PSYCHIATRIC DISORDERS

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Title
PSYCHIATRIC DISORDERS
extracted text
MH M
Reprinted from the BRITISH MEDICAL JOURNAL, 15th December 1984. 289. 1671 -1674

_ Appropriate Technology
Mental health care in the district hospital
H G EGDELL

Psychiatric disorders are not peculiar to Western countries, and
within the community served by a district general hospital in the
Third World the incidence of major mental illness is about 1%;
furthermore, the risk of any individual developing such a disorder
is 10%.1 Other studies in the developing world have found that
5-20% of patients have some form of psychiatric illness—
commonly anxiety and depression—which may present with a
variety of physical symptoms? Few district hospitals have
^Jbcialist psychiatric facilities or trained staff. This means that
general duties doctors may have to take responsibility for provid­
ing care for patients with psychiatric illness. Help from the nursing
and other health care workers is essential, although their co­
operation may be difficult to obtain because of ignorance about,
and prejudice towards, mental illness. My decision to initiate
psychiatric visits to an upcountry hospital in Uganda was at first
met with suspicion by the doctors, who thought that they would
have to admit disruptive patients to their wards. Nevertheless, I
received a warm welcome from medical assistants who were
seeking help in the management of outpatients with somatic
symptoms of anxiety and depression.
If psychiatric care is to be undertaken by general medical staff
they must be familiar with modern psychiatric treatment and take
the lead in preparing the other members of the hospital staff, and
support them through their initial anxieties in looking after
patients with psychiatric illness. It is also essential that priorities
for care should be defined. Thus if Morley’s guidelines are adopted
those conditions that are common, disabling, disturbing, and
treatable must be identified? In a study in seven developing
countries community representatives, health staff, and research
teams selected psychiatric emergencies (acute psychosis, suicide
^fcempts, drug and alcohol abuse), grand mal epilepsy, and
WKronic psychosis as their priorities?

Management of psychiatric emergencies

Community leaders and village health workers have no problems
in identifying patients with psychoses? Many languages have their
own words for the “run mad” and the “quietly mad”—for
example, eddalu and 1’akalogojjo in Uganda?’ Probably, however,
treatment will be sought only when the patient is acutely disturbed
or if a hospital shows a particular interest or success in treating
such patients. Acute psychoses often present with unacceptable
behaviour such as abuse, going naked, overactivity, and de­
structiveness. The patient may arrive at the hospital tied up,
handcuffed, or fastened to a large log of wood. Whatever the
circumstances it is important to obtain a good history from the
relatives, the local headman, or the police. In particular seek
evidence of physical illness, including epilepsy, ask about alcohol
and drug intake, and establish whether the patient is always fully

aware of his surroundings and orientated in time, place, and
person.
Patients often cooperate with the doctor given the opportunity. I
once met a naked young man handcuffed to a hospital bed, which
he dragged behind him through the hospital compound, waving a
large stone in his free hand. The nursing staff had formed a wary
circle around him. On being asked his problem the patient
complained of too many injections in his buttock. After a further
talk and a mug of tea he accepted a large injection of largactil into
his arm. This anecdote illustrates that the staffs natural anxiety
may actually encourage the patient’s disturbed behaviour.
If faced with a violent patient keep calm and ensure that two or
three male staff or relatives are near but not too close to be
intimidating. Tell the patient that the staff are there to protect him
from harm (from himself or others) and encourage him to talk.
Offer food and drink but leave him plenty of “personal space.” If
he remains disturbed and overactive offer chlorpromazine 50-100
mg orally to help him “feel better and be in control.” If he is
cooperative arrange admission to a quiet room with minimal
furnishings. Some hospital staff have an intuitive skill in calming
the disturbed, and it is important to appreciate that time spent
waiting for the patient to decide to accept treatment is more
productive than a hasty attempt to overwhelm him. Physical
restraint is rarely necessary and should be used only if violence
persists. The aim of such restraint is to prevent the patient
harming either himself or others and to administer a tranquilliser.
It is best achieved by holding the patient’s clothes, shoulders, mid­
thighs, and calves, keeping the legs together and avoiding putting
pressure on the neck, chest, or abdomen. The patient is then
forced to lie face down on the mattress or floor. Remove any
objects that may cause injury, such as shoes. Talk to the patient
continuously, telling him when, where, and why the injection is
being given. Chlorpromazine 100 mg intramuscularly (less if the
patient is small or elderly) is effective and may be repeated every
two hours. When oral medication is accepted the dose may be
doubled, and the maintenance dose should be 200 mg (or less) four
times a day. Haloperidol 5-10 mg intramuscularly half to one
hourly (depending on size and age) followed by 10-20 mg given
orally four times a day is an alternative regimen? These drugs may
cause excessive sedation and hypotension, but the commonest
error is to give an inadequate dose for too short a time.
Drug treatment has largely replaced electroconvulsive therapy.
Two 60 bed provincial psychiatric units in Kenya have not used
electroconvulsive therapy for over 18 months (Acuda, personal
communication). On rare occasions, however, patients with
resistant severe psychotic depression or uncontrollable excitement
may need electroconvulsive therapy, and for this they should be
referred to a specialised psychiatric unit.

Making a diagnosis
ORGANIC ILLNESS
Department of Psychiatry, Royal Liverpool Hospital, Liverpool L7 8XP
H G EGDELL, FRcr, mrctsych, consultant psychiatrist

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Any patient who presents in an acutely disturbed state must be
examined and investigated to exclude organic disease. The history

all rights or refrodl’ction or mis rfprim arf rfsf rveo is all countries of the world

1672

BRITISH MEDICAL JOURNAL

is also very important, and evidence of clouding of consciousness,
disorientation, impaired thinking and memory, and marked
anxiety with a fluctuating general state must be sought. Minor
impairment of memory may be established only by questioning
about recent events and asking the patient to remember a name
and address after five minutes. Visual hallucinations are common
in organic psychosis. Table I serves as a guide to the aetiology of
acute organic reactions. The doctor should be particularly aware of
the common local diseases, and in this respect it is of interest to
note that the two most commonly used drugs in Butabika Mental
Hospital, Uganda, were chlorpromazine and chloramphenicol.
This was due to the misdiagnosis of typhoid as a functional
psychosis.

TABLE I—Causes of acute organic reactions. (Reproduced from W A Irishman's Organic
Psychiatry39 by kind permission) r

Encephalitis, meningitis, subacute meningovascular syphilis.

(6) Epileptic
(7) Metabolic
(8) Endocrine

influenza, typhoid, typhus, cerebral malaria, trypanosomiasis,
rheumatic chorea
Acute cerebral thrombosis or embolism, episode in arteriosclerotic
dementia, transient cerebral ischaemic attack, subarachnoid
haemorrhage, hypertensive encephalopathy, systemic lupus
erythematosus
Uraemia, liver disorder, electrolyte disturbances, alkalosis,

Hyperthyroid crises, myxoedema, Addisonian crises,

(9) Toxic

hyperparathyroidism, diabetic prc-coma, hypoglycaemia
Alcohol: Wernicke's encephalopathy, delirium tremens.rugs:

(11) Vitamin deficiency

intoxication, cannabis, LSD, prescribed medications
oxidase inhibitor antidepressants, digoxin, etc). Others: lead,
arsenic, organic mercury compounds, carbon disulphide
Bronchopneumonia, congestive cardiac failure, cardiac
arrhythmias, silent coronary infarction, silent bleeding, carbon
Thiamine (xJernicke's encephalopathy), nicotinic acid (pellagra,
acid deficiency

FUNCTIONAL (NON-ORGANIC) PSYCHOSIS

Schizophrenia with delusions of special powers or persecution
out of keeping with local beliefs, and auditory hallucinations, may
present with or without excitement. The manic patient is overactive, sleepless, and disinhibited with euphoria and grandiose
ideas. Such patients need to be carefully examined for evidence of
^fcsical illness once their excitement has been controlled.
Chlorpromazine 50-200 mg four times a day or haloperidol 10-20
mg four times a day, reducing slowly to smaller maintenance doses
depending on response, usually provides satisfactory control.
Stress induced psychosis is common in developing countries. It
may follow adverse life events such as bereavement or assault, but
more subtle personal precipitants may be difficult to identify. Most
patients with acute psychoses settle rapidly and medication may be
withdrawn slowly. Those with persisting symptoms—usually
chronic schizophrenia (which has a better outlook than in Western
countries)—may need maintenance doses of major tranquillisers.
Depot preparations such as fluphenazine decanoate 25-100 mg
intramuscularly or flupenthixol 40-120 mg intramuscularly every
three or four weeks may overcome problems of compliance with
oral treatment. These preparations are expensive but are cheaper
than repeated admissions to hospital.’ It is advisable to keep a
register of patients receiving maintenance treatment so that a
failure to attend for further treatment and review may alert staff to
take action to prevent a disruptive relapse.
Acute alcoholic psychoses (delirium tremens) may be controlled
by a benzodiazepine—for example, diazepam 50-75 mg daily
reducing after two or three days and stopping in a week. Halo­
peridol is an alternative. These patients and their families will need
counselling on the hazards of excess drink and the benefits of
reduced intake. Patients with epilepsy may also present with acute

psychosis, which usually implies poor compliance with anti­
convulsant treatment. Follow up should include supervision of
medication as well as counselling of the patients and their relatives.

Management of patients with neuroses

A survey of 1624 outpatients in primary care clinics in four
developing countries showed an overall frequency of psychiatric
illness of 13-9%—mainly the physical symptoms of anxiety and
depression.” " More than 20% of outpatients who complained of
weakness, dizziness, or abdominal or chest pain had a psychiatric
disorder. Those with three or more symptoms were twice as likely
to be mentally ill. These patients make huge demands on the
hospital staff and on the hospital budget because many undergo
needless investigations. In my view, the general duties doctor
must be prepared to assess and when necessary treat these patients,
and to do this he must be attuned to looking for depression, stress
reactions, the anxiety aspects of physical illness, and the chronic
symptoms of the anxiety prone individual.'2
Patients with depressive illness may not complain of depression,
but there are cross cultural core symptoms of sadness, joylessness,
anxiety, tension, lack of energy, loss of interests, loss of concentra­
tion, and ideas of insufficiency, inadequacy, and worthlessness."
Antidepressants such as amitriptyline 25-75 mg twice daily may be
very effective in these patients. In patients with anxiety, however,
the doctor’s first task is to help them understand that their
condition has psychosocial rather than disease origins. Appropriate
adjustments to their way of life may then become apparent. The
doctor must promote self help and guide the patients towards
tackling their own problems. Techniques of relaxation, desensi­
tisation, implosion therapy, and brief psychotherapy with clear,
feasible objectives may help the doctor to deal with patients who
are often demanding and difficult to treat." 15 Minor tranquillisers
such as diazepam and chlordiazepoxide should be used to treat
only acute, severely disabling, short lived anxiety. They cannot
solve psychosocial problems, and Third World health services
cannot afford to follow the widespread and largely ineffective use
of minor tranquillisers that has been evident in Western countries.
Patients who deliberately harm themselves or attempt suicide
must be asssessed carefully. Underlying psychosis or severe de­
pression needs to be treated and all cases need close supervision
while the underlying stresses on the patients and their family are
assessed. It may be helpful to refer patients to community or
religious leaders or, in some cases, traditional healers, who can
provide further support and counselling. Nursing staff and
primary health workers seldom have the time or the necessary
skills to provide specialised care for such patients.

Attitudes to mental health

Mental health is now part of modern training programmes, but
many hospital staff are still not yet prepared to manage patients
with psychiatric disorders, especially those with neuroses, which
were given a low priority in recent recommendations by the World
Health Organisation." I think that this is regrettable, especially
with respect to depressive illness, which is common, easy to
recognise, and treatable. In my view a major change in attitudes
and allocation of resources to meet the needs of the mentally ill is
needed. The first step could be to set up a local workshop where
health staff could meet community and religious leaders, members
of voluntary associations, teachers, and other interested persons to
clarify priority problems and consider a community response to
these. On an assignment in Swaziland, funded by the World
Health Organisation, I found that the rural health motivators
(mature and respected individuals with three months’ general
health training) grasped psychosocial concepts rapidly and were
keen to help patients. Simple counselling skills could prepare them
for potentially valuable work with outpatients, especially healthy
young people who present with non-specific complaints such as eye
strain, poor concentration, and academic failure. A manual for the

BRITISH MEDICAL JOURNAL

disabled has been published recently and has many other sug­
gestions for community action.1’
Some traditional healers specialise in mental health,*I2345678910
1819
17
16
15
14
13
12
11
20
'* but does
this mean that the doctor should cooperate with them? I believe
that the wide variations in skill among such individuals must lead
the doctor to be cautious, and that he should make a careful local
assessment of their skills, methods of treatment, and results before
committing himself to any formal liaison. It is salutary to re­
member, however, that patients will attend these healers anyway,
both before and after they receive their Western care, regardless of
the doctor’s views.

1673
TABLE II—Recommended psychotropic drugs for district general hospitals (second choices in
parentheses)

Haloperidol 5 mg tablet
Fluphenazine decanoate 25 mg/rnl injection
(Trifluoperazine 5 mg tablet)
(Flupenthixol decanoate 20 mg/ml injection)
Procyclidine 5 mg tablet
Diazepam 5 mg tablet
Amitriptyline 25 mg tablet
(Imipramine 25 mg tablet)
(Lithium carbonate 250 mg tablet)
(Mianserin and Nomifensine arc

Health staff will need guidance sheets.

Problems in childhood
Primary health care workers in the Sudan, Philippines, India,
and Colombia have reported mental health problems in 12-29% of
children seen.” Symptoms that are inconsistent, unusual, or
associated with special circumstances are helpful pointers to
diagnosis, as is the opinion of the attending adult.21 Hyperkinesis
may be associated with brain damage, developmental problems, or
family problems.2223
25
24
22 Amphetamine up to 30 mg daily may help,
though small doses of chlorpromazine, slowly increasing to 50 to
100 mg daily, may be all that is available. The attitudes of the
family and school are crucial. Hysteria, manifested for example as
^fconia or paralysis without physical illness, usually follows stress,
cVgh details may need tactful exploration. Admission to hospital
may allow a face saving recovery while the underlying stress factors
are explored and ameliorated. Nocturnal enuresis has been
managed effectively by parents in Swaziland by ignoring wetting
and rewarding dry nights using star charts (Guinness, personal
communication). Similar management of encopresis is possible.22
Care of children with epilepsy must include measures to overcome
negative attitudes in the community.
Mental handicap is considered to be untreatable by some
doctors, but communities have placed it high on their priorities for
care.2 Parents lose heart and fail to teach domestic and self care
skills, and unsatisfactory habits are established. A simple approach
is to start with the control of fits or hyperkinesis and then teach
that the mentally handicapped can learn but that they do so slowly.
Various techniques have been devised for family use.17 A scheme
using mothers and village aides as teachers of mentally handi­
capped children is proving successful in Kenya (Horsfield, personal
communication).
Training

^Die doctor in a Third World district hospital should initiate
t^png schemes for health staff concentrating on a few tasks that
are seen as priorities—for example, the use of drugs, restraint of
the violent patient, and community care. Ask the country’s
psychiatrists and health teachers to visit the hospital for joint
discussions with local health trainers and to take part in teaching
the staff and arranging workshops. Brief psychiatric secondment
for selected health staff is feasible in some countries—for example,
in Bangladesh regular courses are run for district hospital doctors
(Dr Hidayetal Islam, professor of psychiatry, Dacca). Zambia has
a well established training scheme for medical assistants, which
was started by Professor Alan Haworth. In India a similar aproach has potentially wider application.22 Further ideas may be
gleaned by reviewing local pilot systems of care.26 2728
32Training
31
30
29
manuals may be most helpful, and several have been produced.21-22
The use of flow charts is another valuable way to teach health
workers.”
It is useful to compile a list of psychotropic drugs that are
available in the hospital, together with standard dose regimens
(table II). A local glossary of psychiatric terms is also helpful
together with a list of local interpreters who need a brief training in
how to elicit a psychiatric history. The use of non-hospital staff
implies that policy decisions should be made to sanction their
participation in the care of patients with psychiatric disorders.
Their responsibilities and training will require the cooperation of

local and probably national health trainers. Finally, the success of
any training programmes should be evaluated.22-21

Conclusion
The general duties doctor can provide effective mental health
care in a district hospital. Although psychoses usually take pre­
cedence over neuroses, local priorities of care must be identified.
Intervention and appropriate management of these disorders may
be achieved with limited facilities and scant resources.” The most
important hurdle may well be that of overcoming local ignorance
and prejudice.
I thank Mrs Irene Tierney for secretarial help and Mrs Betty O’Brien
and Mrs Dorothy Howard for help with references.

References
1 World Health Organisation. Organisation of mental health services in developing countries.
WHO Tech Rep Ser !975;No 564.
2 Egdell HG. Menial health care in the developing world. Brief review of first phase of WHO
collaborative study on strategies for extending mental health care. Trap Doct 1983;13:149-52.
3 Morley D. Paediatnc priorities in the developing world. London: Butterworth, 1973.
4 Climent CE, Diop BSM, Harding TW, Ibrahim HHA, Ladrido-Ignacio L, Wig NN. Mental
health in primary health care. WHO Chron 1980;34:231-6
5 Wig NN, Suleiman MA, Routledge R, et al. Community reactions to mental disorders: a key
informant study in three developing countries. Acta Psychiatr Scand 1980;61:111-26.
6 Orley JH. Culture and mental illness: a study from Uganda. Nairobi: East African Publishing
House, 1970.
7 Edg^rtorigRBg Conceptions of psychosis in four east African societies. American Anthropologist
8 Donlon PT, Hopkin J, Tupin JP. Overview: efficacy and safety of rapid ncuroleptizaiion
method with injectable haloperidol. Am 7 Psychiatry 1979;136:273-8.
9 Brook MG. Community care programme for chronic psychotic patients on a small Caribbean
island. Trap Doct (in press).
10 Harding TW, de Arango MV, Baltazar J, et al. Mental disorders in primary health care: a study
of their frequency and diagnosis in four developing countries. Psychol Med 1980;10:231-41.
11 Harding TW, Climent CE, Diop M, et al. The WHO collaborative study on strategies for
extending mental health care. II The development of new research methods. Am J Psychiatry
1983;140:1474-80.
12 Acuda W, Egdell HG. Anxiety and depression and the general doctor. Trap Doct 1984;14:51-5.
13 Sartorius N, Jablensky A, Gulbinat W, Emberg G. WHO collaborative study: assessment of
depressive disorders. Psychol Med 1980;10:743-9.
14 Wilkinson ICM, Latif K. Behaviour therapy. Derby, England: Pastures Hospital, 1972.
15 Bloch S, cd. An introduction to the psychotherapia. Oxford: Oxford Medical Publications, 1979.
16 Harding TW, Busnello Ed’A, Climent CE, et al. The WHO collaborative study on strategics for
l^Sri^lTsFs 11 heaIth Care‘ 111 ■ Evalualive design and illustrative resultSuAm J Psychiatry
17 Helander E, Mend is P, Nelson G. Training disabled people in the community. A manual on
community-based rehabilitation for developing countries. Geneva: WHO. 1983. (RHB/83.1.)
18 Green EC. Roles lor African traditional healers in mental health care. Medical Anthropology 1980,
autumn:489-522.
19 Kapur R. The role of traditional healers in mental health care in rural India. Indian Social
Science and Medicine 1979;138:27-31.
20 Giel R, de Arango MV, Climent CE, et al. Childhood mental disorders in primary health cart:
fo" developing countries. Pediatrics 1981;68:677-83.
?!
S?'oPnlbJ'."?
'"l 2™1 "he S'""*1 docMr- TmDM I9S4;H: 103-7.
22 Egdell HG, Sunfield JP. Paeduinc neurology in ATria: a Ugandan upon. BrM.dJ 1972U:M«23 Kolvul11, Coodyer I Child psyehiauy. In: Granville-Grosanun K, ed. Rernu utameer u dimal
psychiatry 4. London: Churchill Livingstone, 1982:1-24.
24 Kolvin I, Macmillan A. Child psychiatry. In: Granville-Grossman K, ed. Recent advances m
clinical psychiatry 2. London: Churchill Livingstone, 1976:296-350.
25 Murthy RS, Wig NN. The WHO collaborative study on strategies for extending mental health
care. IV. A training approach to enhancing the availability of mental health manpower in a
developing country. Am J Psychiatry 1983;140:1486-90.
26 Wig NN, Murthy RS, Harding Tw. A model for rural psychiatric services—Raipur Rani
experience. Indian Journal ofPsychiatry 1981^3:275-90.

27 Baasher T, El-Hakim A, Galat A, Habbashy E. Rural psychiatry: the Fayoum experiment.
Egypt J Psychiatry 1979^:77-87.
28 Wankiin VB. Training manual for identification and management of menial health problems (for mid­
level primary health workers). Geneva: WHO.
29 Wankiiri VB. Mental health module (student text). Rural health development project. Maseru,
Lesotho: Ministry of Health and Social Welfare, 1982.
30 Wankiiri VB. Community mental health care—a manualfor health workers. Geneva: WHO, 1982.
31 Swift CR. Menial health: a manual for medical assistants and other rural health workers. Nairobi:
African Medical and Research Foundation. 1977.
32 Murphy RS. Mental health component of primary health care manuals—a review. Journal of the
National Institute ofMenial Health and Neurosciences, Bangalore, India 1983;1:91-8.

1674
33 Ladrigo-Ignacio L, Climent CE, de Arango MV, Bakazar J. Research screening instruments as
,, ,„,ook “* tuning health workers for mental health care. Trap Geogr Med 1983;35:1-7.
34 World Health Organisauon. A manual on child mental health and psychosocial development. 1.i
health care physician. II. For the primary health worker. III. For teachers. IV. i
hiIdten's hornet. New Delhi: WHO, 1982.
35 Essex B, Gosling H. Programme for identification and management of menial health problems.
(Tropical health series.) Edinburgh and London. Churchill Livingstone, 1982.
36 World Health Organisation. Mental health care in developing countries: a critical appraisal of
research findings WHO Tech Rep Ser 1984;No 698.
37 Hassler FR. Evaluation of mental health services. In- Baasher TA, Carstairs GM, Giel R,
Hassler FR, eds. Menial health service! in developing countries. Geneva: WHO, 1975.
38 World Health Organisation. Managerial process far national health development. Geneva; WHO,
39 Lishman WA. Organic psychiatry. The psychological consequences of cerebral disorder. Oxford:
Blackwell Scientific, 1978:182-3.

Suggestions for further reading
management of mental illness in adults and children for the general doctor working independently

BRITISH MEDICAL JOURNAL

Asuni T, Swift CR. Psychiatry in an African setting. (Mental health: rural health series.) Nairobi:
.frican Medical Research Foundation, 1977.
African Medical and Research Foundation, 1977.
Barker P. Basic child psychiatry. 4th ed, London: Granada, 1983. (Paperback £7’95.) Principles
and practice that can be adapted to the Third World.
Essex B, Gosling H. Programme for identification and management of mental health problems.
(Tropical health series.) Edinburgh and London: Churchill Livingstone, 1982. (Softback £2’30.)
Carefully evaluated and practical flow charts especially useful in teaching health staff who will work
in isolation.
World Health Organisation. Organisation of mental health services in developing countries.
WHO Tech Rep Set 1975;No 564. Basic document for all health teachers and administrators.
World Health Organisation. Mental health care in developing countries: a critical appraisal of
research findings. WHO Tech Rep Ser 1984;No 698.

The following publications illustrate that mental health is a broad, positive concept and not
the absence of mental illness. They are helpful in provoking staff to think beyond hospital
World Health Organisation. Promoting health tn the human environment. Geneva: WHO, 1975.
World Health Organisation. Social dimensions of mental health. Geneva: WHO, 1981.

I -1H 1 • >-■

mental health in India

'problems encountered . .
Dr. A. S. Mahal

Mental health is defined as not only
freedom from illness, but as positive
health in the sense that the individual is
happy and satisfied, is adjusted in his
social circle and has good capacity for
work in order to produce enough for his
maintenance and that of his dependents.
The ideal state of health in a community
is that in which all members of the com­
munity are having this standard of health.
All those who are concerned with mental
health, work towards this ideal. We in
India fall much short of this. We arc
in the early stages of organising services
for coping with serious mental health
problems.

phobias, reactive depression, psychopa­
thic personality, drug addiction, alcohol­
ism,
sexual deviations,
etc. The
estimate of minor mental illnesses varies
in different studies. As a conservative
estimate about 10 per cent of the popula­
tion suffer from minor mental illnesses.

Types of illness

Problems encountered

One has to understand the nature and
magnitude of mental health problems, in
order to get a fair idea of the task ahead
of us. Major mental illnesses are named
psychoses. There are gross disturbances
of behaviour in these. One percent of
our population suffer from psychosis at
any time. There are at a conservative
estimate more than five million psychotic
patients in India. Minor mental illnesses
arc called psycho-neuroses and persona­
lity disorders. Examples of minor mental
illnesses are patients of hysteria, anxiety
neurosis, obsessive compulsive neurosis,

Mentally disturbed persons have
difficulties in their life. They fail to form
mutually satisfying interpersonal relation­
ships with other human beings. They
have chronic interpersonal problems,
which do not get solved without expert
help. In this category may be considered
cases of marital discord, some of the
chronic parent-child and employee­
employer problems. These cause a lot
of human suffering, and are both the
result and the cause of mental ill health.
These exist in any community in very
large numbers. Serious emotional upsets

Another major category of mental
health problems is that of mental retar­
dation. About 1 per cent of the popula­
tion suffer from this disability. Still
another major problem is that of
epilepsy. Again, approximately, 1 per
cent of the population suffer from
epilepsy.

Dr. Mahal (M.B.B.S., D.O., M.D., M.R.C. Psych., F.I.P.S.) is a Private Psychiatrist.

also result in such abnormal behaviour
as is seen in cases of suicide and at­
tempted suicide. In each large town and
city in India, a number of persons are
brought to hospitals every day, after
having made an attempt at suicide.
Indequate facilities
For the management of major mental
health problems we have in India 38
mental hospitals spread all over the
country. Most of the states have one
or more mental hospitals. These hos­
pitals have in them about 20,000 beds.
For catering to half a million seriously
disturbed mental patients in our country
this number is utterly inadequate. These
facilities are being utilised by less than
1 per cent of the total number of psy­
chotic patients that we have amongst us.
Most of these beds in our mental hospi­
tals are occupied by chronic mental
patients, who are held in mental hospitals
for indefinite stay without much active
treatment being given to them. Very
few beds are available in our mental
hospitals for admission of new cases.
These mental patients can be treated and
restored back to their homes and jobs.
Most of the first admission cases, if they
are brought early for treatment, recover
from their illness and are able to return
to normal life, and to treatment as out­
patients. More facilities, and preferably
geographically more dispersed, need to
be created for the treatment of these
patients. With the availability of trained
psychiatrists,
clinical
psychologists,
psychiatric social workers, occupational
therapists and psychiatric nurses on the
staff of some of our mental hospitals,
such quick turn over wards are now
being organised in them. Most mental
hospitals have also started outpatient
departments, which give outpatient
treatment to a variety of mental
patients.

In the last decade psychiatry depart­
ments have been added to a number of
medical colleges with facilities for out­
patients departments as well as psychia­
tric wards in their general hospitals.
These O.P.D.s and psychiatric wards are
helping a large number of patients with
minor mental illnesses. This is a welcome
addition to existing mental health facili­
ties.
Urban bias and rural neglect

In large towns and big cities some
charitable hospitals and nursing homes
have also recently started helping mental
patients with the additon of O.P.D. facili­
ties and provision for admission of less
disturbed mental patients. Also these
urban areas have practising psychia­
trists who cater to the needs of patients
who consult them on payment.

Facilities for the care of the mentally
retarded are few. There are a few
institutions in our cities for the care of
the profoundly and severely mentally
retarded. Facilities for the mildly and
moderately mentally retarded are even
fewer in number. Epileptics are cared
for by physicians, neurologists as well
as psychiatrists. Disturbed epileptics
share existing facilities with other mental
patients in our mental hospitals. Child
Guidance Clinics have recently come up
in some cities for helping emotionally
disturbed children.
Almost all these facilities exist only
in towns and cities. The vast rural
population has no facilities for the care
of mentally ill patients. When in serious
need, they have to travel long distances
to avail of these facilities in towns. In
less serious cases and even in serious
cases when they cannot afford it, they do
without any psychiatric help.

Training programmes

The Delhi scene

In India we now have facilities for
the training of personnel for mental
health care. Mental patients are cared
for by a team of professionals consisting
of psychiatrists, helped by clinical
psychologists, psychiatric social workers,
occupational therapists and psychiatric
nurses. We train in India about 100
psychiatrists a year. The major training
institution is the National Institute of
Mental Health and Neurosciences, Bang­
alore. There is another training centre
at Ranchi. Both these institutions also
train clinical psychologists and psychia­
tric social workers. Bangalore trains
psychiatric nurses also. Psychiatrists
are also trained in psychiatry depart­
ments of medical institutes and upgraded
psychiatry departments of some medical
colleges. Courses for psychologists and
social workers are run in 26 universities
in India.

Delhi being the capital city of India,
has a number of institutions giving
psychiatric care. Hospital for Mental
Diseases, Shahdara, has 350 beds. In
addition, 250 newly constructed beds are
ready for occupation as soon as , it is
equipped and staffed. It runs an O.P.D.
which caters to a large number of patients.
There are O.P.D. and psychiatric wards
at A.1.1.M.S., Safdarjung, Willingdon,
Loknayak J.P. Narayan, and Pant Hospi­
tals. Hindu Rao Hospital has an O.P.D.
Sir Ganga Ram, Mool Chand, Kharaiti
Ram, Holy Family and Saint Stephen’s
Hospitals have O.P.D.s as well as
facilities for admission in general, wards
and nursing homes. A number of
psychiatrists in private practice run
clinics for the benefit of patients.

With trained professionals coming
out of our institutions we have the neces­
sary personnel for rapid expansion of
facilities for mental health care of our
people. We can do it as fast as our
resources permit us, and as fast as we
plan to utilise these professionals. It is
tragic that in the absence of rapid expan­
sion of mental health care facilities and
to get better pay, some of the trained
staff is leaving India to go abroad.

For the mentally retarded we have
institutions at Punjabi Bagh and Okhla.
Schools for mentally retarded are there
at Lajpat Nagar and Bhagwan Das Road.
We have Child Guidance Clinics at
A.I.I.M.S., the College of Nursing, and
the Community Centre at Rajinder
Nagar.

A unique voluntary institution func­
tioning in Delhi is Sanjivini, at Bharatiya
Vidya Bhawan, Kasturba Gandhi Marg,
New Delhi, which renders help to those
disturbed and desperate human beings
who have made an attempt at ending
their lives.

befriending

'the one discovery . .
Rev. Cha
In the fields of suicide prevention and
mental health, all new discoveries except
one have been improvements in profes­
sional treatment, and particularly in
psychiatry. Every development in psy­
chological medicine and chemotherapy
spreads relatively rapidly through medi­
cal journals and conferences, and each
new method of psychotherapy or coun­
selling is likely to become a craze for a
while until its solid merit and appropriate
application have emerged and it takes its
place amongst others, both older and
newer.

Varah
The response nearly overwhelmed me,
but kindly disposed men and women
rallied around to try to help by giving
tea or coffee and a kind word and a liste­
ning ear to those who had to wait a long
time for their interview with me.

These
extraordinary
“ordinary”
people, with no qualifications but great
human qualities, soon seemed to me to
be more what the “clients” wanted than
I was. Admittedly, some needed a pro­
fessional like myself, or perhaps a
psychiatrist, at a later stage, but the
first need in the genuinely desperate
The one discovery which does not cases was a listener who truly felt for the
directly involve professionally qualified sufferer and had no advice or expertise
people and which makes its contribution to hide behind. It was a very vulnerable
to suicide prevention and to the mental position and only the most loving souls
health of the community is that which could manage it. These “Samaritans”
is called “Befriending”. 1 was the supported one another and of course
one who noticed it, studied it, and received much appreciation and back-up
.gave it the opportunity to prove its from me. What they were doing was
effectiveness, and count myself very giving instant friendship to a stranger in
fortunate to have been able to make such distress, and thereby giving the person
an observation in 1953 and also to be the emotional support necessary to enable
him or her to see the way forward, just
able to put it to the test.
far enough for a suicidal act to be de­
I had also publicised my telephone ferred. Their spirit was so much that
number and address so that suicidal and of the Samaritan in the Christian parable
other lonely and despairing people might that I felt “Samaritan” was a good name
get in touch with me, day or night. This for these people, only a minority of
was . the origin of the many types of whom were Christians.
“hot lines” which have proliferated in
The word “Samaritan” now has as
countries which make great use of the one of its definitions in the Concise
telephone, but of course these are not Oxford Dictionary, “member of an orga­
necessarily similar to The Samaritans. nisation to befriend the suicidal” and
Rev. Chad Varah is founder of the Samaritai 1 and Chairman of Befricnders International (The
Snmaritians Worldwide)

we hope that in the next edition “Be­
friending” will appear as an effective
therapeutic method for depressed and
lonely potential suicides.
The sense of befriending is its humi­
lity and the fellow human feeling that
goes with it. The befriender has been
selected (there is no way by which selfcentred people can be turned into
Samaritans) because he or she is found
to be one who genuinely cares about the
troubles of others, and who does not feel
in any way superior to those whose lives
are obviously in some disarray. Merely
to be with a befriender for a while makes
you feel better, even though nothing will
have changed except that you have found
acceptance, understanding and com­
passion.

What do the befrienders do! enquires
the person who thinks of clients as
collections of problems to be solved or
operated upon; and the answer to such
people must be “nothing mostly.” That
is to say, they do nothing which would

make any sense to the do-gooder or
impress the narrowest and most insecure
type of professional. To those with open
minds and hearts, the answer would be:
“The befriender is not there to do for
the client what he or she can possibly
be expected to do for himself or herself,
though some form of practical help in
matters in which the client is temporarily
incapacitated is not forbidden; but the
befriender is not to be judged by what
he or she does or even says, but by being
the loving and attentive fellow human
the client needs.”
It is so simple a child can understand
it. It is so profound that sages can
philosophise about it indefinitely. It is
so easy you could burst into joyous
laughter when the miracle has happened.
It is so difficult you sometimes feel you
won’t be able to sustain it for the neces­
sary length of time. It is suffering and
it blesses you. But words cannot make
it clear: you must try to do it; or grate­
fully accept it when it is done to you.

adolescent suicide behaviour in india

‘adolescence is a no mans land . .
Prof. A. Venkoba Rao
Certain general points of relevance
are considered before discussing the
suicide behaviour among the youth of
India.

It is seen that 16.6 per cent of the popu­
lation falls in the age range 15-24. This
indicates that the youth forms a consi­
derable segment of the country’s popula­
tion. Though the second most populous
country in the world, India takes
16th place among the countries for
suicide rate. The annual suicide rate
varies from 6.3 - 8.8 per 100,000. Suicide
is the fifth leading cause of death among
adolescents in the 15-19 year group
(Jacob, 1971). That adolescent suicide
and attempted suicide are common in
India is borne out by published data.
Suicide and attempted suicide in the
college campus is a familiar experience
to administrators of these institutions
and universities. The published records
have all indicated the higher occurrence
of suicide among the younger people, the
greatest ‘rush’ group being that between
20-30 years of age.

The youth of the country has been
drawing attention in recent years, as
perhaps even in the times of Socrates.
Student unrest and indiscipline, distrac­
tions during application to the educa­
tional curriculum, explosive outbursts

for trivial authoritarian actions, strikes
on a smaller or a larger scale in the
schools and colleges, violence in the
college campus, ‘gheraoing’ the so-called
authoritarian figures, non-medical use of
drugs in preference to attending the
classes, frequenting the horror films,
indulging in crime and detective literature
and illicit sexual indulgence; all these
and others indicate a malady of aggres­
sion among them. In a country like
India with its escalating population, the
youth finds itself in a state of frustration
for reasons more than one. It will be
worthwhile to examine them in some
detail: They are of socio-pathological
importance to the topic of suicide
behaviour.

Unemployment: Unemployment is a
daunting problem in India today, and in
urban areas it is worse, especially so
among the educated. This number is
bound to rise in view of the expanding
facilities for literacy and higher studies.
Unemployment among the youthful
members, even though they are supported
by other members of the joint family is
a cause of frustration since it carries a
stigma of social disapproval. The un­
employed youth lacks a feeling of
individuality and prestige and finds him­
self unable to take . responsibility of

Prof. Venkoba Rao (MD; PhD; FRC Psych; FAMS), is Head and Professor of Psychiatry.
Madurai Medical College and Erskine Hospital, Madurai.

running the family in the event of the
disability, or the death of the bread
winner in the family. Most important,
he is not preferred in marriage. His, is a
lot of ‘social ostracism’ or ‘isolation’. It
is interesting to note that in India there
are certain castes whose members feel it
beneath their dignity to work and these
are unemployed but yet are unwilling to
work, even if work , is offered to them.
Unemployment can be a strong motivator
of suicide. In a study on suicide conducted
by Bagadia and colleagues in Bombay
(1976), it was found that 40 per cent
of the group studied had been unemploy­
ed for more than a year. Mention must
be made of suicides among those who
return home after higher qualification
and training abroad. Unemployment
among this group has resulted in suicide
in several instances. In Dr. Venkoba
Rao’s study of 423 suicide attempts
registered in the Madurai Centre, un­
employment was identified as the direct
precipitant of suicide attempts among
190 of the group. Unemployment due
to psychiatric and physical disability can
often lead to self-destructive behaviour.
These are the social consequences of
illness.
Job Satisfaction. Here the situation
appears different from the previous
group. The youth has a job on hand
but finds himself unfit for it or finds it
difficult to realise his desired aims and
goals. This is a familiar picture among
the intelligent and creative youths who
find that official and administrative
machinery are impediments and dampen
their enthusiasm. Suicides have occurred
among the personnel of research organi­
sations in India presumably from these
causes.

Marriage and Sex. In India, marriages
are usually arranged and are determined

by factors like status, economic parity
and caste. Adherence to this may result
often in unwilling and forced marriages.
These may result in suicide attempts or
completed suicide. The boy or the girl
may be forced into marriage against his
or her wish by the authoritative parents.
In some instances they submit in obedi­
ence to the wishes of the elders although
that means the sacrifice of their personal
choice. Where the traditional way
is disregarded, marriage takes place
on the basis of personal choice, but
they do not meet with parental approval.
Or else such a marriage is not allowed
and the lovers, not uncommonly, commit
suicide together, or in some cases the
disappointed one alone succumbs and the
other gets on with a happy marital life
elsewhere. Among the Indians, as in
other cultures, a high.value is placed on
semen as the fountain of robust health.
Its loss through masturbation or noctur­
nal emission may result in under-valuation
or devaluation of the youth’s sexual power
and lead to a fear of impotence and failure
in marital life, or depression and psycho­
genic impotence and suicide behaviour.
Impotence, either from physical or
psychological causes, is not an infrequent
ctiuse of self-destructive behaviour.

Failure in Examination. It is not anunusual experience in India to read in the
newspapers about a minor epidemic of
suicide following . the announcement of
the results of university or school
examinations. Invariably, these are acts
of ‘impulsiveness’. More important are
those instances that are tied up with the
family’s economic status and its prestige.
Indian society attaches a label of superio­
rity to the educated, especially in the
rural areas. There are students from
poverty-stricken homes where parents
stake their all for the youngster’s educa­
tion. Failure under these circumstances

naturally means loss of everything mone­
tary, and the disappointment of cherished
ambitions. The result is suicide by the
student and occasionally by the dis­
appointed person. Failure symbolises
a loss of prestige and a dashing-down of
the expectations of the family and a
bleak future.
Impact of Industrialisation.
The
general trend in suicide in Afro-Asian
countries is one of a higher rate for
younger age groups and a relatively low
rate for the elder group. This is generally
attributed to the cultural values like
respect and reverence for the aged, and
the important role that is played by elders
in the familial and social situations.
Those societies in Asia where the impact
of industrialisation has been intense, this
trend has been found to be gradually
reversed. In India such a reversal has
not yet taken place and the pattern
of suicide is typically that of the report­
ed Asiatic pattern. The few studies
done on suicide in rural areas confirm that
the pattern is similar to that in the
urban settings—youth outnumber the
elderly.

In a recent study from the suicide
centre, at Erskine Hospital, the causes of
suicide were listed as: Misunderstanding
with family members like parents,
spouses and in-laws (28), failure in love
affairs (3), proverty (4) and unemploy­
ment (25) and other miscellaneous causes
like dysmenorrhoea (12), etc. Six were
psychiatrically ill, three had defects such
as stammering, epilepsy, etc., three had
personality disorders, one was psychogenically impotent. Our earlier studies

(Venkoba Rao,
1965) indicated a
ratio of 1:8 to 1:12 for completed to
attempted suicide. In the present series
of 432 cases collected early this
year, there have been only five com­
pleted suicides. This puts the ratio of
completed to attempted suicide at nearly
1:86. This phenomenal improvement of
the situation is to be attributed to the
setting-up of a separate resuscitation and
detoxication unit in the hospital during
the last five years. The new set-up has all
the facilities available for the dangerously
poisoned or accident-involved patient in
a single place. This type of secondary
prevention must answer some of the
' criticism against the suicide prevention
programme. True this type of saving is
not likely to lower the rate of suicide in
a given area. However, as Farberow
(1976) has rightly . remarked the aim of
the movement is not as much to bring
down the suicide rate as the saving of
the life of an individual.

Adolescence is a no man’s land. The
problems of adolescents need identifica­
tion and understanding. Unless tangible
solutions are offered by the conjoint
action of families, educational and social
organisations and governmental machi­
nery, frustration—the final common
pathway and the prime motivation for
self-destruction—is likely to continue
unmitigated. Studies in India have re­
vealed that adolescent suicides and
attempted suicides are common and
social, educational, family, marital and
sexual factors play an important part. If
adolescence has been called a period of
freedom, resorting to suicide behaviour
is a form of escape from it.
*

from one who was helped . . .

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the techniques of counselling

'when stresses mount..
Dr. Mrs. V. Veeraraghavan

Counselling is perhaps the oldest of
human relationships. From time immemo­
rial individuals with problems have
“talked over” their personal difficulties
with friends, relatives, priests and other
close acquaintances. Counselling has come
to be viewed as a professional or semiprofessional service only during the .first
decade of the 20th century.
Counselling is carried on in different
settings with different people with differ­
ent kind of problems. Thus, there are
many types of counselling techniques,
each one of which is applied to a specific
type of problem. For instance, counsel­
ling in a crisis-intervention type situation
is totally different from counselling aimed
at personality growth and development.
Similarly, counselling in colleges and
universities
is very different from
counselling in a school setting or in an
industrial setting. Each of the different
types of counselling connotes a variety
of activities, including friendly listening,
giving of information, psychotherapy to
the maladjusted, referral services and
many more.

Whether it is a problem involving
only the individual, or his entire family, or

a problem of a student or employee or
an individual with a psychological break­
down, counselling has as its main aim of
helping individuals cope with their prob­
lems; it aims to relieve tension, reduce
self-depreciatory feelings, and reinforce
ego strength.
The need for counselling services has
increased in the modern world partly due
to the increasing instability arising out
of various changes in the world, in the
family, in the occupational fields, etc. and
partly due to the inability to make use of
the available psychiatric services because
of the stigma attached to such settings.

Tobe more specific, the changes in
the family structure, the changes in the
school, work situations, etc. have created
more stress for individuals to make an
adequate adjustment and lead a mentally
healthy life. Nevertheless, individuals
somehow move forward overcoming
obstacles and attempt to keep up this
mental equilibrium. However, when
stresses mount and go beyond the indi­
vidual’s coping mechanism a breakdown
results. This need not necessarily be a
neurotic or psychotic breakdown but it
may merely be a state of imbalance or

Dr. Veeraraghavan (M.A. Social Work, M.A. Psychology, Phd.) is a Reader in the Delhi School
of Social Work.

Kuchipud i
1.

.MANDODARI SABDAM :

A popular and traditional mimetic and dramatic dance, wherein the love
and marriage of Ravana and Mandodari is described. In this, (a) The dancer
seeks the permission of King Krishna Deva Rayalu of Vijanagaram Empire to be
allowed to perform the dance, (b) She describes the movements of a frog
which lives in a lake surrounded by bees and flowers in the water, (c) She
shows King Ravana on his magnificent chariot, fully clad in his glittering
jewellery and silken robes, wielding a sword and shield.

As his gaze falls upon the frog, it is transformed into a beautiful princess
who is Mandodari.
(d) The climax of the dance is reached when the dancer alternately
portrays the loving glances of Ravana and Mandodari, culminating in their
marriage.

2.

SWARA-JATHI :

The typical footwork, hand-movements, postures and gestures of the
Kuchipudi style are brought out admirably in this technical dance piece, where
there is no "Abhinaya" or expression. Set in Raga Athana and Adi Tala.
3.

BHAMA-KALAPAM :

This is the'piece de resistance’of Kuchipudi dance, wherein the pride
and vanity of the beautiful and haughty queen, Satyabhama are first described.
She calls herself the most desired consort of Sri Krishna and struts vainly
boasting of her parentage, her wealth and so on.
She asks her friend to go and seek out the Lord Krishna and bring him to
her chamber, and shyly dances, refusing to divulge the name of her Lord, but
only indicating his features.

On hearing Sri Krishna’s flute, she pines for him and wallows in ‘Viraha’
o r separation.

4.

THARANGAM :

The concluding item is a brisk and rhythmic devotional piece, where the
mood projected is one of pure ecstasy, as the dancer executes complex
rhythmic patterns.

Dedicated to Lord Krishna, this is a composition of Saint Narayana
Teertha of the 17th century.

The dance ends with the dancer performing on the edges of a brass plate.

confusion, wherein a little psychological
support, understanding and insight would
put the individual back on the road to
recovery. Some, of course, may need
more than mere support and require help
in handling their personal relationships
more satisfactorily. Still others may
need help in ridding themselves of their
crippling complexes and in development
of a more adequate personality.

Thus, counselling may be carried on
at an individual’level on a one-to-one
relationship or at a group level, with
one or more members of the individual’s
family or with significant ‘others’ in the
individual’s environment. Whether at
one-to-one or group level, the overall
aim of counselling is to help the indivi­
dual enhance his capacity for social
functioning. This goal is achieved pri­
marily through bringing about changes
in the individual’s feeling and through
increasing his self-awareness.
Changes in feeling take place largely
through the medium of relationship
which is deliberately created by the
counsellor so that the individual with the
problem could discuss, frankly and with­
out any inhibition, all his problems and
concerns. This is achieved by the coun­
sellor by maintaining an attitude of
acceptance of the individual, and encou­
raging him to’verbalise his anxiety, fear,
hostility and self-doubts. This very
process of verbalisation contributes to
the relieving of tension in the individual
and also creates in him a hope that a
solution can be found for his problems.
The atmosphere created by the counsel­
lor also helps the individual to absorb
some of the objectivity, calmness and
confidence of the counsellor and this in
turn contributes to gaining emotional
support.

There are many techniques of estab­
lishing rapport with individuals and each
individual needs a different approach
and understanding in order for the coun­
sellor to establish an adequate working
relationship. The person with the prob­
lem should be encouraged to narrate his
story in his own way and the counsellor
should be alert and observant to all the
changes that may occur in the individual
during the interview. The areas of ten­
sion should be recognised and appropri­
ately responded to. While every effort
should be made to secure all the relevant
information, the counsellor should be
careful not to push his inquiries too far
or else the troubled person becomes more
anxious than before.

During the process of counselling,
because of verbalising the most disturbing
thoughts and feelings, the troubled per­
son feels less tense and anxious and thus
is able to develop the capacity to look at
his problems more objectively than be­
fore. The counsellor endeavours to assist
the individual to gain proper, understand­
ing of his situation, his own attitudes and
behaviour that contribute to his prob­
lems. The degree to which the person
would gain an understanding depends a
great deal on the nature and extent of
the problem; for instance, the counsellor
should be able to assess whether in
dealing with the problem only the
patient is involved or one or more of his
family members are also involved. Should
it be necessary, the counsellor should
bring into the therapeutic process the
significant ‘others’ in the patient’s life and
if deemed necessary, may have to help
correct their behaviour also, so that the
patient could lead a more adequately
adjusted life. Thus the social strains
and stresses, physical and mental health
as well as the capacity of the individual
to enable use of‘counselling’ should be

assessed in order to restore the individual
back to a normal level of functioning.
Counselling thus involves much more
than ‘advice rendering’. While an indivi­
dual coming for help may ‘ask’ for
‘advice’ he may not really need advice,
but only an opportunity to discuss his
doubts and problems which are crippling
his capacity to deal effectively with the
environment. Through discussions, the
individual is able not only to gain an
understanding of his problem, the
etiology of the same, but also to
arrive at a self-determined course of
action. It is well for the counsellor to
remember that a solution arrived at on
one’s own is always more acceptable to
the individual than the one given by the
counsellor or ‘others’.

Thus, the techniques of counselling
involve more than rendering advice; it
requires the skill to understand a prob­
lem, its psychodynamics. To a psycho­
logically troubled individual, in addition
to helping him assess his practical diffi­
culties, it also helps him analyse his own
contradictory feelings and attitudes. In
short, the process of counselling is geared
to helping the troubled person to engage
in a process of self-examination.
Thus counselling is a psychological
service rendered to strengthen the capa­
city of the individual to handle and cope
with his life problems. In the process,
it not only deals with the individual

on a one-to-one relationship- but also
endeavours to mobilize the available
resources in the community towards help­
ing the person with his problems. While
involved in these processes, the counsellor
avoids the temptation to “solve” the
problems for the individual or make the
latter dependent on him.
In conclusion it may be stated that
counselling is a developing field and its
role is well recognised as a helping
service. There are many voluntary and
government agencies which employ train­
ed persons as counsellors and thus
meet part of the demand for counselling
services. People facing a crisis in their
personal life, people with family and
marital problems and people with prob­
lems in their occupation and other areas
of life turn to the counsellor for help in
finding a solution to their problems.
Not only adults need counselling services
but also children.
Even though in great demand, such
services cannot possibly be initiated and
maintained by the government in a poor
country like India. The voluntary orga­
nisations should take up the responsibi­
lity and offer such ameliorative and
preventive services to those who need it,
and who cannot and do not make use of
such services offered as part of a psychi­
atric setting. Kudos to Sanjivini which
has come forward to offer services with
a band of young and enthusiastic
workers.

Preventing mental, neurological and
psychosocial disorders

Printed from World Health Forum. Vol. 8, 1987 with the support from WHO Country Funds,
MNH/001 1988-89.

Prevention
Leon Eisenberg

Preventing mental neyrofogacafl

and psychosocial disorders
Mental, neurological and psychosocial disorders constitute an enormous
W' public health burden. A comprehensive programme directed against their
biological and social causes could substantially reduce suffering, the
destruction of human potential, and economic loss. It would require the
commitment of governments and coordinated action by many social
sectors.

In the early decades of the twentieth
century, claims that the mental hygiene
movement would prevent adult psychiatric
disorders proved to be unfounded. Even
today we know so little about such disorders
as schizophrenia, parkinsonism and senile
dementia that we cannot design programmes
for their prevention. Nevertheless,
prevention is important in some areas. At
the turn of the century, mental hospitals
were full of patients with general paresis
and pellagra; today, both diseases are rare in
the developed world, the first because of
effective treatment for syphilis and the
second because of improved diet. Many
other neuropsychiatric disorders can be
tackled effectively. In the schizophrenias and
affective disorders, the frequency with which
there is troublesome behaviour or a chronic
inability of patients to look after themselves

The author is Maude and Lillian Presley Professor and
Chairman, Department of Social Medicine and Health
Policy, and Professor of Psychiatry, Harvard Medical
School. Boston, MA 02115, USA.

World Health Forum Vol. 8

1987

can be reduced if the health team,
community and family respond promptly
and constructively. The public should be
educated about the nature and extent of
mental health problems and, where possible,
about their treatment and prevention.
Without an informed public there is little
hope of persuading governments to make
the necessary policy decisions.

An underestimated problem
The magnitude of the mental, neurological
and psychosocial disorders is usually
underestimated because:

— vital statistics measure mortality rather
than morbidity;
— even where morbidity is recorded, the
extent of neuropsychiatric morbidity is
not properly monitored;
— the tabulation of causes of death
according to disease entities does not
indicate the underlying behavioural

Prevention

causes, e.g., alcohol abuse as the cause of
cirrhosis or motor vehicle accidents.

Mental and neurological disorders
Mental retardation. The prevalence of severe
mental retardation below the age of 18 is
3-4 per 1000; that of mild mental
retardation is 20-30 per 1000. In the
developing world in particular, faulty
delivery methods can lead to birth traumas
and the central nervous system can be
damaged by bacterial and parasitic
infections. Of particular importance is the
mild mental retardation and maladaptation
associated with severe social disadvantage.

Acquired lesions of the central nervous system.
Damage to brain tissue resulting from
trauma, infection, malnutrition, hypertensive
encephalopathy, pollutants, nutritional
deficiency and other factors is a major
source of impairment. It has been estimated
that 400 million persons suffer from iodine
deficiency; their offspring are at risk of
brain damage in utero (1). Particular attention
must be paid to the debilitating effects of

It is wrong to use potentially toxic
drugs when what is needed is
social support, or to rely on
institutional care for patients who
can be restored to function while
in the community.

cerebrovascular accidents secondary to
uncontrolled hypertension, a rapidly
increasing problem in developing countries.
Cerebrospinal meningitis, trypanosomiasis
and cysticercosis are major causes of brain
damage. Persistent infections, even when
the brain is not directly invaded, impair
cognitive efficiency.

Peripheral nervous system damage. Inadequate or
unbalanced diet, metabolic diseases,
infections, traumas and toxins can cause
incapacitating peripheral neuropathies with
numerous social and psychiatric
consequences.
Psychoses. The prevalence of severe mental
disorders such as schizophrenia, affective
disorders and chronic brain syndromes is
estimated to be not less than 1%; somewhat
more than 45 million mentally ill persons
suffer compromised social and occupational
function because of these conditions. The
annual incidence of schizophrenia is
approximately 0.1 per 1000 in the
population aged 15-54 years. The rate for
depressive disorders is several times higher.

Dementia. Dementia can be caused by
metabolic, toxic, infectious and circulatory
diseases. The burden on health services rises
as an increasing proportion of the
population survives to older ages and
becomes vulnerable to senile dementia of
the Alzheimer type.

Epilepsy. The prevalence of epilepsy in the
population is 3-5 per 1000 in the
industrialized world and 15-20 or even
50 per 1000 in some areas of the developing
world. This tenfold difference in prevalence
provides a measure of what could be
accomplished by a comprehensive
programme of prevention in the developing
countries. The extent of social handicap
resulting from epilepsy varies with its type,
the adequacy of medical management, and
community acceptance of or support for
patients.
Emotional and conduct disorders. Such disorders
are estimated to affect 5-15% of the general
population. Not all cases require treatment
but some can lead to major impairment.
Disorders of conduct, which are frequent
World Health Forum Vol. 8 1987

Mental, neurological and psychosocial disorders

among schoolchildren and interfere with
learning in the classroom and with social
adjustment, often respond well to simple
treatments (e.g., behaviour therapy and the
counselling of parents), although recurrence
is common. Learning disorders, whether or
not they are associated with other
psychiatric symptoms, require special help in
the classroom in order to avoid secondary
emotional problems and occupational
handicaps.

Drug abuse. Drug abuse and dependence have
increased in most countries (2). There are
some 48 million drug abusers in the world,
including 30 million cannabis users,
1.6 million coca leaf chewers, and 1.7 and
0.7 million people dependent on opium and

Mental deterioration in the elderly
can also be prevented by avoiding
unnecessary hospitalization.

Behaviour injurious to health

Alcohol-related problems. Recent decades have
witnessed considerable increases in alcohol
consumption and a parallel increase in
alcohol-related problems, including cirrhosis
of the liver, difficulties at work and home,
and alcohol-related traffic accidents. Alcohol
abuse by the individual has devastating
effects on the family. A particularly tragic
consequence of drinking during pregnancy is
the fetal alcohol syndrome.
In the WHO European Region, the number
of countries with an annual per capita intake
of more than 10 litres of pure alcohol
increased from three in 1950 to 18 in 1979.
Countries in the WHO Western Pacific
Region have reported that there were sharp
increases in alcohol-related health damage,
crime and accidents during the 1970s.
Although some countries in Europe and
North America are now reporting a levelling
off or even a modest decline in alcohol
consumption, the global trend is still
upwards, with particularly sharp increases in
commercially produced alcoholic beverages
in some developing countries in Africa,
Latin America and the Western Pacific.
However, it is notable that in Australia
between 1978 and 1984 a 10% reduction in
per capita consumption of alcohol was
accompanied by a 30% reduction in deaths
caused by alcohol.
World Health Forum Vol. 8

1987

heroin respectively. Cocaine abuse is
widespread and increasing. Amphetamines,
barbiturates, sedatives and tranquillizers are
consumed in most countries and their abuse,
as well as multiple drug abuse, is increasing
throughout the world in parallel with their
increasing availability. Large regions have
become dependent on the income derived
from growing cannabis, the opium poppy
and the coca shrub, and this adds to the
difficulty of implementing control measures.

Psychotropic drug abuse. The ready availability
of psychotropic substances, insufficient and
often misleading information and
unjustifiable prescribing practices have led to
the overuse and abuse of psychotropic drugs.
Tobacco dependence. Smoking-is a socially
induced form of behaviour maintained by
dependence on nicotine. It causes a high
proportion of cases of cancer, chronic
bronchitis and myocardial infarction.
Between 1976 and 1980 tobacco
consumption decreased annually by 1.1% in
the industrialized countries but increased by
2.1% annually in the developing countries.
Besides premature deaths, which have been
estimated at over 1 million per annum,
innumerable cases of debilitating diseases,
such as chronic obstructive lung disease, are

Prevention

caused by smoking. The proportion of
women of reproductive age who smoke
regularly, already high in most industrialized
countries, has been increasing rapidly in the
developing world.

Conditions of life that lead to disease
Many health-damaging circumstances are
beyond the control of the individual:
homelessness, unemployment, lack of access
to health and social services, the loss of
social cohesion in slum areas, forced
migration, racial and other discrimination,
forced idleness in refugee settlements, war,
and .the threat of nuclear war.

In addition to these factors, individual
life-styles can influence the risk of disease.
Although the significance of excess animal
fat in the diet, insufficient physical exercise
and psychosocial stress in the epidemic of
cardiovascular disease affecting the
industrialized world cannot be precisely
quantified, most authorities agree that these
are important risk factors. Behavioural
patterns certainly influence disease
pathogenesis and it is important to make full
use of our knowledge of mental health
and our psychosocial skills to design
interventions aimed at preventing disease
that is secondary to unfavourable behaviour.

Disorders of conduct are frequent
among schoolchildren and often
respond well to simple treatments.

In this connection, methods of dealing with
excessive stress merit further study; stress
becomes a pathological agent when it is
intense, persistent, and beyond the coping
capacity of the individual.

Violence. Violence, including accidents,
homicide and suicide, is one of the main
causes of death in most countries.
Psychosocial factors and mental disturbance
play an important role in its occurrence.
Child abuse and wife battering are among
the particularly dramatic indicators of
violence in the family.

Excessive risk-taking by young people.
Experimenting with drugs and alcohol,
sexual activity without precautions against
sexually transmitted diseases, adolescent
pregnancy, driving at excessive speed, and
challenging established guidelines for health
and safety result in serious morbidity and
mortality. Pregnancy in girls aged 15 or less
leads to a cycle of disadvantage. The
immature mother is unable to care properly
for her child, while her maternal
responsibility is a barrier to the education
and employment essential for her own
development.
Eamily breakdown. Family breakdown
interferes with the upbringing of children. A
household headed by a woman is more
likely to be below the poverty threshold
than one headed by a man, adding to the
mother’s difficulty in raising a family.
Weakened family units also contribute to
community disorganization and a variety of
psychosocial and other health problems.

Somatic symptoms resulting from psychosocial distress
Many patients who consult primary health
care workers either have no ascertainable
biological abnormality or, if they have one,
complain disproportionately about their
discomfort and dysfunction. Unless the
psychosocial source of physical symptoms is
recognized, the people affected are likely
to be inappropriately investigated and
treated, cause excessive cost to the health
system or themselves, and become chronic
World Health Forum Vol. 8 1987

Mental, neurological and psychosocial disorders

patients vainly seeking relief. The inclusion
of basic mental health care as part of
primary care reduces the cost of treatment
and improves its outcome.

Proposals for action

It should be noted that intersectoral
coordination is essential for the success of
the measures outlined below.
Measures to be undertaken
by the health sector

Success in carrying out preventive and
therapeutic measures depends greatly on the
psychosocial skills of primary health care
workers, i.e., on their sensitivity, empathy
and ability to communicate, as well as on a
thorough knowledge of the community, its
culture and its resources. Training in these
skills is therefore no less essential than is the
customary technical training. In their
absence, diagnostic errors multiply,
adherence to treatment recommendations
declines, health workers exhibit “burn-out”,
and the health facility fails to achieve its
goals.
Prenatal and perinatal care. In view of the need
to protect the fetus and the newborn child
and to provide optimum conditions for
development, and given the high mortality
and morbidity associated with prematurity
and low birth weight:
— high priority should be given to the
provision of adequate food and to
education about nutrition to all pregnant
women;

— direct counselling of pregnant women
should be practised to reduce the
prevalence of developmental anomalies
and low birth weight caused by cigarette
smoking and the consumption of alcohol
during pregnancy;
World Health Forum Vol. 8

1987

— in areas where neonatal tetanus is
prevalent, pregnant women should
receive tetanus toxoid after the first
trimester and birth attendants should be
trained in sterile techniques for cutting
the umbilical cord;
— in iodine-deficient areas, women of
child-bearing age should be given iodized
oil injections or iodized salt in order to
prevent the congenital iodine deficiency
syndrome;
— birth attendants should be trained to
recognize high-risk pregnancies and to
refer deliveries that are expected to
be complicated to specialist facilities,
since the prevention of obstetrical
complications can reduce the number of
children with central nervous system
damage;
— the promotion of breast-feeding should
be an integral component of primary
health care.

Programmes for child nutrition. These should be a
major component of prevention because
malnutrition can impair cognitive and social
development.
Immunization. The immunization of children
against measles, rubella, mumps,
poliomyelitis, tetanus, whooping-cough, and
diphtheria could make an important
contribution to the prevention of brain
damage.

Family planning. Child development is
adversely affected when mothers have too
many children at unduly short intervals or
when they are too young or too old.
Education on family planning and access to
effective means of contraception are
therefore essential elements in maternal and
child care.

Prevention

Measures against abuse of and dependence
on psychoactive substances

Primary Health care workers should
routinely counsel patients against smoking.
Although only 3—5% will respond by
stopping smoking, there is a large gain from
the public health standpoint because of the
high prevalence of the habit. Repeated
efforts to quit have cumulatively higher rates
of success and a low initial response should
not discourage subsequent efforts.
Health workers can be trained to recognize
the early stages of alcohol and drug abuse,
using WHO manuals and guidelines. Brief
counselling can help a significant number of
patients to alter their behaviour before
dependence and irreversible damage occur.

Crisis intervention in primary health care

course of evaluating new patients. This
enables them to recognize symptoms that
indicate psychological distress and to avoid
the overuse of psychotropic and other drugs
and the iatrogeny that results from such
practices. Brief counselling and, where
necessary, referral to social welfare or
mental health workers can significantly
diminish the number of clinic visits.

Behavioural disorders that are the iatrogenic
effect of prolonged or repeated
hospitalization can be prevented by
minimizing the hospitalization of children,
encouraging family participation when
hospital care is unavoidable, and introducing
certain organizational arrangements in
hospitals (e.g., assigning a primary nurse to
each child). Mental deterioration in the
elderly can also be prevented by avoiding
unnecessary hospitalization.

In the event of acute loss (e.g., the death of
a spouse, which increases morbidity and
mortality among survivors), there is some
evidence that group and individual
counselling of the bereaved can diminish
risk. Self-help and mutual aid groups can
improve health at minimum cost to the
health services. Well-trained crisis
intervention units can handle a variety of
acute mental health problems and thus
prevent chronic difficulties.

Although measures to prevent dementia
must await the results of further research,
cognitive impairment resulting from
depression and infection can be reversed
by prompt treatment. At present, the
distinction between dementia and depression
in the elderly is not recognized by the family
doctor in four out of five cases. A relatively
short period of training can enable
physicians and other health workers to
improve their diagnostic skills in this area.

Prevention of iatrogenic damage

Minimizing chronic disability

Failure to diagnose and correctly treat
psychosocial disorders results in iatrogenic
damage. Thus it is wrong to use potentially
toxic drugs when what is needed is social
support, or to rely oh institutional care for
patients who can be restored to function
while in the community.

Education of primary care workers in the
recognition of sensory and motor handicaps
in children, the use of prosthetic devices to
minimize handicaps, and the referral of
handicapped children to the educational
authorities can prevent both cognitive
underachievement and social maladjustment.
Properly-fitted spectacles and hearing aids
can reduce the likelihood of mental and
social handicap in children.

Health workers can be trained to inquire
routinely about psychosocial problems in the

World Health Forum Vol. 8 1987

*

e

Mental, neurological and psychosocial disorders

Because the incidence of cerebrovascular
disease can be reduced by the effective
treatment of hypertension, primary care
workers should be trained in the diagnosis
and treatment of hypertensive disease;
similarly, acquired lesions of the central
nervous system can be reduced by prompt
treatment of, for example, meningitis.
Health workers should be trained to manage
febrile convulsions, recognize epilepsy, and
control seizures with low-cost anticonvulsant
drugs in order to minimize damage to the
central nervous system, as well as reduce
accidental injury and reduce the psychosocial
invalidism and isolation that result when
treatment is not provided. An uninterrupted
supply of drugs of assured quality is of
paramount importance.

Primary care workers should be trained to
recognize schizophrenia and to manage it
with low-dose antipsychotic drugs, to
counsel relatives with a view to minimizing
chronicity and avoiding the social
breakdown syndrome, and to diagnose and
treat patients suffering from depression.
Such patients, who commonly present
multiple somatic symptoms, may be
inappropriately investigated and treated for
somatic disorders, and are at risk for suicide.
Effective treatment with antidepressants and
prevention using lithium salts can be
provided at relatively low cost.

Action at community level
and in other social sectors

Better day care for children. Retarded mental
development and behavioural disorders
among children growing up in families that
are unable to provide suitable stimulation
can be minimized by early psychosocial
stimulation of infants and by day-care
programmes of good quality, particularly if
the parents participate. However, day care
World Health Forum Vol. 8

1987

must be of adequate quality; child-minding
in crowded quarters by people who are too
few in number and inadequately trained may
retard development, not facilitate it. Among
useful measures that could be taken are:

— surveys of existing day-care facilities and
assessment of the need for them;
— establishment of quality standards and
appropriate regulatory measures;

— setting of targets for quality and for
training staff in the psychosocial
development and needs of children.

Upgrading long-term care institutions. Although
the use of institutions for long-term care can
be minimized by providing alternatives in
the community, they will continue to be
necessary. The quality of the institutional
environment is a major determinant of the
way the patients function. It is therefore
important to subject such institutions to
regular evaluation and to improve their
architectural design and the content of work
programmes where necessary.
Self-help groups and support services. Self-help
groups, organized by lay citizens, are
effective in reducing the chronicity of

In Australia between 1978 and
1984 a 10% reduction in per capita
consumption of alcohol was
accompanied by a 30% reduction
in deaths caused by alcohol.

certain disorders (e.g., Alcoholics
Anonymous), in enabling the handicapped
to improve their functional ability (e.g.,
societies that help epileptics), in educating
the community about the nature of
disorders, and in advocating changes in

Prevention

legislation, better resource allocation, and
satisfaction of the needs of people with
specific disorders. Furthermore, community
self-organization for local development has
been shown to reduce the psychopathology
associated with anomie (a state of alienation
from the community) and helplessness (3).

Support services provided at community
level can enable people to care for relatives
with chronic illnesses who would otherwise
require more expensive and less satisfactory
institutional care. An excellent example is
the organization of “home beds” for
chronically handicapped mental patients in
China: neighbourhood volunteers who are
retired workers care for patients while
their relatives are away at work. To
maintain residual function and to avoid
institutionalization, chronic mental
patients must be provided with housing,
opportunities for sheltered employment, and
recreation.
Schools. The progressive extension of
compulsory schooling provides new
opportunities to broaden people’s
understanding of how they can protect their
health. At the same time it leads to the
identification of child health problems not
previously known to health authorities.
A variety of risks to mental health and
psychosocial development can result from a
lack of parental skills and from parents’
insufficient knowledge of their children’s
needs. Urbanization and other social changes
result in a growing number of young parents
not possessing such skills. Education for
parenthood may well have to become a
public responsibility. Creches and nursery
schools can be sited next to secondary
schools, whose students can be assigned to
work in them under supervision. Trained
leaders for groups of new mothers can guide
discussion on child-rearing and thus provide
a Valuable form of self-help.

Instruction about family planning, sex, child
development, nutrition, accident prevention
and substance abuse are among the subjects
that are most frequently recommended for
inclusion in school curricula. A particularly
promising way of preventing substance
abuse among early adolescents is to
encourage them to acquire the behavioural
skills necessary to resist pressure to use
cigarettes, drugs and alcohol.

If trained properly, teachers can identify
children with sensory or motor handicaps or
with mental health problems that have not
been detected by the health sector.
Collaboration between teacher, parent and
health worker is central to the rehabilitation
of children with chronic handicaps and to
the avoidance of social isolation and other
untoward consequences.
Public health measures for accident prevention. In
view of the high mortality and morbidity
resulting from accidents and poisoning,
measures for their prevention must be
given high priority. Brain damage caused by
toxic substances in the workplace can be
prevented by imposing strict limits on
exposure; untoward effects of shift work
can be avoided using the principles of
chronobiology; child-proof safety caps on
medicine bottles and containers of
household chemicals can reduce the
ingestion of poisons and consequent damage
to the central nervous system; lead
poisoning in children can be prevented by
prohibiting paints containing lead for
household use and by decreasing the lead
content of petrol.

The media. Radio, television, newspapers and
comic strips can play a major role in public
health education—for the better (e.g., by
explaining why sanitation is essential for
health) or for the worse (e.g., by advertising
cigarettes).
World Health Forum Vol. 8

1987

Mental, neurological and psychosocial disorders

Cultural and religious influences. Cultural factors
are among the principal determinants of
human behaviour. A knowledge of cultural
and religious forces can be applied by health
workers in their efforts to reduce
health-damaging practices.

Government action
Prevention works only if governments want
it to work: action must be planned not only
in the health sector but in all other sectors
important for health, such as education,
agriculture, environment, etc. Any country
undertaking a prevention programme should
have a national coordinating group on
mental health with the authority to assign
tasks to the appropriate sectors. The
coordinating group should have at its
disposal an information centre that can
collect and feed back data on changes in the
nature and trends of problems and on the
effects of intervention and task performance.
One of the first duties of the centre should
be to conduct a comprehensive review of
legislation affecting such matters as mental
health, family life, health services, drug
control and schools.

In the area of prevention, government
actions in various spheres may have
implications for health; housing projects may
worsen mental health because of bad design;
industrial development projects may destroy
local culture and lead to family disruption,
child neglect and substance abuse; and the
widespread use of pesticides without
safeguards may lead to brain damage.

results obtained in one country to another
may be entirely misleading. It is therefore
important to foster research programmes of
two kinds:
— studies on the distribution of problems in
specific populations and on changes in
the pattern with time;
— investigations to enable assessments to be
made in particular countries of measures
that have been proposed for large-scale
application.
Both types of study should be carried out at
the national or subnational level. An urgent
task that should be included in programmes
of technical cooperation between countries
is the development of methods for
conducting such studies. The involvement of
institutions in developing countries in
multi-centre research, research training
courses and information exchange should be
used to create and/or strengthen the basis
for a further growth of knowledge in this
field.

Acknowledgements
The author acknowledges with gratitude the helpful
comments provided by staff members of the WHO
Regional Offices and of the Division of Mental Health at
WHO headquarters. He also thanks the members of
Expert Advisory Panels, and others too numerous to
list individually.

References
Hetzel, B. & Orley, J. Correcting iodine
deficiency: avoiding tragedy. World health forum,
6:260-261 (1985).
Hughes, P. H. et al. Extent of drug abuse: an
international review with implications for health
planners. World health statistics quarterly, 36:
394—497 (1983).
3.
Eisenberg, C. Honduras: mental health awareness
changes a community. World health forum, 1:
72-77 (1980).

1.

There is a need for research into the causes
and mechanisms of disease in order to
develop new and better means for
prevention and control. Data on prevalence
and the effectiveness of interventions
frequently do not exist, particularly in
developing countries. The extrapolation of
World Health Forum Vol. 8

1987

2.

World Health Forum
Leon Eisenberg

Preventing mental, neurological
and psychosocial disorders.

For copies of this reprint, please write to:
The Director, NIMHANS, P.B. No. 2900, BangaJore-560 029.

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A SHORT COURSE ON NEUROPSYCHIATRIC PROBLEMS

FOR DOCTORS WORKING WITH

THE UNITED PLANTERS' ASSOCIATION OF SOUTHERN

INDIA

AND

THE ANNAMALAI PLANTERS

ASSOCIATION

6-8 April 1981
VALPARAl.
—00O0O—

CONTENTS

1.

INTRODUCTION

2.

MAJOR SYMPTOMS AND SIGNS

3.

PSYCHOSES:

(i) Functional Psychoses:
(a) Schizophrenia
(b) Manic Depressive Psychoses

(c)
(ii)

Reactive Psychoses

Organic Psychoses

(a)
(b)

Acute
Chronic

4.

NEUROSES

5.

EPILEPSY

6.

MENTAL RETARDATION

7.

PSYCHIATRIC EMERGENCIES

8.

ALCOHOL AND OTHER ADDICTIONS

9.

PSYCHOPHARMACOLOGY.

INTRODUCTION

Research carried out in different parts of the world
suggests that at any one time about 1% of the population are

affected by mental disorder severe enough to require urgent
attention and that about 10% would need such attention at least
once in their lifetime. Fuxrther, no culture or society, urban
or rural, is free from the crippling effects of mental illness.

What do we mean when we use the term mental disorder?
The term covers a wide range of disturbance of human behaviour,
emotion, judgement and thinking - a disturbance serious enough

to bother either the person who is undergoing it, or those
around him or both.

On one hand there are the most bizarre

forms of insanity and on the other hand minor anxieties, ten­

sions, depression etc.
It is not too difficult for most of us to admit the
importance of disorders in which the patient behaves in a
biaarre fashion, suffers from delusions and hallucinations and

says things which are ununderstandable - for these disorders
can in a very obvious manner incapacitate the patient and to
a varying degree those attending to him. But one is less ready
to attach much importance tc patients whose only problem is that
they are excessively anxious or that they tend to get depress­
ed every now and then. However these so called minor disorders
can incapacitate the patient in as crippling though more subtle

a manner.

About 30-40% of the patients who flock every day

at medical out pa.tient departments of various hospital, compl­
aining of vague aches, pains, exhaustion and other apparently
physical disorders are really the victim of these so called

minor psychological difficulties,

Anxieties, tensions and

depressions contribute to more than half of the industrial
absenteeism all over the world. Very often the anxieties
and depressions are counteracted by taking alcohol and other

drugs which alter consciousness. Very soon alcohol and
drugs become the enemy themselves by making the person depen­
dent on them. These drugs act as poison to the nervous
system bringing in their wake a variety of physical, psycho­
logical and social disabilities.
What are the causes of mental disorder? Human
behaviour is a result of a dynamic interaction between brain
processes and the environment. The causes of mental disorder

2

derive from both these sources.'

The cause may lie in an

abnormality of the brain right from birth, at a biochemical,
cellular or anatomical level. It may lie in a structural
damage to the brain at a later date, a damage due to injury,
some physical illness involving brain or a brain tumour.

However a cause may equallyilie in the environment.

Babies

brought up in foster homes have been known to develop a perma­
nent emotional callousness because of the absence of a constant
affection-giving adult. Many a mental disorder can be traced
to a faulty communication in the family.

A disorganised

society may contribute to emotional illness.

It is well known

that suicide rate is highest in those areas of the torn where

the ipoople do not live in cohesive groups.

Are the mental diseases heriditary? A few of them are,
but the heridity must interact with environment and in many
cases a wholesome environment does successfully counteract the
bad effects of the heridity.

The mental disorders can be broadly classified into
following categories:

1.

PSYCHOSES:
In these conditions, the person loses touch with the

surrounding reality, suffers from delusions and hallucinations

and/or behaves in a socially unacceptable fashion.

Main sub-categories:

(i) Organic Psychosis
(ii) Functional psychosis
(a)
(b)

2.

Schizophrenia
Manic Depressive Psychosis

NEUROSIS:

In these conditions the emotional response to stress­
ful situation is heightened and prolonged resulting in dist­
ress and social dysfunctioning.
Main sub-categories:

(i) Anxiety Neurosis

(ii) Neurotic Depression
(iii)

Hysteria

(iv)

Obsessive compulsive neurosis.

PERSONALITY DISORDERS:
In these disorders the personality is deviant from
early childhood bringing the person in conflict with the
community.
3.

3
4.

MENTAL RETARDATION:
In this the intellectual development is poor because

of malformation of the brain from birth or due to brain­

damage in early childhood.

5.

ADDICTIONS:
To various kinds of drugs which alter consciousness.

6.

PSYCHOSOMATIC ILLNESSES:

In these there is a structural damage of bodily systems
because of heightened emotional (autonomic) activity.
What about treatment?

Electric shock treatment which

is extremely painless and safe, and the tranquilizing drugs have
made it unnecessary to put any restraints on even the most
disturbed patients.

The present trend is to treat the pati­

ents in a general hospital setting, patient continuing to live
in his family setting, the supportive effect of which is un­

questionable.

Even some forms of mental deficiency which till

very recently were considered untreatable, can be treated if

the patient is brought early enough.

Other mentally retarded

could be trained and educated to function adequately.

In many

cases our treatment still consists of talking to the patient,

and it is not surprising a disorder arising out of a faulty

human interaction can be treated with a therapeutic human
interaction.

The understanding of the disorder is increasing at a fast
pace;

many different scientific disciplines contributing to

the knowledge. We know more about the physiology of emotion.
We know more about the biochemical basis of emotion. We know
more about the psychology of human communication and we know
more about the social dynamics of human interaction. But we

still have far to go. For example we still have to learn
a lot about preventing mental disorder. While early recog­
nition and proper treatment ensure excellent secondary and
tertiary prevention, primary prevention is still difficult
for most conditions - due to multifactorial aetiology.

4

MAJOR SYMPTOMS AND SIGNS IN PSYCHIATRY
This list is not exhaustive and contains only the
commonly encountered symptoms and conditions.
Amnesia: Disturbances in memory manifested by partial or
total inability to recall past experiences.

Anterograde - Loss of memory for events subsequent to the
onset of amnesia.
Retrograde - Loss of memory for events preceding the onset
of amnesi a.

Immediate memory - The reproduction, recognition or recall of
perceived material within a period of not more than 5 seconds
after presentation.
Short-term Memory (or Recent memory) - The reproduction
recognition or recall of perceived material after a period of
10 seconds or longer (a few days) has elapsed after the
initial presentation.

Long-term Memory (Remote memory) - The reproduction, recognition
or recall of experiences or information that were experienced
in the distant past.

Anxiety - It is characterized by unreasonable feelings of
fear, tension, or panic or of an expectancy that something

unpleasant is going to happen;

almost invariably these are

physical symptoms, such as palpitations, abdominal sensat­
ions (eg, ’butterflies' or a feeling of emptiness) tremul­
ousness, difficulty in breathing, para.esthesiae, chest

discomfort, dizziness, or faintness, diarrhoea, frequency
of mictuition, headache, blurring of vision, sweating,

dryness in the mouth and difficulty in swallowing.
Phobia - Persistent pc.thological, unrealistic, intense fear
of an object or situation. The individual may realize that
the fear is irrational, but is nonetheless, unable to dispel
it.
Attention - Part of higher mental functions, that relate to
the amount of effort exerted in focusing on certain aspects

of an experience or task.

This is also called active

5

When sustained for sufficient length of time

attention.

it is termed concentration.

Poor attention is characterized

hy inability to focus on certain aspect of an experience or
task on hand; shows itself as distractibility. Also celled
passive attention.

Catatonic state - A state characterized by muscular rigidity
and immobility. It is also known as Catatonia.
Catatonic excitement violence

Excited uncontrollable motor activity,

is usually senseless and purposeless.

Delirium - An a.cute, reversible organic mental disorder
characterized by disturbed orientation in relation to time,
place or person, (confusion) and some impairment of consci­
ousness.

It is generally associated with emotional lability,

lack of clarity of thinking, hallucinations, or illusions,

and other motor behaviour.
Delusions

-

A false belief that is firmly held despite

objective and obvious contradictory proof or evidence and
despite the fact that other member of the culture do not
share the belief.
Depression - A mental state characterized by feeling of sad­
ness, loneliness, despair, low self-esteem, and self-reproach.

The term refers to a mood that is so chaiacterized.

Accom­

panying signs include, psychomotor retardation, or at times
agitation, withdrawl from interpersonal contact, and

vegita.tive symptoms like insomnia, anorexia., loss of libido etc.
Disorientation -

Impairment of awareness of time, place

and position of the self in relation to other persons.
Elation -

Extreme joyful excitement.

Associated with

jovial mood which is completely unmotivated. There is a
general sense of well being, with cheerful thoughts, and
a lack of response to depressing influences, so that,
everything is seen in the best possible light.

Flight of ideas - Rapid succession of fragmentary thoughts
or speech contents which come abruptly and may be incoherent.
Association between successive thoughts appear to be due to

6

chance factors which however can usually be understood.

Grandiosity - An exaggerated feeling of one's importance,
power, knowledge or identity.
Hallucina.tion -

A false sensory perception occurring in the

absence of any relevant

external stimula.tion of the sensory

modality involved.

Illusion -

Means a. perceptual misinterpretation of a real

external stimulus.

Hypochondriasis -

A somatoform disorder characterized by

excessive morbid anxiety about one's health. Individuals
exhibit a predominant disturbance in which the physical symp­
toms or complaints are not explainable on the basis of
demonstrable organic findings and are apparently linked to

psychological factors.

Insight - Conscious recognition of one's own condition.
In psychiatry it more specifically refers to the conscious
awareness and understanding of one's own maladaptive
behaviour.

Loss of insight occurs in psychotic illnesses.

Judgement -

Mental act of comparing or evaluating choices

within the framework of a given set of values for the purpose
of electing a course of action. If the course of action

chosen^consonant with reality or with mature adult standards
of behaviour, judgement is said to be normal. It is said to
be impaired if the chosen course of action is frankly
maladaptive.

Mood - Pervasive, and sustained feeling tone tha.t is
experienced internally and tha.t in the extreme, can ma.rkedly
influence virtually all aspects of a person’s behaviour.
Obsession -

Persistent

and recurrent idea, thought or

impulse tha.t cannot be eliminated from consciousness by logic
or reasoning. Individual is aware that these (idea, thought
or impulses) are irrational and silly. Ho tries to controll
them and in the process becomes anxious.

7

Compulsion -

Unacceptable, repetitive and unwonted urge

to perform an act which the pa.tient may carry out (ritual).
Stupor -

A state of decreased reactivity to stimuli, and

less then full awareness of one's own surroundings.

As a.

disturbance of consciousness, it indicates a condition of

partial coma, or semicoma.

In psychiatry,it is also used

synonymously with mutisum , and does not necessarily imply
a disturbance of conciousness.
Thought disorder -

Any disturbance of thinking that affects

language, communication and thought content, failure to form
concepts and follow semantic and grammatical rules that is
not consistent with person's education, intelligence, or

cultural background.

Speech may be too much or too little.

Incoherent talk - Though the patient uses ordinary words
he uses them out of context. Therefore speech is ununder­

stand able.
Irrelevant speech -

Patient does not answer question to

the point though the sentences are understandable in

thoughts.

PSYCHOSES

As referred to earlier the psychoses are a group of severe
mental illnesses producing gross changes in ones personality. The
psychdtic .

looses contact with the surrounding reality, shows

extreme deviations in thought, emotions, speech and actions leading

to severe changes in behaviour which may ultimately be bizarre
and ununderstandable. The behaviour may be dangerous to self or
others.
1.

There are mainly two types of psychoses:
Functional psychoses which includes maihly:
(a) Schizophrenia

(b)
2.

Manic depressive psychosis (MDP)

Ofje aic p sycho se s.

(a)

Acute

(b)

Chronic

The functional psychoses are major illnesses where the

disorder is not directly attributable to impairment in the

functioning of any organ systems of the body whereas the organic
psychoses are due to the effect of physical illnesses and signs
of impairement in the functioning of any of the organ systems will
be found.
The various psychoses and their management are now briefly, .
considered.
1.

Functional Psychoses:

(a) Schizophrenia is one of the common psychoses and it’s
symptoms closely correspond to the layman’s concept of 'madness1.
It is a severe illness which invariably interfers with the indi­

viduals function for at least some time. Usually schizophrenia
starts rather early in life, often the onset is never identifiable
and it may follow either a recurrent or a continuous progressive
course. The patient rarely attains the . pre-illness status withon t
treatment. In most cases it's severity and course can be modi­
fied by regular administration of medications, though in a small

percentage of cases,, illness does not recur after successful
treatment. The psychosis is characterised by disordered thinking
resulting in talk that is often not meaningful. There may be
wide swings in emotions, initially, ultimately resulting in
apaty and 'blunted emotion'. There may.be also inappropriate­

ness of emotions, i.e. the person may laugh when the situation

would be such that others would expect him to cry and vice
versa. Extreme day dreaming may be present. The common presenting

complaints are as follows:

- Sleeplessness
- Aggressiveness
- Being quarrelsome and (abusive and assaultive)

- Aimless wanderings.
- Talking or laughing to self.

- Irrelevant talk (What the patient talks does not make sense)
- Not doing routine work properly and failure in discharging
ones responsibilities
- Withdrawing from the usual social interactions

- Irresponsible behaviour, at times being destructive
- Neglect of self care.

- Preoccupation, perplexity and unexplained or unaccountable
fear.
- Restlessness, often hostility.

- Ideas or firm beliefs that others may be staring at him
watching his activiies or even plotting against him to
haifl* and destroy him.
- Firm belief that his thoughts and actions are controlled
by external agencies through various means.
- Finding special meanings for various things of normal
occurance, around him.

- Hearing voices, when there are none - at times accusing
him, at times his own thoughts.
- Phases of excitement or extreme withdrawal when patient
may remain in uncomfortable and bizarre posture for long
periods of time.
- Other odd and ununderstandable behaviour.
It is very essential to remember that in clinical practice,
only some of the above features may be present in any given

patient. But diagnostically one of the most important finding is
that the examining doctor usually finds that he cannot share or

understand the patient’s experiences.

Both genetic and environmental factors like intrafamily
relationships,socio-cultural factors, severe psychological stresses
of any kind are important in the causation of schizophrenic.

These factors operate in different combinations and degrees to
predispose, precipitate or perpetuate schizophrenic illness in
an individual, Although it's-' etiology is not definitely known,
what is certain is that the causation is multifactria]*.

MANAGEMENT;

'*

Explanation to the patient and the relatives of the nature
of the illness, the need for regular maintenance of medications

and of regular follow up reviews are very essential in the
management of schizophrenia.
The discovery of chlorpromazine - a phenothiazine drug -

(Largactil, Tranchlor) revolutionised the drug treatment of

schizophrenia and brought hope for lakhs of schizophrenics all
over the world. Chlorpromazine and various other similar Phenothia­
zines are the drugs of choice and form the main line of treatment
in schizophrenia. The dosage depends upon the severity of symp­
toms and build of the patient. The treatment of an acute phase of
schizophrenia with phenothiazines must be along the same lines
as one is expected to treat a case of diabetic coma i.e. starting
of treatment with larger, yet safe adequate doses and then gra­
dually adjusting the dose to suitable maintenance levels as
symptoms disappear and improvement sets in.

The following guidelines should be followed while managing
a schizophrenic patient:
(a)

If the patient is excited, start the patient on tablets

of Chlorpromazine in daily doses ranging from 50 mg to 300 mg,
according to the build of the patient and severity of excitement.
If the patient is very excited and unwilling to take oral medi­

cations, the initial one or two doses should be given parenterally
as Inj. Chlorpromazine (50 mg) intramuscularly.
(b)

In patients, who are not excited at the time of texami­

nation but who have various other symptoms of schizophrenia and

tendency to get excited any time, the same dosage schedule should
be followed.
(c) The same dosage is also indicated for patients who
are brought with extreme degree of withdrawal and other symptoms
associated with it. In such patients, 'while the Chrorpromazine

ensures adequate sleep at night, may also cause excessive and

unwanted sleepiness during the whole day. Another type of
phenothiazine namely Trifluperazine (Eskazine, Mephaoine, Trini-

calm, Trankozine, T.F.J>) in doses ranging from 10 mg to 20 mg
may be given instead of Chlorpromazine to overcome the side

effect of excessive drowsiness during the day. However if this
phenothazine is not available, Chlorpromazine in the above doses
should be given.

(d)

The commonest cause of frequent recurrence of symptoms

or of failure to respond sufficiently to treatment is the failure
on the part of the patient (and his relatives) to take the
medicines regularly due to various reasons. In such instances
and in cases of long standing schizophrenic illness (chronic

schizophrenia) ensuring regularity of medications will be very

difficult.

For such patients, the newly available, injectable

and long acting phenothiazines (depot phenothiazine) are of great

help. The p.atient needs to be given.rjust one injection once in
2 or 3 weeks Fluphenazine deconate (Tnj. nnatensdl) available

in vials of 1 ml. equivalent to 25 mg is used.

(e) Chlorpromazine and other phenothiazines are reasonably
safe drugs but have tendency to Wer blood pressure. So it is

advisable to record the blood pressure of all patients started
on Chlorpromazine, initially.

Evidence of liver damage is the

only contraindication for starting chlorpromazine in a schizoph­
renic.

(f)

It is important to be aware of and look for side

effects of the drug when a patient is started on phenothiazines
(Chlorpromazine, Trifluperaxine and Fluphcn -zine)
mild side effects are:
1.
2.
3.

The commonest

Drowsiness
Giddire ss (because of postural hypotension)
Extrapyramidal symptoms (because of a drug induced
parkinsonism)

The usual extrapyramidal (Parkinsonian) symptoms are:,
1.
2.

MeSic. like expressionless face and staring look.
Rigidity of the limbs.

3.

Tremors of the extremities,tongue

4.
5.

Loss of associated movements like swingigg of hands.
Shuffling gait

6.

Motor retardati >n.

7.

Motor restless ness (called Akathisia.

Here the

patient manifests an uncontrollable urge to move about

and cannot sit quietly at a place. This side effect,
may ibe mistaken, sometimes as a symptom of the
illness)

8.

Various bizarre movements of the tongue face and neck

with excessive salivation (Dystonias). This side effect
may get in suddenly in a patient on phenothiazine medi­
cation and may present as an acute emergency. This can
be very painful and distressing to the patient, and
action should be taken to revert it immediately.

(g) Iti a patient develops any of the above side effects,
he and his family should be reassured about these additional
symptoms. The following steps must be taken to reduce these
undesirable side effects:

1,

If excessive drowsiness is the main problem, the dosage

of Chlorpromazine could be reduced.

Rescheduling the

dosage in such a way that most of the fetal dose is
given at bed time (eg. 50 mg in the morning and 250
mg at bed time) also would be helpful to reduce the

day time drowsiness ..

2.

If mild to moderate extrapyramidal symptoms are present,
an antiparkinsonian drug should be intrdduced into tho
treatment schedule. The antiparkinsonian drug advised
in Tab. Trihexyphenidyl hydrochloride (Pacitane,
Parkin, Hexinal) which are available in 2 mg strength.
The dose is 2 mg to 6 mg depending on the severity of
the extrapyramidal symptoms. This is better given during
in
the day time/divided doses (eg. 1 tab. in the morning
and 1 tab. in the afternoon). It is advisable to con­
tinue regularly a minimal dose of antiparkinsonian medi­

cation like 2 mgs of Trihexyphenidyl if the patient has

tendency to develop extrapyramidal symptoms repeatedly.
3.

If any patient develops acute and severe side effects
like bizarre ?nd uncontrollable movements of the tongue
face and neck (to a side), with collection of saliva,

rolling up of eyeballs (Distonias, Torticollis,
Oculogyric crisis, opisthotonus) he should be given by

Promethazine (Phenergan) 1 amp (50 mg) intramuscularly,
immediately and started on tablets of Trihexyphenidyl
2 mg three times a day. If patient continues to get
severe reactions, the dosage of phenothiazine should be
reduced.
(h)

A patient started on 300 mg of Chlorpromazine may not

show improvement on this dosage. In such cases, the dosage can be

steadily increased upto a total daily dosage of 600 mg.
(i)

The dosage of medications should be brought down as

the symptoms of the patient start disappearing and a maintenance
dose decided (usually 50 mg to 200 mg).
(j) The medications should be continued for at least a
minimum period of 1 year in all schizophrenics.

(k) It is advisable to follow up the patient initially,
once weekly and later when the symptoms have remitted once either
fortnightly or monthly.

(1)

Refer the schizophrenic under your treatment to a

psychiatrist if:
1.

His severe excitement is not controlled in 48 hours

in spite of using 600 mg of Chlorpromazine per day.
2.

If the other main symptoms in a non-excited patient
have not come down after 4 weeks of treatment with
doses advised.

3.

If recurrent and severe side effects (dystonic reactions)
occur in spite of taking appropriate measures.

A sympathetic understanding of the patient and his family

by the PHC doctor and health worker team is very important and

this would facilitate the ultimate complete recovery of the

patient. He should be'encouraged to staft working routinely
as his improvement sets in.
(b)

Manic Depressive Psychosis (M.D.D.) is a disorder primarily

of the 'mood* of a person. The mood disturbance in M.D.P. is
both of quality and quantity ranging from severe depression to
elation.

The other mental symptoms which appear are secondary

to this mood disturbance.

A person may get only attacks of mania

or only attacks of depression or both alternatively. Complete
remissions in between attacks at times (even spontaneously)
occur and during these periods the patients would be absolutely
normal. Thus MDP is an episodic illness with varying periods of

normalcy inbetween.

Clinical features:
Manic state: It has a classical triatf of symptoms. Elated
but unstable mood, excessive talk and increased motor activity.

The patient is often colourfully dressed, talks easily and
humorously.

air.

He talks on any matter and builds castles in the

He boasts of himself and his boasts are not really true. He

is warm and very friendly, tries to be very intimate with every­
body. He is very active and never seems to tire. But he is
easily distractable and never completes any work. He is impatient
becomes restless and irritable if his wishes are not filfilled
immediately.

His sleep is markedly disturbed.

He lacks insight

(about his illness).
In severe cases, his talk becomes irrelevant and ununderstandable. He becomes violent and impulsive. At this
stage it would be difficult to differentiate between mania

and schizophrenia.
Depressive State
Retarded Depression: It has the following symptoms depressed mood, minimal and slow talk, sleeplessness, marked

II.

motor retardation, loss of interest in everything around, lack

of initiative, hopelessness, worthlessness, unfounded guilt,

vague and multiple bodily complaints and inability to perform
routine responsibilities.

The patient is usually unconcerned about his dress and
appearance, looks dull and dejected.

He avoids the company

of others and prefers to be alone.

He has to put in a lot of

effort to say or do anything. He lacks initiative to even take
care of his personal requirements. He feels guilty for trivial

or no apparent reasons and at times fir his past deeds. His
apetite has considerably come down and cannot enjoy e&ting. His
sleep is markedly disturbed especially during the early hours
of the day.

He entertains ideas of wandering away or committing

suicide because of his plight,some patients may have vague aches
and pains all over the body and general weakness predominantly, in
addition to some degree of the above complaints. Such patients

go from doctor to doctor and find no lasting relief in symptoms.

In addition to the various complaints listed above, some

patients hear voices saying that they are bad, they are sinners
etc.

Some of them even have wrong beliefs like only death will

solve their problems, they are suffering from the curse of God
etc.
Restless depression:

(Also called agitated depression) In addi­

tion to depression the patient, instead of retardation exhibits
irritability and restlessness.

Anxiety symptoms and multiple

somatic symptoms colour the clinical presentation. This type

of depression is more commonly seen in women during the

in­

volution (menopausal) periods.
Manaqemeiit:
(i) Mania: The following guidelines should be followed:
(a) If the patient is severely disturbed or excited, he
has to be controlled with Inj. Chlorpromazine 50 mgl,M.
repeated every half an hour till the patient is se­
dated. Then change over to tablets of Chlorpromazine
100 to 200 mg given twice or thrice a day.
(b) In less disturbed patients, the treatment can be
started with oral medication. Tab. Chlorpromazine
in doses of 50 mg to 300 mg per day can be given to
start with.

(c)

If patient does not improve with the above dosage,
a daily dosage of upto 600 mg of Chlorpromazine given
in divided doses but (mainly at night) can be attempted

(d)

Look for side effects of Chlorpromazine. The various
side effects and thdir management- are already men­
tioned in the section on management of schizophrenia.

(e)

The medications should be reduced as improvement in
symptoms are noticed but should be continued f>r a minimum
period of 3 months. It should be continued further
if symptoms persist.

(f)

The guidelines for following up the manic patient
and referring him to a Psychiatrist are similar to
schizophrenia.

(ii) Depression: The following guidelines should be
followed in the management of a depressed patient:
(a)

Imipramine hydrochloride (Depsonil • Antidep) - an
antidepressant - is the drug c -’ • lice for treating
depressed patients. It is availaole as tablets of
25 mgs and a patient is started on 75 mg or 3 tablets
per day initially.

(b)

Many of the depressives have sleeplessness as a major
complaint. In such patients a minor tranquilizer like
Diazepam (Valium, Calmpose, Calmod, Tenaril, Pajocm)
should be given at night, in addition to Imipramine.
They are available in tablets of 5 mg and 1 or 2 ta­
blets (10 mg) can be given.

(c)

If patients do not start improving in three weeks time,
the dose of Imipramine should be stepped up by 1 tab.
(25 mg) each weekly upto a total dose of 150 mg per
day. This is the maximum daily dosage of Imipramine
advised. The diazepam could be stepped upto 15 mg. a
day.

(d)

It is worthwhile remembering that ft takes about 10
days to 2 weeks to notice the beneficial effects of
Imipramine.

(e)

Many patients on imipramine experience various unde­
sirable side effects and may stop the drug on their
own. They should be told about these usual side effects
as they are put on this medication. They should also be
reassured that these symptoms are transitory and
harmless and they will subside in a few days time.

(f)

The usual -s;i-de effects of Imipramine are:
i. dryness of mouth
ii. blurring of vision
iii. constipation
iv. giddiness
v. urinary retention (rarfely)

(g)

The usual side effects of diazepam are:

i. drowsiness
ii. dulling
iii. hang over effects.
(h) One must be careful in prescribing imipramine to
people who have symptoms of enlarged prostrate or
increased intra ocular pressure as imipramine can
cause acute retention of urine in the former and
precipitate severe glaucomatous crisis in the latter

(i)

Risk of suicide by the patient must always be kept in
mind while treating a depressed patient. This risk is
higher when a patient has just recovered from the
physical retardation but still feels very sad and
depressed. Patients severe suicidal ideation and past
history of suicidal attempts increase the risk. The
patients family should always bo cautioned about this
risk and advised not to let the patient be alone at
any time.

(j)

The dosage of drugs can be reduced after the patient
has shown improvement in his symptoms. A maintance
dose of 50 mg to 75 mg of Imipramine should be conti­
nued for a minimum period of 4 months to prevent
recurrence of symptoms.

Refer a depressed patient under your treatment to a
psychiatrist in the following situations:
(i) Patient has not shown any improvement in spite of
the maximum advisable dosage of medications given
for 6 weeks regularly.
(ii) If a patient has developed severe side effects
like acute retention of urine
(iii) If it is felt that the family members of a severely
suicidal patient, cannot look after the patient
adequately and protect him from the risk of
suicide.

(k)

Note on M.D.P.: (1) Sometimes a patient, on treatment for mania
may suddenly start showing symptoms of depression and vice versa.
In such cases, the treatment schedules will have to be appro­
priately changed for either mania or depression.
(2) Lithium carbonate is a new anti-manic drug which is also
found to be useful in preventing recurrent manic or manic de­
pressive attacks. But this drug has several serious side effects
and needs frequent monitoring of blood levels-» This drug should
be started only (after the appropriate investigations) by a
psychiatrist. Patients who get very frequent attacks of mania
or manic depressive attacks could be referred to psychiatrist
for consideration of Lithium therapy.
(c)

Reactive psychosis; is a brief psychiatric episode brought

on by any severe emotional stress. The content of the patients
talk and the symptomatology are usually related to the precipi­
tating cause. The illness itself is of short duration and may

recover spontaneously after the stress factor disappears. The
psychosis itself may resemble schizophrenia, mania or depression
in its -clinical pcitures and the treatment is decided according?
The drugs need to be given only for short periods (about 3

months) till the symptoms disappear.
2.

Organic psychoses ; The organic psychiatric problems are

generally classified into (a) Acute organic brain syndrome and
(b) chronic organic brain syndrome.
(a)

Acute organic brain syndrome is generally due to the effect

of physical illnessess and is usually reversible and transient.

The clinical picture would predominantly show fluctuating levels
of consciousness, with erpisodes of confusions: at which time pa­
tient will be disoriented to time place and person.

Memory

deficits for recent events, frequently fluctuating mood which
may range from acute fear and panick to depression and even

bursting out into laughter/crying, and hearing and seeing things
which do not exist are common features. Many of these symp­
toms are worse at night and show considerable fluctuation from

hour to hour and even minute to minute. The commonest causes
of this syndrome are : (1) Drug intoxications including al­
cohol withdrawal states and alcohol toxicity. (2) Infections -

pulmonary, urinary, meningeal, (3) post epileptic (post ictal)
confusion, (4) Post head injury confusion state, (5)
Myxoedema, (6) Hypoglycemia, (7) Pellagfa and other nutri­
tional deficiency states.
Management: Identifying and treating the primary cause ener­

getically is of utmost importance.

If facilities for this

are not available, the patient should be referred to a
specialist. Management of the symptoms of excitement and
other psychiatric symptoms is by the use of Chlorpromazine.

It should be used either orally or intramuscularly in smaller
doses (50 to 300 mg).

(b) Chronic organic brain syndromes start insiduously and
are progressive. They are generally irreversible. The clinical

picture would consist mainly of progressive deterioration of

intellectual functions like memory loss for recent event*,,
improper (judgement, etc. Other symptoms like stereotyped re­
peatition of words or actions, fabricating lies to make up

for the memory loss, quick fluctuations in emotional responses

(lability of emotions). As the illness progresses, patient
will be unable to take care of his personal needs and may
develop symptoms like sleeplessness, restlessness and wandering

tendencies.

Patient may also develop neurological symptoms like fits,
weakness of the limbs or body, difficulty in speech, vision
etc.

The various types of senile and presenile dementias

present with a clinical picture of chronic ofganic brain syn­
drome. Sometimes, a slowly growing tumour in certain areas of
brain may also present similarly.

Management;- Counselling the family members regarding
the nature of the illness is essential for effective mana­
gement of the various problems.Lboking after patients nutri­
tional and hygienic needs are very important. Tablets of

chlorpromazine in comparatively smaller doses (25 mg to 200
mg) can be given when sleeplessness, agitation and wandering ten­
dencies are main probles. Tab. Diazepam in doses of 5 mg to 15
mg also can be given.
A patient of chronic organic brain should be referred to

a specialist if he develops signs and symptoms of neurological
illness like fits, weakness of half of the body(hemiparesis)
etc.

Note (on psychoses): When a pscyhotic pqtient presents to you

in clinic or is referred to you by the health worker, the
important steps to be taken are as follows:
1.

Determine whether it is an organic state or a functional
psychosis.

2.

If it is -rganic, do detailed physical examination to

determine the primary physical illness and institute
appropriate treatment, in addition to managing the psy­

chiatric symptoms.

If facilities-are not available for the

management of the physical illness, refer patient to a
general hospital.
’
3.

If the psychosis is not organic, the type of functional
psychosis needs to be established. In any case the patient may

either be excited and restless or withdrawn, quiet, or

manageable. The initial treatment is the same immaterial
of the type of illness, if excitement is the presenting
feature. On the contrary, if patient is withdrawn,

determine whether it is a. schizophrenic withdrawal or the
patient is depressed, start the treatment accordingly.
4.

Regular frequent follow up initially (weekly) will give
clear picture of the patients symptomatology enabling
better drug management. Refer the patient to psychiatrist,
when there are difficulties.

5.

As a routine all patients and their relatives must bo told
about the necessity for regularly taking medicines for
the advised period of tune. They must be told to report

any serious side effects or any sudden worsening of the
symptomatology either to the health worker or the doctor
at the PHC. The family members should be encouraged to
let the patient get into his normal routine as soon as
possible. The Doctor must, patiently talk to the family
about the various misconceptions which they may have
regarding either the causation or management of these
illnessds.

NEUROSES

The term Neuroses is used to a group of specific condi­
tions where anxiety is a predominant feature: . Neuroses in

general have some common features, some or many of which
will invariably be present in any variety of neuroses:

A.

A skillfully taken history will reveal that in the past,

the patient generally

(a)
(b)

has been a very sensitive individual
has been a worrying kind of individual who tends to

(c)

worry more than others.
has been more easily upset by disappointments and

(d)

set-backs than others.
has been less confident of himself

(e)

has had one or more symptoms of neuroses in childhood:

(i)
(ii)

Enuresis beyond 3-4 years age
Thumb sucking or nail biting which persist.

(iii)

Recurrent minor attacks of headaches, stomach­
aches etc.

B.

Common presenting symptoms:
Loss of memory

(b) Excessive generalised weakness
Difficulty in concentrations
(d) Sleep disturbances
Giddiness
(f) Vague tenseness or fears
(g) Irritability

(h) Lack of appetite
C.

Common presenting signs:
(Sometimes they may present as symptoms also)
(a) Profuse sweating
(b) Tremors

D.

(c)

Palpitations

(d)

Dryness of mouth

Careful and skillful history will always reveal an event
stressful to the pa.tient before the onset of the illness.

Whenever any of the above features are present, it is
essential to inquire and verify for the presence or absence
of the other features also.

VARIETIES OF NEUROSES:
A.

Acute anxiety state:
Predominant feature is a vague sense of anxiety or

tenseness of acute onset and short duration.

There will be

other features of neuroses also.

B.

Phobic anxiety state:
Predominant feature is an intense fear that is asso­
ciated with.certain specific situations only. At those times
the patient.will experience panic: palpitation, trembling,

sweating, and even giddiness. The patient may or nay not
know what his fears are, however he knows that his fear is
unfounded, yet cannot help it. There will be other features
of neuroses also.

C.

Obsessive compulsive neuroses:
Obsession refers to thought, and compulsion refers

to action.

Usually both of then clinically manifest together.

These obsessions and/or compulsions arc the characteristic
feature of this condition.

In case of obsessions, the

patient feels repeated/ compelled, to think about something
that he does not wish to think about, or to carry out an

action that he does not want to carry out, but .he carmnj
help it.
D.

Whenever he resists^becomes extremely anxious.

Hysterical conversion reaction:

The predominant feature is that the presenting sympt­
oms mimic a physical illness, but not satisfying criteria for
physical illness on detailed history and examination. The
patient generally seem apparently happy and unconcerned about
the symptoms which from their report appear severe. The
physical dysfunction if it exists is very selective. It should
be remembered that the patient does not pretend to have the

*

symptoms.
E.

He actually experiences it.

Hysterical dissociative reaction:
The predominant feature is loss of memory for a very

well demarkated, specific recent portion of his life.

F.

Neurotic Depression:

Can manifest either independently or with any of the
above conditions, but less frequently with the hysterical
states. The predominant features are of sadness, severe sleep
disturbances, lack of appetite, crying spells, irritability,

suicidal ideas or even attempts,

.

’ J ■

The following are the main differences between neurotic and
psychotic depression.

Neurotic depression

Psychotic depression

1.

Essential daily activi­
ties like eating, drink­
ing, self care not
affected.

May be affected

2.

Extreme degree of in­
activity or restless­
ness (agitation) absent

Extreme degree of inactivity
or agitation (restlessness)
may be present.

3. Sleep disturbance more
in the form of diffi­
culty in getting sleep
and/or disturbed sleep.

Invariably early morning waking
will be present. May be asso­
ciated with other kinds of
sleep disturbance also.

Patient generally
feels lack of confi­
dence.

There will also be feeling of
dejection and worthlessness.

4.

Neurotic Depression

Psychotic depression

5.

When history of suicidal
attempts are present, the
methods used are relati­
vely less lethal.

Methods for suicidal attempts
will be more lethal.

6.

In history personality
defects more common

Less common.

NOTE: (i)

Often in a depressive patient it may not be
easy to distinguish the neurotic or psychotic
variety.

(ii)

In either varietyz suicidal attempts must always
be taken seriously.

Whenever any of the above^conditions are suspected it
is always essential to inquire about the following without fail:

(a)

Alcohol habits

(b)

Drug intake for non-addictive purposes •

(c)
(d)
(c)

(f)

(i)
(ii)

long-term steroids
oral contraceptives

(iii) some antihypertensives.
How much mental and physical activity is still intact.
Any suicidal ideas or attempts
Specific details about the precipitant event, and its
meaning to the patient.
Thyroid functioning, anaemia, or other debilitating physical

conditions.
The following are the main differences between neuroses

and psychoses.

Neuroses
1.

Personal care
maintained

2. Contact with the surr­
ounding reality maintained
ie., the patient1 s beha.viour is relatively
easily understandable.

Psychoses
Neglected

Contact with the surrounding
reality is deranged and the
patient's behaviour is not
understandable.

Psychoses

Neuroses
3. Perceptual functioning
normal.

Hallucinations will be present
in the majority of cases

4. Thought functions
are normal

Delusions and other disorders
of thought will be present in
the majority.

PSYCHOGENIC SOMATIC CONDITIONS:

A. There are clean cut somatic syndromes where psychosocial
aetiological factors play a large part.

These are called

psychosomatic conditions.

Examples of psychosomatic
conditions

Percentage of conditions in
which psychosocial role was
clearly established.

a) Peptic ulcer
b) Urticaria/ Angio­
neurotic oedema
c) Asthma (after 50 yrs,
of age)
d) Thyrotoxicosis

57%
51%
46%

45%

e) Asthma (16 to 45
years of age)

36%

f) Vasomotor Rhinitis

30%

B.

There are vague somatic symptoms, which are not associated

with any identifiable somatic syndrome, but which are solely

caused and maintained by pqychosoci al stresses:
Examples:

Headaches
Body pains
Psychogenic impotency
P.U.O.
Disproportionate breathlessness
Cardiac neuro sms

It is essential to note that the patients do not malinger;
but.

genuinely experience the symptoms.
While the clear cut pychosomatic conditions do not

offer much difficulty in diagnosis, the more vague psycho­
genic somatic symptoms are not always diagnosed correctly:
the common characteristic features (some or all of them
may be present in any given case) identifiable by skillful

history are:

There is always a stressful event in patients life which

1)

precedes the onset of symptoms.
2)

Also, during the course of the illn'ess, the severity of
symptoms have definite relation to psychosocial setbacks.

3)

There will be sone or more features of neuroses.

4)

The symptoms like headache, body pain etc, are generally"
reported to be present throughout the day, starting soon
after waking up, and also, there will frequently be

diurnal variations (more in the morning or more in the
evening, or more while facing a specific task etc.)
TREATMENT;
The effectiveness of treatment depends on:

1)

The confidence with which the doctor approaches the
problem, backed by his knowledge of the case by skillful

history.
2)

Early diagnosis, and avoidence of iatrogenic factors like
numerous investigations, referrals and prescriptions.

3)

Early specialist consultation.

MANAGEMENT GUIDELINES:

1)

First task is to make it known to the patient, the relat­

ionship between the stress and the onset of symptoms
according to the history provided by him, and explaining
that such things do happen.

2)

Second task is to appreciate and encourage the patient's
positive strengths and qualities by which he is still
managing his life, and assuring him that it should be
possible to get well.

3)

Seek specialist consultation as soon as possible.

4)

Specific conditions:
(a) For acute anxiety state, anxolytics in small or

moderate doses are adequate:
Diazepam 5 mg either y : 0 :

or 0 : 0 : 1

or
£ : 0 : 1.
Phobic anxiety states generally require more

adequate doses.
Diazepam 1 : 1 : 1 ' or

(b)

1:0:2.

Neurotic depression respond well to small doses of

antidepressants like araitryptiline ^5 ng 0 : 0 : 1
or
0:0:2.

vfr
(c)
(d)

Treatiaentj(pbsessive compulsive neuroses is best'
handled by a specialist.

In case of hysterical conditions (both the conversation

reaction and dissociative reaction) the 'first-aid' measure
is to reassure the relatives that there is no harm or
danger to life. The treatment of these conditions are best
handled by a specialist.

(e)

Clear cut psychosomatic syndromes respond better when

conservative treatment is combined with antidepressants
iin small or moderate doses.

(f)

Anitryptiline
mg
0:0:1 to 0:0:3.

For the vague psychogenic somatic conditions, simple
anxiolytics are sufficient if there are no additional

features of depressionj^and small or moderate doses of
antidepressants are helpful if there are additional
features of depression also.
EPILEPSY
Epilepsy can be defined as a paroxysmal stereotyped and
recurrent disorder of movement,feeling and/or emotions, these
disorders occuring almost always in a background of altered

state of consciousness and such disorders being primarily
cerebral in origin. The onset is usually sudden,there may
be podroma of headache and uneasiness in the head. If un­
consciousness is the first thing to occur before any convul­
sive movement,, then it is known as"major epilepsy (grandma!,
generalised).

If any part of the body starts convulsing

or if there is any kind of aura before the onset of uncon­

sciousness, then it is called a focal epilepsy which becomes
generalised. If unconsciousness does not develop at all,
II
u
then it is known as focal epilepsy.

The focal origins may be at the motor area, sensory area
or at the temporal lobe.
The diagnosis of epilepsy would depend entirely on
collecting a good history from a person who has witnessed

an attack. For all practical purposes, diagnosis of epi­
lepsy is a purely clinical diagnosis. EEB and skull arrays
are not of any value generally. Sometimes epilepsy can be
confused with 'hysterical' convulsions. Following are sone

of the points which can distinguish between the two.

Hysterical attack

Epilepsy
1. Sudden onset, lasts for
about a mintte or two though
relatives may report it as
10-15 minutes.

Dramatic onset, dr it may be
gradual; usually lasts longer

2. The body becomes stiff and
then there are jerks till
the whole body relaxes

Biaarre, lashing and flinging
type of movement.

3. The pattern is the same always

The pattern differs in every fit

4. Injury to body parts, tongue
or lips are common

Injuries are uncommon.

5. After the fit the person
remains confused or sleeps
off

No confusion or sleep after
the fit

6-» Occurs in sleep also

Does not generally occurs in
sleep
Almost always in the presence
of other people, the more the
audience, the more vigorous is
the fit.
Pupils are not dilated

7. Occurs even when alone

8. Pupils arc dilated during the
attack
9. Plantars are extensor
during the attack

Management;

Plantars are flexor

The following guidelines should be remembered in

treating an epileptic:
(a)

Usually drug treatment is started only after a person gets
at least 2 attacks during a period of 6 months, ^he

advise to be given to people with one attack is to watch
for further attacks and report, if they occur.

(b)

The commonly prescribed drugs for epilepsy are two, hamely

Phenobarbitone (Gardenal) and Diphenyl hydantoin (Eptoin
Mtoin). It is always better to start a patient on a
single drug. Add the second one only if the first drug
did not control the convulsion.
(c)

Phenobarbitonc should be started in a single dose of 60 mg
per day and increased upto 120 mg per day if the fits arc
not controlled. Add Diphenyl hydeantoin in dosage of 1 tab.

of 100 mg per day and increase it upto 2 tabs (200 mg) when
necessary (i.e when fits are not controlled).
than these doses. It is believed and advised

Do not give more
these

days that it is sufficient if a single dose of the above
drugs are given instead of the old divided dose schedule.

Irrespective of the time of fits, these drugs can be given
as a single dose at bud time.

(d)

The only side effect of phenobarbitone is drowsiness.
Dephenyl hydantoins when taken in excessive doses can

produce ataxic gait and other cerebellar symptoms. Long
consumption of th&s drug may produce hypertrophy of gums.
(e)

The antiepileptic medication should be continued for a
minimum period of two years, after the last fit.

(f)

It is very essential 6r the family to cooperative with

the management. It is important to remember that certain
emotional factors can trigger off an attack. It is

necessary to have an attitude towards them as one would

have towards any normal person.
(g)

Epileptics must avoid, late nights, empty stomach and
alcohol as they may bring down the threshold for convul­
sion.

They must avoid driving, being near fife alone,

heights or swimming.

(h)

Refer the epileptic for treatment to a specialist under
following circumstances:
1. When fits are not under control on the advised dosage

even after a period of a month
2,

3.

when the problems

. j epilepsy is part of a neurological

When p patient develops certain neurological signs of
symptoms during the course of his illness.

(i)

It .is worth emphasising here that in some case both
epilepsy and hysterical convulsions may coexist. The

epilepsy should then be treated with drugs.
(j)

Status epilepticus (patient getting fits continuously

without regaining consciousness inbetween)almost always
respond immediately to diazepam given as intravenous
injection in doses of 5 mg to 10 mg.

Most epilepsies, when correctly diagnosed can be treated
and managed by any qualified medical practitioner provided re­
gular and adequate medication is ensured.

MENTAL RETARDATION
Some people are mentally dull and weak right from child­

hood. The mental retardation first becomes noticed when a
child fails to raise his head, sit up, walk and talk, at the
usual ago (raising head=3 months, sitting up=6 months, walk­
ings! year, talking=l% years). His subsequent’mental growth
and often physical growth remains poor. For example a 10 year

old child may behave like a 2 year old child.

These people are not mentally ill.

Mental illness occurs

later in life in an otherwise normally developed person.

However

sometimes the mentally retarded person may also show strange or aggressive

behaviour.

Very severely retarded persons may have physical abnormalities

also.

Mental retardation can occur as a result of injury to the brain

at birth (as in difficult labour, forceps application^ brain fever,
fits in early childhood, any serious infection which involves brain

Eg: meningitis or fits due to epilepsy.
abnormality leading to

Very often the cause is a chemical

poor sonstruction of the brain while the child

is in the womb.

There is no cure for mental retardation.

Once the brain is

poorly formed

nothing can repair it.

intelligence.

However these children can be trained and learn skills.

There are no drugs which increase

The parents have to be very patient and repeat

instructions many times.

With such patient training, many retarded children can train to look

after themselves and do simple jobs in the farm.

They learn quicker

if the training is given with kindness and the children are rewarded every
time they learn a skill.

A mentally retarded person may have fits or show symptoms of psychosis hyperactivity, violence, destructiveness.

In such cases, the appropriate

medicine to control fits or psychosis should be given.
A L C 0 H 0 L

1.

2.

Signs of Alcohol dependence:
(a)

Increased frequency and quantity

(b)

Drinking alone

(c)

Alcoholic amnesia (Black-out)

(d)

Morning shakes

(e)

Increase in tolerance

(f)

Personality change and social deterioration.

Hazards of Alcohol dependence:
(a)

Poor nutrition

(b)

Delerium tremens

(c)

KorsakdV-’s Ptfyche'ois

(d)

Wernicke'a encephalopathy

(e)

Alcoholic hallucinosis

(f)

Delusions of jealousy

(g)

Dementia

J. Signs of Alcohol withdrawl in a 'dependent' case;

(a)

Agitation, Hyperactivity, Sweating, Tachycardia

(b)

Tremors

(c)

Hallucinations - mainly visual

(d)

Disorientation, Delerium

(e)

Seizure, Fever/diarrhea, dehydration.

4.

Treatment of acute alcoholic intoxication:

(a)

Let the patient sleep off his stupor

(h)

If comatose, pass an endotrachial tube and give 5% glucose.
Enough fluids.

5• Treatment of Alcohol withdrawl:
Chlordiazepoxide 20-40 mg a day

(a)

In Alcoholic hallucinosis - Chlorpromazine 100 - JOO mg a day.

(b)

(c)

In D.T's - Fluids, vit. B complex l/V and, chlordiazepoxide.
Look out for 'fits' and give anticonvulsants if necessary.

PSYCHIATRIC EMERGENCIES

Psychiatric emergencies are any psychiatric conditions or
circumstances of a patient which calls for immediate action.

Here,

the decision as to what is to be done to the patient, has to be taken
soon.

A psychiatric condition or circumstances will present as an

emergency, usually due to one or more of the following reasons:

(a)

The patient may be a source of danger to himself or others
because of his mental state.

(b)

The patient's relatives may be extremely anxious and worried
regarding the patient's condition.

(c)

The patient may create disturbance in the community to an intolerable

or unmanageable degree

(d)

The patient may be in extreme and unbearable distress.

Approach to a psychiatric emergency:
History taking, however brief it nay be, is very essential

and should preferably be proceeded by the examination of the patient.

Inquiry should be made regarding the possibility of any probable

precipitating factors.

A thorough examination of the patient

including

of

measurement

blood

pressure

should

be done. Examination of the patient can preferably be in private.

Do not

Avoiding restraint as far as possible will be useful.

deny the reality of the patient1s experiences. The doctor must
try to express his respect for the patient and by direct verbal

reassurances, ifiform the patient of'his commitment to the patient's
welfare. The doctor can reveal his identity and should try to
avoid pretending otherwise to the patient.

A psychiatric emergency may be the acute onset of a new
illness or an acute exacerbation of a chronic illness.

The various psychiatric emergencies are the following:
1. Suicidal threats, gestures or attempts: No suicidal
threat, gesture, or attempt should be taken lightly. Do not ta’iu.
the assurances of the patient for granted. There are no defmnib.
and fixed criteria to differentiate between genuine and spurious
attempts.

The following points are worth remembering:
(a) An overdosage of drugs or intake of poisonous sub­
stances is seidome accidental and almost always
suicidal.
(b)

An attempt at suicide when patient is alone is always a
serious'
attempt.

(c)

More than one method of attempt, indicates seriousness.

(d)

Above themiddle age, attempts are always serious

(e)

Farewell note, if found, indicates a serious attempt.

(f)

Frank admissions of suicidal intent by the patient
can be relied upon, but never his denials.

Management
(a) It is advisable not to take things lightly even if
the patient assures that it was not a suicidal
attempt or that no further attempts will be made.

It is desirable (and not harmful) to discuss openly
about the risk of suicide/suicidal attempt, with .the
patient and the relatives.
(c) Referral to a psychiatrist and admission under his care
is warranted, if family members are not confident to
look after the patient.
(d) It is preferably not to leave the patient alone and
co-operation of the family members should bo sought
to ensure sympathetic supervision of the patient.

(b)

2.

Excitements:
Excitements may be due to (a) Functional psychiatric ill­
ness like a schizophrenia or mania (b) Organic brain disorders

caused by various CNS or systemic illnesses ,a state called by

the general terms: Acute Brain Syndrome.

When the excitement is due to either schizophrenia or mania ,
it is rarely the first evidence of these illnesses.

Often there

will be history dating back to at least few days prior to the
onset of excitement, of some behavioural abnormalities and

sleep disturbances.

Usually there will be no confusion or

other alterations in the state of consciousness.
The clinical picture of acute brain syndrome would consist

of fluctuations in level of consciousness, disorientation, in­

ability to concentrate-., impairements of memory - in addition to
other features like restlessness agitation, disturbances of sleep

slurred speech, irritability, unexplained fear.

These symptoms

may be more marked in the night.
Management:
(a) Excited patients generally carry the risk also of, self

neglect, exhaustion and malnutrition. These have to be
taken care of.

(b) If the patient is too excited to be without an escort, it is
always advisable to choose an escort who.has not physically

restrained the patient before, because excited patients

generally tend to be uncooperative with those who have phy­
sically and forcefully restrained them earlier. However, one
should not hesitate to take whatever precautions any situa­

tion may demand.

For example, when dealing with a physically

violent patient, it is wise to be out of his arms' reach ex­

cept while giving injections and lye always facing him.
(c)

(d)

If the patient expresses hallucinations or delusions, respect
it and do not argue.

The primary task in any excitement (except head injury) is
sedation. Chlorpromazine (Largetil 100 mg as IM injection
would be an ideal choice and should be given immediately.

It can be repeated as injections of 50 mg. at half hourly
intervals if necessary to control the patient. Later the

injection can be substituted by tablets of 100 mg. Chlor­
promazine given orally (400 to 600 mg per 24 hrs may be

sufficient). Fall of B.P. as a side effect of Chlorpro­
mazine should always be kept in mind. If the excited .patient

has jaundice, do not give any drug other than phenobarbi'e. r-e
for sedating the patient. Following head injuries do not
give any drug to the patient.
(e)

In treating the patient with acute brain syndrome, the

underlying physical condition should be determined and

energetic treatment for the same should be started as
promptly as possible.
3. Side effects of Phenothiazines (Chlorpromazine)/Major tran­
quilizers like Phenothiazino (Chlorpromazine-Largactil) have, many
undesirable side effects,, some of which may present as an
emergency. The commonest side effects are ex^rapyramidal symptoms

I.Anxiolytics (or, "Minor Tranqulisers")
Anxiolytics are effective for symptomatic relief of neurotic
conditions whexeever symptoms of anxietyare present; like:
5
sweating, tremor^, palpitationsy also facilitate sleep. Their

effectiveness as sole curative agents is however very restricted

where the anxiety symptoms are:
(a) of very recent origin,
(b) the patient has in the past shown ability to cope adequately

with stress,
(c)

there are no severe and prolonged interpersonal/familial

problems.

b,

♦

In all other cases the role of anxielytics^limited, and the
management must necessarily include psychotherapy, family coun­
selling, etc.

In such cases, if symptoms of anxiety are severe,

anxiolytics can be used with discretion only as adjuncts to

other modes of managements.

Pharmacological name
of the anxiolytic and
tablet strength

1. Diazepam

5 mg.

Some^proprietory)
7?Cu^enames

Average dose
per day

Diazecalm
Calmpose
Calin-U
Paxum
Calmood

5 mg O.D. or B.D.

2. Lorazepam 1 mg

Larpose

1 mg O.D., B.D.,
or T.D.S.

3. Chlordiaze­
poxide 10 mg, 25 mg

Librium
Equibraum

B.D. or T.D.S.
can be given up
to 10 mg per
day in Tremors
due to alcoholism

not
Diazepam should/be given more than 15 mg per day because

of drowsiness, lethargy and ataxia.
Intravenous diazepam is very effective in cases of status
epilepticus. The injection must be given slowly.
Cultajis

}

~

II. Hypnotic

Hypnotics are used sparingly to facilitate sleep in con­

junction with antidepressants in cases of severe insomnia. The
word "sparingly" is deliberately emphasised because (a) pres­

cription merely of an hypnotic to an insomnic person will do
nothing to his problems which are causing him insomnia, and there

is danger of the individual learning the habit of taking hyp­
notics instead of "rolling up his sleeves" and dealing with
the problems.

If.this happens we will be contributing to the

individual's escape from his healthy and legitimate responsi­
bilities.

(b) In majority of instances, insomnia will auto­

matically set itself right either when the underlying problem
is adequately dealt with or when his anxiety or depression is

relieved.

Pharmacological name of the hypnotic is Kitrazepam, avai­
lable as Hypnotex, Nitravet, sedomon, etc. available .in 5 mg
and 10 mg strengths.

It is administered only at bed time.

Rarely it can cause "hang-over" like symptoms.
Concomitant use of alcohol and hypnotics will cause

excessive drowsiness and should be avoided.
III.

Antipsychotics (or "Major Tranquillisers")
Antipsychotics are effective either in schizophrenic psy­

choses or in manic states, or in those cases of depression
where addictional psychotic features of hallucinations and

delusions are also present, alcoholic psychoses, and when- cau­
tiously nsed in organic and epileptic pbychoses.

Some trade
names

Equi­
potent
dose

Average
therapeutic
dose

(1) Chlorpromazine
50 mg
100 mg

Largactil
tranchlor
Promacid
Widactil

100 mg

100-300 mg
per day

(2) Trifluoperagine
5 mg

Trinicalm
E skaz ine
Trankozine
Mephazine
T.F.P.

5 mg

5 - 15 mg
per day

Pharmacological name and
strength

A.Phenothiazines

(3) Thioridazine
25 mg
100 mg

Melleriptf'’

100 mg

(4) Fluphenazine
Deconoate
(this is a depotphenothiazineparenteral 25 mg/mlj

AnatensolDeconoale

-

Serenace
Depidol

1.5mg

100-400 mg
per day
25 mg IM
once in
2 weekns to
4 weeks

B. Butyrophenones
Haloperidol
1.5
mg

mg
per day

3t9

Note-1; The maximum therapeutic doses mentioned above should not
be exceeded in the out-patient setting.
Note-2; In case of "j^epot phenothiazines- (a) It is used generally
as a maintainance medication for schizophrenic psychoses, (b)

The dose is adjusted by altering the interval between injections
from 2 weeks to 3 weeks and also by altering the dose between
1 ml and Jj ml.

These antipsychotic drugs have differing degrees of
sedative effects, and this can be made use of to meet special

clinical requirements like:
dominant problem,

(a) severe insomnia is a pre­

(b) the patient has to attend work during

daytime though taking antipsychotics in divided doses. The
sedative effect of the drugs is mentioned in decreasing order;

- Chiropromazine - most sedation
- Thioridazine

- Haloperidol - least sedation.

Xhe following are the side effects of the antipsychotic
drugs.

(1)

Minor and transient; They usually disappear spontaneously

after 2-3 days of treatment:
- dryness of mouth
- blurring of vision
- drowsiness.

(2)

Extrapyramidal side effects
(A) Reversible conditions:

It is very important to recog­

nise them so as to institute prompt treatment (a) Acute Dystonic

reaction:- sudden muscular contraction/ most often in neck,
tongue, and pharynx; presenting as occulo-gyric crisis, laryngeal

spasjtm or as protrusion of tongue against clenched teeth. One

of the commonly used dunags in general practice, siquil (a

phenothiazine) frequently causes, this reaction.

Acute dystronic

reaction can be quickly relieved by 50 mg of Intra muscular

phenergan.
(b) Drug induced parkinsonism: The features are:

Excessive salivation
Tremors
Rigidity
Masklike face.

(c)

Akathisia:- It is a condition of motor-restlessness, often

accompanied by mental-restlessness; viz: the patient just cannot
sit or stand at one place quietly for more than a few seconds,

and he is distressed. Though/picture may be^a part of agitated
depression, there will be history of phenothiazine medication

in the last 24 or 48 hours in case of akathisia.
All the three above conditions need antiparkinsonian

drugs.

If the patient already happens to be on antiparkinsonial

drug, the dose will have to be increased.

Antiparkinsonian

drugs should be continued till these extraphyramidal symptoms
disappear.

After that?another phenothazine can emperically

be substituted for the psychosis.

Thioridazine (Melleril) is least known to cause these
extrapyramidal symptoms.
B) Chronic condition: Tardive Dyskinesia

When it does occur, it usually occurs after 5 to 6
;

fb

years use of phenothiazines^P^uterophenones. This
most troublesome iatrogenic condition is difficult to treat.

Refer to a psychiatrist. The clinical feature is one of

Bucco-oro-facio-lingual movements, almost continuously seen in
wakeful state.

There can be classical "fly-catching11 movements

of the tongue and grinding of teeth.

3)

Jo^jfandice; Commonly seen with Chlorpromazine. Stop drugs and

dimmediately refer to the psychiatrist.

4)

Postural Hypotension:

If this is severe, thepatient should

be hospitalised,^ drug stopped; and if necessary nor-adrenaline

or Isophrenaline drip started. Adrenaline is contraindicated

Earliest symptom is giddiness on standing. If so, check B.P.
both standing and lying.Commonest offender is Chlorpromazine.

5)

Skin sensitivity: Exfoliative dermatitis. Stop drugs and refer

to psychiatrist.

6)

Rarely, bone marrow depression can take place. Check blood

counts when this is suspected.
Thioridazine has high anti-cholenergic side effects, and

therefore should be used with caution when prescribing to
elderly patients.

IV.

Antiparkinsonian Agents: Effective against phenothiazine

induced extropyramidal side effects.

As mentioned earlier

Tardine dyskinesia is one drug induced extrapyramindal condi­

tion most difficult to treat and anti-parkinsonian drugs may
aggravate this condition.

Pharmacological name
and strength

Some trade
names

Average daily
dose

1. Trihexyphenedyl 2 mg.

Parkin
Pacitane
Placidyl
Hexinal
Kemadrine

2 to 6 mg.

2. Procyclidine HQ-fi
5 mg

5 to 15 mg.

V. Antedepressant drugs (tricyclic compounds)

Effective against depression of any cay.se when the
depressive features are predominant,

-

'

Pharmacological name jpad"

Some trade names

Average dose
per day

1. Imipramine Hcl

Depsonil
Impranil
Antidep
Restamine

75-150 mg.

2. Trimip ramine

Surmontil

75-150 mg

3. Nortryptaline

Sensival

75-150 mg

4. Amitryptaline

Saro^pna
Tryptanol
Amiline

75-150 mg

5. Doxepin Hcl

Doxetar
Spectra
Sinepan

75-150 mg

Note:

A higher or single night dose is preferable, and equally

effective if the patient can tolerate.

The therapeutic effect takes on the average about 10-14
days to manifest or to be felt by the patient. Therefore, it is
essential to advise the patient to take the drug for a minimum

period of at least 3 weeks before considering any change.

Imipramine causes l^ast sedation.

The following are the

side effects’
- Dryness of mouth
- Blurring of vision
- Constipation

- Rarely, retention of urine and paralytic ileus.
It is essential to advise the patients about these

possible transient side effects so that they are prepared if
it happens and do not stop the medication.

These antidepressants are to be used with extreme caution
and in consultation with the psychiatrist in following condi­

tions:
(a) Glaucoma - Consultation of an ophtholmologist will

also become necessary.
. -J
tft,
(b) Recent Myocgrdia? ^schaemijJ, because of danger of
arrhythmias.

(c)

Enlarged prostate, because of danger of retention of
urine.

Note:

In some families, when there is a death, one or more

members may go into a state of normal grief reaction which can

resemble depression.

If the family members seek consultation,

refer to a psychiatrist .

VI. Prophylactic Lithium:

Lithium carbonate is effective in treating cases of mania,
and it is widely used in preventing recurrent manic depressive

psychoses. The use of the drug may be left to the discretion
of a psychiatrist though the GP can effectively conduct the

maintainance dose follow-ups.
Capsuie Litho-carb

150 mg,

Tab "Lithium"

250 mg,

Tab "Lithanate"

250 mg,

Tab "Licab"

300 mg,

The commonly used dose is 900-1200 mg per day in three

divided doses. It is essential to regularly and periodically
monitor the required dose by doing serum Lithium Estimations
periodically.

The effective serum Lithium level is 0.6 to 1.4

m.Eq/Lit (or milli mo€s/Lt.)

Beyond 1.4 mEq/Lt, toxic effects manifest in the form
of:

- Abdominal discomforts
- Nausea
- Vomiting.
- Diarrhoea
- Tremors of hand

- Drowsiness, etc.
A watch must be kept for these early side effects.

If they

occur^ the drugs must be immediately stopped and the patient

referred to a psychiatrist or physician.
Caution: Before starting this drug, the renal and cardiac functions
must be assertained. The drug should be avoided in 1st tremester

of pregnancy and in known epileptics,

VII. Some undesirable interactions which necessiate caution
and discretion;
Antacids cause delaying of the absorption of the

1.

phenoth iaz ine s.
2.

Both antidepressants and chlorpromazine are liable

to potentiate epileptic fits in known epileptics.
3.

All the commonly used anti-hypertensive drugs can cause

depression, particularly reserpin.
Similarly, oral contraceptives are known to cause psy­

chiatric complications, especially depressive symptamatology.
4.

these drugs

Tricyclic anti­
depressants
n

"interact” with

Adrenaline and 7—Hypertension
non-adrenaline $
Alcohol —--------------- > Increased depressant
effect on CNS
Antihyperten s ive

Barbiturates
It

to produce

Antagonism to
Hypetensive effect

Alcohol,Anaestheti- Increased depressant
cs and anti hista- effect on CNS
mines
Anticoagulants
Antagonism of anti
coagulant effect.
In case of phenytoin
increased Toxicity
of phenytoin

li

Griscofluvin

II

Phenothiazines
Increased depTranquillisers
ressant effect of CNS
Buterophenones________ _____________ __
Anaesthetics
Increased depressant
Alcohol,Barbiteffect on CNS
urates
AntihyperIncreased hypotensive
tensive agents
effect. Methyl Dopa
may cause central
excitation

Phenothiaz ines
II

Atropine like
drugs and
Antihistamines

Reduced Anti­
bacterial activity

Decreased anticholenergic acti­
vity
contd.

these drugs

"interact" with

to produce

Hypnotics

Alcohol
Anaesthetics
Antihistamines
Phenothiazines
Minor tran­
quillisers

Increased
depressant
effect on CNS

alcohol

Tranquillisers
Antihistamines
Antidepressants
Barbiturates
Hypnotics
Phenothiazines

Increased
depressant
effect on
CNS

Cycloserine

Increased risk
of convulsions

ii

mH i.^-

ASPECT OF PREVENTIVE PSYCHIATRY

The expert committee of the W.H,O. on mental defines mental health
as the capacity of an individual to form harmonious relationship with others
and to participate in or contribute constructively to cange in the social
environment. Maninger defines mental health’ as; adjustment of human being
to the world and to each other with a maximum of .effectiveness and happi­
ness. Mental health is not only absence of mental illness, it is also the
development of mature well adjusted personalities., A good adjustment is the
core of mental health. Thus the two main aspects of mental health are
1)
Promotion of well adjusted stable personalities in society and 2) pre­
vention of mental illness.

Promotion of the development of stable personality:- A personality .is the
sum total of one 's physical, emotional and intellectual faculties which
makes one a unique person. The two factors which are important in the deve­
lopment of the personality are early life experiences and genetic factors.
Early experiences mould ones personality to a great extent. A well balanced
home is important for the development of the personality. Overt rejection,
overprotecticn, perfectionish, inconsistencies and unnecessary strictness
on the part of either parent is detrimental to the emotional development of
child.
The next place which is important in the development of the child *s per­
sonality is the school and it is essential that school teachers must be
qualified to be of help in the development of the child.
The next critical phase is the adolescent period which is a transitional
period, bo+hc physically and emotionally and hence a quite vulnerable period.
Sex education, vocational guidance, marriage counseling is essential during
this period.
Thus, for the promotion of overall personality development a child must
have a good emotional climate both at home and school. Social education is
the cornorstone of preventive psychiatry. Parents and teachers must be
taught about this aspects of mental health.
Prevention of mental health:Primary Prevention:- This involves the reduction of new cases appearing in
a year. This is the most difficult part of preventive psychiatry since the
etiological factors of several types of mental illnesses are not yet speci­
fied. But the development of a stable personality will minimize the onset of
some types of mental illness. The most important thing is that the home
atmosphere in which the children are brought up should provide for their
needs which includes security and affection. Child guidance centres, crises
therapy to help people in acute crisds in life, marriage counseling centres,
and centres to prepare people to meet the demands and frustrations of old
age and vulnerable periods of time will serve to minimize many psychiatric
disturbances.'

Secondary prevention:- Involves reduction in the prevalence rate. Prevalance
rate is the measure of the number of mentally ill people at a particular
time. Prevalence rate can be reduced by early detection of cases and their
effective treatment.
The primary role of the general practitioner is in
the secondary prevention of mental illness. They should know the fundamentals
2

- 2 of psychiatry so that they should’be able to detect cases of mental illness,
treat some of them and refer the rest to a specialist. Indian Mental Health
Surveys report that about 20 per 1000 need active psychiatric treatment and
as there are only about 400 psychiatrists and 20,000 hospital beds for the
treatment of more than 12 million patients, the general practitioners must
share a large measure of the load. This makes it imperative that in the
undergraduate medical curiculum, psychiatry must be given an important place.

Tertiary prevention:- involves rehabilitation of the patients who have had
active treatment and recovered.or improved.
The active involvement of the family and the community in the treatment
of. the mentally ill patients should be encouraged. The psychiatry depart­
ments of general hospitals should come to the forefront in treatment of the
mentally ill. The mental hospitals should be reserved only for chronic or
dangerous patients who need custodial care.

MH 1.8

BRIEF BIBLIOGRAPHY ON THIRD WORLD PSYCHIATRY
World Health Organisation (1975). "Organisation of Mental Health Services
in Developing Countries". Technical Report Series No. 564.

World Health Organisation (1984). "Mental Health Care in Developing Countries;
a critical appraisal of research findings". Technical Report Series
No. 698.

Essex, B., Gosling, H. "Programme for Identification and Management of
Mental Health Problems". Tropical Health Series. Churchill
Livingstone 1982.
Tropical Doctor - July 1983 to January 1986 - series of articles on the
mental health care of adults and children for the general doctor.
Egdell, H.G. "Mental Health Care in the District Hospital". British
Medical Journal, 289, 15th December 1984, 1671-1674 - many references.
World Health Organisation (1981).
Geneva, WHO.

"Social Dimensions of Mental Health".

World Health Organisation (1975).
Geneva, WHO.

"Promoting Health in the Human Environment".

Climent, C.E., et al. (1980).
Chronicle, 34, 231-236.

"Mental Health in Primary Care".

WHO

Harding, T.W., Chrusciel, T.L. (1975). "The Use of Psychotropic Drugs in
Developing Countries". Bulletin of the WHO, 52, No. 3, 359-367.
Harding, T.W., et al. (1980). "Mental Disorders in Primary Health Care:
a study of their frequency and diagnosis in four developing
countries". Psychol Med, 10, 231-241.

Edwards, G., Arif, A. (Eds). "Drug problems in the Socio-Cultural Context:
a basis for policies and programme planning". Public Health Papers,
No. 73, WHO, 1980.

Helander, E., Mendis, P., Nelson, G. "Training Disabled People in the
Community". A manual on community-based rehabilitation for developing
countries. Geneva: WHO, 1983 (RHB/83.1).

HGE/IMT 1987

fAH l.q

CHILD PSYCHIATRY IN THE THIRD WORLD BIBLIOGRAPHY

Barker, P. Basic Child Psychiatry.
Paperback, £7.95. 1983.

Fourth Edition.

Egdell, H.G. Problem children and the general doctor.
1984, 14, 103-107.

Granada Publication.

Tropical Doctor,

Giel, R., et al. Childhood mental disorders in primary health care : results
of observations in four developing countries. Pediatrics, 1981, 68,
677-683.
Instruments 3 and 9 used in this study.
children. 10.79.

Reporting Questionnaire for

Helander, E., Mendis, P., Nelson, G. Training disabled people in the t
community. A manual of community-based rehabilitation for
li.
developing countries. Geneva, WHO 1983. (RHB/83.1).

Rutter, M., Hertsov, L. (Eds). Child and Adolescent Psychiatry : modern
approaches. Second Edition. Blackwell Publications 1985.
Sartorius, N., Graham, P. Child mental health : experience of eight
countries. WHO Chronicle, 38 (5) : 208-211, 1984.
World Health Organisation. Mental Retardation - meeting the challenge.
WHO Offset Publication. No. 86, 1985.
World Health Organisation. Child mental health and psychosocial
development. WHO Technical Report Series 613, 1977.
World Health Organisation. A manual on child mental health and psychosocial
development. I for the primary health care physician; II for the
primary health worker; III for teachers; IV for workers in children's
homes. New Delhi, WHO 1982.

HGE/IMT 1987

M. Sc. IN COMMUNITY HEALTH IN DEVELOPING COUNTRIES
MENTAL

HEALTH

UNIT

TUESDAY 17TH MARCH TO THURSDAY 19TH MARCH, 1987

9-30 a.m.________________________________ 11.00 a.m.

•

TUESDAY

3.00 p.m.

Introduction

Classification

Psychotropic
Drugs

Third World
features

Anxiety

Schizophrenia

Psychiatric
concepts

Incidence

Arraning student
speakers

Burden on the
community

Neurosis

Organic States

Depression

Epilepsy

Epidemiology of Third World
Psychiatry
WEDNESDAY

2.00 p.m.

Dr. Paul Williams

W.H.O. Collaborative Study
Methods and findings (Harding et al)
(Climent et al)
(Isaac & Kapur)
(WHO Technical
Report No.698,
1984)

Priorities in Priorities
Primary
in
treatment
Care

(Giel et al)

(Giel &
Harding)

(Harding
&
Chrusciel)

•

THURSDAY

Auxiliaries
& Manuals

Alcohol Problems

(Essex &
Gosling)

Definitions,
Problems
(especially in
the Third World)

Counselling in the Developing
World
Mr. William Reavley

Children's
Problems

Mental Handicap
Preventive
Psychiatry
(WHO 1975 & 1981)

Requested
topics

Feedback

Innovations

Dr. Paul Williams, Epidemiologist, M.R.C. Social Psychiatry Unit, Institute of Psychiatry, London.

Mr. William Reavley, Clinical Psychologist, Dept, of Psychology, Graylingwell Hospital, Chichester, West Sussex.

MENTAL HEALTH PROBLEMS IN DEVELOPING COUNTRIES

INCIDENCE

Seriously incapacitating mental disorders are likely to affect:1% of any population at any one time;

10% at some time in their life.
"An estimated 40 million men, women and children in developing
countries are suffering from serious untreated mental disorders".

(Reference: WHO 'Organisation of Mental Health Services in
Developing Countries'. Technical Report Series No. 564,
1975).

"As many as 20% of all those attending general health care
facilities in both developing and developed countries do so
because of psychological symptoms. These patients often
complain of multiple somatic symptoms".
(Reference: WHO 'Mental Health Care in Developing Countries : a
critical appraisal of research findings'. Technical Report Series
No. 698, 1984).

PRESENT CARE OF THE MENTALLY ILL

No treatment - wander through towns and villages, often disturbing
the community or hidden at home.

Traditional healers - widely available and usually relatives first
choice.
Imprisoned - without offending or receiving treatment.

General Medical Services

Outpatients - wasteful of resources
and time of trained staff.
Inpatients - often disruptive.

Mental Health Services

usually isolated mental hospital or units
in major cities - remote from most patients.
/ Hospital specialists

Private psychiatric care

'General Practitioners

HGE/IT 1985

MO

COMMON PSYCHIATRIC CONDITIONS

Recognition and Management

ANXIETY

This can occur alone or as a complication of physical illness.

Anxiety has three aspects

1.

A feeling of apprehension or unpleasant anticipation.

2.

An impulse to action - "fight or flight".

J.

Physical effects via the autonomic nervous system especially

muscular - chest pain, headache, weakness, tremor;
vascular system - palpitations;

breathing, difficulty taking deep breath;
other sensations;

cardio­

respiratory system - over­
skin - burning and

genito-urinary system - impotence, frequency.

In the developing world it is uncommon for patients to present
complaining of the feeling aspects of anxiety, the usual complaint

is of the physical aspects which doctor and patient may not relate
to anxiety but investigate as a symptom of a physical illness.

Management

1.

Treatment of the underlying cause, whether this is physical
or social.

2.

Symptomatic treatment by use of minor tranquillizers, e.g.

valium, librium.

Expensive, produces only short lived

improvements, if any.

Phenobarbitone is cheap but also has

only short lived benefit.
3.

Community, e.g. leaders (secular and religious).

4.

Possibly traditional healers.

SCHIZOPHRENIA nND MANIA (Psychosis)

Delusions, hallucinations, over­

activity, defending themselves against real or imagined threats of

others, possibly leading to aggression.

Possible social disruption

by removal of clothes and damage to property.

Locally recognised as

"run mad", "quietly mad".
Management
1.

Major tranquillizers, e.g. Chlorpromazine (Largactil) - very
effective in acute phase.

Can help prevent relapse and

chronic disability.

2.

Possibly electrical treatment.

Cont'd/...

Common Psychiatric Conditions (Corrt'd)

DELIRIUM (Acute brain syndrome)

The patient has a physical illness

in which the function of the brain is impaired.

"Clouding of

consciousness" - patient disorientated in time, place and person,
is very anxious, mental condition varies from the patient being
clearly alert to being obviously "not with it".

Causes - almost any physical illness but particularly alcohol,
(both intoxication and withdrawal effects), infections (e.g.

typhoid, cerebral malaria, encephalitis, meningitis, typhus,

trypanosomiasis, septicaemia, pneumonia).

Epilepsy.

Heart

disease, brain disease.

Management
1.

Treatment of the underlying physical illness.

2.

Major tranquillizers, e.g. Chlorpromazine (Largactil).

SEVERE DEPRESSION

Commonly presenting as withdrawal, inactivity, loss

of usual interests, though may complain of persistent misery out of

proportion to any stress.

Hypochondriasis.

Danger of suicide.

Management

1.

Antidepressant drugs, e.g. Imipramine (Tofranil).

2.

Possibly electrical treatment.

EPILEPSY

Major fit with unconsciousness, tonic and clonic movements,

tongue biting, incontinence of urine, other injuries.

Temporal lobe

epilepsy much less common with "clouding of consciousness", multiple
psychiatric symptoms.

Adequate dosage of phenobarbitone controls 90$.

Problems of compliance, maintaining stocks.

Cultural attitudes with

fears of infection and community rejection can lead to lifelong

disability.

SELECTING PBIOBITIES IN MENTAL HEALTH CAPE

..HICE CONDITION?

e.g. excited states, epilepsy, chronic psychoses.

WHO QBEATS IT?

e.g. basic primary health worker, rural nurse and midwife,
medical assistant, medical officer, consultant physician.

WEEBI ?

e.g. village, rural aid post, health clinic, health centre with

beds, district hospital.
WITH LHAT DkUGS?

e.g. phenobarbitone, chlorpromazine, imipramine or amitriptyline

anti-parkinsonian drug, depot major tranquillizer, another

major tranquillizer.

fOH LU

Common sy. fops of mental disorders

Disorders of cognitions- Cognition is the net of knowing and it involves •
attention, perception, memory and thinking.
Attention:- Attention is a preliminary step for observation.
difficulty in arousing attention or sustaining it.

One may have

?erception:r.is the process of getting to know the objects in the environ^
sent. The botrhion disorders, of perception are imperfections, illudiond and
hallucination.
Inperception is a condition in which .stipulation and sensation fail to
produce a correct and complete perceptions Hjrpdcsthcsia Anaesthesia,
paraesthesia are examples of Inperception.
'

Illusion is a misinterpretation of real sensory experience arising from
stimulus .outside the body/ illusions can occur- in normal people. Illusion
are frequently associated "with. delirlm and. twilight states*

Hallucination is a vivid-^perceptual experience- in the absence of .a stimulus.
There is no stimulus to stimulate the sensdiy organs, but the experience of
perception occurs and is ouite real -to the person-involved. Sil.lucinations
can ?-c auditory,, visual, olfactory, gustatory or tactile. Auditory hallu. sinations are common in schizophreniaj usual, hallucinations'- are common in
acute alcoholism. Tactelerhallucinations occur in cacaine poisioning.
Memory:- Memory is the capacity to register, retain and rqcall the objective
reality in the form of images, cCw<fptB cr idooff* - The .-commonest disorder of
memory’is amnesia which is inability to remember* It may be partial or
total. ■ It may be specific like diffieulty>iff’.remem’:eriKig .tximbers, names
etc or it may be general. It nay be temporary or permanent. It can be
with' regard to.- immediate events, recent or remote events^-'H/Poonesia is a partial loss of capacity to recall.'

Petrowrade amnesia

occurs after a, brain trauma involving loss of ebnsciobspess whore the
person is unable to recall what preceded the events. Anterograde amnesia,
is the difficulty-in remembering. the-events.- immediately following the
trauma. The. gap left -by memory is sometimes filled with fabricated stories,
this is'called confabulation:or paramnesia*;.
Thinkinginvolves the organization of symbols which may he words, images or
' gestures which- involves, subjective representation of sone object or situa­
tion whose-meaning depends upon the-past experience of an individual.

•

Shpeech is an expression of thought process anddldtorders of thinking can
manifest in the form or content of speech* In' manic excitement associative
bonds form with great rapidily, resulting in several.thoughts and mental images
is called pressurC'of speech. Logical connection between thoughts is lost
in schizophrenics and this is called losening of association. Sometimes a
patient joins together unconnected concepts and images and ultors a jumble
of words without meaning, this is called word snj,ad.

2

fc
preservation involves persistent- verbal repetition of a thought in response
to repeated external stimulation. Obsessions are repetitive and persistent
intrusions into aonsttiousness of an unwanted thought, desire or-impulse
when obsession is associated with persistent unrealistic affect of fear; it is known as phobia*
Delusion is a dirorder of the content of thinking. Delusions arc
false opinions or beliefs which do not correspond with reality, one *s
level of knowledge, and the cultural beliefs of. the socipl group and which
cannot be dispelled by any correcting influence. .Persecutory delusions
are common in schizophrenia, Delusions of grandeur occur in manic state.
Delusions of inferiority, of hypochondriacal delusions and that.sone organ
is absent ( Ilhilistic delusion) arc common in depression. Paranoid delusions,
are well systeraalized on a false presumption 'cut have s. formally correct
pattern of reasoning.

DISORDERS OF EMOTION*- The pathology of emotions can be judged on three
criteria;p(1) duration (2) Intensity (3) appropriateness.

;

Fear implies irapenfing danger or disaster'and is.-related to an external
object. In phobia the fear is irrational. Anxiety is apprehension and. .. . ;
uneasiness in anticipation of some danger the; natprc.'.pf which is not known.
Elation or euphoria> can be pathological when incongruous (Wither with the
prtients surrounding or with his physical state.- Depression is the lower-:
ing of mood, inconsistent with the actual state.-of affairs. " Emotional
liability occurs in organic psyphosfs whesc the patient' crys ar.d laughs
without adequate external stimuli!,' Incongruity of emotion is commonly
seen in schizophrenia When the patients feelings are in appropriatewith their careser. Emotional apathy is shallowness.of mood or inadequate
mood.
Disorders of Volltion:.
_
Volition is our will. Stupor r where- in psychic inhibi­
tion, partial or general especially in reference to deadened sensibility
occurs, m catatontic stupor there is narked retardation of movement and
speech.
Negativism where the patient refuses to obey commands, automatism
where all commands are passively obeyed are disorders of Volition.
passivity phenomenan where the patient .feels that he is controled by external
forces beyond his control is a common disturbance of voilition in schizophenia.

pnH MX

*

1.

I

COMT^ITY

HEALTH

Although the need for developing indicators is a v;ell accep­
ted area of study developing indicators as such has received
little attention. Indicators in any component of health are a
basic prerequisite at all levels (from needs assessment to measu-ring effectivness) to effectively design appropriate and relevant
programmes. Already well established indicators are in usuage for
many of the communicable diseases.
In the present context of National mental- health programme,
development of indicators assumes greater significance as the pro­
gramme is in its early stages. A the moment, when all attempts
are being made to integrate mental health with total health, deve­
loping indicators from inception will aid ir. monitoring & evalua­
tion of programmes.

Both indicators of health & illness are important for any
health programme and this becomes slightly difficult in the field
of mental health because of practical difficulties in the defini­
tion of mental health and illness at the level of community. In
the field of mental health, the indicators usually involve morbi­
dity, disability, services, provisions, of care etc. as there is
enormous difficulty in deriving the definition of well being,
happiness etc.
2.

PROPERTIES OF INDICATORS :

Indicators are usually based on direct or indirect measure­
ments or observations. These are an indication of a given situa­
tion or a reflection of that situation. Indicators are usually
defined as “variables which help to measure changes^. Being mea-■
sures of a situation, when employed over a period of time, they
help in indicating direction and speed of change and also guide
in comparison of different areas, groups or components of a pro­
gramme. Hence, indicators are the yardsticks to assess changes
in the development-phase of a given situation.

Indicators, objectives and targets are a times considered
synonymous. Objectives are desired aims while targets are objec­
tives that have been made more specific in quantifiable terms or
in terms of time and indicators are used-as larkers of progress
towards achievement of objectives and targets.
Any indicator or a set of indicators (indices) which are
applied to a given situation must be valid, objective, sensitive,
specific simple to collect, inexpensive and easy to apply. Choice
of indicators must be decided based upon the usefulness of their
application. No one indicator can give a complete picture of the
situation and hence a set of indicators are essential.

Finally indicators are unidimensional summary statistics' re­
ferring to a particular situations.
3.

USES OF INDICATC-.-’.o Ix< MENTAL HEALTH

.

Every Mental health programme passes through the phases of
planning, organisation, implementation, surveillance, monitoring
and evaluation when systematically thought about. Indicators
vzill be of greater help in planning, monitoring and evaluation
by providing a continuous feedback. Among the several uses, a
few notable ones are

- for needs assessment

- for prioritisation of problems
- to predict or document a given- situation
- for equitable allocation of. scant resources
- for identification of risk groups in need of immediate services
- to help decision makers in initiating, appropriate action
- to make timely changes for the improvement of programmes
...2/-

- 2 -

- to effectively organise specific types of institutional servi­
ces
- for comparison purposes
- for policy development at higher ]e vel
- for monitoring and evaluation of programmes
- for further research activities.
Some indicators serve a single purpose while several others
serve multiple purposes.
4,

SELECTION OF INDICATORS I’.’ MENTAL__ HEALTH PROGRAMMES

Indicators exist at all levels viz. national, regional, PHC
and even at community levels. A set of indicators at the nation*al level or at any higher level may not be suitable to local le­
vels because of the direction in which they are sought. They
need to be changed, refined, added or deleted to suit the local
situation and also depending upon the characteristics of progra­
mmes, and also with•changing emphasis over a given period of time.
Several aspects need to be considered before construction, sele­
ction and application of indicators, these are

- characteris'ics of catchment area
- availability of resources
- availability of health services (General & Specific)
— level of community development
- characteristics of mental health programm.es in terms of aims,
objectives', coverage etc.
- status of record maintenance
- purpose of indicators
Expression of.indicators also needs to be a given thought.
Indicators can be qualitative (yes - No) or quantitative (percen­
tages, numbers, ratios) depending upon the level. For most of
the community mental health programmes, quantitative indicators
are widely employed.
5. SITUATION-SOURCE—DATA—INDICATORS

Situation - source - data - processing - analysis - conclu­
sions form the back bone of any indicator. In the field of mental
health this task becomes difficult due to the complexities invol­
ved in definition - diagnosis - classification procedures (prob­
lems at field level in terms of various barriers existing for uti­
lisation of services). Determination of source of information,
frequency of data collection, personnel involved in this task
are vital for the formulation of indicators in mental health.
Regular, systematic, continuous and centralised collection of
data is essential which could be.analysed to develop indicators
which can throw light on past, present and future trend of mental
health and illnessess in the community for which effective pro­
grammes could be designed. Both the data that is currently avai­
lable and additional data which needs to be procured should be
considered at the beginning itself.
The type of data at different■levels and different phases
of a community programme should be given a serious thought. At
present, due to lack of uniformity and coordination among diff-’
erent agencies concerned with mental health various sources will
have to be utilised. The data available could be of a direct
nature or an indirect one.
Several sources of information at the community level could
be census data, health service data.(hospital records, PHC reco­
rds, programme records), records of other agencies (other secto­
rs of government) , records of voluntary and other social welfare
agencies, work dairies of health personnel (if maintained? and
how well), Panchayat records, from police files, court files, ...3/-

3
remand homes (if my) and data from any specialised institutions
working in the field of health and mental health in particular.
Apart from official records in,many of these agencies direct
interviews with principle members of community, traditional hea­
lers, village health guides, Anganwadi workers, Traditional birth
attendants, teachers may yield a wide variety of information which
would be useful in framing indicators.
Apart from these sources, periodically conducted community
surveys on the total population or a sample of population will be
a vep? useful way of gathering additional data periodically.

The time interval for collecting information could vary from
annual verification of records to monthly visit.to study area's &
is determined chiefly by the purpose of indicators.
Major mental health problems of community, amount - nature type of data, personnel involved in collecting information, time
interval and purpose of obtaining information are some of the key
issues involved in developing indicators.
6 ._ CAT3GCRIE;J CF INDICATORS
. indicators could be qualitative or quantitative
. expression of indicators could be Yes - No, numbers, percentages
ratios etc.
. indicators could be of direct or indirect relevance to mental
health programmes
. source of information — personnel involved - nature of data periodicity should be considered at the beginning.
. suitable modifications needs to be made to develop applicable
indicators at the community level.
. importance must be given for both numerator & denominator
6.1_30CIC ECONOMIC - DEMOGRAPHIC INDICATORS

The use of this set of indicators is of special importance to
the field of mental health. Nor needs assessment, prioritisation
of problems, risk group identification, resource allocation and
community involvement these indicators might be important. Based
on social area analysis this categi. ry of indicators serve better
where no other information is available.

- Age, sex characteristics of population - especially•children &
elderly
- social rank indicators based on economic status, educational
status and social status
- % of population below poverty line according to national stand­
ards
- °4 of families in poverty
- median income of families
- aged dependency ratio
- A of" aged persons living in isolation
- literacy rates of population
— % of school dropouts
— % of employed persons, male & female
of women in labour force
— % of houses occuped by > 1 person/room (for overcrowding)
- divorced/widowed families
- rate of population growth
- % of population seeking heIp/not seeking help within the
catchment area
6.2

SOCIAL DISRUPTION INDICATORS

- Suicide rates
- crime rates
- accident rates
% of Juvenile delinquents for corresponding total population

- % entry into correctional institutions
- frequency of communal riots
- number of lunatics outside homes
- % of child abuse
- % Marital separations
6^3 MESIAL HEALTH

IKDICATORS

1. Professionals
- Personnel/population ratios
2. Para professionals
3. Non-professionals
- % of doctors & health workers with training and without train­
ing in mental health
- number of health centres where help for mentally ill is avail­
able
- mental health, budget as % of total health budget
- ?o of population residing at specific distance from where they
could reach for help in mental health problems within catchment
area/outside catchment area
- number of G.O/K.G.O where different patterns of care are avail­
able
- expenditure v/s allottment in budgetary terms
- number of bed available for mentally ill patients/1,000 popula­
tion (ch. area chs)
- bed occupancy ratios (Ch. area chs.)

6.4 MENTAL HEALTH SERVICE piSRFCRliAT.'CE INDICATORS
- number of organisations involved in mental health care
- % of referrals (to the centre & from the centre)
- mean time of travelling to the centre
- cost of travelling to the centre
- XaE of catchment area residents
- % of people knowing about services
- % of people knowing how to obtain services at times of help
- proportion of population served by each centre
- ratio of actual outcome to planned outcome

Service performance is usually considered through availabili­
ty. Accessibility, Acceptability, ..wareness, efficacy and effect­
iveness and the choice of indicators depends upon the focus of
measure.

6.5

MENTAI; MORBIDITY . rapIJJ^TCRB

- Prevalence of mental morbidity within specific area
- disease - specific rates
- number of admissions to mental hospitals (on their own, referral)
- number of identified cases in each illness category who are on
treatment or not on treatment
- prevalence of M.R. children to total children population
- number of M.R. Children attending medical institutions
- number of referrals by different categories of personnel
- % of children who are users of alcohol, drugs and tobacoo
- duration of illness before seeking help (Mean number of days)
- inpatient/outputient ratios
- ;< admissions with specific problems
- 7 disabled persons
— measures of intervention and outcome like recovered, improved,
deaths, on maintenance etc.
6,6 UTIIJSaTI0.N INDICATORS
A certain decree of overlapping does occur between indicators
mentioned above while trying to assess the utilisation indicators
- % population knowing about availability of mental health
services in catchment area
- .I of population seeking help from different sources (organised
and unorganised sectors)

5 -

of population knowing how to obtain services.
- number of other organisations from where cases are referred
— % of population living within an area of
12 hrs. travelling
time
- % of users and nonusers of mental health services
- change, in the utilisation of services over a period of time
- % patient on specific patterns of care •
- cost involved per patient management through different approa­
ches
- '/'> dropouts from a specific programme
6.7

OUTCOME INDICATORS

- number of patients counted biased on expected outcome

6

INDIC -TORSION CUSHUNITY PARTICIPATION IN MENT.L NEaLTU
PRQGId TIMES

- participation in programmes
- inclusion of mental health in different activities (qualitative
or quantative)
- KA? of the community
- indirectmeasures
- Contribution in cash or other methods (Place, manpower, suppo­
rtive measures)
- preventive/promotive programmes in community
6.9 POSITIVE INDICATORS OF MENTAL -HEALTH
- Temporal changes in terms of increased awareness and programmes
— Subjective well being
- Social adjustment
- Disability free life
.
- activities of daily living
— Satisfaction in life
.
• •
These indicators are predominantly qualitative. As these
basically reflect on the quality of life and considered as a total
measure of physical, mental ?and social well being, and hence it i‘s
an exhaustive task because of defining these terms. A number of
aspects will have to be selected an,. then a final assessment has
to be made. Mental health as perceived by an individual' being a
part of total environment should be evaluated. The on going work
at Ml? r.LTNf' should be able to throw more light in this area-. . .
6.10, MORTALITY INDICATORS

- Disease specific death rates
- Suicide/poisoning statistics
- Accidents rate
A detailed list of various categories of indicators has
been given and this.is not an end in itself. As mentioned ear­
lier, choosing a set of indicators is determined primarily“by
the use of that indicator and thq suitability of adopting the
same to the given situation. . An attempt has been made to list
out various items which could be used as indicators in each
category.
7.

PROBLEMS TO BE'OVEllCpME

— emphasis must be given for collecting information at community
levels as this is a neglected area
— coordination mechanisms will have to be strengthened at commu‘ nity levels as there is considerable overlapping, duplication
or neglect
- mental health programmes must become totally operational at
lower levels of health care delivery system.
...6/-

- 6 - - suitable legislative measures
- prioritisation of mental health-problems must be done and rele­
vant minimal data must.be collected at lower levels.
- simple methods of case identification and good referral service
need to be established.
- adequate manpower, with basic training in mental health needs to
be made available
- data wastage should be avoided
8.

FOR CUT 'RE WORK

From the list of mentioned indicators, a few selected ones
depending upon the focus of measure could be utilised in any one
of the ongoing or forthcoming projects and then evaluated. Sele­
ction of area - source of information - obtaining information - •;
personnel involved - periodicity of obtaining information - compo­
sition of indicators - further application could be tried.
9.

QUESTIONS TO BE ANSWERED

9.1 What should be the definition of mental health and illness at"
the level of community for the purpose of developing indica­
tors ?
9.2 How should the information be collected at the level of
community ?
9.3 What should be the minimal amount of data tobe collected ?
9.4 Keeping in mind the existing systems of record maintenance
at the community, how could this be improved ?
9.5 For what purpo.es should the data be utilised ?

10j_

RIST

WHO - Development of indicators, for monitoring progress towa­
rds HFA/2,000 AD.
2. HO - Health programme evaluation Guiding Principles
3. Rosen R M, Goldsmith H F & Redick R W - Demographic & Social
indicators; uses in mental health planning in small areas;
World Health Statistics Quarterly; Vol. 32; No.l; 1979,
11-101.
4. Robert Griel - Mental’ Health problems in the- community; A.
discussion of their assessment; W.H.S. Qly; 36; 3/4; 1983;
234-255.
5. Kramer II & Anthony J - Review of differences in mental health
indicators used in national publications; W.H.S. Qly; 36; 3/4;
1983; 256-335.
6. Delieqe D -r Indicators of Physical, mental & social well being;
...H.S. Qly; 36; 3/4; 1983; 349-393.
7. WHO; Indicators for monitoring progress in mental health; in
community mental health unit, reading list; EM 30.6
8. WHO; Indicators for HFA strategies; Vol. 39; 4; 1986
9. A Manual on state mental health planning - NIMH Publication
1977
10. Evaluation in practice - A source book of program evaluation
studies from mental ’health care systems in united states - (
NIMH publication; 1980.
■
11. Robert D, Coursey, Gerry A specter., Stanley Murwell & Barbarahint - Program Evaluation for mental health’- Methods, stra­
tegies & Participants, G S Pub ; 1976.
12. Evaluation of community mental health services - Principles &
practice ; NIMH Publication; 1977.
1.

fGH M

ELECTRICAL

TREATMENT

(E.C.T.)

A psychiatric treatment found to be effective in severe depression

and in some excited states.

The patient is given an artificially induced

fit whilst under a brief ge-’c"?.! anaesthetic and receiving a muscle
relaxing drug.

It is usually given as a course of two or three a week to

a total of four to eight.

The patient is usually in hospital.

The

development of effective antidepressants and major tranquillizers has

markedly reduced but not eliminated its use.

The risks are those of a short anaesthetic.

The side-effects are

.ticipatory fearfulness, post treatment headache, and short lasting

forgetfulness.

There is no permanent damage to the brain or the memory

”i the brief courses given nowadays.

'.’here is much misunderstanding and unnecessary hostility towards
tne use of this treatment.

The patient gives written consent to the

anaesthetic and the electrical treatment.

In the United Kingdom, in

the uncommon circumstances of refusing treatment when urgently required,
the patient would need to be detained under the Mental Health Act 1983.

In addition there would need to be the supporting opinion of an independent
Consultant Psychiatrist appointed by the I-lental Health Commission.

The use of electrical treatment without premedication, an
anaesthetic and a muscle relaxant, eposes the patient to a frightening

the risk of cardiac irregularities and the muscular spasms

and occasional fracture associated with a major fit.

In a developing

country, where some parts of the medical services lack resources and
personnel, it will be necessary to balance these hazards against the

undoubted benefits of electrical treatment in psychiatric conditions

which are seriously disabling and at times fatal.

HGE/IMT 1986

m /.)i+

Etiology

°f Mental Illness

The relative Importance of various causative factors of ncrtowt and
mental illness is difficult to evaluate. There is no specific relationship
between cause and effect such as exists in physical illness, but rather we
are called upon to deal with a constellation of causes of an hereditary
constitutional or personality nature plus an almost bewildering variety
of environmental stresses.

Psychiatric disturbance is a result of a persons failure in coping.
with his responsibilities - a failure in carrying his loads in life
(Verghese) This load refers to a series of psychoFocial stresses. The
failure to carry the load can be either due to the size of the load or
due to the inherent weakness of the personality. A stable personality;
can breakdown if the load is too'much. On the other hand, unstable
personalities who show adjustment difficulties and interpersonal problems
may breakdown even with a very small loads in life.

Breifly, the etiology of mental illnqs.s can be studied under 5 groups.
They are 1) Biological 2) Psychosocial and 3) Socio-cultural.

There are five categories of biological factors that seem particularly
relevant to an understanding of the development of maladoptive behavioura)
Genetic factors b) Constitutional liabilities c) Physical deprivation,
d) disruptive emotional processes e) brain pathology.

Chromosomal aberrations, faulty gives and inherited predispositions .
are defects of major concern.

Downs ( a type of mental retardation) syndrome is an example of
chromosomal investigations have discovered trisomy in chromosome 2%.
The role of hereditary in the transmission of mental illness is very
important, though difficult to study. Kaliman's (1958) study showes a
condordance rate of 86.2 among indentical twins for Sehzophrenia as
apposed to general population where it is only 85. Hereditary factors
in mental illness have goven rest to a lot r6f controversy. As a, conse­
quences-most investigations now take the position that only a predisposi­
tion' to mental illness can be inherited. ;Many genes, rather .than just one
may be involved, in such a predisposition. • Here it is presumed 'that certain
certain individuals are especially prone id'develop mental disorders if
placed under severe stress. Given a favourable life situation the indi­
vidual 's inherent vulnerability may never show up.

The term constitution is used to denote the relatively enduring
biological Make up of the individual'resulting from both genetic and en­
vironmental influences- (coleman) physique, physical handicaps and vulnera­
bility to stress are among the many traits ■ included, in this- category.
While physique is not a primary cause of psychopathology, but it does
presumably influence of type of disorder the individual is likely to deve­
lop under stress. .
physical handicaps, too play a role in the causation of mental illnesses.
"obert-Burton (1579-1640) in his Anatomy of Melancholia whole these .
poignant words "Deformities and insperfections of our bodies, as lameless

.2

- 2 -

deafness,; blidness be they innate or accidental torture many men'1.. The
common arid undesirable reactions to physical,handicaps are feeling of
inferiority,- self-pity and. hostility. •-A^^-doasequence of such obstacles-,
the individual, whether child, adolescent- or adults may develop psychological
handicaps that are much more disabling than his physical impairment.
A wide range of physical deprivations may act as predisposing or precipita­
ting causes in mental illness, the most of;these are malnutritions, sleep
deprivation and fatigue.;.- ~Prolonged emotional ' mobilization produces .-physiological changes which
are harmful to the organism like psychosomatic disorders like asthama, peptic
ulcers, psoriasis etc.
•
‘
Brain pathology wither temporary as in the deliriufli q fever or drug
intoxication or permanent as in the case of syphilitic infection of the brain
may result in precipitating mental abnormalities*

. ...In comparison with the variables associated with biological causes of
maladaptive behaviour, those associated with psychosocial causes are less
understood and more elusive. However, a..good deal has been learned about
psychological and interpersonal factors that appear to play significant roles
in maladaptive behaviour. These factors in brief are
1
a)
meternal deprivation
b)
Pathogenic family pattern
c)
early psychic truraa
d)
disordered interpersonal relationships and
g) key stresses of modern life.
Faulty development has been observed in infants deprived of maternal
stimulation of "mothering", as a consequence of- either (a) separation from
the mother and placement in an institution or (b) lack of adequate "mothering
at home".

In institutions compared to an ordinary home, there is likely to be
less warmth, and physical contact, less, intellectural, emotional and
social stimulation and.a lack of encouragemeht and help in positive learn ing studies show that institutionalized children show a’ general impair­
ment in relationship to people. .Affectionless psychopathic characterized
by inability to form close interpersonal relationships and often by
antisocial behaviour - is a syndrome commonly found among children who have
been institutionalized.at an early age.
.By far the greatest number: of infants subjected to maternal depri­
vation are not those separated from their mothers, but rather the ones
who suffer from inadequate or distorted maternal care* Here the mother
neglects the child, devotes little attention to them and in generally
rejecting.
Faulty parent child relationships like parental rejection over
protectiveness and restrictiveness ( or-, "tfomism"), over permissiveness
and indulgence have undesirable consequences. Some parents place
excessive presures on their children to live upto unrealistically high
standards.
3

- 3 ^aulty discipline, communication failure and undesirable parental models
appear with great regularity in the background of children who show emotional
disturbances.
Certain family typologies have detrimental influence on child develo pment. These are the (1) indadeuato family where the family is characterized
by inability to cope with the ordinary problems of family living.
2)
The disturbed family where the parents because of personal instability
interact with other people in a way that is destructive to other as well
to themselves.

I

3)
The antisocial family where the parents are overtly or covertly engaged
in behaviour that violets the standards and interests of society.

4)
The disrupted family where the families ere incomplete either as a
result of that • divorce, separation or some other condition.

These family patterns have been labelled "pathogenic" because of the
high preguency with which they are associated with problems in child deve 1opinent and later psychopathology, It is relevant to note here that
pathogenic interpersonal relationships and interactions are by no means
confined to the family, but may involve the peer group and other individual
outside the family.
Pathogenic interpersonal relationship especially maretai instability
plays an important role in maladaptive behaviour. Besides there certain
other common sources of stress in our society which appear directly rele­
vant to understanding maladaptive behaviour.

In contemporary life there number of frustrations that lead to. self­
devaluation and hence are particularly difficult to cope with, hmong
these are failure, losses, personal limitations and lack of resources, guilt
and lonliness,
values play a key role in determining over "choice". If our.
value assumptions are unclear or contradictory or if we have little faith
in them, vie are likely to experience difficulties in making choices and
directing behaviour.

Some core conflicts of modern life that frequently lead to tension
and inner turmoil are conformity Vs nonconformity, caring Vs noni'nvolvement, avoiding Vs, facing reality^ fearlessness Vs. positive action, integrity
Vs self advantage, sexual desires Vs restraints.
Further each person faces his own unique pattern of pressures, but in
a general way, most of us face pressures of. modern living such as competi tion, meeting educational, occupational and marital demands and coping
with the complexity of rapid face.of modern living.

Socio-cultural factors:- In addition to the biological, and psychoSocial
factors, conducive to abnormal behaviour they are certain other conditions
special ly characterisitc of our time and place in history that put stress
directly or indirectly on most of us. .Among these are problems of war
and violence, group prejudice and discrimination, economic and employment

.4

problems, rapid social change and existential anxiety.

Accelerating technological and. social change in co‘.r’e;\. -cry world as'
played hovac with established norms and values with many peoples assumption
and meaning of human existance. The rate and .pervasiveness of change and
the new adjustments demanded by these changes with a source of considerable
stress. Infact Toffler proposed the term "future shock" to describe the
profound confusion and emotional upset resulting from social change.that
has become too rapid. As a result many people are groping about bewildered
and bitter unable to find satisfying values to guide their lives. In
essence, they are alienated from broader society and suffering from "exis tential anxiety" - from doubt and concern about their ability to find
meaningful and fulfilling way of life.
These biological, psychosocial and socio-cultural factors interact
in the causal pattern of abnormal and maladaptive behaviour.
Classification of Mental disorders. ’

' ■

Classification of mental disorders according to ICD - 9 is as follows
Organic psychotic conditions (290-294) 290. Senele and presenele organic
psychotic conditions.
291. Alcoholic psychoses
292. Drug psychoses
293. Transient organic psychotic conditions
294. other organic psychotic conditions (chronic)
Other psychoses
i . .
295 Schizophrenic .psychoses
296 Affective psychoses
297 peranoid states
298 Other non organic psychoses
299 Psychoses with’ origin specific to childhood

Nemotic disorders, personality disorders and other nonpsychotic mental
disorders

300 Ifeurotic disorders
301 Personality disorders
302 Sexual deviations and disorders
303 Alcohol dependence syndrome ■
304 Drug dependence
305 jfcndependent abuse of drugs
308 Acute reaction torturs
309 Adjustment reaction
Mental Retardation
317 Mild mental retardation
318 Other specified Mental retardation
319 Unspecified mental retardation.

hi s'

MENTAL RETARDATION
Mental retardation or deficiency is subnormal mental development at birth
or early development which is characterized by low intelligence. It is
estimated that;about 1% of school children are mentally retarded, the majority
belonging to the borderline and mild groups..
General Characteristic;;:- The physical growth may bo stunted, poor Rensoximotor
development is common, Physical stigmata such as large nead or small head,
narrow forehead widening of nasal bridge,.slanting of epicanthal fold, high
arching of palate; polydactgily and congenital abnormalities in the various
systems are usually present. Intellectual faculties are retarded.. Difficulty
in social adjustment results from physical, intellectual and-emotional de­
ficits.

Classification:- Mental retardation can be classified in 2 ways. According to
the IQ and according to the etiological factors IQ or (intelligent Quotient
is the ratio: mental age X 100
Chronological age.

The maximum chronological age is taken as 16 years. IQ is determined by
the use of psychological tests. ICO 9 - makes the following classification
of IQ
3A. Mild mental retardation - Feeble minded moron IQ 50-70.
318, federate MR
Imbecile IQ 35-49
3181 Severe Ml IQ 20-34
3182 Profound MR IQ 10-20 (idiecy)

Etiological classification:-

The common causes of mental retardation are

1.
Parental causes:
a)
Metabolic: Aminoacids eg. phenylketonuria
Fats: eg. Taysach's disease, carbohydrates.
Carbohydrate: eg. Galactosemia, Mucopolysachysacharides: eg.Gargoylism or
Hurler's disease.
b)
Endocrinal: eg- Cretin
c)
Chromosomal: eg. Mongolism. Sex-chromosomes: eg.Klinefelters (XXY); Turner
(X0).
d)
Abnormal development: Autosomal dominant: eg.Epiloia; Sturgewebers;
Marfans; Achondroplasia; Craniostenosis. Autosomal recessive: eg.Microcephaly:
Anencephaly etc.,
e)
Maternal infections; X-rays; drugs.
2.
Natal causes: eg. Trauma; Asphyxia
3.
Postnatal: Trauma; infections; deficiencies; neoplasm; sensory deprivation
(deafness); lack of parental cere and affection (eg.Merasmus).

Diagnosis:- Recognition of mental retardation in infancy and childhood is
very inportant. It is mainly done by getting details of the developmental
milestones. Delayed milestones may indicate mental retardation. While
taking history details of delivery and the condition of the baby immediately
after birth are important. Eg. whether delivery was difficult and whether
asphyxia, convualsions, drowsiness, sucking, difficulties, birth injuries
etc we-o present. Backwardness in school is another important diagnostic
information. Difficulty in social relationships, irrational fears, physical
stigmatas of mental dificiency are also of diagnostic importance.
2

- 2 -

Management:- 1) Prophylactic
Where genetic factors' are strongly involved
Eugenies may help children with phenylketonuria, if diagnosed early enough r .
can be treated by giving food which does not contain phenylhldnino. Congenital
Syphilis can be treated with penicillin. Children with cretinism can be
treated with' thyroid substitution. Regular anticonvulsant medication must
■'be given to' children with epilipsy,. These measures must be taken early*
2.
Mentally retarded children who are trainable should be admitted to special
schools for sub-normal children or special training centres* They should
be employed in some industries etc., for routine type of work. The community
should take the responsibility of looking after them.

The psychological and social implications of having a mentally retarded
child is great indeed. The marked social stigma attached to mental retarded
and their immediate families make it very difficult to seek professional
counsel or openly discuss the problem.r. The’psychological problems seem
greater because of their deep emotional involvements that is guilt feelings,
disappointments and underlying, frustrations, The child's condition may
lead to marital dissentions, self recriminations and considerable anxiety
about the child's future. Moreover the child 's immediate relatives may be
npnacceptable in the circle of acquaintance.

Counseling the parents, of mentally retarded children should focus
upon the world of the parents and.attempt to resolve the anxieties which
retarded children bring to the family structure. This also involves genetic
counseling and management of the child, methods of training etc.’

i.lG

NEUROSES

Neutotic forms of reaction are the bbomonest kinds of manifestations
of psychological ill-health. They are the faulty responses to the stresses
of life and especially to those tensions that come about from confused and
unsatisfactory relationship with other people which hinder adaption.

^he individual is said to exhibit neurotic behaviour if he frequently
misevaluates adjustive demands, becomes anxious in situations that most
people would not regard as threatening .and tends to develop behaviour
patterns aimed at avoiding rather than coping with his problems, the
individual, may realize that his behaviour is maladaptive it does not
involve gross distortion of reality. Rather neurotics are anxious, unhappy,
ineffective and often guilt ridden individuals who do not ordinarily require
hospitalization.

The main type of neuroses are
Anxiety neuroses which involves diffuse but often severe anxiety not
specially referable to a particular situation or threat.
2.
J^rsterdal neuroses which consists of 2 types (a) conversion type in
which symptoms of physical illness that are not caused by organic
pathology such as' paralysis or loss of hearing and
b)
dissociative type includs such reactions as amnesias and multiple
personalities.
5)
Obsessive compulsive neurosis which involves thoughts and actions the
individual recognises as irrational but which still persist
4)
Phobic neurosis involves varied fears which the individual realizes as ‘
irrational but from which he cannot free himself.
5)
Depressive neurosis involve, abnormally prolonged dejection associated
with internal conflict, interpersonal loss or environmental setback.
1.

ANXIETY NEUROSIS •

Anxiety Neurosis is the- commonest of neuroses constituting 30-40% of
all neurotic disorders. Anxiety may occur as a symptom in almost any
psychiatric syndroms - here it is the leading and predominant feature.

Anxiety is defined as a diffuse, highly unpleasant, often vague
feeling of apprehension, uneasiness, uncertainity or helplessness, accom­
panied by one or more badily heaviness of head, palpitation etc.

There is usually anticipation of danger. Anxiety is vague and object­
less in contrast to fear which is a emotional response, consciously recog­
nised, specific and often to external threat or danger.
Clinical features:- Symptoms of morbid anxiety commonly develop in people
of anxious personality - tense, timid, self-doubting worrying people who
tend to expect the worst to happen and "to cross their bridges before they
come to them".

The symptoms of anxiety neurosis are both mental and physical.
The mental symptoms take the form usually of a state of persistent
anxiety, tension, apprehension and worry, lack of concentration, forgetfulness
and general feeling of tiredness. An anxious person has difficulty falling
asleep because worries crowd his mind, night mares ana unpleasant dreams
may disturb his sleep.

2-

The somatic symptoms of anxiety are diffuse and involve several systems.
Palpitation, shortness;of breath, dryness of mouth,, chest pains, abdominal
pains, excessive sweating, headache, heaviness of head, dizzness and steadiness
frequency of micturation diahorrea and disturbance of sleep-are some of the
common symptoms of anxiety. Elevation of blood presure, tachycardia, increased
respiratory rate, sweating and hyper reflexia are common signs. Investigation
of different symptoms will not show any structural changes. The patient may
show some of somatic signs of anxiety - dilated pupels, tremors, clammy and
cold hands, a raised systolic blood pressure and a very brisk tendon reflexes.'
There may be some loss of weight.

A person with anxiety state has a tense, anxious apprehensive appearsnee.

Increased muscular tension is showed in his facial expression and
posture. He usually sets on the edge of his chair during an interview and
jumps at any sudden noise.
In acute attacks of anxiety (panic) the physiological changes are more
obvious and in chronic anxiety, the psychological changes are more obvious.

Etilogy and psychopathology
Though there may be a genetic predisposition to develop
anxiety in many cases, environmental factors are more important in the
etiology of anxiety state. Early emotional conflicts in life interfere with
the normal development of personality and contribute to the development of
anxious type of personality which under the influence of stresses of life
breaks down into attacks of anxiety neurosis. .The life stresses may include
any source of dissatisfactions, whether in personal relationship, domestic,
sexual, social or in connection with employment or financial stress.

Differential Diagnosis:- In acute attacks of anxiety, Pheochromcytoma should
be ruled out. Chronic anxiety state should be differentiated from thyroto­
xicoses.
Further anxiety neurosis must be.differentiated from other psychiatric
symptoms like agitated depression, ii patient who develops symptoms of morbid
anxiety for the first time in middle or late life should be suspected of
suffering from depression rather than anxiety. Anxiety neurosis must be
differentiated from early schizophrenia.
Treatment;- Patient with anxiety neurosis can be treated as an outpatient.
1. Mild tranquilizers eg- diazc-pan 5 mg. meprobamate 100 mg. tds are some
of the conmonly used antianxiety drugs. psychotherapy to help the patient
to cope with the difficult environmental factors is necessary.

L

HYSTERIA

Hysteria has been known since antiquity. The term "Hysteria" is
derived from the Greek work meaning 'Uterus ’. It was thought by Hippro­
crates and other ancient Greeks that this disorder was restricted to women
and that it was caused by sexual difficulties particularly by the wandering
of a frustrated uterus to various.parts of the body because of sexual
deseires and a yearning for children. Thus the uterus might lodge in the
throat and cause choking sensations or in the speen, resulting in temper
tautums etc. Hippocrates considered marriage the best remedy°for the
affliction.

The concept of the relationship of sexual difficulties to hysteria
was later advanced by freud. According to him symptoms of hysteria were
i an expression of repressed and deviated sexual energy.
In contemporary psychopathology, the symptoms of hysteria are usually
seen as serving a defensive function enabling the individual, to escape or
avoid a stressful situation.
Hysteria is more common among women in the age group of 15-25 years,
among those who belong to a low-socio-economic group in rural areas and
in the developing Countries.
Hysteria can be manifested as conversion reaction or dissociative re­
action.
In hysterical conversion reaction the symptoms of physical illness
appear without any underlying organic’pathology. Here the mental conflict
is converted into a physical symptom.
Clinical features:- The patients who develop hysterical symptoms have what
has been called the hysterical or histrionic personality. Such people tend
to be highly.egocentric and immature. They are dramatic, emotional,-depen­
dent, seductive,-unpredictable,, suggestible and attention seeking.The symptoms of hysterical conversion reaction closely mimic those of
organic diseases and greater the patients medical knowledge the closer the
resemblance; The particular symptom chosen depend on a number of factors and
have"symbolic meaning.
The conversion symptoms, involve involuntary-sensorimetor.systems.' The
motor symptoms may involve-complete or partial incapacity involving the
voluntary musculature including paresis, mutism aphonia tremors and ties. ”■?
Sensory symptoms may mimic anesthesias, paraesthesias, hyperaesthesia etc,
{Jomon visceral, symptoms are anorexia, bulina, vomiting, hiccough, flatdlencb airswalloing etc.

The conversion symptoms cannot be explained by any organic ’lession. •
Usually the patients indulge in dramatising"the complaints but appear to
be indifferent to them. This is called La Belle Indifference. Here the
patient makes his complaints in a matter of fact way with little, of the
anxi ety and fear that would be expected in a person with the symptom. Very
often "the symptoms are exaggerated when people are around and very seldom
do the symptoms produce any serious’injuries. Usually the symptoms have cs
some symbolic meaning to‘the original unconscious conflict and thus have
a communicative significance.

, f ; *.. ■ >. -y ■ , .• ■ .>1

..... :•

Uysterical dissbc.ijftti'ye-.sp.'itiq.iTs' . ;rc;
-■- ... 5
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f-vf’-:--c-30 ’<Lf-rri:</ J:.c/

;Jnj 4isep^i?.tiyer4?E^.ti9n, ■- ,tte'sjsifss-iTe-'-'feWy-’'■r- ■-

mental amnesias' (forgetfulness .pf.'.a pa^t event or .series ©f,.‘..eyehts-;.whib^;s)’;B'-;-3^f
occured during ■ 'a ■ partieuiar^'t'^e'-)
a^jjer son _ suij'd.e.hi-y.. leaybs;’hp§',?"4b
previous ■aetiyit^-'and'-' lj0^5'0fr"-'& -jourh^y'w'hi’ciR' fins'' np.'apparant) r.elatipn^ tei^Sp jf^Uot
what hechas'/jus-Vbeeh doi-Hg; and trfor’ wfiidhflfi§<'nds! 'Sbmplete'ffimesia, sqim.a*T-/; --v-'-L-vr.’-{
bulism or sleepwalking and multiple personalities. Here the paiSent.manl-,’” '
fests two or more ^complete systems lof perdo'nal-ity ;each ‘-system-'distinGt’’fjjdmn ”. -r?
one anothersT...Th&':ihdlViduhi':maya&fiangetf?iitnrW tjbrgdhbli'tv^td^o^fer;'K‘:'
Thus personalities -ard^us-Aaliy^dfaniaiida-fy-digfef^Ht^And'
sonality is .unaware-of'ithe^ecifidgry
'<‘L;Jr'vic^
Mr.Hyde, 3-.faces-of Eve); ”-'.W «' ’i: ■-<' :.<-r-.-f--■<,. . -;r..:'?■■'-■ -■
-?---v '• v,-jc-'.uO<■
.d' .;:'?.;::- id ,/•■■'.< i ■/: v..
o1:';i:'-.*<gmye L3'jevBitr.vap
The so called possession syndrome is an example of d-is^<?8fat^v6^?fed?§e-A?This has aroused great interest among Indian psychiatrist as an epidemic. ofit
was seen in Ranchi-in 1966 and in north Karnataka .this- ye.ar (Bananati).
Though epidemics of possession are rate the'possession syndrome itself
;'
is very common in pur country, particularly among females.'
«.-■• - i:

Differential diagnosisIn every case a careful- physical examinat±oh-is
essential to- exclude physical-.diseases.. hysteria is -.of ten mistaken for: - < - '
physical diseases and- physic.al -.ciSeas'e :-ij&-.often.-fealled-'.hysteria.. In.-many'-' -.
cases physical diseases-.and. hysteric-?, 1.Overlay.may .be--present.>together. ' r
Central nervous system diseases may be mistaken for hysteria'. ■ Hysterical ■
symptoms are of dramatically sudden' onset and or common among young people.
Hysteria like symptoms securing for >the first time -in'middle or-’old-age should
always be suspected of being .organically, determined. ■ ' ■b'.'-.uv:..
Hysterical- f its.' may f.be -.difficult .'to <1 istinguish 'from 'epileptic fits"r
A careful discription of-the fit-is essential. ;
.
Hysterical symptoms ^should ■be' -distinguished from amlingering'. .'•■
A malingerer pretends to have'a symptom but will find it 'difficult’’to' •
maintain consistency of symptom for a long time.
. . .. ■ •?■

■’ /
■
■

A hysterical type p.fs personality .presence^ of '-^aotionaT Conflicts'/-1 ' ' ”
sympolic nature of the- symptoms,- absence- of'organic? lesi-ns, and -La'Belle indifference .are -diagnostic-points.-. Hysteria and'-organic lesions'cari':cbexist and. this- has to. be token t^ to account, for treatment.
f
;

Treatment:- The patient must be helped to make a more rational' solutfohof his problems by means of psychotherapy. Sometimes situational readjustment
and social measures may help.

The general.practitioner can. diagnose hysteria and refer the patipn$, to
a specialist as the patient may need specialized therapeutic' procedure to
deal with the symptoms and .'conflicts. It is usually unwise to make a .driect
attack on the conversion symptom because this may lead, to very.disturbed
behaviour. ,.In many.cases the conversion symptoq.is a,-cry for help and.if
the symptom is removed, the patient.becomes helpless. In soine cases, however
symptomatic treatment such as mild tranquilizers, and behaviour therapeutic .
methods like relaxation,, aversion therapy and negative practice can be used.
.....5

5

Pbsessive Compulsive Neurosist- Obsessions are persistant, recurring ideas
accompanied by a subjective feeling of compulsion, which the patient tries
to resist, but cannot get rid of compulsions are irresitible urges to carry­
out meaningless and irrational activities. The patient cannot prevent these
obsessions and compulsions. The more he tries to prevent them, the more
the tension mounts which will he released only by yielding to the obsessions
or compulsions. The patient knows that it is silly to have the symptoms,
but he cannot prevent them. The three elements of obsessive compulsive
neurosis are the feeling of subjective compulsion, the resistance to it
and the retention of insight.
Clinical features:- Obsessive compulsive neurosis is the least common of
neurotic reactions, comprising less than 5% of the total cases.

The majority of those who develop an obsessional neurosis have shown
personality traits which have been discribed as constituting the obsessive
personality. These traits are an unusuall conscientiousness and adherence
to method, order and cleanliness. These people are fastidious, meticulous,
fussy, tidy, punctual, hardworking prone to recheck rigorously what they do
and persistant.
Lady Macbeth persistently washing her hands is a classical illustration
of obsessive compulsive neurosis. Majority of patients are under 40 years
and this illness is more common in women.
Obsessive ideas are disturbing and they may be frightening, blasphemous
disgusting or obscene. The thoughts are persistent ant' the patient tries
to fight them. Obsessive rumination is a continous prc-occupation with some
tonic or group of topics to the exclusion of most other interests, commonly
reglious, philosophical or metaphysical.
The third group of symptoms are compulsive acts like washing hands,
cheeking locks etc. The patient feels compelled to carry them out and gets
anxious if he resists them.

Differential diagnosisObsessive compulsive neurosis should be
distinguished from schizophrenia, rery often obessions can be a symptom of
schizophrenia. A schisophrenic patient does not consider the obsessive
symptom as silly
whereas in- ocw the patient knows that the
symptom is silly and actively tries to prevent it. Further obsessive symptoms
can be present in. depressive psychosis and organic brain damage.
Treatment:- Obsessive compulsive neurosis is difficult to treat tranquilizers
such as chlordi^zepoxides give symptomatic relief. Psychotherapy is useful
in early stages. Behaviour therapy especially systematic desensitisation
gives good results. In very severe chronic cases, prefrontal leucotomy
may be considered. The G.J? should refer Ocw cases to the specialist as it
needs specialized treatment.

- 6 Phobia

A phobia is a recurent intense, unreasonable fear associated with some situa­
tion or object or idea. The patient realizes that his fear is irrational
but is dominated by it. If he enters the fear producing situation acute
anxiety or panic assaits him. Tho list of phobias is very long. The common
phobias are
Aerophobia - fear of high places
Clanstophobia - fear of closed places
Agoraphobia - fear of open places
i’yrophobia
- fear of fire places.

Phobias constitute about 8 to 12% of all neurosis. Phobic reactions
occur more commonly among young adults and are much more common among women
than men.
In some cares, phobic reactions may be obsessive as when a persistent
obsessive fear of contamination dominates the neurotic conxciousness.

Phobias occur in a wide range of personality, patterns and abnormal
syndromes. Traditionally, phobias have been thought of as attempts to cope
with internal or external dangers by carefully avoiding situations likely to
bring about whatever is feared. Phobias most often are learned reactions to
previous trauma.
Treatments- The treatment of choice for phobia is behaviour therapy
Anoiolytics may help.

Organic Mental States
Organic mental disorders are a result of anotomical and physiological
disturbance in the central nervous system caused by physical disease,
intoxication or degeneration.

Organic pathology should be suspected where psychiatric symptoms
occur in the presence of the following.
1. First. onset of psychiatric symptoms in old age.
2.
No positive emotional factors in etiology.
3.
History of trauma, toxic factors and familial degenerative deseases.
4.
Abnormal neurological signs.
5.
Atypical psychiatric symptomatology.
6.
Certain characteristic psychological changes.

(a)
Drowsiness, constriction in the level of consciousness. Impairment
of orientation-, especially for time.
(b)
Sudden or progressive deteriocation for intellectual powers eg.
memory loss especially for recent events. Stereotyped repetition
(perseveration)compensatory fabrication (confabulation) difficulty in
abstract thinking.
(c)
Emotional fluctuations, eg. crying in one moment and laughing in •
the next moment.
(d)
Changes in character eg; A person who had a strict and orthodox code
of ethies becomes lex in his sexual behaviour^ •
Clinical descriptions

1. Acute; Delirinrr; Stupeur.
2.
Chronic; Dementias.
Classification (etiological)

1. Infective,
and -nalcria;•

Encephalitis neurosyphilis (GPI) Typhoid,
■.

■

2.
Trauma; Head injury, Brain damage, subdural haematoma; post-concussional
syndr?3^
3.
Neoplastic example frontal lobe turnons, 4.
Cerebrovascular; Arterioscelerotic dementia; Polyarteritis nodosa;
disseminated lupus; temporal arteritis; hypertensive encephalopathy.
5.
Metabolic and nutritional: a) Carbohydrate: e.g. hypoglycemia.
b) Proteins: Porphyria.
\
o) Vitamin deficiency:
Thiamine: Korsakoff's Psychosis; Wernicke’s encephalopathy. Nictotinic
acid; Pellagra, B12: pernicious anaemia.
d) Hypo and Hyper thyroidism; parathyroid, both hypo and hyper.
Adrenal: Addision's disease} Cushing's syndrome.
Pituitary: Sinmond ’s disease.
6)
Intoxications: Exogenous: Alcohol, drugs, lead.
Endogenous: Uremia; Hepatic coma,
7)
Degenerative disorders:
Senile dementia.
Arterio Sclerotic dementias*
Presenile demintias.
(Alzheimers' disease; Pick's disease; Huntington's chorea).
8)
Epilepsy: Postepileptic confusion;
Psychomotor epilepsy*

—2 Delirium:- Characteristic features 1. Varying degrees of clouding of
consdiousness, usually associated with a disorentation for time, place ar
person.
2)
Attention is disturbed and is difficult to sustain it.
3)
Percetual disorders such as illusions and halluncinations particulary
visual.
4)
Mood varies from mild uncase to perplexity. Fear and suspicion are the
predominant aspects.
5)
Thinking cay be disconnected and speach incoherent.
6)
Misidentification of people.
7)
Symptoms become more marked 'as darkness falls.8)
sleep is disturbed. ’ Patient is drowsy during the day and keeps awake at
night. Restlessness may be present.
9)
On recovery from delirium, patients memory for the period is vague1 or.'absent.

Dementia;- Dementia denotes a loss of mental capacity due to organic
damage of the brain. It is characterized by a) failure of memory mainly
for recent events at first, and subsequently for remote events.
2)
Difficulty to grasp-and comprehension.
3)
emotional instability with emotional outbrusts on minor provocation.
4)
difficulty in forming judgements.
;
Disorientation, delusions, neglect of personal hyhine with incontinence
may be present.
<

Senile dementia:- is characterized by progressive deterioration of memory,
thinking and stability, by blunting and lack of .responsiveness in emotional
reactions and reduction'in interest and initiative. This occured in sene­
scence. The onset is gradual and later becomes more rapidly progressive. .
Delusions of persecution are common. The failure of memory for recent events
tends to recede progressively backwards until ultimately it:involves early
life.
Treatments- Treatment of acutd brain syndromes consists of specific and
supportive measures. . The specific measures depend -on the etioloy eg.
antibiotics for tumor etc* 'Suppative treatment-is aimed at minimising,
confusion, restlessness, dehydration, malnutrition and attending, to bowel
and bladder .functions and care of skin in bed'patients. Phenothiazine
are effective to control agitation and restlessness,.
Treatment of chronic brain syndromes mainly consists of nursing
care.o If there are associated secondary psychiatric symptoms such as
depression paranoid ideas specific.drugs should be given occupational thereby
will be useful if the patients are physically able to participate.

/•Ul 1.12

aERSOKaLITY

Disowns

Personality is the sum total of ones psychological and physical characteri­
stics which makes one a unique person. 1'hysical constitution emotional tem­
perament, the intellectual abilities and general character give a person
his uniqueness. Early life experiences and genetic or constitutional'factors
contribute, to the development of personality. Personality disorders or
character disorders ere developmental defects or pathological trends in per-.
sonality structure with minimal objective anxiety and little a no mark of
distress. There is usually a life long pattern of action or behaviour which
are deviant from the accepted norms of society without the presence of dis­
order of perception, intellectual functions or affect.
They are classified as
1)
Personality pattern deviations such as inadequate personality, schizoid
personality, cyclothymic personality, paranoid personality, hysterical
personality, regid and obsessive personality, aggiessive personality and
obsessive personality.
2)
Psychopathy;- is characterized by irresponsible and antisocial behaviour
in the absence of mental retardation, psychosis, neurosis and eerebral injury
or disease. Absence of guilt or remorse, no response to punishment, inability
to accept blame, shallow and impersonal relationships^ self-centredness, no
regard for others, and immediate satisfaction of desires, are some of the common
features of psychopathy. A psychopath from on e.arly a. e indulges in antisocial
behaviour without due regard to the consequences. There is usually a genetic ;
pudisposition. Environmental factors such as parental depravation broken homes,
abnormal parentchild relationships, unhealthy physical environment are
commonly associated with psychopathy.
Treatment:- Drug treatment is of limited value in the treatment of psychopathic
disorder. Psychotherapy especially group therapy gives better results.

Sexual disorders

These disorders can be discussed as (1) disorders of Heterosexual functioning
eg. Impotence premature ejaculation in men vaginimus and dyspareunin in
b/omen regideiy.

Frigidity:- emotional disturbence is the common cause for frigidity among
women. Emotional disturbance can range from phobic anxiety lording to
dyspareunia to revulsion towards heterosexual experiences due to ignorance
or lesbian tendcnceis. Treatment should concentrate on sex education and
excuseling of husband and wife.
Importance:- The most important cause for imspotcncc in the young male is
emotional factors, though systemic diseases like diabetis, local lesions or intake
of drugs and aging process can produce impotence. Emotional factors like
adjustment problems, frigidity in wife, stressfactors in the life situation
guilt feeling over visit to prostitutes, extramarital affairs and guilt
feeling associated with masturbatim are common causes of impotence

Dhat syndrome, wherein the individual attributes a number of somatic com­
plaints, like weakness, loss semen is a very common in young adults, This is
due to a popular belief that one chop of semen is equivalent to several
ounces of blood and young men who ere ignorant of real factors can get

2

frightened of their sexual adequacy and this fear usually produces functional
impotence.
Psychotherapy should be educative and directive-. Sexual counseling is
useful in impotency and premature ejaculation behaviour therapentic techniques
like relaxation and masters arid totuson techniques will be effective.

2) Disorders in which the aim of sexual'activity deviates from the normal
6g. Homosexuality, exhibitionism , Trasuestiscm, Beastiality, Fetichism,
Voyeurism, Sadism, ifosochism etc.
Treatment:- Psychotherapy behaviour therapentic; techniques like systematic
desensitization, relaxation, aversion therapy are useful-.
Alcoholism and Drug Dependence:- Aldoholisem refers to a state when an in­
dividual develops a physical an? emoti nal dependence on alcohol. ihe sisease
■ is characterized by (a) a pathological desire for alcohol after ingestion •
“ ~ of small quantities which act as a trigger dose.
b) Black-out during intoxication with alcohol.
c)
Physical dependence on alcohol after withdrawal following a drinking bout.
Etiology:- Social pressures, economic trencts and cultural attitudes psy­
chological exert influence on the pattern of drinking and alcoholism.
Personality too is an emportant factor. Many alcoholics start drinking to
alliviate personality problems, to crown-’ worries etc. Alcoholixfu is^common
in psychopathic personality,disorder.
Clinical features:- ^he common neuropsychiatric manifestations of alcoholism
are a cute alcoholic psychosis, Delirium, Tremens, Chronic alcoholism,
Wernicke':s encephalopathy, and Korsakoff's Psychosis.

. .Acute accoholic psychosis is an acute psychotic reaction precipitated
by ingestion of elcohol as a result of direct effect of alcohol on the
brain . Visual hallucinations, usually.of small colourful animals, auditory
hallucinations of an accusatory type, excitement,' sleeplessness and voilent
behaviour are the common features.
The onset of Delirium Tremens is usually when alcohol is withdrawn^,
though it can also appear during an alcoholic.episode. Delirious talk with
confusion and incoherence, frightened look, excessive perspiration, generalized
and diffuse tremor; coated - tongue and paresthesias arc the common
manifestations.
In chronic alcoholism there is slow and gradual personality deterioration
characterized by lack of judgement carelessness at work, antisocial acti­
vity paranoid ideas and unreliable and undependable behaviour.
Wernicke's encephalopathy is characterised by clouding -f consciousness
ophthalmoplegia and ataxia. Korsakoff's psychosis is characterised by polyneu­
ritis, gross memory disturbance mainly of retention, and confabulations,These two conditions are the results of degenerative changes in the brain
most probably due to Vitamin
(Thiamine) deficiency.

.5

5
Treatments- Acute alcoholic psychosis "'-nd delirium Tremens are emergencies
and have to be treated as such after admitting the patient. Heavy doses of
phenothiazines -and non-barbiturate sedatives such ”s Doriden arc useful in
acute alcoholic psychosis. Heavy doses of chlordiazepoxide are useful in
Delirium Tremens.

Since Wernicke's encephclopathy and Kosakoff's psych-sis are both produced
by chronic degenerative changes, no treatment will have and curative*value.

Patients with chronic alcoholism need continious, long term psychotherapy.
This can be supplemented by aversion therapy which uses mall electric shocks,
or drugs as emetine, apomorphine or ant-’buse or antabusc with a view to
produce an aversion in the patient. Belonging to groups such ns alcoholic
anoymous will ' c useful and should be encouraged.

Drug JJegcndcncc

Drug addiction may be defined as a state of periodic or persistent
intoxication, dctrimcnt.nl to the individual to society or both and chara­
cterized by the following features.
1) a strong need, drive or compulsion to continue taking the drug
2) The development of tolerance, with a tendency to increase the dose to
produce desired effects.
3)
Physical and emotional dependence.

Physical dependence results from an altered physiological state, which
necessiates continued administration of the drug in order to prevent the
appearance of.a characteristic ecrics of symptoms referred tb as the
abstinence syndrome or withdrawal state.

The term drug habituation has been applied to the person who has a
strong drive or need or compulsion .to continue taking the drug on which he
is emotionally dependent, hut he does not develop the withdrawal state
characteristic of addiction.
WHO has suggested that the term drug dependence should '-c applied to
both drug addiction, drug habituation and all types of .drug abuse.
Drug dependence is defined as a state arising from repeated adminis­
tration of a drug on a periodic or continous basis. It is characteristics
will vary with the agent involved.

All addictive drugs have powerful actions on the CNS. The nature of
the effects varies according to the class of drugs. All addictive and
dependence - producing drugs enate emotional dependence.-. Physical de­
pendence varies in type and severity according to the class of drugs.
It is marked with apiate drugs and less marked with drugs such as marihuana
and amphetamines.
Deterioration in the patients physical and mental health with consequent
effects family and society arc the main features. Drug dependence can be
a symptom of other mental diseases such as anxiety state, depression or
schizophrenia. It may be a manifestation of personality disorder and the
result of personality difficulties like unstable personalities or of en­
vironmental factors.

4
Psychotherapy and methodonc sulestitution are useful in .treatment of
drug addiction. 'Acre drug addiction is a symptom of ?> ’ illness, the
indulging illness should be treated.
Preventive measures should concentrate on educative measures pbout the
dangers and effects of various drugs with a view to influencing the attitudes
of teenagers, young adults and society generally-to drug usage. Airly
diagnosis, treatment and reha’-ilitation of the addict is needed. Legal
measures such as making the unauthorised possession of drugs illegal would
help to control traffic in drugs. Medical measures sould-include care in
prescribing depending producing drugs. . L.irly diagnosis,..treatment and
rehabilitation of the addict is needed.’

PSYCHIATRIC UhMIN'.TION

Diagnosis in psychiatry depends mostly on a good history. A psychiatric
history taking differs from history taking in other medical dcsciplines. Here
the intimate details of patients life, experiences during childhood, schooling
adoloescence, naritol life, waiting situation etc have to.-be obtain -and
critically evaluated patients personality, the methods of coping with
difficult situations, interpersonal relationships become port of the history.
To get a good history from the patient, the doctor requires to csta’-lish
a relationship with the patient,' wherein the patient cones to trust in the
doctor. Hence the first step in history taking is ’ uLlding up
rapport with
the patient. This requires the doctor to have a proper attitude towards the
patient. These- attitudes include an unconditional positive regard which .
the doctor should have towards the client; Moreover the. doctor should have .
"amphathic understanding that is a kind of ability to sense the feelings which
the client is experiencing in each moment. The doctor should be "blc to. focus
his attention actively on what the. patient is saying and doing. He should
become a participant o'.-server. Though he should not become involved in
patients' feelings, he should nt all times domonstrote respect for the
other personiand awareness of the other' person
feelin..: and nedd for
security. The doctor should be able to communicate in a number of different
ways, he should be able to coimunicate and express his ideas fluently.
The patient must he understood completely. Thus a psychiatric history
taking becomes a therapeutic process §lso.
Further a psychiatric history has to depend quite a lot on the infor­
mation given by close relatives of the patient and other who come into
contact with him.
Psychiatric history taking■should not be rushed. The room must be
quiet with no interruptions. Note taking during interview should be
avoided as it interfere with understadaing of the patient. Questions should
be so framed that they suggest a deseired answer.

5

5

Mental Examination:- is another diagnostic-.tool in psychiatry. Mental
examination tries to assess the functioning of the various mental faculties
at.the time of the interview. General appe-rrencc ard ' r.b’viour, talk, mood,
thinking, perception, orientation, memory, attention -'nd concentration,
intelligence, judgement and insight should 'c tested.
IhySictl Bcanihntirri:- A thorough medical examination must he performed.
Kfeurological signs should be looked fpr.

It is better to interview the patient first and relatives next in neurotic
patients where ss in psychotics it is ''otter to see the rd 'tives first.
A guide to history taking and mental .ex ‘lination is given below:Psychi.ntric Hi stor y:-

Main Complaint: The patient must bo encouraged to describe his symptoms in
his own way. ’What are your main complaints?1 ’What made, you come' to the
hospital?'.
These are-s omc-questions, which will, help the patient to begin
his story. Interruptions must be minimum. Leading questions must be avoided.
A chronological order of.symptoms must be obtained. He must be encc—
to go back to the time when he was quite free of symptoms, ' Once, the patient
finishes giving the symptoms, an. attempt must be made to find out.what the
symptoms mean to him. What does the patient think his symptoms ''are .due to?
In what way do the symptoms interfere with his normal life.
Personal History:- ®he biographical aspects of history talcing should then be
started.

Place and date of birth; mother's condition during pregnancy. Full
term birth. Normal delivery, Breast or bottle fed. Encourage .the patient
to talk about his parents, sibs and others in the f-miljr. This will give
a chance to "know about the family dynamics. Emotional relationships
between members of the family should be assessed. Wat ?crt of childhood
did youhave? Was it a happy one? The patient should be allowed to des­
cribed the early life experience. What is the social position of the family.
Has any member of the family been treated for psychiatric problems?
Details about developmental milestones and neurotic symptoms in child hood (terror; LieDpftr-iantrum, wetting bed after 4-5 years of age; thumb
sucking, nail biting, stammering, walking in sleep are the examples) will
be useful. Hw was the physical health during childhood. Infections?
Convulsions? ^Details of schooling.. Age of beginning and finishing. Stan­
dard reached.
vidence of -backwardness; special abilities; hobbies and
interests; relationship..to teachers and school-mates; was he a loader or
follower.
.

Details of work adjustment: Nature ,of job. Is the work record stable
or h.nVe there been several'changes of jobs? Is the patient happy in the.
present job? Relationship with colleagues.
Menstrual history: age of first period, how did the patient rcgard.it.
Regularity, duration and amount, emotional changes before period. Clima­
cteric symptoms.

6
Sexual inclinations and practices; details about masturbation, sexual
phantasies, homosexuality, extramarital sex:

Marital history: arranged marriage? acquaintance before marriage, age, occu­
pation and personality of spouse; sexual satisfaction? Is marital life
happy. Details about children.
Some of the aboue questions are too personal to be asked in the first
interview. They c^n be taken up subsequently, unless they are raised by the
patient during the first interview.

Medical history: detail previous illness, accidents, operations.
have any psychiatric illness? What type treatment did lie have?

Did he

Personality before illness: (premorbid personality)
In this description of the personality prior to the beginning of the
illness, do not be satisfied with a series of adjectives and epithets, but
give illustrative anecdotes and detailed statements. Aim at a picture of
an individual, not a type. The following is merely a collection of hints
not a scheme:
1. Social relations: To family (attachment, dependency). To friends. To work
and workmates (leader, follower, organiser> aggressive, submissive).
2.
Intellectual activities, hobbies and interests: books, plays and pictures
preferred.
3.
Mood: Cheerful and despondent; strung up or calm and relaxed; worrying or
placid; optimistic or pessimistic; self-depreciative or satisfied or over­
confident; Stable or fluctuating (with or without any odcasion); Controlled •
or demonstrative.
4.
Character.
(a) Attitude to work and responsibility: Welcomes or is' worried by responsi­
bility; makes decisions easily or with difficulty; haphazard or methodical
and meticulous; regid or flexible; cautious, foresightful and fiyen to
checking or impulsive and slipshod;' persevering and determined or easily
bored and discouraged.

(b) Interpersonal relationships: Self confident or shy and timid; insensitive
or touchy and sensitive to criticism; trusting or suspicious and jealous;
emotionally controlled or quick tempered and irritable, tactful or outspoken;
enjgXs or shuns self display; quiet., and self restrained expressive and demon­
strative in speech and gesture; interests and enthusiasms sustained or evan­
escent; tolerant or intolerant of others; adaptable or unadaptable.
c) Standards in moral, religious, social and health natters:
Level of aspiration high or low; perfectionistic and self critical or com­
placent and self approving in relation own behaviour and achievement; stead­
fast in face of difficulties or intolerant of frustration; selfi®^.i and
egoistic or unselfish and altruistic;, given to much or little concern about
own health.

(d)
Energy and initiative* Energetic or sluggish; output sustained or fitful;
fatiguability;

.7

■

7
5.
Fantasy life: day dreaming-frequency and content.
6.
Habits: eating- (fads), sleeping, excretory functions; alcohol consumption,
self medication with drugs or other, medicines;’ specify, amounts taken recently
and earlier; tobacco consumption.

Mental Examination:
General behaviour:- Description as complete, accurate and life-like as possible.
(•‘■he following points mr-.y be considered, though not exclusively). H w does
he come into the office. Is he suspicious.? -lay abnormality about tSe dress
and general appearance? Does the patient look ill? is he in touch with
his surroundings in general and in particulars? Gestures, .grimaces or
other motor expressions? Tics, mannerisms? Mich or little jctivity? Is "
it constant or abrupt or fitful? Free or constrained? Slow, stereotyped,
hesitant or fidgety? Tenseness, scratching or rubbing. Do movements and
attitudes have an evident purpose or meaning? Do real or hallucinatory
perceptions seem to modify behaviour? Does the patient, if inactive, resist
passive movements, or maintain an attidude, or obey commands, or indicate
awareness at all? If the patient does not speak, the description of his
mental state nay be limited to a careful report of his behaviour.
Talk:, he form of the patient's utterances rather than their content is
here considered. Does he say much or little; talk spontaneously,, or only
in answer, alow or fast; hesitantly or promptly; to the point-; coherently;
appropriately; sudden silences; changes or topic; comments on happenings and
things at hand; using strange words or syntax, rhymes, puns? How does the
form of his talk vary with its subject?
Sample of talk: Conversation should be recorded, with physician's remarks
on left side of page and patient's pn iihht«
should be representative
of the form of his talk, his response to questioning and his main preoccu­
pations. In later sections of the mental state, it will be desirable to
record the patient's reported experiences in his own words, but the sample
required at this point need not aim at being comprehensive.

Mood:- The patient's appearance nay be described so far as it. is indicative
of his mood. His answers to 'how do you feel in yourself?' 'What is your
mood?', 'Are you in good spirits'?, or some similar inquiry should be
recorded. Many varieties of mood nay be present*- not merely happiness, orsadness but such states as irritability, suspicion, fear, unreality worry,
restlessness, bewilderment, and many more which it is convenient to
include under this heading. Observe the constancy of the mood; the influ­
ences which change it; the appropriateness of the patient's apparent
emotional state to what he says.
■
Delusions and misinterpretations:- What is the patient's attitude to the
various people and things in his environment? Does he misinterpret what
happens, give it special or false meaning, or is he doubtful about it? Does
he think anyone pays special attention to him, treats him in a special
way, persecutes or influences him bodily, or mentally, in ordinary or sci­
entific or super natural ways? Laughs at him? Shuns him? i!dmires him?
Tries to kill, harm, annoy him?.Docs he depreciate himself in any regardhis morals, possessions, health? Has he grandiose beliefs? These matters
may be complicated or concealed and may need much inquiry. If a whole
conversation dealing with them is reported here, resume the main points at
the end.
......... 8

8
Hallucinations and other disorders of perception:—
Auditory, viual olfactory, gustatory, tactile, visceral, The source,
vividness, reality, manner of reception, content and all other circumstances
of the experience are important. Its content, especially if auditory or
visual, must be reported in detail. When do these experiences occur: at
night, when falling asleep, when alone? Any peculiar bodily sensations:
feeling of deadness? Unreality?

Compulsive Phenomena: Obsessional thoughts, impulses, or acts. Are they
felt to be from without, or part of the patient's own mind? Does their
insistence distress him? Does he recognise their inappropriateness?
Relation to his emotional state? Does he repeat actions such as washing
unnecessarily?
Orientation:Record the patient's answers to questions about his own name
and identity, the place where he is, the tine of day, and the date. Is
there anything unusual to him in the way in which time seems to pass?

ffonory’ This nay-be tested by comparing the patient's account of his life
with the given by others, or examining his account for intrinsic evidence
of gaps or inconsistencies. There should be special inquiry for recent
events. Where there is^selective impairment of memory for special incidents,
periods, recent or remote happenings, this should be recorded in details,
and the patient's attitude towards his forgetfulness and the things forgotten
specially investigated.
Record the patient's sucess or failure in grasping, retaining, and
being able to recall three, or five minutes later a number, a name and add­
ress, or other data. Give the patient a story to read and ask him to
repeat it in his own words. Record his repetition’of the story, verbatim
if possible and say whether he sees the point of it. Give him digits to
repeat forward and then others to repeat backwards and record how many he
can repeat immediately after being told. In describing the state of the
patient's memory do not merely record the conclusions reached but give the
evidence first, in full, and describe at appropriate length such factors
of behaviour as seem to indicate whether he was attending, trying his
hatdest, being distracted by other stimuli, etc.
Attention and Concentration: Is his attention easily aroused and sustained?
Does he concentrate? Is he easily distracted? Pre-occupied? ^o test his
concentration aek him to tell the days or months in reverse order, to do
simple arithmetical problems.
General information:Tests for general information and grasp should be varied
according to the patient's educational level and his experiences and interest
For eg. the following, can be asked: Names of the President and his immediate
predecessors; of the prime minister of India; Capitals of Pakistan, Ceylon,
Burma, U.S.A., Russia. Dates of Indivan Independence end India becoming
a republic; six large cities of India.

9

Intelligence: Assess the patient’s intelligence. Use his history, his
general knowledge, problems of reasoning, his educational background.
Insight and judgement:- Whet is the patient's attitude to his present state?
Does he regard it as fen illness, as 'Mental1 or 'nervous' as needing
treatment? Is he aware of mistakes made spontaneously or in response to
tests? How does he regard them and other details of his condition? .
How does he regard previous experiences, mental illness etc?

HH l-l^
PSYCHIATRIC

GLOSSARY

ABREACTION
A process by which repressed material, particularly a painful
experience of a conflict, is brought back to consciousness. In the process
of abreacting the person not only recalls but relives the repressed material,
which is accompanied by the appropriate emotions.

AFFECTIVE DISORDERS
Illness in which a persisting and severe mood change is
the dominant feature.

AGORAPHOBIA
A phobia is an intense and unreasonable dread of an object or
situation. Agoraphobia is often used for fear of open spaces but actually
includes social phobias - fear of people or crowded situations. Most severe
when there is little opportunity to escape, e.g. public transport, busy
shops. Often associated with panics. Can be severely disabling. Simple
phobias, e.g. of spiders - extremely common.
ALCOHOLICS
Those persons whose drinking interferes with their physical or
mental health, their personal relationships or their working ability. This
definition includes, but is not restricted to, those persons physically
dependent on alcohol. "Alcoholic" is falling out of use, a preferable term
is "problem drinker". The use of the term "alcoholism" distracts attention
from the much larger problem of "heavy drinking" which causes many more
physical, psychological and social problems. Measures to reduce "heavy
drinking" in a community are probably more productive than the treatment of
the smaller number who are physically dependent on alcohol.

AMBIVALENCE
Presence of strong and often overwhelming simultaneous contrasting
attitudes, ideas, feelings and drives, towards an object, person or goal;
AMNESIA
Disturbance in memory manifested by partial or total inability to
recall past experiences.

ANOREXIA NERVOSA
A distorted attitude to body weight and fatness with
deliberate restriction of eating with the aim of drastic slimming. Often
associated with secret disposal of food and vomiting and excessive use of
laxatives. Episodes of over-eating and vomiting may occur (bulimia).
Problems of emotional maturation and relationships with parents. Usually
takes fluctuating course over several years and may leave long-lasting
abnormal eating habits. May endanger life especially by depression and
suicide.

AUDITORY HALLUCINATIONS
False auditory sensory perception, i.e. without
external stimulus. "The voices".
AURA
The warning sensations that a person with epilepsy may feel just
before a seizure.

AVERSION
Stimuli leading to undesirable responses are linked with an
unpleasant experience, e.g. snapping an elastic band on the wrist, or
imagining being arrested. A form of self regulation.
BEHAVIOUR
A series of responses which are observable (e.g. talking,
touching, waving).

Contd

-2-

BEHAVIOUR THERAPY
A type of therapy which focuses on overt and objectively
observable behaviour rather than on thoughts and feelings. It aims at
symptomatic improvement and the elimination of suffering and maladaptive
habits. Various conditioning and anxiety-eliminating techniques derived
from learning theory are combined with didactic discussions and techniques
adapted from other systems of treatment. The additional use of the relation­
ship between therapist and patient, a behavioural analysis of past events
and dynamic factors have led to the current term "Behavioural Psychotherapy".

CHILD PSYCHIATRIC DISORDER
Abnormalities of behaviour, emotions or relation­
ships sufficiently severe and prolonged to cause persisting suffering or
handicap to the child himself or distress and disturbance in the family and
community.
CLINICAL PSYCHOLOGIST
A graduate psychologist with further training in
diagnosis and treatment of psychiatric illness, emotional problems and
mental handicap. May use psychotherapy and/or behavioural treatments and
specialised assessment techniques. Not medically qualified and does not
prescribe drugs. May be part of a mental health team or work independently.
Often skilled in design of research studies.

CLOUDING OF CONSCIOUSNESS
Consciousness is the awareness of the self and
the environment. Grasp is the ability to integrate and give meaning to the
experiences of self and the environment. Clouding of consciousness can
include disorientation, difficulties in concentrating, thinking and grasp
and there may be visual or auditory hallucinations and anxiety. Clouding
occurs when physical illness interferes with brain function.
CONFLICT

Clash of two opposing emotional forces.

CONFUSION
This term is used by different people to mean "clouding of
consciousness", disorientation, being muddled or perplexed. Its use can
therefore be misleading. It is suggested that these terms be used instead
of "confusion".
CONTRACTING
The person negotiates a formal agreement with another party
(e.g. spouse) in which each party contracts to make specific changes in
their behaviour as desired by the other party. These exchanged behaviours
should be clear, simple, active and frequent.

DEFENCE MECHANISMS
A specific defensive process, operating outside of
and beyond conscious awareness. It is automatically and unconsciously
employed in the endeavour to secure resolution of emotional conflict,
relief from emotional tension and to avert or allay anxiety. It is an
attempt to cope with an otherwise consciously intolerable situation.
(E>amples are Repression, Denial, Rationalisation, Compensation, Displacement,
Projection).

DEJA VU
Illusion of visual recognition in which a new situation is
incorrectly regarded as a repetition of a previous experience.
DELIRIUM (Acute Brain Syndrome)
A disturbance in the state of consciousness
that stems from an acute organic illness affecting brain function,
characterised by "clouding of consciousness", restlessness, disorientation,
bewilderment, agitation and rapidly changing emotions. It is associated
with fear, hallucinations and illusions.

Contd

-3-

DELIRIUM TREMENS (D.Ts.) An acute delirium occurring when alcohol is
withdrawn from a person who is physically dependent. There is anxiety,
"clouding of consciousness", terrifying hallucinations (e.g. snakes) and
sometimes fits.
DELUSION
A false, unshakeable belief, which is out of keeping with the
patient's personal, social and cultural background.

DEMENTIA (Chronic Brain Syndrome)
Global deterioration of mental functioning
due to physical changes in the brain, characterised by loss of recent memory,
poor comprehension, emotional lability and tendency to self-neglect.

DEPRESSIVE ILLNESS
Distinguished from the normal experience of depression
or misery by being severe, persistent and disabling. Reactive depression
is related to external stresses and/or a vulnerable personality. It is
usually understandable. Endogenous depression has little or no external
stress, comes "out of the blue" and usually affects weight, sleep, drive
and sexual life. Assessment of suicidal risk is essential in depression.
DISTRACTABILITY
When a person's attention is taken up by every new stimulus
instead of the normal filtering of stimuli.

DRUG DEPENDENCE
A state, psychic and sometimes physical, resulting from
the interaction of an organism and a drug, characterised by behaviour and
other responses which always include a compulsion to take the drug on a
continuous or periodic basis in order to experience its psychic effects
and sometimes to avoid the discomfort of its absence. Tolerance may or
may not be present. A person may be dependent on more than one drug.
DYSPAREUNIA
Physical pain in sexual intercourse. Can affect either sex.
The cause is commonly physical but may be emotional.

ELECTROCONVULSIVE THERAPY (ECT)
A form of treatment empirically found to
be of value in severe depression and some forms of schizophrenia. The
patient is anaesthetised and muscles are relaxed. An electrical charge then
induces a controlled epileptic fit. The main side-effect is transient
memory disturbance. Used less frequently as more antidepressant drugs
become available. Helpful with severe, drug resistant depressions.

ELECTROENCEPHALOGRAM (EEG)
A paper recording of the electrical activity
of the brain obtained by a painless procedure in which electrodes are
attached to the scalp.
EMOTIONS (Affects)
Consist of feelings (e.g. anxiety, anger), physical
aspects (e.g. palpitations, churning stomach), and changes in behaviour
("fight or flight"). An individual with disturbed emotions may complain
only of the physical aspects.

ENCOPRESIS
Passage of stools by children at inappropriate times and
places. May be due to physical illness, poor training or emotional upsets.
It may be associated with retention of faeces.
ENURESIS
Involuntary micturition by day (diurnal) or night after an age
when control would be expected. Primary - failure to acquire control usually familial and probably in part due to slow physical maturation.
Secondary - loss of acquired control - may be emotional.

Contd

EXTINCTION

Planned ignoring of specific undesirable behaviour.

FADING
Gradual reduction of prompts to the patient to carry out targeted
behaviour. Prompts are diminished in frequency or volume, or in other ways,
as the patient acquires competence.

FLOODING
Prolonged exposure in vivo to the worst feared situation, continued
until distress reduces. Requires clear explanations, consent and reasonable
physical fitness.

GRADED EXPOSURE
Facing the feared situation in preplanned steps of increasing
difficulty ("hierarchy"). This can be in fantasy or "in vivo". Progress to a
new step is normally delayed until the previous step can be performed with
relative ease.
GUIDED MOURNING
Reduction of abnormal grief by bringing the person into
repeated, prolonged contact with cues concerning the deceased, both in
imagination and in real life.
HABIT CONTROL
Methods to disrupt or adapt habits, such as stuttering, bed­
wetting etc. These include "massed-practice" (deliberate repetition to the
point of extinction); "habit-reversal" (deliberately performing the
opposite manoeuvre before and after each habit event); feed-back (e.g.
bell and pad for enuresis). Tne setting in which each habit occurs requires
careful attention and different techniques (e.g. graduated social exposure
for stammerers whilst practising their speech, reward for enuretics the
morning after dry nights).

HALLUCINATIONS

Perceptions without an adequate external stimulus.

HOLISTIC
The study of an individual as a distinctive entity rather than
as a collection of various characteristics.
HYPERKINETIC SYNDROME
Disorder of childhood with distractability and a
diminished ability to sustain attention. Associated with overactivity.

HYPOCHONDRIASIS
Excessive concern with health or functioning of part of
the body (or sometimes mind). May be secondary to depression or other mental
disorder.
HYPOMANIA
A prolonged change in mood when the patient is overactive, elated,
feels very well and may have grandiose ideas, spend excessively and be
sexually disinhibited. The mood is out of keeping with the circumstances.

HYSTERIA
Mental disorders in which motives (of which the patient seems
unaware), produce a restriction of the field of consciousness or disturbance
of motor or sensory function. These may seem to have a psychological
advantage or symbolic value. May present as conversion symptoms without
obvious physical cause, e.g. paralysis, tremor, blindness, aphonia, fits.
May present as dissociation, e.g. selective amnesia. The underlying cause
of hysteria may be a psychological stress or a physical illness. The term
is falling out of use as it can be seriously misleading when considered a
final diagnosis.

ILLUSIONS
Misinterpretations of stimuli arising from an external object
(e.g. noisy central heating interpreted as an intruder).
Contd

-5-

INSTITUTIONALISATION
Effects of prolonged living in a regulated community
with little opportunity for individual choice in daily life, possessions,
clothes, activities etc. The person is over-dependent on staff, loses
initiative and is increasingly unable to cope with life outside the institution.
Patients with schizophrenia are very susceptible to this complication.
LABILE

Unstable;

characterized by rapidly changing emotions.

LEUCOTOMY
An operation to cut some of the nerve fibres passing to the
frontal lobes of the brain. Used in severe, intractable and disabling
tension states. Falling out of use because of irreversibility, replacement
by other treatments and danger of permanent personality, change.

MAJOR TRANQUILLIZERS (Neuroleptic)
Used in treatment of psychotic illness
and severe agitation, e.g. Chlorpromazine (Largactil).
M.A.O.I.s (Mono-Amine Oxidase Inhibitors)
A group of antidepressant drugs.
Less commonly used because of serious interactions with certain drugs and
foods (e.g. cheese), e.g. Phenelzine (Nardil).
MINOR TRANQUILLIZERS (Anti-anxiety, anxiolytic drugs)
Used as part of
treatment of anxiety, e.g. Diazepam (Valium). Ineffective after a few
weeks of use. High risk of dependency.

MODELLING
A behaviour is demonstrated then the person is asked to copy it.
The aim is coping rather than perfect behaviour, with some reward for the new
activity. Use brief natural components. The person practises immediately
and is guided on progress and rewarded for good performance.

NEUROSIS
Problems of definition despite wide use of this term. No organic
cause. Presents as anxiety, depression, phobias, hysterical symptoms,
obsessional symptoms. The person can distinguish between his subjective
experiences and external reality. Behaviour may be greatly affected but
usually remains within socially accepted limits. The psychodynamic
explanation is conflict, perhaps unconscious. The learning theory
explanation is that it is a learned habit in a susceptible individual who
has been exposed to stress and therefore had the opportunity to learn the
neurosis.
NORMALITY
A number of different concepts: (1) the average; (2) the ideal;
(3) the statistical normal curve; (A) the absence of signs and symptoms of
abnormality; (5) the continuous process of adjustment and adaptation (and
possibly development). All concepts used in Psychiatry and can be misleading.

OBSESSIONAL PERSONALITY
Feelings of doubt and insecurity lead to excessive
conscientiousness, perfectionism, repeated checking, caution and possibly
stubbornness. There may be insistent and unwelcome thoughts or impulses.
The obsessional personality is reliable and can be very productive
particularly where meticulous activity is required. Indecisiveness carries
the risk of being unproductive.
OBSESSIONS
Unwanted thoughts which are perceived by the person as inapprop­
riate. Efforts to dismiss the thoughts may lead to anxiety. Certain actions
or rituals may be performed to relieve anxiety, e.g. washing hands, counting,
checking.
OPERANT CONDITIONING
Desired behaviour is rewarded and so increases.
Whereas undesirable behaviour is not rewarded or is punished and so
decreases.
Also known as instrumental conditioning.
Contd

-6PARADOXICAL INTENTION
Reduction of anxiety by encouraging the patient to
deliberately practice the feared behaviour, e.g. a patient afraid of fainting
in public is asked to deliberately faint in front of others.

PERSONALITY
The unique, sum total of a person's psychological and physical
characteristics. The established and largely unchanging patterns of relating
to, perceiving, thinking and feeling about the environment and oneself.
Abnormal personalities have patterns which are severely maladaptive and
impair functioning and may have an adverse effect upon the individual and/or
society. Psychopathic personality is an extreme form of abnormal personality.

PHOBIA

Anxiety inappropriately linked with an object or situation.

PREVENTION (After Caplan)
Primary - involves lowering the rate of new cases
of mental disorder in a population over a certain period by counteracting
harmful circumstances before they have had chance to produce illness.
Secondary - aims at reducing the disability rate due to a disorder by early
diagnosis and effective treatment. Tertiary - aims to reduce the rate in a
community of defective functioning due to mental disorder.
PRIMARY GAIN

The reduction of tension or conflict through neurotic illness.

PSYCHIATRIST
Medical graduate with higher training in the assessment and
care of the mentally ill. Treatments are physical (drugs and ECT), psycho­
therapy, behaviour therapy and social care.

PSYCHOANALYSIS
Term used for both Freud's method of psychic investigation
and a form of psychotherapy. As a technique for exploring the mental processes,
psychoanalysis includes the use of free association and the analysis and
interpretation of dreams, resistances and transferences. Uses Freud's libido
and instinct theories and ego psychology, to gain insight into a person's
unconscious motivations, conflicts and symbols. Requires specially trained
therapists and involves extremely prolonged treatment.
PSYCHOSIS
Problems of definition despite wide use of this term. Impairment
of mental function particularly in loss of contact with reality. Lack of
ability to distinguish subjective experience from external reality. Presents
as hallucinations, delusions, abnormal thinking processes, odd behaviour,
reduced ability to cope with ordinary demands of life, loss of drive and
inability to recognise is ill when this is obvious to others.
PSYCHOTHERAPY "Talking treatment"
The treatment by psychological means of
problems of an emotional nature in which a trained person deliberately
establishes a professional relationship with a patient/client with the object
of (1) removing or modifying symptoms (Supportive psychotherapy); (2)
modifying disturbed patterns of behaviour (re-educative psychotherapy); or
(3) promoting development of the full potential of the personality (reconstructive
psychotherapy, psychoanalytic treatment). See behavioural psychotherapy under
behaviour therapy.

PSYCHOTROPIC DRUGS
Those drugs having powerful effects on the central
nervous system and used in psychiatric treatment.
REHEARSAL RELIEF
An exposure method to reduce nightmares by talking and
writing about them repeatedly and giving them a triumphant ending.

REINFORCEMENT

Reward.
Contd

-7RESPONSE PREVENTION
Prolonged exposure to ritual-evoking cues whilst
asking the person to refrain from carrying out the rituals. Continued
until the urge to perform rituals fades.
SCHIZOPHRENIA
A group of mental disorders with no coarse brain damage.
Cannot be understood as arising emotionally or rationally from affective
states, previous personality or current situation. There is characteristic
interference with thinking, emotions, drive and motor behaviour. May
include hallucinations, delusions, thought disorder and thought broadcasting.
Sense of being controlled by alien forces, emotions out of keeping with
external reality and severe withdrawal.
Schizophrenia is one form of
psychosis. The layman's association of schizophrenia with chronic madness
and hospitalisation is outdated. With modern treatments approximately one
quarter recover completely, one quarter have mild disability, one quarter
moderate and one quarter continue with severe disabilities.

SECONDARY GAIN
The obvious advantage that a person gains from his illness
such as gifts, attention and release from responsibility.
SELECTIVE INATTENTION
An aspect of attentiveness in which a person blocks
out those areas which generate anxiety.

SELF REGULATION (self treatment)
The person is taught to monitor, record,
evaluate and reward or punish his current behaviour and also practice new
behaviours.

SICK ROLE
Allocated by society though may be formally supported by doctors.
(1) Exemption from normal social responsibilities. (2) Person not responsible
for the illness and cannot recover by own unaided action. (3) Person must
want to become well again. (4) Must seek and co-operate with treatment.
SOCIAL SKILLS TRAINING
Stepwise training in how to show assertion, warmth,
interest, etc. by use of voice, eyes, posture, gesture and key phrases.
Components are demonstrated and practised in role play with feedback. This
is linked to graduated real life practice. The person finds it helpful and
reassuring when the demonstrator is not perfect in social skills.

THERAPEUTIC ATMOSPHERE
All therapeutic, maturational and growth supporting
agents - cultural, social and medical.
THERAPEUTIC COMMUNITY
Ward or hospital treatment setting where frequent and
regular meetings of patients and staff aim to improve awareness in patients
of their effects on others, to encourage communication, to lessen the
hierarchical authority of staff over patients and to share responsibility for
each other's care. In practice may tolerate and help some personality
disorders not influenced by other forms of psychiatric care.
THOUGHT STOPPING
The person deliberately has the unwanted thought in order
to learn how to stop it. A loud noise or the snapping of an elastic band on
the wrist is an adequate aversive unpleasant experience.
TIME-OUT
Immediately after highly undesirable behaviour the patient is
placed somewhere alone for a few minutes without access to rewards.
TRANS-SEXUALISM
Fixed belief that the overt physical sex is wrong.
Associated with desire to dress and behave as opposite sex. May request
sexual hormones or operations. Distinct from transvestism.

TRANSVESTISM
Sexual gratification by wearing clothes of the opposite sex.
Distinct from and not necessarily associated with homosexuality.
Contd

-8TRICYCLICS, TETRACYCLICS
Commonly used and effective groups of anti­
depressant drugs, e.g. Imipramine (Tofranil), Mianserin (Bolvidon).

UNCONSCIOUS
Thoughts, feelings, impulses, which are not immediately
available to the attention, but nevertheless influence behaviour. Evidence
for this in everyday life from verbal lapses, dreams and forgetting,
indicating a part of the personality not immediately accessible to
consciousness.

HGE/IT, 1985

DM 1.^0

Psychiatric disorders associated with prognancy:Depressive symptoms arc common during 3-4 month of pregnancy especially
if its the first one, and if its an unwanted pregnancy, Psychotherapy and
mild tTanquilisers shculc.be- helpful.
Psychiatrid disorders associated with pnerperium:- Post partum psychosis
usually occurs during the first 4 weeks after delivery. Onset is
usually sudden and clinical features consist of florid symptoms, more
often schizophrenic with a confusional colouring. Preexisting psychosis tend
to get exacerbated during this time. These patients need to be admitted
and treated by a specialist. Depressive symptoms are common during
postpartum period.

Psychiatric Emergencies; ■
A psychiatric emergency may be a new illness with an acute onset or
an acute exacerbation of a chronic illness. These are emergencies, because
of the possibility of harm done either to the patient or to others.

The main psychiatric emergencies are:1. Attempted suicide and suicides- The most common psychiatric cause for
suicide is depression, especially of the indogenous type. The common causes
for suicide in schizophrenia are hallucinations and impulsive behaviour.
The methods adopted are quite brxzzare and cruel.
In hysterical patients, attempted suicide is an acting out behaviour
to get attention. This indicates that the person is in emotional destress.
2, Acute Psychotic states ;a) Schizophrenia! Catatonic excitement or stupor; paranoid excitement with
homicidal tendencies.
b) Depressive illness: Gross degree of depression with self-destructive ideas
c) Manic excitmeht which becomes a problem for management.
d)
Postpartum psychoses.
e) Post epileptic excitement with assaultive end destructive tendencies
f)
Nonspecific acute psychotic excitement.
3) Acute brain syndromes: Intoxication with alcohol or drugs.
4)
Chronic brain syndrome: Explosive outbursts of rage and temper tantrum.
5)
Acute anxiety and panic, usually in reaction to some crises in life;
transient situational reactions; hyperventilation syndrome.
6)
foxic confusional states.
7)
Side effects of psychotropic states.

It is better to admit these patients is psychiatric wards and treated
by specialists.

MH Lrxi

Psychiatric disturbances in Children

The psychiatric disturbances in children can be classified as follows:1. Habit disorders:- Thnnb sucking, nail biting, enuresis, masturbation, loss
of appetite, insomnia, nitht terrors, Dyslaiia.
2. Bahavioural disorders:- stealing truancy, temper tantrums, delinquent
behaviour.
3.
Neurotic dis^ders:- Anxiety state, hysterical reaction, absessive compul­
sive reaction, depressive reaction.

4.

Psychosomatic disorders.

5.

Psychosis: Autism and childhood schizophrenia.

6.
Miscellaneous: Deplexia, backwardness in school, postencephalitic syndrome,
Mental retardation.

Enuresis is repeated involuntary micturition occuring after the fourth year
in the absence of any organic cisease. Insomnia, night terror, and sleep
walking are common disturbances of sleep
In night terros, the child gets up
in a state of great fear, while still aaieep. There will be intense persperation
and the child will go back to sleep.after a while. The nightmare on the other
hand is a terrifying dream which usually wakes up the child. Sleep walking ,=■
is a dissociative state wherein the child walks about in his sleep without
being conscious about it.
Dyslaiia is a defect in articulation. Here there is a tendency to
omnission, substitution and distortion of sounds. Dyslaiia or word blendness
is a condition in which a child is unable to read words inspite of adequate
vision and intelligence. Backwardness in school can be due to emotional
problems or mental retardation* School phobias wherein the child is anxious
about being separated from the mother is also common.
{■fast of the emotional disturbances in childhood are caused by environ­
mental factors such as faulty parental attitudes, parental rejection, over
protection, broken homes, problems in the schools.
Psychotherapy is very effective in the treatment of functional psychiatric
disturbances in children. Family therapy, play therapy and group therapy
and individual psychotherapy are useful techniques. A child guidance filinic
where a team consisting of a child psychiatrist, clinical psychologist a
social worker and a paediatrician is a ideal place for the treatment of the
emotional problems of children.
/--------------------- /

HH I ••

PSYCHIATRIC SERVICE NEEDS OF DEVELOPING COUNTRIES

Based on judgements of local needs.
Emphasis on problems which are:-

common
disabling

)
J
See reference 1

disturbing )

treatable

j

The following list of groups to be rearranged in a local

order of priority.
excited and overactive states

)

epj .epsy
j
chronic withdrawn behaviour following )
excited states
)

see reference 2

abnormal behaviour in the puerperium

senior civil servant/privileged clinic
student/senior school children problems
excess drinking/drug abuse problems
depressive illness

symptoms without signs in general medical clinics
shanty town populations
prison population

migrants

References
1.

Developed from Morley, D. (1973)the Developing World".

2.

"Paediatric Priorities in

Published by Butterworth.

First three priorities derided jointly by W.H.O. psychiatric

experts and local communities in W.H.O. Collaborative Study for
Extending Mental Health Care in Primary Care in Columbia, India,

Senegal, Sudan, Brazil, Egypt and the Philippines.
Climent, C.E. et al. (1980).

Care".

Reported in

"Mental Health in Primary Health

W.H.O. Chronicle, J4, 231-236.

HGE/IT/. 1981

PSYCHIATRY

INTRODUCTION
With the Shore Committee recomendations (1946). Diploma courses
in Psychiatry were started at All India Institute of Mental
Health (now NIMHANS), Bangalore. Later, Post Graduate (M.D.)
courses were introduced in 1966 at National Institute of Mental
Health and Nuero Sciences (NIMHANS).

Mental Health, ignored till recently, is now seen as a major­
component of general health services. The mind and the body
cannot be seen separately and thus, while treating,
the whole
person needs to be understood. Good physical health contributes
to good psycological or mental health and vice versa. Thus were
born professionals working with the mentally ill, one of the
earliest being the Psychiatrist.
Psychiatry

is the science of recognition and treatment

of

dis­

eases of editions and the mind.

COURSES OFFERED

There are two courses in psychiatry which can be taken
basic M.B.B.S. degree.

after

1) Diploma in Psychiatric medicine (DPM) : This is the
degree to practice psychiatry ai=hd—the juration ws', 2 years.

a

basic

2) Doctorate in Medicine (M.D. in Psychiatry) : With an M.D.
degree, apart from practising there are openings for teaching
too, as the University eligibility rules makes it mandatory for a
person to have an M.D. degree to become an examiner and a teach­
er. Duration
3 years.
NIMHANS is the only Deemed University offering both these
courses.
A list of psychiatry departments of the Medical col­
leges in India offering the MD courses are listed in Annexure D.

FUTURE PROSPECTS

Earlier, psychiatry was taught only at intitutions attached to
the Mental Hospitals. Later psychiatry units were started at
General Hospitals. A newer trend is that private hospitals are
also having Psychiatry units.
Today however, there is shift of emphasis from large public
psychiatric hospitals to community based psychiatric
care.
Community psychiatry aims at working at the district,, taluk and
sub-taluk level, reaching out to the villagers at theZir village
itself. With the forms of care moving to the community, there is
a greater need for psychiatrists in India.

MEDICAL AND PSYCHIATRIC SOCIAL WORK

INTRODUCTION
The concept and practice of social work is as old as the human
race itself. But it acquired its professional recognition only
recently in India. On the recommendations of the Shore Committee
(1946),
it was felt that a psychiatric social worker should be
included in the medical health team. Subsequently, Tata Insti­
tute of Social Sciences started the Medical and Psychiatric
social work specialisation in M.A. Social Work programme in 1946.
Following this model, other schools of social work introduced
this specialisation in their Masters in Social Work programme.
At present there are about 15-20 schools of social work offering
this specialisation (see Annexure C). Many of these schools also
offer other specialisations apart from Medical and Psychiatry,
like Family & Child Welfare, Community Development, Criminology
and Correctional Administration.
TYPES OF COURSES

Medical and Psychiatry specialisation is included in the M.A.
Social Work programme. Apart form this a two year M.Phil course
is offered in India by two institutes namely, Central Institute
of Psychiatry, Ranchi and National Institute of Mental Health and
Nuero Sciences (NIMHANS), Bangalore.
In NIMHANS, facilities are
provided to do Ph.D in Psychiatric social work.
FUTURE PROSPECTS

Those who specialise in Medical and Psychiatric social work, get
employment in General Hospitals, Psychiatric Clinic, Rehabilita­
tion centres, Child Guidance clinic. Mental Hospitals, Marriage
and Family Counselling centres, School of Social work, Research
Project etc.

In addition, there is a recent trend in Industries to employ
Psychiatric social workers as social counsellors.
Of the 42
mental hospitals only 22 mental hospitals have employed psychiat­
ric social workers. The State and Central Government need to be
persuaded to fill up the vacancies. Likewise, there is proposal
to start District Mental Health programme in each State. One or
two posts will be created in each of these District Mental Health
programme.

In the educational institutions, there is an increasing awareness
about the needed importance of professionally trained social
workers in schools and colleges.
In this way the medical and
psychiatric social work has a bright future in India.

ANNEXURE
1.

College of Social Work,
Red Hills, Hyderabad 500 004.

2.

Department of Social Work,
Madras Christian College,
Tambaram, Madras 600 059.

3.

Department of Social Work,
Loyala College of Social Sciences,
Sreekariyam, P.O.,
Trivandrum 695 017.

4.

Madurai Institute of Social Sciences
A1agarkoi 1 Road, Madurai 625 002.

5.

Rajagiri College of Social Sciences,
Rajagiri P.O., Kalamassery 683 104,
Kerala.

6.

Karve Institute of Social Service,
Hill Side, Karve Nagar,
Pune 411 052,
Maharashtra.

7.

Department of Social Work,
Jnanabharati, Bangalore 560 056.

S.

Tata Institute of Social Science,
P.8. No. 8313, Sion-Trombay Road,
Deonar, Bombay 400 088.

9.

Department of Social Work,
Karnataka University,
Pavate Nagar, Dharwad 580 003,
Karnataka.

10.

Department of Social Work,
Loyala College, Nungambakkam ,
Madras 600 034.

11.

The Madras School of Social Work,
32,Casa Major Road,
Madras 600 008.

12.

Department of Social Work,
P.S.G. College of Arts and Science,
Coimbatore 641 014.

13.

School of Social Work,
P.B. No.521, Roshini Nilaya,
Mangalore 575 002.

14.

Department of Social Work,
Gulbarga University,
Gulbarga 585 106,
Karnataka.

15.

Department of Social Work,
Andhra University,
College of Arts and Commerce,
Visakapatnam 530 003,
Andhra Pradesh.

15. Indore School of Social Work,
14, Sea Shore Road, Indore 452 001,
Madhya Pradesh.

16.

Department of Social Work,
D.N.R. College, Bhimavaram 534 202,
Andhra Pradesh.

17.

Department of Social Work,
S.P. Mahila Viswa Vidyalayam,
Tirupathi 517 502,
Chitoor District,
Andhra Pradesh.

18.

Department of Social Work,
Bishop Heber College,
Tiruchirapalli 620 017,
Tamil Nadu.

19.

Department of Social Work,
Stella Maris College,
17, Cathedral Road,
Madras 600 086.

20.

Department of Social Work,
Institute of Social Sciences,
Agra University, Agra 282 004.

21.

Department of Social Work,
Viswa Bharati, SriNiketan,
Bhirbhum District 731 236,
West Bengal .

22.

Department of Social Work,
Guru Nanak KhaIsa College,
Yamuna Nagar 135 001,
Haryana.

23.

Department of Social Work,
Dwaraka Doss Goverdhan Doss Vaishnav College,
E.
V.R.
Periyar High Road,
Arumbakkam, Madras 600 106.

24.

Bosco Institute of Social Work,
Sacred Heart College, Tirupattur 635 601,
Tamil Nadu.

25.

Department of Social Work,
Gujarat Vidyapith,
Ahmedabad 380 014,
Guj arat.

26.

Department of Social Work,
University of Delhi,
3, University Road,
Delhi 110 007.

27.

Institute of Social Work,
West High Coast Road,
Bajaj Nagar, Nagpur 440 010.

28.

Department of Social Work,
Udaipur School of Social Work,
Udaipur 313 001,
Raj astan.

29.

Department of Social Work,
M.S. University of Baroda,
Baroda 390 002,
Gujarat.

30.

Department of Social Work,
National Institute of Social Work
and Social Sciences,
Surya Nagar, Bhubaneshwar,
Orissa.

31.

Department of Social Work,
Chatrapathi Shahu Central Institute
of Business Education and Research,
University Road, Kolhapur 416 004,
Maharashtra.

32.

Department of Social Work,
Tirpude College of Social Work,
Civil Lines, Sadar, Nagpur 440 001,
Maharashtra.

33.

Department of Social Work,
Kasi Vidyapeeth, Varanasi 221 002.

34.

Department of Social Work,
Kurukshetra University,
Kurukshetra 132 119,
Haryana.

35.

Department of Social Work,
Hindu College, Guntur,
Andhra Pradesh.

36.

Department of Psychiatric Social Work,
Central Institute of Psychiatry,
Kanke, Ranchi S34 006.

37.

Department of Social Work,
University of Mysore,
Manasagangotri, Mysore 570 006.

A1h

PSYCHIATRY AM> GENERAL PRACTICE
The wide gap that existed Psychiatry and general Medicine i»
being bridged and it may be hoped that in the not too distant future

psychiatry in its preventive aspects will become a part-of general medical
practice.

Psychiatry ofcourse, has specialist aspects but our aim is to

train the practitioners so that they may become as interested in and as

able to treat their psychiatric patients as those who are physically

involved.

The psychic and the soematic constantly react on one another

and cannot be conpletely separated.

That is why the treatment of the

whole man is stressed and not merely the part disease from which he may be
suffering.

To do so effectively we must know his background , his per­

sonality structure plus his environmental situation and the biological

manner in which he is able to adopt to the various exigencies of the physical
or psychological nature to which he has been called upon to me6t.

The

general practitioner therefore must be as expert in conducting a psycholo­

gical examination of his patient as a physical one and in the long run
he can be rest assured that he will Rave time than he wastes.

He will

acquire a more comprehensive viewpoint, he will inspier greater confidence,

he will be able to exercise a stronger influence, he will be able to go to
the core of the situation.

Ajiong other things he will find that many of

the bodily states which have not responded to surgery or pharmocology will

*

disappear miraculously.
been disclosed.

Once the underlying psychological factors have

Hence the body and the mind work in harmony and are

delicately balanced and must be handled with the greatest care.

The one is

complementary to the other.
Psychology is the septematic study of the mind.

study of human behaviour.

It is defined as the

The inportant faculties of the mind are cognition

or knowledge connation or will ard feeling or emotion.
Psychiatry is the branch of medicine which deals with the recognition,
treatment and prevention of mental abnormalities and disorders.

Thus

Psychology deals with normal behaviour while Psychiatry deals with abnormal

behaviour.

What physiology is to general medicine, Psychiology is to

psychiatry.

It is estimated that nearly half of the hospital beds in western

countries are occupied by psychiatric patients.

2?

About 30% of the patients

who attend general practitioners 1 clinic suffer, primarily from psychiatric ,

symptoms,

in India various surveys report about 20% per 1000 in a’i commu­

nity suffer, from gross degrees of psychiatric morbidity,

l^reover a recent

study done in Bangalore shows that 30% of the patients who attend general .
practioners clinic show purely psychiatric symptoms.(Sham Sundar

et al)

This gives a rough estimate of about 12-millipn patients in the whole
country who need psychiatric treatment.

Agonist this need, there are only

20,000 hospital beds for psychiatric patients and there are only .about
400 qualified psychiatrists in our country.

This.emphasizes the need for

general practioners to be more equipped with the 'ability and knowledge to
treat the more simple calls and refer -the others to specialists.

MH

PSYCHOSIS

Psychosis involves a realm of symptoms that typically includes delusions*
hallucinations and various kinds of hizzane behavioural manifestations* The
distinctions between neuroses and psychosis are symptomatic psychopathological
and therapeutic*
A psychosis involves a change in the whole personality of the subject, in
. whom it appears, while in neurosis it'is'’.only a part of the personality thtt
is affected. Furthermore in a psychps.^s'/reality is changed qualitatively
and comes to be- regarded in a way 5^f^’<'diff.spent frofa.the normal and the
patient behaves accordingly. In neurosis ;.rdaiity remains unchanged quan­
titatively, although its1 value may be quantitatively altered.

• In neurosis■language as such is never disturbed, whereas in psychosis
it often undergoes distortion from the psychoanalytical point of view, the
unepnsious comes, to:direct verbal expression in the psychosis ’whereas in
neurosis-; it: pever attains more than symbolic expression in some physical or
’■ 1 acalized., mental disturbance.'• The reactions in a psychosis are much more
primitive-type on the whole than in neurosis. There is often a refression
to an infantile level of activity in the psychotic, for eg. wetting and
soiling without shame are not found in neurotics in the presence of clear
consciousness. ...
;
'
The''main type of psychosis are (1) 3echizophrenia' (2) affective disorders
and (3) Tararioid disorders.
■
SCHIZOPHRENIA

Schizophrenia is one of the common psychosis* It can be defined as a
psychosis’characterised by disturbances in the thinking, emotional, and
volitional faculties in.theipresence of clear consciousnes which usually to
social withdrawal*
/,
;.

Epidemiology:- Sehizophreh’iaiis a “common disease found in all cultures in ••
aLLp^rts of the world. - Several. community 'surveys show'that 3;-.to.4:per
t
1000 in any community suffer from schizophrenia. About 1 per cent'of.,general “
population■ stand the risk of developing the disease in;their lifewtxm^'z.„
About.15. per cent of new admissions to a mental hospital are schizophrenic.
patients. 'Women are more prone tod evelop schizophrenia. About 2/3: of
the cases are in the 15-30 year age group though the paranoid type has a
later age of onset. It is commonly found that the majority of schizophrenic
patients are from the lower social classes wither schizophrenic patients
drift down the ladder of social caass, tjecause of the disease or whether the .
social stresses associated with a lower social class produce the disease,
is not finally proved, ^he former apoears to be a more probable .explanation.

Etiology:- Both genetic and environmental fadtors are iqlortant in. the
etiology of schizophrenia. Family studies show that nearer the blood rala tionship, greater the chances of getting schizophrenia. Several twin
studies show that among manozygo.tic twins, the concordance rate is about
60 per cent where as among the dizyotic twins the concorance rate is only
10 per cent. .Another pieee of evidence for the genetic causation of
schizophrenia comes from adaption studies. An examination of adults who

- 2 -

were separated from their natural mothers from the first few days of life and
adopted by others show that those who are born to schisophrenic mothers mani­
fest more commonly the symptoms of schizophrenia. In some types of schizophrenia
there is a genetically determined biochemical abnormality, which in same
situations produces abnormal metabolites which in turn causes changes in
behaviour. Though the genetic basis of schizophrenia is established, there
is no agreement as tothe mode of transmission. The important environmental
factors attributed to the genesis of schizophrenia are• intrafamily relationships*
and sociocultural factors. All the above theories need’more substantiation
But it is a common finding that physical illness, childbirth and psychosocial
stresses precipitate schizophrenic reactions..

Clinical features:- Schizophrenic patients usually have a particular type of
personality characterised by a tall and lean tody structure (aesthenic body
build) and a withdrawn, aloof, serious and impulsive type of temperament
(schizoid).
The various mental faculties are disorganised in„varying degrees.
Disorders, of thinking:(
- Their thinking is usually bizarre. It is very diffi­
cult to follow their reasoning, since there is a disturbance in the associa­
tion of ideas. Patients sometimes complain that their stream of thinking
suddenly stops and the mind becomes blank. This is called ’thought block*.
Sometimes the ideas rush through,the mind producing a confusion and chaos of
thinking. ' Various, types .of delusions are common. Delusions of suspicion are
characteristic of .paranoid typ,e of schizophonia.. Over-thinking refers to an
inability to preserve conceptual boundaries with the result that distantly
related and irrelevant ideas are regarded as essential parts of a concept.
There is a loosening of associations. The schizophrenic patient coins new words
(neologism)

Disorders of emotion:- Apathy is usually seen in schizophrenia. This inter­
feres in social relationships. .. The patient often''complains that he has last
the ability to feel. Sometimes the emotions become incongruent and the
patient will say something and behave in a different way.

Disorders of volition; Mp.ny patients manifest different degrees of weakness
of willpower or volition. ' They would say that some change has. happened to
■them and that their behaviour is controlled by-some external forces. This
S?ne
any co'™d h°wSr inoon&
This is called automatic obedience often
patients do not have the power to do the normal activities of life, even
though they try hard to do. This is often mistaken for laziness by relatives
Disorders of perception;Additory hallucinations are commonly seen especially
in chronic cases..
Miscellaneous:- Catalonic refers to abnormality of movement, awkwardness,
grimacing and posturing. Some' patients adopt very inconvenient, postures
for a long time, as though they are made of wax. This is called wasy flexi­
bility. Sometimes patients show motor excitement, sometimes 'motor
retardation, even gross degree of stupor.
■3

- 3 Sleep is usually disturbed. 411 the schizophrenic symptoms .are present in the
absence of any disturbance of conscicusneas. The presence of coma would su­
ggest an organic pathology and would be against a diagnosis of schizophrenia
social withdrawal is a common manifestation of schizophrenia especially
in chronic cases. The patient Betreats to his own shell and lives in his
own world.

Clinical Sub-groups:- According to differences in clinical- manifestations,
there arc four main clinical sub-groups of schizophrenia. ■
The hebephrenic group has: a very vogue and insiduous onset late in the
teenage period. .The early symptoms are perplexity, pe'er. concentration, y. mu
vagueness, day-dreaming , self-consciousness, moodiness, apathy, indiscri­
minate concern with pseudophilqsophical-religious ideas, feeling of inferiority
and inadequacy. Thinking disturbances and emotional incongruity are very
marked, thus giving rise to a-silly and impulsive behaviour. Inappropriate
giggling and unpredictable'temperament .are characteristic of hebephrenic
schizophrenia. Chronic cases show a marked degree of mental deterioration

The simple group has also a very insiduous onset during early adolescence
and the diagnosis is usually missed. Emotional blunting is the characteristic
feature. Patients drift from social groups and lead solitary lives. They
thus will settle down into lives of poverty, petty crimes prostitution and
vagrancy. These patients will not have delusions, hallucinations or thought.
The catatonic type shows a less insiduous pinset during any age group and
usually manifest disturbances in motor behaviour such as excitement, restless­
ness, stereotyped behaviour, negativism, posturing immobility, waxy f'e
flexibility and stupor.
•

The paranoid group is characterized by.well systematised delusions of
persecution and'auditory hallucinations. The onset is later in life, the
body build is usually pyknic and meatal deterioration is not marked.
In clinical practise it is difficult to do a; clear sub-typing* The
same patient may show the features of different groups. . There are no welldegined criteria of diagnosis of schizophrenia which are agreed upon by
different investigations from different parts of the1 world.'

Some psychiatrists believe that there are two types of schizophrenia.
One is called the process or nuclear Schizophrenia, which is characterized by
a schizoid, premorbid personality, family history of schizophrenia, inciduous
onset during adolesence, gross hebephrenic features and a poor prognosis.
Such patients are more leptpmorphifl in body build and’ more commonly demonstrate
abnormalities of immunological and autonomic responses.
The other group is called reactive schizophrenia or schizophreni form
psychosis or symptomatic schizophrenia. In contrast to the nuclear type, this
group is characterised by le^s insiduous onset in any age group predominance
of precipitating factors apu change in motor- behaviour and a better res­
ponse to treatment.
.4

4

TREATMENT:1. Drugs: Phenothiazines are the drugs of choice and form the main line of
treatment in schizophrenia, ^he dossage depend upon the severity of the symptoms
and the body weight. The following pb.rno thiazines are usually.used chloro­
promazine (Largac+?3iimgrn per day. Trifluoperazine (Eskazine) 15ngm per
dayThioridazine (Melleril) 300 mgm perday. Newer drug such as Haloperidol and
Ihiozanthines• may be used. If the severity of symptoms continue', these
drugs can be given in a reduce to a maintenance dosage and continued for thelo
long time. The -jdrng tneetnent rust'be supervised by specialist. Long acting
phenothiazines such as Anatenscl Decanoate are recently introduced and are very
useful for chronic schizophrenic patients.
2 Electro Convulsive Therapy:This is usrful in selected cases. It is indicated in catatonic type of
schizophrenia with excitement or stupor. If the response to drugs is very
slow in other types of schizophrnia, a course of E.C.T. may be tried. The
usual course of treatment is between 10 tol5 number of treatments. There
are many individual variations and the treatment must be under the super­
vision of a specialist.

£

3.
Social Therapy: A sympathetic understanding of the patient by the team
of psychiatrists, psychologists, social workers, occupational therapists
and nurses is very important. This total push programme of treatment as
inpatients is very helpful in the rehabilitation of the patients and the
prevention of relapses. Individual supportive psychotherapy will help the
patient to have more confidence. The involvement of the family members in
the treatment will imporve the intrafamily relationships and facilitate
regular follow up.

4.
Prefrontal Leucotoray: This is useful: in selected cases where the other
conservative treatments have failed, and the patient shows aggressive, impul­
sive behaviour which makes management difficult.

Course and Prognosis:- A family history of schizophrenia, schizoid type of
premorbid personality,, early onset, insidious onset,.long duration and
absence of precipitating factors, are bad prognostic factors. In other
words process schizophrenia has a bad prognosis and reactive schizophrenia
has a better prognosis.
It is estimated that about'10 per cent of patients'show spontaneous
recovery, even without treatment. About 30 per cent show various degrees
of recovery with treatment, ' About 20 per cent show gradual deterioration
in spite of treatment.

AFFECTIVE DISORDERS
Affective disorders are illnesses in which,mood changes fora the dominant
and primary features.
'

Depression is the most common affective illness. Depression usually
follows an unhappy life event. Grief reaction or mourning is one example
Depression can also be associated with any physical illness.
5

<

5
Neurotic depression or reactive depression is commonly' precipitated by envi­
ronmental stresses.

Endogenous depression or psychotic depression is not causally related
to any major traumatic situation and are more constitutional or genetic.
Neurotic depression or weactive depression:- Hero the primary characteristic
is a change in mood consisting of a feeling of sadness which may vary from mild
depression to a gross degree of despair. This' may last for days weeks or
even months and produces chances in behaviour, attitude, thinking, effici­
ency and physiological functioning.

Depression, is precipitated by envinonmental factors. Reactive depre­
ssion usually lifts when the precipitating factor is removed.
Clinical features:^
Feeling of insomnia especially sadness, difficulty in faling asleep,
decreased appetite, lack of•concentration and donfidence, lack of interest
in work and people, vague fears are main features. Somatic complaints such
as heaviness of head, chestpain feeling of weakness are common . Suicidal
ideas may be present. Nburotic depression differs from endogeneousdepression
in several wavs. Ifeurotic depression is precipitated by environmental factors
whereas endger.eous depression is not usually precipitated by" extraneous
factors. The neurotic depressive usually finds it difficult to go ; to sleep
(early insomnia) whereas in endogenous depression there is early morning
awakeing. The neurotic depressive feels worse towards evening whereas in
endogenous depression the patient feels better towards evening and worse in ■
the morning, ^he neurotic depressive feels better in company, whereas
endogenous depressive shuns •company.'' Delusions and hallucinations .may be
present in endogenous 'depression-, but1,are absent- in reactive depression.
Treatment:- Psychotherapy' is the main line of treatment,
minor tranquillisen may-be helpful
-:
‘

.‘intidppr ess ants and

mNiC DEGRESSIVE PSYCHOSIS (MD?)

Ganetic constitutional factors aro'-more important in etiology.
factors are important here.

Hereditary

MDr is a circular illness, which pompresis of a series of attacks of elation
and depression with-.periods of normality inbetween and generally favourable
prognosis.
Some individuals evidence only manic reactions and others only
depressive reactions, still others show both.-types of-reactions, either alterna­
ting between two or showing a combination of manic and depressive reactions
sat the same time.
The premabid personality is usually of cyclothymic type- extraverted
and outgoing people liable to mood changes and have a pyknic type of body
build (short and thick)
Depression:- Depression phase of MDP, which is currently known as Bipolar
depression is characterized by depressive feai~res of an endogenous type.

’ 6
The depression is not usually triggered by envinonmental factors and is
quite intense. The patient has morbid guilt feelings feelings of unworthiness
and suicidal preoccupation. Loss of vitality, weakness,
libido is •
common.Anorexia, constipation, weight loss and amenorrhea, are the other.
common physical symptoms.

Elation:- In the manic phase, the patient has great feeling of wellbeing and
his mood is euphor'ic. There is increased mental^’und physical activity. Flashes
ofiirrit-abilitymay be present. Thinking is marked bjr flight of ideas i.e.
ideas rush through the mind one after another, and he jumps1 from one point
to another* Gross degree of extravagance may be present. The patient may
express grandiose delusions* His attention may be difficult to sustain.
He is easily distractible. Libido may be increased during a manic phase.

The depressive phase has to be differentiated from early schizophrenia
and organic cerebrovascular conditions such as cerebral tumour, arteriosclerosis,
and general paresis of insane. The manic phase has also to be differentiated a
from cerebral tumour, general paresis of insane, ,GBI,drug addiction and
catatonic excitement.

Treatment:Drugs:- The common antidepressant drugs are imipramine, amitryptylene and
trimipramine. .The dosage is usually 75 mg per day which can be gradually
reduced to 50- mg.
In recent years Lithium carbonate has been found to be effective for
manic excitement and recurrent attacks of endogenous depression.
E.C.T. Endogenous depression especially withsuicidal preoccupation is an indi­
cation for E.C.T.

Involutional Melvnob»lia
Involutions! melancholia'is differentiated from other de--'
prcssive reactions by the initial appearence of the disorder during the
climacteric. The involutional period in women is usually considered to be
from 40 to 55 and in men 50 to 65.
Here the depression is similar to that of the depressive phase of ND? but
is usually coloured by paranoid delusions and hypochondriacal features.
Restless and agitation is very common. Nihilistic delusions may be present.’:
(intestines are missing etc.,).

The prembrbid..personality is characterized by rigidity, obsessive ten­
dencies, exaggerated concern with health and perfectionisem.
Treatment comprises of E.J^^h^^frtidepressant drugs. Suicidal risk
among these patients in very high and have to bo admitted and.treated by a
specialist.

PARANOID PSYCHOSIS

Paranoid psychoses are psychotic states which are characterized mainly bjc
paranoid delusions. These are paranoia, paranoid state, paraphrenia and
paranoid schizophremia, Paranoid ideas and preoccupations can be associated
with other conditions as secondary symptoms eg, frontal lobe tumors, endogenous
depression, myxodema, toxic psychosis etc.
Paranoia;- Here there is a gradual development of an unshakable delusional
system. This usually occurs late in life. Here the personality is well
preserved and social functioning is not usually handicapped prognosis is
poor.
Paranoid statesThese too have a later age of onset (usually during the
involutional period). There are florid symptoms, paranoid delusions not as
systematised as in paranoia, sleeplessness, fear and anxiety are present.
The onset is sudden. Phenothiazenes and ECT are the lines of treatment
and the response may be good.
Paranoid schizophremia is characterized by gross personality changes such
as paranoid delusions, brizzare thinking, lack of personal care and auditory
hallucinations.

PSYCHOSOMATIC DISORDERS

Psychosomatic disorders refers to a group of diseases where structual
lesions are produced in organs supplied by the autonomous nervous system
by the prolonged influence of emotional factors. The psychological factors
have a definete relationship to the onset and perpetuation of the symptoms.

The word 'psychosomatic' has another connotation. This emphasises the
importance of psychological factors in medicine and the need for treating a
patient as a total personality as psychological factors are relevant in all
disease. If they are not the primary importance in the causation of disease
they can be the results, eg. reaction to chrohio illnesses, pain etc.
Etiology:-The important etiological factors are the personality type
and presence of life stresses. The personality of psychosomatic patients is
described as "Conscientious" regid, ambitious, sensitive and uncompromising.
They usually repress their emotions such as anger and resentement and have
a high motivation to achieve success.
Emotional stresses produce anxiety which brings about disturbances in
hypothalamus and limbic areas, which in turn, through the autonomic nervous
system and endocrinal glands, produce changes in different systems.
Why a patient gets a illness in a particular system is difficult to
answer. It may be because psychosomatic tension take the least line of
resistance. The organs which are weaker because of inherent weakness of
because of injury to he organ by physical disease, generally become the
targets for psychosomatic lesious. The person with a weak gastro intestional
tract may develop pepticulcer when exposed to emotional stress for a long
time. Thus a predisposed personality, organ vulnerability and prolonged
emotional stresses in life are the main factors involved in the production of
psychosomatic disorders.

Clinical features:- Common psychosomatic disorders are
1. Skin disorders- Neurodermatitis cezema, acne, urticaria, some cases of hives
etc.
2. Musculoskelital disorders such as backaches, muscle cramps, tension head-,
aches, Rhumatoid artritis
3.
Respiratory disorders such as browchial asthama, hiecoughs rhinitus etc.
4.
Cardiovascular disorders include essential hypertension, migraine, Vascular
spasms.
5.
Gastro intestinal disorders such as peptic ulcers, ulcerative colitis musoous
colitis.
6.
Genitourinary disorders like amenorrhoea, oysmenhorrea premenstrual tension,
inpotency, frigidity, sterility*
7.
Endocrinal disorders like hyperthyroidism obesity etc.

Diagnosis:- ©notional factors can be demonstrated to be significant in the
production or perpetuation of the disorder. The course of the illness tends
to be phasic with periods of exacerbations, remissions and relapses.

Treatment:- involves both symptomatic treatment for the structural lesion and
psychotherapy, psychotherapy must be aimed to help him to cope with the life
stresses. Life stresses should be minimized where ever possible. The treat­
ment of psychesomatic disorders need good collaboration between the psychiatrict
and the internist.

: 4 :
occupational therapy etc.
The point of consideration here is not the ideal set-up,
but the minimum that is required and could be organised with
the available personnel. Equal emphasis should be paid to
training and service. If training is not adequate, the
growing rate of psychiatric clientele would result in poor
standards of service. Such a growth in psychiatric clientele
can be expected as shown from assessment of many general
hospital units (Jindal, RC,198O).

If properly planned and organised, one professor, one
assistant professor and a lecturer or tutor would be sufficient
personnel for administration, training and,rendering of ser­
vices in the hospital arid at the periphery. In addition, a
senior house-officer could be appointed, who would manage
day to day ward care, while being simultaneously trained to
become a specialist.

with regard to paraclinical staff, the need for a
psychologist is under-rated, by most centres. If a psychologist
is available, most of the psychological testing, behavioural
methods of treatment and long-term psychotherapy can be taken
care of by him, giving the doctor more time fox' other duties.

The social worker is perceived as a hospital-based
person involved in casework and day-to-day treatment programmes.
He can also be utilised in promoting tertiary care and orga­
nising rehabilitatory and placement programmes in co-oporation
with voluntary and governmental services that exist in the
catchment area. In this way, the individual’s organisational
ability is tapped along with his capacity for direct inter­
vention, although today's teaching programmes in psychiatric
social science empnasise the latter.
The inclusion of a trained nurse in this unit will
improve the standard of patient care and promote a positive
attitude towards psychiatry and its patients (Wig, NN,1978).

A statistician whose services will be required only
occasionally, could be shared with other faculties.
The above would form the basic outlay for the staffing
of a General Hospital Psychiatric Unit. As and when the need
for more personnel arises, staff may be co-opted on a temporary
or permanent basis.
: 4 :

Agarwal, A.K.: Psychiatric morbidity in medical students,
Ind. J. Psych., 15:347, 1973
2. ritish Medical Association: The mental health services
after unification, London, 1972.
3. Carstairs, G.M: Psychiatric problems of developing countries,
Ind. J. Psych. 15:147,1973.
4. Jindal, R.C. liemarajani, D K.: A study of psychiatric refer­
rals in a general hospital, Ind.J.Psych., 22:108,1980.
5. Kaufman, M R: The Psychiatric unit in a general hospital:
It's current and future role, International Univer­
sities Press Inc., New York, P:482,1965.
6. Khanna, u C. Wig, N.N. Varma, V.K.: General hospital
psychiatric clini - An epidemological study, Ind.
J. Psych., 16:211, 1974.
7. Malhotra, H.K. Wig, N.N: General physician and the psych­
iatric patient, Ind. J. Psych., 17: 191, 1975.
8. Neki, J.S..: Psychiatry in ^outh Last Asia, Brit. J. Psych.
123: 256, 1973.
9. Raft, D. et al: Inpatient and outpatient patterns of
psychotropic drug prescribing by nonpsychiatrist
physicians, Am. J. Psych., 132:1309,1975.
1C. Sengupta, S K.: Chowla, D.R.: Mental health in India, CBHI
technical studies - Vol. I, Issued by Central Bureau
of health Intelligence, New Delhi, 1970.
11. Sixth report on the world health situation - Part I.,WHO,
Geneva, 153, 1980.
12. Vahia, N.S. Doongaji, D.R. Jeste, D.V.: Twenty-five years
of psychiatry in a teaching general hospital (In
India)., Ind. J. Psych., 16: 221, 1974.
13. Varma, V.K. et al: General hospital psychiatric adult
Out patient clinics: Sociodemographic corrlates,
Ind, J. Psych., 21: 348,1979.
14. West, N.D. Walsh, M.A.; Psychiatry's image today: Results
of an attitudinal survey, Am. J. Psych.132:1318:1975.
15. Wig, N.N.: Psychiatric units in general hospitals: Right
time for evaluation - cditional, Ind. J. Psych.
20:1,1978.
1.

16.

17.

Wig. N.N. Varma, V.K. Khanna, B.C.: Diagnostic Character­
istics of a general hospital psychiatric adult
outpatients clinic, Ind. J. Psych.,20:262,1978.
Wig, N.N. Akthar, S: Twenty-five years of psychiatric
research in India, 16:48, 1974.

: 2 :

GN PLANNIN

A GENERAL HOSPITAL PSYCHIATRIC UNIT

India has achieved impressive levels in the control of
communicable diseases and has improved her sanitation and
nutritional levels, thus increasing the longevity of life.
However, a deplorable status exists in the quality of life
Indians lead. Mental health has remained a low priority in
our health planning.

The country has about 20,000 psychiatric beds for its
5.4 million psychiatric patients in 1973. Only 163,000 of
these patients wore given psychiatric facilities annually,
with one psychiatrist catering for approximately a million
population (Neki, J.S., 1973). Psychiatric units in various
medical colleges were either illequipped or non-existent.
These figures expose the quality of our mental health services.
The conditions have not changed much today.
There have been infrequent studies on the planning of
general hospital psychiatric units. This has resulted in the
isolation of these units into small mental hospitals within
the framework of consultation liasion psychiatry. The teaching
units of such hospitals have seldon imparted knowledge to the
many medical graduates trained in our country. If we have to
take care of the psychiatric morbidity prevalent in this country,
the general hospital psychiatric units have to be reorganised
and their teaching units activated.

NEED FOR GENERAL HOSPITAL PSYCHIATRIC UNITS
Review of mental hospital statistics from all parts of
India indicates that more than 9C% of the patients in mental
hospitals are psychotics (Khanna, BC, 1974), while the prevalence
rates according to epidemiological surveys show a high incidence
of neuroses. Psychoneuroses and personality disorders, many
of which present with somatic symptoms, make up the bulk of
the mental disorders in the rural and urban communities.
However, they are not conspicuous since this population is often
not perceived as mentally disturbed. A large number of them
is hidden among the masses attending the general hospital ser­
vices, where prevalence rates as high as 2Qk have been reported
(Neki, JS, 1973). As primary health services are developed,
increasing numbers of these patients are expected to seek help. T
They could be mismanaged, prescribed expensive drugs and
investigations. The teaching units of the general hospitals
are in a position to train medical personnel to recognise these
symptoms and manage them adequately.

2

: 3 :

The planning o£ a general hospital psychiatric unit

can be divided into three broad categories:
1.
2.

3.

Staffing
Services
A. Hospital Services
B. Peripheral Services
Undergraduate teaching and research.

Some of these units may also serve as post-graduate training
centres. If so, an appropriate programme should be chalked
out and integrated with the above.

STAFFING
The existing staffing pattern, bed strength and services
of psychiatric teaching units in general hospitals vary con­
siderably. There is insufficient guidance on the pattern of
staffing required and on the services that should be made
available at these centres.

The Tripartite Committee in the United kingdom suggested
the following staff for a district general hospital with a
teaching psychiatric unit of 25 to 30 beds (British Medical
Association, 1972).
Professor
1
Assistant Professor
1
Lecturer
1
Senior Registrar
1
Registrar (In training)!
Social Workers
2
Occupational Therapist 1
Psychologist
1
statistician
1

(Part-time)
(Part-time)

The WHO recommended that in countries currently deve­
loping their psychiatric services, a team comprising of one
or two psychiatrists, two social workers, a nurse with some
training in psychiatry and a psychologist may well form the
basic psychiatric service, while provisions are being made
for the development of more elaborate facilities.

Arising from the need for uniformity, the National
Academy of Medical Sciences has si laid down minimum require­
ments for psychiatric units before they can be recognised as
training centres for MNAMS examinations. These include 20
inpatient beds, daily out-patient service, a minimum of two
consultants and special services such as child psychiatry,

4 :

occupational therapy etc.

The point of consideration here is not the ideal set-up,
but the minimum that is required and could be organised with
the available personnel. Equal emphasis should be paid to
training and service. If training is not adequate, th©
growing rate of psychiatric clientele would result in poor
standards of service. Such a growth in psychiatric clientele
can be expected as shown from assessment of many general
hospital units {Jindal, RC,1980).
If properly planned and organised, one professor, one
assistant professor and a lecturer or tutor would be sufficient
personnel for administration, training and rendering of ser­
vices in the hospital and at tha periphery. In addition, a
senior house-officer could b® appointed, who would manage
day to day ward care, while being simultaneously trained to
become a specialist.

With regard to paraclinical staff, the need for a
psychologist is under-rated by most centres. If a psychologist
is available, most of the psychological testing, behavioural
methods of treatment and long-terra psychotherapy can be taken
care of by him, giving the doctor more time for other duties.
The social worker is perceived as a hospital-based
person involved in casework and day-to-day treatment programmes.
He can also be utilised in promoting tertiary care and orga­
nising rehabilitatory and placement programmes in co-operation
with voluntary and governmental services that exist in the
catchment area. In this way, the individual’s organisational
ability is tapped along with his capacity for direct inter­
vention, although today's teaching programmes in psychiatric
social science emphasise the latter.

The inclusion of a trained nursa in this unit will
improve the standard of patient care and promote a positive
attitude towards psychiatry and its patients (Wig, NN,1978).

A statistician whose services will ba required only
occasionally, could be shared with other faculties.
Tha above would form the basic outlay for the staffing
of a General Hospital Psychiatric Unit. As and when the need
for more personnel arises, staff may be co-opted on a temporary
or permanent basis.

: 4 :

: 4 :

SdRViCuS

h^SMir.L Sl.Ax.c-.
The services of a general hospital unit have to be
diversified into hospital care and outreach programmes.
The latter involves more of training than direct patient care
and will be discussed separately.

Daily out-patient service in the hospital is an
essential requirement. Studies pertaining to the inpatient
population showed that 80% of these patients could be managed
cn an out-patient basis, and that only 0.4% of them had to
be transferred to mental hospitals. Of the remaining number
who were treated as in-patients, 6C% had hospitalisation for
less than one month (Shanna, DC; 1974). These statistics give
us an idea of the im-patient requirements. One of the largest
general psychiatric units in the country, the K c M Hospital,
Bombay, has 3% of the total beds allotted to psychiatry
(Vahia, NS; 1974). Although the American Psychiatric Asso­
ciation recommends 15% of total beds in general hospitals for
psychiatry, which is one of the highest percentages recommended
(Kaufman, MR,1965), in our country with other important
priorities, approximately 2-3% of the general hospital beds
would suffice.

Out-,;atient services should also include special
clinics of importance, which are the Child Guidance Clinic,
in which management of the mentally subnormal group would
also be taken care of and the Student Counselling Centre.
Most general hospital^services do not include these special
clinics. The first is mostly forgotten, and the second^never
thought of. The overall frequency of psychiatric morbidity
among me&ical students appaars to be^nearly one-tbird^of^the
student population, with 13.5% oF”these~cases"belonging'^

j_Aqarw aj.. AC.1973)~7 As
compared to many western countries, the geriatric group
constitutes a smaller number of psychiatric patients in India,
and therefore, may not need e separate programme (Varma, VK,
1979). Similarly, alcoholics were not found in large numbers,
to justify a separate programme. However, the need for this
may arise in later years (Wig, NN, 1978),

the severe category__of grading

The tertiary care should preferably start within the
hospital and from there extend to the community. Decision as
to the placement and rehabilitation of the individual is made
and the agency is contacted by the social worker during hos­
pitalisation or active treatment. Once rehabilitated,

: 5 :
follow up of these cases and management of relapses have
to be carried out from the hospital. Apart from these duties,
the trained nurse and the social worker can promote attitudinal
changes in the relatives of patients towards mental illness.
peripheral services

Perpheral services run by hospitals cator to only a
minority of the needy people. Hence, the emphasis should be
on training health personnel located at the peripheral, in
detection and management of common cases. The priority of
services in our rural areas must be extended to three groups.
Firstly, the psychoneuroses and the personality disorders, many
of which present with somatic symptoms. Crosscultural studies
have shown that physical symptoms and hypochondriasis are more
common in Indian psychiatric patients (Neki, J.S.1973). The
psychiatric aspect of the patient’s illness gets clouded by the
physical nature of his complaints, hence he approaches the
general physician more frequently than the psychiatrist (Malhotra,
HK, 1975). Reports on non-psychiatrists* use of psychotropic
drugs show that antidepressants were often not used when indicated.
The major reason for their non-use was the physicians’ lack of
recognition of affective disorders (Raft ,D ,1975). Predominance
of somatic symptoms would increase the possibility of this error.
Training physicians at the Primary Health Centre and private
practioners would reduce the number of patients being errone­
ously managed. The second priority would be the chronically
mentally handicapped group of patients. This population is often
neglected as they do not by themselves come to the hospital. They
are also more susceptible to other illnesses which need attention.
Thirdly, epilepsy, though not a psychiatric illness, can be
easily managed with minimal training and cost.

Training of private practioners and of the doctors at
the Primary Health Centre can be achieved in a short time by the
psychiatric teaching units of general hospitals. They could
could undertake this programme in collaboration with the depart­
ment of community medicine.
The social worker plays a major role in peripheral
services in activating programmes for attitudinal changes, iden­
tification of cases, using traditional healers in health care
(Carstairs, CM, 1973), and promoting tertiary care in these
areas. In addition, periodic filed camps by psychiatric teams
would increase the awareness of psychiatric a care among the
local physicians.

: 6 :

CURRICULUM A-.D T8ADHINC

Psychiatric teaching in general hospitals includes three
different areas, namely, teaching of undergraduates, exchange
of ideas between the psychatrist and other medical disciplenes,
and research. The Medical Council of India gives periodic re­
commendations to medical colleges on the requirements of their
curriculum. However, most institutions fall short of these
guidelines. A separate examination in psychiatry or inclusion
of questions on the subject, as well as a satisfactory intern­
ship programme would reduce the prevailing ignorance. It is
preferable to begin teaching the behavioural sciences, namely,
psychology and sociology in the preclinic al years, and intro­
duce clinical psychiatry when the student enters his clinical
training.

An attitudinal survey on psychatry's image amongst other
medical professionals and students revealed that psychatrists
were viewed, different from other physicians, because, they did
not satisfy their identity as physicians and also isolated
themselves from the rest, of the medical community. The meaning
and use of psychotherapy was little known (West, ND, 1975).
Some of these attitudes have to be chanced before psychiatrists
can become efficient teachers. There is also an emotional
barrier between psychiatry and other hospital services, which
retards the scope for combine work and teaching programmes.
Diagnosis of psychiatric illness and use of psychotropic
drugs by other physicians are far below expectations. In a study
of psychiatric referrals in general hospitals, only 25% of the
referral diagnosis corresponded with the actual psychiatric dia­
gnosis (Jindal, RC, 1980.). The organisation of inter-departmental seminars and discussions would improve psychiatric
awareness in other physicians.
The general hospital units are specially suited for research
on psychosomatic illnesses, neuroses and variants of depression.
Patients with these disorders prefer to attend general hospitals.
In an evaluation of twenty-five years of psychiatric research
in India, the
(Wig, NN, 1974), made the following obser­
vations. There was an extreme lack of mp-to-date laboratory
research, which is probably the result of financial incapacity
and insufficienty of sophisticated equipments. They noted
that there have been very few prospective studies pertaining to
the natural history of mental illnesses, as they exist in India.

:

8 :

: 8 :

Scant attantion has been paid to psychotherapy in this country.
There have been no assessment of the efficacy of undergraduate
education programmes and present-day pattern of mental health
services.

CONCLUSION
Several seemingly contradictory tendencies that characteri­
sed mental health services in the past two decades have found
their resolution in the last few years. Controversies on the
relative priority of reseai'ch and services have also been resolved
by the recognition of effective, economically acceptable techniques
in treatment and prevention of psychiatric illnass (Sixth Report
on the world Health Situation, 1980). Although institutional
treatment still remains necessary for selected conditions at
certain stages of their development, community-oriented services
now have universal support.
Today, the general hospital psychiatric unit holds a key
position in mental health services. It is, therefore^ of vital
importance to strengthen these units and put them into more
effective use.
*********

*Vda

NATIONAL DAY FOR THE
MENTALLY
RETARDED
8 DECEMBER, 1976

A PROFILE IN
COURAGE
The parents of a retarded child
are most directly and cruelly
affected by their child’s handicap.
From the first awful moment of
discovery, and the feeling of utter
despair which slowly gives way to
resignation and through gradual
stages reaches an attitude of
acceptance, these courageous souls
survive an ordeal by fire. The
bravest of them all, rise above
their personal misery to accept
and embrace a larger world of
handicapped children. They start
institutions which cater for many
like their own child and help to
alleviate the sufferings of other
parents. They refuse to be beaten,
they revolt against defeatism.

To these courageous parents
we dedicate this special issue.

Considering the magnitude of the problem of Mental Retardation
in India today, the services to help them are pitifully inadequate. Worse
still, a fog of misconceptions and misunderstanding about the nature
of the problem separates them from an unenlightened public.
Mental retardation is not a medical problem. The condition is
determined before birth, exists at birth or develops in early infancy.
It is a life long condition and as such the question of cure does not arise.
Improvement can be effected but this too with prompt diagnosis, assess­
ment and proper education and training.
The 8th of December of every year has been set apart as the
National Day for the Mentally Retarded. Institutions—dealing with the
Mentally Retarded—all over the country, have programmes to highlight
the activities of the retarded and raise funds to better existing services.
The FWMR is a national body which helps to co-ordinate the
working of all affiliated institutions and encourages the initiation of new
services. We need financial help for our projects and many schemes
have not been implemented solely due to shortage of funds.

Your donation will help us to :

1.

Fund sheltered workshops

2.

Initiate farm—oriented programmes for the adult retarded

3.

Start a Foster Parent Scheme

4.

Build Residential Homes for the adult retarded

5.

Build Holiday Homes for all ages and categories of the
retarded

6.

Build up a Trust Fund

7.

A multi-category service home in Hauz Khas, New Delhi
is our immediate dream project.

May I count on you to help our efforts and donate generously
towards the cause of the Mentally Retarded ?
Yours faithfully,

ANNOUNCEMENT
There will be no separate issue
of our Newsletter in December.
'Your January issue will come to
you in the first week of the New
Year.
FWMR wishes all its readers
a very happy New Year.

(Mrs. Vasanthi A. Pai)
President, FWMR.

ELECTRICITY TO THE FORE IN
THE SERVICE OF MANKIND

Electricity has come to permeate our life as probably nothing else does.
It serves mankind right from the cradle to the grave in a way which is
truly fascinating.

Let us take the case of those who are mentally retarded or physically
handicapped. Electricity becomes a major factor in their rehabilitation
too. The electrical process is a ‘must’ in the manufacture of medicines
for them. Even when the scene shifts to the operation theatre, electricity
it is which keeps the show going.

No less positive is the role of electricity in creating avenues of self­
employment for such afflicted people. For it is through electrically
operated producing, processing or manufacturing equipment that diverse
types of ventures can be started with a view to finding gainful employment
for them.
While always at their service, the BIHAR STATE ELECTRICITY BOARD
assures them of its unstinted co-operation.

Issued by

Director, Public Relations,

BIHAR STATE ELECTRICITY BOARD
PATNA.

'MATION MANUAL 2
■

IELPERS

SORERMCIfONE

INFORMATION MANUAL 2

PSYCHOSOCIAL CARE

for
COMMUNITY LEVEL HELPERS

SUPERCYCLONE

Prepared by:
Dr K V Kishore Kumar - DPM; Senior Psychiatrist

Dr C R Chandrashekar - DPM, MD; Additional Prof, of Psychiatry
Dr Partha Chowdhury - DPM, MD; Assoc. Prof, of Psychiatry
Dr R Parthasarathy - MA, DPSW, PhD; Additional Prof, of Psychiatric Social Work

Dr Satish Girimaji - DPM, MD; Additional Prof, of Psychiatry
Dr K Sekar - MA, PhD; Additional Prof, of Psychiatric Social Work
Dr R Srinivasa Murthy - MD; Prof, of Psychiatry

BOOKS/w; CHANGE
A Unit of ActionAid Karnataka Projects

FOREWORD

Disasters pose a monumental challenge to the total
community. The worst affected are the people whose lives are
disrupted severely by the enormity of the tragedy. Their recovery
capacities are stretched beyond normal human limits. Equally
disturbing is the disruption by the social, economic and political
structures.

o

For too long, psychosocial consequences have been
neglected. It is only since 1984, after the Bhopal Disaster, that
both professionals and administrators have awakened to the need
to focus on mental health care of survivors of disasters.
The ORISSA Disaster like all disasters, poses the enormous
challenge of REBUILDING THE PEOPLE, RECONSTRUCTION
NOT ONLY OF SHELTERS AND LIVELIHOOD but OF
THE HUMAN SPIRIT. This information manual is part of a major
initiative in the overall relief and rehabilitation programme,
to organise mental health care. It is the joint effort of ActionAid
India and NIMHANS, Bangalore, going beyond the initiative
of OXFAM, India, after the National Workshop held in
December 1998.
The information booklet is unique because:
1.
2.

It addresses mental health care;

3.
4.

It is user-friendly;
It is a collaborative effort of professionals, voluntary agencies
and people - both survivors and concerned.

It is made available soon after the disaster;

We sincerely appreciate the contributions of all the authors,
Suresh M B, the artist and the Books for Change team for the
editorial and production assistance.

Dr Srinivasa Murthy R
Prof. Psychiatry Dept
NIMHANS, Bangalore

Harsh Mander
Country Director
ActionAid India

Post Supercyclone - Manual for CLHs

Generally from the same local area, these
people take up the task of helping as a priority.
They include - lay volunteers, basic health
workers, anganwadi workers, gramsevakas,
National Social Service (NSS) volunteers, civil
defence personnel, and other groups.
Role of the CLH
CLHs are a vital link between the affected
population and the helping agencies (individuals, Non-Governmental Organisations,
Governmental Organisations) arriving from outside the community. They are
likely to know the community and area well and have close ties with several people
in the locality.
Psychological problems following disasters often tend to be neglected. This happens
because they are relatively invisible when compared to the damage to life, physical
health and property. But it is important to remember that psychological problems
occur very commonly. Hence, early identification of this problem followed
by intervention help the survivor to recover. The distress is intense and
leads to helplessness, isolation and apathy. No one who witnesses a disaster is
untouched by it.
It is sometimes difficult to draw a line between rescue, relief work and psychological
interventions. An awareness of psychological consequences leads to a frame of mind
of being sensitive to mental health needs of the affected population. Actions can
arise from such a sensitivity.

At the early stages following disaster, most survivors are psychologically open and willing
to talk about their experiences. This may change later into a defensive, non-cooperative
attitude if time passes without attempts at providing help. Therefore, it is of utmost
importance that survivors are encouraged to seek help and talk about their psychological
problems as early as possible. As already mentioned, this intervention will prevent the
persistence of problems and development of further complications.

In general, people do not readily/directly
talk about their psychological problems.
Even during their visits to the health centres,
they generally report physical problems.
Psychological problems may be reported, but
indirectly manifested as vague aches, pains,
headaches, tiredness, etc. Remember, people
do however talk about themselves when given
an opportunity to do so.

Psychological intervention can be provided to the family in the daily visits by
monitoring and noting down information - all by the CLHs. Such visits are to be
utilised for talking about the survivor’s feelings and experiences, imparting health
education, discussion of health problems, motivating individuals to hold group
meetings, and organising educational activities.

Principles of emotional support
Need for emotional support for survivors of a supercyclone disaster is based on the
following broad principles:
® No one who experiences the event or witnesses the event is untouched by it

Disaster, depending on the nature and
magnitude can cause enormous loss to life,
property and the environment of the area.
Grief, sadness, anxiety, anger are common
in such situations. Individuals find comfort
and reassurance when told that their
reactions are normal and understandable
in every way. Therefore, CLHs help
to educate the survivors about common
disaster stress reactions, ways to cope with stressors and available resources to
respond to their needs.

• Disaster results in two types of trauma

Disaster-affected population have individual and collective trauma. Individual
trauma manifests itself in stress and grief reactions, while collective trauma can
severe the social ties of survivors with each other. These ties could provide
important psychological support in
times of stress. The loss of these natural
buffers in the community is less visible
and thus mental health interventions,
such as outreach, support groups
and community organisations which
seek to re-establish linkages between
individuals and groups are essential.
• Most people pull together and function
during and after a disaster but their
effectiveness is diminished
A disaster survivor is confronted with multiple stressors. In the initial phases
there is much energy, optimism and altruism. There is often a high level of activity

Post Supercyclone - Manual for CLHs

with low level of efficiency. As the reality of losses becomes more clear, frustrations
and disillusionment set in, leading to more
stress symptoms. This can impair the
survivor’s ability to make sound decisions
and take necessary steps towards recovery
and reconstruction.

• Disaster stress and grief reactions are
normal responses to an abnormal situation
Stress reactions and grief responses are
common in disaster survivors. Almost all
the individuals who are part of this event experience such reactions. Relief from
stress, ability to talk about the experience and passage of time usually lead to the
re-establishment of equilibrium. Public information about normal reactions,
education about ways to handle them, and early attention to symptoms that
are problematic can hasten recovery and
prevent long-term problems.

0

• Many emotional reactions of disaster
survivors stem from problems of living
caused by the disaster

Disaster disrupts all aspects of daily life
resulting in practical problems like finding
temporary housing, food, clothing, etc.
Timely and appropriate relief and support
measures are very vital to help survivors handle the disruption.

• Disaster mental health service must be uniquely tailored to the communities they serve
Mental health interventions should be based on the demography and characteristics
of the population. It is also essential to consider the ethnic and cultural groups in
the community, so as to provide help in a manner which is culturally relevant and
in the language of the people. Hence the
emphasis is that such programmes are
effective if workers indigenous to the
community and to its various ethnic and
cultural groups are integrally involved
in service delivery.
Survivors respond to active interest and
concern

Survivors will usually be eager to talk
about what happened to them when

I

approached with warmth and genuine interest. Workers should not hold back
from talking with survivors out of fear of intruding or invading their privacy.

• Interventions must be appropriate to the phase of disaster
It is of paramount importance to recognise different phases of the disaster and
varying emotional reactions of each phase. In the initial phase it is listening,
supporting, ventilation, catharsis and grief resolution. While in the latter phase it
involves handling frustration, anger and disillusionment.

• Support systems are crucial for recovery
The most important support group for individuals is the family. Workers should
attempt to keep the family together and the members encouraged to be involved
in each other’s recovery. For those who are orphaned or have become single,
support from other groups can be helpful.
• Attitude of the CLH

The Community Level Helpers need to set aside traditional methods, avoid use
of mental health labels like ‘neurotic’, ‘counselling’, ‘psychotic’, ‘psychotherapy’,
etc., and use an active outreach approach to intervene successfully in disaster.

Understanding the impact of the supercyclone disaster
Disaster-affected population experience various kinds of trauma. Physical injuries,
fractures and infections are common during the actual event, either due to direct
effects of the cyclone or as part of survival efforts used by the victims. Psychological
trauma immediately follows the event while socio-economic trauma like
unemployment, homelessness, environmental distraction and disorganisation
emerges as a consequence following the devastation caused by the disaster.

DISASTER TRAUMA
PHYSICAL

PSYCHOLOGICAL

SOCIO-ECONOMIC

a fractures
a burns
a injuries
a infections

a bereavement
a anxiety
a depression
a alcohol abuse
□ drug abuse
a stress reactions

a unemployment
a homelessness
a environmental
destruction
a disorganisation

After a disaster, the psychological reactions among members of a community may
vary and this also usually undergoes change over time. Therefore, post-disaster
psychological interventions should be flexible and based on an ongoing assessment of
needs, which depend on certain factors and their variables. The factors relating to this
are the following: the nature and severity of the Disaster, the supportive nature, the

Post Supercyclone - Manualfor CLHs

preparedness, previous experience of the Community, the age, character (strong- or weakwilled), single, widowed, married, personal losses of the survivor, etc. These are:
The DISASTER:

® occurrence
■ magnitude
a suddenness
a type

The COMMUNITY:

a level of preparations
a social support
a leadership
a past experience

The SURVIVOR:

a age
a level of education/exposure
a marital status
a physical health
s personality
a coping skills
a losses
a social support

Types of emotional reactions to disasters
It is only in recent years that the importance of emotional and psychological reactions
to disasters has been recognised. It is now clear that these reactions:

• are common and universal (no one who witnesses a disaster is untouched by it)
• manifest differently at different periods of time
after the disaster

• may continue for long periods of time causing
suffering and disability.
The different types of psychological reactions to .
disasters can be broadly categorised under 4
phases:

1. Immediate reactions (i.e. within hours to few
days)
Affecting almost all the population immediate
to the disaster, these reactions can be considered
normal to a traumatic experience and are
generally temporary or short-lived:

•

Tension, anxiety, panic

• Stunned, daze, disengagement

• Relief, elation, euphoria among some survivors
• Flight from the situation
• Restlessness, confusion, sleeplessness, repeated experiences of the events,
‘flash-backs’, nightmares, arousal symptoms

• Disorientation, wandering, loss of identity

• Extreme forms of reaction with agitation, aimless wandering, talking excessively,
crying and withdrawal from others.
• Survivor’s guilt.

2.

Immediate post-disaster reactions (one month to six months)
Reactions mentioned earlier tend to reduce with time, but may give way to other
symptoms, or they may persist. The new reactions that may appear include:

• Grief
• Apathy
• Lack of response to others
• Inhibition of outward activity
• Physical symptoms of anxiety
• Early symptoms of grief, and post-traumatic stress disorder (described later)
may appear during this period.

These are observed in about 40-50 per cent of the population.

o

3.

Delayed reactions (after 6 months)
These may appear after a few months or may manifest as an intensification of
reactions seen earlier (in about 30% of the
population):
• Grief: Grief is the response of the survivor to loss loss of close relatives, home, possessions and
property. People experiencing grief develop:

sadness, distress, depression, yearning for what
has been lost, anger, guilt, sleeplessness, loss of
appetite, severe irritability, suicidal tendencies,
being acutely upset and disturbed by anything
which reminds them of the loss.

Post Supercyclone - Manualfor CLHs

• Post-traumatic Stress Disorder: This is a response
of an individual having exposure to a severely
traumatic event. It manifests in the form of:
- reliving the trauma in intrusive memories or
dreams
- avoidance of all activities and situations
reminiscent of the traumatic event
- numbness, emotional blunting, and detachment
from other people
- hypervigilance (i.e. inability to relax, being always
tense), jumping at the slightest noise, fearfulness,
palpitation
- inability to enjoy anything
- panic reactions
- acute outbursts of violence may also be present.

4.

Other delayed reactions
These are:

• loss of productivity
• family problems

• excessive dependency on external help - alcohol and other substance abuse
• increased vulnerability to stress
• poor physical health

• suicide.
Chances of developing serious psychological reactions can increase because
of the following factors:

® ‘dose of exposure’ to the disaster.
• loss of close kith and kin and valuable property.
• lack of adequate community, social support.
• poor pre-disaster mental adjustment.
® separation/displacement from locality.

• separation from family/primary support group.

• physical injury leading to disabilities.
• absence of emotional support.

EMOTIONAL SUPPORT PRACTICAL GUIDELINES FOR
PSYCHOSOCIAL INTERVENTION
Losses due to the death of a near and dear one, separation from loved ones and material
losses are an inseparable part of human existence. Under normal circumstances, everyone
goes through this process without much difficulty because the family as a whole joins
together to understand the losses. Support from friends, relatives and neighbours occur
automatically. Rituals are initiated soon after the death, e.g.: family temporarily suspends
some activities, prayers are offered to the deceased, arrangements are made for cremation
and rituals are completed on a particular day by conducting the ‘shradh’ ceremony. All
these helps the individuals to understand the personal meaning of loss, and come to
terms with reality and to carry on with their lives.
However, in a disaster situation, normalcy of the social structure is lost because
each one in the area has been affected. The family as a unit no longer exists for many.
This leads to a sense of isolation, helplessness and despair. Therefore, the normal
process of mourning and the related rituals do not occur automatically. This means
that they have to be provided emotional support.
It is important to realise that rebuilding of an individual’s life and reconstruction of
the entire community following the disaster depend upon the survivor’s ability to
accept the losses as early as possible. It will help him/her to understand and
emotionally accept current reality and thereby work towards reconstruction of life
both at the individual, family and community level.

How does this intervention work to heal psychological trauma?
Let us now examine an analogy of a person with
an injury. An injury in any part of the body will
heal over a period of time because the body has
the ability to repair damage. The natural repair
process takes some time.

However, if this person gets immediate first aid
for his injury (e.g. cleaning the wound with
uncontaminated water and covering the wound
with sterile or clean cloth) the healing process will
be hastened, thereby pain and discomfort will
gradually reduce. But on the other hand, imagine
a situation where this help is not available and the wound is unattended. The wound
is likely to be infected and healing will be delayed, leaving a bad scar. This might
even cause some limitation in the normal functioning of that part of the body.

Post Supercyclone - Manualfor CIHs

It is important to note that in either case the scar remains
but in the former situation the scar is light and does
not produce a limitation. In the latter situation the scar
is dense and will produce limitation for a longer time.

Similarly, grief due to loss and death requires help to
facilitate ventilation/reliving and reprieving. This
works similar to a sterile cloth preventing infection,
allowing the body to work and heal. Non availability
of such help to grieve or neglecting the need to grieve,
leaves a scar in the mind. Therefore, it is absolutely
essential for every survivor to share grief and to come
to terms with the loss. This can be facilitated by
contacting survivors and helping them to relive and
grieve the losses...

Wound unattended

Relationship with people and the community
The supercyclone disaster struck the population who were normal people handling
their problems and coping with them in the best way possible. Stress consequent to
the disaster results in certain emotional reactions which are natural and normal.
Relationship with survivors depends on your rapport with them. Rapport refers to
feelings of understanding, interest and concern among two or more people. This can
be facilitated by:
• making sure that each person understands what the other is saying
• having genuine respect and regard for the other
• being nonjudgmental and accepting another even if he has different attitudes
and feelings

• establishing trust by promising only what you can do, not what you would like
to do
• listening several times to an account of the same disaster

• recognising that quite often what is actually said may be a cover for vastly different
feelings underneath.

10

Helping people help themselves

0

Under normal circumstances most people can
take care of their problems. The supercyclone
disaster being an abnormal situation,
equilibrium is temporarily upset because of
emotional reactions. Till such time the
survivors apply successful coping strategies
and handle their lives competently, they need
emotional support and help to identify,
define, evaluate and implement a problem­
solving strategy to reconstruct their lives. It is like extending help to a person who
has fallen on the ground. Extend your hand to help the person sit. Then slowly make
him/her stand and walk few paces with him/her. Gradually he/she will
walk independently.

Listening
Listening is an important skill to help and
provide emotional support. Listening skills
can be effective by using the following .
methods.

• Look at the person while he/she is talking :
This indicates being interested in what is
being said.

0

• Respond occasionally while listening:
This makes the person speaking feel that
what he/she is saying is being understood and taken seriously. Sometimes it helps
to paraphrase what has been said, often giving the speaker another viewpoint.
• Avoid interruptions: Let the other person finish his/her thoughts. Do not interrupt
unless there is confusion and the details are jumbled.
• Be tolerant: Do not prejudge or moralise or condemn. There may interpret how
the other person should feel.
Empathise: Share the experiences of the other person as if they are your own. It is
based on the sensitivity and ability to recognise when the other person is going
through certain feelings or emotional experiences.

Post Supercyclone - Manualfor CLHs

Interventions
Interventions can be planned at three levels, namely - individual, family and
community.

INDIVIDUAL LEVEL

Ventilation: This process involves release of emotions and feelings. It is a very
important intervention and should be used as soon as possible after the supercyclone.
■ STEP ONE:

Show the picture of the supercyclone and its fury - destruction and damage

Talk about the picture: This picture is so
familiar and vivid in your minds. It must
be so painful and traumatic for every one
of you to be in this unfortunate situation.
Your life has changed so much after this
event. Some of you have lost personal
assets, house, property, etc. Much worse
is the loss of your loved ones like parents,
siblings, children, spouse, grandparents
and grandchildren. It is so distressing to
know that they are gone forever. What
remains now are only their memories.
Life appears meaningless, full of pain and
suffering because the loss is too much to
bear. It is understandable that you are sad, grief stricken and preoccupied about
your losses.
■ STEP TWO:

Feelings and emotions associated with loss: unspoken bottled emotions-

Flood Gate: Catharsis

Grief: Need for support

Relief from Suffocation Ventilation : Release Pressure

Open your mind to
help healing

To facilitate reliving or re-experiencing of the painful events: While making the
survivors talk, the following can happen:
® Some of the survivors will talk immediately: Listen attentively. Acknowledge
that you understand his/her pain and distress by leaning forward. Look into the
survivor’s eyes; console him/her by patting on the shoulders or touching. Also
keep reminding him/her, “I am with you; be courageous. Its good you are trying
to release your distress by crying. It will make you feel better. ”

WHAT SHOULD YOU DO?
• Listen carefully and attentively.
• Maintain eye contact.
• Acknowledge distress.
• Do not interrupt.
o Support by patting on the shoulders/hold the hand as they cry.
CAUTION: be sensitive to community norms about touching members of opposite sex.

• Do not ask them to stop crying.
O Some survivors may not talk/they may be very angry or remain mute and

silent: Do not get upset that they are not talking. Remind them that you
understand how they feel, and the pain and suffering they are going through.
“It is true that pain is so much that you will feel that there is no point in talking
about it. I can imagine how much you miss your spouse/siblings/parents/
children/relatives/friends/teacher/neighours/house/cattle/school/roads, etc.
Memories of good days you spent with each one must be alive in your mind
and coming to your mind again and again. You must be tense inside! Try and
let the steam out, I am sure you will feel better.”

'osT Supercyclone - Manual for CLHs

WHAT YOU CAN DO?
• Do not get upset or anxious.
• Maintain interaction by reminding them about
- memories of the loved ones

- pain of separation
- distress of being alone

- helplessness

- isolation.
O Do the following: Do not panic or feel
rejected. Remain calm; tell them you are
here to help them in the best possible way.
Acknowledge that you understand their
distress; the frustration, emptiness and
also the subsequent anger because of the
vacuum created by the loss. Share in their
grief and console them that losing
someone dear is terrible and unfortunate.
Also make them understand that they are
not to blame for the tragedy and need not feel guilty.

In case the person does not wish to talk, tell him /her that you will return the next day
or in a couple of day. Also tell him/her that you are not upset or angry because he/
she did not talk. Meanwhile ask him/her to think about whatever has been told.
• Use the Destiny Story: When the survivor is the only one alive, with all others
dead, he/she must be feeling angry and guilty. This is when you should use the
destiny story to convey that whatever is destined will happen.
“Is zindagi mein hum do din ke mehman hain. Yeh to hakeekat hai. Idhar
kabhi hasna aur kabhi rona hota hai. Is sachhai ko man lene mein hi hamari
bhakai hai”.

(The truth is that each one of us is a visitor in this world. During our stay here there
are some moments ofjoy and some of sorrow. This truth cannot be altered.)

As an example you can narrate a story from an
epic like the Ramayana: Lord Rama had gone into
the forest and had instructed his brother Laxman to
stay in the hut and keep a watch over Seetha Devi.
But when the attractive golden deer was seen outside
the hut, she insisted that Laxman should go out and
bring it to her. He did so and just at that time a
mendicant came by. Seetha realised that she should
not cross the ‘Laxman Rekha ’ but at the same time
she could not refuse him alms. But the mendicant
refused to accept the alms with her across the threshold. Hence, Seetha crossed over and was
kidnapped by the mendicant who transformed into Lord Ravana. This is destiny. Despite Lord
Rama’s instructions, Laxman left Seetha all by herself; despite Laxman’s caution, Seetha was
overcome by her hospitality and ignored the warning. She crossed the threshold and therefore
had to undergo a lot ofagony.
Remember: whatever is destined to happen will happen. No matter what we do, we have
no control over that. Therefore, let us accept reality.

Similar stories can be identified from the community and used appropriate to the
community - something from the Koran, the Bible, etc.
To continue interaction, explain further:
Our life is a mixture ofJoy and sorrow. All of us have our share ofboth and have to experience
this kind of sorrow some day or the other. It’s unfortunate that your turn ofsorrow has come
so early. Tomorrow it could be me. Please remember, all of us will have to go through some
experience of loss.

Be alert: Throughout the interview remember to acknowledge that you can understand
his/her pain. Keep reminding him/her that the responsibility for whatever has happened
does not rest with him/her. For having survived, he/she may feel ashamed and blame
him/herself. But this is understandable and normal to the situation. Getting angry on
this account is natural.

Advise the person that:
• Happy memories about the dead makes us remember them more: Trying to
remember happy memories can sometimes help in a vivid recollection of the
deceased which in turn may lead to an acute sense of loss, sorrow and an emotional
outburst of tears. This recollection would include shared past activities, soft loving
words, and everything he/she did when he/she was alive.

Post Supercyclone - Manna!for CUis

• Every moment in our life is stressful. Such situations make us feel that life has
come to a standstill, feeling all alone. However, the fact is that life should go on.

• The more he/she gives, the more he/she achieves. Once the person has started
talking about the loss and personal grief, he/she feels better. It becomes easier to
take stock of his/her life and understand the vacuum (a feeling of emptiness)
created by the loss. This will facilitate more support to rebuild his/her life.
Hence, the more he/she releases the pent up feelings, the lighter you feel.
To address the other needs of the survivors attempt to do the following:

Once the survivor is willing to talk, maintain conversation using the following
format:

■ How is his/her life and also that of the other family members after the
supercyclone?
■ Focus on various kinds of loss - details about all the losses he/she and the
family have experienced.
■ Feelings associated with loss. How does he/she feel about the loss? - Personal
meaning of loss, etc.

■ Details about the support/help received immediately after the event from
friends/neighbours/relief workers, etc.
■ How has he/she been recovering? - details about how he/she is handling
this situation, (e.g. some individuals become very religious and pray more).
■ Effects of the event on health, like physical problems or problems like aches/
pains, decreased sleep, decreased appetite, fear, loss of interest.
■ How is the future visualised?

■ What is the help/support needed? - Should the CLH visit frequently, talk
about the event, to understand and solve life problems, etc.?

• Relaxation Exercises

Encourage survivors to undertake relaxation/yoga exercises
regularly several times a day. This helps them gain control
over their agitation and anxiety.

Instructions: The person should sit in a squatting posture and
place his/her hands on the knees. Then take a deep breath, hold
it for a few seconds and slowly exhale. Encourage him/her to do
it for 5-10 minutes steadily and slowly. Repeat this at least
twice a day.

The family can undertake this exercise in a group.
Another similar technique very useful for relaxation is:

Instructions: The individual should lie on the floor and relax
his/her entire body. Ask him/her to close the eyes and take a
deep breath, and slowly exhale. This exercise should be done
for 5 minutes several times a day. Concentrate on incoming
fresh air and outgoing warm air.

SC/TT—

Note: These activities can also be repeated at the end of group meetings in the
community settings.
Practical help for the individual:

✓ Listen to authentic information about the supercyclone.
X Do not believe in rumours that go around during such times.

✓ Be together with family members.
X Do not send women, children and the aged to far off places for the sake of safety

as this separation can cause a lot of anxiety to them and you.

✓ Be with people from the same village, i.e. people you are familiar with, even if
you are in temporary dwellings.
✓ Get back to a daily routine as soon as possible to make you feel that you are in
control of the situation.
✓ Make it a point to talk about the supercyclone,
share your experiences and feelings with your
family, your parents, friends, spouse, siblings,
acquaintances. This will help ventilate/release
your emotions.
✓ Restart activities that are special to your family
like having meals together, praying, playing
games, singing, etc.
Keep touching and comforting your parents,
children, spouse and the aged in your family. This
will not only make you feel good but also make
the other person feel the same.
Initiate and participate in rituals like collective
grieving, prayer meetings or group mournings if
you have lost a near and dear one. This will help
you come to terms with the loss of the person.

Post Supercyclone - Manualfor CLHs

✓ Take part in rescue, relief and rehabilitation operations if you are not hurt or
only slightly injured. Work is a good tonic for healing.
✓ Keep in constant touch in case of a member of the family having to be shifted to
a far off hospital or residence. Update him/her about yourself as well as find out
about him/herself. This gives a feeling of being cared for.

✓ Take time of everyday to relax and have a good time by gathering together at a
central place, playing kabbadi, reading, listening to music, visiting shrines, singing
hymns, chanting prayers, reading scriptures.
✓ Make time for yourself and acknowledge and admit that you will not be always
functioning at your usual level of efficiency for a few weeks/months.

Help and seek-help behaviours

Following is a list of behaviour patterns you can use as a guideline to identify
individuals or families with whom you can work and probably help: Some out of
these may be in a state of mind where they may require the help of a mental health
specialist or other professional assistance.
CAUTION: Referring a person to a mental health specialist will require tact and sensitivity
because offactors like social stigma, etc. Help may be essential but the individual may not
readily accept referral for a variety of reasons. However, the first task is to be able to
recognise when it may not be within your own capabilities and skill to help a person and
thus you have to refer him/her for professional attention. Such cases should be discussed
with the trainer.
Considering alertness and awareness:

The CLH can handle the situation if the client is:
• aware of who he/she is, where he/she is, and what has happened

• only slightly confused or dazed, or shows slight difficulty in thinking clearly or
concentrating on a subject.

Consider referral to a mental health agency if the client:
• is unable to give his/her own name or names of people with whom he/she is living

• cannot recollect the date or state where he/she is from or even tell what he/she does
• cannot recall events of the past 24 hours
• complaints of memory gaps.
Considering actions
The CLH can handle if the client:

• wrings his hands or appears still and rigid or clenches his/her fists

• is restless, mildly agitated, and excited
18

• has sleep difficulty
• has rapid or halting speech.

Consider referral to a mental health agency if the client:

• is depressed and shows agitation, restlessness, and paces up and down
• is a pathetic, immobile, unable to move around
• is discontent
• mutilates him/herself
• uses alcohol or drugs excessively
• is unable to care for him/herself, e.g., does not eat, drink, bathe, change into fresh
clothes
• repeats ritualistic acts.
Considering the Speech
The CLH can handle if the client:

• has appropriate feelings of depression, despair, discouragement
• has doubts of his/her ability to recover
• is overly concerned with small things, neglecting more pressing problems
• denies problems or states he/she can take care of everything himself
• blames his/her problems on others, is vague in planning, and bitter with anger
that he/she is a victim.
Consider referral to a mental health agency if the client:

• hallucinates - hears voices, sees visions, or has unverified bodily sensations

• states the body feels unreal and fears he/she is losing his/her mind
• is excessively preoccupied with one idea or thought
• has the delusion that someone or something is out to get him/her and the family
• is afraid he/she will kill him/herself or another

• is unable to make simple decisions or carry out everyday functions
• shows extreme pressure of speech - talk overflows.

Considering emotions

The CLH can handle if the client:
• is crying, weeping, with continuous retelling of disaster

• has blunted emotions, hardly reacts to what is going on around him/her right now

19

Post Supercyclone - Manual for CLHs

• shows high spirits, laughs excessively
• is easily irritated and angered over trifles.
Consider referral to a mental agency if the client:
• is excessively flat (not wanting to move), unable to be aroused and completely
withdrawn
• is excessively emotional and shows inappropriate emotional reactions.

Referral Care Centres

The first referral centre for you would be the Primary Healthcare Centre (PHC). The
doctor at this centre would be able to provide appropriate care.

However, if you feel that visiting a Psychiatrist is more beneficial and if there is a
facility in the neighbourhood, then refer the individual.
FAMILY LEVEL

Practical help for the family

In addition to individual specific interventions, the family as a whole can also be helped
simultaneously. This depends on the number of individuals surviving in the family. If
some family members are present, encourage them to practise the following activities:
® the Family as a group to share the losses

• Encourage family members to contact relatives. This will help mobilise support
and facilitate recovery.
9 Rituals like prayers, keeping the dead persons photographs, preserving the
belongings of the dead person or persons.
9 Encourage the survivors to engage in meaningful activity as a family.

9 Recreation like listening to Radio, TV or visiting melas.
9 Resume normal activities of the pre-supercyclone days with the family
9 Support each other at home. Emphasise that the family should regularly undertake
activities together at home.

COMMUNITY LEVEL
The following activities help in rebuilding of community life:
■ Group mourning: Grief resolution should occur at the personal, family and the
community levels. Group Mourning is a process of mass grieving. It expresses
solidarity of the grief-stricken community and facilitates unity and collective action.
Such activities should be initially organised on a weekly basis, gradually on a
monthly basis, and later annually.
- ----------------- 20 -------------------

a Group meetings: Group meetings are important activities where the community
as a whole participates. This stimulates the people to think, and brainstorm about
various themes for rebuilding the community. This not only helps the community
to come to terms with the reality of loss and emptiness but also helps them to
initiate collective action and rebuild their lives. It is also an important technique
of DISTRACTION.
■ Folk songs: Singing of folk songs about the
supercyclone tragedy, its impact and then
mourning. This helps people gather in a
common place and share their grief. There
is a sense of commonality in grief that
increases the cohesiveness of the
community and motivates them to initiate
collective action.
□ Devotional songs: Singing devotional
songs like hymns/bhajans, etc. is helpful.

□ Rally: Organise a rally to sensitise the administration regarding delays in
implementation of action for restoration, rebuilding, relocation, compensation,
etc. It is also a powerful expression of solidarity, “All for one, one for all”, show
of strength and action to fight for a just cause.

If family members are not available or if he/she is the only survivor with children or
is alone or is old, then the interventions at the individual level should continue in
addition to these activities.
If the survivor is a child or a minor, encourage others in the village to take care of the
child. If there are no takers, think of relocating him in Mamtha Gruha (Home for
children without parents and women who have lost their families).
Remember:

Encourage the family or the survivor to get back to the routine kind of activities
done by him/her/them during pre-supercylone days.

Group participation for rebuilding
facilitated by ‘Shramadhan ’, for e.g.:
clearing bushes to create a playground
for children, putting up a temporary hut
for a school; providing food for those
who are the only survivors or those who
are disabled or dependent.

Post Supercyclone - Manualfor CLHs

• Encourage survivors to discuss about local
problems and initiate collective action like:

Rebuilding schools
Roads
-

Restoration of power/water

Rebuilding houses

Access to medical care
-

Representation if compensation payments are delayed.

© Involve religious leaders, opinion leaders, professional mourners, panchayat
members in all these activities.

• Sensitise the group about ‘rumours’ and ways to handle this as a group.
Encourage people/survivors to share their success stories (recovering from the loss)
with others during group meeting. This will make them feel good and also benefit
others who need help to come to terms with reality.

Issues likely to come up during your work in the Held:
Rumours may become rampant following disasters and they often have a negative
effect on the mental health of the affected population. The daily visits described
earlier can be utilised for rumour control and clarification. Also information meetings
can be organised to communicate available, authentic information.
It is advantageous to speak to the families (including children) in their own homes
(temporary or permanent), about their mental health problems. During these visits
it is important that the CLH accepts hospitality of any family (like drinking water,
juice, coffee/tea, etc. if offered). This will help to build a rapport.

The local community on its own, starts responding appropriately and effectively to
the disaster by using healthy coping strategies. So, one important task of the CLH is
to encourage, initiate, sustain and guide such local community action. The CLHs
can take the initiative to organise community-based actions specific to the local culture
in order to alleviate mental suffering. These activities could involve: chanting prayers,
singing hymns and folksongs, group celebration of rituals/ceremonies, group rituals/
ceremonies, group celebration of religious activities, performing street plays,
folksongs, skits etc.
It is natural to have many misgivings about the encounters with survivors: “Will
they be cooperative? Will they reject me? Will they not get angry with me for making
them talk about painful things? Am I doing something wrong by focussing their
mind on something which is best forgotten? How am I different from crowds who
visit places of disaster just out of morbid curiosity?” Also, the fear of facing the
affected people, feelings of helplessness in the face of the magnitude of the problem
may also be experienced by the CLH.

Note: What has to be constantly remembered is that one’s own genuine concern and
care about human suffering and the need to contribute one s efforts to alleviate suffering
should be the overriding factor.

Some workers may fear that one might lose control and start crying while speaking to
affected people. It is perfectly normal to have this fear and there is nothing wrong in
crying along with people.
Like any problem, early detection of psychological problems and their remedies/
alleviation can prevent them from growing bigger at a later time. This is the preventive
aspect of mental healthcare.
Compensation
Sometimes issues like who should handle compensation money can cause conflicts,
e.g. a young widow might feel that she should handle the money, whereas the motheror father-in-law or brothers-in-law could take offense about this. It is common for
parents of the deceased to feel helpless and let down. Allow the family to think
through the problem and come to consensus themselves. It is important to make the
family feel together and cohesive and take consensus decisions.

Note: Best way to deal with the above issues -you should not take sides or decide for the
family about any issue. Be non- judgmental and neutral.

Other supports
Practical help for the individual and the family:

After contacting the survivor, establish a rapport, facilitate reliving and grief
resolution, look for or enquire about the need for any specific help which could be:

© Compensation
© Guidance to get compensation

© Help in filling forms/opening a bank account or post office account.
• Practical help like getting forms/accompanying survivors to the office or helping
the individual open a bank account, etc.
• Medical help if need be.
• Request/Mobilise help from neighbours/others to support the single young
survivor or old destitute survivor, etc.
• Help with agricultural work
• Food-for-Work Programme
• House building, fishing, etc.
23

Post Supercyclone - Manual for CLHs

Coordination with other agencies:
As part of psychosocial interventions, in addition to providing help for emotional
difficulties, help to network and coordinate with other agencies is also important.
For e.g., coordinating with NGOs working on specific rehabilitation and
reconstructing activities or other governmental agencies.
Tips to make you an effective community worker

DOs
✓ Visit families regularly
✓ Accept food or drinks like coffee or tea if offered

✓ Help survivors to get medical care or other help if needed.
✓ Provide clear guidance about compensation or ways of getting it.
✓ Provide practical help whenever necessary.
✓ Facilitate networking among survivors.

✓ Contact relatives (e.g. writing letters) and appeal to them to meet and support
survivors.

DON’Ts:
X Do not promise things you cannot do or things beyond your control.

X Do not take decisions for them for e.g., marriage or money handling, etc.
X Do not get upset with the behaviour of survivors. Sometimes they are unreasonably

angry/blame you for causing trouble to them by your frequent visits, or at times
they might be very demanding.
X Do not miss appointments.
X Do not overburden yourself with lot of work.
X Do not take sides in family conflicts.

Attention
Community level helpers need to take extra care when providing help to certain special
groups in the affected population. This group may not volunteer for help readily, for
example, children may not talk freely or remain withdrawn. Similarly, marginalised
persons may not come forward for help because ofdiscrimination by the local community.
It is important therefore, to note that disaster has a quality of equity'in all humans and
therefore the healing process automatically should have equity.

24

Conclusion
This section has outlined the various ways of understanding the behaviour of the
disaster-affected population and measures that you can take at the level of individual,
family and community.
The Appendix Section which follows has the following information:

1.

the group activities you can use to facilitate psychological understanding.

2.

illustrative situations.

3.

how to care for yourself?

— 25

Post Supercyclone - Manualfor CLHs

SUMMARY

Levels of Intervention

Family

Community
X Group mourning
x Folksongs
x Group meeting
x Voluntary work
x Rally

x Support each other
x Stay together
x Contact relatives
x Display photo/
belongings
of the dead person
x Family grieving

Individual

Administration
x Compensation
x Help for
reconstruction
x School
x Hospital
x Home

X Ventilation
X Catharsis
X Coming to terms
with loss
x Seek support/
Network
X Resume routine
x Avoid conflicts

x Coordination
x Relief &
Rehabilitation
x Schools
x Homes
x Innovative
agricultural
initiatives

Activities of the CLH

PPENDICES
Appendix 1
GROUP WORK
Group work is a powerful activity to initiate collective action. Experience suggests that in a disaster population
survivors have different needs. Responding to such needs on an individual basis can sometimes be controversial,
for e.g. in a disaster population, the community consists of various strata of people. It is common for people to
demand for a particular type of help. Some might even refuse to participate in community building activities
because of their social status before the disaster. This can be barrier for forward movement. Hence it is imperative
to maintain equity in rebuilding activities and not allow people to bring in their individual bias because of their
social status. Such a delicate issue can be handled by encouraging the survivors to participate in games focussing
on problem-solving techniques.
The knot game is one such game that can be useful in such activities.

How to play:
Knot game is a creative way of generating or stimulating a problem. Select even number of participants, i.e.
10 or 12 members, and create separate male and female groups. Give them the following instructions:

1. Stand in a circle close to your neighbouring partners on the left and right.
2. The knot can be created by each holding the other's hand gently but firmly.
3.
Do not hold the hand of the person who is standing on to your immediate right or the left. Also instruct
them not to hold both hands of the same person.
4.
Do not leave the shake hand grip till the end of the game.
What do you expect?
Formation of one circle or more, with participants holding hands and facing the inside of a circle.

What is the conclusion?
After completion of the game encourage the participants to talk about the various steps/processess involved in
formation of the circle. It will invariably be found that the final result of forming the desired circle was achieved
because of the following:

1. Cooperation of the group
2. Leadership
3.
Hardwork
4.
Examining alternatives
5.
Some problems can be solved, while some cannot.
6.
Managing stress
7.
Working in a goal directed manner
8.
Thinking creatively, etc.
Following rules correctly
Commitment to participate and learning to solve problems.

It is important to link up this issue as the problem and encourage group members to collectively apply their

27

Post Supercyclone - Manualfor CLHs

mind to find common solutions to rebuild their lives. The topics that can be used to understand and work upon

problem-solving methods for the community as a whole follow:
Issue
Reconstruction
What next
Now or Never
Religious meaning
Working with NGOs
Working with Administration

Action
A way to move forward
Examine alternatives
Need for collective action

Grief resolution
Networking
To make administration/assertively demand action, etc.

Appendix 2
ILLUSTRATIVE SITUATIONS
Illustration 1:
Mr A was a very hard working, successful diesel mechanic and he owned a small workshop. He was earning
about Rs500-800 per day and lived with his family consisting of his old father, wife and 2 sons. On the fatal day
he was in the village and was very apprehensive about the consequences of the storm and rising water level.
He lost his father, wife and 2 sons during the cyclone. He also lost his prosperous business, which was located
in Erasama. Since then he is withdrawn, does not mix with others in the village; even when someone talks to
him he hardly speaks, cries silently from time to time, feels that his life is not worth living and feels that it
would be better if he was dead. His sleep is disturbed and he wakes up in the middle of the night because of the
dreams of that fateful night. Even after 8 weeks of the cyclone, Mr A continues to be withdrawn, looks dull and
grief-stricken. As our team was talking to him he reported that the most distressing aspect of the entire episode
was his helplessness in that situation. He could not save and protect anyone of his family members. He, however,
was able to save his brother's son. But this makes him feel very guilty that he could not do the same for both
his sons.
Mr A feels depressed and cries very often. He feels ashamed that he is alive while all his family members are no
more. He was hoping that at least his younger son will survive, but God has not been kind - his younger son
succumbed to pneumonia. Mr A feels his life has no meaning and finds it extremely difficult to handle loneliness.
He however works in the 'Food-for-Work' Programme and earns RslO/- + 2'/2kgs of rice. He finds it very
difficult to accept this option and quality of life. Nevertheless he feels that he should work atleast to feed
himself.

Key aspects of this illustration:
■ A middle class well settled individual who was a successful business man.
■ Multiple losses of all his family members and business.
■ Feels guilty that he is alive while others in the family are no more.
■ Feels depressed, cries often, and questions himself whether he is a weak person because of this
■ Though slow and withdrawn he has decided to work in the 'Food-for-Work' Programme because he has
to survive.
■ Haunted by recurrent memories of the traumatic event.

Illustration 2:
Ms S is an 18-year-old lady who had completed 10 years of schooling. She was married to a man who was the
most educated in that village. She had dreamt of a beautiful life ahead and was happy that God has given her
a very understanding, highly qualified and caring husband. Little did she realise that all her dreams would be
28

shattered by nature s fury on 29 October 1999. Ms S reported that she has not heard from her husband since
ctober and hopes that he will return some day. She however saw the bodies of her father-in-law and two
of her brothers in-law.
Ms S has a faint smile of hope on her face and still entertains the idea that her husband will return some day.
This attitude of hers amuses her neighbours in the village and her own relatives. They often think that there is
something wrong with her because she believes that the death of her husband may not be true. She continues
to wear a bindl, bangles and adorns her hair with flowers.

As we spoke to her about the traumatic event she did not seem distressed. Most of the people around remarked
that she is totally indifferent because she smiles whenever people talk to her about her husband. As we continued
to talk to her about her marriage, husband and what she had thought about their future, tears started rolling
down her cheek slowly and steadily. She said that her husband had completed MA in arts and was due to
appear for the Orissa administrative service shortly. She remarked, "How can I believe that this will not happen?"
and continued to weep. She also reported feeling less energetic, sleepless, and was eating less. She told us that
her mother-in-law, brother-in-law and other relatives had decided about the 'Shraadh' ceremony about a month
later. They have planned this because otherwise they will have to wait for at least 90 days to presume that her
husband is no more. Ms S continued to weep and said, "If this is what God has destined for me what can I do?
I have to accept His verdict and I will do something meaningful in my life". She plans to assist teachers in the
school and help volunteers to take care of children in Mamtha Gruha.

Key aspect of this illustration:
■ A young responsible woman, loved and admired by her husband and in-laws.
■ Multiple losses of her house, her husband, father in-law and several relatives.
■ Did not show any feelings or grief about the loss initially.
■ As the interaction continued she wept continuously.
■ Reported feeling weak, sad, and hoped for another cyclone and wished that she be swept away.
■ Wants to assist school teachers in the care of children, and volunteers to take care of orphaned children and
destitute women.

Illustration 3:
Mr P is 40-years-old and was a happily married man with three children. He lived with his father and mother.
He worked as a labourer and was contended with this life, despite poverty. Little did he realise that his satisfied
life and feeling of contentment would soon lead to helplessness and despair after the cyclone. He says he is
devastated by nature's fury. He cannot tolerate anymore - his house was washed away and his entire family
disappeared in a short time. The trauma has caused such a deep hurt in him that he has migrated to a village 12
kms away from his native village. His new friends are very concerned about him because he remains dull and
preoccupied most of the time. They describe him as a man who walks and follows commands but has no life in
him. They also say that he does not express any feelings like sadness or anger even though others with similar
trauma show it. When we interacted with him he answered in monosyllables. He admitted nodding that he
cannot handle loneliness and is unable to accept the devastation in his life. He wonders why he was given such
a harsh punishment by God and thinks he does not deserve it. Even though he was verbalising very little he
was able to speak out his mind expressing no feelings about the event. He feels that he has reached a point of
no return and does not know what to do about it. His friends in the new village keep talking to him. support
him, they give him food and encourage him to get involved in some activities, while constantly reminding him
that he should talk about what and how he feels.
Mr P responds by nodding that he remains awake most of the night, feels very tired and disinterested, eats less
and moves around slowly. He does report feeling sad but does not elaborate.

Key aspect of this illustration
B A middle aged man who lived a contended life despite poverty.
■ Devastated by multiple losses of his house, three children, wife and parents.
B Remains withdrawn, dull, preoccupied and talks very slowly in a low tone voice.
29

Post Suprrcyclone - Manual for CLHs

■ Does not show any feelings
■ Migrated to another village and is receiving support from friends who did not know him before the cyclone.
■ Has not been working for his living since the event but passively responds to instructions from his friends.
Illustration 4:
Mrs M is a 30 year old married lady who lived happily with her fisherman husband. They had two children
and the family was reasonably well off financially. Since she had two daughters, Ms M longed for a male
child and is currently pregnant. The recent cyclone has devastated her life completely. Both her children and
father in-law were washed away by the massive tidal waves and her husband who went to sea never returned.
Ms M sits alone wondering what has happened to her and her family. She feels isolated and helpless all the
time. She recollects all her family members. All her belongings have been washed away and there is no trace
of her house. She says that her tears have dried up and asks why God has been so cruel. She wonders why
disaster struck her at this stage of her life and is worried as to who will take care of herself and her unborn
child. She currently lives in a family of all widows who have lost their husbands. The head of the family,
Ms N has accepted her as another daughter-in-law and has been caring for her since the disaster struck
Ms M’s family.

Ms M reports feeling sad, cries all the time, has not been in good health and traumatic memories keep hounding
her. She says she would have killed herself but for the support she received from Ms N. Ms M has not been
working in the 'Food-for-Work' Programme, does not want to live in the temporary shed likely to be put up as
a measure of relief because she feels extremely scared. She has to be forced to eat on a regular basis.

-

Ms M is unsure about her future, has lost direction in her life and is totally dependent on the foster family. She
also says that her parents who lived in another village with her brother are also no more and feels this entire
life ahead looks dark for her. She continues to bear her chest and cry.

Key aspects of this illustration:
■ 30 year old housewife from lower middle class.
■ Currenty pregnant and with multiple losses of her house, husband, children, parents.
■ Suffers from depression, sleeplessness, constantly preoccupied with loss and has recurrent traumatic
memories.
■ Has not been working and refuses to live in a temporary house erected as part of the relief programme.
■ Lives with her neighbours where 4 ladies have lost their husbands.
■ Helps in household activities as and when necessary.

Illustration 5:
Mr A M. a 45-year-old married belonging to the upper middle socio-economic strata, lived with his wife and
two children. The family lived in a good house with reasonable comforts. Following the disaster, he says his
house does not exist and all his valuables have been washed away. He reports that the entire family lived on
wet rice for three days and they had to be content with 2 pairs of soiled clothes which they could salvage.
Though the structure of his house exists there are no doors or windows and he feels miserable to live in such
conditions. He feels that he and his family members have to accept this verdict of God and he has no complaints.
He does report feeling tense, anxious, and has headaches from time to time. He also feels like crying but he
feels that by crying, he will let his family down and cause more grief to his wife and children. He also thinks
that his family members will consider him a ’weak man’ and lose hope for the future. He thinks that the best
remedy for him and his family is to forget this entire episode and look at life positively. Despite 8 weeks after
the disaster Mr A M has not talked about this event with his family members. After he goes home the entire
family consisting of wife and two children form three isolated islands of their own, and remain silent and look
at the floor.
Key aspects of this illustration:
■

Upper middle class family.

■

Material losses.

30

'

s

Feels tensed, angry, worried, sleepless and has recurrent memories of the trauma.

□

Feels like crying but never did so.

s

Feels that if he talks about this event, he might cause more grief.

Illustration 1:
How can you help this person:

The illustration clearly reveals multiple losses, sadness and grief consequent to that, guilt that he is alive while
others are no more and feeling of not being in control of the situation.
□ Firstly help him ventilate his feelings and emotions.

□ Reassure him that crying over the loss is not a sign of weakness.

a Help him understand that often as human beings we can be in situations, e.g., supercyclone where we feel
we are not in control of what is happening around us.
□ Emphasise that it would be better for him to share his feelings with friends, relatives, and others.
□ Reassure him that he is not responsible for what has happened in his life and that it is only human to feel
helpless and guilty. Help him understand that he has done his best to his save children.
s Meet him regularly at least once a week.
Illustration 2:
How can you help the person:

>

Hope of return remains strong when survivors do not see the dead person’s body and acceptance of death is
very hard. Therefore do the following.

□ Contact her on a weekly basis and encourage her to ventilate her feelings
□ Help her understand that chances of her husband being dead are very high and therefore emphasise the
need to grieve.
■ Involve family members and others in the village to support her and to talk to her.
□ Positively reinforce her ideas to get engaged in helping other children or destitute women in Mamtha Gruha.
□ Inform family members to maintain a close watch on her because such individuals can become 'suicidal'.
□ Refer her to the doctor if she continues to be in the same state despite meeting her regularly.
Illustration 3.
What can you do?:
□ Meet him regularly and help him talk about his loss.
■ Facilitate ventilation and catharsis using the destiny story.
■ Help him relive and regrieve as often as possible.
■ Emphasise that he should resume work and mix with people.
■ Help him understand that he is not responsible for the calamity in his life in any way.
■ Encourage him to participate in group activities/bhajans and mass grieving activities.
■ If he continues to be the same despite regular visits after 2 weeks, suggest him to see a doctor or personally
you can take him to the doctor for further evaluation.

Illustration 4:
What can you do?:
■ Meet her regularly, preferable with a lady CLH.
■ Help her relive and grieve.
■ Facilitate ventilation/catharsis.
■ Emphasise the need for adequate nutrition and regular ante-natal check ups and encourage her to have the
baby at the hospital rather than at home.

Post Supercyclone - Manual for CLHs

■ Encourage her resume normal activities like cooking, working, mixing with people, talking about her feelings
and future.
■ Encourage her to participate in group activities at the community level.

Illustration 5:
■ Encourage him to ventilate his feelings and emotions.
■ Help him recognise that crying or showing emotions is not a sign of weakness.
■ Clarify that by talking about the loss to his wife and children, he will enable them to ventilate their
feelings also.
■ Encourage him to understand, accept the loss rather than forget the loss.

Appendix 3
HOW TO CARE FOR YOURSELF?
Be it die logistic help or the emotional support, the Community Level Helpers (CLH) do heavy and demanding
work. The day in and day out stressful work does pose a threat to their personal mental health. They need
every day mental health care as well as specific interventions like debriefing to stay clear of excessive stress and
burnout.
The following are suggestions to manage your stress during disaster work:
■ Develop a 'buddy’ system with a co-worker. Agree to keep an eye on each other’s functioning, fatigue
level, and stress symptoms. Tell the buddy how to recognise when you are getting stressed - (“If I start
doing so-and-so, tell me to take a break”). Make a pact with the buddy to take a break when he/she
suggests it, if the situation allows it.
■ Encourage and support co-workers. Listen to each other’s feelings. Do not take anger too personally. Avoid
criticism unless it is essential. Keep telling each other, “You are doing great": “Good job”, etc. Give each
other a touch or pat on the back. Bring each other a snack or something to drink.
■ Try to get some physical exercise.
■ Listen to music, read books, etc.
■ Try to eat frequently, in small quantities and get enough sleep.
■ Humour can break the tension and provide relief. However, use it with care. People are highly sensitive
during disaster situations, and victims or co-workers can take things personally and be hurt if they are the
brunt of 'disaster humour’.
■ Use positive ’self-talk’ like, “I’m doing fine", and “I’m using the skills I’ve been trained to use".
■ Practise relaxation techniques frequently, e.g., breathing exercises (deep breathing and exhaling in a rhythmic
fashion).
■ Take breaks if you find effectiveness diminishing.

On long assignments away from home, remember the following:

■ Make your living accommodations as
personal, comfortable, and homely as
possible, unpack bags and put out pictures
of loved ones.
■ Make new friends. Let off steam with
co-workers.
■ Stay in touch with people at home. Write or
call often. Send pictures. Have the family
visit you if possible and appropriate.
■ Avoid alcohol and tobacco as much as
possible.
■ Keep a diary of your activities and
experiences.

32

INFORMATION MANUAL 2

PSYCHOSOCIAL CARE for
COMMUNITY LEVEL HELPERS

SUPERCYCLONE
Disasters pose a monumental challenge to the total
community. For too long, psychosocial consequences
have been neglected. The ORISSA Disaster like all
disasters, poses the enormous challenge of
REBUILDING THE PEOPLE, RECONSTRUCTION
NOT ONLY OF SHELTERS AND LIVELIHOOD but
OF THE HUMAN SPIRIT.
The information booklet is unique because:

1. It addresses mental health care;
2. It is made available soon after the disaster;
3. It is user-friendly;
4. It is a collaborative effort of professionals,
voluntary agencies and people - both survivors
and concerned.

BOOKS or CHANGE
A Unit of ActionAid Karnataka Projects

S. Fl. Sai Villa. Wood Street, Ashok Nagar. Bangalore - 560 025 Ph: (080) 5098434 5307145
Fax: (080) 5586284 e-mail: bfcbgl@satyam.nct.in website: www.booksforehanee.com

INFORMATION MANUAL 1

INFORMATION MANUAL 1

PSYCHOSOCIAL CARE for INDIVIDUALS

SUPERCYCLONE

Prepared by:
Dr Sreekala Bharat - DPM; Assoc. Prof, of Psychiatry
Dr C R Chandrashekar - DPM, MD; Additional Prof, of Psychiatry

Dr K V Kishore Kumar - DPM; Senior Psychiatrist

Dr Partha Chowdhury - DPM. MD; Assoc. Prof, of Psychiatry
Dr R Parthasarathy - MA. DPSW, PhD; Additional Prof, of Psychiatric Social Work

Dr Satlsh Girimaji - DPM, MD; Additional Prof, of Psychiatry
Dr K Sekar- MA, PhD; Additional Prof, of Psychiatric Social Work
Dr R Srinivasa Murthy - MD; Prof, of Psychiatry

KOOKSJor CHANGE

* Dedicated to Development
A Unit ofActionAid Karnataka Projects

FOREWORD

Disasters pose a monumental challenge to the total
community. The worst affected are the people whose lives are
disrupted severely by the enormity of the tragedy. Their recovery
capacities are stretched beyond normal human limits. Equally
disturbing is the disruption by the social, economic and political
structures.
For too long, psychosocial consequences have been
neglected. It is only since 1984, after the Bhopal Disaster, that
both professionals and administrators have awakened to the need
to focus on mental health care of survivors of disasters.

The ORISSA Disaster like all disasters, poses the enormous
challenge of REBUILDING THE PEOPLE, RECONSTRUCTION
NOT ONLY OF SHELTERS AND LIVELIHOOD but OF
THE HUMAN SPIRIT. This information manual is part of a major
initiative in the overall relief and rehabilitation programme,
to organise mental health care. It is the joint effort of ActionAid
India and NIMHANS, Bangalore, going beyond the initiative
of OXFAM, India, after the National Workshop held in
December 1998.
The information booklet is unique because:
1.
2.
3.
4.

It addresses mental health care;
It is made available soon after the disaster;

It is user-friendly;
It is a collaborative effort of professionals, voluntary agencies
and people - both survivors and concerned.

We sincerely appreciate the contributions of all the authors,
Suresh M B, the artist and the Books for Change team for the
editorial and production assistance.

Dr Srinivasa Murthy R
Prof. Psychiatry Dept
NIMHANS, Bangalore

Harsh Mander
Country Director
ActionAid India

SUPERCYCLONE AFFECTED INDIVIDUAL DISASTER AND MENTAL HEALTH
INFORMATION
Dear Friend,

You, your family and community have recently
experienced the most distressing disaster, i.e. the
supercyclone. The horrific effect of this supercyclone will
be still fresh in your mind as well as in that of others
affected like you. Help has been coming in from different
quarters, to as many people as possible. The painful
experience and its consequences are personal.

The people around
you would be reacting
to this unexpected
event in different ways. Many a time you will
find yourself alone, not even able to talk about
the disaster to others, especially since several of
them too are not in a position to either help or
comfort. In this hour of need, we the mental
health professionals from the National Institute
of Mental Health and Neurosciences
(NIMHANS) recognise the feelings and emotions in you and others around you. We
feel it is imperative and vital for you to recognise these feelings and personally
make an attempt to recover in a healthy and positive manner.
Towards achieving this, the following information, which has been compiled from
the experiences of people who have undergone various types of disasters in the
past, would be helpful. The fact is that there
is commonality between those affected
people and yourself. Knowing this should
reassure you. The information given will
provide you a better understanding of the
difficulties you could face in future in your
efforts to reorganise/rebuild your own life
and that of your family. Here are suggested
ways to recover and rebuild your life:

Post Supercyclone - Manual for Individuals

Immediate (at the time of disaster)
It is necessary to be aware of the various reactions
during and after the cyclone. This will help you
understand your emotions, your behaviour and
the recovery methods adopted by yourself. The
main aim of this understanding is to help you and
others recover in a healthy and positive manner.
During the cyclone each one of you has
experienced the massive loss of either human lives
or property or shelter or cattle, or all. The
emotional reactions to the supercyclone and the
loss are often not recognised and understood by many as being natural and expected.
Let us examine the immediate reactions of people to the supercyclone:

• Shock and or Disbelief
Orissa has often faced natural calamities like drought, cyclone and floods. But this
supercyclone struck at the most unexpected hour. You would have been caught
unawares - totally unprepared. But, in spite of this, you have worked hard to save
your life as well as that of others. Similarly, there would certainly be others in your
community who have gone through the same experience. However, some persons
in the community would have reacted with shock and shown decreased activity.
Another common emotional reaction is to feel that the whole event was not real but
a bad dream, i.e. one of total disbelief.

• Panic
Panic at the time of undergoing very severe stress is common and normal. Hence for
people to panic at the time of a cyclone is normal. Just as an example, imagine a
large number of people entrapped by the surging floods of water in a small space. It
would only be natural that all of them will panic and try to get out at the same time
causing a stampede.

After the Cyclone
• Shock
You find it difficult to believe that the disaster has actually
happened - that the cyclone has ripped through leaving
behind so much death and destruction. All routine activities
have come to a standstill due to the supercyclone and this
adds to feeling lost. The all round confusion further
intensifies this.

• Vigilance
You will find yourself hyper alert - responding to each
and every sound and/or light in the surrounding,
constantly on vigil for signs of further disasters. This can
prevent you from sleeping. Sometimes you can become
irritable and angry. Let not this disturb you. It is only a
protective behaviour which usually decreases gradually
over a period of time (few weeks).

• Despair
In spite of the major disaster being over, often you may feel helpless and abandoned
and look forward for some form of rescue. Even in a
crowd you can feel lonely. You can feel like going away
to a place of refuge. But the safety of your children, old
parents and family overtake you and become more
important than your personal safety. People in disasters
try and stay together giving and taking from each other
help, support and drawing strength from this.

• Elation
Often you can feel very happy that you have survived. But at
the same time this feeling puzzles and disturbs you. You keep
wondering, “How is it that I am feeling happy and relieved
instead of feeling depressed when I have Tost' a near and
dear person? What right do I have to survive when others
have suffered so much of loss?" But do not feel guilty about
feeling so. It is a normal feeling of survivors.

® Guilt
Feelings of guilt and repeatedly blaming yourself for having survived
keep coming back (“I did not save my family/friends”) especially if
other near and dear ones have been injured or have lost their lives in
the supercyclone.

Post Supercyclone - Manual for Individuals

• Reliving the experience and flashbacks
Several times hereafter, you can remember and re-live/
experience the disastrous supercyclone repeatedly
including the raging wind, swirling of the trees in the
gale, gushing sound of the floods, thundering sounds
of trees getting uprooted, shrieking of people. Small
sounds may trigger these experiences. This can happen
more at nights. Being involved in relief work can also
trigger off ‘these attacks’. Having to remove mutilated
bodies or identify dead relatives, may send you into a
state of panic.

o Different ways of reacting

You may find others being ‘numb and empty’. They may fail to feel anything, even
the loss of a near and dear one. This may surprise and worry you.
Krishna, a 40-year-old man, had lost his mother in the cyclone. When offered kerosene
to burn her he said, “I would rather use it to cook food for my family”.

A few others may withdraw into themselves totally. They may not eat or sleep for
many days.

• Poor physical health
It is common for people to feel physically weak, easily exhausted, have symptoms
like headache, chest pain, rapid heart beating, sweating, poor appetite for a few
weeks/months after the disaster.

However, in some:
1.

There may be repeated images and recall of the cyclone, decreased sleep, reduced
appetite, lack of concentration and intense irritability or fatigability may continue
or increase over time. This could interfere with daily functioning and prevent
them from re-organising/rebuilding their lives. These people need professional
help from mental health practitioners.

2.

Very few can have a more severe reaction - excited, confused, wandering, saying
same things over and over again.

They need to see a doctor or a mental health professional.

Future
Some of the difficulties you/others may face in future:
□ If you have lost a near and dear one like spouse, child, parent or sibling you
will feel:

• Why me and my family, when there are others?

• Guilty that you have survived.
• Guilty that you did not try enough to save the dead relative.
• Unable to even mourn for the dead, as you have to protect and provide for the
living. This increases guilt and anguish. Often you may feel that you are being
callous - but recognise it as concern for the protection of the living.
□ If you have not lost any family members but only property, there may be a sense
of relief, elation. However, as days go by, the difficulties in re-establishing yourself
would be due to:

• Loss of house, land, cattle, personal belongings.
• Lack of facilities, at the temporary residence.
• Having to depend on friends and relatives who are not affected by the disaster.
• The help and aid from governmental and non-governmental organisations
involved in relief work may start drying out.
• Help from government to allot you a permanent house, land, job may be slow.
• Often you may have to face obstacles due to bureaucracy, red-tape, etc.

These can make you feel angry or depressed, and add to the troubles you already have.

RECAP
Reactions to a Cyclone
• All people are affected emotionally by the cyclone.
• People react in different ways to the crisis, loss and the survival.

• Usually the symptoms of distress start decreasing few weeks after the
cyclone.

• People start feeling better - enough to rebuild their lives - within a few
weeks.
• Those who continue to be affected and are unable to rearrange their lives,
need professional help.

Post Sttpercyclone - Manual for Individuals

RECOVERY MECHANISMS
Symptoms start decreasing in most people in a few
weeks when they initiate some actions to reorganise
and rebuild themselves. After a few weeks/
months, even though the memories of the disaster
remain, they do not stop you from going ahead with
your life.

HOW CAN YOU RECOVER?
7b promote recovery we suggest the following to be done:

At a Personal Level:

✓ Listen to authentic information about the supercyclone.
X Do not believe in rumours that go around during such times.

✓ Be together with family members.
X Do not send women, children and the aged to far off places for the sake of safety
as this separation can cause a lot of anxiety to them and you.
✓ Be with people from the same village, i.e. people you are familiar with, even if
you are in temporary dwellings.
✓ Get back to a daily routine as soon as possible to make you feel that you are in
control of the situation.

O

Make it a point to talk about the supercyclone,
share your experiences and feelings with your
family, your parents, friends, spouse, siblings,
acquaintances. This will help ventilate/release
your emotions.

Restart activities that are special to your family
like having meals together, praying, playing
games, singing, etc.
✓ Keep touching and comforting your parents,
children, spouse and the aged in your family.
This will not only make you feel good but also
make the other person feel the same.
✓ Initiate and participate in rituals like collective
grieving, prayer meetings or group mournings if
you have lost a near and dear one. This will help
you come to terms with the loss of the person.

Post Supercyclone - Manualfor Individuals

s Take part in rescue, relief and rehabilitation operations if you are not hurt or
only slightly injured. Work is a good tonic for healing.
✓ Keep in constant touch in case of a member of the family having to be shifted to
a far off hospital or residence. Update him/her about yourself as well as find out
about him/herself. This gives a feeling of being cared for.
✓ Take time everyday to relax and have a good time by gathering together at a
central place/point, playing kabbadi, reading, listening to music, visiting shrines,
singing hymns, chanting prayers, reading scriptures.
✓ Make time for yourself and acknowledge and admit that you will not be always
functioning at your usual level of efficiency for a few weeks/months.
At the Community level:

Immediate

✓ Disseminate authentic information about the disaster
and the help available either by going around
personally or using loudspeakers or posters/placards.
✓ Organise groups for rescue operations. Help to remove
debris, shift people to a safe
place, help the disabled,
and share food, water and
medicines. Identify groups
for each activity and a leader for each group. The whole
village should be involved in planning rescue, relief and
rehabilitation operations.

✓ Listen to and encourage other people talking about the disaster, etc.
✓ Encourage the group to focus on the special groups like the children, women,
disabled and elderly.
✓ Organise people to present their needs and difficulties to the administrators in a
collective manner.
✓ Bring together people of the community for sharing of grief/community
mourning.
Organise self help groups to procure aid and to discuss
emotions associated with the disaster. Self-help groups
should have people with similar needs. For example,
people who have lost family members could join
together to grieve and later work on it.

✓ Organise weekly meetings to share information and sing together.
✓ Prepare yourself for delays and difficulties.

In Future

S Seek information about help extended and organise groups to represent your
village to seek help/aid.
✓ Actively mobilise action for reconstruction and rehabilitation work. Take care
that this includes all aspects of a community to be disaster proof, where agriculture,
electricity, health care, education, etc. are concerned.

✓ Continue dialoguing with government officials and NGOs for a persistent effort
on relief and rehabilitation.

Post Supercyclone - Manual for Individuals

SPECIAL GROUPS
Children, women, old people and the disabled are special groups of people who need
special attention. Let us first talk about children.

YOUNG CHILDREN
The child’s mind and emotional state are not yet developed enough to solve problems
as an adult. A child needs to discuss and sort out his/her fears with an adult because
he/she probably does not realise there are other options. He/she becomes dependent
on adults physically and emotionally. Often the child cannot comprehend the
consequences of any disaster - leave alone even this supercyclone. There is a sense
of losing his/her identity. However, events that take place during a disaster, like
darkness, loud noises, commotion, loss of shelter, separation from caring persons
like mother, father and siblings, deprivation of food, and drink, experiencing the
cold, and so on, do impact the child much more than it would an adult.
■ Very young pre-school children react by:

• Crying
• Clinging to adults, especially known people.
Later, often they are known to:

x.y/^c.^1
//

• Cry and excessively cling on to some family member due A

/

to the fear ofonce again losing whatever security they have.

w

<( X

• Become listless and apathetic, especially if they do not
get warmth and a feeling of security from the surviving adults.
• Have disturbed sleep and unhealthy feeding problems.
• Behave like a smaller child much younger than his/her age. For example, a child
of three years may stop talking and may insist on being carried and fed like a
one-year-old child or an eight-year-old and restart wetting the bed at night.

SCHOOL GOING OLDER CHILDREN
Following are the experiences these children can show:
• Have nightmares or talk about the cyclone repeatedly. They are unable to get a
sense of control over what has happened.
• Regress and develop bed-wetting or thumb sucking.
• Refuse to go to school or even separate for a short while from the remaining family
members for fear of losing them.
-------------------- 10--------------------

• Decline in scholastic performance due to preoccupation with and reliving
constantly the disaster scenes.
• Physical symptoms like abdominal pain, headache, movements of the body, which
is one way of communicating distress.
• Feel responsible for the death of the near and dear one(s) and become depressed
and withdrawn, with reduced sleep and appetite.

® Disturbed and angry over what has happened and retaliate with difficult
behaviour, like irritability, quarrels, lying, disobedience and at times stealing.
Sumitra, a 9-year-old impish girl, after the cyclone seems to be coping well - doing her
routine, going to school and helping other children in the family. However, her interest
in studies has suddenly decreased. She no longer shows in terest in doing her homework
given by the teacher. The teacher thought it was natural, with the children having gone
through a lot. To her surprise, Sumitra continued to be disinterested in studies after
many months and later dropped out ofschool, though her father was keen to send her to
school as he felt she was very intelligent. But nobody realised that Sumitra s friend in
class, Sarada had been washed away in the cyclone along with her family. Sumitra used
to compete with her for the first position.

How to help
Often the child does not understand why he/she behaves in a particular manner
and cannot articulate the reasons for the behaviour clearly. It is necessary for the
parents/adults to understand these changes and take certain measures to help the
child get over the stress. The goal is to improve the feeling of security and bonding
between them.
■ Leaving children with known adults, i.e. mother, siblings, known neighbours.
■ Re-establishing at the earliest possible a routine like eating, playing, studying,
sleeping, etc.
■ Actions that are security-giving

• Touching, hugging the child often

• Reassuring them verbally.
• If possible giving a favourite toy, or piece of cloth (mother’s sari)
which the child had used earlier as a soother.

• Keeping a small light on while the child is sleeping.

1 jf

• Allowing the children to talk about the incident and listening
without advising.

K

/|| k_j

■ Activities which will provide a sense of control over the disaster.

fl

Post Supercyclone - Manualfor Individuals

• Encouraging play activities which are related to the incident. For example,
Children can make paper boats and put then in water. The boats may be rocked,
creating a turbulence in the water. The difficulties of people in the boat can be
discussed.
• Story telling, singing songs pertaining to the
cyclone.
® Giving attention to and approving of the child’s
coping behaviour, e.g., praising him/her for going
back to school and following a routine, etc. Routine
also gives a sense of control over oneself.
■ Liaisoning with the teacher to also help in the recovery of the child.
■ Paying more attention and spending more time with them on their studies.

AGED PEOPLE
Aged people like children may not be in total control of situations. This makes them
also very vulnerable to the trauma. They take a longer time and more effort to recover
with the disaster.
When faced with the death of many young
people, the aged can become very depressed.
They may:
• Withdraw, cry and groan repeatedly, for many
months.
• Suffer from sleeplessness and refuse food.

® Be agitated, feel hopeless and have suicidal
tendencies
• Fall ill as psychologically they are affected and their resistance is low and are
susceptible to all types of illness.

Binay Panda's (aged 64) only companion was his ailing wife who was bed-ridden since
the last few years. She died when their hut came down in the cyclone. Others thought
that her death was a blessing in disguise to Panda; he also felt so. However, over the
following weeks, Binay was found to be apathetic, confused and complaining ofmemory
loss. People thought that it was due to his advanced age. But it was, one health worker
who realised that Binay was mourning his wife's death in this manner.

How to help
• Keep them with the near and dear ones as much as possible.

Convey to them positive news without fail and
repeatedly.
Touch them and allow them to cry.
© Re-establish their daily routine.

Give them responsibility which they can carry out
without much difficulty, like for e.g, take care of
children for short periods, distribute food for a small
number of people, etc.

• Consult them in relief activities.
(Note: the above two give them a feeling of control
over the situation.)
Attend to them with immediate medical attention
when necessary.
Conduct prayers in small and large groups,
focussing on religious matters.

Post Supercyclone - Manualfor Individuals

WOMEN
Women feel more vulnerable than men in disaster situations. The poor physical
condition of an average Indian woman and the oppressive social conditions in a
patriarchal society are some of the reasons for this. Women are more emotional than
men and a supercyclone causing such a magnitude of human suffering affects them
significantly. However, women also respond to stress differently from men, which
can be manifested in:
X Exhibiting more emotional symptoms like weeping and
later on becoming depressed.

X Exhibiting symptoms like ‘fainting’.
X Experiencing physical symptoms like aches and pains,
weakness as a response to conflict.
X Showing more ‘resilience’ than the other group to care
for the young.

Among them, more affected are women who are young,
single, widowed, orphaned, disabled, have lost children,
etc. Specific attention has to be given to the affected women during and following a
disaster, like:

Helping women help themselves
Similar to the aged and children, women should stay
together in nearby safe places rather than move to
faraway places.
Obtain information about the safety of family members
especially spouses, offsprings, siblings and parents.

Involve actively in routine activities of the family
pertaining to caring of the young, old, sick members of
the family, etc.
Involve in community level activities, which are
familiar, like preparing food, caring of the sick.

X Involve actively in relief activities of social relevance, like maintenance of
cleanliness of the surroundings, etc.
X Form self-help groups among yourselves to deal with, share the loss, and suffering,
and participate in the rehabilitation activities.

• Create private physical spaces for yourself and
other women for bathing, changing clothes, etc.
• Mobilise resources to help other affected women
in innovative ways like asking women who have
lost children to adopt orphaned children,
suggesting widowed women to start a new life.

• Spend time in singing and other activities that give
you happiness.

Post Supervyclone - Manual for Individuals

DISABLED PEOPLE
People who are disabled like the visually
impaired, hearing impaired, orthopaedically
handicapped, mentally ill and mentally
handicapped are also affected by the cyclone. The
disability often may stretch their recovery skills.
In the face of disasters like the supercyclone, they
need assistance from others to adjust and recover,
without which they can become quite ill.

Amit, is a 40-year-old visually impaired person, who has so far been totally independent,
able to walk freely within the village and to hisjob as a music teacher. During the cyclone,
Amit was totally helpless as he did not know where and how to reach a place ofsafety. He
could not even help his elderly father to a place of safety.
This is to be remembered and recognised.

How to help the disabled
• Explain to and update them of the situation. This gives a feeling of being
involved and not ignored.

• Remove them to any place of safety where they can recover.
• Focus on specific tasks which they can perform within the limitations of their
handicap. Focus on what they can do.
• It is better to have groups comprising differently abled people and some
people without disabilities.

RECAP
• Special groups like children, old people, women and disabled can react
differently to the supercyclone.
• Their distress also starts decreasing after a few weeks.
• Specific efforts can help recovery.

• In some this may not happen and therefore need recognition and intervention.

PERSONNEL INVOLVED IN GIVING
HELP/AID IN A DISASTER

Immediate (at the time of disaster):
• Local administrative officers - District
Commissioner, Tahsildar, Panchayat members,
Block Development Officer.

Post Supercyclone - Manualfor Individuals

• Voluntary organisations

• Media

After the disaster
• Local Administrative Authorities

• Block Development Authorities
• Agricultural Officers
• Veterinary - Animal husbandry officials
® Public Works Department (PWD)
® Local Health Authorities
® District Education Authorities.

Suggestions while using this Document
• Translate into local language.

• Narrate stories and couplets in the local language while talking of recovery.
• Perform skits in the local language giving information about the disaster
and also encouraging recovery.

18

INFORMATION MANUAL 1

PSYCHOSOCIAL CARE for INDIVIDUALS

Disasters pose a monumental challenge to the total
community. For too long, psychosocial consequences
have been neglected. The ORISSA Disaster like all
disasters, poses the enormous challenge of
REBUILDING THE PEOPLE, RECONSTRUCTION
NOT ONLY OF SHELTERS AND LIVELIHOOD but
OF THE HUMAN SPIRIT.
The information booklet is unique because:

1. It addresses mental health care;
2. It is made available soon after the disaster;
3. It is user-friendly;
4. It is a collaborative effort of professionals,
voluntary agencies and people - both survivors
and concerned.

BOOKS or CHANGE
A Unit ol’AciiotiAid Karnataka Projects
No. 8. Fl. Sai Villa. Wood Street. Ashok Nagar. Bangalore - 560 02:
Fax: (080) 5586284 e-mail: blcbgl@satyam.net.in website: wt

BFJ1L HEALTH
A loss of moral values!

A decrease of true spiritual
strengths resulting in a
weakening personalitq seems
to be the order of the daq 1

Can we remedq this state
before it is too late ?

EVERY 10 MINUTES ONE INDIAN ENDS LIFE
Express News Service 1988
Trivandrum, March 6 : One person commits suicide every 10 minutes
in India, while in the United States someone commits suicide or
attempts to commit suicide every minute.
According to the papers presented at the 17th annual conference
of the Indian Society of Criminology, on an average out of evej-'
1,000 suicides in the world a day, 100 are in India.

Available figures say that over 50,000 people in the country com­
mit suicide every year and majority of them are men. Studies on
suicidology undertaken by various sociologists show that physical illness,
mental disorder, economic need, psychic causes and dowry menace, are
among the reasons for the rising trend in suicides in the country.
Though India is still far behind Japan, which has the highest
suicide rate in the world, despite its affluence, or Switzerland, which is
ranked seventh, suicide is on the increase in India as in the case of
many affluent Western countries. The studies have revealed that
persons in the age group of 18-30 are more prone to suicide. Suicide
is less among married couples and theists.

Let us bring Mental and Spiritual health into our
Homes and Institutions !

Mental Health
MENTAL HEALTH AND MENTAL HYGIENE

Mental Health is an integral part of general health.
It can be promoted by mental hygiene which is the
practice and use in daily life of specific convictions and
behaviour that is conducive to the following :
a) dealing satisfactorily with the daily events of life.
-b) working out certain roles relating to different events
'
and persons in stressful situations with least distress
c) resolving conflicts in a self-confident manner
d) seeking help in the above situations whenever
indicated.

Mental Hygiene is in other words a “ personality
development ” effort which grows with the person
promoting “ personhood ” or maturity of emotions and
actions. In the diagram below one can note the com­
ponents of the human person, or the anatomy of self.
ANATOMY OF SELF

MENTAL HEALTH PROGRAMME

The conviction and belief of a positive self-image
and self-acceptance, the behaviour that is consistent with

self-worth and dignity, the understanding that one has to
fit into different roles without much distress, the belief
that one has to be responsible for ones actions, and that
conflicts are a part of life that must be faced are all
part of a positive mental health programme.
Freud defined mental health as the "ability to love
and to work." To love is to be able to enter into a
relationship of mutuality, that is giving and receiving
love.
A mentally healthy person, he said is one who is
strong enough to resolve conflicts between impulses and
morals, that is, he can choose between expressing feel-'A
ings and withholding such expression, and between
pursuing gratification of needs and postponing such a
quest for gratification.
HeiShe can thus make a healthy rational choice
and control any tendency to compulsive behaviour.
Repression ignores this and thus consumes energy which
could go into productive behaviour.
According to Jung, a mentally healthy person is 11
responsible person who has found a meaning for his
existence and has integrated conflicting elements of his
personality into a unique and harmonious pattern.
FEMININITY AND MASCULINITY

fhe correct understanding of one’s personality
e. Feminity and Masculinity will ensure that men and
i.
women understand each other and more important that
5*eYelop their personality to their fullest potentia
health.
eSSent!al recluiremeilt for sound mental^

12.

F,em.ini.nity implies the special charisma of
Empath" °r f°™ing -lafionships.

3‘

s^meJhing’abouth”8 Str°ngly en°Ugh “

4.

Intuitiveness - a foresight into the future.and
Creativity.

char»"r rf'”"’
1•
2.

‘he othCT hand has the specW

Being direct
Logical
2

3.
45.

Rational
Aggressive
Physical

Hence the ancient Greek symbols to represent man
was the arrow and for women the mirror reflecting her
feelings in her countenance.
ANXIETY

Modern psychologists have done an admirable
service in studying anxieties, revealing a phase of human
nature which has been to some extent closed to us. But
(T)he course of anxiety is deeper than the psychological.

Optimal Stress th

to

4
Health.
and
ft^fotmance.

One of the favourite psychological descriptions of
modern man is to say that he has an anxiety complex.
Psychology is more right than it suspects, but for a more
profound reason than it knows. There is no doubt that
anxiety has
been increased and complicated by our
^metropolitan and industrialised civilisation. An increasing
number of persons are afflicted with neuroses, complexes,
fears, irritabilities and ulcers they are perhaps not so much
“ run down ” as “ wound up,” not so much set on fire by
the sparks of daily life as they are burning up from interna)
combustion.

Few of them have the felicity of the good Negro
woman who said, “ When I works, I works hard, when
I sits I sits loose, and when I thinks, I goes to sleep.”
But modern anxiety is different from the anxiety
of previous and more normal ages in two ways. In older
days men were anxious about their souls, but modern
•3

anxiety is principally concerned with the body, the major
worries of today are economic security, health, the
complexion, wealth, social prestige, and sex. To read
modern advertisements one would think that the greatest
calamity that could befall a human being would be to
have pimples or a cough in the T-zone. This over
emphasis on corporal security is not healthy, it has
begotten a generation that is much more concerned about
having life belts to wear on a sea journey than about the
cabin it will occupy and enjoy. The second characteristics
of modern anxiety is that it is not fear of objective, a
vague fear of what one believes would be dangerous if
it happened. That is why it is so difficult to deal with >
people who have today’s types of anxiety, it does no
good to tell them that there is no outside danger, because
the danger that they fear is inside of them and therefore
is abnormally real to them. Their condition is aggravated
by a sense a dispropotion- between their own forces and
those marshalled by what they believe to be the enemy.
These people become like fish caught in nets and birds
trapped in a snare, increasing their own entanglements
and anxieties by the fierceness of their disorderly
exertions to overcome them.
STRESS.

EUSTRESS.

DISTRESS.

Hans Selye has done the most work in the effect
of Stress on man in the University of Montreal. He
has described the ' Gas,’ General Adaptation Syndrome
in three phases (1) the alarm reaction (2) the stage of
resistance and (3) the stage of exhaustion.
.'i'HR.GH Phases of QfiS

Level of_________ I [____________ I
hlovmal fe.sistcmc^' I

\
!

\

j:

Most illnesses occur in stage three, which is when
repair fails. When the diet is adequate, a person can
4

go for years withstanding tremendous stress with little
apparent harm. If the raw materials are insufficient
to meet the needs, there comes the stage of exhaustion,
disease develops and eventually death threatens. During
every illness we are in one of these three phases of
stress, and to regain our health, our diets must be
planned accordingly. Diet is not only for the body, but
also for the mind, since body and mind work in close
harmony. A disturbance in one, disturbs the other.
EUSTRESS AND DISTRESS

x-x
Stress is good and needed for people to grow to
'■ -their full potential. So when we talk of stress manage­
ment, we do not mean eliminating all stress. The
primary stress response is the fight or flight response.
A response helps to ensure our survival and any
threat, physical or symbolic can bring about this
response. Now while physical arousal to physical
threat is appropriate, physical arousal to symbolic or
emotional threat is inappropriate. It is longer in duration,
is not easily dissipated and is physically detrimental to
the body.
Hans Selye says that stress is a process that enables
the body to resist the stressor in the best possible way
by enhancing the functioning of the organ system best
able to respond to it.

He calls optimal stress levels eustress, and this
reaches a maximal point where stress increases health
and performance. He calls overload, distress, where
C^tre'is increases, but health and performance decrease.1’
distress or negative reactions to stress —
MANIFESTATION
1.

Mood and Disposition Signs

Worry, over-excited, insecure, insomnia, confused,
forgetful, uncomfortable, ill at ease, and nervous.
2.

Visceral Signs

Stomach, upset, heart palpitations, profuse sweating,
moist hands, feeling faint or light headed, face hot or
flushed, experience of cold chills.
5

3.

Musculoskeletal Signs

Fingers and hands shake or tremble, cannot sit or
stand still, twitches, headache, tense, stiff muscles,
stuttering, stammering, stiff neck.
Selye Says that our problems evolve quickly, but
our bodies evolve slowly, very slowly. People like to
assume that the body always works intelligently. But
this is not so. The body is like the mind, it too, gets
confused and makes mistakes.

Where stress is concerned, what usually happens is
that mind and body make the same mistakes together^
Selye says that stress is the non-specific response of the
body to any demand made upon it; it can be pleasant or
unpleasant. Stress is not something to be avoided.
Complete freedom from stress is death.
All illnesses have a psychosomatic component. All
disorders are psychosomatic, in the sense that both mind
and body are involved in their aetiology."
COMMON SYMPTOMS OF EMOTIONAL ORIGIN

1.

Exhibiting nervous mannerisms, e.g. biting nails,
jittery speech, shivering.

2.

Overeating. Some people eat a lot more than usual
when they are under stress.

3.

Excessive talking^ Sometimes a person may become
unusually talkative and literally feels compelled to
talk at all times.
0

4.
5.

Escaping into drugs, alcohol or work.
Ignoring it, hoping that denial will help get rid
of it.
F 5

6.

Withdrawal. A person may withdraw within him­
self or to some other refuge to cope with stress. He
may become anti-social and adopt an ascetic life
anTthose
Wh°j a-tempt or commit suicide
are those who have decided to give uo fighting
the.r stresses and !Cek permanent release
*
6

HEALTHY MANAGEMENT OF STRESS OR EUSTRESS

a)

b)
c)

i
"

This is a good or positive response to stress.
Talking it over with a friend who is sympathetic and
understanding.
Taking an inventory of the stress factors in our lives.
Emotional innoculation. By this we mean preparing
oneself mentally and emotionally for the stressful
event. A person taking an examination can prepare
himself by ensuring that he studies, as well as
working out alternatives should he fail. Because he
is prepared for the worst possible outcome, he may
be able to take it better. In this way he|she avoids
“stressor” factors.

MEASURES TO PROMOTE EUSTRESS

d)
e)

Relaxation and body awareness exercises.
Making changes in diet, life style etc.
Being assertive. Center. Imaging and focussing
on self.
g) Seeking professional help.
Depression is to give into the pressures or stresses of life
and go below the normal and healthy feeling of well
being. It is a negative and self destructive reaction and
if unchecked can have serious implications for the
individual.
VICIOUS CIRCLE

PROBLEM

Suicidal tendencies

anxiety

SEVERE DEPRESSION
CONFILCT
DEPRESSION^
Only counselling can break this vicious circle. At
the stage of Severe Depression, professional and
psychiatric help and even hospitalization may be
necessary. Hence we can see how important mental
hygiene is, since it can convert stress into eustress and
solve the problem or resolve the conflict.
7

It is here that spiritual counselling is essential to
give the individual belief in himjherself and that God
cares and loves them, even if all others have disappointed
them.
CASE STUDY

Ramesh’s father had a quick temper and Ramesh
was often his target. At first Ramesh bitterly resented
this injustice and felt humiliated. He tried to react by
staying long hours out of the house and this resulted in
poor results in studies and worsening relations at home.
Ramesh blamed all this on his father. Ramesh went tfc.
a Counsellor who helped him to understand that hi?
father loved him and though he had a quick temper he
forget about his anger soon after. Ramesh realised his
own reaction was childish and that he harmed himself
most. He started staying home more and whenever his
father lost his temper he would wait till he had cooled
down and then tell him his side of the story. This
happened over a period of 6 months and they are now
good friends much to the relief of Ramesh’s mother and
the entire family, who had all been adversely affected.
AWARENESS IN INTERPERSONAL RELATIONS

I
AREA OF
FREE ACTIVITY

II
BLIND
AREA

III
AVOIDED OR
HIDDEN AREA

IV
AREA OF
UNKNOWN
ACTIVITY
1

In quadrant 1 are the behaviours and feelings known
to an individual and also to other people. In quadrant
II called the blind area, are aspects of the individuals
of which he is not aware but which are known to other
people. The avoided or hidden area, quadrent III,
involves personal characteristics which the individual
8

knows about but does not wish to reveal to others. In
quadrant IV, the area of unknown activity are aspects
of behaviour and motivation unknown to the individual
and also unknown to others.
It is very helpful for each person to do this
EXERCISE and then discuss what is listed in each area
with a friend or counsellor (LUFT).
CLASS ACTIVITY

1.

Exercise in Emotional Status.
Do you have Self Confidence ?
Do you have will power ?

AN EXERCISE IN EMOTIONAL STATUS

List 1

List 2

Suspicion
Frustration
Discouragement
Fear
Disappointment
Anger
Guilt
Hostility
Jealousy
Loneliness
Inferiority
Rejection
Envy
r'inpatience
i.
Boredom
Sadness

Peace
Confidence
Exhiliration
Hope
Friendliness
Joy
Enthusiasm
Relief
Trust
Affection
Contentment
Curiosity
Satisfaction
Pride
Excitement
Acceptance

Pick out an emotion from List 1 and 2 and describe
to other group members a recent experience which you
had which makes you feel that emotion. Let the other
members of the group respond to you. Try to talk in
depth about the feeling.
Complete the following statements

1.
2.

When I join a new group I----------I feel most comfortable in a group when ___
9

..

I like people who
Helping others make me feel----------- '
I feel angry when --------I feel happy when —----Now let the listener or listeners complete this
statement :
“ Towards you right now I feel------------ ”
Now let all share with each other what they felt
about this exercise, what they feel about each other, what
they have gathered from this experience.
U ’
Discuss how best you could have adjusted to stressful
feelings. Decide on how to act in the future.

3.
4.
5.
6.

A TEST FOR PERSONALITY DEVELOPMENT
2.

DO YOU HAVE SELF-CONFIDENCE ?

Here is a test you may like to try. Answer “ YES ”
or “ NO ” to the questions before you turn to the key
at the end.

1.
2.

3.
4.
5.
6.
7.
8.
9.
10.
•
11.
12.
13.

Do you believe that you are wanted ?
Yes\No
Do you take success and failure without becoming
unduly elated or depressed ?
Yes\No
Are you good at coping with emergencies ? y<?r|No
Do you regard yourself as a pleasant personality ?
YerlNo
Are you seldom at a loss for words ?
Yer|No
Are you rarely worried about what others think
you ?
Yer|No
Do you seldom feel the urge to justify ?
Fej|2Vo
Is it difficult for people to embarrass you ? Y«|No
Can you laugh at your own mistakes ?
Yer|No
Can you apologize gracefully without feeling
embarrassed or uncomfortable ?
Can you discuss without getting upset ?
Yer|No
Would vou stand up and ask questions in class ?
Yes\No
Do vou enjoy the company of the opposite sex ?
Yes\No
10

14.

Do you look forward to meeting new people ?

15.

Is it easy for you to talk to strangers and get to know
them ?
Yes\No
Can you remain calm when people are unco­
operative ?
Yes\No
Do you think that you are loved ?
Yes\No
Can you be relied upon to cope with most situations?
Yes\No
Do you seldom stammer or blush ?
Yes\No
Would you be thrilled to chair a meeting or lead a
discussion ?

16.
17.
18.
19.

KEY TO QUIZ

Count 5 marks for every yes. Above 75 is very
good. 65 - 75 is good. Below 65 can improve.
How to Gain Self Confidence and improve your score.
DO YOU HAVE SELF-CONFIDENCE ?
Many people feel that problems and difficulties are
often more than they can cope with. They feel beaten by
life and constantly weighed down by problems. They lose
faith in themselves and their ability to make a success of
their lives. There is no worse experience than losing
one’s self-confidence. If a person doesn’t believe in
himself he is- frustrated and beaten at every turn.

TO GAIN SELF-CONFIDENCE — REMEMBER

”1.

2.

3.

You are different from everyone else because you
are unique. This means that you are important.
If you were important, how would you dress, how
would you walk, how would you feel ? When you
have pictured these things, put them into practice.
Choose for yourself some goal which is within the
bounds of possibility. This is what you must try
to achieve.
Having fixed your aim, proceed towards it gradually.
Plan for it and arrange your life in such a way as
to fit in with your aim.
11

4.

5.

6.

7.

8.

Learn from your mistakes, but never let them deflect
you from your goal.
If you lack faith in yourself it is essential that you
set out to be interested in other people. We are
only hesitant to meet people because we are more
interested in ourselves. Make a hobby of people,
and remember all people are interesting to those
who are prepared to find out where their interest
lies.
Learn more about other people. Begin to care
about them and as you lose yourself in caring
passionately for them you will find your self-confidence restored.
v
One of the greatest causes of loss of self-confidence
is tension. This means we must learn to relax.
Practice letting go. Have a few minutes every day
when you consciously let go of life and its problems.
These short “ vacations ” mean so much and it’s
surprising the difference it makes.
Always do the best you can in facing a situation and
then leave the issue to God. If you have done your
best you can do no more.

3.

DO YOU HAVE WILL POWER ?

1.

Can you convince yourself of your strength of will ?
Your possibilities are greater than you think. This
is true on the natural plane alone. From the religious
point of view, your certainty is still greater. God
has a task for you to do, and he will give you all
you need to do it well.
Can you conform your exterior behaviour to you/’
interior ideal ? Your exterior behaviour greatly
influences your thinking. Make your exterior calm,
firm and virile. Cultivate a healthy, straight posture.
Don’t lounge or drag your feet.
Can you profit by every occasion to exercise ener­
getic action ? You must repeat voluntary acts of
energetic effort.
A practical method is the
following.
Determine a certain number of wilful acts to be
accomplished daily for a period of ten days. Do not
relent till you have accomplished them all.

2.

3.

4.

5.

6.

1

7.

8.

9.

Can you take pleasure in work and hardship ? This
may sound impossible, but work can be as enjoyable
as play, and the satisfaction it can bring you is far
deeper than the pleasure you get from fun.
Can you polarize your energies through an apt
slogan ? A good slogan is an effective stimulant.
Invent your own personal formula and repeat it
especially in times of discouragement. Examples,
“I shall overcome." God gave me life to conquer"
etc.
Can you seek perfection in all you do ? “ What is
worth doing is worth doing well ” : Few things
help will-power more than applying a maximum of
concentrated energy to simple tasks.
Can you leave a job half-done ? First draw up a
definite plan of action; then, stick to it. This will
also save you undue worry and loss of time. What
tires you most is not what you have done, but what
you should have done and did not do. Are you
convinced of this truth ?
Can you not give into the first feeling of
tiredness ? Do not underestimate your working
power. If you give in to the first temptation to stop
working real fatigue will soon develop and you will
lose the day. So react promptly.
Can you be flexible, but tenacious ? If you want to
succeed in any walk of life, you need tenacity, a
certain ‘ gentle stubbornness.” As that great soldier,
Marshal Foch said, "Nothing resists tenacity,
But if you accept the very thought of defeat, you are
vanquished beforehand. Victory belongs to the man
who remains firm longer than his opponent," and
“ Nothing ventured, nothing gained ”

To every Question the Answer should be ‘ Yes ’

* Know what you want-and clear-cut decisions will
follow.
* Energetic action is the next requisite.
* Follow through with continuous effort.
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COM A;/

1998 Update

Abnormal Psychology
and Modern Life

Tenth

Edition

Robert C. Carson
Duke University

James N. Butcher
L 'n iversify ofMin ncsota

Susan Mineka
Xorthivesrem University

§ LONGMAN
An imprint of Addison Wesley Longman, Inc.
New York • Reading, Massachusetts • Menlo Park, California • Harlow, England
Don Mills, Ontario • Sydney • Mexico City' • Madrid • Amsterdam

Psychosocial Causal Factors

Such therapy is concerned with verbal and nonver­
bal communication, social roles, processes of accom­
modation, causal attributions (including those sup­
posedly motivating the behavior of others), and the
general interpersonal context of behavior. The ther­
apy situation itself can be used as a vehicle for learn­
ing new interpersonal skills. In recent years, major
progress has been made in documenting the effec­
tiveness of interpersonal psychotherapy in the treat­
ment of disorders such as depression and bulimia, an
eating disorder discussed in Chapter 8 (Fairburn et
al., 1993; Kierman et al., 1994).
Although the interpersonal approach of Sullivan
and others lacks a fully adequate scientific ground­
ing, it has generated considerable enthusiasm among
researchers in recent years and has far more potential
in this regard than docs the humanistic approach.
which does not promote empirical testing of its basic
ideas. The major impact of the interpersonal perspec­
tive has been its focus on the key role a person's close
relationships play in determining whether behavior
will be effective or maladaptive.

Summary
Each of the psychosocial perspectives on human be­
havior—psychodynamic, behavioral, cognitive-be­
havioral, humanistic, and interpersonal—contributes
to our understanding of psychopathology, but none
alone can account for the complex variety of human
maladaptive behaviors. Each perspective depends on
generalizations from limited observations and re­
search. In attempting to explain a complex disorder
such as alcoholism, for example, the psychodynamic
viewpoint focuses on intrapsychic conflict and anxi­
ety; the behavioral viewpoint focuses on faulty learn­
ing and environmental conditions that may be exac­
erbating or maintaining the condition; the
cognitive-behavioral viewpoint focuses on maladap­
tive thinking, including deficits in problem solving
and information processing; the humanistic view­
point focuses on the ways in which a person's strug­
gles with values, meaning, and personal growth mav
be contributing to the problem; and the interper­
sonal viewpoint focuses on difficulties in a person's
past and present relationships.
Thus adopting one perspective or another has im­
portant consequences: It influences our perception
of maladaptive behavior, the types of evidence we
look for, and the way in which we are likely to inter­
pret data. In the following section we will discuss a
range of psychosocial causal factors which have been
implicated in rhe origins of maladaptive behavior.
We will also illustrate how some of these different

95

viewpoints would provide contrasting (or sometimes
complementary) explanations for how they exert
their effects. In later chapters, we will discuss rele­
vant concepts from all these viewpoints as they relate
to. different forms of psychopathology, and in many
instances, we will contrast different ways of explain­
ing and treating the same disorder.

i8l PSYCHOSOCIAL CAUSAL

FACTORS
We begin life with few built-in patterns and a great
capacity; to learn from experience. What we do learn
from our experiences may help us face challenges re­
sourcefully and resiliently. Unfortunately, some of
our experiences may be much less helpful in our
later lives, and we may be deeply influenced by fac­
tors in early' childhood over which we have no con­
trol. In this section we will examine the psychosocial
factors that make people vulnerable to disorder or
that may precipitate disorder. Psychosocial factors
arc those developmental influences that may handi­
cap a person psychologically, making him or her less
resourceful in coping with events.
We begin this section with a brief examination of
the central role played by our perceptions of our-.
selves and our world which derive from our schemas’
and self-schemas. Then we will review specific influ­
ences that may distort the cognitive structures on
which good psychological'functioning depends. We
will focus on four categories of psychosocial causal
factors that exemplify the range of factors that have
been studied: early deprivation and trauma, inade­
quate parenting, pathogenic family structures, and
maladaptive peer relationships. Such factors typically
do not operate alone. They interact with each other
and with other psychosocial factors, with particular
genetic and constitutional factors, and with particu­
lar settings or environments.

Schemas and Self-Schemas
Fundamental to determining what we know, want.
and do are some basic assumptions that we make
about ourselves, our world, and the relationship be­
tween the two. Using terminology' from the cogni­
tive perspective, these assumptions make up our
frames of reference—our schemas about other peo­
ple and the world around us, and our self-schemas or
ideas that we have about our own attributes. Be­
cause what we can learn or perceive directly through
our senses can provide only an approximate repre­
sentation of “reality',” we need cognitive frameworks

96

Chapter 3

Causal Factors and Viewpoints in Abnormal Psychology

to fill in the gaps and make sense out of what we can
observe and experience. A schema is an organized
representation of prior knowledge about a concept
or about some stimulus that helps guide our pro­
cessing of current information (Alloy & Tabachnik,
1984; Fiske 8c Taylor, 1991). Our schemas about
the world around us and about ourselves are our
guides, one might say, through the complexities of
living in the world as we understand it. We all have
schemas about other people (for example, expecta­
tions about their traits and goals), as well as schemas
about social roles’(for example, expectations about
what appropriate behaviors for someone in that role
are) and about events (for example, what appropri­
ate sequences of events are for particular situations)
(Fiske 8c Taylor, 1991). Our self-schemas include
our views on what we are, what we might become,
and what is important to us. Other aspects of our
self-schema concern our notions of the various roles
we occupy or might occupy in our social environ­
ment, such as woman, man, student, parent, physi­
cian, American, older person, and so on. The vari­
ous aspects of a person’s self-schema also can be
construed as his or her self-identity (similar to
Rogers’ self-concept and Sullivan’s self-system).
Most people have clear ideas about at least some of
their own personal attributes, and less clear ideas
about other attributes (Fiske 8c Taylor, 1991).
Schemas about the world and self-schemas arc vi­
tal to effective and organized behavior, but they are
also sources of psychological vulnerabilities. This is
because some of our schemas or certain aspects of
our self-schema may be distorted and inaccurate. In
addition, some schemas—even distorted ones—may
be held with conviction, making them resistant to
change. We are usually not completely conscious of
our schemas. Although our daily decisions and be­
havior are largely shaped by these frames of refer­
ence, we may be unaware of die assumptions on
which they are based—or even of having made as­
sumptions at all. We think tiiat we are simply seeing
things the way they are and often do not often con­
sider the fact that other pictures of die “real” world
might be possible or that other rules for “right”
might exist.
On the one hand, the self-schema can be seen as a
set of rules for processing information and for se­
lecting behavior alternatives; on die odier hand, it
can be seen as the product of those rules—a sense of
selfhood, or self-identity (Vallacher, Wegner, 8c
Hoine, 1980). Deficiencies or deviations in either
aspect of the development of the self can make one
vulnerable to disorder. For example, if a person’s in­
formation-processing rules differ in major respects
from those of his or her peers, then that person’s

Our self-schemas—our frames of reference for u'hat ire
are. what we might become, and what is important to
us—influence our choice ofgoals and our confidence in
being able to attain them. A key element of this older
uvman's self-schema was that she could accomplish her
lifelong goal of obtaining a college education once her
children were grown in spite of the fact that she was
nearly -10 years older than the average college student.

“reality” will be correspondingly different and may
lead to rejection, isolation, despair, and disorder.
As Vallacher and colleagues (1980) have put it,
we look through the rules of the self—rarely at them.
For this reason, die rules, once established, may be
hard to identify, and it may be difficult to change
them deliberately. New experiences tend to be
worked into our existing cognitive frameworks, even
if the new information has to be reinterpreted or
distorted to make it fit—a process known as assimi­
lation. We tend to cling to existing assumptions and
reject or change new information that contradicts
them. Accommodation—changing our existing
frameworks to make it possible to incorporate dis­
crepant information—is more difficult and direatening, especially when important assumptions are chal­
lenged. Accommodation is, of course, a basic goal of
psychosocial dierapies—explicidy in rhe case of the
cognitive and cognitive-behavioral variants, but
deeply embedded in virtually all other approaches as
well. This process makes major therapeutic change a
difficult task.
A person’s failure to acquire appropriate princi­
ples or rules in cognitive organization can make

Psychosocial Causal Factors

him or her vulnerable to psychological problems
later in life. Mischel (1973, 1990, 1993) has iden­
tified five learning-based differences that become
apparent early in childhood: (a) children acquire
different levels of competency in different areas;
(b) they learn different concepts and strategies for
encoding and categorizing their experiences, and
they thus “process” new information differently;
(c)
although they all learn that certain things fol­
low from certain others, what they learn to expect
is quite different, depending on their unique expe­
riences; (d) they learn different subjective values
and goals, which lead to their finding different sit­
uations attractive or disagreeable; and (e) they
learn different ways of coping with impulses and
regulating their behavior—they develop a charac­
teristic “style” of dealing with life’s demands. Dif­
ferences in these general areas continue through
childhood and into the adult years and help shape
later learning.
These learned variations make some children far
better prepared than others for further learning and
personal growth. The ability to make effective use of
new experience depends very much on the degree to
which past learning has created cognitive structures
that facilitate the integration of the novel or unex­
pected. A well-prepared child will be able to assimi­
late or when necessary accommodate new experi­
ence in ways that will enhance growth; a child with
less adequate cognitive foundations may be con­
fused, unreceptive to new information, and psycho­
logically vulnerable. It is mainly for this reason that
most theories of personality development, and all of
the psychosocial viewpoints of abnormal behavior
just described, emphasize the importance of earlv
experience in shaping the main directions that a per­
son’s coping style will take.
A good example is afforded by modern research
on the cognitive antecedents of psychological de­
pression. As discussed in Chapter 6, die onset of
many cases of depression, including severely incapac­
itating depression, has been linked repeatedly with
die prior occurrence of negative life events, such as
illness., divorce, or a serious financial setback. Some
evidence shows that people who respond to such
events with clinically diagnosable depressions are in
some sense “primed” to respond in this way because
of the ways in which they process the negative hap­
penings. Although the details of such a negative
“set” are still being studied, they seem to involve a
kind of overreaction to and overgeneralization of the
meaning of negative events, one that was learned
much earlier and may have remained dormant for
many years (Beck 1967, 1987). Some evidence sug­
gests that traumatic experiences, such as the death of

97

a parent in childhood, may encourage the acquisition
of such maladaptive self-schemas (Boivlby, 1980).
The example just given reminds us that the events
making up one child’s experiences may be vastiy dif­
ferent from those of another, and that many such
events are neither predictable nor controllable. At
one extreme are children who grow up in stable and
lovingly indulgent environments, buffered to a large
extent from the harsher realities of the world; at the
other extreme are children whose experiences consist
of constant exposure to frightening events or un­
speakable cruelties. Such different experiences have
corresponding effects on the schemas about the
world and about the self of adults: Some suggest a
world that is uniformly loving, unthreatening and
benign, which of course it is not; others a jungle in
which safety and perhaps even life itself is constantly
in the balance. Given a preference in terms of likely
outcomes, most mental health professionals would
opt for the former of these sets of experiences. How­
ever, these may not be the best blueprint tor engag­
ing the real world, because it may be important to
encounter some stresses and learn ways to deal with
them in order to gain a sense of control (Seligman,
1975) or self-efficacy (Bandura, 1977a, 1986).
Exposure to multiple uncontrollable and unpre­
dictable frightening events is likely to leave a person
vulnerable to anxiety, a central problem in a number
of the mental disorders to be discussed in this book.
For example, Barlow’s (1988) and Mincka's (1985a)
models acknowledge some biological vulnerability to
stressful circumstances in creating anxiety, but they
also stress the importance of experience with nega­
tive outcomes perceived to be unpredictable and un­
controllable, based on a review of pertinent research
(see also Mineka 8c Zinbarg, 1991; in press-b). A
clinically anxious person is someone whose schemas
include strong possibilities that terrible things over
which he or she has no control may happen unpredictably, and that the world is a dangerous place. It is
not difficult to imagine developmental scenarios that
would lead a person to have schemas with these ele­
ments as prominent characteristics.
Finally, it appears that some uncontrollable expe­
riences to which children are subjected are so over­
whelming that they do not develop a coherent self­
schema. This situation is perhaps seen most clearly
in cases of dissociative identity disorder, where sepa­
rate personalities have developed separate self­
schemas that may be completely walled off from one
another. We have learned in recent years that disso­
ciative identity disorder (formerly called “multiple
personality disorder”; see Chapter 7) may be associ­
ated with repeated, traumatic sexual and physical
abuse in childhood. The main point here is that a

98

Chapter 3

Causal Factors and Viewpoints in Abnccmal Psychology

fragmented sense of identity, whatever its origin—
and it is frequently traumatic—invites the develop­
ment of abnormal behaviors. On this the psychoso­
cial viewpoints all concur; they differ primarily in the
mechanisms through which they hypothesize these
abnormal behaviors develop.

Early Deprivation or Trauma
Fortunately, experiences of the intensity and persis­
tence just noted, although more common than was
thought only a decade ago, are nevertheless rela­
tively rare. There are, however, other kinds of expe­
riences that, while less dramatic and chilling, may
leave children with deep and sometimes irreversible
psychic scars. The deprivation of needed resources
normally supplied by parents or parental surrogates
is one such circumstance.
Parental deprivation refers to an absence of ade­
quate care from and interaction with parents or their
substitutes during the formative years. It can occur
even in intact families where, for one reason or an­
other, parents arc unable (for instance, because of
mental disorder) or unwilling to provide for a child’s
needs for close and frequent human contact. The
most severe manifestations of deprivation are usually
seen among abandoned or orphaned children who
may either be institutionalized or placed in a succes­
sion of unwholesome foster homes.
We can interpret the consequences of parental
deprivation from several psychosocial viewpoints.
Such deprivation might result in fixation at the oral
stage of psychosexual development (Freud); it might
interfere with the development of basic trust (Erik­
son); it might retard the attainment of needed skills
because of a lack of available reinforcements (Skin­
ner); it might preempt self-actualizing tendencies
with maintenance and defensive requirements
(Rogers, Maslow); or it might stunt the develop­
ment of the child's capacity for relatively anxietyfree exchanges of tenderness and intimacy with oth­
ers (Sullivan). Any of these viewpoints might be the
best way of conceptualizing the problems that arise
in a particular case, or some combination of them
might be superior to any one. From the cognitive
perspective, which we have been focusing on, we see
the victims of such experiences as acquiring dysfunc­
tional schemas and self-schemas in which relation­
ships are represented as unstable, untrustworthy,
and without affection.

Institutionalization In an institution, compared
with an ordinary home, there is likely to be less
warmth and physical contact; less intellectual, emo­
tional, and social stimulation; and a lack of encour-

Success al school-—such as winning a spelling bee—may
be a protective factor that helps a child overcome disad­
vantages such as parental deprivation or institutional­
ization.

agement and help in positive learning. A much-ref­
erenced study by Provence and Lipton (1962) com­
pared the behavior of infants living in institutions
with that of infants living with families. At one year
of age, the institutionalized infants showed general
impairments in their relationships to people, rarely
turning to adults for help, comfort, or pleasure and
showing no signs of strong attachments to any per­
son. These investigators also noted a marked retar­
dation of speech and language development, emo­
tional apathy, and impoverished and repetitive play
activities. With more severe and pervasive depriva­
tion, development may be even more retarded.
The long-range prognosis for children suffering
early and prolonged parental deprivation titrough in­
stitutionalization is considered unfavorable (Quinton
& Rutter, 1988; Quinton, Rutter, 8c Little, 1984;
Rutter, 1990; Rutter 8c Quinton, 1984a; Tizard 8c
Hodges, 1978). It is clear diat many children de­
prived of normal parenting in infancy and early child­
hood show maladaptive personality development and
are at risk for psychopathology. Institutionalization
later in childhood in a child who has already had
good attachment experiences is not so damaging
(Rutter, 1987). However, even among those institu­
tionalized at an early age, some show resilience and
do well in aduldtood. One important protective fac­
tor found to influence this was whether the child
went from the institution into a harmonious family
or a discordant one, widi better outcomes among
those who entered harmonious homes (Rutter,
1990). Another influential protective factor was hav­
ing some good experiences at school, whether in the
form of social relationships, or athletic or academic

Psychosocial Causal Factors

success; these successes probably contributed to a
better sense of self-esteem or self-efficacy' (Quinton
& Rutter, 1988; Rutter, 1985,1990).
Deprivation and Abuse in the Home Most infants
subjected to parental deprivation are not separated
from their parents, but rather suffer from inadequate
care at home. In these situations parents typically ne­
glect or devote little attention to their children and
are generally rejecting. Parental rejection of a child is
closely related to deprivation and may be demon­
strated in various ways—by physical neglect, denial of
love and affection, lack of interest in the child’s activ­
ities and achievements, harsh or inconsistent punish­
ment, failure to spend time with the child, and lack of
respect for the child’s rights and feelings. In a minor­
ity’ of cases, it also involves cruel and abusive treat­
ment. Parental rejection may be partial or complete,
passive or active, or subtly' or overtly' cruel.
The effects of such deprivation and rejection may
be very serious. For example, Bullard and his col­
leagues (1967) delineated a “failure to thrive” (F11)
syndrome that “is a serious disorder of growth and
development frequently requiring admission to the
hospital. In its acute phase it significantly compro­
mises the health and sometimes endangers the life of
the child” (p. 689). The problem is fairly common in
low-income families, with estimates at about 6 per­
cent of children born at medical centers serving lowincome families (Lozoff, 1989). Some have sug­
gested that it may occur in a child who has become
severely' depressed (because of the deprivation
and/or abuse) and has developed a neuroendocrine
problem stunting growth (Ferholt et al., 19851, but
it is also now clear that this syndrome often has pre­
natal origins, with a disproportionate number haring
had low birth weights (Lozoff, 1989).
Outright parental abuse of children has also been
associated with many other negative effects on the de­
velopment of its victims, although some studies have
suggested that, at least among infants, gross neglect
may be worse than haring an abusive relationship.
Abused children often have a tendency’ to be overly
aggressive and prone to impulsive behavior (Emery,
1989). Researchers have also found that maltreated
children have difficulties in linguistic development and
significant problems in emotional and social function­
ing, including depression and impaired relationships
with peers (Cicchetti, 1990; Emery, 1989). In addi­
tion, abused children are at heightened risk for later
aggressive behavior (Dodge, Bates, & Pettit, 1990).
Abused and maltreated infants and toddlers are likely
to develop a pattern of disorganized and disoriented
style of attachment (Crittenden 8c Ainsworth, 1989),
characterized by bizarre, disorganized, and inconsis­
tent behavior with the mother. A recent review of re­

99

search in this area concluded that “maltreatment by
the primary' caregiver in early’ childhood appears to
jeopardize the organization and development of the
attachment relationship, the self, and the regulation
and integration of emotional, cognitive, motivational,
and social behavior” (Masten et al., 1990, p. 437).
Nevertheless maltreated children—whether the
maltreatment comes from abuse or from depriva­
tion—can improve when the caregiving environ­
ment improves (Crittenden, 1985; Farber 8c Ege­
land, 1987; Masten 8c O’Connor, 1989; Rutter,
1979). Yet even though subsequent experiences mayhave a moderating influence, for some children the
detrimental effects of such early traumas may never
be completely overcome, partly because experiences
that would provide the necessary relearning may be
selectively avoided. A child whose schemas do not
include the possibility' that others can be trusted
may not venture out toward others far enough to
learn that some people in the world are in fact trust­
worthy. This idea is supported by the findings of
Dodge and colleagues (1990) who found that
abused children tend to attribute hostile intent to
negative interactions with peers. Moreover, this ten­
dency to attribute hostile intent seemed to mediate
the development of aggressive behavior. That these
effects may be enduring is supported by a recent re­
view of the long-term consequences of physical
abuse (into adolescence and adulthood) which con­
cluded that childhood physical abuse predicts both
familial and nonfamiliai violence in adolescence and
adulthood, especially in abused men (MalinoskyRummell 8t Hansen, 1993). Physical abuse was also
found to be associated with self-injurious behaviors
and suicidal behavior, as well as anxiety, depression,
and psychosis, especially in women.
A significant proportion of parents who reject or
abuse their children have themselves been the victims
of parental rejection. Their early history of rejection
or abuse would clearly have had damaging effects on
their schemas and self-schemas, and probably re­
sulted in a failure to internalize good models of par­
enting. Kaufman and Zigler (1989) estimated that
there is about a 30 percent chance of this pattern of
intergenerational transmission of abuse (see also
Widom, 1989). Those who were least likely to show
this pattern tended to have one or more protective
factors, such as a good relationship with some adult
during childhood, higher IQ, positive school experi­
ences, or physical attractiveness, among others.

Childhood Trauma Most of us have had one-time
traumatic experiences that temporarily shattered our
feelings of security', adequacy, and worth and influ­
enced our perceptions of ourselves and our environ­
ment. The term psychic trauma is used to describe

100

Chaptcr3

Causal Factors and Viewpoints in Abnormal Psychology

In February 1994 during a drug raid, Chicago police dis­
covered 19 children in thisfreezing, squalid cockroach-in­
fested apartment. The stove in the kitchen did not work.
and children were found sharing food with dogs off the
floor. The six adults in the apartment were charged with
child neglect, and child abuse charges were also consid­
ered. Growing up in such a setting may predispose chil­
dren to laterpsychological problems.

any aversive (unpleasant) experience that inflicts se­
rious psychological damage on an individual. The
following illustrates such an incident:

I believe the most traumatic experience of my
entire life happened one April evening when I
was 11.1 was not too sure of how I had become
a member of the family, although my parents
had thought it wise to tell me that I was
adopted. That much I knew, but what the term
adopted meant was something else entirely. One
evening after my step-brother and I had retired,
he proceeded to explain it to me—with a vehe­
mence I shall never forget. He made it dear that
I wasn’t a “real” member of the family, that my
parents didn’t “really” love me, and that I was­
n’t even wanted around the place. That was one
night I vividly recall crying myself to sleep. That
experience undoubtedly played a major role in
making me feel insecure and inferior.
Traumas of this sort are apt to leave psychological
wounds that may never completely heal. As a result,
later stress that reactivates these wounds may be par­
ticularly difficult for an individual to handle; this of­
ten explains why one person has difficulty with a
problem that is not especially stressful to another.
Psychic traumas in infancy or early childhood are especially damaging because children have limited
coping resources and are relatively helpless in the
face of threat. They are therefore more readily oyerwhelmed by traumas than an older person would be.
Conditioned responses, which in cognitive terms are
acquired expectancies that a particular event will fol­
low from another, are readily established in situa­
tions that evoke strong emotions; such responses are
often highly resistant to extinction. Thus one trau­
matic experience of almost drowning in a deep lake
may be sufficient to establish a fear of water that en-

dures for years or a lifetime. Conditioned responses
stemming from traumatic experiences may also gen­
eralize to other situations. For example, the child
who has learned to fear water may also come to fear
riding in boats and other situations associated with
even the remotest possibility of drowning. Young
children arc thus especially prone to acquiring in­
tense anxieties that remain resistant to modification
even as their coping resources develop over time.
Bowlby (1960, 1973) has summarized the trau­
matic effects for children from two to five years old
of being separated from their parents during pro­
longed periods of hospitalization. First, there are the
short-term or acute effects of the separation, which
can include significant despair during the separation
and detachment from the parents upon reunion;
Bowlby considers this to be a normal response to
prolonged separation, even in securely attached in­
fants. Children who undergo such separations may
develop an insecure attachment. In addition, there
can be longer-term effects of early separation from
one or both parents. For example, such separations
can cause an increased vulnerability to stressors in
adulthood, making it more likely that the person
will become depressed (Bowlby, 1980). As with
other early traumatic experiences, the long-term ef­
fects of separation depend heavily on the support
and reassurance given a child by parents or other
significant people, which is most likely if the child
has a secure relationship with at least one parent
(Lease & Ollendick, 1993; Main 8c Weston, 1981).
Many psychic traumas in childhood, although
highly upsetting at the time, probably have minor
long-term consequences. Some children are less vulnerable than others and show more resilience and
ability to recover from hurt (Crittenden, 1985). For
example, not all. children who experience a trauma—
even a parent’s death—exhibit discernible long-term
effects (Barnes 8c Prosen, 1985; Brown, Harris, 8c
Bifulco, 1985; Crook 8c Eliot, 1980; Rutter, 1985).

Psychosocial Causal Factors

Inadequate Parenting
Even in the absence of severe deprivation, neglect,
or trauma, many kinds of deviations in parenting can
have profound effects on a child’s subsequent ability
to cope with life’s challenges, and thus create vul­
nerability to various forms of psychopathology.
Therefore, although their explanations vary consid­
erably, the psychosocial viewpoints on abnormal be­
havior all focus attention on the behavioral tenden­
cies a child acquires in the course of early social
interaction with others—chiefly parents or parental
surrogates.
You should keep in mind that a parent-child rela­
tionship is always bidirectional: As with any continu­
ing relationship, the behavior of each person affects
the behavior of the other. Some children are easier
to love than others; some parents are more sensitive
than others to an infant’s needs. In occasional cases,
we are able to identify characteristics in an infant
that have been largely responsible for an unsatisfac­
tory relationship between parent and child. A com­
mon example occurs in parents who have babies
with high levels of negative emotionality'. For exam­
ple, Rutter and Quinton (1984b) found that parents
tended to react with irritability, hostility, and criti­
cism to children who were high in negative mood
and low on adaptability. This in turn may set such
children at risk for psychopathology' because they
become “a focus for discord” in the family (Rutter,
1990, p. 191). Because parents find it difficult and
stressful to deal with babies who are high on nega­
tive emotionality, many of these infants may be
more prone to developing avoidant styles of attach­
ment than are infants who arc not high on negative
emotionality (Rothbart & Ahadi, 1994). Although
these examples illustrate that characteristics of an in­
fant can contribute to unsatisfactory attachment re­
lationships, in most cases the influence of a parent
on his or her child is likely to be more important in
shaping a child’s behavior, as we will see in the fol­
lowing sections.
Parental Psychopathology In general, it has been
found that parents who have various forms of psy­
chopathology’, including schizophrenia, depression,
antisocial personality' disorder, and alcoholism, tend
to have children who are at heightened risk for a
'vide range of developmental difficulties. Although
some of these effects may have a genetic component, many researchers believe that genetic effects
cannot account for all of the adverse effects that
parental psychopathology has on children. For ex­
ample, the children of seriously depressed parents
are at enhanced risk for disorder themselves

101

(Downey 8c Coyne, 1990; Gotlib 8c Avison, 1993),
at least partly because depression makes for unskill­
ful parenting—notably including inattentiveness to a
child’s needs (Gelfand 8c Teti, 1990). Not only do
depressed mothers rate their children as having
more psychological and physical problems than do
nondepressed mothers, but independent observers
also rate infants of depressed mothers as more un­
happy and tenser than infants of nondepressed
mothers. Slightly older children of depressed moth­
ers have also been rated as having a wide range of
problems (see Gotlib 8c Avison, 1993). In addition,
children of alcoholics have elevated rates of truancy
and substance abuse arid a greater likelihood of
dropping out of school, as well as higher levels of
anxiety' and depression and lower levels of self-es­
teem (Chassin, Rogosch, 8c Barrera, 1991; Gotlib 8c
Avison, 1993), although many children of alcoholics
do not have difficulties. Although most research on
this topic has focused on the effects of disordered
mothers on their children, recently attention has
been drawn to the fact that disordered fathers also
make significant contributions to child and adoles­
cent psychopathology’, especially to problems such as
conduct disorder, delinquency, and attention deficit
disorder (Phares 8c Compas, 1992).
In spite of the profound effects that parental psy­
chopathology' can have on children, it should also be
noted that many children raised in such families do
just fine because of a variety of protective factors
that may be present. For example, a child living with
a parent with a serious disorder who also has a warm
and nurturing relationship with the other parent, or
with another adult outside the family, has a signifi­
cant protective factor. Other important protective
factors that promote resilience include having good
intellectual skills and being appealing to adults
(Mastenetal., 1990).
Although not associated with any' particular form
of parental psychopathology', several specific patterns
of parental influence appear in the backgrounds of
children who show certain ty'pes of faulty' development that may increase their risk for psychopathol­
ogy'. Some of these patterns will be discussed in the
following sections.
Parental Warmth and Control In the past, disci­
pline was conceived of as a method for both punish­
ing undesirable behavior and preventing or deter­
ring such behavior in the future. Discipline is now
thought of more positively as providing needed
structure and guidance for promoting a child’s
healthy growth. Such guidance provides a child with
schemas similar to outcomes actually meted out by
the world, contingent on a person’s behavior. The

WM 100

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rthtehw.ifrU liTiiA'A

102

Chapters

Causal Factors and Viewpoints in Abnormal Psychology

•

sMS

person thus informed has a sense of control over
these outcomes and is free to make deliberate
choices. When coercion or punishment is deemed
necessary, it is important that a parent make clear
exactly what behavior is considered inappropriate. It
is also important that the child know what behavior
is expected, and that positive and consistent meth­
ods of discipline be worked out for dealing with in­
fractions. In general, a child should be allowed inde­
pendence in keeping with his or her level of
maturin’. As competent parents would doubtless
agree, this judgment is not always easy to make.
Researchers have been interested in the degree to
which parentiitp styles—including their disciplinary
styles—affect children’s behavior over the course of
development. Four different types of parenting
styles have been identified that seem to be related to
different developmental outcomes for the children:
authoritative, authoritarian, indulgent, and neglect­
ing. These styles vary in the degree of parental
warmth (amount of support, encouragement, and
affection versus shame, rejection, and hostility) and
in the degree of parental control (extent of discipline
and monitoring versus being largely unsupervised)
(Maccoby & Martin, 1983). First, the authoritative
style is one in which the parents are both very warm
and very careful to set clear limits and restrictions
regarding certain kinds of behaviors, but also allow
considerable freedom within certain limits. This
style of parenting is associated with the most posi­
tive early social development, with the children
tending to be energetic and friendly and showing
development of general competencies, for dealing

with others and with their environments (Baumrind,
1967, 1975, 1993). When followed into adoles­
cence in a longitudinal study, children of authorita­
tive parents continued to show positive outcomes.
This parenting style was particularly predictive of
competence in sons (Baumrind, 1991).
Parents with an authoritarian style are high on
control but low on warmth, and their children tend
to be conflicted, irritable, and moody (Baumrind,
1967). When followed into adolescence these chil­
dren had more negative outcomes, with the boys
doing particularly poorly in social and cognitive
skills. If such authoritarian parents also use overly se­
vere discipline in the form of physical punishment—
as opposed to the withdrawal of approval and privi­
leges—the result tends to be increased aggressive
behavior on the parr of a child (Eron er al., 1974;
Faretra, 1981; Patterson, 1979). Apparently, physi­
cal punishment provides a model of aggressive be­
havior that the child emulates and incorporates into
his or her own self-schema.
A third parenting style is the permissive-indulgent
style, in which parents are high on warmth but low
on discipline and control. This style of parenting is
associated with impulsive and aggressive behavior in
children (Baumrind, 1967; Hetherington & Parke,
1993). Overly indulged children are characteristi­
cally spoiled, selfish, inconsiderate, and demanding.
In a classic study Sears (1961) found that much per­
missiveness and little discipline in a home were cor­
related positively with antisocial, aggressive behav­
ior, particularly during middle and later childhood.
Unlike rejected and emotionally deprived children,

Psychosocial Causal Factors

indulged children enter readily into interpersonal re­
lationships, but they exploit people for their own
purposes in the same way that they have learned to
exploit their parents. Overly indulged children also
tend to be impatient, and to approach problems in
an aggressive and demanding manner (Baumrind,
1971, 1975). In short, they have self-schemas with
significant “entitlement” features. Confusion and
adjustive difficulties may occur when “reality” forces
them to reassess their assumptions about themselves
and the world.
Finally, there are parents who are low both on
warmth and on control—the ney/lecting-nniiivolved
style. This latter style of parental uninvolvement is
associated with disruptions in attachment during
childhood (Egeland & Sroufe, 1981), and with
moodiness, low self-esteem, and conduct problems
later in childhood (Baumrind, 1991; Hetherington
& Parke, 1993). These children of uninvolved par­
ents also have problems with peer relations and with
academic performance (Hetherington & Parke,
1993).
When just examining the effects of restrictiveness
(ignoring the warmth variable), research has shown
that restrictiveness can serve as a.protective factor
for children growing up in high-risk environments.
as defined by a combination of family occupation
and education level, minority status, and absence of
a father (Baldwin, Baldwin, & Cole; 19901. Among
high-risk children, those who did well in terms of
cognitive outcome (IQ and school achievement!
tended to have more restrictive and less democratic
parents. Indeed, restrictiveness was positively related
to cognitive outcome only among high-risk children
and not among low-risk children. Restrictiveness
was also particularly helpful for families living in ar­
eas with high crime rates.

Inadequate, Irrational, and Angry Communica­
tion Parents sometimes discourage a child from
asking questions and in other ways fail to foster the
information exchange essential for helping the child
develop essential competencies. Inadequate commu­
nication may take a number of forms. Some parents
are too busy or preoccupied with their own con­
cerns to listen to their children and to trv to under­
stand the conflicts and pressures they are facing. As a
consequence, these parents often fail to give needed
support and assistance, particularly when there is a
crisis. Other parents have forgotten that the world
often looks different to a child or adolescent—rapid
social change can lead to a communication gap be­
tween generations. In other instances, faulty com­
munication may take more deviant forms in which
messages become completely garbled because a lis­

103

tener distorts, disconfirms, or ignores a speaker’s in­
tended meaning.
Not uncommonly children are exposed to high
levels of anger and conflict. The anger can occur in
the context of marital discord, abuse, or parental
psychopathology,and is often associated with psy­
chological problems in children (Emery, 1982;
Porter & O’Leary, 1980; Schneider-Rosen & Cic­
chetti, 1984). That there are psychological problems
is not surprising given findings that children experi­
ence such background anger, like abuse, as emotion­
ally arousing and distressing (Cummings, 1987;
Emery, 1989).

Pathogenic Family Structures
The pathogenic parent-child patterns so far de­
scribed, such as parental rejection, are rarely found
in severe form unless the total familial context is also
abnormal. Thus pathogenic family structure is an
overarching risk factor that increases an individual’s
vulnerability to particular stressors. We will distin­
guish between intact families where there is signifi­
cant marital discord and families that have been dis­
rupted by divorce or separation.
Marital Discord In some cases of marital discord.
one or both of the parents is not gaining satisfaction
from the relationship. One spouse may express feel­
ings of frustration and disillusionment in hostile
ways such as nagging, criticizing, and doing things
purposely to annoy the other person. Whatever the
reasons for the difficulties, seriously discordant rela­
tionships of long standing are likely to be frustrat­
ing, hurtfill, and generally pathogenic in their ef­
fects on the adults and their children.
In more severe cases of marital discord, one or
both of the parents behave in grossly eccentric or
abnormal ways and may keep the home in constant
emotional turmoil. Such families differ greatly, but it
is common to find (a) parents who are fighting to
maintain their own equilibrium and are unable to
give children the love and guidance they need, (b)
grossly irrational communication patterns, and (c)
entanglement of children in the parents’ emotional
conflicts. In all these cases, the children are caught
up in an unwholesome and irrational psychological
environment and as they grow up they may find it
difficult to establish and maintain marital and other
intimate relationships.

Divorced Families In many cases a family is incom­
plete as a result of death, divorce, separation, or
some other circumstance. Due pardy to a growing

jjiL

104

Chapter 3

Causal Factors and Viewpoints in Abnonral Psycholog}’

cultural acceptance of divorce, more than a million
divorces now occur yearly in the United States (U.S.
Bureau of the Census, 1989). Estimates are that
about 20 percent of children under the age of 18 are
living in a single-parent household—some with un­
wed parents and some with divorced parents. About
40-50 percent of marriages end in divorce and
about 60 percent of these divorces involve children
(Hetherington & Parke, 1993). Unhappy marriages
are difficult, but ending a marital relationship can
also be enormously stressfill for the adults, both
mentally and physically. Divorced and separated per­
sons are overrepresented among psychiatric patients,
although the direction of the causal relationship is
not always clear. In their comprehensive review of
the effects of divorce on adults, Bloom, Asher, and
White (1978) concluded that it is a major source of
psychopathology, as well as physical illness, death,
suicide, and homicide.
Divorce can have traumatic effects on children,
too. Feelings of insecurity and rejection may be ag­
gravated by conflicting loyalties and, sometimes, by
the spoiling the children receive while staying with
one of the parents. Not surprisingly, some children
do develop serious maladaptive responses. Tempera­
mentally difficult children are likely to have a more
difficult time adjusting than are temperamentally easy
children < Hetherington, Stanley-Hagan, & Ander­
son, 19891. Somewhat ironically, these also rnay be
the children whose parents are more likely to divorce,
perhaps because having difficult children is likely to
exacerbate marital problems (Block, Block, 8c Gjerdc,
1986). Delinquency and other abnormal behaviors
are much more frequent among children and adoles­
cents from divorced families than among those from
intact families, although it is likely that a contributing
factor here is prior or continuing parental strife (Rut­
ter, 1971, 1979). Moreover, given that both broken
homes and delinquency are more common among
families in lower socioeconomic circumstances, it may
be that disrupted homes and childhood deviance are
both largely caused by the stresses of poverty and ex­
clusion from society’s mainstream. Finally, Amato
and Keith (1991; Amato, 1988) also note that there
may well be long-term effects of divorce on adaptive
functioning in early adulthood in as much as some
studies have found lower educational attainment,
lower incomes, increased probability of being on wel­
fare and having children out of wedlock in young
adults from divorced families.
Nevertheless, many children adjust quite well to
the divorce of their parents. Indeed, a recent quanti­
tative renew of 92 studies conducted on 13,000
children since the 1950s on parental divorce and the
well-being of children concluded that the average

negative effects of divorce on children are actually
quite modest (Amato 8c Keith, 1991). They also
found that the effects seem to be decreasing over
the past four decades (particularly since 1970), per­
haps because the stigma of divorce is decreasing.
The domains of well-being that were examined in­
cluded school achievement, conduct problems, psy­
chological and social adjustment, self-concept, and
parent-child relations. Children in the middle-age
range (grade school to high school) had slightly
worse outcomes than preschool-age and college-age
children (Amato & Keith, 1991).
The effects of divorce on children have been
compared with the effects of remaining in a home
torn by marital conflict and dissension, and the ef­
fects of divorce are often more favorable (Hether­
ington et al., 1989). The Amato and Keith review
. 1991) also demonstrated that children who were in
intact but high-conflict families were worse off than
children in divorced families. At one time it was
thought that detrimental effects of divorce might be
minimized if a successful remarriage provided an ad­
equate environment for child rearing. Unfortu­
nately, however, the Amato and Keith review re­
vealed that such children living with a stepparent
were no better off than children living with a single
parent, although this was more true for girls than
for boys. Indeed, some studies have found that the
period of adjustment to remarriage may be longer
than that for divorce (Hetherington et al., 1989).
Other studies have shown that children—especially
very young children—living with a stepparent are at
increased risk for physical abuse and even death by
the stepparent, relative to children living with two
biological parents (Daly & Martin, 1988).

Maladaptive Peer Relationships
Another important set of relationships outside the
family usually begins in the preschool years—those
involving age-mates, or peers. Normally, these
neighborhood or school relationships involve a
much broader range of possible experiences than do
the more constrained and established relationships
within families. When a child ventures into the
world independently, he or she is faced with a num­
ber of complicated and unpredictable challenges.
The potential for problems and failure is consider­
able.
Children at this stage are hardly masters of the
fine points of human relationships or diplomacy.
Empathy—the appreciation of another’s situation,
perspective, and feelings—is at best only primitively
developed, as can be seen in a child who turns on

Psychosocial Causal Factors

and rejects a current playmate when a more favored
candidate arrives. The child’s own immediate satis­
faction tends to be the primary goal of any interac­
tion, and there is only an uncertain recognition that
cooperation and collaboration may bring even
greater benefits. A substantial minority of young­
sters seems somehow ill-equipped for the rigors and
competition of the school years, most likely by
virtue of constitutional factors and deficits in the
psychosocial climate of their families. A significant
number of them withdraw from their peers; a large
number of others (especially among males) adopt
physically intimidating and aggressive lifestyles. The
neighborhood bully and the menacing schoolyard
loner are examples. Neither of these routes bode
well for good mental health outcomes (e.g., Coie et
al., 1992; Coie & Cillessen, 1993; Hartmann et al.,
1984; Kupersmidt, Coie, & Dodge, 1990).
Fortunately, there is another side to this coin. If
peer relations have their developmental hazards,
thev can also be sources of key learning experiences
that stand an individual in good stead for years, per­
haps for a lifetime. For a resourceful youngster, the
give-and-take, the winning and losing, the successes
and failures of the school years provide superb train­
ing in coming to grips with the real world and with
his or her developing self-—its capabilities and limita­
tions, its attractive and unattractive qualities. The
experience of intimacy with another, a friend, has its
beginning in this period of intense social involve­
ment. If all has gone well in the early juvenile years,
a child emerges into adolescence with a considerable
repertoire of social knowledge and skills. Such an
adolescent can effectively adapt his or her beharior
to the requirements of a situation and communicate.
as appropriate, his or her thoughts and feelings to
others. Practice and experience in intimate commu­
nication with others makes possible a transition
from attraction, infatuation, and mere sexual curios­
ity to genuine love and commitment. Such resources
can be strong protections against frustration, de­
moralization, despair, and mental disorder.
Although the scenario just outlined seems rea­
sonable, it lacked until recently a strong empirical
research foundation. In fact, the developmental pe­
riod it addresses had been largely ignored by the
major personality theorists, Erikson and Sullivan be­
ing notable exceptions. In the last 20 years, how­
ever, research into risk factors associated with chil­
dren’s peer relations has been accelerating. Some of
the more important of these findings are briefly
summarized in the following section.

Sources of Popularity Versus Rejection What de­
termines which children will be popular and which

105

will be rejected? By far the most consistent correlate
of popularity among juveniles is being seen as
friendly and outgoing (Hartup, 1983). The causal
relationship between popularity and friendliness is
indeterminate and probably complexly involved
with other variables, such as intelligence and physi­
cal attractiveness.
Far more attention has been devoted to identify­
ing why some children are persistendy rejected by
their peers. One large factor is an excessively de­
manding or aggressive approach to ongoing peer ac­
tivities, but this factor by no means characterizes the
behavior of all children rejected by their peers. A
smaller group of children is apparendy rejected be­
cause of their own social withdrawal. The remaining
large group is rejected for unknown reasons; evidendy some reasons are quite subtle (Coie, 1990).
Many rejected children have poor entry skills in
seeking to join ongoing group activities: They draw
attention to themselves in disruptive ways; make un­
justified aversive comments to others; arid fre­
quently become the focal point of verbal and physi­
cal aggression (Coie & Kupersmidt, 1983; Coie &
Dodge, 1988; Putallaz & Gottman, 1983). Indeed,
approximately half of rejected boys are highly ag­
gressive (Coie 8c Cillessen, 1993). More generally.
Dodge and colleagues (1980; Dodge 8: Newman,
1981; Dodge 8c Frame, 1982; Dodge, Murphy, 8c
Buchsbaum, 1984) have described these children as
taking offense too readily and as attributing hostile
intent to the teasing of their peers, escalating con­
frontations to unintended levels. They also tend to
take a more punitive and less forgiving attitude to­
ward such situations (Coie et al., 1991). In the end,
rejection leads to social isolation, often self-imposed
(Dodge, Coie, 8c Brakke, 1982; Hymel 8c Rubin,
1985; Ladd, 1983). Coie (1990) pointed out that
such isolation is likely to have serious consequences
because it deprives a child of further opportunities
to learn the rules of social behavior and interchange,
rules that become more sophisticated and subtle
with increasing age. Repeated social failure is the
usual result, with further damaging effects on self­
confidence and self-esteem. Kupersmidt and Coie
(1990) reported that boys who were rejected by
their peers in the fifth grade were more likely to
have nonspecific negative outcomes seven years later
than were average, popular, or neglected boys. Ag­
gression toward peers in the fifth grade was the
best predictor of juvenile delinquency and school
dropout seven years later (see also Coie et al., 1992;
Coie 8c Cillessen, 1993). One causal pathway for this
association has been supported by Patterson, Capaldi,
and Bank (1991; see also Dishion, 19941. Building
on the finding that aggression is the best predictor of

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^i^a^cii,-. LL^ ..^'Afa*

106

Chaptcr3

Causal Factors and Viewpoints in Abnocnal Psychology

I® THE SOCIOCULTURAL
VIEWPOINT

Juvenile socializing is a risky business in which a child's
bard-uxm prestige in a group is probably perceived as be­
ing constantly in jeopardy. Actually, reputation and sta­
tus in a group tend to be stable, and a child who has been
rejected by peers is likely to continue to hare problems in
peer relationships.

peer rejection (Coie ct al., 1990), they found that
peer rejection often leads a child to associate with de­
viant peers several years later, which in turn is associ­
ated with a tendency toward juvenile delinquency.
A child’s position in a group tends, in the absence
of intervention, to remain stable, especially by the
fifth grade and beyond. On average, “stars” tend to
remain stars and “rejects,” rejects. For example, in
one study almost half of the fifth graders who were
rejected by their peers continued to be rejected over
the next five years (Coie & Dodge, 1983). Some of
this happens because other children tend to explain
the behavior of the rejected child in terms of stable
characteristics of the child. Because they have nega­
tive expectations of the rejected child, they act more
negatively toward the child, thus setting up a kind of
self-fulfilling prophecy for the interaction between
the rejected child and his peers.
In summary, both logic and research findings
lead to a similar conclusion: A child who fails to es­
tablish a satisfactory relationship with peers during
the developmental years is deprived of a crucial set
of background experiences and is at higher-than-average risk for a variety of negative outcomes in ado­
lescence and adulthood (Kupersmidt et al., 1990).
Peer social problems in childhood have been linked
to a variety of breakdowns in later adaptive function­
ing, including schizophrenia, school dropout, and
crime. Although these correlational data do not in
themselves permit strong causal inferences, they
constitute important links in a highly plausible
causal chain.

By the beginning of the twentieth century, sociol­
ogy and anthropology had emerged as independent
scientific disciplines and were making rapid strides
toward understanding the role of sociocultural fac­
tors in human development and behavior. Early so­
ciocultural theorists included such notables as Ruth
Benedict, Ralph Linton, Abram Kardincr, Margaret
Mead, and Franz Boas. Their investigations and
writings showed that individual personality develop­
ment reflected the larger society—its institutions,
norms, values, ideas, and technologies—as well as
the immediate family and other groups. Studies also
made clear the relationship between sociocultural
conditions and mental disorders—between the par­
ticular stressors in a society and the types of mental
disorders that typically occur in it. Further studies
showed that the patterns of both physical and men­
tal disorders in a given society could change over
time as sociocultural conditions changed. These dis­
coveries have added another dimension to modern
perspectives on abnormal behavior.

Uncovering Sociocultural Factors Through
Cross-Cultural Studies
The sociocultural viewpoint is concerned with the
impact of the social environment on mental disorder,
but the relationships between maladaptive behavior
and sociocultural factors such as poverty, discrimina­
tion, or illiteracy are complex. It is one thing to ob­
serve that a person with a psychological disorder has
come from a harsh environment. It is quite another
thing, however, to show empirically that these cir­
cumstances were either necessary or sufficient condi­
tions for producing the disorder. Part of the problem
relates to the impossibility of conducting controlled
experiments. Investigators cannot ethically rear chil­
dren with similar genetic or biological traits in diverse
social or economic environments in order to find out
which variables affect development and adjustment.
Nevertheless, natural occurrences have provided
laboratories for researchers. Groups of human be­
ings have been exposed to very different environ­
ments, from the Arctic to the tropics to the desert.
These societies have developed different means of
economic subsistence and different types of family
structures. Accordingly, highly diverse social and
political systems have developed. Nature has indeed

The Sociocultural Viewpoint

done social scientists a great favor by providing
such a wide array of human groups for study.
In the earliest cross-cultural studies, Westerntrained anthropologists observed the behavior of
“natives” and considered those behaviors in the
context of Western scientific thought. One of the
earliest attempts to apply Western-based concepts in
other cultures was the classic study of Malinowski
(1927), Sex and Repression in Savage Society. In this
work, he attempted to explain the behavior of “sav­
ages” through the use of the then-dominant princi­
ples of psychoanalysis. Malinowski found little evi­
dence among the Trobriand Islanders of any
Oedipal conflicts as described by Freud. He con­
cluded that the sexually based behavior postulated
by psychoanalytic theory was not universal but
rather was a product of the patriarchal family struc­
ture in Western society.
Shortly thereafter, Ruth Benedict (1934) pointed
out that even the Western definitions of abnormality
might not apply to behavior in other cultures. Cit­
ing various ethnographic reports, she indicated that
behavior considered abnormal in one society was
sometimes considered normal in another. For exam­
ple, she noted that some cultures valued trancelike
states. Thus she concluded that normality was sim­
ply a culturally defined concept.
Early research also found that some tvpes of ab­
normal behavior occurred only in certain cultures.
Several of these “culture-related” behaviors are de­
scribed in HIGHLIGHT 3.6. These and other earlv
anthropological findings led many investigators to
take a position of cultural relativism concerning ab­
normal behavior. According to this view, one cannot
apply universal standards of normality or abnormal­
ity to all societies. In fact, for a time many people ac­
cepted the anthropologist’s veto: Any general prin­
ciple could be rejected if a contrary instance
somewhere in the world could be demonstrated.
For example, schizophrenia would no longer be
viewed as abnormal if its symptoms were somewhere
accepted as normal behavior.
This extremely relativistic view of abnormal be­
havior is not widely held today (Strauss, 1979). It is
generally recognized that the more severe types of
mental disorder described in Western psychology are
found and considered maladaptive in societies
throughout the world. When people become so
mentally disordered that they can no longer control
their behavior, perform their expected roles, or even
survive without special care, their behavior is consid­
ered abnormal in any society'.
Research supports the view that many psycholog­
ical disturbances are universal, appearing in most

107

Margaret Mead (1901-1978). the world-famous anthro­
pologist. spent years studying other societies and amass­
ing cross-cultural data. Her Coming of Age in Samoa
(published in 1928) gave a favorable picture of many as­
pects oflife in a primitive" society and was influential in
establishing an attitude of cultural relativism among
many scientists and tbinkeis. Ilere she is pictured meet­
ing with schoolchildren in New Guinea.

cultures studied (Al-Issa, 1982; Carpenter &
Strauss, 1979; Cooper et al., 1972; Murphy, 1976;
World Health Organization, in press). For example,
although the incidences and symptoms vary, the be­
haviors we call schizophrenia (Chapter 12) can be
found among almost all peoples, from the most
primitive to the most technologically advanced. Re­
cent studies have also shown that certain psycholog­
ical symptoms, as measured by the Minnesota Multiphasic Personality Inventory fMMPI-2; see
Chapter 15), were consistently found among simi­
larly diagnosed clinical groups in other countries (in
Turkey bv Savacir & Erol, 1990; in China by Che­
ung & Song, 1989; Butcher, 1995).
Nevertheless, although some universal symptoms
appear, cultural factors do influence abnormal be­
havior. Human biology' does not operate in a vac­
uum; cultural demands serve as causal factors and
modifying influences in psychopathology. Sociocul­
tural factors often create stress for an individual (AlIssa, 1982; Sue & Sue, 1987). For example, chil­
dren growing up in an oppressive society that offers
few rewards and many hassles arc likely to expert-

108

Chapter 3

Causal Factors and Viewpoints in Abnormal Psychology

Unusual Patterns of Behavior Considered to Be Culture-Related Disorders
Name of Disorder

Culture

Description

Amok

Malaya (also observed
in Java, Philippines,
Africa, and Tierra
del Fuego)

A disorder characterized by sudden, wild outbursts of
homicidal aggression in which an afflicted person may kill or
injure others. This rage disorder is usually found in males
who are rather withdrawn, quiet, and inoffensive prior to
the onset of the disorder. Stress, sleep deprivation, extreme
heat, and alcohol are among the conditions thought to pre­
cipitate the disorder. Several stages have been observed:
Typically in the first stage the person becomes more with­
drawn; then a period of brooding follows in which a loss of
reality contact is evident. Ideas of persecution and anger
predominate. Finally, a phase of automatism or Amok oc­
curs, in which the person jumps up, yells, grabs a knife, and
stabs people or objects within reach. Exhaustion and de­
pression usually follow, with amnesia for the rage period.

Anorexia nervosa

Western nations
(particularly the U.S.)

A disorder occurring most frequently among young women
in which a preoccupation with thinness produces a refusal to
cat. This condition can result in death (sec Chapter 8).

Latah

Malay

A fear reaction often occurring in middle-aged women of
low intelligence who arc subservient and self-effacing. The
disorder is precipitated by the word make or by tickling. It is
characterized by echolalia (repetition of the words and sen­
tences of others) and echopraxia (repetition of the acts of
others). A disturbed individual may also react with nega­
tivism and the compulsive use of obscene language.

Kdro

Southeast Asia
(particularly Malay
Archipelago)

A fear reaction or anxiety state in which a person fears that
his penis will withdraw into his abdomen and he will die. This
reaction may appear after sexual overindulgence or excessive
masturbation. The anxiety is typically ven’ intense and of sud­
den onset. The condition is “treated” by having the penis
held firmly by the patient or by family members or friends.
Often the penis is damped to a w ooden box.

Windigo

Algonquin Indian
hunters

A fear reaction in which a hunter becomes anxious and agi­
tated, convinced that he is bewitched. Fears center on his
being turned into a cannibal by the power of a monster
with an insatiable craving for human flesh.

Kitsunctsuki

Japan

A disorder in which victims believe that they are possessed by
foxes and are said to change their facial expressions to resem­
ble foxes. Entire families are often possessed and banned by
the communin'. This reaction occurs in rural areas of Japan
where people are superstitious and relatively uneducated.

Taijin kyofusho (TKS)

Japan

A relatively common psychiatric disorder in Japan in which
an individual develops a fear of offending or hurting other
people through being awkward in social situations or be­
cause of an imagined physical defect or problem. The ex­
cessive concern over how a person presents himself or her­
self in social situations is the salient problem.

Based on Kiev (1972), Kirmayer (1991), Lebra (1976), Lehmann (1967), Simons and Hughes (1985), and Yap (1951).

The Sociocultural Viewpoint

ence more stress and thus be more vulnerable to dis­
order than children growing up in a society that of­
fers ample rewards and considerable social support.
Growing up during a period of great fear, such as
during a war, a famine, or a period of persecution,
can make a child vulnerable to psychological prob­
lems.
Sociocultural factors also appear to influence
what disorders develop, the forms that they take,
and their courses. A good example of this point is a
comparison study of psychiatric patients from Italy,
Switzerland, and the United States carried out by
Butcher and Pancheri (1976). Patients grouped ac­
cording to diagnostic categories produced similar
general personality patterns on the MMPI. How­
ever, the Italian patients also showed an exagger­
ated pattern of physical complaints significantly
greater than that of the Swiss and the American pa­
tients, regardless of clinical diagnosis. This finding
was consistent with earlier work by Opler and
Singer (1959) and Zola (1966). Zola attributed
this difference to a defense mechanism, which he
called dramatization, that led the Italian patients,
once identified as ill, to exaggerate or dramatize
their physical problems to a greater extent than the
Irish patients.
In another example, Kleinman (1986) traced the
different ways that Chinese people (in Taiwan and in
the People’s Republic of China) deal with stress
compared with Westerners. He found that in West­
ern societies depression was a frequent reaction to
individual stress. In China, on the other hand, he
noted a relatively low rate of reported depression.
Instead, the effects of stress were more typically
manifested in physical problems, such as fatigue.
weakness, and other complaints. Moreover, Klein­
man and Good (1985) surveyed the experience of
depression across cultures. Their data show that im­
portant elements of depression in Western soci­
eties—for example, the acute sense of guilt typically
experienced—do not appear in other cultures. Thev
also point out that the symptoms of depression (or
dysphoria), such as sadness, hopelessness, unhappi­
ness, lack of pleasure in the things of the world and
in social relationships, have dramatically different
meanings in different societies. For Buddhists, seek­
ing pleasure from things of the world and social re­
lationships is the basis of all suffering; a willful disen­
gagement is thus the first step on the road to
salvation. For Shi’ite Muslims in Iran, grief is a reli­
gious experience, associated with recognition of the
tragic consequences of living justly in an unjust
world; the ability to experience dysphoria fully is
thus a marker of depth of personality and under­
standing.

109

Fascinating issues are also raised by recent stud­
ies of childhood psychopathology in different cul­
tures. In certain cultures like that of Thailand,
adults are highly intolerant of undercontrolled be­
havior such as aggression, disobedience, and disre­
spectful acts in their children. Children are taught
to be polite and deferential and to inhibit any ex­
pression of anger. This raises interesting questions
about whether childhood problems of undercon­
trolled behavior would be lower in Thailand than in
the United States where such behavior is tolerated
to a greater extent. Conversely it also raises the
question of whether overcontrolled behavior prob­
lems such as shyness, anxiety, and depression would
be overrepresented in Thailand relative to the
United States. Two recent cross-national studies
(Weisz et al., 1987, 1993)have confirmed that Thai
children and adolescents do indeed have a greater
prevalence of overcontrolled problems than do
American children. Although there were no differ­
ences in the rate of undercontrolled problems be­
tween the two countries, there were differences in
the kind of undercontrolled behavior problems re­
ported. For example, Thai adolescents had higher
scores than American adolescents on indirect and
subtle forms of undercontrol not involving inter­
personal aggression, such as having difficulty con­
centrating or being cruel to animals; American ado­
lescents on the other hand had higher scores than
Thai adolescents on behaviors like fighting, bully­
ing, and disobeying at school (Weisz et al., 19931.
Related findings have also emerged from studies
comparing Jamaican and American children. Ja­
maicans come from an Afro-British tradition that is
also intolerant of acting out behavior and that pro­
motes politeness and respectfulness. Accordingly, it
is not surprising that Jamaican children were more
likely to be referred to a clinic for overcontrolled
behavior than were American children, wher.eas
American children were more likely to be referred
for undercontrolled behavior than were Jamaican
children (Lambert, Weisz, 8c Knight, 1989).
All of these findings illustrate an important
point—the need for greater study of cultural influ­
ences on psychopathology'. This neglected area of
research may yet answer many questions about the
origins and courses of behavior problems (Draguns,
1979; Marsella et al., 1985). Yet even with strong
evidence of cultural influences on psychopathology,
many professionals may fail to adopt an appropriate
cultural perspective when dealing with mental ill­
ness. Clark (1987) notes a reluctance of “main­
stream” psychologists and psychiatrists to incorpo­
rate the cross-cultural perspective in their research
and clinical practices even when their patients or

110

Chapter 3

Causal Factors and Viewpoints in Abnormal Psychology

subjects are from diverse cultures. In a shrinking
world, with instant communication and easy trans­
portation, it is crucial for our sciences and profes­
sions to take a world view. In fact, Kleinman and
Good consider cultural factors so important to our
understanding of depressive disorders that they have
urged the psychiatric community to incorporate an­
other axis in the DSM diagnostic system to reflect
cultural factors in psychopathology.

adopt the prevailing cultural patterns. This situation
is especially common in Western society, where we
arc exposed to many competing values and patterns.
We will also examine the particular factors in the so­
cial environment that may increase vulnerability: low
socioeconomic class, disorder-engendering social
roles, prejudice and discrimination, economic and
employment problems, and social change and un­
certainty.

Sociocultural Influences in Our Own Society

The Sociocultural Environment

As was noted in Chapter 1, the study of the inci­
dence and distribution of physical and mental disor­
ders in a population (as in the research just cited) is
called epidemiology. The epidemiological approach
implicates not only the social conditions and highrisk areas that are correlated with a high incidence of
given disorders, but also the groups for whom the
risk of pathology is especially high—for example,
refugees from other countries (Vega & Rumbaut,
1991). Throughout this text we will point out many
high-risk groups with respect to suicide, drug de­
pendence, and other maladaptive behavior patterns.
This information provides a basis for formulating
prevention and treatment programs; in turn, the ef­
fectiveness of these programs can be evaluated by
means of further epidemiological studies.
With the gradual recognition of sociocultural in­
fluences, what was previously an almost exclusive
concern with individual patients has broadened to
include a concern with societal, communal, familial,
and other group settings as factors in mental disor­
ders. Sociocultural research has led to programs de­
signed to improve die social conditions that foster
maladaptive behavior and to community facilities for
the early detection, treatment, and long-range pre­
vention of mental disorder. In Chapter 18 we will
examine some clinical facilities and other pro­
grams—both governmental and private—that have
been established as a result of community efforts.

In much the same way that we receive a genetic in­
heritance that is the end product of millions of years
of biological evolution, we also receive a sociocul­
tural inheritance that is the end product of thou­
sands of years of social evolution. The significance of
this inheritance was well pointed up by Aldous Hux­
ley (1965):

SOCIOCULTURAL CAUSAL
FACTORS
We will begin our discussion of the sociocultural
causal factors that increase our vulnerability to the
development of abnormal behavior by considering
the role of culture in determining an individual’s be­
havior patterns. For reasons of temperament, condi­
tioning, and other individual factors, not all people

The native or genetic capacities of today’s bright city
child arc no better than the native capacities of a
bright child born into a family of Upper Paleolithic
cave-dwellers. But whereas the contemporary bright
baby may grow up to become almost anything—a
Presbyterian engineer, for example, a piano-playing
Marxist, a professor of biochemistry who is a mysti­
cal agnostic and likes to paint in water colours—the
paleolithic baby could not possibly have grown into
anything except a hunter or food-gatherer, using the
crudest of stone tools and thinking about his narrow
world of trees and swamps in terms of some hazy
system of magic. Ancient and modern, the two ba­
bies are indistinguishable. .. . But the adults into
whom the babies will grow are profoundly dissimi­
lar; and they are dissimilar because in one of them
very few, and in the other a good many, of the baby’s
inborn potentialities have been actualized, (p. 69)

Because each group fosters its own cultural pat­
terns by systematically teaching its offspring, all its
members tend to be somewhat alike—to conform to
certain basic personality types. Children reared
among headhunters become headhunters; children
reared in societies that do not sanction violence
learn to settle their differences in nonviolent wavs.
In New Guinea, for example, Margaret Mead
(1949) found two tribes—of similar racial origin and
living in the same general geographical area—whose
members developed diametrically opposed charac­
teristics. The Arapesh were a kindly, peaceful, coop­
erative people, while the Mundugumor were war­
like, suspicious, competitive, and vengeful. Such
differences appear to be social in origin.

Sociocultural Causal Factors

The more uniform and thorough the education
of the younger members of a group, the more alike
they will become. Thus in a society characterized by
a limited and consistent point of view, there are not
the wide individual differences typical in a society
like ours, where children have contact with diverse,
often conflicting, beliefs. Even in our society, how­
ever, there are certain core values that most of us
consider essential.
Subgroups within a general sociocultural envi­
ronment—such as family, sex, age, class, occupa­
tional, ethnic, and religious groups—foster beliefs
and norms of their own, largely by means of social
roles that their members learn to adopt. Expected
role behaviors exist for a student, a teacher, an army
officer, a priest, a nurse, and so on. Because most
people are members of various subgroups, they are
subject to various role demands, which also change
over time. In fact, an individual’s life can be viewed
as a succession of roles—child, student, worker,
spouse, parent, and senior citizen. When social roles
are conflicting, unclear, or uncomfortable, or when
an individual is unable to achieve a satisfactory role
in a group, healthy personality development may be
impaired—just as when a child is rejected by juvenile
peer groups.
The extent to which role expectations can influ­
ence development is well illustrated by masculine
and feminine roles in our own society and their ef­
fects on personality development and on behavior.
In recent years, a combination of masculine and
feminine traits (androgyny) has often been claimed
to be psychologically ideal for both men and
women. Many people, however, continue to show
evidence of having been strongly affected by tradi­
tional assigned masculine and feminine roles.
Moreover, there is accumulating evidence that the
acceptance of gender-role assignments has sub­
stantial implications for mental health. In general,
studies show that low “masculinity” is associated
with maladaptive behavior and vulnerability to dis­
order for either biological sex, possibly because
this condition tends to be strongly associated with
deficient self-esteem (Carson, 1989). Baucom
(1983), for example, has shown that high-feminine-sex-typed (low masculinity) women tend to
reject opportunities to lead group problem-solving
situations. He likens this effect to learned helpless­
ness, which, as we have seen, has in turn been sug­
gested as a causal factor in anxiety (Barlow, 1988;
Mineka, 1985a) and depression (Abramson et al.,
1978). Given findings like these, it should not be
too surprising that women show much higher
rates of anxiety and depressive disorders (see
Chapters 5 and 6).

111

Pathogenic Societal Influences
There are. many sources of pathogenic social influ­
ences, some of which stem from socioeconomic fac­
tors, and others of which stem from sociocultural
factors regarding role expectations and the destruc­
tive forces of prejudice and discrimination. Some of
the more important ones will be examined in the
following sections.

Low Socioeconomic Status In our society, an in­
verse correlation exists between socioeconomic sta­
tus and the prevalence of abnormal behavior—the
lower the socioeconomic class, the higher the inci­
dence of abnormal behavior (e.g., Eron & Peterson,
1982). The strength of the correlation seems to vary
with different types of disorder, however. Some dis­
orders may be related to social class only minimally
or perhaps not at all. For example, the incidence of
schizophrenia is inversely correlated with social
class, while that of mood disorders bears a less dis­
tinct relationship to class.
We do not understand all the reasons for the
more general inverse relationship. There is evidence
that some people with mental disorders slide down
to the lower rungs of the economic ladder and re­
main there because they do not have the economic
or personal resources to climb back up (Gottesman,
1991). These people will often have children who
also show abnormal behavior for a whole host of
reasons, including increased risk for prenatal com­
plications leading to low birth weight. At the same
time, more affluent people are better able to get
prompt help or to conceal their problems. In addi­
tion, it is almost certainly true that people living in
poverty encounter more, and more severe, stressors
in their lives than do people in the middle and up­
per classes, and they usually have fewer resources
for dealing with them. As Kohn (1973) pointed
out, the conditions under which lower-class chil­
dren are reared tend to inhibit the development of
the coping skills needed in our increasingly complex
society. Thus the tendency for some forms of ab­
normal behavior to appear more frequently in lower
socioeconomic groups may be at least partly due to
increased stress in the people at risk (Gottesman,
1991). Nevertheless, findings from a longitudinal
study of inner-city children in Boston showed that
in spite of coming from high-risk socioeconomic
background, many of the boys did very well and
showed upward mobility. Resilience here was best
indicated by childhood IQ and having adequate
functioning as a child in school, family, and peer re­
lationships (Long 8c Valliant, 1984; Felsman & Val­
liant, 1987).

112

Chapter 3

Causal Factors and Viewpoints in Abnormal Psychology

In our society the lower the socioeconomic
class, the higher the incidence of abnormal
behavior The conditions under which
lower-class youngsters are reared tend to
inhibit the development of coping skills.
Many individuals, however, emerge from
low socioeconomic environments with
strong, highly adaptive personalities and
skills.

Disorder-Engendering Social Roles An organized
society, even an “advanced” one, sometimes asks its
members to perform roles in which the prescribed
behaviors either are deviant themselves or may pro­
duce maladaptive reactions. A soldier who is called
upon by his superiors (and ultimately by his society)
to deliberately kill and maim other human beings
may subsequently develop serious feelings of guilt.
He or she may also have latent emotional problems
resulting from the horrors commonly experienced in
combat and hence be vulnerable to disorder. As a
nation, we are still struggling with the many prob­
lems of this type that have emerged among veterans
of the Vietnam War (Kulka et al., 1990). The diag­
nosis of posttraumatic stress disorder was added to
DSM-III (1980) largely in response to the problems
of Vietnam veterans. Although this condition can
occur following a range of highly traumatic events
(such as rape, torture, and natural disasters), as dis­
cussed in Chapter 4, the feeling of guilt over atroci­
ties committed were especially pronounced in Viet­
nam veterans.
Militaristic regimes and organizations are espe­
cially likely to foster problematic social roles. Mili­
tary’ and civilian officials in Germany during the
Nazi Holocaust and in the Soviet Union during
Stalin’s collectivization of rural areas in the 1930s
(Conquest, 1986) willingly participated in history’s
most heinous and cold-blooded mass murders.
Some American street gangs demand extreme cru­
elty and callousness on the part of their members.
Well-organized terrorist groups, feeling that the

world is ignoring their just claims, train their mem­
bers for taking hostages, mass destruction, and murThere is, of course, no easy’ answer to the prob­
lems of violence and coercion in the modern world;
people will often resort to force when other reme­
dies fail. As long as such actions are taken, many
people will be subjected to conditions of extraordi­
nary stress and will feel compelled to enact difficult
and painful social roles. In some cases, the end result
will be psychological disorder.

Prejudice and Discrimination Vast numbers of
people in our society have been subjected to demor­
alizing stereotypes and overt discrimination in areas
such as employment, education, and housing. We
have made progress in race relations since the
1960s, but the lingering effects of mistrust and dis­
comfort among various ethnic and racial groups can
be clearly observed on almost any college campus.
For the most part, students socialize informally only'
with members of their own subcultures, despite the
attempts of many well-meaning college administra­
tors to break down the barriers. The tendency of
students to avoid crossing these barriers needlessly
limits their educational experiences and probably
contributes to continued misinformation about, and
prejudice toward, others.
We have also made progress in recognizing the
demeaning and often disabling social roles our soci­
ety has historically assigned to women. Again,
though, much remains to be done. As already

113

Unresolved Issues

noted, many more women than men seek treatment
for various emotional disorders, notably depression
and many anxiety disorders. Mental health profes­
sionals believe this is a consequence both of the vul­
nerabilities (such as passivity and dependence) in­
trinsic to the traditional roles assigned to women,
and possibly of the special stressors with which many
modern women must cope (being full-time moth­
ers, full-time homemakers, and full-time employees)
as their traditional roles rapidly change. However, it
should also be noted that working outside the home
has also been shown to be a protective factor against
depression under at least some circumstances (e.g..
Brown & Harris, 1978).

Economic and Employment Problems Economic
difficulties and unemployment have repeatedly been
linked to enhanced vulnerability and thus to elevated
rates of abnormal behavior (Dew, Penkower, &
Bromet, 1991; Dooley 8c Catalano, 1980). Reces­
sion and inflation coupled with high unemployment
are sources of chronic anxiety for many people. Un­
employment has placed a burden on a sizable seg­
ment of our population, bringing with it both finan­
cial hardships, self-devaluation, and emotional
distress. In fact, unemployment can be as damaging
psychologically as it is financially. Research on the ef­
fects of unemployment was intense in the 1930s
(Eisenberg 8c Lazarsfeld, 1938), but during the pe­
riod of economic prosperity following World War II
interest in the topic waned. However, interest was
rekindled in the 1970s and 1980s when severe eco­
nomic recessions were experienced worldwide and
moderately high rates of employment became a
seemingly permanent part of modern society. We
certainly have not come close to solving the human
problems such major economic shifts entail. The
philosophies of free enterprise and rugged individu­
alism run deep in American culture and politics, and
they are shared by many unemployed people. The re­
sult is self-blame and personal demoralization.
Periods of extensive unemployment are typically
accompanied by adverse effects on mental and physi­
cal health. In particular, rates of depression, marital
problems, and somatic complaints increase during
periods of unemployment, but usually normalize fol­
lowing reemployment (Dew et al., 1991; Jones.
1992). These effects occur even when mental health
status before unemployment is taken into account:
thus, it is not simply that those who are mentally un­
stable tend to lose their jobs. The psychological and
physical health problems are more severe in lower so­
cioeconomic groups (Jones, 1992). It also seems
that physical violence among couples is associated
with unemployment, although the causal direction is

unclear (Dew et al., 1991). Not surprisingly, the
wives of unemployed men also are adversely affected,
with higher levels of anxiety, depression, and hostil­
ity. These effects appear to be mediated by the dis­
tress of the unemployed husband (Dew, Bromet, 8c
Schulberg, 1987). In addition, children can be seri­
ously affected. In the worst cases, the unemployed
fathers engage in child abuse, with many studies doc­
umenting an association between child abuse and fa­
ther’s unemployment (Dew et al., 1991). In one
prospective study, all the children born on Kauai,
Hawaii, in 1955 were followed until age 18 (Werner
8c Smith, 1982). One of the best predictors distin­
guishing children (especially boys) who experienced
significant problems with mental health or delin­
quency from those who did not was whether the fa­
ther had lost his job when his children were small.
Social Change and Uncertainty The rate and per­
vasiveness of change today are different from any­
thing our ancestors ever experienced. All aspects of
our lives are affected—our education, our jobs, our
families, our leisure pursuits, our finances, and our
beliefs and values. Constantly trying to keep up with
the numerous adjustments demanded by these
changes is a source of constant and considerable
stress. Simultaneously, we confront inevitable crises
as the earth’s consumable natural resources dwindle
and as our environment becomes increasingly nox­
ious with pollutants. Certain neighborhoods have
increasing problems with drugs and crime. No
longer are Americans confident that the future will
be better than the past or that technology will solve
all our problems. On the contrary, our attempts to
cope with existing problems increasingly seem to
create new problems that arc as bad or worse. The
resulting despair, demoralization, and sense of help­
lessness are well-established predisposing conditions
for abnormal reactions to stressful events (Dohrenwend et al., 1980; Frank, 1978).

qBj UNRESOLVED ISSUES

.

j

on Theoretical Viewpoints and
Causation of Abnormal
Behavior
The viewpoints described in this chapter are the­
oretical constructions devised to orient psycholo­
gists in the study of abnormal behavior. As a set of
hypothetical guidelines, each viewpoint speaks to
the importance and integrity of its own position to

114

Chapter 3

Causal Factors and Viewpoints in Abnonzal Psychology

the exclusion of other explanations. Most psychoan­
alytically oriented clinicians, for example, value
those traditional writings and beliefs consistent with
Freudian or later psychodynamic theory, and they
minimize or ignore the teachings of opposing view­
points. They usually adhere to prescribed practices
of psychoanalytic therapy and do not use other
methods, such as desensitization therapy.
Theoretical integrity and adherence to a system­
atic viewpoint has a key advantage: It provides a
consistent approach to orient one’s practice or re­
search efforts. Once mastered, the methodology can
guide a practitioner or researcher through the com­
plex web of human problems. Theoretical adherence
has its disadvantages, however. By excluding other
possible explanations, it can blind researchers to
other factors that may be equally important.
The fact is that none of the theories to date ad­
dresses the whole spectrum of abnormality-—each is
limited in its focus. Two general trends have oc­
curred as a result. The first involves revisions of an
original theoretical doctrine by expanding or modi­
fying some elements of the system. The second in­
volves making use of two or more diverse ap­
proaches in a more general, eclectic approach. We
will now examine how effectively each of these
trends brings order to theoretical complexity.
1. The revision of theoretical viewpoints. The
emergence of diverse viewpoints to explain abnor­
mal behavior has led to criticisms of each viewpoint
and thus to attempts to accommodate these criti­
cisms. There are many examples of such corrective
interpretations, such as Adler’s or Jung’s modifica­
tion of Freudian theory or the more recent cogni­
tive-behavioral approach in behavior therapy. But
many of the early Freudian theorists did not accept
the neo-Freudian additions, and many classical be­
havior therapists today do not accept the revisions
proposed by cognitive behaviorists. Therefore, theo­
retical viewpoints tend to multiply and coexist—:
each with its own proponents—rather than being as­
similated into previous views. In effect, at least some
“revisions” of an original doctrine tend to survive as
new, alternative interpretations of psychopathology.
The result is a cumbersome backdrop of many theo­
retical viewpoints from which to study abnormal be­
havior. This situation also complicates communica­
tion among psychologists who may adhere to
different perspectives, and with so many different
perspectives, it is nearly impossible to have a clear
grasp of them all.

2. The eclectic approach. As already noted, expla­
nations based on single viewpoints are likely to be
incomplete. In practice, many psychologists have re­

sponded to the existence of many perspectives by
adopting an eclectic stance—that is, they accept
working ideas from several existing viewpoints and
use whichever they find to be useful. For example, a
psychologist using an eclectic approach might ac­
cept causal explanations from psychoanalytic theory
while applying techniques of anxiety reduction de­
rived from behavior therapy. Another psychologist
might combine techniques from the cognitive-be­
havioral approach with those from the interpersonal
approach. Purists in the field—those advocates of a
single viewpoint—are skeptical about eclecticism,
claiming that the eclectic approach tends to lack in­
tegrity and produces a “crazy quilt” of activity with
little rationale and inconsistent practice. This criti­
cism may be true, but the approach certainly works
tbr many psychologists.
Typically, those using an eclectic approach make
no attempt to synthesize the theoretical perspec­
tives. Although the approach can work in practical
settings, it is not successful at a theoretical level be­
cause the underlying principles of many of the theo­
retical perspectives arc incompatible as they now
stand. Thus the eclectic approach still falls short of
the final goal, which is to tackle the theoretical clut­
ter and develop a single, comprehensive, internally
consistent viewpoint that accurately reflects what we
know empirically about abnormal behavior. It may
be unrealistic to expect a single theoretical view­
point to be broad enough to explain abnormal be­
havior in general and specific enough to accurately
predict the symptoms and causes of specific disor­
ders. Nevertheless, such a unified viewpoint is the
challenge for the next generation of theorists in the
field of abnormal psychology.
At present the one attempt at such a unified view­
point is called the biopsychosocial viewpoint. This
viewpoint acknowledges the interaction of biologi­
cal, psychosocial, and sociocultural causal factors in
the development of abnormal behavior. The biopsy­
chosocial model was first articulated in order to ac­
count for the effects of psychological and sociocul­
tural factors in physical health and has now become
the dominant viewpoint in the fields of health psy­
chology and behavioral medicine (sec Chapter 8).
However, it has also now been extended to the
study of many other disorders as well.
The biopsychosocial viewpoint fits well with die
conclusion that most disorders, especially beyond
childhood, are the result of many causal factors—bi­
ological, psychosocial, and sociocultural. Moreover,
for any person the particular combination of causal
factors may be relatively unique, or at least not
widely shared by large numbers of people with the

Summary

same disorder. For example, some children may be­
come delinquents because of having a heavy genetic
loading for antisocial behavior, while others may be­
come delinquent more because of environmental in­
fluences such as living in an area with a large num­
ber of gangs. Nevertheless, we can still have a
scientific understanding of many of the causes of ab­
normal behavior even if we cannot predict such be­
havior with exact certainty in each individual case.
However, there may also remain a rather large array
of “unexplained” influences.

In most instances the occurrence of abnormal or
maladaptive behavior is the joint product of a per­
son’s vulnerability (diathesis) to disorder and of cer­
tain stressors that challenge his or her coping re­
sources. Such vulnerabilities may be necessary or
contributory causal factors, but they are not gener­
ally sufficient to cause disorder. Some of the major
contributory causal influences are reviewed in this
chapter. We also distinguished between relatively
distal causal factors and more proximal causal fac­
tors. There are also a variety of protective factors
that can promote more positive developmental out­
comes even in persons who have the diathesis for a
disorder.
Both the distal and the proximal causes of mental
disorder may involve biological, psychosocial, and
sociocultural factors. These three classes can interact
with each other in complicated ways. At present
there are manv different points of view on the inter­
pretation and treatment of abnormal behavior. We
discussed biological, psychosocial, and sociocultural
viewpoints, each of which tends to emphasize the
importance of causal factors of the same type.
The early biological viewpoint focused on brain
damage as a model for the understanding of abnor­
mality. Modern biological thinking about mental
disorders has focused more on the biochemistry of
brain functioning, as well as other more subtle forms
of brain dysfunction. In examining biologically
based vulnerabilities, we must consider genetic en­
dowment (including chromosomal irregularities .
physical deprivation, primary reaction tendencies.
and temperament. Investigations in this area show
much promise for advancing our knowledge of how
the mind and the body interact to produce maladap­
tive behavior.
The psychosocial viewpoints on abnormal behav•or, dealing with human psycholog}’ rather than bi°l°gy, necessarily are more varied than the biological

115

perspective. The oldest of these perspectives is
Freudian psychoanalytic theory. For many years this
view was preoccupied with questions about libidinal
energies and their containment, but more recently it
has shown a distinedy social or interpersonal thrust
under the direction of object-relations theorv. Psvchoanalysis and closely related approaches are
termed psychodynamic in recognition of their atten­
tion to inner, often unconscious forces. An integra­
tion of psychodynamic and interpersonal perspec­
tives (as suggested by Sullivan’s work) would seem
possible as we move into the future.
The behavioral perspective on abnormal behav­
ior, which was rooted in the desire to make psychol­
ogy an objective science, was slow' in overcoming a
dominant psychodynamic bias, but in the last 30
years it has established itself as a significant force.
Behaviorism focuses on the role of learning in hu­
man behavior. It views maladaptive behavior either
as a failure of learning appropriate behaviors, or
learning maladaptive behaviors. Its therapeutic
methods have achieved excellent results, and its abil­
ity to accommodate itself to the current dominance
of cognitive thinking in psychology ensures its con­
tinued growth and importance.
Initially a spinoff from (and in part a reaction
against) the behavioral perspective, the cognitivebehavioral viewpoint attempts to incorporate the
complexities of human cognition in a rigorous, information-processing framework. This viewpoint at­
tempts to alter maladaptive thinking and improve
people’s abilities to solve problems and to plan. As
we will discuss in Chapter 17, the treatment proce­
dures incorporating cognitive processes are highly
effective in treating a variety of disorders.
The humanistic perspective does not chiefly con­
cern itself with the origins and treatments of severe
mental disorders. Rather, it focuses on the condi­
tions that can maximize functioning in individuals
who are just “getting along.” It views abnormality
as a failure to develop individual human potential.
As such, it has to do with personal values and per­
sonal growth.
The originators of the interpersonal perspective
were defectors from the psychoanalytic ranks who
took exception to.the Freudian emphasis on the in­
ternal determinants of motivation and behavior. As a
group, interpersonal theorists have emphasized that
important aspects of human personality have social
or interpersonal origins. This viewpoint sees unsatis­
factory relationships in the past or present as the pri­
mary causes of maladaptive behaviors.
For psychosocially determined causes or sources
of vulnerability, the situation is somewhat more
complicated than for biological causes. It is clear,

116

Chapter 3

Causal Factors and Viewpoints in Abnortnal Psychology

however, that people’s schemas and self-schemas
play a central role in the way that they process infor­
mation and in the kinds of attributions and values
concerning die world that they have. The efficiency,
accuracy, and coherence of a person’s schemas and
self-schemas appear to provide an important protec­
tion against breakdown. Sources of psychosocially
determined vulnerability include early social depri­
vation, severe emotional trauma, inadequate parent­
ing, and dysfunctional peer relationships.
Any comprehensive approach to the study of hu­
man behavior—normal or abnormal—must take ac­
count of the sociocultural context in which a given
behavior occurs. Cultural influences on psy­
chopathology are important in understanding the
origin and course of a behavioral problem. The so­
ciocultural viewpoint is concerned with the social
environment as a contributor to mental disorder be­
cause sociocultural variables are also important
sources of vulnerability’, or, conversely, of resistance
to it. The incidence of particular disorders varies
widely among different cultures. Unfortunately, we
know little of the specific factors involved in these
variations. In our own culture, certain prescribed
roles, such as those relating to gender, appear to be
more predisposing to disorder than others. Low so­
cioeconomic status is also associated with greater
risk for various disorders, possibly because it is often
difficult for economically distressed families to pro­
vide their offspring with sufficient coping resources.
Additionally, certain roles evolved by given cultures
may in themselves be maladaptive, and certain largescale cultural trends, such as rapid technological ad­
vance, may increase stress while lessening the effec­
tiveness of traditional coping resources.
Finally, we are still a long way from the goal of a
complete understanding of abnormal behavior. The
many theoretical perspectives that exist have given
us a start, and a good one at that—but they fall
short. To obtain a more comprehensive understand­
ing of mental disorder, we must draw on a variety of

sources, including the findings of genetics, bio­
chemistry, psychology’, sociology', and so forth. The
biopsychosocial approach comes closest, but in
many yvays it is merely a descriptive acknoyvledgment of these complex interactions rather than a
clearly articulated theory of hoyy’ they interact. It is
the task of future generations of theorists to devise a
general theory of psychopathology’, if indeed one is
possible.

etiology’ (p. 64)
necessary’ cause (p. 64)
sufficient cause (p. 64)
contributory cause (p. 64)
diathesis-stress models
(p. 65)
protective factors (p. 66)
resilience (p. 66)
neurotransmitters (p. 69)
hormones I p. 69)
genotype (p. 71)
phenotype ip. 71)
temperament (p. 75)
libido (p. 79)
pleasure principle (p. 79)
primary process thinking
(p. 79)
ego (p. 79)
secondary process thinking
(p. 79)
reality’ principle (p. 79)
superego (p. 79)
intrapsychic conflicts
(p. 79)
ego-defense mechanisms
(P- 79)
psychosexual stages of
development (p. 81)
Oedipus complex (p. 81)

castration anxiety (p. 81)
Electra complex (p. 81)
introjcction (p. 82)
classical conditioning
(p. 84)
extinction (p. 84)
spontaneous recovery
(p. 84)
operant (or instrumental)
conditioning (p. 84)
reinforcement (p. 84)
generalization (p. 85)
discrimination (p. 85)
cognitive-behavioral
perspective (p. 87)
attributions (p. 88)
humanistic perspective
(p. 89)
self-actualizing (p. 92)
interpersonal perspective
(p. 92)
social-exchange view
(P-94)
interpersonal accommodation
(P- 94)
schema (p. 96)
self-schema (p. 96)
assimilation (p. 96)
accommodation (p. 96)
psychic trauma (p. 99)

KW I .

■ MENTAL HEALTH
IMH, numbering over 1,500, were in a sit­
uation hardly better than at Erwadi. The
death of some inmates in October 2001
owing to diarrhoea, the collapse of the
main building a month later, and some
The mentally challenged people rescued from Erwadi are in no
incidents of violent inmates killing each
a state in
surroundings. A review of the mental
other, brought to light the abysmal con­
ditions ar the IMH.
Shunned by family and society, most
IMH inmates live without dignity and
i
ingamentallyillper- basic human rights. The plight of some
h:c. two daughters to be 600 of them who have been in the IMH
■ .1002, Raghu was for decades is especially bad. For them,
. . ■ ling'centre closer home. death may well be the only means ofdeliv­
;s like Gowri, who had erance. For instance, Thangam and
a ■
. in. Erwadi mental home Noyola Mary, who had been there for 60
jjamanathapuram district it
■ ■
n.gedly in an attempt to and 50 years respectively, died last year
>t. .-•r:i dispute, and Murugan, who (but no one claimed the bodies).
They had come under the I amil Nadu
■ ■, ■■■■;:
: in Erwadi to separate him Viswanathan, who has been at the IMH
government’s care after all the “mental ttoin his girlfriend, are back at the ‘faith- for 20 years, says, “I look forward to the
homes” in Erwadi were closed down fol­ hea'ing’ dargah at Erwadi. While the pri­ day (of my death).”
lowing a fire in the Moideen Badusha vately run mental homes in Erwadi were
Says an IMH psychiatrist: “The IMH
Mental Home on August 6, which killed ordered closed on August 13, 2001, follows the 18th century concept of the
28 inmates who were chained to their posi­ patients who stayed within the precincts mental asylum. It is like a concentration
tions. Of the 571 persons who were res­ ofthe dargah were allowed to remain there, camp. Patients are checked once in 15
cued, 152 were sent to the Government provided each had an attendant.
days. They are paraded outside their wards
Institute of Mental Health (IMH) in
Even for the 152 patients brought to while a psychiatrist checks each one quick­
Chennai, while 11 patients who had vio­ the IMH, the only government hospital ly. There are no doctors. Patients with
lent tendencies were admitted to the for the mentally challenged in Tamil physical complications are referred to
Ramanathapuram Government Hospital. Nadu, life is no different except that they other government hospitals. Some of the
The rest were returned to the care of their are no longer in chains. Also, according to 21 wards do not have toilets.” The abysmal
families. (Some have returned to their fam­ a psychiatrist at the IMH (who prefers to level ofcrisis management at the IMH was
ilies from the IMH.)
remain anonymous), “because of the revealed by the diarrhoea deaths there last
But nothing has changed for them - media attention, the Erwadi patients at the year.
they continue to live in misery, stripped of IMH get some special treatment”.
According to the psychiatrist, the sys­
dignity and shunned by their families and
The patients who were already in tem followed at the IMH is similar to that
society. Most of those who
followed in jails: lunch is
were forced back onto their
B served at 1 p.m. and dinner
Allies have been sent to
5 at 4 p.m. At 5 p.m. all
healing’ centres
> patients are locked in their
attached to various temples
wards until 8.30 a.m. the
or dargahs. The rest, who
next morning, when they
remain with their families,
are given breakfast. Says the
are mostly isolated and
IMH psychiatrist: “Most
ostracised.
patients skip dinner as it is
For instance, Raghu,
too early. Thus most
from one of Erwadi’s “men­
patients eat at 1 p.m. and
tal homes”, was sent back to
then only 8.30 a.m. the next
his family in Sikkil in
day. This is particularly bad
for the diabetic, the old and
Thanjavur
district
in
August 2001, since the gov­
the infirm.”
ernment doctors who exam­
Says the psychiatrist:
ined him soon after the
“Ward 21 is the de-addic­
Erwadi incident found him
tion ward. But several
“fit for discharge”. But his
patients in this ward abuse
father, Raghavan, did not
heroin and cannabis regu­
know what to do with tire
larly.”
“mentally ill” son. Neither Women patients who were brought to the Institute of Mental Health
There is no emergency
did he have the means to In Chennai following the Erwadi fire Incident of August 2001. Life Is
room or an intensive care
rehabilitate Raghu in a pri­ no different for the 152 patients brought to the IMH except that
unit at the IMH. Patients in
vate hospital nor could he they are no longer In chains.
serious condition are exam­

Beyond Erwadi

better

their new

0

FRONTLINE, AUGUST 2, 2002

113

ined just outside the ward.
Most often the ‘golden
hour’ is lost by the time
these patients are taken to
an ICU of a government
hospital.
Says another IMH psy­
chiatrist: “Treatment at the
IMH is not holistic.
Addressing the social con­
text — environmental and
social stress - is not consid­
ered important. The focus
is narrow, and is limited to
neuro-transmitters
and
generics.
Rehabilitation,
occupational therapy and
social integration are poor.
That is why most inmates
remain there for decades.”
There seems to be no pro­
tocol for drug treatment.
Mentally challenged patients bioii^
The mentally challenged
last year.
seem to be dumped at the
healing. Professional hcio -nardly; - ■.
IMH for life.
When this correspondent approached The NHRC report also points re
the IMH Director for comments, he deprivation of human rights to the n..
refused to talk and denied her permission tally ill.
The mental health care system in
to visit the hospital premises.
According to an administrative staff Tamil Nadu has been in a deplorable state,
member, the IMH is plagued by many with successive governments failing to act
problems. Many inmates, though cured, on the various reports and studies on the
continue to remain at the IMH as the plight of the mentally ill. The Erwadi
addresses given at the time of admission tragedy, which caught the attention of
are'false. The arrears that “old” patients even the international media, forced the
owe the IMH add up to over Rs.3 lakhs. State government to act. It decided to
Although the number of in-patients implement, after 14 years, certain sections
(1,654) is lower than the sanctioned bed of the Mental Health Act, 1987, and
strength of 1,800, maintenance has announce some measures to deal with the
become difficult, with several ‘basic ser­ situation. The State Human Rights
vant’ posts remaining vacant for long. For Commission, which studied the cause of
instance, of the sanctioned 202 posts of the Erwadi incident, came up with 19 rec­
warders, 47 are vacant, while 20 of the 79 ommendations including penal action
sanctioned posts of ayahs are vacant. Of against private mental homes operating
the 91 sanctioned posts of male sanitary without a licence.
Among the immediate measures
workers, 28 remain vacant, as do 12 of the
announced by the State government were
20 sanctioned posts of dhobis.
the closure of all “mental homes” func­
ITH just one bed for every 40,000 tioning in thatched sheds and the
patients and one psychiatrist for “unchaining” of all inmates. The govern­
every one million patients, India’s infra­ ment also made it mandatory for anyone
structure for treating the mentally ill is setting up such a home to obtain a licence,
abysmal. The only comprehensive report as stipulated by the Mental Health Act,
on the 37 mental hospitals in the country, 1987. It also ordered the setting up of a
brought out by the National Human monitoring cell under the Collector in
Rights Commission (NHRC) in 2001, every district to make sure that the homes
points to the scanty availability offacilities conform to norms. The government also
such as beds, medicines and toilets; insuf­ launched the District Mental Health
ficient professional help; and inadequate Programme (DMHP) in Ramanathatreatment and rehabilitation facilities. puram and Madurai districts, with help
Lack ofawareness and infrastructure forces from such rehabilitation centres as Shristi
families of the mentally challenged to in Madurai run by the M.S. Chellamuthu
resort to witchcraft, black magic and faith- Trust under the guidance of the psychia-

W

114

5 trist
Dr.
C.
z Ramasubramanian.
The
“ IMH is to be the nodal
agency for the programme.
The basic idea of the
DMHP is to provide pri­
mary mental health services
on a sustained basis and to
put in place a system for
early detection of mental
disabilities and treatment.
Under the DMHP, the
Ramanathapuram district
administration conducted a
survey of the district, iden­
tified over 25 handicapped
and mentally challenged
persons and provided rheip
will: a re!: ,1
p;
:>>.?. ti'.ar ii-cb' ! re.ume^p
training.

pro­
cures
people,
.1, are to
,t. r the Erwadi
incident, the Supreme Court suo motu
issued notices, on die basis of media
reports on the tragedy, to the State and
Central governments asking them to sub­
mit a “factual report” and ordered the
mapping of all faith-healing homes in the
country. This process is under way. The
Centre also ordered the implementation
of the guidelines for maintaining mini­
mum standards in mental homes.
Says Dr. Ramasubramanian: “A piece­
meal approach will not help the millj^h
of hapless mentally ill people and tn^
families. Treating the mentally ill does not
stop with medicines. It involves a multi­
dimensional approach including rehabili­
tation and integration into the family and
society.” This should be the approach of
all mental hospitals, including the IMH.
The complex problem of mental health
care can be addressed only through a sus­
tained programme of education and
awareness generation, along with improv­
ing the infrastructure for treatment. It is
important to expand, encourage and push
community-based treatment and rehabil­
itation. The system of “care givers” start­
ed by the government early this year, by
which youth in the rural areas are trained
to take care of the mentally ill in the local
areas, needs to be expanded. While the
government seems to have taken some
steps in the right direction, a lot depends
on sustaining them. ■
FRONTLINE, AUGUST 2, 2002

■ MENTAL HEALTH

Deliverance in Erwadi
The death by fire of 28 persons while still in chains in a 'mental home' in a Tamil Nadu town draws
attention to the lack of facilities for humane and scientific treatment of the mentally ill in the country.
in Erwadi

Many of them end up being exploited at
homes that are set up illegally. They are

HE chain is blackened and the tin. is
horribly twisted but still fastened ■”
the charred stump - of a leg. Went. ■_
challenged and physically shackled h :■ \
Munigaraj had desperately trice o’ .
Btnself. Twenty-seven more men
people died with him in the early >u
August 6 when a fire engulfed the u veh -d
roof of the Moideen Badusha Mental
Home at Erwadi, a fishing village 27 km
south of Ramanathapuram town in south­
ern Tamil Nadu. They were stripped of
dignity when they lived - chained, con­
fined and ill-treated. The manner of their
death was even worse.
Their death highlights the deplorable
state of mental health care in the country
and the need for the government to reach
out to the mentally ill. Caught up in eco­
nomic, social, cultural, religious and legal
problems, most of the mentally ill persons
are deprived of the right kind of treatment.

Sethupathy, the Raja ofRamanarhapuran.,
got an heir to his throne alter he offered
prayers and drank the water at the dargah,
which is considered to be holy, for 41 days.
The king endowed over 6,000 acres (2,400
hectares) to the dargah. This apparendy is
at the root of the belief that the holy water
and the oil from a lamp in the dargah can
cure all ailments.
People have been coming to the dargah

ASHA KRISHNAKUMAR

T

Charred remains of the victims and the Moideen Badusha Mental Home at Erwadi.
128

for the last 200 years in search of a cure,
mostly for mental disorders. About 1,000
■;’:,i;ri'.'.s. belonging to different religious
■ •?.. -Lit the dargah every day. When
•
< f cuie-seekers increased, ‘homes’
< .
Ac care of the mentally ill.
'.
co dargah committee man:l Ibrahim, these homes prolifcr■i. die last ;> years. Ironically, many of
■ i an- run by persons who were brought
re Erw.idi 15 to 20 years ago for a cure, or
'
■■ who came here with their wards.
: 'ic person who ran the Moideen Badusha
Mental Home had come to Erwadi from
• o cicorin 15 years ago with a mental illness.
.’ iis home had 43 inmates as on August 6
(28 of them died, nine survived with minor
burns and six arc missing). Similar is the case
of the Darbar Mental Hostel, whose owner
Bashir came from Kerala 20 years ago for
treatment. The home, run by Bashir and
wife Najima, has 15 inmates.
The 17 homes around rhe dargah
together have about 550 inmates, and some
100 patients are’ kept in the dargah com­
pound. Most of them are
chained. They go to the dar­
gah in the evening, drink the
water and dab themselves with
oil from the lamp. They wait
for the “divine command” in
their dream to go back home.
For the “command” to come
it may take anything from two
months to several years.
Men and women are kept
separately in the dargah. There
are a few toilets, and these are
used by the pilgrims also. The
tank near the dargah is like a
cesspool, but many inmates
bathe in it. A few go to the sea.
While some inmates seem to
have been there for long, many
come on the “divine call” and
stay for a few months. Lakshmi
of Chennai has been visiting
the dargah for 17 years, and has
stayed for periods ranging
from six months to a year
depending on the “divine
command”. (Some names of
FRONTLINE, AUGUST 31, 2001

same period. Agricultural imports into
developing countries increased by nearly
4 per cent during this period compared
to less than 2 per cent for developed
countries. The U.S.-based Institute for
Agriculture and Trade Policy com­
plained in a recent note to the U.S. Trade
Representative that American agribusi­
ness corporations were “dumping” their
products across the world because of the
“export credit, insurance and transporta­
tion subsidies” that they receive from rhe
U.S. government ar the expense of the
taxpayer.

nforcement of intellectual

E

property rights is an emotive issue
that is threatening to assume serious pro­
portions in the Third World. At the very
least, developing countries want com­
pulsory licensing of patents so that they
are able to address their public health pri­
orities. The development and availabili­
ty of drugs for the treatment ofAcquired
Immune Deficiency Syndrome (AIDS) is
among the most significant issues.
African governments are under pressure
to ensure that the drug monopolies are
not allowed to override the need for treat­
ment of life-threatening epidemics.
Although some individual companies
have offered concessions, developing
countries would like the WTO to pro­
vide a more durable arrangement.
On the issue of trade in services,
developing countries have time and again
called for more liberal provisions for the
“movement of natural persons” so that
they could benefit from selling labour
■skills, priced cheaper, in advanced coun­
tries. This has met with stiff resistance
although the value of trade in the “move­
ment of natural persons” amounted to a
mere $30 billion, compared to $820 bil­
lion in the case of the services trade via
commercial presence. Developing coun­
tries also favour a more transparent and
. equitable dispute settlement mechanism
at the WTO.
Although trade in textiles is of sig­
nificant export interest to developing
countries, very little has been done to
remove the barriers to trade. Although
member-countries are to remove all
restrictions by 2005, till date only a frac­
tion of such restrictions have been
removed in the developed countries.
The Like-Minded Group (LMG), an
informal group that includes India,
Pakistan and other developing countries,
has categorically rejected a new round.
Srinivasan Narayanan, the Indian
Ambassador to the WTO, said recendy:
FRONTLINE. AUGUST 31.2001

“We are not ready for it (a new round).
We will lose more than we gain.”
India also articulated its concerns in
its communique to the G-77 in mid­
June. Union Minister for Commerce and
Industry Murasoli Maran pointed out
that rhe Uruguay Round, which laid the
basis for the establishment of the WTO,
had “resulted in serious imbalance and
asymmetry to the detriment of the devel­
oping countries.” He also pointed out
that although rhe WTO’s General
Council had decided in May 2000 that
all “implementation issues" would be
resolved before the Doha Conference,
developed countries now insist that these
issues will be settle*.*, as p-«:. o: i new

round.
The LMG insists t.t •• the '*.„:;
mentation-related concern-. ,i-. ?
over from the pre-Wl O
rr-.mp
claims that developing ci>:;m.i..s have

already paid heavily by undertaking
obligations arising out of deviations from
the standard agenda of trade negotiations
under the auspices of the General
Agreement on Tariffs and Trade
(GATT), the forerunner of the WTO.
These obligations included those relating
to intellectual property rights and Trade
Related Investment Measures (TRIMS).
Developing countries now demand that
implementation issues be settled “up­
front”, before other issues are taken up for
negotiations.
Indeed, Uganda’s Ambassador to the
WTO Nathan Irumba has argued that
the demand for a new and extended
round is flawed. “There is a systemic issue
here," he said. Arguing that “the whole
notion of rounds was before the WTO
was created,” Irumba claimed that the
WTO is “supposed to be a continuous
negotiating forum”. Developing coun­
tries have called for a “realistic assessment”incorporating their concerns.
They warn that if this does not happen,
the “level ofambition will have to be low­
ered”.
A confidential memo circulated
among member-countries before the
Geneva meet admitted that the
“entrenched nature” of the differences
among member-countries did not augur
well for starting a new round at Doha.
Mike Moore, Director-General of the
WTO, could barely conceal his own
position in favour of a new round, when
he warned that another failure, at Doha,
“would certainly condemn us to a long
period of irrelevance". He asked mem­
ber-countries “to get real” on the agenda
for Doha. ■
127

‘State intervention is important’
Interview with Dr. C. Ramasubramanian.
Shristi is a cluster of homes at
Musundagiripatti, 20 km from Madurai,
where the mentally challenged are treated
after initial medical care. It is more like a
resort. The inmates are not chained or
manacled
gardening
soap pccooking.

are hardly 10,000 hospital beds for the
mentally ill and a few doctors to treat
them.
The stigma associated with mental
illness, the fear of social ostracism, unaf-

span.
object iv<

Chcllamudtu
Research Foundation unde
the guidance of its founder­
trustee Dr. C. Ramasubra
manian, a well-known
psychiatrist
based
in
Madurai, is to enhance the
quality of life of the mental­
ly challenged and reintegrate
them into society. Started in 1992, Shristi
now offers de-addiction therapy, helps the
mentally retarded, organises community
support groups, and provides vocational
and skill-development training. To meet
the recurring expenditure and to help
impart skills to the inmates, Shristi runs a
printing press, small industrial units mak­
ing chalk, soap and agarbathi, a dairy ferm
and a computer centre.
Shristi was chosen as the best non-gov^kimental organisation (NGO) by the
T^unil Nadu government in 1996-97. It
is recognised as a research institution in
the field of mental health by the
Department of Science and Technology,
Government ofIndia. The Rehabilitation
Council of India recently recognised
Shristi as a training institute. Dr.
Ramasubramanian was a member of the
Regulatory Committee set up by the
Tamil Nadu government last year to look
into the condition ofthe homes in Erwadi.
Dr. Ramasubramanian spoke to Asha
Krishnakumar at his Madurai clinic.
! Excerpts from the interview:
► What is the incidence ofmental illness
in India and how do people deal with the
problem?
There are today an estimated 70 mil! lionmentallyillinthecountry.Thedegree
j of their illness ranges from marginal to
j severe, yer they all need treatment. There

FRONTLINE, AUGUST 31. 2001

hypnotism. Minor prob­
lems arising from pressure
and fatigue, such as feint­
ing spells, chest pain and
breathlessness can proba­
bly be cured using this method. But major
problems cannot be addressed.
Another method is shock treatment.
This is usually a painful procedure in
which some special herbs and leaves are
made into a paste and administered
through the nose, mouth and eyes. Or, the
patient is suddenly pushed into a deep
well.
If all this fails, they are taken for ‘reli­
gious’, ‘divine’ or ‘faith’ healing in Erwadi,
Gunaseelam (nearTiruchi), orCourtallam
(Tirunelveli district). Here, most often the
patientsare chained. They are beaten when
they become violent. Faith-healing has no
role to play in treating the mentally ill. It
is a waste of valuable time.
Most patients stop with feith-healing;
only some take the next step - ofgoing to
a psychiatrist. Unfortunately, by the time
they come to us their situation would have
become chronic.
► What should be the nature ofthe treat­
mentfor the mentally challenged?
Total cure is possible. Mental illness,
like any other illness, is curable, treatable
and preventable. Most important is early
detection, followed by effective treatment
and appropriate rehabilitation. Treatment
is incomplete if the patient is not inte­
grated into society. He needs to be accept­
ed by the family and then society.
Vocational trainingandskill development

are crucial for the patient to develop self­
esteem, to be independent and to live with
dignity. Follow-up and continuing med­
icines are a must.
► Has pharmacology kept pace with the
increase in the incidence ofmental illness?
A silent revolution has been on in psy­
chiatry. Some wonder drugs have been
developed in the last five years. Drugs such
as lithium have revolutionised treatment.
Several medicines that do not make
patients drowsy have also been developed.
But, even the rich and educated do
not accept mental illness as a disease that
can be cured. There is an urgent need to
change society’s attitude towards mental
illness. For this, educating the people and
creating an awareness is very important.
How expensive are the treatment and the
medicines?
Right now the medicines are expen­
sive. But the prices will come down. State
intervention is important. Drugs should
be subsidised. There should be commu­
nity-based rehabilitation and self-help
groups to deal with such problems.
► Is the Mental Health Act, 1987, imple­
mented in Tamil Nadu?
Only a few States have implemented
the Act. Tamil Nadu has not. Had the Act
been implemented, the Erwadi problem
would have never happened. As, accord­
ing to the Act, no home could have been
set up.
But under the Act, it is an elaborate
and cumbersome process before a patient
can be given treatment. A ‘Magistrate’ and
an ‘Inspection Committee’ need to
approve a case for treatment. There is a
need to simplify these procedures before
implementing the Act, for which there is
an urgent need.
► What needs to be done immediately to
help the hapless people whofall into the trap
of "faith-healers" and quacks?
Inmates ofall faith-healing homes in
Tamil Nadu should be given immediate
medical attention. There should be an
outpatient psychiatric department in
every taluk. There should be a wellequipped van (with a psychiatrist) to visit
every taluk at least once a week.
Generating awareness that the disease is
totally curable and even preventable, and
educating people on the various treat­
ment opportunities and the availability
of drugs can go a long way in addressing
the problem. The success of the pro­
gramme would, however, depend on
how well the NGOs and the communi­
ty are involved. ■

129

(From left) A woman patient In chains; one of the survivors of the tragedy, outside a home for the mentally ill;
chained together, at a home in Erwadi.

patients in this article have been changed, in
order to respect their privacy.)
Those who run the homes pay a rent of
Rs.500-700 for the thatched sheds, which
do not even have basic amenities. They
charge between Rs.500 and 1,500 a month
for each inmate, apart from taking an ini­
tial deposit. Each home has between 15 and
125 inmates. Some even engage touts who
wait at the bus station and the railway sta­
tion to lure relatives of the mentally ill.
For at least some people, putting their
kin in the homes has become an easy way
out of family disputes, often relating to
property; in some cases even mentally
healthy people are admitted to the homes
in order to settle scores. For instance, Gowri
(22), who was doing her B.Sc. in Psychology
in Coimbatore, was left in Erwadi two years
ago by her brothers after a property dispute
among them made her depressed and
moody. She gets a money order from her
brothers every month. Murugan (25) was
forced to stay in a home so that he is sepa­
rated from his lover who comes from an
influential family. Sundar (38), abandoned
in Erwadi, is not sure where he is from. He
stays chained and is made to beg.
The only records the homes maintain
are the addresses of the patients’ kin, to
make sure that the money order arrives
every month. Some relatives are prompt in
sending the money, perhaps just to ensure
that their wards do not return home.
Defaulting in payment is common, espe­
130

cially by the relatives of inmates from poor
families. In such cases the inmates are made
to beg, with the binding chains intact so
that they do not escape.
No distinction is made among the
inmates depending on the nature of their
illness or its intensity. They are all chained
- mostly sue or seven of them together and
at times individually - day and night. The
plight of those chained together is especial­
ly heart-rending. Ifone needs to answer the
call of nature, all the others have to accom­
pany him. It is worse when one ofthem suf­
fers from diarrhoea or gets an attack of
epilepsy, or is violent or has an abnormal
sexual orientation.
The inmates huddle together in small
thatched sheds, which are mostly left open
in the sides. A typical home, measuring 100
sq ft, houses about 20 persons. In some
homes, men and women are kept together.
Fungal infections and skin diseases are commonamongthemastheydonotwash them­
selves regularly. They are allowed to bathe
in the rank once in two or three weeks. The
inmates get no medical attention; beating is
the only treatment.
Few homes have kitchens. The inmates
are malnourished and weak. Most of them
get only the food offered by die pilgrims. It

is hardly an environment to treat the men­
tally ill. Yet people come to Erwadi, believ­
ing stories of people having been cured.
T is not as if the condition of the homes
was not known earlier. Only, successive
governments have failed to act. In July 1998,
I.Nazneen, Principal of die Women’s Arts
Collegeat Ramanathapuram, brought to the
government’s notice the inhuman treatment
of the mentally ill at the Sultan Alayudeen
Dargah at Goripalayam in Madurai and
asked the authorities to look into the
of all faith-healing centres, indu^mg
Erwadi. The District Collector dismissed

I

The Erwadi dargah. People have been
coming to the dargah for the last 200
years In search of a cure, mostly for
mental disorders.
FRONTLINE, AUGUST 31.2001

her findings as a “gross exaggeration”.
Nazneen then made a representation to the
National Human Rights Commission.
The NHRC, under the chairmanship
ofJustice M.N. Venkatachaliah, urged the
State government to address the issue
urgently. As nothing was done in spite of
repeated reminders, the NHRC deputed
D.R. Karthikeyan, who was Director
General (Investigations) then, to probe the
stare ofaffairs at the homes in Goripalayam
and Erwadi. Karthikeyan confirmed
Naznecn’s findings.
The dargah management committee
and the Society for Community
Civilisation Trust. a Madurai-based non-

governmental organisation, also made rep­
resentations to the NHRC. The NHRC set

FRONTLINE, AUGUST 31,2001

up a committee under the chairmanship of at the homes.
Prof K.S. Mani of the National Institute of
The PHC is of little help. According to
Mental Health and Neuro Sciences S. Paneerselvam, who runs the New Limras
(NIMHANS), Bangalore, to study the con­ Mental Homewhich has 120 male inmates,
dition ofdie mentally ill at Goripalayam and it is practically impossible to take inmates
Erwadi. The NHRC sent the committee’s who require quick medical attention to the
report to the State government along with PHC, which is 3 km away. But, according
its recommendations. The State govern­ to S. Vijayakumar, District Collector of
ment took no action.
Ramanathapuram, although a psychiatrist
It was only when eight inmates of the was posted at the PHC and the inmates
Erwadi homes died owing to diarrhoea in were given slips that would facilitate treat­
April 2000 that the State government set ment at the Government Hospital in
up a District Mental Home Regulatory Ramanathapuram, none from die Erwadi
Committee. The committee recommend­ homes visited the hospital.
ed that the homes should register them­
In September 2000, People’s Watch, a
selves with the respective local bodies; Madurai-based human rights organisation,
inmates should not be chained; basic sought the NHRC’s intervention in the case
amenities such as toilets should be provid­ ofMurugan after verifying a complaint that
ed; nutritious and hygienic food should be he was forcibly lodged at a home in Erwadi.
offered; the sheds should be made pucca; K.R. Venugopal, the NHRC’s Special
and the inmates should be admitted to hos­ Rapporteur, conducted a probe and the
pitals through the dargah haqdar manage­ Commission issued a notice to the Chief
ment committee. These recommendations Secretary to the Tamil Nadu government
were not implemented. The Dargah and the State’s Director-General of Police
Committee has also been urging the on October 3,2000.
Collector to close down the homes.
Governmental inaction is glaring. But
The only Fallout of the recommenda­ its greatest blunder is the failure to imple­
tions, according to Dr. A. Ganesan, Deputy ment the Mental Health Act, 1987. Section
Director, Health, Paramakudi, who was on 4(1) of the Act states: “The State govern­
the Regulatory Committee, was that a pri­ ment shall establish an Authority for Mental
mary health centre (PHC) was set up at Health with such designation as it may
Erwadi and Health Department personnel deem fit... to be in charge of regulation,
started visiting die homes once in two development and coordination of mental
weeks. Health Department personnel, who health services... and supervise the psychi­
had only monitorial powers, could not do atric hospitals and mental homes (includ­
much beyond recording in the inspection ing places where the mentally ill may be kept
books their observations about the poor or detained).” Section 6(1) prohibits the
hygiene and the absence of infrastructure running ofa home for die mentally ill with­
131

the dargah committee, said that the dargah National Calamities Fund was disbursed;
management was ready to participate in any the rest would be distributed later.) The
programme initiated by the State govern­ Collector has asked the relatives of the
ment to improve the condition of the inmates of the other homes to take back
homes. Some home-owners, who maintain their wards. Only a fourth of the inmates
the infrastructure and keep the conditions have been taken back by their families.
The families hesitate to take their kin
of hygiene at reasonably good levels, have
appealed to rhe Collector not to close down back because, according to Dr. C.
' I ’HE August 6 fire, which is believed to the homes. Says Paneerselvam of the New Ramasubramanian, a psychiatrist and a
X have been caused by an overturned Limras Mental Home: “After die district member of the District Mental Home
kerosene lamp (though sabotage is not administration issued strictures (unofficial­ Regulatory Committee, many ofthem con­
ruled out and an investigation is on) seems ly, following the death of eight inmates in sider the homes a convenient place to aban­
to have galvanised the administration at April 2000), I spent Rs.4 lakhs to upgrade don their mentally ill wards in order to
last. The District Collector has sent a report all amenities to conform to the standards set escape the stigma attached to mental ill­
nesses (see interview). Myths
to the State government with suggestions by the District Mental Homes
that mental illnesses are incur­
to improve the conditions ofthe homes and Regulatory Committee. The
government should differen­
able and contagious and the
regularise them.
lack of proper medical infra­
On August 10, the government tiate between homes."
structure for the trcatmcr^^f
On August 9, Dr. K.
announced a series of measures to regulate
such diseases are also fad^l
Deputy
the funaioning of homes for the mentally Balagurunathan,
that have influenced the deci­
ill. It has ordered the immediate closure of DirectorintheDistrictHealth
sion of the relatives of the
all homes functioning in thatched sheds. Department, examined the
inmates of these homes. As a
Other homes should obtain a licence with­ inmates in all the homes in
result, such homes have pro­
in a month and no home can be set up with­ Erwadi and ordered the trans­
liferated. There are about 35
out a licence. A cell will be set up in every fer of 10 patients (by August
of them around various tem­
district under the chairmanship of the 11, the number rose to 20),
ples and dargahs in Tamil
Collector to ensure that the homes conform who were prone to violence, to
Nadu.
' to norms. The government has also ordered the Government Hospital in
According to Dr. Rama­
that the inmates of all homes be Ramanathapuram. A clinic S. Vljayakumar,
subramanian, some 70 mil­
“unchained” immediately and those prone has been set up in a room given District Collector,
lion people are mentally ill in
to violence be admitted to government hos­ by the dargah committee to Ramanathapuram.
the country. According to the
pitals. It has decided to take the inmates of treat the others. The govern­
all the homes at Erwadi into its care; those ment plans to create a separate ward for the publication Mental Health in India 1950whoare“actuallymentallyiU”wlllbemoved mentally ill at the Ramanathapuram hospi­ 2000,2 per cent of the population is affect­
to government hospitals and the others sent tal. Says State Health Secretary Syed Munir ed severely and 20 per cent in varying
back to their families, or to old-age/desti- Hoda: “The government is looking at the degrees. But, according to estimates, there
tutes homes run by the government or social, legal and medical issues to deal with are hardly 10,000 hospital beds in India for
reputed non-governmental organisations the problem. A comprehensive programme the mentally ill. The only mental hospital
(NGOs). Those who are not mentally ill but for the mentally ill will soon be put in place.” in Tamil Nadu is the Institute of Mental
are abandoned by their families will get an The Departments of Health, Social Welfare Health in Kilpauk, Chennai, with 1,800
£
old-age pension (regardless of their age) and Law would be involved in the pro­ beds.
Dr. Ramasubramanian said rhiTin
under the category of destitutes.
gramme.
Various political parties are conducting recent times die treatment for mental ill­
The
District
Mental
Health
Programme, sanctioned last year by the independent inquiries into the Erwadi inci­ nesses has made rapid advances. The con- ■
Centre, will be implemented immediately dent. There is, however, a general sense of dition of most inmates of the homes for the
in Ramanathapuram and Madurai dis­ caution as the issue involves “religious faith”. mentally ill can be improved with the right
Immediately after the incident on medicines. But with dieir families unwill­
tricts. Each district will get Rs. 1 crore.
According to Health Minister S. Semmalai, August 6, rhe police arrested Moideen ing to take them back and with a dearth of
Rs.57 lakhs has been released by the State Badusha, his wife Suraiya Begum and rel­ hospitals to treat them, what is the choice
government for the programme in the two atives Badsha and Mumtaj. The govern­ before them? Says Dr. Ramasubramanian:
districts. Psychiatrists will be posted at all ment announced a solatium of Rs.50,000 “Trearing the mentally ill does not stop with
the 25 district headquarters hospitals. Only each to the families of the 28 people who medicines. It involves a multi-dimensional
died (Rs.15,000 from the National approach including rehabilitation and inte­
14 have psychiatrists now.
In the wake of the Erwadi tragedy, the Calamities Fund and Rs.35,000 from the gration into the family and society."
According to Nazneen, this complex
Centre has ordered the mapping of all State Relief Fund); Rs.15,000 to the fami­
“faith-healing" centres for the mentally ill lies ofthe inmates with major burn injuries; problem can be addressed only through a
in the country. Union Health Minister and Rs.6,000 for the families of those with sustained programme of education and .
C.P. Thakur has ordered the implementa­ minor burns. While the families of 15 of awareness generation, along with improv- ,
tion of the guidelines for maintaining min­ the inmates who died claimed the ex-gratia ing the infrastructure for treatment and
imum standards in homes for the mentally payment, money has been disbursed to only providing medicines free or at subsidised
ill. The Centre also plans to modernise all seven families as in the case of others the rates. Says Nazneen: “We hope the mar­
legal heirs of the victims could not be ascer­ tyrs ofErwadi will open the eyes ofthe peo­
mental health hospitals in the country.
Thulkarni Badsha, former secretary of tained. (Only the amount from the ple and the authorities.” ■

out a licence. According to Seaion 11 (lb),
the licensing authority can revoke the
licence if the maintenance of the “home is
being carried on in a manner detrimental to
the moral, mental or physical well-being of
the inpatients." None of the homes in
Erwadi meets the standards set by the Act.

132

FRONTLINE, AUGUST31, 2001

and attendon-deficit/hyperactivity disor­
der (adhd)—a decidedly lousy trifecta. If
that was what eighth grade was, ninth was
unimaginable.
But that was then. Andrea, now 18, is a
freshman at the College of St. Catherine in
St. Paul, Minnesota, enjoying her friends
her studies and looking forward to a
cmeer in fashion merchandising, all thanks
to a bit of chemical stabilizing provided by
a pair of pills: Lexapro, an antidepressant,
and Adderall, a relatively new anti-ADHD
drug. “I feel excited about things,” Andrea
says. “I feel like I got me back.”
So a little medicine fixed what ailed a
child. Good news all around, right? Well,
yes—and no. Lexapro is the perfect answer
for anxiety all right, provided that you’re
willing to overlook the fact that it does its
work by artificially manipulating the very
chemicals responsible for feelings and
thought. Adderall is the perfect answer for
adhd, provided that you overlook the fact
that it’s a stimulant like Dexedrine. Oh,
yes, you also have to overlook the fact that
Adderall has left Andrea with such side ef­
fects as weight loss and sleeplessness, and
both drugs are being poured into a young
brain that has years to go before it’s finally
fully formed. Still, says Andrea, “I’m just
glad there were things that could be done.”

46

Those things—whether Lexapro or
Ritalin or Prozac or something else—are
being done for more and more children the
world over. In the U.S., they are being done
with such frequency that some Americans
have justifiably begun to ask, “Are we rais­
ing Generation Rx?”
Just a few years ago, psychologists
couldn’t say with certainty that kids were
even capable ofsuffering from depression the
same way adults do. Now, according to
PhRMA, a pharmaceutical trade group, up to
10% of all American kids may be suffering
from some mental illness. Perhaps twice that
many have exhibited some symptoms of
depression. Up to a million others may be
suffering from the alternately depressive and
manic mood swings of bipolar disorder (bpd),
one more condition that was thought until
recently to be an affliction of adults alone.
adhd rates are exploding too. According to a
Mayo Clinic study, American children be­
tween the ages of 5 and 19 have at least a 7.5%
chance of being found to have adhd, which
amounts to nearly 5 million kids. In Japan, tire
Asian country most attuned to psychological
problems in children, a survey of more than
40,000 elementary and middle school kids—
the first such large-scale study by the govern­
ment-revealed that 2.5% were suffering
from adhd, which translates into one child in

Photographs for TIME by Steve Liss

Frankie Castillo, 15
Charlie Inguanzo, 11
HOMETOWN: Laredo, Texas

BIO: Brothers by blood and disorders,
Frankie and Charlie are both on meds. Less
than three years ago, Frankie was found to
have ADHD and depression; he is taking a
three-drug cocktail. Charlie, disruptive in
class since age 4, takes one drug for ADHD

every schoolroom. Kwai Chung Hospital in
Hong Kong, which runs one of the five main
child psychiatric centers in the territory, has
seen a doubling of adhd cases since 1998
and an even bigger jump in kids diagnosed
with schizophrenia. Other maladies affecting
children: obsessive-compulsive disorder, so­
cial-anxiety disorder, post-traumatic stress
disorder, pathological impulsiveness, sleep­
lessness, phobias and more.
Has the world simply become a more
destabilizing place in which to raise children? Probably so. But other factors are at
work, including sharper-eyed parents and
doctors with a rising awareness of childhood

ttOUR USAGE EXCEEDS
BE USED FOR, BUT LETS

Joel Flynn, 14
Jefferson City, Missouri
: He might not look it, but Joel feels the
drug he takes for his ADHD has flattened his
personality some. That’s a price the straight-A
student is willing to pay, given that when his
conditr was diagnosed, at age 6, his
fidgeti. -> made it impossible for him to play
baseball, much less do schoolwork. The drug
that calms him is, paradoxically, a stimulant

mental illness and what can be done for it.
“While we don’t know exactly why the inci­
dence of psychopathology is increasing in
children and adolescents, it probably has to
do with better diagnosis and detection,” says
Dr. Ronald Brown, professor of pediatrics at
the Medical University of South Carolina.
Also feeding the trend for more diag­
noses is the arrival of whole new classes of
psychotropic drugs with fewer side effects
and greater efficacy than earlier medica­
tions, particularly the selective serotonin re­
uptake inhibitors (ssris), or antidepressants.
While an earlier generation of antidepres­
sants—tricyclics such as Tofranil—didn’t

work in kids, ssris do. According to a study
by Professor Julie Zito of the University of
Maryland School of Pharmacy, use of anti­
depressants among children and teens in­
creased threefold between 1987 and 1996.
And that use continues to climb.
Nobody, not even tire drug companies,
argues that pills alone are the ideal answer
to mental illness. Most experts believe that
drugs are most effective when combined
with talk therapy or other counseling.
Nonetheless, the American Academy of
Child and Adolescent Psychiatry now lists
dozens of medications available for trou­
bled kids, from the comparatively famUiar
Ritalin (for adhd) to Zoloft and Celexa
(for depression) to less familiar ones like
Seroquel, Tegretol, Depakote (for bpd), and
more are coming along all the time. There
are stimulants, mood stabilizers, sleep
medications, antidepressants, anticonvul­
sants, antipsychotics, antianxieties and
drugs to deal with impulsiveness and posttraumatic flashbacks. A few of the newest
meds were developed or approved specifi­
cally for kids. The majority have been
okayed for adults only but are being used

“off label” for younger and younger patients
at children’s menu doses. The practice is
common and perfectly legal but potentially
risky. “We know that kids are not just little
adults,” says Dr. David Fassler, professor of
psychiatry at the University of Vermont.
“They metabolize medications differently.”
Within the medical community—to say
nothing of the families of the troubled
kids—concern is growing about just what
psychotropic drugs can do to still develop­
ing brains. Few people deny that mind pills
help-ask the untold numbers who have
climbed out of depressive pits or shaken off
bipolar fits thanks to modem pharmacolo­
gy. But in America, few deny that a quick­
fix culture exists, and if you offer a feel-good
answer to a complicated dilemma, people
will use it with little thought of long-term
consequences. “The problem," warns Dr.
Glen Elliott, director of the Langley Porter
Psychiatric Institute’s children’s center at
the University of California, San Francisco
(ucsf), “is that our usage exceeds our
knowledge base. We’re learning what these
drugs are to be used for, but let’s face it:
we’re experimenting on these kids.”

OUR KNOWLEDGE BASE WE'RE LEARNING WHAT THESE DRUGS ARE TO
FACE IT: WE’RE EXPERIMENTING ON THESE KIDS.W

HOW THEY WO
HOW IT
WORKS

SIDE EFFECTS

TESTED/
APPROVED

ADDERALL

A once-a-day
amphetamine, it
puts the brake on
areas of the brain
responsible for
organizing thoughts

Rapid heartbeat,
high blood pressure
and, in rare cases,
overstimulation, it
can also become
addictive

Approved in the
U.S. to treat ADHD
in children of
age 3 and older

CONCERTA

It keeps neurons
bathed in
norepinephrine and
dopamine, which
reduce hyperactivity
and inattention

Headache, stomach
pain, sleeplessness
and, in rare cases,
overstimulation

STRAITERA

Approved in the U.S.
a year ago, it’s the
first nonstimulant
for ADHD; enhances
norepinephrine
levels in the brain

Decreased appetite,
fatigue, nausea,
stomach pain

Its active agent,
methylphenidate,
stimulates the brain
to filter and
prioritize incoming
information

Headache, lack of
appetite, irritability,
nervousness,
insomnia

The patch form of
the stimulant
methylphenidate, it
delivers continuous
low doses
through the skin

Similar to those
for oral
methylphenidate

Approved in the U.S.
in 1987, it’s the first
antidepressant aimed
at regulating sero­
tonin, a brain chemi­
cal involved in mood

Insomnia, anxiety,
nervousness, weight
loss, mania

•

•

RITALIN

METHYPATCH

PROZAC

IS ASIA CATCHING UP?
SHOHEIASAKURA WAS A RESTLESS AND TROU-

bled child since he was several months old.
He didn’t respond normally to his peers, and
his language development lagged behind
other kids’ in his neighborhood in Japan’s
Fukushima prefecture. At age 3, Shohei was
diagnosed with ADHD and pervasive devel­
opment disorder, but for a year his parents
refused the doctor’s offer of a “miracle
drug,” Ritalin. When they finally relented in
1999, Shohei’s behavior changed almost
overnight. He was more comfortable
around his mother, Rei, and could concen­
trate for extended periods of time. But Rei is
still apprehensive about her son’s depend­
ence on drugs and is sometimes criticized

Inside the brain
Frontal lobe
Organizes and plans,
as well as controls
movement
■ Depression,
ADHD. OCD

/
Approved in the
U.S. to treat ADHD
in kids of age
6 and older

Approved in the
U.S. to treat ADHD
in children of
age 6 and older

Approved in the
U.S. to treat ADHD
in children of
age 6 and older

Developed to treat
ADHD, but the FDA
has deemed drug
'‘unapprovable" in
the U.S. until more
studies completed

Approved in the
U.S. for depression
and OCD in kids of
age 7 and older

by people who respond to her website,
which chronicles her son’s struggle. “I could
tell them only that I got him to take it be­
cause it was absolutely necessary,” she says.
Asia is far behind the West in diagnos­
ing kids with mental illness. “A gross num­
ber of children and teenagers who really
need help are untreated," says Dr. Alm Dong
Hyun, president of the Korean Academy of
Child and Adolescent Psychiatry. In all of
India, for example, there are only a dozen
child psychiatrists. In China, most parents
have never even heard of conditions such as
adhd. “They tend to think their kids are
misbehaving, disobedient, or that they don’t
like going to school,” says Du Yasong, direc­
tor of the department of child and adoles­

Basal ganglia
Control anxiety
level, coordinate
motor behaviors
•Anxiety, OCD,
depression, panic,
bipolarity

Putamen
Involved in
regulating
motor functions
and attention
•ADHD

Hippocampus
Essential to
formation of
memories and
higher learning
• Depression,
anxiety, panic,
bipolarity

Amygdala
Hub of fear an*J
emotions
•
■ Depression,
anxiety, panic, posttraumatic stress

cent behavior at the Shanghai Mental
Health Center. “Their reaction is to blame
the children, scold them, even beat them.”
And from that foundation of ignorance
springs many more problems. Ritalin, for
example, isn’t approved in Japan for treating
hyperactivity (although it is for severe
depression and narcolepsy). The drug isn’t
officially sanctioned for any condition in
China (although it is available to doctors
there). Ritalin’s manufacturer, Novartis
Pharmaceuticals, doesn’t even bother mar­
keting the drug in Asia. But adhd, the ail­
ment for which Ritalin is most frequent!;.
prescribed, is at least starting to be diag­
nosed in Asian kids—far more than depres­
sion, bpd or OCD. “The problem here” says

«WE KNOW THAT FRONTAL LOBES, WHICH MANAGE FEELINGS AN 3

RK

Children are just as vulnerable as adults to mental illness, uut tnougn tne
pharmaceutical pantry is filling up with more medications designed and tested for
kids, in some cases they still have to settle for smaller doses of drugs made for adults
HOW IT
WORKS

------ Prefrontal cortex
Regulates attention span
and impulse control; also

Upset stomach, dry
mouth, agitation,
decreased appetite

Not approved for
kids but prescribed
pediatrically based
on adult data for
depression, anxiety,
OCD and others

Like Prozac and
Zoloft, it elevates
levels of serotonin
in the brain

Nausea, drowsiness,
insomnia

Not approved for
kids but prescribed
pediatrically based
on adult data for
depression, anxiety,
OCD and others

It targets two brain
chemicals—
serotonin and
norepinephrine—
to regulate mood

Nausea,
constipation,
nervousness, loss of
appetite, drowsiness

Not approved for
kids but many
doctors prescribe
it for childhood
depression based
on adult data

DEPAKOTE

This antiseizure
medication is
particularly effective
in treating the
grandiose, hyperagi­
tated state of mania

Liver and white
blood cell
abnormalities,
headache, nausea,
drowsiness

Not approved for
kids but many
doctors use it to
treat childhood
bipolar mania
and seizures

ZYPREXA

It's a mood
stabilizer designed
to balance levels
of serotonin
and dopamine
in the brain

Weight gain,
drowsiness, dry
mouth, seizures

Not approved for
kids but many
doctors use it to
treat childhood
bipolar mania and
schizophrenia

It stabilizes the
episodes of elated,
intensely joyous
moods associated
with mania

Nausea, loss of
appetite, trembling
of the hands

Not approved for
kids but many
doctors use it to
treat childhood
bipolar mania

PAXIL

•

<:§

EFFEXOR

Cingulate
synis
Critical to
adaptation,
cognitive flexibility
and cooperation
■ OCD

TESTED/
APPROVED

It enhances the
levels of serotonin
in the brain to
maintain feelings
of satisfaction
and stability

ZOLOFT

Thalamus
Relay station
for all incoming
sensory
information
BOCO

SIDE EFFECTS

2

•'

THE HUMAN BRAIN does
not —ach full cognitive and
en
>nal maturity until a
person reaches his or her 30s

LITHIUM

Dr. Angeline Chan, a child psychiatrist in
Hong Kong, “is undermedication.”
Which suggests that Asian kids are im­
pervious to the dangers of these drugs—but
that’s not true either. School performanceoften the first thing to be affected in a child
with mental illness—is an obsession with
middle-class Asian parents, and a whole lot
of kids are hauled off to unqualified physi­
cians who can dispense a pharmacopoeia
of potentially dangerous drugs. Varkha
Chulani, a Bombay-based child psycholo­
gist, saw a seven-year-old boy with adhd
last year who had suffered problems at
school. His parents had brought him to
a doctor who prescribed a slew of medica­
tions, including Valium and Alprax. “The

child was on so many drugs, he had become
a zombie,” she says. In South Korea,
school-obsessed teens self-medicate on
powerful over-the-counter drugs, includ­
ing amphetamines (to concentrate) and
opiates (to counter anxiety and depression).
“When we see these kids at the hospital,”
says Kim Hun-Soo, a psychiatrist at Seoul
Asan Hospital, “it’s because these drugs
have changed their behavior so much that
their previously nonchalant parents finally
were able to notice a difference.’’ Once the
kids get off the street drugs, Kim says, some
are found to have undiagnosed mental ill­
ness such as adhd, depression and social­
anxiety disorder, which should have been
treated with entirely different drugs.

THE CASE FOR MEDICATION

Untreated depression has a lifetime suicide
rate of 15%—with still more deaths caused
by related behaviors such as self-medicat­
ing with alcohol and drugs. Kids with seaccording to some studies, to higher rates of
substance abuse, dropping out of school
and getting into trouble with the law.

themselves and others with uncontrolled
ing. They are also more prone to suicide.

THOUGHT, DON’T FULLY MATURE UNTIL AGE 30.W

-STEPHEN HINSHAV
University of California, Berks!:

HEALTH
Wayne, Indiana, hesitated little when it
came time to put her granddaughter
Monica on medication. Hatten’s grown
daughter, Monica’s mom, suffers from bpd,
and so does Monica, 13. To give Monica a
chance at a stable upbringing, Hatten took
on the job of raising her, and one of the first
things she had to do was get the violent
mood swings of the bpd under control. It’s
been a long, tough slog. An initial drug
combination of Ritalin and Prozac, pre­
scribed when Monica was six years old,
simply collapsed her alternating depressed
and manic moods into a single state with
sad and wild features. By the time she was
eight, her behavior was so unhinged that
her school tried to expel her. Next, Monica
was switched to Zyprexa, an antipsychotic,
that led to serious weight gain. “At 12 years
old she had stretch marks,” says Hatten.

Now, a year later, Monica is taking a fourdrug cocktail that includes Tegretol, an an­
ticonvulsant, and Ability, an antipsychotic.
That, at last, seems to have solved the prob­
lem. “She’s the best I’ve ever seen her,” says
Hatten. “She’s smiling. Her moods are con­
sistent. I’m cautiously optimistic.” Monica
agrees, “I’m in a better mood.” Next up in
the family’s wellness campaign: Monica’s
eight-year-old cousin Jamari, who is on
Zyprexa for a mood disorder.
All along the disorder spectrum there
are such pharmacological success stories.
In the October issue of the Archives
of General Psychiatry, Dr. Mark Olfson
of the New York
State Psychiatric
Institute reports
that every time
the use of anti-

depressants jumps 1%, suicide rates among
kids 10 to 19 years old decrease, although
only slightly. But that doesn’t include the
nonsuicidal depressed kids whose misery
is eased thanks to the same pills.
ARE WE MEDDLING WITH
NORMAL DEVELOPMENT?
FOR CHILDREN WITH LESS SEVERE PROB-

lems—children who are somber but not
depressed, or antsy but not clinically hy­
peractive, or who rely on some repetitive
behaviors for comfort but are not patently
obsessive-compulsive—the pros and cons
of using drugs are far less obvious.
“Unless there is care­
ful assessment^^ve
might [inadvert^ty]
start medicating nor­
mal variations [in

University Blues: a Crisis
oing away to college isn't
the same these days.
Once upon a time—at
least in the U.S.—mom
and dad unloaded the station
wagon as their starry-eyed
scholar surveyed the campus
with a heart full of hope and a
mind on fire with plans. The
mood was wistful and
optimistic; the future looked
bright despite the tearful
farewells. But a shadow has
fallen among the ivory towers.
A growing number of students
arrive on U.S. campuses
suffering from depression and
other emotional disorders—
some diagnosed, some hidden.
So that traditional moment of
new beginnings Is haunted by
deep anxiety and gloom.
A rapid-fire trio of student
suicides at New York University
this fall has focused attention
on the problem. On Sept. 12, a
day after celebrating his 20th
birthday, Jack Skolnik of
Evanston, Illinois, leaped to his
death from the lOth-fioor Inner
balcony ofthe campus library.
A month later, Stephen Bohler,
18, of Dayton, Ohio, made the
same fatal dive. And on Oct. 16,
Michelle Gluckman, 19, a
sophomore from Brooklyn,
New York, threw herselffrom
the slxth-floorwindow of an
off-campus apartment.
Behind these deaths lurk an
array of grim statistics that show

G

how prevalent mental disorders
have become on campus. Data
from a 2001 survey of college
mental-health counselors, when
compared with past findings,
revealed that the percentage of
students treated at college
counseling centers who have
had psychological problems
diagnosed and are taking
psychotropic drugs increased
from 7% in 1992 to 18% in 2001,
according to Greg Snodgrass,
director of the counseling center
at Texas State University. The
survey also found that during the
previous five years, 85% of North
American student counseling
centers reported an increase
in students with "severe
psychological problems."
Colleges have responded by
beefing up their mental-health
services, includingsuicide-watch
programs. Harvard set the
standard in 1998—aftera
widely publicized campus
murder-suicide case—by
increasing staff 25%. "One huge
issue was access," explains
Dr. Richard Kadlson, who heads
mental-health services there.
Are today's students more
emotionally fragile than their
predecessors? No one can say,
though some point to grueling
pressures to succeed In an
era of economic uncertainty
and heightened parental
expectations. Hal Pruett, director
of student psychological services

at UCLA, recalls a tense
freshman who became so
distracted by innerturmoil that
he couldn't study. “He kept
saying, 'I can’t afford to get a C.'
I asked why, and he said, 'I won’t
get into medical school, and my
parents will disown me.’"
Hara Estroff Marano, an
editor at Psychology Today
who has interviewed college
counselors and their students
about depression, wonders
what happened tosharing one’s
worries with roommates and
friends. A depressed student told

Marano she
wouldn't dream of
telling peers about
her darker fears
because she saw
them as rivals,
scramblingforthe
same grades and
grad-school slots.
“For many in this
generation," says
Marano, “there is
a sensethatyou
cant show any
vulnerability."
Pruett wonders if
the reliance on
medication to
handle the blues
hasn't weakened some> students
■
nonpharmaceutical coping skills.
"Sometimes we need to value
our ability to solve and work
through problems,” he says.
“Prescribing a drug sometimes
deprives these young people of
that age-old human ability."
The prescriptions may be
saving lives, though. As the rate
of their use on campus has gene
up, overall reported U.S. college
suicide rates, despite the cluster
at N.Y.U., have fallen noticeably.
from a total of 122 in 2000 to 80
in 2001. “It’s the Prozac payoti. ’’
says Marano. Thai and ’. re­
determined efforts of cam- , s
mental-health profes.-:jn.-.,s to
diagnose depress^:'..-! ear.,, freat
it aggressively ni.drea- w
stude t, tiia tths- .tunc.■ college
ca.eersofy-..
-■ :

behavior],” says Stephen Hinshaw, chair­ helping patients reframe their view of the
man of psychology at the University of world so that setbacks and losses are put in
less catastrophic perspective. “The thera­
California, Berkeley.
The world would be a far less interest­ pist teaches relaxation skills and positive
ing place if all the eccentric kids were thinking” says Denise Chavira, clinical
medicated toward some golden mean. psychologist at the University of California
Besides, there are just too many unan­ at San Diego. “It goes beyond talk therapy.”
swered questions about giving mind drugs Unfortunately, medical insurance pays
to kids to feel comfortable with ever broad­ more readily for pills than for these other
ening usage. What
worries some doctors
is that if you medicate
a child’s developing
brain, you may be
burning the village to
HOMETOWN
save it. What does any
Fort Wayne, Indiana
l^ul of psychopharBIO Monica, whose
i^Jblogical meddling
mother has BPD and
do, not just to brain
whose cousin might
too, needs a four-drug
chemistry but also to
regimen to control her
the acquisition of emo­
own BPD. It took
tional skills—when, for
much trial and error
example, antianxiety
to hit on the right mix,
drugs are prescribed
and that meant a lot
for a child who has not
of side effects and
yet acquired the expe­
discomfort. Now,
rience of managing
however, her
stress without the
symptoms are under
meds? And what about
control. "She's
smiling," says her
side effects, from
grandmother
weight gain to jitteri­
ness to flattened per­
sonality—all the things
you don’t want in the social crucible of treatments for adults and children alike.
For kids with more serious symptoms,
grade school and, worse, high school.
Adding to the worries is a growing experts are worried that undermedicating
body of knowledge showing just how in­ is a bigger risk than overmedicating. “Say
completely formed a child’s brain truly is. you’ve got a kid who’s severely obsessive
“XjMkow know from imaging studies that and literally can’t leave the home because
fromal lobes, which are vital to executive of the fears and rituals he’s got to perform,”
functions like managing feelings and says ucsf’s Elliott. “Think about what any­
thought, don’t fully mature until age 30,” one age 2 to age 16 has to learn to function
says Hinshaw. That’s a lot of time for drugs in our society. Then think about losing two
to muck around with cerebral clay.
of those years to a disorder. Which two
For that reason, it may not always would you choose to lose?” Also on the side
be worth pulling the pharmacological rip of intervention is the belief that treating
cord, particularly when symptoms are rel­ more kids with mental illness could reduce
atively mild. Child psychologists point out its incidence in adulthood.
that often nonpharmaceutical treatments
can reduce or eliminate the need for drugs. HOW CAN WE MEASURE THE RESULT?
Anxiety disorders such as phobias can re­ PREVENTING SYMPTOMS, OF COURSE, IS NOT
spond well to behavioral therapy—in which everything. A sleeping child is completely
patients are gently exposed to graduated asymptomatic, for example, but that’s not
levels of the very things they fear until the same as being fully functioning. If the
the brain habituates to the escalating risk. drugs that extinguish symptoms also alter
Depression, too, might respond to new, the still developing brain, the cure might
streamlined therapy techniques, especially come at too high a price, at least for
cognitive therapy—a treatment aimed at kids who are only mildly symptomatic. To

determine if this kind of damage is being
done, investigators have been turning
more and more to brain scans such as from
magnetic resonance imaging (mri). The re­
sults they’re getting have been intriguing.
mris had already shown that the brain
volumes of kids with adhd are 3% smaller
than those of unafflicted kids. That con­
cerned researchers because nearly all

Monica
Moore, 13

those scans had been taken of children al­
ready being medicated for the disorder.
Were the anatomical differences there to
begin with, or were they caused by the
drugs? Attempting to answer that, Dr. F.
Xavier Castellanos of the New York
University Child Studies Center took other
scans, this time using only kids with adhd
and comparing those who were taking
medication with those who were not.
Reassuringly, he discovered that they all
shared the same structural anomaly, a find­
ing that seems to exonerate the drugs.
Dr. Steven Pliszka, chief of child psy­
chiatry at the University of Texas Health
Center in San Antonio, went further. He
conducted scans that picked up not just the
structure but the activity of the brains of
untreated adhd children, and compared
these images with those from afflicted chil­
dren who had been medicated for a year or
more. The treated group showed no signs
of any deficits in brain function as meas
ured in blood flow. In fact, he says, “we saw
hints of improvement toward normal.”

MA GROSS NUMBER OF CHILDREN AND TEENAGERS WHO
REALLY NEED HELP ARE UNTREATED.»

HEALTH
The news was less positive when it
came to bpd. Dr. Kiki Chang of Stanford
University has looked at the brains of
kids treated with Depakote, and while
his study is as yet unpublished, he says
he noticed some anatomical differences
that could have resulted from treatment—
and he wasn’t necessarily happy with
them. “We are seeing that medications
do affect the brain acutely,” he says. “Is
that a good thing, a bad thing? We just
don’t know.”
What nobody denies is that more re­
search is needed to resolve all these ques­
tions—and that it won’t be easy to get
it started. The first problem is one of time.
It was only in the early 1990s that the anti­
depressant Prozac exploded into pharma­
cies. It’s hard to do a lifetime of longitudinal
studies on a drug that’s been widely used
for just over a decade. And each time the
industry invents a new medication, the
clock rewinds to zero for that new pill.
The pharmaceutical companies could
be doing better in research, too—and if
they don’t, governments must push them

LI

FE

ON

to do it. There is a lot of money to be made
in developing the next Prozac, but there is
less profit if you test it for longer than the
law demands. The U.S. Food and Drug
Administration (fda) doesn’t require long­
term studies that follow patients over
decades. Its only requirement is toxicity
trials that span six to eight weeks. In an
effort to entice companies to conduct
lengthier studies, the agency now grants
an extension of six months of exclusive
marketing rights to any firm engaging
in studies of a drug’s effects on a minimum
of 100 children for more than six months.
“It’s a relatively small amount of data,”
acknowledges Dr. Thomas Laughren, a
psychiatrist with the fda’s psychopharmacology division, “but it’s better than what
we had before, which was nothing.”
Until all these
things happen,
the heaviest lift­
ing will, as always,
be left to the
family. Perhaps
the most powerful

MEDICATIO

medicine a suffering child needs is the ed­
ucated instincts of a well-informed par­
ent-one who has taken the time to study
up on all the pharmaceutical and nonphar­
maceutical options and pick the right ones.
There will always be dangers associated
with taking too many drugs—and also
dangers from taking too few. “Like every
other choice you make for your kids,” says
Chang, “you make right ones and wrong
ones.” When the health of a child’s mind is
on the line, getting it wrong is something
that no parent wants.

—With reporting by
Dan Cray/Los Angeles, Chaim Estulin and Austin
Ramzy/Hong Kong, Meenakshi Ganguly/Bombay,
Mingi Hyun and Kim Yooseung/Seoul, Susan
Jakes/Beijing, Kathie Klarreich/Miami, Mce
Park/New York City, Michiko Toyama/TokyQd
Leslie Whitaker/Jefferson City

N

"I Am a Different Person”
’ve had ADHD for 10 years
now. I was diagnosed with it
in kindergarten. Truthfully, I
don’t remember every detail
of my life before ADHD, but
there are some things I can't
help remembering. For example,
in kindergarten I was sent to the
“time-out chair” about two or
three times daily. The reason? I
would say things that would hurt
the other kids. Why did I say
these mean things? Because I’d
never think about what 1 was go­
ing to say or the consequences.
Another thing I'll never forget is
how antsy and talkative I was.
Every day after lunch, there was
a competition to see whose
table was quietest. Of course, I
could never stop talking or mov­
ing, so my table was always last.
I have taken two
medications to treat my ADHD.
From first through fifth grade, I
took Ritalin, which was not very
good for me. Ritalin took away
my appetite completely, so I lost
dramatic amounts of weight.
My teachers had to inspect my
lunch to see if I ate it! Now I
take Adderall. It has worked for
me, but it has taken so long to
find the right dosage.
I guess you could say my life

I

changed a good deal after
the treatment, because I had a
lot more focus. But to tell you
the truth, I could not see the
difference until the seventh
grade. By then, I was a
straight-A student because of it.
I may be naturally smart, but I
never could have applied myself
as much without it Nowadays, I
know when I need my medicine
because it lets me perform to
my full ability.
Recently I've become aware
of the side effects of my
medicine, which are a problem.
I am a totally different person
on it than off it. This is called
emotional lability. While on the
medicine in school, I rarely ask
my friends what there is to do on
the weekend. At lunch, I literally
sit at the table without saying
a word, and because of that,
I have lost a whole bunch of
friends. I drift from table to
table, but I don’t have one true
group that I belong to. This gets
me depressed at times. But
when I am off my medicine, I am
this outgoing, spontaneous,
hilarious person. When I go to
parties, I do not take my
medicine, and I go absolutely
wild. I will dance the entire night,

walk up to anyone and start
talking. People who know me
say, “Jessi, you're so different at
parties and outside of school."
Truly, they are right. I do not like
suffering from emotional lability,
and it sometimes makes me cry.
It also affects how I am with
my family. When I am off my
medication, I am hysterically
funny with my parents and a lot
more imaginative in playing with
my younger sister and brother.
But I also have a shorter
tempo., which leads to conflicts
with .ny sister. We make each
other cry. So my condition and
treatment have definitely affect­
ed my family, for good and bad.
Feeling different rom other.
kids ha3 never baen aij issue for
me.I just see myself as
someone who has tn have
medicine to concentrate better.
I will tell my friends straight off
that I have ADHDjif they don’t
like that, well, them too bad. In

eighth grade, we were given
nicknames (“most likely’s,”
actually) and mine was Miss
Hyper! It didn't bother me. I
think it showed my classmates
are cool with it My teachers are
very accepting of my condition,
but I find it difficult when a
teacher does not know I am
allowed extra time on tests. 1
used to feel guiity about getting
extra time, but now I accept it
because 1 know ! need it.
I'll never know what the
future holds for me. but I do
expect to remain on the
medication, because I want to. I
erjoy how I can focus and apply
myself. Maybe my parents want
me to stay on It as well, but it s
not the . . (dice. It >s mt choice.

■or.
stu.

. AidsCrisis

NURTURING HOPE: A nurse with an HIV-positive
orphan at the Freedom Foundation in Bangalore

Growing pains
Karnataka has the most number of
cases among pregnant women
By N.BHANUTEJ

atha’s little sons tug at her lean
frame for attention. But what is
shaking her inside is the
thought that she and her three-yearold son are HIV positive. Her
husband, a driver, who was HIV
positive died of a TB relapse when
Latha was seven months pregnant
with her second child. She is now
awaiting the six-month-old infant’s
blood report.
Latha was married to Lokesh
when she was 12. She had a child at 15,
but the baby did not survive. They
lived in a rented house belonging to
Lokesh’s relative in Bagalkot in north
Karnataka. “My husband looked after
me well,” she said. “But he has left us

L

nothing.” Two years ago when
Lokesh’s health began to fail,
he
was
treated
for
tuberculosis before the doctor
detected something more in
the blood report. He was
referred to the HIV/AIDS
centre run by the Freedom
Foundation in Bangalore.
Dr Nirmala Skill ofthe HIV/AIDS
centre told them about the disease
and how it spreads. That did not,
however, stop the couple from having
a second child. Lokesh' died at tire HIV
centre less than a year ago. “When he
died, I needed Rs 300 to come to
Bangalore,” said Latha. “I worked as a
coolie to raise the money.” Now, Latha
has nowhere to go and no means of
earning an income. “I can’t go back to

Graphics/B. MANOJKU.MAR

my maternal home in Bagalkot
because my brother’s family does not
want us there and we were also turned
out of our rented house,” she said.
The foundation gives her the
cotrimoxazole medication to prevent
infections, but it is yet to find anyone
to sponsorthe expensive anti-retroviral
drugs that can delay the onset ofAIDS.
“We are hoping to find a job for her,"
said Nirmala. “We will also try to
convince her family to look after her.
Karnataka is a “high prevalence”
Dec 14, 2003 kni£L:.'?u3 31

AidsCrisis

N. BHANUTEJ

state in HIV graphs. National AIDS
Control Organisation figures say that
5 per cent or more in the high-risk
groups are testing positive for HIV. On
World AIDS Day on December I, a
random HIV test in Bellary by an
NGO showed that 10 out of the 110
persons tested were HIV positive.
More worrying, experts have
detected a shift in demographic
patterns in the incidence of infection.
Earlier, sex workers, intravenous drug
users and truck drivers were the mainhigh-risk groups. Gradually, middle­
class housewives are becoming part of
the statistics.
“Hundreds of men visit red-light
areas,” said Christopher Skill of the
Freedom Foundation. “And they are
not just truck drivers. They are
businessmen or office workers and
they transmit HIV to a population that
was hitherto considered low-risk.” The
National AIDS Control Organisation’s
2001 report indicates that two-thirds
ofsex workers’ clients are married men
or those with partners.
It was a statistic waiting to be
revealed. Now, Karnataka has the
highest number of HIV cases among
pregnant women. That is 1 per cent, or
more, of women who attend antenatal
clinics during pregnancy. The sudden
32 KJEE53 Dec 14,2003

Experts stress the importance
of education. (Above) A
street play at a Bangalore
slum on World AIDS Day.
increase may be partly due to
education, detection and follow-up,
but that does not mean the situation is
not serious, said Christopher.
Programmes like the Prevention of
Mother to Child Transmission Project
in Karnataka have increased the
awareness among women. “Now,
almost 99 per cent of women who

come to antenatal clinics voluntarily
go for the HIV test,” said Hepzibah
Sharmila, the project’s director.
Vandana Gurnani, project
director ofthe Karnataka State AIDS
Prevention Society, said the incidence
of.HIV among those who visit
antenatal clinics was a worrisome
indicator of its prevalence in the
general population.
There are differences of opini^fcn
statistics and their interpretation^ut
experts unanimously stress the
importance of education, counselling
and community support. To educate a
rural population of which, according
to a National AIDS Control Organi­
sation report, only 30 per cent know
about condoms, is a challenge, but the
government and NGOs have set up
counselling centres across the state.
The Karnataka State AIDS Prevention
Society itself runs 33 centres.
But, like most women’s issues, HIV
is linked inextricably with empower­
ment. While the millions of dollars of
donations flowing into India to check
HIV/AIDS can only help educate and
counsel, little can be achieved until the
larger issue of socio-economic
empowerment ofwomen is addressed.
But in keeping with third world logic,
something is better than nothing. ■

AssimBiYQnm
ELECTIONSZUUO

CoverStory

THE DREAM GIRLS
The success of Uma Bharati, Vasundhara Raje and Sheila Dikshit
could trigger a search for more charmers in other states
By SACHIDANANDA MURTHY

igvijay Singh is no Laloo Prasad Yadav. The
irrepressible Bihar leader had promised
roads which would be smooth as the cheeks
ofre-election
dream girl,onHema
Malini,
and roads.
yet won
a
horribly
potholed

D

But the Dream Girls of the BJP—Uma Bharati in
Madhya Pradesh and Vasundhara Raje in Rajasthanproved to be too powerful for Digvijay and Ashok
Gehlot. They became heartthrobs by narrating heart­
rending tales of poor development in their states. The fact
that one was a sanyasin representing the backward castes
and the other was a princess foraying into a man’s world
helped in a big way.
The BJP had gone wrong in 1999 by projecting Sushma
Swaraj just six weeks before the Delhi Assembly elections.
This time they began projecting Uma and Vasundhara a
year in advance. As Chief Minister Sheila Dikshit romped
home to a massive victory, BJP strategists rued the fact that
they did not think of a feminine alternative to Dikshit. Only
Chhattisgarh was the male bastion.
It was a big gamble for the BJP to project two
women, but the gamble paid off because of their
natural appeal and because they touched the rural
womenfolk in search of a better life.
Uma was at her best in selling dreams to
women voters. During campaigning she would ask
whether they wanted a life of drudgery or the
comforts of development. She promised them a life of
dignity in a feudally ossified society. Her biggest punch line
was on unemployment under Digvijay and how her party
would create millions of jobs. Vasundhara struck an
emotional chord with rural women by wearing their
traditional dress and eating from their humble plates.
Sheila Dikshit scored because she was the
neighbourhood aunt. She addressed the public’s ire against
an erratic power supply by ensuring they got the best service
this summer, coupled with uninterrupted water supply. She
won the hearts ofyoung mothers by organising periodic and
compulsory polio drop camps in schools. She accepted every
invitation and sat among the audiences without fanfare.
Does the success of the three mean there will be more
women leaders to come? The only other woman who has
won a comfortable majority in recent times is Tamil Nadu
Chief Minister Jayalalithaa.
The BJP thinks it can experiment further by projecting
more women. The parliamentary board, which met on
34 EE32Z33 Dec 14,2003

illustration/HADiMANi

COMMUNITY HEALTH CELL
Society for Community Health Awareness Research and Action
No. 367, Srinivasa Nllaya, Jakkasandra I Main, I Block
Koramangala, Bangalore - 560 034.

BUDGET ESTIMATES 2003 - 2004
EXPENDITURE

SI No.

01.

Head of Account

Funds for Capital Purchase
Total

Budget 20032004 (as per 3
year Budget)

Budget 20032004 (Revised)

Remarks

160,000.00

Additional Office and Storage Furniture • Computer A
160,000.00
Accessories will be purchased.

160,000.00

160,000.00

RECURRING
^^eoplos Health Watch Unit (now Global
^Jple's Health Movement (PHM) Secretariat]

1

inclusive of Information Centre
I

Programme Costs

01.

Papers / Periodicals / Journals

48,400.00

48.400 00

02.

Postal Document Service

4,800.00

4,800.00

03.

CHC Reports. Pamphlet and Newsletter

26,100.00

100,000.00

Books

42,400.00

42.400.00

26,400.00

Telephone No. 5525372 - This telephone is being used
35,000.00 as Telephone, Fax & Internet dial-up. lienee the
increase.
13.200 00

04.
05.

Telephone (including Fax, Email, Internet

Three to four publications based on the work done in the
past will be brought out, this year being the 20th
milestone of CHC. Besides, the cost of printing has
gone up. Hence the increase

06.

Photocopying

13,200.00

07.

Travel / Conveyance

13,200.00

13,200.00

Contingency

8,700.00

12,900.00 5% of Items A 1 to 7 and rounded off

08.
S

Salaries and Allowances :

01.

02

CH Adviser and Coordinator PHM

Associate / Assistant (Fellowship) - One

250,600.00

268,500.00

129,600.00

120.000.00

RN (from PHM Secretariat)

Fellowship being negotiated (from RTT). This is of one
year duration al Rs. 10.000 per month.

03.

ScK.iulury io Adviser / Convenor

108,100.00

92,000.00 DGS (from PHM Secretariat)

04.

Library / Documentation Officer

122,500.00

82,800.00

05.

Information Assistant

82,800.00

91.800.00 * HRM

06.

Office Cum Media Assistant

78,200.00

82,200.00

07.

Staff Welfare Fund

3,600.00

3,600.00

VNR - Presently this position is occupied by a part-lime
official. Hence the difference.

CJ (50% from PHM Secretariat)

08.

Provision (or Provident Fund

54,000.00

51,600.00 7% of items All 1 to 6 and rouncied off

09.

Provision for Gratuity

27,000.00

25,800.00 3.5% of items All 1 to 6 and rounded off

10.

Internship (2 persons)

129.600.00

Shortterm internship being negotiated (from RTT) This
60,000.00 is for two persons for a duration of 6 months each pei
year at Rs. 5,000 per month. (Rs.5.000X6monthsX2)

Total

* Increase is due to upward revision of salary

1,169,200.00

1,148,200.00

_____________________________ASIA________________________

Get This arty Started
After nearly five decades in power, Japans LDP
faces an election surprise: credible competition
By JIM FREDERICK TOKYO

VER A FEW ROUNDS OF THE BOARD

O

game Go earlier this summer, Jap­
anese political veterans Naoto Kan and
Ichiro Ozawa brokered an alliance that
could forever alter their country’s political
^kiscape. For years, these rivals had led
Span’s two major opposition parties, each a
swom enemy of the Liberal Democratic
Party (ldp) that has ruled the country almost
continuously for 48 years. Alone, neither had
been able to mount more than a token chal­
lenge. But Kan and Ozawa agreed that the
ldp’s once fearsome power base was erod­
ing. Even its popular leader, Prime Minister
Junichiro Koizumi, was having trouble keep­
ing its squabbling factions in line. Suddenly,
they reasoned, the ldp seemed vulnerable to
an opposition party with real clout. The
answer: to join forces. So Ozawa agreed to let
his Liberal Party be acquired by Kan’s
Democratic Party of Japan (dpj). “There has
never been a major political power shift be­
tween the ruling party and the opposition
party," Ozawa told Time shortly before the
merger. “Japan needs that power transfer to
establish a true parliamentary government.”
Since that epochal decision, a genuine
two-party democracy has begun to emerge in

Japan. For the first time in the country’s his­
tory, a political party is putting unprecedent­
ed power in the hands ofvoters by mounting
a serious challenge to the ldp directly at the
polls, rather than cobbling together an oppo­
sition parliamentary majority through al­
liances of previously unaffiliated parties.
Old-fashioned Japanese politics-including
backroom deals and rule by faction—won’t
disappear overnight. But “aside from the
random Communist running around, it’s a
two-party system now,” says Steven Reed,
professor of modem government at Chuo
University in Tokyo. And that’s what makes
the run-up to the Nov. 9 general election such
an intriguing —and heartening-spectacle.
It’s already one of the most hard-fought,
liveliest Japanese elections in memory.
Diking a cue from the charismatic Koizumi,
who has hung onto his job largely by
charming the masses, the dpj has fielded
younger, more telegenic candidates to battle
the ldp gerontocracy. The dpj recently hired
U.S. public relations giant Fleishman-Hillard
as image consultants, and its candidates
received a booklet of tips on wooing voters—
particularly women. Among other advice,
candidates were told that bad breath, dirty
fingernails and poorly knotted ties are
all electoral turnoffs.
TIME, NOVEMBER 10,2003

The dpj’s chances of capturing the 104
seats necessary for a majority in the powerful
lower house (thus catapulting Kan into the
Prime Minister’s seat) remain slim. But at the
very least, dpj candidates are generating un­
usually robust political debate. Besides zeal­
ously portraying the opposition as corrupt
and anachronistic, die dpj took the
unorthodox step of publishing a 60-page
manifesto that’s rich in specifics, from slash­
ing government spending on large public
works projects by 30% by 2006 to decreasing
the size of grade school classes.
In the past, politicians tended to avoid
taking detailed stands on issues, fearing they
could later be held accountable for broken
promises. But now the ldp has been com­
pelled to release a manifesto of its own.
Among its pledges: to privatize the postal
service within four years and increase
tourism from today’s 5 million visitors per
year to 10 million by 2010. “This is without a
doubt the most policy-oriented election
campaign in postwar Japanese history" says
Ellis Krauss, professor of Japanese politics at
the University of California, San Diego.
Kan himself admits only to modest ex­
pectations for the upcoming election. He
says his goal is to take 63 seats, far short of a
majority but enough to embarrass the ldp
and wound Koizumi. Kan has already suc­
ceeded in convincing many Japanese citi­
zens and businesses that a strong second
party is essential to economic and political
rejuvenation. For example, a coalition of ex­
ecutives led by Kyocera’s Kazuo Inamori
recently took out newspaper ads spelling out
the benefits of a two-party system. “I want
Japan to be like the U.S., England. Taiwan or
South Korea, where we can have a change in
government every five or ten years,” Kan said
during a recent election rally. Considering
tire Japanese government has barely
changed in half a century, shaking things up
even once would be progress, -waft report-

by Ilya Garger, Toko Sdoguchi ant) Gregory
Turk/Tokyo

Ing

29

Stigmatized
Asia’s mentally
A Time si

By Hannah

posts,
Fujishiro
recalls:
the
elemen
tary-school
bullying
that
broke
one­
his mother failed to see the sign­
of his fingers, the obsession with comput­
er games,
the
increasing
hours
spent
gauge as the ebb of a high tide. Even
cloistered in his cluttered bedroom. These
were, it seemed, the normal teethings
A BOYimperceptible,
DISAPPEARS
AND
of a F
preteen
in postindustrial
Tokyo,
almost
as NOBODY
hard
to
notices,geeky
is he kid
really
gone? Hisaki
just another
wandering
awk­
withdrawal
been
wardlyFujishiro
through’s childhood.
Buthad
gradually
Fujishiro retreated completely.
The first tangible danger sign was an
obsessive-compulsive disorder that mani­
fested in Fujishiro when he entered junior
high. He would write a character, erase it
and rewrite it hundreds of times. Or he
would frenetically wash his textbooks, as if
the act of scrubbing them would somehow
cleanse his troubled mind. Despite his ec­
centricities, Fujishiro managed to enter
Tokyo’s Chuo University in the mid-1990s.
But soon he had withdrawn almost com­
pletely into the safety of his little room in
student housing. Most days he would go to
bed early and sleep through the morning,
only venturing outside for exams or to buy
a stash ofjunk food at the local 7-Eleven. He
had no friends, preferring to spend his time
with car magazines, which were stacked to
the ceiling. “My curtains were always
closed,” recalls Fujishiro, now 29. “I didn’t
feel like I had a place where I belonged.”
Fujishiro was hardly alone in his terri­
fying isolation. A generation of Japanese
youngsters has dropped out of society en­
tirely, unable to cope, it seems, with the rap­
id syncopation of life in Asia’s most
developed nation. The phenomenon has
been dubbed hikikomori, or social with­
drawal, by psychiatrist Tamaki Saito, who
estimates that one in every 40 Japanese
households has such a loner. That’s an as­
tounding 1 million social dropouts, most of
whom are male. For Fujishiro, a support
group at his university coaxed him out of his
room, and he has now started reintegrating
into society after eight years of seclusion.
Today, he runs an online outreach program
for other hikikomori slowly emerging from
their shells. So far the disease has been di­
agnosed only in Japan, except for a handful
of cases in South Korea. But these alienated
youngsters might be a harbinger of what’s
to come for the rest of Asia, emblems of a
continent hurtling so quickly into the future
that its citizens have few tools to cope with
the dizzying speeds.

HEALTH

I

Asia's mental health is, more than ever. | A who study found that as many as onein a perilous state. The Global Burden of ; quarter of all Indians currently suffer from
Disease study commissioned jointly by | some sort of mental illness. The region also
the World Bank, the World Health j boasts some of the highest suicide rates in
Organization
(who)
and
Harvard I the world. In China, for instance, suicide is
University predicts that by 2020 depression : the No. 1 cause of death •ntong those aged
will be the leading cause of disability in 1 18-34. according to the Beijing Suicide
Asia, measured by the number of years a Research and Prevention Center. At least
person lives with a debilitating health con- ; 250,000 Chinese have killen themselves
dition. Already, mental illnesses account for each year since the mid tu90x
five of the 10 leading causes of disability in I
Yet only a sinull ere .., ■ of these
Asia, including disorders such as depres- : troubled indi- !■ .h <
,eek help-or
sion and schizophrenia. That’s a bigger . even possess the opportunity to do so. In
health burden to the continent than c tncer. I Asia’s mo developed countries, ordered,

MEIffALIllJIlESSESATOOiiNTFaRWiBT
32

Y

Confucian cultures are loath to confront
mental illness. Its victims commonly en­
dure workplace discrimination, receive
scant family support and feel obliged to
hide their symptoms for fear of unsettling
the people around them. Du Yasong, a
psychiatrist at the Huashan Hospital in
Shanghai, estimates that as many as onethird of all people who go to general prac­
titioners in China are actually suffering
from mental-health problems expressed
psychosomatically through symptoms such
as headaches or insomnia. Yet 95% of those
with depression in China are untreated, ac­

Even when the severity of the prob­
lem is acknowledged, treatment is ham­
pered by a disastrous lack of resources.
This is especially true in Asia’s poorer
countries, where conditions for the men­
tally ill are often horrific. Many patients
are locked up in hospitals no better than
prisons. At the Panti Bina Laras Cipayung
mental-health center in east Jakarta, just
10 minutes off a modem expressway, the
air is thick with flies and the stench of fe­
ces. Originally intended for 200 patients,
the government-run facility is crammed
with 305 inmates. Most are naked, some
are shackled or chained to window bars.
Others, emaciated or showing oozing
lesions, curl up on the soiled floor of the
latrines. A doctor stops by the center only
once a week for two to three hours; he has
numerous other similar institutions to
attend to. Though the center’s number of
patients has nearly doubled since 1996, its
funding has not increased because of the
weak economy—less than $1 is spent on
each patient per day.
Indeed, most Asian nations spend trag­
ically small amounts on mental-health
care. In Cambodia, for instance, the coun­
try’s entire mental-health budget is far less
than what it would take to fund one
topflight mental hospital in the U.S. In
Pakistan, the government has all but given
up on caring for the mentally ill and private
donors have had to pick up the slack. More
than 1,000 mentally ill patients live
jammed together in the privately funded
Karachi commune called Edhi Village, run
by the prominent social worker Abdus
Sattar Edhi. Iron gates lock the inmates in,
some of whom, stark naked, slam their
heads against the walls of their dark cells.
“Our center is becoming a dumping
ground for people who consider mentally
ill people as the dirt of society,” says
Ghazanfar Kar im, the complex’s overbur­
dened supervisor.
The grim irony of Asia’s mental-health
cording to Ji Jianlin, a medical professor at
crisis is that it seems to be escalating even
Shanghai’s Fudan Universit)' who advises
while much of the region is getting richer.
the central government on mental-heakh
Some experts see the continent’s transfor­
policy. Japan has the highest number of
mation as a profoundly mixed blessing,
hospitalized, mentally ill patients in the
carrying with it dreams of cell phones and
world, yet psychiatry is still considered a
cable for all but also exacting an immense
crackpot discipline by many doctors there.
psychological toll on those who are strug­
“There is so much stigma when it comes to
gling to keep up with the manic pace of
mental health,” says Osamu Tajima, a lead­
change. Tradition and a sense of security
ing psychiatrist in Tokyo. “The perception
that it’s a personality weakness prevails not I have given way to upheaval and uncertain­
just among ‘normal’ people. I’ve heard * ty. A farmer bom of fanners, the father of
many doctors tell patients to stop com- i future farmers, would work from dawn; to
dusk like everyone else he knew. Because
plaining and tough it out.”
he entertained no hope of an altema*1-.
lifestyle, he didn’t agonize over >’ . Im.

10 LEADING CAUSES OF DISABILITY IN ASIA

today the characteristics of a modem exis­
tence—the potential to get ahead, the rat
race, even die crushing traffic—mean that
Asians feel more psychological pressure
than ever before. Psychiatrists in China,
for instance, estimate diat the rate of
anxiety disorders is higher now than it was
during the chaotic years of the Cultural
Revolution. This, then, is the dark side of
Asia’s economic miracle.

Money Disorder
BORN TO PEASANTS IN CHINA’S SOUTH

central province of Sichuan, Song L. had
wanted to go to Shanghai for as long as he
could remember. For him, China’s biggest

34

city was where dreams were made, where co-worker who accused him of shoddy
farmers morphed into millionaires, in workmanship cost him his job. “I couldn’t
truth, Shanghai is also where thousands of cat, I coiddn’t sleep and I felt dizzy all the
migrants lose their way in a pell-mell rush time,” Song recalls. “When I closed my
to riches. Fudan University professor Ji es­ eyes and tried to sleep, I had nightmares
timates that the incidence of mental ill­ where everything was spinning.’’
ness among China’s 100 million migrants
Song soon landed another job. but the
might be twice as high as in the rest of dizziness didn’t subside—a dangerous con­
Chinese society, due to the pressures of ex- dition for a man who was supposed to
isting on the margins both economically i make his living scrambling up the half­
and socially. But when Song, headed to > built skeletons of Shanghai's skyscrapers.
the big city in 2000 for const! action work, i He was quickly fired again. After 19 years
he knew only of Shanghai’s possibilities. I in a tightly knit village, he was now alone
At first, things went well for the then
in the citv No one could help me,” says
year-old, but an
altercation with a

HEALTH
Song. “All I had to keep me com­
pany were my thoughts, but my
thoughts were already bad.”
Details of events after his second
sacking are jumbled in Song’s
clouded mind: there was a des­
perate 16-hour, standing-roomonly train ride up to Beijing,
where he had heard of a job open­
ing; a curt foreman who wouldn’t
take Song because he didn’t look
sturdy enough; and—the final
blow—a robbery that stripped
him of most of his savings. After
that, Song wandered the streets
for days—or was it months? He
doesn’t remember. Everywhere
he went, the dizziness followed,
even to the jail where Song was
locked up for 30 days as a vagrant.
“Sometimes I would see other
people like me, alone, walking
the streets, and I wondered if
they had problems too, and want­
ed to make friends,” he says. “But
when I would go up to them, they
would turn away.”
One morning last spring,
Song decided he wanted to die.
He gathered his final pennies,
bought some pesticide and swal­
lowed it. When he woke up in a
hospital, a nurse derided him for
being cowardly and a drain on
medical resources. “The nurse
told me not to waste her time,”
says Song. “She said I was so stu­
pid that I couldn’t even kill myself
correctly.” Upon finding out that
Song had no money, she forced
him to check out of the hospital
the next day, even though his
throat still burned from the poi­
son. No one came to pick him up,
because no one knew he was
there. Even today, Song does not
know what to call the dizziness and bad
thoughts that continue to haunt him. He
has never heard of the word depression.
All he knows is that he is a failure. “I can­
not go home now,” he says. “I would be an
embarrassment to my parents and they
would lose face in our village.”
The vast majority of China’s burgeon­
ing mental-health patients suffer in si­
lence. The nation’s psychiatrists have seen
a remarkable upswing in the kinds of
. mental disease linked to fast-paced soci1 eties, particularly depression and anxiety
y disorders. But, says Professor Ji, “Outside

the big cities, most doctors have never
heard of things like anxiety disorders or
obsessive-compulsive disorders or even
depression. So most people are never
treated.” According to the Global Burden
of Disease survey, mental health consti­
tutes only 2% of China’s health budget, but
psychiatric disorders account for 20% of
the nation’s health burden. The situation
is particularly acute for serious mental dis­
eases. The same study asserts that al­
though 60% of schizophrenics are treated
in hospitals in the U.S., 90% of China’s
schizophrenics remain hidden at home
without access to medication or therapy.
“Many people in China just want to hide
the mentally ill person at home,” says Du
of Huashan Hospital. “They don’t want
outside people to see their crazy relative
and think they are crazy too.” Not that
most could afford the cost of treating such
major illnesses. Only about 15% of mainlanders currently have health insurance,
and in most places expensive antipsychot­
ic medicine is not subsidized.
The continuing stigma of mental dis­
ease in China—and, indeed, in much of
Asia—is so pervasive that even the care­
givers fall prey to misconceptions. Nurses
who worked with Canadian psychiatrist
Michael Phillips in the town of Shashi in
central China confided to him that they
didn’t tell their families the true nature of
their work, because it was widely believed
that mental illness is contagious. Such ig­
norance isn’t surprising given that many

nursing schools in China don’t even offer
courses on psychiatry—it only became a
formal discipline in mainland universities
in 1995. There are only 2,000 fully quali­
fied psychiatrists for a country of 1.3
billion people, compared with 10.5
psychiatrists per 100,000 in the U.S. The
majority of China’s psychiatrists never
chose their field: they were assigned to it
by their medical school.
Nevertheless, there are hopeful signs
that China is trying to combat its growing
mental-health scourge. The country re­
cently passed a law that tries to address the
basic rights of victims through education
and increased funding for mental-health
care. But as is often the case in China, the
law has been implemented fully only in
the big cities. In Shanghai, mental
hospitals are clean, safe and orderly. But
several Western-trained Chinese psychia­
trists in the metropolis wonder whether
overmedication is the cause of the eerily
quiet halls. Indeed, the country still com­
bats mental health by focusing on con­
trol—a fundamental difference with the
West, where psychiatric disorders are rec­
ognized as a medical condition that often
can be treated with therapy as well as
drugs. By contrast, in East Asia social de­
viance is an issue typically addressed by
the law. In China, it is the Ministry of
Public Security that oversees many of the
country’s mental-health policies, not the
Ministry of Health. Until recently the
security bureau was also in charge of the

INPATIENT MENTAL HOSPITAL THE MAHON HAS 0»

nation’s suicide statistics—and did not
make them public. “We are still not facing
up to our mental-health problem fully,”
says Du. “Unless all of us face up to the cri­
sis, things will not change enough. We will
be rich, but we will be sick.”

War Wounds
PERHAPS NO COUNTRY IN ASIA NEEDS MEN-

tal-health care more than Cambodia, a tor­
mented nation where the scars of the
1975-79 Khmer Rouge regime are still fresh
even a quarter-century later. According to
a survey conducted by the TYanscultural
Psychosocial Organization (tpo), an nco
with ties to the who, 75% of adult
Cambodians who lived through the Khmer
Rouge era suffer from either extreme stress
or post-traumatic stress disorder. Children
bom to this broken generation haven’t
fared much better. Aid workers estimate
that 40% of young Cambodians suffer from
stress disorders caused by growing up in a

Awareness of mental illness
is almost nonexistent.
With only 360 psychiatrists,
most of Pakistan's
estimated 1.5 million
mentally ill suffer in silence;
others are locked up in
asylums that resemble jails

chinaZZ1
Because of rapid economic
change and social
dislocation, anxiety
,
disorders are more common
now than during the Cultural
Revolution. China is the only
country with more female
schizophrenics and more
female suicides than male

Brain Damage
Mental illness is a major health threat across
Asia—one.that is-barely addressed-in countries
plagued by poverty, lacltufawareness and
inadequate health-care systems

Best known for its
depressed salarymen,
Japan has also b^m hit by
a rash of hikikon^^ases
of younger JapanSe
withdrawing from daily life.
Still, few other Asian
countries spend as much
on mental-health care

Domestic violence and
and suicide among wdjnen i
in this male-dominated
society. Depression is
little understood and
rarely diagnosed

1S R I

Psychiatrists estimate that
more than a fifth of Taiwan's
23 million populace might
be suffering various degrees
of mental illness. A recent
survey found that a
charter of fourth-grade
'
students in Taipei had
thought about suicide

L A N K A

Two decades of civil war
plus widespread political
violence have contributed to
a suicide rate that is more

W -■

than the global average

With some 1 million Thais
suffering from mental illness
and only 400 psychiatrists
in state-run health-care
institutions, Thai officials
recently admitted that they
are ill-equipped to deal with
this mounting “social crisis"

The worst job market in 17
years has seen depression
and anxiety disorders on
the rise, yet mental illness
remains deeply stigmatized.
In a 2002 survey, 60% of
surveyed Singaporeans
said those suffering
depression could snap out
of it if they wanted to

An estimated 75% of adults
who lived through the Khmer
Rouge era suffer from
extreme stress or posttraumatic stress disorder.
Poverty and ongoing political
instability have intensified
the problem

Job-reiated stress is
rampant in the workaholic
SAR. High unemployment
contributed to a record
suicide rate in 2002:
almost half of the 1,100
victims were jobless

I d . O N E S I A
In a country with a
disastiously low budget for
heair . care in general, the
mentally ill are all but ’
discarded. Almost no otlier
Asian nation offers less lar
with just two psychiatrists
per 1 million people

TIME Map by Dennis Wong: Text by Nick Papadopoulos

HEALTH

DONTDOiT
Japanese authorities
installed mirrors above
Tokyo’s Chuo line tracks
to dissuade people from
jumping to their deaths

MENTAL-HEALTH SPENDING

tattered social network. Yet in all of
Cambodia there is not a single inpatient
mental hospital. The nation of 11 million
has only 20 psychiatrists. Mental-health
funding didn’t even figure into the nation­
al budget until nine years ago. “The
mental-health situation is bad in many
countries,” says Muny Sothara, a psychia­
trist at an outpatient clinic at Preah Bat
Norodom Sihanouk Hospital in the capital,
Phnom Penh. “But I don’t know of any
place worse than Cambodia.”
Every day, hundreds of bedraggled cit­
izens line up from dawn at the Preah Bat
hospital’s mental-health clinic. Most have
traveled for hours by oxen-drawn cart or
packed bus to reach the venue. Chan
Muoy, a gaunt, 41-year-old snack vendor,
has not been able to sleep soundly for
years. Images of past torture creep into her
mind before slumber does. Now, though,
things have got even worse. Cambodia has
just gone through dangerously polarizing

parliamentary elections, and many fear 6
that violence might erupt once again. So J
nervous is Chan Muoy that she has lost her |
appetite and the tortured flashbacks are A
beginning to blur the line between reality j
and hallucination. While speaking to a psychiatric nurse, Chan Muoy’s eyes bulge 6
out and dart wildly as she recounts her f?
trauma; how her father, brother and sister |
were killed by the Khmer Rouge, the latter .?
for the crime of stealing a potato; how a ?
troop of machete-wielding child soldiers =
came to get her one night when she was 18 ?
and lashed her to a post in crucifixion pose
before inexplicably releasing her hours j,
later; how she wandered the streets for £
years after that, suffering rapes and beat- S
ings. “Everyone has gone through hard J
times here,” says Chan Muoy, who was di- °
agnosed with post-traumatic stress disor- S
der by the nurse. “I’m not unusual. We all 5
relive bad memories that make
us shake and cry.”

It’s in Your Mind
An estimated 450 million people worldwide—200 million in
Asia alone—suffer from a mental or behavioral illness.
The major disorders include:

3 MENTAL-HEALTH BEDS
(per 10,000
people, 2001)

PSYCHIATRISTS
(per 100,000
people, 2001)

SUlCiDE
Note: Global average i$ 14.5
•t
hr 2001

DEPRESSION
(Unipolar Depressive Disorder)
□ What it is: An illness
characterized by lackluster energy
and a general lack of interest in
life. Often recurrent or even chronic
■ Symptoms: Poor self-esteem;
a sense of sadness, dejection or
hopelessness without any clear
cause; suicidal thoughts
■ How it’s treated: With
antidepressant medications such
as Prozac and/or psychotherapy,
through which patients can learn
to overcome—among other
things—their negative self-image

MANIC DEPRESSION
(Bipolar Affective Disorder)
U What it is: Alternating bouts
of mania and depression
□ Symptoms: Feeling dramatical­
ly more active, confident and
sociable, then depressed or
intensely irritable; delusions
■ How it’s treated: Mainly
by mood-stabilizing drugs
such as lithium or
anticonvulsants such
as sodium valproate
(Depakote) and
carbamazepine (Tegretol)

SCHIZOPHRENIA
HWhat it is: A psychotic

disorder that severely alters
the way a person usually thinks
and behaves
□ Symptoms: Hallucinations;
delusions; confusion; withdrawal;
agitation; emotional numbness
H How it’s treated: Therapy,
along with antipsychotic drugs.
Success rate is fairly high—about
50% of patients can expect a full
and lasting recovery

POST-TRAUMATIC
STRESS DISORDER
: J What it is: A delayed psycholog­
ical reaction after witnessing or
experiencing a highly traumatic
event, like a war, natural disaster
or a violent physical assault
;■ Symptoms: Anxiety; flashbacks;
recurring nightmares; emotional
numbness; chest pain
. How it’s treated: Therapy, in
which patients talk through the

I

traumatic
event,
helping them
accept the incident and regain
control. New antidepressant drags
can also relieve symptoms
OBSESSIVECOMPULSIVE DISORDER
■ What it is: Repeated, unwanted
thoughts, or unnecessarily
repeating actions such as
washing hands or counting
■ Symptoms: Extreme anxiety
or depression. Obsessions and
compulsions
; How it's treated: Drugs are
effective, enabling some 75% of
patients to recover. Therapy helps
the sufferer confront the problem
and alter his or her behavior

PANIC DISORDERS
;; What it is: Sudden and
recurrent attacks of intense
fear or panic
'■ Symptoms: Palpitations;
chest pain; shortness of breath;
hyperventilation. Fear of being
alone or of dying
How it’s treated: Therapy
involves repeated exposure
to the patient's anxiety or
fear in order to change his
or her thinking patterns
and actions. Medication
might also be prescribed

HEALTH
The lack of mental-health infrastruc­
ture gives Cambodians few options to treat
their woes. Kum Kim, a 47-year-old from
Kampong Thom province, was diagnosed
as a schizophrenic by a health worker from
tpo earlier this year. She says evil spirits
poke sticks through the floor slats some­
times when she is resting in her wooden,
stilted house. She says she must hop
around her home to avoid the sharp jabs.
Desperate for help, she goes to a krukmai,
or witch doctor, named Son Mao. The krukmai’s house—the only one in the village
whose owners can afford a corrugated iron
roof—has been prepared for Kum Kim’s vis­
it. There is an offering of fruit on the floor
and whirls of incense meant to lure the vil­
lage spirits in for a chat. As pigs squeal
nearby, the krukmai touches Kum Kim’s

forehead and conjures up the spirits. They
tell her that Kum Kim has been possessed
by evil spirits. The reason? While Kum
Kim’s husband was commune chief many
years ago, he promised to build a road for
the village. Yet he never did. Now, the spir­
its are out to punish the whole family. "If
the spirits are angry, you have to soothe
them,” explains Son Mao. “Once they for­
give you, your craziness is gone.”
Despite the krukmai’s ministrations,
Kum Kim’s craziness has not disappeared.
The spirits in her house still jab her with
pointed sticks. Other families in the village
have begun shunning her family, worried
that the spirits might haunt them, too. In
Cambodia, though, the haunted seem too
numerous to avoid. “So many people are
sick in the head here,” says Chea Dany, a

nurse at the Preah Bat hospital. “But no
one wants to be with them. Our society is
divided into two: people who are sick, and
people who are O.K. and want to ignore the
sick. We cannot grow up as a country if we
are divided like this.”

Suicide Nation
THE PLACID POSTWAR HISTORY OF JAPAN

has little in common with the devastation
Cambodia has endured. In Japan the
streets are neat, and the government cof­
fers are full despite more than a decade of
economic stagnation. And yet there is a
melancholy in the country that has caused
more than 30,000 Japanese to commit sui­
cide every year since 1998, compared with
fewer than 15,000 a year in the IffiQs.
That’s the highest suicide rate in Easl^^a,

I

I

and one of the highest in the
world. In part, the malaise
that is gripping Japan seems
to be a product of a hyper­
commercial society where
so many feel the need to
compete—and so many fall
apart when they slip be­
hind. “We are very devel­
oped economically, but
Japanese are still intent on
getting ahead,” says Yukio
Saito, who runs a suicide­
prevention hot line head­
quartered in Tokyo. “That
pressure makes it very hard
to sustain a healthy life.”
J’o its credit, Japan
h^^ried to heal its peren­
nially depressed populace.
Already, the nation has the
most inpatient psychiatric
beds in the world, and
recent regulations have
raised standards at private
hospitals
where
care
was often substandard.
Government bureaucrats
have also loosened strin­
gent regulations on im­
ports of Prozac and other
badly needed medication.
There has been a push to
allocate more money for
outpatient care and com­
munity-based
education
through posters. And on
the Chuo train line, a wellknown final destination for
terminally depressed,
1 authorities have installed mirrors in
the train tunnel because studies show that
looking at one’s own reflection helps
check suicidal impulses.
Yet, for all its efforts, Japan’s suicide
statistics remain desperately high. The
phenomenon strikes most frequently
among middle-aged men, precisely the
same group most affected by Japan’s long
economic downturn and ensuing corpo­
rate restructuring. Among government
■ bureaucrats, for instance, suicide is the
second leading cause of death. “These
people, who were used to lifetime em­
ployment, have seen a huge shift in the
social system,” says Saito. “But they can’t
admit to themselves that they’re de­
pressed, and they don’t see any other
noble way out.” Even suicide itself is
a shamefol topic—ironic for a nation

A

weaned on tales of kamikaze pilots and
hara-kiri samurai. Saito remembers talk­
ing to a widow who couldn’t admit to her
family and friends that her husband had
committed suicide. “She told everyone he
died of a heart attack,” he recalls. “That
was the best way not to embarrass the
family and his company.”
In Japan, as in many other East Asian
nations, such avoidance of social humilia­
tion guides people’s lives. “In America,
people talk about going to the psychiatrist
like going to the grocery store,” says
Tokyo-based psychiatrist Osamu Tajima.
“But here, it’s still quite taboo.” Even after
several nationwide education campaigns,
mental illness is still widely seen in Japan
as largely incurable. And though mental­
health spending is higher in Japan than in
other Asian nations, the country’s legisla­

tion allows mental hospitals
to have up to 48 patients
per doctor, while regular
hospitals are limited to just
16 patients per physician.
In tackling Asia’s men­
tal-health crisis, perhaps
the most important task is
to make smart spending a
priority. Eight years ago,
South Korean government
officials tried just that,
shifting resources from fullfledged mental institutions
to community mental­
health centers. The majori­
ty of patients who visit
the 40 nationwide centers
suffer from severe mental
illnesses such as schizo­
phrenia and bipolar disor­
der. But with rehabilitation
courses and occupational
training, many can reinte­
grate into a society that
once
shunned
them.
“Helping patients realize
that they can manage their
illness without being insti­
tutionalized is my duty,”
says Hong Joo Eun, who
heads the Sungdong dis­
trict community mental­
health center in Seoul. Still,
Hong notes that staff at
such centers are paid half
of what those in general
hospitals earn, and the
turnover rate among center
workers is high.
The weight of battling on the front line
of Asia’s mental-health epidemic seems to
hang heavy on psychiatrist Tajima. Sitting
in his claustrophobic, fluorescent-fit con­
sulting room in Tokyo, he rubs his eyes
and cups his head in his hands. He has a
bad headache that simply will not go away.
Then, Tajima looks up and smiles a pecu­
liarly Japanese smile-half apology, half
wistfulness, without a hint of humor in it.
“You know, I fit the profile of a high-risk
suicide candidate in Japan,” he says,
massaging his temples. “I am a middleaged man who is overworked and can’t see
that situation changing anytime soon.”
And with that thought, Tajima bows his
head ever so politely and walks slowly out
of the room.
—With reporting

by Bis Hoc.'
Shanghai, Juliana Han/Seoul, Hanna KtelTo'.tyo
and Owais Tohid/Karachi

CONSIDER MENTALLY 111 PEOPLE ASTHEDIRTOFSOCIETW dKSSSSS

THE “BOSS": Mallya
at his home in Goa
By ARAV1ND ADIGA BANGALORE

Group, India’s largest liquor con­
glomerate, is getting a touchup.
The businessman and flamboyant
socialite-whose toys include race­
horses, sports cars and soccer teams
—lounges beside the swimming pool of his
seaside mansion in Goa while a makeup
artist brushes dye into his beard. The hues
perfectly match the copper tints already
gleaming in Mallya’s hair. Rifle-toting securi­
ty guards keep watch while his wonderstruck guests sip beer and wander about the
pleasure dome’s grounds.
His new highlights suitably dry, Mall­
ya—known inside his palace as “Boss”
—makes for the pool. Wearing red-tinted

V

downtrodden. Mallya is campaigning hard to
establish himself as a political force in his
home state of Karnataka. He’s already spent
time and money stumping for candidates
from an affiliated party in a recent election for
the state assembly, and he says he plans to
field candidates of his own in future elec­
tions. Emulating his heroes—American tycoon-tumed-politician Ross Perot and Ital­
ian media magnate-tumed-Prime Minister,
Silvio Berlusconi—Mallya is pushing hard to
break down the barrier traditionally separat­
ing business from politics in his country.
“This is the first time a major businessman
has officially entered politics in India,” says
P.S. Jayaramu, a professor of political science
at Bangalore University. For many, Mallya
could be the welcome harbinger of a new
kind of reformer ready to storm Indian poli-

Karnataka, below

LIFE OF
One of India’s richest men, liquor baron Vijay Mallya has houses, racehorses, fane;
sunglasses, diamond studs and thick gold
bracelets, he wades into the cool tur­
quoise water, lights up a cigarillo and bel­
lows out a limerick that begins, “There
once was young man from Madras, whose
balls were made of brass...”
After a sumptuous lunch served by uni­
formed waiters, the Boss heads for the Goa
airport, where his private Boeing 727 is
prepped for take-off. Is the destination Mo­
naco, Gstaad or any number of other interna­
tional playgrounds befitting the 47-year-old
glamour boy of Indian business? Hardly.
Vijay Mallya is hitting the campaign trail.
Already a member of India’s upper house
of Parliament, he’s also a new and improbable
leader of the Janata Party, a socialist outfit fa­
mous for its commitment to farmers and the

rrruption scandals inv i •

r urmined ws
HOI DO SUL
Former presidential
s cretary, high school chum
> d one of Roh’s closest
les who is known as
re eternal butler”
Arrested in October
gt allegedly receiving an
Segal donation of more
rcan $900,000 from the SK

conglomerate. He resigned,
b: it denies the charges

N BONG SUL
Pop's longtime friend,
business partner, and
former chauffeur
Brought in for
questioning in relation to
SK bribery case, but
<> .iies any wrongdoing.
■ . ■ secutors allege he
received about $195,000 of
1 .money they say the SK
• .up gave to Choi Do Sul

kang keum won

Textile businessman and
longtime Roh supporter
Barred from leaving
the country; his offices

were raided in an
investigation of alleged
illegal contributions to
Sun Bong Sul and to Roh’s
election camp last year. He
denies any wrongdoing
AHN HEE JUNG
Deputy head of a ruling
party think tank and
the first of Roh’s close
aides to be engulfed
In scandal
Was indicted in
May and is presently on
trial for diverting
funds from the
now defunct
Nara Merchant
Bank to the

cep'.ing bribes, and Ahn Hee Jung, a presidentjal aide who is currently on trial for al^Hly funneling $166,000 from a faltering
commercial bank into a private political re^Hh institute set up by Roh. Meanwhile,
sHStigators from the Supreme Public
^^Kcutors’ Office recently raided offices at
^^Kung Electro-Mechanics, part of the
Samsung Group, the country’s largest conglomerate; Hyundai Capital, the auto finance
arm|)f automaker Hyundai Motor; and LG
Shopping, an online shopping subsidiary
wfirea’s No. 2 conglomerate. Prosecutors
limit the
.campaign-financing
President
George
W. companies
^Seeking
evidence
that laws
the
leastcan
$125
million,
morefrom
thancamthat
money that
be raised
legally
eep
^Contributions
illegally
to political
pocket contributors
to ’$208,000
each. Says
H,
including Roh
s. A spokesman
for
alysts estimate that Roh’s campaign
Mung said the group was “not involved
IKthe election process illegally.” Tire othdeclined
spanies
Winning
officetois comment.
expensive—politnth Koreans have seen corruption
owns before. The country’s tradrhonbetween government and '^stry
m incestuous
of mutual back
ing
that is rifesystem
with under-the-table

I

think tank (which he
denies doing)
YANG GIL SEUNG
Former personal secretary
to the President, he
resigned in August
after he was videotaped
with a nightclub owner
under investigation for
tax evasion, pimping
and instigation of murder
Statu* Prosecutors
are investigating the
club owner, Lee Won Ho,
to determine whether
he tried to bribe Yang.
The National Assembly

passed an independent
counsel bill requesting
an investigation into
the Yang case, vetoed
by Roh last week. Both
Lee and Yang deny any
wrongdoing

Roh Kwan Kyu, budget and accounting
committee chairman for the Millennium
Democratic Party (under whose banner
Roh ran for the presidency): “It would be
extremely difficult to get elected within the
legal amount of money that is allowed.”
The current campaign-financing inves­
tigation is different from past scandals, how­
ever, because it is the first to take aim at a
sitting President. Touched off this year
when auditors looking into possible ac­
counting fraud at SICs trading arm, SK
Global, uncovered a multimillion-dollar po­
litical slush fund and bank accounts linked
to both Roh’s campaign and those of the
opposition Grand National Party (gnp), the
probe is unprecedented in scope and scale.
Political pundits are comparing the dragnet
to Italy’s “Clean Hands” crackdown of the
early 1990s, when reform-minded investi­
gators sent hundreds of businessmen, bu­
reaucrats and prominent politicians to jail.
gnp members are also under investigation:
gnp lawmaker Choi Don Woong has already
admitted to taking $8.3 million from SK.
If Roh is feeling the heat, he has only
himself to blame. In the past, the Blue House
could sway—or kill—sensitive investigations
by putting pressure on senior prosecutors, an­
alysts say. But Roh’s promise to clean up South
Korea’s dirty politics has given a freer hand
TIME, DECEMBER 8,2003

to law-enforcement officials. At a town-hallstyle meeting in March, Roh told a gathering
of prosecutors that “there will be no phone
calls” from the Blue House squashing investi­
gations. And the public is squarely behind a
cleanup drive. The lead prosecutor for the
campaign-financing investigation, Ahn Dae
Hee—known to be fearless in pursuing polit­
ically sensitive cases-even has an Internet
fan club. Under the circumstances, the Blue
House "can’t make the phone call even if they
want to,” says Kim Young Ho, an expert on
Korean politics at Inha University in Inchon.
Smelling blood, the gnp is working
overtime to keep investigators focused on
the administration. The centerpiece of the
strategy was the bill that Roh vetoed last
week, gnp chairman Choi Byung Yul imme­
diately protested the veto by launching a
hunger strike and ordering gnp lawmakers
to boycott the National Assembly. The gnp
wants to prove that after the elections, Roh’s
aides accepted illegal donations with the
President’s knowledge. "Ifwe find that Roh’s
involved, well impeach him,” says gnp law­
maker Hong Joon Pyo. Another gnp legisla­
tor, Won Hee Ryong, remarks, “To put it in
football terms, this is about who can stay on
offense until the April [legislative] elections.”
Offense, in this case, means looking less
guilty than the other guy. Roh strategists
figure the President will triumph because
the prosecutors’ probe will likely show the
gnp, whose candidate was the favorite to
win last fall’s presidential elections, took in
more illegal contributions. But incalculable
damage to Roh’s once clean image has al­
ready been done. One of the biggest embar­
rassments came in July when a national
television network ran a videotape of Roh’s
personal secretary Yang Gil Seung cavorting
in a sleazy nightclub south of Seoul with the
club’s owner—a man who has been under
investigation for tax evasion, pimping and
instigation of murder.
Yang resigned. But gnp members are
pushing hard to continue the investigation,
hoping to show that he accepted bribes from
the nightclub owner, Lee Won Ho, in ex­
change for political help with his legal trou­
bles. (Yang denied accepting bribes.) A key
unanswered question: Was Lee involved in
illegal fund raising for Roh’s campaign? Lee,
who is under arrest but denies any wrong­
doing, has testified that he helped round up
voters for Roh during primary elections. He
even got a certificate of appreciation from
Roh campaign officials, according to his
lawyer. With friends like these, Roh might
have all the enemies he needs to lose the
public’s trust—and his job.

-With reporting by
Jutiane Han and Kim YooseungJSeoul

41

THE PLAGUES
China is reeling from an
onslaught of communicable
diseases

ASIA
By HANNAH BEECH XINMIN
INMIN IS A VILLAGE ON THE VERGE OF

X

UNHAPPY

extinction. Nearly every resident of
this swampy, 1,000-strong hamlet in
the central Chinese province of Hu­
nan is infected by the parasitic worm Schis­
tosoma japonicum. It spreads through the
bloodstream, lays eggs in the liver and blad­
der, wriggles into the brain or embeds itself
in the spine. Renal failure and paralysis
may follow; death is painful and untimely.
That is the grim fate awaiting Xinmin vil­
lager Wang Zengkun. The 45-year-old rice
China’s public-health system
fanner first experienced the stomach
cramps and bloody diarrhea that signal
was told to make its way in
schistosomiasis three years ago. For a while,
the free market. Now, the
Wang fought the disease by spending his
life savings, some $4,830, on medication
underfunded network can’t
and operations that removed calcified egg
cope with re-emerging diseases
deposits and polyps from his body. But ear­
lier this year, when doctors told Wang that
he needed more surgery, he had to forgo it.
He had no money left. Wang is not alone.
Four of his neighbors who lived along the
fetid stream that oozes with microscopic
Schistosoma worms—the vectors are fresh­
water snails—have died in recent months.
“The government does not care about us
farmers, only about economic develop­
ment,” says Wang, cradling his distended
belly with gnarled hands. “There’s no one to
protect us anymore.”
Half a century ago, Chairman Mao Ze­
dong, himself a native of Hunan province,
declared war on the diseases ravaging Chi­
na’s countryside. One of his major battles
was against the fearsome Schistosoma
fluke, which infected 12 million Chinese in
1949 and, according to the World Health
Organization (who), is still the world’s sec­
ond-most-debilitating parasitic disease, I immunization drives for more profitable
after malaria. Employing troops of pesti­ ventures, like selling medicine and services
cide-wielding workers to eradicate snails at inflated prices. The social pitfalls of this
and offering free health checkups and med­ system were laid bare in a 1998 United
icine for all those living in the schistoso­ Nations-led survey, which found that almost
miasis-prone Yangtze River region, China half of those who had fallen below China’s
slashed the number of victims to 2.5 million poverty line did so only after suffering from
in 1975. By 1988, that had shrunk even fur­ a major disease. Today, just 15% of Chinese
ther, to 400,000. So proud was the Great have health insurance. The nation's recent
Helmsman that he wrote a poem, called sabs crisis served as another reality check;
“Sending Away the God of Plague,” com­ crucial weeks were lost because only a trick­
memorating the People’s Republic’s fight le of funding had gone to important but
money-losing services, such as outbreak
against a tiny worm.
But beginning in the 1980s, as China’s response and epidemiological research.
drive to capitalism kicked into higher gear, Despite the lessons learned during sars, the
Beijing extended market reforms to health nation’s 4,000 local centers for disease con­
care—with disastrous consequences. Local trol (ones)—key institutions on the front
health bureaus were stripped of their gov­ lines of China’s battle against disease—still
ernment funding and forced to become must privately finance more than 50% of
financially self sufficient. To survive, many their budgets, according to the who, where­
local clinics eschewed public-minded as similar institutions in most other nations

42

RETURNS

TIME, DECEMBER 8,2003

are government funded. Says Lisa Lee, a
medical officer with the who in Beijing;
“China’s health care focuses on how to max­
imize revenue, not coverage.”
Many infectious diseases that were near­
ly tamed during Mao’s era are now rebound­
ing or, at the very least, the battle against
them has stalled. Schistosomiasis is just one
example. Diseases like tuberculosis and hep­
atitis B, which could have been curbed by a
more public-minded health-care system, are
now spreading largely unchecked. China has
had a cheap vaccine for hepatitis B available
since 1985. But local health bureaus were
loath to offer it free of charge, because the
vaccine was a crucial source of income. As a
result, 10% of Chinese are now carriers ofthe
potentially fatal liver disease, compared with
less than 1% of Americans. Even today,
China is the only one of the 37 nations in the
who’s westem-Pacific region that requires

snail-fever prevention and to land year-end ?
bonuses. “The local government is lying’
about thenumberof people with the disease is
to make itself look good,” says Jiang, who has =
contracted schistosomiasis himself. “But IJ
am a member of the Communist Party, and I feel it is my duty to report the truth.”
2
Underreporting is also rampant among \
■ SCHISTOSOMIASIS
China’s 100 million-strong migrant popula- j
•4 Caused by parasitic worms
tion, which relies on health care from unli-1
carried by freshwater snails.
censed fly-by-night clinics that rarely report ?
Leads to liver, urinary, lung
epidemiological figures to local cdcs. The >
\
and nervous-system disorders
who estimates that one-third of China’s J
V
SUFFERERS: Nearly 1 million
measles and tuberculosis cases are never re- J
ANNUAL DEATHS: Unknown
ported, in part because they disproportion- g
■ TUBERCULOSIS
ately affect migrant workers. Without access I
A chronic bacterial infection spread
to proper health care, these itinerant com- s
through the air. Leading killer of
munities are virtual petri dishes of disease, g
adults worldwide
Recent outbreaks of measles and Japanese 2
SUFFERERS: 1.3 million new cases
encephalitis in the southern province ofg
annually on average
Guangdong—where sars first appeared— =
ANNUAL DEATHS: 250,000
are believed to have originated in this 3
so-called “floating population.” An |
■AIDS
► Caused by the Human
article this year in the U.S.-based ;
Immunodeficiency Virus
Bwi Journal of Infectious Diseases re(HIV), which can be passed ■
jflK j ported that the number of peofrom one person to another
; pie getting measles in migrant
through infected blood and
\iQB| ■y
populations was almost eight
sexual contact
times higher than in resident comSUFFERERS: 1-1.5 million
munities, largely because migrants
ANNUAL DEATHS: 30,000*
are either too broke or too disenfranchised
■ MEASLES
to get routine childhood immunizations.
▼ Highly contagious viral disease
Indeed, two of China’s poorer neighbors,
characterized by high fever, cough,
Vietnam and Mongolia, boast higher rates
runny nose and rash
of routine childhood immunization than
SUFFERERS: 58,341**
China, because of their greater public­
ANNUAL DEATHS: 7,000
health commitment. “All of the internation­
■Figure for 2001 ••figure lor 2002
al organizations in China have sent clear
Sources: World Health Organization; World Bank;
signals that the public-health system needs
Chinese Ministry of Health: Institute cl
Development Studies
to be reformed," says the who’s Lee. “But so
far, we’ve had almost no response.”
for sexually transmitted dis­
Back on Dongting Lake, a reed cutter
eases and osteopathy. Conse­
sumamed Song is resigned to the worms in­
quently, just as China was proudly
vading his body. During the colder months he
announcing that it had defeated snail fever,
serves as the plantation’s caretaker, living in a
the mollusk began returning. Last year, ac­
makeshift lean-to made of reeds. One of the
cording to statistics from the Ministry of
few ornaments inside his cramped quarters is
Health, 810,000 people contracted schisto­
a portrait of antidisease crusader Chairman
somiasis, more than double the number of
Mao. Outside, the ground is littered with the
cases in 1988. But experts caution that the
shells of snails whose worms infect workers
real figure is much higher and could spiral
in warmer weather Song’s drinking and
further upward upon completion of the
washing water, drawn from a brackish pit by
Three Gorges Reservoir, which might cause
his huL also teems with Schistosoma > orms
the nails to spread eastward. Jiang Changz.••■ii, a former official at China’s largest reed
agnosed with
j-.antation, which supplies pulp for paper,
•ays that almost every reed cutter working
be knov
the fields near Dongting Lake is now infect­
ed with schistosomiasis. He charges staff at
tire local health bureau with consistently un­
choici
derreporting the number of people infected
in recent years in order to meet quotas on
■ HEPATITIS B
Viral infection of the liver spread by
contact with infected blood or through
sexual contact. Can cause cirrhosis
and liver cancer
SUFFERERS: 130 million
ANNUAL DEATHS: 250,000

20 years of reform, the government
y focused on economic development,”
ys Song Wenzhi, a professor at the Peking
niversity Public Health Institute in Bei­
ng- “It neglected social issues, such as
ealth.” No surprise, then, that a 2000 who
tudy ranking the health systems of 191
member countries placed China 144th, beind Indonesia and Bangladesh.
Such chronic neglect has decimated vilrges like Xinmin. By the early 1990s, local
ealth workers no longer had a budget to
pray antisnail pesticide around Dongting
,ake, where Xinmin is located. Free schis-

s well. Now funding for local clinics once
roudly designated as “antisnail-fever bujaus” has also dried up; to make ends meet,
rany have opened up moneymaking clinics

TIME, DECEMBER 8,2003

YOUNG MINDS
Drugs have become increasingly popular for treating
kids with mood and behavior problems. But how will
that affect them in the long run?
1
etting by is hard enough in middle school, it’s harder

still when you’ve got other things on your mind—and Andrea
Okeson, 13, had plenty to distract her. There were the con­
stantdistractibility,
stomach pains
consider; there
was
nervousness,
the
theto
overwhelming
need
to the
be alone.
And, of
course, there was the business of repeatedly checking the locks on the
doors. All these things grew, inexplicably, to consume Andrea, until by
the time she was through with the eighth grade, she seemed pretty
much through with everything else too. “Andrea,” said a teacher to her
one day, “you look like death.”
The problem, though neither Andrea nor her teacher knew it, was
that her adolescent brain was being tossed by the neurochemical
storms of generalized anxiety, obsessive-compulsive disorder (ocd)

G

SWEET RELIEF: Okeson,
18, fought hard for her
peace of mind. A pair of
pills help her hold on to it

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6

I MENTAL HEALTH

Escape from Erwadi
The State government comes to the rescue of the mentally ill lodged in Erwadi's faith-healing homes,
but a lot more needs to be done for their complete cure and integration into society.
ASHA KRISHNAKUMAR

“unchaining” of all inmates. Inmates of
all “frith-healing” homes in the State are
to be examined by doctors, and those with
violent tendencies will be admitted to gov­
ernment hospitals. Those found to be nor­
mal are to be reunited with their families;
those abandoned will be given an old-age
pension and sent to homes for destitutes
run by the government or reputed non­
governmental organisations (NGOs).
All 15 mental homes at Erwadi were
closed on August 13 and their 571 inmates
taken under the government’s care. As
stipulated by the Mental Health Act, all
inmates were produced before the District
Magistrate, and a team led by Dr. M.

Soundararajan, Professor of Psychiatry at
the IMH, the Secretary to the State
Mental Health Authority and the coordi­
nator of the District Mental Health
Programme (DMHP), examined them.
Many are now being treated for schizo­
phrenia, cerebral palsy, epilepsy and men­
tal retardation. While 11 inmates, who
had a tendency to become violent, were
admitted to the Ramanathapuram
Government Hospital, 152 were sent to
the IMH and the rest back to their fami­
lies. According to Tamil Nadu Health
Minister S. Semmalai, all government
hospitals and primary health centres
(PHCs) in the State will provide medical
attention to the inmates who have
5 been sent home.
Twenty families have so far
received the ex gratia payment of
Rs.50,000 announced by the
State government to the families
of those who died in the Erwadi
fire. The Tamil Nadu Medical
Supplies Corporation has sanc­
tioned Rs.5 lakhs to procure
drugs for the 152 inmates admit­
ted to the IMH, while the gov­
ernment has sanctioned another
Rs. 15 lakhs to improve the basic
amenities at the IMH to accom­
modate the new patients.
Ramanathapuram Collector
S. Vijayakumar has set up a mon­
itoring committee comprising
the
Village
Administrative
Officer, the Revenue Inspector,
the Health Inspector and the
Erwadi village panchayat presi­
dent to prevent the setting up of
any more mental homes and to
ensure the monitoring of the
mentally ill who are staying with
their families within the premises
of the Erwadi dargah.

HANTI shuffles along, dragging her
feet, as if she were chained. She is not,
but she is yet to realise fully that she is free
of the fetters that bound her for eight
years. Shanti is one among the many men­
tally ill persons who were transferred to
nstitute of Mental Health (IMH) in
nnai following the closure of the
“mental homes" at Erwadi in Tamil
Nadu’s Ramanathapuram district. Such
has been the treatment meted out to her
at the mental home that even if she were
to be cured of her illness, the trauma of
having been chained, confined
and ill-treated is sure to haunt her.
Yet Shanti is lucky at least to
be alive, and she owes her “free­
dom” to the 28 chained inmates
of the Moideen Badusha Mental
Home who died on August 6
unable to escape the fire that
engulfed the thatched shed that
housed them (Frontline, August
31,2001).
The mental health care sys­
tem in Tamil Nadu has remained
in a deplorable state, with successiv^overnments failing to act on
^^Plrious reports and studies on
the plight of the mentally ill at the
various faith-healing centres. The
Erwadi tragedy, which caught the
attention of even the internation­
al media, has forced the Stare gov­
ernment to act. It has decided to
implement, after 14 years, certain
sections of the Mental Health
Act, 1987, and has announced
some immediate measures to deal
with the situation. However, this
will be done without addressing
the larger issues of treatment, care
and rehabilitation of the mental­
ly ill.
The measures announced on
August 10 to regulate mental
homes include the immediate clo­
sure of all such homes function­ Mentally III patients who were brought from Erwadi to
ing in thatched sheds and the the Institute of Mental Health In Chennai on August 16.

S

■

FRONTLINE. SEPTEMBER 14, 2001

HE belief that “holy water”
from the dargah and oil from
the lamp burning there have the
power to cure all illnesses, partic­
ularly mental disorders, had peo­
ple flocking to Erwadi in search of

T

27

and paramedics is also planned.
a cure. The situation worsened
Psychiatrists are to be posted at
with some people (mosdy those
ail district headquarters hospitals;
who themselves had come to
14 ofthe 25 such hospitals do not
Erwadi in search ofa cure) setting
have psychiatrists now.
up “homes” for the mentally ill.
The government has now
HILE something is hap­
made it mandatory for anyone
pening in the case of the
setting up such a home to obtain
mentally ill who have been taken
a licence as stipulated by the
under the government’s care,
Mental Health Act, 1987. It has
what of those sent back from the
also ordered the setting up of a
‘homes’ to their families? Raghu,
monitoring cell in every district,
an inmate of a home in Erwadi,
under the Collector, to make sure
has been sent back to hsi family
that the homes conform to
in Sikkil (Thanjavur district), but
norms.
his father, Madhavan, does not
On August 7, a five-judge
know what to do with him. With
Bench of the Supreme Court,
two daughters to be married,
comprising Chief Justice A.S.
Raghu is a burden. Madhavan
Anand, Justices K.T. Thomas,
neither has the money to have
^C. Lahoti, N. Santosh Hegde
Raghu treated in a private hospi­
S.N. Variava, suo motu
tal nor can he bear the stigma of
issued, on the basis of media
having a mentally ill person at
reports on the Erwadi tragedy,
home. The important question
notice to the State and Central
is: What happens to the millions
governments asking them to sub­
of such families with mentally ill
mit a “factual report” of the inci­
persons to take care of, and, more
dent. The Bench observed that
important, what happens to these
the issue “raises important ques­
patients?
tions concerning human rights of
The State government has
inmates of the mental asylum,
responded to the situation, but
who could not escape the blaze as
central to addressing the problem
they had been chained to poles or
beds”. The Centre has ordered A chained mentally ill person In the premises of the
is the care ofthe patients and their
integration with their families
the mapping of all faith-healing Erwadi dargah.
and society. According to Dr. C.
homes for the mentally ill in the
country. Union Health Minister C.P. ly, screen people for mental illness, and Ramasubramanian, a Madurai-based psy­
Thakur has ordered the implementation provide treatment for those who are ill. chiatrist and the founder-director of the
of the guidelines for maintaining mini­ Those needing hospitalisation would be M.S. Chellamuthu Trust and Research
Foundation, changing public apathy and
mum standards in mental homes. The referred to government hospitals.
Tamil Nadu, which implemented the attitude to the mentally ill is crucial to
Centre also plans to modernise all gov­
DMHP four years ago in Tiruchi (the addressing the problem. Given the enor­
ernment mental hospitals.
August 20, the Tamil Nadu gov- other three States that have the pro­ mity of the problem - considering that it
^Bent launched the DMHP in gramme are Assam, Andhra Pradesh and has cultural, religious, economic, social
Ramanathapuram and Madurai districts Rajasthan) as part of the NMHP, has and medical ramifications - the govern­
withan initial fond ofRs.27 lakh each (the made some success; 42,000 patients have ment cannot tackle it on its own. Only
total project cost is Rs. 1 crore). The pro­ come for review and 2,700 have been community-based rehabilitation, with
gramme consists of three components - identified as needing medical attention. the active participation and help ofNGOs
health care, training, and education and The thrust of the programme has been on and philanthropists, can offer a lasting
communication. According to Collector training village and community leaders, solution.
Medical help, vocational training,
Vijayakumar, the main objectives of the providing medical help at the taluk level,
programme are to provide basic mental and generating awareness, particularly in and rehabilitation with family and com­
health services on a sustained basis and to the rural areas. This success, according to munity support are essential for the com­
put in place a system for early detection Dr. Soundararajan, is largely because of plete treatment and cure of the mentally
the massive strides made in public educa- ill. For this, society at large should parand treatment.
The IMH in Chennai will be the tion, and this will be replicated in ticipate. This requires a mass awareness
nodal agency, and its Director the officer Ramanathapuram and Madurai districts. campaign - to break the myths and to
The State government is planning to educate people on the curability of the
in charge ofthe programme. The five-year
programme, sanctioned in 2000 by the build a 10-bed hospital exclusively for the diseases. Says Dr. Ramasubramanian: “It
Centre under theNational Mental Health mentally ill in every district. An awareness is imperative that the government initi­
Programme (NMHP), is to reach every programme that will cover the symptoms, ates the next step soon as it is an instance
taluk in the two districts. According to treatment and management of mental ill­ of now or never for the millions of the
Semmalai, a team of doctors and para­ nesses, is also to be initiated in every dis­ hapless mentally ill persons and their
medical staff will visit every taluk regular- trict. A training programme for doctors families.” ■

W

30

FRONTLINE. SEPTEMBER 14, 2001

MH- \

EMBARGOED 18 March, 2004, 1600 CET

Neuroscience of Psychoactive Substance Use
and Dependence report: Key conclusions
A complex disorder
•

Substance dependence is a complex disorder with biological mechanisms
affecting the brain and its capacity to control drug use. It is not only determined
by biological and genetic factors, but psychological, social, cultural and
environmental factors as well. Currently, there are no means of identifying those
who will become dependent - either before or after they start using drugs.

•

Dependence is not a failure of will or of strength of character, but a disorder
that could affect any human being. Dependence is a chronic and relapsing
disorder, often co-occurring with other physical and mental conditions. Given the
long term alterations in brain functioning, it is unknown to what extent it is
curable, but there are effective treatments.

•

Significant co-morbidity of substance dependence with mental disorders
indicates that these two conditions should not be treated as entirely separate
entities, and that treatment and research would be most effective if an integrated
approach were adopted. Treatment and prevention insights from mental illness
or substance use disorders can be used to inform treatment and prevention
strategies in the domain of the other.

•

Use of psychoactive substances might be expected because of their effects
on the brain as well as peer pressure and the social context of their use.
Experimentation does not necessarily lead to dependence, but the greater the
frequency and amount of substance used, the higher the risk of becoming
dependent.

•

Investments in neuroscience research must continue and expand to include
investments in social science, prevention, treatment and policy research. The
reduction in the burden from substance use and related disorders must rely on
evidence-based policies and programmes which are the result of research and its
application.

•

Harm to society is not only caused by individuals with substance
dependence^ Significant harm also comes from non-dependent individuals,
stemming from acute intoxication and overdoses, and from the form of
administration (e.g. through unsafe injections). There are, however, effective
public health policies and programmes which can be implemented and which will
lead to a significant reduction in the overall burden related to substance use.

Intervention and treatment
•

Effective treatments and interventions for substance dependence do exist,
and involve both pharmacological and behavioural interventions:

•

Treatment for substance dependence is not only aimed at stopping drug
use - it is a therapeutic process, which involves behaviour changes,
psychosocial interventions and, for opioid dependence, the use of substitute
psychotropic drugs. Dependence can be treated and managed cost-effectively,
saving lives, improving the health of affected individuals, their families and
reducing costs to society.

•

Treatment is more effective if supported by reintegration/rehabilitation the dynamics of substance dependence are such that treatment is less likely to
be effective if it does not also include efforts to encourage and facilitate
rehabilitation and social reintegration.

•

Harm reduction approaches are not synonymous with legalizing all drugs.
Harm reduction includes a range of interventions to reduce the risk to health of
substance dependent individuals, some of which have been proven to be
effective in reducing public health threats, and some of which have no evidence
of effectiveness. This includes access to clean needles and syringes and needle­
exchange programmes, among others.

•

Treatment must be accessible to all in need and the most cost-effective
treatments need to be provided by the health care sector. Effective interventions
exist, are not costly, and can be integrated into health systems, including primary
health care.

•

All psychoactive substances can be harmful to health, depending on how
they are taken, in which amounts and how frequently. The harm differs between
substances and the public health response to substance use should be
proportional to the health-related harm that they cause.

•

One of the main barriers to treatment and care of people with substance
dependence and related problems is the stigma and discrimination against them.
Regardless of the level of substance use and which substance an individual
takes, they have the right to health, education, work opportunities and
reintegration into society. We should empower individuals to recognize their
problem and seek help, and provide full access to care and treatment.

WHO Contacts: Dr Isidore Obot, Mental Health and Substance Abuse, +41-22-791-1269 (o), +41-76415-7014(m); David Porter, Media Officer, +41-22-791-3774 (o) +41-79-477-1740 (m)

2

WHO PRESS RELEASE
March 18,2004
Brasilia/Geneva
EMBARGOED Thursday, 18 March, 2004 1600 CET
SUBSTANCE DEPENDENCE TREATABLE, SAYS NEUROSCIENCE
EXPERT REPORT

Psychosocial, environmental, biological and
genetic factors all play significant roles in dependence,
says new report published by WHO

The World Health Organization (WHO) today launched Neuroscience of
Psychoactive Substance Use and Dependence, an authoritative report summarizing
the latest scientific knowledge on the role of the brain in substance dependence. The
report*, released in Brasilia, Brazil, is the first of its kind produced by WHO, and
cites an explosion of advances in neuroscience to conclude that substance dependence
is as much a disorder of the brain as any other neurological or psychiatric disorder.
Substance dependence is multifactorial, determined by biological and genetic factors,
in which heritable traits can play a strong part, as well as psychosocial, cultural and
environmental factors, says the report. It has been known for a long time that the brain
contains dozens of different types of receptors and chemical messengers or
neurotransmitters. The report summarizes new knowledge on how psychoactive
substances are able to mimic the effects of the naturally occurring or endogenous
neurotransmitters, and interfere with normal brain functioning by altering the storage,
release and removal of neurotransmitters.
The report discusses new developments in neuroscience research with respect to
craving, compulsive use, tolerance and the concept of dependence. The report shows
that psychoactive substances have different ways of acting on the brain, though they
share similarities in the way they affect important regions of the brain involved in
motivation and emotions. The report discusses how genes interact with environmental
factors to sustain psychoactive substance-using behaviours. This knowledge is the
basis of novel diagnostic tools and behavioural and pharmacological treatments.

The report urges increasing awareness of the complex nature of these problems and
the biological processes underlying drug dependence. And it supports effective
policies, prevention and treatment approaches and the development of interventions
that do not stigmatize patients, are community based and cost-effective.
“The health and social problems associated with use of and dependence on tobacco,
alcohol and illicit substances require greater attention by the public health community
and appropriate policy responses are needed to address these problems in different
societies,” says WHO Director-General Dr Jong-wook LEE. “Many gaps remain to be

filled, but this important report shows that we already know a great deal about the
nature of these problems.”
United Nations Office on Drugs and Crime (UNODC) data estimates about 205
million people make use of one type of illicit substance or another. The most common
is cannabis, followed by amphetamines, cocaine and the opioids. Illicit substance use
is more prevalent among males than females, much more so than cigarette smoking
and alcohol consumption. Substance use is also more prevalent among young people
than in older age groups. UNODC data shows that 2.5% of the total global population
and 3.5% of people 15 years and above had used cannabis at least once in one year
between 1998 and 2001.
“Substance dependence is a chronic and often relapsing disorder, often co-occurring
with other physical and mental conditions,” said Dr Catherine Le Gales-Camus,
WHO’s Assistant-Director General, Noncommunicable Diseases and Mental Health.
“While we still do not know to what extent it is curable - given the long-term
alterations in brain functioning that result from substance abuse - we do know that
recovery from dependence is possible through a number of effective interventions.”

The Global Burden of Disease (GBD) from the use of all psychoactive substances,
including alcohol and tobacco, is substantial: 8.9% in terms of DALYs (Disability
Adjusted Life Years). However, GBD findings re-emphasize that the main global
health burden is due to licit rather than illicit substances. Among the 10 leading risk
factors in terms of avoidable disease burden cited in The World Health Report 2002,
tobacco was fourth and alcohol fifth for 2000, and remains high on the list in the 2010
and 2020 projections. Tobacco and alcohol contributed 4.1% and 4.0%, respectively,
to the burden of ill health in 2000, while illicit substances contributed 0.8%. The
burdens attributable to tobacco and alcohol are particularly acute among males in the
developed countries (mainly Europe and North America). Measures to reduce the
harm from tobacco, alcohol and other psychoactive substances are thus an important
part of the public health response, says WHO.
“The explosive growth in knowledge in neuroscience in recent decades has
contributed new insights into why many people use psychoactive substances even
though it causes them harm,” says Dr Benedetto Saraceno, Director of WHO’s
Department of Mental Health and Substance Abuse. “The need for this report comes
from these advances, which have shown that psychoactive substances, regardless of
their legal status, share similar mechanisms of action in the brain, can be harmful to
health and can lead to dependence. The public health impact is enormous and requires
a comprehensive approach to policy and programme development.”

* The Neuroscience of psychoactive substance use and dependence report is a
product of three years work involving the contributions ofmany experts from around
the world. The project began in 2000 with a consultation in New Orleans, USA,
during the Congress on Neuroscience. A meeting convened by WHO was attended by
representatives of international societies and selected experts in the field. Twenty-five
reviews were commissioned, completed and submitted and these formed the basis of
the final report. Meetings were held in Geneva and Mexico to discuss the outline of
the report and the background papers.
2

Contacts:

WHO:
Dr Catherine Le Gales-Camus, Assistant-Director General, Noncommunicable
Diseases and Mental Health, +41-22-791-2999 (o); Dr Isidore Obot, Mental Health
and Substance Abuse, +41-22-791-1269 (o); +41-76-415-7014 (m); David Porter,
Media Officer, +41-22-791-3774 (o) +41-79-477-1740 (m); Dr Maristela G.
Monteiro. Regional Advisor on Alcohol and Substance Abuse, Pan American Health
Organization, Washington, USA. +1 202 974 3108

External Experts:

Australia
Dr Wayne Hall, Professional Research Fellow, Institute for Molecular Bioscience
University of Queensland, Australia. Tel.: 07 3346 9176 (o), 0421-059-009 (m), Fax
+ 07 3365 7241,e-mail: w.hall@imb.uq.edu.au
Professor Richard Mattick. Executive Director, National Drug and Alcohol Research
Centre University of New South Wales, Sydney, Australia. Phone: 02-9385-0333 (o),
0419-409-010 (m), E-mail: r.mattick@unsw.edu.au
Brazil
Professor E.A. Carlini, CEBRID, Depto de Psicobiologia, Universidade Federal de
Sao Paulo Centro Brasileiro de Informapoes Sobre Drogas Psicotropicas, Sao Paulo,
Brazil, Tel: 11 5539 0155; Fax: 11 5084 2793 E-mail: cebrid@psicobio.epm.br

Dr Flavio Pechansky, Associate Professor of Psychiatry, Director, Center for Drug
and Alcohol Research, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
Phone: (55-51) 3330-5813, Fax: (55-51) 3332-4240, E-mail: cpad.celg@terra.com.br
Canada
Dr Franco Vaccarino. Centre for Addiction and Mental Health, Toronto, Canada, Tel:
1 416 979-4675, Fax: 1 416 979-4695, E-mail: franco vaccarino@camh.net

China
Professor Wei HAO, Professor of Psychiatry, Director of WHO Collaborating Center
for Drug Abuse and Health, Co-director of Mental Health Institute, Central South
University (Hunan Medical University), Changsha, China. Tel: +86-731-5550294,
Fax: +86-731-5360160, email: weihao57@china.com, or bmwhomhi@public.cs.hn.cn

Russia
Dr Edwin Zvartau, Professor of Pharmacology and Research Director, Pavlov
Medical University. Russia. Tel: +7-812-238-7023 (o); +8-921-6532938 (m); Fax:
+7-812-346-3414, E-mail: zvartau@spmu.rssi.ru

3

South Africa
Dr Charles D.H. Parry, Alcohol & Drug Research Group, Medical Research Council
of South Africa, Tygerberg (Cape Town), South Africa. Tel: + 27 21 9380419 (o),
+2782 4595964(m), Fax: + 27 21 9380342, Email: cparry@mrc.ac.za

Spain
Dr Rafael Maldonado, Laboratory of Neuropharmacology, Health and Life Sciences
School, University of Pompeu Fapra, Barcelona, Spain.. Tel. + 34 93 542 2845; Fax +
34 93 542 2802, E-mail: rafael.maldonado@cexs.upf.es
Sweden
Dr Robin Room, Centre for Social Research on Alcohol and Drugs, Stockholm
University, Stockholm, Sweden. Tel: 46 86 747 047; Fax: 46 86 747 686, E-mail:
robin.room@sorad.su.se

Switzerland
Professor Ambros Uchtenhagen, Institut fur Suchtforschung-Addiction Research
Institute, Zurich, Switzerland. Tel: +41 1 273 4024141 1 81166; Fax: +41 1 273 4064,
Email: uchtenha@isf.unizh.ch
UK
Dr Michael Farrell, London, Tel: 44 171 740 5701 or 44 207 701 8454, Fax: 44 171
701 8454 or 44 171 740 5729, E-mail: m.farrell@iop.kcl.ac.uk

USA
Dr Athina Markou. Department of Neuropharmacology, CVN-7, The Scripps
Research Institute, University of California, USA. Tel: 858 784 7244, Fax: 858 784
7405, E-mail: amarkou@scripps.edu

4

EMBARGOED 18 March, 2004, 1600 CET

Neuroscience of Psychoactive Substance Use and Dependence report
QUESTIONS + ANSWERS

1. Is substance dependence a disease?

Before answering this question it is important to clarify certain terms. Psychoactive
substance use refers to any form of self-administration of any substance that has the
potential of altering the way we behave or think. It is a broad term which is
sometimes used to encompass all levels of drug involvement from occasional use to
prolonged involvement with the substance. The terms substance abuse and substance
dependence are technical terms with specific meanings. Abuse refers to a maladaptive
pattern often involving continued use despite social, occupational, psychological or
physical problems associated with the use of the substance. Dependence refers to a
cluster of physiological, behavioural and cognitive phenomena and implies the need
for repeated use of the drug to feel good or avoid feeling bad.
Substance dependence is classified in the tenth edition of the International
Classification of Diseases (ICD-10) among other mental and behavioural disorders,
such as depression and schizophrenia, and those who are substance dependent should
enjoy the same rights to treatment as any other individuals. Some people do not like
the term disease because it seems too biological and may give the impression that
dependence is not related to social factors, so we often use the term disorder in this
particular case as a synonym for disease, and acknowledge that environmental factors
do play a role in its etiology. It should, however, not be forgotten that most
psychoactive substance use (especially alcohol consumption) is not associated with
dependence.

2. Is smoking a disease too?
Tobacco dependence is a disease and the majority of people who smoke are
dependent on nicotine from tobacco. But strictly speaking, smoking is a way of using
tobacco and not a disease.

3.

What does the report say about harm reduction interventions?

In the context of substance use, the term harm reduction describes policies and
programmes that focus on reducing the social and health consequences resulting from
the use of substances, without necessarily eliminating the underlying behaviour of
substance use.

WHO supports harm reduction strategies proven to be effective, e.g. substitution
therapies, needle exchange programmes, condom distribution, drunk driving laws and
seat belt use. But harm reduction has been a term sometimes used to mean legalisation
of all psychoactive substances, and a whole range of unproven strategies. We need to
be carefill about what we are talking about and to recommend what is evidence-based.

4.

What can we learn from the report about the medical use of cannabis?

DeZta-9-tetrahydrocannabinol (THC), the active principle in cannabis, is potentially
effective for some health conditions (e.g. as anti-emetic agent in cancer
chemotherapy) and medications containing THC are available for treating them. Some
patients find relief of their symptoms through smoking cannabis, although it is
difficult to control the dose. There is limited evidence of the effectiveness of smoking
cannabis, given the difficulties of conducting controlled trials of this nature. Delivery
of THC through cannabis smoking presents problems, as it carries the negative effects
of the elements which are present in the cigarette.
5. Are methadone and other substitution drugs harmful to the brain? If so, why
are they prescribed?

Despite the fact that substitution drugs do act on the brain, as other psychotropic
medicines, they actually have the capacity to normalise some disrupted brain
functions. Being involved in substitution maintenance therapy, patients actually can
have normal lives, take a job, drive a car, etc, while avoiding withdrawal symptoms.
Substitution medicines are prescribed for the treatment of heroin dependence to
improve health and social functioning of the patients.
6- What is the WHO position on legalization of cannabis?
WHO is mostly concerned with the negative health consequences of cannabis use and
how they can be prevented and treated.

7. Is WHO recommending vaccines against nicotine and cocaine? Who should be
vaccinated?

WHO does not have sufficient scientific evidence about their efficacy to have a
position on their usefulness. Vaccines or immunotherapies are in their early stages of
development and there are many issues to be resolved. They appear to help in the
recovery from dependence, but their potential use to prevent cocaine use among non­
users (e.g. children, adolescents) has not been investigated and it would likely raise
very important ethical questions that would have to be addressed first.
8. Where should countries invest their resources to reduce the burden of drug
use?

There is a great need to invest in a comprehensive public health response, which
includes epidemiology, prevention, treatment and reintegration/rehabilitation. Each of
the four pillars is important and the resources should be distributed according to the
effectiveness of available interventions.

9.
Are the public health messages of the report compatible with law enforcement
and control over the supply of drugs? Is WHO in favour of revising the UN
Conventions?

Investment in public health measures to reduce the burden of substance use can be
compatible with and supplement law enforcement and control. WHO supports the UN
Conventions and any potential revision of the UN Conventions is beyond the mandate
of WHO.
10.

Why is khat not discussed in the report? Why is khat not controlled?

Khat is a mild stimulant which has not been well studied, although its use is
widespread in Africa. There are reports of a variety of medical problems, including
cancers and mental disorders. It is less well understood to what extent dependence
occurs and whether withdrawal syndromes exist as a result of prolonged use. A
comprehensive review of all its consequences to health is needed in order to make
appropriate recommendations about the need for its control under the UN
Conventions.
11.

What will WHO do in relation to alcohol?

The WHO Executive Board meeting in January 2004 accepted a draft resolution for
World Health Assembly 2004, which urges Member States to give attention to the
prevention of alcohol-related harm and promotion of strategies to reduce the adverse
physical, mental and social consequences of alcohol, especially among young people
and pregnant women, in the workplace and when driving.

12. What does WHO recommend that countries do to reduce alcohol problems?

According to their levels of per capita consumption and patterns of alcohol
consumption, a mix of effective policies can be implemented, ranging from increases
in price/taxation; regulation of the physical availability of alcohol, including increase
in minimum legal purchase age; drinking-driving countermeasures; treatment and
early interventions. Depending on the social, political, economic and cultural
environment, other strategies such as prevention programmes, community projects
and harm reduction efforts, can also play an important role.

13.

What is WHO expecting from launching of this report?

To raise awareness of public health officers, Ministries of Health, and relevant policy
makers, to the need to include the health sector in policy making in these areas. There
are effective policies and interventions which work and can decrease the health
burden of substance abuse, but there is an urgent need to invest human and financial
resources to prevention, policy implementation and treatment.

14.

What are the major implications of this report?

Substance dependence is a multifactorial disorder, which has several implications for
prevention and treatment. First, that all substances need to be considered in the
framework of a comprehensive public health approach, regardless of their status.
Second, ,that all levels of use should be addressed: experimentation, harmful use, and
dependence. Third, that policies and programmes should be tailored to the needs of
the population, the threats to health and safety, and adapted to the culture and values
of the particular society. All countries can do better in relation to substance abuse
problems, both developed and developing ones.

15. What should be the role of the public health sector in managing psychoactive
substance use problems?
Substance abuse and dependence are public health problems and they contribute
significantly to the global burden of disease. The public health sector, including the
World Health Organization, is concerned about this and should work towards
reducing the burden. Adopting a public health approach, which goes beyond issues of
security and control, allows us to widen the range of options and possible
interventions. The public health approach involves the use of a variety of approaches
and strategies involving the participation of stakeholders from all relevant sectors. As
the leading global public health organization, WHO is active in providing the
evidence necessary for the development and implementation of prevention and
treatment strategies, and policies.
16. What is the role of prevention in reducing the burden attributable to
substance abuse and dependence?
It is common knowledge that prevention is better than cure. This is even more true
with substance use problems, where cure is difficult, although treatment can be
effective. We have learned a lot over the years about how we can make prevention
more effective than it is at present. What we have learned includes the following: that
teaching young people to say ‘no’ to drugs in the classroom is not enough, though it is
good practice; that prevention programmes should be broadly based enough to include
skills to resist drugs; that the community (parents, churches, etc.) as a whole should
be involved; and that prevention programmes should be part of an overall strategy of
changing societal attitudes towards the use of psychoactive substances.
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