MENTAL HEALTH /PSYCHIATRY nursing/

FOR NURSING STUDENTS

 Course Outline
Course description

• This course is designed to help nursing students in

understanding human behavior and differentiate
between normal and abnormal behavior.
• It will help student to develop basic skills in therapeutic
communication and nursing patient relationship, to
manage, support and rehabilitate patient with mental
illness in the hospital and community level.

2
 Course Contents
Chapter 1: Introduction
Definition of psychiatry
Chapter 2: History and therapeutic communication
Chapter 3: Mental Health Assessment
History taking
Mental status examination

3
 Conti…
Unit 4: Psychotic disorder
Unit 5: Mood disorders
Unit 6: Anxiety and Somatoform disorders
Unit 7: Substance related disorders
Unit 8: personality disorders
Unit 9:Role of nurse in:
 Child psychiatry
 Psychopharmacology
 Psychotherapy 4
 Teaching Methods & Evaluation
Teaching Methods
Lecture
Exercise
Group work
Evaluation
• Attendance is mandatory
• Continuous assessment ( Quiz, tests, 15%)
• Individual and group Assignment :20%
• Mid Exam : 20%
• Final Exam: 50%
5
 CHAPTER ONE
INTRODUCTION TO PSYCHIATRIC NURSING

Learning objectives
After studying this chapter, the student should be able to:
1. Define psychiatry
2. Describe normality/mental health
3. Describe mental illness
4. Mention the common causes of mental illness.

6
 Definition
Psychiatry: is a branch of medicine which deals with
mental disorder and their treatment.

Psychiatric nursing: is the branch of nursing concerned

the prevention, cure of mental disorders and their
sequel.

7
 Group activity

• Define mental health

• Define mental illness
• Causes of mental illness

8
 Normality may be:
- A sense of well-being
- The use of sublimation as the main defense mechanism
- The ability to postpone present pleasures for future ones
- The presence of an intact sense of reality
- Good interpersonal relationship
- Optimal adjustment.

9
 Mental health

Mental health is a state of well being in which the

individual:
realizes his/her own abilities
can cope with the normal stresses of life
can work productively and fruitfully, and
is able to make a contribution to his or her
community.
(WHO) 2001
10
 Mental illness
Mental illness is defined as illness with:
 psychological or behavioral manifestation and/ or
 impairment in functioning due to:
social,
psychological,
spiritual,
physiological disturbance

11
ENTAL HEALTH MENTAL ILLNESS
1. Accepts self and others 1. Feelings of inadequacy
- Poor self-concept

2. Ability to cope or tolerate 2. - Inability to cope

stress. Can return to normal - Maladaptive behavior
functioning if temporarily
disturbed

3. Ability to form close and lasting 3. Inability to establish a meaningful

relationships relationship

4.Uses sound judgment to make 4. Displays poor judgment

decisions

5. Optimistic 5. Pessimistic

6. Recognizes limitations (abilities Does not recognize limitations (abilities

and deficiencies) and deficiencies)

12
 Causes of mental illness
Multi factorial
1. biological
• Heredity
• Neurochemical imbalance
• Prolonged brain trauma and brain tumor
• Medical illness
• Excessive and/or consumption of psychoactive
substances

13
2. Psychosocial factors

Natural and man made disasters

Sexual abuse and domestic violence
Broken marriage, single parent home
Loss-bereavement, jobs, property
Interpersonal dispute and
Change in role and social status

14
 Prevalence of mental illness in Eth
Mental health problem Percent prevalence
CMD 12-17%

15
Schizophrenia 0.6-1%
Mood disorders 3.8-5%
Childhood disorders 12-24%
Substance dependence 4.0%
Problem drinking 2.7-3.7%
Khat abuse 22-64%
Suicide attempt 0.9-3.2%
Completed suicide 7.7/100,000/year
 CHAPTER TWO
History and therapeutic
communication of psychiatry

16
 Learning objectives

After studying this chapter, the student should be able to:

Describe history and trends psychiatric nursing in
Ethiopia
 Explain therapeutic communication

17
 Conti…
 Mental illness began in the primitive age as
human existence began.
 It was thought to be caused by evil sprits entering
and take over the body.

People were attempted to drive these evil sprits

from the body through the use of prayers and
magic.
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 Conti…
• In the ancient civilization, Greeks, Romans and Arabs viewed mental
deviations as natural phenomena and treated the mentally ill humanely.
• Care consisted of sedation with opium, music, good
physical hygiene, nutrition and activity.
• Hypocrites were concerned about the treatment of the mentally ill.
• Described a variety of personalities and attempted to classify people
according to their behavior.

19
 Conti…
• Bethlehem Royal Hospital, the first mental hospital in England, was
opened during the 17th Century.
• In this hospital, the public was allowed to wander through the hospital
and see the patients, and nurses lacked any interest in improving the
care of mentally ill.

20
 Conti…
• The first hospital in America to admit mental patients was the Pennsylvania Hospital
located in Philadelphia.
• The first American textbook on psychiatry was written, during this period by Benjamin
Rush (1745-1813) a physician who used a humanistic approach in the treatment of
mental illness. He is considered by many to be the father of American psychiatry.
• The first psychiatric training school in United States was established in 1882 at
McLean Hospital in Belmont.

21
 Cont…
 In the 20th century an Austrian neurologist,
Sigmund Freud made a significant contribution to
the understanding and treatment of mental illness.
 In Ethiopia the first mental hospital (Amanuel
Hospital) was established in 1930 after the end of
Ethio - Italian war that is to protect the royal family
from mentally ill patients.
 The patients were collected and taken to jails to the
corner of the town which is now known as Amanuel
22
 Cont…
 Slow and gradually humanitarian type of care was
started by one psychiatrist Dr. Fikire workineh.

 The first psychiatric nursing school was established in

Amanuel hospital in 1991 and 12 nurses was
graduated for the first time.
 The service was started to be decentralized to other
corners of the country

 By now some of hospitals/HC in Ethiopia have

psychiatric units even though the Quality is not to the
expected level 23
 Therapeutic communication
• Clinician- patient relationship
• Strategies to establish effective rapport
• Challenging situation in the consultation

24
 Clinician patient relationship/communication

• The quality of patient “therapist” relationship is crucial

to the practice of medicine and psychiatry.
• The following concepts are highly significant as
therapeutic tool:
• Rapport - feeling of acceptance, warmth, friendliness,
common interest.
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 Conti..
Trust – feel of confidence in that person’s presence,
reliability and sincere desire to provide assistance
when requested.
Respect – is to believe in the dignity and worth of an
individual regardless of his or her unacceptable
behavior.
Genuineness – is the ability to be open, honest and
real in interaction.
Empathy – is the ability to share another person’s
feelings and emotions as if they are your own
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 SETTING THE SCENE

Room and seating arrangement

Use a room or an area that is calm enough.
Use two or more comfortable chairs, of the same
height, orientated to each other at an angle.
Always consider your personal safety when
interviewing.

27
 Introductions

Introduce yourself and any accompanying staff members

by name and status.
It is best to introduce yourself by title and surname and
refer to the patient by title and surname.
Ensure that you know the names and relationships of
any people accompanying the patient.
Ask the patient if they wish these persons to be present
during the interview.

28
 Interview process

Beginning the Interview

Patients are often anxious on first encounters with
clinician and feel vulnerable and intimidated.
Explain the purpose of the interview.
It is helpful to indicate to the patient how long the
interview will last.

29
 Conti…
Advise them that you may wish to obtain further
information after the interview from other sources.

A useful and appropriate opening remark is “Can you tell

me about the troubles that bring you in today?” or “tell me
about the problems you have been having.”

30
 Supportive techniques during interview

Acknowledging emotion of the patient

 Facilitation
 Reassurance and maintaining nonverbal
communication
Reflection
Clarification
Summation

31
 Obstructive techniques during interview

• Compound questions, trapping the patient in his or her

own words, why questions and premature advice and
not following the patient's lead will obstruct the fellow of
interview.
• Transference - is the unconscious transfer of special
feelings from a client to the therapist.

• Counter-transference - is the projection of the

therapist’s feelings about a significant others to the
patient during therapy.
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 SIGN AND SYMPTOMS OF PSYCHIATRIC ILLNESS

Psychopathology, which is referred to as study of

abnormal state of mind, denotes three distinct approaches
among which phenomenological psychopathology
(Phenomenology) is considered to be the most appropriate
in a day-to-day clinical practice. In contrast to
psychodynamic and experimental psychopathology,
phenomenological psychopathology is concerned with an
objective description of abnormal states of mind in a way
that avoids preconceived theories.
 Definitions of common psychopathological terms

1.Disorders of Emotion:
Disorders of Emotion are central features of mood
disorders, but could also be found in other disorders.
• Emotion: is a feeling state
• Affect: is a short-term emotional state or feeling
tone as perceived by the clinician during the
interview.
• Mood: is a subjective experience of sustained and
pervasive emotional state.
• Depression: psychopathological feeling of sadness
 Con…
 Elation: Mood more cheerful than normal.
 Irritability: Getting easily annoyed and provoked to
anger
 Anxiety: Feeling of apprehension due to anticipation
of danger which may be internal or external
 Fear: anxiety due to consciously recognized and
realistic danger
 Panic: Acute, episodic, and intense attack of anxiety
associated with overwhelming feeling of dread and
autonomic discharge.
 Apathy: without feeling, total loss of emotion
 Cont…
• Blunt or flat affect: Normal variation of
emotional feeling tone is reduced.
• Labile affect: Excessively rapid and abrupt
change of emotional feeling tone
• Incongruent affect: emotional feeling tone not
congruent with ones thoughts, actions and
circumstances.
 2. Disorders of Perception

Perception is the process of becoming aware

of what is presented through sense organs.
 Illusion: Misperception of external stimuli
 Hallucination: Perceptions experienced in
the absence of an external stimulus to the
corresponding sense organ. Hallucinations
are experienced as true and they seem to
come from the outside world.
 Cont…
Hallucinations could be classified in
to five types according to sense
organs involved as follows:
• Auditory hallucination
• Visual hallucination
• Olfactory hallucination
• Tactile hallucination
• Tactile hallucination
• Gustatory (taste) hallucination
Eg. Hearing a voice when no one is speaking is a form of auditory
hallucination.
 3. Disorders of Thought

Disorders of thought are usually recognized

from speech and writing. The disorder may
involve the stream, form and/or its content.
a.Disorders of stream of thought
 Pressure of thought: is a condition
whereby ideas arise in an unusual variety
and abundance and pass through the
mind rapidly
 Cont..
• Poverty of thought: is a condition where there
are few thoughts in the person’s mind that
lack variety and richness, and they seem to
move through the mind very slowly.
• Thought blocking: Abrupt and complete
emptying of the mind that leads to abrupt
interruption of conversation
 Cont…

B. Disorders of form of thought

 Flight of ideas: Thoughts and conversation move quickly
from one topic to another. So that one train of thought is not
completed before the next is taken up.
 Perseveration: Persistent and inappropriate repetition of the
same sequence of thoughts, as shown by repetition of speech
or action.
 Loosening of associations of thought: is a lack of logical
connection between the parts of a train of thoughts, which is
not explained by the process described under flight of ideas,
as a result the person’s conversation becomes muddled and
hard to follow.
 Cont…
• Incoherence (word salad): Not only the
connection between sentences and phrases but
also grammatical structure of speech will be
disrupted.
• Verbigeration: Stereotypy in which sounds,
words, or phrases are repeated in a senseless way.
• Neologism: usage of words or phrases invented
by the person himself often to describe his/ her
morbid experience. But this needs to be
distinguished from incorrect pronunciations,
wrong use of words by people of limited
education, and dialect words etc.
 Cont..
C. Disorders of content of thought
 Delusion: is a belief that is firmly held but on
inadequate grounds, it is not affected by rational
argument or evidence to the contrary, and is not
a conventional belief that the person might be
expected to hold given his cultural background
and level of education. Do not assume that a
belief is delusional simply because of its oddness.
Main delusional themes are the following:
• Persecutory delusions: Are delusions which are
concerned with people or organizations that are
believed by the patient to be trying to inflict harm
on him, damage his reputation, or make him insane.
• Delusion of reference: Concerned with the idea that
objects, events or actions of people have special
significance for the person. E.g., Gesture by
somebody is believed to be directed specifically to
the patient.
• Grandiose or expansive delusion: are beliefs of
exaggerated self-importance, becoming wealthy,
being endowed with special power etc.
 Cont..

• Delusion of guilt and worthlessness: are beliefs that the

person has done something shameful or sinful. Usually
the belief concerns an innocent error that did not cause
guilt at the time.
• Nihillstic delusion: is a belief about the non-existence of
some person or thing, but the meaning is extended to
include beliefs that the person’s career is finished, that
he is about to die or has no money or that the world is
doomed.
• Hypochondriacal delusion: Are false beliefs about
having an illness. The person gets fully convinced that he
is ill in the face of convincing medical evidence to the
contrary.
 Cont…
• Delusion of being controlled: is a belief that
personal actions, impulses, or thoughts are
controlled by an outside agency.
• Thought insertion: A belief that one’s thought
has been implanted by an outside agency.
• Thought withdrawal: a belief that one’s thoughts
have been taken away by an outside force
• Thought broadcast: a belief that one’s thoughts
are known to other people through telepathy,
radio, or in some other unusual way.
 Cont..
• Obsessions: are recurrent and persistent
thoughts, impulses, or images that enter
one’s mind despite efforts to exclude
them.
• Compulsions: are repeated, stereotyped,
and seemingly purposeful actions, which
the person feels compelled to carry out
but resists, recognizing that they are
irrational.
4.Abnormal motor symptoms and signs
Abnormalities of facial expressions, posture and social behavior
are common in mental disorders of all kind.
• Tics: Are involuntary, irregular and repeated movements
involving groups of muscles. E.g., raising shoulder
• Mannerisms: repeated movements that appear to have some
functional significance. E.g., saluting
• Stereotypies: Repeated movements that are irregular (unlike
ticks) and without obvious significance (unlike mannerisms).
E.g., rocking to and fro
• Posturing: Adoption of unusual bodily posture continuously
for a long time. E.g., standing on one leg.
 Cont..
• Negativism: Patient does the opposite of what is
asked and actively resists efforts to persuade them to
comply.
• Waxy flexibility: The patient’s limbs can be place in a
position in which they remain for a long periods
whilst at the same time muscle tone is uniformly
increased.
• Echopraxia: Pathological imitation of movement of
one person by another even when asked not to do so
• Echolalia: Pathological repeating of words or
phreases of one person by another.
 Cont…
• Mustism: Becoming voiceless without
structural abnormalities.
• Gegenhalten: opposition of all passive
movements with the same degree of
force as applied by the doctor.
• Catalepsy: Rigidity of the limbs which can
lead to posturing for long intervals.
• Cataplexy: an attack of muscular
flaccidity.
 5.Disorders of memory
• Amnesia: Partial or total inability to recall past
experiences
• Hypermnesia: Exaggerated degree of retention and
recall.
• Anterograde amnesia: it is impairment of memory for
events between the ending of complete
unconsciousness and restoration of full consciousness.
• Retrograde amnesia: it is loss of memory for events
before the onset of unconsciousness.
• Confabulation: it is the reporting as “Memories”
events that did not take place at the time in question.
 6.Disorders of consciousness
Consciousness is awareness of the self and the
environment.
 Clouding of consciousness: Refers to a state of
drowsiness wit incomplete reaction to stimuli, impaired
attention, concentration and memory, and slow
muddled thinking.
 Stupor: a state in which the person is mute, immobile,
and unresponsive, but appears to be conscious because
the eyes are open and follow external objects. If the
patient’s eyes was closed, he will resist opening them.
 Cont…
• Confusion: Inability to think clearly often
occurs in organic mental disorders.
• Attention: Ability to focus on the matter
in hand
• Concentration: Ability to maintain that
focused attention.
 7.Insight
Insight is a correct awareness of one’s own
mental and physical condition
 8.Judgment
• The ability to make sound decisions in the
interest of self and others.
 CHAPTER THREE

MENTAL HEALTH ASSESSMENT

56
 Learning objectives
At the end of this class the students will be able to:

Describe how to take history from psychiatry patient

Explain the components of mental status
examination

57
 Mental health assessment

The best method of collecting data in mental illness

includes:
History taking.
Mental status examination

58
 1.History taking
1.Identifying Data - name, age, marital status, sex, address,
educational status, occupation, ethnicity, religion, current living
circumstances, the source(s) reliability of the source(s), and episode
of current disorder, the condition at which patient came to hospital.

2.Chief Complaint – is taken from the patients own words,

 states why he/she has come or been brought in for help.

 It should be recorded even if the patient is unable to speak, and the

patient’s explanation, regardless of how bizarre or irrelevant it is.
59
 example
1. Patient identification
• Ms.X is a 23 years old single female patient who is Muslim
in religion and Oromo in ethnicity and lives with her parents
currently in Jigjiga town. She is single and currently
student. She completed grade ten.
• She was brought by her sister.
• It is her first visit
• Source of information: Client, sister
2. C/C - Feeling sadness
like to sit alone 01yr duration
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 3.History of Present Illness

 Onset, course and duration of illness

 Chronological order of illness
 Negative and positive symptoms
 Precipitating and triggering and protective
events
 Impact of illness and risk assessment
 Assess by using MAPSS model
61
 Example
History of present illness/HPI
• Ms.X had been in a state of relatively mental health until 01 year
back after when she gradually started to show behavioural
changes after quarrelling with her father.
• She started to complain feeling sadness, feeling of loneliness
and need to sit alone in quiet place.
• She had also excessively think about her father condition of not
stop to smoke cigarette for a long period of time and to change
the job of farmer and to become merchant.
• She also complains of poor appetite, lack of energy, decreased
interest to perform her daily activities, irritability, feeling of
heaviness on her upper extremities.
62
 Conti…
• she had sleep disturbance which is difficult to fall to sleep and
pass the mid night without sleep thinking about her family. Her
condition worsen difficulty in falling to sleep continues.

• She had also difficulty to control her guilt feeling. Repeatedly

she thinks about her boy friend, which is lived in her neighbour
and learned together; due to her family unable to have good
relations with his family for many years, they get difficulty to
have good relationship.
• She had hopelessness and crying during irritability time and
need to sit alone in quiet place. 63
 Conti…
• She start hearing of voices which tells her day to day activity after
she start the illness since 04months.
• She had history of suicide attempt by poison after quarrelling with
her father in order to stop cigarette since 09 months. Suicide was
done in the absence of other people at time of five local time
morning and her friend was reached and saved her life by sending
to health facility.
• She had difficulty to concentrate things and difficult to make
decision.

64
 Conti…
• Otherwise, her denial of fearfulness, palpitation.
• She has no idea of other people are knowing about her before
she explained it, has no idea of special talent that makes her
different from others.
• She has no idea of people are talking about her. She has no
history of singing or dancing.
• She has no happy feeling and
• She has no history of homicidal intent.
• She has no history of any substance use.

65
 Conti…

4.Past psychiatric history – previous similar

different episodes, any treatment response and
side effect and suicide .
5.Past Medical and surgical history - obtains a
medical review of symptoms, allergic reaction &
note any major medical or surgical illnesses and
major traumas, particularly those requiring
hospitalization including seizure.

66
6.Family history - any psychiatric illness, substance use
history, hospitalization, and treatment of the patient's
immediate family members, suicidal history and history
epilepsy, family tree

 Does the family have a history of substance use?

alcohol and other substance abuse or of antisocial
behavior?
 Does the patient feel that the family members are
supportive, indifferent, or destructive?
 What is the role of illness in the family?
67
7.Personal history
Prenatal and peri-natal circumstances
 Full-term pregnancy or premature
 Vaginal delivery or caesarian, defects at birth
 Drugs taken by mother during pregnancy
 Pregnancy wanted or planed, birth complications
and
 Maternal starvation, viral infection or falling injuries
during pregnancy
68
 Infancy and early childhood ( up to 3 years)
 Infant mother relationship
 Problems with feeding and sleep
 Significant milestones
 Standing/walking
 First words/two-word sentences
 Bowel and bladder control
 Unusual behaviors (e.g. head-banging)
69
 Middle childhood(3-11years)
 Preschool and school experiences
 Separations from caregivers
 Friendships/play or hobby
 Methods of discipline
 Illness, surgery, or trauma

70
Late childhood (puberty through adolescence)
 Adolescence
 Onset of puberty and any reaction
 Academic achievement
 Organized activities (sports, clubs)
 Areas of special interest, work experience
 Romantic involvements and sexual experience
 Drug /alcohol use/
 Symptoms (moodiness, irregularity of sleeping or
eating, fights and arguments)
71
Adulthood
 Occupational history
 Marital and relationship history
 Military history , educational history
 Religion and Social activity
 Current living situation & Legal history/forensic hx
8.Sexual history
9.Fantasies and dreams
10.Pre-morbid personality – social relations, activities and
interests, mood, character, standards, religious and
reaction to stress.
72
 Mental status examination

Mental status examination is carried out orderly and

systematically. It Includes examination of:
1. General description;
• Appearance: dress: color, cleanness,
inadequacy for the weather.
• self care (neglect): unshaven, uncombed
hair,
• Unusual combination of clothing;
• Unusual accessory.
73
 Conti…
2. Motor activity:
• Gait: unusual fast, slow or unusual characteristics.
• Abnormal motor activity: tic, stereotypes etc.
3. Speech: speed, volume, quantity, tone or non social
speech.
4. Emotion:
- mood and
- affect
5. Perception: hallucination, illusion, depersonalization and
derealization.
6. Thought: content, and
form. 74
7. Sensorium and cognition
– Alertness and level of consciousness.
– Orientation to time place and person.
– Memory: remote ask life events that happen in this
country 10 years or 20 years back, recent what he had for
break fast and immediate you tell your name and
addresses and then ask him after some time
– Concentration and attention: subtract serial 7 from 100 for
concentration test and ask the patient to call days of the
week forward and back ward for attention 75
 Cont..

• Judgment: ask some general knowledge the

patient to evaluate the general knowledge.
• Insight:The patients level of awareness about his
illness and sick treatment. is the patient belief
that he is ill?. If so he need treatment or not.

76
 Further Diagnostic Studies

 Physical and Neurological examination

 Additional psychiatric diagnostic Interviews with
family members, friends, or neighbors by a social
worker.
 Psychological, neurological, or laboratory tests as
indicated.

77
 Diagnosis

DSM-IV-TR - This uses a multi-axial classification of

five axes.
Axis I: Clinical syndromes (e.g., Major Depressive
disorders, schizophrenia, generalized anxiety
disorder) and other conditions that may be a focus of
clinical attention and Differential diagnosis.
Axis II: Personality disorders and mental retardation

78
 Conti…
Axis III: Any General Medical Condition (e.g.,
epilepsy, cardio vascular disease, endocrine
disorders)
Axis IV: Psychosocial and environmental
problems (e.g., divorce, injury, death of a loved
one) relevant to the illness
Axis V: GAF exhibited by the patient during the
interview
Plan to management 79
 Unit 4
Anxiety Disorder
 Learning objectives

At the end of this unit, the student will be able to

1.Define anxiety disorder
2.Differentiate between normal anxiety and pathological anxiety
3.Describe various type of anxiety disorder
4.Identify ethological factors
5.Identify topics for client and family teaching relevant to anxiety
disorder
6.Discuss various modalities relevant to treatment of anxiety disorder
- Anxiety disorder is a condition in which anxiety dominates the
patient’s life
- Anxiety is the subjective emotional response to that stress
 Anxiety disorders

- Anxiety disorders are among the most prevalent

mental disorders in the general population
- With women affected nearly twice as frequently
as men
- Anxiety disorders are associated with significant
morbidity and often are chronic and resistant to
treatment.
- Anxiety generally divided in two group
- The first group is normal anxiety
 Every one experience anxiety. It is characterized
 Most commonly as a defuse, unpleasant, vague
sense of apprehension
 Often accompanied by autonomic symptom such as
headache, perspiration, palpitation, tightness in the
chest, mild stomach discomfort and rest less ness,
 Indicated by an inability to sit or stand still for long.
 The particular constellation of symptoms present during
anxiety tend to vary among persons.
 The 2nd group is pathological anxiety
 The anxiety disorder make up one of the most common
groups of psychiatric disorders
 The national co-morbidity study reported that one of four
person met the diagnostic criteria for at least one anxiety
disorder and that there is a 12month prevalence rate.
Under the 2nd group anxiety disorder 5 sub types

1.Panic anxiety du
2.Specific phobia and social phobia
3.Obsessive compulsive anxiety
disorder
4.Post-traumatic stress disorder
5.Generalized anxiety d/o (disorder)
6. Other anxiety disorder
 Anxiety disorder due to a general
medical condition
 Substance induce anxiety d/o
 Mixed anxiety – depressive disorder
Type of anxiety disorder

1.Panic anxiety disorder is an acute intense attack of anxiety

accompanied by feeling of impending doom is known as panic
disorder.
 The anxiety is characterized by discrete period of intense fear that
can vary from several attacks during one day to only a few attacks.
 During a year patient with panic disorder present wide a number of
co-morbid condition
 Most commonly agoraphobia
 Which refers to fear of or anxiety require ding place from which
escape might be difficult
•Epidemiology: - the life time prevalence of
panic disorder 1-4%
•Women are 2 – 3 times more likely to be
attack than men
•Etiology: - Biological factor
Genetic factor
Psycho, social factor
Diagnosis: HX taking
DSM IV T.R criteria for panic attack

A discrete period of intense fear or

discomfort in which four or more of the
following symptom developed abruptly
and reached peak with in in 10 minute
1.Palpitation, accelerated heart rate
2.Sweating
3.Trembling or shaking
4.Sensation of shortness of breath
5.Chest pain
6.Nausea or abdomen distress
7.Fear of losing control
8.Fear of daying
•DDX = anemia
Congestive heart failure
Epilepsy
Diabetes
Hypertension
•Treatment
Pharmacotherapy
Cognitive behavioral therapy
Family therapy
SSRI group drug = fluoxetine or clomipramine
2. Specific phobia and social phobia
• The term phobia refers to an excessive fear of specific object,
circumstance, or situation.
- A specific phobia is a strong persisting fear of an object or
situation.
- Where as a social phobia is a strong persisting fear of situation
in which embarrassment can occur
- Such as in speaking in public
- Specific phobia is more common than social phobia
- Specific phobia is the most common mental disorder among
women and the second most common among men
 2.1. Social phobia
 Various studies have reported a live time prevalence ranging
from 3 – 13% for social phobia
 In epidemiological studies. Females are affected more often
than males
 The peak age of onset for social phobia is in the teens,
although onset common as young as 5 year of age and as old
as 35
- Epidemiology 5 -10% of the population
- Etiology = Both specific phobia and social phobia biological
and Genetic factor and Environmental factor
DSM IV T.R diagnostic criteria for specific
phobia
A marked and persistence fear that is
excessive or un-reasonable, cued by the
presence or anticipation of a specific object
or situation
Eg. Flying, heights, animals
Receiving an injection, seeing blood)
 Specific type
 Animal type
 Natural environment type (Eg. height, storm,
water)
 Blood, injection
 Situational type = (Eg. Airplane, enclosed place)
 Other type (Eg. Fear of loud sound in children)
•Example of phobias {common one}
1.Acrophobia – fear of height
2.Agoraphobia – fear of open place
3.Hydrophobia – fear of water
4.Claustrophobia – fear of closed space
5.Cynophobia – Fear of dogs
6.Mysophobia – fear of dirt and germ
7.Pyrophobia – fear of fire
8.Xenophobia – fear of strangers
9.Zoophobia – fear of animal
10.Nocto phobia – fear of dark place
Social phobia/ Diagnostic criteria
1.A marked and persistent fear of one or more
social or performance situation in which the
person is exposed to un-familiar people
2.Exposure to the feared social situation
Clinical feature
- Patient are exposed to specific situation or
object
- Exposure to the phobic stimulus
•Differential diagnosis
- Appropriate fear and normal shyness
- Schizophrenia
- M.D.D
•Course and Prognosis
• Chronic
• Poor prognosis
Treatment
1.Systematic desensitization
2.Insight – oriented psychotherapy
3.Supportive therapy and family therapy
4.The common treatment for specific phobia exposure
therapy
5.Pharmacotherapy/ Eg. Benzodiazepine/
For social phobia:- both psychotherapy and
pharmacotherapy Eg. SSRI benzodiazepine
- Propranolol 20 – 40 mg another option
- Lorazepam or bromazepam 3mg
3.Obsessive compulsive anxiety disorder
- Is represented by a diverse group of symptom that include
intrusive thought, rituals, per occupation, and compulsion.
- Recurrent, intrusive, in appropriate and un-wanted thought,
or image causing significant anxiety that inter fear with usual
functioning
- Obsession – means a recurrent thought, feeling or action that
is un-peasant and provokes anxiety
- Which is a mental event
- A compulsion is a behavior. Specifically
- A compulsion is a conscious standardized recurrent behavior
such as counting checking or avoiding.
•Epidemiology: - 2 – 3 percent (life time
prevalence)
M – F equal attack
•Etiology: - biological factor
Neurochemical disturbance
Genetic
Behavioral factor and psychosocial factor
•Clinical Features
- Both obsession Preoccupied by mental stress
- And compulsion
•Diagnostic criteria for obsessive compulsive disorder
1.Recurrent and persistent thought in appropriate and that
cause marked anxiety or distress
2.Excessive worries about real – life problem
3.The person recognize that the obsessional thought impulse
or image are a product of his or her own mind
4.Compulsion as defined by
• Repeated behavior Eg. Hand washing, ordering checking
(mental act)
1.At some point during the course of the disorder the person
has recognized that the obsessions or compulsion are
excessive or un-reasonable.
•Differential Diagnosis
- Medical condition
- Neurological disorder
Course and prognosis
50-70% of patient occurs after a stressful event such as
pregnancy, sexual problem or death of a relative
The course is usually long
About 20 – 30% significant improvements
40 – 50% moderate improvement
20 – 40% the remaining of patient either remain ill or their
symptom worsen
Treatment
1.Pharmacotherapy 8 – 16 weeks
S.S.R.T or clomipramine
2.Psychotherapy
4. Post-traumatic stress disorder and acute stress disorder
- Posttraumatic stress disorder (P.T.S.D) is a condition marked by
the development of symptom after exposure to traumatic life event.
- P.T.S.D:- with 4 week of event and remains within 2 days to 4
week. If symptom persist after that time, a diagnose of PTSD
- They can Arise from experience in war, torture natural
catastrophe’s, asult, rape and serious accident for example in car,
and burning.
Epidemiology:- Life time incidence of PTSD 9 – 15%
Etiology: - Stressor (Traumatic event)
•The response to the traumatic event
Risk factor for P.T.S.D
- Even when faced with over whelming trauma
- Most person do not experience P.T.S.D symptom
- The national comorbidity study found that 60% of male
and 50% of female had experienced
- Some significant trauma
- Whereas the reported life time prevalence of PTSD was
only 6.7%
Diagnostic criteria for post-traumatic stress disorder
1.Exposed to traumatic event
2.Recurrent and intrusive distressing recollection of the
event
3.Acting or feeling as if the traumatic event
4.Intense psychological distress at exposure to internal
or external cues
5.Persistent avoidance of stimuli associated with the
trauma
6.Markedly diminished interest
C/F
 Painful re-experiencing of the event
 Emotional numbing
 Impaired memory
 Aggression, violence
 Poor impulse control
Differential Diagnosis
- Epilepsy
- Substance related psychiatric ph
- Border line personality
- Head injury
Course and prognosis
• About 30% patients recover completely
• About 40% continue to have mild symptom
• About 20% continue to have moderate symptoms
• About 10% remain un-changed
• About 50% of patient will recover
Pharmacotherapy
•Rx: - selective serotonin reuptake inhibitor
1.Such as Sertraline 50 mg R- and paroxetine 25mg
2.Psychotherapy
1.Generalized anxiety disorder
 Generalized anxiety disorder as excessive anxiety and worry about
several events or activities for most days during at least 6 month
period.
 The worry is difficult to control and Is associated with somatic
symptom.
 Such as muscle tension, Irritability, difficulty sleeping and
restlessness.
 The anxiety is not focused on feature of another axis I disorder. Is not
caused by substance use or general medical condition.
 And does not occur only during a mood or psychiatric disorder.
 The anxiety is difficult to control
 Is subjectively distressing and produces impairment in important area
of a person’s life
Epidemiology: - A common condition 3
-8% women to men 2:1 in elderly
Etiology: - Biological – Genetic
Neurochemical in balance
• Psychological: - stress full life event
• Social factor: - Low socio economic
Diagnostic criteria for generalized anxiety disorder
1.Excessive anxiety and worry
2.Difficult to control the worry
3.Rest less or being easily fatigue
4.Difficult concentrating or mind going blank
5.Irritability
6.Muscle tension
7.Sleep disturbance
8.Clinically significant Distress or impairments in social,
occupational or other important area of functioning
9.The disturbance is not due to the direct G.M.C and other
substance abuse
C/F
1.Excessive worryness
2.Motar tension
3.Cognitive dysfunction
4.Head ache, restlessness
5.Excessive sweating
6.Palpitation
DDX:- Panic D/o
•O.C.D
•PTSD
Course and prognosis
•Any age group occur Difficult to predict chronic
one
Treatment
Combines psychotherapeutic and pharmacho
therapeutic
- Benzodiazepine group shart course 1 – 2 weeks
- SSRI group long term 6-12 months
6. Other anxiety disorders
A. Anxiety disorder due to general medical
condition
- Many medical Disorder are associated with
anxiety symptoms
Epidemiology:- Is common
Etiology:- A wide range of medical condition
can cause symptom similar to those anxiety
disorder
Diagnostic criteria
1.Prominent anxiety symptom
2.There is evidence from the History, physical
examination
3.The disturbance cause clinically significant distress or
impairment in social, occupational days function
DDX:- Associated with many psychiatric disorder
Treatment:- treat the underline medical condition
•6 B. Substance induced anxiety disorder
- Direct result of toxic substance including drug of
abuse, medication, poison and alcohol, among other
Epidemiology: - The result of the ingestion of so-called
recreational drugs and as the result of prescription drug use
•Diagnostic criteria for substance induced anxiety disorder
1.One month of substance intoxication
2.There is evidence from the history physical examination or
laboratory finding
3.The disturbance cause clinically significant distress or
impairments in social, occupational
DDX: - Anxiety D/o due to GMC
Course and prognosis:- Depending on the patient condition
Treatment: - Removal of the cause involving substance
6C Mixed anxiety depressive disorder
- Patient with both anxiety and
depressive symptom who do not meet
the diagnostic criteria
Epidemiology: - 1% from general
population
Etiology: - Hormonal Disturbance
Diagnostic criteria for mixed anxiety- depressive
1.Difficult concentrating
2.Sleep disturbance
3.Fatigue or low energy
4.Worry
5.Be-ing easily moved to tears
6.Hopelessness
7.Low self esteem
DDX: - GAD
Dysthymic disorder
Prognosis: - Not known
RX: - Psychotherapy
Pharmacotherapy
 Unit five
SOMATOFORM DISORDERS
The term somatoform derives from the Greek word
soma for body.
Somatoform Disorders: psychiatric disorders
characterized by the presence of physical symptoms
in the absence of demonstrable pathology or known
pathophysiology.
 SOMATOFORM DISORDERS

Somatoform disorders are of different classes:

1. Somatoform disorder
2. Hypochondriasis
3. Conversion disorder
4. Pain disorder
5. Body dysmophic disorder
 SOMATOFORM DISORDERS
• Patients who present with multiple,
unexplained physical complaints make up a
significant proportion of primary care practice.
• 38% of them complain of symptoms that have
no serious medical basis
• 46% percent of new complaints or new
symptoms contain some element of
somatization. 10% of these represent pure
somatization.
 SOMATOFORM DISORDERS
• Somatization disorder is characterized by
many somatic symptoms that cannot be
explained adequately on the basis of physical
and laboratory examinations.
 Etiology
•The cause is not known
•Different factors/hypotheses exist.
Psychosocial factors
Psychosocial formulations of the cause involve
interpretations of the symptoms as social communication
whose result Is to:
1. Avoid obligations
Eg: Going to a job a person does not like
2. Express emotions
Eg: Anger at a spouse
3. Symbolize a feeling or a belief
Eg: Pain in the gut
Psychoanalytic explanation: Substitute for repressed instinctual
impulses
 Etiology
Biological factors:
•Genetic
•Abnormal regulation of cytokines
•Cognitive and attention impairments that result in faulty
perception and interpretation of sensory stimuli
Physiological mechanisms
•Autonomic arousal
•Muscle tension
•Hyperventilation
•Vascular changes
•Cerebral information processing
•Physiological effects of inactivity
•Sleep disturbance
 EPIDEMIOLOGY CONTD…
•About 2/3 have identifiable psychiatric
symptoms and up to'12 have other mental
disorders
•Avoidant, paranoid, self-defeating obsessive-
compulsive personality traits or disorders
commonly associated
•Bipolar I disorder and substance abuse are not
commonly seen in patients with somatization
disorder
 Etiology
• Behavioral explanation:
 Parental example
 Ethnic mores
 Unstable homes
 Physical and sexual abuse etc
 EPIDEMIOLOGY
Usually begins before the age of 30, often
begins in teenage years
Lifetime prevalence, 0.2 to 2.0% in women and
0.2% in men
Female: Male= 5:1
5-10% of patients in the general outpatient
clinic
Commoner among those who have little
education and low income
Coexists with other mental disorders
 Clinical Manifestations
DSM-IV requires four pain, two GI, one sexual and one pseudo-
neurological symptoms all of which are not fully explained by
medical condition.

Examples of symptoms:

1.Neurological: Impaired coordination, weakness

2.GI: Nausea, bloating, vomiting etc
3.Pain: pain in the head, abdomen, back, joints, extremities,
chest, rectum, urogenital
4.Sexual: Sexual indifference, erectile problems
 DDX
Nonpsychiatric medical conditions must be ruled out
Several medical conditions often show nonspecific transient
abnormalities in the same age group
The medical disorders include:
•Multiple sclerosis
•Myasthenia gravis
•Systemic lupus erythematosis
•AIDS
•Acute intermittent porphyria
•Hyper and hypothyroidism
•Chronic systemic infections
 Specific components of MSE in the patient
with somatic symptoms
Signs of abnormal illness behavior
Quality of the patient's description of his/her
symptoms
Thoughts behaviors, and emotions associated with
symptom occurrence
Range and depth of emotional response level of denial
Patient's explanation of the physical symptoms and
negative tests
Presence of abnormal hostility to physicians
 DXX Contd….
•Mental disorders
•Depression
•Generalized anxiety disorder
•Schizophrenia
•Panic disorder
• other somatoform disorders
Hypochondriasis
Pain disorder: limited to one or two symptoms
Conversion disorder: Limited to one or two neurological
symptoms
 Treatment
The key to the management of patients with somatization disorder
is to adopt “caring” rather than "curing” as a goal.
Principles of management of somatization and somatoform
disorders
•Emphasize explanation
•Arrange for regular follow-up
•Treat mood or anxiety disorders
•Minimize pot pharmacy
•Provide specific therapy when needed
•Change social dynamics
•Recognize and control negative reactions and countertransference
 Hyopochondriasis
•Hopochondriasis is defined as a person’s
preoccupation with the fear of contracting or
the belief of having a serious disease even
though no known medical causes can be found
•This arises when a person misinterprets bodily
symptom or functions.
•It causes significant distress and impairs
personal, social and occupational functions of
individuals.
 Clinical Features
•Fear of disease or conviction that one has
disease
•Bodily preoccupation with particular body
function. Eg: heart beat
Or disease, Eg. Cancer
•Increased vigilance toward bodily sensations
or trivial physical state
• Eg: Cough
 Epidemiology
•Current 6 month prevalence 4-6% in clinical
setting
•It estimated to be as high as 15% in the
general population
•Men and women are equally affected
•Most commonly occurs between 20 to 30
years of age
•Blacks > whites
•About 3% of medical students in the first two
years of their study
 Associated features
 High medical utilization
 Latrogenic damage from repeated
investigations
 Deterioration of interpersonal relations
 Compromised occupational function because
of preoccupation
 Increased time taken off work
 DDX
• General medical conditions
- Early stages of
• Rheumathological
• Immunological
• Endocrine and
• Neurological diseases
Maybe associated with subtle pathology that
may not be detected by physical or laboratory
examinations
 DDX cont..d
• Psychiatric disorders
• Depression
• Dysthymia
• Anxiety disorders
• Somatization disorder
• Schizophrenia
• Delusional disorders, somatic type
 Treatment
 Patients usually resist psychiatric treatment
 Psychotherapy
• Group psychotherapy often helps
• Other forms of psychotherapy
• Individual insight-oriented
• Behavioral
• Cognitive
• Frequent, regular physical examination help to reassure and let the patient
know that he/she is not abandoned
• Investigation when there is only objective evidence that suggests a physical
condition
• Pharmacotherapy if there is underlying conditions such as depression or
anxiety disorder.
 Course and prognosis
• The course is usually episodic
• There maybe obvious association with a
stressors and exacerbations
• 1/3 to ½ are estimated to show significant
improvement
• Good prognosis associated with high
socioeconomic status
• Absence of PD, good prognosis
• Children recover by late adolescence or
adulthood
 Conversion disorder
• Conversion disorder is loss or change in
voluntary motor or sensory functioning that
cannot be explained by a known neurological
or medical disorder.
• In addition, the diagnosis requires association
of psychological factors with the initiation or
exacerbation of the symptoms
 Common symptoms of conversion
disorder
• Motor symptom's • Sensory deficits
• Involuntary • Blindness
movements • Deafness
• Tics • Tunnel vision
• Seizures • Visceral symptoms
• Abnormal gait • urinary retention
• Falling • Diarrhea
• Paralysis
• Weakness
 Epidemiology
 1/3 of the general population experiences mild type
conversion during lifetime
 One community study, 22 per 100,000
 5 to 15% in general indexical clinics
 Women: men 2:1
 There is even higher dominance in girls than in boys
 Can occur at any age but most common in adolescence
and young adult hood
 More common in low IQ and socio economic group
 Commoner in military personnel who were involved in
combat
 Commonly associated with comorbid diagnosis of
depression anxiety disorders and schizophrenia
 Clinical features
• Paralysis, blindness and mutism are the most
common conversion disorder symptoms
• Maybe most commonly associated with
Passive – aggressive
Dependent
Antisocial and
Histrionic personality disorders
• Depression and anxiety often accompany the
disorder and affected patients are at high risk
for suicide
 Other associated features
o Several psychological symptoms have also been associated
with conversion disorder
o Primary gain: keeping internal conflicts out of awareness
o Secondary gain: receive support from others of gel exempted
from responsibility which may not be achieved otherwise
o La belle indifference: being unconcerned about what has
happened to her/him (not specific to conversion disorder,
other medical conditions)
o Identification: Modeling their symptoms on someone
important for them.
o Eg. Bereaved person may have symptoms of the decresed
 DDX
• difficult to rule out medical disorder
• 25 to 50% of cases eventually receive neurological or
medical diagnosis that explains the symptoms
• Dementia and other neurodegenerative diseases
• Brain tumors
• Optic neuritis
• Neurological manifestation of AIDS etc
• Abreaction or hypnosis might help to diagnose
conversion disorder
 Treatment
• Symptoms usually resolve spontaneously
• Psychotherapy focused on stress and coping
• Parenteral amobarbital or loazepam
 Course and outcome
• Symptoms, perhaps 90 to 100% resolve in few
days or less than a month
• About 75% may not have additional episodes
• Sudden onset, easily identifiable stressor,
good premorbid adjustment, absence of
comorbid psychiatric or medical disorders are
good prognostic factors
• The longer the symptoms stay, the worse the
prognosis
 Pain Disorder
• Pain disorder is essentially mono symptomatic
somatoform condition, with the predominant symptom
being pain
Clinical features
 Pain is the predominant focus of presentations
 Significant distress or impairment of function
 Psychological factors play important role in onset
exacerbation or maintenance
 Often related to environmental stressors
 Psychiatric symptoms such as depression often denied
 The common pain syndromes

 Lower back pain

 Headache
 Chronic pelvic pain
 Atypical facial pain
In order to diagnose pain disorder, there must
be clearly known psychological factor that can
be attributed for the pain
 Treatement
• Establish supportive relationship
• Different psychotherapies
• Tricyclic/SSRI antidepressants
 Etiology
• Similar theories to those applied for somatization disorder apply for is
disorder as well
Epidemiology
 Pain is the most common symptom people seek doctors for
 In general practice pain is a common symptom fore emotional
problems
 1/5th of psychiatric inpatients and ½ of outpatients response to pain
 Pain is particularly associated with depression, anxiety, panic and
somatoform disorders
 Conversely, patients with multiple pain are likely to suffer from
mental disorder
 Women: men, 2.1
 Peak age of onset is in the 4th and 5th decade
 BODY DYSMORPHIC DISORDER
 Body dysmorphic disorder is a disorder in
which patients become preoccupied with
imagined or greatly exaggerated defects in
their physical appearance.
 the preoccupation may involve any body part
 The common complaints are about: nose,
ears, mouth, breast, buttocks, penis and hair
 Treatment
• Establish supportive relationship
• Psychotherapy
• Anti depressants
• If secondary, treat the underlying psychiatric
condition
 Body dysmorphic
• It is usually an over valued idea
• But some individuals may receive additional
diagnosis, delusional disorder, somatic type
• Thus, the separate of this syndrome is not yet
well established.
• ICD-10 classifies it as a subgroup of
hypochondriasis
• Many patients request surgery
 Chapter 6
Mood disorders/Affective disorder
Mood is a pervasive and sustained felling to that is experienced internally and that influence a
person’s behavior and perception of the world.
Affect is the external expression of mood.
Mood can be normal, elevated, or depressed.
Healthy person experience a wide range of moods
Mood disorders are a group of clinical condition characterized by a loss of that sense of control and a
subjective experience of great distress.
Patient with elevated mood demonstrate expansive ness, flight of Idea, decreased sleep and
grandiose idea,
Patient with depressed mood:- Experience a loss of energy and loss of interest, feeling of guilt,
difficult in concentrating, loss of appetite and thoughts of death or suicide
Other sign and symptom of mood disorder include change inactivity level, cognitive abilities speech
and vegetative functioning eg( sleep sexual activity, and other biological RHY them
•Classification of mood disorders

1.Depressive disorders
 Major depressive episode:- life time prevalence 5 – 17%
 Dysthymic Disorder:- Life time prevalence 5%
 Minor depressive disorder:- life time prevalence 10%
 Recurrent brief depressive disorder 16%
1.Bipolar I disorder :- life time prevalence0 – 2.4
 Bipolar II disorder:- Life time prevalence 0.3 -4.8
 Cyclothymia disorder:- life time prevalence 0.5 – 6.3
 Hypo mania disorder:- life time prevalence 2.6 – 7.8
1.Other categories
 Mood d/o due to G.M.C
 Substance induced mood disorder page
1.Major depressive episode must last at least 2
weeks and typically a person with diagnosis of a
major depressive episode
- Also experiences at least for symptom from a list
that includes changes in appetite and weigh,
changes in sleep and activity, lack of energy,
feeling of guilt, problems thinking and making
decisions, and recurring thoughts of death or
suicide
1.Major depressive episode must last at least 2 weeks
and typically a person with diagnosis of a major
depressive episode
- Also experiences at least for symptom from a list that
includes changes in appetite and weigh, changes in
sleep and activity, lack of energy, feeling of guilt,
problems thinking and making decisions, and
recurring thoughts of death or suicide
•Major Depressive episode

•Epidemiology: - major depressive disorder has the highest lifetime

prevalence 17% sex ratio greater prevalence of major depressive disorder
in women than in men

- The reason for the difference are hormonal differences

- Age:- major depressive disorder can also begin in child hood or in old
age
- Recent epidemiological data suggest that the incidence of major
depressive disorder may be increasing among people younger than 20
year of age. This may be related to the increased use of alcohol and
drugs of abuse in this age group
- Marital status:- M.D.D. occurs most often in persons without close
inter personal relationships or divorced or separated
•Socio economic and cultural factor more common in rural area than in urban area
•Ethology:- Biological factor

- Neurotransmitter alteration
- Alteration of hormonal regulation
- Sleep disturbance
- Immunological disturbance genetic factor,
psychosocial factor
- Stress full life event
- Environmental stresser
Diagnosis/Criteria for major depressive episode

Five or more of the following symptoms have been present during the same 2
weeks

1.Depressed mood most of the day nearly every day

2.Markedly diminished interest or pleasure
3.Significant weight loss
4.Insomnia or hypersomnia nearly every day
5.Psychomitar agitation or retardation nearly every day
6.Fatigue or loss of energy nearly everyday
7.Feeling of worth less ness or excessive or in appropriate guilt
8.Diminished ability to think or concentrate or indecisiveness nearly every
day
9.Recurrent thoughts of death
DDX:- medical disorder

Mood D/o due to GMC

Substance induce mood D/o

Course and prognosis: - poor bad prognoses

Treatment: - Antidepressant

1.Amitriptyline 75mg – 300mg r divided dose

2.Imipramine 75 – 300 mg po
1.Dysthymia:- this disorder as characterized
by at least 2 year depressed mood that is not
sufficiently severe to fit the diagnosis of major
depressive episode
• Epidemiology:- is common among the general
population no gender difference are seen
• Etiology:- Biological factor psycho social
factor
• Diagnosis and clinical feature
- The presence of a depressed mood most of the time for at least 2 year or 1 year
for children and adolescent
- Diagnostic criteria dysthymic disorder
 Depressed mood for most of the day for at least 2 year
 Poor appetite, insomnia or Hypersomnia
 Poor appetite or overeating
 Low energy or fatigue
 Low self – esteem
 Poor concentration or difficulty making decisions
 Feeling of hopeless ness
 Duration the 2 year period (1 year for children)
 The symptoms are not due to G.M.C
 The symptoms cause clinically significant distress or impairment in social,
occupational
DDX: - MDD

Many substance and medical illness can Couse chronic

depressive symptom

Course and prognosis

- About 25% of all patients with dysthymic disorder never attain

a complete recovery.
- Overall, however, the prognosis is good with treatment

•Treatment:- long term – insight oriented psychotherapy and

pharmacho therapy SSRI
•Minar depressive disorder

- Miner depressive disorder is limited

• Epidemiology:- Miner depressive disorder may be as common as
major depressive disorder that is about 5% prevalence in the general
population
- The disorder is more common in women than men
- The disorder any age groups

•Ethiology:- both biological and psychological factor

•Diagnosis and clinical features

•The same as in major depressive disorder, but less severe

- The central symptom of both disorders is the some a depressed mood

DDX:- Dysthymic disorder
Course and prognosis:- no definitive data on the
course and prognosis of miner depressive
disorder available.
Treatment:- Psychotherapy, pharma chotherapy
or both
RX: selective serotonin reup take inhibitors
(S.S.R.is)
Recurrent Brief depressive disorder
-Recurrent brief depressive disorder is characterized
by multiple, relatively brief episodes (Less than 2
weeks) of depressive symptom that, except for their
brief duration, meet the diagnostic criteria for major
depressive disorder.
Epidemiology:- the 10 years prevalence rate for the
disorder is estimated to be 10 percent for people in
their 20s; the 1 – year prevalence rate for the general
population is estimated to be 5%. These numbers
indicate that recurrent brief depressive disorder is
most common among young Adult.
Etilogy:- may share several biological abnormalities with
patient with major depressive disorder
-Closely related to major depressive disorder in its cause
and pathophysiology
Diagnosis and clinical feature
-The symptom duration for each episode is less than 2
weeks
-Otherwise the diagnostic criteria for recurrent brief
depressive disorder and major depressive disorder are
essentially identical
DDX:- Bipolar disorder major depressive disorder
Course and prognosis:- Similar to major depressive
disorder
Treatment:- The treatment, of patient with recurrent
brief depressive disorder should be similar to the
treatment of patient with major depressive disorder.
DSMIV T.R defines:- Additional symptom features that
can be used to describe patients with various mood
disorder. Two of the features (melan cholic and atypical)
are limited to describing depressive episode. - Two
others (catatonic features and with postpartum onset)
can be applied to depressive and manic episode
Major depressive disorder with psychotic feature
-This is a poor prognostic indicator
-These patients typically require antipsychotic drugs in addition to
antidepressant or mood stabilizers and may need ect to obtain
clinical improvement
With melancholic features:- it is still used to refer to a depression
characterized by severe an hedoniag, early morning a weakening,
weight loss and profound feeling of guilt.
With typical feature:- depression with atypical feature is response
to very eating and over sleeping
With catatonic feature:- can be present in several mental disorder
most commonly, schizophrenia and the mood disorder. The hall
mark symptoms of catatonia, stupors ness, blunted affect extreme
with drawl, Negativism and marked psychomotor retardation.
With postpartum onset:- means postpartum mood disorder
The 2nd classification of mood disorders
Bipolar disorder
-Bipolar disorder is a recurrent mood disorder featuring
one or more episode of mania or mixed episodes of amnia
and depression
-Bipolar I disorder one or more manic episode and one or
more depressive episode
-Bipolar II is at least one hypmame episode and one or
more episodes of major depression
-Bipolar disorders less prevalent than unipolar 0.8 – 1.6%
of population
-Hyp mania less severe form of mania
How does hypomania affect a sufferer?
Hypomania is a less severe of mania
Self-confident and euphoric but may also react
with sudden anger, impatience, or become
irritable.
More ideas than usual, very creative more
reckless, more talkative or more challenging
Summary
-Mood disorders are very common mental disorders
yet they often go undetected and untreated
-There are gender differences in rates of diagnosed
depression
-The 2 main types of mood disorder are unipolar and
bipolar
-Within these 2 categories there are wide differences
in severity and duration of symptoms
-Bio psychosocial model appears to give the best
account of mood disorders
Treatment of Bipolar disorders
-Mood stabilisers
-Antidepressants (with caution)
-Antipsychotic medication
-Talking therapies
-Self-management and recovery approaches
Bipolar disorder
-Bipolar disorder is a recurrent mood disorder featuring
one or more episodes of mania or mixed episodes of
mania and depression
- Hypomania: less severe form of mania
Bipolar disorders
Bipolar illness (mani depression) involves extreme
swings of mood ranging from severe depression to
severe mania (‘lows’ to ‘highs’).
Core symptoms
-High or irritable mood- out of keeping for the person
-Increase in energy
-Thoughts become racing
-Over activity
-Pressure of speech – flight of ideas
-Sleep pattern changes
Clinical features
-Elated or irritable mood
-Increased energy,
-Reduced need for sleep
-Flight of ideas
-Increased speech
-Over – inflated
-Poor concentration/distractibility
-Poor judgment and disinhibiting
Dsm-IV-Mania
A significant period of abnormal persistent elevated or irritable
mood and 3 or more of mania symptoms.
Core symptoms
-Self-esteem increase
•Grandiose ideas/behavior
•Social inhibitions reduced
•Over familiarity
-Lack of attention/distracted
•Spending
•Uncharacteristic interest in sexual encounters
-Engage in activities with serious consequences
Core symptoms
•Other behaviors
-Excitable
-Irritable
-Aggression
-Suspicious
UNDERSTANDING A PATIENT WITH BIPOLAR DISORDER
•there may be Long periods of stability between
•Each patient will have a unique pattern of severity and
duration.
•The most common types of Bipolar disorder are known
as: Bipolar 1 & bipolar 2
Bipolar disorders- bipolar I and II
•Bipolar I – one or more manic episodes and one
or more depressive episodes
•Bipolar II – at least one hypomanic episode and
one or more episodes of major depression
•Bipolar disorders less prevalent than unipolar,
0.8 – 1.6% of population
•Age of onset in 20s
•Rapid cycling depression/mania – 4 or more
episodes per year
Other features
•Disruption to
-Family
-Work
-Education
•Psychotic symptoms (Severe forms)
How does mania affect a sufferer?
Incoherent, rapid or disjointed
though
paranoia
Hallucinations affecting vision
Hearing or perception
Grandiose delusions or ideas
Psychosis – losing touch with reality
Cyclothymic Disorder
-Is symptomatically a mild form of Bipolar II
disorder. Characterized by episodes of
hypomania and mil depression
-Cyclothymic disorder is defined as a chronic
fluctuating disturbance “with many periods of
hyr mania and of depression”
Epidemiology 3-5%
Etiology:- Related to the mood d/o
-Biological factor 30% family history
-Psychosocial factor
Diagnosis and C/f
Many patient seelc psychiatric help for depression
DDX:- possible medical and substance related cause of
depression
Course and prognosis
Differ from person to person
-Treatment:- psycho therapy
-Psycho social therapy
Other categories
-Mood d/o due to GMC
-Substance induced mood disorder
Psychiatric aspects of pregnancy
1.Postpartum depression
-Many women experience some affective symptoms
-During the post-partum period 4-6 weeks following delivery
-Must of these women report symptoms consistent with “baby blues”
-A transient mood disturbance characterized by mood liability,
sadness, dysphoria, subjective confusion and tearfulness.
-These feelings, which may last several days
Have been ascribed to rapid changes in women’s hormonal level.
-The stress of childbirth and the awareness of the increased
responsibility than mother hood bring
-No professional treatment is required other than education and
support for the new mother
-If the symptoms persist longer than 2 week
-Evaluation is indicated for postpartum
2.Postpartum psychosis
-Postpartum psychosis (sometimes called puerperal psychosis)
is an example of psychotic disorder not otherwise specified that
occurs in women who have recently delivered a baby.
-The syndrome is often characterized by the mother depression,
delusion and though of harming either herself or her infant
-Such ideation of suicide or infanticide must be carefully
monitored; Although rare some mother have acted these ideas
must available data suggest a close relation b/n postpartum
psychosis and mood disorder, particularly bipolar disorder and
major derisive disorder
-The incidence off postpartum psychosis is about 1 – 2 per 1000
child birth
-The symptoms of postpartum psychosis
 Chapter 7
Psychotic Disorders
Schizophrenia and other
psychotic disorder
Objectives
-At the end of this lesion the students will be able to
-Understanding “Psychosis”
-Diagnosis and manage for psychotic patient
Psychosis
-DSM IV = definition = gross impairment n reality
testing
-Hallucinations, delusions, bizarre behavior and in-
coheren speech are considered direct evidence of
psychosis
Classification of psychotic disorders (DSM – IVT.R)
-Schizophrenia
-Schizophreni form disorder
-Schizo affective disorder
-Brief psychotic disorder
-Delusional disorder
-Psychotic disorder due to a G.M.C
-Substance induced psychotic disorder
-Culture – bound psychotic syndrome
1.Schizophrenia:- is a serious mental Disorder
characterized by
-Impaired communication with loss of contact with
reality and
-Deterioration from a previous level of functioning in
work
-Social relationship, or self-care
Epidemiology:- lefe time prevalcne of schizophrenia 1%
from general population
-General population = 1%
-Child with one parent schizophrenia = 12%
-Child of two & aren’t schizophrenia = 40%
Gender and age:- men and women equal attack
The peak ages of onsets are
10 - 25 year for men
AND 25 – 35 years for women
Before age 10 or after 60 is extremely rare
Etiology:- Genetics factors
Biological factors
E.g too much dopaminergic activity
Both psychosocial and Biological factor
affecting schizophrenia
DSM – IV T.R diagnostic criteria for schizophrenia
A. Two or more of the following symptom present for one month
1.Delusions
2.Hallucinations
3.Disorganized speech
4.Grossly disorganized or catatonic behavior
5.Negative symptoms (ie affective flattening, a logia or an hedonia)
B. Decline in social and/or occupational functioning since the onset of illness
C. Continuous signs of illness for at least six months with at least one month
of active symptoms
D. Schizo affective disorder and mood disorder with psychotic feature have
been excluded
E. The disturbance is not due to substance abuse or medical condition
Features weighting to ward goal to poor prognosis in
schizophrenia
Good Prognosis Good support system positive
symptoms
-Late onset - Delusion
-Obvious precipitating factors - Hallucination
-Acute onset - Agtation
-Good premorbid, social and work Histories
-Mood disorder symptom
-Marriage
-Family history of mood disorder
 Poor prognosis
-Young on set
-No precipitating factors
-Insidious onset
-Poor – premorbid, social, and work history
-With drawn
-Single, divorced or widowed
-Family history of schizophrenia
-Poor support sptem
-Negative symptoms
Blunted affect
Emotional with drawal
Alogia, an hedonia
-History of perinatal trauma
-No remissions in 3 years
-Many relapses
Sub-types of schizophrenia
1.Patanoid type of schizophrenia is characterized by
preoccupation with one or more delusion
-Classically the paranoid type of schizophrenia is
characterized mainly by the presence of delusion of
persecution or grade or
-No prominent disorganized behavior or speech
-Old age of on set
-Typically tense, suspicious, garded
-And sometimes houstile or aggressive
-Better premorbid functioning
-Better out comes
2.Disorganized (hebephrenic) type of schizophrenia
Characterized by marked regression to primitive.
Disinhibited, and disorganized behavior
Prominent disorganized speech/ behavior
Delusion/Hallucination – absent
Disturbance of affect – silly, child – like giggling,
grimacing
Early onset before the age 25
Poor premorbid functioning
Poor long term prognosis
3.Catatonic type of schizophrenia
The classif feature of the catatonic type is a marked disturbance in
motor functioning
-The disturbance may involve stuper, negativism rigidity,
excitement or posturing
-Mutism, sterio type
-Ealiest age of onset
-Most chronic course
-Poor rest social and occupational functioning
-Mutism is particularly common
-During catatonic excitement, patient need careful supervision to
prevent them from flurting themselves or other
-Medical care may be needed because of malnutrition
-Exhaustion, or self-inflicted injury
4.Un- differentiated type:- frequently, patient who are clearly
schopheric cannot be easly fit in to one type or ari ather dsm IV
TR classifies these patient as having schizophrenia of the
undifferentiated type
-Do not meet criteria for paranoid, disorganized, or catatoric type.
5.Residual type:
-According to DSMIV T.R the residual type of schizophrenia is
characterized by continuing evidence of the schizophrene
disorder
-In the absence of a complete set of active symptoms or of
-Sufficient symptoms to meet the diagnosis of another type of
schizophrenia
-Emotional blunting, social with drawal, eccentric behavior
-Illogical thinking, and mild loosening of association.
Clinical features
-Intermitent hallucination
-Intermittent delusion
DDX = psychotic D/o due to Gmc
Substance indical psychotic D/o
Delusional D/o
Brefe psychotic D/o
Schizoaffective D/o
Schizophreniform D/o
Course and prognosis
10 -20 good out comes mort than 50% poor out come
Treatment
-Psycho social intervention
Including psychotherapy can augment the clinical improvement
-Pharmacological agent are used to treat presumed chemical
imbalances
-Rx= chlorpromazine 100 mg ___ 1000 mg
-Phases of treatment in schizophrenia
Treatment of acute psychosin 4 – 8 weeks
Treatment during stabilization and maintenance phase 1- 2
years
Treatment protocol
1.First episode 1-2years
2.More than two episodic symptoms 2 -5 years
3.Multiple episodic symptoms lifelong treatment
Other psychotic disorder
1.Schizophreniform
- Is to describe a condition with sudden onset and benign course
associated with mood symptoms and clouding of consciousness.
- The text revision of the fourth edition of the diagnostic and
statistical manual of mental disorder (DSM-IV-T.R)
- Describe schzophreniform disorder as similar to schizophrenia,
except that its symptoms last at least 1 month but less than 6
month

•Epidemiology: - 0.2 percent

•Etiology: - the exact cause is not known

Diagnostic and clinical feature

The initial symptom profile is the same as that of schizophrenia

(Hallucination, Delusions, disorganized speech)

DSM IV T.R diagnostic criteria for schizophreniform disorder

- An episode of the disorder lasts at least 1 month but less than 6 month
- Without good prognostic feature
- With good prognostic feature as evidenced by two or more of the
following
 Onset of prominent psychotic symptoms within 4 weeks
 Confusion or perplexity at the height of the psychotic episode
 Good premorbid social and occupational
 Absence of blunted or flat affect
DDX:- Substance- Induced psychosis disorder
Course and prognosis:- Poor prognosis
Treatment: - Hospitalization
Antipsychotic drugs (Resperidone) 2mg R
Psychotherapy 2 year duration
Electro convulsive therapy
1.Schizoaffective disorder
- As the term implies schizoaffective disorder has ure feat of both schizophrenia
and affective disorders
- Epidemiology:- 0.5 0.8 percent
•Gender and age differences more common in order
• person than in younger persons.
•M – F = lower in men than in women
•Etiology: Unknown
:studies designed to explore the etiology have examined
family history, biological markers.
Diagnosis and clinical features
A.An uninterrupted period of illness during which, at some time, there is
either a major depressive episode, a manic episode or mixed episode
concurrent with symptoms that meet criteria A for schizophrenia
B.During the same period of illness, there have been delusion or
hallucinations, for at least 2 week in the absence of prominent mood
symptom
C.Symptoms that meet criteria for a mood episode are present for a
substantial portion of the total duration of the active and residual
periods of the illness
D.The disturbance is not due to the direct physiological effects of a
substance {Eg:- a drug of abuse, a medication} or a general medical
condition
DDX:- substance induced psychotic disorder
Course and prognosis :- It is difficult to determine the long term course
and prognosis
Treatment:- 1. Tegretol {carbamazepine} 200 mg po bid
• 2. chlorpromazine 100 mg po l tab at bad time for one month
• 3. fluoxetine 20 mg po one tab morning
• 4. last option { electro convulsive therapy }
In addition to that psychosocial treatment family therapy
1.Delusional disorder
 Delusions are false fixed beliefs not in keeping with the culture.
 The diagnosis of delusional disorder is made when a person exhibits non-
bizarre delusions of at least 1 month duration
 Non – bizarre means that the delusion must be situation that can occur in
real life.
 Such as being followed, infected, loved at a distance.
Epidemiology: - Un – common 1 to 3 new cases per
100,000 person
Ethology:- Un – known some research done Biological
factor con cause the disorder
Risk factors associated with delusional disorder
 Advanced age
 Sensory impairment
 Family HX
 Social isolation
 Recent immigration
Diagnosis and clinical features
The DSM IV T.R diagnostic criteria for Delusional disorder
are
A.Non bizarre delusion (I, e involving situation that occur in
real life, such as being followed poisoned, infected, loved at a
distance of at least 1 month’s duration
B.Tactile and olfactory Hallucination may be present in
delusional disorder
C.Functioning is not markedly impaired
D.The disturbance is not due to the direct physiological effect
of substance (E.g a drug of abuse, a medication) or a general
medical condition
Type of delusional disorder
1.Jealous type:- the delusion that one’s sexual partner
is unfaithful
2.Erotomanic type:- a delusion that another person
usually of higher status is in loved with the
individual
3.Somatic type:- a delusion whose main content
pertains to the appearance or functioning of one’s
body
4. Grandiose type:- delusion of inflated worth, power
knowledge, identity, famous person
DDX:- many medical condition can be associated
Course and prognosis
Poor prognosis
Treatment:- Antipsychotic:- Eg. Haloperidal 2 mag po or
Risperdal 2 mg po and
psychotherapy
4. Brief psychotic Disorder
 As a psychotic condition that involves the sudden onset of
psychotic symptom, which lasts 1 day or more but less than 1
month
 In this case remission is full
 
Epidemiology:- un – common
Etiology:- Un-known
It may have biological or psychological
Diagnosis and clinical feature
- Emotional volatility
- Strange or bizarre behavior
- Muteness
- Impaired memory
DSM IV. T.R diagnostic criteria for brief psychotic disorder
A.Presence of one or more of the following symptom
1.Delusion
2.Hallucination
3.Disorganized speech (eg. Frequent derailment or in – coherence)
4.Grossly disorganized or catatonic behavior
A.Duration of an episode of the disturbance is at least 1 day but less
than 1 month
B.The disturbance is not better accounted for by a mood disorder with
psychotic feature and other psychotic disorder Specify if
•With marked stressors
•Without marked stressors
•With postpartum on set
DDX:- Psychotic D/o 20 gmc
Substance in ducal psychotic D/o
Course and prognosis
Treatment: Hospitalization
Antipsychotics: eg. Haloperidol
Benzodiazepine: Bromazepham 3mg
Psychotherapy
5.Postpartum psychosis
-Postpartum psychosis (sometimes called puerperal psychosis).
-Is an example of psychotic disorder no otherwise specified that
occurs in woman who have recently delivered a baby; the
syndrome is most often
-Characterized by the mother’s depression, delusion and thoughts
of harming either her infant or Herself
-For a complete discussion on postpartum condition and other
disorders related to
-Such ideation of suicide or infanticide must be carefully monitored
-Although rare
-The incidence of postpartum psychosis is about 1 to 2 per 1,000
child birth
-About 50 – 60 percent of affected woman have just had their first
child.
-And about 50 present of cases involve delivery associated with non-
psychiatric perinatal complications
-About 50 present of the affected women have a family history of mood
disorder
-The symptoms of postpartum psychosis can often begin within days of
the delivery, although the mean time to on set is within 2 to 3 weeks
and almost always within 8 weeks of delivery
-Characteristically, patients begin to complain of fatigue, insomnia, and
restlessness and they may have episodes of tear fullness and emotional
liability. Later, suspiciousness, confusion in –coherence, irrational
statements. And obsessive concerns about the baby’s health and
welfare may be present
-Delusional material may involve the idea that the baby is dead or
defective
-Hallucination with similar content may in value voice telling the patient
to kill the baby or herself
-Depending on the content of her delusional system
and her degree of agitation.
-In one study 5 percent of patients committed suicide
and 4 percent committed in feticide
-Postpartum psychosis is a psychiatry emergency
-Antipsychotic medication and lithium. Often in
combination with an antidepressant, are the
treatment of choice
-No pharmacological agent should be prescribed to a
women who is breast feeding.
-Suicidal patients may require transfer to psychiatric
unit to help prevent a suicidal attempt
6.Psychotic disorder due to GMC and disorder
-The evaluation of a patient with psychotic d/o requires
consideration of the possibility that the psychotic symptoms
result from a general medical condition such as a brain
tumor or the ingestion of a substance such as phencyclidine.
-Epidemiology :- relevant epidemiological data about
psychotic disorder caused by a general medical condition
and substance induced psychotic disorder are lacking
Ethology:- physical conditions such as cerebral neoplasm
particularly of the occipital or temporal area
-Psycho active substance are common cause of psychotic
syndrome
Diagnosis
DSM IV T.R diagnostic criteria for psychotic
disorder due to General medical condition
A. Prominent hallucination or delusions
B. There is evidence from the History, physical
examination or laboratory finding that the
disturbance is the direct physiological
consequence of a general medical condition
C. The disturbance is not better accounted for by
another mental disorder
D. The disturbance does not occur exclusively
during the course of a delirium
DSMIV T.R diagnostic criteria for substance _ Induced
psychotic disorder
A. Prominent hallucinations or delusion
B. There is evidence from the history, physical
examination or laboratory findings
C. The disturbance is not better accounted for by a
psychotic disorder that is not substance induced.
Evidence that the symptoms are better accounted for
by a psychotic disorder
DDX:- psychotic do due to A G.M.C and substance
induced psychotic disorder Psychotic mood disorder
Treatment:- Treat the underline cause
Chapter 8

Personality disorder

- Personality disorder is a common and chronic disorder

- Its prevalence is estimated between 10 and 20 percent in the
general population
- Approximately one half of all psychiatric patients have personality
disorder
- Personality disorder is also predisposing factor for other
psychiatric disorder
- DSM IV T.R:- Defines personality disorders as enduring subjective
experiences and behavior that deviate from cultural standards.
- Are rigidly pervasive, have an onset in adolescence or early adult
hood
- Personality is the total of a Peron’s internal and external
patterns of endowment and life experience.
- In general, personality is the sum of all somatic process plus
psychological phenomena
- Personality disorder is described as a non- psychotic illness
characterized by mal adaptive behavior, which the person
utilizes to fulfill his/ her needs and bring satisfaction to self.
Classification

Personality disorder sub types classified in

DSMIV T.R are

Schizotypal

Schizoid Cluster A (With odd, aloof feature

more common in the

Paranoid biological relatives of

patient with schizophrenia)
 - Dramatic
Narcissistic
Cluster B (Impulsive feature ERRatic
Border line
Antisocial - Depression iscommon in the family back
ground
Histrionic
Obsessive compulsive Cluster C – sharing Anxious and fear ful feature
Dependent - Often have high anxiety level
Avoidant
Ethology:- Genetic factor
Biological factor Hormones
Childhood experience can faster the
development of mal adaptive behavior
environmental factor
Characteristics of personality disorder
1.The person denies the maladaptive behavior she/he
exhibits: such behavior has become a way of life for him
2.The mal adaptive behaviors are inflexible
3.The person is in contact with reality although she/he
has difficulty of dealing with it
4.Minor stress is poorly tolerated, resulting increased
inability to cope with anxiety
5.Disturbance of mood, such as anxiety or depression
6.Psychiatric help rarely is sought since the person is
un-aware or denies that his/her behavior is
maladaptive.
DSM-IV-T.R General diagnostic criteria for a personality
disorder
A. An enduring pattern of inner experience and behavior
that deviates markedly from the expectations of the
individual’s culture.
-This pattern is manifested in two (or more) of the following
area
1.Cognition (I.e ways of perceiving and interpreting self,
other people, and events)
2.Affectivity (i-e, the range, intensity, liability and
appropriateness of emotional response)
3.Interpersonal functioning
4.Impulse control
B. The enduring pattern is inflexible and pervasive across a
broad range of personal
C. The enduring pattern leads to clinically significant distress
or impairment in social, occupational, or other important
areas of functioning
D. The pattern is stable and of long duration and its onset
can be traced back at least to adolescence or early
adulthood.
E. The enduring pattern is not better accounted for as a
manifestation or consequence of another mental disorder
F. The enduring pattern is not due to the direct physiological
effects of a substance (eg. A drug of abuse, a medication) or
a general medical condition (eg. Head trauma)
1.Paranoid personality disorder
-Persons with paranoid personality disorder are characterized by
long – standing suspiciousness and mistrust of persons in general
-They refuse responsibility for their own feelings
-They are often hostile, irritable, and Angry
-Pathologically jealous spouses
Epidemiology:- 0.5 to 2.5 percent of the general population The
disorder is more common in men than in womenThe prevalence
persons who are deaf
Diagnosis:- on psychiatric examinations, patients with
Paranoid personality disorder may be for mal in manner
Clinical Features:- Excessive suspiciousness and distrust of others
-They frequently dispute, without any justification
-This tendency begins by early adulthood
DSM – IV – TR diagnostic criteria for paranoid personality disorder
A.A pervasive distrust and suspiciousness of others such that their motives
are interpreted as male violent beginning by early adulthood and present
in variety of contexts, as indicated by four (or more) of the following
1.suspects, without sufficient basis, that other are exploiting, harming, or
deceiving him or her
2.Is preoccupied with un-justified doubts about the trust worthiness of
friends or associates
3.Is reluctant to confide in others because of unwarranted fear that the
information will be used maliciously against him or her
4.Reads hidden de meaning or threatening meanings in to benign remarks
or event
5.Persistently bears grudges, i.e is un forgiving of insult injuries, or slights
6.Perceives attacks on his/her character
7.Has recurrent suspicious without justification regarding fidelity of spouse
or sexual partner
IDX: Delusional disorder
Course and prognosis: Poor prognosis
Treatment:- Psychotherapy Pharmacotherapy: halo peridol
small dose
2.Schizoid personality disorder
-Is diagnosed in patient, who display a lifelong pattern of
social withdrawal,
-Their discomfort with human interaction,
-Their introversion
-And their bland, constricted affect are not worthy
-Eccentric, isolated or lone’ly
Epidemiology:- 7.5 percent of the general population the sex
ratio 2 to 1 = male to female
DSM IV T.R diagnostic criteria for schizoid personality
disorder
Four or more of the following
1.Neither desires nor enjoys close relationship
including be-ing part of family
2.Al most always chooses solitary activities
3.Has little, if any interest in having sexual experience
with another person
4.Takes pressure in few, if any activities
5.Lacks close friends or confidents other than first
degree relatives
6.Fear of criticism of others shows emotional coldness
Diagnosis:- Poor eye contac
Aloof
Clinical feature
Cold and aloof
DDX: schizophrenia
Delusional disorder
MDD & psychotic feature
Course and prognosis
-Poor prognosis
Treatment
-Psychotherapy
-Pharmacotherapy
-Small dosage of
-Antipsychotics
-Antidepressant
-Benzodiazepine may help
3.Schizotypal personality disorder
-Persons with schizotypal personality disorder
are
-Strikingly odd or strange, even to layperson
-Magical thinking, peculiar notion,
-Ideas of reference, illusion, and decreolization
-Are part of a schizotypal person’s every day
Epidemiology: - About 3 percent of the
population the sex ratio is unknown
Diagnosis: on the basis of the patients
“Peculiarities of thinking, behavior, and
appearance.
Clinical feature
-Patients with schitypal personality disorder
exhibit disturbed thinking and communicating.
DSM IV. T.R
Diagnostic criteria for schizotypal personality disorder pervasive
pattern of social and inter personal deficit as indicated by five or
more of the following
1.Ideas of reference
2.Odd belief or magical thinking that influence behavior –
superstation belief
3.Unusual perceptual experiences,
4.Odd thinking and speech
5.Suspiciousness or paranoid ideation
6.In appropriate or constricted affect
7.Behavior or appearance that is odd, eccentric
8.Lack of close friends or confidents
9.Excessive social anxiety
DDX:- schizoid personality disorder avoidant personality disorder
Course and Prognosis:- Poor prognosis
Treatment: Psychotherapy Pharmacotherapy
-Antipsychotic medication
-Antidepressant
4.Antisocial personality disorder
-Is an inability to conform to the social norm that orderly given
may aspects
-Although characterized by continual anti-social or criminal acts,
Epidemiology:- 30% in men
1 % in women
It is most common
The onset of the disorder is before the age of 15 years
Diagnosis:- In an interview hostility, irritability
Clinical features:- lying
Running away from home thefts, fights, substance abuse and illegal
activities
DSM IV T.R. Diagnostic criteria for antisocial personality disorder
A. Pervasive pattern of dis regard for and violation of the rights of other
As indicated 3 or more of the following
1.Failure to conform to social norm
2.Deceit fullness, as indicated by repeated lying
3.Impulsivity of failure to plan a head
4.Irritability and aggressiveness, as indicated by repeated physical fights
or assault’s.
5.Reckless disregard for safety of self or other
DDX: Neurological or mental disorder
Substance induced psychotic disorder
Course and prognosis:- The prognosis is varies
Treatment:- Psychotherapy
Pharmacotherapy
Methylphenidate
Carbamazepine
5.Border line personality disorder
-Patient with border line personality disorder
stand on the border between neurosis and
psychosis and they are characterized by extra
ordinarily unstable affect mood, behavior,
Epidemiology:- 1 to 2% the population twice as common in women
as in men
DSM IV T.R Diagnostic criteria for border line personality disorder
A pervasive pattern of instability of interpersonal relationship
-As indicated by 5 or more of the following
1.A pattern of un-stable and intense interpersonal
2.Personality – stable self – image
3.Impulsivity in at least two area that are potentially self –
damaging
4.Recurrent suicidal behavior
5.Affective instability due to a marked reactivity of mood
6.Chronic feeling of emptiness
7.In appropriate, intense anger
Diagnosis:- Sleep disturbance
Abnormal thyrotropine releasing hormone test result
Depressed symptom
Clinical feature
-Mood swings are common
DDX: Schizophrenia
Course and prognosis:- Poor prognosis
Treatment: Psychotherapy
Pharmacotherapy
Antipsychotics
Antidepressants
6.HISTRIONIC personality disorder
-Person with histrionic personality disorder are
excitable and emotional and behave in a colorful,
dramatic, extroverted fashion.
- Accompanying their flamboyant aspects, however
is often an inability to maintain deep, long lasting
attachment
Epidemiology: 2 to 3% from general population
Diagnosis: In interviews, patient with histrionic
personality disorder are
generally co-operative and eager to give a
detailed history
Clinical feature:- high degree of attention seeking behavior
DSM IV T.R diagnostic criteria for Histrionic personality disorder
A pervasive pattern of excessive emotionality and attention seeking

-As indicated by five or more of the following

1.Is un – comfortable in situation in which he or she is not the
center of attention
2.Interaction with others is often characterized by in appropriate
sexually seductive or provocative behavior
3.Displays rapidly shifting and shallow expression of emotions
4.Consistently uses physical appearance to draw attention to self
5.Has a style of speech that is excessively impression is artic and
lacking in detail
6.Shows self – dramatization, exaggerated expression of emotion
7.DDX :- somatization disorder
 Corse and prognosis :- good prognosis
Treatment:- psychotherapy
Pharmacotherapy
Antidepressant
Anti-anxiety agent
Anti-psychotic
7.Narcissistic personality disorder
-Person with narcissistic personality disorder are
characterized by a heightened sense of self
importance and grandiose feeling of uniqueness’s
Epidemiology:- 2 16 percent
DSM IV TR diagnostic criteria for narcissistic personality
disorder
A pervasive pattern of grandiosity
As indicated by five of more of the following
1.Has a grandiose sense of self – importance
2.Is preoccupied with fantasies of un- limited success
3.Believes that he or she is “Special” and unique
4.Requires excessive admiration
5.Lacks empathy:- is un willing to recognize or identify with
the feelings and needs of other shows arrogant
6.Shows arrogant
Grandiose sense of self – importance
DDX:- Borderline :- personality disorder
Histrionic: - personality disorder
Antisocial: - personality disorder
Course and prognosis:- Chronic and difficult to treat
Treatment:- Psychotherapy
Pharmacotherapy
Antidepressant
8. Avoidant personality disorder
- Person with avoidant personality disorder show
extreme sensitivity to rejection and may lead a
socially with drawn life
- Although shy
Epidemiology:- Is common
Prevalence of the disorder is 1 to 10% of the
general population
Diagnosis: In clinical interviews patient most
striking aspect is anxiety about
talking with on interviewer.
Clinical feature
- Hyper sensitivity to rejection by other
DSM IV TR Diagnostic criteria for avoidant
personality disorder
A pervasive pattern of social inhibition
1.Avoids occupational activities
2.Is un-willing to get involved with people unless certain of be-ing
liked
3.Shows restraint with in intimate relationships because of the fear
of be-ing shamed
4.Is pre occupied with being criticized or rejected in social situation
5.Is inhibited in new inter personal situation because of feeling of in
adequacy
DDX: Schizoid personality disorder
Course and prognosis:- good prognosis
Treatment:- Psychotherapy
Pharmacotherapy
Atenolol 50 mg p/day
9.Dependent personality disorder
-Person with dependent personality disorder subordinate
their own needs to those of others, get others to assume
responsibility for major area of the their lives,
-Lack self – confidence and may experience intense
discomfort when alone for more than a brief period
-More frequently in women
Epidemiology:- More common is women than in men
Diagnosis:- During interviews, patients, appears compliant
Clinical feature: Characterized by a pervasive pattern of
dependent and sub missive behavior
Person with the disorder cannot make decision without an
excessive amount of advice
DSM IV R.R Diagnostic Criteria for dependent personality disorder
A pervasive and excessive need to be taken care of that leads to
submissive
-As indicated by five or more of the following
1.Has difficulty making everyday decisions without an excessive
amount of advice and reassurance from others
2.Needs others to assume responsibility for most major area of his or
her life
3.Has difficulty expressing disagreement with other
4.Has difficulty initiating projects or doing things on his or her own
because of a lack of self – confident,
5.Goes excessive length to obtain support from other
6.Feels uncomfortable or helpless when a lone
7.Is un-realistically pre occupied with fear of be-ing left to take care of
himself or her self
DDX:- Histrionic personality disorder border line
personality disorder
Course and prognosis: poor prognosis
Treatment:- Psychotherapy
In sight – oriented therapies
Pharmacotherapy
Imipramine
10.Obsessive – compulsive personality disorder
-Obsessive – compulsive personality disorder is
characterized by emotional constriction, orderliness,
-He essential feature of the disorder is a pervasive pattern
of perfection ism and inflexibility
-They have difficulty of decision making
-The disorder is more common in men than in women
Epidemiology: - Unknown
It is more common in men
Diagnosis: - In interviews, patients with obsessive
compulsive personality
Disorder may have stiff or rigid
Clinical feature:- Pre occupied with rules, and regulation
DSM IV TR Diagnostic criteria for obsessive compulsive
personality disorder
A pervasive pattern of preoccupation with order lines
Indicated by four or more of the following
1.Is preoccupied with details, rules list order
2.Shows perfectionism that inter fears with task completion
Eg. Un-able to complete a project because his or her own
-Overly strict standards are not meet
3.Is excessively devoted to work and productivity to the
exclusion of leisure activities
4.Is over conscientious
5.Is unable to discard worm – out or worth less
DDX;- Delusional disorder
Course and prognosis: Differ from person to
person
Treatment: - Psychotherapy
Pharmacotherapy
Clonazepam
Benzodiazepine with anticonvulsant
Clomipramine
Fluoxetine 60 – 80 mg po-/day
Unit nine

psychopharmacology
 psychotherapeutic drug in current use are
• Antipsychotic agent
• Antidepressant
• Ant anxiety agent and hypnotic
• Anti cholinergic(anti parkinsonism drugs)
 psychopharmacology is the study of drug
used to treat psychiatric disorders.
 Antipsychotic agent
• Antipsychotic are drug used for the treatment of psychosis
such as
- schizophrenia
- schizoaffective disorder
-Brief psychic disorder
-schizophreniform disored
-Bipolar disored antipsychotic are used in combination with
mood stabilizar and gradually with draw the antipsychotic
- MDD with psychotic feature
 classification
1.First generation typical antipsychotic
1.phenothiazine
.Alphatic e.g chlorpromazine dosag
50-1000mgld
.pipeline e.g thioridazine dosage range 50-800mg/d
. Prperazine e,g fluphenazine dosage rang 2-20mg/d
2. Butyrophenone e.g haloperidol dosage range 2-20mg/d
Anitpical antipsychotic medication
-olanzapine 5-20 mg/d Available in oral
tablets and dissolving tables
-Risperidone 2.8MG/D Available inoral
tables,dissolving tablets,liquid form
- clozapine (clozaril)150-600
 ANTIPSYCHOTICS

• 1, Conventional/typical antipsychtics
-Chlorpromazine
-Thioridazine
-Fluphenazine
-Haloperidol(Haldol)
2.A typical or noval or sda’s
-Clozapine (clozarii)
-Risperidone(Risperdal)
-Olanzapine(zyprexa)
-Quetiapine(Seroquel)
-Ziprasidone(Geodon)
 Action antipsychotic
• Excessive dopamine activist is believed to be import ants
factors in developing schizophrenia.
• Antipsychotic drugs are act primarily by occupying dopamine
receptor in brain tissue there by decreasing the effect of
dopamine neurotransmitters.
• The drugs act in hours to alleviate manifestation of hyper
arousal ,anxiety, agitation , insomnia, aggressive, behavior,
hallucination and delusion.
 Cont………
• Conventional neuroleptics differ in their potency
and side-effect profile.
• Older agents, such as chlorpromazine and
thioridazine, are more sedating and antichoilnergic
and more likely to cause orthostatic hypotension

• Higher potency antipsychotics, such as haloperidol

perphenazine, and thiothixene, are more likely to
induce extrapyramidal side effects.
 High potency Antipsychotics

1,Higher binding to d2 receptors:

1. Higher Efficacy
2.More EPS(Extra pyramidal
symptoms)
3.Higer incldence of TD (Tardive
Dyskinesia)
2,Less cognive problems
3.Less cardiovascular and other side effect
LOW Potency Antipsychotic Benefits &Risks

1.Lowerbinding to D2 receptors:
1.Lower Efficacy
2.Less Eps (Extra pyramidal symptoms)
3.Lower incidence of TD (Tardive Dyskinesia)
2.More congnitive problem
3.More cardiovascular se and other se6
1.sedation
2.drowsiness
3.Weight gain
4.postural hypotension
5.Reflex tachycardia
6.Dizziness
 Con’t
• The serotonin dopamine antagonists (SDAS)and
partial dopamine agonists. (PDAS), also called
second –generation etc…….

1.cause fewer extra pyramidal side effects,

2.greater effects against negative symptoms of
schizophrenia.
3,cognitive defects and depression that may
coexist with psychosis.
2. Antidepressants:
• Drugs used for the treatment of depression
and anxiety.
 Typeof Antidepressants
1.Selective serotonin reuptake inhibitors(SSRls)
• it is thougth that one cause of depression is
an inadequate amount of serotonin

• ssRls are said to work by preventing the

reuptake of serotonin by the presynaptic
neuron thus maintaining higer levels of 5-
Htinthe synapse.
• This family of drugs includes fluoxetine
(prozac)10-80mg/d, and sertraline 50-
200mg/d, paroxetine (paxil)20-60
• These antidepressants typically have fewer
adverse events and side effects than the
triclics or the MAOls,
2,Tricyclic antidepressants(TCAS)
• The older class of antidepressant drugs and
include such medication amitriptyline and
imioramine.
• Tricyclice block the reuptake of certain
neurotransmitters such as nor epinephrine and
serotonin.
• They are used less commonly now due to the
development of more selective and saferdrugs.
3,Monoamine oxides inhibitor (MAOls)
• Monoamine oxides inhibitors such as phenelzine
may be used if other antidepressant medications
ineffective.
• Because there are potentially fatal interactions
between this class of medication and certain
foods(particularly those containing Tyramine
• Phenelzine(nardil)45-90
tranylcypromine(parnate)20-50
 indication
1.Depression
2.Anxiety disored
3,bipolar disored
4.Obsessive compulsive disored
5.Eating disoreders and
6.Chronic pain
7.Bipolar and schizoaffective disoreds
8.Sleep disored
 Side effect
1.increased heart rate
2.Drowsiness
3.Dry mouth
4.Constpation
5.Urnary reention
6.Blurred vision
7.Dizziness
8.contusion,and
9.Sexual dysfunction
3,Anxiety agents and sedative-hypnotics

• Are used to relieve moderate to severe anxiety

and tension
• Classification
1.-Benzodiazepine
2.Non benzodiazepines
 1.Benzodiazepines
• Hypnotic ,sedative ,anxiolytic , anticonvulsant
music relaxant and amnesic properties.
• Indication in treating
1.Anxiety
2.insomnia
3.Agitation
4.seizures
5.Music spasms
 Cont….
• Alcohol with drawal
• Prior to some unpleasant medical procedures in
order to induce sedation and amnesia for the
procedure.
• Another use is to counteract anxiety-related
symptoms upon initial use of ssRls and other anti
depressants ,or as an adjunctive treatment
• The long –term use of benzodiazepines can
cause physical dependence
• Types of benzodiazepine
1.Long active e.g diazepam 5mg/d chlorediazepoxide
10mg/d clonazepam 0.5mg/d
2.intermidiate acting e.g lorazepam
3.short acting e.g triazolam
• Mechanism of action
- modulating the GABA receptors.the most prevent
inhibitory receptor with in the brain
Side effect: nausea , vomiting ,hypotension ,sleep
disturbance ,fever ,delirium,
2. Non benzodiazepine ant anxiety agents

• Buspirone 7.5mg/d
.its mechanism of action is unclear, but it
apparently interacts with serotonin and
dopaimine receptors in the brine.
. Compared to others it cause less sedation
 Mood,stabilizers
 Medications have been shown to be effective
in the treatment of biplar disorders.
 The three mood stabilizers which are
approved include lithium, sodium valprroate
olanzapine ,carbamazepine lamotrigine
oxcarbazepine, Topiramte ,Gabapentin
,Risperidone ,aripiprazole ,& ziprasidone.
 Anti manic (mood stablizers)
• Lithium is the primary drug of choice in client
with bipolar disored.
• Lithium is effective in controlling mania
inabout 80% of clients.
• When used prophylactic the drug decrease
the frequency and intensity of manic cycles.
 Lithium
 Fetal exposure has high risk of developing
ebstein’s anomaly (teratogenesity for heart)
 Has a narrow therapeutic window and as a resuit
it can be toxic even a therapeutic dosage.
 It is toxic above the serum level 1.5 and toxicity
include confusion increased deep tendon reflexes
cardiac arrhythmia seizure and coma.
 Treatment for toxicity is supportive i.e fluid
maintenace.gastric lavage
• Lithium toxicity occur when serum lithium
level exceed 1.2.1 1.5 Meq/little
• Start at 300mg tid with a goal of 900-
1200mg/d patient going lithium therapy
should be giveen the drug during or after
meals to decrease gastric irritation.
 valproate
• It is extensively metabolized by the liver & is also highly
protein bound
• Toxicity can happen by co-administering with highly
protein-binding drugs(e.g.aspirin)
• Valproate is very efficacious in the treatment of acute
mania
• It also works well in certain bipolar groups (rapid
cycling dysphoric mania, comorbid sub. Abuse )
• It is even more efficious when administered
concomitantly with other mood stabilizers
• Side effects include sedation Gl distress weight
gain hair loss and rarely it can cause acute
pancreatitis (especially in children) & polycystic
ovary disease
• Use in pregnancy has been association in neural
tube defects in the fetus cranio facial abnormality
• Dosing oral loading 20-30mg/kg/day
• Therapeutic serum levels are from 50-125mcg/ml
 carbamazepine
• Evidence of its effectiveness in acutely manic
bipolar patient has been demonstrated in 19
studies to date
• A comparison of unipolar and bipolar
depression studies noted a55%open-label
response rate and 44% controlled response rate
• Comparison studies between lithum and
carbamazepine showed that carbamazepine to
be as effective
 Carbamazepine

• It is highly protein bound

• It is metabolized liverer
• Common side effects in include: dipllopia, fatigure, nausea and ataxia
• Other infrequent side effects are: rashes, mildlukopenia, hyponatremia
and thromoctocyopenia
• Initiating treatment
 Chek CBC, LFT
 Start with 200 mg po tid as patient tolerates and increase up to
maximum 1800mg\day
 Chek serum level and it shoud be b\n 4-12mcg\ml
 Anticholinergic/anti parkinsonism

• Are drug to treat extra pyramidal effect including akathaisia, acute

dystonia and parkinsonism
– Eg- trihexphenidyl(artane)
• Diphenhydramine 25-200mg/d
PSYCHOTHERAPY
WHY PSYCHOTERAPY?

• Bio-psycho- social model

• Increase therapeutic alliance and compliance

Psychotherapy and medication give better therapeutic results than

medication alone
 Defininition ’’Psychotherapy’
• Is a mode of treatment of patients with psychological problems , conflicts
or disturbances

• By a scientifically based way of establishing, modeling and handling of a

relationship b\n with the patient.
Universal elements

1. Trusting relationship
2. Special setting –impressive –generates trust and hope
3. Conceptual framework that makes clear the cause of the problem(telling
the cause due to….)
4. Procedure generates installation of hope
Psychotherapy helps people with a mental disorder

Understand the behaviors, emotions, and ideas that contribute to illness

and learning how to modify them.
• Understand and identify the life problems or event
• a major illness
• a death in family
• a loss of job
• a divorce that contribute to their illness and them
understand which aspects of those problems they
may be able to solve or improve
Recreational therapy

- Recreation is a form of activity therapy used in most psychiatric settings.

- Provide patients with the opportunity for fun and for feeling good.
- It tends balance to their daily schedule and helps in treating the whole
patient.
Therapeutic recreation can occur as:-

1) Card games
2) Trips out side the hospital
3) Structured soft ball
4) Basket ball or volley boll games
5) Attending sport events and so on
Occupational therapy

• Definition: Occupation is variously defined as ’any activity which engages

resources of time and energy and is composed of skills and values.
Points to be kept in mind
-Select an activity that interests the client
-start at point the client is at and progress slowly
-Provide ample in enforcement for even shall achievements
Advantages:

• It helps to build a more healthy and integrated ego

• It helps to express and deal with needs and feelings
• Assists in a gratification of frusted basic needs
• Reverses psychopathology
• Facilitates personality integration
• Offers opportunities to explore and see valuate self concepts and object
concepts
• Develops a more realistic view of the self in relation to action and others
 Psychotherapy helps people a mental
disorder
• Understanding the behaviors, emotions, and ideas
that contribute to illness and learning how to modify
them.
• Understanding and identify the life problems or events
• a major illness
•A death in the family
•A divorce that contribute to their illness and help
them understanding which aspects of those problems
they may be able to solve or improve
 Recreational therapy
• Recreation is a form of activity therapy used in
most psychiatric settings
• Provide patients with the opportunity for fun
and for feeling good.
• In tends balance to their daily schedule and
helps in treating the whole patient
 Therapeutic recreations can occur as :-

• Card games
• Trips out side the hospital
• Structured soft ball
• Basket ball or volley bal games
• Attending sport events and so on
 Occupational therapy
• Definition: occupation is variously defined as any
activity which engages a persons resources of time
and energy and is composed of skills and values
Points to be kept in mind:
• Select an activity that interests the client
• Start at the point the client is at and progress
slowly
• Provide ample in enforcement for even shall
achievement
Advantage
• It helps to build a more healthy and integrated ego
• It helps to express and deal with needs and feeling
• Assists in a gratification of frustrated basic needs
• Reverses psychopathology
• Facilitates personality integration
• Offers opportunities to explore and see valuate self
concepts and object concepts
• Develops a more realistic view in relation to action
and other
 Group psychotherapy
• A form of psychotherapy in which one or more
therapists treat a small group of clients together

• Are used to treat psychological and behavioral

disturbances
 Reasons to used Group Therapy(GT)
• GT allows people to receive the support and
encouragement of the other members of the
group
• Group members can serve as role models to
other members of the group
• GT is very cost effective
• By working in a group ,the therapist can see first
hand how each person responds to other people
and behaves in social situations
• Principle of GT
-installation of hope
- Releasing emotion
- Giving information
- Providing rational
- Advice & guidance
- Interpersonal learning
- Interpersonal learning
 SETTING UP THE GROUP
• Optimum size of the group is 8 members
• Members should have some problems in common
• A room of adequate size
• Chairs arranged in a circle so that members can see
one anther
• Meeting last 60-90minute
• Usually once a week
• Most groups are closed
SOME PROBLEMS IN GROUP THERAPY

• Formation of sub groups

• Members who talk too much
• Members who talk too little
• Conflict between members
• Avoidance of focus