mental health. David Manyiel Agok MLT pptx

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1. RUMBEK HEALTH SCIENCE INSTITUTE C OURSE UNIT MENTAL HEALTH DEPARTMENTS CLINICAL MEDICINE AND PUBLIC HEALTH CLASS SECOND YEAR SECOND SEMESTER PREPARED BY Dr. ATER MAYEN MBBS UNIVERSITY OF BAHR EL GHAZAL

2. Learning objectives At the end of this lesson you will be able to learn the following History of mental health Define term mental health Describe concept of mental health List characteristics of mental health Discuss things that affect people mental health Define mental illness Explains classification of mental illness

3. A paper in the World Psychiatry journal states that mental health officially emerged as its own field of study in 1946 during the International Health Conference. It was during this conference that the World Health Organization (WHO) was founded. The WHO Constitutions stated that mental "well-being" is an integral part of overall health, even in the absence of psychiatric illness. Before mental health, "mental hygiene" was a term used in the 19th and 20th centuries to refer to the impact that mental processes have on overall health.

4. A mental hygiene movement had formed in the United States in 1908. Its goal was to advocate for people who were "mentally sick," or people who had psychiatric conditions, in a more humane way as historically, people with mental illnesses were abused, neglected, and lacked adequate care . Though  stigma surrounding mental illness still exists, more and more people have realized the importance of receiving treatment like  psychotherapy—for maintenance of their mental well-being, regardless of whether they have a mental illness.

5. Additionally, an abundance of research has found that positive mental health is linked with improved quality of life, including better productivity, closer social connections, higher educational achievement, and improved relationships.

6. Definition of mental heath Is define as state of well being in which individual realizes his or her own abilities can cope with the normal stresses of life can work productivity and is able to contribute to his or her community Is refers to our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices Mental health is define as a state of physical, mental and social well being, not mere absence of disease According to WHO, mental health is the capacity of an individual to form harmonious relationship with others and participate or contribute constructively to changes in the social environment

7. State of emotional well-being which enable one to function comfortably within society and to be satisfied with one own achievements. This is a state of balance between an individual and surrounding world a state of harmony between oneself and others a co-existence between realities of oneself and that of others people and the environment.

8. C oncepts of mental health Positives attitude toward self This is an objectives view of self eg knowledge and acceptance of strengths and limitations. Individual feel a strong sense of personal identity and security within the environment Growth development and the ability for self actualization This indicator correlates whether the individual successfully achieves the task associated with each level of development

9. Integration Integration includes ability to adaptively respond to the environment and the development of philosophy of life both of which help the individual maintain anxiety at manageable level of respond to stressful situations Autonomy Refer to the individual ability to perform in an independent self-directed manner the individual make choices and excepts responsibilities for outcomes

10. Perception of reality This includes perception of environment without distortions as well as capacity for empathy and social sensitivity, respect and concern for the wants and needs of others Environment mastery This indicators suggests that the individual has achieved a satisfactory role within the group, society and environment and is able to love and accept the love of others.

11. Characteristics of mental health person Has sense of responsibilities Has ability to make adjustment in life Has ability to solves problems Has ability to make decision Has ability to give and accept love Has ability to control emotion and develop capacity to tolerate frustration and disappointment in day to day life activities Has varieties of interests and generally lives a well balanced life of work rest and recreation

12. They have respect for themselves and for others even if there are differences. They are able to accept life’s disappointments. They can meet life’s demands and handle their problems when they arise. They make their own decisions. They shape their environment whenever possible and adjust to it when necessary.

13. Factors affecting mental health Poverty Imprisonment Divorce/separation Loneliness/ isolation Long-term illness Relationship Unemployment Caring responsibilities

14. Mental illness:- Is define as disorders of brain that affects person thinking mood and behavior Some can occur for short time and some occur over an on going time period. It’s also Refers to the disorder of the mind resulting into abnormal behavior NB ; what is consider abnormal in one society may be normal in another society

15. Classification of Mental illness Psychosis / major mental illness Neurosis / minor mental illness Psychosis (major mental illness) Is a severe form of mental illness in which there is ; Disorder of sensory perception Thought disorder Loss of touch with reality

16. Types of psychosis Functional psychosis Organic psychosis Functional psychosis is a severe form of mental illness without involvement of injury to the brain tissues/cells. E xample include:- Depression, Mania and schizophrenia

17. Organic psychosis is Refers to the condition due to impairment of brain function as a result of trauma to the brain tissue cells or toxic substance in the blood stream Examples includes; Delirium Delirium tremors Epilepsy Substances abuse

18. Neurosis( minor mental illness ) Is Refers to less severe form of mental disorder where patients show either excessive or prolonged emotional reaction to any given stress. Examples include; Anxiety General anxiety Simple anxiety Panic disorder Obsessive compulsive disorders

19. Any questions???? Thanks.

20. Evaluation questions Define term mental health Describe concept of mental health List characteristics of mental health Discuss things that affect people mental health Define mental illness Explains classification of mental illness

21. Reference Luvsannyam E, Jain MS, Pormento MKL, et al. Neurobiology of schizophrenia: A comprehensive review  Cureus . 2022 Cheslack-Postava K, Brown AS. Prenatal infection and schizophrenia: A decade of further progress  Schizophr Res . 2022 Patel S, Khan S, M S, Hamid P. The association between cannabis use and schizophrenia: Causative or curative? A systematic review  Cureus . 2020 Şar V, Dorahy MJ, Krüger C. Revisiting the etiological aspects of dissociative identity disorder: A biopsychosocial perspective  Psychol Res Behav Manag . 2017 National Institute of Mental Health. Schizophrenia

22. Learning objectives Identify Characteristics of person with mental illness describe general causes of mental illness

23. Characteristics of person with mental illness His/her behavior causes distress suffering to him/her self and people around Abnormal changes in one ‘s thinking, feeling, memory, perceptions and judgment resulting into changes in speech and behavior Abnormal behavior causing disturbances in the person’s daily activities like jobs and interpersonal relationship

24. General causes of mental illness Biological factors Psychological factors Environmental factors Socio-economic factors

25. What Biological Factors Are Involved in Mental Illness Some mental illnesses have been linked to abnormal functioning of nerve cell or pathways that connect particular brain regions. Nerve cells within these brain communicate through chemicals called neurotransmitters. In addition , defects in or injury to certain areas of the  brain have also been linked to some mental conditions. Other biological factors that may be involved in the development of mental illness include :

26. Genetics (heredity) : Mental illnesses sometimes run in families, suggesting that people who have a family member with a mental illness may be more likely to have mental illness. This is passed on in families through genes. Experts believe that many mental illnesses are linked to abnormalities in many genes, rather than just one or a few, and that how these genes interact with the environment is unique for every person (even identical twins). That is why a person inherits a likeliness to have a mental illness and doesn't necessarily get the illness. Mental illness itself comes from the interaction of multiple genes and other factors – such as  stress abuse, or a traumatic event – which can influence, or trigger, an illness in a person who has an inherited likeliness to have it.

27. Infections : Certain infections have been linked to brain damage and the development of mental illness or the worsening of its symptoms. For example, a condition known as pediatric autoimmune neuropsychiatric disorder associated with the streptococcus bacteria has been linked to the development of obsessive compulsive disorder and other mental illnesses in children.

28. Brain defects or injury : Defects in or injury to certain areas of the brain have also been linked to some mental illnesses. Prenatal damage : Some evidence suggests that a disruption of early fetal brain development or trauma that occurs at the time of birth – for example, loss of oxygen to the brain – may play a part in certain conditions, such mental disorder. Substance abuse : Long-term substance abuse, in particular, has been linked to anxiety, depression , Other factors : Poor nutrition and exposure to toxins, such as lead, may play a role in mental illnesses.

29. Psychological Factors Contribute to Mental Illness Psychological factors that may contribute to mental illness include: Severe psychological trauma suffered as a child, such as emotional, physical, or sexual abuse An important early loss, such as the loss of a parent Neglect Poor ability to relate to others

30. Socioeconomic Factors Contribute to Mental Illness Research continues to show a link between social and economic inequality and poor mental health. Adults and children/adolescents alike seem to be affected, along with immigrants. Socioeconomic factors that contribute to mental illness include: Unemployment  Low income  Poverty   Poor or unstable living conditions Education  Socioeconomic factors are often connected to environmental factors.

31. Environmental Factors Contribute to Mental Illness Certain stressors can trigger an illness in a person who is more likely to have mental illness. These stressors include: Death or divorce A dysfunctional family life Feelings of inadequacy, low self-esteem, anxiety, anger, or loneliness Changing jobs or schools Social or cultural expectations (For example, a society that associates beauty with thinness can be a factor in the development of eating disorders) Substance abuse by the person or the person's parents

32. Complex post-traumatic stress disorder ( PTSD ) is a mental health problem that can affect people who have experienced prolonged or repeated trauma. It causes a range of symptoms, such as re-experiencing the trauma, avoiding reminders of the trauma, difficulty controlling emotions, self-harm and feelings of being in a dream . Negative thoughts.  Constantly putting yourself down or expecting the worst can get you stuck in a cycle of depression or anxiety. Unhealthy habits:  like not getting enough sleep, or not eating. Drugs and alcohol:  Abusing drugs and alcohol can be bad for your mental health. It can also make it harder to recover from mental illness.

33. Genetics.  Mental illness often runs in the family. Environment.  Living in a stressful environment can strain your mental health. Things like living in poverty or having an abusive family put a lot of stress on your brain and often trigger mental health concerns. Stressful events:  like losing a loved one, or being in a car accident. Childhood trauma.  Even if you’re no longer in a stressful environment, things that happened to you as a child can have an impact later in life. 

34. Physiological factors ; Severe psychological trauma suffered as a child, such as emotional, physical, or sexual abuse An important early loss, such as the loss of a parent Neglect Poor ability to relate to others

35. Social factors ; Poverty Unemployment Injustice Insecurity Rural urban migration

36. Others Predisposing factors Precipitating factors, events which trigger the onset of mental illness like physical stress Perpetuating factors; those which prolong the cause of mental illness after it has been provoke e.g. Loss of economic power Loss of job Stability or loss of dear ones

37. Symptomatology of mental illness Sign and symptoms of mental illness slowly emerge over a period of time and the are ; Appearance Self neglect, dirty look etc Change of behaviors e.g. polite to rude Facial mood changes Eating habit changes

38. Evidence of recent loss of weight Posture and movement changes, demoralized Negativism , disobedience automatism , obeying instruction without talking Repetition of one word over and over again

39. Speech disorder Speech is the process of putting thought into audible words and the following has to be monitors ; The rate of speech Content of speech Muteness Pressure of speech Poverty of speech, lack of substance in word the person said

40. Mood changes Mood is the state of one’s feeling or emotion, check; Mood elevation e.g. excessive feeling of wellbeing which not realistic Mood depression; feeling of sadness associated with slowlines of speech etc Apathy mood; flat mood, person not happy not sad Emotion imbalance; too aggressive over small disappointment

41. Perception changes Perception is the ability to be aware of the environment through senses, disorders include ; Hallucinations of seeing, tasting, hearing, feeling smelling and etc Lilliputation hallucination; objects appear small or very pleasant color or amusing to patient, common in organic brain syndrome Autoslopic hallucination; experience of seeing one’s own body projected into the space

42. Other important of symptoms Delusion; fixed false belief without reasonable ground or base Types of delusions ; Delusion of persecution, god send me to liberate Americans Delusion of imposing Iam the president of china Delusion of guilty and worthlessness Delusion of broadcasting Delusion of thought withdrawal Delusion of perception

43. Illusion; means misinterpretation or perception of external stimuli e.g. he think the doctor is a policemen Amnesia ; inability to recall the past experiences, paramnesia refers to distortion of memory Euphoria ; exaggerated feeling of wellbeing Insomnia; not sleeping in absence of any pain

44. Describe Challenges for Mental Health The National Alliance on Mental Illness (NAMI) states that an estimated one in five U.S. adults experiences a mental health problem each year. There are a number of risk factors that can increase the likelihood that a person may experience poor mental health.

45. Discrimination Being treated unfairly due to personal characteristics such as age, race, ethnicity, disability, sexual orientation, or gender identity is linked with increased anxiety and depression. Exposure to Trauma Trauma is linked with anxiety, depression, changes in mood (increased anger and irritability), feelings of hopelessness, and post-traumatic stress disorder (PTSD ).

46. Family History of Mental Illness Research suggests that a variety of mental illnesses run in families such as   attention-deficit/hyperactivity disorder  (ADHD),  major depressive disorder  (MDD), and  schizophrenia Low Income Low income is linked with increased levels of stress, anxiety, and depression.  Low income may also prevent someone from accessing necessary mental health services. Medical Illness Illnesses, particularly those that are chronic and force a person to adjust their lifestyle, can create psychological distress (especially depression ).

47. Poor Access to Health Services Access to health services is linked to positive long-term health outcomes. However, when people can't get access to the health care they need, their physical and mental health may suffer as a result. Poor Self-Esteem Having low self-esteem often means you don't believe you're worthy of being happy or having positive relationships. People with low self-esteem are at higher risk of developing substance use disorders, anxiety, and depression. Poor Social Skills Having poor social skills is linked with loneliness and increased stress levels, as well as worsened physical health.

48. Social Inequalities Lacking access to goods and services in society based on personal characteristics like your age, gender, religion, race, disability, or another social category can increase the risk of depression. Substance Use Substance use is linked with high rates of anxiety, depression, and insomnia.

49. Concept of Mental Health and Related Terminologies Mental health  refers to our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices. Key terminologies include Mental Health Condition : A set of related symptoms recognized by the mental health community, such as depression or anxiety Coping Skills : Strategies to deal with difficult situations and lessen unpleasant emotions Neurotransmitters : Chemicals that carry messages throughout the brain Stigma : Negative attitudes and discrimination towards mental health challenges

50. Classification of Major Mental Illnesses and Their Characteristics Major mental illnesses include Depression : Persistent sadness, loss of interest, changes in appetite and sleep, fatigue Anxiety Disorders : Excessive worry, restlessness, fatigue, difficulty concentrating Bipolar Disorder : Mood swings between mania (high energy, euphoria) and depression Schizophrenia : Delusions, hallucinations, disorganized thinking, impaired functioning Obsessive-Compulsive Disorder (OCD) : Recurrent, unwanted thoughts (obsessions) and repetitive behaviors ( compulsions)

51. Preventive Measures of Mental Illnesses in the Community Education and Awareness : Conduct community workshops to educate people about mental health, signs of mental illness, and the importance of seeking help early Support Networks : Establish support groups and peer counseling programs to provide emotional support and reduce stigma Access to Services : Ensure that mental health services are accessible and affordable for all community members

52. Psychiatric assessment Good history taking from patient or relative Examination of mental state by asking simple question Physical examination Formulation of plan of action depending diagnosis

53. Psychiatric History taking Patient’s personal details Name: Age: Gender: Marital status: Address: Occupation: R eligion/ethnic group: Informant: Reason for referral

54. Presenting complaint: Document this in patient own words Document how long the patient has had the problem History of presenting complaint; When did the problem start? Has it change over time? Were there any precipating events, e.g. bereavement, divorce? Any other psychological symptoms Screen for any other problems, suicide, violence tendency. Screen for biological symptoms, sleep, appetite, sexual drive. Effects on patients’daily activities

55. Past psychriatric history Any similar or other psychriatric problems in the past. Note GP visits, use of psychriatric services or any hospitalization Note when the problems occurred, for how long they lasted and treatment received. Contact with traditional healers, spiritual or community healers

56. Family history Collect information about parents, siblings and other significant relatives. Enquire about any psychriatric disorders/ other health problems, relationship with patient. Make a genogram of the information

57. Personal background and personal history Childhood; birth history( difficulties, prematurity); developmental mile stones. School: entering and leaving age; any truancy or school refusal, bullying, relationship with peers, teachers, exam taken and qualifications, further education. Occupations: list all jobs and duration of employment, reason for leaving and any periods of unemployment. Relationships and psycho sexual history: age at puberty, current relationship, any sexual experiences, and sexual abuse. Marital history: married to who and for how long, type and quality of marriage, children, divorced/separated/widow, domestic violence. Habits/ dependencies: alcohol, tobacco and illegal drugs, record amount, any problem in the work or anywhere.

58. Forensic history: record all offences whether convicted or not. Present social situation: type of housing, who else is at home; financial circumstances Premorbid personality: Consistent patterns of behaviours through out life. This part should include an account from an informant, as no individuals can objectively describe their own personality. Areas of include: attitudes to others in relationships, attitude to self e.g. likes oneself, confident, predominant mood.

59. Mental status examination Appearance and behaviour Dress, appropriate for sex, self care weather and circumstances. Behaviour during interview: restlessness, tearfulness, eye contact, irritability, appropriateness, distractibility. Psychomotor: poverty rituals and other abnormal behaviours. Speech Rate (speed) Rhythm: normal, flattened or excessive intonation Volume: whisper, quiet, loud Content: excessive punning, clang association, monosyllabic, spontaneous or only in answer questions Dysarthia

60. Mood Observe the patients’ mood during the interview and also how they are feeling. Objectively how you perceive his/her mood and subjectively how he describe his/her mood Thought - Thought tempo, accelerated or retarded - Abnormal thought possessions - Delusion and over valued ideas Perceptions Illusions: misinterpretation of normal stimuli Hallucinations: false perceptions in the absence of any stimulus; perceived to be coming from outside the person Check all sensory modalities: auditory, visual, olfactory and tactile hallucinations.

61. Cognitions Consciousness, orientation, concentration, attention, memory. Concrete and abstract thinking Intelligence and general knowledge Judgement Insight - How well the patients understand their condition? - Are the patients aware that anything is wrong? - What do the think is causing it? - Are they willing to accept help?

62. Performing Physical Examination A physical examination for patients with mental health problems includes: General Appearance : Observing the patient’s appearance, behavior, and mood. Vital Signs : Checking blood pressure, heart rate, temperature. Neurological Examination : Assessing reflexes, motor skills, sensory perception. Mental Status Examination : Evaluating cognitive functions, such as memory, attention, language, and executive function.

63. Taking and Recording Comprehensive Patient History When taking a comprehensive patient history for mental health issues, consider the following steps: Identifying Information : Name, age, gender, occupation. Chief Complaint : The main reason for the visit. History of Present Illness : Detailed description of symptoms, onset, duration, and impact on daily life .

64. Past Psychiatric History : Previous mental health issues, treatments, hospitalizations. Medical History : Any physical health conditions, medications. Family History : Mental health issues in family members. Social History : Living situation, employment, relationships, substance use. Review of Systems : Comprehensive review of other symptoms.

65. Define term schizophrenia Is a chronic severe form of mental disorder that affects the way person thinks acts express emotions Is define as a thought disorder that impairs judgment, behavior & ability to interpret reality Symptoms must be present at least 6 months to be able to make a diagnosis is a severe brain disorder that can cause hallucinations, delusions and make a person withdraw from a society is a mental disorder that affects the way brain processes outside stimuli is a chronic condition that affects both sexes of all ages equally but more common in early adulthood in men and late 20s and 30s in women

66. Signs and symptoms schizophrenia Hallucinations Delusions Disorganized speech or behavior Negative symptoms Usually experience social &/or occupational dysfunction Unusual movements.

67. Difficulty sleeping Slow movement Unusual movements. Lack of pleasure Decreased desire to socialization Lack of motivation Depressed mood

68. Delusions Hallucinations Disorganized thinking Unusual motor behavior Social withdrawal Lack of emotional expression Cognitive deficits

69. Diagnosis of schizophrenia Brain Imaging Findings CT : Lateral and third ventricular enlargement , MRI: Increased cerebral ventricles Hypo activity of the frontal lobes Psychological Tests IQ tests: intelligence Neuropsychological: Tests consistent with bilateral frontal & temporal lobe dysfunction (deficits in attention, retention time & problem-solving ability) Personality (Projective Tests): Abnormal findings, such as ideations , etc.

70. Differential Diagnosis of schizophrenia Substance-induced : Psych stimulants alcohol hallucinosis etc. Consider urine drug screen to rule out . Epilepsy : Temporal lobe epilepsy. Other psychotic disorders : like brief reactive psychosis, delusional disorder . Factitious disorder :  is a mental disorder in which a person acts as if they have a physical or psychological illness when they themselves have created the symptoms

71. Mood disorders : Look at duration of mood symptoms; these tend to be brief in schizophrenia. Medical : HIV, steroids, tumors, cerebral vascular accidents, etc. Personality disorders : (patient is functioning in contrast with Schizophrenia)personality disorders (have short duration of psychosis). Must look at duration of symptoms as well as patient’s level of functioning

72. Depression ; low or sad mood, pessimism and feeling of guilty Bipolar disorders ; mania excitement, elevated mood and exaggeration of self worth are prominent Alcohol or drug abuse ; chronic intoxication or withdrawal from drug causing psychotic symptoms NB; patients with chronic psychosis may also abuse drug.

73. Delusion; false fixed baseless belief Types of delusion ; Persecutory delusion; belief that someone want to harm you without evidence, patients usually responded by; hiding, running away or confront the enemy of self defense, May happen in present of hallucination, it is most common Delusion of reference; patients refers what he see or hear to him on TV or in churches e.g. the preacher is talking about me

74. Delusion of grandiose; patients believes contrary to the existing evidence, he may believes he has superpower etc Delusion of jealousy; patients believes he is being cheated without evidence to support Somatic delusion; false belief that patients has physical defect, e.g. I have crack on my nose Catatonic symptoms; patients adopt one posture for long time e.g. standing with one leg

75. Delusion of volition motivation and will; inability or lack of will to make a decision, even a simple one to do e.g. remaining in bed for whole day Social and occupational dysfunction associated with schizophrenia, complete decrease work performance in employment, school and personal relationship Issue of insight; patient does not know or belief that he or she is sick, believe in what he is doing as a real live experience and resist any attempt to convince him Cognitive; difficulties in attending to end processing information, understand the environment and not remembering simple tasks NB; these symptoms are usually periodic

76. Management of schizophrenia; Chemotherapy Psychotherapy Electroconvulsive therapy Medication and prescription guidelines; Chlorpromazine (CPZ); 100 -400 mg daily, 8 hourly, maintenance dose; 100-200 mg daily for 3-6 months(present in health unit ) Continue anti psychotic medication for at least 6 months after symptoms resolves Close supervision is usually needed in order to encourage the patient take drugs

77. Halopendol oral; 5-10 mg daily 12 hourly , maintenance dose, 1.5-5 mg daily 3-6/12 in regional hospital Fluphenazine decanoate; test dose; 12.5. mg if no side effect, give 2.5. - 50 mg every 4-6 weeks in regional or referral hospital Haloperidol/decanoate injection; 50- 100 mg IM monthly in regional hospital Anti-anxiety medication like diazepam may be use for short time in combination with narcoleptics to control acute agitation

78. Monitor for side effects of medication; Common side effects; Parkinson an symptoms; muscle stiffness, tremors, and stiffing giant Akathisia Other neurological symptoms Adverse effects are best avoid by use of oral or IV artane 10 mg daily in 3 divided dose during course of treatment 3-6/12 months NB; schizophrenia patient can also suffers from any other medical condition, at any level and patient should be screen time to time and treated medically if any is found Referral; last refer the patient for better advice to a regional or international hospital

79. Complication of schizophrenia ; Easily kill High chances of patient suicide Drugs abuse Economic impact on family and community

80. Advice and support for patients and relatives; tell them ; Symptoms may come and go overtime Medication will reduce the current difficulties and prevent relapse Provide stable lining condition housing support to relative are important for recovery; minimize stress and stimulants, do not argue with psychotic thinking, avoid confrontation and critisms, compliance with the treatment Encourage patients to function at the highest reasonable level in work and other daily activity Check on patient’s physical health including health promotion and smoking

81. Delirium Delirium is define as a condition in which a patient become acutely confused because of rapid changes in brain function It also means the clinical syndrome comprising of ; Dimished level of consciousness Cognitive impairment Perceptual abnormalities including hallucination and illusions Organic psychosis is suspected when there is delirium Common in elderly people and may result from many physical and mental illness Among young people delirium is more commonly related to a reaction or withdrawal from drug/alcohol It is always a medical emergency NB; delirium is a sign that something is wrong with the normal physiology

82. Risk factors and causes of delirium Delirium is common among people with brain damage especially those that cause lack of oxygen flow to brain tissue and this may include; CNS disorders; head injuries, brain tumours, meningitis, encephalitis, epilepsy and AIDS Nutritional and vitamin defiencies (severe anemia) Systemic infections; septicaemia, severe pneumonia etc Toxins ; drug intoxication, heavy mental like lead and mercury Drug withdrawal

83. High risk group Children due to severe acute illness Elderly Clinical features of delirium Impairment of consciousness with fluctuating intensity and always worse at night (key feature that separate delirium from other psychosis disorders ) Appearance and behavior; look unwell, agitation, hypo activity or drowsiness Mood; intermittent periods of anxiety or depression, occasionally elated with irritability

84. Speech ; mumble or incoherent Perception ; visual, illusion Thought ; reduced speech and delusion Cognitive; recall impaired, not oriented to person, time and place with poor concentration Insight; impaired, do not understand why psychiatric assessment are being done on them

85. Treatment of It is a medical emergency, act quickly; treatment in hospital may follow the steps below ; Obtain information from next of kin Confirm the diagnosis of delirium AQAP (as quick as possible) Determine the physical cause Treat the physical cause if treatable like meningitis, pneumonia etc Also consider supportive management; provision of oxygen, monitoring of vital sign closely, reduced fever Prognosis of delirium The outcome depends on the actual cause and the treatment given. Serious causes that are not treated well may result in much damage or even death

86. Dementia Is define as An irreversible progressive degeneration of brain cells following old age or organic cerebral diseases Characteristics of dementia ; Poor memory Poor Intellect judgment Poor personal and emotional control NB ; there is no clouding of consciousness in dementia

87. Causes of dementia Chronic infection e.g. HIV/AIDS Cardiovascular disorders e.g. multiple impacts like arteriosclerosis or cerebro-embolism Subarachnoid hemorrhaged or subdural hematoma Inflammatory conditions like encephalitis and meningitis Neoplasmic disorders of brain e.g. tumours

88. Metabolic/endocrine disorders and nutritional deficiency Direct trauma to the brain tissues (contusion and concussion ) Intoxication and anoxia

89. Clinical features of dementia Impair memory; poor short term memory, cannot remmeber recent event and explain simple proverb, Patient cannot remember or repeat series of numbers or addresses, name and faces of relatives etc Forgetfulness complain, decline in mental functioning or feeling depressed Poor orientation in time, person and place i.e. can tell correctly what time it is, where he is etc Increased appetite/greedy Changes in personality, paranoid thinking, and patient become very suspicious Development of hallucination Decline in routine function e.g. dressing, bathing etc Common in old age( 5% in people over 65 and 20% in people over 80%), very rare in youth and middle age

90. Diagnostic features Get history from relative, friends or acquaintances, because the patient will not be able to give correct history Physical examination Test of memory and thinking; ability to repeat the names of 3 objects immediately and recall the after 3 minutes, Ability to identify the day of week, month and years, Ability to give their full name and relatives

91. Differential diagnosis dementia Urinary tract, chest, skin and ear infections Cardiac failure Prescribed drugs especially psychiatric and antiparkinsonian drugs or alcohol Cerebro-vascular ischemia or hypoxia

92. Management of dementia Admission in the ward depending on severity Observation of vital sign very closely Provision of balance diet regularly Plan of treatment depend on the cause Psychotherapy including counseling patients and caretakers and physiotherapy (massages) may be needed Medication used Chlorpromazine 25-50 mg a day It sometimes manage some of the behavioral problems like aggression and restlessness Referral Refer the patient to district, regional or national hospital for further investigation

93. Information to family members Tell family members that Dementia is frequent at old age Memory loss and confusion may cause behavior change Memory loss usually grow slowly Physical illness and stress can increase the confusion; patient may get more confused when put in strange environment Don’t abuse patient for their behavior and assist patients as often as possible

94. Substance and drugs abuse Alcohol abuse; Social drinking which does not harm individual health physically, psychologically and socially is allow however consumption in excess is an abuse Rapidly absorbed into the circulation and reaches the brain within 5-10 minutes with effects which last for several hours Factors that determine the effects of alcohol on the consumer ; Strength of alcoholic drink Quantity taken Body size Content of stomach, the rate of absorption is very high in an empty stomach The active ingredient in alcohol

95. Terminologies used in drug abuse Tolerance ; adaptation of the body to the repeated presence of drug in which the effect of drugs increase with dose Dependence ; compulsion to take a drug following its repeated administration or consumption Addiction ; situation where individual taking excessive drug cannot do without Alcoholic ; individual who has developed physical or psychological change due to consumption of alcohol Alcoholism ; condition in which the excessive consumption of alcohol has become harmful to individual health, mentally, physically, socially and interpersonally

96. Reasons for drinking alcoholic Pleasure / socialization Addiction and dependency Escape pain and stress Influence from peer groups Curiosity , just to have experience Out of ignorance about the potential dangers

97. Causes of alcoholism Genetic factors/hereditary Social and cultural factors Physical illness Signs of alcohol addiction No work before drinking Early morning sweat, anxiety, tremors etc Increasing dose without effect/drunk Difficult to stop drinking despite advice, work, family and social problems

98. Complication of alcoholism Physical complication; Encephalopathy leading to epilepsy in long run Hypoglycemia, intoxication and dehydration common Thiamine deficiency which present by confusion, disorientation, memory impairment and ataxia Peripheral neuropathy like tremors Evidence of self neglect, poor hygiene Alcoholic myopathy, muscle wastage and damage Cardiomyopathy due to toxic effect of alcohol in heart tissue Liver cirrhosis due to metabolism of excessive dose Impotence in men Early dementia

99. Social complication ; Selective personality or anti social behaviors Financial problems leading to divorce Physical injuries Anxiety and depression Loneliness and feeling of guilty

100. Psychological complication ; Dipsomania , urge to drink alcohol Acute Alcoholic dementia Chronic delusion and hallucinations Suicidal tendency or attempts Alcoholic fits or rampage violence behaviors, on women most Delirium Poor memory or concentration

101. Complications of alcoholism Marital problems Domestic violent Child abuse or neglect Absenteeism from work Sign of alcohol withdrawal like sweating Diagnostic features Heavy alcohol misused Physical problems e.g. liver diseases Psychological harm like depression etc Addiction Withdrawal signs when cease from alcohol for short time like tremors, sweating Continue consumption despite harmful consequences

102. Differential diagnosis ; Anxiety or depression because of similar signs Information for patient and family Alcohol dependency is an illness with serious consequences Stopping alcohol or reducing its consumption is beneficial physically and mentally Drinking during pregnancy may harm the fetus Abrupt withdrawal may bring withdrawal symptoms and signs, medical supervision are necessary Discuss costs and benefits of drinking from the patient perspective and give a clear advice on how to change habit of living

103. Medication; Diazepam 10-40 mg a day in divided doses and reduces this by 10 mg every alternate day until zero for withdrawal symptoms Referral to specialist if withdrawal symptom are severe and continues/fits, very ill and severe tremors

104. Drug misuse/drug abuse Drugs are chemical agents which are used for cure and prevention of disease Misuse is nonmedical use of drug for wrong purpose Abuse is a misused of drug Common drugs of addicts; eg Opium/opiates – all narcotics drugs Cannabis/ marijuana Other drugs like diazepam and marungi

105. The route for their administration ; Opium Central nervous system stimulant with effect similar to amphetamine Administration; smoke, sniff or injection Effect of opium; Excitement, Dilation of pupils, Dizziness and tremors High dose cause; Confusion, Seizures, Cardiac and respiratory arrest Long term use may cause; Development of psychiatric symptom; paranoid, visual and tactile hallucination

106. Presenting compliant of drug abuse ; Family may request help before the patient due to irritability or abstinence from home Depressed mood, nervousness or insomnia Direct request for prescription of narcotics or other drugs Request for help to withdraw or stability of their drug use State of intoxication or withdrawal with physical complication of drug use e.g. abscesses

107. Diagnostic features Physical Injuries while intoxicated, physiological harm/symptom of mental disorder due to drug Harmful social consequences like loss of job, severe family problems or criminality Difficulty controlling drug use Strong desire to use drugs Tolerance( take heavy dose with no effects ) Withdrawal signs, anxiety, tremors etc

108. Differential diagnosis Alcohol abuse Symptoms of anxiety or depression may occur with heavy use Depression Generalized anxiety Psychotic disorders Delirium

109. Information for family and patient ; Drug misuses is a chronic, relapsing problem, and controlling or stopping, use often needs several attempts from close relatives and government organs, relapse is always very common Ceasing or reducing drug use will bring psychological, social and physical benefits Using some drugs during pregnancy risks harming the baby For IV drugs users there is high risk of infection with diseases of blood contact

110. Medication Don’t give any medication Convince patient to see specialist Referral; all case of drug abuse should be referred to the specialist May God blesses the work of my hands

111. Reference Luvsannyam E, Jain MS, Pormento MKL, et al. Neurobiology of schizophrenia: A comprehensive review   Cureus . 2022 Cheslack-Postava K, Brown AS. Prenatal infection and schizophrenia: A decade of further progress   Schizophr Res . 2022 Patel S, Khan S, M S, Hamid P. The association between cannabis use and schizophrenia: Causative or curative? A systematic review   Cureus . 2020 Şar V, Dorahy MJ, Krüger C. Revisiting the etiological aspects of dissociative identity disorder: A biopsychosocial perspective   Psychol Res Behav Manag . 2017 National Institute of Mental Health.  Schizophrenia

112. World Health Organization.  Schizophrenia Devillé C, Moeglin C, Sentissi O. Dissociative disorders: between neurosis and psychosis   Case Rep Psychiatry . 2014 Atilan Fedai Ü, Asoğlu M. Analysis of demographic and clinical characteristics of patients with dissociative identity disorder   Neuropsychiatr Dis Treat . 2022 U.S. National Library of Medicine.  Schizophrenia Kothari CL, Butkiewicz R, Williams ER, Jacobson C, Morse DS, Cerulli C. Does gender matter? Exploring mental health recovery court legal and health outcomes Health Justice . 2014

113. Define term child abuse Is define as Any intentional harm or mistreatment to a child under 18 years old

114. Physical abuse signs and symptoms Unexplained injuries, such as bruises, broken bones (fractures) or burns Injuries that don't match the given explanation Injuries that aren't compatible with the child's developmental ability Sexual abuse signs and symptoms Sexual behavior or knowledge that's inappropriate for the child's age Pregnancy or a sexually transmitted infection Genital or anal pain, bleeding, or injury Statements by the child that he or she was sexually abused Inappropriate sexual behavior with other children

115. Emotional abuse signs and symptoms Delayed or inappropriate emotional development Loss of self-confidence or self-esteem Social withdrawal or a loss of interest Depression Avoidance of certain situations, such as refusing to go to school or ride the bus Appears to desperately seek affection A decrease in school performance or loss of interest in school Loss of previously acquired developmental skills

116. Neglect signs and symptoms Poor growth Excessive weight with medical complications that are not being adequately addressed Poor personal cleanliness Lack of clothing or supplies to meet physical needs stealing food Poor record of school attendance Lack of appropriate attention for medical, dental or psychological problems or lack of necessary follow-up care

117. State types of child abuses Physical abuse.   Physical child abuse occurs when a child is purposely physically injured or put at risk of harm by another person . Emotional abuse.   Emotional child abuse means injuring a child's self-esteem or emotional well-being. It includes verbal and emotional assault ignoring or rejecting a child.

118. Sexual abuse.   Child sexual abuse is any sexual activity with a child. This can involve sexual contact, such as intentional sexual touching, oral-genital contact or intercourse. This can also involve noncontact sexual abuse of a child, such as exposing a child to sexual activity or pornography; observing or filming a child in a sexual manner; sexual harassment of a child; or prostitution of a child,

119. Medical abuse.  Medical child abuse occurs when someone gives false information about illness in a child that requires medical attention, putting the child at risk of injury and unnecessary medical care. Neglect.  Child neglect is failure to provide adequate food, clothing, shelter, clean living conditions, affection, supervision, education, or dental or medical care. In many cases, child abuse is done by someone the child knows and trusts — often a parent or other relative. If you suspect child abuse, report the abuse to the proper authorities.

120. Complications of child abuse Physical issues Premature death Physical disabilities Learning disabilities Substance abuse Health problems, such as heart disease, diabetes, chronic lung disease and cancer

121. Behavioral issues Illegal or violent behavior Abuse of others Withdrawal Suicide attempts or self-injury High-risk sexual behaviors or teen pregnancy Problems in school or not finishing high school Limited social and relationship skills Problems with work or staying employed

122. Emotional issues Low self-esteem Difficulty establishing or maintaining relationships Challenges with intimacy and trust An unhealthy view of parenthood Inability to cope with stress and frustrations An acceptance that violence is a normal part of relationships

123. Mental health disorders Eating disorders Personality disorders Behavior disorders Depression Anxiety disorders Post-traumatic stress disorder (PTSD) Trouble sleeping (insomnia) Attachment disorders

124. Preventives measures of child abuse in the community Be a nurturing parent. Children need to know that they are special, loved, and capable of following their dreams. Help a friend, neighbor, or relative. Being a parent isn’t easy. Offer a helping hand take care of the children, so the parent(s) can rest or spend time together. If your baby cries… It can be frustrating to hear your baby cry. Learn what to do if your baby won’t stop crying. Never shake a baby—shaking a child may result in severe injury or death. Get involved. Ask your community leaders, and schools to develop services to meet the needs of healthy children and families.

125. Help to develop parenting resources at your local library. Find out whether your local library has parenting resources, and if it does not, offer to help obtain some. Promote programs in school. Teaching children, parents, and teachers prevention strategies can help to keep children safe. Monitor your child’s television, video, and internet viewing/usage. Excessively watching violent films, TV programs, and videos can harm young children . Report suspected abuse or neglect. If you have reason to believe a child has been or may be harmed, call your local department of children and family services or your local police department.