REVISON OCP 110

CONTENT:

1. I‌ntroduction to psychiatric disorder and classification

2. ‌General signs and symptoms in psychiatric disorder
3. ‌Anxiety disorder
4. ‌Child and adolescents psychiatric
5. ‌Schizophrenia
6. ‌Subtance use disorder
7. ‌Mood disorder
8. Psychological Intervention in Psychiatry
9. Neurocognitive disorder
10. Pharmacological interventions in psychiatry

‌INTRODUCTION TO PSYCHIATRIC DISORDER AND CLASSIFICATION

a) Concepts of Mental Illness:

 Classification is needed in psychiatry for several purposes:

I. So that doctors can talk to each other about the diagnoses they give to their patients.
II. To help patients and their families by letting clinicians give them a framework for
understanding their symptoms and problems, as well as treatments that might help.
III. To understand what these diagnoses mean in terms of symptoms, prognosis, treatment, and
sometimes even the cause.
IV. To connect the results of clinical research to the patients they see every day.

 Two main difficulties in classification:

a) Conceptual: about the nature of mental illness and the question of what, if anything, should
be put into a category.
b) Practical:how categories are defined and how they are put together in a classification
scheme.

 Definition of mental illness

I. Lack of health: The World Health Organisation defines health as "a state of complete
physical, mental, and social well-being, and not just the absence of disease or infirmity."

II. Doctors can treat disease: The idea that doctors can treat disease is a bit more plausible,
since there is evidence that as more medical treatments become available for a condition,
the condition is more likely to be seen as a disease.

III. Biological disadvantage: This term has been used in psychiatry to describe things like lower
fertility (reproductive fitness) and higher death rates. It is similar to the idea of seeing
disease as a "evolutionary disadvantage."
 IV. Pathological process: Szasz (1960) says that illness can only be defined in terms of physical
pathology. This means that doctors don't treat mental disorders.This kind of argument can
only be made if you look at pathology in a very narrow way.

V. The presence of pain has some practical value because it shows which people are likely to go
to the doctor. One problem is that the term can't be used for everyone who would be
considered sick in everyday language.

 Three related terms used to describe the harmful:

a. A pathological defect is an impairment.

• For example, a stroke can cause hemiparesis.

b. Disability is the inability to do things physically or mentally because of an impairment.

• For example, the hemiparesis makes it hard for the person to take care of himself or herself.

c. The social problems that come from having a handicap.

• For example, someone with hemiparesis might not be able to work.

 Diagnoses, Disease, and Disorders: The term ‘diagnosis’ has two somewhat different meanings.

a) General meaning of ‘telling one thing apart from another’.

b) Specific meaning in medicine of ‘knowing the underlying cause’ of the symptoms and signs about
which the patient is complaining.

 The definition of psychiatric disorder in ICD-10 is:

“…a clinically recognizable set of symptoms or behaviour associated in most cases with distress
and with interference with personal functions. Social deviance or conflict alone, without
personal dysfunction, should not be included in mental disorder as defined here.”

 The definition of psychiatric disorder in DSM-5 is:

“…a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion

regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental
processes underlying mental functioning. Mental disorders are usually associated with significant
distress or disability in social, occupational, or other important activities. An expectable or culturally
acceptable response to a common stressor or loss, such as the death of a loved one, is not a mental
disorder. Socially deviant behavior (e.g. political, religious, or sexual) and conflicts that are primarily
between the individual and society are not mental disorders unless the deviance or conflict results
from a dysfunction in the individual, as described above.”

b) History of Classification

 Aetiological principle: that mental illnesses were disorders of the nervous system.
 Descriptive principle: distinguishing individual clinical syndromes within the neuroses.
 Organic disorders are those that arise from a demonstrable cerebral or systemic pathological
process.
 ‘Functional disorder’ is consequently an umbrella or default term for all other psychiatric
disorders.
 Psychosis refers broadly to severe psychiatric disorders, including schizophrenia, and some
organic and affective disorders. Psychosis remains a convenient term for disorders that are
usually severe, and which feature delusions, hallucinations, or unusual or bizarre behaviour
(presumed to be secondary to these phenomena), especially when a more precise diagnosis
cannot yet be made.

a. Severity of the illness

b. Lack of insight
c. Inability to distinguish between subjective experience and external reality (presence of
delusions and hallucinations)

 Neurosis refers to specific disorder cannot yet be determined, to indicate disorders that are often
comparatively mild, and usually associated with some form of anxiety.

a. Difficult to define.

b. The conditions that neurosis embraces have little in common.

c. More information can be conveyed using a more specific and descriptive diagnosis.

a) Categorical classification
 Since we don't know what's wrong at the root, we can only define these groups by how the
symptoms show up and how long they last.Such grouping makes it easier for clinicians to decide
how to treat and care for patients, but there are two problems with it:

a. People can agree on definitions and descriptions, but they don't all agree on how much these
categories represent different things.
b. A lot of patients don't fit the descriptions of any disorder very well, or they meet the criteria
for two or more groups.

b) Dimensional classification
 Scores on two or more dimensions are used to describe the subject.Epidemiological surveys have
brought back the idea of dimensionality and made it clear that there is a continuum between
healthy people and those who have been diagnosed with psychiatric disorders.Dimensions are
not very useful in clinical practise, which is a problem.

c) Multiaxial approach- Applied to schemes of classifications in which two or more separate sets of
information (such as symptoms, aetiology, and personality type) are coded.

 Comorbidity also called dual diagnosis.

 More emphasis on comorbidity usage compared to hierarchy because:

a. Research has shown that comorbidity is very common.

b. It reminds the clinician to focus on all the various disorders that may be present.
 c. The diagnostic rules used in current classificatory system allow multiple diagnoses to be made.

 Reliability of psychiatric diagnoses- Consistency of psychiatrist to reach to the same diagnosis.

 Two main reasons for diagnostic disagreement:

a. The interviewing technique and characteristics of the psychiatrist.This included the way in
which symptoms and signs were elicited and interpreted and the weight attached to them.

b. The differing use of diagnostic terms and criteria.At the time, there were no widely accepted
glossaries or definitions of key terms.

 Standardized interview schedules- Minimize the variations in interviewing technique and

symptom rating between psychiatrists.Specify the content and sequence of the interview, and
provide scoring rules by which the presence and severity of symptoms are rated.

 Diagnosis by computer- Computer programs like CATEGO generate diagnoses using symptom
ratings, eliminating personal bias and chance errors. Although they may reflect the program's
preferences, they are valuable for epidemiological studies and widely used in research.

 Validity of psychiatric diagnoses- Validity refers to the extent to which a concept means what it is
supposed to mean → closely connected with usefulness (utility).

 Face validity is the degree to which the test results match the clinical concepts and descriptions
that are currently used in clinical practise.

 Predictive validity is how well disorders can predict how people will respond to treatment and
how things will turn out.

 Construct validity means that there is a clear link between a disorder and its underlying cause
and effect.

c) Current Psychiatric Classifications

 The International Classification of Disease (ICD), Chapter V is produced by the World Health
Organization (WHO) as an aid to the collection of international statistics about disease.

 The current version is the 10th edition (ICD- 10). & Of the 21 chapters, Chapter V is devoted to
psychiatry

 The objectives of the international collaborative effort to Chapter V are:

a. suitable for international communication about statistics for morbidity andmortality.

b. a reference standard for national and other psychiatric classifications.
c. acceptable and useful to a wide range of users in different cultures.
d. an aid to education.
 Diagnostic and Statistical Manual (DSM) containing five main innovations:

a. For each diagnosis, there were clear rules about who could be included and who couldn't be.
This was the first full classification to do so, and it was also the first to use criteria that had been
tested in the field.

b. A classification with five axes and more than one axis was chosen.

c. The names were changed, and some syndromes were put together with others. For example,
the words "neurosis" and "hysteria" were taken out of the dictionary and all mood disorders
were put together.

d. It took a quantitative method, and most psychodynamic ideas were left out.

e. The length of illness was added as a diagnostic factor for some conditions.

 DSM-5
 When planning for DSM-V (later renamed DSM-5), it was hoped that the classification could be
based on aetiology instead of description.It was also meant to use dimensions instead of
categories in a much bigger way.However, it became clear that both steps were too soon for all
major disorders, so DSM-5 keeps the same main parts as its predecessors but adds and changes
some diagnostic criteria and other parts.

 Differences between ICD-10 and DSM-5

 Specific examples of differences:

a. How long the symptoms have to last for a person to be diagnosed with schizophrenia. ICD10
says it has to be one month, but DSM-5 says it has to be six months, including a prodromal
period.
b. The DSM-5 does not use words like "neurotic," "neurasthenia," or "mental retardation."
c. In ICD-10, bereavement was a reason to rule out a depressive episode, but this reason has
been taken away in DSM-5.
d. In DSM-5, dementia and amnesic syndromes have been put into a new group called "major
neurocognitive disorder."
 Current and Future Issues in Psychiatric Classification

 Cultural issues

a. Cultural syndrome: syndromes characteristically found in one cultural group.

b. Cultural idiom of distress: terms, phrases, and ways of communicatingsuffering that are
characteristic of a cultural group.
c. Cultural explanation or perceived cause: a label for, or attribution of, a cause of symptoms or
distress that is accepted within a cultural group.

 Research domain criteria- Such domains may include neuropsychological constructs (e.g. working
memory, or reward sensitivity) or brain systems (e.g. corticostriatal circuits), which underpin and
are thought to cut across the current diagnostic categories.

GENERAL SIGNS AND SYMPTOMS IN PSYCHIATRIC DISORDER

a) General Issues for Describing Signs & Symptoms

 Psychopathology also known as the study of abnormal states of mind

 Descriptive psychopathology = Symptomatology, also known as phenomenological

psychopathology, is an objective description of abnormal mental states without preconceived
ideas or theories. It aims to understand the causes of bad mental experiences and patients'
feelings of illness, requiring the ability to identify and identify psychiatric disorders' symptoms.

 Experimental psychopathology = psychodynamic psychopathology aims to explain and describe

abnormal mental phenomena using empirical methods and experimental methods.

 Objective: features observed during an interview (i.e. the patient’s appearance and behaviour).
 Subjective: features reported by the patient.
 Form: the type of abnormalities.
 Content: actual thoughts described.
 Primary: arising directly from the pathological process.
 Secondary: arising as a reaction to a primary symptom.
 Verstehen (German for "understand") means trying to understand how the patient feels (what
does it feel like?).
 Erklaren, meaning "to explain," defines events in terms of outside factors. For example, the
patient's bad mood can be "explained" by the fact that he or she has recently heard the same
information more than once.
 b) Descriptions of Symptoms & Signs

1. Disorders of Mood = Changes in mood

 SUBJECTIVE MOOD - Ask the patient, "How are you feeling right now?" or "Can you tell me how
you're doing?" or "What do you believe?" Don't change what the patient says. For example,
write down "Great, never felt better," "OK, not too bad," or "Awful, terrible, desperate."

 OBJECTIVE MOOD - The nature, constancy, and congruity of a patient’s observed mood should
be described:

I. Nature of mood or moods: The interview seems to be dominated by one or more feelings, such
as sadness, happiness, anger, worry, suspicion, or confusion. You can record more than one
feeling.

 Euthymic mood, or unremarkable mood that is neither sad nor happy, means that the person
doesn't seem to be feeling anything in particular.

II. Constancy of mood: It is normal for a person's mood to change based on what is going on inside
(like what they are thinking about) and outside (like being reminded of a failed relationship or
doing well on an exam).

 Emotional lability is when a person's mood changes quickly and often in a big way. They also
have strong emotions or feelings.
 Emotional incontinence is showing too much or the wrong kind of emotion.
 Reduced reactivity, dulling, or flattening: less emotional display.
 Irritability is a term that covers two parts of a mood assessment that can be done by a third
party.
 main feelings (in the case of irritability, this could be tension and anger).
 Changes in mood (in irritability, this would be unstable and make it easy to get angry).

III. Congruity of mood : proper association between mood, thoughts, and perception.

 Incongruity of mood: poor linkage between mood, thoughts, and perception (e.g. person
appears cheerful while describing sad events.)

2. Disorders of Perceptions

 Perception is the process of figuring out what comes to the body through the senses and what
those things are and what they are not.
 Imagery is a mental experience that usually doesn't have the sense of reality that comes with
perception.Unlike perception, it can be started and stopped whenever the person wants to.
 Eidetic imagery is a type of imagery that is as clear and exact as perception.
 Four kinds of abnormalities of perception:

I. Changes in intensity - The colours may be very bright and clear, the sound of a pin dropping
may seem loud, and the colours may be toned down so that the world looks dull and grey.

II. Changes of quality- Perceptions can seem wrong or bad, like when food tastes bad or flowers
smell bad.

III. Illusions - Misinterpretation of a real outside stimulus; one or more of the following is true:
a. loss of senses
b. lack of focus
c. loss of consciousness
d. emotional protests

IV. Hallucinations - A perception that happens when there is no outside stimulus for the
corresponding sense organ. For example, hearing voices when no one is talking or seeing
bright lights flashing when there is no light source.

 Modalities of hallucinations - can occur in all sensory modalities.

I. Auditory hallucinations - Voices, noises, or music; may seem to speak words, phrases, or
sentences.
 Second-person hallucination: address the patient as “you”
 Third-person hallucinations: talk about the patient as “he” or “she”.
 Thought echo: repeat what the patient just been thinking.

II. Visual hallucinations - As simple as a flash of light or as complicated as a man's shape.Size is

sometimes normal, but sometimes it's small or big.Usually linked to organic mental
disorders, but can also happen in other situations.

III. Hallucinations of smell and taste - Taste or smell may seem to be recognizable but more
often it is unlike any smell or flavour that has been experienced before and has an
unpleasant quality.

IV. Tactile hallucinations- Feelings on the surface, like being touched, poked, or strangled.
Sometimes, there are feelings just under the skin that may be caused by insects or small
animals burrowing through the tissues.Could be linked to a delusional understanding.

V. Hallucinations of deep sensation - They felt like their organs were being pulled or pushed
out, or that they were being stimulated sexually.May be linked to a delusional understanding.

 Disorders of Thoughts

 If we want to know what someone is thinking, we can:

 a. Listen to what they say, whether they say it on their own or in response to a question from
us or someone else.
b. Read what they are writing, whether it's on paper, on a computer, or in a text message.
c. Pay attention to how they look and act, and use those clues to help us figure out what they
might be thinking.

 Abnormalities of the stream of thought (cont.)

i. Pressure of thoughts: thoughts are unusually rapid, abundant, and varied.This disorder is
a sign of mania, but it can also be a sign of schizophrenia.

ii. Lack of thoughts: Thoughts are slow, few, and don't change much. This disorder is a sign
of severe depression, but it can also be a sign of schizophrenia.

iii. Blocking of thoughts: the experience of having the mind suddenly and completely empty
of thoughts.

 Abnormalities of the form of thought

I. Flight of ideas: thoughts and any accompanying spoken words move quickly from one topic
to another, so that one train of thought is not completed before the next begins

II. Loosening of association: lack of logical connection between a sequence of thoughts, not
explicable by the links described under flight of ideas.

III. Perseveration persistent and inappropriate repetition of the same sequence of thought, as
shown in either speech or actions.

 Preoccupations - Thoughts that keep coming back, but you can force yourself to forget them.

 Morbid thoughts- Thoughts that are especially connected to certain illnesses.

A. Depression can cause thoughts of suicide, self-criticism, hopelessness, helplessness, low self-
esteem, and feelings of guilt.

B. Suicide thoughts and plans are an important part of the MSE, and they should always be
asked about and written down.

 Suicidal thoughts are personal and sensitive, so it's important to get used to asking about
them in a way that is supportive but direct.

 Delusions - Most of the time, this is not true, but not always because there are so many themes.

 Primary delusions happen all of a sudden and are not caused by anything else strange in the
mind.
 Secondary delusions are caused by a strange thought or experience that happened before:

a. hallucination (e.g. a person hears a voice and believes he is being followed)

b. mood (e.g. person with deep depression feels worthless and believes that other people think
the same about him)
c. another delusions → delusional system: one delusion gives rise to another in a sequence
resulting a network of interrelated ideas.

 Three mental phenomena that are closely related to delusions, but are not delusional in nature,
despite their names incorporating the term ‘delusional’.

i. Delusional mood: an unexplained feeling of fear that is soon followed by a delusion that
explains it (for example, a person feels scared for no reason and then believes that someone
is following him and wants to hurt him).

ii. Delusional perception is when someone misunderstands the meaning of something they
normally see. For example, a patient may suddenly think that the way things are arranged on
his desk means that his life is in danger.

iii. Delusional memory: Retrospective delusional misinterpretation of memories of real

events (such as the belief that the patient's food was poisoned by persecutors the last time
he got sick, even though he didn't think this before or during the illness).

 Delusional themes

a) Persecutory delusions: thinking that people or groups are out to hurt the patient, hurt his
reputation, or drive him crazy.

b) Delusion of reference: the idea that objects, events, or the actions of other people have a
special meaning for the patient. For example, the patient might think that a comment they
heard on TV was made just for them, or that a stranger's gesture says something about the
patient.

c) Grandiose and expansive delusions: people think they are more important than they really
are. For example, they may think they are rich, have special skills, or are special in some
other way.

d) Delusions of guilt and worthlessness: Beliefs that the person has done something shameful
or wrong. Usually, the belief is about an innocent mistake that didn't cause guilt at the time
(for example, a small mistake on an income tax return that the patient now fears will be
found and lead to prosecution).

e) Nihilistic delusions: thinking that the patient's career is over, that he is about to die, that he
has no money, or that the world is doomed.
 f) Hypochondriacal delusions: False beliefs about the presence of disease. For example, a
patient may think he has a disease even though there is strong medical evidence to the
contrary.

g) Dysmorphophobic delusions: worried about how parts of the body look, such as thinking
that a person's (normally shaped) nose is very wrong-shaped.

h) Delusions of jealousy: thinking that your partner is cheating on you

i) Sexual and romantic delusions: thinking that someone who has never spoken to them loves
them.to or inaccessible.

j) Religious delusions: believing that God punishes small sins. Before deciding that such beliefs
are delusional, it's important to find out if other people in the patient's religious or cultural
group also believe them.

k) Delusions of control: Believing that your actions, impulses, or thoughts are controlled by
something outside of yourself. This experience is different from:

 willingly following orders from voices in their heads.

 It is a common cultural belief that God controls what people do.

l) Delusions concerning the possession of thoughts:thinking that the thoughts aren't their own
or that thoughts can be revealed without speaking or doing anything.

 Delusion of thought insertion: the person thinks that someone from the outside has put
some of their thoughts in their head.
 Some of their thoughts have been taken away, which is a delusion called "thought
withdrawal."
 Delusion of thought broadcasting: They think that other people can hear some of their
thoughts through telepathy, radio, or some other strange method.

 Obsessional and compulsive symptom

 Obsessions are repeated, strong thoughts, suggests, or images that a person can't get out of
their mind, even though they know they don't make sense and that they are coming from their
own mind.

a. Obsessive thoughts: repeated, intrusive words or phrases, which can be obscenities,

blasphemies, or thoughts about upsetting things (like that the patient's hands are dirty
and will spread disease).

b. Obsessive ruminations: having the same thoughts over and over, such as about the end
of the world.
 c. Obsessive doubts: recurring doubts about something you did in the past, like whether or
not you turned off an electrical appliance that could start a fire.

d. Obsessive urges: the need to do things that are usually aggressive, dangerous, or socially
embarrassing, like stabbing someone with a knife, jumping in front of a moving train, or
swearing in church.

e. Obsessional images are repeated, vivid mental pictures that are unexpected,
unwelcome, and usually upsetting. For example, an image of oneself sick and dying in a
hospital, covered in human waste from an overflowing sewer in the street, or standing
still and helpless while supposed to be giving an important talk to colleagues.

 Compulsions, compulsive rituals, or obsessional rituals are repetitive, stereotyped actions that a
person feels compelled to do but knows are pointless and are made up in their own head.

3. Disorders of Cognition

A. Consciousness- Awareness of self and the environment.

i. Clouding of consciousness: a state of drowsiness with incomplete reactions to stimuli, poor

attention, concentration, and memory, and slow, confused thinking.
ii. Stupor is a state in which a person is silent, can't move, and doesn't respond, but their eyes
are open and follow things.
iii. Confusion is a state of confused thinking. It can be short-term or long-term, like delirium and
dementia.

B. Orientation- Assessed by asking about awareness of time, place, and person.

C. Attention - the ability to focus on the matter in hand.
D. Concentration: the ability to sustain the focus
E. Memory- Tests are given to assess immediate, recent, and remote memory
 Digit span test: Patients are asked to repeat sequences of digits right after hearing them spoken
slowly enough for them to catch each one.

 Specific disorders of memory:

I. Anterograde amnesia happens after being unconscious for a while. It is when you can't
remember what happened between the end of being completely unconscious and when you
come back to full consciousness.

II. Retrograde amnesia is when you forget things that happened before you fell asleep.It
happens when a person has a head injury or gets electroconvulsive therapy (ECT). They
won't remember things like waking up and taking a shower in the early morning before their
treatment.

III. Jamais vu means not being able to remember things that have happened before.

IV. Déjà vu is when things seem familiar even though you have never seen them before.
 V. Confabulation is when people say they remember things that didn't happen at the time in
question.

4. Disorders of Body Image

 Body image: a person’s subjective representation against which the integrity of their body is
judged and the movement and positioning of its parts assessed

 Specific abnormalities of the body image arise in neurological disorders such as:

a. Phantom limb: awareness of the presence of the limb after amputation.

b. Unilateral lack of awareness or neglect usually after stroke.
c. Hemiasomatognosia: a person feels that a limb is missing when it actually it not.
d. Anosognosia: lack of awareness of loss of function.

 Coenestopathic states: localized distortions of body awareness. Example: when the nose feels as
if it is made of cotton wool.

 Reduplication phenomenon: the experience that the body has doubled, or that part of the body
has done so. Example: that there are two left arms.

5. Disorders of Self

I. Disturbances concerned with activities- Patients with delusions of control have the experience
that thoughts are not their own and believe instead that these have been inserted from outside.

II. Disturbed awareness of the unity of the self- Typically, we recognize that we change over time,
we retain a conviction of being the same person. A patient may say that he is a different person
from the one who existed before the disorder began, or that a new self has taken over from the
old one.

III. Disturbances of the boundaries of the self - This type of disorder is experienced by some people
after taking LSD or other drugs, who may report that they felt as if they were dissolving. A loss of
awareness of what is within the self and what is located outside.

6. Insight - The level to which the patient's view of their symptoms, illness, prognosis, and
treatment is the same as that of their doctor. This is a very important factor in figuring out how
likely a patient is to cooperate with treatment.

 Insight can be described briefly as ‘good’, ‘moderate’, or ‘poor’. Can also be specific:

i. Being aware that you do things that other people think are strange.
ii. Being aware that these things are strange.
iii. Accepting that mental illness is the cause of these strange things
iv. Knowing that you need treatment vs. Agreeing to the professional's specific treatment
suggestion
 ANXIETY DISORDERS

 Normal anxiety is the response to threatening situations → accompanied by physiological

changes that prepare for defence or escape (‘fight or flight’) (i.e. increases in heart rate, blood
pressure, respiration, and muscle tension).

 Abnormal anxiety is a response that is similar but out of proportion to the threat and/or is more
prolonged, or occurs when there is no threat.

1. Generalized Anxiety Disorder (GAD)

 Excessive, uncontrolled, and irrational worry about everyday things that is out of proportion to
what is causing the worry. The worry makes it hard to do things because the person tends to
think the worst and worry too much about normal things like health, money, work, and
relationships.
 Only diagnosed when anxiety symptoms have been present for at least six months (in DSM-IV).
When symptoms have only been there for a short time, stress or adjustment disorder is the most
likely cause.

 Psychological & Physical Symptoms

 I. Sleep: When patients go to bed, they worry and stay awake. When they finally fall asleep, they
wake up often. They often have bad dreams, and sometimes they have "night terrors," where
they wake up feeling very scared, sometimes remembering a nightmare and sometimes not
knowing why they are so scared.

II. Hyperventilation is a common symptom that includes rapid, shallow breathing, dizziness,
tinnitus, headache, chest pain, weakness, fainting, numbness and tingling in the hands and feet,
and carpopedal spasm.

III. Panic attacks: Some patients have panic attacks, which are sudden, very intense bouts of anxiety.
But panic disorder is more often marked by panic attacks.

 Prevalance

 About 3% of the population will have generalised anxiety disorder in any given year. The risk of
getting it over a lifetime is 4 to 5%.
 It's twice as common in women as in men, and it's more common in Caucasians and people from
lower socioeconomic groups.
 The average age of onset is 21, but there's a second peak between 40 and 59. The disorder is
long-lasting, so it's common among people who go to primary care.

 Co-morbidity

 Recent studies have shown that approximately 68 per cent of patients with a primary diagnosis
of GAD meet criteria for another psychiatric disorder → most common are depression, social
phobia, and panic disorder, but alcohol and drug misuse also frequently occur.

 Differential Diagnosis

a. Depressive disorder: Mistakes in diagnosis can be reduced by routinely looking for signs of
depression in people who come in with anxiety.

 Most of the time, the mood symptoms are worse than the anxiety symptoms and came on first.
There will also be other signs of depressive disorder.

b. Schizophrenia can be diagnosed more accurately if all patients are routinely checked for
psychotic symptoms, like paranoia.

 People with schizophrenia sometimes complain of anxiety before they show any other signs of
the illness.

c. Errors in diagnosing dementia can be cut down on by evaluating memory in the right way,
especially when older patients are anxious.

 The doctor may not notice the memory problem that goes along with it or blame it on a lack of
focus.
d. Drugs, whether they are prescribed or not, can cause symptoms like anxiety. In psychiatry,
alcohol, cannabis, antidepressants, antipsychotics, benzodiazepines, caffeine, and sedatives are
often to blame. However, bronchodilators, antihypertensives, anti-arrhythmics, anticonvulsants,
thyroxine, chemotherapy, and antibiotics are also often to blame.

 Withdrawal from drugs or alcohol can also cause anxiety, and the cause may be missed because
people want to hide their drug or alcohol use.

e. When it comes to physical illnesses, screening for thyrotoxicosis, hypoparathyroidism,

hypoglycemia, temporal lobe epilepsy, and respiratory disease can help reduce diagnostic
mistakes.

 May show signs like those of an anxiety disorder, especially if the signs come and go.

 Thyrotoxicosis makes people angry, restless, tremble, and have a fast heart rate. Patients should
be checked for an enlarged thyroid, atrial fibrillation, and crossed eyes, and when necessary,
thyroid function tests should be set up.

 Aetiology

1. Genetic → five times more prevalent in those with first-degree relatives with GAD than in the
general population.

2. Neurobiological mechanisms → the response to stimulation of the autonomic nervous system is

prolonged in patients with GAD, and negative feedback of the hypothalamic– pituitary–adrenal
axis by cortisol is reduced.

3. Childhood upbringing → inconsistent parenting, poor attachments, and a chaotic lifestyle in

childhood may cause apprehension and anxiety which persists into later life.

4. Personality traits → anxious and worry-prone personalities are linked to anxiety disorder but
other personalities can predispose by making people less able to cope with stressful events

 Prognosis

 GAD can't be diagnosed until the symptoms have been there for at least 6 months.
 Without treatment, about 80% of people with the disorder still have it 3 years after it started,
and many people have it for the rest of their lives.

 People with GAD are more likely to be unemployed and to get a separation or divorce than the
rest of the population. • The outlook is worse when symptoms are severe and when there are
agitation, derealization, conversion symptoms, or suicidal thoughts.

 People who have GAD for a long time often have short bouts of depression, and it is often during
one of these bouts that they look for more help.

 Some specific things to talk about are;

a. current symptoms and how they affect life at home, work, school, etc.
b. A history of anxiety disorders, mood disorders, eating disorders, obsessive-compulsive
disorder (OCD), or other mental health problems.
c. past mental health treatments and how well they worked
d. Medications you are taking right now (legal, illegal, over-the-counter, alcohol, caffeine,
nicotine)
e. signs of a disease before it happens
f. current social situation—accommodation, employment, finances.

 General management

1. Make a clear plan. Uncertainty makes anxiety worse, so making a clear plan with the patient
helps to lessen it. Try not to talk to more than one named doctor.

2. Give information and talk about it (psychoeducation). The way the condition is explained should
be based on the patient's specific worries, but it is usually important to explain how worrying
that symptoms are caused by physical illness can lead to vicious circles of anxiety.

• Written information is important because people who are anxious often have trouble focusing.
Having a family member or caretaker present can also help people understand.

3. Figure out what stresses you out and get rid of it or avoid it. Learning how to solve problems is
an important part of this.

4. Advice on how to help yourself People with anxiety disorders can help themselves in simple
ways, such as managing their time, planning their activities, taking time off to relax, and drinking
less caffeine.

• Relaxation training can be given by a primary care team or at home using yoga or mindfulness
exercises. To be effective, it needs to be done regularly, and some patients are more likely to stick
with it if they do it with a group rather than on their own.

• Patients should be told about support groups in their area and national charities.
  Psychological treatments

I. Psychoeducation, support, and problem solving as outlined above are important for all patients,
and may be all that is needed.

II. Self-help books or computer courses based on the principles of cognitive behavioural therapy
may be useful prior to individual therapy. An example of this is dealing with worrying thoughts. A
patient could:

1. write down the worrying thoughts so that they can be considered more objectively.

2. consider, for each problem, whether anything can be done to resolve the worrying problem.

3. if possible take the appropriate action; if no action is possible, set aside a brief ‘worry time’
each day, and for the rest of the day endeavour to use distraction to prevent worrying

III. Refer for cognitive behaviour therapy. The treatments described so far can all be carried out by
generic members of a primary care team

 Pharmacotherapy

I. Antidepressants have been proven to be effective at reducing anxiety even in patients

who do not have co-morbid depression. The main advantage of them over anxiolytic drugs
is that they do not produce dependence, and therefore can be used long term.

II. Limit the use of anxiolytics. Anxiolytic drugs (such as benzodiazepines) can bring rapid relief from
anxiety at times of crisis, and are frequently used to cover the 2–3 weeks it takes for an
antidepressant to work

III. Buspirone is a non-benzodiazepine anxiolytic which can be used for short-term relief in GAD. It is
less likely to cause dependence than a benzodiazepine, but does take up to 4 weeks to work.

2. Phobic Anxiety Disorders

I. Anxiety only happens in certain situations. How long a person is nervous depends a lot on how
often they are in situations that make them anxious, like being in a crowded place, seeing
something scary like a spider, or hearing thunder.

II. Situations that make you anxious should be avoided.

III. When these things are likely to happen, people get anticipatory worry.

 Simple Phobia - is too anxious around a certain item or situation or when thinking about it, and
wants to avoid it.There is a strong desire to avoid the stimulus, and most people actually do.
Anticipatory worry is often very bad.
  Prevalance =e of 12.5 per cent, and a 12-month prevalence of 8.5 percent.

 Common simple phobias

 Co-morbidity - 83.4 per cent will meet criteria for another psychiatric diagnosis at some time in
their life. These are most commonly other anxiety disorders or depression.

 Differential diagnosis- Some patients with long-standing simple phobias seek help when an
unrelated depressive disorder makes them less able to tolerate the phobic symptoms. Apart
from this association, simple phobia is seldom mistaken for another disorder.

 Aetiology - phobias of adult life begin in childhood when simple phobias are extremely common;
simple phobias that begin in adult life often develop after a very frightening experience.
suggestion is that phobias are due to classical conditioning, the individual reinforcing a learned
behaviour after a negative experience with an object or situation → the most important
behaviour that maintains the fear and makes it hard to eliminate is avoidance.

 Prognosis - Patients with simple phobias will change their lives to stay away from the thing or
setting they are afraid of. This keeps the disorder going.

 Treatment

I. Cognitive behaviour therapy -a is graded exposure therapy, which is a structured programme

aiming to gradually reintroduce the patient to the phobic situation in a supportive manner.
II. Medication

 Social Phobia -a can't handle social situations because of too much anxiety, which makes them
want to run away or avoid them.

 Clinical features:

I. They have specific fears (that they know are irrational) about being judged by others.
II. Situations that make you feel anxious and times when your actions are open to scrutiny. The
thing that all of these situations have in common is that you might be watched and judged
negatively.
III. Anxiety about what's to come. People who have social phobia also get nervous when they think
about going into these situations.
IV. Don't let these things happen. Sometimes the avoidance is only partial, like when someone goes
to a social gathering but doesn't talk to anyone or sits in a place where they won't be noticed.
V. The symptoms are similar to those of other anxiety disorders, but twitching and blushing happen
more often. People often worry that these symptoms will be noticed by others and show that
they are not good enough.
VI. Use of alcohol. Some people drink to calm their nerves, and people with social phobia are more
likely than people with other phobias to abuse alcohol.
VII. People with social phobia often have low self-esteem and a need to be perfect.

 Prevalence - 12.1 per cent, whilst the 12-month prevalence is about 6.8 per cent. Social phobia is
about equally common in men and women. Mean age of onset for the condition is 13–20 years,
but often the patient will recall having had symptoms as far back as early childhood.

 Co-morbidity - About 80 per cent of patients with social phobia will fit diagnostic criteria for
another psychiatric disorder. The most common are other anxiety disorders, depression, post
traumatic stress disorder (PTSD), and alcohol use disorders.

 Differential diagnosis

I. Generalized anxiety disorder → social phobia is distinguished by the pattern of situations in

which anxiety occurs.

II. Depressive disorder → social phobia is distinguished by the pattern of situations and the absence
of the core symptoms of low mood, anhedonia, and loss of energy. Sometimes people who have
previously coped with social phobia seek help when they become depressed.

III. Schizophrenia → occasionally, patients with schizophrenia are anxious in, and avoid, social
situations because of paranoid delusions. iv. Anxious/avoidant personality disorder →
characterized by lifelong shyness and lack of self-confidence, may closely resemble social phobia.
However, personality disorder starts at a younger age and develops more gradually than social
phobia.

IV. Panic disorder with agoraphobia → can usually be distinguished from social phobia by the fact
that panic attacks are typically unexpected, whereas the anxiety or panic that comes with social
phobia occurs in anticipation of negative evaluation by others.

 Aetiology - cause of social phobia is uncertain. Symptoms usually start in late adolescence, a time
when many young people are concerned about the impression they are making on other people.

 Treatment

I. Antidepressant medication - Paroxetine, fluvoxamine, escitalopram, and sertraline have been

reported to be effective in social phobia in the short term although the long-term benefits are
less certain. A second-line option is the SNRI venlafaxine, which is of similar efficacy to SSRIs but
has a poorer side-effect profile
II. Anxiolytic medication provides immediate short-term relief before more lasting treatment has
taken effect → anxiolytics should not be used regularly because of the risk of dependence.

III. Beta-adrenergic antagonists (e.g. propranolol) are sometimes used to treat tremors and heart
palpitations that don't respond to other anxiety treatments. When used regularly, though, they
haven't been shown to be better than a control group at treating social anxiety.

 Agoraphobia - condition in which the patient experiences anxiety in situations that are
unfamiliar, from which they cannot escape, or in which they perceive they have little control.

 Clinical features

I. Anticipatory anxiety
II. Avoid situations that cause anxiety
III. Anxious thoughts

 Prevalence - 20 years, but there are two peaks; 15–30 years and 70–80 years.The 1-year
prevalence of agoraphobia without panic disorder is about 18 per 1000, whilst the lifetime risk is
1–2 per cent.Approximately twice as many women as men are affected.

 Co-morbidity -panic attacks, but agoraphobia is also associated with other anxiety disorders,
depression, and alcohol misuse disorders

 Differential diagnosis

I. Generalised anxiety disorder is not the same as agoraphobia, which is a pattern of avoiding
public places. The person usually worries too much about all parts of life, not just being far away
from home, being in a crowd, or being locked up.

II. Even though people with agoraphobia feel anxious in social situations and some people with
social phobia avoid crowded buses and stores, the overall pattern of situations that make people
feel anxious is different.

III. Simple phobias can cause panic attacks, but they only happen when a certain situation or object
is present. They don't fit any of the above common themes.

IV. When depressed, people who have had agoraphobia for a long time sometimes look for help.
They will have low mood, a lack of pleasure, and low energy, which are the main symptoms of
depression.
V. Patients with schizophrenia who have paranoid delusions rarely avoid meeting people in a way
that looks like agoraphobia. If they try to hide their delusions, it may be hard to figure out what's
wrong with them, but a thorough history and mental state exam will usually show what's wrong.

 Treatment

I. Antidepressants- general anxiolytic effect but also because some have anti-panic effects. SSRIs
are the first-line choice, with the best evidence being for fluoxetine, fluvoxamine, citalopram, and
sertraline.
II. Anxiolytics - (e.g. benzodiazepines) → should be avoided, except for the short-term alleviation of
incapacitating symptoms or when waiting for an SSRI to take effect

3. Panic Disorder - is a condition in which a person has repeated panic attacks that happen out of
the blue and aren't caused by drugs, health problems, or another psychiatric disorder.

 Clinical features

I. Over the course of a few minutes, a person's anxiety rises to a point where they fear something
terrible will happen, like a heart attack.

II. The number and severity of panic attacks vary from patient to patient, but most people have one
or two attacks per week.

III. Panic attacks are scary, and people who have them often become afraid of having more attacks
and of being in places where they have had attacks before.

IV. Patients with panic disorder often go to their family doctors, cardiologists, and other doctors for
help. They don't want to talk about their anxiety, but rather about physical symptoms like
palpitations.

 Prevalence - averages 7 to 9 per cent of the population, at least twice as frequent among
women. There are two peaks of onset: 15 to 24 years and 45 to 55 years. It is rare for the
disorder to begin after the age of 65.

 Differential diagnosis - Panic attacks occur in many conditions other than panic disorder, both
psychiatric and physical

i. Depression
ii. Post-traumatic stress disorder
iii. Obsessive-compulsive disorder
iv. Drugs – intoxication or withdrawal
v. Endocrine disorders
vi. Cardiovascular disorders & respiratory disorders

 Aetiology

I. Genetics→ there is good evidence that the rates of panic disorders amongst first-degree relatives
of those with the disorder are seven to eight times higher than average.
II. The biochemical hypothesis → suggests that panic disorder is due to an imbalance in
neurotransmitter activity in the brain. —these agents include yohimbine (an alpha-adrenergic
antagonist), isoproterenol (a betaadrenergic agonist), and inhaled carbon dioxide.
III. The cognitive hypothesis → based on the observation that compared with other anxious
patients, patients with panic disorder more often have fears concerning physical symptoms of
anxiety → e.g. fear that palpitations will be followed by a heart attack which then produces a
vicious cycle
 Prognosis- Some patients who experience panic attacks recover within weeks of the onset/panic
disorder that has persisted for 6 months or more the disorder usually runs a prolonged, although
often fluctuating, course which may last for many years.

 Treatment

1) Psychological treatment -Information (psychoeducation) → clinicians who see patients soon after
an initial panic attack should attempt to prevent progression to panic disorder by explaining that
the physical symptoms are caused by anxiety and that, while frightening, they are harmless.
2) Pharmacotherapy –

I. Antidepressant drugs → SSRIs are the first-line choice for panic disorder—there is no
evidence that any one drug is more effective than another, but the most studied are
fluvoxamine, paroxetine, and sertraline.
II. Anxiolytic drugs → used only for short periods, usually while other treatment is being
initiated

4. Obsessive-compulsive Disorder(OCD)

 is a mental illness in which a person has obsessions and/or compulsions that they feel forced to
do in accordance with the rules in order to stop an imagined bad thing from happening.

 Clinical features

1. Obsessions - Thoughts, urges, or images that keep coming back into your mind even though you
try to get rid of them. Obsessions are characterized by the feeling of being forced to deal with a
thought, impulse, or image that keeps coming back, as well as the resistance that comes up
against them.

I. Obsessional thought: force themselves into the patient's mind, and the patient tries to get
rid of them. They can be single words, phrases, or rhymes, and they are usually unpleasant,
shocking, obscene, or blasphemous to the patient.
II. Obsessional images: Usually, they take the form of vividly imagined scenes, which are often
violent or disgusting to the patient, like abnormal sexual practices.
 III. Obsessional ruminations: internal debates where the same arguments are over and over
again
IV. Obsessional doubts: Thoughts about things you may have done wrong, like not turning off a
gas tap all the way, or things you may have done that could have hurt other people
V. Obsessional impulses: urges to perform acts, usually of a violent or embarrassing kind; the
urges are resisted strongly, and are not carried out, but the internal struggle may be very
distressing.
VI. Obsessional rituals: repeated but senseless activities; may be mental activities (e.g. counting
repeatedly in a special way or repeating a certain form of words), or behaviours (e.g.
excessive handwashing or lock checking).

 Anxiety and depressive symptoms - present in patients with OCD; some may be understandable
reaction to the obsessional symptoms but some are recurring depressive moods that arise
independently of the other symptoms; depersonalization can also sometimes occur.

 Obsessional personality - Do not have a simple one-to-one relationship with OCD; is over-
represented among patients who develop OCD, but about a third of obsessional patients have
other types of personality

 Prevalance - general population is 2 to 3 per cent, whilst the 1- year prevalence is about 8 to 10
per 1000/ Men and women are affected about equally.

 Co-morbidity - The lifetime risk for a major depressive episode in these patients is 60 to 70 per
cent.

 Differential diagnosis

I. Anxiety disorders → obsessional symptoms are less severe than those of anxiety and develop
later in the course of the disorder.

II. Phobias → the fears in OCD tend to relate to concerns of harming others, rather than that
harm will come to themselves; the stimuli in phobias are usually specific avoidable situations
whereas phobic symptoms in OCD are more generalised.

III. Depressive disorder → obsessional symptoms follow the depression in depressive disorders
and precede it in obsessional disorder; the correct diagnosis is important because
obsessional symptoms in depressive disorders usually respond well to antidepressant
treatment.

IV. Schizophrenia → when obsessional thoughts have a peculiar content, the clinical picture may
suggest schizophrenia; repeated mental state examinations will reveal other symptoms of
schizophrenia and an informant may describe other behaviours that suggest this diagnosis.

V. Organic cerebral disorders → although obsessional symptoms may occur in dementia, they
are seldom prominent and other features of dementia are present
 Aetiology

i. Genetics: First-degree relatives of OCD patients have a tenfold lifetime risk of OCD. Large-scale
twin and adoption studies have not been done to determine if this familial pattern is genetic or
environmental.
ii. Structural organic abnormalities → OCD parents have a higher rate of minor, non-localizing
neurological signs but no specific neurological lesion.OCD patients have increased frontal lobe,
caudate nucleus, and cingulum activity on PET and functional MRI.
iii. Neurotransmitters → randomized controlled challenge studies have shown that 5HT antagonists
increase OCD anxiety.Dopaminergic pathways are implicated in OCD because basal ganglia
disorders have high obsessive symptoms.
iv. Autoimmune factors—Sydenham's chorea, an autoimmune disease of the basal ganglia, is
associated with OCD in two-thirds of cases, and Group A streptococcal infections have been
linked to OCD/tic disorders.
v. Early experience → obsessional mothers may teach their children to be obsessive.
vi. Psychological causes—obsessions are conditioned responses to anxiety-provoking events.

 The patient develops avoidant behaviors (including compulsions) to avoid the anxiety-
provoking event.
 Psychoanalysis suggests that OCD symptoms stem from unresolved violent or sexual
impulses that cause anxiety and are avoided by defense mechanisms.

 Prognosis - The remaining third run a prolonged and usually fluctuating course with periods of
partial or complete remission lasting a few months to several years.

 Treatment- should be screened include those presenting with depressive disorder; anxiety
disorders; alcohol or substance misuse; eating disorders; body dysmorphic disorder.

 Psychoeducation → OCD patients fear they are "going mad" and may act on their impulses. OCD
does not progress this way.

 Self-help techniques Patients should avoid rituals because they may maintain the disorder while
providing temporary relief.Patients need support to resist rituals. Books, computers, and self-
help groups can start or sustain change.

 Treatment for patients with mild functional impairment - Brief cognitive-behavioral therapy (CBT)
based on exposure and response prevention is the best treatment, and it can be done in a
number of ways, such as with structured self-help materials, over the phone, or in a group.
  Treatment for patients with moderate functional impairment

I. Antidepressants → 5HT reuptake inhibitors reduce obsessive-compulsive symptoms without

antidepressant effects.The tricyclic drug clomipramine, a non-specific 5HT uptake inhibitor,
may be better than the SSRIs (fluoxetine, citalopram, sertraline, paroxetine). All these drugs
take 6 weeks to work. After symptoms subside, treatment continues for 12 months. Because
high-dose clomipramine can cause anticholinergic and cardiac side effects, SSRIs are usually
the first choice.
II. Anxiolytic drugs → not recommended to be used routinely in OCD, although they may be
used in the short term whilst waiting for an SSRI to take effect

 Treatment of patients with severe functional impairment= Combined treatment with an SSRI and
a full course of individual CBT

I. People who are physically healthy and haven't gotten better after trying two SSRIs should
think about taking clomipramine.

II. If this doesn't work, the person should be sent to a mental health specialist.

III. Rarely, a person with OCD may need more intensive treatment, like being admitted to a
hospital. This is only true if there is a high risk of self-harm or suicide, dangerous self-neglect,
or severe depression, anorexia nervosa, or schizophrenia that is also present.

SCHIZOPHRENIA

 Introduction= A mental illness that causes psychosis to happen over and over again.related to
problems with getting along with other people and doing your job.One of the worst medical
conditions in terms of how it affects people's lives and the economy.The disorder is one of the
top ten diseases that add to the number of sick people around the world, according to the World
Health Organization. (Fischer and Buchanan ,2022)

 Phases of Schizophrenia

I. Prodromal: The early stage of a disease is often not noticed until the illness has gotten
worse. This is the "brewing" stage.

II. Active: Symptoms of schizophrenia, such as hallucinations, paranoia, and delusions, show up
as psychosis, which is also called acute schizophrenia.

III. Residual: Less obvious signs of psychosis (the schizophrenia is less severe).Still, there are still
some signs.

 Pathophysiology

I. The neurochemical abnormality hypothesis is based on the idea that there is an imbalance of
dopamine, serotonin, and glutamate in the brain.
• Dopamine:

i. Positive symptoms are caused by too many receptors being activated.

ii. Motor symptoms are caused by not enough dopamine.

iii. Low levels of dopamine in the mesocortices cause the bad symptoms of the disease.

iv. Not having periods and having less sexual desire may be caused by high levels of the hormone
prolactin, which is responsible for lactation, breast tissue growth, and milk production.

• Positive and negative symptoms get worse because of the possible role of glutaminergic
hypoactivity (which affects learning and memory).

• Serotonergic hyperactivity (which affects mood, sleep, digestion, nausea, wound healing, bone
health, blood clotting, and sexual desire) plays a role in the development of schizophrenia.

2. Neurodevelopmental disorder suggestion - abnormalities present in the cerebral structure

 Changes in the nervous system—noticing that patients had trouble moving and thinking before
they got sick.

3. Disconnect hypothesis

 Changes in the way the brain looks, as seen on PET and fMRI scans.
 There is less grey matter in the temporal and parietal lobes of people with schizophrenia.
 Differences in the frontal lobes and hippocampus, which may be the cause of a number of
memory and thinking problems that come with the disease.

 Clinical features

1. Positive Symptoms : Well- known type of symptom of schizophrenia. These are : Delusions &
Hallucinations

A. Hallucinations - perception of a sensory process in the absence of an external source

B. Delusion -fixed (ie, resistant to change, even in the face of overwhelming contradictory
evidence), false belief, are present in approximately 80% percent of people with schizophrenia
2. Negative symptoms : Known so as they reflect a loss of normal functioning.

 4As :

a. Affective flattening: A face that doesn't change, doesn't move on its own, doesn't use
expressive gestures, doesn't make eye contact, doesn't show emotion, and doesn't change the
way it sounds.

b. Alogia: Lack of speech, blocking of thoughts, and slower responses

c. Avolition: less goal-oriented activity because motivation is low

d. Asociality/Anhedonia: less pleasure, can't socialize with peers, doesn't like stimulating
activities, doesn't like sex much, and doesn't get close to other people.

3. Behavioural disorganization : This includes

a. Formal thought disorder (abnormalities in the flow and sequence of thoughts

b. Inappropriate affect and bizarre behaviour

 Schizophrenia patients experience disorganization in behavior and/or thinking that can be

directly observed identified from the speech.

4. Cognitive Impairment Fischer, Marder & Friedman (2021) f that cognitive impairment include:

I. Processing speed
II. Attention
III. Working memory
IV. Verbal learning and memory
V. Visual learning and memory
VI. Reasoning/executive functioning
VII. Verbal comprehension
VIII. Social cognition
  Catatonic Behavior : Abnormality of movement and behaviour arising from a disturbed mental
state

• Stupor, which is a state of being less alert.

• Catatonia, which is when a person stays in the same position for a long time.
• Flexibility like wax (light resistance to being moved).
• Mutism, which is having little or no speech.
• Negativism, which is the automatic and unmotivated refusal to do what you're told.
• Posturing, which is when people take strange positions and stay in them for a long time.
• Mannerism, which is an exaggerated version of normal behavior, situational changes to normal
actions).
• Stereotypy (doing the same thing over and over, doing it a lot, and doing it for no reason)
moved in a certain way).
• Grimacing, which is a fixed expression on the face.
• Echolalia, which means repeating what someone else says.
• Echopraxia, which means copying someone else's movements.

 Acute Schizophrenia -Positive symptoms are the most noticeable, and acute schizophrenia is
diagnosed based on how noticeable different positive symptoms are. Patients may get better
from an acute illness, but it is common for the illness to turn into a chronic syndrome.

 Chronic Schizophrenia -Characterized by negative symptoms.Few patients recover completely.

 AETIOLOGY- Exact causes of schizophrenia are unknown. Research suggests a combination of

physical, genetic, psychological and environmental factors can make a person more likely to
develop the condition.

 Management of schizophrenia

I. Pharmacological Intervention
  Antipsychotic Drugs -Used to treat acute psychosis from any cause and to manage chronic
psychotic disorders including schizophrenia

A. First-generation antipsychotics (FGAs) or typical antipsychotics which causes :

 Extrapyramidal effects =Tardive dyskinesia - movement disorder characterized by uncontrollable,

abnormal, and repetitive movements of the face, torso, and/or other body parts.
 Incidence of the akathisia (inability to remain still), rigidity, bradykinesia (movement slowness) ,
tremor, and acute dystonic reactions (involuntary contraction of muscles)
 These drugs include : fluphenazine, haloperidol, loxapine, pimozide, and thiothixene

B. First-generation antipsychotics (FGAs) are less likely to cause extrapyramidal symptoms and
tardive dyskinesia than second-generation antipsychotics (SGAs) or atypical antipsychotics.

 Examples of SGAs :

• Aripiprazole

• Asenapine

• Clozapine

• Iloperidone

• Lurasidone

• Olanzapine

• Paliperidone

• Quetiapine

• Risperidone

• Ziprasidone

II. Non Pharmacological Interventions

1) Cognitive remediation -When combined with psychiatric rehabilitation, cognitive

remediation helps people with schizophrenia function better. (Wykes et al., 2011)

2) Psychoeducation for patients.- Compared to standard care, psychoeducation programs

improve treatment adherence, social functioning, and the number of relapses and
readmissions. (Xia et al., 2011)

3) Training in social skills -Helps people with bad symptoms and those who want to improve
their learning and social skills. (Kurtz and Mueser, 2008)

4) Family psychoeducation. -Family interventions can reduce the number of relapses for up to
two years, improve drug adherence, raise family awareness of the disease, and lessen the
burden on the family. (Pharoah et al., 2010)
 5) Physical Aspect: Physical fitness is an important part of rehabilitation and self-management
because it helps people feel good about their bodies and minds.

6) Daily Living Performance: OT can help with this and a lot of other things. One of the main
goals of occupational therapy rehabilitation is to help people learn how to take care of
themselves and live on their own in the community.

7) Work Rehabilitation - Supported employment is a type of psychosocial therapy that

combines job training with work-related social skills training. It has been used to help people
with schizophrenia in mainland China do better at work and in other areas of their lives.
Supported employment has been shown to work in different countries and has a positive
effect on competitive employment rates for about two years, no matter how the economy is
doing.

MOOD DISORDERS

 Used to talk about all kinds of depression and bipolar illnesses in a general way.At any age, mood
problems can happen, but the signs can be different.Diagnosing a mood problem in a child is
hard because of how they show how they feel.

 Mood disorders based on DSM-5 classification

 1. Bipolar and related disorders with its clinical features

A. Episodes Related to Bipolar and Related Disorders

I. Manic - Elevated, expansive, or irritable mood and increased activity or energy present most
of the day, nearly every day/Symptoms:

1) A big head or a sense of self-importance.

2) Less need for sleep, like feeling relaxed after only 3 hours.

3) More talkative than normal or feeling pressured to keep talking.

4) Having a lot of ideas at once or feeling like your mind is rushing.

5) Distractability, which means that the person's attention is too easily drawn to outward
stimuli that are not important or not relevant.

6) An increase in goal-directed activity (socially, at work or school, or sexually) or

psychomotor agitation, which is movement without a clear goal.

7) Spending too much time doing things that could hurt you in the long run, like going on
uncontrolled shopping sprees, having sexual affairs, or making bad business decisions.

 The mood disorder made it hard to get along with other people or do your job, or you needed to
be hospitalized to keep from hurting yourself or others, or there were signs of psychosis.

 Not because of the effects of drugs or medical problems on the body

II. Hypomanic

a) High, expansive, or irritable mood and more action or energy most of the day, almost
every day.
b) The symptoms are the same as those of a manic episode (see slide 7).
c) Changes in behavior and mood that are out of character for the person can be seen even
when there are no symptoms.
d) The changes in how the person works and how they feel can be seen.
e) The episode isn't bad enough to make it hard to get along with people or do your job, or
to require you to go to the hospital. When there are signs of psychosis, the event is
called manic.
f) Not because of how the substance (drug or medicine) affects the body.

III. Major Depressive Episode -Symptoms

a. Depressed mood most of the day, almost every day, as reported by the person (feels sad,
empty, or hopeless, for example).
b. Less interest or pleasure in most or all tasks for most of the day, almost every day
 c. Significant weight loss or gain when not on a diet (for example, more than a 5% change
in body weight in a month), or a decrease or increase in hunger.
d. Lack of sleep or too much sleep.
e. Psychomotor restlessness or delay, which means being nervous or moving slowly.
f. Loss of energy or feeling tired.
g. Feelings of being useless or having too much or the wrong kind of guilt (which could be
delusions), not just self-reproach or guilt about being sick.
h. Less ability to think or focus, or being unable to decide what to do.
i. Having repeated thoughts of death (not just fear of dying), repeated thoughts of suicide
without a plan, a suicide attempt, or a plan to kill oneself.

 Symptoms cause clinically significant discomfort or problems in social,occupational, or in other

important areas of operating.

 Not because of how the drug affects the body

B. Common Types of Bipolar Disorders

I. Bipolar I Disorder

 A person would have had all three episodes (manic, hypomanic, and major depression) in their
life.

1. A high, wide, or irritable mood and more energy or activity. lasting at least one week
(manic) or four days in a row (hypomanic) and being there most of the day.
2. You have at least three signs when you are manic or hypomanic.
3. If you have five or more symptoms during a depressive phase that lasts for two weeks,
you must be either sad or lose interest in things you used to enjoy.

II. Bipolar II Disorder

  A person would have experience hypomanic and major depressive episodes

1. A high, wide, or irritable mood and more energy or activity. going on for four days in a
row (hypomania) and being there most of the day.
2. Three or more signs of hypomania.
3. If you have five or more symptoms during a depressive phase that lasts for two weeks,
you must be either sad or lose interest in things you used to enjoy.

III. Cyclothymic Disorder

1. Many periods of hypomanic symptoms and depressive symptoms that don't meet the
standards for an episode for at least 2 years (1 year for children and teens).
2. During the period, hypomanic and depressed periods happen at least half the time, and
the person doesn't go more than two months without having symptoms.
3. There aren't enough signs of a major depressive, manic, or hypomanic attack.
4. The symptoms are not caused by something else.
5. Symptoms are not caused by the way a drug affects the body.
6. The symptoms cause distress or problems in social, occupational, or other important
areas of performance that are clinically important.

 Cyclothymia is a milder form of bipolar disorder, featuring emotional ups and downs but with
less severe symptoms than bipolar I or II.

2. Depressive disorders with its clinical features

 Common Types of Depressive Disorders

I. Disruptive Mood Dysregulation Disorder

A. Disruptive mood dysregulation disorder (DMDD): extreme irritability, anger, and frequent,
intense outbursts of rage.
B. DMDD is more than just being "moody." It causes serious problems that need help from a
doctor or nurse.
C. Symptoms:

1. Severe, repeated outbursts of anger, either verbally (e.g., verbal rages) or physically (e.g.,
attacking people or things with your body), that are too strong or last too long for the
situation or cause.
2. The episodes of anger don't fit with the child's age.
3. The anger tantrums happen three or more times a week, on average.
4. The person's mood is restless or angry most of the day, almost every day, and others (like
parents, teachers, and peers) can see it.
5. These things can happen at home, at school, or with friends.
II. Major Depressive Disorder (MDD)

1. There are five or more symptoms for the same two-week time and there is a change in
how the person functions. At least one of the signs is either (1) feeling sad or (2) losing
interest or pleasure in things.
2. (See the list of 9 signs of a big depressive episode).
3. The symptoms cause distress or problems in social, occupational, or other important
areas of performance that are clinically important.
4. The episode wasn't caused by the effects of a drug on the body or by another medical
situation.
5. The episode was not caused by any other mental health problem.
6. There are no episodes of either mania or hypomania.

III. Dysthymia (Persistent Depressive Disorder)

 Depressed mood for most of the day, many days, for at least two years (either reported by the
patient or seen by others).
 Two or more of the following signs are present (while sad)

1. Loss of hunger or eating too much.

2. Lack of sleep or too much sleep.
3. Lack of energy or being tired.
4. Low sense of oneself.
5. Trouble paying attention or making choices.
6. A feeling that there is no hope

 The patient has signs of the problem for two months.

 There is neither a manic episode nor a hypomanic episode, and cyclothymic disease is not linked
to either one.

 The problem isn't caused by another mental health problem.

 Symptoms aren't caused by the way a drug affects the body or by another medical problem (like
hypothyroidism).

 Symptoms cause clinically significant distress or problems in social, work, or other important
areas of functioning.

IV. Premenstrual dysphoric disorder

 Premenstrual dysphoric disorder (PMDD) - woman experiences severe depression symptoms,

irritability, and tension before menstruation which are more severe than those seen with
premenstrual syndrome (PMS).
 occur about 5 to 11 days before menstrual cycle

 5 symptoms is present in menstrual cycle:

  Emotional instability, such as mood swings, feeling sad or tearful out of the blue, or being more
sensitive to rejection.
 irritability, anger, or more fights with other people.
 Sadness, feelings of hopelessness, or negative thoughts about yourself.
 Feelings of anxiety, tension, and/or being on edge.
 Loss of interest in regular things like work, school, friends, and hobbies.
 Trouble paying attention.
 Feeling tired, lethargic, or like you have no energy.
 Changes in appetite, eating too much, or cravings for certain foods.
 Too much or too little sleep.
 The feeling of being too busy or out of control.
 Physical symptoms, such as sore or swollen breasts, pain in the joints or muscles, a feeling of
"bloating," or gaining weight

3. Pathophysiology and aetiology of mood disorders

I. Pathophysiology - Neurobiological Approach

 Excessive dopamine activity, which can be caused by drug abuse and lead to manic states. Some
signs of acute mania include a high mood, less need to sleep, a lot of talking, and a reckless
desire to do things that make you feel good.
 The monoamine hypothesis says that depression is caused by a problem with a monoamine
neurotransmitter system at one or more places in the brain.
 Hormone: Noradrenaline hormone seems to have less of an effect on growth in people with
depression.
 Research suggests that glutamate levels may be higher in people with bipolar disorder, which is
different from what has been found in people with major depression.
 Cortisol: Too much cortisol in the body has been linked to cognitive impairment in people with
bipolar disorder.
 Imaging studies of bipolar patients have shown that they have abnormalities in certain white
matter tracts, where abnormal myelination or orientation of axons are mostly found in the
frontal lobes and parts of the temporal white matter can be seen.
 Patients with major depression and bipolar disorder are proof that neurological
 Changes happen: oligodendroglial cells die off and gamma-aminobutyric acid levels drop.
(GABA).
 Changes in the brain, such as problems with executive function, verbal memory, attention, and
how fast they can think

II. Genetic Studies

a) Bipolar Disorders

 First-degree relatives of bipolar individuals (the first person in the family to have the disease) are
more likely to have both bipolar and unipolar mood disorders.
 Twin studies show a high heritability, which has been estimated at around 85% (Bienvenu and
colleagues, 2011).
b) Depressive Disorders

 Depression tends to run in families, and the chance of it happening to a first-degree relative
went up by about three times.
 Twin studies: The heritability of major depression has been estimated to be 37%, which is
much lower than that of bipolar disorder or schizophrenia (Bienvenu et al., 2011).

c) Bipolar Disorders

 Experiences in childhood: people with bipolar disorder are more likely to have been sexually
abused as children than people without the disorder.
 Life events: Both depression and mania can be caused by bad things that happen in life.
 Mania can also be caused by things that have to do with reaching a goal, like less sleep or
messed up sleep and activity cycles.
 Current social support. Alloy et al. (2005) found that high levels of expressed emotion in a
family can make affective symptoms worse, and treatment that addresses this issue can
lower the risk of relapse.

d) Environmental Factors

 Depressive Disorder = Precipitating Factors

 Parental deprivation, which leads to fights in the family and not enough care (Brown, 2009).
 Relationships with parents, such as physical and sexual abuse, parents who don't care or who
are too protective, neglect, and emotional apathy.
 Recent life events, such as loss, being in a dangerous situation, or being bullied by peers.
 Being weak and having a hard life, like a bad marriage, problems at work, or bad housing.
 The effects of being sick.

4. Functional limitations of patients with mood disorders

 “Quality of life, cognitive (i.e., executive function, speed of processing information, attention
span, working memory, verbal learning, visual learning, reasoning and problem solving),
behavioral (motivation, task completion), social (withdrawal, eye contact, listening skills,
interpersonal conflicts), and physiological (sleep difficulties,restlessness, fatigue).

 Daily routines for sleep, meals, selfcare, and social relationships are often disrupted,particularly
in individuals experiencing manic episodes. Such difficulties can greatly impact performance in
school, work, home, and community (Bilsker, Gilbert, Myette, & Stewart-Patterson, 2004;
Michalak, Yatham, & Lam, 2005; Young et al, 2010).”

5. General management of mood disorders

a) Electroconvulsive Therapy (ECT)

 ECT is a short amount of electrical stimulation of the brain while the person is asleep. A doctor,
an anesthesiologist, and a nurse or physician assistant work together to give the medicine.
 ECT is a quick and successful way to treat severe depression, catatonia, and manic episodes that
last a long time or are very severe.
 ECT is used when it's important to get better fast.
 It can be used when there is a high risk of suicide right away, a person is very depressed, or there
is a risk to their physical health, such as not eating enough to put themselves in danger or cause
conditions like kidney failure.
 ECT How it works -"Electrical pulses are sent to the brain through electrodes on the head of a sad
person who has been put to sleep and given a muscle relaxer. The seizure is caused by electrical
stimulation. A few times a week for a short amount of time.ECT gets rid of depressive symptoms
for a long time in many people, period."

b) Pharmacological Intervention- Psychotropic Drugs

 Antidepressant – Specific Serotonin Reuptake Inhibitors (SSRIs), Selective Serotonin and

Noradrenaline Reuptake Inhibitors (SNRIs), Tricyclic Antidepressants,Monoamine Oxidase
Inhibitors (MAOIs).
 Antipsychotics – FGAs and SGAs
 Mood stabilisers - reduce symptoms of bipolar disorder and increase people’s ability to pursue
their interests and participate more fully in their relationships (Lithium,Carbamazepine,
Lamotrigine

SUBSTANCE USE DISORDERS (SUDS)

 Terms Related

1. Tolerance =Having to use a lot more alcohol to get drunk or get the desired effect. The same
amount of alcohol having a lot less of an effect as time goes on.
2. Withdrawal =When someone who has been using a drug for a long time cuts down or stops
using it.
3. Intoxication =There are direct, dose-dependent, and time-limited effects of the drug on the mind
and body.
4. Dependence =A group of symptoms that include withdrawal, tolerance, and continuing to use
drugs though they hurt you.Can be both physical and mental (when physiological tolerance sets
in)
5. Substance-induced psychosis =Hallucinations and/or delusions that are caused by using drugs.
This can happen during intoxication, withdrawal, or as a long-term effect of addiction.

 Alcohol Related Disorders

• A pattern of drinking that is not healthy and causes clinically significant impairment or distress.

1. Often taken in larger amounts or for longer periods of time than was intended.
2. A strong desire or repeated attempts to cut down or control alcohol use that don't work.
3. Time spent doing things you need to do to get alcohol, drink it, or recover from it. works
really well.
4. Craving, which is a strong need or urge to drink.
5. Frequent use of alcohol that makes it hard to do important jobs at work,home, or school.
 6. Continuing to drink even though there are ongoing or recurring social or interpersonal
problems problems because they drink too much.
7. Important social, work, or leisure activities are stopped or cut back on.
8. Drinking alcohol often when it's physically dangerous to do so.
9. Continuing to drink even though you know you have a persistent or recurrent.Alcohol
use can cause problems with the body or mind.

1. Substance related classes - common form intended effects and clinical manifestations
2. Reasons for abuse

 Lancaster and Chacksfield, 2014 “Alcohol, for example, is widely used as a social lubricant, to
reduce tension, to intoxicate as a way of coping with negative feelings or as a sedative. Heroin
use is described as offering a warm, dreamy ‘cocoon’ and, for many users, it serves as an antidote
to emotional pain and the stress of a life lacking in meaning (Tyler 1995).”
  In relation to occupation:

1. To enable occupation
2. To avoid occupation
3. Coping mechanism
4. Alter perception
5. Develop meaning in life
6. To enhance occupation
7. Manage occupational risks

3. Pathophysiology & aetiology

I. Pathophysiology

a. Severe dependence means you can't control how much you use.
b. SUDs and addiction are caused by changes in the brain that happen as it tries to get back
to normal.
c. When these substances are used, neurotransmitters are released in large amounts,
which part of the brain (the reward area) is stimulated.
d. Long-term use leads to tolerance, which makes receptors less sensitive and needing
more to do what you want it to do.

II. Neurobiological Approach

a. Twin studies show that when one twin has an SUD, the risk of the other twin developing
an SUD is twice as high for monozygotic twins as for dizygotic twins.

b. Adoption studies show that people with a biological parent who uses drugs are more
likely to also use drugs even if they grow up in a family without any SUDs, they have a
problems with using drugs.

c. People who abuse drugs may deal with the drugs and their experiences in different ways
that cause people to use too much. For example, people who use drugs too much brains
of people with disorders often don't have enough inhibitory control (Koyama, Parvaz, &
Goldstein, 2017). Goldstein, 2017).

III. Psychological and Environmental Factors

a) A tendency toward SUDs is caused by biological, psychological, and environmental factors.

b) Personality traits like impulsivity and seeking pleasure are linked to a higher risk of chance of
having problems with drugs (Hamdan-Mansour, Mahmoud, Al Shibi, and Arabiat,2017)
c) A way of thinking that says change is unlikely can also get in the way of use ways to deal with
health problems.
d) Poverty, exposure to trauma, and social approval of drug use. For example, a history of physical
and sexual abuse before age 11 Violence in childhood makes a person much more likely to have
an SUD as an adult.Carliner and others (2016)
 e) Social approval is a culture or social setting that encourages drug use can also put people in more
danger. Young people, for example, are more likely to drink too much when they hang out with
friends who drink a lot and go to fraternity parties, where drinking too much is the norm,
(Kuntsche, Thrul, Gmel, and Kuntsche, 2017)

4. Functional limitations

 Both SUD and severe mental illness can make it hard to do any of the jobs listed in the
Occupational Therapy Practice Framework (AOTA, 2014) at some point during the course of
both conditions.

 User's routines and the whole family - hard to get meaningful engagement Jobs like being a
parent, taking care of an animal, or driving a car,keeping track of money, taking care of a
home, and taking part in local gatherings. For example, a parent who has a problem with
drugs may not be able to be able to take their child to school during the day.

 Changes in drug use or worsening of mental health symptoms can have an effect ability to
fall asleep or stay asleep, or the quality of one's sleep. • Performance in school and work,
which can lead to missed classes and other problems or days off work; bad grades or
performance at school or work; attention from teachers,supervisors or peers if they have
problems with their work).

5. General management for substance abuse

I. Pharmacological Interventions

 Medications to combat substance-related dependence and cravings

a) Oral medications and injectable naltrexone

b) Naltrexone - effective in reducing drinking relapses in the first 3 months of use and effective
for opiate addiction
c) Acamprosate - reduces unpleasant symptoms associated with abstinence such as insomnia,
restlessness, and dysphoria.
d) Disulfiram – inhibits metabolism; when taken together with alcohol, flushing,nausea, and
tachycardia will be experienced.

 Methadone - used to treat heroin addiction, mimics drug to reduce cravings and prevent relapse.
While addictive, it does not have the negative effects such as overdose,mortality, and risk of
infections.

II. Non - Pharmacological Interventions

III. Coping Strategies
 CHILD & ADOLESCENCE PSYCHIATRY

1. Classification of Psychiatric in Children & Adolescents

 Many "adult" mental disorders start before the age of 18. There are mental illnesses in children.
Child psychiatry and adult psychiatry are very different:

a. Children can't get help on their own.

b. Think about how the child's body and mind are growing.
c. Children don't talk as much.
d. Most kids go to schools with different sizes, funding, ideas, and effects.

 Different things are put into treatment. Ethical concerns make it hard for children to do study,
especially on drug therapies.

 Common problems in middle childhood: fears, nightmares, minor difficulties in relationship with
peers, disobedience, and fighting

 Common problems in late childhood and early adolescence include mood swings and low moods
that don't go away, a variety of anxiety issues, trouble getting along with peers, disrespect and
anger, such as skipping school, trying drugs, fighting, and stealing.

 General issues regarding childhood psychopathology:

i. Genes matter. Autism, ADHD, and specific reading disorder are genetically predisposed.

ii. Environment: Certain environmental factors can increase the risk of or disorders and sustain
them. They may also prevent other disorders.

iii. Genes and the environment interact to make certain exposures more likely or change their
effects.

iv. Most childhood disorders are borderline.Because they are at the extreme end of a normal
behavior scale and treatment decisions require "yes" or "no" answers, we study them
categorically.The cut-off point for a category is often made up on the spot.

v. Continuities and breaks: Some childhood symptoms and behavior problems are linked to adult
problems and could make a person six times more likely to have problems that lead to bad
things.

 Parent-child interactions: Maternal behaviour affects the child, but children also elicit behaviours
from their parents

 Seven main groups of childhood psychiatric disorders that are generally recognized by clinicians
are:

a. Adjustment reactions
 b. Autism spectrum disorders

c. Specific developmental disorders

d. Conduct (antisocial or externalizing) disorders

e. Attention-deficit hyperactivity disorders

f. Emotional (internalizing) disorders

g. Symptomatic disorders

 Many child psychiatric disorders cannot be classified in a satisfactory way by allocating them to a
single category → multiaxial systems was proposed by ICD- 10 which has six axes:

a. Clinical psychiatric syndromes

b. Specific delays in development

c. Intellectual level

d. Medical conditions

e. Abnormal social situations

f. Level of adaptive functioning

2. Epidemiology

 Six categories of risk factors that increase likelihood of mental, emotional, and behavioural
disorders are:

a. Child: e.g. self-regulation problems.

b. Family: e.g. quality of parent-child attachment.
c. Peer: e.g. isolation.
d. Demographic: e.g. family income and family structure.
e. School: e.g. school climate
f. Community/policy: e.g. neighbourhood policy and crime rates.

 Homotypic: The same disorder keeps happening over time.

 Heterotypic: Later disorders seem to be of another type.

 Studies have shown that children who have early episodes of emotional disorders are at
increased risk into adulthood and that about half of those with depression in youth will have an
adult episode of a depressive or anxiety disorder.

3. Aetiology
  Genetic Factors - studies indicate that there is a significant genetic contribution to some
psychiatric disorders, especially to ASD, hyperactivity, and anxiety disorders (with a heritability of
around 40%).

 Temperament and Individual Differences - the first 2 years, one group of children (‘difficult
children’) tended to respond to new environmental stimuli by withdrawal, slow adaptation, and
an intense behavioural response.

 Brain Disorders

I. Maturational changes and delayed effects

 This has two consequences:

a. Greater ability to make up for damage: Because it is more flexible, the brain of a child is
better able to make up for damage in specific areas than the brain of an adult.

b. Delayed effects: Early damage may not show up as a disorder until a later stage of
development, when the damaged area is needed for a key function.

II. The consequences of head injury in childhood

III. Epilepsy as a cause of childhood psychiatric disorder

 Environmental Factors

a. The effect of life events -Life events can cause or prevent disorders.Events can be categorized by
severity, social characteristics (e.g. family problems, parent death), or general significance (e.g.
exit or entrance events).Chronic stress may cause psychiatric disorder when life events occur.

b. Family influences:

1. Maternal deprivation and attachment

 Attachments have been divided into four types:

a. Secure: About 60% of infants feel this way, and it's linked to caregiving that is sensitive to the
child's needs.
b. Avoidant: About 15% of people with autism have this trait, which is linked to caregiving that is
rejecting or intrusive.
c. Disorganized: This happens in about 15% of cases and is linked to giving care that is
unpredictable or scary.
d. Resistant–ambivalent: About 10% of people have this trait, which is linked to caregiving that is
inconsistent or not there at all.

2. Family risk factors- severe marital or other relationship conflict, low social status, large size or
overcrowding, paternal criminality, and parental psychiatric disorder
 3. Protective factors- include good parenting, strong affectionate ties within the family, including
good sibling relationships, sociability, and the capacity for problem-solving in the child, and
support outside the family from individuals, or from the school or church.

4. Child-rearing practices -Verbal or physical abuse, scapegoating and sexual abuse is another
important risk factor to psychiatric disturbance in the child.

5. Effects of alternative childcare- High quality care with sufficient individual attention can result in
improved development of cognitive, social, and language skills.

6. Effects of parental mental disorder- Perinatal mental illness can cause emotional or behavioral
issues, insecure or disordered attachment, inferior cognitive development, and physical growth
and development until early adulthood. Children with depressed or anxious parents have a
higher chance of depression and anxiety disorders and behavior disorder at school age.Complex
genetic and environmental causes are probable.Parenting helps children cope with parental
depression.Socioeconomic position, education, and chronicity of parental mental health illnesses
moderate the effects on children.

7. Effects of parental separation -two main effects of childhood parental separation (including
divorce): economic difficulties and exposure to interpersonal conflict.

8. Death of a parent

c. Social and cultural factors -patterns of family life → as the child grows older and spends more
time outside the family, they have a direct effect as well

d. Effects of neighbourhood =features that increase the risk of psychiatric illness: . Lack of play
space,Inadequate social amenities for older children and teenagers,Exposure to violence,
Overcrowded living conditions, Lack of community involvement

e. Effects of school = Factors in school that reduces the risk: Teachers praise ,Teachers
encouragement, Responsibility given to their pupils ,Set high standards for pupils ,Organize
teaching well

 Bullying / peer victimization: a student is exposed, repeatedly and over time, to negative actions
on the part of one or more other students.

 Bullying can cause long-term effects and adjustment issues for all groups.Bullies can cause
victims' sadness, criminality, and other issues Bullied 5-year-olds had a higher risk of emotional
issues and disruptive behavior at 2-year follow-up.Bullying in older children is linked to self-harm,
violence, and psychotic symptoms.Social media and cyberbullying aggravate peer relationships.

4. Syndromes Related to Child & Adolescents Psychiatry

A. common problems in preschool children

I. Temper tantrums: extreme episodes of frustration or anger, with mood and behaviour returning
to normal between tantrums.
II. Sleep problems - difficulty is wakefulness at night, which is most frequent between the ages of 1
and 4 years.

 Wakefulness at night: at least an hour to get to sleep or are wakeful for long periods during the
night
 two possible causes should be considered: (emotional disorders, autism, ADHD) or physical
illness.

III. Feeding problems

 delayed development of feeding/ eating skills, difficulty managing or tolerating foodstuffs, and
reluctance or refusal to eat based on taste, texture, and other sensory factors
 Pica: eating of items that are generally regarded as inedible (e.g. soil, paint, or paper).

IV. Disorders associated with adverse caregiving

 Reactive attachment disorder (RAD): there is an absence of attachment behaviour secondary to

social neglect.
 Disinhibited social engagement disorder (DSED): the child lacks appropriate reticence with
unfamiliar adults and violates socially sanctioned boundaries.

B. Specific Learning Disorders

I. Dyslexia -Difficulty in learning to decode, leading to poor appreciation of the spelling patterns of
words and their pronunciation. Errors in reading and spelling include omissions, substitutions, or
distortions of words, slow reading, long hesitations, and reversals of words or letters.

II. Reading comprehension impairment -able to read aloud accurately but have difficulty
understanding what they have read

III. Mathematics disorder(dyscalculia)

 Problems include:

a. failure to understand simple mathematical concepts

b. failure to recognize numerical symbols or mathematical signs
c. difficulty in carrying out arithmetic manipulations
d. inability to learn higher level mathematical skills such as geometry and algebra

IV. Possible factors:

 A disorder of brain maturation affecting one or more of the skills required in reading; difficulty in
visual scanning, confusion between right and left, and general improvement with age.
 Parental educational level and range of vocabulary at home may reflect differences in amount

C. Autism Spectrum Disorders (ASD) -pervasive developmental disorder (ICD-10): characterized by

abnormalities in communication and social interaction and tendency to engage in stereotyped
patterns of restricted repetitive behaviours, interests, and activities.
  Three main categories of abnormalities:

I. Abnormalities of social development –Autism aloneness means the youngster may not smile or
cuddle when their parents show affection.They don't like other kids and sometimes don't
respond to their parents.Gaze avoidance is an indication

II. Abnormalities of communication -Speech may develop late or never appear; occasionally, it
develops normally until about the age of 2 years and then disappears in part or
completely.Echolalia: rote and literal repetition of the speech of other

III. Restriction of interests and behaviours -Obsessive desire for sameness" describes how children
with ASD behave predictably and react negatively to change. Some kids spin, twist, flap, rock, or
rock back and forth.

IV. Other features- show anger or fear without apparent reason.

V. Risk factors - Strong genetic basis, brain matures in along an atypical trajectory, birth defects,
immune dysfunction, migration of mothers, and exposure to drugs and toxins.

VI. Differential diagnosis

VII. Management -Management of abnormal behaviour: psychosocial and behavioural Interventions;

early intensive behavioural intervention (EIBI) includes strategies for parents, teachers, and
carers to improve joint attention skills and reciprocal communication, often through interactive
play and action routines.

D. Attention-Deficit Hyperactivity Disorder (ADHD) -inattention, hyperactivity, and impulsivity.

I. Diagnostic criteria -impaired attention, hyperactivity, and impulsiveness starting in childhood and
lasting for at least 6 months to a degree that is maladaptive and inconsistent with the
developmental level of the child

II. Possible factors -Reduction in volume and cortical thickness in certain areas of the brain,
especially the grey matter of the basal ganglia.

III. Treatment:

1. Psychosocial interventions such as parent training, social skills training, cognitive training, and
specific classroom interventions
2. Educational interventions to support teachers are also important, and special education
provision may be needed.
3. Behavioural interventions often include parent, child, and school-based elements, and seem to
be most effective in combination with medication.
4. Parent training focuses on making unwanted behaviours for the child explicit, clarifying family
rules, and anticipating potentially difficult times in the day, such as transition times
5. Dietary advice → A minority of children with ADHD might benefit from free fatty acid
supplementation
 6. Medication → There are two main groups of clinically effective drugs for ADHD: stimulants and
others

E. Oppositional and Conduct Disorders -antisocial behaviours outside of socially acceptable norms
and often intrude on other people’s expectations or rights.

I. Clinical features

 The most important sign is abnormal behavior that lasts for a long time and is more serious than
normal childhood mischief. • The most common abnormal behaviors are defiance, violence, and
antisocial acts.
 There can be a lot of upset, trouble, and costs for the family, friends, schools, and society as a
whole.
 Oppositional defiant behavior usually shows up as rebellious behavior in preschool aggressive
behavior at home, which is often caused by being too active. These behaviors include
disobedience, temper tantrums, and physical aggression towards kids or adults destructiveness.
 CD shows up in the home as stealing, lying, and disrespect in older children along with aggressive
words or actions.
 Later, the commotion is often clear both inside and outside the house especially at school, as
truancy, delinquency, vandalism, and risky behavior, or as abusing booze or drugs.
 Teenage girls who act badly include those who are mean, who emotionally bully their peers, and
who run away.
 For ODD and CDs to be present, these behaviors have to last longer than a reaction to different
situations.
 There isn't a clear line between these illnesses and bad behavior in general;Instead, diagnostic
factors set a cut-off point along a continuum.

II. Classification -In ICD- 10 ODD is a subtype of CD, whilst in DSM- 5 it is a separate entity. • ODD is
usually a diagnosis given to younger children whilst CD is typically given to older children and
teenagers.

III. Aetiology

a. Individual-level influences
b. Family-level influences

IV. Prognosis -About 40% of conduct-disordered children had antisocial personality disorder in their
twenties, and many of the rest had persistent and widespread social difficulties below the
threshold for a personality disorder. CDs that first appear in adolescence have a better prognosis,
with about 80% no longer exhibiting significant antisocial behavior in adulthood.

V. Management:

c. Parent training programmes.

d. Anger management.
e. Intervention in school
F. School Refusal -one of several reasons for repeated absence from school. Associated with anxiety
and depressive disorders

I. Clinical picture

 Some factors that causes school refusal to occur are:

a. Enforced absence due to physical illness.

b. After an event at school such as transferring class.
c. A problem in the family member to whom the child is closed with.

II. Aetiology

 Individual factors: behavioural inhibition, fear of failure, low self- efficacy, and physical
illness
 Family factors: separation and divorce, parental mental illness, overprotective parenting
style, and dysfunctional family interactions.
 School factors: bullying, physical education lessons, transition to secondary school
 Community factors: increasing pressure to achieve academically and inadequate support
services.

III. Treatment
 discussion with the schoolteachers, who should be asked about the child’s problems
 Individual treatment, some level of parental involvement, consultation with school staff,
and between-session tasks are important
 Graded exposure to school attendance
 Problem-solving training with the young person and family work on communication and
problem-solving

G. Selective mutism -In some social situations, a child always refuses to talk, but in others, they
do.After a child learns to talk, it usually starts between 3 and 5.Parents and other participants'
statements are crucial to the diagnosis.Ask the parents if speech and understanding are normal
at home when you talk to them.

i. Treatment

• Aim to lower the anxiety that a child has for speaking in certain situations and increase
the contexts in which the child may speak comfortably.

• Behavioural treatments, cognitive behaviour therapy, and play therapy are the first choice
of treatment
 NEUROCOGNITIVE DISORDERS

 Classification of NCD based on DSM-5

 Delirium
 Mild or major NCDs (this may due to Alzheimer’s disease, Frontotemporal lobar degeneration,
Lewy body disease, Vascular disease, Traumatic brain injury, Substance/medication use, HIV
infection, Prion disease, Parkinson’s disease, Huntington’s disease, etc.
 This lecture will look into Delirium and Alzheimer’s disease specifically, and the rest generally.

 What is Delirium?

 Delirium is characterized by an acute change in cognition and a disturbance of consciousness,

usually resulting from an underlying medical condition or from medication or drug withdrawal.
(Gleason, 2003)

 What is Dementia?

 Acquired syndrome due to disease/disorder of the brain affecting cognition, or thinking and
memory.
 Results in disturbance of “perception, information processing, problem-solving, judgment,
sequencing of tasks, recognition and naming of objects, mood and affect, writing and calculating,
and other functions necessary to carry out daily activities” (Abraham, 2005).
 Progressive in nature – gradual decline in functioning which is characterized by behavioral
difficulties, including aggression, agitation, and altered sleep/wake cycles that can require 24-
hour supervision and care.
 Most common form - Alzheimer’s disease, a chronic, neurodegenerative disease.
 Cinical features

 Delirium

1. A problem with attention (less ability to direct, focus, hold, and switch attention) and awareness
(less ability to pay attention to the world around you).
2. Develops quickly (usually in a few hours to a few days) and tends to get worse and better over
the course of a day.
3. An extra problem with thinking, such as a problem with memory, getting lost, language, visual-
spatial skills, or perception.
4. The problems aren't caused by another neurocognitive disorder that was there before, is still
there, or is getting worse, and the person is in a very low level of awareness, like coma.
5. Disturbance is a direct physiological result of another medical condition, intoxication or
withdrawal from a substance (such as a drug of abuse or a medication), exposure to a toxin, or
exposure to more than one cause.

 Major NCDs

1. According to clients, clinicians, and assessments, there is a significant cognitive decline from a
previous level of performance in one or more cognitive domains.
2. The cognitive problems make it hard to do everyday things on your own. At the very least, you
will need help with complex instrumental activities of daily living, like paying bills or taking
medications.
3. Is not madness.
4. Doesn't describe another mental disorder, like schizophrenia or major depression.

 Mild NCDs

1. Based on what clients, clinicians, and assessments show, there is a small drop from a previous
level of performance in one or more cognitive domains.
2. Cognitive deficits do not affect the ability to do everyday tasks on your own. This means that
complex instrumental activities of daily living, like paying bills or taking medications, can still be
done on your own, but it may take more effort, different strategies, or accommodations.
3. Is not madness.
4. Does not talk about other mental health problems, like schizophrenia or major depression.

 Symtomps:
 Pathophysiology

 Delirium

a) Neurotransmitter hypothesis

 Metabolism issues in the brain causes cerebral dysfunction due to abnormalities of

various neurotransmitter systems.
 Impaired function and activities of neurotransmitters in the brain may underlie the
different symptoms and clinical presentations of delirium.

b) Inflammatory hypothesis

 Increased cerebral secretion of cytokines (small proteins controlling growth and activity
of cells) due to a wide range of physically stressful events plays an important role in the
occurrence of delirium.

 Dementia

 Most types of dementia, except vascular dementia, are caused by the accumulation of
proteins in the brain.
 Alzheimer disease (AD) - widespread atrophy of the cortex and deposition or tangles of
protein in the neurons which contribute to their degeneration.
 A genetic basis has been established for both early and late-onset AD.
  Depression, traumatic head injury, cardiovascular disease, family history of dementia,
smoking, and the presence of APOE e4 allele (gene) - increase the risk of the
development of AD.

 Aetiology

 Delirium

 According to Medline Plus (n.d), delirium can be caused by :

 Alcohol or drugs, either from intoxication or withdrawal. Serious type of alcohol
withdrawal syndrome called delirium tremens usually happens to people who stop
drinking after years of alcohol abuse.
 Dehydration and electrolyte imbalances
 Dementia
 Hospitalization, especially in intensive care
 Infections, such as urinary tract infections, pneumonia, and the flu
 Medicines side effects such sedatives or opioids (medication – painkillers).
 Organ failure, such as kidney or liver failure
 Serious illnesses
 Severe pain
 Sleep deprivation
 Surgeries, including reactions to anesthesia

 Alzheimer’s Disease

 Mechanisms that cause Alzheimer’s disease is unknown.

 Neurons are destroyed, and there is atrophy of the brain tissue.
 Plaques and tangles are present and are thought to prevent interneuronal
communication, however how this happens is not known.
 Genetic link to in adults under age 55 and is familial.
 Risk factors for Alzheimer’s disease include age and a first-degree relative with the
disease.
 Cruchaga et al (2012) – mutation of chromosomes positively correlate with young and
old onset.
 AD – hippocampus region issues (brain structure embedded deep into temporal lobe and
has a major role in learning and memory), initially causing memory difficulties as the
primary symptom.
 Problems in declarative memory, and initial difficulties with language and executive
dysfunction.

 Functional Limitations

 Early stages - work, leisure, social participation, and complex IADLs are affected.
 Progressive stages - IADLs, ADLs, and rest and sleep are affected.
 Occupation
 Work or volunteer experiences that demand complex thinking and new learning.
 Withdrawal from leisure activities that demand high-level cognitive skills.
 Social participation - declines with language skills, and social circles diminish from big to small
members.
 Initial stage – financial management, complex home maintenance, driving, errors in taking
medications and shopping challenges.
 Later stage – self care, incontinence and disturbances in sleep/wake cycle.
 Final stage – dependence on others on feeding, resistance and refusal.

 Managing delirium

1. Treatment Of The Cause

 Infections treated with antibiotics, dehydration with fluids and electrolytes given intravenously.

2. General Measures
 Environment - quiet and calm
 Well-lit spaces – allows recognition
 Use of orienting modalities - clocks, calendars, and family photographs
 Reassurance and reminders
 Use of aids when needed – hearing aids or glasses

3. Managing Agitation
 Medications – antipsychotics or anxiolytics (benxodiazepines) are used when other measures are
not working.

 Managing Mild and Major NCDs

1. Medications
 No disease-modifying medications that slow or stop the progression of NCDs.
 The acetylcholinesterase inhibitors or donepezil (Aricept), rivastigmine (Exelon), and galantamine
(Reminyl) - enhance thinking, memory, and communication, which promote the ability to carry
out daily activities.
 Antipsychotic medications - used to treat agitation, aggression, delusions, and hallucinations
(Vigen et al, 2011).

2. Reality Orientation (RO) Technique

 Reality orientations : Time, place, people. Can be used for Alzheimer’s Disease, other forms
of dementia or delirium.
 The goal of reality orientation : reestablish and maintain contact with reality, reducing their
disordered behavior.
 Caregivers : actively and repetitively provide information needed to relocate oneself in time
and place.
  “To function adequately in the environment one must have clues such as date, time and
place which help form a basic framework necessary for developing behavior and daily
routines.” (Texas A&M System, 2014)

 RO Strategies

 Tools and mass media /Examples : large clocks, large calendars, name tags, broadcasting,
information boards, sign-posts, alarm clocks, etc.
 Various information should be used persistently and repeatedly
 Content of tools or medias used in an activity include:

 Date, time, venue / place, weather

 Participant / people
 Timetable or daily schedule / routine
 Festivals
 Personal hygiene or self-care
 Numbers and colors concept
 Fruit, etc.

 Intervention : Stimulating Reminiscence Activity

Using Senses…

1. Smell: use of client’s favorite perfume around the room or on their clothes.
2. Touch: playing with sand or making dough
3. Taste: favourite food or drink that they enjoy.
4. Sound: favourite music related to their favourite decade
5. Sight: use of pictures - memories of pleasure

PHARMACOLOGICAL INTERVENTIONS IN PSYCHIATRY

 What is Psychotropic Substance?

 "A substance that alters brain function and affects mood, awareness, thoughts, feelings, and
behavior." Alcohol, caffeine, nicotine, marijuana, and some painkillers are psychotropic. Heroin,
LSD, cocaine, and amphetamines are psychotropic. "Psychoactive substance."

 Pharmacokinetics of Psychotropic Drugs

 Classifications of Drugs in Psychiatry

1. Anxiolytics – Benzodiazepine

 "Mild tranquilizers," or anxiolytics, treat and prevent anxiety symptoms and disorders
(Holstege, Ray, and Fuentes, 2014).
 Short-term use helps them focus on specific issues.
 Anxiety drugs include benzodiazepines and buspirone.
 Psychotic patients are now quickly calmed with benzodiazepines and antipsychotics.

2. Hypnotics

 To induce, extend, or improve the quality of sleep, and to reduce wakefulness during sleep
 Examples of hypnotics – Benzodiazepines, Cyclopyrrolones (zopiclone), Zolpidem

3. Antipsychotics

 reduce psychomotor excitement and control symptoms of psychosis.

 Reduce hallucinations, delusions, agitation, and psychomotor excitement in schizophrenia,
mania, or psychosis secondary to a medical condition
 Prevent relapses of schizophrenia and other psychoses
 Typical Antipsychotics also known as first generation antipsychotics (FGAs) .These drugs
include : fluphenazine, haloperidol, loxapine, pimozide, and thiothixene
  Atypical Antipsychotics n also as second generation antipsychotics (SGAs). • The drugs
include : risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole,paliperidone,
asenapine, lurasidone, iloperidone, cariprazine, brexpiprazole, and clozapine

4. Antidepressant - to treat clinical depression.

a) Monoamine reuptake inhibitors : tricyclic antidepressants, selective serotonin reuptake

inhibitors (SSRIs), selective noradrenaline and serotonin reuptake inhibitors (SNRIs), and
selective noradrenaline reuptakeinhibitors (NARIs).
b) Monoamine oxidase inhibitors (MAOIs).

5. MOOD STABILIZING DRUGS

 found to be efficacious in the treatment of bipolar disorder.

 effects in treatment of acute mania.
 prevention of recurrent affective illness.
 Examples of the medication : Lithium, carbamazepine, sodium valproate, Lamotrigine and
Gabapentin
6. PSYCHOSTIMULANTS – can be defined as a psychotropic substance with the capacity to stimulate
the central nervous system. It causes excitation and elevated mood, as well as increased
alertness and arousal.”

 reduce symptoms of Attention Hyperactivity Deficit Disorder (ADHD) in both young children
and adult.
 Example of medication : amphetamine (Adderall) and methylphenidate (Ritalin)

 Health Maintenance (AOTA, 2020)

 This basically means: "Activities related to developing, managing, and maintaining health and
wellness routines, including self-management, with the goal of improving or maintaining
health to support participation in other occupations."Clients should be able to take care of
themselves, including taking care of their medications, so that their conditions can be
managed.

 Things to do:"Talking to the doctor about prescriptions, getting prescriptions filled at the
pharmacy, understanding how to take medications, and taking medications on a regular
basis refilling prescriptions on a regular basis and on time."
 Psychoeducation – Medication Adherence

 Psychoeducation involves teaching patients about their illness and helping them understand
it. This helps them learn how to manage their condition and take the appropriate
medication.
 It is important to have meetings for the patient's family members and future caregivers who
will take care of the patient's health once they leave the hospital.
 Individual therapy: help the patient feel better about themselves and more confident, so
they can rejoin into the community after being released.

 Elements of Psychoeducation

 Prescription communication – patient and family to understand the condition,importance of

medication, its side effects and consequences of non-adherence.

 Prescription filling – understanding where and when the medication should be refilled,
where to get the medication (as instructed by seeing psychiatrist).

 Interpreting medication instructions – understanding when the medication must be taken

(i.e before or after meal), how many to take. Information must be based on client’s
prescription.

 Establishing the routine of medication – temporal wise (e.g before work, morning,evening).

PSYCHOLOGICAL INTERVENTION IN PSYCHIATRY

1. Psychological Treatments in Psychiatry

 Psychological treatment is not given in isolation, and this chapter complements the chapters on
physical treatment and services.
 The word psychotherapy is used in two ways:

a. can denote all forms of psychological treatment, including counselling and cognitive behaviour
therapy (CBT).
b. More traditionally it indicates established psychotherapies (usually broadly psychodynamic) that
require a specific and elaborate training

 The basic concepts underlying basic psychodynamic techniques are:

a. To achieve recall, the patient would lie on a couch and were encouraged to let their mind wander
while the therapist was not in sight. This technique is called "free association."
b. In time, he started paying attention to the strength of the relationship with his patients, which is
called "transference".
 Behaviour therapy: treatment based on scientific psychology using learning principles for
children’s fear, aversion therapy for alcoholism, and phobic disorders.
 Cognitive therapy: Beck noticed that depressed patients had recurring thoughts, and he came to
the conclusion that these thoughts were an important part of the disorder and needed to be
changed by challenging them in certain ways.

 Cognitive behavior therapy (CBT) is the best psychological treatment for many disorders because
it is based on strong evidence, has clearly described steps, and takes a short amount of time.

2. Classification of Psychological Treatments

 Psychotherapy can be classified based on numerous categories.

a. Psychodynamic
b. Cognitive behavioural
c. System theory •

 Classification based on number of patient taking part:

a. Individual therapy
b. Group therapy
c. Family therapy

 Planning the use of therapy within a public health service has generated three classification

a. Mental health is a simple part of all health care. This refers to skills and methods that can help
people deal with stressful situations or make hard decisions. These are often seen as important
parts of a good relationship between a doctor and a patient.

b. Not too hard to understand, and most mental health professionals can help.
This includes CBT that is easier to understand and short dynamic psychotherapies. Most of the
time, these treatments are part of a plan for care that also includes medication and social
measures.

c. Very complicated and given by therapists who have been trained in a formal way. This
bunch includes CBTs and the more complicated psychodynamics. These are used to treat
disorders that are more severe or complicated, either on their own or as part of a larger plan.

 Transference: intense feelings in the patient towards the therapist.

 Countertransference: intense feelings in the therapist towards the patient.

 Client-centred approach: in this the counsellor largely restricts his interventions to helping the
client understand their feelings better by reflections back to the emotional content of the client’s
utterances, often simply repeating the last statement with an interrogative tone.
 Interpersonal counselling: attention is focused on current problems in personal relationships
within the family, at work, and elsewhere.

 Psychodynamic counselling: places more emphasis on unconscious processes by which previous

relationships influence current feelings and relationships → the patient’s emotional reactions
(transference) are used to understand problems in other relationships

 Debriefing - to recall the distressing events, with emphasis on emotional release,and responses
to the immediate problems.

 Counselling for relationship problems Couples are encouraged to talk constructively about
problems in their relationship. The focus is on the need for each partner to understand the point
of view, needs, and feelings of the other, and also to identify positive aspects of the relationship
and potential strategies to move forward.

 Bereavement counselling - Draws heavily on following the identified stages of normal grief. It
combines an opportunity for emotional release (including anger), information about the normal
course of grieving, and sensitive encouragement about viewing the body and disposing of
clothing.

 Originated in dealing with disasters and draws on Caplan’s four stages of coping:

a. Emotional arousal with efforts to solve the problem.

b. Increasing arousal leading to a disorganization of behaviour.
c. Trials of alternative ways of coping.
d. Exhaustion and decompensation.

 Supportive psychotherapy - Basic elements are:

a. The therapeutic relationship (trusting, supportive and acceptance with realistic dependency)
b. Listening (provide full attention and sympathy)
c. Information and advice (careful timing, accurate information, provide gradually to be absord)
d. Emotional release (acceptance of emotional expression of patient)
e. Encouraging hope (reassurance should be specific and based on full understanding of
patients condition; capitalize on patients assets and opportunities)
f. Persuasion (persuade patients to take difficult but necessary actions or decisions)

 Interpersonal psychotherapy - as a structured psychological treatment for the interpersonal

problems of depressed patients.

 Cognitive behaviour therapy (CBT) =CBT aims to change cognitions and behaviour directly →
focusing on what is maintaining the disorder

 General features of CBT:

a. The patient is involved in the process. The patient is involved in his or her treatment, and
the therapist acts as an expert guide who asks questions, gives information, and gives
advice.
 b. Questioning like Socrates. When you question automatic thoughts, you put them to the
test—are there other ways to understand what's going on? What does it mean that you
think this way?
c. Pay attention to what causes and keeps the problem going. The patient keeps a daily
record to find out what happened before or after the disorder and what may have
caused or kept it going. Sometimes this kind of evaluation is called the ABC approach,
which stands for Antecedents, Behavior, and Consequences.
d. Paying attention to how the person thinks, which can be shown by writing down the
thoughts that go along with the behavioral or emotional problems.
e. Treatment as research (also called "collaborative empiricism"). The procedures used in
therapy are most of the time, the information is given as experiments that, even if they
fail, help us learn more about the condition.
f. Homework assignments and experiments on how people act. Patients get used to
new behaviors between sessions with the therapist, or do tests to find out what
works explanations that the therapist came up with
g. Sessions with a lot of structure. At each meeting, a plan is made, and progress has been
made since we go over what happened in the last class, including any homework. New
ideas are thought about, the assignments for the next week is planned, and the main
points of the class are summed up.
h. Keeping watch. The patient's daily records are checked as part of the
assessment includes scales for rating.
i. Treatment manuals explain what to do and how to do it. Guides make sure that
therapists stick to procedures that work

 Self-monitoring: records of thoughts, behaviours, and experiences over days or weeks, made in
real tim → record sheet usually has columns for symptoms, thoughts, emotions, and actions, plus
the day and time at which they occurred.

 Laddering: a series of questions, each about the answer to the previous question.

 A formulation is guided by a cognitive model of the disorder:

 Presenting problem: This goes beyond diagnosis to include what the person and clinician identify
as difficulties, how the person’s life is affected, and when a particular difficulty should be
targeted for intervention.

 Predisposing factor: This comprises identifying possible biological contributors, genetic

vulnerabilities, environmental factors and psychological or personality factors which may put a
person at risk of developing a specific mental health difficulty.

 Precipitating factor: This can include significant events preceding the onset of the
disorder;events that provoke the symptoms.

 Perpetuating factor: This comprises factors which maintain the current difficulties.

 Protective factor: This involves identifying strengths or supports that may mitigate the impact of
the disorder.
 Behavioural techniques - Focuses on what provokes symptoms or abnormal behaviour

 Relaxation training: patients are trained to relax individual muscle groups one by one, and to
regulate their breathing.

 Exposure: can be carried out in practice by confronting the actual situations that provoke anxiety
or in imagination by imagining the phobic situations vividly enough to induce anxiety.

 Assertiveness training: a form of social skills training in which patients practise appropriate self-
assertion.

 Anger management: patients are helped to identify situations that lead to anger, identify
attitudes that lead to anger that is out of proportion, identify factors that reduce restraints on
anger, and finally discover and practise alternative ways of dealing with situations that provoke
anger.

 Self-control techniques: attempt to increase patients control over their own behaviour without
the intermediate step of changing thoughts or emotions as in cognitive therapy.

 Small-group psychotherapy

a. Structure: the enduring reciprocal relationships between each member of the

group and the therapist, and between the members.

b. Process: the short-term changes in emotions, behaviours, relationships, and

other experiences of the group.

c. Content: the observable events in the group meetings—the themes, responses,

discussions, and silences.

 Patients are prepared for their experience in a group by emphasizing:

a. Confidentiality: the proceedings of the group are confidential.

b. Reliability: members must attend regularly and on time, and not leave early.
c. Disclosure: members are required to disclose their problems.
d. Concern: members must show concern for the problems of others.
e. Disappointment: at first members may be disappointed by the lack of rapid change, or
frustrated by the need to share the time available for speaking.
f. Keeping apart: The group members should not meet outside the group, and if they do so this
should be reported at the next meeting.
g. Duration: the length of the group is explained, together with the need to remain until the
end.

 common problems in group therapy:

a. Formation of subgroups.
b. Members who talk too much.
c. Members who talk too little.
 d. Conflict between members.
e. Avoidance of the present
f. Potentially embarrassing revelations

 Autonomy - need for informed consent is as great in psychological treatments as in any other
medical procedure

 Confidentiality - Patients should understand fully the requirement to talk of personal matters in
the group, but they need to understand equally clearly the requirement to treat as confidential
all they hear in the group.

 Exploitation - Private practitioners may prolong treatment to make more money.Professional

conduct prohibits sexual exploitation.The patient is exploited when the therapist imposes their
values. Direct or indirect. Group therapy patients may exploit each other. One person may blame
another or try to find a sexual partner outside of the sessions.Stressing therapy rules reduces the
issue.