General principles of assessment

and management of mental health

problems in primary general health
care practice

District Mental Health Cell

District Lucknow
 Learning Objectives

• Psychiatric Problems are commonly seen in

General Practice
• Scope and need of mental health service
delivery in primary care general health clinical
practice.
• Principles of assessment, including indicators
of “abnormal” behavior, as symptom or sign.
PREVALENCE OF PSYCHIATRIC DISORDERS
IN GENERAL PRACTICE
• World Health Organization (WHO)- 25% of the attendees at
GP/PHC suffered from one or more diagnosable psychiatric
disorders.
• Bangalore Centre found that 22.4% of the attendees at
GP/PHC suffered from one or more diagnosable psychiatric
disorders.
• Commonest psychiatric disorders found in General Practice
are Depression, Anxiety disorder, Alcohol dependence and
Somatoform disorders.
• 30%-50% of the patients with psychiatric problems in GP tend
to have protracted course leading to the disability.
 ….Prevalence
• About one third of the patients with psychiatric
problems in GP have coexisting physical illnesses
• Inadequate exposure to psychiatry during
undergraduate training in India.
• Identification rate for psychiatric illnesses in General
Practice / PHC can be significantly enhanced after
adequate training of concerned staff in Mental
Health.
Scope of Mental health service delivery in primary
general health care (what can be done?)

• Emergency Care: for persons suffering from episodes

of suicidal tendency, excitement and violence
• Acute and short term care: for some common mental
disorders (mild forms), substance use disorders and
psychological aspect of medical illness
• Referral: for severe mental illnesses, severe and
chronic forms of Common Mental Disorders and
Substance Use Disorders, Personality disorders and
Mental sub normality
• After care: for Schizophrenia and Mood disorders
• Advisory
 गलत धारणाएं ..
• मानसिक रोग या पागलपन एक ऐसा शब्द है जिससे इसके
कारण ों एवों उपचार के जवषय में न िाने जकतनी भ्ाों जतयााँ एवों
आशोंकाएाँ िुडी हैं ।
• कुछ ल ग इसे एक असाध्य, आनुवाों जशक एवों छूत की बीमारी
मानते हैं , त कुछ िादू -ट ना, भूत-प्रेत व डायन का प्रक प।
• कुछ ल ग इसे बीमारी न मानकर जिम्मेदाररय ों से बचने का नाटक
मात्र भी मानते हैं ।
• अज्ञानी ल ग उपचार के जलए स्थानीय या निदीक ओझा, पोंजडत,
मुल्ला आजद के पास िाकर अनावश्यक भभूत, िडी-बूटी का
सेवन करते हैं तथा अमानवीय ढों ग से सताये िाते हैं ताजक
'जपशाचात्मा' का प्रक प दू र जकया िा सके।
• यह सब गलत है । सही धारणा यह है जक यह बीमारी है और
वैज्ञाजनक ढों ग से जचजकत्सा जवज्ञान द्वारा इसका इलाि सोंभव है ।
 गलत धारणाएं ..
• मानजसक जवकार क ई र ग नहीों हैं बल्कि बुरी आत्माओों की विह से पैदा
ह ते हैं ।
• दवाओों के सेवन से बचना चाजहए।
• आपक यह र ग अपनी कमि री से हुआ है और इससे बचाव करना
चाजहए।
• दवाएों नुकसानदायक ह ती हैं , ये जनभभरता बढाती हैं और िीवनभर लेनी
पडती हैं ।
• ज्यादातर मन जवकार ों का क ई इलाि नहीों ह ता।
• बच् ों क दवाएों नहीों दी िानी चाजहए।
• इलाि के जलए नीोंद की ग जलयाों दी िाती हैं ।
• अवसाद िैसे मिभ अपने आप ठीक ह ते हैं या प्रभाजवत व्यल्कि के प्रयास ों
से।
• दे वी दे वताओों या झाडफूोंक से र ग सही ह सकता है ।
 तथ्य
• मन र ग जचजकत्सक द्वारा दवाएों बतायी गई हैं त इनका सेवन अवश्य
करना चाजहए।
• दू सरी बीमाररय ों की तरह यह र ग भी आों तररक स्तर पर िैजवक असोंतुलन
की विह से ह ता है ।
• जनगरानी में दवाएों लेना कारगर ह ता है , अब त नई दवाओों के उपलब्ध
ह ने के बाद लोंबी अवजध तक दवाएों लेने के मामले कम ह रहे हैं ।
• दवाओों के सेवन से मन जवकार ों में काफी कमी ह ती है , खासतौर से तब
िबजक इलाि शुरूआती चरण में आरों भ ह िाए।
• मन जवकार ों के उपचार में दी िाने वाली दवाएों रासायजनक असोंतुलन क
बहाल करती हैं , कुछ दवाओों से नीोंद आती है लेजकन वे नीोंद की ग जलयाों
नहीों ह तीों।
• अवसाद िैसे मन जवकार भी मधुमेह या उच् रिचाप की तरह के र ग ही
ह ते हैं और इनके जलए भी जवषेशज्ञ की दे खरे ख में इलाि कराने की
आवश्यकता ह ती है ।
 Key points
• Range of mental health problems exists
• Medical and psychiatric problems often
coexist.
• Mental health service delivery in primary
general health care setting is possible.
• Knowledge of principles of assessment for
paramedical staff to deal with psychiatric
problems
 Psychiatric disorders
Broadly classify into:
• Common mental disorders (CMDs):
depression, anxiety disorders

• Severe mental illnesses (SMIs):

schizophrenia, bipolar disorders
 Common Psychiatric Conditions

• ALCOHOL USE & DRUG USE DISORDERS

• PSYCHOSIS & SCHIZOPHRENIA

• SOMATOFORM DISORDERS
• EMOTIONAL & BEHAVIOURAL PROBLEMS IN
CHILDREN & ADOLESCENTS
• PSYCHIATRIC EMERGENCIES
 ALCOHOL USE
&
DRUG USE DISORDERS
 WHAT IS A DRUG ?
Drug is defined as

“any substance that, when taken into the living

organism, may modify one or more of its
functions.”
This definition conceptualizes ‘drug’ in a very
broad way,
 PSYCHO-ACTIVE SUBSTANCE?

• Substance affecting the way a person:

– Thinks
– Feels
– Acts
A psychoactive drug is one that is capable of altering
mental functioning.
These drugs could be Licit or illict
 PSYCH-ACTIVE SUBSTANCES

• 4,000 plants yield psycho-active substances,

• About 60 of these drugs have been in constant
use, somewhere in the world, throughout
history –
• Cannabis, opium, cocaine, tea, coffee, tobacco
and alcohol predominantly.
• Range of psycho-active substances continues
to expand.
 DRUG USE BEHAVIOUR
• DRUG ABUSE is the use of a drug without medical
prescription.

• DRUG DEPENDENCE refers to the

- progressive adaptation of cells, circuits, and organ systems in
response to excessive exposure to a drug.
- dependence represents a new equilibrium of physiological
functions in response to the repeated, continuous exposure
to a drug and the related organism’s compensatory counter-
mechanisms.

• DRUG ADDICTION a chronic, often relapsing brain

disease with strong craving and compulsive use despite
adverse consequences and loss of control over its use.
 FOUR CARDINAL FEATURES OF DRUG
ADDICTION
• Loss of control over the use of drug.

• Continuous use despite of adverse

consequences.

• Compulsive use

• Craving when the drug is withheld.

 PSYCHO-ACTIVE SUBSTANCES
• Alcohol
• Opioids i.e. opium, heroin
• Cannabinoids, i.e. Cannabis, Marihuana
• Cocaine
• Amphetamines and other sympathomimetic drugs
• Hallucinogens i.e. Lysergic acid diethylamide (LSD), Phencyclidine
(PCP)
• Sedatives and hypnotics i.e. barbiturates
• Inhalants i.e. volatile solvents
• Nicotine, and
• Other Stimulants i.e. Caffeine
• Mephedrone/Ecstacy/Club Drugs
 PATTERNS OF DRUG USE DISORDERS

There are follows 4 patterns:

• Acute Intoxication
• Withdrawal State
• Dependence Syndromes
• Harmful Use: continuous drug use, despite the
awareness of harmful medical and/ or social effect of the
drug being used.
• A pattern of physically hazardous use of drug i.e. driving
during intoxication
 ALCOHOL WITHDRAWAL STATES

• Alcoholic Tremulousness
• Alcoholic Hallucinosis
• Rum Fits
• Delirium Tremens
 NON-PHARMACOLOGICAL TREATMENT

Essential component to
• Motivate the patient to undergo treatment– to enhance
pharmacotherapy
• Have better compliance
• Prevent dropout from the treatment
• Relapse prevention
• Long-term abstinence
Can be used alone or in combination with pharmacotherapy, combination
therapy is more effective
 CANNABIS DEPENDENCE
GENERAL

• Derived from Cannabis sativa, has many chemicals

affecting cannabinoid receptors, delta-9-
tetrahydrocannabinol (THC) most prominent.
• Acute effects: euphoria, relaxation, dream-like state,
altered perception, anxiety, paranoia, increased appetite.
• 160 million cannabis users in the world, most common
dependence on a illicit drug.
 NARCOTICS
• Lower perception of pain & include Opium, Morphine, Codeine, Oxycodone,
Heroin. OPIOIDS ARE:
• Natural Alkaloids of opium
– Morphine
– Codeine
– Thebaine
– Noscapine
– Papaverine
• Synthetic Compounds
– Heroin
– Nalorphine
– Hydromorphine
– Methadone
– Dextropropoxyphene
– Meperidine (Pethidine)
– Cyclazocine
– Levallorphan
• Diphenoxylate
 OPIOID DEPENDENCE MANAGEMENT WITHDRAWAL
SIGNS

• Elevated HR & BP, diaphoresis, restlessness,

pupil size, bone or joint aches, runny nose or
tearing, GI upset, tremor, yawning, anxiety or
irritability, gooseflesh skin
• Score items stage to withdrawal
 LEARNING OBJECTIVES

To be able to identify depression in

outpatient settings

To distinguish between unipolar

depression and bipolar mood disorders

To know when to refer

 Affective disorders

Affective
disorders Recurrent
Manic depressive
episode episode

Bipolar Depressive
affective episode
disorder
 Risk factors for depression

Female sex

Age <40 years

Impaired interpersonal relationships

Divorced, widowers

Family history of depression

Negative life events

 For a depressive episode: diagnostic
criteria
For at least 2 weeks, has the person had at least 2 of the •Symptoms should be
following core symptoms: causing significant socio
•Depressed mood (most of the day, almost every day), occupational dysfunction
(for children and adolescents- irritability or depressed •Rule out bereavement in
mood) past 2 months
•Rule out the possibility of
•Loss of interest or pleasure in activities that are
bipolar depression.
normally pleasurable
•Decreased energy or easily fatigued
If 2 other features Mild
During the last 2 weeks has the person had at
depressive episode
least 2 other features of depression
•Reduced concentration and attention If 3 other features Moderate
•Reduced self-esteem and self-confidence depressive episode
•Ideas of guilt and unworthiness
•Bleak and pessimistic view of the future If 3 of the core features and 4
•Ideas or acts of self-harm or suicide other symptoms Severe
•Disturbed sleep depressive episode
•Diminished appetite It may be with or without
psychotic features
An episode can be with or without Somatic syndrome (4 or more of the following)

loss of interest in activities and lack of emotional reactivity, Loss of appetite,

Weight loss, Insomnia mainly as early morning awakening, depression worse in
morning, Low libido, Psychomotor retardation or agitation

Recurrent Repeated episodes of depression

depressive with current episode being mild,
disorder moderate or severe

A chronic depressive state that does

Dysthymia not meet criteria for a depressive
episode anytime and lasts for at least 2
years
 Domains of symptoms
psychological somatic psychotic suicidal thoughts

• sadness • weight loss or • delusions • always enquire

• hopelessness gain (pertaining to about ideas of
• helplessness • insomnia or ideas of sin, self harm
hypersomnia poverty, deserved proactively
• worthlessness
• loss of libido punishment,
• guilt imminent
• psychomotor • present plan
• pessimism disasters for
slowing or • available means
• anhedonia which patient
agitation • previous attempt
• difficulty feels responsible)
concentrating • Hallucinations • family history of
( usually auditory suicide
• loss of interest
of accusations • any impulsive act
and defamation • how impulse is
or olfactory of resisted
rotting things) • any psychotic
• stupor (if marked feature leading to
slowing) such ideas
 Mental status examination

 Generalised psychomotor retardation ( or agitation in elderly),

stooped posture, slow spontaneous movements, downcast gaze
 decreased rate of speech with increased reaction time
 depressed mood and restricted affect
 delusions or hallucinations in perceptual disturbance
 Thought process- may be slow with poverty of ideas
 Memory may be impaired with increased impulsivity (assess for
suicide) with impaired judgement (too pessimist) and insight may
be impaired
 Classic triad of pessimist thoughts about self, future and others
 MANAGING DEPRESSION
• Psychoeducation
• Relieve the symptoms of present
episode (remission)
• Frequent follow ups until remission
• Restore premorbid functioning of
individual
• Maintain treatment to prevent relapse
(usually if no or minimal depressive
Goals symptoms for 9 – 12 months and ability
to carry out routine activities for that
time period consider tapering and
stopping the antidepressant)
 When to refer

Patient has severe depression with psychotic features

Suicidal ideations

Failure of 2 or more antidepressants

Psychological intervention needed ( lack of resources)

Bipolar affective disorder

Multiple comorbid conditions

Special population if not manageable

 Bipolar affective disorder (BAD)
• An episode of mania or hypomania, may or may not be followed by a
subsequent mood episode
• 5-10% of patients with initial diagnosis of major depressive episode have
a manic episode later

• Mania: Diagnostic criteria

Elevated, expansive or irritable mood + 3 of the following(4 if mood is
irritable)
 Increased activity, restlessness, excitement Multiple symptoms, lasting for at
least 1 week
 Increased talkativeness
 Loss of social inhibitions Severe enough to interfere
 Decreased need for sleep significantly with work and social
activities or requiring
 Overspending or other reckless behaviours hospitalization
 Distractibility
 Elevated sexual energy
 Management

• Psycho education
• Treat the present episode
• Prevent relapse by maintenance
treatment ( at least 2 years after last
bipolar episode )
• Know when to refer
Goals • rehabilitation (appropriate economic,
social, cultural and educational activities)
 Pearls to remember

Depression is the commonest psychiatric morbidity in General Practice and should

not be overlooked

A depressed patient usually presents with physical symptoms that should be

explored

Comorbid psychiatric and general medical conditions are common and should be
treated

It is also important to ask about prior manic or hypomanic episode to avoid

misinterpreting bipolar disorder for unipolar depression.

Physicians should not be reluctant to ask about suicide as proactive questioning

may be life saving

Not just short term treatment but maintenance treatment, relapse prevention and
psycho social rehabilitation should be the goal
Psychosis
 Learning objectives

• Identify cases of psychosis

• Preliminary assessment of psychosis
• Effective follow up care of patients with
psychosis
 Psychosis
• Psychosis (is a Greek word, "psyche" refers to
mind/soul and “-osis" refers to abnormal condition or
derangement) meaning ‘’an abnormal condition of the
mind’’.
• Characterized by an individual’s loss of contact with
reality; distortions in thinking and perceptions, as well
as inappropriateness in emotions and behaviour.
• Occurs in schizophrenia, depression, bipolar disorder
and sometimes with alcohol abuse; medical and
neurological conditions and caused due to
medications.
 Schizophrenia
• Schizophrenia and other forms of psychoses that affect
young people represent a major public health problem.
• Common myth in general public to consider it due to
religious and supernatural causes than illness, which
often leads to delay in treatment seeking.
• Moreover, due to stigma attached to mental health
services, there is often a delay in reaching to the
psychiatrists.
• Thus, general physicians can be effective bridge if
diagnosing, managing and effectively referring such
patients.
 Clinical features
• Abnormal/ disorganised behaviour /unusual
appearance
• Un-understandable talk/Non-sensible speech
• False beliefs (e.g. ‘’people are planning to kill me’’)
• False perception (e.g. hearing voices of people not
around)
• Social withdrawal and neglect of usual responsibilities
related to work/school/domestic chores
• Talking to self
• Violent/aggressive behaviour
• Restless and running here and there
 ….classify symptoms
Clinical symptoms and signs for evaluation of
psychosis for ease of understanding can be
divided into following two groups:
• Positive symptoms
• Negative symptoms
 Positive symptoms
• Called ‘positive’ since the person’s thoughts, beliefs or sensations
seems to be ‘’abnormally expanded or greater’’ than normal;
suggest person having lost contact from reality and of having
created one’s false world.
• Hallucinations: refers to perceiving any sensations in absence of a
real stimulus, e.g. hearing or seeing things that are not there.
• Delusion: refers to false beliefs that are held with extraordinarily
conviction and are not shared by other members of the society.
• Thought disorder: refers to the disorganization in thought as
reflected by speech or sentences which are disjointed or cannot be
understood e.g. while speaking person looses chain of thought or
one thought has no connection with other.
 Negative symptoms
Called ‘negative’ since they involve ‘’decrease’’ in
a person’s usual experiences and functioning.
They include:
• Little/ no drive to do things
• Lack of energy and interest
• Little display of feelings
• Speaking very less
 Schizophrenia
• More than two symptoms of the following if
present for more than one month duration
causing disturbance in functioning:
– delusions
– hallucinations
– disorganized speech
– grossly disorganized or catatonic behavior
– negative symptoms
 Assessment
• Good clinical history, thorough medical
examination and mental status examination
are the keys to make diagnosis.
• Take history from patient, accompanying
caregivers and screen relevant treatment and
investigation records
Psycho-education: Discuss with the patient and family
regarding:
-The person’s ability to recover;
-The importance of continuing regular social, educational
and occupational activities, as far as possible
-the suffering and problems can be reduced with
treatment
-the importance of taking medication regularly;
-the right of the person to be involved in every decision
that concerns his or her treatment
-Importance of staying healthy (e.g. following healthy
diet, staying physically active, maintaining personal
hygiene).
 Vocational rehabilitation

• Actively encourage the person to resume social,

educational and occupational activities as
appropriate and advise family members about
this.
• Facilitate inclusion in economic and social
activities, including socially and culturally
appropriate supported employment.
• Work with local agencies to explore employment
or educational opportunities, based on the
person’s needs and skill level.
 Follow-ups
Follow up frequency:
• Acute phase: Follow up once or twice weekly.
• Maintenance phase: Follow up every one to three month.
Follow up assessment: During follow up visits, assess for the
following:
• -Level of symptoms
• -Side-effects of medications
• -Treatment adherence: Treatment non-adherence is
common, address it
• -Assess for and manage concurrent medical conditions
• -Assess for the need of psychosocial interventions at each
follow-up
• -Maintain realistic hope and optimism during treatment
• -Involvement of carers is critical during such periods
 Referrals
Nature of illness
-Severe level of symptoms and distress
-Suicide or risk of harm to others
-Marked violent aggressive behavior
-Catatonic symptoms
-Poor general medical status
-Refusal to accept orally (meals/ medications)
Nature of treatment
-Partial or no response to treatment
-Need to start modified electroconvulsive therapy
-Need to start clozapine
-Need of specific psychological therapies or vocational rehabilitation
Support system
-Poor social support system (e.g. homelessness)
-Family needs psycho-education about nature of illness and need of
treatment
 Table of contents
Learning objectives

Introduction

Types of Anxiety Disorders

For individual anxiety disorder- Case vignette and diagnostic criteria

Management
Pharmacological Non pharmacological

When to refer

Pearls to remember
 Learning objectives

Understand the whole range of anxiety disorders

To be able to identify and differentiate various anxiety

disorders

To understand the other conditions that may masquerade

as anxiety disorders and vice versa

To be able to treat adequately these disorders

 What is anxiety???

12-month prevalence rate of anxiety disorder is 17.7 percent

ANXIETY FEAR
 Diffuse, vague, unpleasant sense of  Response to external, known,
apprehension that is felt as psychic definite, non conflictual threat
tension and restlessness or  Alerts the individual
autonomic arousal
 Usually insidious to an unknown,
internal, vague, conflictual threat
 Normal but if causes excessive
arousal and impairment in
functioning- pathological needs to be
treated
 Types of Anxiety Disorders

Obsessive
Phobic anxiety Generalised anxiety
Panic disorder compulsive
disorder disorder
disorder

Anxiety disorders
Acute stress Post-traumatic due to general
disorder stress disorder medical condition
and substances
Phobic anxiety disorder

Agoraphobia

Specific Social
phobia phobia
 Diagnostic criteria and clinical
features
• Marked and consistent fear or avoidance of at least two of the following
situations: crowds; public places; travelling alone; travelling away from
home.
• Symptoms of anxiety in the feared situation at some time since the onset of
the disorder, with at least two symptoms

Autonomic arousal symptoms General symptoms

Palpitations, Sweating Trembling, Dry mouth
Symptoms concerning chest and abdomen
Difficulty breathing, Feeling of choking, Chest pain or
discomfort, Abdominal distress
Symptoms concerning brain and mind
Feeling dizzy or light-headed
Derealization depersonalization
Fear of losing going crazy, Fear of dying.
Hot flushes or cold chills, Numbness or tingling
sensations.
Significant emotional distress due to the avoidance or
the anxiety symptoms, and a recognition that these are
excessive or unreasonable.
Symptoms predominate in the feared situations or when
thinking about them.
Agoraphobia CAN BE without panic disorder
 Case vignette-social phobia

20 year old female patient, complaint from college - does not participate
in any group activities and has become irregular

Patient reported that she felt extremely nervous in groups where she was
expected to perform

Felt she will embarrass herself, people will mock at her, she will end up
making a fool of herself

Avoided any school group activities, felt pensive as she felt she is missing
out on a lot of stuff but goes blank whenever she tries to do it

Even thinking about it gave her butterflies

 Diagnostic criteria
Social phobias
Either (1) or (2):
(1) Marked fear of being the focus of attention, or fear of behaving in a way that will
be embarrassing or humiliating
(2) Marked avoidance of being the focus of attention or situations in which there is
fear of behaving in an embarrassing or humiliating way.
These fears are manifested in social situations
At least two symptoms of anxiety in the feared situation at some time since the onset
of the disorder, as defined in Agoraphobia and in addition one of the following
symptoms: Blushing; Fear of vomiting; Urgency or fear of micturition or defecation
Significant emotional distress due to the symptoms or to the avoidance and
recognition that the symptoms or the avoidance are excessive or unreasonable
Symptoms predominate in the feared situation or when thinking about it
 Diagnostic criteria
Either (1) or (2):
(1) marked fear of a specific object or situation other than agoraphobia or social
phobia
(2) marked avoidance of such objects or situations
Symptoms of anxiety in the feared situation at some time since the onset of the
disorder, as defined in agoraphobia.
Significant emotional distress due to the symptoms or the avoidance, and a
recognition that these are excessive or unreasonable.
Symptoms are restricted to the feared situation, or when thinking about it.

It can be : animal type (e.g. insects, dogs); nature-forces type (e.g. storms, water);
blood, injection and injury type; situational type (e.g. elevators, tunnels); other type
 Panic disorder
• Lifetime prevalence - 1-4%
• Women twice more likely to be affected
• Mean age of presentation 25 years

Diagnostic Criteria
• Recurrent panic attacks that are not consistently associated with a specific
situation or object and often occurring spontaneously
• The panic attacks are not associated with marked exertion or with exposure to
dangerous or life-threatening situations.
• A panic attack is characterized by all of the following:(a) it is a discrete episode of
intense fear or discomfort; (b) it starts abruptly; (c) it reaches a crescendo within a
few minutes and lasts at least some minutes; (d) at least four symptoms of anxiety
must be present as described in phobic disorder above
 Generalised anxiety disorder (GAD)

 A period of at least six months with prominent tension, worry and feelings of
apprehension, about every-day events and problems.
 Four symptoms out of the following list
1. Autonomic arousal 3. Symptoms concerning 4. General symptoms
symptoms brain and mind Hot flushes or cold chills,
Palpitations, Sweating Feeling dizzy or light- Numbness or tingling
Trembling, Dry mouth headed. Feelings that sensations.
2. Symptoms concerning objects are unreal Symptoms of tension
chest and abdomen derealisation, Muscle tension or aches and
Difficulty breathing, Feeling depersonalization pains, Restlessness and
of choking, Chest pain or Fear of losing going crazy, inability to relax, Feeling
discomfort, Abdominal Fear of dying. keyed up, or on edge, or of
distress mental tension, A sensation
of a lump in the throat, or
difficulty with swallowing.
 Obsessive compulsive disorder
• Fourth most common psychiatric disorder
• Equal prevalence in men and women
• Mean age of onset in 20 years
• Diagnostic criteria
Either obsessions or compulsions (or both), present on most days for a period of at
least two weeks
Obsessions (thoughts, ideas or images) and compulsions (acts) share the following
features
1. They are acknowledged as originating in the mind of the patient and are not
imposed by outside persons or influences.
2. They are repetitive and unpleasant, and at least one obsession or compulsion
must be present that is acknowledged as excessive or unreasonable.
3. The subject tries to resist them but at least one obsession or compulsion must be
present which is unsuccessfully resisted.
4. Carrying out the obsessive thought or compulsive act is not in itself pleasurable.
The obsessions or compulsions cause distress or interfere with the subject's social or
individual functioning, usually by wasting time.
30 year old male patient, appeared unkempt

Since last 10 years, preoccupied with cleanliness

Used to wash his hands multiple times after touching anything and even if anyone
touched him

Bathing took almost an hour

Told he knew his doubt was unreasonable and excessive, tried not to act on it but
doing this would make him extremely uncomfortable and he was driven to clean

Wasted a lot of his time, his skin was all dry and shrivelled but

To resist all this he had stopped going out and used to go for bathing and
defecation only once in 4 days so that he would have to spend less time in cleaning
 Acute stress disorder
Exposure to an exceptional mental or physical stressor

Followed by an immediate onset of symptoms (within one hour)

(1) The criteria for symptoms as mentioned in generalized anxiety disorder

(2) Withdrawal from expected social interaction; narrowing of attention; apparent
disorientation; anger or verbal aggression; despair or hopelessness; purposeless over-
activity; uncontrollable and excessive grief (judged by local cultural standards).

If the stressor is transient or can be relieved, the symptoms must begin to diminish
after not more than eight hours. If the stressor continues, the symptoms must begin
to diminish after not more than 48 hours.
 Post-traumatic stress disorder
Exposure to a stressful event or situation of exceptionally threatening or catastrophic
nature, which is likely to cause pervasive distress in almost anyone
Persistent remembering or reliving the stressor by intrusive flash backs, vivid
memories, recurring dreams, or by experiencing distress when exposed to
circumstances resembling or associated with the stressor
Avoidance of circumstances resembling or associated with the stressor
Either (1) or (2):
(1) Inability to recall, either partially or completely, some important aspects of the
period of exposure to the stressor
(2) Persistent symptoms of increased psychological sensitivity and arousal shown by
any two of the following: difficulty in falling asleep, irritability, difficulty in
concentrating; hyper-vigilance; exaggerated startle response.
Symptoms occurred within six months of the stressful event, or the end of a period of
stress.
 Pearls to remember

Anxiety disorders are very common in general practice

It may often be overlooked or misdiagnosed as a medical

disorder

Proactive exploration may lead to timely treatment and

improved quality of life

BZD’s should not be overused and should be tapered over

few weeks
 Learning Objectives

• Evaluate and recognize common childhood

psychiatric disorders
• Learn few behavioural principles used in
management of childhood psychological problems
• Enlist the indications for referring the patient for
specialist care
 Introduction
• Remember that the developmental stage influences
the presentation of behaviours in children
• Transient symptoms and behavioural disturbances
are common in children of all ages.
• There is need to differentiate between normal vs
‘abnormal’ behaviours.
• Remember that children are often brought for
consultation. Parents often seek help for various
concerns regarding their children.
 Epidemiology of child psychiatric disorders

• Most disorders :Boys > girls.

• Commonest diagnosis: conduct disorder and
emotional disorders.
• Common in children with Mental Retardation,
epilepsy, and medical illnesses.
• Mostly Western data available. Indian data is meager.
 Aetiology in Child Psychiatry

• Same broad range of etiological factors operates in

childhood as in adulthood namely Bio-Psycho-Social factors
• There is a genetic component to most disorders, mediated
partly through its influence on intelligence & temperament.
• Major environmental factors include Family & Social
circumstances.
• The family factors: Parenting styles, parental health,
parental conflict/ separation and social factors include
deprivation.
• Other factors like medical disorder (Epilepsy) might also
increase the risk
 Assessment Process

– Assessment of Childhood Psychiatric problems involve

talking with the child, as well as parents supplemented by
information from teachers
– Try to obtain information from multiple informants
about specific events & behaviours
– Parents if available, can be interviewed alone first to
establish the history.
– One may use Play & non-threatening conversation to
gain trust with the child with ease .
– Adolescents can be interviewed separately .
– School reports, IQ testing and use of tools (CBCL) can
supplement the information of child.
 Key points to remember during assessment

• Do not use stigmatizing words and phrases

• Communication with the child should be clear and coherent
• Identifying a child with having one or another problem
behavior by no means is proof of a clinical diagnosis
• Process of identification is only to help out children with
possible underlying mental health problem
• The identification of mental health problem should not lead
to ‘labeling” a child or use of pejorative comments
 How to recognize the ‘ pathological’ nature of
behavior / symptom pattern

• occurs more commonly than usual

• are inappropriate for the child's age;
• are of reasonable intensity;
• persists for reasonable length of time;
• Interferes with the child's life
 Range of childhood psychiatric disorders
• Hyperkinetic Disorders (ADHD)
• Conduct Disorder
• Learning Disorders (SLD)
• Pervasive Development Disorders (Autism)
• Mental Retardation
• Depression and associated suicide
• Enuresis (bedwetting)
• Substance Abuse
• Anxiety Disorders
• Psychosis (schizophrenia)
• Tic Disorders (including Tourette’s Syndrome)
 Attention Deficit Hyperkinetic Disorder (ADHD)
• Onset is usually in early childhood (before age 7) but the problem
is usually identified when the child starts going to school
 The main feature is  The other characteristic is poor
Hyperactivity: attention span and Impulsivity
- Restless and cannot sit still. - These children do not
- Fiddle with everything around concentrate on any task and
- Cannot concentrate on any given leave most tasks unfinished.
task - These patients may have many
- Show episodes of rage or crying other associated symptoms like ,
- Show temper tantrums poor scholastic performance and
antisocial behaviour.
 Management of ADHD
Pharmacotherapy:
• The CNS stimulants: These drugs reduce hyperactivity and
improve attention span
– Methylphenidate (0.25-1 mg/kg/day )
• Non-stimulant: Atomoxetine (1- 1.4 mg/kg qd)
• Antidepressants, like imipramine in the dosage from 50 - 150
mg/day have been used
Psychological Treatment:
• Behaviour Modification
• Their hyperactivity could be channelized into outdoors sports
• Role of Social skills training, and parent training.
Note: Combination of Pharmacological and psychological therapy is
better than either
 Conduct disorder
These children may show any one or more of the following:
• excessive level of fighting or bullying
• cruelty to animals or other people
• fire setting
• stealing
• repeated lying
• truancy from school and running away from home
• frequent and severe temper tantrums; defiant provocative
behavior and persistent severe disobedience
 Management of Conduct disorder

• Conduct disorders require “psychological management”

– Family should always be involved and attempt should be
made to help the family to provide consistent upbringing
– Behaviour modification with positive reinforcement

• “Medication” may be needed to control aggressiveness or

hyperactivity.
-- Haloperidol in small doses & mood stabilizers like
Carbamazepine may be helpful.
 Childhood Depression

May present with

• Irritability
• School refusal
• Somatic complaints (Pain abdomen)
• Friendship difficulties / social withdrawal
IMPORTANT:
• Assess for suicide risk
 Learning Disorders

• Learning disorders are diagnosed when the

individual’s academic achievement in reading,
mathematics, or writing is substantially below what
would be expected for age, schooling and intellectual
ability

• Treatment is limited and basically school focused and

aims at obtaining occupational self-sufficiency
 Learning Disorders
Reading Reading skills significantly below expectancy
disorders Significantly interferes with academic
achievement or activities requiring reading skills
Mathematics Mathematics skills significantly below
disorders expectancy
Significantly interferes with academic
achievement or activities requiring mathematics
skills
Disorder of Writing skills significantly below expectancy
written Significantly interferes with academic
expression achievement or activities requiring writing skills
 Autistic Spectrum Disorders

• Also called Pervasive developmental disorders.

• Includes Childhood Autism, Asperger’s disorder, Rett’s syndrome etc
• Is characterized by significant problems in three domains of:
– Communication
– Social interactions
– Stereotyped patterns of behaviour

 Associated with hyperactivity, Self injurious

behaviour, epilepsy (in 25% cases), and
low IQ (<70 in 75% cases)

 Idiot savants/splinters

 High functioning autism

 Autism
Clinical features:
– Marked impairment in the use of non-verbal behaviours
– A decrease or lack of spontaneous seeking to share enjoyment,
interests, or achievements with other people
– Decreased or lack of social or emotional reciprocity
– Failure to develop peer relationships appropriate to develop. level
– Delay or total lack of development of spoken language
– Stereotyped or repetitive use of language or idiosyncratic language
– Lack of spontaneous make-believe play or social imitative play
Treatment of Autism:
• Behavioural, psychotherapeutic as well as pharmacologic approaches
• There is no cure for the core disorder
• The goal of treatment is to lessen symptoms as well as to help the
individual achieve the maximally feasible quality of life
 Mental Retardation
• Mental retardation is defined as:
– IQ below 70
– Impairment across a wide range of functions
– And onset in childhood
• The assessment of a child with suspected mental
retardation encompasses:
– Making the diagnosis
– Evaluating concurrent psychiatric problems
• Management is aimed at maximizing potential and
quality of life, and treating concurrent psychiatric
problems.
 Mental Retardation
• Mental Retardation is not equivalent to
mental illness.
• Mental Retardation are of 4 categories;
• Mild (IQ = 50 – 69)
• Moderate (IQ = 35 – 49)
• Severe (IQ = 20 – 34)
• Profound (IQ = less than 20)
Note: Children with MR can avail disability benefits
 Mental Retardation

• Marked delay in development (including

sitting, standing, walking, speaking etc.)
• Inability to carry out age appropriate
activities for personal living including eating,
drinking, bathing, dressing etc
• Inability to understand and learn at home or
in school
• Inability to recognize colour, shape, size,
direction, weight or any such concepts
 Mental Retardation

• Inability to recognize, count, and operate

money
• Inability to travel independently and make
purchases
• Inability to judge right or wrong
• Inability to behave age appropriately in social
situations
• Behavioral problems
 Non-Organic Enuresis (Bedwetting)
• Majority of children become dry by about 5 years
• Enuresis is characterized by involuntary voiding of urine
by day or night
• It is not caused by neurological or other organic factors
 School refusal
• School refusal is not a psychiatric disorder, but it is a common
cause of consultation and is frequently caused by emotional
disorder (social phobia, specific phobia, separation anxiety
disorder) or possible child abuse.
• Assessment of suspected school refusal:
– Why is the child absent from school?
– What does the school refusal reflect?
– What are the other factors affecting the presentation?
• Management:
– Should aim at a rapid return to school before avoidance is
too ingrained. Always involve parents & teachers
– Beh Therapy in form of a graded re-exposure is useful
– Need to address any specific fears of stress, and treat any
associated psychiatric disorder
 Poor School Performance (PSP)
Evaluate by ruling out sequentially the following
causes of PSP:
• Sensory impairments (blindness, deafness)
• Intellectual Disability/MR
• Learning Disorders/SLD (Dyslexia)
• Behavioural Disorders (ADHD)
• Emotional Disorders (Anxiety disorders)
 Disorders of adolescence
Are classified in terms of:
• Residual childhood problems (e.g. conduct
disorder)
• Problems of adolescent transition (adjustment
disorder, eating disorder, Para suicide/DSH,
drug abuse)
• Early adult disorders (e.g. Schizophrenia,
bipolar disorder, OCD)
 Management in Child Psychiatry

• Management of children with psychiatric disorder is based

upon several principles:
– Take the child’s developmental stage and overall level of
functioning into account.
– Most problems are treated initially with reassurance,
support and behavioural interventions.
– Whatever the treatment, involve the family.
– Avoid removal from school or home wherever possible.
– Medication has a limited role in most disorders.
 General principles of behaviour therapy

• Desired behaviours need to be reinforced and

unwanted behaviour should be decreased

• Positive reinforcement is used to promote

desired behaviours. It involves the use of
rewards which include tangible rewards-
food/toy etc and social rewards - praise.
 General principles of behaviour therapy

• Unwanted behaviours can be decreased by

ignoring them or taking away existing
privileges . For example: withholding TV
viewing or a regular excursion.
• Punishment should not be used to bring about
a behaviour change
• One has to be consistent in providing
reinforcements and they should be contingent
to the behaviour
 Indicators for Referral to Specialized mental health
centres
• If the child is suicidal
• If the child exhibits verbal, physical or sexual
aggression
• If the child is suspected of using drugs
• If the child has made attempts in the past to
harm oneself and continues to do so.
• If the child exhibits behavior, which is difficult
to control.
 When should you refer?

• When treatment is unclear

• If the medications indicated are not available
• In cases of psychiatric co-morbidity
• When first line therapy fails
• Presence of Suicide Risk

* Some cases may be referred in first instance. Others

may be treated and then referred
 Consider referral
Psychological Problems REFER TO

Mental retardation Psychiatrist, Clinical

Psychologist, Speech therapist,
ENT specialist, Special educator
Autism Psychiatrist, Occupational
therapist
Significant learning/ academic Psychiatrist, Special educator
problems
Suicidal or self-injurious behaviour, Psychiatrist
severe aggression
Psychosis, Substance abuse Psychiatrist

Attention Deficit hyperactivity Psychiatrist, Clinical psychologist

Disorder, Conduct disorder
Mood disorder, anxiety disorders Psychiatrist, Clinical psychologist
Psychiatric Emergencies
 Introduction
• A psychiatric emergency is defined as - “any
disturbance in thoughts, feelings or actions
for which immediate therapeutic
interventions are necessary”.
• Patients may cause harm to themselves or
others or suffer immense, acute distress
which is intolerable.
 General principles
• The principles underlying many
psychiatric emergencies remain the
same.
• The emergent task at hand - triage,
evaluation, formulation, and disposition,
keeping safety for the patient, others,
and oneself
• Always err on the side of caution
• Ensuring the safety of the patient, others and
oneself is the challenge.
• The management of a psychiatric emergency is
a team effort in which both medical
professionals and hospital staff have crucial
roles.
•Appropriate management of psychiatric
emergencies saves lives.
 Examples

1. Suicidal patient,
2. Violent patient,
3. Substance withdrawal,
4. Severe anxiety/ panic attack,
5. Drug toxicity/ intoxication,
6. Drug induced Parkinsonism.
 SUICIDE
•Defined as:- termination of one’s life
intentionally.
•3rd leading cause of death between 15-24 yr.
•Suicidal patient is one- who attempted, tried to
attempt or frequently thought of attempting
suicide.
•Emergent intervention is required- as suicide can
be prevented.
•Prevalence of suicide- 10-15% in depression,
10% in schizophrenia, number rises when
alcoholism is comorbid.
•Rate is 11.2 per lac in 2011, India
•One person commit suicide every 40 sec.
globally
•Poisoning ,hanging, self immolation, slitting of
wrist & overdose of sleeping pills are some
common means.
•“Risk assessment is the integral part of
evaluation and management”.
 Warning signs of suicide
1. A person talks about death, threatens of committing/
discussing suicide.
2. Discuss different methods of suicide.
3. A person mentions suicide ideation.
4. A person attempts an act of deliberate self harm.
5. A person is seen making good bye gestures or
communications, writing of will/ other acts suggestive of
suicidal plan.
6. A person has suffered recent major loss of life or
property.
7. Hopelessness.
8. Severe agitation/ anxiety.
 Presentation
1. Such patients have either-
frequently thought of/
contemplated suicide/have
planned the act/ have attempted
the act.
2. Such patients are brought by
family members.
 Risk factors
1. Female gender,
2. Elderly age group,
3. Depression/ psychiatric illness
4. Poor social support,
5. Single status,
6. Alcohol abuse,
7. Chronic physical illnesses,
8. Family history.
 Suicide risk assessment
• Integral part of management of such
patients.
• Establishes severity of situation and
likelihood of future death by suicide.
 Types of suicide risk

1. Low suicide risk:- less severe psychiatric illnesses, better

social support, fewer attempts, have employed less lethal means
of suicide such as superficial cut marks on wrist.
2. Moderate suicidal risk:- presence of psychiatric disorder,
multiple attempts, attempts in last few days, low-moderate
lethality attempts like pills, alcoholism.
3. High suicide risk:- severe psychiatric illness, attempt in last
few hours, lethal attempts like hanging/ gunshot/ pesticide, poor
social support.
 Factors associated with high
suicide risk
1. Psychotic symptoms.
2. Lethal attempt.
3. Accessible weapon.
4. Alcohol use.
5. Suicidal plan.
6. Suicidal intent.
 General Interventions of emergency
management
• Physical restraint
• Pharmacotherapy
• Hospitalization
• Management of medical problems
• Crisis intervention:
1. Supportive psychotherapy
2. Environmental manipulation
3. Dealing with spouse, friends
 Management
•Goal of intervention- to prevent completed suicide.
•If intervention done timely, suicide is preventable.
•Suicide risk assessment is important.
Steps in management of suicide:-
Step 1:- Assess physical condition of the patient.
( vitals, pallor, cyanosis, higher mental functions, local
injury/wound etc.)

Step 2:- If found medically stable, calm down patient, do

risk assessment.
 Steps conti.

Step 3:- Evaluate for underlying psychiatric illness,

history and mental status examination need to be done.
Step 4:- Once suicide risk assessed, admit the patient.
-Instruct hospital staff and family member for 24
hour vigilance.
-Remove potentially harmful objects from patients
vicinity.
-All medications should be supervised.
 Prevention
1. Early recognition of suicide risk factors.
2. Early diagnosis and prompt treatment of mental
disorders like schizophrenia, depression, bipolar disorder
and substance abuse.
3. Identify warning signs- talks, threats, thoughts or
previous attempts of deliberate self harm.
4. Directly asking patients about - death wishes, suicidal
ideations, intentions.
5. 24 hour strict vigilance is advised till underlying
psychiatric illness responds to treatment.
 When to refer a suicidal patient

1. All suicidal patients require psychiatric

evaluations once medically stable.

2. Hospitalization in psychiatry ward

recommended for all patients who have made
lethal attempts of deliberate self harm/ who
exhibit high risk of suicide.

3. Early psychiatric intervention can prevent

suicide.
 VIOLENT PATIENT

Violence include:- physical assault/ threat,

breaking of property, verbal abuse.
Psychiatric disorders commonly associated with
violence are:-
-Psychosis,
-Mania,
-Schizophrenia,
-Substance intoxication.
-Personality Disorders
-Mental Retardation
 Medical conditions presenting with
violence

:-
- Ictal and post-ictal states.
- Head injuries.
- Frontal & temporal lobe
pathologies
- Dyselectrolemias.
- Delirium & dementia.
- Renal & hepatic failure.
- Endocrine disorders.
 Management
1. Ensure the safety of others including oneself.
2. Restrain or seclusion may be required. ( care to be
taken not to violate human rights of any patient by
forceful restraint/ injection unless as last resort).
3. To rule out organicity and look for treatable medical
cause and if needed prescribe Medication oral or
parentral to control agitation.
5. Psychiatric assessment by history and MSE to establish
underlying diagnosis and treat underlying psychiatric
disorder.
“Management of a violent patients require patience,
vigilance, team effort and preparedness”.
 Special precautions
1. Don’t approach a violent patients alone, staff should
be present.

2. Ensure removal of potentially harmful objects from

patients vicinity.

3. Assess for the possibility of possession of weapon by

patient.

4. Ensure suitable escape route in case of uncontrollable

violence.
 Special precautions (conti.)

5. Don’t intimidate, argue or pose any threat to the

patient.

6. Approach patient in calm and non threatening

manner.

7. Maintain at least 3-6 feet distance from patient.

8. If patient agrees to speak with you, sit him down and

listen him, let him know you are there to help him and he
need not to fear.
 When to refer a violent patient
- Allsuspected cases of organicity should be investigated
and referred to concerned speciality.

- All stabilised patients should be sent for psychiatric

evaluation and management.

- Medical conditions should be examined and stabilised

before a psychiatric referral.

- Very severe cases need inpatient management.