There are different types of mental distress ranging from minor anxiety to severe depression and disorders of thinking (Psychotic disorders).  The impact of these illnesses varies according to the nature and severity of the symptoms. According to the Diagnostic and Statistical Manual of Mental Disorders (DSMV) and International Classification of diseases (WHO 2019W), the common mental disorders are:

Anxiety Disorders

In simple words, anxiety is a normal reaction to any stressful situation. Anxiety-related issues are the most common type of mental health issue in India. Evidence suggests that 20.7% of the population has anxiety-related issues. Many people confuse anxiety disorders with day-to-day tension and stress. All of us become anxious when we are awaiting results for an important exam or when we are late to submit our assignment. But these anxieties are temporary and subside as the situation is over. But in anxiety disorders, the symptoms prolong over some time and seriously impairs their day-to-day functioning.

Anxiety disorders have physical as well as psychological symptoms. Though the manifestation and intensity of symptoms are quite different in each anxiety disorder, the distress causes interruptions to daily functioning. The symptoms of anxiety are manifested in physical disturbances, distressing thoughts and emotional disturbances which will have various behavioural implications. The various symptoms of anxiety are: –

Physical symptoms of anxiety

•         A feeling of restlessness, feeling “on-edge;”

•         Shortness of breath, or a feeling of choking

•         Sweaty palms and racing heart

•         Chest pain or discomfort

•         Muscle tension, trembling, feeling shaky

•         Nausea and/or diarrhoea

•         “Butterflies” in the stomach

•         Dizziness, or feeling faint

•         Hot flashes or Chills

•         Numbness, or tingling sensations

•         An exaggerated startle response

•         Sleep disturbance and fatigue

Psychological symptoms of anxiety

•         Feeling of excessive worry or apprehension

•         distress

•         feeling overwhelmed

•         uneasiness, irritability

•         fear or terror

•         restlessness

•         Problems with concentration, or difficulty with staying on task

•         Memory difficulties

•         Depressive symptoms such as hopelessness, lethargy, and poor appetite

Behavioural symptoms of anxiety

•         Avoidance behaviours such as avoiding anxiety-producing situations

•         Escaping from an anxiety-producing situation

•         Engaging in unhealthy or maladaptive ways of coping with anxiety

Common types of anxiety disorders are:

• Generalised Anxiety Disorder (GAD):  It is a chronic anxiety disorder where the individual experiences uncontrollable worry over common situations in life. Individuals may worry over almost all situations and most of the time they don’t know what is the exact thing which makes them concerned. They feel something bad is going to happen and always take unnecessary precautions which might affect various interpersonal relations. The anxiety is free-floating and not situation specific.

• Post Traumatic Stress Disorder: This is a disorder that develops after experiencing or witnessing a traumatic event like an accident, disaster or abuse. The images/ thoughts/ memories of the event may repeatedly haunt the person leading to anxiety symptoms and emotional distress. Any event/object/sound/person related to the traumatic event may induce intense fear and worry or the person may re-live and experience the traumatic event. Usually, the symptoms start within 3months of the trauma.

• Obsessive Compulsive Disorder (OCD):  A person with OCD experiences recurring, unwanted thoughts, images or urges, called obsessions causing distress or anxiety. To reduce the anxiety the person engages in repetitive actions or behaviours called compulsions which may or may not have a direct association with the thought. The person himself feels that the thoughts are illogical or unwanted but not able to control. They may try to control compulsive behaviour but often fail.

• Panic Disorder: Panic attack is a sudden episode of intense anxiety or fear. During the attack, the person might experience the symptoms of anxiety in high intensity which will be quite frightening for the individual. The person may have a feeling of losing control or dying. Usually, the episodes are short-lived and last for 3-4 minutes. When a person has frequent episodes of a panic attack for a period of time, then it will be termed as panic disorder.

• Phobia: Intense fear towards a specific object/place/situation/animal is called phobia. The mere site or talk about it may induce fear and related anxiety symptoms. The most common phobias are claustrophobia (fear of closed space like lift) acrophobia (fear of height) and agoraphobia (fear of open spaces or going to shops and outside spaces).

• Social Anxiety or otherwise called social phobia, is intense fear and anxiety in social situations and activities. This can have a negative effect on one’s ability to build and maintain relationships with peers. The symptoms include hesitance and discomfort in social situations, avoiding or refusing conversations, mumbling, appearing isolated from the group, sitting alone, being overly concerned about humiliation and embarrassment, and difficulty in public speaking.

A Case Vignette

Rupa is a 23-year-old female from an urban area. In 2020 she along with her family members met with an accident. She was asleep during the accident. Her father lost his life on the spot. She was admitted to the critical care unit for almost one week. After discharge, she found it difficult to sleep. Every time she lies down to sleep, she experiences the “shake” similar to what she experienced during the accident. She then suddenly wakes up and re-experiences the accident again. The thoughts and images of the accident repeatedly come into her mind. Even when she sleeps, she experiences nightmares and wakes up in between only to have a panic attack. Thus, she became afraid to sleep. Rupa spends her nights reading or watching movies. Later in the day, she becomes tired and it affects her studies. She was diagnosed with PTSD and received proper treatment and psychotherapy which helped her to sleep well.

Mood Disorders

Mood disorders are a group of disorders in which the emotional state or mood of a person gets affected. Everyone goes through various states of emotions or moods in their life. This becomes a disorder when a particular state of mood persists for two or more weeks and adversely affects their day-to-day life and activities like sleep, work, and family life.

The two main types of mood disorders are depression and bipolar disorder.

Depression:-  Depression is one of the most common mental illnesses. India has over 45 million (4.5 Crores) cases of depression a year. In mood disorder, a person experiences prolonged sadness and low mood. The individual may have sleep disturbance, fatigue, lack of energy and interest in any daily activities. The person may often cry for small reasons or even without a reason. Depression can also affect a person’s attention, concentration and memory making it difficult for daily functioning. The common thought patterns seen in depressive patients are:- ideas of guilt, shame, worthlessness, hopelessness. The individual may feel that no one loves them, and often withdraws themselves from friends and social functions. Suicide is the riskiest element of depression. Most of us may go through sadness/ depression where we may experience some or all of these symptoms and will recover the next day. But clinical depression is diagnosed only if the symptoms persist for at least 2 weeks continuously, and severely affect their life in all respects.

Bipolar Affective Disorder (BPAD):-  A person with BPAD experiences extremities of mood, depression and mania over a period of time. During the depressive phase, the individual will experience the symptoms of depression like low mood, sadness etc and during the manic phase, he/she will be in an excited state. Each phase may prolong over weeks to months. During the manic phase, the individual will have an elevated mood without sufficient reason, uncontrollable excitement and may talk more than usual. The person may speak more than he/she usually does. Sometimes they may show overfamiliarity to strangers as if known for many years. He/she may tend to spend more money on unnecessary things. Pleasure seeking will be given priority over moral values. There will be no inhibitions in any form of sexual or aggressive desires. Irrespective of the surroundings or situation these desires will be expressed.

Persistent Mood Disorder:- Another very rare condition in which the mood disturbance may be present for years but does not have all the symptoms to diagnose depression or mania. The symptoms need not be as significant as in depression but the individual’s major mood would be sadness.

Case Vignette of Depression

Raghu is a 21-year-old male from rural background. From his childhood, he liked to dress up like a girl. He found comfort while playing with his peer girls. He used to be teased and bullied by his classmates and cousins “behaving like a girl”. While doing his degree course he identified himself to be transgender. This was followed by numerous sleepless nights. At the age of 21, he disclosed his identity to the world. As a result, he was thrown out of the family. Though he was a graduate he could not find any job. He was not even able to rent a house. As these stigmatising attitudes started to get worse, he started to isolate himself from others. He rarely slept at night and lost interest in having food. He used to enjoy painting. But now he gets irritated when he sees the brush and canvas. He spends his time in bed. He cannot control his tears. He considers himself a failure. He had no hope for the future and felt that everyone hated him. He somehow wanted to get rid of all these and slowly he decided to end his life. Though he attempted suicide by drowning in a nearby river, he was saved by fishermen. He was admitted to the hospital and given life-saving treatment. He was referred to the psychiatry department and was diagnosed with severe depression and received appropriate therapeutic help and support.

Psychotic Disorders (Disorders of Thinking)

Psychotic disorders comprise a group of disorders in which a person’s thinking is affected and cut him/ her off from the world of reality. Disorders with psychotic symptoms are much more severe but less prevalent. In India, if you take any 1000 people there are only 5-10 people affected with psychotic disorders.

A psychotic disorder causes significant impairment in one’s ability to think clearly, make good judgments, show adequate emotional response, communicate effectively, understand reality, and behave appropriately. Patients with mild symptoms might be able to manage their day-to-day functions while those with severe symptoms might find it difficult to meet the day-to-day requirements of life. The common symptoms of psychotic symptoms are hallucination, delusion and negative symptoms.

• Hallucination is a disorder of false perception where an individual sense non existing stimulus, which means seeing, hearing, smelling or feeling the touch of something which does not exist. E.g., hearing a name being called out without anyone being around, seeing God.

• Delusion is a false unshakable belief about something. Though the belief may seem irrational or illogical for others, the person strongly believes in it and is not ready to change it even if alternative evidence is provided. E.g., false belief of having magical powers, belief that someone is trying to harm them Catatonia is a psychotic symptom related to body movements where the person may maintain odd postures and have repetitive purposeless movements.

• Negative symptoms are a set of symptoms where a person shows lack of motivation, lack of emotional expression, coldness and detachment from others.

Psychotic symptoms are seen in disorders like schizophrenia, bipolar affective disorder, and severe depression. Schizophrenia is a typical psychotic disorder where the individual experiences all of the above-mentioned symptoms. Various types of schizophrenia are diagnosed based on psychotic symptoms. Delusional disorder is yet another psychotic disorder that often fails to reach the clinic as most of the time it does not get medical attention. In delusional disorder, the individual may have irrational suspicious ideas. There is a wide range of delusions like doubting the partner’s fidelity, or strong belief that someone is trying to harm/attack him/her. In some cases, the person may feel that he/she has magical powers or is a famous personality or God himself.

Based on these illogical beliefs the individual may behave in a strange and socially unacceptable way. For example:  following the partner, repeatedly checking the partner’s phone or workplace, filing complaints in the police station, attacking those whom they feel will harm them.

Case Vignette of Psychotic Disorder

Mara, a 45-year-old married man, was referred to a psychiatrist after he tried to harm his neighbours. After an assessment, it was found that he had a suspicion that his neighbour was trying to kill him and his family. His wife reported that the neighbours were very supportive and helpful. She reported that for about 4 years Mara was worried about the neighbour. He covered the right side of the house with a sheet so that the neighbour’s family won’t be able to see them. He had also filed several complaints against the neighbour in the police station. The neighbours were found innocent and no action was taken. One day the neighbour came to Mara‘s house. Mara became violent and attacked the neighbour with a stick. He was taken by the police and admitted for psychiatric treatment. He was then diagnosed with delusional disorder.

Alzheimer’s Disease and Dementia

Dementia is a group of symptoms that is usually long term and worsens with time. There will be a marked deterioration in cognitive ability or thinking and related functions like memory, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not affected. The impairment in cognitive function is commonly accompanied and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation. Dementia is usually seen in the older population but younger people can also be affected. Alzheimer’s is the most common type of dementia where there will be significant impairment in memory.

Childhood Disorders

Mental illnesses are not particular to adults alone. Children are also vulnerable to most of the disorders. Many of the above-mentioned disorders start showing symptoms in late childhood. Other common childhood disorders are: –

Attention Deficit Hyperactivity Disorder (ADHD) is the most common childhood mental health issue. In India, 11.32% of primary school children were found to have ADHD. The two main characteristics of ADHD are lack of attention and hyperactivity. A child with attention deficiency rarely completes his or her task, he/she keeps shifting from one activity to another.

Children with hyperactivity tend to be more active when compared to other kids of their age. A child may keep walking or distracting others. He/she may show irritability, fidgeting like fine movements with fingers while doing some other work.  The child may not be able to wait for his or her turn. E.g., waiting in long queues, answering before the question is completed, etc. Many children may display these issues to some extent, but children with ADHD create disturbance to others more than other students. Parents may receive multiple complaints from teachers regarding their child’s behavioural issues and disturbing nature in class. Attention deficiency and hyperactivity can either occur together or separately.

Autism Spectrum Disorder (ASD): Autism is an umbrella term for a wide range of disorders in which there will be marked impairment in social communication and interaction. It covers a spectrum of disorders with various ranges and severity of symptoms. Autism is not a curable disease but a lifelong manageable condition. Many individuals with ASD lead a fruitful and productive life.

Parents may observe early symptoms of ASD by the age of 2-3 years. They may feel that the child does not meet certain development milestones or displays certain odd behaviours when compared to other children of the same age. At times parents may also notice that the child is gradually losing already gained skills like talking and use of language.

The early signs of ASD include:

Impairments in social interaction:-

•  Makes little or no or less eye contact

• Shows no response to a parent’s smile or other facial expressions

• May not look at objects or events a parent is pointing to

• May not point to objects or events

• May not have appropriate facial expressions

• Has difficulty perceiving what others might be thinking or feeling by looking at their facial expressions

• Less likely to show concern (empathy) for others

• Has difficulty making and keeping friends

Impairment in Communication

• Difficulty in telling their needs or wants or sharing the feelings

• May not point out objects needed

• Delay in language development and speaking

• Repeating what others say without understanding the meaning

• May not respond to name being called

• Difficulty in language comprehension e.g., May refers to self as “you” and others as “I” and may mix up pronouns

• May show no or less interest in communicating

• Less likely to start or continue a conversation

• Less likely to use toys or other objects to represent people or real life in pretend play

Behavioural differences (repetitive & obsessive behaviours) in children with autism

• Rocks, spins, sways, twirls fingers, walks on toes for a long time, or flaps hands (called “stereotypic behaviour” or stereotypies)

• Likes routines, order, and rituals; has difficulty with change or transition from one activity to another

• May be obsessed with a few or unusual activities, doing them repeatedly during the day

• Plays with parts of toys instead of the whole toy (e.g., spinning the wheels of a toy truck)

• May not cry if in pain or seem to have any fear

• May be very sensitive or not sensitive at all to smells, sounds, lights, textures, and touch

• May have unusual use of vision or gaze—looks at objects from unusual angles

Intellectual Disability (ID): Formerly known as mental retardation, ID, is a neurological developmental disorder, meaning immature development of the nervous system. Individuals with ID may show impairments in their intellectual functioning which makes it difficult for them to learn, do higher thinking processes like judgement, decision making, problem-solving etc. This makes significant impairments to their daily living activities. Individuals with ID could be easily manipulated and exploited as they lack a higher level of thought process. Hence, they are the most vulnerable populations in society.

In simple words, individuals with ID do not possess age-appropriate skills and thinking ability to deal with normal life situations. Symptoms of ID could be identified from a very young age. As children with ID may lag in the development when compared to those of similar age groups it is parents and teachers who identify early signs of ID based on the severity of condition there are mild, moderate, severe and profound intellectual disabilities.  Those with mild and moderate ID can learn and should be educated through school and colleges.  Those with moderate ID can be trained in certain vocational activities. Severe and profound disabilities need full-time care and support from caregivers.

Conduct Disorders

Conduct disorder is a group of emotional and behavioural problems among children as well as adolescents. These children are often labelled by others as ‘bad’, rather than having a mental health problem. Children with conduct disorders experience difficulty following rules and behaving in a socially acceptable way. The following symptoms are shown by children with conduct disorders:

• Aggression to people and animals

• Destruction of property

• Deceitfulness, lying or stealing

• Serious violation of rules

Conduct disorder must be treated early and comprehensively, to prevent the child from carrying this into adult behaviour and behaving in an antisocial manner. Children with conduct disorders may also be found to have ADHD and learning disorders. Treatment includes behaviour therapy and other psychotherapies to manage and control behaviour, and special education may be needed in the case of children with learning difficulties.

Anxiety Disorder in Children

Children also experience anxiety disorders. This may affect childhood in several ways like performing poorly in school, missing social experiences, engaging in substance abuse and many more. Anxiety disorders like the GAD, OCD, Social anxiety extra can be seen in children too. The other anxiety disorders seen among children are:-

Separation Anxiety

Children up to the age of three normally experience some amount of separation anxiety when the parents or significant others are out of sight. Usually, children can be distracted and get engaged in the new environment over time. But if the child still feels unable to leave a family member and takes a longer time to calm down, even when slightly older (usually 7 to 9 years old) then it might be separation anxiety. In separation anxiety, a child experiences excessive anxiety or worry when they are away from parents or home. The symptoms may include refusing to go to school, with friends or demanding parents to stay with them during bedtime. They might feel extreme homesickness and misery when they are away from their loved ones, and they fear something bad or dangerous might happen to their loved ones.

Problem behaviours and behavioural disorders

Some children have challenging behaviours that are not typical of their age. When these behaviours start to exert a significant effect on the child’s performance and their daily functioning, these become problem behaviours and behavioural disorders.

Some of the problem behaviours include:

• Excessive over activity: This includes behaviours like excessive running, inability to remain seated, excessive talking or making continuous movements

• Impaired attention: The child may have difficulty sustaining attention to a task and may switch between different tasks

• Defiance: Defiant behaviour includes acting disrespectfully, not obeying rules, arguing, deliberately annoying and blaming others.

• Impulsive behaviours: These include engaging in dangerous activities without considering the after-effects, difficulty in waiting or difficulty to wait for their turn, interrupting conversations