Dokumen - Pub Psychiatry Made Easy

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■ . ■
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Including
Cases, MCQs
Previous
Exam Q,u^stion
Mahmoud Sewilam
Kasr Al-Ainy School of Medicine
Cairo University
‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬
Psychiatry Made Easy
By:
Mahmoud Sewilam
Kasr Al-Ainy School of Medicine
Cairo University
Second Edition
All thanks to Allah and special thanks for
all those people who are always encouraging
me to do more than my best and who have 1
never stopped believing in me,
Thanks for:
V My father, you are the greatest gift I have ever taken from Allah, you
gave me the greatest gift anyone could wish; you believed in me.
V My mother, the most beautiful woman I ever saw. All I am I owe to my
mother. I attribute all my success in life to the moral,intellectual and
physical education I received from her.
V My brothers;
♦ Mohammed, when I talk about love I talk about you.
Thanks for all of your advices to me & for the attracting design.
♦ Ahmed,thanks for supporting me every time.
V My little beautiful sister. Reman: you are a gift to my heart, a friend to
my spirit & a golden thread to the meaning of life.
V My friends, I love you all, and special thanks for Mohammed Hassan,
without your efforts this book would have never seen the light.
V For my students: you should always do more than your best, be yourself,
be the change that you want, don't let anyone break you, you are the
future, make it always full of whatever you want.
V For her!
I would like to tell you that I love you so much!
You are the only one who deserves my feelings, time, effort
and everything I have, that's for you!
Finally I dedicate you my success.
Mahmoud Sewilam
Email: mr.sewilam@gmail.com
Mobile No.: 01008855731
‫‪.v-‬‬
Table of Contents
Chapter number Name Page
1. 1. Introduction 1
2. II. Etiology of Psychiatric Disorders 2
3. III. Psychiatric Symptoms and Signs 3

4. IV. Organic Mental Disorders 17
5. V. Psychosomatic Disorders 22
6. VI. Substance Abuse and Dependence 23

7. VII. Anxiety Disorders 31
8. VIII. Somatoform Disorders 38
9. IX. Dissociative Disorders
40
10. X. Adjustment Disorders
11. XI. Mood Disorders 42
12. XII. Schizophrenia 45
13. XIII. Delusional Disorders 48
14. XIV. Psychosexual Disorders 49
15. XV. Eating Disorders 52
16. XVI. Child Psychiatry 54
17. XVII. Mental Retardation 57
18. XVIII. Personality Disorders 58
19. XIX. Psychopharmacology 60
20. XX. Electro Convulsive Therapy 66
21. XXI. Psychotherapies 67
22. XXII. Psychiatric Emergencies 72
Questions
CHAPTER I: Introduction
IJ Psvchiatrv & Psycholo

❖ Psychiatry ❖ Psychology: Jj®!' liljLu o-jJjj
❖ [)efinition
• Branch of Medicine that deals with the • The scientific study ofindividual human behavior e.g.
diagnosis and treatment of psychiatric thinking
disorders. • Human behavior in groups is the domain of sociology.
• Psychiatric disorders are disorders in • It is NOT concerned with the diagnosis and treatment of
mental or psychological functions e.g. disorders of these functions.
disorders ofthinking. • Psychology is NOT a branch of medicine.
I. Psychiatric disorders are widely spread, may be more prevalent than most other medical disorders.
II. In October 2001, the WHO Yearly Report cited Four Psychiatric Disorders among the top ten diseases
that caused worldwide disability in all age groups ;
1. Unipolar Depression (ranked 1st).
2. Alcohol Use Disorders(ranked 5th).
3. Schizophrenia (ranked 7th). A!
4. Bipolar Mood disorder(ranked 2th).
s. The Mind-Brain Relationship ; da ^

A. The mind and brain are understood as one and the same.
B. Mind is the product of biological processes in the hrain visualized by special neuroimaging techniques.
C. For example, Consolidation of memory is now believed to be the product of long term potentiation
inside the neuron.
uC-
D. Brain plasticity:
• The ability of brain synapse to alter its configuration in response to experience, y..
4. Evaluation of Normality and Abnormality :
❖ In psychiatry, a person is considered abnormal (disordered) if he displays two major
characteristics:
1. Clear psychiatric symptoms and signs:
> Leading to significant distress to the patient or suffering to others
> Should not occur in normal life, such as hallucinations and delusions.
2. Manifest decline in social and vocational adjnstment:
> Psychiatric patients always perform at a lower level than expected making them a great economic
burden and a source of lots offamilial and social problems.
CHAPTER II: Etiology of Psychiatric Disorders
❖ The complexity of Psychiatric Disorders arise from:
1. Interaction of combined factors together to develop psyehiatrie disorders i.e. uy '"
the Bio — Psycho-Social Model of Etiology fj
1. Separation of time between the cause & effect.
■£
❖ Etiology of Psychiatric Disorders: v

1. Biological Factors
A. Genetic Factors : ^ ii^

• Evidenced by genetic studies_e.g. Adoption studies
• Mode of inheritance is £olygenic
• Interaction of Combined factors may be necessary to develop psychiatric disorders e.g. genetic
factors with environmental factors or psvehosoeial
• The Degree of genetic contribution to disorder Differs in relation to Different psychiatric disorders.
B. ^turochemical and neuroendocrine factors:
> Dvsregulation in neurotransmitters > Dvsflmction in neuroendocrine sv.stems

e.g. Schizophrenia —»• dysfunctions in e.g. Depressive Disorders hypothalamo-
dopamine & serotonin pituitary-adrenal axis over activity.
C. Neuronhvsioloeical and neuronatholoeical factors:
> Neuronhvsiological fi e. functionab changes

> Neuronathological changes in brain anatomical
e.g. changes in cerebral blood flow —>■ structures —»• psychiatric disorders.
psychiatric disorders.
NB: 'Neurochemical. neuroendocrine. neuvophysioloeical & neuropatholopical represent the

biological mechanisms mediating the disease process i.e. they are Intermt^diatp. Cau\fis rather than
being the original causes of disorder.
2. Psychological Factors
> Start since early stages of child development:
A. Traumatic psychological experiences e.g. sexual abuse
B. Defective development of personality e.g. defective needs by caregivers.
C. Pathological patterns of relationships e.g. conflicts with parents
3. Social Factors
A. Stressful life events, e.g. death of loved people

B. ^tresses of^pcial milieu, e.g. stresses related to social class
C. Society nature e.g. rural versus urban
Psychiatric disorders can be classified in terms of:
1. Predisposing Factors 2. Precipitating Factor 3. Perpetuating

(Maintaining)Factors
• Factors which operate from •

© Definition
Factors and events that occur • Factors that prolong the

early life and determine the shortly before the onset of a course of illness and
person's vulnerability to the disorder and appear to have counteract therapeutic efforts
disorder induced it
e.g.
• Genetic factors, intrauterine • Physical e.g. Trauma, or • Biological or psychosocial in

factors, physical, Psychological e.g. Conflicts or nature.
psychological and social social factors.

factors.
N.B.
• Predisposing Factors & • They do not influence the

Constitutional factors pattern ofthe illness or its
(physical and mental factors) intensity.
form together the type ofthe
individual's personality
CHAPTER III: Psychiatric Symptoms and Signs
1. Disorders of Attention
2. Insight
3. Judgment
4. Disorder of Orientation
5. Disorders of Perception
6. Disorders of Consciousness
7. Disorders of Motor Behavior(Conation)
8. Disorders of Speech
9. Disorders of Memory
10. Disorders of Emotions
11. Disorders of Thinking
1. Disorders of Attention
1. Attention 2. Concentration
• The ability to focus awareness on certain • The ability to sustain or maintain that focus.
important task.
Disorders of Attention
1. Distractibillty 2. Selective inattention 3. Hypervigilance (hyperprosexia)
aLjIIVI aJbj
• Inability to focus and • Blocking out stimuli that • Excessive attention and focus on
maintain attention. generate anxiety. all stimuli.
• It is found in mania and paranoid

patients.
2. Insight
2efinition : refers to the patient's conscious recognition of his condition, i.e., awareness that:
I. He is disturbed or ill
II. His illness is psychiatric in nature
III. He should seek professional help
IV. He should cooperate with the offered treatment
3. Judgment j>»Vt^jvSaJll:
iirartiTfiTiBT
• The ability to assess a situation rationally and to act appropriately within that situation.
4. Disorder of Orientation
• Orientation is awareness of time, place and persons.

• Disorientation: disturbed orientation to time, place or persons. It is usually related to disturbed
consciousness.
5. Disorders of Perception
neural causes
and correlates
Definition of Perception : a CAT Bs-percewed
bv S
Ol consciousness
The process by which sensory stimuli (physical stimulation) apresentation
are transferred into a meaning (psychological information)

CAT n perceived by
Disorders of Perception :
Illusions :
Misinterpretation of REAL external sensory stimuli e.g. mistaking a rope for a snake.
May affect any sensory modality (visual, auditory, etc...).
May occur in normal OR pathological conditions (e.g., delirium).
2. Depersonalization and Derealization
C* Definition : Disturbed perception of oneself or the surrounding environment

A. Depersonalization B. Dereallization ^
' J
H:m r> i
a The person perceives himself, his body or parts • The person perceives the external world, objects
of his body as different, unreal or unfamiliar. or people as different, unreal or unfamiliar.
•NB: Depersonalization and Derealization :

• Mav occur in normal people (during stress), ^^
• In anxiety disorders, mood disorders, schizophrenia, and in organic conditions (e.g., temporal lobe
- HQl .ir-mQtir,n k p PAlSF nprp ntin in tho sihsence ofanv external st.imu^^^^^^^^^^^^^^^
• Tvpes of hallucinations classified according to: HUV
A. Sensory modalities B. Complexity
> Auditory Hallucinations > Elementary (e.g., noises, Hashes of light).

> Visual Hallucinations > Complex (voices, music, faces, scenes).
> Tactile Hallucinations
> Olfactory (smell) and Gustatory (taste)

Hallucinations
> Somatic Hallucinations
Types of hallucinations according to Sensory modalities
1. Tactile Hallucinations 2. Auditory Hallucinations 3. Somatic 4. Olfactory (smell) and 5. Visual Hallucinations
Hallucinations Gustatory (taste)
Hallucinations
Uyiill t n.-k-ilsii
False perception oftouch. • The most common type of • False sensation of Most common in organic Most common in
E.g.: ^ hallucinations. things occurring in conditions, e.g. temporal organic mental
Phantom limb from • Occur in psychotic disorders the body lobe epilepsy e.g. burned conditions,(e.g.,
amputated limb especially schizpphrenja (Mostly visceral). rubber car delirium, substance
• VARIETIES: • They usually occur May occur in intoxication or
A. Voices talking to the patient in psychotic scbizpph renia or severe withdrawal).
12"'* nersoni. i.e., addressing or disorders, mood disorders. May occur in
commanding particularly .schjzpp.hrenja, severe
B. Voices talking about the patient schlzophrênia^^ mood disorders or
(3*^ nersont. e.g., commenting dissociative disorders.
on his thoughts or actions
• Voices repeating patient's
Crawling sensation on or thoughts(echo de nenseei
under the skin in COCAINE
intoxication and withdrawal.
6. Disorders of Consciousness
Definition of Consciousness:
The general state of awareness of the self and the environment.

Disorders of Consciousness:
1. Somnolence 2. Clouding of Consciousness:
It is excessive drowsiness. • It is INcomplete clear-mindedness in which the

person is NOTfully alert.
• Attention, memory and thinking are impaired to
varying degrees.
3. Stupor JjAill 4. Coma:
' ■ -trsi.
Sr-is'- ■ V,
State of lack of reactivity to stimuli and State of profound unconsciousness from which the
awareness ofthe surroundings (partial or person cannot be aroused by painful stimulation.
semi-coma)
The patient is immobile, mute and

N.B.: Most symptoms indicating disturbances in
unresponsive but appears to be conscious
consciousness, orientation, memory, and
and aware of his surroundings, e.g.,
attention highly suggest an Organic Mental
catatonic and depressive stupors.
Disorder.
5. Dream-like state (oneroid or twilight state):
State of disturbed consciousness associated with dream like imagery or hallucinations.
7. Disorders of Motor Behavior (Conation)
1. Tics
V ,5-»JV
Involuntary, Irregular, repeated simple movements involving a group of mus
e.g. turning the head jiV (>
In stress or anxiety, rarely organic disease
2. Mannerisms 3. Stereotypy
J*i jIjSj jIjSj
(JjU IjIjIjj
dl <
Repeated, habitual movements that appear to Repeated complex movements that are
have some functional significance e.g. saluting. /?egular (unlike tics) and
Without obvious fimctional significance
(unlike mannerisms).
E.g. rocking to and fro.
4. Psychomotor agitation 5. Excitement
Physical and mental over actiyify-, in response to • Extreme degree of agitation.

anxiety, inner tension. • It occurs in acute psychotic condition and acute
organic brain disorders (e.g., drug intoxication)
6. Psychomotor retardation 7. Lack of Volition (Avolition);
Lack of will
• Decreased motor and cognitive activity as • Reduced impulse to act and think
observed in slowing ofthought, speech and • Occurs in Schizophrenia, depression and some
movements. organic conditions.
• Commonly seen in depression.
8. Catatonic Symptoms
A. Catalepsy B. Catatonic Posturing
JlAjj
aiklj
General term for an immobile position that is • Voluntary adoption of an unusual or bizarre
constantly maintained. bodily posture continuously for a long time
(e.g., standing on one leg).
C. Catatonic rigidity D. Waxy flexibility (Flexibilitas cerea)
uiLd ûaj jL»ij|

JjIS tte.
(^1^1 (JSj(JjjJa
Voluntary assumption of a rigid posture held The patient can be molded into a body position
against all efforts to be moved. which is maintained (as if made of wax).
E. Catatonic excitement F. Catatonic stupor
JjAil)
lipnilol com 44?t4!j
• Agitated, purposeless motor activity Markedly slowed motor activity (up to

uninfluenced by external stimuli (often violent). immobility).
The patient seems unaware of the surroundings,
although he is usually totally aware.
G. Negativism H. Automatic obedience(Command automatism)
; Ûah
uUaj L> JS Jxiu
<ULuJ
l_t4A
Aj^Jatit^lj
Motiveless resistance or opposition to outside Automatic following of suggestions or orders.

suggestions or efforts to be moved, or doing the
opposite of what is asked.
I. Echolalia J. Echopraxia
jjjjj
>1
Pathological repetition of the words or phrases Pathological imitation of the movement of one
of one person by another. person by another.
8. Disorders of Speech
Volubility :
Volubility is excessive but coherent and logical speech.
It typically occurs in mania and hypomania.
2. Poverty of speech ^:
It is restriction in the amount of speech.
It typically occurs in depression.
3. Mutism :
It is organic or flinctional MARKED reduction in the amount of speech.
4. Poverty of content of speech (poverty of thought) ulJai:
Speech is normal in amount but conveys little meaningful information
(Because of vagueness, emptiness or stereotyped phrases).
5. Stuttering and stammering :
Stuttering is frequent repetition of syllables. o-O-oo
Stammering is prolongation of consonants, especially letter "m".
6. Dvsarthria :
It is difficulty in articulation.
It is seen in organic disorders (peripheral upper or lower motor diseases)^
7. Aphasia SjJaII 0'-^:
It is disturbance in language output caused by brain lesion.
Types:
A. Motor aphasia (expressive) B. Sensory aphasia C. Nominal aphasia
(receptive)
> The patient can understand spoken and > The patient cannot > It is difficulty in finding
written language but cannot express understand the the correct name for an
himself in proper words. meaning of words. object.
9. Disordersof Memory
the psychological function by which information stored in the brain is later
recalled in consciousness.
Clinicallv, 4 levels of memory are described
1. Immediate 2. Recent (short-term) 3. Recent Past 4. Remote (Long-term)
I— oo -JR.
/-— OO 3k
/—oo^
Extended
Hours pEQQnjj pKESMIIIj I /-~<2!OOS
/^!!^200'7
r-ii ,^200^
CJ 20W
Recall of Events several minutes • It is recall of events It describes events 2
perceived material to hours old over past few or more years old
within seconds of Evaluated by giving the months. Evaluated during
presentation to the patient names of3 obtaining histories.
individual unrelated objects and
Evaluated by asking them to repeat
series of after 10 minute.
numbers.
10
Amnesia SjSIjII jl-^ partial or complete Inability to recall past experiences
> It may be organic (amnestic disorder) or emotional(dissociative amnesia) in origin
> Types :
A. Retrograde B. Anterograde C. Circumscribed amnesia (amnestic gap)
dll^VI (jUrUlj JafiS (jLti-iu
Amnesia for events Amnesia for events Amnesia limited to a particular period of time
occurring before a occurring After a and events with intact recall of events before or
point in time e.g., point in time e.g., after this gap.
before a head trauma After a head trauma It occurs in dissociative (hysterical) amnesia
II. inWWffTiTCTI SjSljll Sja : Exaggerated degree of retention and recall.

^ Seen in mania and paranoid patients.
III. Paramnesia SjSIj]| Dyltti: falsification or distortion of recalled memories

> Common types of paramnesia:
A. Confabulation B. Retrospective Falsification
51
The cat called the fire brigade
because the chair was on fire
Filling of gaps in memory by imagined or Unintentional distortion ofa true memory by

untrue events. adding false details.
Associated with organic pathology (e.g.
dementia).
C. Deja vu AilVt SjAlia D. Jamais vu SjiLd) Aj )j1)
Illusion of visual recognition, in which a new False Feeling of UNFamiliarity

situation is regarded as a repetition of a
previous experience.
11
lO.Disorders of Emotions
Emotion is a complex feeling state with psychic, somatic and behavioral components.
A. Affect: iilaUII B. Mood:
1—1
'1^ r
A
1<'
(t P(VlANTkKT<OM
<♦ Represents the ... & e.g.:

■ Outward exnression of emotion i.e. external ■ F,motional tone i.e. the patient's inner
experience ofemotions feelings.
■ E.e. Facial expression. ■ E.2. Depression.
❖ Characterized by:
■ Subjective ■ Subjective
■ Siltort lived "Immediate"& transient ■ Sustained & pervasive
❖ Reported by:
■ The person's nonverbal behavior ■ The patient's own words
1 11. Disorders of Mood: 1

A. Unpleasant moods: B. Pleasant Moods:
f r.
Mm
1. Irritable mood jj*^l ^y-»: easily A. Eiinhoria

annoyed and provoked to anger.
2. Anhedonia AjaI jS) jiUjaVI uIja®: jack o/the : exaggerated feeling of well-being that is
abilitv to experience pleasure and loss of interest inaoDroDriate to real events.
in all regular pleasurable activities. B. Elation: elevated mood with feelings ofjoy,
3. Anxiety: feeling of apprehension caused by euphoria and intense self-satisfaction and
ant icipation of an ill-defined danger. optimism.
4. Ehobia ; fear related to a
C. Ecstasy: feeling of intense elation.
particular object or situation.
5. Free-floating anxiety: peiwasive unfocused fear not attached to any idea.
6. Fear: unpleasant emotional state in response to a realistic threat or danger.
7. Depression: feeling of sadness.
8. Dysphoric mood kJajll^ an unpleasant mood; a mood of general dissatisfaction.
9. Tension : unpleasant increase of motor and psychological activity.
NB: Euthvmic mood is normal range of mood (implying absence of abnormal or pathological moods)
12
II Disorders of Affect
1. Inappropriate affect (incongruity of affect): 2. Ambivalence:
L4 (_>2a3uj
£jj".,>i>i .
dl^
k
• Disharmony between expressed atfect and the Coexistence oftwo opposing affects or
situation. impulses toward the same object at the
same time.
3. Constricted or restricted affect: REDUCED intensity of externalized feeling tone (i.e., affective
expression and responsivity).
4. Blunted affect: SEVERE reduction in the intensity of emotional expression and responsivity.
5. Flat affect(Apathy): ABSENCE or near absence of any signs of emotional expression or responsivity.
6. Lability of affect 7. Swings of affect:
(emotional incontinence):
iihtXaa
[lawshdgya.atg
• Affective expression characterized by frequent Oscillation of a person's emotional feeling tone

and abrupt changes unrelated to external between periods of elation and periods of
stimuli. depression.
cjiUisyij on Cy*
13
11.Disorders of Thinking (Form,stream ,content)
A. Disorders of Form of Thinking = Formal Thought Disorders;
❖ Definition :
• Abnormalities in the logical structure & thoughts —>■ failure in producing coherent and logically
connected meanings.
Occur in psychotic disorders and some organic mental disorders-
Types :
1. Loosening of associations: 2. Incoherence:
OljjVIj
I ihtllj
Shifting between UNreiated and UNconnected This is a SEVERE degree of loosening of

ideas and subjects. association.
Dorailrneni is a special form of loose association Thoughts or words run together with no
in which the train of thought gradually shifts to logical or grammatical connection resulting in
another subject without any logical connection. DiSORii I ^ /Z i <& thinking.
3. Word Salad: 4. Verbigeration:
This is EXTREME INCOHERENCE. This is meaningless repetition of specific
words. ^ >tj ■bJjiiil
5. Perseveration: 6. Neologism
jjjji CjLaK jj Nehl
|e,9
Cj^ V
/ ' ^
5ixu,Vl 1^
Versistent repetition of the same response to New words invented by the patient
different stimuli (e.g., same answer to different
questions).
Seen in organic mental disorders and deteriorated
schizophrenia.
7. Clang associations aUKil .^tjj;
• Association of words Similar in Sound not in meaning (may include rhyming) e.g. male & mail.
i: Disorders of Stream of Thinking jUuu
Definition :
Abnormalities in the progress of thought including its speed (tempo) and continuity.
1. Flight of ideas: 2. Circumstantiality:
^ <Ua.uU.4 ® Jj'
^ Vj 11 j ijj fajjlt
Flow of thoughts and speech is:
Rapid Slow «04t
Shifting from one idea to another is
Constant Frequent
a central idea or goal
Does not reach Finally reaches
❖ Observed in:
Mania. • Mania, obsessive disorders and dementia.
3. Blocking tiSjill :
Sudden arrest of the train ofthought before a
thought or idea is finished leaving a blank or empty mind.
Observed in Schizophrenia and severe anxiety.
14
C. Disorders of Content of Thinking
Definition :
Abnormalities in the ideas or beliefs contained in thought
I. Delusions: II. Obsessions:LHj'-»j
A delusion is afalse belief. are recurrent, persistent
It is based on incorrect inferences about reality. thoughts, impulses or images that canNOT be
It is NOT consistent with the patient's cultural eliminated Ifom tansciousness by logic or
background. reasoning although the person is aware that
It canNOT be ^flirected by reasoning. they are unreasonable, absurd and alien to him
DELUSIONS MAY BF: (eô- dystonic).
Fixed (complete conviction all the time)or shakable (lacking They are time consuming or associated with
full conviction sometimes). distress and anxiety which increase when the
person resists them.
Systematized (i.e., united by or centered on a single theme or Comnulsinns: If the thought urges the patient
idea with many connected details) or to perform a certain ACT, e.g., obsession of
malsystematized (i.e.. disconnected or shifting from one dirt leads to compiilsiye washing.
theme to another).
Bizarre (i.e., with very strange or absurd content).
N.B. Delusions and Hallucinations occur in
psychotic disorders such as:
■ Delusional disorders.
■ Schizophrenia.
■ PSychotic mood disorders.
■ Some organic or Substance related mental
disorders.
i
1
iisl
1. Delusion ofiGrandeur(grandiosity): Delusion of Guilt or self accusation.
JS I
^ ujUl
JS
• This is false belief ofexaggerated one's • This is a false belief that one is sinful or
importance, power or identity. guilty of bad deeds.
3. Delusion of reference: 4. Delusion of persecution:
bl
cflUA £)Ij
O-jadill Jjj
ftfIjutj
This is a false belief that the behavior of others This is a false belief that one is being
refers to the patient, e.g. belief that people on harassed, cheated or persecuted. The patient
teleyision are talking about the patient. belieyes that some other person or
organization is plotting to harm him.
15
5. Delusion of infidelity 6. Erotomania
(delusional jealousy): (delusion of love):
4
(jlj
This is a false belief(derived from jealousy) that This is a false or delusional belief that
one's lover or spouse is unfaithful. someone is deeply in love with the patient.
7. Hypochondriacal delusion: 8. Somatic delusion:
lit it
j*Ai
AjU
^jc. j»cj (i<aj
This is a false belief, against all medical evidence, This is a false belief involving functioning of
that one is suffering from a disease. the body (e.g., that the brain is rotting or
melting).
9. Nihilistic delusion A^-i*Jl :
• This is a false belief that self, some part of body, others or the world are non-existent.
10. Delusions of influence & control(Passivity phenomena) :
• This is a group of delusions in which the patient experiences an outside control or interference with
his thoughts, feelings or behavior.
a) Delusions concerning the possession of thoughts jtsaVI b) Delusions of control
> Thoiipht insertion ^ AÛ Aîj^ Ijliai At (joaui ; This is a false belief that a
• This is a delusion that thoughts are being implanted in one's mind by person's thoughts, feelings,
other people or forces. actions or will are being
Thought withdrawal j(> »jissl' '"j tyaLA ; controlled bv external
This is a delusion that thoughts are being removed from one's mind fgrtgs-
by other people or forces.
> Thought broadcastiiip jtilj (> ji Aj :
• This is a delusion that one's thoughts can be heard by others, as if
they were being broadcast into the air.
16
CHAPTER IV: Organic Mental Disorders
Definition:
• Group of disorders caused by "demonstrable" organic pathological
conditions affecting the brain.
There are two major categories of O.M.D.
A. Cognitive disorders
These conditions may affect the brain directlv They may be secondarv to general systemic
e.g., trauma. medical diseases e.g. metabolic.
Organic mental disorders in which the most Organic mental disorders in which clinical
prominent features are disturbances of cognitive manifestations resemble those offunctional
functions which may be associated with nsvchiatric disorders (e.g., anxiety, mood,
disturbed consciousness. delusional or personality disorders) but are
Cognition is a elohal term which implies a group caused by a specific organic factor or medical
of psychological functions including attention, condition.
perception , prientation, memory, and thinking.
Cognitive disorders include ❖ Medical disorders include such syndromes:
such syndromes:
1. Delirium Too Much hormone ^
Produced ^ Ta
2. Dementia
3. Amnestic disorders St?
1. Organic anxiety disorder e.g. with

pheochromocytoma and hyperthyroidism
2. Organic behavioral and personalil^ disorders
e.g. following brain surgery and
postconcussional states f\, " MlJt
3. Organic mood disorders e.g., due to hypo- or

hyperthyroidism, and Gushing and Addison's
disease
4. Organic hallucinosis e.g. substance-related
hallucinosis
5, Organic delusional disorder e.g. alcohol-relatqd

disorder
Etiology of Organic Mental Disorders:

1. Head Trauma
2. Brain Tumors, infections, ,cerebrovascular or degenerative diseases
3. Metabolic disorders (e.g., Tyrosinemia, hypoxia, uremia, hypoglycemia, etc...)
4. Endocrine disorders (e.g. Thyroid, adrenal, etc...)
5. Nutritional deficiencies (e.g., deficiency of Thiamine, niacin, etc...)
6. J' jomRS (e.g., lead, organic phosphorous, etc...)
7. SKbstmm-rdated disorders (e.g., alcohol, opium, sedatives,
delta-9- Tetrahydrocannbinol(THC), etc...)
17
Delirium Dementia Amnestic Disorders
^Liuuitl
KMiratfiTftrmff"
Delirium is an acute reversible • Dementia is a chronic nropressive They are isolated
state of global cortical state of global cortical dysfunction. disturbances of
dysfunction. • It is characterized by ppss without
It is characterized by - Mood & Memory disturbance significant
Mood & Memory disturbance - behavioral changes & impairment of other
behavioral changes & - Multiple Cognitive defects cognitive functions.
Multiple iôgnitive defects kMllili[HMl disturbance of
Q3l3lJ disturbance of Consciousness.
Consciousness.
Epidemiology:
10% of hosnitalized surgical or • 2^ of elderly over 65 years
medical patients • 20% of elderly over^ years
20% ofICU patients are reversible if the cause is
Elderlv and voung children treatable
more susceptible, i-*!
Equal prevalence in males and
females
❖ Onset, Course and Prognosis:
• ONSET: ONSET:
- Acute or rapid (over hours or Usually insidious, over months or
Tr^lamus
days). years. Hypothslamus
• COURSE:
'-islA May be acute after severe head
trauma or vascular lesions of the
Shows typical diurnal brain.
fluctuations ofsymptoms with COURSE:
nocturnal worsenin I Usually chronic and progressive
• PROGNOSIS: (over years) ending in death. They are due to
It is a transient condition that May be remittent (e.g., vascular pathological
resolves within days to few dementia). conditions causing
weeks ifthe cause isJreated. PROGNOSIS: damage ofcertain
May be reversible(15%), if the cause diencephalic
is treatable (e.g., endocrine causes). (thalamic) and
midtemporal
❖ Pathogenesis: structures,(e.g.,
• Causes are acute conditions hippocampus,
affecting the brain primarily or • Brain neuronal loss due to neuronal mamillary bodies and
secondary to systemic disease. degeneration or cell death secondary fornix).
to organic diseases ofthe brain.
Deliriu lAmnestic Disorders!

1. Epilepsv (ictal and postictal) 1. Degenerative diseases: 1. Korsakoff s
2. Multifactorial: al Alzheimer's disease jiyiBlrping;
A combination of M bick's disease (frontal lobe - It is the most
minor illnesses and dementia) common cause.
minor metabolic disturbances b) £arkinson's disease - It is caused by

(especially in the elderly) Wilson's disease thiamine deficiency
(Copper accumulates in tissues) usually associated
2. Demyelinating disease, e.g. with alcohol
bisseminated (multiple) sclerosis dependence.

3. Hereditary Dementia, e.g.
Huntington's disease
18
> Head trauma.
> Cerebrovascular disease e.g. strokes
> Meta ?olic, endocrine & nutritional disorders:
Electrolyte imbalance (e.g., Chronic anoxic or Hvpoxic states Hypoglycemia
Hvponatremia, Hvpokalemia, Chronic metabolic disturbances (e.g., Hypoxia
hyperealeemia) renal or Hepatic- failure)
Fluid imbalance e.g. Heart Vitamin deficiency (e.g., tJiiamine,
failure. folate, B12)
Hypoxia e.g._Heart failure.
Hepatic or renal failure •. „ f V
(encephalopathy)
Severe anemia and vitamin
V"*
deficiency (e.g., tliiamin,
niacin)
Substance related (intoxication > Substance related (chronic exposure): > Substance related:
or withdrawal), e.g.. Alcohol Alcohol e.g. Alcohol and
and Henzodiazepines > Toxins e.g. Heavy metal £oisoning, £enzodiazepines
Toxins (e.g., £0, £0 poisoning > iMins e.g.(£0
organophosphorus compounds) > Medications and irradiation. poisoning).
Medication induced (e.g.,
anesthesia, anticholinergic
drugs, Hopaminergics,
antibiotics,).
> Brain Tumor > Brain tumor
> Postsnrgical conditions > Brain surgery
> Infections (e.g., meningitis, > Chronic Infections e.g.
sepsis, urinary tract infection, a) aids dementia (virus)
etc ...) b) £rion causing £reutzfeldt-Jacob
Hisease
Delirium Amnestic Disorders

1. Disturbance of consciousness. 1. disturbed conscious level. 1. Memory impairment
2. Global disturbance of 2. Global disturbance of cognitive Inability to learn new
cognitive functions including: functions including: information or recall
a) /Ittention: reduced ability to a) Disturbed attention, perception and previously learned
focus attention. orientation information.
b) Perception: prominent illusions b) Memory impairment They involve
and hallucinations (mainly Inability to learn new information or O^cent memory
visual). recall previously learned information. and
c) Orientation: disorientation for 1. Initially involves [mote memory
time, followed by place and |H3cent memory imediate recall
persons. followed later by remains
3. T/emory: disturbed immediate jmote memory.
and recent memory.
3. Other manifestations: 2. Other manifestations:
Emotional disturbances! A. Emotional disturbances:
âthy and/or emotional - Apathy and/or emotional lability
lability - Anxiety & Depression(40-50% of
Anxiety, depression. patients)
Agitation, £erplexity & fear. A. Aphasia
A. Apjifixia finability to carry out motor activities)
A. AsnQsia (inability to recognize objects)
19
B. £sychomotor Behavior: B Esychotic symptoms:
Hypo- or Hyperactivity(may - Delusions and hallucinations(20-40%
alternate). of patients).
Sleep-wake Cycle: C. CNS manifestations:
Insomnia, fragmented sleep or Usually late
Reversal of sleep-wake cycle. - Various sensory and motor
Irregular
manifestations
periods
of sleep
- Ultimately the patient becomes
incontinent and bedridden.
D. nisturbance of Executive Eunctions
(planning and organizing thoughts and
actions).
J. Impairment of Judgment leads to
impaired social behavior
(inappropriate or bizarre behavior).
kM,»JIHIlHMlHllHl
❖ Most common type(50-60% of all dementias) ❖ The second most common type (15-30% of all
dementias)
❖ More common in males
Onset earlier than Alzheimer's disease
Onset, Course & Prognosis:

ONSET: ONSET:
Gradual onset, Acute.
May be late (after age 65)or COURSE:
Early (before 65). Stepwise as it reflects recurrent infarcts.
COURSE:Progressive
PROGNOSIS:
Death within 2- 8 years from onset
Degenerative changes, predominantly in parietal ♦> Cerebral infarction and multiple areas of
and temporal lobes (diffuse cortical atrophy, neuronal loss
amyloid plaques and neurofibrillary tangles)
Decreased acetylcholine metabolism and
Slioke
Degeneration ofchoiinergic neurons

❖ Etiology:
Genetic factors nlav a maior role: Risk factors include:
Familial in 40"/o of cases CerebroXascular disease (atherosclerosis,
Significantly more in monozwo^ embolic or thrombotic occlusionêmorrhage)
than dizygotic twins Cardiovascular disease j
Related to Down syndrome (/fypertension, /zeart disease)
4
1. Condition starts with gradual memory 1. Focal neurological(CNS) manifestation^
impairment followed by deterioration of other 2. Patchy Cognitive impairment
cognitive aspects.
2. Aphasia, agnosia and apraxia develop after
several years.
3. Motor and gait disturbances develop later.
4. Finally, the patient becomes incontinent &
bedridden.
0)
20
Delirium Dementia
Treatment of the cause. Treatment of the cause in REVERSIBLE

TYPES (e.g.. vitamin deficiency.
No specific treatment for IRREVERSIBLE
TYPES
Anticholine-esterase (inhibitors) may help
delay memory and cognitive decline.
• Siinnortive measures: tREDt

a) Rehabilitation (physical and psychological)
b) Emotional support for the patient and his family
c) Safe, calm and orienting Environment
d) Maintaining proper Diet, exercise and activities
e) Maintaining physical health and treatment of associated medical Diseases (e.g., diabetes, heart disease,
etc...)
HAimmooL
05
mg Vallum'
IfV-Ofcc.
Rj5P®;STablets Diazepam
FillD'CO Q20tabJ<'
5 mg
Symptomatic treatment for anxiety, agitation or psychotic symptoms, e.g. Haloperidol, Risperidone,
or Benzodiazepines
21
CHAPTER V: Psychosomatic Disorders
■ Psychosomatic medicine deals with the relation between psychological and physiological factors in
the causation or maintenance of disease states.
■ Psychosomatic disorder is considered if psychological factors have influenced the course ofthe
general medical condition.
Most physical disorders are influenced by: stress, conflict, or generalized anxiety.
1. Specific stress factors: 2. Non-specitlc stress factors:

Certain personality are specific for a specific prolonged stress can cause physiological
psychosomatic disorder. changes that result in a physical disorder
E.g. Type A personality Chronic depression.
4.; Neurophysiologic pathways
The general adaptation syndrome : Mediate stress reactions include the cerebral
Prolonged stress activation of hypothalamic- cortex, limbic system, hypothalamus, adrenal
pituitary-adrenal axis —* excess secretion of medulla, and sympathetic nervous system.
cortisol —^ damage to various organ systems. Neuromessengers include cortisol and thyroxin.
[•Ill.llilll.Ulilil msm
1. Skin: alopecia areata. neurodermatitis & pruritis
2. MusculoSkeletal system: tension headaches, backache &
myalgias.
3. Special senses; blurring of vision & tinnitus

4. Immune system: Lupus Ervthematosus. Rheumatoid Arthritis.
5. Endocrinal system: Thvrotoxieosis. Diabetes Mellitus.
6. Respiratory system; Bronchial asthma and hiccough.

7. Cardiovascular system: Paroxysmal tachvcardia. essential
hypertension, migraine, and coronary artery diseases.
8. Gastrointestinal system:
- Peptic ulcer, heartburn,
- Constipation, ulcerative eolitis and spastie eolon.
9. Genitourinary system:
- Disturbances in micturition and menstruation, dyspareunia and
impotence.
REASSURANCE[program in mild cases.

Minor tranquilizers e.g.Qenzodiazepines may give some relief but are liable to induce addiction,
[behavioral therapy includes desensitization; biofeedback techniques are also partially included in
cognitive therapy.
Autonomic blockers (as Seta Sloekers)to eut the vieious circle ofautonomic arousal.
Treatment of Underlying psychiatric disorders.
22
Chapter VI; Substance abuse and dependence
1. Tolerance 2. Dependence
Previous exposure to a drug or to a similar one. This is an adaptive psychological, physiological

Quantitative response characterized by either: and biochemical state caused by the repeated
A usual dose no longer evokes its desired effect exposure to a drug.
A LARGER dose than the previous one must be Continued use of the drug becomes necessary
used to produce the same effect. for the wellbeing ofthe individual.
Sometimes the word "dependence" is used as a
synonym of addiction.
3. Addiction
THE DIAGNOSIS OF ADDICTION: implies the use of a DRUG with the following clinical
criteria:
1. The use of the drug is not upon medical indication
2. Tolerancetsee above).
3. Withdrawal: X
Withdrawal syndrome: psychological or physiological symptoms may occur.
A closely related substancejs, taken to relieve withdrawal symptoms.
4. Compulsive substance taking behavior:
A. The substance is taken in larger amounts or over a longer period than intended
B. A great deal oftime is spent in recovery from substance effects.
C. Unsuccessful efforts to reduce substance use.

D. Social, occupational or recreational activities are reduced.
E. Continuing despite physical or psychological problems.
4. Craving
It is a strong subjective drive to use the substance.

It is experienced by most individuals with substance dependence.
23
5. Substance abuse Gateway substances
It is Repetitive use of substances resulting in These are addictive substances, such as

Recurrent and significant adverse eonseauences: (Tobacco, Cannabinoids; Hashish,
failure to iiulfill major role obligations at work, marijuana, bango) their frequent use has
school or home. been directly related to subsequent abuse and
Recurrent substance use in situations in which it is dependence ofOTHER MORE
physically hazardous fe.g. driying an automobile). DANGEROUS substances, such as Heroin
and cocaine.
Recurrent substance related legal problems.
They are the best predictor of other drug use
during adoleseence.
£ Types of drugs of abuse and Dependence
> Most of substances known to be amenable for abuse and dependence (addiction) can be grouped
into the following classes:
1. Alcohol.
2. Amphetamines and other stimulants.
3. Anxiolytics, sedatives & hypnotics.
4. Phencyclidine [e.g. Ketamine]
5. Caffeine.
6. Cocaine.
7. Cannabinoids [e.g. Bango - hashish - marijuana].
8. Cigarette smoking (Tobacco)
9. Opioids [e.g. Heroin, opium, morphine. Codeine and Codeine-Containing Cough sedatives].
10. Hallucinogens [e.g. LSD,anticholinergics, mescaline ...]
11. Volatile solvents.
> N.B:
- Poly-substance abuse and dependence is common.

Substances may be mixed with others.
24
Nicotine Cannabinoids Cocaine Hallucinogens
Pharmacodynamics
• In the United States nicotine is the FIRST <♦ Cannabinoids; in ACUTE ❖ Cocaine is a ♦> They are central
widely used of all habit forming substances effects, are central nervous psychoactive nervous system
♦♦♦ Nicotine, in mild to moderate doses^ is system STIMULANTS. Stimulant. Stimulants.
STIMULANT effect on CNS by ❖ Cannabinoids exert their ❖ Its action by is ❖ They have both an
enhancing CENTRAL cholinergic receptors effects by increasing : competitive antagonist and an
activated by acetyl Choline. > Acetvlcholine. DOPAMINE, bloekade of agonist effect on
• Nicotine increases: gamma-amino-butyric acid dopamine reuptake Serotonergic^systems.
> DOPAMINE which is responsible for the histamine, serotonin, ^ elevation of ❖ Examples are
DEPENDENCE effect. norepinephrine, opioid DOPAMINE in lysergic acid
> Nor epinephrine, epinephrine, and serotonin. peptides, and prostaglandins. synaptic clefts. diethylamide(LSD)
♦♦♦ Nicotine, in LARGE toxic doses is ❖ The Esychoactive <♦ Cocaine is a white and amphetamines.
INHIBITORY effect on PERIPHERAL compound in cannabinoids powder referred <♦ LSD is Synthetic
cholinergic receptors. is THC.(delta-9- as crack, snow, derivative of ergot
N)
Ol ❖ Nicotine addiction: tetrahydrocannabinol) cock, girl and lady. fungus.
- The criteria of tolerance, withdrawal, and - THC is lipid soluble &
❖ Taken by: <♦ It is ingested :
compulsive taking behavior are easily rapidly absorbed after
inhalation, - Orally or through
established in the daily smoker inhalation & released from
smoking or - Mucous membranes
its adipose tissue stores into
injection. (Sublingual, orally or
ASKvoursell? the blood stream.
❖ One of the most
comeal).
❖ Common forms of
What is the effect in CNS? cannabinoids include addictive & ♦♦♦ It is extremely
How does it exert their effects? hashish, marijuana & bango. dangerous effective even in
❖ Taken by: substances Smalfdoses.
What are the examples? - Cigarette Smoking, orally & ❖ DEPENDENCE
♦♦♦ NO physical
^ How are taken? mixed with tea or food. on cocaine can
dependence.
• Causing abuse and develop after a
^ Is there dependence? Single use.
DEPENDENCE 9
X
DANGER
*1* Toxicity:
❖ Nicotine toxicitv; ♦> Specific criteria for ♦♦♦ Cocaine Hallucinogens
> In low doses: cannabis intoxication intoxication in causing psychiatric
a. Dizziness a. Anxiety high doses disorders:
b. Headache b. Euphoria causing :
c. Cold sweats c. Impaired iudgment

d. Salivation d. Social withdrawal
.'attack
e. Pallor
1. Delirium, seizures.
f. Tachycardia 2. CerebroVascular
g. Hypertension e. Sensation of slowed time Disease. 1. A drug precipitated
f. Impaired motor coordination 3. Cardiovascular psychosis may
h. Nausea & vomiting Disease e.g. continue following
i. Abdominal pains & diarrhea f ❖ Chronic cannabinoids use myocardial the cessation of
& abuse is associated with: infarction which hallucinogen use.
j. Tremors /'\
/ j\ 1. Amotivational syndrome may lead to death. 2. Flashbacks are
k. Weakness leading to poor social and *1* Cocaine -related - Brief spontaneous
> At higher doses: vocational functioning. disorders ; recurrences of
1. Seizures 2. £sychiatric disorders such - Anxiety disorders percevtual chanses.
2. Hypotension as anxiety, bipolar mood - Psychotic such as experienced
3. Respiratory arrest disorder, depersonalization, disorders while using
and dissociative - &xual dysfunction hallucinogens.
❖ NB; Death is the primary adverse effect of 3. Cannabinoids increase risk - Seep disorders - They have been
cigarette smoking. for - Mood disorders reported days, months
Causes of death include: Decompensation of or years after druy
1. Cerebrovaseular disease. pre-existing psychiatric use.
2. Cardiovascular disease. disorder &
Exacerbated of affective
3. Chronic bronchitis. disorders and paranoid
4. Emphysema. symptoms.
5. Bronchogenie cancer.
❖ Nicotine withdrawal (nicotine abstinence Cannabis withdrawal: <♦ Cocaine Hallucinogens
syndrome): Anxious mood or Irritable withdrawal Tolerance quickly
Symptoms : Tremor symptoms: develops, leading to
Anxiety. M?.W..dMVKkQRQ.?:S - Depressed mood ingestion of larger
Irritability, restlessness, impatience, Perspiration (Sweating) - Dysphoria doses or increased
confusion. Nausea frequency of use.
Depressed mood or Dysphoria They are NOT highly
Decreased concentration. addicting.
Desire for nicotine. Have weak
Signs: reinforcing properties
Insomnia^ Neither physical
Increased reaction time (reaction is slowed dependence nor a
down). withdrawal syndrome
••
Decreased heart rate Fatigue, been demonstrated in
> N.B. HyperSofMolence animals or humans
I. Most symptoms and simis:
- Develop within hours after stopping
- Reach a maximum intensity within
1-2 days.
- Then gradually decrease over the following
2-3 weeks.
- However, urge or desire for nicotine (craving),
can recur for years after cessation. Strong Craving
II. In presnant womeiu Suicidal ideations
- nicotine crosses the placenta to the fetus
causes:
1. Slow growth in utero and lower than Symptoms persist

average birth weights.(lUGR) for a few days up
2. Increased incidences of persistent Pulmonary to one week.
hypertensiorii
pulmonary hypertension. tPPH)
Qpioids Alcohol Benzodiazepines
G Pharmacodynamics
Opioids are CNS suppressants 90 % of USA population are using alcohol. Benzodiazepines are
❖ Qpioids exert their effects bv activation of In the United States alcohol is SECOND psychoactive depressant
endogenous opioid receptors. most widely used of all habit forming drugs; used to control:
❖ Forms of opioids; substances. Induction of Anesthesia.
Opium, morphine, heroin, codeine and some ❖ Effect on the brain: Anxietv
analgesic opiate derivatives. 1. No mediator for the effect of ethyl alcohol. Epilepsy
Opioids are highlv addicting. 2. Alcohol enhances : Tolerance & dependence
Acetyl choline, to benzodiazepines is
❖ Acute effects of onioids Serotonin and GABA receptors common either
1. Central nervous system effects: 3. Alcohol inhibits glutamate receptors alone which is more
Analgesia 4. Alcohol is a CNS suppressant in common in females
Sedation descending manner : or
Mood changes Higher cortical centers are inhibited first —> In combination with other
Mental clouding. euphoria and then disinhibition. drugs e.g. heroin, cocaine,
Central nausea and vomiting In larger doses, alcohol and stimulants.
2. Pupillary constriction (???) lower vital centers are inhibited —>■
3. Respiratory depression: hypotension and respiratory depression.
This is the usual cause ofdeath from opioid
overdose ❖ Alcohol-related disorders : <♦ Benzodiazepines
4. Gastrointestinal effects: 1. Alcohol abuse and dependence. Intoxication
Decreased gut motility. 2. Alcohol induced amnestic disorders. includes:
3. Alcohol induced psychotic disorders e.g. 1* Aggression and
❖ N.B. severe intoxication delusions and hallucinations. Behavioral disinhibitiom
is diagnosed by the triad of: 4. Alcohol induced dementia. A 2. In higher doses causing :
Coma 5. Alcohol related mood disorder. ' - LOW Blood pressure
Pinpoint nunilst???! 6. FETAL ALCOHOL SYNDROME :\ ^ - Central respiratory
Respiratory depression. • In mothers, drinkins alcohol fetuses are depression, particularly if
It is a medical emergency that requires immediate exposed in utero to alcohol causing : taken with another
attention - Mental retardation depressant drug e.g.
- 35 % risk of having a child with deficits. alcohol.
Qpioids withdrawal syndrome: 7. Alcohol withdrawal syndrome due to Benzodiazenines
Time of onset differs according to the half-life of sympathetic over activity, Withdrawal symptoms
the drug used: e.g. > Clinical presentation ; xV
4-6 hours after the last use of heroin but up to 36

hours after the last use of methadone.
Severity varies with the dose and duration of drug
use.
Early findings "N
mmm
m mOER
-QEIHELP
imm
NORXMl
^ Rebound Anxiety,
Agitation & restlessness
B. HIGH Blood Pressure &,
tachyCardia.
C Epileptic Convulsions
(Seizures) is a serious
1. Qpioids Craving. emergency and may be
A. Agitation, tremulousness, sweating, fatal.
2. Central nervous system symptoms
include irritability, restlessness and insomnia. restlessness and excitement.
3. Cutanepus and mucocutanepus symptoms R Psychotic symptoms e.g. delusions and ^ Hosnitalization and
include lacrimation, rhinorrhea and piloerection, hallucinations gradual withdrawal are
also known as gooseflesh. C. Epileptic Convulsions (Seizures) the main lines of
D. Delirium tremens treatment.
4. TachyCardia, hypertension, pupillary dilatation,
and diffuse musculo-skeletal pains. Prevention of seizures by
5. GaMrpinte^ are anorexia, N.B.; Benzodiazenines ^ treatment of antiepileotics.
vomiting, abdominal Colics, and diarrhea. choice for alcohol withdrawal svndrome.
Management of substance abuse/dependence
£ Pharmacological treatment
1. Addiction is not a matter of moral weakness or lack of will. 1. Search for agents that may:
- It occurs when a drug hijacks one's brain & then one's life. a. Decrease the reinforcing properties of substances
2. Initial drug use is a voluntary behavior. b. Decrease craving associated with substances
- However over time, users lose control over their drug use. c. Replace the function of the drug abuse
To deal with addiction effectively requires a shift from blaming 2. Nicotine replacement in nicotine dependence:
addicts to treating them. • Using nicotine gum, patch, spray and inhalation
4. Substance abuse is a highly heterogeneous eondition that • Successful results especially when combined with behavioral
requires a wide range of treatment modalities. and psychosocial treatments in the management of nicotine
dependence.
5. Two major goals for substance dependence have to be 3. Naltrexone : 4. Methadone :

determined: • An opiate receptor • An opiate receptor agonist
- Thefirst IS Abstinence from the substance. blocking agent
- The second is Physical, Psychiatric, and Psychosocial wellbeing • Decreasing alcohol • Effective in abstinence
of the patient. consumption and relapse in from opiate use.
6. Initial treatment approaches may be conducted in either
alcoholic patients.
inpatient or outpatient settings.
7. After initial periods of detoxification, patient needs a sustained

period of rehabilitation.
8. Self-help groups e.g. Alcoholics (or narcotic or cocaine)
anonymous are considered the mainstay oflong term treatment
9. Throughout treatment, individual, family, and group therapies
can be effective.
10.Any underling psychiatric disorder should be diagnosed and
appropriately treated.
CHAPTER VII: Anxiety Disorders CjUtjlofcil|
[XMiratrnnrnfl
• They are the most prevalent group ofpsychiatric disorders.
• Anxiety is a feeling of apprehension caused by anticipation of an
ILL- defined threat or danger that is NOT realistically based.
• It is differentiated from/ear which is the emotional reaction to a
known, well defined external threat or danger.
Normal and Abnormal.Anxietv:^^^K^^^
❖ Normal Anxietv: cjULaiaVl Abnormal Anxietv:
■ Anxiety to serve an adaptive function ■ Anxiety Disorders due to maladaptive use ofego
■ Alerting signal that warns of a threat and defenses in controlling the anxiety provoked by
motivates the person by improving the the conflict.
performance e.g. anxiety associated with ■ Abnormally severe, pervasive, persistent,
examination. irrational, inappropriate, handicapping &
deterioration in performance.
♦♦♦ Etiology of.Anxiety Disorders:

• It is a comulex interaction of biological, psychological and social factors. |
1. Biological Factors: 11. Psvchosocial Factors:
I. Genetic Factors: I. Behavioral(Learning)theory:
• More frequent in First degree relatives of • Faulty of conditionina e.a. Fear non-harmful
patients than in normal. stimuli or
• More frequent in Monozveotic than in dizvaotic • Observational learnina e.g. Modeling bv an
twins. overanxious adults
2. Autonomic over activity: 2. Cognitive theory:
• Overactive autonomic nervous system ■ Overestimation of danaer in a aiven situation
—>■ t Svmoathetic tone leadina to: ■ Underestimation of the ability to cope with
—»■ Excessive response to moderate stimuli Ar, perceived stress.
Slow adaptation to repeated stimuli.
2. Neurotransmitter dysfunction: 3. Dynamic views
• Dvsreaulation of neurotransmitter svstems are ❖ Vulnerability to anxiety disorders start since
implicated in anxiety disorders: early staaes of child develonment. e a :
A. Norepinephrine A. Traumatic psycholoaical exneriences e.g. sexual
B. Serotonin abuse
C. Gamma amino butvric acid (GABA) B. Defective ego development due to defective
parenting..
C. Unresolved intrapsvchic conflicts over the
expression of instinctual drives e.g. sexual
impulses aaainst the re.straints ofthe superego or
external reality.
❖ N.B. Anxietv disorders associated with substance abuse/dependence or with a eeneral
condition are diaanosed accordina to their etiolopical factor.
E Classification of Anxiety Disorders:

1. Phobic Disorders
2. Panic disorder.
3. Generalized anxiety disorder(GAD).
4. Obsessive-Compulsive Disorders(OCD).
5. Posttraumatic Stress Disorder(PTSD).
31
MaiiirestiUions of Anxietv:
I.
Physica Symptoms:
A. Symptoms of autonomic arousal (sympathetic B. Somatic Symptoms:
and parasympathetic):
1. Feeling dizzy, unsteady & fainting. 1. Fatigue
2. Flushing or pallor 2. Headache
3. Sweating 3. Parasthesia (numbness or tingling)
4. Dry mouth 4. Muscle tension

5. Difficulty swallowing 5. Muscle aches
6. Tremors
6. Palpitation ,Tachycardia ,missed beats
7. Chest pain or discomfort.
Physical Effects of Anxiety Disorders
8. Shortness of breath ,Hyperventilation Dizziness, decreased
9. Hypo or hypertension sex drive, irritability
10. Nausea or abdominal distress & colics Sweating Increased muscle

11. Diarrhea tension
Chest pain
12. Frequent or urgent micturition
Rapid breathing &
13. Sexual dysfunction breathlessncss
14. Menstrual disturbances e.g. amenorrhea Heart palpitations
Increased blood
pressure
Nausea or diarrhoea
11. Psychological Symptoms:

1. Fearful anticipation (sense of impending danger)
2. Insomnia
3. Irritability (^VWAT IF^.^
4. Restlessness
5. Worrying thoughts
6. Poor concentration
7. Hypervigilance (over-alertness, startle response
Restless
32
I. Panic Disorder c^tjiaJal
• piscretg. attacks of anxiety with NO external stimulus.

nnânTmnrg
Male to Female ratio is 1 to 2
Lifetime prevalenee: 3-5 %
Most ofthe patients have Other psychiatric disorders e.g. depressive disorders.
Age at onset, course & prognosis:
ONSET: early adulthood, mean age at onset is 25 years.
COURSE: Chronic course with remissions and exacerbations
PROGNOSIS: Good to excellent prognosis with therapy
m
1. Recurrent spontaneous or unexpected tAcute) panic attacks.
2. The Panic Attack:
• A discrete period of intense anxiety NOT related to any particular situation.
• It develops Abruptly (Acutely):
Reaches the peak over 10 minutes, and lasts for a limited time; 5-30 minutes.
During the attack there are a MIXTURE ofthe following symptoms :
A. Physical anxiety symptoms: B. Psychological symptoms
1. Feeling dizzy, unsteady & fainting.
2. Hot Flushes VM AFIVÎD
3. Sweating
4. Palpitation, Tachycardia
5. Chest pain or discomfort.
6. Shortness of breath 1. Fear o/'loss of Control or going Crazv.
2. Fear ofDying.
7. Nausea or abdominal distress & colics
8. Diarrhea 3. Depersonalization and/or Derealization
7. Parasthesia (numbness or tingling)
8. Shivering (chills)
9. Shaking or trembling
10.Sense of chocking
11.Sense of Smothering
3. It may be associated with Agoraphobia (about 1/3 of patients).
4. Diagnosis of panic disorder is made if:
The attacks are Repeated (4 attacks in a month).
Anticipatory Anxiety i.e. the patient becomes concerned about haying additional attacks & worry about
the imnlications of the attacks e.g. deyeloping a heart attack.
5. Differential Diagnosis of Panic disorder:
Asthmatic attack
Eheochromocytoma
Acute£ardiac conditions (ischemic attack or arrhythmia) because of abruptness of the attacks and their
typical physical symptoms
Decreased blood glucose leyel( Hypoglycemia)
33
11. Phobic Disorders
• Phobic disorders are the most common psychiatric disorders.

• Phobia is FEAR related to a particular certain object, situation, stimuli.
• Diagnosed if:
The experienced fear is intense or
Causing the patient to avoid the phobic object that limits his activities and impairs his functioning.
According to the phobic object, they are classified into:
AgoraphobialHH
1
■ Male to Female ratio is 1 to 2 ■ Males and females are ■ Male to Female ratio is 1 to 2
■ Lifetime prevalence is 2-6 % EQUALLY distributed ■ 6-month prevalence is 5-10 %.
■ 50-75 % of patients have a co- ■ Lifetime prevalence is 10-15 ■ Lifetime prevalence is 10-25
morbid PANIC disorder. %. %
■ Patients may have other e.g. ■ 25% of patients develop - THE MOST COMMON
depressive disorder. major depression. ANXIETY DISORDER
■ Its name came from Agora -
market
Age at Onset, Course «& PrognosisrHH^^^^^^^^^^^^^^H
■ ONSET: at any age, usually ■ ONSET: in teens or later in ■ ONSET: childhood.
late 20 years. life - COURSE: chronic.
■ COURSE:chronic. ■ COURSE: chronic ■ PROGNOSIS:
■ PROGNOSIS: ■ PROGNOSIS: good with Good to excellent with therapy
Association: therapy If untreated, it may spread to
Panic disorder is common include more objects.
Agoraphobia usually improves
with reduction in panic attacks.
1. It is Intense Irrational 1. It is Intense Irrational 1. It is Intense Irrational

FEAR of being in places in FEAR ofscrutiny i.e. being FEAR ofSpecific object or
which escape is difficult or critically observed by other Specific situation NOT
embarrassing e.g. crowded or people. including the situations
mentioned in agoraphobia and
social phobia.
e.g., flying, heights, animals,
blood, etc...
2. The patient FEARS and 2. The person FEARS of 2. The phobic situation is
avoids wide places, highways, negative evaluation & avoids avoided, or tolerated with
bridges. all situations in which he intense anxiety or distress.
anticipates anxiety
3. It may occur alone or in 3. The person recognizes that his 3. The person recognizes that his
association with panic fear is excessive or fear is excessive or
disorder unreasonable. unreasonable.
4. It may be complicated by 4. It may be complicated by functional impairment due to loss of
substance abuse, e.g. alcohol opportunities in education & due to social restrictions.
and benzodiazepines to
alleviate anxiety and social
distress.
34
III. Generalized Anxiety IV. Obsessive-Compulsive V. Posttraumatic Stress
Disorder(GAD) Disorder(CCD) Disorder(PTSD)
abdt uljiaJat Jxj La ut
• Generalized, persistent • Anxiety is provoked by • Anxiety symptoms following

state of anxiety not related attempts at resisting exposure to a life-threatening
to a certain stimulus. obsessions and compulsions. situation
• Male to Female ratio is 1 Lifetime prevalence is 2-3 % 1. Exposure to a severe traumatic

to Z across different cultures. event that involves threat of
• 1-year prevalenee: 2-8 % It is slightly more common in death, serious injury, or personal
• Lifetime prevalence; ^5 % safety, e.g.
Males than in females.
• 50-90 % of patients have ■ War, violent assault, rape,
Two third of cases develop
other psychiatric disorder explosion, torture, natural
M A.fOR denression
e.g. depressive disorders. disasters, etc...
2. Witnessing the traumatic event
being inflicted on somebody else.
Age at onset, course & prognosis:
ONSET: early 20 years. ONSET: adolescence or early ■ ONSET: following exposure to a
COURSE: chronic, but adulthood. life-threatening situation
symptoms may decline COURSE: chronic with waxing ■ COURSE: Chronic with re-
with age and waning of symptoms. experienced periodically for
PROGNOSIS: PROGNOSIS: several years.
VaRlAbLe with treatment Most cases improve with SSRIs ■ PROGNOSIS: WORSE with
preexisting psychiatric
Association: Secondary
conditions.
depression is common
4 i t t e
[
1. All psychological or 1. Patient experienees obsessions 1. Persistent re-experieuciug of
physical symptoms of and/or compulsions. They are : the trauma:
anxiety may be 2. OBSESSIONS are REcurrent A. Recurrent recollection ofj^ges

experienced. Intrusive Ideas, Images, ofthe trauma. 7m.
2. Apprehensive Impulses or thoughts. B. Recurrent illusions, 'llyj
expectations i.e. 3. rOMPIIl SlONS are
hallucinations, flashback .
excessive anxiety or REuetitive:
C. Recurrent distressing dreams of
the event
worry over several - Behaviors e.g.. hand washing
2. Efforts to avoid recollecting the
activities in life e.g. work &
trauma:
3. Anxiety is Eersistent for Mental acts e.g., counting
A. Avoidance of stimuli associated
more than 6 months. 4. Obsessions and compulsions
experienced by the patient with the trauma e.g. places
4. Control of anxiety is B. Amnesia for important aspects
characterized hv:
difficult ofthe trauma
5. Anxiety causing C. Numbing of general
Recurrent
significant Distress & Causing anxietv. distress & responsiveness e.g. diminished
impairment of function. impairment in functioning. interests
3. Hx'perarousal:
Time consuming & ^.
A. Exaggerated Startle response
- Ego- alien (unwanted)^'^^^^.^ R Sleep disturbance
- £xeessive & Hwreasonable. C. Difficulty concentrating
D. Irritability
35
I. Pharmacotherapy: ABCs II. Psychotherapy: BCDE
1. Anxiolytics e.g. Benzodiazepines e.g. B. BehavioralTherapy:
• Alprazolam ■ It is indicated for phobias, OCD and panic attacks.
• Diazepam ■ Techniques used include;
y They are mainly used to control acute symptoms & for short term - Exposure techniques
therapy. - Response prevention and stop-thought techniques (for O.C.D.)
• Caution: - Relaxation techniques.
- Lon^ term use causes physical devendence.
2. Beta-blockers e.g. C. Cognitive-behavioral therapy:
• Eropranolol to control symptoms due to sympathetic activity ■ It is indicated for GAD and Panic disorder.
3. TriCyclicantidepressantse.g. D. PsychoDynamic (insight-oriented) therapy
• Clomipramine ■ Its goal is to develop insight into intrapsychic conflicts with positive
• Imipramine changes.
> Tricyclic antldepressants are effective in most anxiety disorders hut have
much more adverse effects.
4. Selective Serotonin Reuptake Inhibitors(SSRIs) e.g. E. Supportive Psychotherapy:
• Sertraline ■ It can provide an Emotional support.
• Fluvoxamine
> SSRIs are particularlv useful in OCD,phohic disorders & panic disorder.
> SSRIs are effective in most anxiety disorders & characterized by less
adverse effects.
MENTAL REST
3 Dreams
is not what you see
in sleep
is the thing which

doesn't let you sleef
- A. p. J. Abdul Kalam
rTFTTTTfTT1 erne gene rator.not
One day,
QUOTE BY ABDUL KALAM: ^ youll be
jMsf a
I'm Not a HANDSOME Guy, 'memory
IBut I Can Give My for some
IHAND-TO-SOME One people.
'Who Needs Help..
Do your
Beauty is in Heart, is best
to be
!Not in Face..
a good
one.
Lesîonii Learned /n Life

CHAPTER VIII: Somatoform Disorders
KMiTgrmrmni
Somatoform disorders: group of disorders that include nhvsical enmnlaints without adegnam nhvsical exnlanatinn.
There is usually an absence offindings or only minor findings on physical or laboratory examination.
❖ Types:
I. Somatization Disorder II. Conversion Disorder III. Hypochondriasis
uljlaJaj JjiUjll uljiauftj ijfa ^jj uljIaJaj
a Dctinitioii & Course and prognosis:^^!
• A disorder involving one or more • lExcessive concern about diseasi and
- Cannot be exnlained medically and is associated with: neurological (sensory or motpr breoccunation with one's health.
- Psychosocial distress and fevmntomsl e.g.. naralvsis. blindness • It is a chronic, relapsing condition with
Medical help- seeking. or parasthesia that waxing and waning symptoms.
It requires a history of persistence for several vears - Cannot be explained bv a known • Favorable nropnosis is with-
duration, beginning before the age of30. medical or neurological disorder. Acute onset.
• It is a chronic illness with fluctuating course. - Absence ofpersonality disorder.
Presence of a treatable anxiety or depression.
Stable socioeconomic status.
• Lifetime prevalence is 0.2 - 0.4%. • The lifetime prevalence is 33% • It represents 3-14 % of all patients in general
• 5-20 more common in women than in men. • It is more common in females. medical practice
• Common in illiterates with low socio-economic classes • Common in illiterates with low • More common in MEN
• It runs in families. socio-economic classes & rural
population.
1. 1. Augmentation of normal bodily sensations

2. Cognitive impairment that result in faulty perception of personality disorder e.g. histrionic by sick role.
somatosensory input. 2. Emotional stress & conflict. 2. Due to underlying disorders e.g. depressive
disorder, panic disorder, GAD or OCD.
0^ ^"HI-)It (jiljcVl j&i

1^1 J 4 nil ftb ^ ftjjjill ^1^
JU llfti ôlui AJL
Somatization Disorder Conversion Disorder Hypochondriasis
1. Conversion or pseudo-neurological sympto The patient has one or more
see
A. Amnesia, Aphonia (loss of voice) neurological (Sensory or motor) wlxiclx
B. JBlurred vision, Blindness symptoms illness I
C. Loss ofConsciousness, Convulsion It is associated with pAychological liave
D. dizziness & Fainting Stresses e.g. frustration. today!
Deafhes^'
Double ■vision
> Difficulty swallowing,
> Difficulty walking, muscle weakness,
> Difficulty urinating , urinary retention The symptoms are UNconsciously
produced to
2. Cardiopulmonarv symptoms: Alleviate the anxiety and to
• Shortness of Breath without exertion, Gain sympathy& attention. 1. Unrealistic physical symptoms leading to
Palpitations, chest Pain. Physical symptom is NOT UNder fear that one has a serious disease.
3. Gastrointestinal symptoms: voluntary control.
• Abdominal pain , Bloating 2. Persistent fear of disease despite appropriate
• Nausea, vomiting. Diarrhea, medical reassurance.
• Dyspepsia
c)
The patient is abnormally calm^^—y
despite the seriousness of symptoms
4. Pain symptoms: (Belle Indifference).
• Pain in extremities, back & It was previously called Conversion 1. Treat any comorhid psychiatric disorders
joint pain, & Pain during urination Hysteria. e.g. depressive disorder, panic disorder, GAD
5. Sexual symptoms: or OCD.
• Painful menstruation Short term psychotherapy, including 2. High doses of SSRIs show promising results
• Pain during intercourse family education 3. Behavioral Cognitive psychotherapy
• Burning sensation in sexual organs. Conscious solving of the stress 4. Group psychotherapy
• Sexual Indifference & Impotence Minimal dose of anxiolytics
LMiillfJilJilfJ'.liJ NB : Telling such patients that their

1. Long term psychotherapy, empathic relationship with a symptoms are imaginary often makes
single physician. things worse.
2. Behavioral Cognitive psychotherapy.
3. Avoid unheeded medication e.g. analgesics.
CHAPTER IX CHAPTER X
Dissociative Disorders Adjustment Disorders
S
State of disrupted : The development of emotional or
Memory,£ereeption of the environment, behavioral Symptoms in presense
Consciousness or identity. of/iSychosocial Stressors.
They are Short episodes & there is Symptoms are:
Synchronization (association) in time between Either: Functional impairment
the onset of Symptoms and Stressfiil events. e.g. social, occupational or
There is NO evidence of a medical or educational
neurological disorder that explains those Or: marked distress in excess of
symptoms. what would normally be expected
Dissociation arises as a defense against trauma for the given stressors.
produced unconsciously for helping victims to I he symptoms:
remove themselves from trauma at the time it Must occur within 1-3 months of
occurs. the occurrence of the stressor, and
They were previously called Dissociative Must remit within 6 months
Hysteria following the cessation ofthe
stressor.
The disturbance must NO 1' fulfill

the criteria for another major
psychiatric disorder.
More common in females than in males. • Male to female ratio is 1 to 2.

It is more seen in younger individuals and • More common in adolescents,
decreases with age. hospitalized medical and surgical
Dissociative symptoms may co- exist with patients
conversion symptoms
<♦ Clinical Types:
1. Dissociative Amnesia: I. Adjustment disorder with
depressed mood;
• Insomnia
• Low self-esteem
• Depression
1. It is the commonest tvne . • Suicidal ideations
of dissociative disorders. K
2. There is amnesia about a stressful event.
3. Apart from amnesia, the patient appears
completely intact and functions coherently.
- There is intact memory of general information.
- The capacity to learn new information is
retained.
4. Amnesia is
- Commonly selective to the event (localized
amnesia), or
- Less commonly global (generalized amnesia)
40
2. Dissociative Stupor: 2. Adjustment disorder witf
anxiety:
• GAD I f-
• There is marked • Increased motor activity
diminution of voluntary movement and speech.
• There is normal muscle tone, reflexes and
breathing.
3. Dissociative Fugue 3. Adjustment disorder with
disturbance of conduct:
• Impulsivity
• Lack of insight
• Violent behavior.
• The individual travels in a journey away from
his usual places.
• There is partial or complete amnesia for the
iournev.
4. Dissociative Identity Disorder 4. Adjustment disorder with
jLkijVt ujljiaJal disturbance of emotion and
conduct:
• Mixture of mood and conduct
disturbances.
• Two or more distinct personality controls the

individual's behavior.
• Each personality state has its own pattern
thinking.
• Almost all patients report dissociative amnesia,
a loss of memory for personal history.
5. Dissociative Trance and Possession Disorder
Trance cj|jla*ial is '
Narrowing of awareness of immediate
surroundings or
Stereotyped behaviors i.e. being beyond one's
control.
Possession ujljkua) is r"' rVi V
Replacement of the customary sense of
personal identity by a new identity attributed to
the influence of a spirit, power, holy being, or
other person; and associated with
Involuntary movements^
There is usually amnesia about what happened
during the episode.
1. Anxiolytics & Antidepressants.

2. Psychotherapy to the patient.
3. Psycho-education to families.
41
CHAPTER XI: Mood Disorders
Definition: Mood Disorders are a group of psychiatric disorders where a disturbance of mood is the
salient feature either low mood (depression) or high mood (elation).
I. Depressive Disorders(Maior depressive disorder & dysthvmic disorder)

II. Bipolar Disorders
I. Depressive Disorders H. Bipolar Disorders
. Major depressive disorder ulailt Ûj(jiajA
(unipolar depression)4^1
❖ Epidemiology
Sex: Twice in women than in men. Sex: NO difference between males and
Age at onset: all age groups, most commonly 20-40 years. females.
Marital Status: More in divorced and widowed than in Age at onset:
single and married persons. All age groups; it has an earlier age of
Socio-economic Status: More common lower socio onset than major depression with an
economic classes. average of30 years.
I. Biological Factors:
1. Genetic Factors: A. Genetic Factors::
First degree relatives of patients are 2^ more likely to
1^ IIIUIA- l.\J First-degree relatives of bipolar
have major depression than controls. disorder are 8-18 more likely to have
Concordance rate for: the disease than controls.
MfllUizygotic twins is 50 % &
Dizygotic twins is 25 %
2. Neurochemical Factors:
9) Concordance rate for
Mono/vgotic twins is 60 % &
Dizygotic twins is 15 %
B. Substance Abuse:
There is dvsregulation in norepinephrine, serotonin and Adolescents who use cannabinoids
dopamine. are at risk at developing bipolar
A Hormonal Factors: disorder.
Hyperactivity ofthe Hypothalamic-Pituitary- Adrenal axis
cortisol secretion ^ suppression ofthe immune
functions.
II. Psychosocial factors
Negative Life Events e.g. divorce, reported 6-12 months C. Negative Life Events
before the onset of first episode of major depression.
Reported 6-12 months before the onset
of manic episodes.
2. Early trauma in childhood e.g. death of one parent
3. Chronic Stress
Prolonged stress attitude of learned helplessness —>:
Corticosteroid levels remain elevated,
I Norepinephrine, serotonin dopamine, and GABA
BgtifTmiiMBS
I. Major depression may manifest as a single episo^ oi^: Bipolar disorders are a group of mood
recnrrent episodes. .J disorders characterized by :
2. Diagnosis is based upon the presence of: ' Recurrence of either manic or
A. Depressed mood : sadness, hopelessness, hypomanic episodes.
, helplessness or With or without history of a major
B. Anhedonia for two weeks; is diminished interesti depressive episode.
or pleasure in all or almost all activities. • V3i ^ There may be a mixed episode, i.e.
3. The patient is typically worse in the morning (diurnal AManic and /Major depressive symptoms
variation). iji the same episode.
42
4. Other symptoms of major depression include;
■ Sleep disturbances: typically there is insomnia (there may be
hypersomnia).
■ Poor concentration.
■ Depersonaiization and derealization

■ Tendency to social withdrawal.
■ Decline in vocational functioning.
2. Manic episode (at least for 1 week , or
any duration if hospitalization is
"N.,',1,1 — required) consists of a :
A. Hyperactive, increase in goal-directed
activities.
Fatigue or loss of energy. B. Distinct £eriod of£ersistently
Psychomotor retardation: slow mental and motor performance. elevated, expansive, or irritable mood.
Diffuse bodily complaints, pains of no possible physical origin.
Loss of appetite with loss of weight or overeating. C. There may be p5v3ioBH[ea!u^

Loss of libido, impotence in males
Feeling of worthlessness ,. D. decreased need for sleep,

Excessive self-blame and guilt. , 12istractibility.
Recurrent thoughts of death ' E. Excitement and aggressive behavior
(fear of death or suicidal ideation). F. Elight of ideas, volubility
5. Cognitive misinterpretations:
The patient only perceives the negative aspect of self and G. £irandiose thinking or inflated self-
life experiences^ esteem
There may be in the form of
j: When present they are either. 3. Hvpomanic episode is
• Similar to a manic episode, but the
Symptoms are flat severe
- ^psychotic features.
Hospitalization is not required.
❖ N.B.: Manic or hvpomanic episode:

Mood Congruent i.e. psychotic symptoms accusing the patients or depressive svmptoms transientlv
insulting him e.g. delusion of sin, nihilistic delusions, or hallucinations,) or precede the appearance offlorid manic
Mood incongruent i.e. psychotic symptoms not appropriate with mood or hypomanic symptoms.
e.g. commanding hallucinations.
4. Depressive episode with past history
of a manic or hypomanic episode
6. Major depression is complicated bv malignancies. 5. Mixed episode
infections and coronary ischemia, uncontrolled diabetes.
The Economic and Social impact
In October 2001, the WHO published in its yearly report In 2001, the WHO published in its
that: yearly report that:
Unipolar Depression occupies the Eirst position in the list Bipolar Disorders occupy the 9th
of causes ofdisability in the age range of 15-44 years. position in the list of causes of
It was the Fourth leading cause of death in the same age disability
range.
It was estimated that by the year 2020, it will rank second
on the list of causes of death after ischemic heart disease.
Course and Prognosis
THE COURSE: up to 2 years or longer. PROGNOSIS is less favorable :
THE PROGNOSIS: 45 % have a chronic disorder with
Recovery from an acute episode is good partial improvement on medication.
75 % of patients experience recurrences episodes. 50 % of patients experience
recurrences episodes.
43
Dysthymic disorder (Depressive Neurosis)
❖ It is a chronic depressive illness with insidious onset
More common among the first degree relatives with major

depression.
2. Less severe than Major Depressive.
3. Age of onset is usually younger than in major depression.
Those with onset during childhood or adolescence have a
greater risk to develop major depression later in life
(Double Depression).
The clinical picture includes a persistent depressed mood
for MORE THAN two years & at least two ofthe
following symptoms:
A. Sleep problems
B. Poor concentration or - /o/ ^ iOsi
difficulty making decisions.
C. Fatigue.
D. Poor appetite or overeating.
E.
disorderill^l^Hljj^l Bipolar Disorders

1. Hospitalization ,indication :
• Severe cases • Patient represents a potential threat to
• Mandatory in suicidal cases. himself or to others.
• To start pharmacological treatment.
2. Pharmacotherapy:
❖ Antidepressants: 1. Mood stabilizers e.g. Lithium &
1. Tricyclic and tetracyclic antidepressants: antiepileptics.
Inexpensive with many side-effects. 2. Antipsychotics :
2. SSRIs: A. High-potency antipsychotics e.g.
Expensive with less side-effects. Haloperidol to control of psychotic
Used if no response to TCA. features
Dmgs of choice for Dysthymic Disorder. B. Low-potency antipsychotics, e.g.
❖ General rules : Chlorpromazine to control agitation
A. Maintenance treatment should be continued for :
At least 6 month to prevent relapse.
B. Long treatment is needed with: Ifthe patient presents with a
9
chronic or recurrent major depression depressive episode: DANGER
C. Maximum Dose for sufficient Duration should be Antidepressants are avoided to
administered before shifting to second lines oftreatment. prevent shifting the patient into
D. Efficacy of antidepressants is reinforced by addition of Rapid Cycling Bipolar Disorder, i.e.
other drugs such as: the patient had at least 4 episodes
Mood stabilizers e.g. Lithium & antiepileptics. within 12 month period.
- Antipsychotics
3. Electro-Convulsive Therapy(ECT),indications:
1. Refractory Depression Resistant cases.
2. Drugs (antidepressants) are contraindicated for medieal reasons. To coxAxol pSvchotic features.
3. Associated pSvchotic features
4. Suicidal patients
4. Psychotherapy: 4. Prevention of relapses:
❖ Psychotherapy in conjunction with antidepressants is more 1. Prophylaxis by the use of mood
effective than either alone : stabilizers (lithium or anticonvulsants)
1. Cognitive Therapy: the negative cognitive symptoms. 2. Therapeutic alliance with the patient and
2. Supportive Psychotherapy: to prove emotional support. his family to monitor early signs
3. Family therapy: when patient's depression due to family events. 3. Family education about management.
44
Chapter XII: Schizophrenia
KMiTgrtmJmTP
Chronic heterogonous psychotic disorder that shows marked disturbance in thought, behavior & mood
that lead to impaired functioning and deterioration of personality.
The disturbance lasts for at least 6 months with at least a month of active phase symptoms; that is,
two or more ofthe following:
|Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative
symptoms.
Epidemiology:
• Eauallv prevalent in men and women.
Peak age at onset: 15-25 years for males, and 25 - 33 years for females,
[increased prevalence in high density population and with immigration.
Chronic course with remissions and exacerbations.

Exacerbations are caused hv :
A. Psycho-social stresses e.g. family environment.
B. Residual svmptoms after the active phase.
6 raaatkd
C. Non-compliance to medications.
Dramatic improvement in prognosis due to introduction of atvpical antipsvchotics
because of their low side-effects, and their effectiveness against the negative symptoms
30 % of all schizophrenic patients are able to lead a normal life.
30 % of patients continue to experience moderate symptoms .
40% of patients are significantly impaired.
tress-diathesis tvulnerabilitvf model is a model that integrates biological, psvchosqcial and

environmental factors i.e. biopsvchosocial interactions.
I Biological factors:
A. Anatomical changes:
Abnormal function of the limbic system, frontal cortex and basal ganglia.
B. Brain imaging
Variable findings bv CT. MRI.MRS and PET.SPECT which indicate:
i. Cerebral Asymmetry
11. Frontal /ivpo-Activitv
iii. Decreased cerebral Blood flow in dorsolateral prefrontal cortex.
iv. Reduced cerebellar Volume
V. Ventricular enlargement
C. Chemical Neurotransmitters
Excessive dopaminergic activity. /
Other neurotransmitters are as serotonin, norepinephrine, and glutamate 0
D. Genetic Factors(DNA & RNA):
Polvpenetic factors nlav a role in the etiologv of schizonhrenia as evidenced bv:
1. Family studies: Higher incidence in close relatives of patients.
2. Twin studies: Higher incidence in monozygotic twins than in dizygotic twins
3. Adoption studies: higher incidence in adopted children of biological parents .
4. Genetic study: Abnormalities in chromosomes 5, 11, 18, and 19 & X- chromosomes
E. Evoked potentials
[Smaller and delayed P300 wave indicate blunting ofthe information processing at hjgher cortical
level.
II. Psychosocial Factors:

A. Role of family: abnormal relations between family members.
B. Learning theories: the patient learns irrational reactions by imitating parents with emotional problems.
C. Social theories: immigration & industrialization.
45
:s Clinical picture & Diagnosis
Symptoms of schizophrenia should be FIXED AND PROIVTINENT in the course of illness & are
generally divided into :
I. Positive symptoms II. Negative symptoms
I. Disorders of Perception I. Disorders of Motor Behavior:
Auditory hallucinations • Avolition
Third person auditory hallucinations
Commanding auditory hallucinations with the patient 2. Disorders of Emotions ; Disorders
obeying those commands even if dangerous. of Affect:
2. Disorders of Thinking: Inappropriate affect
A. Disorders of Form of Thinking = Formal Thought Marked ambivalenee
Disorders: Flattening of affeet
Loosening of association, derailment, and incoherence s v,' 3. Marked social withdrawal.

(disorganization of speech & thinking) NOT secondary to a delusion or a
B. Disorders of Content of Thinking: depressed mood. ^ lj|| |f|
Bizarre delusions and behavior
Delusions of influence & control (Passivity phenomena):
Delusion of control, thought insertion, thought withdrawal They do not respond to typieal
and thought broadcasting antipsychotics, but improve on using
They usually respond to typical antipsychotics atypical antipsychotics.
I. Simple 2. Paranoid 3. Undifferentiated 4. Disorganized 5. Catatonic

Schizophrenia Schizophrenia Schizophrenia Schizophrenia Schizophrenia
❖ Severity :
• It is one of the It is an All types of • Catatonic
most intermediate disorders are features
malignant form between present dominate the
types of paranoid and clinical
schizophrenia disorganized picture e.g.
types waxy
flexibility
Negative symptoms; social and occupational deterioration is
Very gradual Mild: Less Intermediate Marked PROFOUND
but than all the between the
PROFOUND other types. paranoid and the
disorganized
type.
Positive symptoms; Delusions «&: hallucinations :
No positive Preoccupation • Delusions and Delusions are • Other
symptoms; with hallucinations are bizarre, symptoms of
there is only One or more less than fragmented and schizophrenia
Vague thinking, delusions, or paranoid malsystematize are present.
flat affect. Frequent schizophrenia d
hallucinations.
lOnset & Course! Other symptoms; disorganization of speech and behavior
Onset: early • Disorganization Disorganization Gross
adolescence. & affect is less than disorganization
Course: very disorders is not disoiânized ofspeech and
gradual over prominent. schizophrenia behavior
many years ,
slowly
progressive
46
6. Schizoaffective Disorder 7. Residual Schizophrenia
• Prominent and Persistent mood disturbance in the form of Symptoms and deterioration in
depression or elation, in the presence of schizophrenic symptoms. functioning are less than
• It is an intermediate disorder between mood disorders and UNdifTerentiated type.
schizophrenia. It is usually the result of
• Two types are recognized: partial improvement on
A. Schizoaffective disorder - depressive type treatment
B. Sehizoaffective disorder - bipolar type
1. Hospitalization, indications :
Ensure safety ofthe patient and his relatives.
Obser\'ation to complete psychiatric assessment and diagnosis.
Ensure compliance to treatment.
Initiation of Therapeutic alliance & rehabilitation programs.
2. Pharmacotherapy:
A. Typical antipsychotic: B. Atypical antipsychotic;
For positive symptoms, they show 60-70% • For both positive and negative symptoms,& in
response. resistant cases.
High side-effects • Less side-effects.
Examples: haloperidol, chlorpromazine. & • Examples: risperidone, clozapine & olanzapine.
trifluoperazine.
3. Psychotherapy:
All models of psychotherapy are indicated e.g. behavioral, cognitive, supportive and family therapy.
They may be in the form ofindividual or group therapv.
4. Electro-Convulsive Therapy (ECT),
❖ Doses: 4-8 sessions up to 16(2-3 sessions per week)
*V Indications: T-APC- MS
I nadequate response to pharmacotherapy
Acute cases, or Acute exacerbation of chronic cases
Prominent delusions and hallucinations.
Catatonic patients
Associated Mood symptoms.

Suicidal patients
47
Chapter XIII; Delusion Disorders LjljkJaVI
Psychiatric disorders in which the predominant

lant symptoms are delusions.
<
MaBF.HWatffiir
The annual incidence of delusional disorder is 1 to 3 new cases per 100.000 people.
A sudden onset is more common than an insidious onset.

Few cases are later diagnosed as schizophrenia or as mood disorder
• The cause of delusional disorder is unknown.

• Increased in some personality traits e.g. suspiciousness, jealousy.
I. Biological Factors 11. Psychosocial Factors
Substance abuse e.g. psychoactive stimulants and Socially isolated patients and hostile families.
alcohol Some paranoid patients & lack oftrust in
Neurological conditions that affect the limbic relationship.
system and the basal ganglia. Patients with delusional disorder use primarily
Delusional disorders may arise as a normal the defense mechanisms ofreaction
response to abnormal experiences in the formation, denial, and projection.
environment.
:s Clinical Features & Types
1. Grandiose type: 2. Persecutory Type:
The patients believe that has a great but The most common type of delusional disorders.
unrecognized talent or has a special relationship Patients are angry and may resort to violence
with a prominent figure. against those they believe to be hurting them.
3. Jealous type: 4. Erotomanic(delusion of love) Type:
• Men are more commonly affected than women. The patient believes that he/she is loved
• The patient can inflict verbal and physical intensely by another person.
abuse on the spouse. That person may be a famous figure or a superior
at work or any other person.
The patient is usually isolated, single withdrawn
life, has had limited sexual contacts.
5. Somatic type:
• The most common delusions are :
- Infection. Infestation of insects in skin, Dvsmorphophobia.
- Bodv odors coining from the skin, mouth or vagina.
Differential Diagnosis. MPCs
1. Malingering , Mood Disorders,
2. Paranoid Personality Disorder ,Obsessive-Compulsive Disorder,
3. Somatoform Disorders, Schizophrenia,
❖ N.B. The differentiation between hypochondriasis and the somatic tvpe of delusional disorder rests on
the degree of conviction that patients with delusional disorder have about their presumed illness.
1. Hospitalization, indications :
• Ensure safety of the patient and his relatives.
• Observation to complete psychiatric assessment and diagnosis.
• Ensure initiation of treatment due to loss ofinsight
• Complete medical and neurological evaluation
2. Pharmacotherapy:
• Antipsychotic drugs are the treatment of choice.
3. Psychotherapy:
• Therapeutic alliance:patient begins to trust a therapist
• Individual psychotherapy more effective than group therapy.
4. Family therapy: The family is involved in the treatment plan.
48
CHAPTER XIV: Psychosexual Disorders
Normal sexual behavior:
> If achieves three maior functions for human beings. Thev are:
1. £rocreation (reproduction)
2. £astirne, £leasure
3. Object relation: preserves £onds between families. This is themosthnp^^
Brain and Sexual Behavior:
• The limbic svstem is directly involved with elements of sexual functioning.
• Brain neurotransmitters are related to sexual function:
A. Increase in dopamine is presumed to increase lihidfl.
B. Serotonin is presumed to have an inhibitory effeet on sexual function.
C. Erection is mediated by cholinergie innervation.
D. Ejaculation is mediated by alpha-1 adrenergic fibers.
E. The uterus receives both cholinergie & adrenergic fibers.
• Sexual behavior that is destructive to self or to others;

• That is not directed towards a partner or excludes stimulation of the genitalia.
:s Factors in Normal or abnormal sexuality:
1. Sexual behavior:
It is a series of psychological and physiological responses that represent the sexual cycle.
Abnormalities in this domain eause Sexual Dysfunctions.
Sexual identity:
It is the pattern of a person's biological sexual characteristics.
It is influenced by genetic, hormonal and anatomical characteristics.
3. Gender identity:
It refers to the sense of knowing and experiencing to which sex one belongs.
It is formed by the age of 2-3 years
Abnormality in this domain causes Transsexualism.
The sexual eycle (response) is a true psvchophvsioiogical experience.

Four phases are recognized in the human sexual cycle.
1. Phase I: Desire
• The desire& willing to have sexual activity.
• It may be expressed in sexual fantasies.
2. Phase II: Excitement
It a Subjective Sense of pleasure.
It Starts with the initiation ofthe Sexual act (including foreplay) till orgasm.
Stimulation done by :
Psychological stimulation (fantasy), Physiological stimulation (kissing), or a combination ofthe two.
Initial excitement may last several minutes to several hours,
o It is characterized bv:
■ In males In females:
The nipples of both sexes become erect.
Voluntary contractions of large muscle groups occur, rate of heartbeat and respiration increases, and
blood pressure rises.
The testes increase in size 50 % & elevate. Breast increase in size 25%
Penile tumescence leading to erection The clitoris becomes hard and turgid, and her
labia minora become thicker as a result of venous
engorgement.
Vaginal lubrication
Vaginal barrel shows a characteristic constriction
along the outer third
49
> Heightened excitement lasts 30 seconds to several minutes.
o It starts with penile insertion into the vagina,
o It immediately precedes orgasm.
3. Phase III; Orgasm
• The peak of sexual pleasure, with release of sexual tension and rhythmic contraction ofthe pcrincal
muscles and pelvic reproductive organs.
• Oreasm lasts from 3 to 25 seconds and is associated with a slight clouding of consciousness.
o It is characterized by ;
■ In males : ■ In females :
Voluntary and involuntary movements ofthe large muscle groups, including facial grimacing and
carpopedal spasm.
Blood pressure rises 20 to 40 mm (both systolic and diastolic), and the heart rate increases up to 160
beats a minute.
Subjective sense of ejaeulatory inevitability 3 to 15 involuntary contractions ofthe lower
triggers the man's orgasm third ofthe vagina and by strong sustained
- Forceful emission ofsemen follows. contractions ofthe uterus.
4. Phase IV: Resolution
• Disgorgement of blood from the genitalia fdetumescence), which brings the body back to its resting
state.
• If orgasm occurs, resolution is rapid:
• If it does not occur, resolution mav take 2 to 6 hours and be associated with irritability and discomfort
o Resolution through orgasm is characterized by :
■ In males : ■ In females:
- Subjective sense of well-being, general relaxation, and muscular relaxation.
- Men have a refractory period that may last from The refractory period does NOT exist in
several minutes to many hours; in that period they women, who are capable of multiple and
cannot be stimulated to further orgasm. successive orgasms.
• Non-organicallv sexual disorders in which the individual is unable to participate in a sexual

relationship because of difficulties in normal sequences ofthe sexual cycle.
I. Erectile dysfunction (impotence) 2. Premature Ejaculation
• It is the persistent inability to obtain an erection sufficient for • The man recurrently achieves
vaginal insertion orgasm and ejaculates before he
Or to maintain it until completion ofthe sexual activity. wishes to do so.
• It may be due to organic or psychological causes or a • There is no definite time frame
combination of both. within which to define the
• If a man reports having spontaneous erections or morning dysfunction.
erections, organic causes ARE EXCLUDED. • The diagnosis is made when the
• The condition may accompany some other psychiatric man regularly ejaculates before or
disorders e.g. depression and schizophrenia immediately after entering the
Or may occur due to a pharmacological substance or vagina or following minimal
psychoactive substance abuse. sexual stimulation.
3. Female orgasmic disorder 4. Dyspareunia
• Inhibited female orgasm or anorgasmia is manifested by the • Recurrent and persistent pain
recurrent delay in, or absenee of, orgasm after a normal sexual related to intercourse.
excitement phase judged to be adequate in foeus, intensity, and • It is usually a disorder of women
duration. presented by vaginismus.
• May be due to psychological factors as: • Caused by anxiety about sexual
Guilt concerning sexual impulses. intercourse, and history of rape or
- Fear of rejection by a sex partner. childhood sexual abuse.
Hostility toward men.
50
5. Paraphilias
This a group of sexual deviations in which sexual arousing fantasies involve:
Nonhuman objects; or
Children or other-non-consenting persons; or suffering of oneself or one's partner.
Paraphilias are diagnosed if the deviant behavior replaces normal sexual behavior.
Thev include the following examples:
1. Fetishism 2. Exhibitionism
t^tAKeO IN RUaLICi
Sexual arousal is achieved by using inanimate Sexual arousal and orgasm are associated by
objects or a non-genital body part. public Exposure of one's own genitals to a
stranger.
3. Vo;^nrism 4. Frottenrism
it involves seeking out or observing (evel It is characterized by male's rubbing his penis
people who are naked or are engaged in sexual against the body of a Fully clothed woman to
activity achieve orgasm. These acts usually occur in
crowded places.
5. Sexual Sadism 6. Sexual Masochism
It involves acts causing It involves the act of being humiliated, or
psychological or physical physically suffering (beaten, bound, etc...) to
suffering of the victim to achieve sexual excitement and orgasm to the
produce sexual excitement victim.
to the Sadistic person.
7. Eedophilia
Sexual excitement and orgasm involve sexual ai iiMties with Prepubescent children.
6. Homosexuality
Some authors consider homosexuality as pathological if only accompanied with distress,
dissatisfaction.
Authors from other cultures still consider homosexuality as a pathological deviation.
Management of Psychosexual Disorders
1. Prppgr
To diagnose a psychosexual disorder, the abnormal sexual behavior should be :
Medical causes and substance-induced disorders should be excluded.
Recurrent or persistent,
Replacing normal sexual behaviors
Causing problems to Self or to others.
2. Psvchotherapv:
Sexual education to the couple is enough to solve the problem.
Behavioral and cognitive behavioral psychotherapies are the most widely used techniques.
3. Pharmacological treatment:
Sildenafil (Viagra) for erectile dysfunction
Local anesthetic Sprays for premature ejaculation
SSRls are used for premature ejaculations
Pharmacological treatment of any underlying pS.vchiatric disorders e.g. depression.
51
• They are a group of disorders where there is excessive preoccupation with weight,food, and body
shape.
• Two main types are recognized :
A. Anorexia Nervosa B. Bulimia Nervosa
• Much higher nrevalence in females • Much higher nrevalence in females

• Age at onset is in the early adolescence. • Age at onset is in late adolescence or early
adulthood (later than anorexia nervosa)
• Four times more common than anorexia nervosa
1. Biological Factors
• Diminished norepinephrine turnover. • Diminished norepinephrine & serotonin turnover.
• Higher concordance rate in monozygotic than in
dizygotic twins
• Genetically related to major depression
2. Psychodynamic Factors
• Self- discipline over eating in an attempt to gain • Self- discipline over eating in an attempt to gain
autonomyfrom the mother. autonomyfrom the mother.
• Fears concerning acquisition offeminine shape • They are more out-going, angry leading to bouts
ofbody of binge-eating as ego-dystonic
3. Social Factors
• Common in societies with emphasis on thinness • Patients respond to societal pressures to be slim.
and exercise
>■ Ten-vear outcome studv in the United States: • The Ions-term outcome is still under studv.
• Complete recovery : 25% • Without treatment, nersists for at least several
• Partial improvement: 50 % years.
• Poorly fimctioning: 25%, including • With treatment: Up to 70% benefit from it: fiill
7 % mortality rate. recovery is achieved in 50 % of cases.
• Mortality rate is 1%.
-i |UJ 1
Miilfinpntimiip
iireiiatgnna
A. General changes |
1. Weight loss «&Amenorrhea in females 1. The natient is within normal weight & normal
2. Intense fear of weight gain. menses.
3. Intense disturbance of bodv image 2. Recurrent Behavior to nrevent weight gain, such
(the patient perceives herself as overweight as self-induced vomiting, purgatives or laxatives.
despite the clear evidence of her thinness) 3. Recurrent enisodes of Binge-eating & lack of
4. Anorexia is NOT an essential feature. control over eating
4. At least twice a week for 3 months
B. Physical Changes |
• dizziness or fainting • dehydration, fatigue, swollen salivary glands
• decreased vital signs. • Loss of dental enamel
• diarrhea or Constipation • Esophageal or gastric tears
• dysplastic Changes in the quality of skin • Side effects of Emetics, or purgatives.
52
C. Psychological Changes C. Behavioral Changes
• Anxiety, Fatigue • Secretive behavior e.s. snendine lone neriods in
• Depressed mood, social withdrawal the bathroom.
• Loss of interest in usual activities • Over-concern with dieting and nutrition
EWWiffi
• Due to chronic severe malnutrition and marked • Medical & Social Problems :
reduction in caloric intake.
. 1. Nervous: neuropathies, cognitive impairment, 1. Muscle cramping due to electrolyte imbalance
seizures 2. Cardiac complications (e.g. arrhythmia)
2. Endocrine: /owT3,LH and FSH 3. Gastro-esophageal bleeding
3. Electrolytes: Aypokalemia, /jy/xsmagnesaemia 4. Renal failure
4. Cardiological: arrhythmias, Ararfycardia
prolonged QT interval, loss of cardiac muscle, 5. Social isolation
sudden death. 6. Impairment in family relationships due to lying.
5. Hepatic: fatty degeneration
6. Hematological: anemia, leucopenia
1. Skeletal: osteoporosis
• It has one ofthe highest mortality rates for

young females
• Mortality rate 5 - 15 %
• With comorbid medical conditions, mortality
approaches 50%
• Anxiety disorders, major depression & • Anxiety disorders, major Depression & psychotic
psychotic disorders. Disorders.
• Deliberate gelf-harm, e.g. reckless driving
• Alcohol and substance misuse
n
1. Hospitalization is indicated in severe cases, 1. Psychotherapy:
with marked weight loss and with medical - Cognitive-Behavioral Therapy
complications. - Group Therapy
2. Psychotherapy e.g. behavioral, cognitive - Family Therapy
behavioral psychotherapy in addition to 2. Pharmacotherapy:
pharmacotherapy. - antidepressants e.g. SSRIs
3. Pharmacotherapy to the underlying or co-
morbid psychiatric disorder e.g.
antidepressants, anxiolytics & antipsychotics
53
CHAPTER XVI CHILD PSYCHIATRY
p«mf7iTirTTgfl!ff w
Child psychiatric disorders as are first diagnosed in infancy, childhood or adolescence.
1. Conduct Disorder 2. Attention Deficit Pervasive Developmental
Hyperactivity Disorder Disorders
(ADHD) (Autistic Disorder)
iaji.4 sLiljyi uljlxual
Disruptive behavior in whieh • It is a triad of; • Expected social skills,

the basic rights of others and 1. Inattention language behavior are
society rules are violated. 2. Hyperactivity either not developed or are
3. Impulsivity lost in early childhood
before the age of 3 years.
• The most common type is
Autistic Disorder.
Epidemiology
• It usually starts in early It usually starts in early • It usually starts in early
childhood. childhood. childhood.
More prevalent in males. More prevalent in males. More prevalent in males.
❖ Etiology
*1* It is a multifactorial disorder: ❖ The exact e cause ofthe ♦♦♦ It is a multifactorial
1. Genetic factors: disorder is UNKNOWN, disorder:
• Evident by positive family history. however the following factors 1. Genetic factors:
2. Organic factors: are implicated : • High concordance in
• Increased incidence of BEG 1. Genetic factors: monozygotic twins, compared
changes. • Evident by high concordance in to dizygotic twins.
3. Family factors: monozygotic than dizygotic twins • Translocation of fragile X
• Neglecting mother 2. The frontal lobe in children of chromosome in 15% of
• Frequent punishment ADHD does not exert its autistic children.
• Marital conflicts, divorce. inhibitory mechanisms on lower 2. Biochemical factors:
4. Environmental factors: structures, leading to disinhibition. • Increased plasma serotonin
• Increased incidence in low 3. Perinatal complications. • Increased CSF homovanillic
socioeconomic. 4. Food additives and colorings acid (metabolite of dopamine)
5. Social Modeling: 5. Exposure to Toxins, heavy • Increased incidenee of EEG
• Effect of mass media as TV. metals, aleohol (pre- or postnatal) ehanges
3. Perinatal complications
4. Psychogenic factors
parental rejection.
KMnmrnniiigBHr
The disorder is either conducted V It includes three main 1. Inability to develop
solitary or in a group (gang). criteria: relationship with people
❖ Aggression may be : I. Inattention = Disturbed e.g. defect in eye to eye
1. Direct(Overt) aggression is attention or concentration: contact.
directed to people, animals with A. Easily distractible 2. Delayed development of
the aim of destruction e.g. using B. Difficulty to sustain attention in language skill, e.g.
weapons, initiating fights. tasks repetitive use of words.
2. Indirect aggression e.g. lying, C. Child does not listen to what is 3. Repetitive or stereotyped
and staying out late at night said movements, e.g. twisting.
despite of parental prohibition. 4. Insistence on sameness i.e.
54
2, Hyperactivity: Marked rigidity and distress
A. Difficulty in sitting still when trying to change the
B. Excessive movement child's behavior.
C. Talks excessively
3. Impulsivity
A. Answers before question is
completed
B. Difficulty waiting turns in
games
C. Engages in dangerous without
caring.
❖ For a diagnosis of ADHD,
symptoms must be present for
at least 6 months in at least
two settings.
Managemen
1. For the Child : Pharmacotherapy: 1. Pharmacotherapy:
A. Behavioral therapy V^YCHOSTIMULANTS, e.g., • High potency neuroleptics
B. Group therapy dextroamphetamine, • Selective Serotonin
C. Pharmacotherapy methylphenidate Reuptake Inhibitors (SSRJ)
• Lithium carbonate & clonidine Antipsychotics 2. Parental &family
to control aggression Antidepressants education programs
• Anticonvulsants for treatment of Lithium carbonate education programs to
underlying epilepsy. Family therapy provide a supportive home
2. Family therapy to resolve Special education programs environment
family conflicts. 3. Special education
3. Parental education programs programs to each child to
to change the destructive pattern promote linguistic skills
of behavior. and social interactions.
4. Institutionalization in severe
eases.
FM
❖ Developmental Learning Disorders

SMiramrnTim
• These disorders are termed academic skills disorders . f*— i
• They are psychological problems in understanding or in using spoken or written language.
nmg
Neocortical deficits in cognitive processing e.g. visual problems.

Clinical picture
1. Poor scholastic achievement despite their average 3. It may be associated with:
intelligence A. Anxiety and other emotional problems.
2. Impairment in : B. Behavioral problems e.g. alienation or
• Reading, written expression, mathematics. rebellion.
C. Delayed speech
1. Special assessment including IQ, EEG, plain X ray skull, and CT scan brain
2. Special educational programs for the family & the teacher.
3. Special scholastic placements.
4. Psychotherapy for the patient and family.
55
❖ Elimination Disorders
I. Functional EnuresiS II. Functional Encopresis
miliHilFiTfl
• Repeated voiding of urine into the child's • Fecal soiling of clothes.
• R^^^^^^ûntary or intentior^^^^^^^
the most common form.
• N.B. Daytime control usually
precedes nocturnal control
by 1-2 years.
^■ann
• In United States 7 % of 5 year olds are enuretic. • More common in males than females
1. Primary: 1. Primary :
• If bladder control has never been achieved • If no bowel control has never been achieved.
2. Secondary: 2. Secondary:
• If the child has learned control for 1 year. • If the child has learned control for I year.
• Other classification
A. With constipation and overflow:
• 75 % of encopretic children have constipation
• There is fecal concretion with overflow offluid
fecal mailer.
B. Without constipation:
• Incontinence without constipation results in
intermittent production offormed stools.
(HBlJ
1. The child must be at least 5 years old 1. The child is at least 4 years old.
2. Wetting is repetitive 2. Encopresis occurs at least once a month for at
3. Medical causes should be excluded e.g. urinary least 3 months.
tract infection. 3. Medical causes should be excluded.
^■1
1. Restricting fluids before bedtime and waking 1. For children with severe retention or
the child during the night. impaction:
2. Rewarding successful dry nights. • Cleaning out the bowel e.g. enema followed by
3. Bladder training during the day. retraining the bowel e.g. high roughage diet.
4. Medications: before bedtime e.g. 2. For encopresis without constipation:
• Imipramine • Behavioral program.
• Desmopressin (synthetic anti- diuretic hormone) 3. In resistant cases individual and family
• Anticholinergic drugs. psychotherapy
56
Chapter XVTI; Mental Retardation
I. Biological Causes:
1. Genetic Factors:
Autosomal dominant e.g. phakomatoses as tuberous sclerosis.
Autosomal recessive e.g. inborn errors of metabolism as phenyl ketonuria.
Chromosomal abnormalities e.g. Down sjmdrome and Fragile X Syndrome.
2. Prenatal Factors:
Maternal illness e.g. intrauterine infection & Brain malformations
3. Perinatal Factors:
Brain trauma & Blood group incompatibility.
4. During Infancy or childhood:
Brain infections (encephalitis or meningitis or postimmunization)& Lead intoxication & malnutrition.
II. Psychosocial Causes:
Psychiatric disorders (living with psychotic parents)& Drug abuse
> Classification & Clinical Description:
1 • The Intelligence iiuotient was calculated from the following formula:
1 ■ IQ = mental age / chronological age x 100
1 1. Severity: |
Mild M.R. Moderate M.R. Severe M.R. Profound M.R.
2. IQ:
50-69 35- 49 20 - 34 below 20
3. Incidence: |
85% 10% 1 4% 1 1% 1
4. Self-care and living skills: 1
• No difficulty. • Retarded & can be trained • Markedly impaired. • Need constant help
• Need help with • Find difficulty in • Dependent on and supervision.
paying a budget. calculating the change others for money
due. arrangement
5. Language and communication skills:
• Able to use • Slow in developing. • Very limited. • Severely limited
6. Education and occupation:
• Educable. • Limited. • Not trainable. • Extremely limited
I Diagnosis requires both
A. Low intelligence (IQ less than 70) and
B. Deficits in adaptive functions during the developmental period (before the age of 18 years).
1 Co-morbidity
• Mentally retarded children are four to five times at a higher risk to have a psychiatric disorder than
normal children.
• The most common symptoms suggestive of Co-morbiditv includes:
A. Irritability,
B. Impulsivity & hyperactivity,,
C. Short attention span and language delay.
D. Frustration may lead to aggressive temper outbursts.
❖ Managemen
1. Early detection oftreatable Causes e.g. hypothyroidism.
2. Treatment of Co-morbid conditions e.g. depression or ADHD.
3. Proper evaluation of the Case to manage the Complications.
4. Monitoring speed of progress.
5. Specialists for speech therapy.
6. Parental support.
7. Psychotherapy (mild MR)to enhance self-esteem
8. Behavior modification e.g. self-injury.
57
CHAPTER XVIII: Personality Disorders
E• Definition of personality
• Personality describes the characteristic cognitive, behavioral and emotional traits.
*X* Definition of personality disorders:
1. It cannot be diagnosed before the age of 18 years.
2. It has an onset in Adolescence or early Adulthood
3. It is an Extreme set of characteristics beyond the range found in most people.

4. An Enduring pattern of maladantive behavior i.e. deviates markedly from the
Expectations of the individual's culture.
5. Pervasive and inflexible.

6. It is Stable over time.
7. It leads to distress or impairment of functioning.
1. Biological Factors:
Expressed through the actions of a key neurotransmitter e.g. dopamine, serotonin, and norepinephrine.
2. Psychological Factors:
Personality becomes disordered by the maladaptive use of ego defenses (Defense Mechanisms).
3. Social Factors:
Character of a person is developed through socialization and experience
1. Schizoid Personality Disorder 2. Paranoid Personality Disorder

AJV l^.r-l a".v| y ilLu y
<U^ Aj y
Jjgy'iltj jcLulaII JjU y
Socially withdrawn. • Suspicions in others.
Sensitive to feeling of rejection •••• • • Overestimates minor events.
Humorless.
• Grandiose feelings.
Prefers night Jobs • Anger and hostility
Patient works below his potentials
• Humorless.
Cold. • Criticism
Constricted emotions. N.B.:
Deficient motivation. The main defense mechanism is nroiection. in
which own faults are unconsciously attributed to
N.B.:
others.
No relation between Schizoid Personality No relation to Paranoid schizophrenia (absence of
Disorder and Schizophrenia.
psychotic symptoms).
3. Obsessive-Compulsive Personality Disorder
Indecisiveness and hesitancy.
Over concern with details.
i.ilno JdU » ^ JJJm y
Over conscientious. JIaII jC'Luut y
Perfectionist.
Rigid and inflexible, insists that things be done in his own way.
Emotional constriction.
Hoards money, objects.
Humorless with lack ofspontaneity.
N.B.:
It has to be differentiated from Obsessive- Compulsive Disorder in which there are clear obsessions and
compulsions. In personality disorder, there are no symptoms but a pattern of obsessive compulsive
behavior.
58
4. Antisocial Personality Disorder 5. Histrionic Personality Disorder
jClAoj V Jila V UVt jcUi4 y

' *■ y
hU'ift y IjiiJiA AjV c"in4i*fcU y

• Childhood onset, • Emotionally unstable
- Before the age 18 years, it is known as conduct • Egocentric.
disorder.
• Avoids responsibility for actions. • Suggestible
• Lack of care for the feelings of others. • Dependent.
• Criminal versatility. • Over dressing & make-up.

• Abusive and manipulative of others. • Sexually provocative and seductive.
• Abuse of substance • More prevalent in females.

• Promiscuity. • She works to be center of attraction.
• • Dramatization of situations
• Likely to abuse relation with doctor to obtain
benefits and avoid responsibility.
Why Recognize Personality Disorders?
A. Tn the nsvchiatric settinp:
As association with any other psychiatric disorders.
Affect the prognosis, compliance to treatment and choice of therapy.
They are egosvntonie in the majority of cases& discovered during treatment, or the family complains of
them.
B. In the medical setting:
Different tvpes of personality disorders react differently to their illness, doctor and treatment plans.
For examnle:
Obsessive Personalitv Disorder would question about every detail in his treatment plan.
The Histrionic would dramatize complaints.
1. Aim:
To improve the social adaptation and vocational functioning of the patient
To reduce the suffering of his surrounding family members.
2. Psychotherapy:
The modality and type is chosen according to the individual patient.
E.g.
Individual psychotherapy is helpful in Paranoid personality disorder.
Group therapy is helpful in Schizoid Personality Disorder.
3. Medication:
Treatment of any associations e.g. Depression , anxiety.
Mood stabilizers (antiepileptics or lithium) use to control violence in the Antisocial Personality
Disorder
SSRIS are helpful in Obsessive-Compulsive personality disorder.
59
CHAPTER XIX: Psychopharmacology
I. Antipsychotics = neuroleptics
They are classified into:
Typical Antipsychotics 2. Atypical Antipsychotics
imiiMiii'ii irairr
Donamine receptors antagonists in mesolimbic mesocortical and • More selective donamine-serotonin receptors antagonists
tubuloinfudibular tracts. • Much less ofthe side-effects.
Blockage of histamine, cbolinergic and noradrenergic receptors. • They have the advantage ofimproving the negative symptoms of
schizophrenia.
A. High Potency Antipsychotics e.g. Risperidone: tab. 2 and 4 mg.

- Haloperidol tab 1.5 mg and 5 mg OXamapine;. tab. 5 and 10 mg.
Trifluoperazine tab 5 mg. C\ozgpine\ tab. 25 and 100 mg.
B. Low Potency Antipsychotics e.g.
Chlflrpromazine tab 25 and 100 mg.
MIltilfWIMHT
1. In small doses, they are used to control GAD and psvchosomatic disorders
2. SCHIZOPHRENIA and DELUSIONAL disorder and bipolar disorders.

3. Psychotic symptoms in association with maior depression
4. Psychotic disorders secondary to organic mental disorders

5. To control behavioral symptoms in autism and msutal retardation in children.
A. Non-Neurological Side-Effects:
1. Convulsions (lowering epileptic threshold).
2. AntiCholinergic side effects:
• //wnairment of cognitive functions e.g. Defective memory and concentration,
• Hot flushes, blurring of vision, dryness of mouth,
• Arrhythmia, Cto
• Constipation and urine retention.
3. Orthostatic /lypotension.
4. Weight sain (antihistaminic effeet).
5. Imnntence and amenorrhea(due to increased prolactin).
B. Neurological side-effects
> Emergency cases; > Non-Emergency cases:
1. Acute dvstonic reaction 2. Akasthlsia 3. Neuroleptic malignant syndrome Tardive Dyskinesia 5. Parkinsonian-like
side effects
• It may occur after a • It occurs at It occurs at any time during It occurs after prolonged • Due to blockade of
Single dose ofthe drug any time in the the course oftreatment. use of typical D2 receptors in the
• 10% of cases. course of It is more common with: antipsychotics. basal ganglia
treatment. High potency antipsychotics Most commonly with • 15% of cases
liigh doses in an elderly or a High potency drugs &
dehydrated patient. less with atypical.
Jot weather
Mmiiiiiiiiiyiiiiiiaii
It is a Severe âstic Feeling of Increasing fever, tachycardia & • Static tremors
Abnormal involuntary
contraction in a group of MUSCLE MUSCLE rigidity.
purposeless movements • dradykinesia.
MUSCLES. discomfort disturbance ofconscious & cdmh if n( MiubLilLtlwJbcejjnpu^^^^
It occurs in the form of (restlesnesss) treated.
QUdjonguee,g._ grimacing,
Qculo_g}iric ajsis, without feeling death may occur due to : tongue protrusion, lip
anxious. Acute heart failure due to exhaustion. smacking, puckering and
lQl'}W'?PLdysjQniQ & Acute renal failure due to muscle necrosis pursing of the lips, and
torticollis. CPK more than 1000 units rapid eye blinking.
IMJWi
Injection of Decreasing the Stoppage ofthe drug. • Addition of oral
anticholinergic, dose ofdrug Monitor of vital signs, monitor of renal anticholinergic
antihistaminic drugs, or £ropranolol functions, drugs.
by benzodiazepines. and dath & cold compresses Stop drug
lienzodiazepin Beta- blockers e.g. £ropranolol Switch to atypical
e are added to d2 dopamine agonists e.g. bromocriptine antipsychotics,
control it. direct muscle relaxants e.g dantrolene particularly clozapine.
ll. Antidepressants |
HiiininHnTSHi
|1. Other Newer Antidepressants
• Venlafaxine: tab. 37.5 and 75 mg. Mirtazepine: tab. 30 mg.
^H3^_Se^tonin specific reuptakej^^
^H^^^linhibitors(SSRIs)^HÎ
action
• Reuptake inhibition of norepinephrine CNE) and serotonin 15- • Thev have a more selective
HT)resulting in increased NE and 5-HT in the synaptic cleft. inhibitory effect on reuptake of
serotonin.
• Less side effects than TCA.
pSÎ^TRTiTTS:
Tricvclic antidepressants: VlwoxetlM'- capsules 20 mg
tab. 10 and 25 mg Faxoxetine; tab. 20 mg
Amitryptiline: tab. 25 mg Citalopram: tab. 20 mg
C\omipxgmine\ tab. 25 and 75 mg Sertraline: tab. 50 mg
Tetracvclic antidepressants: Fluvoxamine: tab 50 and 100 mg
Maprotiline (Ludiomil). > N.B.: SSRls are the treatment of
> The effective dose in Major Depression is 100-300 mg/day & choice in obsessive compulsive
for other indications, a lower dose may be used. disorder, panic disorder, and
different types of phobias
MBfiMWBT
1. Depressive disorders
2. In addition to antipsychotics in schizoaffective disorder depressive type.
3. Ajaxkl)Ldi&Qrd£]t:s as obsessive compulsive disorder (clomipramine), panic disorder, and different types
of phobias
4. Some sexual disorders as (clomipramine)
5. Sleep disorders in children as Nightmares (amitryptiline) 5. EatinP disorders, particularly
6. Nocturnal enuresis (imipramine) bulimia Nervosa.
❖ Adverse effects:
Tricyclic and Tetracyclic Antidepressants(TCAs) Serotonin specific reuptake
inhibitors
1. Seizures: especially in epileptic patients. Seizures, in susceptible
2. Anticholinergic side effects: patients, particularly with
A. Central anticholinergic effects: fluoxetine
• Decreased ability to concentrate and memorize, delirium in high doses Headache, disturbed sleep
B. Peripheral anticholinergic effects: continuity anxiety &
Blurred vision, raised intraocular pressure, dry mouth, tachycardia, irritability.
constipation & urine retention. GIT upset: anorexia,
3. Central A!pha-1 adrenergic effects: nausea, and vomiting
Hypotension, drowsiness, syncope. Sexual: delayed
4. Cardiac Side-effects: ejaculation, anorgasmia
Arrhythmia and heart block and impotence
Tachycardia
Direct toxic effect on myocardium leading to death in toxic dose.
5. Anti-histaminic effects:
Sleepiness, weight gain.
6. Sexual side effects: mostly
Due to reuptake inhibition of eertain subtypes of5-HT receptors.
Decreased libido.
DELAYED EJACULATION, ANORGASMIA & IMPOTENCE
PNLE
especially with clomipramine.
7.
8.
Exacerbation of MANIC episode in bipolar patients.
Exacerbation ofPSYCHOTIC episode in predisposed patients.
62
,.{1
ni. Mood stabilizers
❖ These are a group ofpharmacological agents that are used mainly to control and nrevent hinnlar disorders
Their anti-mani mechanism ofaction is not clear.
nciiuli
Imim SB
Lamotrigh^^ mg and 100 mg • Topiramate: tab. 25 mg and 100 mg|• Gabapentine: caps. 400 mg
3. Sodium valproate 4. Carbama/cpinc
• Lithium is a mon ova lent ion. They are some conventional antiepileptics.
• It is iMil metabolized by the liver.
• It is excreted by the kidnevs.
Lithium carbonate (Prianel) tab. 400mg Depakine tab. 200 and 500 mg Tegretol tab. 200 and 400 mg
B|ggli£ Disorders Same indications of lithium. Same indications of lithium.

Bigglgr type ofschizoaffective disorder
Resistant cases of major depression Perfect in the MIXED and ranid Treatment of Alcohol and
Resistant schizophrenia. JBipfllaiL£n isodes. fienzodiazepine withdrawal.
Aggressive behavior in mental retardation and dementia.
1. Teratogenicity in pregnant patients Neural tube defect if used during 1. Neural tube defect if used
2. Epilepsy in susceptible patients pregnancy. during pregnancy.
3. Tremors Tremors & Sedation 2. Sedation, memory disturbanc(
4. Hyperthyroidism or HYPOthyroidism. Hair loss 3. Hypersensitivity & skin rash.
Cardiac toxic: manifestations of HYPOkalemia in F.CG Hepatotoxicity especially if used in Elevate Hepatic enzymes.
children(<2 years). Carbamazepine is an inducer of liver
enzymes, so it can decrease the blood
level of many drugs e.g. haloperidol,
TCA and anticoagulants.
6. GIT: nausea, vomiting, and Diarrhea 5. Nausea, and vomiting Nausea, and vomiting.
7. Polvuria (Diabetes insipidusl: 6. Weight gain- 7. Agranulocytosis.
• It occurs due to inhibition of ADH that leads to (Low WBCs)
decreased re-absorption offluids.
• It is treated by fluids and K. retaining diuretics.
❖ lîthium toxicity (emergency):
A. Early signs: B. Signs of severe toxicity: C. Death due to:

1. Ataxia 1. Ataxia 1. Neurotoxicity
2. Tremors 2. Convulsions 2. Cardio-toxicity e.g. Arrhythmias
3. Nausea
4. Polyuria 3. Renal failure 3. dehydration
5. diarrhea 4. delirium, and coma
mrHnToxicafionl
STOP u
SIGllS
Blood removed for
cleansing
Dialyzer
Clean
blood
returned
1. Stoppage of the drug.
to the
2. Monitoring of vital signs.
body
3. Mental status examination.
4. ECG, renal functions, electrolytes assessment.
5. Serum lithium level monitoring must be done regularly :
The first sample can be taken after 5 days oftreatment, then every month after stabilization ofthe level.
The blood sample is collected 8-12 hours after the last dose.
6. Hydration and restoration of electrolyte balance
7. Heamodialysis if lithium level is more than 4 mEq / litter.
IV. Benzodiazepines
^"GliWMlH'liaccordmg to the duration of their action in the body(plasma half-life) into:
m. 2.| Intermediate acting U
5-20 hours 10-30 hours 30-100 hours 40-200 hours
• Alprazolam • Bromazepam • Clonazepam Flunitrazepam
• Lorazepam • Clobazam • Clorazepate
• Diazepam
Mechanism of action
• They are agonists of benzodiazepine receptors which bind to GABA receptors, increasing the affinity of these receptors to GABA.
• There are two types of benzodiazepine receptors:
1. BZ 1 which is responsible for sleep.
2. BZ 2 which is responsible for cognition and motor activity.
Clinical effects of BZ II n.
1. Anxiolytic effect: reducing anxiety 1. Anxiety disorders such as generalized anxiety 1. Withdrawal symptoms
f1.a1| jjt,
O) disorder, panic disorder, and phobias - Anxiety, irritability,
oi
insomnia, depression and seizures can occur.
2. Tolerance, dependence and addiction.
2. Sedation: 2. Insomnia 3. Drowsiness.
- Sleep inducing effect, 4. Memory impairment.
- Induction of anesthesia
3. AntiEpileptic effects 3. Depression especially Alprazolam.
4. Bipolar disorders especially clonazepam.
4. Direct muscle Relaxant effect 5. Akathisia, Agitation. 6. Paradoxical increase in agitation.
6. Alcohol withdrawal 7. Overdose:
• Benzodiazepines are safe as they have a high
lethality index.
• Symptoms include respiratory depression, coma
and death
• Death occurs ifthey are combined with another
CNS depressant drug such as alcohol.
CHAPTER XX: Electro-Convulsive Therapy(ECT)
The mechanism ofaction is not clear.

Passage of an electric current înducing a generalized seizure activity in the brain.
The most efficient methods oftreatment in psychiatry& the least complications.
❖ Technique:
1. £hysical examination.
2. £atient is fasting and artificial dentures are removed & mouth gag is applied.
3. £remedication and anesthesia:
• Atropine (0.5 mg I.M.)to protect the heart from parasympathetic overtone and reduce bronchial
secretions.
• Short acting anesthesia e.g., thiopental I.V.: a sleeping dose is needed.
• Muscle relaxant e.g. succinylcholine: in full dose to minimize or prevent convulsions.
4. Eosition of electrodes:
• Bilateral fmore effective): bifrontotemporal application ofthe electrodes.
• Unilateral applied to /lo/i-dominant hemisphere (less cogmtiv
nere (less cognitive side-effects).
1. Acute psvchotic disorders:

• Acute delusional disorders.
• Undifferentiated and brief psychotic disorders.
2. Major Depression.
3. Bipolar Mood Disorder.
4. Schizoaffective disorders.
5. Schizophrenia:
• With catatonic symptoms.
• With mood (depressive symptoms).
• With acute exacerbation ofsymptoms.
Contraindications (Relative Not Absolute):
1. Increased intracranial tension, cerebral aneurism or hemorrhage.
2. Extreme hvnertension.
3. Recent mvocardial infarction

4. Significant arrhythmias.
5. Fever
6. Acute respiratory infection.
Complications:
1. Transient short-term Memory loss and confusion
2. Mvocardial infarction, Arrhythmias, cardiac Arrest.
3. Miscarriage, if patient has threatened Abortion.
4. Apnea
5. If Muscle relaxant is not adequately used —> Fractures or dislocations.
66
CHAPTER XXL Psychotherapy
• A process which attempts to help the patient Klieve symptoms, jcssolve problems with a trained
professional therapist e.g. psychiatrist, a psychologist, a nurse, ete...
Types of Psychotherapy
A. Accoraing to fdrmat: ceordm^ônTe^
he applied personaI^^ffiff|^
1. Individual therapy. 1. Supportive.
2. Group therapy. 2. Expressive (dynamic or insight oriented).
3. Family therapy. 3. Behavioral.
4. Marital therapy. 4. Cognitive-Behavioral
5. Community or Milieu therapy. 5. Experiential (Humanistic approach).
6. Biofeedback
7. Rehabilitation and activity therapies.
1. Bioteedbac
mm
Physiological functions e.g. musele tension, ft is management of disabilities and handicaps
which are resulting from psychiatric disorder conducted by
not controlled voluntarily trained therapists
can be brought
under voluntary control through operant
conditioning if a person is provided with
feedback information about these functions.
In psychosomatic conditions e.g. hypertension In chronic psychiatric disorders e.g. chronic

schizophrenia and mood disorders
Information from measuring devices e.g. EMG, Personal hygiene and self-eare skills.
Is transformed by electronic instruments Social skill training
Into signals that can be perceived by the patient Occupational therapy e.g. work & educational
e.g. a sound & reach a euthymic mental state. skills.
Recreation and activity therapies e.g. art
67
u Supportive Psychotherapy
Therapy that deals with conscious conflicts and Group of deep therapies that aim at
current problems. symptom resolution & producing positive
fundamental changes in the patient
personality.
Aims achieved through:
• Supporting the patient &helping him to: A. Shifting of uncovering unconscious
A. Relieve symptoms. conflicts to the conscious awareness ofthe
B. Regain equilibrium. patient.
C. Achieve better functioning. / i*! B. Resolving the conflicts.
C. Induce change motivated by insight.
D. Corrective relational and emotional
experiences with the therapist.
1. Crisis & acute adjustment disorders. Selected cases with enough ego-strength
2. Chronic patients e.g. chronic Schizophrenia. to tolerate the experience ofchange and
3. Patients NOT fit for deeper expressive therapy, growth.
(lacking ego-strength) The patient should also be capable of
expressing his thoughts and emotions.
Duration of Psychotherapy:
According to the patient's needs, it could be a single It can be long term (years) but short-term
session or prolonged to many years. models are more commonly used.
1. Therapeutic alliance i.e. emphatic relation by 1. Classical psychoanalysis (limited use now)
understanding & active listening. 2. Psychoanalytic Qriented models
2. Improving insigliL 3. Object relation
4. Self-psychology models
5. Short-term models characterized by being:
3. Education ofthe patient regards ways ofcoping. • More commonlv used.
4. Environmental modification. • Time-limited i.e. Weekly sessions for 3-6
5. Encouragement & Reassurance months.
• Prohlem-focused i.e. Focused on limited
6. Suggestion & advice. key aspects of the patient's
7. Strengthening useful defenses. psychopathologv.
8. Suppression of unwanted conflicts.
9. Improving ego Strength e.g. autonomy.
It is usually individual but can be used in all formats.
Mainly dependency on therapist
68
5. Behavioral Therapies 6. Cognitive-Behavioral Therapy
Definition & theory :
Symptoms are persistent maladaptive behaviors Person's affect and behavior are largely
acquired by conditioning or learning. determined by the way in which he cognitively
Therapy consists of deconditioning or unlearning structures and interprets the world.
of such behavioral habits and relearning of new
• Re-educate the patient new styles of situations • To correct maladaptive behaviors & cognitive
that control this abnormal conditioned reflex. distortions i.e. automatic thoughts & underlying
beliefs (cognitive schemata).
EIB'iiniiii'iiFn
TliVIWVl
According to the technique used. Substance related disorders.

Anxiety disorders e.g. panic, phobic and
generalized anxiety disorders.
Depressive disorders (non-psychotic).
Obesity & eating disorders. ; ..
What you think
Thoughts Emotions
What you do How you f id
A. Systematic desensitization I. Cognitive (verbal) techniques:

• Graduated exposure in imagination to anxiety Identify and test automatic thoughts i.e. test their
provoking situation while in a state of rationality.
relaxation. Identify and test the core beliefs.
Correcting the distorted cognitions and
B. Graded exposure Replacing them with positive habits.
• Similar to systematic desensitization but Rehearsal ofthe new cognitive and behavioral
performed in real- life situations without responses.
relaxation.
C. Flooding II. Behavioral Techniques:

• The patient confronts the undesired situation 1. Graded task assignment e.g. graded social
directly without graduation or relaxation and activity to correct social withdrawal.
remains in the situation until he becomes calm 2. Activity scheduling.
3. Diversion techniques: e.g. social contact.
❖ N.B. The above techniques are useful in
phobic, and obsessive compulsive disorders and 4. Rehearsal of new behavior.
some sexual disorders. 5. Rating of progress in the amount of pleasure.
D. Aversive conditioning Characteristic Features:
• Pairing of a 1. Structured:
maladaptive behavior Agenda prepared for each session.
with a noxious stimulus Problems and goals operationally defined.
e.g. in treating alcoholism, 2. Duration:
patients are given a drug Short-term and time limited, usually 15-20
(Disulfiram) which causes sessions, over 3 months
severe nausea and Focused on:
vomiting if the patient Conscious aspects of experience and behavior.
drinks alcohol. Current (here and now) problems.
69
E. Positive reinforcement(reward): 4. Format:
• Pairing of a positive desired behavior with a w • Usually individual but can be used in other
reward e.g. food, leads to reinforcing the formats
behavior 5. Therapist role:
• Helps well in rehabilitation & chronic patients] • Active, directive, understanding and empathic.
e.g. schizophrenia, autistic disorder, M.R..
F. Participant modeling
f"
• Based on learning by observational &

imitation e.g. a child fearful of dogs can
overcome his fears by watching and imitating
other children playing with it.
1
Family Therapy
Definition & theor\'

• Patient's psychological disturbance reflects a • Concerned with maladjnsted marital
significant disturbance of his family. couples.
Aims of
• Helping family members: • Resolving interpersonal and related
1. Gain insight into their problems intrapsychic individual problems ofthe
2. Change their dysfunctional into a healthier couple.
pattern.
• This will be reflected in positive changes for the
patient as well as other family members.
1 BI* The
• The therapy is focused on the family as a whole • The therapy is focused on the relationship
rather than the individual patient. rather than any ofthe individual partners
70
3. Milieu Therapy
KMi^rmTiTiTin
• An environment that is organized to assist Interactions of patients with other patients and at
patients to: least one trained professional therapist in a group
1. Control maladaptive behaviors. setting.
2. Promote adaptive psychosocial skills in coping
yyith the self, others and the environment.
• Improvement of social relationships & 1. Relief of symptoms.

occupational and recreational activities. 2. Resolution of interpersonal & intrapsychic
problems through insight and corrective
experiences.
3. Encouraging personality development.
• Behavioral problems • Almost All diagnoses except:

• Personality disorders Acute manic
Antisocial personality disorder
P.vychotic episodes
Techniques:
Group therapies. > Techniques= Model of therapy (content):
Different rehabilitative and activity therapies A. Most models, including supportive,
(occupational, art, music and recreational psyehodynamic experiential, cognitive and
activities). behavioral models
Structured activities of daily living for all B. Some special models are mainly concerned with
patients. the group formal e.g.
Interaetional model(Yalom).
Transactional analysis(Bern)
Psychodrama
Characteristic Features
Therapy is based on the : 1. Size:
A. coordinated work of a multidisciplinary team • 6-12 patients(optimum 8).
which includes the psychiatrists, psychologists, 2. Type of patients:
psychiatric nursing staff, and social workers • Heterogeneous (different diagnoses).
B. Occupational, art, play and recreational • Homogeneous (single diagnosis)
therapists.
C. Can be established in different locations, e.g. 3. Time:
psychiatric hospitals, psychiatric inpatient ward • 1 -2 hours once or twice weekly.
of a general hospital. 4. Duration:
• Months to years depending on goals and therapy
model.
5. Techniques= Model of therapy (content).: see

before.
71
CHAPTER XXII: Psychiatric Emergencies
Psychiatric emergencies include the following conditions:
Acute Organic Mental Disorders:
Alcohol and substance abuse, intoxication, or withdrawal
Acute psychiatric conditions associated with medical emergency such as stroke & AIDS.
Delirium
Suicide and Parasuicide
Complications of ECT;see before.
Drug related emergencies:
Antidepressant overdose
Anticholinergics overdose and Delirium.
Acute Dvstonia
Neuroleptic malignant syndrome
Serotonergic syndrome
Hypertensive crisis
Lithium intoxication
I. Violence and Excitement

!❖ The causes of violence and excitement are:
■ Cause: ■ Example:
I. > Acute Intoxication • Psychoactive stimulants, and
• Withdrawal phase of psychoactive depressant
substances
A. > Anxiety and Dissoeiative • Panie, grief reaction, post-traumatic stress disorder,
Disorders: group crisis and hysteria
B. > Other Psychoses • Delusional disorders, puerperal psychosis, infanticide
C. > Schizophrenic excitement • Catatonic, homicidal behavior

D. > Delirium due to an acute organic mental disorder
E. > îleptic excitement
F. > Mood disorders • Agitated depression, bipolar disorder
!<♦ Management:
1. The first priority Is hospitallzation to ensure the safety ofthe patient & the society.
2. Parenterai medications are essential.
• Avoid medications that cause hypotension (e.g. Valium) if acute OMD are suspected.
3. Exclude organic mental disorders(OMD)
4. Exclude substance related disorders.
5. Treat the cause.
N.B.: Difference between hysterical fit & epileptic

A. Hysterical fit B. Epileptic fit
o Occur in the presence of people o Occurs at anytime
o Rarely hurt themselves o Usually injury themseves
o May be either tonic or clonic o Tonic then clonic
o Doesn't occur during sleep o Can occur during sleep
o No incontinence of urine o Usually incontinence occur
o Attempt to pull their hair o absent
o EEC is usually normal o EEG is usually abnormal
72
11. Suicide & Parasuicide
KMirarfiiTffid~
Suicide is a Successful attempt to kill one Self.
Unsuccessful suicide is called Parasuicide.
It is an intentional Self-inflicted death, arising from:
Depressed person's feeling that life is unbearable
Death is the only escape from this great pain and distress.
Suicidal persons experience hopelessness & conflicts between life and unending stress.
No possibilities for improvement.
Suicide is currently ranked as the 9^*^ overall cause of death in USA
|a. Sociological Factors(Durkheim's Theory):
Suicide is divided into:
1. Egoistic suicide: 2. Altruistic suicide: 3. Anomic suicide
Definition : Applied for those people who are :

Not strongly integrated into Excessive integration into a • Integration into the society is
any social group. group. disturbed so that they cannot
cope with any drastic stress or
socio-economic changes.
Suicide represents:
Lack of empathy to the Sacrificing oneself for the • Sense of loneliness due to
feelings of others who may sake of others. social instability and
suffer due to committing Response to a sense of guilt breakdown of society's
suicide. toward loved others standards and values.
Lack of significant others.
|b. Psychological Factors:
1. Freud's Theo 2. Menninger's Theory
^(jJaSLiill Ûall ji ^3^ jUojyi

Olilt Alia 1-1^ 2^) ditfcjyi jji
Suicide represents Suicide is an inverted It is It could be a wish of

aggression turned homicide, where the hopelessness revenge, power,
inward against an patient's anger towards due to control, punishment,
ambivalent love another one is directed intolerable sacrifice, escape, or
object. to one's self. depression rebirth.
|G. Biological Factors:
1.
Suicide runs in families.
1 degree relatives of suicidal cases are 8 times greater than in the general population.
SIBnlCTHBTHHBWthe CSF of suicidal cases show :
Increase in the tree eortisol (stress hormone) level.
Decrease in :
I 5- HIAA (5-Hydroxyindoleacetic acid)^ vf serotonin
I mono-amine oxidase enzyme -> 4/ turnover of norepinephrine, serotonin(5-HT)& dopamine.
IS Associated factors (in USA): APO .MRS
More risky among young individual around the age of30 vears.
In USA, suicide is now the third cause of death in the age group 15-44 after accidents and homicide.
Older neonle attempt less frequently but more often sueeessflil.
73
2. Physical healthj^
32% of all people who commit suicide have been under medical attention-
System affection Example
Central nervous system Epilepsy, multiple sclerosis, head injury, Huntington's disease,
dementia &AIDS.
Endocrine Porphyria, Cushing's disease, Klinefilter's disease
Cancer Breast Carcinoma
Gastrointestinal tract • Peptic ulcer and liver cirrhosis(may be related to alcohol
dependence).
Urogenital Prostatic hypertrophy treated by prostatectomy,
Renal failure treated by dialysis(may be related to depression).
❖ Medical conditions cause suicide because of the following:

• Chronic intractable pain
• Lnxfi of mobility
• Loss of work
• Disfigurement
• Disruption of relationships
Depression caused by Drugs e.g. corticosteroids, anticancer and antihypertensive drugs
ilÔccupationf
• Work protects against suicide.
• The rate of suicide is higher in high socio-economic levels.
• The rate increases if there is a fall in the social status.
[arital status:!
• Marriage and children lessen the risk of suicide.
«■ fahnds iisedi
• Males use firearms, hanging, and jumping from high places.
• Females prefeyroisons and drug overdose.
❖ INCIDENCE :
■ 95% of all people who commit or attempt suicide have a diagnosed mental disorder
■ Mental disorder: ■ Incidence:
Depressive disorders 80%
Alcohol or substance dependence 25%
Schizophrenia 10%
Dementia or delirium 5%
> Psvchiatric oatients are at risk of suicide 3 to 12 times greater than non-nsvchiatric patients.
> Hosnitalized patients are of greater risk of suicide than outpatients 5 to 10 times.
Mental disorder: Risk of suicide increase with :

Depressive disorders: Early in the illness and during recovery and regaining power
(paradoxical suicide).
Alcohol dependence: Depresiiyejymptomy, Single, Isolated, Impulsive.
Schizophrenic • First vears of illness
patients: • Dppipssjye,symptoms
• Suicidal Ideations
• Socially Isolated patient
Anxiety disorders: Panic disorder and social phobia.
Depressiye_ symptoms
74
>. RBI
Rate of Suicide in Catholics is less that in Protestants and Jews.

RATE AMONG MOSLEMS IS BY FAR T ESS.
This reflects the importance of religious faith as a protection against suicide
Whites form 2/3 ofthe cases.

Suicide rate increases in immigrants.
I I
Males commit successful suicide more than females(3:1)

Fernales_attempt suicide more than males(4:1)
• A past suicidal attempt is the best indicator ofa next attempt.

The risk ofa second attempt is highest duringth^^ after a previous attempt.
Treatment of Suicide
1. Hospitalization
2. Psychotherapy
3. Pharmacotherapy according to the diagnosis
4. Electro-convulsive therapy
5. Hot line for cases in crisis
Don't be the second edition of others, but be the first of yours!
of own
Algorithm for diagnosis for most common psychiatric cases;
Thinking, perception, personality
I 1
Normal Abnormal
Neurosis Psychosis
Neurosis
(J M Mfl > (JS(> (2)112 \.^1a (,^>»U
^ ji (JiuOJ dJ (Jl« (J^>»3| JA
MI iAjil AjLa iÂXi ^jjL ji Sj^ 1is (JjsSw ji (_p*L ji Jljlj
^Llu& CiLilefr uU^jcI
Panic attack o Agoraphobia : o GAD o OCD o PTSD
(2)^ (2)Sa4j o places in which

(2)SU'!?I(> uiji escape is difficult
4juui1a3I or embarrassing
agoraphobia o Social phobia :
scrutiny
Specific : flying,
heights, animals,
blood ... etc.
❖ Psychosis
(^^(2)1-22 (^jU (2)lJl2 V 4^jll (2)Ij12j : cjI
'»jSlill Jh JISjSQl jSbj.. (^J (jUSSVI (jialjcij hjnilj ^ ji 4.a1S2j im
immediate recent then jt (jSLi Qjiil (jSjiU (j.ujl2 LjijAdJJJ ^ jjlSjj) Aljjla(^ 4JajaJ^
& recent remote ji AjJljiajt jl Ûj 1.1^ jjjS SJjAu jjCrLuUll (_^ AjajaJ
(> jjSI jaaij jSiu
o Delirium o Dementia o Major o Manic episode o Schizophrenia

depressive of bipolar
disorder disorder
76
MCQs answers I
1Psychiatric Symptoms and
1. C 2. D 3. B 4. E 5. D 6. C 7. B 8. E 9. B 10. A
11. A 12. A
Mental Disorder
1 1
13. D 14. B 15. A 16. D 17. D 18. C 19. C 20. A
21. C 22. D 23. D
Substance Abuse and Dependence^^^^^^^^^^^^^^^^^^H
24. C 25. A 26. D 27. C 28. A 29. A 30. C
31. D 32. D 33. B 34. E 35. A 36. E
Anxiety Disorders
37. A 38. B 39. E 40. E
41. C 42. D 43. D 44. B 45. T 46. T 47. T 48. T 49. T 50. T
51. T 52. T 53. D
Somatoform Disorders
54. B 55. A 56. D i 57. C 58. B 59. T 60. T
Mood Disorders!
61. B 62. D 63. D 64. A 65. E 66. C 67. B 68. D 69. A 70. C
71. T 72. E
|Schizo p h reni
73. C 74. C 75. E 76. A 1 77. A 78. B
|Delusional Disorders!
79. A 80. T
82. T 83. T 84. T
'sychosexual Disorder3
85. B 1
Child Psychiatry!
86. T 87. A 88. C 89. A 90. B
91. D 92. D 93. D
|Personality Disorders
94. B 95. T 96. T 97. T 98. T 99. T 100. D
101. B 102. C 103. T 104. T

|Psychopharmacology| 1
105. T 106. T 107. T 108. T 109. E 110. E
111. B 112. E 113. E 114. A 115. C 116. B 117. C 118. B 119. B 120. C
H
121. B 122. D 123. B 124. E 125. E 126. C 127. D 128. A 129. E 130. T
00
131. T 132. C 133. B
Psychotherapiesl 1
134. D 135. E 136. B 137. D 138. D 139. T 140. T
141. A 142. E 143. C 144. T 145. T 146. A 147. B 148. E 149. A 150. A
77
The CD contains Cases for the Psychiatry
Cases Answers
Number [Answer, diagnosis]

Organic Mental Disorders
Delirium
Dementia
[Substance Abuse and Dependence]

Alcohol Dependence
Substance-Induced Mood Disorder
Cocaine intoxication
Opioid withdrawal
Alcohol withdrawal
Benzodiazepine withdrawal
[Anxiety Disorders
Panic Disorder versus Thyroid Medication Overuse
10. Generalized Anxiety Disorder
11. Obsessive-Compulsive Disorder (Child)
12. Posttraumatic Stress Disorder
13. Anxiety disorder secondary to general medical condition

14. Social phobia
Somatoform Disorders
15. Hypochondriasis
16. Somatization Disorder
17. Conversion Disorder
[Adjustment disorder]
18. Adjustment Disorder
Mood Disorders
19. Major depression, recurrent.

20. Bipolar disorder (child)
21. Major Depression in Elderly Patients
22. Bipolar Disorder, Manic(Adult)
23. Major Depression with Psychotic Features
24. Dysthymic Disorder
78
|Schizophrenia|
25. Schizophrenia, Paranoid
26. Schizoaffective Disorder
Delusional disorder
27. Dissociative fugue
[Psychosexual Disorders
28. Gender Identity Disorder
29. Fetishism
[Eating disordersi
30. Anorexia Nervosa
31. Bulimia nervosa
[Child Psychiatryj
32. Conduct Disorder
33. Attention-Deficit/ Hyperactivity Disorder
34. Autistic Disorder
Mental retardation
35. Mild Mental Retardation
[Personality Disorders
36. Obsessive-Compulsive Personality Disorder
37. Antisocial Personality Disorder
38. Histrionic Personality Disorder
39. Paranoid Personality Disorder
40. Schizoid Personality Disorder
[Psyehopharmacology
41. Extrapyramidal Symptoms(Acute Dystonic Reaction)
❖ Other Available Books By The Author;

Internal Medicine : Clinical
Dermatology
ECG
X-Rays Of Internal Medicine
Clinical Pathology
Psychiatry
79
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‫[\‪S9;0‬‬
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‫‪X:-‬‬ ‫‪..v.-zxi‬‬
‫‪■- •■ -\"-‬‬ ‫•>•'‬ ‫• • ‪':• x'.‬‬
Other available books
BY THE Author :
Essentials for Sixth year
Înternal Medicine : Clinical
* Dermatology
* EGG
* X'Rays Of Internal Medieine
* Clinieal Pathology
* Psyehiatry
& More.
University Book Centre

Sayed Mahmoud
103 matehaf el maniei-cairo
tel.:012236986G0 - 01091111168
^l?Ahraiu Commercial Press - Kalyoub - Egypt

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Kasr Al-Ainy School of Medicine

Mobile No.: 01008855731

3. III. Psychiatric Symptoms and Signs 3

6. VI. Substance Abuse and Dependence 23

IJ Psvchiatrv & Psycholo

s. The Mind-Brain Relationship ; da ^

2. Manifest decline in social and vocational adjnstment:

❖ Etiology of Psychiatric Disorders: v

A. Genetic Factors : ^ ii^

> Dvsregulation in neurotransmitters > Dvsflmction in neuroendocrine sv.stems

> Neuronhvsiological fi e. functionab changes

NB: 'Neurochemical. neuroendocrine. neuvophysioloeical & neuropatholopical represent the

A. Stressful life events, e.g. death of loved people

1. Predisposing Factors 2. Precipitating Factor 3. Perpetuating

• Factors which operate from •

Factors and events that occur • Factors that prolong the

• Genetic factors, intrauterine • Physical e.g. Trauma, or • Biological or psychosocial in

psychological and social social factors.

• Predisposing Factors & • They do not influence the

CHAPTER III: Psychiatric Symptoms and Signs

• It is found in mania and paranoid

• Orientation is awareness of time, place and persons.

The process by which sensory stimuli (physical stimulation) apresentation

are transferred into a meaning (psychological information)

C* Definition : Disturbed perception of oneself or the surrounding environment

•NB: Depersonalization and Derealization :

> Auditory Hallucinations > Elementary (e.g., noises, Hashes of light).

> Olfactory (smell) and Gustatory (taste)

> Somatic Hallucinations

The general state of awareness of the self and the environment.

It is excessive drowsiness. • It is INcomplete clear-mindedness in which the

The patient is immobile, mute and

5. Dream-like state (oneroid or twilight state):

State of disturbed consciousness associated with dream like imagery or hallucinations.

Physical and mental over actiyify-, in response to • Extreme degree of agitation.

uiLd ^uaj jL»ij|

E. Catatonic excitement F. Catatonic stupor

lipnilol com 44?t4!j

• Agitated, purposeless motor activity Markedly slowed motor activity (up to

Motiveless resistance or opposition to outside Automatic following of suggestions or orders.

II. inWWffTiTCTI SjSljll Sja : Exaggerated degree of retention and recall.

III. Paramnesia SjSIj]| Dyltti: falsification or distortion of recalled memories

Filling of gaps in memory by imagined or Unintentional distortion ofa true memory by

Illusion of visual recognition, in which a new False Feeling of UNFamiliarity

A. Affect: iilaUII B. Mood:

<♦ Represents the ... & e.g.:

1 11. Disorders of Mood: 1

1. Irritable mood jj*^l ^y-»: easily A. Eiinhoria

• Affective expression characterized by frequent Oscillation of a person's emotional feeling tone

Shifting between UNreiated and UNconnected This is a SEVERE degree of loosening of

jjjji CjLaK jj Nehl

^jc. j»cj (i<aj

1. Organic anxiety disorder e.g. with

3. Organic mood disorders e.g., due to hypo- or

5, Organic delusional disorder e.g. alcohol-relatqd

Etiology of Organic Mental Disorders:

days). years. Hypothslamus

Deliriu lAmnestic Disorders!

minor metabolic disturbances b) £arkinson's disease - It is caused by

bisseminated (multiple) sclerosis dependence.

Delirium Amnestic Disorders

Onset, Course & Prognosis: