Repression

Emotion-focused

This is considered the central and basic


psychological defence mechanism. Other defence
mechanisms only come into play when repression
fails. Thoughts or feelings which our consciousness
nd unacceptable are repressed. Thus, repression is
a way of dealing with unbearable aspects of inner
life; so that aggressive or sexual feelings, fantasies
or desires are thrust into the unconsciousness. It
is considered to be a mental process arising from
the pleasure principle (Id) and the reality principle
(Ego), indicating that when impulses and desires
are in conict with enforced standards of conduct
(Superego), painful emotions arise and the conict
is resolved by repression. Hence, normality is once
again attained and sustained.

These are used when the problem is uncontrollable.


There are two types:
Behavioural strategies

Exercising
Using alcohol or other drugs
Venting anger
Seeking emotional support from friends.

Cognitive strategies
Temporarily setting aside thoughts about the
problem.
Changing the meaning of the situation.
Reappraising the situation.

Displacement
This is the transfer of affect, usually fear or anger
from one person, situation or object to another. An
example is the wife who is furious and irritated
by her husband for always coming home late or
giving her no support with the children. She vents
her anger, not on her husband, but on the children.

Other coping strategies

Isolating oneself
Thinking about how badly one feels
Worrying
Repetitively thinking about how bad things
are.
Engaging in pleasant activity e.g. going to
parties.

Rationalisation
Rationalisation is the process of justifying by
reasoning after the event. This is the act of providing

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The African Textbook of Clinical Psychiatry and Mental Health

logical and believable explanations for behaviour,


to persuade self and others that the irrational
behaviour is justied and therefore should not be
criticised.

aggressor. The same applies to a father who was a


victim of child abuse.
Identication
People who feel inferior may identify themselves
with successful causes, organisations or persons in
the hope that they will be perceived as worthwhile.
In this case, identication is utilised as a defence
mechanism against anxiety of inferiority.

Projection
During projection an individual unconsciously
disowns an attitude or attribute of his own and
ascribes it to someone else. An example is when a
child tells the mother, Mummy the dog will bite
you, while actually he is the one who feels like
biting the mother. Another example is I hate you
becomes you hate me.

Compensation
This consists of the masking of perceived
weaknesses or developing certain positive traits
to make up for limitations. People who are
intellectually inferior may develop the physical
aspects of their bodies. People who are socially
incompetent may develop their intellectual
capacities and spend most of their time in lonely
academic pursuits.

Isolation
In this defence mechanism, dangerous memories
are allowed back into the consciousness, but the
associated motives and emotions are not recalled.
Hence, the memories are isolated from their
associated feelings. This mechanism is sometimes
seen in people who suffered severe physical or
psychological trauma such as in concentration
camps.

Ritual and undoing


Anxiety is sometimes reduced when people use
methods to make right the wrong they feel for some
perceived misdeed. A rejecting father may attempt
to alleviate his guilt by showering his child with
material goods.

Denial
This is the involuntary and automatic distortion of
an obvious aspect of external reality. When a doctor
informs a patient that he has cancer, this fact may
be denied at subsequent interviews even though
a clear concise explanation was given which the
patient obviously understood.

HEALTH PROFESSIONALS AND


WORK STRESS

Reaction formation

Every profession has some work stress, although


some are more stressful than others. For example,
studies have shown that doctors and lawyers work
under a lot of stress and tend to drink more alcohol
compared to other professionals.

In this case, the repressed wish is warded off by


its diametrical opposite. The young girl who hated
her sister and was punished many times for this
behaviour, may shower her sister with exaggerated
love and tenderness, but the repressed hostility can
still be detected underneath the loving exterior.

General sources of stress


Poor working conditions
- Lack of facilities to facilitate recovery
- Lack of equipment
- Lack of ofce space as is the case in most
public hospitals
Poor relationships e.g. professional conicts
with colleagues over duty roster or patients
Long working hours
Heavy workload e.g. having many patients
and heavy clinical load and responsibilities
Not receiving gratitude from clients
When the health worker has high goals and
cannot achieve them

Sublimation
This occurs when potentially dangerous urges are
given a socially acceptable expression. Thus sexual
or aggressive impulses instead of being given free
expression are sublimated to other activities, which
are carried out with great vigour and often with
great success.
Introjections
In this defence mechanism the victim takes
in and swallows the values of others. In
concentration camps, some of the prisoners deal
with overwhelming anxiety by accepting the
values of the enemy through identication with the

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Feel drained, empty and fragmented


Feel impaired of therapeutic skills

When transference interferes with the treatment


process. Transference is the process whereby
the patient or client projects onto the therapist
past feelings or attitudes they had towards
signicant people in their lives. The feelings
experienced in transference may include love,
hate, anger, ambivalence and dependency.
Counter-transference occurs when the health
worker projects onto their client past feelings
or attitudes they had towards signicant
people in their lives e.g. early childhood
unresolved conict due to emotionally intense
relationships. Counter-transference can exist
as a result of being overprotective of a patient,
rejection of patients or dual relationship
Dealing with severely ill patients or when a
patient dies.

Symptoms of burnout:

Daydreaming and fantasies


Cancellation of important appointments
Tendency to abuse drugs e.g. heavy drinking
Therapy sessions lose their excitement and
spontaneity
The health workers social life suffers
Health workers are reluctant to explore the
causes and cures of their conditions.
Coping with work stress
A high degree of self-awareness and a
deep respect and concern for patients are
safeguards.
Ability to build therapeutic relationships
with the patient is important because this
will go a long way in lessening anxiety in the
relationship
The health worker should be able to recognise
transference and counter-transference in the
relationship and deal with it.

Outcome of stress
Professional burnout
Burnout is a state of physical, emotional and mental
exhaustion characterised by:
Physical depletion, feelings of hopelessness,
helplessness or powerlessness
Negative attitude towards oneself, others,
work and life
Fatigue, loss of energy and loss of enthusiasm

Further Reading
1. Lazarus P. S. (1966). Psychological Stress and the
Coping Process. McGraw-Hill. New York.

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16
Crisis and Crisis Management
David M. Ndetei, Francisca Ongecha-Owuor
Abdulreshid Abdullahi Bekry, Ruthie Rono

It is at this point that a stressful event becomes a


crisis situation.
Individuals go through many stressful situations
and learn to make the necessary adjustments to deal
with the problems that they face. These adjustments
may involve the way of looking at problems, and
changing the situation or environment. This is
known as coping. Coping involves making changes,
controlling the situation, avoiding the stressful
situation, changing the way one thinks about the
problem and changing the way one responds to the
problem.

WHAT IS A CRISIS?
There is no simple denition for the term crisis.
It is used to describe a state of emotional upset. It is
a state of disequilibrium and disorganisation. It is
a situation in which the affected individual is faced
with a problem which needs an urgent solution. A
crisis situation is overwhelming and may involve
danger to the individuals personal security. A
characteristic feature of a crisis is the search by the
affected person for a solution.
When events are overwhelming, the affected
persons become disorganised. They initially feel
powerful and mobilise extra reserves to ght the
stressful event; the muscles become tense; the heart
beats faster and works extra hard to pump blood to
the muscles that need food and oxygen in the ght
against the stress. The individuals become mentally
alert and their pupils become dilated. Extra heat
generated by increased muscular activity is lost
through sweating.
When the threat of personal danger posed by
the event is over, the muscles relax, the heart rate
drops, sweating stops, mental alertness drops and
the pupils assume their usual size. The individual
is then said to have achieved a state of relaxation.
When stress together with the accompanying sense
of threat persists, the level of mental alertness and
the state of readiness persist. The end result is the
development of a stress-related state of fatigue.

TYPES OF CRISES
There are two main types of crises: maturational or
transitional and situational crises

Maturational crisis
This is part of growing up and occurs as a result of
human development from one developmental stage
to another. Maturational crises include such crucial
stages as beginning school, leaving home, beginning
rst employment, marriage and retirement. At
each stage one is forced to make adjustments,
resolve anxiety and conicts necessitated by the
transition. Successful resolution of a maturational
crisis normally leads to personal growth, emotional
stability and good mental health. Unsuccessful
resolution may result in unresolved anxiety and

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Crisis and Crisis Management

or adjustment disorder. It thus calls for immediate


action.

internal conicts, which may lead to unstable


emotional disposition, depression, maladaptive
behaviour or disorders of personality.

SOURCES OF CRISES

Situational crisis
This results from a specic and intense
environmental stressor, hazardous event or threat
to ones life. These include:

Loss of a dearly beloved person, possession or


status.
A severely disabling accident, e.g.
causing paraplegia, amputation or severe
disgurement.
Natural or unnatural disasters causing
unanticipated change in one's life circumstances
or loss, e.g. oods, earthquakes, cyclones or
war.
Being diagnosed with a potentially fatal
disease such as AIDS or inoperable cancer, or
confronted by a life-threatening situation e.g.
after being bitten by a highly poisonous snake,
being trapped in a mine, cave or an aeroplane
facing the possibility of a crash.
Coronary thrombosis/myocardial infarction
(heart-attack).
Being raped.
Being arrested for a serious offence.
Break-up of a relationship, e.g. divorce or
termination of an engagement.
Failure of examination.
Forced retirement.
Separation or threatened separation of a child
from its parents.
Stressful events often occur in human experience
without undue effects. A series of such events do
have a cumulative effect and one last event may act
as the triggering stressor, however trivial this may
be. Thus, people who normally experience crises
might have been under difcult life circumstances
for sometime before the development of the crisis.
The crisis usually assumes special meaning for
the individual, affecting ones self-esteem, or
threatening their sense of security and dignity.
People who experience crises are usually not
prepared for the event causing the crisis, and
therefore have very limited resources to cope with
the stressful event.

Suicidal behaviour
Suicide is dened as the human act of self-iniction,
self-intentional cessation. Suicidal behaviour is
due to the following factors:
Biological factors: vulnerability to depression,
which is the leading cause of suicide.
Psychological factors: hostility, despair,
shame, guilt, dependency and helplessness.
Intra-psychic factors.
Interpersonal factors, for example, rejection
and feelings of inferiority.
Family history of suicide, which can cloud
the life of a person who may later commit
suicide.
Attempted suicide
During suicidal acts death is not always the
objective. Where the goal is to attract attention, the
act is called attempted suicide. Attempted suicide
should be taken seriously and the survivor assessed
for suicide intent. This helps the assessor predict
occurrence of future suicide.
Accidents
Accidents are events that occur unexpectedly.
They may cause physical injuries, destruction of
property, loss of life and destruction of lifestyles and
livelihoods. Accident proneness is the tendency to
have accidents as a result of psychological causes
such as perceptual distortions, personality type and
aggressive tendency in dealing with conict.
Death and bereavement
Thanatology is the study of the phenomenon
of death, emotional and psychological process
involved in reaction to death, grief, bereavement
and mourning.
Emotional and psychiatric disorders linked
to situational crises tend to be self-limiting and
usually never last more than 6 weeks. A crisis period
must always be regarded as a form of medical or
psychiatric emergency. An unresolved situational
crisis may lead to suicide, violence, homicide,
acute stress reaction, post-traumatic stress disorder

MANIFESTATION OF CRISES
People in crisis experience varying features of
anxiety, depression, shame, guilt, anger, problems
with thinking and coping with ordinary day-to-day
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There is an urgent need for help in overcoming


the situation.
The situation has disrupted the life of the
individual.
The individual feels uncertain about what
might happen next.

experiences and change in behaviour patterns. The


affected individual loses the ability to settle down;
becomes restless, cannot sleep, loses appetite
for food and is unable to relax emotionally and
physically. The person is worried, anxious, tense
and pre-occupied with the problem. In time, the
individual begins to suffer from the physical effects
that result from a persistent state of muscular tension
and state of readiness. The person becomes jittery
and may be aware of the heart pounding away. The
person might sweat a lot, feel dizzy, light-headed
and may tire easily.
Memory may be defective with the person failing
to remember the contents of conversations or other
events. One might begin to avoid social contact,
or ordinary activities, hobbies or pastimes. Instead,
they might become preoccupied with aspects of
the situation which gave rise to the crisis state.
Guilt might develop and the person might blame
himself or herself for the crisis. Intense depressive
feelings might develop along with suicidal feelings.
Feelings of unreality might develop with loss of
pleasure feelings for social activities and company,
which used to evoke pleasurable feelings. On the
other hand, the individual might become angry,
irritable and exhibit outbursts of aggression over
trivial events.
The clinical behavioural manifestations of a
crisis state can be summarised as follows:
The individual is unable to function in the
usual manner.
The person withdraws from the usual social
groups or contacts.
The person feels distant or detached from other
people.
The person acts impulsively.
The person might refuse or reject help from
others.
The person demands too much attention from
others.
The person might behave as if nothing wrong
had happened.
The features of crises situations that distinguish a
crisis from a stressful event include:
There is a triggering unexpected event.
The situation is overwhelming and
uncomfortable.
The situation is distressful.
The situation creates a sense of powerlessness,
danger or humiliation.
There is a sense of loss of control over personal
affairs.

SEVERITY OF CRISIS STATES


Not all crisis states are of the same magnitude. The
severity of a given crisis depends on an individuals
previous experience with and ability to handle
stressful events. This of course depends on the
persons pre-morbid personality. People with long
history of stressful experiences tend to suffer more
severe forms of crises than the average person.
Individuals who have a personal or family history
of mental disorders also tend to be vulnerable to
severe crisis states. Lack of a signicant social
support system, or the existence of signicant
family or marital discord tend to predispose to
severe forms of crisis.

ASSESSMENT OF CRISIS STATE


A crisis assessment is a difcult, but necessary
step. In many crisis situations there is no time for
an elaborate assessment, especially where life is in
danger, e.g. the person may be threatening to jump
off a tall building, bridge or cliff, hang himself,
shoot or stab himself or may be threatening the life
of others.
Thus, the emergency may be such that there is
little or no time for full assessment. Intervention
must be given immediately through rapid, but
tactful establishment of rapport with the patient,
followed by gentle and pleading persuasion away
from danger. However, where there is no immediate
threat to life or as soon as the dangerous situation is
averted, data must be collected.

Levels of crisis assessment


Crisis assessment is essential in determining the
nature of appropriate help that the affected person
needs. An appropriate assessment consists of two
levels:
Level 1
This is concerned with the assessment of the risk
of suicidal behaviour, assault or homicidal threat
or action. Since the experience of a crisis might

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Biographical data about the patient, including


biomedical data and a brief psychosocial
history.
All factors which have contributed to the
current crisis. Focus must be on the current
problems.
How the patient perceives the crisis
and stressors causing it.
How the family perceive the crisis.
The health worker's objective evaluation of the
nature and seriousness of the crisis compared
to the patient's perception and that of the
family.
Any underlying psychological, social or
personality problem, e.g. psychiatric illness,
emotional disorder, substance abuse and
marital strife.
The patient's usual coping mechanisms and
other coping skills or strategies which can be
utilised to cope with the current crisis.
The available social or human resources
which can be mobilised and utilised to assist
the patient cope with or overcome the current
crisis.
Assessment of the current mental state.
Assessment of the current physical medical
state as warranted by the crisis.
People in crisis also experience some of the
following signs and symptoms, which should be
evaluated and taken into account as part of the
management

involve the risk of personal injury to the person


concerned or others in the life of the individual,
assessment at level 1 is important and should be
carried out in all cases.
Level 2
This is concerned with the assessment of the impact
of the crisis situation on the individual. Assessment
at level 2 aims at dening the origins of the crisis
situation; the development of the crisis; the
manifestations and impact of the crisis situation on
the individual; what actions the individual might
have taken to control the crisis; what personal,
family, and interpersonal resources are available;
and the social and cultural atmosphere of the
person in crisis. The primary objective of the crisis
assessment process is crisis resolution. To do this,
emphasis is placed on the identication of immediate
problems that can be addressed in the actual crisis
management process. History of the persons usual
problems-solving skills and strategies should be
obtained. An assessment of available social support
system should be made along with an evaluation
and the nature of the emotional atmosphere within
which the person in crisis lives. The subjective
experience and interpretation of the crisis situation
should also be assessed as this will determine the
risk of self-destructive behaviour.
The crisis assessment process might need to be
extended to the entire family or community, as
certain crisis situations often involve whole families
or communities as may occur during disasters.

The assessment interview

Psychological

The actual aim of the interview is to identify recent


events that preceded the crisis state, including the
reasons for seeking help. Detailed inquiry seeks to
establish what happened within the 24 to 48 hours
before the actual onset of the crisis. Such an inquiry
will establish the presenting current problems,
nature of help already sought, and details of social,
occupational, and family responsibilities of the
person.
Information on social and family responsibilities
will be useful in re-assigning family responsibilities,
should it be necessary. Later on, an assessment of
the mental state of the person should be made.
In particular, the presence of suicidal ideation,
the levels of agitation, anxiety, restlessness and
distress should be noted. The physical state of
the person should be noted, including the degree
of dehydration, and the presence and extent of
physical injury. This includes the following:

Unexplained fear (anxiety).


Irritability.
Sadness, tearfulness and a feeling of
helplessness.
Labile mood (mood that changes rapidly).
Forgetfulness, misplacing items, poor recall.
Brooding over the same issue for an endless
period.
Apathy (reduced interest in surroundings).
Somatic
Headache, body aches and pains, fatigue.
Pounding heart, missed heartbeats, fear of
heart stopping.
Feeling as if one is short of air (air hunger).
Poor appetite.

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The African Textbook of Clinical Psychiatry and Mental Health

accepting or rejecting responsibility (recognising that one is at least partly responsible for
the problem and can deal with it or that one is
not responsible and need not react).
This approach is often not adaptive (avoidance may
delay attention to physical illness). Maladaptive
coping strategies reduce emotional response in
the short-term, but lead to greater difculties
in the long-term (use of alcohol or drug abuse,
deliberate self-harm, histrionic behaviourexcept
when culturally sanctioned in bereavementand
aggressive behaviour. One needs good judgment
when choosing an appropriate coping strategy.
The Alcoholics Anonymous (AA) recognise
this fact in their prayer which says To be granted
the courage to change what can be changed, the
serenity to accept what cannot be changed, and the
wisdom to know the difference.

Behavioural
Reduced level of activity, lack of energy.
Over-activity and restlessness (inability to
settle).
Poor, lack of, or too much sleep.
Loss of regard for personal care, appearance
and well-being.
Excessive alcohol consumption.
Suicide behaviour.
Interpersonal
Lack of pleasure for social contact.
Inability to share emotions with others.
Disagreements and arguments over trival
issues.
Acts of violence on imsy reasons.
Excessive dependence on others.

Direct coping
Here the individual makes an objective analysis
of the problem, how it came about and how one
is responding. Individuals develop clear ideas of
what they wish to achieve to solve the problems
(goals) and come up with mental road maps or lists
of approaches to reach the desired end.
Individuals who employ a step-by-step approach
in analysing the situation and choosing the best
option for dealing with the problem are likely to
cope better and learn from the experience. This is
their problem-solving strategy:
seek help from others
obtain information or advice
problem solvingmaking and implementing
plans to deal with the problem
confrontationdefending ones rights or
persuading another person to change their
behaviour.

COPING WITH CRISES


There are two types of coping in a crisis: avoiding
the problems is defensive coping, and meeting
the problem head-on is direct coping.

Defensive coping
In defensive coping, the individual either runs
away from the problem and avoids going near the
stress-inducing situation, or blocks it out of their
mind and denies that the situation is stressful. In
defensive coping, therefore, the individual uses
emotion-reducing strategies. These include:
ventilation
avoidance (refusing to think, avoiding people
or reminders)
positive reappraisal (recognising that the
problem has led to some good, e.g. selfbetterment)

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17
Critical Incident Stress Debrieng
(Psychological Debrieng)
Francisca Ongecha-Owuor, David M. Ndetei

SETTING OF A
PSYCHOLOGICAL DEBRIEFING

DEFINITION
Critical incident stress debrieng (CISD) is
also known as psychological debrieng. It is a
structured intervention designed to promote the
emotional processing of traumatic events, through
the ventilation and normalisation of reactions and
preparation for possible future experiences. It helps
survivors:
Understand and manage intense emotions
Identify effective coping strategies and
Receive support from peers.
CISD aims at minimising the adverse effects of the
normal stress response.

1.

2.

HISTORY
Critical incident stress debrieng was rst used to
mitigate the stress among ambulance personnel,
resulting from the traumatic events they confronted
in the course of their work. It has since been modied
to include other groups of personnel working in
different traumatic situations. Today, psychological
debrieng (PD) is the term frequently used.

3.

85

The setting will take into consideration the


following:
The participants
Their leader
The timing of the debrieng
The location
The procedure.
It should be attended by:
People who have experienced the same
critical event and either work together or
know each other.
Only those directly involved in the
incident.
In some instances it may include family,
friends and strangers drawn in the incident
by chance.
It should ideally be conducted by a specialised
trained team which may include:
Mental health workers
Physicians
Nurses
Chaplains

The African Textbook of Clinical Psychiatry and Mental Health

4.

5.

6.

Timing:
When everyone involved has had enough
rest.
It should be conducted 8 to 72 hours after
the event.
The session should run for 2 to 3 hours,
depending on the number involved and the
complexity of the critical incident.
Setting: Since it deals with a traumatic event
whose effects have not been resolved it is
important to ensure:
Tranquillity
Safety
Lack of distraction
An emotionally neutral place, well
ventilated, well lit and sheltered from the
elements of the event.
There should be a maximum of 25 people per
group.

2.

Phase 3: Thought phase


1.

THE SEVEN PHASES OF CISD


2.

Phase 1: Introduction, the setting and roles


1.

2.

3.

4.

5.
6.

The facilitator briey explains the purpose of


the debrieng process with an assurance to
the participants that the symptoms that they
may be experiencing are normal reactions by
normal people to an abnormal event.
Introduction of both the debrieng team and
participants with specic information on
name, home, vicinity and whether or not there
has been previous experience with disaster.
The group agrees on ground rules which are:
participation is encouraged
length of time the session should take
that everyone must stay until the end
there will be no breaks.
The reasons for these are explained:
To prevent any adverse events since a lot of
intense emotions will be aroused and these
need to be detected and dealt with
Reducing any disruptions.
Notes are not to be taken.
The facilitator then asks if anyone cannot meet
these requirements and reconcile accordingly.

3.

Participants are asked to describe cognitive


reactions or thoughts about their experience,
especially the most prominent thoughts or
thoughts that have been ignored since the
event.
The facilitators can ask specic questions:
each participant to recall thoughts about
the one thing you constantly think about
what were their rst thoughts when the
event occurred
what are their thoughts now that the
immediate threat is over
what thoughts they will carry with them.
To normalise a participants cognitive
reaction, the facilitator may interrupt to ask if
other participants have had similar thoughts
and again reassure them that these are normal
reactions.

Phase 4: Reaction phase


1.

Phase 2: Fact phase


1.

What happened
Where they were
What they did and what they experienced
via their senses (sight, smell, touch, hearing
and taste).
Alternatively the facilitator may facilitate this
by asking questions:
Where were you when it happened?
What did you do rst?
Then what did you do?
What do you remember seeing, smelling
and hearing?
Where was your family?
Where were other people?
Is there anything anyone said to you that
stands out in your memory?

Asking participants to describe from their own


perspective,

86

Participants are encouraged to discuss the


emotions they experienced during and after
the disaster by asking:
How they felt when the event occurred
How they are feeling now and
How this experience has affected their:
- marriage
- work
- appetite
- sleep

Critical Incident Stress Debrieng (Psychological Debrieng)

2.

3.

4.

- interest in sex and


- any other areas of functioning.
This is the most delicate phase.
The articulation of painful or frightening
feelings and emotional catharsis is
considered therapeutic for some survivors
The participants in the debrieng have not
been previously assessed by the facilitators,
on their coping skills such as coping
strengths, psychiatric history and quality
of social support
Limited time and possibly no follow-up
opportunity may result in arousal of intense
emotions that may not be manageable in
the circumstances, even if the facilitator is
highly trained and experienced.
For the above reasons, the facilitator should
take a conservative approach, i.e. not
exploring emotional material that generates
overwhelming feelings of vulnerability,
helplessness and anxiety.
The facilitator needs to normalise these
emotions as common reactions.

3.

4.

Phase 5: Symptoms (Stress reaction) phase


1.

2.

Stress reactions are reviewed in a temporal


context:
What survivors experienced while the
disaster was taking place
What stress reactions have lingered
What they are experiencing at present.
This helps participants recognise the various
forms of stress reactions:
emotional
cognitive
biological
psychosocial.

5.

6.

Phase 6: Teaching phase


1.

2.

Throughout the process of debrieng there is


a lot of teaching that takes place. During this
phase the facilitator should:
Assess what participants know, and dont
know
Ensure that they have accurate information
about stress reactions and stress
management strategies
Decide what information is most relevant to
the participants given the time constraint.
Educational topics addressed include:
Denition of traumatic stress, common
stress reactions

7.

The reactions of children and elderly


people
Fight-ight-freeze response
The fact that in the midst of disaster the
victims experience some physiological
changes due to the outburst of adrenaline
and thus will have a pounding heart, tensed
muscles, fast breathing and sweating. Point
out that it is like:
- Irritation and anger (the desire to ght
back),
- Fear and worry (the desire to ee
from danger),
- So much fear that it causes temporary
immobilisation (freezing).
Explain that each response has potential
survival value as follows:
Fighting back means taking action to
stop further harm from happening
Taking ight can mean nding a safe
place
Freezing can buy time to evaluate the
situation and plan an intelligent response.
Inform them that survivors often feel guilty or
ashamed for having reacted in these normal
ways, believing that they should somehow
have been immune to the bodys healthy
response of getting geared up automatically
in the face of danger. They should realise that
it is the emotional shock of trauma, the terror,
grief, helplessness, horror and confusion that
is the real problem, not the normal reactions
of ght, ight or freezing. They are reassured
that with the passage of time their symptoms
will taper off.
Verbal and written (if available) instructions
are distributed describing stress reduction
techniques.
Lists of mental health providers (all of whom
have the requisite specialised training and
experience in traumatic stress) are provided
for participants who may desire further help.
It is presumed at this point that participants are
now back to a normal cognitive level.

Phase 7: Closing (Re-entry) phase


This phase brings the debrieng to an end.
Each participant is allowed to give one last
comment or closing statement which helps the
facilitator:
- Understand what needs to be done next
- Whether there is need for further counselling

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The African Textbook of Clinical Psychiatry and Mental Health

or a particular physical need presenting


itself.
The socialisation (refreshments with free
informal association) at the end of the closing
phase provides attendees a transition between
the debrieng process and the resumption of
their daily lives.
2.

FACTORS INFLUENCING THE


DEBRIEFING PROCESS AND
OUTCOME
1.

2.

3.

4.
5.
6.
7.
8.

COMMON STRESS REACTIONS


OF PRIMARY VICTIMS (AFTER
TRAUMA)

Trauma exposure:
Multiple versus single (multiple makes it
worse)
Perceived life threats (depends on the
individuals total interpretation of the event.
Most of this interpretation is unconscious)
Concomitant physical injuries
Loss of either lives or property would
complicate the debrieng process by
lengthening its duration as well as arousing
very intense emotions that may be difcult
to handle.
Physical injuries may delay the timing of the
debrieng if there are emergency issues as
well as accompanying physical pain that may
hinder active participation thereby not being
fully benecial to the attendee
Situations of perceived continued life threat:
it may be difcult to reassure the survivor or
normalise the reactions experienced
Individual factors which include training,
experience and acceptability of facilitators
Whether the survivors had been exposed to
trauma before
The availability of support networks
Gender factors
Group factors such as size, cohesiveness,
debrieng environment and timing of
debrieng after trauma all inuence the
process and outcome of debrieng.

Four clusters of stress symptoms commonly


experienced by individuals following a traumatic
event:
1. Emotional: Shock, anger, disbelief, terror,
guilt, irritability, helplessness, loss of pleasure
in activities, regression to earlier developmental
phase
2. Cognitive: Impaired concentration, confusion,
distortion, self-blame, intrusive thoughts,
decreased self-esteem
3. Biological: Fatigue, insomnia, nightmares,
hyperarousal, somatic complaints
4. Psychosocial: Alienation, social withdrawal,
increased stress within relationships, substance
abuse, vocational impairment.
Further Reading
1. Mitchel, JT. When disaster strikes: the critical incident
debrieng process, (1983). Journal of Emergency
Medical Services 8: 36-9
2. Armstrong K., O Callaham W. Marmar CR. Debrieng
Red Cross disaster personnel: the multiple stressor
debrieng model, (1991). Journal of Trauma Stress 4,
581-93.
3. Talbor A. Manton M. Dunn PJ Debrieng the debriefers:
an intervention strategy to assist psychologists after a
crisis, (1992). Journal of Trauma Stress 3: 45-62.

RISKS OF PSYCHOLOGICAL
DEBRIEFING
1.

to traumatic experiences. Therefore, they


also need to go through a debrieng process
after the closing phase. During the debrieng,
the facilitators discuss what went well, what
could and should be done differently and how
individually they are coping with the emotions
stirred by the debrieng.
Mandatory psychological debrieng may
lead to passive participation and resentment.
Hence there is need to solicit for voluntary
participation.

Service providers i.e. facilitators may become


secondary victims, as a result of listening

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Section II Part B:

Medical Sociology
and Anthropology

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The African Textbook of Clinical Psychiatry and Mental Health

90

18
Introduction to Medical Sociology and the Family
Anne Obondo, Eddie Mbewe, O. Morakinyo

OTHER SUB-DISCIPLINES OF
SOCIOLOGY

DEFINITION OF SOCIOLOGY
The word sociology was rst coined by Auguste
Comte in 1837. He combined the Latin word
socio meaning society with the Greek word
logy meaning science. Briey, sociology is the
science of society. It is dened as the scientic
methods used to study social relationships between
people as individuals and groups, and the inuence
of social conditions on these relationships.
Hebert Spencer viewed sociology as the study of
social control, politics, religion, family, individual,
communities and social stratication. Max Weber
viewed sociology as a science, which attempts to
understand social action. In other words, according
to him sociology is the study of social acts and
relationships. Similarly, Durkhiem also stressed the
interaction among social institutions that constitute
society. All the four founders agreed that sociology
was an attempt to understand human society as one
whole by examining the relationship among its
various parts. Sociology, therefore, is the discipline
which studies and analyses human behaviour, the
patterns of interaction and relations in a social
context.

Sociology as a discipline has different subdisciplines which include amongst others, urban
sociology, rural sociology and medical sociology.
Medical sociology began as a specialised eld
in the 1940s. This branch of sociology attempts
to understand the relationship between social
behaviour and health. It tries to understand the
social, environmental and cultural determinants of
health and disease.

Medical sociology dened


Medical sociology is concerned with the social
causes and consequences of health and illness.
What makes medical sociology important is the
critical role social factors play in determining the
health of individuals, groups and the larger society.
Over time medical sociology has grown into two
distinct branches i.e. sociology of medicine and
sociology in medicine. In the former, sociologists
working in university sociology departments apply
sociological theories and concepts to understand
the functioning of health care institutions as well

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The African Textbook of Clinical Psychiatry and Mental Health

same way as that of the west. Instead we observe


that consanguinity (people of the same blood) is
the common type where one of the relatives either
from the fathers or mothers side live with the
nuclear family. The nuclear family most often has
kinsmen within reach who may be called upon in
emergency situations.

as how the health professionals relate amongst


themselves and patients. In the latter, medical
sociologists work with other health professionals in
medical institutions to provide solutions to health
problems.

THE FAMILY, MARRIAGE AND


ITS RELATIONSHIP TO HEALTH

Extended family
The extended family includes grandparents,
uncles, aunts, cousins, nephews and nieces
usually traceable through blood relationships over
generations. In such a situation, the aspects of
patrilineal and matrilineal have a major inuence
when it comes to assigning roles to members of the
family. In the latter, it is the uncles and aunts from
the mothers side who usually have a say in any
major decision-making.
Some special attention needs to be paid to
emerging trends in family types in our society.
This is as a result of the acquired human
immunodeciency syndrome (AIDS) which has
wiped out a large proportion of the sexually active
and bread-winning age group. Most families have
disintegrated and regressed from relative comfort
into poverty. The result is single parent, or child- or
grandparent-headed families.

The family is regarded as the basic unit of society.


Societies are derived from family units. Thus, the
family as an institution serves to legitimise sex,
marriage, parenthood and reproduction of new
members into society, without which society would
disappear.

Denition
The family is a social group characterised by
common residence, economic co-operation and
reproduction. It includes adults of both sexes and
one or more children, own or adopted. A family has
also been dened as any union between a couple
with or without children, or single adults living
with their own or adopted children.
A family in its simplest form includes a husband
and a wife and their offspring (nuclear family). It is
a universal and dynamic unit. Members of a family
play different roles at different times, because
members pass through a life cycle and also, because
it exists in a society which is dynamic.

Single parent family


There are single parent families, which are either
headed by male or female parents. While this may
not be viewed as an uncommon phenomenon,
what ought to be stressed is the rate at which such
families are emerging. In the past it was possibly
due to divorce or death of one parent resulting from
some rare conditions, while now it is largely due
to HIV/AIDS which has dealt a devastating blow
on the family structure.

Type of families
These include nuclear, extended, polygamous,
single parent, child- and grandparent-headed
families. Family patterns vary in relation to ethnic
background, race, age, marital status and roles
played by each person. Other attributes of family
include the aspects of tracing descent from either
of ones parents. Thus, we have patrilineal and
matrilineal type of families. In patrilineal families
the offspring traces the descent through the fathers
line, while in matrilineal the offspring traces the
descent through the mothers line, in which case
uncles have more say in terms of decisions that
touch on family matters.

Child-headed family
Child-headed families are usually a result of the
devastating effect of HIV/AIDS. While 20 to 30
years ago this was unthinkable, we not only have to
deal with child-headed families, but disintegrated
families where children have resorted to begging
in the streets. The children end up assuming adult
roles at an immature age. The aspect of childheaded families is akin to street kids syndrome
as most of the time it is children who spend time on
the streets begging. The psychological effects on
these children, whose progress in life is suddenly
changed for the worst, cannot be overemphasised.
They nd it virtually impossible to be absorbed by
the extended family system mainly due to the fact

Nuclear family
A nuclear family mainly consists of a father, mother
and children living together under one roof. The
child or children may have been born or adopted
into the family. In Africa the typical isolated
nuclear family, does not seem to exist in exactly the

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Introduction to Medical Sociology and the Family

that death would have taken all their dependable


relatives like uncles and aunts.

Economic production
The family, in addition to procreation, has an
important economic function. It is engaged in
economic production for its own survival and for
the social and economic development of a country.
It also allows division of labour to take place
between men and women. Some duties are broken
down by gender, for instance, land clearance,
house building and cattle rearing. However, it is
not uncommon nowadays to see a compromise
of gender roles in almost every culture.

Grandparent-headed family
Deaths among young couples, not only results in
child-headed families, but also poses a challenge
to the elderly people who have to look after their
grandchildren.

Functions of the family


Regulation of sex and reproduction
Sex is important in a marriage and its importance
ranks rst in the hierarchy of needs. Sexual
intercourse in marriage is the duty of both the
partners and a right that must be accorded. Social
gratication is achieved, although not necessarily
through regular sexual contact as in marriage.
However, the general practice postulates that
social functions be performed by the legal partner
and hence, conception must also be by the legal
partner.

Factors contributing to family problems


Urbanisation
Urbanisation has led to the disintegration of
the extended family. Men and women migrate
to cities in search of employment. Urban areas
are characterised by poor housing and living
conditions and problems of diseases, especially in
the slum areas. High population density in cities
has also resulted in impersonal relationships since
it becomes difcult to develop intimate social
relationships with too many people.
Alcoholism and drug abuse are rife. Sex
ratio is also unequal in urban areas, leading to
increase in prostitution and high illegitimacy
rates, which affects family stability. When sex
ratio is imbalanced, problems arise, e.g. husbands
establishing second homes, and may cut links with
their home and family.
Housing design in the cities also affects family
relationships, because houses in urban areas cannot
accommodate relatives. There is also lack of
privacy in the slum areas where the unit is a single
room. Children and parents share the same space
for sleeping, eating and some leisure activities.
Children are likely to be affected psychologically.
The cash economy has also altered family
structure and functioning. Division of labour has
changed drastically, forcing families to change
internal sex roles and authority patterns.

Care and socialisation


The family also functions to regulate inheritance
and give protection to children. Unlike many other
animals, human beings are born utterly helpless.
Children must be socialised into the complex
network of norms, values and culture. They must
learn everything, from which words to use, how to
eat, dress, to what they can reasonably expect from
life. Neither physical care nor socialisation need be
the exclusive responsibility of the childs parents,
but also that of a large network of aunties, uncles,
grandparents and cousinsthe extended family.
Socialisation is the process where the individual
personality is prepared to take an autonomous
role in the society. It is also an interactive process
between the mother and the child, where the child
learns to identify with the mother and internalise
her values.
Initially the child identies with the mother. The
child ultimately learns to distinguish between the
mother and the family sub-systems. Later the child
learns the large family concept and how it ts into
the social framework.

Marital problems
Conicts in marriages are more common today
than in the traditional African family. Selection in
marriages today is an individual affair, whereas in
the traditional African society it was a family affair
and relationships were well dened for the couple,
which resulted in less conict or no conict at all.
Huge sums of money spent on weddings today lead
to nancial strain thus creating conict in marriages
and adjustment problems.

Acquisition of sex roles


Children are made aware of their sexes right from
infancy through activities and when different
behaviours are demanded from boys and girls.
From an early age, boys and girls learn about and
acquire socially approved sex roles.

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The African Textbook of Clinical Psychiatry and Mental Health

Separation between a husband and wife because


of employment, has generated a lot of problems
for the woman who has to look after the children
single-handedly, attend to the farm, and attend to
numerous demands made on her by the in-laws.
She actually becomes a servant of the family.
Failure to perform well leads to poor relationship
between the husband and wife. The woman, feeling
unsupported, may walk away from the marriage.
Separation also leads to lack of development of
the home, problems of disciplining the children are
solely left to the woman and there may be a lack of
sense of belonging on the part of children.
Polygamy today has resulted in numerous
problems. Educated men marry without the
knowledge of the rst wife, who is expected to live
with her co-wife. Such behaviour leads to family
instability. The family suffers nancially, because
family resources are wasted in other forms of extramarital relations. Polygamy in the urban setting
may be unmanageable, because of the cost of
housing and food. The wives are likely to compete
for assistance and when there is inequality conict
may result. Polygamy, which has in the past been a
noble practice in Africa, creates untold conict in
todays families leading to instability.

Problems in marriage
Role confusion.
Increased burden on women in the labour
force.
Arrival of children, especially when one or
two children are pre-scholars.
Disruption of normal life results in
disagreements on how to handle child caring.
A husband may become jealous when too
much attention is given to the children.

Divorce
Divorce refers to the dissolution of a marriage. In
traditional systems divorce resulted in the woman
returning to her family, and depending on the
circumstances, a portion of the bride wealth could
be returned. In patrilineal systems, children would
normally stay with the mother until they are older,
then they would go to live with the father.
Reasons for divorce are usually role conicts.
Deviation from the traditional wives role of caring
for the husband and children within the family
context affects the marital relationship. When the
women are involved in career-related activities
more than they should be, there exists the potential
for reduced marital quality. In addition, marriages
in which the wife earns higher wages or the
husband is unemployed run the risk of divorce. If
the husband is supportive then this role conict can
be diffused.
The following factors may lead to instability in
marriages:
Financial instability. When the husband is
unable to provide for his family nancially
Alcoholism or any other mental impairment
Polygamy
Ill-treatment and neglect of wife by husband
Marriage forced by parents against their
daughter's wish
Rejection of a husband by the wife's family
Poor relationship between wife and mother-inlaw
Poor sexual relationship or lack of sexual
relationship between the spouses
Infertility.
Divorce seems to have been more peaceful and less
disturbing to the spouses and children in traditional
African systems. Currently, however, divorce is
highly disruptive since many people use the courts

Working mothers
Working mothers are faced with various challenges
which include working and caring for children.
This calls for engaging house-helps who may not
care for the children adequately and may physically
or sexually abuse them. The house-help might also
be sexually exploited by the husband, resulting in
family conict and instability.
Marriage
Marriage is a legal union between man and woman
for the purpose of living together and procreating.
Traditionally, marriage is an institution and
arrangement for and between kin groups designed
to effect rights and obligations between two
people and groups of kin. Marriage also serves the
purpose of continuity of lineage and establishment
of alliances.
Benets of a marriage
The fullment of the need for interpersonal
interaction on a very intimate level with the
opposite sex (including fullment of sexual
needs).
Marriage can be a source of increasing maturity
and personal development.

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Introduction to Medical Sociology and the Family

to ght over children and property. Uncertainties


over legal rights and conicting normative systems
make such ghts more common today.

Divorce usually marks a problem in adolescent


adjustment and hence, rebellion. There is a higher
likelihood of transmission of intergenerational
marital instability. Children of divorced parents
often lack the interpersonal skills of bargaining,
negotiation, problem-solving and conict
resolution.
Divorce may also lead to alcoholism or depression
in one or both of the spouses. It can also lead to
suicide.

Consequences of divorce
Several studies have shown that juvenile
delinquency is usually associated with broken
homes. Boys of divorced parents show a higher
rate of behavioural disorders and problems with
interpersonal relationships.
Divorce leads to two families in distress instead
of onedevastating both the children and spouse.
Children of such families have lower self-esteem.
They are characterised by psychosomatic illness,
delinquent behaviour and parent-child adjustment
problems.

Further reading
1. Huxley P. (1998) Social Work Practice In Mental
Health. Gowe. Publishing Company, Vermont.
2. Lask J. And Lask B. (1981). Child Psychiatry And
Social Work. Tavistock, London.

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19
Health and Illness Behaviours
Duncan Ngare, Anne Obondo, Stella Neema, Benedicta Yetunde Oladimeji,
David M. Ndetei, Jeremiah Chikovore

HEALTH BELIEF MODEL

HEALTH BEHAVIOUR AND


LIFESTYLES

This model is one of the most inuential sociopsychological perspectives used to explain how
preventive behaviours are acquired. Behaviours
undertaken by individuals in relation to health are
inuenced to a large extent by self perceptions.
Thus, if an individual perceives himself as being
susceptible to a certain illness or disease they
are likely to take some positive action to prevent
themselves from getting the condition. Similarly,
the severity of a disease as well as the perceived
threat of the disease will also inuence the
likelihood of taking action. However, while this
would be the expected course of action there are
other factors which could modify the desired action,
therefore resulting in a different action being taken
or no preventive action being taken at all. These
factors are called modifying factors which include
demographic variables such as sex, age, ethnicity
and race; socio-psychological variables such as
personality, social class, peer and reference group
pressure; structural variables such as knowledge
about the disease, prior contact with the disease;
cue to action; mass media campaigns; advice from
others; reminder postcard from physician or dentist;
illness of a family member or friend; newspaper
or magazine article. It further argues that the
likelihood of taking action is also dependent, not

As health professionals it is important to understand


the relationship between human behaviour and
health. Human behaviour, which is the sum of
the activities that individuals engage in can be
broadly classied into health and illness behaviour.
The former are those behaviours or activities
that individuals will engage in, consciously or
unconsciously, to prevent illness occurrence or to
maintain a healthy state. The latter refers to those
activities that ill individuals will undertake in
order to restore a healthy state. This is important
because it informs our knowledge in preventive
medicine and health seeking behaviour of different
individuals.
Healthy lifestyles are ways of living that
promote good health and longer life expectancy.
Healthy lifestyles include contact with health
care professionals, but the majority of activities
lie outside the formal health care systems. These
activities include good diet, rest and relaxation,
avoidance of stress, alcohol and drug abuse, and
proper hygiene. Life choices are determined by an
individuals socio-economic status, age, sex, class,
race and ethnicity. The choices have a positive or
negative effect on the body and mind.

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only on the inuence of the modiers, but also on


the consideration of the perceived benets minus
perceived barriers of the preventive action. This
model is crucial for the understanding of how our
clients conceptualise preventive and promotive
health behaviours and the kind of considerations
that they make. It has been employed successfully
in many studies of preventive health behaviour.

account for social change and the fact that conict


is regarded as always dysfunctional. This led to
the formulation of a counteracting theory of social
conict.

STRUCTURAL FUNCTIONALISM
AND SYSTEMS THEORY

The symbolic interactionist approach to human


behaviour views human group life from the
perspective of the individual. It sees the individual
as a creative, thinking organism who is able to
choose his or her behaviour instead of reacting
mechanically to the inuence of social processes.
This approach is of profound importance in trying to
understand stress in society. It also helps to clearly
understand the concept of social stigma as a social
construction originating from the interaction of the
individual and society. In this era of HIV/AIDS
the issue of stigma is so important that we must
comprehend it in order for us to be able to address
the problem and assist those who are affected.

SYMBOLIC INTERACTION
THEORY

This theory postulates that units within a structure


function to maintain that structure. Various parts
of the body, like the heart and kidney have certain
functions to perform in the body. Similarly, in the
family the father and the mother perform the roles
of providing education, food and shelter for the
children who in turn have to respect their parents.
The family as a social structure is maintained by
continuous role interaction among the various
units. The units therefore function to maintain the
structure.
Every social system is characterised by a
functional unit, i.e. the various parts function in such
a harmonious manner that they are well integrated
and regulated. Conict is avoided and the social
system therefore tends towards equilibrium. The
main functions of the social systems are pattern
maintenance, referred to as the AGIL function.
Where A stands for adaptation, G stands for goal
attainment, I stands for integration and L stands for
maintenance and tension management.
These functions are important for an individuals
well-being in the society. In the case of adaptation,
an individual has to adjust to his environment to be
able to function normally. In goal attainment there
are certain goals people want to attain and failure to
attain such goals may lead to problems of low selfesteem. Regarding integration, it is important for
an individual to be integrated into their community,
because in the absence of this, various problems
may ensue. Isolation of individuals may result in
problems such as alcoholism and drug dependence
or psychological disturbance. Maintenance and
tension management is a function measured by
the various institutions in the community and the
functions they perform, e.g. the family, school and
health institutions. All the functions performed
by institutions are important for the individuals
well-being. The main weakness of structural
functionalism and systems theory is the inability to

Social meaning of stigma


The word stigma was used by the Greeks to
refer to bodily signs, usually inicted cuts or
burns, designed to expose the unfortunate bearer
as a slave, criminal or social outcast. Today, it is
applied more generally to any condition, attribute
or trait which marks an individual as culturally
unacceptable or inferior. In different communities
similar conditions can yield different reactions
where one disease condition may be stigmatised
in one but not in another. As health practitioners
we must be aware of this fact as we deal with our
patients.

SOCIAL CONFLICT THEORY


This theory argues that conict in relations is
normal because conict itself can be functional.
Conict helps to sharpen appetite for action, since
many begin to think quite sharply in response to
conict or threat, in order to nd a way out of it.
They demonstrate remarkable solidarity when
exposed to external threats of danger, and thus,
a system behaves like a biological organism
threatened with extinction when responding to
danger. Social conicts help a group to redene its
goals and group boundaries through a screening
process. Social conict generates creativity and

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the nding by the medical worker that the


patient has a disordered function of the body
the patients symptoms conforming to a
recognisable clinical pattern.
In medical sociology, disease is seen as an adverse
physical state, consisting of a physiological
dysfunction within an individual; an illness is
a subjective state, pertaining to an individuals
psychological awareness of having a disease
and usually causing that person to modify his or
her behaviour; while sickness is a social state,
signifying an impaired social role for those who
are ill.
Illness can be deemed to be a deviance because it
is an unwelcome state. Illness represents a deviation
from culturally established norms or standards
of good health. Therefore, anyone acknowledged
to be ill properly desires and is the recipient of
treatment to correct the state of body or mind.
A sick person is exempted from their usual roles
or responsibilities due to the nature of their ill state.
From this perspective it can be argued that the
individual is not doing what is expected of him or
her and has digressed from the norm. If the person
is, however, responsible for the illness or has faked
illness he or she is classied as a malingerer. As
a malingerer, the behaviour deviates from what
is expected and required of that individual, and is
therefore deviant.
A third perspective that can be used to view
illness as deviance is through the stigmatising
illness. Some illnesses, such as AIDS are regarded
as deviant by lay populations. Society seems to
view AIDS patients as if they have done what is
not acceptable, that is, having sexual intercourse.
Illness behaviour can be dened as those
activities undertaken by a person who feels ill for
the purpose of dening that illness and seeking
relief from the illness. Illness behaviour refers to
the varying ways individuals respond to bodily
indications, how they monitor internal states,
dene and interpret symptoms, make attributions,
take remedial actions and utilise various sources
of formal and informal care. Although individuals
respond to illnesses differently, there are various
stages they undergo. The ve stages are:
symptom experience
assumption of the sick role
medical care contact
dependent-patient role
recovery and rehabilitation.

innovativeness; this being a crucial determinant of


social change and development.
Relationships are often in conict. It is wrong
in most societies to covet another mans wife, but
when a man and a woman are seriously attracted
to each other the norm of avoiding entering into
any illicit relationship may not work. If the
husband nds out, then conict arises. Hence, at
the level of real human action, conict is endemic.
However, while conict is normal and can be seen
not to disintegrate society, society is hardly ever in
equilibrium.
The proponents of social conict theory say that
equilibrium theory consciously becomes a support
for the status quo. Instead of being a lens which
sharpens our perspective and puts social reality in
focus, it becomes a pair of rose-coloured glasses
which distort reality, screening out the harsh facts
of conict.

ILLNESS BEHAVIOUR AND


DEVIANCE
The Deviance Theory
This theory uses the concept of anomie to explain
deviant behaviour, e.g. suicide or attempted suicide.
It focuses on conditions that ultimately produce
a breakdown in regulatory norms such as rapid
social change or economic crisis and prosperity. As
a result of these conditions there is normlessness
which leaves the society and individuals without
moral guidance and therefore, they experience all
sorts of problems.
It uses deviance to explain different kinds of
suicide in society, which is also used to explain
other types of individual and societal malfunctions,
such as drug abuse and alcoholism. An alcoholic
may be considered deviant when drinking takes
the form which deviates from socially controlled
traditions and customs or regulatory norms.

Illness and deviance


Illness is viewed medically as deviance from a
biological norm of health and feeling of well-being.
A person is therefore seen as ill if their symptoms,
complaints, or the results of a physical examination
or laboratory tests indicate an abnormality.
Traditional identifying criteria for disease are:
the patients experience of subjective feelings
of sickness

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also seen as being in need of care. However, it is


important to realise that all these privileges are
considered not only temporary but also conditional.
Therefore the patient is expected to co-operate with
the doctor and to strive to leave the undesired state.
Parsons analysis of the roles of the doctor and the
patient is summarised below.
The relationship between a patient and a doctor
and the attendant roles can be summarised as
follows:
On the part of the patient the sick role entails
certain obligations and privileges. They:
o Must want to get well as quickly as
possible
o Should seek professional medical advice
and co-operate with the doctor
o Are allowed (and may be expected) to shed
some normal activities and responsibilities
o Are regarded as being in need of care and
unable to get better on their own.
The doctor has both expectations and rights
o The doctor is expected to:
- Apply a high degree of skill and
knowledge to the problems of illness
- Act for the welfare of patients and
community rather than for own
self interest, desire for money and
advancement
- Be objective and emotionally detached
(i.e. should not judge patients behaviour
in terms of personal value system or
become emotionally involved with
them)
- Be guided by rules of professional
practice.
o The doctor is granted the following rights:
- To examine patients physically and to
enquire into intimate areas of physical
and personal life
- Considerable autonomy in professional
practice
- Occupies position of autonomy in
relation to the patient.
Three basic types of doctor-patient relationship can
be observed in relation to respective roles. These
are:
1. Activity-passivity,
The doctor does something to a patient who
is not able to respond as happens when the
patient is unconscious i.e. the doctor has
complete control over the patient.

Although an illness experience may not involve all


the stages and can be terminated at any particular
stage through denial, each stage requires the sick
person to take different kinds of decisions and
actions.

The Sick Role Theory


The concept of the sick role is based on the
assumption that being sick is not a deliberate choice
of the sick person, though illness may occur as a
result of motivated exposure to infection or injury.
The sick persons are considered deviant because
they cannot help it. The specic aspects of the
sick role can be described in four basic categories:
The sick persons are exempted from their
normal social roles. An individuals illness is
the ground for exemption from social roles
and responsibilities. For this exemption to
be accepted by society the illness has to be
certied legitimate by a medical practitioner.
The exemption also depends on the nature and
severity of the illness.
The sick person is not responsible for the
condition. It is assumed that the illness is not
self-inicted.
The sick person should try to get well. Given
that the sick person is not responsible for
the illness he or she is expected to have the
willpower to get well. Illness is considered
undesirable and therefore the sick person is
expected to desire to get out of the undesirable
condition and regain normal health
The sick person should seek technically
competent help and co-operate with the
physician.

DOCTOR-PATIENT
INTERACTION
The way the doctor interacts with the patient
has been a subject of study for decades. It is
important because depending on the circumstances
surrounding a certain treatment the relationship
might differ. The doctor and the patient have been
assigned specic roles by society. The patients
role, for example, is seen as one that is temporary
and undesirable and therefore the patient has an
obligation to return to a state of health as soon
as possible. The patient is also accorded certain
privileges such as giving up social activities or
responsibilities due to their condition. They are

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their patients. The patient is no longer that passive


being who would get information from their doctor
without uttering a word. The society has gone
through transformations in terms of social and
economic development which has in turn impacted
on the change in this relationship. Although our
relationships will basically remain to the greater
extent as described by different scholars, we need to
appreciate the fact that our clients will be different
and therefore we have to adjust accordingly for
our treatments to be acceptable and effective. This
dictates that we understand our patients very well.
The behavioural sciences are therefore important
in facilitating this role.

2.

Guidance-co-operation,
The doctor tells the patient what to do and
the patient co-operates or obeys as happens
when the patient is acutely unwell i.e. the
patient is dependent on the doctor.
3. Mutual co-operation.
The doctor helps the patient to help himself
or herself as happens in psychotherapies
i.e. the doctor and the patient are partners.
It is important to recognise that the relationship
continues to change with changing times. For
example, there are times when the patient could not
question what their doctor told them. These days
medical information is readily available. This ease
of availability of information has transformed the
practice of medicine especially in the developed
world. Even in the African continent we have
seen drastic changes in how the doctors relate to

Further reading
1. Huxley P. (1998) Social Work Practice In Mental
Health. Gowe. Publishing Company, Vermont.
2. Lask J. and Lask B. (1981). Child Psychiatry And
Social Work. Tavistock, London.

100

20
Culture, Health and Illness
Stella Neema, Nhlanhla Mkhize, Gad Kilonzo,
Nora M. Hogan, Jeremiah Chikovore, David M. Ndetei

practices relate to biological changes in the human


organism, in both health and disease.

INTRODUCTION

Culture, health and illness

Anthropology is the holistic study of humankind


that includes its origin, development, social and
political organisation, religion, languages, art and
artefacts. Derived from the Greek word meaning
the study of man, anthropology has been
considered as the most scientic of the humanities
and the most humane of the sciences. As an academic
discipline it has several branches which include
physical/human social and cultural, environmental
and medical anthropology. This chapter primarily
addresses issues related to medical anthropology.

Culture is dened as a set of guidelines, which


people inherit as members of a particular society. It
includes knowledge, beliefs, art, morals, customs
and any other capabilities and habits acquired by
the person as a member of society. It comprises
systems of shared ideas, systems of concepts and
rules, and meanings that underlie and are expressed
in the ways that human beings live. Culture is
dynamic.
Cultural background has an important inuence
in many aspects of peoples lives including
their beliefs, behaviours, perceptions, emotions,
language, religion, rituals, family structure, diet,
dress, body image, and attitude towards illness, pain
and other forms of misfortune. It should be noted,
however, that it is not only culture that may have
an inuence on an individual; other factors include
age, gender, appearance, personality, intelligence,
experience, educationboth formal and informal.
Socio-economic factors such as social class,
economic status, occupation and the network of
social support from other people are also factors
inuencing the health status of individuals.
Political factors also inuence peoples
behaviour. People may have high levels of anxiety

What is medical anthropology?


Medical anthropology is the branch of social
and cultural anthropology, which is concerned
with a wide range of biological phenomena,
especially health and disease. It is a bio-cultural
discipline concerned with both the biological and
socio-cultural aspects of human behaviour and
particularly the ways in which the two interact to
inuence health and disease. Medical anthropology,
therefore, is concerned with how people in different
cultures and social groups explain the causes of ill
health, the types of treatment they believe in and
the people to whom they turn if they do become
ill. It is also the study of how these beliefs and

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worker. The anthropologist, on the other hand,


will consider what people know about malaria, the
local terminologies used to describe malaria, and
the help and health seeking or treatment practices.
In that way, a better understanding of the context in
which malaria is experienced is elicited for better
intervention strategies.

in their daily lives not because their culture makes


them anxious, but because they are suffering
discrimination or persecution from other people.
Students of culture and illness should therefore take
into consideration the impact of social, economic
and political factors.

Cultural relativism
Relativism is the view that cultures are varied and
may not be comparable as they are unique in their
own right. According to this view, cultures have to
be appreciated and understood in their contexts.
Beliefs or practices that seem to be normal may
be considered strange in another culture. Eating
grasshoppers, women kneeling while greeting an
adult person, or squatting while giving birth, may
all seem strange to those outside the culture where
they are practised. Similarly, a health worker may
nd it strange if a patient mentions family spirits
as the cause of a disease and that these spirits need
to be consulted as part of the cure. So, cultural
relativism is the view that no culture is superior
to another and that beliefs, values, behaviours and
practices of all cultures are rational and should not
be judged on the standards of other cultures.
However, there are arguments that cultural
relativism does not mean that one does not make
a value judgement. This would mean that practices
like ritual sacrice, wife battering, and cannibalism
should be overlooked. Radical relativism is
problematic: it makes it impossible to adjudicate
between competing cultural points of view.

HEALTH AND ILLNESS


The culture of a society constructs the way its
members think, perceive and feel about sickness
and healing. It is thus important to conduct a
cultural analysis of the presenting problem in order
to identify culture-based concepts of health and
illness (including its causes and treatment options)
and to understand help-seeking pathways. Health
problems should be viewed as cultural phenomena:
they are associated with the persons conditions of
existence, communicated in culturally-prescribed
ways, labelled in accordance with cultural concepts,
and experienced in a manner that is inuenced by
prevailing cultural ideas.

Health problems and living conditions


Health problems often originate in peoples living
and working conditions (e.g. poor, crowded
places and slums) and life styles (e.g. smoking,
unprotected sexual intercourse, having several
sexual partners).

The cultural communication of health


problems

Ethnocentrism
Ethnocentrism is the view that ones own culture
is superior to all other cultures. In ethnocentrism,
other peoples cultures are evaluated with reference
to ones own cultural assumptions, values and
customs. Other peoples beliefs and practices are
seen as inferior or wrong.

Health problems are communicated to others in


ways that are culturally prescribed. A sick person
in one culture may be expected to show pain, while
in another culture suffering in silence is prized.
Among some groups in central Uganda, especially
the Baganda, people express bereavement by
crying loudly and chanting many words about
the deceased. However, this is not acceptable
in the southern parts of the country, among the
Banyankole. In some cultures, people aficted
with disease are secluded, while in other cultures
they are expected to be in the company of others.

Anthropology and contextualisation


In order to gain insight into peoples way of life,
practices and ideas, one has to examine them in
their context. To have a better understanding and
interpretation of phenomena, one has to contextualise
them. Unlike the natural sciences where the object
of research is taken out of its context and reduced
to smaller parts, anthropology includes all relevant
contextual information about the object. In the
study of malaria, a medical professional will draw
blood to check for the malaria parasites. Once
found, anti-malaria drugs are dispensed. Nothing
much is said between the patient and the health

Labelling and explaining health problems


Health problems are labelled and explained in
accordance with existing cultural concepts. Some
cultures believe that illness is caused by imbalances
between hot and cold states. If an illness is described
as hot then cold remedies are prescribed to

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combat the heat. Other cultures believe in spirit


causation of illness. A distinction is drawn between
benevolent spirits, which are believed to provide
prosperity, fertility and luck when invoked, and
the malevolent ones, which cause afiction and,
sometimes death. People can also subscribe to
biomedical as well as traditional explanations of
illness. Most people know that malaria is caused
by parasites carried by mosquitoes, yet others
attribute it to eating a lot of mangoes and maize or
playing in the rain (for the children).

with both an objective and a subjective reality.


A persons experience of ill health includes both
behavioural changes and feelings of being sick,
each of which are intimately related to the persons
social context. It is possible for an individual
to have a disease, yet be unaware of it. It is also
possible for one to feel and act ill without showing
evidence of any objectively veriable diseases. In
the former, there is no illness though there may be
disease. Without consciousness of ill health there
can be no such thing as illness behaviour.

The cultural experience of health problems

Sickness

The manner in which people experience health


problems is inuenced by prevailing cultural ideas.
An illness may be regarded as fatal in one culture
while the same illness is regarded as harmless
in another culture. Such perceptions may affect
peoples help-seeking behaviours, as well as their
responses to and experience of that illness. Among
the Basoga of Eastern Uganda, it is believed that
hydrocoele (empanama omushuha), affecting men,
is a sign of wealth and not a disease. Similarly
among the Baganda, there is a belief that if a man
has a sexually transmitted disease (STD), especially
gonorrhoea, it is a disease of the brave (obulwadde
bwabazira).
Clinicians should be aware of these sociocultural inuences that affect ill health and its
treatment when interacting with patients. Otherwise
biomedicine will be rendered irrelevant if the
illness experienced is not addressed.

The term sickness refers to the inuence of society at


large on illness and the individual suffering from ill
health. Society gives those aficted a sick role and
they are relieved of their normal responsibilities.

Disease without illness and illness without


disease
It is important to note that there are situations
where illness is present, while the disease is absent.
Alternatively, the disease could be present without
an illness.
Illness without disease
In situations where illness is present and disease
is absent, the persons feel unwell. They describe
their situation as health problems that need medical
attention. These are their feelings or subjective
appraisal of their situation. However, when
diagnostic tests and other physical examinations
are conducted, nothing is detected. The persons are
well as diagnosed by a medical expert though they
feel unwell. Psychosocial problems or physical
sensations for which there are no physical causes
are among the problems that bring feelings of being
unwell. These include:
Stressful disorders
Psychosomatic disorders e.g. irritable
colon, hyperventilation syndrome
Hypochondria
Folk illnesses such as demon possession, high
blood pressure (susto), and too much gas in
the intestines (ekintu/ekirwaire)
It is very difcult for the medical expert to explain
to the patient and family members that there is
nothing wrong, because the aficted person has
already identied and perhaps even labelled the
problem. The problem is culturally experienced:
it is expressed in the familys accepted language
of distress. This could possibly be one of the
factors causing non-compliance and lack of faith

The distinction between disease, illness and


sickness
Most individuals do not distinguish between
disease, illness and sickness. In most cases, these
concepts are used interchangeably.
Disease
Disease is dened in biomedical terms. It is a
biological or medical conception of pathological
abnormalities in peoples bodies. Diseases are
indicated by certain abnormal signs and symptoms,
which can be observed, measured, recorded,
classied and analysed according to clinical
standards of normality or abnormality. Biomedical
disease presents no data for sociological analysis;
it reveals no social facts.
Illness
Illness is the individuals experience of a
conditionit refers to the persons lived experience
of the disease. It is an explicitly social phenomenon
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have coined the term masculinity crisis to refer


to the responses of those men who fail the test of
manhood. This crisis has a negative impact on
mens well-being and health. In Zimbabwe, men
who spend time away from their families as migrant
labourers experience high levels of anxiety. The
anxiety stems partly from the fear that their wives
or partners could be engaged in illicit sexual affairs.
Reports of men assaulting their partners whom they
suspect of being sexually involved with other men
are not uncommon.

in biomedical care among such patients. In most


cases, such patients visit various health facilities
several times looking for a cure. The treatment
prescribed by the medical expert may fail to deal
with the illness. Generally 50 percent of visits to
the doctor are for complaints without ascertainable
biological bases.
The medico-centric orientation disregards illness:
it does not take into consideration cultural beliefs
and explanations. This has led to patient mistrust
of and dissatisfaction with professional health care.
Some patients resort to non-biomedical care such as
traditional and faith healers as a result. Clinicians
should attend to both illness and disease, bearing
in mind that patients cultural categories play a big
role in the perception and labelling of symptoms
and treatment expectations.

The distinction between masculine and


feminine activities and emotions
Through socialisation, a distinction is often drawn
between feminine and masculine behaviours
and emotions. Men are expected to be physically and
mentally strong. Men often build muscular bodies
and exude an air of invincibility in their gait to live
up to this image. Those that express feminine
mannerisms (e.g. those that cry or acknowledge
pain with ease) are considered effeminate. This
means that men may delay presenting for health
care. When they eventually do, they may omit the
less visible symptoms or those symptoms they
consider mild. Instead, they may opt to focus
on symptoms with socially acceptable levels of
seriousness, which in their opinion clearly warrant
intervention. This means that illnesses are not
detected early enough for treatment.

Disease without illness


In this situation the medical expert does tests and
physical examinations and nds disease present
in body uids and cells. The person, however,
does not feel ill or complain that there is anything
wrong. Such a person may not take medications
prescribed by the health practitioner. Alternatively,
he may fail to complete the course, which could
lead to resistant strains of the disease. HIV/AIDS
and some STDs that manifest among women are
good examples.

THE RELATIONSHIP BETWEEN


CULTURE AND HEALTH

Violence associated with bride price


Bride price traditionally forms part of the marriage
transactions in most sub-Saharan African countries,
parts of Asia and the Middle East. Incidentally,
bride wealth, be it dowry (Asia and Middle East)
or bride price (Africa) seems to cause a certain
measure of violence, especially against women. In
Zimbabwe, men objected to sexual activity among
their unmarried girl relatives and daughters. One
of the reasons was that sexual activity threatened
bride wealth returns on the girl. Evidence of sexual
activity was therefore met with physical and verbal
violence.
It could be argued that the violence now
associated with bride price may signify the
increasing monetary value of the transaction.
Previously, bride price was a symbolic gesture in
most societies: it could be paid in various ways,
ranging from labour to livestock. In a context where
money has become central to survival and prestige,
the institution also appears to have undergone
dramatic transformation.

People are socialised to take on certain roles and


responsibilities in society. Some of these roles are
detrimental to health. The roles people play may
motivate behaviours that place them at risk. Four
common risk factors are discussed: the expectation
that men should be bread-winners, the distinction
between masculine and feminine behaviours
and emotions, violence associated with bride price,
and the value placed on the virginity of unmarried
girls. Effects of culture on the clinical presentation
of symptoms are briey discussed.

Men should be bread-winners


In most cultures, it is generally expected that men
should provide for their families. The manhood
of those who fail in this role may be questioned.
Continued failure may lead to other high-risk
behaviours such as excessive drug and alcohol
consumption, violence and suicide. Some writers

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The value placed on the virginity of


unmarried girls

The popular sector


This comprises the lay, non-professional domain of
society, where illness is rst recognised, dened and
treated. Initiation of health care activities begins in
this domain. The popular sector incorporates the
following activities:
Therapeutic options that are utilised without
payment and consultation.
Self care, treatment and medication.
Advice given by relatives, friends and
neighbours.
Healing and counselling in churches, mosques
or temples.
The family is the main source of health care in this
sector. This is where the problem is rst identied
and suggestions made on what to do. Healers
and advice givers in this domain include women,
mostly the mothers, grandmothers and aunts who
are knowledgeable about the health problems and
remedies for those problems. Up to 90 percent of
health care takes place in this sector.
Home remedies provided by this sector include
local herbs. Food can also be used as medicine, an
example being soup from tiny sh in Uganda called
nkeje, given to children when they have measles.
In the popular sector, certain individuals tend to
act as health advisers more than others:
Those with a long experience of particular
illnesses or types of treatment.
Those with extensive experience of certain life
events (e.g. women who have raised several
children).
Paramedics such as nurses and hospital
workers, who are consulted informally about
health problems.
Doctors wives or husbands who share some
of their spouses experience if not trained.
Members or ofcials of certain healing
churches or cults.
One of the disadvantages of this sector is that overreliance on home remedies when the condition is
life threatening could delay life-saving treatment.

Many culturesincluding sub-Saharan Africa


countriesplace a high value on the virginity of
unmarried girls. Without similar expectations, men
and young boys may express their masculinity
by having multiple sexual partners, and in some
instances, by deowering girls. According to press
reports, virginity tests performed on unmarried
young girls have resurfaced in several southern
African countries, as communities struggle to
deal with the AIDS pandemic. However, some
organisations in Zimbabwe expressed concern
with this development, arguing that targeting only
girls merely exposes them to men who might feel
the virgin girls are safer to have sex with. Girls
conrmed to be virgins may also be exposed to
the risk of rape by men who think having sex with
virgins is a cure for AIDS.

HEALTH SYSTEMS AS
CULTURAL SYSTEMS
A health system is synonymous with the medical
system. On the other hand, a cultural system is a
coherent whole of beliefs, norms, arrangements,
institutions and patterns of interaction. Ideas and
practices concerning health may be called a health
or medical system. A health system includes beliefs
related to causes of illness, norms governing
choices and evaluation of treatment, roles, power
relationships, interactions, setting and institutions.
Traditional healers in most parts of Africa
dispense biomedicines to their clients in addition
to local remedies. Traditional birth attendants in
Uganda have provided ergometrine injections to
mothers after delivery. Biomedical doctors have
also used alternative therapies such as acupuncture.
In Uganda a renowned biomedical doctor was
dispensing herbal tablets called mariandina to treat
AIDS. Mainstream doctors opposed his actions,
but the patients reported relief from the remedy.
In any given society there are three overlapping
and interconnected sectors of health care: the
popular, folk and professional sectors. Within the
three sectors, individuals have different beliefs
about the causes of illness, and help seeking
practices. The three sectors may or may not overlap
in some settings. However, there are points of
entrance and exit.

The folk sector


This is the intermediate position between the
popular and the professional sectors. This sector
consists of a heterogeneous group of traditional
healersboth sacred and secularthat include
bone setters, herbalists, traditional birth attendants,
faith healers, shamans, diviners and tooth

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extractors. Some work as individuals, while others


are organised in associations of healers with rules
that govern them. Most of these folk healers
share the worldviews of the communities they
operate in, including views concerning the causes
of the ailments and the cures. They have little or
no formal training, acquiring their skill mostly
through inheritance or apprenticeship. It should be
noted that some healers can be located somewhere
between the folk and professional sectors, such
as those who practise acupuncture, homeopathy,
meditation and hypnosis.

The professional sector


This consists of well organised, legally sanctioned
medical experts. These include physicians,
paramedics and other professions, such as
ayurvedic, yunan and Chinese medicine. The
professional sector is the benchmark by which the
folk and popular sectors are measured.
In most developing countries, there is a shortage
of personnel and resources in the professional sector.
Sometimes people cannot afford consultation fees
and drugs charged by those in the professional
sector. As a result, they often resort to the folk and
popular sectors before consulting the professional
sector.

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21
Culture and Mental Health
A.B.T. Byaruhanga-Akiiki, Nhlanhla Mkhize, David M. Ndetei

Diseases of the digestive system

THE NATURE OF MENTAL


ILLNESS

With regard to diseases of the digestive system, one


may fail to eat, drink or even swallow food. Some
eat but get severe reactions. In such cases, some
Africans argue, poisoning of the stomach organs
with physical or non-physical means (in Bunyoro,
bihara) or the poisoning of any organ using physical
or non-physical means (in Buganda, ddogo) is at
work! This means that Satan or resentful spirit
persons have taken hold of ones stomach, thus
causing pain or obstructing the functioning of the
stomach. The person may then be prevented from
fullling his divine mission as he may waste a lot
of money in hospitals, but there is no cure.

Mental illness in the Western classication


systems, include schizophrenia, psychosis, p
aranoia, depression, delirium and anxiety. In
Africa, the above categories of mental illness are
not recognised. In some African societies, there
are diviners (Bunyoro-Toro), baraguzi who are
believed to be capable of diagnosing the causes
of mental illness through consultations with the
spirit world. The reality, however, is that many
suffer without knowing the cause. The picture is
complicated by psychosomatic ailments, which
make it difcult for both traditional and modern
doctors to prescribe medication.

Diseases of the prostrate gland


When diagnosed, diseases of the prostate gland
can be treated (e.g. surgically). Seen spiritually, the
cause is latent. Men are considered to have been
born with original sin. The seed of sin is in the
male sperm; it is contained in the genes. The whole
situation becomes very complicated, because of
the complex interaction of lineages, mistakes
committed by individuals or the mistakes of
husband and wife. Adultery may also be diagnosed
as the cause of the prostate problem. In such cases,
to get cured, one rst has to pay indemnity in cash
or kind.

Mental illness and disease: The role of


ancestors
In African traditions, ancestors play an important
role in the conceptualisation of the causes of
mental illness and disease. Since time immemorial,
ancestorsalive or deadhave always had power
to bless or curse. In the event of a curse, the one
cursed may suffer from a serious mental disorder.
One becomes sad, unhappy and mentally deranged.
The curse can affect ones physical body or
property. The diagnosis and treatment of the curse
are considered beyond western medicine.

Diseases of the circulatory system


The heart is part of the circulatory system and is
often associated with stress or mental pressure.

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A heart can develop a disease because of joy or


sadness. Besides, evil persons or Satan are believed
to put a lot of worries, insecurity and fears in ones
mind and heart, leading one to needless disturbing
thoughts. In such cases, one experiences a lot of
pain. If one suffers great stress for many days, one
may die of shock. It is advisable to consult modern
medicine as well as people of faith in order to
restore ones health. Traditional religious wisdom
teaches that for heart problems, the most precious
medicine given by God is love! So, people are
advised to resolve all through the medicines of
faith and love.

CONTRIBUTIONS FROM
CULTURAL PSYCHOLOGY
Cultural psychology is the study of the way cultural
traditions and social practices regulate, express and
transform the human psyche, resulting less in psychic
unity for humankind than in ethnic divergences in
mind, self and emotion. Cultural psychology also
postulates that subject and object, self and other,
psyche and culture, person and context, gure and
ground, and practitioner and practice, live together,
require each other, and dynamically, dialectically,
and jointly make each other up. It recognises the
dynamic interdependence between human action
and culture.

Diseases of the respiratory system


Human beings cannot go a single moment without
breathing. The respiratory system can become
ill as a result of physical causes; the person
suffers from high or low fevers for a long time.
Biochemical medicine can be used to treat the
fevers. The problem arises when the medicines
have no effectwhere fevers recur, causing the
body to break down. The person ends up suffering
psychologically, physically and nancially.
Culturally, English speakers have coined the term
that some diseases are caused by spiritual germs.
This is where, it is believed that Satan or other evil
spirits grab onto peoples respiratory systems and
torment them. Sometimes the disease moves from
one part of the body to another. One time it may
be a cough, another time it is the fever. Sometimes
symptoms appear in the form of typhoid fever.
There is no medicine for such diseases.

The relationship between culture and


mental health
There are two major competing paradigms
concerning the relationship between culture and
mental disorder: universalism and relativism.
Universalism, the dominant model of mental
illness in the biomedical sciences, assumes that
underlying psychological processes are the same
across all cultural groups. This is known as psychic
unity. Culture is thought to mask basic underlying
psychological universals. The view that culture
only modies the expression of psychological
distress is consistent with universalism. Culture
is thought to exercise an exterior actionit
affects only the symptomatic form that psychiatric
disorders take in different cultures. The clinicians
role under these circumstances is to strip off the
layers of culture to uncover the basic underlying
bases of human distress. Diagnostic categories
are thought to be equivalent. The universality of
conceptual and diagnostic categories developed
in the west has been questioned. Universalists are
victims of category fallacy, which is the tendency
to impose their own conceptual categories on
deviant behaviours observed in other cultures.
The universal applicability of western-derived
assessment instruments has also been questioned.
From a relativistic perspective, culture plays
a fundamental role in psychopathology: it is
impossible to speak of mental illness behaviour
without taking cognisance of the cultural context in
which it is manifest. Culture is not just an exogenous
force that exerts an inuence on behaviour; mental

Depression and mental derangement


One may be depressed when in deep agony and
unable to escape from a painful life. Generally,
patients suffering from depression hate the company
of others. They are gloomy and unable to correctly
express their thoughts. Mentally deranged patients
cannot fully express what is in their mind. From
the spiritual perspective, depression and mental
derangement are the same, coming from Satan and
evil spirits that cause mental difculty, leading to
anxiety, fear and fright. These are associated with
feelings of loneliness, isolation, sorrow, despair,
humiliation and anger. Eventually, some commit
suicide.

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formulation. However, it assumes that culture only


inuences symptom expression; the underlying
disorder is presumed to be universal. Further, the
culture-bound syndromes described are limited
to culturally different groups. The term culturebound syndromes refers to localised or culturespecic disorders. Culture-bound disorders present
with a cluster of symptoms or behavioural changes
that are recognised by locals and responded to in
a particular manner. Folk diagnostic categories
have been developed to refer to these localised
troubling sets of experiences. An example is
amafufunyane, a form of spirit possession which
the Nguni of South Africa attribute to sorcery.
Critics note that disorders such as anorexia nervosa
and chronic fatigue syndrome could be regarded as
western culture-bound syndromes, attributable to
the meanings assigned to the (female) body and
work in western culture. However, these were
not included in the DSM-IV list of culture-bound
syndromes, thus reinforcing the view that culture
only pertains to minority groups or people in
distant, places.
Culture plays a central role in diagnosis. It
suffuses all aspects of the diagnostic process and the
rst task for the clinician is to determine whether
the presenting symptoms can be explained by the
patients cultural patterns. For example, hearing
voices is not uncommon among some religious
groups. Among the Nguni in South Africa, there
is a condition known as ukuthwasa, an ancestral
calling (usually involuntary) to become a traditional
healer. It is characterised by hearing voices. This
could be misconstrued as a symptom of psychosis.
However, individuals initially considered to be
undergoing ukuthwasa are sometimes re-classied
as mentally ill if hearing voices does not lead to a
positive outcome (becoming a traditional healer).
The distinction between positive ukuthwasa
and negative ukuthwasa is not an easy one. The
clinician should consult with a multi-disciplinary
team, including traditional healing experts, when
confronted with such cases.

illness and culture are mutually embedded. The


relativistic position has been brought to the fore.
Universalism ignores peoples real life suffering,
concentrating only on a limited range of symptoms.
It tends to focus on the disease, rather than illness.
The feelings of hopelessness associated with
depression in western culture constitute a desired
state of affairs for Buddhist monks, who see
hopelessness as a vehicle to achieve salvation.
The solution to the problem of culture does not
reside in either universalism or relativism. Radical
relativism makes cross-cultural comparisons
impossible, thus ruling out any possibility of
developing a unied theory of knowledge. Others
have argued that a unied theory of knowledge could
be developed from the bottom up by conducting
studies in different cultures. Another potential
problem with relativism is that there is a danger
of stripping culture of its ideological and political
character, especially if it is only conceptualised
psychologically, in terms of values and beliefs.

CULTURE AND DIAGNOSIS


Cultural factors are increasingly recognised in
mental health literature. In 1993 the American
Psychological Association published guidelines
highlighting how to frame assessment and
interventions with respect to the patients culture,
including religion and indigenous practices,
the patients support systems and psycho-social
stressors. The DSM-IV acknowledges the
importance of locating assessment and diagnosis
in relation to the patients culture. The introduction
to the DSM-IV notes that:
Special efforts have been made in the preparation
of DSM-IV to incorporate an awareness that the
manual is used in culturally diverse populations in
the United States of America and internationally.
Clinicians are called on to evaluate individuals
from numerous different ethnic groups and
cultural backgrounds (including many who are
recent immigrants). Diagnostic assessment can
be especially challenging when a clinician from
one ethnic or cultural group uses the DSM-IV
Classication to evaluate an individual from a
different ethnic or cultural group. A clinician who
is unfamiliar with the nuances of an individuals
cultural frame of reference may incorrectly judge
as psychopathology those normal variations in
behaviour, belief or experience that are particular
to the individuals culture.

CULTURE AND AETIOLOGY


Problems and misfortune may be seen in a group,
rather than individual terms. Among the Shona of
Zimbabwe, a relatives actions may affect the whole
family, for instance in cases of murder. Solutions
must therefore involve clans. Moreover, whereas
in Western understandings the consultation process

The DSM-IV includes a framework for taking culture


into consideration in psychiatric and psychological

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enabling, predisposing, evaluation, perception and


experience factors.

involves a physically present patient, in some


African settings, the patient could be absent, with
treatment sometimes taking place miles away from
where the patient lives.
In New Guinea, it has been observed that a
sick person withdraws into a wretched state,
shuns company and certain foods, eats alone, and
begrimes himself or herself with dust and ashes.
The patient is said to display rather than report
illness. This withdrawal is said to be an attempt to
deceive the evil spirits that caused the illness into
believing that they have succeeded.
Whilst on a eld trip in a rural area in southern
Zimbabwe, one of the authors of this chapter
stumbled upon different accounts of illness. A
second wife narrated how her predecessor had
been divorced for refusing to confess her sexual
misdemeanours (aramba kudurira mwana). As
a result, it was believed, her child had refused to
breastfeed and eventually died. In another account,
a belief was said to be common that as long as a
married man has sex with his wife, it is his wife
that is capable of killing him. The wife was always
blamed for her husbands death. This is despite
the fact that men in the community were migrant
labourers who confessed to having extramarital
sexual relationships, and were therefore exposed
to HIV/AIDS.
These examples illustrate different accounts of
the causes of illness. Understanding these may help
medical and health policy practitioners appreciate
why people behave the way they do with regards
to health matters.

Enabling factors
These are factors such as the availability,
accessibility and affordability of health services.
Services might not be accessed easily due to long
distance. Alternatively, people may not have the
means (e.g. monetary) to access health services.
Predisposing factors (socio-demographic factors)
Socio-demographic factors such as social class
inuence the utilisation of health services. People
of low social class are known to delay seeking
health care, perhaps due to the accessibility factors
mentioned earlier.
Evaluation factors
The chosen place of delivery depended on the
pregnant mothers or health workers evaluation of
the pregnancy (i.e. healthy or not healthy). Chances
of delivering at a health facility were higher if the
pregnancy was evaluated negatively.
Perception factors
Place of delivery also depended on how the
pregnancy and the hospital were perceived. If the
hospital is generally perceived as a place visited
by the sick and the pregnancy is not perceived as
a sickness, women are less likely to deliver in a
health facility.
Experience factors
Experienced women who have delivered at home
feel more comfortable about delivering at home.
Apart from beliefs and the practices highlighted
earlier that inuence exposure to illness, cultural
factors also play a role in shaping peoples
understanding of the causes of illness (aetiology)
and hence, how it is dealt with (treatment).
The following examples illustrate how culture
inuences perceived causes of illness.

SOCIAL AND CULTURAL


DETERMINANTS OF HEALTH
SEEKING BEHAVIOUR
Health seeking behaviour usually depends on the
type and severity of symptoms, the cause of the
illness and the labels and aetiologies attached to
it. Other factors include socio-economic status,
age, sex, educational level, occupation, residence
(urban or rural) and family role. Social and cultural
determinants of health seeking behaviour are:
characteristics of the condition, the patient, the
healer and service.

Culture and health: the benets and


pitfalls
Understanding cultural and social factors inuencing
health is important for the medical practitioner as it
provides a more complete view of health problems.
Aubel et. al. studied communication patterns
between patients and health workers in . They found
that lay understandings of illness were in general
derogated, and home management practices and
traditional consultations discouraged. What was
signicant, though, was that mothers identied

Models and concepts regarding health care


utilisation
The utilisation of health care services depends on a
number of factors. A distinction is drawn between

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Culture and Mental Health

international boundaries are becoming uid,


thus making such generalisations even more
problematic. They should assess a persons ethnic
identity through a careful consideration of his or
her developmental and family history. Patients
could be asked to describe their grandparents and
parents country of origin, religion and primary
language. The extent to which patients rely
on extended family networks for help is another
indicator of their degree of closeness or distance
from their primary reference group. The familys
participation in cultural practices should also be
assessed.

no less than a dozen types of diarrhoea, each with


specic management techniques. Raguram et. al.
studied clinical depression in India. They found
that pains reported by patients are the pains that
people in similar situations experienced in their
daily lives. When patients explanations become
disconnected from health workers understandings,
the health worker might become impatient. It is
therefore important that health workers initiate
culturally informed inquiries, so that interventions
may become relevant to the content of the problem,
its context, and the underlying structure of beliefs
and expectations.
There are instances where an over-reliance on
the concept of culture in health policy and practice
may become counter-productive. There have been
examples of misuse of anthropology or cultural
data. A case was reported in 1991 where a European
anthropologist wrote a report in an un-reviewed
journal that monkeys blood was rubbed into cuts
as love magic in Eastern Democratic Republic of
Congo (DRC), and that this might be the source
of AIDS. This report was found to have originally
been invented by an ethnographer at the urging of
his European publisher who sought exotic stories
to boost the sales of his book.
When practitioners cannot cure a disease, they
advise patients to go and settle matters with the
family. This referral practice has been justied on
the grounds that most people presume that fatal
conditions are socially or supernaturally caused.
However, the poor service received even by those
people seeking biomedical care is often ignored.
The existence of a folk belief model was used to
excuse the lack of measles vaccine in Lubumbashi
(Democratic Republic of Congo) in the late 1970s.
One of the ofcials said that uneducated mothers
would not bring their children for vaccination
anyway. However, it turned out that the mothers
were in fact interested, but that malnutrition and
poverty meant that even after vaccinating their
children, mortality levels remained at the same
levels as before. Thus, issues of inequity were
sidelined in favour of explanations that favoured
doing nothing.

Immigrant and refugee populations


The increasing number of immigrant and refugee
populations in many African states necessitates a
careful analysis of the patients migration history,
which is an important part of cultural identity
for recent immigrants. In the case of refugees,
the health worker needs to explore the degree
of loss and trauma to self and family members.
Immigrants and refugees experience the stresses
of being extracted from one social stratication
system and inserted into another. This leads to loss
of supportive social networks and acculturation
problems.
In assessing the mental health of immigrant and
refugee populations the following psychosocial
aspects and issues must be explored.
It is also important to note the following:
The health worker is advised not to stereotype
people on the basis of group identity. Some
people reject their cultural traditions in
order to identify with the traditions of the
dominant group, while others have developed
mechanisms enabling them to participate in
the activities of both cultures.
The health workers task is to identify how
cultural identity affects the patients mental
health. An arranged marriage could be a source
of great distress for a young and independent
woman. Further, fear of being isolated and
disowned by ones family group poses an
additional source of stress. The health worker
should assess the persons cultural identity and
level of acculturation as described earlier.
Health workers should familiarise themselves
with the competencies and standards required
to work effectively with multi-cultural
individuals.

Implications for practice


Health practitioners should be careful not to
make decisions about an individual based on
the stereotypes associated with that individuals
racial, ethnic or linguistic group. National and

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1. Pre-migration history
Issues: Country of origin, education, socio-economic status, community and family support, political
issues, war, trauma.
2. Experience of migration
Issues: Migrant versus refugee: Why did they leave? Who was left behind? Who paid for their trip?
Means of escape
3. Degree of loss
Issues: Loss of family members, relatives, friends, material losses: business, careers, properties,
4. Traumatic experience
Issues: Physical: Torture, rape, starvation, imprisonment
Psychological: Rage, depression, guilt, grief, post-traumatic stress disorder of cultural milieu,
community, religious and spiritual support.
5. Work and nancial history
Issues: Original line of work, current occupation, socio-economic status.
6. Support systems
Issues: Community support, religion, family
7. Medical history
Issues: Beliefs in traditional medicines, somatic complaints, familys concept of illness. What
do family members think the problem is? Its cause? What do they do for help? What result is
expected?
8. Level of acculturation
Issues: First or second generation, languages spoken, degree of identication and interaction with
local culture (host community) versus socialising, mainly with members of ones original culture.
9. Impact on development
Issues: Level of adjustment; assess extent to which living in new culture is being negotiated, such as
attainment of housing, employment, mastery of public transport.
(Adapted from Lee, 1990)

beyond the borders of the therapeutic houra


situation that emanates from their conception
of human relationships as lasting and mutually
interdependent. Requests of this nature are
not an indication of the absence of personal
boundaries and should not be pathologised as
such. They stem from a particular perception
of human relationships. Failure to realise this
may lead to loss of therapist credibility (the
perception that the therapist is capable of
dealing with the clients problem) and giftgiving (the perception that the client has gained
something from the therapeutic relationship).

Values
It is important for the health practitioner to take note
of how these values impact on their relationship
with the patient:
The division of therapeutic sessions according
to segments of 50 minutes each, which forms
an important part of the therapeutic frame,
is more in line with the Anglo-American
conception of time.
The expectation that the patient should take
charge of therapy sessions, with the therapist
providing reassurance and acceptance, tends to
suit western, educated and verbal clients who
share this assumption. African clients, most
of whom are likely to be having pressing and
concrete real life problems, may expect the
therapist to be actively involved in assisting
them.
The client-therapist relationship is perceived
by traditional African clients to extend

Language
Language is the mental health practitioners most
important tool. Social constructionists have noted
that it is by means of language that we appraise
reality. Clinicians should try to learn the main
language of the patients whom they serve.

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Culture and Mental Health

Inappropriate affect.
Poor family relationships (the individuals
symptoms interferes with his or her ability to
full family obligations). Cited from Idemudia,
(2004).

Beliefs about health and illness


Group and individual identity are derived from
shared beliefs. Further, the manner in which the
self is dened has implications for how health and
disease are understood. In the west, physical illness
is explained primarily in terms of germ theory: it is
biological in origin. This explanation is extended
to mental health problems, where biological and
psychological explanations (in terms of intrapsychic factors) have dominated thinking. The
majority of problems brought to mental health
practitioners stem from patterns of interaction
within families, communities and the broader
social sphere. The following sections discuss
ways of understanding illness in different cultural
contexts.

Illness and explanatory models


It is important to take into account patients
explanatory models of their illness. Explanatory
models consist of notions about the causes of
illness, timing, onset, and its pathophysiology,
severity and natural history, and treatment options
available to the individual. This is because the
explanatory model used by the clinician is often
not the same as the one used by the patients. While
acknowledging biomedical causation of illness,
patients also hold additional explanatory models
accounting for their illness in terms of cultural
and spiritual factors. Family members could see
mental illness as indicative of a breakdown in the
relationship between the family and the ancestors.
Under such circumstances, the family becomes the
focus of treatment, the affected individual being
perceived as a means through which ancestral
displeasure is manifested. It is thus important for
the clinician to inquire about the causes of the
illness. It is important for the clinician to ask the
patient or family what has happened, why it is
happening and at this point in time, and what they
think will happen if the condition goes untreated.

Beliefs about the causes of illness (Why am I


sick?)
Biological, psychological, spiritual and other
reasons may be used to explain the cause of the
illness. It is important to understand how patients
view their illness in order to develop effective
assessment and intervention plans. This may also
help the health worker to identify other members
of the multi-disciplinary team who may be coopted to assist with the management of the patients
condition.
Contrary to the biological orientation of western
psychiatry, the view of illness in traditional African
thought is comprehensive. It incorporates biological,
social, as well as spiritual dimensions. Illness in
traditional Africa is considered an indication of
distress in social and communal relationships. The
healthy person is harmonised with self, others,
nature, the spirit world and universe by connections,
interactions, and meetings, using an oral tradition.
An example of this view of illness given by Nzewi
maintains that the Ibo of Nigeria distinguish ve
ways through which psychosocial disorders could
be identied. These are:
Benecial reciprocitywhen an individual
is unable to socialise adequately with his or
her neighbours; the need to maintain good
interpersonal relationships with others being
one of the most highly prized virtues.
Degree of shame people experience (nonconformity). Well-adjusted people are
expected to evidence some degree of shame if
their behaviour deviates from societal norms.
Absence of shame is indicative of mental
illness.
Disorientation with respect to time and
inappropriate behaviour and speech.

Somatisation of psychiatric symptoms


To some extent, culture denes the way community
members express physical and mental disturbances.
Complaints and symptoms are expressed in
the idiom of the community. Tanzanians may
often express emotional discomforts in physical
symptoms. Physicians have called this hapa
hapa syndrome. The patient is very distressed
and complains of multiple physical pains. Mental
evaluation usually reveals emotional discomfort,
anxiety or depression.
There are other ways in which culture denes
the presentation of symptoms. The content of
patients delusions (irrational false beliefs that
are not in keeping with ones cultural beliefs
and amenable to logical persuasion) also varies
according to their culture. Patients might believe
that the hyena, computer, or laser beams from
satellites are controlling their thoughts and actions.
The disturbance is the same (thought control),
but the way it is expressed is due to the different
cultural expression of the symptom. This is called
pathoplastic inuence of culture.

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The African Textbook of Clinical Psychiatry and Mental Health

often co-exist with anxiety symptoms, and patients


do not draw sharp distinctions between these
experiences.
The somatisation of psychiatric symptoms is not
unique to African patients. It has been observed
in a number of societies, including some western
societies. The body becomes an important vehicle
for communicating psychological distress in most
non-western societies. The clinician should thus
question the patient about bodily symptoms that do
not have an organic basis to establish a diagnosis
of depression.
A word of caution is necessary in dealing with
somatising patients. While people who present
with somatic complaints could be depressed, health
workers should not dismiss somatic complaints
as merely psychogenic. This could deny patients
much needed physical care. This is particularly so in
cases where resources are limited and the exclusion
of medical conditions cannot be undertaken. They
should move away from focusing on somatisation
as a symptom and concentrate on the meaning of
somatisation in the patients life.

It has now been established that depression and


psychiatric disorders in general are very common
in developing societies. Those at the bottom
of the social stratication system experience a
disproportionate amount of mental health problems
and are least likely to receive professional help.
Depression is one of the most important causes of
morbidity and disability in developing societies,
where it is often exacerbated by poverty. It is most
pronounced among women, who constitute the
most disadvantaged segments of society.
The reason depression was thought to be nonexistent or negligible in Africa was that guilt, one
of the key symptoms of depression in standard
classication systems, is largely absent among
African patients. Instead, depression tends to be
somatised. Nigerians who are depressed complain
of burning bodily sensations, heaviness or heat
in the head, and crawling sensations in the head
or legs. Depressed Zimbabweans present with
multiple somatic complaints. Likewise, depressed
Zulu patients (South Africa) present with bodily
symptoms such as headache, back pain (iqolo)
and stomach ache (isisu). Symptoms of depression

114

22
Mental Health, Spirituality and Religion
Tarek Okasha, David M. Ndetei

understanding and describing human experience


and behaviour.
Recent psychiatric literature and contemporary
socio-political developments suggest a need to
reconsider the place of religion and spirituality
in psychiatry. Despite the secularising effects of
science, the presence and inuence of religiosity
remains substantial not only in traditional, but
in western culture as well. The literature puts
emphasis on the central importance of religion and
spirituality for mental health, and the difculty of
integrating these concepts with scientic medicine.
Psychiatry would benet if the vocabulary and
concepts of religion and spirituality were more
familiar to trainees and practitioners. Patients
would nd better understanding from mental health
workers, and fruitful interdisciplinary dialogue
about mutual issues of ultimate concern might
ensue.

Psychiatry and religion both draw upon rich


traditions of human thought and practice. In fact,
psychiatry is the branch of medicine that most
prominently incorporates the humanities and social
sciences in its scientic base and in its treatment
of illness. The rich intellectual traditions of Chris
tianity, Judaism, Islam, Hinduism and Buddhism
have made unique contributions to the treatment of
the mentally ill. Throughout history, these religious
traditions have made major contributions to
peoples perceptions of mental illness. They have
also offered a range of treatment options.

SPIRITUALITY AND RELIGION


Spirituality refers to the experience of contact with
a higher power. Five aspects of spirituality that
should be considered by the psychiatrist include
looking for the meaning of life, human solidarity,
wholeness of the person being body, mind and spirit,
moral aspects and awareness of God. Religion
contains so many unrelated variables that it cannot
be considered as a one-dimensional concept. It is
the outward practice of a spiritual system of beliefs,
values, codes of conduct and rituals.
Throughout history, the functions of religious
practices and healing were performed by a
single individual. With the explosive growth of
scientic knowledge in the twentieth century,
the roles of religious and medical healers were
separated. Psychiatry and religion are parallel
and complementary frames of reference for

THE ROLE OF RELIGION IN


MENTAL HEALTH
Religion has many psychological functions. It is
a source of support for the ego throughout life.
Religion plays a major role during life events
such as birth, death, life passages, marriage, childrearing, and ageing. It also functions as a source
of meaning in the individuals life. There is a
very clear relationship between religious beliefs
and mental well-being In a 12-year review of all
articles appearing in the American Journal of
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The African Textbook of Clinical Psychiatry and Mental Health

Psychiatry and the Archives of General Psychiatry,


72 percent of the religious commitment variables
were benecial to mental health: participation
in religious rituals, social support, prayer and a
relationship with God were benecial in 92 percent
of citations.
Religion also provides a worldview by means
of which we understand ourselves, our purpose in
the world and the nature of the universe in general.
All religions offer some type of explanation
concerning the origin of the universe, how life is
maintained, and what happens when life ceases to
exist. All religions attempt to give their followers
explanations of the meaning of life, including
rationales for the reality of human suffering.
Religious symbols, beliefs, myths and rites enable
individuals and groups to deal with the ultimate
conditions of existence that are experienced by
members of every society.
Most importantly, religion plays a major role
in symptom formation, psychopathology and
management of many psychiatric patients. The
expression of symptoms may differ according
to the religious upbringing of the patients. In a
study in Egypt, almost 60 percent of obsessive
compulsive Muslim patients were found to present
with religious content. This gure was comparable
to that of patients with a Jewish upbringing, but
higher than that of British and Indian patients.
The content of delusions and hallucinations is
frequently of a religious nature. The dissociation
and conversion disorders are over-represented with
ideas of possession, witchcraft, envy and djinnies
inuence, which have cultural-religious bases.
Religious leaders could also play a major role in
changing the attitude of the population. When
health professionals in Egypt wanted to promote
family planning or address narcotics, religious
clergy were an asset.
Religion also plays an important role in causal
attributions and patient management. Psychological
symptoms are attributed not only to individual
factors such as weakness of personality but also to
factors such as the disconnection of the relationship
between the individual and God. Likewise,
treatment options take into consideration external
power such as God. Statements such as if God
is willing, I seek refuge in God, and God is
the healer, are widespread throughout Africa and
the Arab world, indicating a belief that there are
instances where human beings are not in control.
Faith in God may have biological effects, be it
on physio-chemistry and the immune or endocrine

systems. Feelings of joy, peace and comfort on


the part of the believer could be associated with
an increase in endogenous opioids, the facilitatory
neurotransmitters like GABA, and the sensitivity
of serotonin receptors. The positive relationship
between mood and the immune system has a direct
role in ghting pain, illness, and even death. Faith
possibly provides relief from pain, peace with
the self, and altruism. Lack of interest in worldly
possessions could be a mental health asset as well.

TRADITIONAL AND RELIGIOUS


HEALERS
Traditional and religious healing play a major role
in most peoples lives in developing societies.
According to WHO, close to 80 percent of the
population in developing societies rely on traditional
and religious healers for health care. Healing takes
place mostly within the persons community:
it involves the family as a whole. Physical,
emotional and spiritual needs are all catered for.
One of the factors that attract people to traditional
healing is its communal nature, as opposed to the
individualistic orientation of western medicine.
Traditional and religious healers are also likely
to explain symptoms and to provide treatment
options that resonate with the patients worldview.
The main differences between traditional African
societies and western societies are summarised in
Table 22.1. Health workers should use this table
with caution as there are likely to be individual
differences on how people select and use aspects
of their culture.
Traditional and religious healers in primary
psychiatric care, deal with minor neurotic,
psychosomatic and transient psychotic states using
religious and group therapies, suggestion devices,
amulets and incantations.
Okasha has suggested a model curriculum for
the training of mental health workers. Its objectives
are to establish the knowledge, skills and attitudes
components to enable them deal effectively with
various patients, especially those presenting with
religious beliefs.

The knowledge component


Health workers should demonstrate competence
in dening the religious and spiritual aspects of a
persons life. This encompasses the understanding
of the:

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Mental Health, Spirituality and Religion

Table 22.1: A comparison of traditional African and western values


TRADITIONAL SOCIETY

WESTERN SOCIETY

Family and group oriented

Individual oriented

Extended family (not so geographical as before, but


conceptual)

Nuclear family

Status determined by age and position in the family,


care of elderly

Status achieved by own efforts

Relationship between kin obligatory

Determined by individual choice

Arranged marriages with an element of choice


dependent on interfamilial relationship

Choice of marital partner, determined by


interpersonal relationship

Extensive knowledge of distant relatives

Restricted only to close relatives

Decision-making dependent on the family

Autonomy of individual

Locus of control external

Locus of control internal

Respect and holiness of the decision of the physician

Doubt in doctor-patient relationship

Rarely malpractice suing

Common

Deference is Gods will

Self-determined

Doctor-patient relationship is still healthy

Mistrust

An individual can be replaced. The family should


continue and the pride is in the family ties

Irreplaceable, self pride

Pride in family care for the mental patient

Community

Dependence on God in health and disease, attribution


of illness and recovery to Gods will

Self-determined

Okasha, 2000

unique impact of religious and spiritual


experiences on physical and psychological
development
in
infancy,
childhood,
adolescence and adulthood.
differential diagnostic features of religious and
spiritual experiences at both the individual and
organisational level.
religious and spiritual factors that affect the
course and treatment of psychiatric disorders.
impact of religious and spiritual experiences
on the relationship between the medical
worker and patient, including transference
and counter-transference.
effect of the religious and spiritual issues
on medical ethics as applied to psychiatric
practice.
various religious and spiritual experiences and
traditions, each with its unique perspective on
transpersonal issues.

The skills component


Health workers should demonstrate competence in
interviewing spiritually committed patients with
sensitivity to communication styles, vulnerabilities,
and strengths as follows:
Listening to the spiritual issues in the patients
personal narratives, and eliciting accurate and
complete histories that reect an understanding
of the importance of these issues in patients'
lives.
Assessing and diagnosing patients, and
formulating treatment plans, in a manner that
reects an understanding of patients' spiritual
experiences.
Recognising the features that differentiate
normative religious and spiritual experiences
from pathological phenomena.
Providing appropriate psychotherapeutic
interventions that reect an understanding of
patients spiritual experiences.

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The African Textbook of Clinical Psychiatry and Mental Health

evolution to provide some relief for the inevitable


problems that occur in the course of family and social
interactions. In that respect, both are important
in the maintenance of health and recovery from
illness. They also prepare people psychologically
and otherwise to deal effectively with problems in
life. The common elements of a very widespread
pattern of symbolic healing represented here in the
language of psychiatry, but correlatively echoed
in the behavioural aspects of religion, include the
special relationship between the healer and the
patient, shared worldview, expectant hope of the
patient, naming of the illness, attribution of cause,
prescription of treatment by the healer, and the
central role of suggestion. The challenge, then,
is to combine traditional scientic and religious
conceptual schemes in such a way that the patients
benet.
Science and technology have made lives easier,
but they do not teach how to live. Taking spirituality
and religion seriously could possibly lead to better
mental health. Likewise, harmony between the self
and the environment could be improved. It could
also add meaning to lives.

Recognising and using specic transference


and counter-transference reactions (negative
reactions may indicate unresolved therapist
issues in this area).
Recognising possible biases against religious
and spiritual issues in the psychiatric literature
and understanding their origins.

The attitude component


Health workers should demonstrate in their
behaviour and demeanour an awareness of their
own religious and spiritual experiences and the
impact of these experiences on their identity and
worldview. This includes the following:
An awareness of their own attitudes toward
various spiritual experiences and the possible
biases that could inuence their assessment and
treatment of patients with these experiences.
Empathy and respect for patients from various
religious and spiritual backgrounds.
Patient care.
Both mental health and religion are institutions
that were developed over the course of cultural

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23
Culture, Spirituality and Management
A.B.T. Byaruhanga Akiiki

CULTURE-BOUND DISORDERS

OTHER TREATMENTS

Folk illnesses are syndromes that affect members


of a particular group. These illnesses have peculiar
symptoms and signs. Culture-bound syndromes
have not been adequately classied, because they
are culture-specic. They are caused and maintained
by culture-specic psychological factors such as
beliefs, values and attitudes.
Culture-bound syndromes are generally associated
with urbanisation and cultural change. With culture
change, individuals adaptive mechanisms and
social support systems are overwhelmed, leading
to anxiety, depression and a sense of isolation.
In diagnosis, the health worker should consider
whether the culture to which the patient belongs
regards the syndrome as pathological or not, failing
which they may impose their own cultural ideas on
the observed behaviour.
Culture-bound syndromes are generally treated
according to their predominant symptoms using
antidepressants, anxiolytics and tranquilisers.
Brief psychotropic chemotherapy usually achieves
temporary remission. Counselling that includes
family members is also useful. Culture shock is
also minimised if refugees are clustered in a few
central locations rather than dispersed throughout
the nation. Community education and awareness of
mental illness could be helpful.

From the African point of view, the treatment of


mental illness is most important. This is reected
in the saying: Health is better than wealth and
mental health is the best. Treatment involves
the restoration of harmony, balance and correct
alignment.
The treatment of poor relationships at whatever
leveleither on earth or in the spirit worldis
very complex. It is a big challenge to all health
practitioners, be they modern or traditional. Some
African traditional healers talk of consulting with
spirits. Afrming relationships with good spirit
persons is therapeutic, whereas relationships with
evil spirit persons are pathological. Evil spirit
persons are believed to cause all sorts of mental
illnesses. It is also believed that the majority of
behaviour disorders are inherited. This makes
treatment more complex. These beliefs have not
been empirically veried, however, health workers
need to be aware of them because they inuence
peoples perceptions of the causes of illness and
the treatments sought.
In the west, there is an observation that
biochemical medicine fails to treat patients as whole
living persons. It does not account for the spiritual
as well as physical dimensions of patients. This
explains why patients are sometimes dissatised
with biomedical care. In Europe and America

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The African Textbook of Clinical Psychiatry and Mental Health

for the sake of others and loved others while they


lived in the physical world, are allowed to reside in
a better part of the spirit world after they shed their
physical bodies. Those who do not live a good life
on earth end up in the lower part of the spirit world;
literally sick with spiritual diseases like hatred and
jealousy.

such dissatisfaction is driving modern patients to


the so-called alternative, complementary, holistic,
traditional and natural remedies. There is a continual
need for a balanced and critical evaluation of what
holistic medicine can and cannot realistically
provide. Medical practitioners have to include
aspects of this thinking in their practice.
There are marvellous developments that have
taken place in modern medicine, especially in the
past century. Biomedicine has made tremendous
strides in eliminating contagious infectious diseases,
reducing infant mortality and extending the human
life span. It is said that generally peoples lives in
the so-called rst world are far safer, cleaner and
happier due to improvements of public hygiene
and emergency medicine. Unfortunately, a good
number of modern developments are giving rise to
new problems: economic, ethical, biological and
spiritual. There is not enough money to provide
everyone with high-tech treatment, even in the
west.
Many modern developments in biochemical
medicines are leading to ethical problems. This
includes issues such as how to prioritise health care
needs and delivery services. Further, the use of
antibiotics and sterilisation has given rise to strains
of super-bacteria resistant to these agents. Postindustrial diet and lifestyles challenge humankind
with new diseases like cancer and HIV. While
the role of health workers has changed from one
of caregiver to one of being clinical technicians,
the psycho-spiritual needs of patients are often
ignored. This increases the need for religious or
spiritual treatment.

Faith and the treatment of mental illness


Faith is very important in the treatment of mental
illness as in all healing. Apart from religious
specialists, leaders, teachers, health workers
and almost all human beings qualify as Gods
instruments to treat themselves or others. In the
treatment of mental disorders, therapy involves
truthful communication, through counselling,
which cleanses the mind, body and emotions. Often
there is need for additional physical rituals.

Counselling and guidance


In the western tradition, the aim of counselling and
guidance is to bring the patients system back on
track. This involves self-analysis, psychoanalysis,
and helping the patient treat himself or herself.
From the African point of view, patients are
encouraged to have faith and to obey God and
lawful authorities. Unity, respect, co-operation,
harmony, understanding, forgiveness and patience
with other people are all seen as antidotes for
mental illness. Gods thoughts, words and actions
or those of His agents, constitute the best medicine
for mental illness.
From the African religious and cultural points of
view, authority is very important in the treatment
of mental disorders. God remains the number one
healer.

Life in the spirit world


The African view of medicine takes a holistic
standpoint: it afrms the existence of both the
Master Creator and the spirit world. The lifestyles
of those in the spirit world are no different from
those of the living: people in the spirit world live
in houses, wear clothes and eat and drink. They are
believed to communicate among themselves and
with people on Earth. Further, spirit lings (people in
the spirit world) both experience and practise love
at different levels, just as earthlings (people living
on earth) and womb lings do. Thus it is believed
that the two worlds mingle most intimately.
Earthlings cherish the little information they have
about life in the spirit world. This is especially so
with the teaching that ones life on earth determines
ones status in the spirit world. The experience and
practice of love is most fundamental in both worlds.
There is a belief that those spirit persons who lived

CULTURE AND MENTAL


HEALTH: IMPLICATIONS FOR
TREATMENT
Mental health practitioners in Africa should take
culture into consideration in planning interventions.
They should therefore develop the necessary
knowledge, competencies, skills and attitudes to
deal with all types of patients.
Depression could be diagnosed as a brain disease
which should be treated with antidepressants.
Alternatively, it could be diagnosed as dhat
syndrome, as is the case in India. Dhat syndrome
is characterised by symptoms such as fatigue, loss
of interest, insomnia, severe headaches, weakness,
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Culture, Spirituality and Management

heart palpitations, and suidicial feelings. These


symptoms would lead to a diagnosis of major
depression in western psychiatry. In India, these
symptoms are associated with the loss of the
essential element (semen) in the body due to
excessive sexual intercourse. In this case culturally
appropriate treatment would include abstinence.
In African societies, harmony between the
community and their ancestors is critical to the
diagnostic procedures of a traditional healer.
Harmony exists if the family has met its sociospiritual obligations to the ancestors. Ancestral
displeasure resulting from failure to meet these
obligations results in illness. Diagnosis is
concerned with more than what am I suffering
from? It also considers questions such as why
the illness is happening at this point in time
and why it is affecting a particular individual.
Rigorous diagnostic questioning of the patient is
not emphasised; the healer focuses on interpreting
the patients experiences (e.g. by means of dream
analysis). Appropriate treatment such as a ritual
offering, restores the balance between ones family
and the ancestors. This does not mean that other
treatment options are not considered.
There is strong evidence suggesting that
schizophrenia has a better outcome in developing
countries or rural areas in comparison to the
developed world or urban areas. This has led
to suggestions that culture has a protective or
therapeutic element in schizophrenia. There is a
lot of literature exploring the relationship between

schizophrenia and expressed emotion (EE). It


has been suggested that if the family is tolerant
of schizophrenic individuals, accepting them
and making an effort to nd them employment
appropriate to their level of functioning, the
outcome is better. It is hypothesised that negative
outcomes result from a critical and intolerant
attitude on the part of family members and the
community. Intolerance and personal isolation are
typical of large industrialised societies.

RACIAL TRANSFERENCE
AND COUNTER-TRANSFERENCE
A health practitioner should be prepared to deal
with cultural transference and counter-transference.
Patients may believe that health worker of their own
ethnic group is less competent than one of another
group. The opposite is also true, where patients
perceive a clinician of their own ethnic group as
a special hero. It is thus important for clinicians to
be aware of the impact of their ethnicity, race or
culture on the clinician-patient relationship. This
awareness could be achieved through personal or
group supervision, where clinicians come together
to reect on their own values.
The following questions should be discussed in
groups situations where there is need for cultural
identity awareness.

Table 23.1
i.

What is your ethnic background? What has it meant to belong to your ethnic group? How has it felt to
belong to your ethnic group? What do you like about your ethnic identity? What do you dislike?
ii. Where did you grow up, and what other ethnic groups resided there?
iii. What are the values of your ethnic group?
iv. How did your family see itself, as similar to or different from other ethnic groups?
v. What was your rst experience with feeling different?
vi. What are your earliest images of race or colour? What information were you given about how to deal with
racial issues?
vii. What are your feelings about being white or a person of colour?
a. To whites: How do you think people of colour feel about their colour identity?
b. To people of colour: How do you think that whites feel about their colour identity?
(Adapted from Pinderhughes, E, 1989)

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The African Textbook of Clinical Psychiatry and Mental Health

and life and death have cultural dimensions. In


other words, these aspects are dened from the
points of view of the people concerned. Culture is
a very important variable as far as conceptions of
health and illness are concerned.

THE THERAPEUTIC VALUE


OF MAINTAINING GOOD
RELATIONSHIPS
In many parts of Africa, there is an assumption
that some illnesses defy western scientic
methods of diagnosis and treatment. This applies
to psychosomatic, spiritual and mental illnesses.
People automatically resort to folk-practitioners
who have cultural ways of handling such illnesses.
It is not only the less educated who utilise the
services of traditional healers, even some of the
most educated do so when the chips are down.
The goal of African medicine is holistic treatment;
it caters for the patients physical, mental, social,
environmental and spiritual well-being.

African spirituality
The term spirituality does not translate easily in
African languages, and no African language denes
spirituality. Since time immemorial, Africans
know that the human being has a body and a nonphysical mind (soul) when alive. When one dies,
the invisible soul becomes the ghost or spirit. The
soul has all the characteristics of a human being in
terms of spiritual senses and capabilities.
The disembodied spirit person knows, loves,
feels and communicates. In short, the dead remain
honourable members of their families, clans,
societies and communities at different levels;
capable of communicating with those living on
earth. They support, protect and help the living in
many ways. They also participate in life activities
of their descendants, relatives, friends and even
enemies. The philosophy embedded in this thinking
sounds amazing, surprising, incredible and
unimaginable. It is truly the legacy of spirituality
in traditional African religious thought.

AFRICAN SPIRITUALITY, FAITH


AND MENTAL HEALTH
Health practitioners of whatever categories
have to be cognizant of the fact that they are
commissioned to treat people as whole persons
body, mind, soul and spirit. There is an assumption
that religious commitment has benecial health
effects. Spirituality should play a greater part
in care and prevention of physical, mental and
spiritual disorders. Truly then, in putting healing
powers in so many herbs and other creatures, the
Master Creator and Master of Science to whom
healers in Africa traditionally pray, remains the
healer number one.
There are ve related phenomena namely:
African spirituality, treatment of mental illness,
counselling and guidance, nature of mental illness,
ancestors and mental illness.

Further reading for Chapters 20-23


1. Byaruhanga-Akiiki, A.B.T. (1998). Traditional
healing and mental health. Paper read at a Workshop
for Parents/Carers of people with chronic mental
health. Pope Paul Memorial Community Centre.
Sept.24, 1998.
2. Lee, Sang Hun (1996). Life in the spirit world and on
earth. Paragon.
3. Makinde, A. (1990). African philosophy, culture and
traditional medicine. Chicago, Ill.
4. Michael, K. (1988). The missionary and the diviner.
Orbis
5. Orley, J. (1995). Culture and mental illness (Uganda
case). Oxford.
6. Shorter, A. (1991). Jesus and the witchdoctor: an
approach to healing and wholeness. Heinemann.
7. Thairu, K. (1975). The African civilization: Utamaduni
ya Kiafrica. EALB.

African religion and culture


In Africa, it is well known that all human theories
and practices of medicine, as well as conceptions
of physical or mental illness, diagnosis, treatment,

122

Section III:

Behavioural Neurosciences

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The African Textbook of Clinical Psychiatry and Mental Health

124

24
Neuroanatomy and Psychiatry
John Mburu, David M. Ndetei, Francisca Ongecha-Owuor, Benson Gakinya

The pathophysiology of majority of psychiatric


disorders is now better understood following many
advances made in the elds of neuroanatomy, brain
imaging, neurochemistry and neurophysiology.
Neurosciences can be justiably considered
the biomedical foundation of psychiatry and
psychology since they offer clear understanding of
human experiences and behaviour.

GROSS ANATOMY OF THE


BRAIN
The brain is a highly complex organ consisting
of two hemispheres, which are connected by
the corpus callosum and other smaller commissural
tracts. The brain has an extension called the spinal
cord. The spinal cord and the brain constitute
the central nervous system (CNS). The brain has
gray and white mater. The three areas of the gray
mater are cerebral cortex, cerebellar cortex, and the
sub-cortical cerebral and cerebellar nuclei.

Occipital Cortex

Cerebellar Cortex

Figure 24. 1: Mid sagittal view of the brain

125

The African Textbook of Clinical Psychiatry and Mental Health

The cerebral cortex is heavily folded with


convolutions (gyri) and ssures (sulci or grooves)
and contains about 70 percent of the nerve cells in
the CNS. The cerebral cortex has four lobes, namely
the frontal, parietal, temporal and the occipital
lobe. The part called the brain stem comprises
the medulla oblongata, pons and mesencephalon.
The peripheral nervous system consists of cranial

and peripheral nerves. The function of the peripheral


nervous system is to relay sensory information to
the CNS and conduct motor information from the
CNS to the periphery. A third system is referred
to as the autonomic nervous system, whose main
function is to innervate the internal organs.

-FGUWFOUSJDMF

3JHIUWFOUSJDMF

JSEWFOUSJDMF
JOUIFNJEEMF

'PVSUIWFOUSJDMF

5PBOEGSPNUIF
TQJOBMDPSE

Figure 24.2: The ventricular system

information in psychiatry; neurotransmitter


metabolites contained in the CSF can be
biological markers and a measure of response
to pharmacological treatment. Blockade in CSF
drainage causes CSF pressure to rise within the
ventricles resulting in hydrocephalus. Computed
tomography (CT) scan of such brains show
dilated ventricles. The other disorder is known as
normal pressure hydrocephalus which presents as
treatable dementia with enlarged ventricles. This
is a rare condition. Symptoms of normal pressure
hydrocephalus include abnormal gait, urinary
incontinence and progressive dementia. Treatment
of hydrocephalus is surgical and involves shunting
the CSF from the ventricular system, to either the
atrium or peritoneal space.

Ventricular system
This consists of two lateral ventricles each with
an anterior and posterior horn, third and fourth
ventricles all located within the depth of the brain
mass. The central part of the ventricular system
is located between the two lateral ventricles. A
communication called inter-ventricular foramen
of Monro connects to the third ventricle at the
midposterior section of the central part of the
ventricular system. Cerebral spinal uid (CSF)
circulates within these ventricles.

Clinical implications
Cerebrospinal uid (CSF) reects neurochemical
activity in the brain. It is a source of research

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Neuroanatomy and Psychiatry

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Figure 24.3: Sagittal view of the skull and brain

inammation of one of the meningial layers results


in meningitis.

Meninges
The brain is covered by layers of tissue referred to
as meninges in the following order from without,
dura mater which is attached to the skull, the
arachnoid mater is beneath the dura mater, the
space in-between is called the sub-dural space.
The third layer is known as the pia mater and is
attached to the cerebral cortex. The space inbetween is called the subarachnoid space which
is lled with cerebro spinal uid (CSF). Sub-dural
haematoma, epidural haematoma and meningitis
are associated with neuro-psychiatric disorders.
Whereas subdural haematoma is due to slow
blood accumulation beneath the dura mater caused
by ruptured veins, epidural haematoma is due to
rapid accumulation of blood between the dura
mater and skull caused by rupture of an artery. The
latter is a life threatening condition. The patient may
show signs and symptoms of delirium, behavioural
and psychological symptoms. The infection or

Neurons and glia


A neuron is the basic functional unit of the nervous
system. Neurons are also called nerve cells. Glial
cells (neuroglia) are a class of neuronal cells in CNS.
There are four types of glial cells, the astrocytes,
oligodendrites, ependymal and microglia cells.
The latter two types of cells line the brain
ventricles and the central canal of the spinal cord.
They facilitate the ow of the CSF. The glial cells
also contribute to blood brain barrier (BBB), a
semi-permeable membrane between blood vessels
and the brain.
The ability of compounds to pass from the blood
into the brain and vice versa depends on their
molecular size, electrical charge, solubility, and
specic transport syste m. The BBB is important in
regulating the brain chemistry.

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The African Textbook of Clinical Psychiatry and Mental Health

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Figure 24.4: Parts of the brain associated with specic functions


days later and went back to work six months after
the accident.
Mr. K was a 35-year-old married salesman, well
mannered, loving, admired individual, and was
a successful businessman. Upon resuming duty,
Mr. K was on several occasions noted to be
caressing female workmates and lacked etiquette
and manners. It was noted that although Mr. K
worked, he on most occasions provided details
and information that was rather untrue. As time
went on, he became uninterested in his duties;
became more irritable and hostile. Making
simple decisions affecting the life of his young
family and work became very difcult. Mr. K
received a suspension letter from his employer on
account of his incompetence. The wife described
her husband as a changed person.

Cerebral cortex
Seventy (70) percent of the neurons are located in
the cerebral cortex. It is the most developed area
of the brain and its injury causes characteristic
neuropsychiatric symptoms. The cerebral cortex has
four different anatomical lobes, each performing
some core functions through reciprocal connection
to each other.
Frontal lobe
This is basically involved in motor behaviour,
expressive language, ability to concentrate and
attend, reasoning and thinking, and orientation
to time, place, and person. Lesions in the frontal
cortex cause frontal lobe syndrome where all these
functions are disordered. This may manifest as gross
change in personality characterised by the following
symptoms: inappropriate behaviour, disinhibition,
irritability, labile mood, depressive feelings, lack
of motivation, difculties with attention and
expressive aphasia (Brocas Aphasia).

This case illustrates the behavioural and


psychological symptoms of frontal lobe syndrome.
The injury that occurred two years ago led to total
change of Mr. Ks personality.
Temporal lobe

Case vignette 1
Two years ago, Mr. K was involved in a road
trafc accident in which he sustained a depressed
fracture on the frontal skull and craniotomy had
to be performed. He regained consciousness four

This consists of a group of neurons including the am


ygdala, hippocampus and limbic system. The main
functions of this lobe are memory development,
storage and retrieval especially in the hippocampus
gyrus, language comprehension, interpretation of

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Neuroanatomy and Psychiatry

of these hallucinations. Evaluation revealed that


Mrs. P had a fast growing tumour on the dominant
hemisphere that had caused tremendous pressure on
the contra lateral temporal lobe. Surgical treatment
was followed by recovery.

gustatory and olfactory sensation and regulation of


emotions and certain sexual and aggressive drives.
The temporal lobe is of interest to psychiatry
due to three clinical syndromes associated
with lesions in the region namely, Kluver Bucy
syndrome, Korsakoffs syndrome and aggression.
Lesions in the temporal lobe may mimic thought
disorder where there is uent but incoherent
speech. Kluver Bucy Syndrome is characterised
by placidity, apathy, bulimia, hyper-sexuality,
visual and auditory hallucinations, amnesias,
aphasias, dementia and seizures. Causes of Kluver
Bucy syndrome include tumours, trauma, herpes
encephalitis, Alzheimers disease and bilateral
temporal surgery.
Korsakoffs syndrome is characterised by
amnesia, either retrograde or anterograde, due
to chronic thiamine deciency associated with
alcoholism. Aggression is a common psychiatric
symptom and it is now postulated to have an
association with the limbic system. This is
suggested by the docility of animals with lesions
of the limbic system. An important observation is
that lesions of amygdala may lead to symptoms
similar to those of schizophrenia, depression or
mania. It is important that before diagnosis is made
the differential diagnosis of amygdala lesions is
excluded

Parietal lobe
This is the part of the brain that receives, identies
and associates, visual, tactile and auditory sensory
inputs. It is involved in the development of
intelligence and verbal processing. Dysfunctions of
the dominant parietal lobe include, Gerstmanns
syndrome, alexia, agraphia and aphasia.
Gerstmanns syndrome is characterised by agraphia
(failure to write), the patient may have left-right
disorientation and difculties doing calculations
(acalculia). Alexia is an acquired disorder in
reading ability. There is loss of the ability to
grasp the meaning of written or printed words and
sentences. It is not the same as dyslexia, which is a
developmental problem in reading.
Agraphia is the acquired inability to write and
always accompanies the aphasias. Aphasia is a
disturbance in speech due to organic brain disorder.
The patient has difculties expressing thoughts
verbally. There are four types of aphasia:
Motor
Sensory
Nominal
Syntactical.
Motor aphasia occurs when one lacks the ability
to speak, although comprehension remains intact.
Sensory aphasia is the inability to comprehend the
meaning of words or the use of objects. Nominal
aphasia is where there are difculties in nding the
right name for an object and the patient uses vague
words like it and thing. Syntactical aphasia is
inability to arrange words in proper sequence.
If the lesion is on the non-dominant parietal lobe
the patient suffers from illness denial also called
anosognosia. The patient completely denies that
they have, for example, suffered a stroke. There is
also impaired spatial abilities, inability to recognise
body parts (autotopagnosia), and difculty in
dressing and constructional apraxia. There is selfspatial neglect.

Case vignette 2
Mrs. P, a 38 year old, progressively developed
strange symptoms over a period of 6 months that
were characterised by euphoria, silly manners
and irritability. Although she liked music and
art a lot, her abilities to sing and paint or recall
obvious things decreased tremendously in the
course of the illness. To her friends she was
described as uninhibited. For example, she made
sexual advances to strangers and at times had
temper tantrums. She made fascinating claims
that the mayor of the city was responsible for
the persistent and intense taste and smell of
rotten eggs around her She was referred to a
psychiatric unit due to the progressive signs of
dementia in which she was unable to understand
spoken language. A computerised brain scan
revealed a tumour.

Mrs. P displays a short history of disturbed


behaviour, which includes mood disturbance,
diminished language comprehension and inability
to control her sexual and aggressive drives. Her
cognitive function was also affected, where the
memory was impaired, had receptive aphasia and
developed olfactory and gustatory hallucination.
She even had explanatory delusions of the source

Case vignette 3
Mr. J, a 55 year old, retired teacher was
progressively noted to have problems reading
bible verses (alexia) at his local church where
he served as a lay preacher. His capacity to

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The African Textbook of Clinical Psychiatry and Mental Health

preach dramatically became impaired and the


congregation was concerned that his sermons
no longer had meaning since he could not
communicate effectively (aphasia).
As time went by the bank manager alerted Mr.
Js relatives about his difculties in signing
documents in the bank and that he found it difcult
to calculate his nances and transactions in the
bank (agraphia and acalculia).
Two months down the line relatives reported
that Mr J had gradually lost his ability to name
objects, had become very vague and words in his
speech were poorly arranged losing the intended
meaning (nominal and syntactical aphasia).
By the fourth month of his illness he had
developed left hemiplegia. Despite this obvious
physical disability Mr. J denied having any
illness. (anosognosia due to lesion on the nondominant hemisphere)

health deteriorated and he complained of severe


headaches, weakness and inability to walk
or stand. There was a ve-month progressive
history.
Mr. T had just been released from prison, and
was only frustrated by the loss of his job and
humiliation of being jailed for a crime he felt
he was not individually responsible for. General
practitioners had put him on several treatments
for malaria and other ailments, but eventually
committed him to psychiatric hospital for
possible conversion reaction.

Careful history and examination revealed that Mr.


T. was of a good pre-morbid personality. There were
no head injury and the onset of his illness, though
gradual, got worse very rapidly. Neurological
examination revealed cerebellar dysfunction and
that he had partial blindness. Mr. T. was referred to
neurologists, but died ve days later. Postmortem
results revealed a large tumour in the occipital lobe
embedded in the calcarine gyrus and herniating into
the cerebellum. This case shows how psychological
symptoms may predominate over neurological
symptoms and cause delay in diagnosis.

This case illustrates parietal lobe dysfunctions due


to a lesion on the dominant hemisphere caused by
a tumour, which later caused pressure to the nondominant parietal lobe causing hemiplegia which
the patient denied.
Occipital lobe

Basal ganglia

Its chief function is the interpretation of visual


images and visual memory. The lesions in this lobe
may result in visual illusions, hallucination and
blindness. Since major psychiatric disorders such
as schizophrenia present with visual disturbances
the health worker should attempt to exclude
organic causes of such perceptual disturbances to
avoid misdiagnosis.

Basal ganglia consist of a group of nuclei that


contain cholinergic neurons. It has corpus striatum,
substantia nigra and innominata, and subthalamic
nuclei. It is involved in initiation of movement. This
anatomic area is associated with a number of clinical
disorders such as Parkinsons disease, Huntingtons
chorea, Wilsons disease and Fahr syndrome. These
are neurological disorders mostly associated with
symptoms of psychosis, depression and dementia.
Untreated schizophrenics show many movement
disorders: extreme opening and closing of eyes,
aring of the nose, grimacing, protrusion of the
tongue, and shaking of head all of which imply an
involvement of the basal ganglia.

Case vignette 4
Mr. T, a 25-year-old single man, was admitted into
a psychiatric ward with a history of progressive
irritability and complaints that the television
screen was irritating his eyes. He would get
into trouble with relatives as he insisted that
the television should be off all the time. His

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Neuroanatomy and Psychiatry

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traumatic lesions and tumours have been known to


cause Parkinsons disease.
In pathophysiological terms, there is loss of cells
in the substance nigra, a decrease in dopamine
and degeneration of dopa-minergic tracts. Using
a dopamine precursor L-dopa that is able to
cross the blood brain barrier is the cornerstone of
treatment. Amantadine, which acts synergistically
with L-dopa, can also be used in treatment.

Parkinsons disease
This is a basal ganglia disorder. The clinical
features of Parkinsons disease are tremors, which
are characteristic pin rolling and are prominent
especially when the patient intends to initiate an
action. They disappear with sleep. Rigidity is a
disabling symptom and is described as cogwheel
type of rigidity, which is most apparent in the neck
and upper extremities. Akathisia is a symptom
characterised by inability of the patient to sit still.
The symptom tends to present very early in the
course of the illness. The gait becomes shufing
and the patient bends forwards as though chasing
their centre of gravity while walking.
Depression and dementias are common in
Parkinsons disease. There is 50-90 percent
incidence of depression, and it is higher in males
than females. Prevalence and incidence gures are
unknown in our region, but in developed countries
it is estimated at 200 per 100,000 persons during
adult life.
Parkinsons disease may be environmentally
induced. Thus, infections resulting into encephalitis,
neurotoxicity, especially with carbon monoxide,

Huntingtons chorea
It was described by George Huntington in 1872.
It is an autosomal dominant motor disorder.
The diagnosis depends on identication of
progressive choreiform movements and dementia.
The presence of a family history of the disorder
makes the diagnosis stronger. It commonly occurs
in middle life and has no specic treatment though
antipsychotic medication may be used to treat
accompanying psychotic and personality changes.
It is a rare disease.
The onset is insidious with progressive
choreiform movements, and psychiatric symptoms
that may include preceding personality changes
and inability to adapt to the environment. Dementia
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The African Textbook of Clinical Psychiatry and Mental Health

which, may afict as many as 90 percent of patients, is


called subcortical dementia when there is associated
movement disorder. Depression is a psychiatric
symptom affecting 40 percent of the patients while
suicide is a major complication. Psychosis occurs in
as many as 20 percent of the patients.
Aetiologically it is an autosomal dominant disorder
with complete penetrance causing atrophy of caudate
nuclei as visualised on computed tomography.
The specic gene involved is yet to be identied.
However, it is thought that human chromosome four
is the site of the genetic abnormality. There is gradual
progression with death occurring 15-20 years after
the onset. The only effective treatment is genetic
counselling, but antipsychotic medication tends to
offer some symptomatic relief of the choreiform
movements.

the differential diagnosis. Clinical features include


Parkinson movement disorder, neuro-psychiatry
symptoms and calcication of the basal ganglia on
computed tomograms

Thalamus, hypothalamus and pineal body


Thalamus is located above the hypothalamus and
consists of various nuclei. It is an integral part of
the limbic system. Thalamus is involved with
perception of pain. The nociceptors (pain receptors)
receive nerve impulses from the peripheral organs
that are relayed and eventually ascend along spinothalamic and reticulothalamic tracts to the thalamus,
from where the impulses are relayed to the somatic
sensory cortex. Dysfunctions of the thalamus are due
to many factors including tumours which produce
severe pain syndrome.
Pain transmission to the thalamus can be inhibited
by projections from periaqueductal region of the
midbrain and the nucleus raphe of the medulla.
These regions have high concentrations of opiate
receptors and these endogenous opiates (endorphins
enkephalins) play a role as neurotransmitters for
the control of pain. The hypothalamus is located
beneath the thalamus and on either side of the third
ventricle. It has many nuclei and those relevant to
psychiatry include: mamillary, supra-chiasmatic,
optic and paraventricular nuclei. The hypothalamus
has several connecting pathways to other parts of
the brain. It is a major integrating and output system
of the entire CNS. It controls biological rhythms and
regulates the immune systems. It is also involved with
appetite and sexual regulation, since it is a part of the
limbic system. The pineal gland secretes melatonin
which is useful in sleep regulation and also secretes
various peptides.

Wilsons disease
It is due to hepato-lenticular degeneration. Related
symptoms include a number of motor disorders.
Clinical features are found in two organs: the CNS
where irritability, depression, psychosis, dementia
of the sub-cortical type, rigidity and dysarthria
occur; and liver failure characterised by jaundice,
Kayser-Fleischer rings in the cornea, blue moons on
the nger nails and apping tremors of the arms.
Aetiologically, Wilsons disease is an autosomal
recessive disorder associated with the abnormalities
in copper metabolism. Ceruloplasmin levels are
low and copper which is supposed to bind to this
enzyme is left free and deposited both in the liver
and the lenticular nuclei, thus causing damage to
these organs.
Fahr Syndrome
This is clinically similar to negative symptoms of
schizophrenia and must always be considered in

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Neuroanatomy and Psychiatry

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The second important function of the brain stem is


hosting of the medial forebrain bundle, the nuclei
of ascending biogenic-amine pathways. Thus, there
are high concentrations of dopamine, noradrenalin
and serotonin levels in the brain stem

Cerebellum
Consist of cerebellar cortex, the middle cerebellum
vermis and deep cerebellar nuclei. There are
projections to the cerebral cortex and other brain
areas such as the limbic system, brain stem and the
spinal cord. Functions of the cerebellum are control
of movement and posture and therefore its lesions
will cause loss of balance. It is also involved in
higher mental functions.

Reticular activating system


This is a system of loosely organised network
of neurons located in the brain stem, which receive
input from cerebellum, basal ganglia, hypothalamus
and cerebral cortex. The reticular activating
system also sends projections to the hypothalamus,
the thalamus and the spinal cord. Since the
reticular activating system is responsible for
the state of alertness and wakefulness, those
psychiatric disorders where motivation and arousal
are affected, may be due to pathology within the
reticular activating system.

Brain stem
The brain stem comprises three parts: the
mesencephalon, pons and medulla oblongata.
Functions of the brain stem are control of
cardiovascular activity, sleep and levels of
consciousness. It is also involved in respiratory
activities. All these physiological activities are
under involuntary control.

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The African Textbook of Clinical Psychiatry and Mental Health

25
Psycho-neurochemistry
Francisca Ongecha-Owuor, David M. Ndetei, John Mburu, Benson Gakinya

the detection of the neurotransmitter by the receptor


proteins (synaptic connection) leading to activation
of post-synaptic neuron causing membrane
depolarisation (excitation) or hyperpolarisation
(inhibition). The activities that take place in the
synapse are important in the understanding of
many other physiological changes that are relevant
to psychiatry. The synapse is the major site of
action for neuro-messengers and drugs used in
psychiatry.

The human brain is made up of cells called neurons.


These cells comprise four parts: cell body,
dendrites, the axon and the pre-synaptic terminal.
A gap called the synapse exists between a presynaptic terminal and the next neuron. There are
several millions of these neurons in the brain
whose main function is information processing
following either excitation or inhibition. Neurons
communicate to and with each other through signal
transduction and chemical neurotransmission.
Signal transduction refers to the general process
by which electrical signals (the nerve impulse) are
converted into chemical signals (neurotransmitter
release) by the pre-synaptic neuron and the process
by which the chemical signals are converted back
into electrical signals by the post-synaptic neuron.
Chemical neurotransmission refers to the release of
a neurotransmitter by the pre-synaptic neuron and

SYNAPSE
There are three types of synapses: chemical
(humoral), electrical (gap junctions) and conjoint.
Chemical synapses use neurotransmitters to relay

Figure25.1: The Nerve Structure

134

Psycho-neurochemistry

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Figure 25.2: Nerve Ending

Biogenic neurotransmitters include cate-cholamines


(dopamine, epinephrine and norepinephrine);
indole amines (serotonin, also called 5-hydroxy
tryptamine), quaternary amines (acetyl-choline)
and ethyl amines (histamine).
Research techniques used to study neurotransmitters involve measuring the neurotransmitter synthesising enzymes, quantities
of neuro-transmitters and neuro-transmitter
metabolites that are found in samples of blood, urine
and cerebrospinal uid. Clear understanding of the
nature of receptors allows the neuroscientists and
clinicians to appreciate the mechanisms involved
in the actual disease pathology and what remedies
to develop.

messages while electrical synapses use electric


current and ow of charged ions to relay messages.
Conjoint synapses contain both chemical and
electrical synapses. Synapses can either be
excitatory or inhibitory, depending on whether
they induce membrane depolarisation (excitation)
or membrane hyperpolarisation (inhibition),
following release of the neuro-messengers and its
effect on the post-synaptic neuron.

NEURO-MESSENGERS
Neuro-messengers, also known as neurotransmitters or neuro-modulators, are grouped
as biogenic amines, amino acids, peptides and
endocanna-binoids. Biogenic amines constitute
about 5-10 percent of the available neuromessengers in the CNS while amino acids
constitute approximately 60 percent. Peptides
which constitute the rest of the CNS neuromessengers include encephalins which act on
the opiate receptors; B-endorphins, substance
P, vasopressin, cholecystokinin (CCK), neurotensin
(NT), thyrotrophin releasing hormone (TRH),
neuropeptide Y., adrenocorticotropin hormone
(ACTH), corticotrophin releasing factor (CRF) and
rexins. They all play a role in behaviour regulation.
Endocannabinoids are some of the least understood
neuro-messengers.

NATURE AND FUNCTIONS OF


RECEPTORS
Receptors are made up of proteins and are found in
neuronal membranes. They are located on both the
pre-synaptic and post-synaptic neurons. Receptors
are congured in such a way that each receptor
only recognises a specic neurotransmitter. They
are designed in the key and lock format where
a lock will only accept the correct key for the
locking or unlocking operation to occur. The
molecular structures of receptors have also been
studied using the techniques of pharmacological

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The African Textbook of Clinical Psychiatry and Mental Health

The function of the receptors involves translating


the rst messenger into the second. The rst
messenger could either be a neuro-messenger,
hormone or nerve impulse. The second messengers
include cyclic adenosine monophosphate (cAMP),
cyclic guanosine monophosphate (cGMP) and
calcium ions. When a receptor is stimulated, it can
then activate adenylate cyclase to produce cyclic
AMP (or open chloride ion channels), to change
the neuronal electric potential and hence, transmit
messages and cause information processing to take
place in the brain.

and molecular biology, where the specic amino


acid sequences of receptors have been identied.
Two types of receptors are the polypeptide chains
and nicotinic acetylcholine receptors. Polypeptide
chains include the following sub-types of receptors,
the adrenergic, the D2 dopaminergic and the MI
muscarinic.
Nicotinic acetylcholine receptor is a complex of
several proteins. When acetylcholine binds on this
receptor complex, ion channels are opened which
allow ions to traverse the membrane and initiate
metabolic changes. The efcacies of receptors
depend on their sensitivity to neurotransmitters,
which could be either supersensitivity or
subsensitivity. Such sensitivity determines how
receptors respond to neurotransmitters once they
are released into a synapse. Sensitivity of receptors
depends on three receptor-related changes, that
is, the number of receptors available, the afnity
for the neurotransmitters and the efciency of the
receptors which may be high or low.
There are three types of receptors; ionlinked receptors (ionotropic receptors) which
are protein structures upon which binding of
the neurotransmitter open ion channels within
milliseconds, the G protein receptors whose
actions are linked to binding of guanyl nucleotides
and membrane-linked kinase receptors.

HOW THE CHEMISTRY OF


THE NEURONS INFLUENCES
BEHAVIOUR
Biogenic amines were the rst neurotransmitters to
be discovered. They are synthesised in the nerve
terminals.

The role of dopamine in psychiatry


Dopamine-containing neuronal cell bodies
are located in the nigrostriatal, mesolimbic,
mesocortical, and tubero-infundibular path-

Figure 25.3: Synthesis of Dopamine and Catecholamines (Noradrenaline and Adrenaline)


TYROSINE
Tyrosine hydroxylase (Tetrahydrobiopterin)

DOPA
L-aromatic amino acid decarboxylase
(Pyridoxal phosphate)

DOPAMINE

Breakdown (See separate chart)

Dopamine-beta hydroxylase
(Ascorbic acid)

NORADRENALINE/NOREPINEPHRINE
Phenylethanolamine N-methyltransferase

ADRENALINE/EPINEPHRINE

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Psycho-neurochemistry

of supersensitive post-synaptic dopamine receptors


following chronic blockade. Lack of dopamine
due to degeneration of neurons in the basal ganglia
results in Parkinsons disease, which is characterised
by rigidity, akathisia and tremors.
Dopamine acts as a prolactin release inhibiting
factor in the anterior pituitary, which is the main
source of prolactin, a hormone that induces lactation
and breast engorgement. Antipsychotic drugs that
block dopamine receptors in the tuberoinfundibular
pathways lead to excess prolactin release. This
may result in gynaecomastia (enlarged breasts),
galactorrhea and amenorrhea.
There is a relationship between dopamine
and psychopathology of schizophrenia. It is
postulated that hyperactivity of the dopaminergic
systems results in symptoms of schizophrenia.
Circumstantial evidence is obtained from the fact that
antagonising or blocking dopaminergic pathways
with antipsychotics results in the alleviation of
schizophrenic symptoms such as hallucinations
and thought disturbances. Secondly, the use of
dopamine-like substances such as amphetamines
may exacerbate or induce schizophrenia-like
symptoms.

ways. Dopamine is synthesised from tyrosine


through hydroxylation by tyrosine hydroxylase
to form dihydroxyphenylanine (DOPA). This is
followed by decaboxylation to dopamine by DOPA
decaboxylase. Dopamine is metabolised by two
enzymes, the monoamine oxidase (MAO) and the
membrane-bound catechol-O-methyl transferase
(COMT). The end product is called homovallinic
acid (HVA).
There are 5 major types of dopamine receptors.
The D1 and D5 receptors are members of the D1like family of dopamine receptors, whereas the
D2, D3, D4 receptors are members of the D2-like
family. Activation of the D1-like family receptors
is typically excitatory, while D2-like activation is
typically inhibitory.
The D2 family of receptors is the most relevant
in psychiatry. The function of dopamine involves
the initiation and co-ordination of movements. The
clinical potency of antipsychotic drugs is associated
with their binding afnity to the D2 receptors
in the caudate and putamen whose blockage
produce unwanted motor disturbances such as
extra pyramidal side effects (Pseudoparkinsonism)
and tardive dyskinesia, a compensatory development
Figure 25.4: Breakdown of Dopamine

DOPAMINE

Monoamine oxidase

Catechol-o-methyltransferase

DIHYDROPHENYLACETALDEHYDE

3-METHOXY-4-HYDROXYPHENYLETHYLAMINE

Monoamine oxidase

Aldehyde dehydrogenase

DIHYDROXYPHENYLACTIC ACID

3-METHOXY-4-HYDROXYPHENYLACETAL DEHYDE

Catechol-o-methyltransferase

Aldehyde dehydrogenase

HOMOVALLIC ACID (HVA)


(3-methoxy-4-hydroxy-phenylacetic acid)

(Transported for excretion)

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Thirdly, the metabolites of dopamine tend to increase


during schizophrenic illness indicating excess
dopamine. Finally the efcacy of anti-psychotic
drugs depends on their blockade of dopaminergic
receptors, especially the D2 receptors.
Another role of dopamine is in the
pathophysiology of mood disorders. Mania is
theoretically due to dopaminergic hyperactivity,
while depression is due to dopaminergic
hypoactivity. For example, patients suffering from
Parkinsonism are treated with L-dopa (levodopa),
which is a precursor of dopamine.
Secondly, L-dopa is used to treat depression
associated with Parkinsonism or other types of
depression. Thirdly, symptoms of tardive dykinesia
worsen when a patient is depressed (low levels
of dopamine) and improve during mania (high
levels of dopamine). Lastly, dopamine levels
and its metabolites are high in mania and low in
depression.

The role of norepinephrine and epinephrine


Norepinephrine (noradrenaline) is formed by the
action of dopamine -hydroxylase, which converts
dopamine to noradrenaline. Noradrenaline is
metabolised by the monoamine oxidase (MAO)
and catechol-O-methyl transferase (COMT) to 3methoxy-4-hydroxyphenylglycol (MHPG). In the
periphery, it is metabolised to vanylmandellic acid
(VMA). Adrenergic neurons are fewer compared
to the noradrenergic neurons located in the locus
ceruleus within the pons. From locus ceruleus
neuronal projections go to brain stem, cortex
(concerned with arousal), spinal cord, thalamus,
hypothalamus and limbic system (concerned with
drive, motivation, mood and response to stress).
Norepinephrine plays a major role in the
pathophysiology of mood disorders. Monoamine
hypothesis of mood disorder assumes that
depression is due to too little noradrenergic and
serotonergic activity. Evidence is adduced from the

Figure 25.5: Breakdown of Noradrenaline


NORADRENALINE

Catechol-Omethyltransferase

Monoamine
Oxidase

3, 4-DIHYDROXYPHENYLGLYCOLALDEHYDE

Aldehyde
dehydrogenase

DIHYDROXYMANDELIC
ACID

Aldeyhde
reductase

DIHYDROXYPHENYLGLYCOL

Catechol-Omethyltransferase

NORMETANEPHRINE

Monoamine
Oxidase

3-METHOXY-4-HYDROXY
PHENYLGLYCOL (MHPG)

Aldeyhde
reductase

3-METHOXY-4-HYDROXYPHENYLGLYCOL
ALDEHYDE

(Conjugated)
Catechol-Omethyltransferase

Aldehyde dehydrogenase

3-METHOXY-4-HYDROXYMANDELIC ACID
(VANILLYLMANDELIC ACID, VMA)
(Transported)

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Psycho-neurochemistry

in the treatment of lithium-induced tremors, social


phobia and akathisia.

fact that tricyclic antidepressants and monoamino


oxidase inhibitors (MAOIs) result in improvement
of depression. Tricyclic antidepressants block reuptake of norepinephrine and serotonin, increasing
their concentration in the synapse.

The role of serotonin


The highest concentration of neurons is in the upper
pons and mid-brain. A precursor amino acid called
tryptophan is acted upon by the enzyme tryptophan
hydroxylase and an amino acid decarboxylase
and is converted to 5-hydroxyl-tryptamine also
called serotonin. Serotonin is metabolised into 5hydroxyindoleacetic acid (5-HIAA). Serotonin is
involved in pain regulation and has antidepressant
properties. Agents that selectively block the reuptake
of serotonin cause accumulation of this amine,
which is positively correlated with amelioration
of depressive symptoms. Low levels of serotonin
are implicated in the pathophysiology of mood
disorders, anxiety, violence and schizophrenia.

Due to blockade of the 1 receptors, sedation


and hypotension are experienced as side effects.
MAOIs inhibit the oxidation of adrenaline and
noradrenaline and their consequent accumulation
ameliorates symptoms of depression.
Clonidine (catapres), an 2 agonist
antihypertensive, is also useful in the management
of heroin withdrawal symptoms. It acts by
stimulating pre synaptic 2 receptors and therefore
minimising the adrenergic activity associated with
the withdrawal symptoms.
-blocking agents such as propranolol (inderal)
used as an antihypertensive has also proven useful

Figure 25.6: Synthesis and Breakdown of 5-Hydroxytryptamine - Serotonin


TRYPTOPHAN
Tryptophan hydroxylase
(tetrahydrobiopterin)

5-HYDROXYTRYPTOPHAN
L-aromatic amino acid
decarboxylase (Pyridoxal phosphate)
5-HYDROXYTRYPTAMINE (SEROTONIN)
Monoamine
oxidase

N-methyltransferase

BUFOTENIN

5-HYDROXYINDOLEACETALDEHYDE

Sulphotransferase

SEROTONIN-OSULPHATE
Adelhyde dehydrogenase

Adelhyde reductase

5-HYDROXYTRYPTOPHOL

5-HYDROXYINDOLEACETIC
ACID

(Conjugated)

(Transported)

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receptors include the nicotinic receptors and


the muscarinic. Acetylcholine is implicated in
the pathology of a number of degenerative and
other psychiatric disorders: dementia, Downs
syndrome, Parkinsons and Alzheimers disease.
Acetylcholines muscarinic receptors are blocked
by many psychotropic drugs, causing the side
effects of blurred vision, dry mouth, pseudoparkinsonism and constipation.

The role of acetylcholine


Acetylcholine neurons are located in the midand hind-brain and have projections from the
nucleus basalis of Meynert to the hippocampus.
Acetylcholine is synthesised from choline and
acetyl coenzyme A through the action of choline
acetyl transferase enzyme. It is metabolised by
acetyl cholinesterase to form choline which can be
reutilised to synthesise acetylcholine. Acetylcholine
Figure 25.7: Synthesis and Breakdown of Acetylcholine

CHOLINE + ACETYL CO-ENZYME A (AcCoA)

Back to the presynaptic


neuron to be re-cycled

Choline acetyltransferase
ACETYLCHOLINE (Ach)
Acetylcholinesterase (AchE) or Butyrylcholinesterase,
BuchE (also known as pseudocholinesterase/non
specic cholisnesterase)

ACETIC ACID

CHOLINE

blockade is the mechanism of action of anti-allergic


medications. Some antidepressants act through
blocking H2 receptors, for example, doxepin. Of
the amino acid neurotransmitters, gamma amino
butyric acid (GABA) and glutamate are the
most important. GABA neurons are distributed
throughout the brain with high concentrations in
the amygdala, basal ganglia, hypothalamus and the
limbic system. The enzyme glutamate decarboxylase
converts glutamate to GABA. Benzodiazepines,
barbiturates, alcohol and neurosteroids act through
GABA receptor complex. Thus, GABA is the main
inhibitory neurotransmitter in the CNS, while
glutamate is excitatory.

Confusion and delirium occur following excessive


blockade of the central nervous cholinergic
receptors, a condition referred to as neuroleptic
malignant syndrome. Acetylcholine has been
implicated in mood disturbances where overactivity of cholinergic pathways has been associated
with depression and sleep disorders.

Other neurotransmitters
Other neurotransmitters of signicance in
psychiatry include histamine and amino acids.
There are three types of histamine receptors, H1,
H2 and H3 whose blockade is the basis of sedation
associated with antihistamine drugs. Histamine (H1)

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Psycho-neurochemistry

Figure 25.8: Synthesis and Breakdown of GABA


GLUTAMIC ACID
Glutamic acid decarboxylase (Pyridoxal phosphate)
GAMMA-AMINOBUTYRIC ACID (GABA)
GABA: Glutamate aminotransferase (Pyridoxal phosphate)
SUCCINIC SEMIALDEHYDE
Succinic Semialdehyde dehydrogenase
(nicotinamide adenosine dinucleotide, NAD)
SUCCINIC ACID

TO THE KREBS CYCLE

Peptides may perform different functions in


different target organs. The same peptide may
function as a hormone in one setting and as a
neurotransmitter in another. Vasopressin acts as a
hormone when released by the pituitary and as a
neurotransmitter when released by neurons.
Peptides are involved with regulation of stress
and pain, especially the endogenous opioids as

well as in the normal homeostatic regulation of


mood. Neurotensin, somatostatin and vasopressin
have been implicated in the pathology of schizop
hrenia, Huntingtons chorea and mood disorders
respectively.
Many more neurotransmitters have been
discovered and new ones are being discovered.
Their functions and roles are being studied.

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26
Psychoendocrinology
John Mburu, Francisca Ongecha-Owuor, Benson Gakinya, David M. Ndetei

thus reducing dopamine activity just like


the antipsychotics. If female patients on L-dopa
for treatment of Parkinsons disease develop
dyskinesia, and are given oestrogen, the dyskinesia
improves by reducing dopamine in nigrostriatal
pathways. Chorea is due to low dopaminergic
activity. In pregnancy, the oestrogen levels
diminish dopaminergic activity and chorea may be
a complication. Oestrogen containing pills are also
known to induce chorea.
Endocrine disorders such as hypothyroidism
or hyperthyroidism, Cushings syndrome
(hyperadrenalism), and Addisons disease
(hypoadrenalism) tend to be associated with classic
psychiatric presentations such as depression,
psychosis, hypomania, anxiety and irritability, which
often precede the endocrine symptoms. Whether
a disease process is diagnosed as a psychiatric or
an endocrine disorder depends more on whether
a particular person has more marked behavioural
or hormonal abnormalities. Schizophrenic patients
have ventricular enlargement. Enlargement around
the third ventricle tends to interfere with the
hypothalamus.

Psychoendocrinology is dened as the study


of the interaction between the nervous system
and endocrine system. The latter consists of the
pituitary, thalamus, hypothalamus, pineallocated
in the brain and the target glands thyroid, parathyroid,
thymus, breasts, adrenal and the gonads located
in the periphery. The hypothalamus produces
releasing or inhibitory factors that inuence the
anterior pituitary gland to release hormones. These
hormones inuence the peripheral endocrine
glands to release hormones into the circulation.
The posterior pituitary produces vasopressin
and oxytocin hormones. The vasopressin hormone
is involved in the control of blood pressure, uid,
and electrolyte balance. The release of vasopressin
is inuenced by pain, stress, morphine, barbiturates
and alcohol. The functions of oxytocin include,
stimulating glandular contractions of the breast
and uterine contraction during parturition.

INTERACTION BETWEEN THE


ENDOCRINE AND NERVOUS
SYSTEMS

CHRONOBIOLOGY

If oestrogen is administered together with


antipsychotic
medication, there is a higher
increase in the number of dopamine receptors.
This is clinically evident in tardive dyskinesia
(antipsychotic-induced motor system symptom)
which is more prevalent in women than men.
The explanation for this is that oestrogen tends
to increase the number of dopamine receptors,

Chronobiology is the study of biological rhythms


in the following biological functions: endocrine
secretion, neurotransmitter synthesis, receptor
numbers, enzyme levels and brain electrical
activities, which vary with time of the day, week,

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Psychoendocrinology

subjective experience of fatigue and dysphoric


mood, which is also experienced on travelling east
to west.
Depression is accompanied by disturbances of
sleep cycle with early morning awakening. This
is a phase advanced phenomenon. Seasonal mood
disorders have also been noted in some individuals
who tend to experience fatigue. As soon as the sleep
cycle is normalised many patients with depression
experience some relief.

month or year. The following cycle lengths have


been found to occur in human beings: infradian
cycle takes less than a day, circadian cycle
approximately 24 hours, ultradian cycle more than
one day and circaseptan cycle approximately one
week. Finally the circannual cycle is a cycle taking
approximately one year. Examples of rhythms
are sleep-wake cycle, hormone levels, body
temperatures and menstrual cycles in females.
In normal and good health, these rhythms are in
normal relationship with each other, and are said
to be in phase. Disease states tend to disrupt the
phases and one of the rhythms may be out of phase.
The rhythm may occur before the due time and is
said to be in phase advance or begins later than
usual and is said to be in phase delay. The body
has synchronisers, which ensure that the rhythms
are in phase. The supra-chiasmatic nuclei of the
hypothalamus are thought to be the site responsible
for synthesising and releasing synchronisers. The
synchronisers are also called time givers or time
clues. Exogenous synchronisers include the light
day cycle, patterned meals, time and the eight to
ve work days.

PSYCHOIMMUNOLOGY
This is the study of the interaction between the
immune and nervous systems. Immunological
mechanisms can cause psychiatric disorders
by allowing neurotoxins such as viruses to
infect the brain. A good example is the human
immunodeciency virus (HIV) that causes acquired
immunodeciency syndrome (AIDS). Immune
systems can interfere with normal endocrine and
brain tissue resulting in autoimmune diseases.
However, it is not clear how psychiatric disorders
affect the immune system. It is postulated that
certain psychological disorders or stressors have
a role in immune suppression. Systemic lupus
erythematosus (SLE) is an example of an immune
disorder in which there are associated psychiatric
symptoms that appear as the initial presentation,
although the actual pathophysiology remains
unknown. Grief reaction and depression are known
to be associated with certain immune changes such
as decrease in T cell proliferation, natural killer cell
activity and overall number of lymphocytes.

Relevance to psychiatry
Jet lag and mood disorders are the two conditions
that are clinically important to the practice of
psychiatry. Passengers travelling from west to
east tend to gain time. This is an example of phase
advance, which opposes the natural tendency. The
individual has to cope with a situation where the
body needs time to adjust to the new schedule
of exogenous clues. There is an accompanying

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27
Psycho-neurological Investigations
Benson Gakinya, John Mburu, Francisca Ongecha-Owuor, David M. Ndetei

EEG frequencies are divided as follows:


Delta activity where there are less than 4 cycles
(<4HZ) per second. These waves are normally
present in sleep.
Theta activity is characterised by 4 to 8 cycles
per second (4-8HZ) and is also present during
sleep.
Alpha activity has 8 to 13 cycles per second
(8-13HZ) and is present in the normal awake
adult with closed eyes.
Beta activity occurs where the frequency is
more than 13 cycles per second (>13HZ).
Beta activity replaces alpha activity when the
person is stimulated or opens his eyes.
The EEG recordings may be inuenced by scalp
muscle activity. While reading the EEG one
assesses frequencies, amplitude, distribution of the
wave forms and paroxysmal events such as spikes
and wave bursts, abnormally slow or fast activity,
abnormal asymmetry and suppression of EEG
amplitude.

BRAIN IMAGING
A variety of techniques are now available that
can take an image of the living human brain.
These include computed tomography (CT) used to
assess the structure of the brain, positron emission
tomography (PET) assesses both the structure
and functions of the brain, while electroencephalography (EEG) assesses the brains electrical
activity. Other techniques used for clinical and
research purposes are evoked potential (EPs),
polysomnography and magnetic resonance imaging
(MRI). Magneto-encephalography (MEG) and
single positron emission tomography (SPECT) are
mainly for research purposes.

ELECTROENCEPHALOGRAPHY
(EEG)
This was developed by Hans Berger in 1929 and is
widely used in psychiatry and neurology. Clinically,
EEG is used in evaluation of epilepsy, dementia,
delirium, brain injury and research activities. The
technique of EEG involves placing electrodes on
the scalp in specic positions according to the
international 10-20 system. The system is based on
measurements made from nasion (depression at the
bridge of the nose) to the inion (raised position of
the skull at the back of the head) and also from the
left to right auricular depression (slight valleys just
in front of and above the earlobes).

POLYSOMNOGRAPHY
This is an EEG recording that is performed on a
person who is asleep. Other measurements are done
simultaneously and they include electromyogram
(EMG), electrocardiogram (ECG), blood oxygen
saturation, galvanic skin response, penile
tumescence, body movements, temperature,
and gastric acid secretion. Clinical indications

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images of the brain. Lesions larger than 0.5 mm


can be visualised.
The indications of a CT scan are the evaluation
of patients with stroke, tumours, trauma, and in the
work-up of psychiatric patients presenting with
confusion and dementia of unknown cause. CT
scan is mandatory in patients presenting with rst
episodes of psychosis or depression, especially
after age 50, in the rst episode of psychiatric
symptoms such as aphasia, and convulsions in a
person with a history of alcohol abuse, tremors and
seizures.
Other indications include movement disorders
of unknown cause such as prolonged catatonia,
and in psychiatric research in which the ventricles,
cortical and cerebral sizes and brain symmetry are
studied. CT scan is unable to detect some lesions,
because they are too small, the density of the lesion
is not distinguishable from that of healthy tissue or
due to their position in the brain.

for polysomnography in psychiatry include the


study of the normal and abnormal sleep architecture
in individuals. Out of these studies two types of
sleep patterns have been found. One is the rapid
eye movement (REM) sleep and the second one
is the non-rapid eye movement (non-REM) sleep.
There are four stages of normal sleep:
Stage I: stage of light sleep. The EEG shows
alpha activity when an adult lies
down with their eyes closed.
Stage II: alpha activity gradually disappears.
Stage III: delta activity becomes more prevalent
as stage IV approaches.
Stage IV: deep sleep characterised by delta
wave activity.
During the REM stage, the high amplitude slow
waves are replaced by beta-like activity (>13 HZ).
The wave activity resembles that of an awake, alert
person although the person is asleep. During this
time the eyes oscillations are faster as though the
person is awake. The REM stage occurs several
times during sleep and is associated with dreams.

MAGNETIC RESONANCE
IMAGING (MRI)

EVOKED POTENTIALS (EP)


Magnetic resonance imaging is a superior technique
to CT scan. A strong magnetic eld is applied to
the brain and causes hydrogen nuclei to become
aligned in a certain way and produce characteristic
electromagnetic energy. The released energy is
analysed by a computer to produce a nal image.
Indications of MRI are same as those for CT scan,
but it is likely to yield more ndings due to its
ability to distinguish grey matter from white matter.
It is also able to detect lesions less than 0.5mm.
However, MRI is unable to pick calcication and
cannot be used in patients with cardiac pacemakers,
metal or steel such as metal skull plates.

Evoked potentials (EP) is essentially an EEG


except that it is intended to measure how the
cortex responds to a particular sensory stimuli. A
visual stimulus is evoked and presented several
times, while the EEG recording is made. The brain
electrical activity on the EEG that follows each
repeated stimuli is then averaged by a computer
to reduce non-stimuli related activity. The result is
a smooth curve (the EP) which has various peaks
and valleys.
Clinically, people with certain predisposition,
for example alcoholism, have been found to have
characteristic EPs which can be used as a biological
marker. It has been used to predict alcoholism in
siblings of alcoholic parents. EPs have been used
in the evaluation of de-myelinating disorders such
as multiple sclerosis.

SINGLE PHOTON EMISSION


TOMOGRAPHY (SPECT)
AND POSITRON EMISSION
TOMOGRAPHY (PET)

COMPUTED TOMOGRAPHY (CT)


Single photon emission tomography (SPECT) and
positron emission tomography (PET) are similar
in that they use organic compounds that have been
labelled with positron-emitting isotopes. Such
radioactive substances are introduced into the
body and once they reach the brain they produce
rays that are detected and analysed by a computer

This is a very common technique which is based


on x-ray technology where x-ray photons emitted
from a source are passed through the tissue being
studied. The resulting data is fed into a computer
and presented as saggital transverse and coronal

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The African Textbook of Clinical Psychiatry and Mental Health

to produce tomographic images of the brain which


can be visualised. Functional aspects of cortical
and subcortical areas of the brain can therefore be
studied.
In conclusion, brain imaging techniques are
now highly advanced and have led to better

understanding of the various functions and


defects within the human brain. All brain imaging
techniques have direct clinical signicance in
diagnosis and assessment of impact of treatment.

146

28
Genetics of Mental Disorders
John Mburu, Francisca Ongecha-Owuor, Benson Gakinya, David M. Ndetei

Three-quarters of the genes every child receives


are identical to those received by every other child.
They are called monomorphic genes and dene
characteristics that make a person recognisably
human. One-quarter of the genes are called
polymorphic genes and they dene each person as
an individual. Except for monozygotic twins, it is
not possible for two individuals to receive exactly
the same combination of genes.

Genetics is the study of the hereditary mechanisms


in a population. Over the last 30 years the genetics
of human diseases have been revolutionised. By
1992, about 2372 human genes had been mapped,
611 of which are known to contribute to medical
disorders. Some psychiatric disorders have been
known to run in families and hence the need to
study the various processes of inheritance.

MECHANISMS OF HEREDITY

Patterns of genetic transmission


Genes that affect a particular trait, for example, the
ability to curl the tongue, are referred to as paired
alleles. Every person receives a pair of alleles for
a given characteristic, one from each biological
parent. When both alleles are the same, the person
is homozygous (identical alleles) and heterozygous
when the alleles are different.
There are two types of inheritance to genetic
material: dominant and recessive. Dominant
inheritance is when a person is heterozygous for
a particular trait, but only the dominant allele
expresses itself. On the other hand, the expression
of a recessive trait occurs only when a person
receives the recessive allele from both parents
referred to as recessive inheritance. Observable
characteristics of a person, for example, maleness
or height is referred to as the phenotype while
genotype refers to genetic make-up of a person
which contains both expressed and unexpressed
characteristics.

Genes and chromosomes


The basic unit of heredity is the gene. It contains
all the inherited materials passed from biological
parents to children. Each cell contains 80,000
to 100,000 genes. Genes are made up of the
chemical, deoxyribonucleic acid (DNA), which
carries the biochemical instructions to the cells to
synthesise the proteins that enable them to carry
out each specic body function.
Each gene seems to be located by function in a
denite position on a rod-shaped structure called a
chromosome. A chromosome is one of the 46 rodshaped structures that carry the genes. Every cell
has 23 pairs of chromosomes. Through meiosis,
the pairs are halved so that each gamete or sex cell
(ovum or sperm) contains 23 single chromosomes.
During fertilisation the 23 chromosomes from the
sperm join the 23 chromosomes from the ovum so
that the zygote receives 46 chromosomes.

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affective disorders, in the relatives of patients


with eating disorders and of sociopathy in relatives
of patients with somatisation disorder.

WHY GENETICS IN MENTAL


HEALTH?

Twin studies

The aim of studying genetics is to establish and


specify the genetic component of the aetiology
of psychiatric syndromes. This will assist in
determining to what extent a psychiatric disorder
is genetically caused, the DNA re-arrangement
of the genetic contribution, the biophysiological
abnormalities associated with the gene involved
and the process by which genetic abnormalities
lead to symptoms.
Given that most psychiatric disorders have a
multi-factorial aetiological contribution, genetic
studies will help distinguish the non-genetic
components of psychiatric syndromes that act
independently of or interact with vulnerable
genotypes to produce or increase the likelihood of
a disorder. Genetics studies also help in improving
the diagnostic criteria by determining genetic
associations between sub-types of a disorder.

Twin studies examine the concordance or the


coincidence of a disorder in monozygotic (MZ)
genetically identical and dizygotic (DZ) or fraternal
twins. These studies are useful for separating the
genetic and environmental inuences. They are also
useful for looking at protective and precipitating
factors. Monozygotic twins share the same ovum
and contain identical genetic material. It is expected
that a genetic disorder should occur, that is, be
concordant in monozygotic twins more often than
in dizygotic twins. Dizygotic twins develop from
two different ova and are not different from nontwin siblings in average genetic material shared.

Adoption studies
Adoption studies are based on the fact that adoption
separates the two major inuences parents have on
their children, namely genes and rearing. Adoption
studies are useful in studying the effect the
environment has on the expression of genes. They
answer the question of whether a disorder is familial
due to genetic factors or the shared environment.
There are different types of study designs. Adopted
study designs involve the study of adopted away
children of a parent with a disorder. If it is found
that these children have a higher rate of developing
a psychiatric disorder despite being reared by
normal adoptive parents, then a genetic factor from
the biological parents is implicated. Under these
type of studies, the monozygotic twins are studied
by rearing them together in the same environment
either with biological or adoptive parents or rearing
them apart in different environments, one with a
biological parent and the other with an adoptive
parent. The cross-fostering method involves
studying children born of non-disordered parents
adopted into a family with a disordered parent.

THE STUDY OF GENETICS IN


PSYCHIATRY
These are family, twin, adoption and high-risk
studies.

Family studies
In family risk studies the affected persons are rst
identied. They are called index cases or probands.
The prevalence of the particular psychiatric
disorder among the relatives of the probands is
then determined. The prevalence of this particular
psychiatric disorder among the relatives is then
compared with its prevalence in the general
population. Generally, the rst-degree relatives
(mother, father and siblings) are more likely to
have the disorder of the proband than are more
distant relatives or the general population.
Family studies may reveal an increase not only
in the disorder in question, but also in other types
of psychopathology. At times this increase has
been in milder or related disorders (syndromes)
of the major disorder, such as dysthymia in the
relatives of patients with major depression or
unipolar depression in the relatives of patients with
bipolar depression. In other illnesses, more distant
syndromes have appeared such as an increase of

High-risk studies
These distinguish the offspring of disordered parents
from those of control subjects. The children are
followed from early ages and their characteristics
noted over a span of time. It offers researchers a
naturalistic experiment that has the potential
to answer the questions of whether a disorder is
familial, because of genetic transmission or the
shared environment.

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Genetics of Mental Disorders

wise concordance rate for MZ twin pairs and 14


percent rate for DZ pairs.

Genetics of common psychiatric disorders


Schizophrenia
Family studies

Adoption studies
The children of mothers with bipolar illness or major
depression have higher rates of major affective
disorders than do the adopted away children of
mothers with other psychiatric conditions.

Various studies have consistently demonstrated


elevated morbid risk for schizophrenia in rstdegree relatives of schizophrenic probands in the
range of 5.6 percent for parents, 10.1 percent for
siblings and 12.8 percent for children, compared
with those in the general population that was 0.9
percent. This suggests that schizophrenia is a
familial syndrome.

High-risk studies
Studies of children of parents with major affective
disorders have quite consistently reported high
rates of social and psychiatric impairment, such as
increased prevalence of major depression, conduct
disorder, attention decit disorder (ADD), anxiety,
substance abuse and poor social functioning among
these children.

Twin studies
Estimates of proband concordances have varied
and this may reect differences in diagnostic
criteria, across studies. However, concordance
for monozygotic and dizygotic twins have been
estimated at 59.2 percent and 15.2 percent,
respectively

Alcohol-related disorders
Family studies
Many studies have demonstrated that alcoholrelated disorders are familial since the risk in
rst-degree relatives is seven-fold. The presence
of alcohol-related disorders in biological parents
predicted the same disorder in their male offspring
even in cases where the latter were reared by
unrelated adoptive parents. Alcohol-related
disorders co-exist with antisocial personality
disorder and affective disorders which complicate
diagnosis thus resulting in varied ndings. The risk
of alcohol-related disorders was found to be 16
percent in the fathers and 7 percent in the siblings
of alcoholic subjects versus a risk of 1.6 percent
and 0.5 percent for the relatives of matched control
subjects by Pitts and Winokur in 1966.

Adoption studies
All the four varieties of adoption studies have been
applied to schizophrenia and the role of genetic
inuences have been demonstrated. For example,
an adoptee study carried out by Heston in 1966
found signicant greater risk for schizophrenia
among the offspring of schizophrenic mothers
separated at birth than among adopted away
offspring of controlled mothers.
High-risk studies
By one year of age high-risk infants are more
likely than controlled infants to show anxious
attachment behaviour and sensory motor decits,
traits which persist over time. High-risk studies
are useful in predicting pre-morbid features of
schizophrenia among high-risk children.

Twin studies
The results for twin studies have produced varied
results with some reporting rates of up to 59
percent for the MZ versus 36 percent for DZ males,
25 percent and 5 percent for female MZ and DZ
twins, respectively.

Mood (Affective) Disorder


Family studies
High family rates of affective disorders have been
found in a number of studies. First-degree relatives
of bipolar probands have an elevated morbid risk for
both bipolar and major depressive illness, whereas
relatives of major depressive illness probands
have an elevated risk for major depression but not
bipolar disorder.

GENE AND CHROMOSOMAL


ABNORMALITY
Defects and diseases are due to abnormalities in
genes and chromosomes, including mutations,
which are permanent alteration in genes or
chromosomes. Not all gene and chromosomal
abnormalities manifest at birth. For example, TaySachs degenerative disease of the central nervous

Twin studies
Twin studies have supported the importance
of genetic factors in the transmission of major
affective disorders to the rate of 65 percent pair

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system (CNS) which occurs at 6 months and


Huntingtons diseases which occurs during middle
age.

Autosomal Chromosomal Abnormality

Those relevant to psychiatry are Klinefelters


syndrome, Triple X, Turners syndrome, Fragile X
and XYY.

Down Syndrome is the most common and well


described autosomal syndrome. It is a chromosomal
aberration
disorder
typically
involving
chromosome 21 (Trisomy 21). Mental retardation
is the overriding feature accompanied by various
emotional difculties, behavioural disorders and
rarely, psychotic disorders.

Klinefelters syndrome

Sex-linked disorders

This sex-linked chromosomal abnormality has a


genotype of XXY. Phenotypically, the individual is
a male with underdeveloped sexual characteristics,
small testes and sterility and may often have
gender disturbances, emotional instability, mental
retardation and learning disorders.

Sex-linked conditions are associated with


mental retardation in both males and females.
Examples are Lesch Nyan syndrome and glucose
dehydrogenase deciency.

Triple X

Gene abnormalities are either dominant or


recessive. The dominant conditions are rare and
examples include neurobromatosis in which
mild mental retardation occur in up to one-third
of those with the disease. Recessive conditions
constitute the largest group and include most
of the inherited metabolic conditions such
as galactosaemia and phenylketonuria. The latter
presents with bizarre movements of the body and
upper extremities, temper tantrums and mental
retardation.

Sex chromosomal abnormalities

Gene abnormalities

Genotypically XXX, and phenotypically a female


with normal appearance. However, the individual
may have menstrual irregularities, learning disorder
and mental retardation.
Turners Syndrome
Genotypically XO, and phenotypically a female
of short stature, webbed neck, no menses,
underdeveloped sex organs with incomplete
development of secondary sexual characteristics.

Further reading for Chapters 24-28


1. Synopsis of Psychiatry: Behavioural Sciences Clinical
Psychiatry: 9th edition (2003). Editors: Benjamin J.
Saddock, Virginia Alcott Sadock. Lippincott Williams
& Wilkins
2. Textbook of Psychiatry 2nd edition (1994). Editors:
Robert E. Hales, Stuart Yudofsky and John A. Talbott.
Published by American Psychiatric Press Incorp.,
Washington D.C

Fragile X
The syndrome results from a mutation on the Xchromosome at what is known as the Fragile site.
Phenotypically they have enlarged long head, ears,
short stature, hyperextensible joints and postpubertal macro-orchidism. They are known to
suffer mental retardation, impaired speech and are
hyperactive.
XYY Abnormality
This affects males, who are usually tall and of low
intelligence quotient (IQ). They display abnormal
aggressive behaviour.

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Section IV:

Clinical Adult Psychiatry

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152

29
Aetiology in Psychiatry
Tarek Okasha, Khalifa Mrumbi, Gad Kilonzo, Seggane Musisi,
Christopher P. Szabo, Mohamedi Boy Sebit, David M. Ndetei

Aetiology in psychiatry can be classied into three


broad categories namely: biological, psychological
and social factors. However, it is often not easy to
draw a sharp distinction between the predominant
inuences of each of these factors in the causation
of mental illness in the individual.

PSYCHOLOGICAL FACTORS
A number of psychological theories exist that have
attempted to explain the basis of psychopathology
and clinical presentations. Below are some
examples of these theories.

BIOLOGICAL FACTORS

Psychoanalysis formulated by Sigmund


Freud

Constitutional factors refer to genes that


control various aspects of human life including
intellect, temperament, body size and the bodys
biochemistry. Such factors may predispose an
individual to developing a mental illness. Physical
illnesses, chemical intoxications, trauma involving
the brain and infections may lead to the development
of a psychiatric disorder. Neurochemical studies
indicate that episodes of major neuropsychiatric
disorders may be due to imbalances of
neurotransmitter levels in specic regions of the
brain. Violence and suicide behaviour in depressed
individuals has been associated with low levels
of serotonin in the limbic area of the brain. Episodes
of major depression are believed to result from
low levels of either serotonin or noradrenaline and
manic episodes, to enhanced activity of dopaminecontaining neurons.

Psychoanalytic theory is based on the premise


that impaired psychosexual development in early
childhood will lead to the development of
psychopathology in adult life. According to this
theory, the mind consists of three distinct structures:
the Id, the Ego and Superego. According to
Freud, all behaviour is caused or determined by
psychological factors. All our actions including
dreams, errors, and slips of the tongue or pen have
meaning. Humans are all born with innate instincts
which govern behaviour. Unsatised instincts
create tension within the individual, and these
manifest in the form of psychological illness. When
individuals understand the nature and sources of
their symptoms through therapy, a cure is achieved.
The problem with Freuds theory of psychoanalysis
is that all symptoms have to be traced to unresolved
sexual conicts in the life of the individual.

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physical health and diminished psychological


coping ability. The mortality rate among bereaved
elderly spouses increases signicantly within the
rst two years of the death of the partner. The
inuence of stress in the precipitation of mental
disorder is stronger in the case of depressive
disorders. However, this does not mean that all
cases of depressive illness, or indeed, of any other
episode of mental disorder, arise as a direct result
of a stressful life event. Individuals may develop
a major episode of mental disorder in response
to the most trivial precipitating life event but
remain relatively stable when faced with a major
catastrophe.

The psychosocial theory of Erik Erickson


This theory is an extension of the psychoanalytic
theory of Sigmund Freud and includes social
and cultural dimensions. The theory emphasises
the development of the opposing dimensions of
life namely; trust and mistrust; identity and role
confusion, intimacy and isolation, generativity and
self-absorption, and integrity and despair.

The attachment theory of Bowlby


This theory is premised on the observation that
babies are totally dependent upon their parents
or caregivers for their survival. The development
of a warm and caring relationship between the
infant and the caregivers is important for the
survival of the baby. This development depends
on the reciprocal behaviours of the baby and the
caregiver. Initial behaviours of the infant that
elicit nurturing responses from the parent include
sucking, cuddling, looking, smiling, crying and
even sleeping.
Infants are usually afraid of strange and difcultto-understand situations, and will react with fear if a
new face appears on the scene. The presence of the
caregiver usually provides security for the infant to
get used to strangers, explore the environment and
develop social skills. Successful interaction with
the family and peers is perhaps the most important
factor in the development of social skills. The lack
of adequate social attachment during infancy and
childhood leads to lack of trust and difculties in
establishing lasting relationships with others in
adulthood.

CULTURAL FACTORS
A variety of social and cultural beliefs exist in Africa.
Such beliefs attempt to explain mental disorders in
terms of personal deeds, general social conduct and
individual or collective group relationships with
ancestral spirits. Mental illness results from a variety
of factors, such as possession by spirits who want
a home to reside in, punishment by angry ancestral
spirits for alleged evils committed, witchcraft as a
result of envy or the presence of a lizard or worm
in the brain of the victim. Most forms of mental
disorder, including depression and anxiety, are
not easily recognised as illnesses, although some
communities may be able to recognise the physical
and behavioural manifestations of these disorders.
Traditional cultural formulation of mental disorders
has important implications for therapy and use of
hospital treatment facilities.

SOCIAL FACTORS
CONCLUSION
It is usual for episodes of mental disorder to occur
in association with stressful life events. Examples
include suffering from a severe life-threatening
illness, bereavement, separation, divorce, loss of
employment, recent promotion and anniversary of
the death of a relative. The impact of the stressful
life events is particularly great if the event has a
signicant meaning to the individual. The impact
is also greater for those individuals who rely
on outside social support in coping with their
problems. Thus, the impact of stress is particularly
great if no outside social support is available at the
right time.
The experience of stress is associated with
signicant immuno-suppression resulting in poor

No single theory is sufcient to explain the


phenomena and mechanisms involved in the
development of mental illness. It is best to adopt
the biopsychosocial model of disease for an
adequate understanding of disease processes. It is
becoming obvious that the biological, psychological
and social factors in peoples lives interact with
one another to inuence all aspects and response
to treatment. Comprehensive management of all
health problems requires the appropriate application
of physical, social and psychological principles.

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Aetiology in Psychiatry

2. N.R. Carlson. (1990). Psychology. The Science of


Behaviour. 4th edition. Allyn and Bacon. Boston.
Boston.

Further Reading
1. H.G Harmatz. (1978). Abnormal psychology, Prentice
Hall, Inc., Engelwood, New Jersey.

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30
Psychopathology
John Mburu, David M. Ndetei, Benson Gakinya, Francisca Ongecha-Owuor,
Seggane Musisi, Gad Kilonzo, Christopher P. Szabo, Mohamedi Boy Sebit

of dynamic, unconscious, psychic determination


and the role of childhood development in shaping
the adult mind. All major schools of thought view
developmental success and failures as central to
the evolution of adult character and inuential in
the pathogenesis of mental illnesses.
Diverse aspects of human experiences including
psychiatric symptoms, dreams, occupational
choices and selection of partners were perceived
to have meaning with thoughts, behaviours, feeling
and symptoms being the common pathways of the
unconscious process of the mind. Several intrapsychic factors operate simultaneously to produce
a certain set of symptoms. By observing hysterical
patients, Freud designed the construct of the
unconscious mind in which he noted that the long
forgotten memories re-emerged in the process of
treatment. These led him to conclude that the human
mind has a censor that dims certain memories,
thoughts and feelings that were unacceptable.
Such unacceptable materials were repressed from
the conscious mind and only became evident as
symptoms of mental illness. As a result of this
work, Freud initially developed the topographical
theory of the mind that included the conscious, preconscious and the unconscious, which gave way to
the structural theory that included the Id, the Ego
and the Superego.
In the structural theory, the mind goes through
various stages of development that Freud
associated with libido energy and called them
sexual stages of development. Failure to navigate

Psychopathology is the study of abnormal states of


mind. It can be viewed as an attempt to understand
the disease processes of the mind in terms of signs
and symptoms, including their causes and how
they develop. There have been two main schools
of thought regarding psychopathology:
The dynamic or psychoanalytic which
emphasises the unconscious processes. It was
founded by Freud at the beginning of the 20th
century but has been contested in recent times
on the basis of its lack of scientic validity.
Clinical or descriptive psychopathology which
puts emphasis on phenomenology. This is the
understanding of the mental phenomena in
terms of signs and symptoms.

DYNAMIC PSYCHOPATHOLOGY
The dynamic system starts with the patients
description of their mental experiences and the
medical workers observation of behaviour. It
then seeks to explain the causes of abnormal
mental events by postulating unconscious mental
processes. It was developed in an attempt to make
the human experience and behaviour intelligible
without leaving out their irrational components.
The contributions of Freud have undergone
considerable revision over the past 100 years
evolving to the psychoanalytic school of thought.
Included in his original work were the crucial role

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Psychopathology

stressful experiences like bereavement, severe


illness and loss of income or livelihood.

through either of the stages successfully is


associated with certain character traits and even
symptoms. Using a similar model, Erik Eriksson
developed the epigenetic principles that were more
elaborate and included several stages in a human
life cycle. Failure to go through either of the stages
successfully was associated with development of
symptoms of mental illness.
Psychoanalysis is therefore valuable in
understanding and explaining psychopathological
mechanisms in spite of great strides made in
biological research.

Disturbances of attention
Attention refers to the ability to direct ones activity.
It is the amount of attention exerted in focusing
on certain portions of an experience; the ability
to concentrate. It may be impaired in dissociative
states, anxiety states and in depressed patients.
Patients experiencing psychotic symptoms may
appear inattentive due to their concentrating on
psychotic experiences at the exclusion of all other
external experiences. The examples of disturbances
in attention include:
Distractibility which is the inability to
concentrate; attention is easily diverted to
other activities that are irrelevant. It commonly
occurs in manic states.
Trance, a dream-like state when attention is
focused on one thing and the person seems
oblivious of his surroundings. It occurs
in hypnosis and dissociative disorders.
Selective inattention in which one blocks
away from consciousness things that generate
anxiety.
Hypervigilance in which excessive attention is
concentrated on a stimuli. It is often secondary
to paranoid and delusional states.

DESCRIPTIVE
PSYCHOPATHOLOGY
This is the objective description of abnormal
states of mind. It is concerned with the conscious
experience and observable behaviours and denes
the essential qualities of morbid mental experiences.
These descriptive states include:

Disturbances of consciousness
Consciousness is the state of awareness of the self
and the environment. Its disturbances are more
often associated with apparent brain pathology, for
example brain tumours, infections of the central
nervous system, epilepsy, narcolepsy and physical
trauma. Levels of consciousness may range from
a slight alteration noticeable as confusion to deep
unarousable coma. Altered states of consciousness
include:
Clouding of consciousness, which describes
a state of unclear mindedness or thinking
that may be associated with disorder of
perception, attention, registration, orientation
and attitudes.
Stupor which is a lack of response and
unawareness of surroundings.
Delirium which is a dream-like change in
consciousness that is often accompanied by
an impaired reality testing. The patient may
be anxious, confused, disoriented, restless and
might experience hallucinations.
Coma: deep unconsciousness.
Depersonalisation: disturbance in the way one
experiences the self
Derealisation: a disturbance in the way one
experiences ones physical environment
The latter two are associated with psychological
stress and often occur in persons undergoing

Disturbances in emotions
Emotion is the feeling or response to sensory input
from the external environment or mental images. Its
sustained and pervasive inward subjective feeling is
referred to as a mood while its related somatic and
behavioural changes (the outward expression of the
emotion) is the affect. The affect and the mood may
be incongruent as occurs in schizophrenia. Affect
is said to be blunted when there is a reduction in
the intensity of outward expression. The affect is
at when there are no outward signs to express the
emotional feeling. Rapid changes in emotion occur
when the mood is labile as in bipolar disorders.
Mood
This is the emotional state subjectively experienced
by the patient. It is inuenced by the patients
experiences and expectations, as well as the
presence of disease. An individual is expected to
be anxious when anticipating something good or
bad, sad in grief, and euphoric in victory. Mood
may, however, be altered by use of psychoactive
substances like alcohol and opiates. The variations
in mood include

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Depression: a pathological feeling of sadness.


Dysphoric mood: an unpleasant mood.
Euthymic mood: normal moodneither elated
nor depressed.
Irritable mood: easily offended leading
to anger.
Elevated mood: cheerful, happy mood.
Euphoria: intense elation of mood.
Anhedonia: loss of interest or the inability to
enjoy previously pleasurable activities.
Apathy: blunted emotion associated with loss
of energy and drive.

Disorders of form of thoughts (disorders in the


ow and structure of thoughts)
Autistic thinking: preoccupation with the
inner, private world.
Neologisms: new word created by a patient or
a normal word used to mean a different thing.
World salad: several words put together with
no clear meaning.
Incoherence: thinking that does not ow
logically.
Echolalia: psychopathological repetition of
words or phrases said by another person.
Derailment: sudden or gradual deviation in the
ow of thoughts without blocking.
Flight of ideas: rapid thought manifested by
fast verbalisation and shifting of ideas which
tend to be connected to one another.
Thought block: sudden interruption in the
stream of thought before an idea or thought is
completed.
This disorder commonly occurs in schizophrenic
patients, though ight of ideas is seen in elated
mood disorder patients (mania). Patients with
various levels of intelligence and at different ages
may show variable degrees of deviations in the
thought processes which may not necessarily be
abnormal.

Motor behaviour
These are externally observable behaviours that
depict aspects of psyche, for example impulses,
motivations, drive, instincts and wishes. They
may be observed in all forms of mental illness and
include:
Echopraxia: imitation of one persons
movements by another.
Catatonia: abnormalities in motor functioning
as may be seen in schizophrenia.
Catalepsy: a position maintained for a long
time.
Catatonic excitement: purposeless motor over
activity, which sets on suddenly as may be
seen in schizophrenic patients.
Negativism: resistance to efforts to move on
for no reason
Cataplexy: sudden temporary loss of muscle
tone
Mannerism: habitual involuntary movement
and attitudes.
Mutism: voicelessness without an underlying
organic pathology
Akathisia: subjective feeling of restlessness
and the need to keep on moving; usually an
adverse effect of antipsychotic treatment.
Compulsion: an uncontrollable urge to perform
an act repeatedly.

Disorders of content of thought


Delusion
False unshakable belief not consistent with the
persons intelligence or cultural belief. Various
types of delusions occur with different illnesses
e.g. delusions of grandeur in manic patients,
anhedonia in depression, and delusions of control
in schizophrenia. There are different types of
delusions:
Persecutory: paranoid
Reference: that objects, people or events have
a special signicance to the patient
Grandiose or expansive: exaggerated selfimportance, ability, wealth, associations with
important people
Guilt or worthlessness
Nihilistic: patient believes he does not exist,
extreme pessimism
Hypochondriac: belief in ones illness contrary
to all medical evidence

Thought
Thinking can be described as a goal-directed ow
of ideas, symbols and associations leading to
reality-oriented conclusion. Thinking is said to be
normal when a logical sequence occurs.

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Psychopathology

Religious: special relation with God.


Jealousy: doubt about the delity of the sexual
partner

Sexual or amorous delusion (love delusions)


also called de Clerambaults syndrome
Delusions of alienation.

Table 30.1
DSM-IV-TR Denition of Delusion and Certain Common Types Associated with Delusional
Disorders
Delusion A false belief based on incorrect inference about external reality that is rmly sustained despite
what almost everyone else believes and despite what constitutes incontrovertible and obvious proof of
evidence to the contrary. The belief is not one ordinarily accepted by other members of the persons culture
or subculture (e.g., it is not an article of religious faith). When a false belief involves a value judgment, it is
regarded as a delusion only when the judgment is so extreme as to defy credibility. Delusional conviction
occurs on a continuum and can sometimes be inferred from an individuals behavior. It is often difcult to
distinguish between a delusion and an overvalued idea (in which case the individual has an unreasonable
belief or idea but does not hold it as rmly as is the case with a delusion). Delusions are subdivided
according to their content.: Some of the more common types are listed below:
BizarreA delusion that involves a phenomenon that the persons culture would regard as totally
implausible.
Delusional jealousy The delusion that ones sexual partner is unfaithful.
ErotomanicA delusion that another person, usually of higher status, is in love with the individual.
GrandioseA delusion of inated worth, power, knowledge, identity, or special relationship to a deity or
famous person.
Mood-congruent(Dened below)
Mood-incongruent(Dened below)
Of being controlledA delusion in which feelings, impulses, thoughts, or actions are experienced as
being under the control of some external force rather than being under ones own control:
Of referenceA delusion whose theme is that events, objects, or other persons in ones immediate
environment have a particular and unusual signicance. These delusions are usually of a negative or
pejorative nature, but also may be grandiose in content. This differs from an idea of reference, in which the
false belief is not as rmly held nor as fully organized into a true belief.
PersecutoryA delusion in which the central theme is that one (or someone to whom one is close) is being
attacked, harassed, cheated, persecuted, or conspired against.
SomaticA delusion whose main content pertains to the appearance or functioning of ones body.
Thought broadcastingThe delusion that ones thoughts are being broadcast out loud so that they can be
pc others.
Thought insertionThe delusion that certain of ones thoughts are not ones own, but rather are inserted
into ones mind.
Mood-congruent psychotic featuresDelusions or hallucinations whose content is entirely consistent
with the typical themes of a depressed or manic mood. If the mood is depressed, the content of the delusions
or hallucinations would involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved
punishment. The content of the delusion may include themes of persecution if these are based on selfderogatory concepts such as deserved punishment. If the mood is manic, the content of the delusions
or hallucinations would involve themes of inated worth, power, knowledge, or identity, or a special
relationship to a deity or a famous person. The content of delusion may include themes of persecution if
these are based on concepts such as inated worth or deserved punishment.
Mood-incongruent psychotic featuresDelusions or hallucinations whose content is not consistent
with the typical themes of a depressed or manic mood. In the case of depression, the delusions or
hallucinations would not involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved
punishment. In the Case of mania, the delusions or hallucinations would not involve themes of inated
worth, power, knowledge, or identity, or a special relationship to a deity or a famous person. Examples of
mood-incongruent psychotic features include persecutory delusions (without self-derogatory or grandiose
content), thought insertion, thought broadcasting, and delusions of being controlled whose content has no
apparent relationship to any of the themes listed above
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

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Overvalued ideas

Sensory distortions

These are similar to delusions but less rmly


held and can therefore be reasoned away. They
can occur in normal persons undergoing stressful
experiences.

They arise from changes in intensity and quality


of the stimuli or the spatial form of the perception.
They include:

Disorders of control of thought (alienation)

Increase in intensity of sensation, also known as


hyperaesthesia. It may result from intense emotions
or lowering of the physiological threshold, thus
a patient may perceive a cow as a lion. These
disturbances may occur as a result of delirium states,
anxiety, and even in hypochondriacal states.

Changes in intensity

These are delusions of control of ones thoughts by


outside forces. They commonly occur in psychotic
disorders such as schizophrenia and include:
Thought withdrawal in which other people or
agents remove ones thoughts from the mind.
Thought insertion where other people or forces
are putting thoughts into ones mind against
their wish.
Thought broadcasting in which ones thought
is made known to others without being talked
out by the one thinking.

Changes in quality
These are visual distortions usually brought
about by effects of toxic substances which colour
perception. They are not hallucinations but
qualitative changes of perception caused by use of
a substance e.g. seeing green as blue following use
of alcohol.

Obsession

Changes in spatial forms

Pathological persistence of an irresistible thought


or feeling that cannot be eliminated from the mind
easily. The patient recognizes these as his own
thoughts, but he cannot get rid of them. This often
happens in obsessive-compulsive disorders.

This is also called dysmegalopsia and occurs in the


visual eld. The patient may see things as smaller
(micropsia) or bigger (macropsia or megalopsia)
than they actually are. These often result from
retinal diseases, disorders of accommodation
and temporal lobe lesions. Micropsia is also
called lilliputine hallucinations.

Phobia
A pathological irrational fear occurring in particular
situations and leading to avoidance of the feared
object or situation.

Sensory deceptions
These are divided into illusions and hallucinations.
Illusions arise from false interpretation of stimulus
and could be as a result of fantasy, intense emotions
and lack of perceptual clarity or disease.

Speech
This generally refers to the communication through
the use of words and language. It includes:
Pressure of speech: the patient talks a lot and
rapidly and it may be difcult to follow the
speech. It is common in manic states.
Poverty of speech: scanty speech as occurs in
psychomotor retardation or depression.
Dysarthria: difculty in articulation.
Aphasia: disturbances in speech outputmay
be motor or sensory.

Hallucination
This is a false sensory perception not associated
with real external stimuli. It may be in any of the
ve sensory modalities (visual, olfactory, auditory,
gustatory, touch). They should be differentiated
from vivid mental images which arise from ones
mind in an ordinary thinking process. Hallucinations
occur at the same time as normal perceptions. The
normal hallucinations include:
Hypnagogic hallucinations, which are false
perceptions that occur while waking up from
sleep.
Hypnagogic hallucinations that are false
perceptions that occur while falling asleep.
The abnormal hallucinations occur in mental illness
and include:

Perception
These can be divided into disorders of sensory
distortion and sensory deceptions. In distortions,
there is a real stimulus which is perceived in a
distorted way while in deception, perception occurs
without an external stimulus.

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Psychopathology

The hallucinations may be mood congruent in


which the content is consistent with the prevailing
mood. They may also be mood incongruent in
which the content is inconsistent with the mood
like it occurs in some schizophrenic patients.

Auditory hallucination in which the patient


hears a sound or a voice without any stimulus.
The voices may include music, animal sounds
or even conversations between people or
with the patient. They could be familiar or
unfamiliar to the patient and could also be
derogatory or pleasant. They are common in
psychotic disorders e.g. schizophrenia. The
different types of auditory hallucinations are:
o Third person hallucinations in which
voices talk among themselves about
the patient usually associated with
schizophrenia.
o Commentary voices a voice or voices
talking or describing what the patient is
doing or thinking.
o Second person hallucinations talking
directly to the patient. Depending on their
content they could be due to depression or
schizophrenia. In depression the patient
normally agrees with what the voices say
but in schizophrenia the patient normally
resents the voices.
Visual hallucinations involving sight of both
formed images e.g. people or unformed images
e.g. light. They occur commonly in medical
disorders affecting the CNS but may also be
present in psychotic patients.
Tactile hallucinations, which include false
perception of touch (haptic), surface sensation
as in amputated limb (phantom limb) or
even crawling sensation on or under the skin
(formication). These occur in substance abuse
as well as mental illnesses.
Olfactory and gustatory hallucinations are
common in medical conditions affecting the
CNS e.g. epilepsy.

Cognitive disturbances
Memory
This is most affected in medical illnesses that affect
the brain e.g. dementias and other degenerative
disorders. Para amnesias may also occur in some
patients going through stressful life experiences e.g.
bereavement and terminal illnesses or following
abuse of substances like alcohol. This presents
as an impairment of immediate, intermediate
or long-term memory and is clinically noticeable
as confabulation (unconscious lling up of lapses
in memory by made up experiences the patient
believes), dj vu or jamais vu.
Intelligence
This is the ability to constructively integrate and
utilise new information with previous experience.
It includes aspects of mathematical and language
abilities, abstraction and concrete thinking
and judgement-making abilities. These are
affected in mental retardation, dementias and in
psychotic disorders. They usually lead to patients
experiencing difculties in their workplace and
relationships.
Further Reading
1. Synopsis of Psychiatry: Behavioural Sciences Clinical
Psychiatry: 9th edition (2003): Editors: Benjamin J.
Saddock, Virginia Alcott Sadock. Lippincott Williams
& Wilkins

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31
Psychiatric Interview, Assessment and Classication
David M Ndetei, Francisca Ongecha-Owuor, John Mburu,
Benson Gakinya, Fikre Workneh

receive the full attention of the medical practitioner.


The sitting positions determine how the interview
proceeds and what is said during the interview.
To facilitate easy communication and to reduce
discomfort, the patient should sit at right angles to
the clinician with the distance between the patient
and the clinician permitting easy communication
without shouting and at the same time avoiding
the discomfort of close physical proximity. Some
practitioners advocate that there should be no table
between the patient and the clinician and that the
clinician should not wear a white gown, but these
are not universally practised.

THE PSYCHIATRIC INTERVIEW


The psychiatric interview is the most important
tool in psychiatry. It is used to understand the
patients problem, elicit signs and symptoms, make
appropriate diagnosis, initiate treatment and predict
outcome. The psychiatric interview offers patients
an opportunity to express themselves and others
in a non-critical and non-judgmental atmosphere.
It is based on a good working knowledge of
psychopathology and the principles of dynamic
psychiatry. The medical practitioner should know
what to ask, how to ask, when to ask and how to
interpret the response of the patient.
There are various reasons why a patient consults
a mental health worker. The individual may see
a mental health worker voluntarily because of
disturbing experiences or because of pressure from
the family, relatives, friends or employer. Others
may have been forced through the courts. Their
willingness to communicate varies depending on
the nature of the underlying illness and on the
circumstances under which they came to see the
medical worker.

General principles in psychiatric


interviews
Active observation and awareness of behaviour
This begins from the moment the patient walks into
the consultation room. The gait, physical appearance
and greetings, as well as the general attitude to the
interview are all important. The clinician should
focus on the verbal as well as the non-verbal
communication. Non-verbal communication
such as facial expressions, hesitancy during the
interview, absence of eye contact and constant
checking around the room, are all important cues.

The setting of the psychiatric interview

Assessment and evaluation is a two-way process

The setting of the interview should provide privacy


and assure condentiality. The patient should

While the medical worker is assessing the patient,


the patient is also evaluating the medical worker on

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Psychiatric Interview, Assessment and Classication

sensitivity and genuine desire to help. The patient


may not reveal a great deal about himself unless he
senses that the clinician is interested and concerned
about him. If, for instance, the medical worker
looks at his watch, it may give the impression that
he nds the patient boring. The best interview is one
where there is a good rapport and shared feelings of
mutual respect and understanding. The interviewer
has to develop the art of listening. Statements like
as I told you before are warning signals by the
patient that the medical worker is not paying full
attention.

example, they may end up suggesting it to the


patients. The important point is when and how
to ask such questions. When the patient is telling
the clinician his feeling of hopelessness, posing
a question such as Dont you think of suicide?
is not appropriate. It would be appropriate to ask,
When you feel so low, do you sometimes feel
that life is not worth living? and to proceed from
there.
The clinician should focus on feelings and
emotionally charged areas should be explored. At
times the patient may show resistance and these
should be kept in mind for further discussion later
in the interview or some other day. Sensitive topics
should be handled carefully and tactfully. It is best
to introduce them gradually. Many people, for
example, may nd it difcult to talk about their
sexual life. The clinician should show concern and
understanding for such feelings. Remarks such as
I know that most people nd it difcult to talk
about their sexual life, but I feel it is important that
you tell me something about your sexual life, may
encourage the patient to begin the discussion.

Acceptance of the behaviour of the patient


All behaviour including what appears at rst sight
as odd has a meaning to the patient. Such behaviour
may invite ridicule and laughter. The clinician
should accept such odd behaviour. Acceptance
does not, however, mean approving it.
Avoid arguments with the patient
Avoid getting drawn into an argument with the
patient. It may be the patients way of relating to
others or seeking help. The clinician should try to
nd the underlying relationship problems.

Focus on interpersonal relationships


When taking family history in general medicine,
the focus is mainly on the age of the parents and
siblings, their health and, if dead, the cause of
death. The emphasis is almost exclusively on
hereditary disease. In psychiatric interviews,
while due attention is given to these issues, the
important areas are the interpersonal sense of love,
acceptance, security and discipline. These facts
reveal the psychodynamic factors responsible in
shaping the personality of the patient.

Do not assume you understand the patient


At all times the clinician should make sure he
understands what the patient says or feels. Very
often what the patient expresses may be about
problems close to our own, for example, ordinary
feelings like depression. One has to nd the depth
of the depression, whether he cries, has feelings
of hopelessness and suicidal thoughts and the
presence or absence of associated symptoms, such
as change in appetite and weight, and disturbance
of sleep.
One method of clarifying ones thoughts of what
the patient says and feels, is for the clinician to
summarise a number of times during the interview
by repeating what the patient has said and the
feelings the patient has expressed. The patient can
correct the clinician if he has been misunderstood.

Avoid being moralistic or judgmental


Some patients may come to the interview, expecting
the worst with a great deal of anxiety or guilt.
That is one of the main reasons why people avoid
sharing their problems and feelings. The clinician
should avoid being moralistic or judgmental.
Show empathy

Stress on feelings

Empathy is direct identication with, understanding


of, and experience of another persons situation,
feelings and motives. Carl Roger denes empathy as
sensing the clients inner world of private personal
meaning as if it were your own, but without losing
the as if quality.

The feeling of the patient may be difcult for the


new clinician to understand. First, the beginner
may feel awkward and at a loss of what to do with
an outpouring of feelings, for example, crying
by the patient. The patient should be offered the
opportunity to unburden these feelings, which may
have a cathartic effect.
The second dilemma encountered by novices is
when a patient talks about suicidal feelings. For

Try to tolerate silence


The novice may nd it difcult when the patient
does not respond to the posed questions right away.

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The period of silence may be as a result of the


patient trying to sort out his thoughts, or the patient
may not wish to respond to that particular question,
probably due to the illness itself or feelings aroused.
Often the clinician may try to ll the silence with
more questions. Such an approach creates more
problems in the interview process.

THE PSYCHIATRIC
ASSESSMENT
The psychiatric history is obtained from the patient
as well as from the family, relatives or friends. This
is because in some cases the patient may not be
responsive or may be confused and in others the
history given by the patient may be inaccurate.
An alcoholic, for example, tends to conceal his
drinking or a schizophrenic patient may not reveal
his abnormal experiences, such as delusions or
hallucinations.
An accurate history and mental status
examination are the cornerstones of diagnoses
and treatment in psychiatry. The ndings should
be as comprehensive as possible and it should be
recorded systematically. Mental status examination
can be done in one session. The interviewer selects
an area that is essential as the interview proceeds.
In seriously sick, agitated or confused patients,
the observation of behaviour and a brief history may
be all that is required to begin treatment. A more
detailed history and mental status examination can
be obtained later from relatives or can wait until
the patient improves.
Clinical judgment, experiences and common
sense determines what to ask and the areas on
which to put emphasis. This ability to judge and
discriminate is acquired through experience
and knowledge of psychopathology. The art of
interviewing is rened and polished through
practice and by observation of more experienced
interviewers.

The stages in a psychiatric interview


The initial phase
This phase begins from the rst contact with the
patient. The clinician should greet the patient
and introduce himself. Both of them should sit
comfortably. The patient should be addressed
properly and correctly in keeping with traditional
norms, age, sex and social status.
Questions such as What was the reason you
wanted to see me? may open the interview. If the
patient was referred by another health worker, a
summary of the note may help start the interview.
Questions should be open-ended and simple.
Questions that begin with why are usually
difcult to answer, and create resistance, thus
should be avoided. The interviewer should also
avoid technical terms. The initial phase mainly
covers the patients illness.
The middle phase
This part of the interview focuses on the background
of the patient, his upbringing, family life,
educational and vocational life, and interpersonal
relationships, both past and present. The medical
practitioner tries to nd out the inuences of these
factors on personality and current problems of the
patient.

When do you write the psychiatric history?

Closing phase

It is best to write the entire history and mental


status examination at the end of the session. It is,
however, important to write down important points
like dates and the presence of psychopathological
symptoms during the interview, since one may not
recall all these later.

It is important to give the patient some minutes


before closing the interview to ask questions or
express the points that were not covered during
the interview. Questions such as, Before we nish
for the day, is there any question you wanted to
ask? or Are there points which you feel that you
wanted to discuss now?
This may open new areas for interview. The
patient may raise points already discussed showing
the areas of his particular concern. It is important
to discuss the patients areas of concern and the
feelings associated with it.

When do you interview the family?


In severely disturbed patients, it is important to
involve the family during the initial interview. A
great deal of information may be obtained from the
family, which may not be readily available from
the patient.

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Psychiatric Interview, Assessment and Classication

or extended family? In the latter, grandparents or


other members of the family may play an important
role. For each family member it is important to
note the name, age, sex, marital status, occupation,
and their relationship, past and present, with the
patient, and state their current health condition. If
dead, the age at time of death and cause of death
should be enquired. Find out if the parents or any
of the siblings are partially or totally economically
dependent on the patient and how he feels about
it. Find out if there is any family history of mental
illness among the nuclear and extended family.

Components of the psychiatric history


Identifying data
The name, age, sex, marital status, residence,
religion and occupation of the patient need to be
clearly noted down.
The referral system
Note the sources of referral, whether by a health
worker, brought by family members or self accord,
indicating the main reasons for referral.
Chief complaint

Personal history

The chief complaint is a brief statement of why the


patient seeks help. It should contain the description
of the problem and should be stated in the patients
own words. Where a patient does not see himself
as needing help or in the case of a patient being
unable or unwilling to speak, the chief complaint
can be obtained from relatives. The source should
be recorded.

The past period of the life of the patient should be


reviewed. The aim is to obtain a comprehensive
picture of the patient and to nd out factors in his
past which may explain his psychological make-up,
personality and present problems. Since it is neither
possible nor practical to cover all the past personal
history, more detailed early developmental history
may be necessary in children than in adults. The
personal history may be divided into the following
periods:

History of present illness


The patients problems are explored in detail and
in chronological order. It starts from the time when
the patient started feeling discomfort, which may
predate on his social interactions with others both
at home and work, its consequences on his family
life and his occupation are investigated. Other
symptoms associated with the chief complaints
are documented in this section. The present illness
should contain the psychosocial stress factors in
the life of the patient, as well as physical illness
and their time relationship with the presenting
symptoms.
It may not be possible to get all the details of
the present illness in one session. There may also
be gaps in the history of the patient or his relatives
may not provide a chronological narration of the
present illness. The psychiatrist needs to organise
the history in such a way that one reading it can get
a good picture of the illness.

Pregnancy, birth and early development up to


around 6 years
The interviewer should ask the following
questions:
Was the pregnancy unwanted, or out of
wedlock and what were the consequences on
the relationship of mother and child and other
members of the family?
Was there any problem during pregnancy and
delivery?
Was it an extended or nuclear family? In
the case of an extended family, who in the
family was closely attending to the patients
needs? The interpersonal relationship of the
individuals in the family unit, its cohesiveness,
and the socio-economic situation of the family
should be investigated.
Have there been signicant incidents in the
family like separation, divorce, illness and
death of signicant people? Was there any
problem with separation and socialisation?
How was the performance at school? Were
there any early neurotic traits like nail biting
or thumb sucking?
This section tries to understand the early childhood
developmental stages of the patient, and whether
needs were met or frustrated.

Past psychiatric and medical illnesses


This contains the physical and emotional illnesses
of the patient in the past, the type of investigation
and their results, diagnoses, treatment received and
outcome of such interventions.
Family history
The components of the family history depend on the
type of family and its composition. Is it a nuclear

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Six years to puberty

with sexual problems, a detailed sexual history is


necessary. The patients attitude towards sex, the
sexual partners, sexual experiences in the past, its
frequency, the moral and religious attitude of the
patient and the feelings associated with it, are areas
to evaluate.

This section focuses on the individuals sense


of identity, participation in structured activities,
whether they like school, their school performance,
type of discipline and attitude towards authority
(both at home and in school), peer group activities
and its inuence on the patient, as well as coping
mechanisms.

Mental status examination


Inevitably, there is bound to be an overlap in what
is recorded in the present illness and the ndings
of the mental status examination. A great deal of
the mental status examination is obtained during
the interview about the present illness. In some
cases information on delusions or hallucinations
may not be readily obtained from the patient.
Such information, however, may be obtained from
relatives. Sometimes the patient may reveal such
information only after treatment and following
improvement. In order to avoid pitfalls in reporting
psychopathology the interviewer should be familiar
with culturally accepted beliefs, which may appear
to be a delusion or hallucination. The following
outline is generally accepted in reporting mental
status examinations ndings:

Adolescence to 19 years
This is a period of heightened sexual awareness. The
onset of puberty for girls and rst menstruation and
the reactions to it are important. Did the girl have
any pre-knowledge about it? In some societies the
girls may have been married or betrothed before
menarche. Boys are concerned about sexual matters
and masturbation related anxiety and worry about
physical as well as mental illnesses. In the older
ones a sense of guilt, school achievements, social
relationship both at home and in school with other
students and teachers should be explored. What are
the patients professional interests and future goals,
involvement in any extra-curricular activities?
Daily activities and social contacts are explored for
the patient who did not go to school.

General appearance
Note the grooming, posture, gait, physical
characteristics, facial expression, eye contact,
motor activity and specic mannerisms. Note the
state of awareness or consciousness, drowsiness,
clouding of consciousness, stupor, delirium,
eeting consciousness and coma.

Occupational history
The age and which work the patient rst engaged
in, any income generating activity or employment,
the nature of work, social and occupational
relationships, job satisfaction, growth and
improvement or deterioration in the job are
considered. Repeated absenteeism from work or
deterioration of work activity, for example, may
indicate alcoholism, depression or schizophrenia.

Speech
Note the rate, pitch, volume, clarity, speech
abnormalities, such as dysarthria.

Marital history

Mood

The interviewer should ask the age when the


patient got married, whether the marriage was a
personal decision or arranged by the family, and
the individuals feelings towards the marriage. If
the decision was a personal one, a negative reaction
to the marriage by one or both families may have
a signicant impact. The health and personality of
the marriage partner plays an important role in the
relationship, so does the religion if different from
the partners. The birth dates of children, their
health and educational achievements are assessed.

Mood refers to expression of emotion, which is


subjective, while affect is objective. Note the
variability or range, intensity and appropriateness.
Emotion is a complex state with psychic, somatic
and behavioural aspects. Mood would be described
as dysphoric, euthymic, expansive, irritable,
labile, elevated, euphoric, ecstatic, depressive
or anhedonic. Affect is said to be appropriate or
inappropriate, blunted, restricted, at or labile.
In some cases the patient may have difculty
expressing feelings or emotions referred to as
alexithymia.

Sexual history
Extra care is necessary in interviewing patients
about their sexual life. The medical practitioner
should try to elicit information without
embarrassing the patient. If the patient presents

Thoughts
Two components of thoughts are assessed: the
thought process and thought content. Thought
process, includes the ow of ideas and quality
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Psychiatric Interview, Assessment and Classication

of associations: the process of thinking should


include rate and ow of ideas. Thoughts can
be racing or totally slowed down. There may be
circumstantiality, blocking or perseveration as
occurs in schizophrenia. Thought broadcasting and
insertion are pathognomic features of schizophrenia.
Associations dened as the relationships between
ideas can be exhibited by loosening, ight of ideas,
neologisms, word salad or echolalia.
Thought
content
includes
distortions,
delusions, ideas of reference, depersonalisation,
derealisation,
preoccupations,
obsessions,
phobias, somatic concerns, suicidal or homicidal
ideation. In suicidal and homicidal ideation the
interviewer needs to assess the thoughts, plans,
feelings, and potential for actions and deterrents
to action.

subtracting 7 from 100 (serial seven) up to 65 or


3 from 20 (serial three) or by means of simple
problems.

Perception

Intelligence

Enquiries about perceptual disturbances require


careful approach and should evaluate the
presence or absence of illusions, hallucinations,
depersonalisation, or derealisation. Hallucinations
should focus on all the ve sense organs (sight,
hearing, taste, touch and smell) involved, with
their contact, frequency and circumstances of their
occurrence recorded.

Determine the general level of intelligence


compared with his level of education, and social
and cultural background vis-a-vis the mental
age. This can be objectively assessed using the
intelligence quotient (IQ).

Memory
Memory is assessed in three categories, immediate
(recall), recent and remote. Immediate memory,
which pertains to retention and recall involves
events occurring in the last few seconds to minutes,
can be assessed by giving the patient telephone
numbers with 5 to 6 digits and asking them to
repeat. Recent memory is hours to 2-3 days, thus
involves asking patients what they ate for breakfast
or where they were in the last few days. Remote
memory involves past years events. Important
family or historic dates in the patients sociocultural context may be used.

Judgement
Does the patient understand the harmful
consequences of his behaviour to himself, the
family and community? Would the patient make
wise decisions, for example, in case of re,
drowning or any life-threatening situation?

Cognitive functions
Sensorium
Disturbance of consciousness usually denotes
organic brain conditions. Determine the level of
consciousness and any uctuations if present. This
may range from mild clouding of consciousness
to stupor or coma.

Insight
The awareness of the patient about his illness
and its implication varies depending on whether
the patient is psychotic or non-psychotic. The
psychotic is said to have insight if he realises that
he is sick and that his delusions and hallucinations
are normal experiences. A neurotic, on the other
hand, is said to have insight if he understands that
his symptoms are due to environmental factors or
internal emotional causes.

Orientation
This is to check if the patient knows the time, place
and person. Does the patient know the time of day,
day of the week, month and year? The responses
expected are determined by the social and cultural
background of the patients. For place, ask about
familiar places. For person, ask about his name,
age, names of children, parents and siblings. These
should be counter-checked with family members.

MINI-MENTAL STATUS
EXAMINATION

Attention and concentration


Naming three objects to the patient or giving a
telephone number which the patient is told to repeat
after the interviewer can assess whether they are
attentive. By this time in the interview process one
can gauge a patients attention span by how they
answer the questions and their participation in the
whole process. On the other hand, concentration
can be determined using simple calculations like

The Mini-Mental Status Examination questionnaire


can be used in surveys as well as in clinical practice
by clinicians as well as trained non-mental health
workers. It can differentiate organic mental illness
from non-organic mental illness easily. Before
anybody can use it they need to be trained by an
experienced user. It tests for:

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Orientation:
o Place: name of place where the clinical
setting is located, town, country and
region
o Time: year, month, date, day of the week,
season of the year
Registration of names of three objects
Attention and calculation - the 7 from 100
series up to 65
Recall of the three objects
Language: confrontation naming, repetition,
comprehension of simple instructions, reading
and performing and sentence construction,
Construction of simple designs.
It is however critical that such instruments be
locally adopted and validated.
Finally physicals are done. Investigations are
ordered depending on the history and ndings on
the physicals.

Has he received any treatment in the past


and what were the outcomes? Knowledge
of the kind of procedures and examinations
performed, the diagnoses made, treatments
given and the outcome of treatment will save
unnecessary extra expenditure of time and
money.
To facilitate decision-making in psychiatric
diagnosis, the following decision tree could be used:
the rst important decision to make is whether the
patient is psychotic or not. This is because it is more
urgent to treat a psychotic patient. If psychotic, it is
further differentiated into organic and non-organic
and into the different sub-divisions in the decision
tree. Such a decision is based on knowledge of
psychopathology, the psychiatric history and
the mental status examination results. The same
principle applies in the non-psychotic condition.

SUMMARY, FORMULATION AND


DECISION-MAKING

Classication in psychiatry attempts to bring


some order into the great diversity of phenomena
encountered in clinical practice. It enables health
professionals to communicate easily about the
nature of a patients problem, prognosis and
treatment. There are two main sets of classication
used in psychiatry:
The International Classication of Diseases,
version 10 (ICD 10) -- chapter V by the World
Health Organisation (WHO)
The Diagnostic and Statistical Manual for
Mental Disorders, fourth edition (DSM-IV
TR).
These two classications only deal with the major
psychiatric illnesses. The DSM-IV TR takes a
holistic approach, hence the biopsychosocial
model. In this book the DSM-IV TR classication
has been adopted. Its multiaxial approach is
described in detail below.

PSYCHIATRIC CLASSIFICATION

All the signicant ndings from the interview, mental


status examination, physical ndings and other
tests are summarised and evaluated. The nal goal
is to make a diagnosis and differential diagnosis to
treat the patient and also predict the outcome with
or without intervention. The formulation should try
to answer the following questions:
Who is this person? This section tries to
assess his upbringing, the signicant events
and conicts in the life of the patient, about
his likes and dislikes and how he deals with
people and situations.
Why is he seeking help now? Included in this
section are the summary of the reasons for
seeking help, the present illness and mental
status ndings. In some cases the problem has
existed for a long time. The reason for seeking
help may be due to a pressing life situation. An
alcoholic may seek help, because of a pending
divorce or the threat of losing his job.
Who are the signicant people in his life?
This deals with the human relationships past
and present.

MULTIAXIAL ASSESSMENT3
A multiaxial system involves an assessment on
several axes, each of which refers to a different
domain of information that may help the clinician
plan treatment and predict outcome. There are

This account is adopted from and reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (Copyright 2000). American Psychiatric Association.

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Psychiatric Interview, Assessment and Classication

environmental problems, and level of functioning


that might be overlooked if the focus were on
assessing a single presenting problem. The
multiaxial system promotes the application of
the biopsychosocial model in clinical, educational
and research settings.

ve axes included in the DSM-IV multiaxial


classication:
Axis I:
Clinical Disorders
Other Conditions That May Be a
Focus of Clinical Attention
Axis II:
Personality Disorders
Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental
Problems
Axis V:
Global Assessment of Functioning
The use of the multi-axial system facilitates
comprehensive and systematic evaluation with
attention to the various mental disorders and
general medical conditions, psycho-social and

Axis I: Clinical Disorders


Other Conditions That May Be a Focus of
Clinical Attention
Axis I is for reporting all the various disorders
or conditions in the Classication except for
Personality Disorders and Mental Retardation
(which are reported on Axis II). Also reported on
Axis I are Other Conditions That May Be a Focus
of Clinical Attention.

Table 31.1
Axis I
Clinical Disorders
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
(excluding Mental Retardation, which is diagnosed on Axis II)
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Mental Disorders Due to a General Medical Condition
Substance-Related Disorders
Schizophrenia and Other Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual and Gender Identity Disorders
Eating Disorders
Sleep Disorders
Impulse-Control Disorders Not Elsewhere Classied
Adjustment Disorders
Other Conditions That May Be a Focus of Clinical Attention
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Axis II: Personality Disorders

When an individual has more than one Axis I


disorder, all of these should be reported. If more
than one Axis I disorder is present, the principal
diagnosis or the reason for visit should be indicated
by listing it rst. When an individual has both
an Axis I and an Axis II disorder, the principal
diagnosis or the reason for visit will be assumed to
be on Axis I unless the Axis II diagnosis is followed
by the qualifying phrase (Principal Diagnosis)
or (Reason for Visit). If no Axis I disorder is
present, this should be stated. If an Axis I diagnosis
is deferred, pending the gathering of additional
information, this should also be stated.

Mental Retardation
Axis II is for reporting Personality Disorders
and Mental Retardation. It may also be used for
noting prominent maladaptive personality features
and defence mechanisms. When an individual has
both an Axis I and an Axis II diagnosis and the
Axis II diagnosis is the principal diagnosis or the
reason for visit, this should be indicated by adding
the qualifying phrase (Principal Diagnosis) or
(Reason for Visit) after the Axis II diagnosis.

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Table 31.2
Axis II
Personality Disorders
Mental Retardation
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder

Dependent Personality Disorder


Obsessive-Compulsive Personality Disorder
Personality Disorder Not Otherwise
Specied
Mental Retardation

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Some general medical conditions may not


be directly related to the mental disorder but
nonetheless have important prognostic or
treatment implications
The choice of pharmacotherapy is inuenced
by the general medical condition
When a person with diabetes mellitus is
admitted to the hospital for an exacerbation of
schizophrenia, then insulin management must
be monitored.
When an individual has more than one clinically
relevant Axis III diagnosis, all should be reported.

Axis III: General Medical Conditions


This is for reporting current general medical
conditions that are potentially relevant to the
understanding or management of the individuals
mental disorder. The purpose of distinguishing
general medical conditions is to encourage
thoroughness in evaluation and to enhance
communication among health care providers.
General medical conditions can be related to mental
disorders in a variety of ways. In some cases it is
clear that the general medical condition is directly
aetiological to the development or worsening of
mental symptoms and that the mechanism for this
effect is physiological. When a mental disorder is
judged to be a direct physiological consequence of
the general medical condition, a Mental Disorder
Due to a General Medical Condition should be
diagnosed on Axis I and the general medical
condition should be recorded on both Axes I and
III.
In those instances in which the aetiological
relationship between the general medical condition
and the mental symptoms is insufciently clear to
warrant an Axis I diagnosis of Mental Disorder Due
to a General Medical Condition, the appropriate
mental disorder (e.g. Major Depressive Disorder)
should be listed and coded on Axis I; the general
medical condition should only be coded on Axis
III.
There are other situations in which general
medical conditions are recorded on Axis III because
of their importance to the overall understanding
or treatment of the individual with the mental
disorder:
An Axis I disorder may be a psychological
reaction to an Axis III

Axis IV: Psychosocial and Environmental


Problems
Axis IV is for reporting psychosocial and
environmental problems that may affect the
diagnosis, treatment, and prognosis of mental
disorders (Axes I and II). So-called positive
stressors, such as job promotion, should be listed
only if they constitute or lead to a problem, as when
a person has difculty adapting to the new situation.
In addition to playing a role in the initiation or
exacerbation of a mental disorder, psychosocial
problems may also develop as a consequence of
a persons psychopathology or may constitute
problems that should be considered in the overall
management plan.
When an individual has multiple psychosocial
or environmental problems, the health worker
may note as many as are judged to be relevant. In
general, only those psychosocial and environmental
problems that have been present during the year
preceding the current evaluation should be noted.
However, the health worker may choose to
note psychosocial and environmental problems

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Psychiatric Interview, Assessment and Classication

information is useful in planning treatment and


measuring its impact and in predicting outcome.
The reporting of overall functioning on Axis V can
be done using the Global Assessment of Functioning
(GAF) Scale given below. The GAF Scale is useful
in tracking the clinical progress of individuals in
global terms, using a single measure. The GAF
Scale is rated with respect to psychological, social,
and occupational functioning. The instructions
specify, Do not include impairment in functioning
due to physical (or environmental) limitations.
The GAF scale is divided into 10 ranges of
functioning. Making a GAF rating involves picking
a single value that best reects the individuals
overall level of functioning. The description of
each 10-point range in the GAF scale has two
components: the rst part covers symptom severity,
and the second part covers functioning. The
GAF rating is within a particular decile if either
the symptom severity or the level of functioning
falls within the range. For example, the rst part
of the range 41-50 describes serious symptoms
(e.g., suicide). In situations where the individuals
symptom severity and level of functioning are
discordant, the nal GAF rating always reects
the worse of the two. For example, the GAF rating
for an individual who is a signicant danger to self
but is otherwise functioning well would be below
20. Similarly, the GAF rating for an individual
with minimal psychological symptomatology
but signicant impairment in functioning (e.g. an
individual whose excessive preoccupation with
substance use has resulted in loss of job and friends
but no other psychopathology) would be 40 or
lower.
In most instances, ratings on the GAF scale
should be for the current period (i.e., the level of
functioning at the time of the evaluation) because
ratings of current functioning will generally reect
the need for treatment or care. In order to account
for day-to-day variability in functioning, the
GAF rating for the current period is sometimes
operationalised as the lowest level of functioning
for the past week. In some settings, it may be
useful to note the GAF scale rating both at time
of admission and at time of discharge. The GAF
Scale may also be rated for other time periods (e.g.,
the highest level of functioning for at least a few
months during the past year). The GAF Scale is
reported on Axis V as follows: GAF = , followed
by the GAF rating from 0 to 100, followed by the
time period reected by the rating in parentheses.
For example, (current), (highest level in past
year), (at discharge).

occurring prior to the previous year if these clearly


contribute to the mental disorder or have become a
focus of treatment.
In practice, most psychosocial and environmental
problems will be indicated on Axis IV. However,
when a psychosocial or environmental problem is
the primary focus of clinical attention, it should
also be recorded on Axis I.
For convenience, the problems are grouped
together in the following categories:
Problems with primary support groupdeath
of a family member; health problems in the
family; disruption of family by separation,
divorce, or estrangement; removal from the
home, remarriage of parent; sexual or physical
abuse; parental overprotection; neglect of
child; inadequate discipline; discord with
siblings; birth of a sibling
Problems related to the social environment
death or loss of a friend; inadequate social
support; living alone; difculty with
acculturation; discrimination; adjustment to
life-cycle transition (such as retirement)
Educational problemsilliteracy; academic
problems; discord with teachers or classmates;
inadequate school environment
Occupational
problemsunemployment;
threat of job loss; stressful work schedule;
difcult work conditions; job dissatisfaction;
job change; discord with boss or co-workers
Housing problemshomelessness; inadequate
housing; unsafe neighbourhood; discord with
neighbours or landlord
Economic
problemsextreme
poverty;
inadequate nances; insufcient welfare
support
Problems with access to health care services
inadequate health care services; transportation
to health care facilities unavailable; inadequate
health insurance
Problems related to interaction with the
legal system, crimearrest; incarceration;
litigation; victim of crime
Other psychosocial and environmental
problemsexposure to disaster, war, other
hostilities; discord with non-family caregivers
such as counsellor, social worker or physician;
unavailability of social service agencies.

Axis V: Global Assessment of Functioning


Axis V is for reporting the clinicians judgment of
the individuals overall level of functioning. This

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The African Textbook of Clinical Psychiatry and Mental Health

with life, no more than everyday problems or


concerns (e.g., an occasional argument with family
members).
80-71 If symptoms are present, they are
transient and expected reactions to psychosocial
stressors (e.g., difculty concentrating after
family argument); no more than slight impairment
in social, occupational or school functioning (e.g.,
temporarily falling behind in schoolwork).
70-61 Some mild symptoms (e.g., depressed
mood and mild insomnia) or some difculty in
social, occupational or school functioning (e.g.,
occasional truancy, or theft within the household),
but generally functioning pretty well, has some
meaningful interpersonal relationships.
60-51 Moderate symptoms (e.g., at affect and
circumstantial speech, occasional panic attacks)
or moderate difculty in social, occupational, or
school functioning (e.g., few friends, conicts with
peers or co-workers).
50-41 Serious symptoms (e.g., suicidal ideation,
severe obsessional rituals, frequent shoplifting) or
any serious impairment in social, occupational,
or school functioning (e.g., no friends, unable to
keep a job).
40-31 Some impairment in reality testing or
communication (e.g., speech is at times illogical,
obscure, or irrelevant) or major impairment
in several areas, such as work or school, family
relations, judgment, thinking, or mood (e.g.,
depressed, avoids friends, neglects family, and is
unable to work; child frequently beats up younger
children, is deant at home, and is failing at
school).
30-21 Behaviour is considerably inuenced by
delusions or hallucinations or serious impairment
in communication or judgment (e.g., sometimes
incoherent, acts grossly inappropriately, suicidal
preoccupation) or inability to function in almost all
areas (e.g., stays in bed all day; no job, home or
friends).
20-11 Some danger of hurting self or others
(e.g., suicide attempts without clear expectation
of death; frequently violent; manic excitement) or
occasionally fails to maintain minimal personal
hygiene (e.g., smears faeces) or gross impairment
in communication (e.g., largely incoherent or
mute).
10-1 Persistent danger of severely hurting self
or others (e.g., recurrent violence) or persistent
inability to maintain minimal personal hygiene
or serious suicidal act with clear expectation of
death.

In order to ensure that no elements of the GAF


scale are overlooked when a rating is being made,
the following method may be applied:
STEP 1: Starting at the top level, evaluate each
range by asking is either the individuals
symptom severity or level of functioning
worse than what is indicated in the range
description?
STEP 2: Keep moving down the scale until the
range that best matches the individuals
symptom severity or the level of
functioning is reached, whichever is
worse.
STEP 3: Look at the next lower range as a doublecheck against having stopped prematurely. This range should be too severe
on both symptom severity and level of
functioning. If it is, the appropriate range
has been reached (continue with step 4).
If not, go back to step 2 and continue
moving down the scale.
STEP 4: To determine the specic GAF rating
within the selected 10-point range,
consider whether the individual is
functioning at the higher or lower end of
the 10-point range. For example, consider
an individual who hears voices that do not
inuence his behaviour (e.g., someone
with long-standing schizophrenia who
accepts his hallucinations as part of his
illness). If the voices occur relatively
infrequently (once a week or less), a rating
of 39 or 40 might be most appropriate.
In contrast, if the individual hears voices
almost continuously, a rating of 31 or 32
would be more appropriate.

Global Assessment of Functioning (GAF)


Scale
This gives a score that ranges from a possible
maximum of 100 to a possible 0 as indicated
below.

Code
100-91 Superior functioning in a wide range of
activities, lifes problems never seem to get out of
hand, is sought out by others because of his many
positive qualities. No symptoms.
90-81 Absent or minimal symptoms (e.g., mild
anxiety before an exam), good functioning in all
areas, interested and involved in a wide range of
activities, socially effective, generally satised

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Psychiatric Interview, Assessment and Classication

Non-axial format

Throughout this book the DSM-IV-TR


classication is used, with permission from the
American Psychiatric Association. The DSM-IVTR Code numbers, where such codes are in use,
are reproduced in the tables.

Health workers who do not wish to use the


multiaxial format may simply list the appropriate
diagnoses. Those choosing this option should
follow the general rule of recording as many
co-existing mental disorders, general medical
conditions, and other factors as are relevant to the
care and treatment of the individual. The Principal
Diagnosis or the Reason for Visit should be listed
rst.

Further reading
1. Concise Textbook of Clinical Psychiatry Second
Edition:Derived from Kaplan & Sadocks Synopsis
of Psychiatry, 9th Edition. (2004) Editors: Benjamin J.
Sadock & Virginia A. Sadock Published by Lippincott
Williams & Wilkins
2. Diagnostic and Statistical Manual Disorders Fourth
Edition (2000): DSM-IV-TRTM Published by American
Psychiatric Association

0 Inadequate information.
Note: Use intermediate codes when appropriate,
e.g., 45, 68, 72.

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The African Textbook of Clinical Psychiatry and Mental Health

32
Somatoform and Dissociative Disorders
Nora M. Hogan, David M. Ndetei, Gad Kilonzo, Richard Uwakwe

The current classication of somatoform disorders


reects recent historical changes in the theoretical
understanding of somatisation and dissocation.
Prior to the third edition of DSM in 1980, all
mental disorders that were considered to be
forms of somatoform were grouped together.
Since 1980, the term hysteria has been dropped
from DSM-IV/ICD-10 and the terms conversion
and dissociation used to distinguish conditions
with physical (sensorimotor disturbances) and
mental (disturbance of cognition and awareness)
symptoms, respectively.
Somatoform disorders are characterised by
physical complaints that appear to be medical
in origin, but cannot be explained in terms of a
physical disease, the results of substance abuse, or
by another mental disorder. In order to meet DSMIVs criteria for a somatoform disorder, the physical
symptoms must be serious enough to interfere with
the patients employment, relationships, or other
areas of functioning, and must be symptoms that
are not under the patients control. These disorders
are classied as follows (DSM IV-TR):

Somatisation Disorder (SD)

Hypochondriasis

Conversion Disorder

Body Dysmorphic Disorder

Pain Disorder.

DIAGNOSIS
As these disorders are associated with physical
symptoms. Patients are often diagnosed in a
general medical clinic and are referred to mental
health workers after a long process of unnecessary
surgery, laboratory tests, or other treatments.
Accurate and efcient diagnosis of somatoform
disorders is important and essentially requires:
A medical work-up: a thorough physical
work-up to exclude medical and neurological
conditions, or to assess their severity.
Comorbidity: in addition to ruling out medical
causes, a medical worker who is evaluating a
patient for a somatoform disorder will consider
the possibility of other psychiatric diagnoses
or of overlapping psychiatric disorders.

EPIDEMIOLOGICAL SURVEYS
Clinical and epidemiological surveys over the past
two decades suggest that acute forms of somatoform
disorders are invariably present in all primary care
settings. Prevalence rates and sex ratios vary. In
most somatoform disorder categories, a female
preponderance exists and onset can be as early as
childhood, adolescence or early adulthood.

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Somatoform and Dissociative Disorders

MORTALITY AND MORBIDITY

misdiagnosed as suffering from a medical condition


and suffer iatrogenic complications due to invasive
diagnostic procedures or surgical operations.

Somatoform disorders do not appear to


independently increase the risk of death. However,
patients with somatoform disorders may be

SOMATISATION DISORDER

Table 32.1
300.81 Somatisation Disorder
A.

B.

C.

D.

A history of many physical complaints beginning before age 30 years that occur over a period of several years
and result in treatment being sought or signicant impairment in social, occupational, or other important areas
of functioning.
Each of the following criteria must have been met, with individual symptoms occurring at any time during the
course of the disturbance:
(1) four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head,
abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or
during urination)
(2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g.,
nausea, bloating, vomiting other than during pregnancy, diarrhoea, or intolerance of several different
foods)
(3) one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g.,
sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding,
vomiting throughout pregnancy).
(4) one pseudoneurological symptom: a history of at least one symptom or decit suggesting a neurological
condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis
or localised weakness, difculty swallowing or lump in throat, aphonia, urinary retention, hallucinations,
loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such
as amnesia; or loss of consciousness other than fainting)
Either (1) or (2):
(1) after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known
general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
(2) when there is a related general medical condition, the physical complaints or resulting social or occupational
impairment are in excess of what would be expected from the history, physical examination, or laboratory
ndings
The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering).

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 32.2
300.82 Undifferentiated Somatoform Disorder
A.
B.

C.
D.
E.
F.

One or more physical complaints (e.g., fatigue, loss of appetite, gastrointestinal or urinary complaints).
Either (1) or (2):
(1) after appropriate investigation, the symptoms cannot be fully explained by a known general medical
condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
(2) when there is a related general medical condition, the physical complaints or resulting social or occupational
impairment is in excess of what would be expected from the history, physical examination, or laboratory
ndings
The symptoms cause clinically signicant distress or impairment in social, occupational, or other important
areas of functioning.
The duration of the disturbance is at least 6 months.
The disturbance is not better accounted for by another mental disorder (e.g., another Somatoform Disorder,
Sexual Dysfunction, Mood Disorder, Anxiety Disorder, Sleep Disorder, or Psychotic Disorder).
The symptom is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

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The African Textbook of Clinical Psychiatry and Mental Health

lowered self-esteem, guilt and hopelessness),


may need to be elicited.
Hyperventilation occurs in about 60 percent of
patient with panic attacks and it is important to
note its diverse somatic manifestations.
Personality disorders may predispose a person
to amplify somatic symptoms.
Abnormal psychosocial situation or stressors
need to be evaluated.
Patients belief or perception about physical
symptoms may need to be explored.
Existence of any abnormal hostility towards
medical workers who have previously treated
the patient may need to be dealt with.
There may be co-morbid substance abuse.
In assessment it is important to:
Pay attention to certain aspects of the clinical
history especially, somatic complaints that
may have occurred during periods of adversity
or life change.
Enquire about parental illness especially during
the patients formative years and its effect on
the patient (parent able or unable to care for the
patient).
Physical illness and hospitalisation in childhood
can have an enduring psychological effect,
especially if it is accompanied by parental overconcern and injudicious advice from doctors
(leading to long absences from school).
In taking history of current physical symptoms,
it is important to take note of what was going
on in the patients life at the time.

Epidemiology
Based on the most restrictive DSM-1V criteria SD
is relatively rare with prevalence rates as low as
0.1 percent. Lifetime prevalence rates for women
may be as high as 2 percent. Lifetime prevalence
rates among men maybe as low as 0.2 percent. The
disorder is more common in rural areas and among
the educationally deprived.
A study in Belgium reported that somatisation
syndrome is the third highest psychiatric disorder,
with a prevalence rate of 8.9 percent. The rst and
second most common psychiatric disorders were
depression and anxiety disorders.
Sex ratios
There may be a ratio as high as 20 females to every
1 male.
Onset
The average age of onset is 15 years and the
condition generally becomes full blown by the
early 20s and then slowly and gradually improves,
such that after the age of 40, it has settled down to,
perhaps, less than 50 percent of what it was in the
early 20s. New onset of unexplained SD in older
adults should prompt a search for occult medical
illness or evidence of major depression associated
with somatisation.

Aetiology
The aetiology of somatisation and SD is not only
multi-factorial, but also exceedingly complex. In
addition, there are some indications that there may
be a heredity basis. Approximately 20 percent of
rst-degree female relatives will have SD. If you
have a female patient there is a 1 in 5 chance that
her rst-degree female relative, e.g. mother or sister
will have SD. However, there is a 1 in 5 chance that
her rst-degree male relative will develop antisocial
personality or be alcoholic.

Differential diagnosis
Medical disorders: The differential diagnosis
of SD includes medical disorders that present
with non-specic, vague or multiple somatic
symptoms. There are three factors that
might suggest a diagnosis of SD rather than
a general medical condition: involvement
of multiple organ systems, early onset and
chronic course without the development of
physical signs or structural abnormalities and
absence of laboratory abnormalities that are
characteristic of the general medical condition.
It is important to rule out medical conditions
characterised by vague, confusing somatic
symptoms (e.g. multiple sclerosis, systemic
lupus erythematosus, hyperparathyroidism).
Schizophrenia with multiple somatic delusions
needs to be differentiated from the nondelusional somatic complaints of SD.

Assessment and diagnosis


Psychiatric assessment includes:
A review of patients medical case record.
Full comprehensive psychiatric history with a
focus on the aspect of particular importance in
patients somatising.
Rule out depression. About 50 percent of
patients attending a general hospital somatising
are shown to have affective disorders and mode
of expression is primarily somatic. The more
cognitive component of depression (sadness,

176

Somatoform and Dissociative Disorders

all that is required for some somatisers. Patients


who respond easily to reassurance probably have
somatic symptoms in the context of anxiety and mild
depression. However, a hypochondriacs illness
may be sustained by seeking reassurance from
health workers. It is important to attempt to give
the patient a plausible explanation for somatisation
and information that is relevant to the patients
clinical condition. For example, a stabbing chest
pain may be ascribed to overstretching or tension
of muscles. Explanation should be congruent with
the patients socio-cultural background. Timing of
reassurance is important and not effective if given
before results of investigations or before the patient
has been allowed to air his concerns and has felt
understood. Information intended to reassure must
be accurate. Ambiguous statements, such as thats
not bad for your age are not helpful.
Preparing the patient for referral is an important
step that needs to be dealt with tactfully. It is
important to avoid giving the message that the
patient is not genuine, not ill, bothers doctors
unnecessarily or is mad, and that you are not just
packing him off to a psychiatrist. If the referring
health worker says something like I cannot nd
anything wrong with you. I think you need to see a
psychiatrist, is likely to be equated by the patient
as saying you are imagining it and I think you
are mad. If anger or resentment at the referral
becomes evident, these negative emotions should
be dealt with.

Major depression may present with somatic


complaints most commonly headache,
gastrointestinal disturbance or unexplained
pain. Individuals with SD have physical
complaints recurrently throughout their lives
regardless of their current mood state, whereas
physical complaints in depressive disorders
are limited to episodes of depressed mood.
Anxiety disorders: In panic disorder, multiple
somatic symptoms are also present, but these
occur primarily during the panic attack.
Generalised anxiety may also have a multitude
of physical complaints associated with general
anxiety, but the focus of the anxiety and worry
is not limited to the physical complaints.
Other somatoform disorders: conversion
disorder in which certain physical symptoms
are present, but do not full the criteria for
SD.
Factitious disorder: may be differentiated by the
presence of voluntary control of symptoms.
Co-morbidity: Somatising patients are
signicantly more likely to experience comorbidity, particularly depressive, anxiety
disorder or substance abuse.
Course and outcome
Somatisation causes signicant impairment in
role function, for which there are no demonstrable
organic ndings or known physiological
mechanisms. As the onset is typically before
age 30, and the multiple unexplained complaints
generally persist for several years, somatisation is
a common cause of absenteeism from work. An
extraordinarily large portion of a medical workers
time and effort is spent with individuals who seek
medical attention, not simply because of the nature
of the symptoms, but more as a result of their
frequency, severity and persistence.

Psychosocial treatment interventions


Basically, treatment consists of helping the patient
acknowledge the reality of stressful factors in
his life, reduction of stress factors, encouraging
verbal expression of distress and shaping adaptive
strategies to enable him cope with future stress.
Different approaches can be adopted depending
upon the orientation of the medical worker
(behavioural, cognitive or psychodynamic) and the
nature of the patients problem. The most common
interventions include:
Psychodynamic theory, which has proposed
that unexplained physical symptoms are
produced to protect the somatiser from
traumatic, frightening or depressing emotional
experiences. If an individual fails to process
a trauma adequately, it is hypothesised, that
the original affect later may be converted into
physical symptoms. Short-term, dynamically
oriented treatments for somatisers focus on the
stress and emotional distress associated with
physical symptoms.

Management and treatment


Good management depends on establishing
the correct diagnosis as soon as possible after
presentations and communicating this to patients
in terms which they can understand and accept.
The aim is to prevent the development of a pattern
of abnormal illness behaviour, chronic somatising
which once established is notoriously difcult to
overcome.
Reassurance
If this is an early onset the patient may respond
to simple reassurance. Simple reassurance is
very powerful if given appropriately and may be
177

The African Textbook of Clinical Psychiatry and Mental Health

Figure 32.1: Explaining to the patient the nature of psychosomatic symptoms is part of the treatment

The cognitive-behavioural therapy (CBT) of


somatisation emphasises the interaction of
physiology, cognition, emotion, behaviour
and environment. Specically, an individuals
interpretation of physical sensations may bring
on heightened awareness of bodily sensations,
increased emotional distress, and self-defeating
behaviour (such as avoiding activities), all of
which may exacerbate the physical symptoms.
In turn, the environment, including family,
friends, and medical workers, may respond in
ways that reinforce the individuals somatic
distress. Short-term CBT has been used with
somatisers to alter dysfunctional cognitive
processes and behaviour. Cognitive therapy
teaches patients to identify associations
between thoughts and physical symptoms and
to modify dysfunctional beliefs.
Re-attribution approach involves getting the
patient to accept a psychological view of their
symptoms during the rst interview. Patients
more suitable for this approach are those who
have some psychological understanding, are
not overtly hostile and whose symptoms are
relatively mild or of a short duration. Goldberg
and colleagues have proposed a three stage
model to encourage somatising patients to
reattribute their bodily symptoms and relate
them to psychological problems as follows:
o Feeling understood.
o Changing the agendagradually asking
about how the symptom affects the persons
life.
o Making the link between bodily symptoms
and emotional disorder.

Withdrawing unnecessary medication may be an


element of the re-attribution process. As such, the
patient is invited to move from sick role to healthy
role. This process must be carefully handled.
Behaviour therapy for somatic complaints
uses the methods for pain management and
increasing of avoided activities through operant
conditioning.
Psychophysiologists have described several
mechanisms that produce somatic symptoms
in the absence of organic pathology. These
mechanisms
include
over-activity
or
dysregulation of the autonomic nervous system,
smooth muscle contractions, endocrine overactivity, and hyperventilation. Miscellaneous
techniques directed at reducing somatisers
physiological arousal and physical discomfort
have been studied within controlled experimental
designs, including hypnotherapy, progressive
muscle
relaxation,
electromyography
(EMG), biofeedback, auto-genic training and
multifaceted relaxation training programmes.
Exercise treatments have been developed
for somatisers in accordance with evidence
suggesting that exercise improves mood,
pain thresholds and sleep. One theory
explaining the benets of exercise proposes
that exercise produces increases in serum
levels of -endorphin-like immunoreactivity,
adrenocorticotropic hormone, prolactin and
growth hormone.
Group psychotherapy. The group treatment is
aimed to enhance emotional expression, peer
support and coping skills.

178

Somatoform and Dissociative Disorders

and begin to incorporate being sick into their


self-concept and the sick role into their repertoire
of social behaviours. The early start of somatisation
and the relatively long hospital career in some
patients, emphasise the importance of developing
means by which those at risk of somatisation
can be identied early so that their utilisation of
medical services can be tracked prospectively and,
hopefully, effective interventions can be devised.

Prognosis: clinical features that predict


good response to treatment
No single predictive factor has been identied.
However, some general rules serve as a guide.
Psychological treatment is more likely to be
successful if:
The patients attribution of his symptoms can
be altered from organic to psychological or
rather the idea that there are multiple causes
for symptomsthe full range of aetiological
factors that apply.
The patient is able to agree to treatment
goals.
The patient engages in the treatment.
Patients with more dysfunctional illness beliefs
and assumptions about aetiology have a worse
outcome. Once symptoms have been established,
the management becomes difcult, because the
patients perception of the illness differs sharply
from that of the health practitioner. A breakdown
in the relationship is common and patients
unsuccessfully consult a succession of clinicians in
the hope of meeting one who can offer them relief.
This patient is on the path to chronicity.

HYPOCHONDRIASIS
Hypochondriasis is a somatoform disorder
characterised by a belief that real or imagined
physical symptoms are signs of a serious illness,
despite medical reassurance and other evidence to
the contrary.

Clinical features
In common language hypochondriac indicates
a person who thinks he is ill or merely imagines
that he has symptoms. The essential features are
the conviction that the disease exists, fear of the
disease and preoccupation with bodily symptoms
and signs. The physical symptoms are typically
normal always subjective physical signs (like
headache, belly pain, dizziness, fatigue, nausea
and numbness), which are misinterpreted as more
dangerous than they really are (e.g. I have a
headache, I must have a brain tumour). Common
physical symptoms that may be misinterpreted
include borborygmi, abdominal bloating and
crampy discomfort, cardiac awareness, and
sweating and dermatological concerns.

Preventive intervention
Somatisation disorder is commonly identied
during middle age. It should be noted that one of the
criteria for the diagnosis is a longstanding history
of multiple, unexplained medical complaints.
Thus, the natural history of somatisation probably
begins as early as adolescence or even childhood.
Children may develop a mental representation of
illness and its personal and social consequences,
Table 32.3
300.7 Hypochondriasis

A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the persons
misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not
restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).
D. The preoccupation causes clinically signicant distress or impairment in social, occupational, or other
important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by Generalised Anxiety Disorder, Obsessive-Compulsive
Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform
Disorder.
Specify if:
With Poor Insight: if, for most of the time during the current episode, the person does not recognise that the
concern about having a serious illness is excessive or unreasonable
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

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The African Textbook of Clinical Psychiatry and Mental Health

It is important to understand that hypochondriasis


is not a way of seeking attention from others by
prentending to be sick. Individuals honestly believe
that they are suffering from a medical condition,
the symptoms are real and they feel misunderstood.
Most individuals are not concerned with the pain
but rather with what the physical symptoms may
imply in terms of real disease.

Management and treatment


A supportive relationship with a health worker is the
mainstay of treatment. There should be one primary
provider to avoid unnecessary diagnostic tests and
procedures. The health worker should inform the
person that no organic disease is present, but that
continued medical follow-up will help control the
symptoms. Specialist referral may be considered.
Various forms of psychotherapy may be useful.

Assessment and diagnosis


Hypochondriasis must be positively diagnosed.
It is not enough to exclude physical disease. The
exaggerated health anxiety or obsessive irrational
fear must also be found. A thorough physical
examination is indicated to rule out any pertinent
medical conditions, along with a psychosocial
history and a mental status examination. Patients
with hypochondriasis often seek exhaustive
batteries of tests, which are often excessive relative
to their symptoms.

Prognosis
Generally, the disorder is chronic, unless the
psychological factors or any related underlying
mood disorders are addressed. People with
hypochondriasis seldom acknowledge that their
illness has a psychological component and usually
reject mental health treatment.

CONVERSION DISORDER

Course
Historically the terms conversion, hysteria and
conversion hysteria were used interchangeably
to describe a condition characterised by a single
somatised symptom, often a pseudoneurologic
one, for example, blindness. With the introduction
of the DSM classication system, the hypothesis
was that an individuals somatic symptoms

Hypochondriasis may persist over a number of


years, but usually occurs as a series of episodes
rather than continuous treatment-seeking. The
are-ups of the disorder are often correlated with
stressful events in the patients life. Depression
with somatisation must be excluded and properly
treated.
Table 32.4
300.11 Conversion Disorder

A. One or more symptoms or decits affecting voluntary motor or sensory function that suggest a neurological
or other general medical condition.
B. Psychological factors are judged to be associated with the symptom or decit because the initiation or
exacerbation of the symptom or decit is preceded by conicts or other stressors.
C. The symptom or decit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).
D. The symptom or decit cannot, after appropriate investigation, be fully explained by a general medical
condition, or by the direct effects of a substance, or as a culturally sanctioned behaviour or experience.
E. The symptom or decit causes clinically signicant distress or impairment in social, occupational, or other
important areas of functioning or warrants medical evaluation.
F. The symptom or decit is not limited to pain or sexual dysfunction, does not occur exclusively during the
course of Somatisation Disorder, and is not better accounted for by another mental disorder.
Specify type of symptom or decit:
With Motor Symptom or Decit (e.g., impaired coordination or balance, paralysis or localised weakness,
difculty swallowing or lump in throat, aphonia, and urinary retention)
With Sensory Symptom or Decit (e.g., loss of touch or pain sensation, double vision, blindness, deafness,
and hallucinations)
With Seizures or Convulsions: includes seizures or convulsions with voluntary motor or sensory components
With Mixed Presentation: if symptoms of more than one category are evident
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

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muscle weakness) and Guillain-Barr syndrome


(motor and sometimes sensory).
Psychiatric conditions that must be differentiated
include the following: dissociative disorder,
psychotic disorders, mood disorders, factitious
disorders and malingering, pain disorder or sexual d
ysfunction, somatisation disorder, undifferentiated
somatoform disorder, adjustment disorder.

represented a symbolic resolution of an


unconscious psychological conict that reduced
anxiety and served to keep conict away from
awareness (primary gain). The DSM-IV uses the
term conversion disorder and simply requires that
psychological factors are judged to be associated
with the symptoms or decit as the initiation or
exacerbation of the symptoms is often preceded by
conict and other stressors.
Conversion disorders are characterised by a
sudden loss of neurological-like function, usually
in the context of a severe stressor. It is dened as a
condition that presents as an alteration or loss of a
physical function, suggestive of a physical disorder.
However, conversion disorder is more precisely
understood as the expression of an underlying
psychological conict or need.

Course
Generally, individual conversion symptoms are
self-limited, usually last for days to weeks and
may resolve spontaneously. The symptom itself
is not life-threatening, but the development of
complications as a result of the symptom can be
debilitating. Over 90 percent of patients recover
within a month, and most do not have recurrences.
Data for hospitalised patients suggest that more
than half of patients with this disorder have
improved at the time of discharge. However, 20-25
percent relapse in the rst year

Associated characteristics of conversion


disorder
La belle indifference
This is dened as a relative lack of concern about the
nature or implications of the symptom manifested
on the part of the patient.

Treatment
Patients with conversion disorder are suggestible,
but reassurance that symptoms will go away is
rarely effective unless it is predicted that it may
be gradual with specic recommendations for
exercises or referral to a physiotherapist. It is
also important to communicate to patients that
their symptoms have been taken seriously and
acknowledge the stress and strains in the patients
life. Suggesting that symptoms will persist for
a time may provide time to establish therapeutic
relationships. The patient should be allowed to
eliminate the symptoms as slowly as is needed and
with dignity. Colluding family members must be
carefully handled and the symptoms explained. A
health workers tasks include:
Providing education about conversion disorder,
while carefully ruling out contributing medical
conditions and attending to the views of the
patient and family.
Discussion of the interplay between emotional
and physical stress can be helpful to the patient
and family.
Referral to a trained professional in mental
health diagnosis and treatment may be
necessary if progress is not made in coping
with symptoms.
The health worker must be satised with the
completeness of the physical evaluation and should
use discretion regarding the extent of the organic
work-up.

Primary versus secondary gain


The resolution of the emotion that underlies
the physical symptom or the extent to which a
conversion symptom diminishes the unpleasant
emotion and communicates symbolically the
unconscious wish by keeping the internal conict
out of awareness is called the patients primary
gain. Secondary gain is achieved when the patient
has been removed from the uncomfortable situation
by virtue of the symptom.
Somatic compliance
The choice of symptoms (e.g. inability to swallow
or speak, going blind or deaf; or having seizures, or
convulsions) symbolically reect the psychological
trauma and effectively achieves the primary gain.
Symptoms are more common on the left side than
the right.

Differential diagnosis: making the


diagnosis
Medical conditions that may mimic conversion
symptoms include the following: multiple sclerosis
(with blindness secondary to optic neuritis),
myasthenia gravis (with muscle weakness), periodic
paralysis (with muscle weakness), myopathies
(with muscle weakness), polymyositis (with

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The African Textbook of Clinical Psychiatry and Mental Health

arthritis, muscle aches and cramps, or pelvic pain.


In some cases the patients pain appears to be
largely due to psychological factors, but in other
cases the pain is derived from a medical condition
as well as the patients psychology.

PAIN DISORDER
Pain disorder as a category of somatoform disorder
covers a range of patients with a variety of ailments,
including chronic headaches, back problems,
Table 32.5
Pain Disorder

A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of
sufcient severity to warrant clinical attention.
B. The pain causes clinically signicant distress or impairment in social, occupational, or other important
areas of functioning.
C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or
maintenance of the pain.
D. The symptom or decit is not intentionally produced or feigned (as in Factitious Disorder or
Malingering).
E. The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria
for Dyspareunia.
Code as follows:
307.80 Pain Disorder Associated With Psychological Factors: psychological factors are judged to have
the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a general medical condition
is present, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) This
type of Pain Disorder is not diagnosed if criteria are also met for Somatisation Disorder.
Specify if:
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 32.6
307.89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition:
both psychological factors and a general medical condition are judged to have important roles in the onset,
severity, exacerbation, or maintenance of the pain. The associated general medical condition or anatomical
site of the pain (see below) is coded on Axis III.
Specify if:
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer
Note: The following is not considered to be a mental disorder and is included here to facilitate differential
diagnosis.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 32.7
Pain Disorder Associated With a General Medical Condition: a general medical condition has a major
role in the onset, severity, exacerbation, or maintenance of the pain. (If psychological factors are present,
they are not judged to have a major role in the onset, severity, exacerbation, or maintenance of the pain.) The
diagnostic code for the pain is selected based on the associated general medical condition if one has been
established or on the anatomical location of the pain if the underlying general medical condition is not yet
clearly establishedfor example, low back (724.2), sciatic (724.3), pelvic (625,9), headache (784.0), facial
(784.0), chest (786.50), joint (719.40), bone (733.90), abdominal (789.0), breast (611.71), renal (788.0), ear
(388.70), eye (379,91), throat (784.1), tooth (525.9), and urinary (788.0).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

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treated, external reinforcements are removed and


possible underlying conditions, such as depression,
are effectively treated.

Differential diagnosis
Appropriate medical investigations should be
carried out in respect of the systems or anatonomical
sites implicated. Pure pain may be difcult to
exclude or differentiate from psychogenic pain as
they are not mutually exclusive. The features are
as follows:
Physical pain tends to uctuate in intensity
and is highly sensitive to emotional, cognitive,
attentional and situational inuences, whereas
pain that does not vary and is not affected by any
of these factors is likely to be psychogenic.
Pain
must
be
distinguished
from
other somatoform disorders in which pain is
one of the core features.
Malingerers consciously provide false reports.
They usually have clearly identiable goals
and rewards to achieve, secondary to the
pain.
Psychiatric disorders such as schizophrenia,
major depressive or anxiety disorders often
present with associated pain symptoms that
may not be physical.
Identifying and treating a depressive disorder
that may be associated with the pain may
signicantly reduce the subjective experience
of pain.

Treatment
With acceptance of a biopsychosocial model of
pain, therapists use a variety of biopsychosocial
interventions aimed at addressing such factors. An
illness such as chronic pain may require attention
to numerous factors interacting in non-linear
relationships.
General treatment approaches used by
clinicians have focused on identifying and
altering psychological and social factors that
can inuence pain and disability.
Cognitive
behaviour
therapy,
selfhypnosis, behaviour therapy and pain control
programmes are useful. To be effective, all
treatment approaches require that the medical
worker establish a supportive relationship
with the patient that will help prevent
unnecessary medical and surgical procedures
and treatments. Psycho-education about the
nature of the pain disorder is also effective.
Medication. Antidepressants reduce pain
intensity in patients with psychogenic pain
or somatoform pain disorder and they help
ameliorate any underlying depression.

Course and outcome

BODY DYSMORPHIC DISORDER


(BDD)

Pain can transition from abrupt acute onset to


chronic pain disability in stages, from weeks to
months. Chronic pain disorder can be distressing
and totally disabling with the patients assuming
the sick role. This excuses patients from their
normal responsibilities and social obligations,
which may become a potent reinforcer for not
becoming healthy. It is better if psychological
factors associated with the pain are identied and

The primary distinguishing feature of BDD is an


obsessive preoccupation with an imagined defect
in ones physical appearance (width of the lips or
shape of the nose) or an exaggerated distortion of a
minimal or minor defect.

Table 32.8
300.7 Body Dysmorphic Disorder
A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the persons
concern is markedly excessive.
B. The preoccupation causes clinically signicant distress or impairment in social, occupational, or other
important areas of functioning.
C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body
shape and size in Anorexia Nervosa).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

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The African Textbook of Clinical Psychiatry and Mental Health

Patients obsessed with facial deformities may


resort to compulsive face picking and skin digging,
sometimes to the point of actually scarring the
face. Patients may become obsessed with a pimple,
and in their attempt to get it out they dig their nails
into their skin. If that does not work they may try
tweezers and sometimes even carving the pimple
out with a knife. Self-mutilation may also take the
form of face picking or pulling on the nose with
pliers to even it out. Other behavioural responses
to BDD obsessions include compulsive mirror
checking, episodic avoidance of mirrors, excessive
grooming, camouaging, reassurance seeking,
surgery and unnecessary usage of dermatological
products.

confused with BDD are neglect caused by a parietal


lobe brain lesion and gender identity disorder.
Onset and course
The average age of onset is in mid-adolescence,
and the course tends to be chronic and uctuates
over the course of time with new imagined defects
being added over time.

Treatment
The following steps may be the most effective way
of managing the patient:
The clinician should acknowledge the patients
concern.
The clinician should seek additional
information to determine the severity of the
disorder.
A discussion about how much time and worry
is devoted to the perceived defect will help.
The clinician should also ask what the patient
has done to remedy the defect, and how the
defect has altered the patients social, academic
or occupational activities.
Psychoeducation about the nature of the
disorder can be very helpful, particularly if
patient conviction about their defect is not too
strong or symptoms do not have a delusional
quality.
The potential benets of psychiatric referral
may be discussed.
Most
often
these
patients
need
pharmacological interventions combined with
cognitive approach. Effective medications
include clomipramine, uoxetine, uvoxamine
and pimozide. Selective serotonin reuptake
inhibitors (SSRIs) are effective for BDD, even
if symptoms are delusional. The medication
may not always cure the disorder, but it makes
the person more amenable to psychotherapy
and hopefully more open to receiving ongoing
treatment. In some cases, these medications
are lifesaving, especially for those who
have attempted suicide in despair over their
appearance.

Differential Diagnosis
Anorexia nervosa
This is where the persons obsessive interest is in
their weight, body shape and size. A differential
diagnosis of anorexia nervosa may be made.
BDD is different from eating disorders, because it
involves other factors besides ones weight or body
size. Those with BDD have several cognitive
distortions about how they look.
Delusional disorder, somatic sub-type
The strength of the overvalued idea at times may
be close to delusional. Patients in this class might
qualify for a diagnosis of another syndrome relevant
to the self-image, delusional disorder, somatic subtype.
Major depressive disorder
Chronic BDD is often associated with or can lead
to major depressive disorder, because patients
cannot convince others of the problem and are not
able to change. In one study, more than 90 percent
of respondents were found to have had a major
depressive episode in their lifetimes. Some 70
percent had suffered an anxiety like social phobia.
Psychotic disorder
It is important to distinguish BDD from psychotic
patients and those with highly disturbed global and
body self-images. Other conditions that might be

184

Somatoform and Dissociative Disorders

Table 32.9
300.82 Somatoform Disorder Not Otherwise Specied
This category includes disorders with somatoform symptoms that do not meet the criteria for any specic
Somatoform Disorder. Examples include:
1. Pseudocyesis: a false belief of being pregnant that is associated with objective signs of pregnancy,
which may include abdominal enlargement (although the umbilicus does not become everted), reduced
menstrual ow, amenorrhea, subjective sensation of foetal movement, nausea, breast engorgement and
secretions, and labour pains at the expected date of delivery. Endocrine changes may be present, but the
syndrome cannot be explained by a general medical condition, that causes endocrine changes (e.g., a
hormone-secreting tumour)
2. A disorder involving non-psychotic hypochondriacal symptoms of less than 6 months duration
3. A disorder involving unexplained physical complaints (e.g., fatigue or body weakness) of less than 6
months duration that are not due to another mental disorder
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

symptoms in the absence of (signicant) external


incentives, which can be attributed to a need to
assume the sick role.
Patients with this disorder knowingly fake
symptoms, but do so for psychological reasons.

FACTITIOUS DISORDERS
Factitious disorder represents the intentional
production of physical or psychological signs and
Table 32.10
Factitious Disorder

A. Intentional production or feigning of physical or psychological signs or symptoms.


B. The motivation for the behaviour is to assume the sick role.
C. External incentives for the behaviour (such as economic gain, avoiding legal responsibility, or improving
physical well-being, as in Malingering) are absent.
Code based on type:
300.16 With Predominantly Psychological Signs and Symptoms: if psychological signs and symptoms
predominate in the clinical presentation
With Predominantly Physical Signs and Symptoms: if physical signs and symptoms predominate in the
clinical presentation
300.19 With Combined Psychological and Physical Signs and Symptoms: if both psychological and
physical signs and symptoms are present but neither predominates in the clinical presentation
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 32.11
300.19 Factitious Disorder Not Otherwise Specied
This category includes disorders with factitious symptoms that do not meet the criteria for Factitious
Disorder. An example is factitious disorder by proxy: the intentional production or feigning of physical or
psychological signs or symptoms in another person who is under the individuals care for the purpose of
indirectly assuming the sick role
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

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The African Textbook of Clinical Psychiatry and Mental Health

clinical approach. Re-dening the factitious illness


as psychiatric with continued involvement of a
primary clinician and family support are helpful
to successful management. Underlying psychiatric
disorders need to be thoroughly evaluated and
treated, especially depression. An essential
and probably most difcult step is to secure an
enduring and stable patient-clinician relationship.
To achieve this goal, most clinicians advocate a
non-confrontational strategy and reframing the
factitious manifestation as a cry for help.

They usually prefer the sick role and may move


from hospital to hospital in search of care. They are
usually loners with an early childhood background
of trauma and deprivation and are unable to
establish close interpersonal relationships. Unlike
the malingerers, they follow through with medical
procedures, are at risk of drug addiction and may
suffer the complications of multiple operations.
Other forms include Munchausens and Ganser
Syndrome, as well as Factitious Disorder by
Proxy or Munchausen Syndrome by Proxy. The
major feature of factitious disorder by proxy is the
deliberate production or feigning of physical or
psychological symptoms in another person who is
under that individuals care, usually a child. The
motive for the perpetrators behaviour is thought
to be a psychological need to assume the sick role
by proxy.

DISSOCIATIVE DISORDERS
A mentally healthy person has a unitary sense
of self as a single human being with a single
personality. The essential feature of dissociation
is an alteration in this unitary state, which results
in a lack of connection in a persons thoughts,
memories, feelings, actions or sense of identity.
The disturbance may be sudden or gradual,
transient or chronic. Individuals with dissociative
disorders can experience headaches, amnesias,
time loss, trances, and out-of-body experiences.
This group of conditions include: Dissociative
Amnesia, Dissociative Fugue, Dissociative Identity
Disorder, and Depersonalisation Disorder.

Differential diagnosis
The following disorders need to be ruled
out to establish a precise diagnosis: genuine
psychiatric pathology, neurological disorders,
other somatoform disorders and malingering
(where there is external motivation for symptom
production). The patient with factitious disorder
produces symptoms without external motivation.

Management and treatment


Dissociative amnesia (formerly known
as psychogenic amnesia)

Overall, the results of psychotherapy are not


encouraging. Therefore, treatment should be based
on focusing on the management of the disorder
rather than on a cure. An appropriate index of
suspicion and non-judgemental confrontation and
psychiatric consultation facilitate a successful

The essential feature is reversible memory


impairment due to psychological causes usually
following a severe physical or psychological
conict or stressor.

Table 32.12
300.12 Dissociative Amnesia (formerly Psychogenic Amnesia)
A. The predominant disturbance is one or more episodes of inability to recall important personal
information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary
forgetfulness.
B. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder,
Dissociative Fugue, Posttraumatic Stress Disorder, Acute Stress Disorder, or Somatisation Disorder
and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a
neurological or other general medical condition (e.g., Amnestic Disorder Due to Head Trauma).
C. The symptoms cause clinically signicant distress or impairment in social, occupational, or other
important areas of functioning.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

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Somatoform and Dissociative Disorders

by the assumption of a new identity and inability


to recall some or all of ones past. Perplexity and
disorientation may occur.

Dissociative Fugue
Dissociative fugue is characterised by sudden,
unexpected travel away from home or ones
customary place of daily activity and is characterised
Table 32.13

300.13 Dissociative Fugue (formerly Psychogenic Fugue)


A. The predominant disturbance is sudden, unexpected travel away from home or ones customary place of
work, with inability to recall ones past.
B. Confusion about personal identity or assumption of a new identity (partial or complete).
C. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder and is
not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., temporal lobe epilepsy).
D. The symptoms cause clinically signicant distress or impairment in social, occupational, or other
important areas of functioning.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association

states, which may eventually take on identities of


their own. These entities may become the internal
personality states of a DID system. Changing
between these states of consciousness is often
described as switching. These alternate states
may appear to be very different, but they are all
manifestations of a single person.

Dissociative Identity Disorder (DID)


In the DSM-IV multiple personality disorder
(MPD) was changed to DID, reecting changes in
professional understanding of the disorder resulting
from signicant empirical research. DID may be
seen as a process where repeated dissociation may
result in a series of separate entities, or mental
Table 32.14

300.14 Dissociative Identity Disorder (formerly Multiple Personality Disorder)


A. The presence of two or more distinct identities or personality states (each with its own relatively enduring
pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the persons behaviour.
C. Inability to recall important personal information that is too extensive to be explained by ordinary
forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic
behaviour during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures).
Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

occurs in an individuals self-awareness such that


they feel detached from their own experience, with
the self, body and mind. These periods of unreality
can last for days, weeks or months. As a result
of this sustained distress, the sufferer can rapidly
become deeply depressed and anxious. It can then
be difcult to establish whether this is a result of,
or the cause of the depersonalisation.

Depersonalisation disorder
Transient feelings of unreality are quite normal
in healthy individuals. Alternatively, they can be
a co-symptom of psychiatric or physical illness,
in which case they will often disappear when
the sufferer recovers from their primary illness.
However, in depersonalisation disorder, a change

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The African Textbook of Clinical Psychiatry and Mental Health

Table 32.15
300.6 Depersonalisation Disorder
A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of,
ones mental processes or body (e.g., feeling like one is in a dream).
B. During the depersonalisation experience, reality testing remains intact.
C. The depersonalisation causes clinically signicant distress or impairment in social, occupational, or
other important areas of functioning.
D. The depersonalisation experience does not occur exclusively during the course of another mental
disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder,
and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or
a general medical condition (e.g., temporal lobe epilepsy).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

disorders
(especially
intoxication
and
withdrawal), anxiety disorders, personality
disorders, epilepsy and substance abuse.

Differential diagnosis
Depersonalisation may be a symptom in
schizophrenia, mood disorders, other mental
Table 32.16

300.15 Dissociative Disorder Not Otherwise Specied


This category is included for disorders in which the predominant feature is a dissociative symptom (i.e.,
a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the
environment) that does not meet the criteria for any specic Dissociative Disorder. Examples include
1. Clinical presentations similar to Dissociative Identity Disorder that fail to meet full criteria for this
disorder. Examples include presentations in which a) there are not two or more distinct personality
states, or b) amnesia for important personal information does not occur.
2. Derealisation unaccompanied by depersonalisation in adults.
3. States of dissociation that occur in individuals who have been subjected to periods of prolonged and
intense coercive persuasion (e.g., brainwashing, thought reform, or indoctrination while captive).
4. Dissociative trance disorder: single or episodic disturbances in the state of consciousness, identity,
or memory that are indigenous to particular locations and cultures. Dissociative trance involves
narrowing of awareness of immediate surroundings or stereotyped behaviours or movements that are
experienced as being beyond ones control. Possession trance involves replacement of the customary
sense of personal identity by a new identity, attributed to the inuence of a spirit, power, deity, or other
person, and associated with stereotyped involuntary movements or amnesia and is perhaps the most
common Dissociative Disorder in Asia. Examples include amok (Indonesia), bebainan (Indonesia),
latah (Malaysia), pibtoktoq (Arctic), ataque de nervios (Latin America), and possession (India). The
dissociative or trance disorder is not a normal part of a broadly accepted collective cultural or religious
practice.
5. Loss of consciousness, stupor, or coma not attributable to a general medical condition.
6. Ganser syndrome: the giving of approximate answers to questions (e.g., 2 plus 2 equals 5) when not
associated with Dissociative Amnesia or Dissociative Fugue.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

settings, traditional healers may have a role to


play. These treatments have included behaviour
modication therapies, psychodrama, relaxation
therapy and various psychotherapies of a traditional
nature. The use of symbolism and ritual is deeply
entrenched in the African traditional healers
practices. Practitioners of meditation describe

Management
Dissociative disorders can be responsive to
individual psychotherapy, or talk therapy, as
well as to a range of other treatment modalities,
including medications (for co-morbid psychiatric
conditions) and hypnotherapy. Outside of western

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Somatoform and Dissociative Disorders

states of possession which contain many features of


depersonalisation. They often describe therapeutic
experiences which help deeply distressed patients
by allowing them abreaction and carthasis.

Further Reading
1. American Psychiatric Association (1980). Diagnosis
and Statistical Manual of Mental Disorders (DSM
111), 3rd Edition. Washington: American Psychiatric
Association

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33
Mood Disorders
David M. Ndetei, Caleb Othieno, Seggane Musisi, Gad Kilonzo

disease as the leading source of disease burden


worldwide.
Major risk factors for depression appear similar
in developed and developing countries and
include family history of the disease, life events,
chronic social adversity, poverty, and gender. The
course of depression is inuenced by several factors,
including the type, causes, severity, duration prior
to treatment, and underlying presence of chronic
minor depression. Depression in children and
adolescents is often chronic and continues into
adulthood with higher rates of overall impairment
and signicant rates of attempted suicide.
Because depression typically results from a
combination of causes, effective prevention and
treatment demands a multifaceted approach. In
developing countries, this may translate into a
combination of health care health education,
community care and socio-economic development.
Effective pharmacotherapies and psychosocial
treatments exist for depression. Though no
treatment has been shown to cure all forms of the
illness, a large number of effective and low-cost
treatments are available.

INTRODUCTION
Mood disorders are a group of psychiatric
disorders whose main feature is a peculiar and
characteristic state of altered mood or feeling.
Such an altered mood state may be in the form of
extreme happiness (manic disorder) or unusual
sadness (depressive disorder). The dividing line
between what may be regarded as abnormal mood
state, and therefore an illness, is often difcult to
draw. This difculty often gives rise to delayed
or inappropriate diagnoses being made with
subsequent inappropriate medication being offered
to those in distress. An abnormal and distressing
mood state has the following additional features:
is persistent and is experienced by the individual
or family or other relatives as distressing and
requiring professional help, and leads to helpseeking behaviour.

Summary of ndings on depression in


developing countries4
Depression, estimated to be the leading cause of
disability worldwide, accounts for more than 1
in 10 years of life lived with disability, as well as
for signicant premature mortality due to suicide
and physical illness. By 2020, unipolar major
depression will rank second only to ischemic heart

Primary mood disorders


Bipolar Mood Disorder: mania alternating with
major depressive episodes or manic episodes
alone.

4.

Source: N. Sartorius, W. Gulbinat, G. Harrison, E Laska and C. Siegel. Long-term follow-up of schizophrenia in 16 countries.
A description of the international study of schizophrenia conducted by the World Health Organisation. Social Psychiatry and
psychiatric Epidemiology, 31: 249-258 1966.

190

Mood Disorders

system, such as thyroid abnormalities,


Cushings syndrome or Addisons disease can
lead to mood disturbances. A number of drugs,
used to treat medical conditions, such as antihypertensives or steroids may also cause mood
disturbances.
Substance induced mood disorder: mood
disorders may coexist with substance use
disorder. The use of substance in the rst
instance could lead to a mood disorder.
Alternatively, having a mood disorder can
lead to substance use.

Major Depression Disorder: characterised by


one or more depressive episodes.
Dysthymic Disorder: symptoms are similar to
those of major depression, but are less severe.
Cyclothymic Disorder: symptoms are similar
to those of bipolar I disorder, but are less
severe.

Secondary mood disorders


Mood disorder due to a medical condition:
systemic diseases and disorders of the endocrine
Table 33.1
A CLINICAL OVERVIEW OF MOOD DISORDERS
1.

2.

3.

4.
5.
6.

7.

8.

9.

(A) Different types of Mood Disorders


Major Depressive Disorder is characterised by:
One or more Major Depressive Episodes, (at least 2 weeks of depressed mood or loss of
interest plus at least four additional symptoms of depression).
Dysthymic Disorder is characterised by:
At least 2 years of depressed mood for more days than not, plus
Additional depressive symptoms that do not meet criteria for a Major Depressive Episode.
Depressive Disorder Not Otherwise Specied
Depressive features that do not meet criteria for any of the other specied depressive disorders
(described in the text) including Adjustment Disorder With Anxiety and Depressed Mood (or
depressive symptoms about which there is inadequate or contradictory information).
Bipolar I Disorder is characterised by:
One or more Manic or Mixed Episodes, usually accompanied by Major Depressive Episodes.
Bipolar II Disorder is characterised by
One or more Major Depressive Episodes accompanied by at least one Hypomanic Episode.
Cyclothymic Disorder is characterised by
At least 2 years of numerous period of hypomanic symptoms that do not meet criteria for a Manic
Episode and numerous periods of depressive symptoms that do not meet criteria for a Major
Depressive Episode.
Bipolar Disorder Not Otherwise Specied
Disorders with bipolar features that do not meet criteria for any of the specic Bipolar Disorders
dened in this section (or bipolar symptoms about which there is inadequate or contradictory
information).
Mood Disorder Due to a General Medical Condition
Prominent and persistent disturbance in mood that is judged to be a direct physiological consequence
of a general medical condition.
Substance-Induced Mood Disorder is characterised by

Prominent and persistent disturbance in mood that is judged to be a direct physiological consequence
of a drug of abuse, a medication, another somatic treatment for depression, or toxin exposure.
10. Mood Disorder Not Otherwise Specied

Disorders with mood symptoms that do not meet the criteria for any specic Mood Disorder and in
which it is difcult to choose between Depressive Disorder Not Otherwise Specied and Bipolar
Disorder Not Otherwise Specied (e.g., acute agitation).

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B. Further Clinical Overview


1. Mood Episodes
Major Depressive Episode
Manic Episode
Mixed Episode
Hypomanic Episode
2. Depressive Disorders
Major Depressive Disorder
Dysthymic Disorder
Depressive Disorder Not Otherwise Specied
3. Bipolar Disorders
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Bipolar Disorder Not Otherwise Specied
4. Other Mood Disorders
Mood Disorder Due to ... [Indicate the General Medical Condition]
Substance-Induced Mood Disorder
Mood Disorder Not Otherwise Specied
C. Speciers to describe current or most recent Mood Episode
1. These are for the following purposes
Increase diagnostic specicity,
Create more homogeneous subgroups,
Assist in treatment selection and
Improve the prediction of prognosis.
2. Speciers describing the most recent mood episode
Mild, Moderate, Severe Without Psychotic Features,
Severe With Psychotic Features,
In Partial Remission,
In Full Remission (for Major Depressive Episode, for Manic Episode, for Mixed Episode,
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
3. Speciers describing course of recurrent episodes
Longitudinal Course Speciers (With or Without Full Inter-episode Recovery)
With Seasonal Pattern
With Rapid Cycling
Adopted and Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (Copyright 2000). American Psychiatric Association.

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Mood Disorders

CLINICAL DEPRESSION
Table 33.2: 1CD-10 Criteria for depressive episode
General

Key symptoms (n=3)

Ancillary symptoms

Episode must have lasted at least two weeks with symptoms nearly every day
Change from normal functioning
Depressed mood
Anhedonia
Fatigue/loss of energy
Weight and appetite change
Sleep disturbance
Subjective or objective agitation/retardation
Low self esteem/condence
Self reproach/guilt
Impaired thinking/concentration
Suicidal thoughts

Criteria

Mild episode: 2 key, 4 symptoms in total Moderate episode: 2 key, 6 symptoms


in total Severe episode: 3 key, 8 symptoms in total

Exclusions

No history ever of manic symptoms Not substance related Not organic

Source: N. Sartorius, W. Gulbinat, G. Harrison, E Laska and C. Siegel. Long-term follow-up of schizophrenia in 16 countries.
A description of the International study of schizophrenia conducted by the World Health Organisation. Social Psychiatry and

feelings of sadness and lack of interest in previously


enjoyable activities.

Clinical presentation
Major Depression (Unipolar Disorder) is a mood
disorder characterised by profound and sustained
Table 33.3

Major Depressive Episode


A. Five (or more) of the following symptoms have been present during the same 2-week period and represent
a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss
of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood incongruent
delusions or hallucinations.
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g.,
feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and
adolescents, can be irritable mood
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly
everyday as indicated by either subjective account or observation made by others.
(3) signicant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body
weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider
failure to make expected weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective
feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every
day (not merely self-reproach or guilt about being sick)

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The African Textbook of Clinical Psychiatry and Mental Health

(8)

B.
C.
D.
E.

diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective
account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specic
plan, or a suicide attempt or a specic plan for committing suicide
The symptoms do not meet criteria for a Mixed Episode.
The symptoms cause clinically signicant distress or impairment in social, occupational, or other
important areas of functioning.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., hypothyroidism).
The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the
symptoms persist for longer than 2 months or are characterised by marked functional impairment, morbid
preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 33.4
296.2x Major Depressive Disorder, Single Episode
A. Presence of a single Major Depressive Episode.
B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not
superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specied.
C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion
does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment
induced or are due to the direct physiological effects of a general medical condition.
If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or
features:
Mild, Moderate, Severe Without Psychotic Features/ Severe With Psychotic Features
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of
the Major Depressive Disorder or features of the most recent episode:
In Partial Remission, In Full Remission
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 33.5
Criteria for Severity/Psychotic/Remission Speciers for current (or most recent) Major Depressive
Episode
Note: Code in fth digit. Can be applied to the most recent Major Depressive Episode Major Depressive
Disorder and to a Major Depressive Episode in Bipolar Disorder only if it is the most recent type of mood
episode.
.x1-Milod: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result
in only minor impairment in occupational .functioning or in usual social activities or relationships with
others.

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Mood Disorders

.x2-Moderate: Symptoms or functional impairment between mild and severe


.x3Severe Without Psychotic Features: Several symptoms in excess of those required to make the
diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities
or relationships with others.
.x4Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the
psychotic features are mood-congruent or mood-incongruent:
Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely
consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism,
or deserved punishment.
Mood-incongruent Psychotic Features: Delusions or hallucinations whose content does not
involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved
punishment. Included are such symptoms as persecutory delusions (not directly related to depressive
themes), thought insertion, thought broadcasting, and delusions of control.
.x5In Partial Remission: Symptoms of a Major Depressive Episode are present but full criteria are
not met, or there is a period without any signicant symptoms of a Major Depressive Episode lasting less
than 2 months following the end of the Major Depressive Episode. (If the Major Depressive Episode was
superimposed on Dysthymic Disorder, the diagnosis of Dysthymic Disorder alone is given, once the full
criteria for a Major Depressive Episode are no longer met.)
.x6In Full Remission: During the past 2 months, no signicant signs or symptoms of the disturbance
were present.
.x0Unspecied.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 33.6
Criteria for Melancholic Features Specier
Specify if:
f
With Melancholic Features (can be applied to the current or most recent Major Depressive Episode in
Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or Bipolar II Disorder only if it
is the most recent type of mood episode)
A. Either of the following, occurring during the most severe period of the current episode:
(1) loss of pleasure in all, or almost all, activities
(2) lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when
something good happens)
B. Three (or more) of the following:
(1)

distinct quality of depressed mood (i.e., the depressed mood is experienced as distinctly different
from the kind of feeling experienced after the death of a loved one)

(2)

depression regularly worse in the morning

(3)

early morning awakening (at least 2 hours before usual time of awakening)

(4)

marked psychomotor retardation or agitation

(5)

signicant anorexia or weight loss

(6)

excessive or inappropriate guilt

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

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The African Textbook of Clinical Psychiatry and Mental Health

Table 33.7
Criteria for Atypical Features Specier
Specify if:
With Atypical Features (can be applied when these features predominate during the most recent 2 weeks
of a Major Depressive Episode in Major Depressive Disorder or in Bipolar I or Bipolar II Disorder when
the Major Depressive Episode is the most recent type of mood episode, or when these features predominate
during the most recent 2 years of Dysthymic Disorder)
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)
B. Two (or more) of the following features:
(1) signicant weight gain or increase in appetite
(2) hypersomnia
(3) leaden paralysis (i.e., heavy, leaden feelings in arms or lees)
(4) long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood
disturbance) that results in signicant social or occupational impairment
C. Criteria are not met for With Melancholic Features or With Catatonic Features during the same episode.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 33.8
296.3x Major Depressive Disorder, Recurrent
A. Presence of two or more Major Depressive Episodes
B. Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in
which criteria are not met for a Major Depressive Episode.
C. The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and are not
superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specied.
D. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion
does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatmentinduced or are due to the direct physiological effects of a general medical condition.
If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or
features:
Mild, Moderate, Severe Without Psychotic Features/
Severe With Psychotic Features
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of
the Major Depressive Disorder or features of the most recent episode:
In Partial Remission, In Full Remission
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
Specify:
Longitudinal Course Speciers (With and Without
Interepisode Recovery)
With Seasonal Pattern
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

196

Mood Disorders

Table 33.9
Criteria for Longitudinal Course Speciers, with or without interepisode recovery
Specify if (can be applied to Recurrent Major Depressive Disorder or Bipolar I or II Disorder):
With Full Interepisode Recovery: if full remission is attained between the two most recent Mood
Episodes
Without Full Interepisode Recovery: if full remission is not attained between the two most recent Mood
Episodes
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 33.10
Criteria for Seasonal Pattern Specier
Specify if:
With Seasonal Pattern (can be applied to the pattern of Major Depressive Episodes in Bipolar I Disorder,
Bipolar II Disorder, or Major Depressive Disorder, Recurrent)
A. There has been a regular temporal relationship between the onset of Major Depressive Episodes in
Bipolar I or Bipolar II Disorder or Major Depressive Disorder, Recurrent, and a particular time of
the year (e.g., regular appearance of the Major Depressive Episode in the fall or winter).
Note: Do not include cases in which there is an obvious effect of seasonal-related psychosocial
stressors (e.g., regularly being unemployed every winter).
B. Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic
time of the year (e.g., depression disappears in the spring).
C. In the last 2 years, two Major Depressive Episodes have occurred that demonstrate the temporal
seasonal relationships dened in Criteria A and B, and no non seasonal Major Depressive Episodes
have occurred during that same period.
D. Seasonal Major Depressive Episodes (as described above) substantially outnumber the nonseasonal
Major Depressive Episodes that may have occurred over the individuals lifetime.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 33.11
Criteria for Chronic Specier
Specify if:
Chronic (can be applied to the current or most recent Major Depressive Episode in Major Depressive
Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of
mood episode)
Full criteria for a Major Depressive Episode have been met continuously for at least the past 2 years.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

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Table 33.12
300.4 Dysthymic Disorder
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or
observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and
duration must be at least one year.
B. Presence, while depressed, of two (or more) of the following:
poor appetite or overeating
insomnia or hypersomnia
low energy or fatigue
low self-esteem
poor concentration or difculty making decisions
feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been
without the symptoms in Criteria A and B for more than 2 months at a time.
D. No Major Depressive Episode has been present during the rst 2 years of the disturbance (1 year for
children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive
Disorder, or Major Depressive Disorder, In Partial Remission.
Note: There may have been a previous Major Depressive Episode provided there was a full remission
(no signicant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In
addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be
superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when
the criteria are met for a Major Depressive Episode.
E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have
never been met for Cyclothymic Disorder.
F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as
Schizophrenia or Delusional Disorder.
G. The symptoms are not due to the direct physiological effects of substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically signicant distress or impairment in social, occupational, or other
important areas of functioning.
Specify if:
Early Onset: if onset is before age 21 years
Late Onset: if onset is at age 21 years or older
Specify (for most recent 2 years of Dysthymic Disorder):
With Atypical Features
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

Table 33.13
311 Depressive Disorder Not Otherwise Specied
The Depressive Disorder Not Otherwise Specied category includes disorders with depressive features that
do not meet the criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder With
Depressed Mood, or Adjustment Disorder With Mixed Anxiety and Depressed Mood. Sometimes depressive
symptoms can present as part of an Anxiety Disorder Not Otherwise Specied. Examples of Depressive
Disorder Not Otherwise Specied include:
1. Premenstrual dysphoric disorder: in most menstrual cycles during the past year, symptoms (e.g.,
markedly depressed mood, marked anxiety, marked affective lability, decreased interest in activities)
regularly occurred during the last week of the luteal phase (and remitted within a few days of the onset
of menses). These symptoms must be severe enough to markedly interfere with work, school, or usual
activities and be entirely absent for at least one week postmenses.
2. Minor depressive disorder: episodes of at least 2 weeks of depressive symptoms but with fewer than
the ve items required for Major Depressive Disorder.

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3. Recurrent brief depressive disorder: depressive episodes lasting from 2 days up to 2 weeks, occurring
at least once a month for 12 months (not associated with the menstrual cycle).
4. Postpsychotic depressive disorder of Schizophrenia: a Major Depressive Episode that occurs during
the residual phase of Schizophrenia
5. A Major Depressive Episode superimposed on Delusional Disorder, Psychotic Disorder Not Otherwise
Specied, or the active phase of Schizophrenia.
6. Situations in which the clinician has concluded that a depressive disorder is present but is unable to
determine whether it is primary, due to a general medical condition, or substance induced.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.

as bereavement, interpersonal problems and


poor examination results may be reported in a
proportion of cases. The aetiology of primary
mood disorders is considered to be multi-factorial.
Aetiological factors include genetic, biochemical,
psychological, social and personality factors.

Many African patients do not volunteer feelings


of sadness, loneliness or guilt. Instead they have
physical complaints such as headaches, muscle and
joint pains, as well as generalised malaise. This
leads to many laboratory investigations and selfreferral to various health workers, as well as diverse
treatments without amelioration of symptoms.
The clinical condition can be recognised by
direct enquiry about the depressed mood (whether
or not it is referred to as the physical pains), lack of
pleasure, negative anticipation of the future, lack
of energy, sleep disturbance, lack of appetite and
lowered libido. Ideas of suicide and suicide attempt
are commonly experienced. Psychotic features
may be present. The hallucinations or delusions,
however, are congruent with the depressed mood,
self-deprecation and negative anticipation of the
future. Patients often believe they are suffering
from a serious and incurable physical condition.

Genetic factors
Clinical observations and family and genetic studies
indicate that affective disorders run in families.
Twin follow-up studies indicate that the chances
for an identical twin developing bipolar affective
disorder is 40 percent if the other twin is already
sick with the illness. Among dizygotic twins this
concordance rate is 11 percent.
Biochemical factors
It is now widely understood that mood disorders
are associated with abnormal brain biochemistry
involving various neuro-transmitters including
noradrenaline and serotonin (5-hydroxytryptamine). It has also been suggested that abnormal
functioning of certain hormone systems, particularly
involving cortisol and thyroid hormones, may be
responsible for episodes of major depression.

Epidemiology
It is estimated that depression affects 3 percent
of men and 4-9 percent of women. The lifetime
prevalence for depression is 8-12 percent for men
and 20-26 percent for women. About 12-20 percent
of individuals who experience an acute episode
of depression will develop a chronic depressive
syndrome mainly due to inappropriate diagnoses
and wrong drug management; and 15 percent of
persons who suffer from depression will eventually
die of suicide. This makes depression the leading
cause of deaths in psychiatric practice.
The lifetime risk of developing a manic disorder
is 1-2 percent. Manic illness occurs in relatives of
patients with the disorder much more frequently
than in relatives of patients with depression.

Psychosocial factors
Various
environmental
factors
and
psychosocial stressors may precipitate a mood
disorder. Examples include recent bereavement,
job loss, failed relationships, business failure and
failure in a major school examination.
Personality factors
Clinical experience suggests that those who develop
major depressive disorder tend to be either anxious,
fearful or i