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Non-Communicable Diseases, Emergency Care and Mental Health Module: 16. Mental Health Problems in Daily Life

Study Session 16  Mental Health Problems in Daily Life


In the course of your daily work, you will commonly find people who have the following problems:

  • physical complaints that don’t seem to have a medical cause
  • worries that seem too much
  • difficulty with sleep.

People may be very troubled by these problems and need help. Without treatment these problems can interfere with a person’s work and relationships. Sometimes, but not always, these symptoms indicate the presence of mental disorder. In this session you will learn how to assess people who have these problems and detect any underlying mental health problems. A small proportion of people will need referral for further assessment, but many people can be helped with simple interventions. You will learn how to give advice on relaxation, ways of managing anxiety and panic, and sleep problems.

Another common experience that can affect a person’s mental health is exposure to violence or life-threatening accidents. Individuals can be exposed to violence by being the victims of it or because they have witnessed violent acts on others. Violence can occur at home, in the fields, in meeting places, in the bar and in other places. It affects children, women and men. Although violence is often assumed to be physical, it can also be psychological violence (violence that negatively affects the self-confidence and dignity of an individual). A person who experiences a life-threatening accident can also suffer from disabling mental health problems. The expectation, after completing this study session, is that you will understand the serious nature of violence, the common mental health consequences of violence and life-threatening accidents, and what you can do to support people who suffer from these kinds of mental health problems.

Learning Outcomes for Study Session 16

When you have studied this session, you should be able to:

16.1  Define and use correctly all of the key words printed in bold. (SAQ 16.1)

16.2  Describe what somatisation is, identify when it may be present and explain how you could help. (SAQ 16.3)

16.3  Explain how you would give advice to a person who is worrying too much. (SAQs 16.1 and 16.2)

16.4  Explain how you would help people with sleep problems. (SAQs 16.1 and 16.2)

16.5  Describe how you would detect mental health problems arising from violence or life-threatening accidents. (SAQ 16.4)

16.6  Explain how you would help women who are victims of intimate partner violence. (SAQ 16.4)

16.1  Physical complaints without an identifiable medical cause

It is a common experience in primary healthcare that a person comes with a physical complaint but no medical cause can be found. The most common explanations for this situation are:

  • A medical cause is actually present, but can’t be detected with the facilities available.
  • The physical complaint is due to undetected depression or anxiety.
  • The physical complaint is due to somatisation. This is when mental or social distress (e.g. chronic poverty, marital problems) comes out as a physical symptom (Figure 16.1). Often the person doesn’t realise that this is happening. For example, a woman who is distressed because she is not able to get pregnant may develop a chronic headache as a result of her distress. Somatisation can also occur as part of depression.
A person with multiple physical complaints characteristic of somatisation
Figure 16.1  A person with multiple physical complaints characteristic of somatisation.

Studies from Ethiopia have shown that around one in five people attending a general medical out-patient clinic with a physical symptom actually have an undetected mental health problem. This is very similar to the situation in other countries. It is important to recognise when a person’s physical health complaint is being caused by an underlying mental health problem, otherwise there is a risk that they will repeatedly attend health services without getting relief. They may spend a lot of money on traditional treatments that don’t help, or may receive inappropriate treatment or investigations; for example, they may be given antimalarial medication for a headache that is actually caused by depression. Ultimately, they continue to suffer and be disabled because they don’t get the treatment they really need.

Some of the physical symptoms that can be caused by depression or anxiety are shown in Table 16.1.

Table 16.1  Physical symptoms in depression and anxiety.

Loss of appetite

Weight loss


Low energy


Multiple aches and pains




Poor digestion

Tense muscles

Heart racing

Shortness of breath

Chest pains


In Ethiopia, there are some other physical complaints that seem to be more typical of somatisation than a medical illness or condition. These are listed in Box 16.1. In your area you may know of some additional physical symptoms that people use to express their mental or social distress. Make a note of them here.

Box 16.1  Common somatisation symptoms in Ethiopia

  • Burning sensations on the head or body
  • Buzzing in ears
  • Crawling sensations under the skin
  • Stabbing/pricking pains
  • Fluid in the head
  • Back pain.

Some indicators that physical symptoms might be related to a mental illness or somatisation are as follows:

  • Medical investigations give no abnormal results
  • The person has three or more physical complaints
  • The physical symptoms don’t fit in with usual patterns of any known disease
  • Other features of depression (e.g., low mood, hopelessness, loss of interest, guilt, etc.) or anxiety (e.g., excessive worry) are also present (depression was covered in Study Session 12 and you will learn more about anxiety in Section 16.2)
  • The symptoms are chronic
  • The person has repeatedly consulted healthworkers.
  • Read Case Study 16.1 about Mrs Abeba carefully. List which features of her case are indicators of possible mental health problems and which features make it more likely that she has a physical health problem.

    Case Study 16.1  Mrs Abeba

    Mrs Abeba is a happily married woman with two healthy children. The family does not have any major financial concerns. One morning she noticed a pain in her lower back while she was picking up a bundle of wood. She tried to ignore the pain but it quickly became worse and would not go away. The pain was particularly bad in the mornings and became so severe that she would often cry. Antipain medication only helped for a short while before the effect wore off. She was seen by a hospital doctor three times within just two weeks, but he was not able to find anything significantly abnormal. There was a small cyst which the doctor removed in case it was the reason for the pain. However, the pain continued. The doctor thought the pain was due to a mental disorder and referred her to a mental healthworker.

  • Indications that Mrs Abeba’s back pain could have a physical cause are: that the pain is very severe, it is the only symptom Mrs Abeba has, there is no evidence of depression/anxiety and there are no obvious psychosocial stressors (i.e. stressful circumstances in her life). On the other hand, the doctor could not find any cause and the pain had become chronic, which could suggest a psychosocial cause.

This is a real case. Mrs Abeba went on to develop some other symptoms – including fluid coming out of her spine and loss of feeling in her leg – and was eventually diagnosed as having tuberculosis of the spine. This example shows the importance of keeping an open mind and being prepared to review the original diagnosis when new information becomes available.

Important!Even if you think an unexplained physical complaint is due to mental illness, review if new symptoms develop – don’t miss a physical cause!

16.1.1  Physical complaints without an identifiable medical cause: what can you do to help?

When somebody from your local community has physical complaints that don’t seem to have a medical cause, the first things you need to do are:

  • make sure that the person has been properly medically assessed
  • screen for depression, anxiety and alcohol misuse/abuse.

If any of these conditions are present then refer for treatment.

If the physical complaint doesn’t seem to be due to a medical cause, or to depression, anxiety or alcohol abuse, it might be due to somatisation. In this situation there are a few things that you can do to help:

  • Reassure the person that there doesn’t seem to be a serious or dangerous cause for their symptoms.
  • It can be difficult to explain to people that their physical symptoms may come from mental distress. They may think that you don’t believe them or that you are saying they are crazy. Instead, ask them about any life difficulties.
  • You can explain that:
    • Physical symptoms can be made worse by worrying about life’s problems.
    • Worry can make people tense their muscles which in turn can lead to pain, e.g. tension headaches.
    • If we feel sad, worried or frightened then we become more sensitive to pain.
  • If the person is repeatedly attending different health facilities or looking for treatment from traditional healers, build up their trust and encourage them to come to you first if they have any new physical complaints.
  • Be prepared to review the assumption that symptoms are due to somatisation. If an underlying physical condition is present then it will usually progress and become easier to detect with time.
  • Medication is not indicated unless the person also develops depression. In that case, the health centre staff may prescribe antidepressant medication (see Study Session 12).

16.2  Anxiety disorders: worries that seem too much

All of us worry about things from time to time, especially if we have a lot of problems, but for some people the worry can become excessive. Anxiety disorders occur when a person worries without sufficient reason (Figure 16.2). Some examples of normal worry could be a student worrying on the night before an exam, a woman worrying about her child who is ill, or a man worrying about how he can provide for the family after the crops have failed. Some examples of abnormal worry (an anxiety disorder) could be a student who worries all the time, even when their exam results are good, a woman who worries constantly about her child even though the child is healthy and happy, and a man who worries about the harvest even when the crops are growing well.

A person who is suffering from anxiety
Figure 16.2  A person who is suffering from anxiety.

Anxiety can be distressing and disabling, for example, preventing people doing things that they used to such as going out of the house and meeting up with other people. As well as causing a person to worry too much, anxiety can lead to physical symptoms (as you have already discovered in Table 16.1). Anxiety often goes hand-in-hand with depression. Also, people who are worrying too much may use alcohol and khat as a way of trying to cope with their symptoms. Although this might help them to feel better in the short term, alcohol and khat usually make anxiety worse in the longer term (see Study Session 14).

Here are some ways that you can help a person if they are suffering from an anxiety disorder (worrying too much):

  • Show the person that you take their problem seriously.
  • Screen for depression and refer for treatment if needed (see Study Session 12).
  • If they are using alcohol and/or khat then advise them to stop (see Study Session 14).
  • Suggest cutting back on coffee as this can make anxiety worse.
  • If they have sudden attacks of severe anxiety, tell them to breathe into a paper bag. This will help to calm them down.
  • Depending on the person, regular exercise could help.
  • For the person who worries about lots of different things at the same time, problem solving (a simple, structured way to approach problems; see Box 16.2) can also be a useful approach.

If none of these approaches helps or the anxiety is severe, refer to the next level health centre for further assessment.

Box 16.2  Problem solving for the person with many worries

  • Sit with the person and help them to make a list of all their worries.
  • Focus on just one worry – the main one.
  • Help the person to think of step-by-step actions to tackle that single problem.
  • Involve a family member if appropriate.
  • Encourage the person to try to solve the problem and check on their progress.

Next we would like you to complete Activity 16.1.

Activity 16.1  Learning how to use problem solving

Think of something that you are worried about (or have been worried about in the past) and try to use the problem-solving approach on yourself. Once you feel confident, try it on a friend or family member.

Write about your experiences of trying this technique in your Study Diary and discuss them with your Tutor at the next Study Support Meeting.

This activity is also relevant to SAQ 16.2.

16.3  Difficulty with sleep

A woman who is unable to sleep at night
Figure 16.3  A woman who is unable to sleep at night.

Sleep problems are common: in the USA 1 in 10 people have chronic insomnia. This is when a person has difficulty getting enough good quality sleep (Figure 16.3). Not everybody needs the same amount of sleep, but most adults seem to need between 7 and 9 hours of sleep in order to function properly. Children need more sleep and older people don’t need so much sleep.

  • From your general knowledge, can you think of five reasons why somebody might have problems sleeping?

  • Common causes of sleeping problems include: bad sleeping habits, undetected mental illness (depression, anxiety, psychosis), social problems (e.g. somebody has died, not enough food for the family), stimulants or other drugs (coffee, alcohol, khat, prescribed medications), a physical health problem (e.g. painful conditions, diabetes, breathing problems, epilepsy), late pregnancy, having a young child, something in the environment (uncomfortable sleeping place, cold, noisy).

Sleep problems can be very frustrating and distressing. People with sleep problems are more likely to be involved in road accidents because they are tired and don’t concentrate properly. Sleep problems can also lead to mental illness or make mental illnesses worse. People may try to treat their sleep problems through self-medication, either with sedative medication (usually diazepam) or alcohol. Sedative medication is medication that makes a person feel sleepy. Both alcohol and diazepam can lead to addiction and, instead of solving the sleep problem, can make it worse. Because of all these reasons, it is important to take sleep problems seriously. Simple advice can be very helpful.

If somebody tells you that they have a sleep problem, you need to do the following:

  • Try to work out whether there is an obvious reason for it.
  • Screen for depression (see Study Session 12) or anxiety (Section 16.2). If present, refer for treatment.
  • Ask the person about their use of alcohol, khat and coffee. If present, explain that these stimulants may be affecting their sleep and advise them to cut down or stop.
  • If you think they have got into bad sleeping habits, you can use the advice in Table 16.2 on sleep hygiene — that is, getting into good sleep habits.
Table 16.2  Advising people on good sleep hygiene.

Go to bed and get up at regular times

Make sure you have regular exercise

Take time to talk with family and relax before trying to sleep

If you are worried about something, write it down/tell somebody about it and deal with it in the morning

Sleep during the day

Eat a heavy meal just before bed

Drink coffee in the afternoon or evening

Chew khat

Smoke a cigarette

Use alcohol to help you sleep

16.4  Violence, accidents and mental health

If a person experiences or witnesses very severe violence (e.g. due to physical or sexual assault, or fighting in a war) or a life-threatening accident (e.g. being thrown off a horse, a serious road traffic accident) then it is normal for them to become mentally distressed. In most cases, their distress will get better with support from family and friends, and with the passing of time.

16.4.1  Mental health problems due to life-threatening violence or accidents

For some people the effect of violence or major accidents on their long-term mental health will be very serious and they may develop one of the following mental illnesses:

  • Depression (see Study Session 12)
  • Anxiety (see Section 16.2 above)
  • Alcohol misuse (see Study Session 14)
  • Post-traumatic stress disorder.

In post-traumatic stress disorder (PTSD), the person remains very distressed because of the violence or accident they experienced. You can screen for PTSD by looking for the following symptoms:

  • horrible and persistent memories or nightmares about the bad event
  • unable to relax because they are expecting more bad things to happen
  • avoiding anything that reminds them of the bad event.

The person with PTSD may not be able to work properly and they may develop problems in their relationships with other people. In Box 16.3 are some suggestions for how you can help when a person develops mental health problems as a result of life-threatening violence or accidents.

Box 16.3  How you can help with the mental effects of life-threatening violence or accidents
  • Reassure the person — usually mental distress lessens with time
  • Encourage family and friends to be supportive
  • Talking about their experience doesn’t always help – let the person decide if they want to discuss it or not
  • Encourage the person to continue with their normal activities as much as possible — having a routine is helpful
  • If they are very severely distressed, refer to the next level health centre straight away
  • If the person’s distress lasts for more than one month, screen for mental illness (depression, anxiety, alcohol problems, PTSD) and refer if signs of these disorders are present
  • You can explain to the person and their family that PTSD can be helped by medication and by talking to a trained health worker.

16.4.2  Intimate partner (‘domestic’) violence

A woman being beaten in her home
Figure 16.4  A woman being beaten in her home.

Violence against women, usually carried out by their husband or another family member (intimate partner violence, Figure 16.4), is sadly common in all cultures and societies around the world. Studies show that Ethiopia is no exception: nearly 3 out of 4 women experience violence at some point in their life. Of course, men can also be the victims of violence carried out by women, but this is much rarer and so we won’t focus on that problem here. Violence against women can be physical (e.g. beating), sexual (e.g. rape) and/or psychological (e.g. saying things that make the woman feel bad about herself). Violence tends to be worse when a woman is pregnant. Women who have just given birth may also be at increased risk because the tradition means that they should stay inside their home after giving birth and so they may not be able to escape from a bad situation.

Women who experience violence are at increased risk of developing mental illnesses. These women are more likely to develop depression or anxiety disorders, somatisation (see Section 16.1) and/or become so desperate that they consider ending their lives (suicide).

  • Read about the case of Mrs Alemtsehay, a postnatal woman living in a rural area (Case Study 16.2). This shows you the effect of violence on one woman’s mental health (this is a real case but the woman’s name has been changed). As you read about Mrs Alemtsehay’s experience, can you identify possible symptoms of mental illness?

    Case Study 16.2  Mrs Alemtsehay’s story

    ‘First, we quarrelled and then he [her husband] started to beat me. I cried. I became angry about having a baby at that time. I was irritated. After that day, I couldn't sleep. All I did was cry. … At that time, had I been God or had I been the person who can do anything, I thought of killing her [her baby] and killing myself. … Since I didn't have the guts to kill the baby or kill myself, I just thought about it.’

  • Mrs Alemtsehay is showing possible symptoms of depression: sleep problems, crying, hopelessness and suicidal thoughts. It may not be abnormal for a woman to feel like this if she is being beaten by her husband, but it is important to check that she hasn’t also developed a depression. The thoughts of wanting to harm her child suggest that severe depression is present. If she does have depression, this might make her situation even worse. She may even try to end her life. If her depression is treated, she might be able to think more clearly and be more motivated to try to find ways to solve the problem.

As well as mental health effects, violence can lead to physical injury (see Study Session 7). If a pregnant woman is the victim of violence can lead to pain or bleeding and even cause her to lose her baby. If the baby survives, violence can cause the baby to be born early, have a lower birth weight or develop other health problems.

A woman who is the victim of violence may not know how to get help. Often women blame themselves even when it is not their fault. For example, they might say ‘I deserved to be beaten because I forgot to fetch the water’, or ‘He is my husband so it is his right to have sex with me even when I don’t want to have sex’. They may also be frightened that the violence will get worse if they tell an outsider (and this could be true). If they have also developed depression, this may be another obstacle that stops them looking for help.

See Box 16.4 for some ways in which you can help with the mental health effects of intimate partner violence.

Box 16.4 Intimate partner violence: what can you do to help?
  • Educating the community to prevent violence happening in the first place. (We will discuss this further in Study Session 18.)
  • Be ready to detect violence, particularly among pregnant and postnatal women.
  • When asking a woman about violence, make sure the discussion is private.
  • If you find out that a woman is the victim of violence:
    • Be supportive by listening to her difficulties
    • Screen for mental illness and suicidal thoughts or plans
    • Encourage her to speak with another family member or community elder
    • Advise her of any local organisations or charities that offer help to vulnerable women
    • Offer to speak with a community elder who could then help to sort out the problem.

Summary of Study Session 16

In Study Session 16, you have learned that:

  1. Physical complaints without an identifiable medical cause are often caused by depression, anxiety and/or somatisation.
  2. It is important to detect and treat the mental health causes of a person’s physical complaints so that their suffering can be relieved, they won’t spend lots of money on unhelpful treatments, and they won’t repeatedly attend health facilities.
  3. Always remember that unexplained physical complaints could have a physical cause that is difficult to detect – be prepared to review the diagnosis of somatisation if new evidence comes to light.
  4. People who worry too much can be helped with simple advice and the specific techniques of relaxation exercises and problem solving.
  5. Sleep problems are common and disabling. You can help to identify the cause of the sleep problem, refer for treatment if needed and advise on healthy sleep habits.
  6. Self-medication of anxiety and sleep problems, for example by drinking alcohol, chewing khat or taking sedative medication, is a common problem and often makes the problem worse.
  7. If a person is exposed to severe violence or a life-threatening accident then they are at increased risk of developing a mental illness.
  8. Intimate partner violence is a common problem that mainly affects women. You can help by detecting the problem, screening for mental illness and informing the woman of any local organisations that could help them.

Self-Assessment Questions (SAQs) for Study Session 16

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 16.1 (tests Learning Outcomes 16.1, 16.3 and 16.4)

Which of the following statements is false? In each case explain why it is incorrect.

A  Sleep hygiene means making sure that a person is clean before they go to sleep.

B  Problem solving involves telling a person how to solve their problems.

C  Sedative medication is good for people who can’t sleep.

D  In post-traumatic stress disorder the person keeps remembering the bad event that happened to them.

E  Avoiding drinking coffee after lunchtime can help to improve sleep problems.


A is false. Sleep hygiene does not have anything to do with personal hygiene. It is the term used to describe good sleeping habits.

B is false. Instead of telling the person how to solve their problems, problem-solving means helping the person to find their own solutions to their problems.

C is false. In general, sedative medication is not the solution for people who have chronic sleep difficulties because of the risk that they will get addicted to the medicine.

D is true. A person with post-traumatic stress disorder typically has the following symptoms: (1) horrible memories or nightmares about the bad event; (2) not being able to relax because they are expecting more bad things to happen; (3) avoiding anything that reminds them of the bad event.

E is true. Coffee can disturb a person’s sleep if drunk too late in the day.

Read the case study below and answer the questions that follow.

Case Study 16.3  Mr Ato Debela the farmer

Mr Ato Debela has always been somebody who tends to worry about things more than other people. But since his father died a year ago, his worry has increased. Mostly he worries about how he is going to manage to provide for his wife and three children. He has lots of aches and pains in his muscles, especially in his head and neck. His hands shake and he sweats a lot. He also feels his heart beating faster than usual and sometimes feels as though he can’t breathe properly. At night time he finds it difficult to sleep because he is thinking so much about different things. At the health centre he was given some vitamin tablets but they haven’t helped. He is unable to work properly because of his condition.

SAQ 16.2 (tests Learning Outcomes 16.3, 16.4)

  • a.Identify the possible symptoms of anxiety.
  • b.What advice could you give Mr Ato Debela to help improve his sleep?
  • c.How could you help him with his anxiety?
  • a.Mr Ato Debela has the following symptoms of anxiety: worrying without good reason, tense muscles, racing heart, tremor, sweating, shortness of breath and disturbed sleep.
  • b.Check for possible causes of sleep problems and try to correct them. For example, a person with anxiety may use alcohol to try to make them feel calmer but this will disturb their sleep. You can explain the importance of sleep hygiene (Table 16.2).
  • c.Problem solving could help Mr Ato Debela. He is worrying about lots of different things. You can encourage him to focus on just one problem at a time (see Box 16.2).

SAQ 16.3 (tests Learning Outcome 16.2)

One of the nurses working in the nearby health centre tells you about a patient who keeps coming to the clinic with different complaints – one week they have abdominal pain, another week they complain of headaches, the next week they say they feel dizzy. The patient has had a proper examination and all investigations are normal. The nurse asks whether you can help.

  • a.What do you think the problem could be?
  • b.What extra information would you like to find out from the patient?
  • c.Can you suggest how you could work together with the health centre nurse to help this patient?
  • a.The person has a physical complaint without an identifiable medical cause. It could be due to an undetected physical problem, depression, anxiety and/or somatisation.
  • b.You should screen for depression and anxiety. It would also be useful to find out whether the person has any social difficulties that could be leading to somatisation.
  • c.Assuming that the person has somatisation, it is important to work with the health centre staff to try to stop the person having unnecessary investigations and treatments.

SAQ 16.4 (tests Learning Outcomes 16.5 and 16.6)

Look back at Case Study 16.2. How could you help Mrs Alemtsehay?


As we discussed earlier, Mrs Alemtsehay seems to have a level of depression that needs urgent treatment. You should refer her to the next level health facility which is able to provide mental healthcare. You can also provide her with confidential support and try to encourage her to speak to a family member or community elder about the problem with her husband. You may also be able to put her in touch with local organisations that could help her.