Mental Diseases

What to remember

• Mental health is a state of well-being in which a person realises their abilities, copes with normal stress, works productively and contributes to the community; it is more than the absence of mental illness.
• Mental disorders are grouped into neurotic disorders (insight kept, reality contact kept), psychotic disorders (insight lost, reality contact lost), mood disorders, dementia, substance use disorders and intellectual disability.
• The Mental Healthcare Act, 2017 gives every person a right to mental health care; the health worker's work is to identify, refer, support and follow up patients and to reduce stigma.

1. Mental health and its determinants

The World Health Organization describes health as physical, mental and social well-being. A mentally healthy person has self-acceptance, a sense of reality, good relationships, the ability to meet life's demands, and emotional balance.

Factors that affect mental health:

• Biological: heredity, brain chemistry, infection, injury, nutrition.
• Psychological: personality, childhood experience, coping style.
• Social: poverty, family conflict, violence, migration, unemployment, loss of a loved one.

Stress is the body and mind's response to a demand. Coping can be healthy (talking, exercise, problem solving) or unhealthy (alcohol, withdrawal).

Common defence mechanisms (unconscious ways to reduce anxiety):

2. Classification of common mental disorders

Neurosis versus psychosis

3. Key disorders

Schizophrenia. Positive symptoms: hallucinations (false perception, such as hearing voices), delusions (fixed false belief, such as being followed), disorganised speech. Negative symptoms: flat emotion, poor speech, social withdrawal. It often begins in young adulthood. Treatment: antipsychotic drugs and rehabilitation.

Depression. Low mood, loss of interest, tiredness, sleep and appetite change, guilt, hopelessness and thoughts of self-harm for at least two weeks. Treatment: antidepressants, psychotherapy and support. Postpartum depression can follow childbirth, so the ANM should watch new mothers.

Bipolar disorder. Mood swings between mania (elation, over-activity, less need for sleep, grand ideas) and depression. Lithium is a mood stabiliser.

Anxiety disorders. Generalised anxiety: constant worry. Panic disorder: sudden attacks with palpitations and fear of dying. Phobia: irrational fear of an object or situation. OCD: recurrent unwanted thoughts (obsessions) and repeated acts (compulsions) such as hand washing.

Dementia. Gradual loss of memory and thinking in old age; Alzheimer's disease is the commonest cause. Delirium is a sudden confusion with fluctuating awareness, often from fever, infection or drugs, and is usually reversible.

Epilepsy. A brain disorder with recurrent seizures. It is not a mental illness and not contagious. During a seizure: protect the head, turn the person to the side, do not put anything in the mouth.

Substance abuse. Alcohol dependence causes liver damage, accidents and family problems. Withdrawal may cause tremor, sweating and delirium tremens. Tobacco and drugs also cause dependence. Treatment: detoxification, counselling, and rehabilitation. Prevention: health education, regulating sale, and life skills.

Intellectual disability (earlier called mental retardation). Low intelligence with poor adaptive behaviour, beginning before 18 years.

Intelligence quotient: IQ = (mental age ÷ chronological age) × 100. Worked example: a child of 10 years with mental age 7 years has IQ = 7 ÷ 10 × 100 = 70. A child of 8 years with mental age 6 years has IQ = 75. Average IQ is about 90-109. Causes include Down syndrome, iodine deficiency, birth injury and infections in pregnancy.

Childhood problems. Autism: poor social communication and repeated behaviour. ADHD: inattention, over-activity and impulsiveness. Enuresis: bedwetting after the usual age. Conduct disorder: repeated antisocial acts.

Suicide. A major cause of death in young adults. Warning signs: talk of death, giving away belongings, sudden calm after depression, previous attempts. Do not leave the person alone, listen without judging, remove means of harm, and refer urgently.

4. Treatment methods

Medicine must be taken regularly and for long periods. Stopping on one's own causes relapse.

5. Laws and programmes

• Mental Health Act, 1987 was replaced by the Mental Healthcare Act, 2017, which gives a right to access mental health care, to confidentiality and to dignity; it allows an advance directive and a nominated representative, and a person who attempts suicide is presumed to be under severe stress and is not to be punished.
• National Mental Health Programme started in 1982; the District Mental Health Programme was added in 1996 to bring care to the district level and train primary care staff.
• Rights of Persons with Disabilities Act, 2016 covers intellectual disability and mental illness.
• Tele-MANAS is a national tele-mental health helpline launched in 2022.
• Rashtriya Kishor Swasthya Karyakram includes adolescent mental health.

6. Role of the health worker

• Identify early signs in the community: sleeplessness, withdrawal, talking to oneself, sudden change of behaviour.
• Refer to the medical officer or the district mental health team; do not rely on faith healers alone.
• Ensure medicine adherence and follow up after hospital discharge.
• Give family counselling and fight stigma; explain that mental illness is treatable and not caused by curses.
• Promote mental health: stress control, school and women's groups, safe drinking water and nutrition (iodine), and safe pregnancy care to prevent disability.
• Prevention levels: primary (mental health promotion, life skills), secondary (early diagnosis and treatment), tertiary (rehabilitation).

7. Counselling and community mental health

Good counselling skills help the health worker. Listen without judging, keep the talk private, use simple words, show care and give hope. Ask open questions such as "How have you been sleeping?" Do not argue with a delusion; instead, accept that the person feels afraid and encourage treatment. A patient discharged from hospital needs family support, regular medicine, a daily routine and a chance to work. Community programmes include school mental health education, support groups for families, de-addiction camps and old-age care. Early childhood stimulation, good nutrition and prevention of birth injury lower the risk of developmental problems. Anganwadi and school staff can notice children who are slow to learn or very restless, and refer them for assessment.

Exam traps

• In neurosis insight is kept; in psychosis insight is lost.
• Hallucination is a false perception; delusion is a false belief.
• Obsession is a thought; compulsion is an act.
• Mania is elation; depression is low mood; bipolar disorder has both.
• Dementia is slow and permanent; delirium is sudden and often reversible.
• Mild intellectual disability has IQ 50-69; profound is below 20.
• Epilepsy is a neurological disorder, not a mental disease.
• NMHP began in 1982; DMHP in 1996; Mental Healthcare Act in 2017.

One-liners

• Lithium is used in bipolar disorder.
• Chlorpromazine is an antipsychotic drug.
• IQ = mental age ÷ chronological age × 100.
• Hearing voices that are not there is an auditory hallucination.
• Alzheimer's disease is the commonest cause of dementia.
• Delirium tremens can follow alcohol withdrawal.
• ECT is given under anaesthesia.
• Projection means blaming others for one's own faults.
• Sublimation turns an urge into a useful activity.
• The District Mental Health Programme started in 1996.
• Tele-MANAS is a mental health helpline.
• Down syndrome is a common cause of intellectual disability.

Practice questions

1. In psychosis, compared with neurosis, the patient typically

   1. keeps insight and reality contact
   2. never needs hospital care
   3. loses insight and contact with reality
   4. shows only mild worry
   Answer

   C. loses insight and contact with reality

   Loss of insight and reality contact marks psychosis.

2. A false perception without any external stimulus, such as hearing voices, is a

   1. hallucination
   2. compulsion
   3. delusion
   4. obsession
   Answer

   A. hallucination

   Hallucination is a false perception.

3. A fixed false belief that cannot be corrected by reasoning is a

   1. illusion
   2. hallucination
   3. phobia
   4. delusion
   Answer

   D. delusion

   This is the definition of delusion.

4. Recurrent unwanted thoughts are called

   1. obsessions
   2. delusions
   3. compulsions
   4. illusions
   Answer

   A. obsessions

   Obsessions are thoughts; compulsions are repeated acts.

5. Repeated acts such as hand washing performed to reduce anxiety are

   1. delusions
   2. hallucinations
   3. compulsions
   4. obsessions
   Answer

   C. compulsions

   Compulsions are acts in OCD.

6. Mood swings between elation and depression are typical of

   1. bipolar disorder
   2. phobia
   3. dementia
   4. schizophrenia
   Answer

   A. bipolar disorder

   Bipolar disorder has manic and depressive episodes.

7. The drug commonly used as a mood stabiliser in bipolar disorder is

   1. chlorpromazine
   2. lithium
   3. haloperidol
   4. diazepam
   Answer

   B. lithium

   Lithium is the classic mood stabiliser.

8. Chlorpromazine belongs to the group of

   1. anxiolytics
   2. antidepressants
   3. mood stabilisers
   4. antipsychotic drugs
   Answer

   D. antipsychotic drugs

   It is an antipsychotic.

9. Fluoxetine is a

   1. anticonvulsant used in epilepsy only
   2. antipsychotic
   3. selective serotonin reuptake inhibitor used in depression
   4. drug for alcohol withdrawal
   Answer

   C. selective serotonin reuptake inhibitor used in depression

   Fluoxetine is an SSRI antidepressant.

10. The commonest cause of dementia in old age is

    1. schizophrenia
    2. Alzheimer's disease
    3. phobia
    4. epilepsy
    Answer

    B. Alzheimer's disease

    Alzheimer's disease is the commonest cause.

11. Sudden onset of confusion with fluctuating awareness, often due to fever or infection, is

    1. autism
    2. mania
    3. dementia
    4. delirium
    Answer

    D. delirium

    Delirium is acute and usually reversible.

12. Delirium tremens follows

    1. tobacco use
    2. alcohol withdrawal
    3. cannabis use
    4. sleep deprivation only
    Answer

    B. alcohol withdrawal

    It is a severe alcohol withdrawal state.

13. Turning an unacceptable urge into a socially useful activity is called

    1. sublimation
    2. regression
    3. denial
    4. projection
    Answer

    A. sublimation

    Sublimation redirects an urge into a socially useful activity.

14. Blaming others for one's own faults is

    1. repression
    2. rationalisation
    3. displacement
    4. projection
    Answer

    D. projection

    This is projection.

15. Refusing to accept a painful reality is the defence mechanism of

    1. regression
    2. sublimation
    3. denial
    4. displacement
    Answer

    C. denial

    Denial rejects the painful fact.

16. Going back to childish behaviour under stress is

    1. regression
    2. projection
    3. sublimation
    4. denial
    Answer

    A. regression

    Regression is return to an earlier stage of behaviour.

17. The National Mental Health Programme was started in

    1. 1982
    2. 1996
    3. 1952
    4. 2017
    Answer

    A. 1982

    NMHP began in 1982.

18. The Mental Healthcare Act was enacted in

    1. 1987
    2. 2017
    3. 2005
    4. 1996
    Answer

    B. 2017

    It replaced the Mental Health Act of 1987.

19. The District Mental Health Programme was introduced in

    1. 2005
    2. 2014
    3. 1982
    4. 1996
    Answer

    D. 1996

    DMHP was added to NMHP in 1996.

20. Tele-MANAS is a

    1. mental hospital in Bengaluru
    2. school curriculum
    3. national tele-mental health helpline
    4. drug for depression
    Answer

    C. national tele-mental health helpline

    Tele-MANAS launched in 2022 offers tele counselling.

21. Which of these is NOT a mental illness but a neurological disorder?

    1. Epilepsy
    2. Schizophrenia
    3. Panic disorder
    4. Depression
    Answer

    A. Epilepsy

    Epilepsy is a brain disorder with recurrent seizures.

22. During a convulsion the best first aid is to

    1. hold the limbs tightly
    2. give water
    3. turn the person to the side and protect the head
    4. put a spoon in the mouth
    Answer

    C. turn the person to the side and protect the head

    Protect the airway and head; nothing in the mouth.

23. The IQ range of mild intellectual disability is

    1. below 20
    2. 50-69
    3. 20-34
    4. 35-49
    Answer

    B. 50-69

    Mild is 50-69.

24. Profound intellectual disability has an IQ

    1. 50-69
    2. 35-49
    3. 20-34
    4. below 20
    Answer

    D. below 20

    Profound is below 20.

25. Down syndrome is a common cause of

    1. intellectual disability
    2. bipolar disorder
    3. dementia
    4. schizophrenia
    Answer

    A. intellectual disability

    It is a chromosomal cause.

26. A child of 10 years has a mental age of 7 years. The IQ is

    1. 7
    2. 70
    3. 77
    4. 143
    Answer

    B. 70

    7 ÷ 10 × 100 = 70.

27. A child of 8 years has a mental age of 6 years. The IQ is

    1. 80
    2. 133
    3. 75
    4. 60
    Answer

    C. 75

    6 ÷ 8 × 100 = 75.

28. A child of 12 years has a mental age of 12 years. The IQ is

    1. 120
    2. 144
    3. 50
    4. 100
    Answer

    D. 100

    12 ÷ 12 × 100 = 100.

29. A child of 10 years has a mental age of 5 years. The IQ is

    1. 200
    2. 50
    3. 5
    4. 15
    Answer

    B. 50

    5 ÷ 10 × 100 = 50, the lower edge of the mild range.

30. A child of 9 years has an IQ of 80. The mental age is

    1. 7.2 years
    2. 8 years
    3. 11.25 years
    4. 6.4 years
    Answer

    A. 7.2 years

    MA = IQ × CA ÷ 100 = 80 × 9 ÷ 100 = 7.2.

31. A child of 15 years has an IQ of 40. The mental age is

    1. 4 years
    2. 37.5 years
    3. 6 years
    4. 8 years
    Answer

    C. 6 years

    40 × 15 ÷ 100 = 6.

32. A mental health camp screens 400 persons and finds 36 with depression. The percentage is

    1. 36%
    2. 3.6%
    3. 11%
    4. 9%
    Answer

    D. 9%

    36 ÷ 400 × 100 = 9%.

33. Out of 250 adults, 20 are found to have alcohol dependence. The rate per 1,000 is

    1. 20
    2. 125
    3. 80
    4. 8
    Answer

    C. 80

    20 ÷ 250 × 1,000 = 80.

34. A PHC area has 60,000 population. If 0.5% are on treatment for psychosis, how many patients are there?

    1. 300
    2. 600
    3. 120
    4. 30
    Answer

    A. 300

    60,000 × 0.5 ÷ 100 = 300.

35. Statements: 1. Insight is retained in neurosis. 2. Hallucinations are common in neurosis. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    Hallucinations are features of psychosis.

36. Statements: 1. Dementia usually begins suddenly and is quickly reversible. 2. Delirium is a state of acute confusion. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    Dementia is gradual and mostly progressive; delirium is acute.

37. Statements: 1. Epilepsy is contagious. 2. A person with a seizure should not have anything forced into the mouth. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    Epilepsy is not contagious.

38. Statements: 1. The Mental Healthcare Act, 2017 recognises a right to access mental health care. 2. It treats a person attempting suicide as a criminal. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    The Act presumes severe stress in a person attempting suicide and limits punishment.

39. Statements: 1. Mania is characterised by elation and over-activity. 2. Depression is characterised by low mood and loss of interest. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are correct.

40. Statements: 1. Antidepressants may be stopped by the patient whenever he feels better. 2. Long-term regular treatment helps prevent relapse in many mental disorders. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    Stopping medicine on one's own often leads to relapse.

41. Statements: 1. Obsessions are repeated acts. 2. Compulsions are unwanted thoughts. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    D. Neither 1 nor 2

    Obsessions are thoughts and compulsions are acts; both statements are reversed.

42. Match: (a) phobia, (b) delusion, (c) hallucination, (d) mania with (i) false perception, (ii) irrational fear, (iii) false belief, (iv) elation. Choose the correct pairing.

    1. a-iv, b-iii, c-i, d-ii
    2. a-ii, b-i, c-iii, d-iv
    3. a-iii, b-ii, c-i, d-iv
    4. a-ii, b-iii, c-i, d-iv
    Answer

    D. a-ii, b-iii, c-i, d-iv

    Phobia-fear, delusion-belief, hallucination-perception, mania-elation.

43. Match the drug with its main use: (a) haloperidol, (b) lithium, (c) fluoxetine, (d) diazepam.

    1. a-psychosis, b-depression, c-anxiety, d-bipolar disorder
    2. a-anxiety, b-bipolar disorder, c-psychosis, d-depression
    3. a-depression, b-psychosis, c-bipolar disorder, d-anxiety
    4. a-psychosis, b-bipolar disorder, c-depression, d-anxiety
    Answer

    D. a-psychosis, b-bipolar disorder, c-depression, d-anxiety

    Haloperidol is antipsychotic, lithium stabilises mood, fluoxetine is an antidepressant and diazepam relieves anxiety.

44. Which is the best role of a health worker when a family believes a mentally ill member is cursed?

    1. Advise a ritual only
    2. Explain that it is a treatable illness and refer to the medical officer
    3. Ask the family to hide the patient
    4. Stop all medicines
    Answer

    B. Explain that it is a treatable illness and refer to the medical officer

    Education, referral and follow-up reduce stigma and delay.

45. Which sign is a warning of suicide risk that a health worker should take seriously?

    1. Regular sleep
    2. Good appetite
    3. Talk of death and giving away belongings
    4. Attending school
    Answer

    C. Talk of death and giving away belongings

    These are recognised warning signs.