A Guide to Mental Health and Psychiatric Nursing R Sreevani
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Mental Health and Mental Illness1

 
 
MENTAL HEALTH
It is a state of balance between the individual and the surrounding world, a state of harmony between oneself and others, a co-existence between the realities of the self and that of other people and the environment.
 
Definitions
Karl Menninger (1947) defines mental health as “An adjustment of human beings to the world and to each other with a maximum of effectiveness and happiness.”
The American Psychiatric Association (APA 1980) defines mental health as: “Simultaneous success at working, loving and creating with the capacity for mature and flexible resolution of conflicts between instincts, conscience, important other people and reality”.
Thus mental health would include not only the absence of diagnostic labels such as schizophrenia and obsessive compulsive disorder, but also the ability to cope with the stressors of daily living, freedom from anxieties and generally a positive outlook towards life's vicissitudes and to cope with those.
 
Components of Mental Health
The components of mental health include:
  • The ability to accept self: A mentally healthy individual feels comfortable about himself. He feels reasonably secure and adequately accepts his shortcomings. In other words, he has self-respect.
  • The capacity to feel right towards others: An individual who enjoys good mental health is able to be sincerely interested in other's welfare. He has friendships that are satisfying and lasting. He is able to feel a part of a group without being submerged by it. He takes responsibility for his neighbors and his fellow members.
  • The ability to fulfill life's tasks: The third important component of mental health is that 2it bestows on an individual the ability to meet the demands of life. A mentally healthy person is able to think for himself, set reasonable goals and take his own decision. He does something about the problems as they arise. He shoulders his daily responsibilities, and is not bowled over by his own emotions of fear, anger, love or guilt.
 
Criteria for Mental Health
  • Adequate contact with reality
  • Control of thoughts and imagination
  • Efficiency in work and play
  • Social acceptance
  • Positive self-concept
  • A healthy emotional life
 
Indicators of Mental Health
Jahoda (1958) has identified six indicators of mental health which include:
  1. A positive attitude towards self
    This includes an objective view of self, including knowledge and acceptance of strengths and limitations. The individual feels a strong sense of personal identity and security within the environment.
  2. Growth, development and the ability for self actualization
    This indicator correlates with whether the individual successfully achieves the tasks associated with each level of development.
  3. Integration
    Integration includes the ability to adaptively respond to the environment and the development of a philosophy of life, both of which help the individual maintain anxiety at a manageable level in response to stressful situations.
  4. Autonomy
    Refers to the individual's ability to perform, in an independent self-directed manner; the individual makes choices and accepts responsibility for the outcomes.
  5. Perception of reality
    This includes perception of the environment without distortion, as well as the capacity for empathy and social sensitivity-a respect and concern for the wants and needs of others.
  6. Environmental mastery
    This indicator suggests that the individual has achieved a satisfactory role within the group, society or environment. He is able to love and accept the love of others.
 
Characteristics of a Mentally Healthy Person
  • He has an ability to make adjustments.
  • He has a sense of personal worth, feels worthwhile and important.
  • He solves his problems largely by his own effort and makes his own decisions.
  • He has a sense of personal security and feels secure in a group, shows understanding of other people's problems and motives.
  • He has a sense of responsibility.
  • He can give and accept love.
  • He lives in a world of reality rather than fantasy.
  • He shows emotional maturity in his behavior, and develops a capacity to tolerate frustration and disappointments in his daily life.
  • He has developed a philosophy of life that gives meaning and purpose to his daily activities.
  • He has a variety of interests and generally lives a well-balanced life of work, rest and recreation.
 
MENTAL ILLNESS
Mental illness is maladjustment in living. It produces a disharmony in the person's ability to meet human needs comfortably or effectively and function within a culture.
A mentally ill person loses his ability to respond according to the expectations he has for himself and the demands that society has for him.
In general an individual may be considered to be mentally ill if:3
  • the person's behavior is causing distress and suffering to self and/or others
  • the person's behavior is causing disturbance in his day-to-day activities, job and interpersonal relationships.
 
Definition
Mental and behavioral disorders are understood as clinically significant conditions characterized by alterations in thinking, mood (emotions) or behavior associated with personal distress and/ or impaired functioning. (WHO, 2001)
 
Characteristics of Mental Illness
  • Changes in one's thinking, memory, perception, feeling and judgment resulting in changes in talk and behavior which appear to be deviant from previous personality or from the norms of community
  • These changes in behavior cause distress and suffering to the individual or others or both
  • Changes and the consequent distress cause disturbance in day-to-day activities, work and relationship with important others (social and vocational dysfunction).
 
Features of Mental Illness
The features of mental illness are classified under four headings
  1. Disturbances in bodily functions
  2. Disturbances in mental functions
  3. Changes in individual and social activities
  4. Somatic complaints
 
 
1. Disturbances in Bodily Functions
  • Sleep: Disturbed sleep throughout the night, or no sleep at all, or difficulty in falling asleep, or waking up in the middle of night and failing to fall asleep again. In addition, the individual may experience lethargy and lack of freshness in the morning.
  • Appetite and food intake: Increased appetite or decreased appetite, weight loss or weight gain, nausea, vomiting.
  • Bowel and bladder movement: Diarrhea or constipation, increased micturition, bed-wetting.
  • Sexual desire and activity: Decreased interest in sex, premature ejaculation, impotence or lack of sexual satisfaction. In some conditions there can be excessive sexual desire or lack of social inhibitions.
 
2. Disturbances in Mental Functions
  • Behavior: The patient may exhibit over activity, restlessness, irritability, may be abusive to others for trivial or no reasons at all, or the patient may become dull, withdrawn and not respond to external or internal cues. At times the patient may behave in a bizarre way which the family members may find irritating. Sometimes the patient's behavior can be dangerous to self or others.
  • Speech: Patient talks excessively and unnecessarily or talks very little or stays mute. The talk becomes irrelevant and un-understandable (incoherent).
  • Thought: Patient expresses peculiar and wrong beliefs which others do not share.
  • Emotions: Patient may exhibit excessive emotions like excessive happiness, anger, fear or sadness. Sometimes emotions can be inappropriate to situations. He may laugh to self or weep without any reason.
  • Perception: The patient may perceive without any stimulus. There can be misinterpretation of perception. For example a mentally ill person can see things or hear sounds or feel objects which do not exist or which others do not see. This is known as hallucinations. A patient who is hallucinating is seen talking to self, laughing or weeping to self, wandering in the streets and behaving in a manner which others may find abnormal.
  • Attention and concentration: Patient may have decreased attention and concentration; he may get distracted easily, or have selective inattention.
  • Memory: Patient may lose his memory and start forgetting important matters.4
  • Intelligence and judgment: In some mental illnesses, intelligence and the ability to take decisions deteriorate. Patient loses reasoning skills and abilities, may not be able to perform simple arithmetic, or commits mistakes in routine work.
  • Level of consciousness: In some mental illnesses due to possible brain damage there may be changes in the level of consciousness. Patient fails to identify his relatives. He can be disoriented to time and place. He may remain confused or become unconscious.
 
3. Changes in Individual and Social Activities
Patients may neglect their bodily needs and personal hygiene. The patient may also lose social sense. They behave in an inappropriate manner in social situations and embarrass others. They behave strangely with their family members, friends, colleagues and others. They may insult, abuse/assault them.
 
4. Somatic Complaints
Patient may complain of aches and pains in different parts of the body, fatigue, weakness, involuntary movements, etc.
 
Common Signs and Symptoms of Mental Illness
 
Disturbances in Motor Behavior
Motor retardation, stupor, stereotypes, negativism, ambitendence, waxy flexibility, echopraxia, restlessness, agitation and excitement.
 
Disorders of thought, language and communication
Pressure of speech, poverty of speech, dysarthria, flight of ideas, circumstantiality, loosening of association, tangentiality, incoherence, perseveration, neologism, clang association, thought block, thought insertion, thought broadcasting, echolalia, delusions, obsessions and phobias.
 
Disorders of perception
Illusions, hallucinations, depersonalization, derealization.
 
Disorders of emotion
Blunt affect, labile affect, elated mood, euphoria, ecstasy, dysphoric mood, depression, anhedonia.
 
Disturbances of consciousness
Clouding of consciousness, delirium and coma.
 
Disturbances in attention
Distractibility, selective inattention.
 
Disturbances in orientation
Disorientation of time, place or person.
 
Disturbances of memory
Amnesia, confabulation.
 
Impaired judgment
 
Disturbances in biological function
Persistent deviations in temperature, pulse and respiration, nausea, vomiting, headache, loss of appetite, increased appetite, loss of weight, pain, fatigue, weight gain, insomnia, hypersomnia and sexual dysfunction.
 
CONCEPTS OF NORMAL AND ABNORMAL BEHAVIOR
Psychiatry as evident from the above is concerned with abnormal behavior in its broadest sense, but defining the concepts of normal and abnormal behavior as such has been found to be difficult. These concepts are much under the influence of sociocultural factors.
Several models have been put forward in order to explain the concept of normal and abnormal behavior. Some of them are:
 
 
Medical Model
Medical model considers organic pathology as the definite cause for mental disorder. According to this model abnormal people are the ones who have disturbances in thought, perception and psychomotor activities. The normal are the ones who are free from these disturbances.
 
Statistical Model
It involves the analysis of responses on a test or a questionnaire or observations of some particular 5behavioral variables. The degree of deviation from the standard norms arrived at statistically, characterizes the degree of abnormality.
Statistically normal mental health falls within two standard deviations (SDs) of the normal distribution curve.
 
Sociocultural Model
The beliefs, norms, taboos and values of a society have to be accepted and adopted by individuals. Breaking any of these would be considered as abnormal. Normalcy is defined in context with social norms prescribed by the culture. Thus cultural background has to be taken into account when distinguishing between normal and abnormal behavior.
 
Behavior Model
Behavior that is adaptive, is normal, maladaptive is abnormal. Abnormal behavior is a set of faulty behaviors acquired through learning.
 
PROBLEMS OF MENTAL DISORDERS
  • Self-care limitations or impaired functioning related to mental illness
  • Significant deficits in biological, emotional and cognitive functioning
  • Disability, life-process changes
  • Emotional problems such as anxiety, anger, sadness, loneliness and grief
  • Physical symptoms that occur along with altered psychological functioning
  • Alteration in thinking, perceiving, communicating and decision making
  • Difficulties in relating to others
  • Patient's behavior may be dangerous to self or others
  • Adverse effects on the well-being of the individual, family and community
  • Financial, marital, family, academic and occupational problems.
 
BURDEN OF MENTAL DISORDERS
Mental disorders are common, affecting more than 25 percent of all people at some time during their lives. They are also universal, affecting people in all countries and societies, individuals of all ages, women and men, the rich and the poor, from urban and rural environments. They have an economic impact on societies and on the quality of life of individuals and families.
  • Mental disorders at any point of time are present in about 10 percent of the adult population. Around 20 percent of all patients seen by primary health care professionals have one or more mental disorders.
  • During the last two decades many epidemiological studies have been conducted in India, which show that mental disorders prevail in 18 to 207 per 1000, with median 65.4 per 1000 at any given time. About 2.3% of the population suffers from seriously incapacitating mental disorders or epilepsy. A large number of adult patients (10.4% to 53.0%) coming to the general out patient department are diagnosed as mentally ill.
  • It is estimated that in 2000, mental disorders accounted for 12% of the total Disability Adjusted Life Years (DALYs) lost due to all diseases and injuries. Common disorders, which usually cause severe disability, include depressive disorder, substance use disorders, schizophrenia, epilepsy, Alzheimer's disease, mental retardation and disorders of childhood and adolescence.
  • More than 450 million people today suffer from mental and behavioral disorders. Within the next 20 years depression will have the dubious distinction of becoming the second biggest cause for global burden of disease.
  • Worldwide 70 million people suffer from alcohol dependence, 50 million from epilepsy, 24 million from schizophrenia and another 20 million people attempt suicide every year.
  • Global Burden of Disease (GBD) 2000 estimates show that mental and neurological conditions account for 30.8% of all Years Lived with Disability (YLD). Depression causes the largest amount of disability, accounting for almost 12% of all disabilities. Six neuropsychiatric conditions figured in the top 6twenty causes of disability worldwide which include:
    • Unipolar depressive disorders
    • Alcohol use disorders
    • Schizophrenia
    • Bipolar affective disorders
    • Alzheimer's and other dementias
    • Migraine
  • Mental illnesses cause massive disruption in the lives of individuals, families and communities. Individuals suffer the distressing symptoms of disorders. They also suffer because they are unable to participate in work and leisure activities often as a result of discrimination. They worry about not being able to shoulder their responsibilities towards their family and friends and are fearful of being a burden to others. Mental illnesses are common to all countries and cause immense suffering. People with these disorders are often subjected to social isolation, poor quality of life and increased mortality. These disorders are thus the cause of staggering economic and social costs.
  • It is estimated that one in four families has at least one member currently suffering from a mental illness. These families are required not only to provide physical and emotional support, but also to bear the negative impact of stigma and discrimination present in all parts of the world.
  • Families in which one member is suffering from a mental disorder make a number of adjustments and compromises that prevent other members of the family from achieving their full potential in work, social relationships and leisure. These are the human aspects of the burden of mental disorders that are difficult to assess and quantify.
  • The impact of mental disorders in communities is large and manifold. There is the cost of providing care, the loss of productivity and certain legal problems associated with some mental disorders.
 
MENTAL HEALTH FACTS
  • One in four patients visiting a health service has at least one mental, neurological or behavioral disorder but most of these disorders are neither diagnosed nor treated.
  • Barriers to effective treatment of mental illness include lack of recognition of the seriousness of mental illness and lack of understanding about the benefits of services. Policy makers, insurance companies, health and labor policies and the public at large—all discriminate between physical and mental health 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 facilities, and treatment for people with mental illness are not given the priority they deserve.
  • More than 40% of countries have no mental health policy and over 30% have no mental health program. Over 90% of countries have no mental health policy that includes children and adolescents. In addition health plans frequently do not cover mental and behavioral disorders at the same level as other illnesses, creating significant economic difficulties for patients and their families. Therefore, the suffering continues and difficulties grow.
  • There is a wide gap between availability and implementation of effective interventions, e.g. in India, treatment rates for schizophrenia and epilepsy are reported to be 20% of all cases in need of treatment, compared to 80% for the same disorders in the west.
  • There is an urgent need to sensitize governments on the importance of mental health and clearly define the goals and objectives of community-based health programs. Mental health services should be integrated into the overall primary health care system. Innovative community-based health programs which are culturally and gender appropriate and reach out to all segments of the population need to 7be developed. Well-organized community-based care is urgently required besides increasing the number of psychiatric beds in the general hospitals; governments must take the responsibility for ensuring that mental health policies are developed and implemented. Strategies like including the integration of mental health treatment and services into the general health system, particularly into primary health care, must be pursued.
 
MENTAL HEALTH ISSUES
There are a number of new issues that have come up in the country with implications for mental health. The most notable are alcohol policies, violence in society, the growing population of elderly persons, urbanization, mental health of women, disaster care, migrants and refugees, street children, and stress at the work place. These new problems pose serious challenges to existing mental health services and infrastructure.
The National Rural Health Mission (NRHM) has overlooked various ground realities related to mental health. There is a shortage of manpower, and training programs are not able to meet the demands in providing training to all medical private practitioners and medical officers. Appropriate mental health can be provided at the sub centre and village level by minimum training of the health workers that will help in providing comprehensive health care at the most peripheral level. It is necessary to integrate National Mental Health Program and District Mental Health Program and include mental health in National Rural Health Mission to achieve health for all.
 
MINIMUM ACTIONS REQUIRED
  • Formulating policies designed to improve the mental health of populations
  • Assuring universal access to appropriate and cost-effective services (including mental health promotion and prevention services)
  • Ensuring adequate care and protection of human rights for institutionalized patients with most severe mental disorders
  • Assessing and monitoring mental health in communities
  • Promoting healthy lifestyles and reducing risk factors for mental disorders
  • Supporting stable family life, social cohesion and human development
  • Continuing research in related areas
  • Introducing mental health care activities in workplace and schools
  • Use of mass media to promote mental health, foster positive attitude, and help prevent disorders.
    (Source: Syed Amin Tabish, JK-practitioner 2005, 12 (1): 34 – 38).
 
MAGNITUDE OF THE PROBLEM IN INDIA
The common psychiatric illnesses encountered in a clinic of a General Hospital are—Neurotic disorders (e.g. anxiety neurosis, obsessive-compulsive disorder and reactive depression), psychosomatic disorders (e.g. hypertension, diabetes mellitus, peptic ulcer, tension headaches, etc.), functional psychosis (e.g. schizophrenia, mania and depression) and organic psychosis.
In a child guidance clinic, the common mental illnesses include mental retardation, conduct disorder, hyperkinetic syndrome, enuresis, etc. In a geriatric clinic the common disorders are depression, dementia, delusional disorders, etc. In a psychosexual clinic the common problems include Dhat syndrome, premature ejaculation, erectile impotence and so on.
The prevalence of psychiatric disorders is 58.2 per thousand which means that there are about 5.7 crore people suffering from some sort of psychiatric disturbance. Out of this 4 lakh people have organic psychoses, 26 lakh people have schizophrenia and 1.2 crore people have affective psychosis; thus there are about 1.5 crore people suffering from severe mental disorders, besides 12,000 patients in government mental hospitals in the country (Reddy et al, 1996).
 
ETIOLOGY OF MENTAL ILLNESS
Many factors are responsible for the causation of mental illness. These factors may predispose an 8individual to mental illness, precipitate or perpetuate the mental illness.
 
 
Predisposing Factors
These factors determine an individual's susceptibility to mental illness. They interact with precipitating factors resulting in mental illness.
These are:
  • Genetic make up
  • Physical damage to the central nervous system
  • Adverse psychosocial influence
 
Precipitating Factors
These are events that occur shortly before the onset of a disorder and appear to have induced it.
These are:
  • Physical stress
  • Psychosocial stress
 
Perpetuating Factors
These factors are responsible for aggravating or prolonging the diseases already existing in an individual. Psychosocial stress is an example.
Thus etiological factors of mental illness can be:
  • Biological factors
  • Physiological changes
  • Psychological factors
  • Social factors
 
Biological Factors
 
 
Heredity
What one inherits is not the illness or its symptoms, but a predisposition to the illness, which is determined by genes that we inherit directly. Studies have shown that three-fourths of mental defectives and one-third of psychotic individuals owe their condition mainly to unfavorable heredity.
 
Biochemical Factors
Biochemical abnormalities in the brain are considered to be the cause of some psychological disorders. Disturbance in neurotransmitters in the brain is found to play an important role in the etiology of certain psychiatric disorders.
 
Brain Damage
Any damage to the structure and functioning of the brain can give rise to mental illness. Damage to the structure of the brain may be due to one of the following causes:
  • Infection: E.g. Neurosyphilis, encephalitis, HIV infection, etc.
  • Injury: Loss of brain tissue due to head injury
  • Intoxication: Damage to brain tissue due to toxins such as alcohol, barbiturates, lead, etc.
  • Vascular: Poor blood supply, bleeding (intracranial hemorrhage, subarachnoid hemorrhage, subdural hemorrhage)
  • Alteration in brain function: Changes in blood chemistry that interfere with brain functioning such as disturbance in blood glucose levels, hypoxia, anoxia, and fluid and electrolyte imbalance
  • Tumors: Brain tumors
  • Vitamin deficiency and malnutrition, in particular deficiency of vitamin B complex
  • Degenerative diseases: Dementia
  • Endocrine disturbances: Hypothyroidism, thyrotoxicosis etc.
  • Physical defects and physical illness: Acute physical illness as well as chronic illnesses with all their handicapping conditions may result in loss of mental capacities
 
Physiological Changes
It has been observed that mental disorders are more likely to occur at certain critical periods of life namely – puberty, menstruation, pregnancy, delivery, puerperium and climacteric. These periods are marked not only by physiological (endocrine) changes, but also by psychological issues that diminish the adaptive capacity of the individual. Thus the individual becomes more susceptible to mental illness during this period.
 
Psychological Factors
  • It is observed that some specific personality types are more prone to develop certain 9psychological disorders. For example those who are unsocial and reserved (schizoid) are vulnerable to schizophrenia when they face adverse situations and psychosocial stresses.
  • Psychological factors like strained interpersonal relationships at home, place of work, school or college, bereavement, loss of prestige, loss of job, etc.
  • Childhood insecurities due to parents with pathological personalities, faulty attitude of parents (over-strictness, over leniency), abnormal parent-child relationship (overprotection, rejection, unhealthy comparisons), deprivation of child's essential psychological and social needs, etc.
  • Social and recreational deprivations resulting in boredom, isolation and alienation.
  • Marriage problems like forced bachelorhood, disharmony due to physical, emotional, social, educational or financial incompatibility, childlessness, too many children, etc.
  • Sexual difficulties arising out of improper sex education, unhealthy attitudes towards sexual functions, guilt feelings about masturbation, pre and extra-marital sex relations, worries about sexual perversions.
  • Stress, frustration and seasonal variations are sometimes noted in the occurrence of mental diseases.
 
Social Factors
  • Poverty, unemployment, injustice, insecurity, migration, urbanization
  • Gambling, alcoholism, prostitution, broken homes, divorce, very big family, religion, traditions, political upheavals and other social crises
 
MISCONCEPTIONS ABOUT MENTAL ILLNESS
Beliefs about mental illness have been characterized by superstition, ignorance and fear. Although time and advances in scientific understanding of mental illness have dispelled many false ideas, there remain a number of popular misconceptions. Some of them are:
  • Mental illness is caused by supernatural power and is the result of a curse or possession by evil spirit: Many people do not consider mental illness as an illness, but possession by spirits or curse that has befallen on the patient or family because of past sins or misdeeds in previous life.
  • Mentally ill people show bizarre behavior: Patients in mental hospitals and clinics are often picturised as a weird lot, who spend their time exhibiting useless bizarre behavior like twisting of hands, etc.
  • Mentally ill people are dangerous: People who have or had a mental illness are viewed with suspicion and as dangerous persons.
  • Mental illness is something to be ashamed of: This idea arouses an unsympathetic, cruel attitude towards a mentally ill person. This is the reason why many people hide mental illness in the family.
  • Mental illness is not curable: People object to have normal relationship with mentally ill people, or to give them employment even after being cured, or even to accept them as neighbors.
  • Mental illness is contagious: The fear that it is contagious is the main false notion which leads people to view suspiciously, or object to marital relations with a person belonging to the household of the mentally ill.
  • Mental illness is hereditary: It is not a rule that children of mentally ill patients should become mentally ill.
  • Marriage can cure mental illness: A mentally ill person can get worse if he gets married when he is ill, as marriage can become an additional stress. A patient who has recovered can get married and live a normal life like any other person.
  • Mental hospitals are places where only dangerous mentally ill individuals are treated and restraint is a major form of treatment: People hesitate to take their relatives to mental hospitals for treatment because of fear. Further, as ex-patient of a mental hospital, he, as well as his family members are often isolated. Therefore, people seek help from mental hospitals only as a last resort.
10
 
General Attitude toward the Mentally Ill
  • In general the community responds to the mentally ill through denial, isolation and rejection. There is also a lack of understanding of mental illness as any other illness, and a lack of tendency to reject both the patients and those who treat them.
  • Mentally ill are viewed as people with no capacity for understanding.
  • People feel mental illness cannot be cured, and even if the patient gets better, complete physical rest is considered essential.
  • The mentally ill are by and large perceived as aggressive, violent and dangerous.
An individual's values and personal beliefs affect his attitude about mental illness, the mentally ill and treatment of mental illness. There still exists a stigma surrounding individuals who need or use psychiatric mental health services. The need continues for public education to modify or alter misconceptions about mental illness and people with mental disorders.
 
MENTAL HEALTH TEAM OR MULTIDISCIPLINARY TEAM
Multidisciplinary approach refers to collaboration between members of different disciplines who provide specific services to the patient.
The multidisciplinary team includes:
  • A Psychiatrist
  • A Psychiatric nurse
  • A Clinical psychologist
  • A Psychiatric social worker
  • An Occupational therapist or an Activity therapist
  • A Pharmacist and a dietitian
  • A Counselor
A Psychiatrist is a medical doctor with special training in psychiatry. He is accountable for the medical diagnosis and treatment of patient. Other important functions are:
  • Admitting patient into acute care setting
  • Prescribing and monitoring psychopharmacologic agents
  • Administering electroconvulsive therapy
  • Conducting individual and family therapy
  • Participating in interdisciplinary team meetings
  • Owing to their legal power to prescribe and to write orders, psychiatrists often function as leaders of the team.
A Psychiatric nurse is a registered nurse with specialized training in the care and treatment of psychiatric patients; she may have a Diploma, MSc., M.Phil. or Ph.D in psychiatric nursing. She is accountable for the bio-psychosocial nursing care of patients and their milieu. Other functions include:
  • Administering and monitoring medications
  • Assisting in numerous psychiatric and physical treatments
  • Participate in interdisciplinary team meetings
  • Teach patients and families
  • Take responsibility for patient's records
  • Act as patient's advocate
  • Interact with patients' significant others
A Clinical psychologist should have a Masters Degree in Psychology or Ph.D in clinical psychology with specialized training in mental health settings. He is accountable for psychological assessments, testing, and treatments. He offers direct services such as individual, family or marital therapies.
A Psychiatric social worker should have a Masters Degree in Social Work or Ph.D degree with specialized training in mental health settings. He is accountable for family case work and community placement of patients. He conducts group therapy sessions. He emphasizes intervention with the patient in social environment in which he will live.
An Occupational therapist or an Activity therapist is accountable for recreational, occupational and activity programs. He assists the patients to gain skills that help them cope more effectively to gain or retain employment, to use leisure time.
A Counselor provides basic supportive counseling and assists in psycho educational and recreational activities.11
 
CLASSIFICATION OF MENTAL DISORDERS
Classification is a process by which complex phenomena are organized into categories, classes or ranks so as to bring together those things that most resemble each other and to separate those that differ.
Like any growing branch of medicine, psychiatry has seen rapid changes in classification to keep up with a conglomeration of growing research data dealing with epidemiology, symptomatology, prognostic factors, treatment methods and new theories for causation of psychiatric disorders.
At present there are two major classifications in psychiatry, namely, ICD10 (1992) and DSM IV (1994).
 
 
 
I. ICD10 (International Statistical Classification of Disease and Related Health Problems) – 1992
This is WHO's classification for all diseases and related health problems. The chapter ‘F’ classifies psychiatric disorders as mental and behavioral disorders and codes them on an alphanumeric system from F00 to F99.
The main categories in ICD10
F00–F09
Organic, including symptomatic, mental disorders
F00
Dementia in Alzheimer's disease
F01
Vascular dementia
F04
Organic amnestic syndrome
F05
Delirium
F06
Other mental disorders due to brain damage and dysfunction and to physical disease
F07
Personality and behavioral disorders due to brain disease, damage and dysfunction
F10-F19
Mental and behavior disorders due to psychoactive substance use
F10
Mental and behavioral disorders due to use of alcohol
F11
Mental and behavioral disorders due to use of opioids
F12
Mental and behavioral disorders due to use of cannabinoids
F13
Mental and behavioral disorders due to use of sedatives or hypnotics
F14
Mental and behavioral disorders due to use of cocaine
F16
Mental and behavioral disorders due to use of hallucinogens
F20–F29
Schizophrenia, schizotypal and delusional disorders
F20
Schizophrenia
F20.0
paranoid schizophrenia
F20.1
hebephrenic schizophrenia
F20.2
catatonic schizophrenia
F20.3
undifferentiated schizophrenia
F20.4
post-schizophrenic depression
F20.5
residual schizophrenia
F20.6
simple schizophrenia
F21
Schizotypal disorder
F22
Persistent delusional disorders
F23
Acute and transient psychotic disorders
F24
Induced delusional disorders
F25
Schizoaffective disorders
F30-F39
Mood (affective) disorders
F30
Manic episode
F31
Bipolar affective disorder
F32
Depressive episode
F33
Recurrent depressive disorder
F34
Persistent mood disorder
F40-F49
Neurotic, stress-related and somatoform disorders
F40
Phobic anxiety disorders
F41
Other anxiety disorders
F42
Obsessive-compulsive disorder
F43
Reaction to severe stress, and adjustment disorders
F44
Dissociative (conversion) disorders
F45
Somatoform disorders
F50-F59
Behavioral syndromes associated with physiological disturbances and physical factors
F50
Eating disorders
F51
Non-organic sleep disorders
F52
Sexual dysfunction, not caused by organic disorder or disease
12
F60–F69
Disorders of adult personality and behavior
F60
Specific personality disorders
F60.0
paranoid personality disorder
F60.1
schizoid personality disorder
F60.2
dissocial personality disorder
F60.3
emotionally unstable personality disorder
F60.4
histrionic personality disorder
F60.5
anankastic personality disorder
F60.6
anxious personality disorder
F60.7
dependent personality disorder
F61
Mixed and other personality disorders
F62
Enduring personality changes, not attributable to brain damage and disease
F63
Habit and impulse disorders
F64
Gender identity disorders
F65
Disorders of sexual preference
F70–F79
Mental retardation
F70
Mild mental retardation
F71
Moderate mental retardation
F72
Severe mental retardation
F73
Profound mental retardation
F80–F89
Disorders of psychological development
F80
Specific developmental disorders of speech and language
F81
Specific developmental disorders of scholastic skills
F82
Specific developmental disorder of motor function
F83
Mixed specific developmental disorders
F84
Pervasive developmental disorders
F90–F98
Behavioral and emotional disorders with onset usually occurring in childhood and adolescence
F90
Hyperkinetic disorders
F91
Conduct disorders
F93
Emotional disorders with onset specific to childhood
F94
Disorders of social functioning with onset specific to childhood and adolescence
F95
Tic disorders
F98
Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence
F99
Unspecified mental disorder
 
II. DSMIV (Diagnostic and Statistical Manual) -1994
This is the classification of mental disorders by the American Psychiatric Association (APA). The pattern adopted by DSM IV is of multiaxial systems.
A multiaxial system that evaluates patients along several versatiles contains five axes. Axis I and II make up the entire classification which contains more than 300 specific disorders.
 
The five axes of DSM IV are
  • AXIS I: Clinical psychiatric diagnosis
  • AXIS II: Personality disorder and mental retardation
  • AXIS III: General medical conditions
  • AXIS IV: Psychosocial and environmental problem
  • AXIS V: Global assessment of functioning in current and past one year
 
III. Indian Classification
In India Neki (1963), Wig and Singer (1967), Vahia (1961) and Varma (1971) have attempted some 13modifications of ICD8 to suit Indian conditions. They are broadly grouped as follows:
zoom view
 
B. Neurosis
  • Anxiety neurosis
  • Depressive neurosis
  • Hysterical neurosis
  • Obsessive compulsive neurosis
  • Phobic Neurosis
 
C. Special disorders
Childhood disorders
  • conduct disorders
  • emotional disorders
Personality disorders
  • sociopath
  • psychopath
Substance abuse
  • alcohol abuse
  • drug abuse
Psycho physiological disorders
  • asthma
  • psoriasis
Mental retardation
  • Mild
  • Moderate
  • Severe
  • Profound
In everyday practice classification is made after the history and examination of mental state have been completed.
 
REVIEW QUESTIONS
  • Concepts of normal and abnormal behavior (Nov 2001,Oct 2006)
  • Components of mental health (Nov 2003)
  • Meaning of mental illness (Feb 2001, Oct 2004)
  • Features of mental illness
  • Mental health issues
  • Characteristics of a mentally healthy person (Nov 1999, Apr 2003, Nov 2003)
  • Misconceptions about mental illness (Nov 2003)
  • Community attitude towards mentally ill (Nov 2002)
  • Etiology of mental illness (Feb 2001, Apr 2002, Apr 2005, Oct 2006)
  • Classification of mental disorders (Apr 2006)
  • International classification of diseases (Oct 2004, Apr 2006)
  • DSMIV (Nov 2003)
  • Multidisciplinary team or mental health team
  • Defence mechanisms— rationalization, projection, identification, reaction formation, undoing, negativism, repression (Oct 2000), regression, suppression (Oct 2000), fantasy or day dreaming.