General Introduction To Mental Illness
by Dr Wong Yip Chong,
Senior Consultant Psychiatrist
Adam Road Hospital, 19 Adam Road, Singapore 289891
Depressive Illnesses
Manic-Depressive or Bipolar Illness
Schizo-Affective Illness
Puerperal or Post-Partum Psychosis
Other Psychoses
The Psychopath
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Case Study

Yong Jue is an 18 year old preparing for his A level examinations. He is a good student with many friends and is aiming to get into engineering in the local university. He disciplines himself and studies at home every night. But as time goes on he begins to have difficulties sleeping and concentrating at school. His appearance begins to deteriorate, as he often forgets to bathe. He continues staying up well into the early morning hours. His parents are proud of their son's diligent academic pursuit. Yong Jue begins to withdraw from his friends and spends more time on his own; he is often seen walking alone, talking to himself. His parents and teachers think he is stressed due to the examinations. On the day of the A levels, Yong Jue sits staring blankly at the examination questions, not knowing what to write. To his teacher's disbelief, he hands in a blank paper.

Upon deeper investigation, it is discovered that Yong Jue is hearing voices and believes that secret agents are chasing him, sending him warning signals via the radio. His parents are aghast at this news and don't know where to turn. They seek advice from their temple priest, who recites many prayers over him to cast out an evil spirit. Yong Jue's condition persists, gradually getting worse, as he becomes increasingly more aggressive and violent. One day, he throws his computer on the floor, in belief that he is saving his family from being eliminated by secret agents. His parents seek help from a psychiatrist.

The most major of mental illnesses is Schizophrenia, a psychotic (out of touch with reality) illness, where mental changes are now held as due to biochemical abnormalities in the space between brain cells in their circuitous connexions - technically referred to as disturbances in the neurotransmitters of the brain. As a result, wrong messages are received or sent out with consequent abnormal behaviour.

In the thinking area, thoughts may be simply disordered or may be organised into systems of delusions or false beliefs without basis.

Generally, schizophrenia affects those in the 15 - 25 years age group. Increasingly, the individual tends to withdraw from their already little social contact. They become apathetic and lose interest. Emotionally, they can be irritable, angry, aggressive even violent at times. At other times, they can be depressed even to levels of wanting to commit suicide. Voices can be heard or visions seen. School or work performance and home relationships suffer. But the reasons for this change often appear inexplicable to relatives, friends, school teachers or work colleagues. Some try to explain off this new behaviour as due to stresses, past or present, especially from interpersonal difficulties and mishaps. Supernatural forces or chance occurrences are often implicated in explanations. Allegations of laziness or even malingering may be levelled against the individual.

The incidence of this illness world-wide, is about 1%. It is genetically transmitted though evidence may not be readily apparent in some families especially when numbers of relatives are small.

Spontaneous recovery occurs in a small percentage of cases.
The majority requires anti-psychotic medications. Some need specialised treatments as electroconvulsive therapy (ECT), psychotherapy or counselling. Some recover fully from their first attack though some will manifest residual symptoms. Relapses are common. A small number end up chronic and significantly disabled. 10% of all Schizophrenics succeed in committing suicide.

It is generally a devastating illness troublous to the patient and painful to the relatives and sometimes offensive to society.


Depressive Illnesses
Endogenous Depression

Endogenous depression is a disorder characterised by at least two weeks of nearly constant depressed mood severe enough to cause distress and dysfunction.

Here the change is largely confined to the emotions. Endogenous Depression (of internal causative factors) is contrasted with Exogenous or Reactive Depression (of external causative factors) - the common sadness from the common misfortunes of living. In Endogenous Depression, the adult, for no appropriate reason, suddenly or gradually feels sad and depressed with guilty or inferiority feelings, ideas of unworthiness, loss of confidence and interest with lots of self blame and hopelessness. Physical symptoms include insomnia (especially early awakening) and loss of appetite and weight. The individual has crying spells with depressive thoughts and may be preoccupied by death. Of most concern is suicidal ideas and the high chance that the individual may attempt suicide.

Mental functioning including concentration, interest and drive are reduced but there are no inappropriate thoughts.

Endogenous Depression is also now held as biochemically based and not caused by past or present adverse stresses, although these stresses are often readily ascribed by relatives as causative.


Psychotic Depression

Sometimes in Endogenous Depression, psychotic symptoms may suddenly or gradually appear with consequential inappropriate behaviour whereby the Endogenous Depression is then referred to as Psychotic Depression.

With onset of psychotic symptoms, a patient's behaviour becomes bizarre and disordered. He has hallucinations and delusions which can be peculiar to Depression vis., delusions of guilt, worthlessness, or nihilism.

With these psychotic symptoms, the presentation proximates to that of Schizophrenia, distinguishable however by the dominance of depressive feelings, older age of onset and otherwise general lucidity. The prognosis is better with higher chances of a good recovery and one without residual symptoms.
With rationality increasingly reduced from these psychotic symptoms, suicide becomes a real hazard.

In the initial and mild states of both Endogenous and Psychotic Depression, the early symptoms are often regarded as stress caused with again the same attempts to explain them off as for Schizophrenia. Likewise, as for Schizophrenia, while they may not be causative, they can be aggravating factors.



In some patients, the downward emotional disturbance is replaced by an upward disturbance. The upward disturbed state is referred to as Mania with Hypomania as the mildest, acute Mania as the more serious and Delirious or Delusional Mania as the worst.

In Mania with a prevalence of approximately 0.6% to 0.9%, the patient is, like in Depression, largely emotionally disordered. Thinking remains generally rational. With emotions upwardly disordered, the patient is, for no appropriate reason, elated, over talkative and hyperactive. The early stage is often mistaken, especially when encountered superficially, as one with infectious hilarity and rich associations of ideas wherein he can appear charming, sparkling or entertaining.

With intensity heightening, the behaviour becomes obnoxious, disruptive, threatening or even dangerous. In the more severe stages, hallucinations and delusions appear to augment the disordered mind. Untreated they can damage others and themselves.


Manic-Depressive Or Bipolar Illness

Not infrequently emotionally ill patients swing from depression to mania and vice-versa. In such cases, they are referred to as suffering from Bipolar or Manic-Depressive Illness.


Schizo-Affective Illness

In some other cases, they have a variable amount of thought disorder conferring upon it a Schizophrenic flavour and hence are referred to as suffering from Schizo-affective Illness (affect = emotion).

The outcome of Schizo-affective Illness is often better than Schizophrenia with minimal, if any, residual symptoms in some cases.


Puerperal Or Post-Partum Psychosis

Another major mental illness is the relatively uncommon Puerperal or Post-partum Psychosis, soon after childbirth. The incidence is 1:500 deliveries. The mother suffers a change in behaviour consequent to her disordered thoughts and emotions. The potential of harming not only herself but also her infant should be taken seriously. A chemical imbalance consequent upon the hormonal changes associated with pregnancy appears to be responsible.


Other Psychoses

These include Senile Psychosis, Toxi-confusional Psychoses as from Amphetamines, Alcohol, hallucinatory drugs like LSD, Ecstasy, Marihuana and some organic conditions of the brain as encephalitis, tumour, epilepsy, arteriosclerotic (narrowing of brain blood vessel) dementia. They all lead to significant mental illnesses with a variably disordered mind.


The Psychopath

Another major mental illness is the severe psychopath also known as antisocial personality. Some particularly active and naughty boys continue to be naughty persistently and increasingly despite usual intervention attempts including counselling and punishment.

By puberty, these individuals are well started on the path to delinquent/criminal activities including truanting, property destruction, lying, stealing, cheating, forging, pursuing an illegal occupation as drug-taking. They cause immense social problems in school, family, marriage, work, and society, despite their relatively small numbers.

Many are loners unlike the common gang-orientated criminals. Gene studies appear to support the theory that they can be inborn with this affliction. Current understanding is that they are born with a sluggish-to-stimulus response with a need for greater stimulation or excitement to maintain their well-being state and as illicit and illegal activities are pregnant with stimulation or excitement, they readily incorporate these activities early and increasingly into their lifestyle. They practically do all the ³wrong² things known to man at the expense of those who love them, are close to them with consequent misery and pain for them. Many are unable to ³reform². When coupled with some Schizophrenic features they are referred to as Schizoid psychopaths. They are then the most brutal and dangerous of criminals



Most psychiatric disorders are treatable. Available and acceptable modes of treatment include medication, electro-convulsive therapy (ECT) and counselling and psychotherapy. Strong family support is also paramount in promoting recovery.

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