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Principles and concepts in mental health

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Principles and concepts in mental health

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Principles and concepts in mental health

  1. 1. Principles and Concepts of Mental Health Nursing Mr. Johny Kutty Joseph Assistant Professor SMVDCoN
  2. 2. Signs and Symptoms of Mental Illness • Alterations of Personality & Behaviour  A confirmed atheist turns into religious  Social and outgoing person turns to isolation. • Alterations of Biological Functions  Sleep: its pattern, quality, and duration Appetite: pica, bulimia, anorexia Sexual desire: libido, erectile dysfunction, ejaculation disturbances.
  3. 3. Signs and Symptoms of Mental Illness • Disorders of Consciousness  Clouding of Consciousness: diminution of alertness. Organic and functional psychosis.  Drowsiness: slipping into sleep though awake.  Coma: unconscious and non responsive  Qualitative changes: confusion, disorientation, stereotypism etc.  Fugue and dissociation: temporary alteration of consciousness and identity.  Stupor: conscious but unresponsive to environment.
  4. 4. Signs and Symptoms of Mental Illness • Disorders of Attention and Concentration  Distraction.  Decreased span of attention.  Narrowing of attention.  seen in anxiety, mania, depression, schizophrenia, substance abuse etc.
  5. 5. Signs and Symptoms of Mental Illness • Disorders of Orientation  Time, Place, Person.  Disorientation to own identity. • Volitional Disturbances: It is the willful initiation and control of one’s behaviour.  Seen organic and functional disorders  Immobility  Mutism  Stupor  decreased drives (sleep, appetite, thirst etc.)
  6. 6. Signs and Symptoms of Mental Illness • Disorders of Motor Activity  Increased Activity Level: Hyperactivity may be goal oriented or not. (mania)  Impulsivity, Restlessness, Agitation & Excitement Decreased activity: Depression, slow and lack of initiation of activities (akinesia) mutism, stupor etc. Qualitative disturbances of movement: sudden involuntary twitching of movement, facial expression like blinking, sniffing, throat clearing. Tics and mannerisms, tremors odd acts such as scratching of head, nose pulling, ear pulling. Negativism.
  7. 7. Signs and Symptoms of Mental Illness • Disturbance in Posture and Expression  Voluntary assumption of inappropriate and bizarre positions.  Waxy flexibility.  Maintaining Psychological Pillow (head raised)  Extremely cheerful, Odd Facial expressions or grimacing.
  8. 8. Signs and Symptoms of Mental Illness • Disturbance in Motor Speech  Echolalia and Palialia • Disorders of perception • Disorders of Mood • Disorders of Memory  Amnesia: partial or total failure to recall past. Seen in trauma, infection etc. Due to defective registration of information under influence of drug or alcohol.
  9. 9. Signs and Symptoms of Mental Illness  Hypermnesia: Extreme degree of retention and recall of events.  Paramnesia: Distorted or falsified recall of events. Confabulation (unintentional filling of gap of memory with material which is untrue and fanciful) Déjà vu ( an event though occurring for first time seems familiar) jamais vu (feeling of strangeness to familiar situations or events )  Ganser syndrome: Approximate answers to the questions asked; Eg. How many legs does the cow has ? A: 3
  10. 10. Signs and Symptoms of Mental Illness • Disorders of Thought • Disorders of Intelligence: Mental Retardation, Intellectual deterioration occurs in dementia and other organic conditions. • Disorders of Insight and Judgment: • 1: Personal judgment, • 2: social judgment, and • 3: test judgment.
  11. 11. Signs and Symptoms of Mental Illness • Insight is level of self awareness of his disability and the need for help. • 1: complete denial of illness • 2: Slight awareness of being sick • 3: Awareness of being sick attributed to external or physical factor • 4: Awareness of being sick due to something unknown to self. • 5: Intellectual insight • 6: True emotional insight
  12. 12. Classification of Mental Illness • Classification is a process by which complex phenomena are organized into categories, classes or ranks so as bring together those things that most resemble each other & to separate those that differ. • At present there are two major classification in psychiatry, namely ICD 10 (1992) & DSM V (2013). • It helps in making generally acceptable diagnosis, communication of professionals, generalization in treatment and a framework for research.
  13. 13. ICD 10 (International Statistical Classification of Disease & Related Health Problems)- 1992 • This is WHO’s classification for all diseases & related health problems. • • The chapter ‘F’ classifies psychiatric disorder as mental & behavioral disorders & codes them on an alphanumeric system from F00 to F99. • The Main Categories in ICD 10:-
  14. 14. ICD 10 - 1992 • F00 – F09 Organic, Including Symptomatic, Mental disorders • F00 – Dementia in Alzheimer’s disease • F01 – Vascular dementia • F04 – Organic amnestic syndrome • F05 – Delirium • F06 – Other mental disorders due to brain damage & dysfunction & to physical disease • F07 – Personality & behavioral disorders due to brain disease, damage & dysfunction
  15. 15. ICD 10 - 1992 • F10 – F19 Mental & behavioral Disorders due to Psychoactive Substance use • F10 – Mental & behavioral disorders due to use of alcohol • F11 - Mental & behavioral disorders due to use of opioids • F12 – Mental & behavioral disorders due to use of cannabinoids • F13 – Mental & behavioral disorders due to use of sedatives & hypnotics • F14 – Mental & behavioral disorders due to use of cocaine • F16 – Mental & behavioral disorders due to use of hallucinogens (Eg. LSD/Lysergic Acid)
  16. 16. ICD 10 - 1992 • F20 – F29 Schizophrenia, Schizotypal & Delusional Disorders • F20 – Schizophrenia • F20.0 – Paranoid Schizophrenia • F20.1 – Hebephrenic Schizophrenia • F20.2 – Catatonic Schizophrenia • F20.3 – Undifferentiated Schizophrenia • F20.4 – Post-schizophrenia depression • F20.5 – Residual Schizophrenia • F20.6 – Simple Schizophrenia
  17. 17. ICD 10 - 1992 • F21 – Schizotypal disorder • F22 – Persistent delusional disorders • F23 – Acute & Transient psychotic disorders • F24 – Induced Delusional disorders • F25 – Schizoaffective disorders
  18. 18. ICD 10 - 1992 • F30 – F39 Mood (affective) Disorders • F30 – Manic episode • F31 – Bipolar affective disorder • F32 – Depressive episode • F33 – Recurrent depressive disorder • F34 – Persistent mood disorder
  19. 19. ICD 10 - 1992 • F40 – F49 Neurotic, Stress-rapid & somato-form disorders • F40 – Phobic anxiety disorders • F41 – Other anxiety disorders • F42 – Obsessive – Compulsive disorder • F43 – Reaction severe stress & adjustment disorders • F44 – Dissociative (Conversion) disorders • F45 – Somatoform disorders
  20. 20. ICD 10 - 1992 • F50 – F59 Behavioral syndromes associated with physiological disturbances & physical factors • F50 – Eating Disorders • F51 – Non-organic sleep disorders • F52 – Sexual dysfunction
  21. 21. ICD 10 - 1992 • F60 – F69 Disorders of adult personality & behavior • F60 – Specific personality disorders • F60.0 – Paranoid personality disorders • F60.1 – Schizoid personality disorders • F60.2 – Dissocial personality disorders • F60.3 – Emotionally unstable personality disorder • F60.4 – Histrionic personality disorders • F60.5 – Anankastic (OCD) personality disorders • F60.6 – Anxious personality disorders • F60.7 – Dependent personality disorders
  22. 22. ICD 10 - 1992 • F61 – Mixed & other personality disorders • F62 – Enduring personality changes, not attributable to brain damage & disease • F63 – Habit & impulse disorders • F64 – Gender identity disorders • F65 – Disorders of sexual preference
  23. 23. ICD 10 - 1992 • F70 – F79 Mental Retardation • F70 – Mild Mental Retardation • F71 – Moderate Mental Retardation • F72 – Severe Mental Retardation • F73 – Profound Mental Retardation
  24. 24. ICD 10 - 1992 • F80 – F89 Disorders of psychological development • F80 – Specific developmental disorders of speech & language • F81 – Specific developmental disorders of scholastic skills • F82 – Specific developmental disorders of motor function • F83 – Mixed specific developmental disorders • F84 – Pervasive developmental disorders
  25. 25. ICD 10 - 1992 • F90 – F98 Behavioral & emotional Disorders with onset usually occurring in childhood & adolescence • F90 – Hyperkinetic disorders • F91 – Conduct disorders • F93 – Emotional disorders with onset specific to childhood • F94 – Disorders of social functioning with onset specific to childhood & adolescence • F95 – Tic Disorders • F98 – Other behavioral & emotional disorders with onset usually occurring in childhood & adolescence
  26. 26. ICD 10 - 1992 • F99 – Unspecified mental Disorders
  27. 27. DSM – V (2013) • DSM V (Diagnostic & Statistical Manual) – 2013. • This is the classification of mental disorders by the American Psychiatric Association (APA). • The pattern adopted by DSM V is of Multi-axial systems. • A multi-axial system that evaluates patients along several versatile contains Five axes.
  28. 28. DSM – V (2013) • The Five Axes of DSM V Are:- • Axis I : Clinical psychiatric diagnosis • Axis II : Personality disorder & mental retardation • Axis III ; General medical conditions • Axis IV : Psychosocial & environmental problems • Axis V : Global assessment of functioning in current & past one year.
  29. 29. DSM – V (2013) • The diagnostic criteria and codes in DSM 5 are • 1.2.1: Neurodevelopmental disorders • 1.2.2: Schizophrenia spectrum and other psychotic disorders. • 1.2.3: Bipolar and related disorders. • 1.2.4: Depressive disorders • 1.2.5: Anxiety disorders • 1.2.6: OCD • 1.2.7: Trauma and stress related disorders • 1.2.8: Dissociative disorders • 1.2.9: Somatic symptoms and related disorders.
  30. 30. DSM – V (2013) • 1.2.10: Feeding and eating disorders • 1.2.11: sleep wake disorders • 1.2.12: sexual dysfunction. • 1.2.13: gender dysphoria /identity • 1.2.14: disruptive, impulse control and conduct disorders. • 1.2.15: substance related and addictive disorders. • 1.2.16: Neuro cognitive disorders • 1.2.17: paraphilic disorders • 1.2.18: personality disorders.
  31. 31. Indian Classification 1971 It is modification to ICD 8 by Indian Psychiatrists. • A: Psychosis Functional (Schizophrenia / simple / hebephrenic / catatonic / paranoid) Affective: (mania and depression) Organic: (Acute and Chronic) • B: Neurosis  Anxiety Neurosis  Depressive neurosis  Hysterical neurosis  OCD Phobic Neurosis
  32. 32. Indian Classification 1971 • C: Special disorders  Childhood disorders Personality disorders Substance abuse Mental retardation
  33. 33. Factors influencing Personality • Biological Factors  Heredity: gene and its traits Endocrine glands: thyroid gland can cause mania / depression. Parathyroid glands monitor calcium that cause nervous excitability. Physique: size, strength, physical appearance and dominance or inferiority. Nervous System: rate of transmission and level of neurotransmitters.
  34. 34. Factors influencing Personality • Environmental Factors.  Family (family reactions, parents, morality, social norms, tolerant fathers increase emotional stability and self confidence, overprotective mothers, submissive mothers, Birth order etc.)  School (friendships, type of curriculum, facilities) Teacher (reactions, personality and relationship) Peer Group (development of self concept, sharing, cooperation, sexuality, intimacy etc.)
  35. 35. Factors influencing Personality • Environmental Factors.  Sibling relationship (number of children, developing cooperation / sharing/ aggressiveness traits, jealousy, rivalry, unhealthy comparisons by parents, ) Mass Media (attitudes, values, beliefs, role models, addictive programmes) Culture ( moral values, beliefs, religion, geographical / dietary / hormonal influence on personality.)
  36. 36. Theories of Personality Development • Psycho Analytic Theory  Oral, Anal, Phallic, Latent, Genital • Psycho social development theory  trust vs mistrust, autonomy vs shame, initiative vs guilt, industry vs inferiority, identity vs role confusion, intimacy vs isolation, generativity vs stagnation, ego integrity vs despair.
  37. 37. Theories of Personality Development • Theory of Cognitive development  Sensori-motor (0-2), pre-opeartaional (2-6), concrete operational (6-12), formal operational (12- 15). • Theory of Moral Development Level 1 4-10 years (Pre - conventional / self centered orientation, egocentric judgment, punishment and obedience etc) Level 2 10-13 years ( Conventional Level: interpersonal orientation, law / order orientation ) Level 3 (13 +) (Post conventional level) (social contract legalistic orientation, universal ethical orientation)
  38. 38. Theories of Personality Development • Humanistic Theories; • Carl Rogerson’s theory: The organism is the individual’s entire frame of reference. It represents the totality of experiences ie. conscious and unconscious. The self is the accepted awareness part of experience Maslow’s hierarchy of needs. Behavioral Theories: (classic conditioning and operant conditioning) Revise defense mechanisms.
  39. 39. Etiology of Mental Illness • Predisposing Factors: The factors that determine an individual’s susceptibility to mental illness. • Genetic make-up • Physical damage to CNS • Adverse psychosocial influence. • Precipitating Factors: these are events that occur shortly before the onset of a disorder an dappear to have induced it. • Physical stress • Psychosocial stress • Perpetuating Factors: responsible for aggravating or prolonging the diseases.
  40. 40. Etiology of Mental Illness • Perpetuating Factors: • Biological Factors • Physiological Factors • Psychological Factors • Social Factors.
  41. 41. Etiology of Mental Illness • Biological Factors  Heredity: sibling studies have shown that unfavorable heredity causes on third of the mental problems.  Biochemical Factors: disturbance in neurotransmitters.  Brain Damage: Infections (HIV, encephalitis), Injury (RTA), Intoxication (alcohol, lead, poison), Vascular (ICH, SAH, SDH, CVA etc), Functional problems (change in RBS, hypoxia, anoxia fluid imbalance), Tumors, Vitamin deficiency (Vitamin B), degenerative disorders (dementia), Endocrine disorders (hypothyroidism), Physical defects (any chronic illness).
  42. 42. Etiology of Mental Illness • Physiological Factors Critical periods of life such as puberty, menstruation, pregnancy, delivery, peurperium and climacteric.  These periods are marked not only by endocrine changes but also diminished psychological status and adaptive capacity.
  43. 43. Etiology of Mental Illness • Psychological Factors Unsocial and reserved people may develop schizoid personality disorders.  strained IPR at home, work, school, loss of prestige, loss of job etc.  Childhood insecurities due to faulty parenting, over strictness, over leniency, over protection, rejection, unhealthy comparisons, etc.  social and recreational deprivations resulting in boredom, isolation etc.
  44. 44. Etiology of Mental Illness • Psychological Factors Marriage problems like forced bachelorhood, disharmony due to childlessness, educational and financial incompatibility. Sexual difficulties such as unhealthy attitude, guilt feelings of masturbation, pre and extra marital relationship and worries.  Stress, frustration etc.
  45. 45. Etiology of Mental Illness • Social Factors Poverty Unemployment Injustice Insecurities Migration Urbanization Social problems such as Gambling, Alcoholism, Prostitution, Broken homes, Divorce, religion, traditions, political problems etc.
  46. 46. Psychopathology of mental illness • It is the scientific study of mental disorders, including efforts to understand their genetic, biological, psychological and social causes, effective classification schemes, course across all stages of development, manifestations and treatment. • It was found by Karl Jaspers in 1913 and termed as mental phenomena. • This tries to define the 4 D’s of an abnormality are: Deviance, Distress, Dysfunction and Danger.
  47. 47. Psychopathology of mental illness • A. Deviance: the deviation of individual actions or unacceptability of his behaviour. • B. Distress: feeling of deep trouble affected by illness. • C. Dysfunction: a maladaptive behaviour that impairs the individual’s ability to perform normal daily functions. • D. Danger: dangerous and violent behaviour directed to others.
  48. 48. Review Nervous System • CNS  Forebrain: thalamus, hypothalamus, limbic system and cerebrum. Thalamus and hypothalamus control autonomous system, sleep, emotions and motivation. Sensory and motor processing centers are in forebrain. Limbic system controls memory, smell, pleasure, pain, aggression, affections, sexual desire etc. Functional areas of cerebrum are also important.
  49. 49. Review Nervous System • CNS  Midbrain: relaying message sto hugher brain centers. It has RAS center of consciousness.  Hindbrain: it has medulla, pons and cerebellum. It controls digestions, respiration, impulse transmission, coordination of body movement, and circulation. Spinal Cord: Channel of communication. Reflex centers • PNS; role of somatic and autonomic nervous system.
  50. 50. Review Nervous System • Integrative functions of the Nervous System:  the cerebral cortex integrates sensory input and motor output.  Structure of neuron Synapses: synaptic transmission. Neurotransmitters Four categories of neurotransmitters are cholinergics, amino acids, monoamines, neuropeptides.
  51. 51. Review Nervous System Significant Neurotransmitters.  Acetylcholine: the pathology and treatment of Alzheimer’s disease and Parkinsonism.  Dopamine : the pathology and treatment of schizophrenia and Parkinsonism.  GABA: the pathology and treatment of anxiety.  Glutamate: the pathology and treatment of Alzheimer’s disease.  Norepinephrine: the pathology and treatment of mania and depression.  Serotonine: the pathology and treatment of mania and depression.
  52. 52. Review Nervous System Biological theories: mental disorders are caused by imbalance in the complex process of brain structures communicating with each other through neurotransmission. The neuro endocrine theories: interaction between nervous an dendocrine systems and the hormones that stimulate the neurone. Psychoimmunology: stress and its effect on body’s immune system.
  53. 53. General Principles of Mental Health Nursing Patient is accepted as exactly he is  being non judgmental and non punitive. No chaining. Being sincerely interested in the patient  recognizing and reflecting on the feelings which patient may express.  Talking with a purpose.  Listening  Permitting the patient to express strongly held emotions.
  54. 54. General Principles of Mental Health Nursing  Use self understanding as a therapeutic example.  Consistency is used to contribute to patient’s security.  Reassurance should be given in a subtle and acceptable manner. Patients behaviour is changed through emotional experience and not by rational interpretation. Unnecessary increase in the anxiety of patient’s should be avoided
  55. 55. General Principles of Mental Health Nursing  objective observation of the patient to understand his behaviour.  maintain realistic nurse patient relationship.  Avoid physical and verbal force as much as possible.  Nursing care is centered on the patient as a person and not on the control of symptoms.  all explanations of procedures and other routines are given according to the patients level of understanding.  many procedures are modified but basic principles remain unaltered.
  56. 56. Standards of Mental Health Nursing The standards help in fulfilling the professions obligation and to provide quality of care. This was proposed in 1973. Professional Practice Standards  Theory  Data Collection  Diagnosis  Planning  Intervention (psychotherapeutic, health teaching, activities of daily living, somatic therapies, therapeutic environment, psychotherapy )  Evaluation
  57. 57. Standards of Mental Health Nursing Professional Performance Standards: the nurse evaluate responses to nursing actions in order to revise database, nursing diagnosis, and nursing care plan  Peer Review  Continuing Education  Interdisciplinary collaboration  Utilization of community health systems.  Research
  58. 58. Qualities of Mental Health Nurse  Self awareness Self acceptance Accepting the patient Sincere interest on patient.  Empathizing with patient.  Reliability  Professionalism  Accountability  Critical thinking ability.
  59. 59. Skills of Mental Health Nurse  Personal skills: Self awareness and Adaptability  Care values and attitudes  respect rights, self esteem, honest, confidence, ethical boundaries.  Counseling Skills.  Behaviour Skills  to increase adaptive behaviour (reinforcement, token economy)  to decrease maladaptive behaviour (extinction, restraining, overcorrection)  To teach ne behaviour. (modeling, shaping, chaining etc.)
  60. 60. Skills of Mental Health Nurse  Supervisory skills  Teaching skills.  Crisis Skills
  61. 61. Conceptual Models  It is organize a complex body of knowledge ie. human behaviour.  The following models tries to explain human behaviour.  Existential Model Psychoanalytical Model  Behavioral Model  Interpersonal Model  Medical Model  Nursing Model
  62. 62. Existential Model  Unlike other models it centers on the person’s present experiences rather than past ones. The major Concepts are:- Rational emotive therapy: people have automatic thoughts, that cause them unhappiness in certain situation. Here the patient can follow A (identify thoughts) B (blank space to be filled) C (reaction to stimuli). Gestalt therapy: Self awareness leads to self acceptance and responsibility for ones own thoughts and feelings. It can be motivated.
  63. 63. Existential Model Reality Therapy: people who are unsuccessful often blame their problems on others, system, society. The people need to find their own identity through responsible behaviour. Role of Patient and Therapist: Patient participates in meaningful experiences to learn about self. Therapists helps in this clarification. Application to Nursing: nurse works to restore the patient to a state of full life from self alienation.
  64. 64. Psychoanalytical Model Psychoanalytical model was first conceptualized by Sigmund Freud in the late 19th century Psycho analytical model mainly focused on Nature of deviant human behaviour Proposed a new perspective on human development
  65. 65. Psychoanalytical Model: Basic Assumptions All human behaviour is caused and thus is capable of explanation. All human behaviour from birth to old age is driven by an energy called libido. This will reduce the tension through the attainment of pleasure. This libido is closely associated with physiological or instinctual drives eg. Hunger, thirst, elimination and sex Personality of human being can be understood by 3 major segments . They are ID, EGO and superego.
  66. 66. Psychoanalytical Model: Basic Assumptions ID represents the most primitive structure of the human personality. Id is based on impulsive, pleasure oriented principle and disconnected with reality of mind. Ego is also called the rational self or reality principle. It represents the feeling of I concept and touch with reality and it includes logical thinking, reasoning, intelligence and also it helps to gain strength. SUPER EGO referred as “perfection principle” and which internalizes the values, legal and moral regulations, social expectations set forth by primary care givers.
  67. 67. Psychoanalytical Model: Basic Assumptions The human personality functions on three levels of awareness. They are Conscious, Preconscious and unconscious. Human personality development unfolds through five innate psychosexual stages. They are Oral stage, Anal stage, Phallic stage, Latency stage, Genital stage. Psychoanalysis uses free association and dream analysis to reconstruct the personality as developed by Freud.
  68. 68. Psychoanalytical Model: Process Free association is the verbalization of thoughts while they occur, with any conscious screening or censorship. It is always unconscious censorship of thoughts and impulses that threaten the ego. Dream analysis refers to an analysis of patients dreams, which symbolically communicate areas of intra-psychic conflicts.
  69. 69. Psychoanalytical Model: Roles Role of patient Freely revealing all his thoughts, feeling & dreams. Patient uses free association. Social interaction. Establish IPR Role of Therapist. Shadow person. Reveals nothing personal. Uses dream analysis he searches for patterns in verbalizations and the areas of intra-psychic conflicts.
  70. 70. Psychoanalytical Model: Roles Role of Therapist Helps the patients to recognize intrapsychic conflicts by using interpretation. Therapist encourages verbalization. He is usually out of the patients sight, To ensure that non-verbal responses do not influence the patient. Should have a some limit/ boundaries. Conflicts are worked out through a healthier resolution. This releases previously invested libido for mature adult functioning.
  71. 71. Behavioral Model: Assumptions All behaviour is learnt  all behaviour occurs in response to stimulus.  human being are passive organisms that can be conditioned. Deviation from normal behavior occur when undesirable behaviour has been reinforced.
  72. 72. Behavioral Model: Therapeutic approaches Systemic Desensitization Token Reinforcement Shaping: teaching new behaviour eg eye contact Chaining: helping to perform complex task step by step. Prompting/Persuading Flooding Aversion Therapy Assertiveness and social skill training.
  73. 73. Behavioral Model: Roles Therapist  helps to unlearn maladaptive behaviour.  use anxiety as a motivational force.  teach new behaviour. Provide reinforcement. Patient  active participant  practice behavioral techniques Does homework and reinforcement exercises.
  74. 74. Interpersonal Model: Assumptions Human being are social beings Human personality is determined in the context of social interactions. Anxiety motivates human behaviour and helps in building the self esteem. Security mechanisms are used to reduce the anxiety. Early life experiences with parents especially mother influence development. Human development proceeds through infancy, childhood, juvenility, pre adolescence, early adolescence, and late adolescence.
  75. 75. Interpersonal Model: Role Patient  share his concerns with therapist and participate in the relationship to the best of his ability. Relationship making itself is the model As the patient matures his ability to related improves and it broadens the life experience. Therapist Therapist is a participant observer who always remain in the relation. Active engagement to establish trust and uncritical acceptance.
  76. 76. Medical Model Deviant behaviour is a manifestation of a disorder of CNS. It suspects abnormality of brain, neurotransmitters, impulses etc. It focus on diagnosis and treatment based on condition. Environmental and social factors are also considered. Stress and stressors are also considered and the stress threshold is genetically determined.
  77. 77. Medical Model The psychiatrist examines the patient H/C, P/E, MSE. Collect additional data if any. Make diagnosis and carry out further observations of patients behaviour. Plan the treatment such as somatic treatment such as pharmacology, ECT, and other.

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