Signs and Symptoms

Of
Mental Disorders
Dr.issam Bannoura: MD JB Psychiatry
Clinical tutor, Bethlehem Mental Hospital

Psychiatry can be practiced only, if the psychiatrist develops two

distinct capacities: One of the capacity to collect clinical data objectively,
and accurately by history taking, and examination of mental state, and to
organize the data in a systemic and balanced way. The other is the
capacity for intuitive understanding of each patient, as an individual. Both
capacities can be developed by accumulation experience of talking to
patient.
Once the psychiatrist has elicited a patient signs and symptoms , he
needs to decide how far these phenomena , resemble or differ from those
of other psychiatric patient.

Psychopathology:

That means abnormal state of mind, and denotes three distinct

approaches:
1.phenomenological psychopathology: which is concerned with objective
description of abnormal state of mind, it concerned with conscious
experience and observable behavior.
2.psychodinamic psychopathology: it goes beyond description , and seeks
to explain the causes of abnormal state of mind, by postulating
unconscious mental process.
3.experimental psychopathology: abnormal phenomena , are examined by
inducing a change in one of the phenomena , and observing changes in
the other.

The significance of individual symptoms

A single symptom does not necessarily indicate mental disorder, it is
necessary grouping of symptoms into syndrome. Symptoms are more
likely to indicate, mental disorder, when they are intense and persistent.

Primary and secondary symptoms

The term is used in describing symptoms, but has two meanings:
-Temporal: primary means antecedent, and secondary means subsequent.
-Causal: primary means a direct expression of the psychological process,
and secondary means a reaction to the primary.
Disorders of perception
A- Illusion: illusions are misperception of external stimuli, they are
more likely when the general level of sensory stimulation is
reduced. They are also mire likely when level of consciousness is
reduced. For example it happens in delirious patients, and
frightened persons.
B- Hallucinations: a hallucination is a percept experienced in the
absence of an external stimulus, with similar quality to a true
percept. Hallucinations are not restricted to the mentally ill, some
people experience them when tired, and during the transition
between sleep and wakening ( they are called hypnogogic if
experienced while falling asleep, and hypnopompic if experienced
during awakening ).

Types of hallucinations
1. According to complexity:
-Elementary: such as bangs, whistles and flashes
-Complex: such as hearing voices, or music, or seeing faces
and scenes.

2. According to sensory modality:

a- Auditory: occasionally called phonemes. and they may be:
- Second person hallucination, they seem to address the
patient directly (e.g. you are going to die), or give
command (e.g. hit him). They mostly suggest depressive
disorder, or other mental, or organic disorder.
- Third person hallucination: voices which appear to be
talking to each other, referring to the patient as third person
(e.g. he is a homosexual). They are associated particularly
with schizophrenia but may be experienced in other mental
or organic disorders.
- Voices which anticipate echo, or repeat the patient’s
thoughts also suggests schizophrenia.
b- Visual hallucinations:
- Lilliputian: they are visual hallucinations of dwarf figures
- Extracampian: are experienced as located outside the filed
of vision.
Visual hallucinations may occur in hysteria, affective
disorders and schizophrenia, but should always raise the
possibility of organic disorder
 c- Olfactory and gustatory hallucinations are frequently
experienced together, as unpleasant taste or smell, they may
occur in schizophrenia, or severe depressive disorder, but
they should also suggest temporal lobe epilepsy or irritation
of olfactory bulb or pathways by a tumor.

d- Somatic hallucinations (tactile or of deep sensation).

- tactile called haptic, as sensation of being touched, pricked
or strangulated.
- of deep sensation as feeling of viscera being pulled, or of
sexual stimulation, or electric shock.
They are weakly associated with particular disorders, but
they may suggest schizophrenia. The sensation of insects
moving under the skin may suggest cocaine abuse (cocaine
bugs).

e- other hallucinations:
- autoscopic hallucination: is the experience of seeing ones
body projected into external space, may suggest temporal
lobe epilepsy, or other organic disorder.

- reflex hallucination: for example the sound of music may

provoke visual hallucination that may occur after talking
drugs such as LSD or rarely in schizophrenia.

- as already mentioned hypnopompic and hypnogogic

hallucinations occur at the point of waking or falling asleep.

C- Pseudo hallucination:
They are vivid mental images that may be within the mind, or the
experience of perceiving something from the external world, but
recognized as unreal, they have no diagnostic significance because
patients are often uncertain themselves.

Disorders of thinking
They are usually recognized from speech and writing, they denote for
groups of phenomena:
A- Disorders of the stream of thought.
B- Disorders of the form of thought.
C- Particular kinds of thoughts - delusions
- obsessions
D- Abnormal believes about possession of thoughts
Disorders of the stream of thoughts

Both amount and speed of thoughts are changed, they may be:
1-pressure of thought, when ideas arise in unusual variety and abundance,
and pass through the mind rapidly. They suggest mania and may be
experienced in schizophrenia or organic disorder.

2- poverty of thought, when patient has only few thoughts, occurs in

depressive disorders, and may be in schizophrenia or other organic
disorders.

3. Thought blocking, when stream of thought interrupted suddenly, the

patient experiences as his mind going blank, this experience strongly
suggests schizophrenia specially when interruptions in speech are
sudden, striking and repeated.

Disorders of the form of thought (formal thought disorder)

It can be divided into three subgroups:
1-Flight of ideas: the patients thoughts and conversation move quickly
from one topic to another, so that train of thoughts is not completed
before another appears, but the links between topics are normal. They
are characteristic of mania.

2. Loosening of association: that denotes a loss of the normal structure of

thinking, the patient changes the topics with no connection between
them, the interviewer appears as muddled and illogical. It can takes
several forms:
a- knights move or derailment refers to transition from one topic to
another between sentences or in mid sentences, with no
relationship between the two topics.
b- word salad or verbigeration, refers to a kind of stereotypy in which
sounds, words, or phrases are repeated in senseless way.
c- talking past the point, when the patient seems always about to get
near the matter, but never quite reach it.
Loosening of association occurs most often in schizophrenia.

3. Perseveration: is the persistent and inappropriate repetition of the same

thoughts, occurs in dementia but not confined to this condition.

Particular kinds of abnormal thoughts

 DELUSIONS
 OBSESSIONS
Delusions
A delusion is fix false belief that is firmly held on inadequate
grounds, can’t be altered by evidence of the contrary, and isn’t a
conventional belief that the person might be hold, upon his educational or
cultural background.

Delusions must be distinguished from overvalued ideas

(Wernicke1900) which are preoccupying belief, they are neither
delusional nor obsessional in nature, which comes to dominate a persons
life for many years, and may affect his actions (e.g. a person whose
mother and sister suffered from cancer, he may preoccupied with the
conviction that cancer is contagious.

Delusion is called complete when the belief is firmly held, with total
conviction, other delusion develops more gradually, called partial
delusions, similarly partial delusion may appear during recovery. Partial
delusion usually followed or proceeded by full and complete delusion.
A primary delusion is one that appears suddenly, without any mental
events leading to it. But secondary delusions can be understood as
derived from some preceding morbid experience, such as hallucination or
delusion. The accumulation of secondary delusions may result a
delusional system and sometimes called systematized.

Systematized delusions may be bizarre (impossible), or nonbizarre

(Possible).

When there is a mood from which a delusion arises, it is called

delusional mood. When familiar percept has new significance, for the
patient, it is called delusion perception. Finally, some delusions concern
past rather than present event, and are known delusional memory.

Occasionally, a person who lives with a deluded patient, comes to

share his delusions, this condition is known as shared delusions.

Delusional themes
1-persecutary delusions:
are often called paranoid. Many writers applied the term paranoid to
grandiose, erotic, jealous, and religious delusions, for this reason it is
preferable to avoid the term paranoid. Persecutory delusion are most
commonly concerned with persons, or organizations, that are to be trying
to inflect harm on the patient, damage his reputation or poison him, they
can occur in schizophrenia, severe affective disorders, and organic
disorder
2-delusions of reference: are concerned with the idea that objects,
events, or people have a personal significance for the patient . they
occur in schizophrenia, severe affective disorders, and organic
disorders.

3-grandiose delusions: or expansive delusions, are beliefs of

exaggerated self importance, and may be of grandiose ability which
occur in mania, may be in schizophrenia, or in organic disorders.

4-delusions of guilt and worthlessness: are found in depressive illness,

and the person concerned of shame and guilt, for what he had done in
the past.

5-nihilistic delusions: are beliefs about the nonexistence of some person

or thing, concerning failures of body function, that he had to die, and the
patient’s career is finished. They are associated with severe depressive
illness (cotard’s syndrome ).

6-hypochondriacal delusions: are concerned with illness, such as cancer

venereal disease, and they belief they are ill, they occur in
schizophrenia, delusional disorder, or organic disorders.

7-religious delusions: are delusions with religious content, many appear

in schizophrenia, affective disorders, or organic disorders.

8-delusions of jealousy: are more common among men, and are

concerned with doubts about the spouse’s fidelity. They occur in
delusional disorder (morbid jealousy) and in schizophrenia.

9-erotomanic delusions: are more common in women, are concerned

when a female has a belief that she is in love with a famous person,
they occur in delusional disorder(erotomania) or in schizophrenia.
They may called sexual or amours delusions.

10-delusions of control: the patient believes that his actions, impulses

or thoughts, are controlled by an outside agency, they suggest
schizophrenia, and may occur in affective disorders.
Delusions concerning the possession of thoughts

11-delusions of thought insertion: are a person’s belief that some of his

thoughts, are not of his own, and have been implanted by an outside
agency.

12-delusions of thought withdrawal: are beliefs, that thoughts of the

patient, have been taken out of the mind.

13-delusions of thought broadcasting: the patient believes that

unspoken thoughts are known to other people, through radio, telepathy,
or through other way.

The last three delusions, concerning the possession of thought, are

more common in schizophrenia, than in other disorders.

Obsessional and compulsive syndromes:

Obsessions are recurrent persistent thoughts, impulses, or images, that
enter the mind, known to be silly, senseless, unreal, they are generally
about matters which the person finds distressing and unpleasant, the
presence of resistance is important.

Obsessions can occur in several forms:

1-obsessional thoughts: are repeated words, or phrases, which are
usually upsetting the patient

2-obsessional ruminations: are repeated worrying themes of a more

complex kind, for example about the ending of the word.

3-obsessional doubts: are repeated themes expressing uncertainty about

previous actions.

4-obsessional impulses: are repeated urges to carry out actions, that are
usually aggressive. The person who has urges to pick up knife, may
develop fear of knives(obsessional phobia)
.
Thoughts about illness of fearful kind, or dread of illness such as
cancer, are called illness phobia.

Themes of obsessions can be grouped into six categories:

Dirt, contamination, aggression, order line, illness, sex, and religion.
Compulsions: are repeated purposeful behaviors, performed as
stereotyped way, they are accompanied by a sense that they must be
carried out, and by an urge of resistance. Usually the result of repeated
compulsive rituals, the person has slow performance and delay, the
condition called obsessional slowness.
Compulsive rituals are of many kinds:
-checking are concerned with safety.
-cleaning are concerned with dirt and contamination.
-counting
-dressing.

Phobias
A phobia is a persistent irrational fear of, and wish to avoid a specific
abject, activity, or situation.
Phobias may be:
1-simple: irrational fear of simple objects, or situations, such as high
places, spiders…etc.
2-social: irrational fear of social situations.
2-agoraphobia: irrational fear to be away from home and in situations a
person cannot escape easily.

Motor and catatonic signs

1-tics: are irregular repeated movements involving a group of muscles.

2-mannerisms: are repeated movements that have some functional

significance (e.g. saluting).

3-stereotypies: movements that are regular (unlike tics) and without

obvious significance (e.g. rocking to and fro).

4-posturing: is the adoption of unusual bodily postures for long time.

5-negativism: when they do the opposite of what is asked.

6-echopraxia: is the imitation of the interviewer’s movements

automatically, even when asked not to do so.

7-echolalia: is the repetition of the interviewer’s speech, and talk.

8-ambitendance: when they alternate between movements, for example
putting hands to shake and withdrawing it, and so on.
9-waxy flexibility: (catatonia) or catalepsy, when parts of the body can
be placed for long period at the same position.
Depersonalization and derealization
Depersonalization is a change of self awareness, that a person feels
himself unreal or lifeless.
Derealization : objects usually appear unreal, and people appear
lifeless.
The symptoms have been reported after sleep deprivation, sensory
deprivation, tiredness, as an affect of hallucinogenic drugs, and may be
associated with generalized anxiety disorder, dissociative disorder,
phobic disorders, depressive disorders, and schizophrenia.

Disorders of mood
Mood: is the long term emotional state.
Affect: is short term or present emotional state.
Changes in the nature of mood can be towards: anxiety, depression,
elation, anger, and irritable mood.
Apathy: total loss of emotions, and inability to feel pleasure.
Blunted or flattened affect: when the emotions are reduced, rather than
lost.
Labile affect: when emotions change in a rapid and abrupt way.

Disorders of memory
Failure of memory is called amnesia.
Short term memory: or primary memory, has two stores:
- Immediate memory being stored for 15-20 seconds.
- Recent memory in which information can be stored for hours.
Long term memory has been selected for more permanent storage.

Memory is affected by several kinds of psychiatric disorders, specially

organic mental disorders.
In some neurological and psychiatric disorders, patients have a
disturbance of recall or recognize events that have been known(jamais
vu) . or unknown events seem to be already seen(déjà vu)

Anterograde amnesia is poor memory for the interval between the ending
of unconsciousness and full conscious

Retrograde amnesia is inability to recall events, before the

onset of unconsciousness, some causes of
unconsciousness are head injury, and ECT.
Disorders of consciousness
Consciousness is awareness of the self and the environment. The
level of consciousness can vary between the extremes of alertness and
coma.
Coma: the patient shoes no mental activity or respond even to strong
stimuli.
Sopor: the person can be aroused only by strong stimulation.
Clouding of consciousness: the patient is drowsy and reacts
incompletely to stimuli(muddled thinking).
Confusion: means inability to think clearly.
Stupor: refers to condition in which the patient is immobile, mute,
motionless, but appears to be full conscious.

Disorders of attention and concentration

Attention is the ability to focus on the matter, concentration is the
ability to maintain that focus.
Attention and concentration may be impaired in a wide variety of
psychiatric disorders, including depressive disorder, mania, anxiety,
schizophrenia and organic disorders.

Insight
Insight may be defined as awareness of one’s own medical
condition. Most psychotic patients have no insight, e.g. schizophrenic and
manic patients do not consider themselves ill.
To consider insight, it is better to ask four separate questions:
1. is the patient aware of the phenomena?
2. does he recognize that phenomena is abnormal?
3. does he consider that they are caused by mental illness?
4. does he need treatment?
The answers to these questions are informative, and the doctor can
know if the patient, has insight into his illness, and is likely to cooperate
with treatment.

Standard criteria for rating symptoms

Standardized methods of interviewing have been developed in which
standard questions are used and criteria are provided to decide whether a
symptom is present or absent. Among the best known schemes are:
1- SCAN schedule of clinical assessment in neuropsychiatry.
2-SCID the structured clinical interview for diagnosis.
3-CIDI the composite international diagnoses and interview.

Further reading Oxford textbook of psychiatry-1996 -

 Classification and diagnoses in psychiatry
Dr. issam bannoura MD JB Psychiatry
Clinical tutor, Bethlehem mental hospital

The purpose of classification is to identify groups of patients, who

share similar clinical features, so suitable treatment cab be planned. Most
systems of classification are based on diagnosis categories, such as
schizophrenia, or affective disorders. It may also be convenient to add
various other characteristics of a patient, such as social functioning.

In psychiatry classification is needed for tow main purposes:

The first is to enable clinicians to communicate, with one another, about
their patient’s symptoms, prognoses, and treatment.
The second is to ensure that research can be conducted.

Neurosis and psychosis

In the past the concepts of psychoses and neuroses, were included in
most systems of classification, but recently, these terms have little usage
and value in classification, because they give less precise diagnoses.
The term psychosis refers broadly to severe forms of mental disorder,
such as schizophrenia, affective disorder, and organic mental disorders.
Lack of insight is often suggested as a criterion for diagnoses, as well as
the presence of delusions and hallucinations.
The term of neuroses refers to mental disorders that are generally less
severe that psychoses, and characterized by symptoms closer to normal
experience, as anxiety, obsessive compulsive disorder, panic disorder,
phobia, conversion and dissociative disorders.

Types of classification:
1-catigorial classification: psychiatric disorders have been classified by
dividing them into categories, which are supposed to represent discrete
entities, and have been defined in terms of symptoms, course and
outcome of different disorders.
2-dimentional classification: Eysenck proposed a system of three
dimensions: psychoticism, neuroticism and introversion-extroversion.
Patients are given scores which locate them on each of these three
axes.
3-the multiaxial approach: Essen Moller proposed that clinical
syndrome and etiology should be coded separately, in this scheme
separate sets of information, such as symptoms, and etiology are
coded. The introduction of multiaxial classification was a major
innovation in DSM III
The DSM IV multiaxial classification and diagnoses:
Axis I clinical psychiatric disorder.
Axis II personality and developmental disorder .
Axis III general medical condition.
Axis IV psychosocial and environmental problems.
Axis V global assessment of functioning.

Standardized interview schedules:

1-presents state examination (PSE). Was developed by Wing 1974, was
used by many countries, contain 140 items for principle features of
clinical examination. Computer programs (catego) were derived from it
2-schadules for clinical assessment in neuropsychiatry (SCAN).
Which can be used to diagnose a broader range of disorders, including?
eating disorders, somatoform disorders, drug abuse and cognitive
disorders.
3-diagnoses interview schedule (DIS). Was developed in USA
(Robins1981). It covers the most common adult psychiatric diagnoses,
which was made as life time diagnoses.
4-structured clinical interview for diagnoses (SCID). It can be used by
clinicians as part of a normal assessment procedure, to confirm a
particular diagnoses, and based on DSM.
5-composite international diagnoses interview (CIDI). Derived from
DIS, and used for assessment of mental disorders, and provide
diagnoses according ICD and DSM.
6-the international classification of diseases (ICD). Mental disorders
were not included in the ICD until its sixth edition produced by WHO
in 1948: -ICD 6 ------1948
-ICD 7 ------1958
-ICD 8 ------1968
-ICD 9 ------1978
-ICD 10 -----1992
-ICD 11 ------will be launched in 2017
7-the diagnoses and statistical manual (DSM). In 1952 the American
Psychiatric association published the first edition of the DSM, as an
alternative to ICD 6 which is mentioned above:
-DSM I -----1952
-DSM II -----1968
-DSM III -----1980
-DSM IIIR----1987
-DSM IV -----1994
-DSM 5 -------2013
 As a result DSM 5 is technically compatible with ICD 11, although
there are a number of specific differences, both classifications contain
basic categories for classification in psychiatry, including the following:

1-Neurocognitive disorders :
-delirium -dementia
-amnestic disorder -other cognitive disorders
2-substance-related disorders:
-substance use disorders
-substance abuse disorders
-pathological gambling
-alcohol -amphetamine
-caffeine -cannabis
-cocaine -hallucinogens
-inhalants -nicotine
-opoids -phencyclidine
-sedative, hypnotic, anxiolitic drugs
-polysubstance -others
3-schizophrenia spectrum and other psychotic disorders
-schizophrenia.
-schizophreniform disorder.
-schizo-affective disorder.
-brief psychotic disorder.
-delusional disorder (paranoia).
-psychotic disorders due to general medical condition.
-substance –induced psychotic disorders.
-psychotic disorders NOS.
4-Depressive disorders
-major depressive disorder
-persistent depressive disorder or Dysthymia
-premenstrual dysphoric disorder
-substance induces depressive disorder
-depressive disorder due to GMC
-other depressive disorder
-Disruptive mood Dysregulation disorder
5-Bipolar and related disorders
-bipolar I disorder
-bipolar II disorder
-cyclothymic disorder
-substance induced bipolar disorder
-bipolar disorder due to GMC
-other bipolar disorder
6-anxiety disorders:
-panic disorder
-agoraphobia
- specific phobia
-social phobia
-generalized anxiety disorder
-substance induced anxiety disorder
-anxiety disorder due to GMC
-other anxiety disorder
-separation anxiety disorder
-selective mutism
7-Obsessive compulsive and related disorders
-obsessive compulsive disorder (OCD)
-body dysmorphic disorder
-hoarding disorder
-trichotilomania or hair pulling disorder
-excoriation or skin picking disorder
-substance induced OCD
-OCD due to GMC
-other OCD

8-Trauma or stress related disorders

-reactive attachment disorder
-disinhibited social engagement disorder
-acute stress disorder
-post-traumatic stress disorder (PTSD)
-adjustment disorders
-persistent complex bereavement disorder
9-dissociative disorders
-dissociative amnesia
-dissociative fugue
-dissociative identity disorder
-dissociative trance(possession) disorder
-depersonalization disorder
-Gancer syndrome
-brain washing
-dissociative disorders nos
10-somatic symptom and related disorders
-somatic symptom disorder
-illness anxiety disorder
-functional neurological symptom disorder (conversion)
-factitious disorder
- other somatic symptom disorder
 11-personality disorders
-paranoid personality disorder
- schizoid personality disorder
-schizotypal personality disorder
-antisocial personality disorder
-borderline personality disorder
-histrionic personality disorder
-narcissistic personality disorder
-avoidant personality disorder
-dependent personality disorder
-obsessive personality disorder
-personality disorders nos
12-Disruptive,impulse control and conduct disorders
-oppositional defiant disorder
-intermittent explosive disorder
-kleptomania
-pyromania
-conduct disorder
-impulse disorders nos
13-Feeding and eating disorders
-anorexia nervosa
-bulimia nervosa
-binge eating disorder
-pica
-rumination disorder
-avoidant, restrictive food intake disorder
-obesity and the metabolic syndrome
-other eating disorders
14-Elimination disorders -enuresis
-encopresis
15-sleeping disorders
-dyssomnias –primary insomnia
-primary hypersomnia
-narcolepsy
-breathing related sleep disorders
-circadian rhythm sleep disorders
-parasomnias –night mare
-night terror
-sleep walking
-sleep disorders due to mental condition
-sleep disorders due to general medical condition
-substance induced sleep disorders
-sleep disorders nos
16-sexual disorders
-sexual dysfunctions –sexual desire disorder
-sexual arousal disorder
-orgasmic disorders
-sexual pain disorder
-sexual disorder due to GMC
-substance induced sexual dysfunctions
-sexual dysfunctions nos
-abnormalities of sexual preference (paraphillias)
-exhibitionism -fetishism
-transvestic fetishism -frotteorism
-pedophilia -masochism
-sadism -voyeurism
-others
-gender identity disorders(gender dysphoria)
-in children –effeminacy in boys
-tomboyishness in girls
-in adults -transsexualism
-dual –role transvestism
-sexual disorders nos
17-neurodevelopmental disorders
-intellectual disability or intellectual developmental disorder
(Mental retardation)
-communication disorders
- autism spectrum disorder
-attention deficit hyperactivity disorder (ADHD)
-specific learning disorders
-motor disorders
18-geriatric psychiatry
19-forensic psychiatry
-laws regulating psychiatric services
-civil laws
-criminal laws.

Further reading:
Oxford textbook of psychiatry 1996
Comprehensive textbook of psychiatry 1997.
 Etiology of Mental Disorders
Dr. Issam Bannoura MD JB Psychiatry
Clinical tutor, Bethlehem Mental Hospital

Psychiatrists are concerned with etiology in two ways: First, in everyday

clinical work they try to discover the causes of the mental disorders. Second,
for seeking a wider understanding of psychiatry.

They are interested in etiological evidence obtained from clinical studies,

community surveys, or laboratory investigations.

In psychiatry the study of causation is complicated by two problems, the

first is that causes are often remote in time from the effects that they produced
the second is that a single cause may lead to several effects, conversely a
single effect arise from several causes.

The classification of causes

1-predisposin factors:
These are factor, many of them operating from early life that determines a
person’s vulnerability to causes, acting close to the time of the illness. They
include genetic, environmental factors in utero, physical, psychological and
social factors, in infancy and early childhood. For the etiology of individual
case the personality is always an essential element.

2-precipitating factors:
These are evens that occur shortly before the onset of a disorder, and
appear to have induced it. They may be physical, psychological, and social
factors, such as loss of job, moving home ----etc.

3-perpetuating factors:
These factors prolong the causes of a disorder after it has been provoked,
they may be social and personal factors, such as uncompliance with treatment,
high emotional expression, and withdrawal from social activities.

The contribution of scientific disciplines to psychiatric etiology

1-Psychology:
Psychoanalysis arose from clinical experience, and not from work in the
basic sciences. Freud originated the psychoanalysis, a central feature of his
work, was the concept of the unconscious mind, and all mental processes
originated their .
According to Freud the unconscious mind had three characteristics that were
important for the genesis of neuroses:

A-it is divorced from reality: it tended to telescope situations and fantasies

that were separated in time, these features were will illustrated, by dream
analysis. The translation was affected by a series of mechanisms, such as
condensation, displacement, and secondary elaboration.

B-the unconscious mind is dynamic: and contains impulses, these

impulses were regarded as sexual, and aggression. Persons have to pass
smoothly through psychosexual stage of development, oral anal and genital.
If the libido became fixated at any stage, the person regress to such pattern
under stress and this may determine the nature of neuroses that will develop
later in life.

C-there is struggle between unconscious and conscious mind: this conflict

was regarded as giving rise to anxiety, and that could generate neurotic
symptoms. one of the Freud’s lasting contribution was his idea that anxiety,
could be reduced by a variety of defense mechanisms.

Mechanisms of defense:
-Repression: is the exclusion from unconsciousness impulses, emotions, or
memories that cause distress.

-Denial: is inferred when a person behaves as if unaware of something that he

may expected to know.
-Displacement: is the transfer of emotions from a person, object, or situation
with which it is associated, to a less patent source of distress.
-Projection: is the attribution to another person of thoughts on feelings
similar to ones own.
-Regression: is the adoption of behavior appropriate to earlier stage of
development.

-Reaction formation: is the adoption of behavior opposite to behavior that

would reflect true feelings and intentions.

-Rationalization: is the unconscious provision of a false but acceptable

explanation of behavior that has a less acceptable origin.

-Sublimation: is the unconscious diversion of unacceptable impulses into

more acceptable.
-Identification: is the adoption of the characteristics or activities of another
person, to reduce pain of separation or loss.
 A characteristic feature in the psychology is the idea of continuity between
the normal and abnormal, and the interaction between the person and his
environment. For the determining of normal behavior many psychodynamic
theories were done:
a. learning theory: this theory propose mechanisms by which experiences in
childhood and later life give rise to neuroses.
b. Behavior theory: Mowrer 1950 tried to resolve this neurotic paradox by
proposing a two stage theory, first neutral stimuli become sources of
anxiety through classical conditioning, and the second avoidance responses
reduce the anxiety.
c. Cognitive theory: Beck 1967 has proposed that depressed patients have
pessimistic thoughts which consist of negative evaluation of self, world
and future and these develop automatic thoughts that may lead to
depression . cognitive-behavior therapy
Automatics thoughts are:
-arbitrary inference: drawing a conclusion
-abstraction: focusing in detail
-overgeneralization: drawing a general conclusion
-personalization: relating to oneself

2-Etiological causes in the environment:

Many environmental factors may predispose persons to mental disorder,
either directly or through their effect on family life, these conditions are:
-poor living conditions
-noise
-working conditions
-unemployment
-prison
-migration

3-Phisique and personality factors:

Kretchmer 1936 attempted to define psychological types, and link them to
recognizable types of body build, pycknin (stocky and rounded), athletic (with
strong development of muscles and bones), and asthenic (lean and narrow).

He suggested that the pycknic body build was linked to the cyclothymic
personality type, while the asthenic to schizotypal personality disorder, and he
suggested an association between personality disorder and mental illness.
There could be some less specific genetic connection between mental
disorders, for example schizoid personality is considered to be partial
expression of schizophrenia, and cycloid personality for manic depressive
psychoses.
4-The study of early development and life events:
Many early environmental factors may play a major roll in the geneses of
some mental disorders. Some of these factors are: pregnancy, health of mother
during pregnancy, malnutrition of mother, prematurely, low birth weight,
obstetric complication, cyanosis of the enfant, low abgar score, kernicteros,
and any other postnatal difficulties.
There are association between illness and certain kinds of events in
persons life, the studies suggested that the risk of illness was greeted at
periods of life change; e.g. residence, finance, departure of a person, loss,
imprisonment, immigration. ------etc.

5-Causes within family:

It has been suggested that some mental disorders are an expression of
emotional disorder within a whole family; as a result family problems are
common among neurotic patients.

6-Social factors:
There have been studies that correlated between social class and certain
mental disorders, thus schizophrenia is 11 times more frequent in social
Class V than social class I, depression is more frequent in social class V and
mania in social class I.
The social class classified as the following:
-social class I high professionals (doctors, politicians ….etc.)
-social class II low professionals (teachers, nurses ….etc.)
-social class III skilled workers.
-social class IV semiskilled workers.
-social class V unskilled workers

7-Genetic factors:
Genetic investigations are concerned with three issues; the contribution of
genetic and environmental factors to etiology, the mode of inheritance, and
the mechanism of inheritance. There are three studies that explain the roll of
inheritance in mental disorders.

-family studies: investigate the risk of psychiatric condition among the

relatives of affected persons, and compares it with the expected risk in the
general population.
-twin studies: this investigation seeks to separate genetic and environmental
influences, by comparing the concordance rate in MZ and DZ twins. If
concordance for psychiatric disorder is substantially higher in MZ twins than
in DZ twins, a major genetic component is presumed.
-adoption studies: provide another useful method of separation genetic and
environmental influences, and compared the frequency of the disorder
between two groups of adopted people, the rate of illness is higher in persons
if the biological parents are ill.

The mode of inheritance may be monogenic or heterogenic, recessive,

dominant, sex linked or mixed model. The studies have been successful in
Alzheimer disease, and Huntington chorea. Attempts to study other
psychiatric disorders in this way, have led to equivocal results, particularly
schizophrenia and affective disorders.

8-Biochemical studies:
These studies can be directed either to the cause of the disease, or to the
mechanism by which the disease produces its effects. Methods of biochemical
investigations are too numerous, such as :
- levels of metabolite of neurotransmitter in CSF fluid, blood, and urine.
- Post-mortem studies, which identify the density of specific receptors,
for example the density of dopamine receptors has been found to be
increased in nucleus accumbens and caudate nucleus in schizophrenic
patients.
Studies of receptor bindings in different groups of patients, by using
positron imaging, these methods include; magnetic resonance imaging
MRI, positron emission tomography PET, single photon emission
computerized tomography SPECT. These three methods may measure the
regional blood flow, structure, energy and metabolism of the brain.

There are three major types of neurotransmitters in the brain:

-The biogenic amines
-The amino acids
-The peptides
I The biogenic amines:
The six biogenic amine neurotransmitters are ;dopamine D, adrenalin A,
noradrenalin NA, serotonin S, acetylcholine Ach, and histamine H.

-Dopamine: Dopamine, noradrenalin, and adrenalin are all synthesized from

same amino acid precursor, Tyrosine. Serotonin is synthesized from precursor,
Tryptophan

Tyrosine + T.hidroxilase → L. Dopa + LD decaboxilaze → Dopamine.

Dopamine (metabolism) +MAO or COMT →HVA (homovanilic acid)
 The most important dopamine tracts are the nigrostriatal, the mezolimbic,
and the tuberoinfundbular tract. It is metabolized to homovanilic acid, and its
receptors are concentrated in the nucleus accumbens, and frontal cortex. It
was suggested that dopamine secretion is high in schizophrenia. Dopamine
may also involve in mood disorders, may be low in depression and high in
mania.

-Noradrenalin and adrenalin: they are synthesized from the same precursor
Tyrosine

Dopamine + dopamine B carboxylase → Noradrenalin (NA)

Noradrenalin (metabolism) +MAO → 3M4HPG (3methoxy4hydroxy phenyl
glycol)
noradrenalin + PNMT(phenylN. Methyl transferase → Adrenalin

The major concentration of NA and Adrenalin cell bodies in the brain, is in

locus ceruleus in the bons. NA is involved in mood disorders and its secretion
is low in depression and may be involved in other mental disorders.

-Serotonin :
Serotonin is synthesized from precursor tryptophan.

Tryptophan (T) + T.hydroxilase → 5HT (5hydroxytryptamin)

5HT (metabolism) + MAO → 5HIAA (5 hydroxyindoloacetic acid )

The major site of serotonin cell bodies is in the median and dorsal raphe
nuclei in the upper pons and the midbrain. Serotonin levels become low in
depressive disorders, and may be involved in other psychiatric conditions such
as anxiety and panic disorder.

II Amino acids:
Amino acid neurotransmitters are the most abundant in the brain, the major
excitatory is Glutamate, and the inhibitory are GABA and Glicine.
Glutamate has an excitatory effect in schizophrenia, and there is an
association between benzodiazepines and GABA-ergic system and its
potential role in pathogeneses of anxiety disorder.

III Peptides:
They may be 300 peptides in human brain; they are made in neuronal cell
body. Selected peptide neurotransmitters are: endogenous opoids, substance P,
cholesystokinin, somatostatin, vasopressin, and oxytocin.
9- Physiology:
Physiological methods can be used to investigate the cerebral and
peripheral disturbance associated with disease state. Several methods have
been used:-studies of cerebral blood flow in chronic organic syndromes.
-EEG.
-psychological methods.
-pulse rate.
-blood pressure and blood flow.
-skin conductance.
-evoke potentials.

10-Neuropathology:
Neuropathological studies attempt to answer the question, whether a
structural change in the brain, localized or diffuse, accompanies a particular
kind of mental illness? Such studies have an obvious application in the
etiology of dementia, and some other mental disorders. It was showed and
demonstrated the enlargement of the lateral ventricles in schizophrenia. The
major brain areas implicated in mental disorders are the limbic structure, bazal
ganglia, frontal lobe, thalamus, and the brain steam.

11-Endocrinilogy:
Changes in the concentration of the circulating hormones can have
profound effects on mood and behavior. Hormones may alter brain function
and have implication for pathophisiology of mental disorders, for example;
the adrenal axis, thyroid axis, growth hormone, prolactin, and melatonin.

Further reading:-Oxford textbook of psychiatry

-Comrehensive textbook of psychiatry.
 Schizophrenia
And
Schizophrenic like disorders
Dr. Issam Bannoura MD JB.Psychitry
Clinical tutor Bethlehem Mental Hospital

Of all the major psychiatric syndromes, schizophrenia is much the most

difficult to define and describe. Over the past 100 years many concepts of
schizophrenia have been held in different countries. It is useful to start with
comparison between two concepts, acute schizophrenia and chronic
schizophrenia.

The predominant clinical features in acute schizophrenia are; delusions,

hallucinations and interference of thinking, features are often called positive
symptoms. In contrast, the main features of chronic schizophrenia are; apathy,
lack of drive, slowness, and social withdrawal, these features are often called
negative symptoms. Some patients recover from the acute illness, whilst
others progress to the chronic syndromes. Once the chronic syndrome is
established few patients recover completely.

Epidemiology:

The life time prevalence of schizophrenia is one percent (1%) and the
annual incidence is between 0, 1-0, 5%. The onset of schizophrenia occurs
between the ages of 15-45 years. While schizophrenia occurs equally in men
and women, the mean age of onset is about five years earlier in men.

Persons who have schizophrenia are more likely to have been born in the
winter, and early spring, from January to April in the northern hemisphere.

High rates of schizophrenia were reported in law social class, in some

regions e.g. north of Sweden and in migrating persons, and maybe the rate is
falling in industrialized countries.

Schizophrenic persons have a high mortality rate from accidents, and

natural causes, up to 80% of all schizophrenic have concurrent medical
illnesses. Suicide is common, about 50% of patients attempt suicide at least
once in their life, and 10% die by suicide 20 year follow up period. The major
risk factors; depressive symptoms, young age, and high level of premorbid
functioning.
Clinical features

The acute syndrome:

The main clinical features in the acute syndrome are; prominent

persecutory ideas and delusions, that may be several, paranoid, of reference,
grandiose, jealous, of control …etc., odd ideas with auditory hallucination,
mainly third person auditory hallucination, thought echo and repeat, other
hallucinations are less frequent. Gradual social withdrawal and impairment at
work and total functioning is common.

In appearance and behavior, some patients are normal, others seem

changed and different, some smile and laugh alone, some appear confused, or
perplexed, some are restless and noisy, some show sudden unexpected change
of behavior.

The speech reflects underlying thought disorder; some have difficulty in

dealing with abstract ideas (concrete thinking). Other become preoccupied
with vague or mystical ideas. Disorders of stream of thought include pressure
of thought, poverty of thought and thought blocking maybe present.

Loosening of association, that may detect illogical thinking (knights move)

or talk past the point, or word salad or neologisms.

Abnormalities of mood are common, such as anxiety, depression irritability

or euphoria. There maybe blunting or flattening of affect or incongruity of
affect.

Orientation is normal in acute schizophrenia, impairment of attention and

concentration is common. Insight is usually impaired.

The chronic syndrome:

In contrast with the positive symptoms of the acute syndrome, the chronic
syndrome is characterized by thought disorder and negative symptoms of
under-activity, lack of drive, social withdrawal, and emotional apathy. The
patient is usually unshaven, behavior seems odd, and speech is slow,
incoherent, with few signs of emotions. He withdraws himself from social
encounters with diminished volition that is lack of drive and initiative.
 Disorders of motor activity may occur in chronic syndrome, they are often
called catatonic, and they have variations:
-motor immobility including catalepsy (waxy flexibility)
-excessive motor activity
-extreme negativism, that is resistant to all instructions, or mutism
-peculiarities of voluntary movements;e.g, posturing, stereotypy,
mannerisms, or grimacing.
-echolalia or echobraxia
-stupor and excitement,

In the other side the patient may show mannerisms, ambitendence, and
automatic obedience. Social behavior maybe deteriorated, some patients
collect and hoard objects, talking and shouting in public.
Speech is abnormal; affect is blunted, or flat or incongruent. Hallucinations
are common in any form. Delusions are often systematized, delusions are with
little emotional response, and may also be encapsulated.
Orientation is normal, impairment of attention and concentration is
common, and may result memory impairment or delusional memory. Insight
is partially or completely impaired.
Schizophrenic patients do not necessary experience all symptoms; the
clinical picture is always variable.

Factors modifying the clinical features:

1-social stimulation: under stimulation provoke negative symptoms, and
over stimulation provoke the positive symptoms.

2- social background: may affect the content of some symptoms.

3-age: age also modify the clinical picture, in young adults the clinical picture
include, thought disorder, mood disturbance, passivity, thought insertion
withdrawal, and broadcasting, with increasing age paranoid
symptomatology is more common and well organized.

4-low intelegance: also affect the clinical picture.

Diagnostic problems:
The development of ideas about schizophrenia:

-Griensinger in the 19-Th century, called all psychotic disorders “unitary

psychoses”
-Morel in 1852, called them “demence praecox”
-Kahlbaum in 1863 described the syndrome of catatonia.
-Hecker in 1971 wrote about hebephrenia.
-Emil kraepellin (1855-1926) derived his ideas from study of the course and
symptoms of the disorder, he proposed the division of mental disorders into
two categories:1- demence precox, of four types, paranoid, catatonic,
hebephrenic and simplex type.
2-manic depressive psychoses.

-Eugen Bleuler (1857-1959) he proposed the name schizophrenia to denote a

splitting of psychic functions, he believed that schizophrenic patients had
four fundamental symptoms, he called them 4As, include disturbance of
association, affect, autism, and ambivalence. Accessory symptoms include
delusions, hallucinations, catatonia, and abnormal behavior.

-Kurt Schneider (1887-1967) tried to make the diagnoses more reliable, by

identifying a group of symptoms, characteristic for schizophrenia, he called
these symptoms Schneider’s first rank symptoms and include:
 Hearing thoughts spoken aloud.
 Third-person hallucinations.
 Hallucinations in the form of commentary.
 Somatic hallucinations.
 Thought insertion, withdrawal, broadcasting
 Delusional perception.
 Made actions (delusion pf control)
-Langfeldt (1930) proposed the distinction between true schizophrenia and
Schizophreniform states.
-Leonhard (1957) described the cycloid psychoses.
-International differences in diagnostic practice: By the 1960’s there were
differences in the criteria for the diagnoses of schizophrenia. Two studies
were done –the US-UK diagnostic project showed the differences of
diagnoses between USA and England.
-the international pilot study in schizophrenia (IPSS) was
concerned of the diagnoses of in nine countries.
-Standardized diagnoses:
-Present state examination (PSE) developed by Wing.
-CATEGO a computer program of diagnoses derived from PSE
-Feighner criteria (1972) six months of continuous illness are needed for
the diagnoses of schizophrenia.
-Research diagnostic criteria RDC (Spitzer 1978) made two weeks instead
of six months, needed for diagnoses of schizophrenia.
-Both Feighner criteria and RDC criteria influenced the development of
DSM III and DSM IV.
-International criteria: criteria for diagnoses in ICD10 and DSM IV are with
little differences, the essential features are present on both criteria.
DSM 5 criteria for diagnoses of schizophrenia

A-Characteristic symptoms of the active phase:

Two or more of the following symptoms for at least one month (or less if
treated):1- Delusions.
2- Hallucinations.
3- Disorganized speech.
4- Disorganized or catatonic behavior.
5- Negative symptoms: apathy, alogia, avolition, and associability
B- Social, occupational dysfunction.
C-Duration of illness persistent for at least six months
D-Exclusion of schizo-affective disorder and affective disorder
E- Exclusion of psychosis due to general medical condition, or substance
induced psychoses.
F-Exclusion of autistic spectrum disorder or other childhood disorder

Subtypes of schizophrenia:

Subtypes of schizophrenia are no more present in DSM5 but they still make
important attention as specifiers for clinical practice and management.

1-Paranoid type: clinical picture is dominated by well organized delusions,

thought process and mood are relatively spared, the patient may appear
normal until his abnormal beliefs are uncovered, no disorganized speech,
and behavior no catatonic symptoms, no flat or inappropriate affect.

2-Disorganized (hebephrenic) type: the patient often appear silly and

childish, affective symptoms and thought disorder are prominent, delusions
are common and not highly organized, hallucinations are common,
catatonic symptoms are absent.

3-Catatonic type: is characterized by motor symptoms described before, and

changes in motor activity varying between excitement and stupor.
Delusions, hallucinations and affective symptoms may occur but less
obvious.
4- Undifferentiated type: a type of schizophrenia that not met other types,
paranoid, disorganized, or catatonic.

5- Residual type: a type of schizophrenia which had met full diagnoses

before, but now few residual and negative symptoms are prominent, in the
absence of disorganized speech, delusions, hallucinations, and grossly
disorganized catatonic behavior.
 Other forms or types of schizophrenia:
worst type 1-Simple schizophrenia: is characterized by insidious development of odd
behavior, social withdrawal and declining performance at work, since clear
no positive symptoms
schizophrenic symptoms are absent.

2-Post schizophrenia depression: it is not well known to be part of

schizophrenia, or separate type, it occurs mostly in young patients, educated
and with high inelegance.

3-Schizotypal disorder: it is mostly type of personality rather than form of

schizophrenia.

4-Symptomatic schizophrenia: it is part of schizophrenia secondary to other

medical condition: -Temporal lobe epilepsy (complex partial seizure).
-Encephalitis.
-Amphetamine abuse.
-Alcohol abuse.
-Post-partum psychoses.
-Post-operative psychoses

Schizophrenia-like disorder:

1-Brief psychotic disorder or acute psychotic reaction: this syndrome is

characterized by at least one of the acute phase positive symptoms. The
disorder lasts for at least one day, but not more than one month, by which
time full recovery has occurred. The disorder may or may not follow a
stress events, but psychoses due to GMC or drug induced are excluded.

2-Schezophreniform disorder or schizophrenia like disorder: this

syndrome is similar to the symptoms and diagnoses of schizophrenia, but
has lasted more than one month, but less than six months required for the
diagnoses of schizophrenia. Social and occupational dysfunctions are not
needed, but they may occur.

3-Schizo-affective disorder: Some patients have a more or less equal mixture

of schizophrenia and affective symptoms, the mood disturbance may be
depressed manic or mixed. The schizophrenic and mood symptoms can
present together or in alternative fashion. For the diagnoses of schizo-
affective disorder, the patient must have had delusions and hallucinations
for at least two weeks in the absence of prominent mood disorder syndrome.
4-Type I and type II schizophrenia. Crow and his colleagues have described
two syndromes. Type I schizophrenia is said to have acute onset, positive
symptoms, good social functioning during remission, and good response to
antipsychotic drugs. Type II schizophrenia, is said to have insidious onset,
negative symptoms, poor outcome, and poor response to antipsychotic
drugs.

5-Delussional disorder (paranoia): characterized by the presence of

nonbizare, well systematized and organized delusions, in the absence of any
other mental disorder. The syndrome will be described later.

Differential diagnoses of schizophrenia:

1-Medical and neurological:

a-substance induced disorders: amphetamine, hallucinogens, belladonna,
alkaloid, alcohol hallucinosis, barbiturates withdrawal, cocaine and
phencyclidine (PCP).

b-psychotic disorder due to general medical condition: temporal lobe

epilepsy, neoplasm, cerebrovascular disease, frontal or limbic trauma,
dementia, encephalitis, porphyries, Wilson disease and other conditions.

2-Psychiatric conditions: -brief psychotic disorder, schizophreniform

disorder, schizo-affective disorder, delusional disorder, atypical psychoses,
mood disorders, autistic disorders, factitious disorder, malingering,
obsessive compulsive disorder, personality disorders (schizoid, schizotypal,
paranoid, borderline).

Etiology of schizophrenia:
It may be helpful to outline the main areas of inquiry:
1-predisposing causes: are genetic, environmental factors, neurological
damage at time of birth, biological, social and interpersonal influences,
psychological and psychodynamic factors of etiology.

2-precipitating causes: has been concerned mainly with life events, physical
social, psychological factors may play roll.

3-perpetuating factors: social and family high emotional expression seem to

be important, as well as the patients compliance with treatment.
Genetic factors:
A wide range of genetic studies strongly suggest a genetic component to
the inheritance of schizophrenia:
Family studies: proved that the rate of schizophrenia is higher in some certain
families, and the risk of schizophrenia is increased in relatives of
schizophrenic patients.
Normal prevalence of schizophrenia…………..1%
Life time risk for siblings……………………...5%
Risk for nephews and nieces…………………..3%
Risk for parents………………………………..5%
Risk if one parent schizophrenia……………..15%
Risk if both parents schizophrenic…………...45%
 The risk of schizophrenia, schizo-affective disorder, and schizotypal
personality disorder is increased in first degree relatives of
schizophrenic patients.
 The risk of schizophrenia and mood disorder is increased in first degree
relatives of schizo-affective patients.
 The risk of bipolar disorder is not increased in relatives of
schizophrenia.
Twin studies: these studies compare the concordance rate between the MZ and
DZ twins for schizophrenia, (MZ: DZ=50:10).
Adoption studies: suggested increase risk of schizophrenia in children those
biological parents had schizophrenia.
The mode of inheritance may be monogenic, polygenic or heterogenic,
many genes were suggested, but studies are not satisfactory and exclusive.
There was an association between schizophrenia and chromosome 5,X, and
later chromosome 22.

Changes in brain structure in schizophrenia:

1-Neuropathological:
Many investigations searched for gross pathological changes in the brain of
schizophrenic patients. Recent post-mortem studies have shown that the brains
of schizophrenics are lighter and somewhat smaller, and there is a consistent
enlargement of lateral ventricles, associated with reduction in volume of
hypocampus and parahypocampus gyrus. There is disturbance related to
neuronal migration during development, more pronounced in the left side of
the brain.
Structural brain imaging showed lateral ventricular enlargement, the most
consistent association male sex, and early age of onset, neuropsychological
impairment, and poor response to treatment.
MRI studies have confirmed reduction in the volume of the left temporal
lobe in schizophrenia, some abnormalities also been found at frontal lobes,
basal ganglia and thalamus.
2-Soft neurological signs:
Neurological signs without localizing significance have been reported in
many studies, the commonest abnormalities are in; stereognosis,
graphaesthezia, balance, and proprioception.

3-Nenophysiological changes in schizophrenia:

The EEG of schizophrenic patients generally show increased amount of
theta activity, fast activity, and paroxysmal activity compared with those of
healthy controls.
Studies of evoke potentials have also shown abnormalities among
schizophrenics, that the amplitude of P300 wave response is reduced in
schizophrenia.
There is evidence that patients with schizophrenia have defective tests of
eye tracking (abnormal saccadic eye movement).

4-Functional brain imaging:

A number of techniques, particularly PET, SFECT have been used to asses
patterns of cerebral blood flow in brains of schizophrenics, it is found that
there is a decrease in blood flow in frontal and prefrontal cortex
(hypofrontiality). Moreover there is a reduced hypocampal volume, which
correlates with decrease in prefrontal blood flow, and suggests abnormal
function of temporal and frontal lobes.

Biochemical abnormalities in schizophrenia:

1-The dopamine hypotheses: Many studies attempt to clarify the roll of

dopamine in schizophrenia:
a-amphetamine which releases dopamine at central synopses induces a
disorder indistinguishable from acute schizophrenia.
b-antipsychotic drugs which share dopamine receptor blocking effects and
improve symptoms of schizophrenia.
c-most post-mortem studies of the brains of schizophrenics, reported an
increase of dopamine receptor density in caudate nucleus, putamen and
nucleus accumbens.
d-most receptors involved, with their clinical potency are D2 and D4
receptors
e-high levels of dopamine metabolite homovanilic acid were reported at
blood, urine, and CSF.
2-Serotonin: serotonin has became of much interest in schizophrenia, after
the introduction of so called atypical antipsychotic drugs, with serotonin
related activity (e.g. clozapine, risperdal, olanzepine).
3-Noradrenaline: an increasing data suggests that noradrenergic system
modulates the dopaminergic system.
4-Amino acids: Glutamate is a major excitatory neurotransmitter in the
cortex, and has extensive interactions with dopamine. Other studies proved
that patients with schizophrenia have a loss of GABA-ergic neurons in the
hypocampus.
5-Peptides: some studies show an increase of the peptide cholecystokinin,
somatostatin, and vasoactive polypeptide in the limbic region.

Developmental aspects of etiology

1-Perinatal factors: early environmental factors play a roll:
a-season of birth, the risk of schizophrenia is increased among winter births,
than among those born in summer. This may suggest the influence of viral
cause, may be involved in the incidence of schizophrenia, with parental
exposure to influenza virus in winter season.
b-obstetric complication may also increase the risk of schizophrenia.
2-Childhood development: Fish reviewed the prevalence of pan-
dysmaturation in a number of studied children. The study predict
schizophrenia in children who had poor rapport at interview, with social
isolation, disciplinary problems, passive and shown short attention span as a
child.
3-Personality factors: Kretschmer proposed that both personality type and
schizophrenia were related to asthenic type of body build. Current findings
from family studies suggest that schizophrenic illness may share a common
diathesis with schizotypal personality, and some related personality
disorders. Only a minority of people with schizotypal or schizoid
personalities develop schizophrenia.

Dynamic and interpersonal factors in schizophrenia

Psychodynamic theories suggest that patients with schizophrenia have
abnormal social development during childhood.

According to Freud, in the first stage of development, libido was

withdrawn from external objects, and attached to the ego, the result was
exaggerated self-importance, since the withdrawal of libido made the external
world meaningless, and he restore meaning by developing abnormal believes.

Melanie Klein believed that the origins of schizophrenia were in infancy,

when the infant may take two positions, paranoid or schizoid position, the
infant was thought to deal with innate aggressive impulses by splitting his
own ego towards his mother, one wholly bad and the other wholly good.
Failure to pass through this stage was the basis for later development of
schizophrenia.
The family as a cause of schizophrenia:
1-Deviant role relationships: some writers found that mothers of
schizophrenics showed an excess of psychological abnormalities
(schizophrenogenic mothers). Lidz described two types of families:
-marital skew, in which one parent usually mother dominate the family
-marital schism, in which the parents maintained contrary views, so child has
divided loyalty.
2-Disordered family communication: Bateson developed the double bind
theory, this theory occurs when an instruction is given to the child, but is
contradicted by a second construction, that leave the child to make
ambiguous and meaningless responses. Schizophrenia develops when this
process persists.

Social factors of etiology:

-culture: differences of the incident might be expected in countries with
contrasting cultures.

-occupation and social class: schizophrenia is over represented among

people of lower social class.

-place of residence: schizophrenia is over-represented in the disadvantaged

inner city areas and unsatisfactory living conditions.

-migration: high rates of schizophrenia have been reported among migrants.

-social isolation: schizophrenics often live alone, unmarried and with few
friends.

-psychosocial stresses: the rate of events were increased in three weeks

before the onset of acute symptoms, these events include; moving house
starting or loosing a job, and domestic crises.

Course and prognoses:

It is generally agreed that the outcome of schizophrenia is worse than that

of most psychiatric disorders.
Johnston found that 25%of schizophrenics had good outcome
50% had good social outcome
17% can’t function outside the hospital.
 Factors predicting the outcome of schizophrenia:

Good prognostic features Poor prognostic features

-sudden onset -insidious onset
-older age of onset -younger age of onset
-short episode -long episode
-no past psychiatric history -previous psychiatric history
-prominent affective symptoms -prominent negative symptoms
-paranoid type of illness -hebephrenic type
-married -single, separated, divorced
-high intelligence -low intelligence
-good psychosocial adjustment -poor psychosocial adjustment
-stable premorbid personality -abnormal premorbid personality
-good work record -poor work record
-good social support -social isolation
-good compliance -poor compliance
-high emotional expression -no emotional expression

Social factors play a roll in the onset and the level of symptomatology, the
emotional involvement of relatives can affect the risk of relapse. Too much
stimulation, and high emotional expression, appears to precipitate relapse into
positive symptoms, while under stimulation leads to worsening the negative
symptoms.

Effects of schizophrenia on the family

Relatives of schizophrenics describe two main groups of problems:
1-social withdrawal, because the patients do not interact with others, they
seem slow, lack conversation and neglect themselves.

2-social embracing because some patients express disturbed behavior, such as

restlessness, odd, uninhibited behavior and threat of others.
Relatives often felt anxious, depressed, guilty, or bewildered. Many were
uncertain how to deal with difficult and odd behavior. Further difficulties
arose from lack of understanding and sympathy among neighbors and friends.

Treatment of schizophrenia
The treatment of schizophrenia is concerned with both the acute illness
and chronic disability. The best results are obtained by combining drug and
social treatments. Three methods of treatments are used:
-drug treatment
-physical treatment (ECT)
-psychological treatment
Hospitalization:
The primary indications for hospitalization are
-diagnostic purposes
-stabilization on treatment
-patients safety of suicidal or homicidal ideation
-grossly disorganized or inappropriate behavior
-inability to take care of basic needs, such as food, clothing and shelter
Hospitalization decreases stress on patients and their families, short
hospitalization 4-6 weeks are just as affective as long term hospitalization.
The hospital treatment plan should have a practical orientation towards
issues of living, self care, quality of life, employment and social relationships.

Somatic treatment:
The antipsychotic drugs are sometimes referred as neuroleptics or
dopamine blockers or major tranquilizers, they include:
-typical drugs that act on D2 receptors;
-haloperidol (halidol)…………10-20 mg daily
-Chlorpromazine (largactil)…...300-800 mg daily
-fluphenazin (modicate)………25-75 mg im /monthly
-halidol deaconate …………....100-200 mg im/ monthly
-atypical drugs that act on D2, D4 and 5HT1a receptors;
-risperidone (resperidal)……….4-8 mg daily
-clozapine (leponex)…………...400-800 mg daily
-olanzepine (zyprexa)…………..5-10 mg daily
- quetiapine (seroquell)…………300-600mg daily
- Zyprazidone (Geodon)…………..80-160 mg daily

The various antipsychotic drugs do not differ in therapeutic effectiveness,

but they vary in their side effects. Recent studies suggest modest doses are as
effective as high doses, and have less risk of unfavorable side effects. If rapid
sedation is needed it is preferable to combine a benzodiazepine.

Unwanted effects of typical narcoleptics:

1-Antidopaminergic effects:

a- acute dystonia; the main features are torticollis, tongue protrusion,

occulogiric crises, grimacing, and opisthotonus, it may develop within few
days of treatment, it can be controlled by reducing the dose, giving
anticholinergic drug such as Benzhexol( partane) or biperiden lactate
(dekinet) or antihistaminic promthiazine ( histanil).
 b- Akathisia: the main features are motor restlessness and need to move, it
occurs in the first two weeks of treatment , and can be controlled by
reducing the dose, or giving beta-blockers(propranolol) or
benzodiazepine as short term.

c- Parkinsonism : it is an extra pyramidal symptoms characterized by

akinezia, expressionless face, rigidity, coarse tremors and stooped
posture. The condition can be controlled by, reducing the dose, giving
antiparkinsonian or anticholinergic drugs, antihistaminic promthiazine .

irreversible d- Tardive dyskinezia: it is an extra-pyramidal side effect that comes

secondary to prolonged dopamine blockage. It does not always recover
when the drugs are stopped. It is characterized by chewing and sucking
movements, choreo-athetoid movements, grimacing and possible
akathisia. Most cases are irreversible and need to be maintained on
therapy that may reduce the condition.

MNS e- Malignant neuroleptic syndrome: it is a life threatening complication that

can occur during the course of antipsychotic treatment, it develops
secondary to sudden dopamine blockage and rabdomyelises, with death
rate about 15% characterized by rigidity, dystonia, akinezia, mutism,
agitation, hyperpyrexia, sweating, increased pulse, and blood pressure
with clouded consciousness. Laboratory findings include increased WBC
and CPK. The patient may show urine incontinence, and dehydration .
the first step of treatment is to stop medication, cool the patient,
monitoring of vital signs, electrolytes, fluids and fever. Antiparkinsonian
and Dantrolene(Dantrium) may reduce rigidity, Bromocriptine( parlodel )
can help to reduce symptoms also amantadine can be added to the
regimen.

f- neuroleptics increase the firing of Prolactine and that may cause

amenorrhea, galactorrhoea to females, gynecomastia and impotence to
males. The condition can be treated by giving bromocriptine or reducing
the dose.

2- Anticholinergic effects:
These include dry mouth, urinary hesitancy and retention, constipation,
reduced sweating, blurred vision, and rarely precipitation of glaucoma.

3-Antiadrenergic effects:
These include sedation, postural hypotension, reflex tachycardia, nasal
congestion, and inhibition of ejaculation.
4-Anti-noradrenergic effects:
Cardiac arrhythmias are some times reported, ECG changes in the form of
prolongation of the QT and T wave blurring.

5-Antihistaminic effects:
they can cause sedation and weight gain.

6-Other effects:
- they can cause hypothermia
- seizures can be caused by CPZ
- photosensitivity by CPZ.
- retinal degeneration by thioridazine.
- cholestatic jaundice by CPZ
- rare leucopenia

Adverse effects of clozapine:

The use of clozapine may be associated with leucopenia and
agranulocytoses ( 2-3%) also can cause hyper salivation, drowsiness, postural
hypotension, weight gain, seizures, and hyperthermia. Agranulocytoses is
dangerous and may be irreversible so it is wise to start treatment with 25 mg
daily and to increase the dose 25mg every three days up to 400-600mg daily
and to do CBC and differential every week up to 18 weeks then every month,
and to stop treatment if WBC below 1500.

Adverse effects of Risperidone

Risperidone can cause sedation, fine tremors rigidity, and weight gain, and
diabetes

Adverse effects of Olanzepine,Quetiapine,and Ziprasedone:

they can cause sedation , weight gain, diabetes.

Treatment after the acute phase:

Many controlled trials have shown the effectiveness of continued oral and
depot therapy in preventing relapse, but the duration of treatment vary, thus:

-for one single episode duration of treatment, after the acute phase, at least
two years,
-if the patient had had two episodes, needs treatment for five years,
-if three or more episodes, long life treatment is needed
Electroconvulsive therapy (ECT)
The traditional indications for ECT are:
 Catatonic type of schizophrenia
 Severe depressive symptoms accompanying schizophrenia
 Schizophrenia with severe agitation and aggression

Psychotherapy:

-Some kind of psychotherapies like individual psychotherapy and

psychoanalytic psychotherapy may cause overstimulation and consequent
relapse.

-The work with relatives to reduce the high levels of expressed emotions on
the patient, is beneficial in preventing relapse.

-Behavior treatment: token economy, a method of behavior treatment is used

to alter the behavior of the patient, by using the positive and negative
reinforcement.

-Cognitive therapy: however, direct confrontation is avoided; similarly it may

be possible to modify the patients beliefs about omnipotence identity and
purpose of symptoms.

Treatment of violent patient:

While homicide is rare, self-mutilation is more frequent, and about one

schizophrenic in ten dies by suicide, which may be associated with positive
symptoms as delusions and hallucinations.

General management for violent patients is same as that for any other
schizophrenic patient, although a compulsory order is often needed to bring
disturbed behavior under control. A special ward area with an adequate
number of experienced staff, is much better than use of heavy medication.
The danger usually resolves as acute symptoms are brought under control, but
only a few patient pose a continuing threat.

Further readings:-comprehensive textbook of psychiatry

-oxford textbook of psychiatry
 Paranoid symptoms and paranoid syndromes
Dr. Issam Bannoura, MD JB Psychiatry
Clinical tutor, Bethlehem Mental Hospital

The term paranoid can be applied to:

1-paranoid symptoms: they are delusional beliefs which are most commonly
persecutory, and less common grandeur, jealousy, and sometimes of love,
litigation, and religion. When they occur in association with schizophrenia,
mood disorder or organic disorder, the main etiological factor is the primary
illness.
2-paranoid disorder: (paranoia) now it is called delusional disorder, they are
those syndromes, in which paranoid symptoms form part of a characteristic
constellation of syndromes, such as pathological jealousy, and erotomania.
3-paranoid personalities: are those personalities in which there is excessive
self-reference and undue sensitiveness, combined with self importance,
combativeness, and aggressiveness.

Paranoid psychoses (delusional disorder)

DSM IV uses the term delusional disorder, for the disorder with persistent,
non-bizarre delusions that is not due to any other mental disorder. The
delusions are that of a permanent and unshakable delusional system,
developing insidiously in a person, in middle or late life. The delusions are
encapsulated, well organized, systematized and unitary, with no
hallucinations, or some hallucinations that are related to content of their
delusional ideas.
The patient with delusional disorder can often go to work, and his social
life sometimes well maintained.
According to DSM IV there are seven subtypes:
1. Persecutory type: delusions that the person is being malevolently
treated in some way.
2. Jealous type: delusions in which the individual sexual partner is
unfaithful.
3. Erotomanic type: delusions that another person, usually of higher status,
is in love with the individual.
4. Grandiose type: delusions of inflated, worth, power, knowledge,
identity, or of a famous person.
5. Somatic type: delusions that the person has some physical defect or
general medical condition.
6. Mixed type: delusions of more than one type, but no theme
predominates.
7. Unspecified.
Special paranoid conditions:

1- Pathological jealousy (Othello syndrome): An abnormal belief that the

marital partner is being unfaithful, it is more common in men. The condition
is often accompanied by strong emotions and characteristic behavior. A man
who believes that his wife is in bed with another man may behave in an
uncontrolled way. The patient may be accompanied with other abnormal
beliefs, for example, that the spouse is plotting against him, trying to poison
him, or infecting him.
The mood is often a mixture of misery, apprehension, irritability and anger.
The behavior is often characteristic; commonly there is intensive seeking for
evidence of the partner’s infidelity.

Etiology:
Pathological jealousy was found to be associated with a range of primary
disorders; for example, paranoid schizophrenia, depressive disorder,
personality disorder, alcoholism, organic disorders, and substance induced
disorders, such as amphetamine and cocaine.

Freud believed that unconscious homosexual urges played a part of all

jealousy, that dealt with defense mechanism if repression, denial and reaction
formation.

Pathological jealousy may be induced by the onset of erectile difficulties in

men, or sexual dysfunctions in women, or by social isolation, deafness, and
sensitive personalities.
Prognoses is often poor, it can be of higher dangerous, and there may be
risk of homicide, physical injury, or suicide.

2-Erotic delusions: the syndrome is called Erotomania, the subject usually is

a single woman, believes that an exalted person is in love with her, the loved
person is already married, may be of much higher social status, famous or
public figure. The patient is convinced that the object cannot be happy or
complete person without him.

3-Querulant or reformist delusions: the patients with such delusions often

have complaints against the authorities, they are preoccupied with religious,
philosophical, or political themes, and their behavior may be violent.

4-Capgras delusions: the patient usually believes that a person closely related
to him, has been replaced by a double. The condition is more common in
women, and may associate with schizophrenia or mood disorder.
5-Fregoli delusions: this name derived from the name of an actor called
Fregoli, who had skill in changing his face. The patient identifies a familiar
person usually a persecutor, always changes his facial appearance. The
condition may be associated with schizophrenia.

6-Paranoid conditions occurring in special situations:

- Induced delusional disorder: which appears to have developed in a

person who has close relationship with another person, already established
delusional system, usually there is a dominant partner, and both share the
same delusional ideas. The condition is more common in women, the
delusions are nearly always persecutory, they are called shared psychotic
disorder or induced delusional disorder.

-Migration psychoses
-Prison psychoses
-Cultural psychoses

Treatment of delusional disorders:

Both psychological and physical measures should be considered, they may

be helped by psychological support, encouragement, and assurance.
Interpretive psychotherapy and group psychotherapy are unsuitable.
Treatment with medication may be indicated for a primary psychotic
disorder. Delusional disorders with no primary disorder, symptoms are
sometimes relieved by antipsychotic medication, such as trifluperazine,
chlorpromazine, or halidol, but in low doses, the choice of drug depends on
patient’s age and agitation.

Several studies support the use of Pimozide (2-4 mg daily), for various
forms of delusional disorder. If there is failure of drug treatment, it will be
necessary to prescribe a long acting drug such as fluphenazine decanoate
(modecate).

Further readings: Oxford textbook of psychiatry

Comprehensive textbook of psychiatry
 Mood Disorders
Dr.Issam Bannoura MD JB Psychiatry
Clinical tutor, Bethlehem Mental Hospital

The mood disorders are so called, because one of their main features is
abnormality of mood.
Mood may be normal, depressed or elevated.
The central features of those syndromes, called depressive disorders are
depressed mood, pessimistic thinking lack of enjoyment, reduced activity and
slowness. Those disorders are:
 Major depressive disorder
 Seasonal affective disorder
 Premenstrual dysphoric disorder
 Dysthymia

Syndrome in which the main features are elation, over activity, mood
change and self important ideas is often called Mania, and the less severe form
is called Hypomania. These disorders are:
 Bipolar I disorder (Manic depressive disorder)
 Bipolar II disorder
 Rapid cycling and mixed affective states
 Cyclothymia

Major depressive disorder

Clinical picture:
The central features of major depressive disorder are low mood, lack of
enjoyment, pessimistic thinking, and reduced energy, which leads to
decreased functioning.

The patients appearance is characteristic, dress and grooming may be

neglected, the patient sometimes may speak of a black cloud pervading all
mental activities.
Pessimistic thoughts are important, which can be concerned with past,
present or future. Lack of interest and enjoyment is frequent; the patient may
show no interest for activities, with reduced energy, psychomotor retardation,
anxiety, irritability and agitation, some of these symptoms may dominate the
clinical picture.

A group of symptoms called geological are important, these biological

symptoms include; sleep disturbance, early morning awakening, diurnal
variation of mood, loss of appetite, loss of weight, constipation, loss of libido,
and among women amenorrhea.
Sleep disturbance is of several kinds, most characteristic feature is early
morning awakening, but delay sleep and waking during sleep also occur.

Several other psychiatric symptoms may occur, they include;

depersonalization, obsessional symptoms, phobias, and dissociative symptoms
such as fugue. Complaints of poor concentration and poor memory also may
occur.

Types of depression:

1) Moderate depressive disorder: This disorder described above.

2) Severe depressive disorder: when depressive disorder becomes

severe, all features described above occur, with greater severity and
intensity. In addition other features may occur, in the form of delusions
and hallucinations, sometimes called psychotic depression.

3) Agitated depression: this term is applied to depressive disorder, in

which agitation is prominent. Agitated depression is seen more
commonly among the middle aged and elderly, than among younger
patients.

4) Retarded depression: this name is applied when psychomotor

retardation is prominent.

5) Depressive stupor: in some severe forms of depression, the patient

appears mute, motionless, immobile but aware of surroundings.

6) Masked depression: this term is applied when the depressive mood is

not clear, conspicuous, it is important to detect the loss of pleasure and
poor concentration.

7) Atypical depression: the term atypical has been applied to several

different clinical syndromes; it has included features such as variable
mood, phobic anxiety, overeating, and leaden paralysis.
8) Brief recurrent depression: some patients experience depressive
episodes of short duration, typically 2-5 days, about once a month on
average, they are associated with personal distress with social and
occupational impairment.
9) Mild depressive disorder: this syndrome would present with
symptoms similar to those of the major depressive disorder already
described, but with less intensity.
Classification of depressive disorders:

Classification based on etiology:

1. Reactive and endogenous depression: in endogenous disorders,
symptoms were caused by factors within the individual person, and
were independent of outside factors. In reactive disorders, symptoms
were a response to external stressors, and were sad to be characterized
by anxiety, irritability and phobias. In the other side endogenous
depression in characterized by biological symptoms.
2. Neurotic and psychotic depression: neurotic depression is used when
there is no evidence of loss of contact with reality, in the other side
psychotic depression is applied when delusions and hallucinations are
present in the course of disorder.
3. Melancholic and somatic depression: in which the most prominent
features are loss of interest and pleasure, distinct quality of mood,
morning worsening of mood, early morning waking, psychomotor
agitation or retardation, significant anorexia or weight loss, excessive
guilt and loss of libido.
4. Primary and secondary depression: This is based on etiology. The
aim was to exclude cases of depression that might be caused by another
disorder.

Classification by course and time of life:

1. Unipolar and bipolar disorder: Leonhard suggested a division of
affective disorders into three groups; patients who had had only a
depressive disorder called unipolar depression. Those who had had only
mania called unipolar mania, and those ho had had both depression and
mania called bipolar.
2. Seasonal affective disorder: some patients repeatedly develop a
depressive disorder at the same time of year; the characteristic features
of this syndrome are hypersomnia and increased appetite with craving
to carbohydrate. The most common pattern in onset in autumn or
winter, and recovery in spring or summer, this pattern has led to the
suggestion that shortening of day light is important, and to attempts at
treatment by exposure to bright artificial light during hours of darkness.
Improvements may be related to known effect of light in suppressing
the nocturnal secretion of melatonin.
3. Involutioanal depression: in the past, depressive disorders starting in
middle life were thought to be a separate group characterized by
agitation and hypochondriacal symptoms, it was suggested that they
might have a distinct etiology such as involution of sex glands.
4. Senile depression: elderly patient with depressive disorders were also
regarded as separate group.
 Classification based on ICD 10 and DSM 5
-Major depressive disorder –mild
-moderate
-severe
-severe with psychoses
-Dysthymic disorder.
-Depressive disorder not otherwise specified

Diagnoses of depressive episode (DSM 5):

A. Five of the following (or more) have present at least for two weeks
period, symptoms (1) or (2) must always present:
(1) Depressed mood most of the day and every day.
(2) Diminished interest in pleasure activities.
(3) Significant weight loss or weight gain (Appetite change).
(4) Insomnia or hypersomnia.
(5) Psychomotor agitation or retardation.
(6) Fatigue or loss of energy.
(7) Feeling of guilt and worthlessness.
(8) Diminished ability to think and concentrate.
(9) Recurrent thoughts of death and or suicidal ideation.
B. The symptoms do not meet criteria for mixed episode.
C. Significant impairment in social and occupational functioning.
D. The symptoms are not due to GMS, or substance induced.
E. The symptoms are not due to bereavement.

The most recent type (severity):

1. Mild: minor impairment, no psychotic symptoms.
2. Moderate: moderate impairment may pass in some psychosis.
3. Severe: severe impairment passes in some psychosis.
4. Severe with psychosis: the clinical picture is dominated with psychotic
symptoms:

Diagnoses of major depressive disorder (DSM 5):

A. Presence of at least one single depressive episode.

B. The episode is not due to schizophrenia, schizo-affective disorder,

schizophreniform disorder or delusional disorder.

C. Never been manic episode, mixed episode or hypomanic episode.

 Special features that may associate the clinical picture:
-with catatonic features
-with melancholic features
-with atypical features
-with post partum onset
-with seasonal pattern
-with anxious distress
-with mixed features
-Mood-congruent psychotic features: guilt, death, nihilism.
-Mood-incongruent psychotic features: persecutory, reference, thought
insertion, withdrawal and broadcasting. happen normally

Premenstrual dysphoric disorder: is a severe and disabling form of premenstrual syndrome

The pattern of symptoms occurs at a specific time during the menstrual

cycle, symptoms are present during the luteal phase, and began to remit during
menstruation. The criteria include abnormal behavior, mood and somatic
symptoms.
The most common symptoms are, liability of mood, anxiety, irritability,
fatigability, poor concentration, change in appetite and sleep, headache,
abdominal distention, breast tenderness and edema.

Dysthymic disorder:
The diagnoses criteria for dysthymia is the same as minor depressive
disorder, except the duration of symptoms are too long, two years for adults
and one year for adolescents and children. Dysthymia also called neurotic
depression; patients are often anxious, obsessive, and prone to somatization.
Some patients develop major depressive disorder in the course of their
dysthymic disorder, and are called to have double depression.

Mania
Clinical picture:
The central features of the syndrome of mania are elevation of mood,
increased activity, and self important ideas. The appearance reflects his
prevailing mood, clothes may be brightly colored, manic patients are
overactive their speech is often rapid, with flight of ideas or pressure of
thought, sleep is often reduced, appetite and sex are increased and uninhibited.

Expansive ideas are common; many patients become extravagant,

overspending, with reckless spending. Sometimes their expansive themes are
accompanied by grandiose delusions, hallucinations also occur, and insight is
invariable impaired.
Mixed affective states:
Depressive and manic symptoms sometimes occur at the same time, for
example a manic patient may become intensely depressed for few hours, and
then return quickly to his manic state.

Manic stupor:
In this unusual disorder, patients are mute immobile and motionless, but
their facial appearance and expression suggests elation.

Rapid cycling disorders or periodic psychoses:

Some bipolar disorders recur regularly, with intervals of only weeks or
months between episodes, usually at least four episodes of mania or
depression a year are needed for the diagnoses of rapid cycling disorder.
They are much more common among females.

Classification of bipolar disorders:

Manic episode----Mania- mild-severe
-severe with psychoses
----Hypomania
Bipolar disorders-Bipolar I disorder
-Bipolar II disorder
Cyclothymia.

Diagnostic criteria for manic episode (DSM 5):

A. Elevated, expansive, or irritable mood for at least one week.
B. During the mood disturbance, at least three or more of the following
(1) Inflated self esteem or grandiosity.
(2) Decreased need for sleep.
(3) More talkative than usual.
(4) Flight of ideas or pressure of thought.
(5) Distractibility.
(6) Increased activity.
(7) Excessive involvement in pleasure activities.
C. the symptoms do not meet criteria for mixed episode.
D. Marked impairment of social and occupational functioning.
E. The episode is not related to substance use, or due to GMC.
Severity: the most recent type:
Mild: minimum symptoms and no psychoses.
Moderate: increased activity and occasional psychoses
Severe: severe symptoms and psychotic features
Severe with psychoses: the psychotic symptoms dominate the clinical
picture—Mood-congruent psychotic features; grandiosity
-Mood-incongruent psychotic features; persecution
Diagnostic criteria for hypomanic episode (DSM 5):
The diagnostic criterion of hypomanic episode is similar to manic episode
with two main differences:
1-The duration of symptoms are less of one week needed for manic episode
2-The episode is not severe enough to cause marked impairment of social and
occupational functioning.

Diagnostic criteria for bipolar I disorder (DSM 5):

A: Presence of at least one manic episode, past depression is not needed.
B: The manic episode is not accounted for schizophrenia, schizo-affective
disorder, schizophreniform disorder, or delusional disorder.
The disorder may be associated with special features:
-with anxious distress
-with melancholic features
-with atypical features
-with catatonic features
-with post-partum onset
-with seasonal pattern
-with rapid cycling
-with mixed episode
-with mood congruent psychotic features
-with mood incongruent psychotic features

Diagnostic criteria for bipolar II disorder (DSM 5):

A: Presence of one or more depressive episode.
B: Presence of at least one hypomanic episode
C: Never been a manic episode.
D: Symptoms are not accounted for schizophrenia, schizo-affective disorder,
schizophreniform disorder or delusional disorder.

Cyclothymic disorder:
Cyclothymic disorder is symptomatically is a mild form of Bipolar II
disorder, it is characterized by alternation of episodes of hypomania and
episodes of minor depressive disorder, with long duration of time, at least two
years for adults, and one year for adolescents and children, with no remission
period for at least two months.

Epidemiology of mood disorders:

Disorder Major depressive Bipolar I
Prevalence 6-10% 1%
Sex f : m 2:1 1: 1
Mean age of onset 27 years 21 years
Social class low high
Etiology of mood disorders:
Genetic causes:
Genetic data, and several genetic family, adoption, and twin studies,
indicate that a significant genetic factor play roll in the development of mood
disorders. In addition there is a stronger genetic component for the
transmission of bipolar I disorder, than that of the depressive disorder.
The concordance rate in twin studies for bipolar I disorder is 69MZ to
13DZ, and for depression 55MZ to 15DZ. The mode of inheritance is not
clear yet.

Environmental causes:
Predisposing factors that may play roll are:
1-Many studies suggested that childhood deprivation, through separation or
loss predisposes to depressive disorders in adult life.
2-Parents of depressed patients have been described as less caring, and more
overprotective.
3-Unhappy marriage.
4-Problems at work
5-Unsatisfactory housing
6-Low self-esteem and poor social support
7-Brown and Harris studied four vulnerable factors for women:
-having the care of three or more young children
-not working outside home
-having no one to confine in
-loss of mother by death or separation before the age of 11
Recent life events may play major roll as precipitating factors, there is an
excess of life events in the months before the onset of depressive disorder,
also it has been suggested that loss by separation or death is particularly
important.

Biological factors:
The monoamine hypothesis suggests that depressive disorder is due to an
abnormality in the monoamine neurotransmitters system, at one or more sites
in the brain. Three monoamine transmitters have been implicated:
-5hydroxytryptamine (5HT) or serotonin
-Noradrenalin (NA)
-Dopamine (D)
-Others, such as GABA and vasopressin

The hypothesis has been tested by observing three kinds of phenomena:

1- Low levels of metabolites (5HIAA, 3M4HPG) are detected in blood, urine,
and CSF of depressive patients, and increased dopamine metabolite (HVA)
in mania.
2- The effects of selective drugs, and the pharmacological proprieties shared
by antidepressant drugs.
3-The studies of post-mortem brain, that the density of neurotransmitters
receptors in certain cortical regions is changed, in patients with mood
disorders that can be an adaptive or compensation change.

Neuroendocrinal causes:
1- The hypothalamus is central to the regulation of endocrine axis, and itself
receives many neuronal inputs, that use biogenic amine neurotransmitters.
The major neuroendocrine axis of interest:
-Adrenal axis: hypersecretion of cortisol in depression
-Thyroid axis: blunted release of thyrytropine in depression
-Growth hormone: blunted growth hormone release in depression

2- Sleep abnormalities; common abnormalities are:

-delay sleep onset
-shortened REM latency
-increased length of first REM period
-impaired sleep continuity and duration
-decreased deep sleep (stages III and IV)
These sleep abnormalities are suggesting that Melatonin secretion is
decreased, as a marker of circadian rhythm deregulation.

3- Kindling theory is the electrophysiological process in which repeated sub

threshold stimulation of a neuron, eventually generates an action potential,
that led to the theory of kindling in the temporal lobe may cause manic
symptoms. And the clinical observation that anticonvulsants (Carbamazepine,
Depakin) are useful in the treatment of mood disorders, rise and support that
theory.

Neuroanatomical considerations:
Brains imaging (CT, MRI, PET, and SPECT) have provided a number of
abnormal brain functions of patients with mood disorders. The data indicate
the following: -Enlargement lateral ventricles in bipolar I disorder
-Patients with major depression have smaller caudate nuclei
and smaller frontal lobes
-Mood pathology involves the limbic system, basal ganglia
and the hypothalamus.
Physique and personality:
Kretchmer (1936) proposed that patients of picnic body built were prone to
develop mood disorders
Kraeplin suggested that people with cyclothimic personality were more
prone to develop manic depressive disorder.
Psychological theories of etiology:
1- Psychoanalytic theory:
Freud in 1917 developed a paper called “mourning and melancholia” he
suggested that as mourning results from loss by death, the same melancholia
results from loss of other kinds. Freud termed the loss of an object, as main
cause of depression.
Klein 1934 suggested that at the early stage of development, the infant,
gradually when mother leaves him, he proposed the depressive position, if this
stage is not passed successfully; the child will be more likely to develop
depression in adult life.
Psychoanalytic theory explains mania as a defense mechanism against
depression.
2- Learned helplessness:
Seligman suggested that repeated unacceptable stimulation, may lead to
helplessness and depression.
3- Cognitive theory:
Beck has proposed that depressive cognitions consist of automatic
thoughts, may reveal negative views of self, word and future.
4- Behavior theory:
According to classical conditioning theory, developed by Pavlov, a person
may respond to stressful life events by depressive or manic symptoms.

Course and prognoses

Bipolar disorders:
Bipolar I disorder most often starts with depression (90%), and is a
recurring disorder, most patients experience both depressive and manic
episodes, although 10%-20% experience only manic episodes. Manic episode
may have a rapid onset, with duration over few weeks, untreated lasts about
three months. As the disorder progresses, the time between episodes often
decreases, after about five episodes, the interepisode interval stabilizes at six
to nine months. Some patients have rapidly cycling episodes. Patients with
bipolar I disorder have a poorer prognoses than do patients with major
depressive disorder.

Good prognostic features:-short duration of manic episode

-advanced age of onset
-few suicidal thoughts
-few coexisting psychiatric or medical problems

Poor prognostic features: -poor premorbid occupational status

-alcohol dependence
-psychotic symptoms
-male gender
Major depressive disorder:

The age of onset is later than in bipolar I disorder (27- 40 years). The
course is variable, untreated lasts 6- 13 months, most treated last about three
months. As the course of the disorder progresses, patients tend to have more
frequent episodes that last longer. It tends to be a chronic disorder, only 50%
have a chance of recovery in the first year, 10 – 20% have not recovered. By
time a patient experiences more and more depressive episodes, the time
between episodes decreases, the severity of each episode increases.

Good prognostic features: -mild episodes

-absence of psychotic symptoms
-short hospital stay
-good social functioning
-stable family functioning
-absence of premorbid psychiatric illness
-absence of premorbid personality disorder

Poor prognostic features: -coexisting dysthymic disorder

-abuse of alcohol or other substances
-coexisting anxiety disorder
-previous psychiatric disorder

Mood disorders and suicide:

Between 11 and 17 per cent of people who have suffered a severe

depressive disorder, at any time will eventually commit suicide.
Suicide is more common for male gender, older age, single, or separated,
divorced, unemployed, with previous suicidal attempts, with social isolation,
with premorbid personality disorder, past forensic history and with alcohol
and drug abuse.

Circumstances that suggesting high suicidal intent:

1-planning the act
2-precautions are taken to prevent discovery
3-no attempts are taken to obtain help afterwards
4-using dangerous methods
5-final act: writing a suicidal note or a will.
Differential diagnoses:
Major depressive disorder:
Depressed patients should be differentiated from other medical disorders, such
as: - temporal lobe epilepsy
-mononucleosis
-cerebrovascular disease
-dementias
-infectious diseases including HIV
-Cushing and Addison disease
-hypothyroidism
-hyperparathyroidism
-premenstrual depressive symptoms
Also depressive disorder should be differentiated from substance induced
depression, such as: cardiac drugs, antihypertensive drugs, sedatives,
hypnotics, antipsychotics, antiepileptics, antiparkinsonian, analgesics,
antibacterials, and antineoplastics.

Depression can be a feature of many mental disorders, such as:

1-other mood disorders
2-psychotic disorders
3-anxiety disorders
4-uncomplicated bereavement

Bipolar I disorder:
Manic episodes have to be distinguished from schizophrenia, schizo-
affective disorder, organic brain disorder involving the frontal lobe, and states
of excitement induced by amphetamine, alcohol, cocaine, opoids, or other
drugs.

Treatment of mood disorders

Treatment of depression:
- Antidepressant drugs such as: -tricyclic antidepressants
-MAOI
-SSRI
-Lithium
-Anticonvulsants
-Electroconvulsive therapy (ECT)
-Psychotherapy
Treatment of mania:
-Antipsychotic drugs
-Lithium
-Anticonvulsants
-Electroconvulsive therapy (ECT)
-Psychotherapy

Acute treatment of depression:

The use of pharmacotherapy approximately doubles the chance that a
depressed patient will recover in one month. Generally it will take 2-4 weeks
to exert significant therapeutic effects. Patients may show the effect of
treatment earlier, the first symptoms to improve are; poor sleep, and appetite
pattern. The duration of antidepressant treatment is at least six months.

1- Cyclic antidepressants:
-Tricyclic - Imipramin (Tofranil) in dose 75-250 mg daily
- Amitriptylline (Elatrol) in dose 75-250 mg daily
- Clomipramin (Anafranil) in dose 75-250 mg daily
- Trimipramin (surmontil) in dose 75-250 mg daily
-Bicyclic, Desipramin, Nortriptylline, Protriptylline.
-Tetracyclic; Maprotilline, Amoxapine, Mianserine.

Side effect profile of cyclic antidepressants:

- anticholinergic
- sedation
-hypotension
-seizures
-cardiac changes
-toxic in high doses

2- Monoamineoxidase inhibitors (MAOIs) : they are effective in the treatment

of depression with melancholic features, wild form, and atypical
depression. MAOI drugs;
- Phenelzine (Nardil) in dose 15-60 mg daily
- Tranylcypromine (Parnate) 10-30 mg daily
- Moclobemide (Mobemide) 300 mg daily

Unwanted effects of MAOIs:

- anticholinergic
-hypotension
-cardiac effects
-edema of the ankle
-jaundice
-tyramine reaction, or cheese reaction, patients should avoid some foods and
drinks: - all cheeses except cream cheese
- red wine, been, liquors
-pickled or smoked fish
-packed soups
-beef and chicken livers
-some sausage
-aged, unfresh food

3-Selective serotonin reuptake inhibitors: (SSRI)

The SSRIs have minimal effects on blood pressure and cardiac function.
The major unwanted effects are nausea, anorexia and diarrhea, sometimes
weight loss. They have no anticholinergic side effects, and not toxic in
overdose, the most important SSRIs are
- Flouxetine (Prozac) in dose about 20 mg daily
- Fluvoxamine (Favoxil) in dose about 100 mg daily
- Paroxetine (seroxat) in dose about 20 mg daily
- Sertaline (Zoloft) in doze about 50 mg daily
- Cipram (Cipramil) in dose 20 mg daily

4- Lithium carbonate:
Studies have shown that Lithium has antidepressant effects, but the onset
of action is slower, and the serum level of lithium must be between 0.8-1.2
mEg/L. It has been reported that the therapeutic effects of tricyclic
antidepressants can be increased if lithium is added.
Unwanted effects of lithium:
- Tremors, dry mouth and metallic taste.
- Muscular weakness and fatigue
- Polyuria, polydipsia, diabetes inspidus
- Weight gain, edema
- Hypothyroidism, hyperparathyroidism
- Hypokalemia and ECG changes
- Anorexia, nausea and vomiting
- Leococitosis
- Structural renal tubular change and damage
- Toxic effects in overdose, the dose are over 1.5
mEg/L and include ataxia, poor coordination,
muscle twitching, slurred speech and confusion.
- Congenital malformation (teratogenic)

5-Anticonvulsant drugs: they can be used for depression, such as

-Carbamazepine (Tegretol) in dose about 600-1200 mg daily
-Sodium Valporate (Depalept) in dose of 20 mg/Kg body
6- Bright light treatment for atypical depression

7- ECT therapy: indications

- Severe depressive disorder
-Weight loss and early morning awakening
-Psychomotor retardation and delusions

8- Psychotherapy: the most important methods are

-clinical management
-supportive psychotherapy
-dynamic psychotherapy
-marital therapy
-interpersonal therapy
-cognitive behavior therapy

Acute treatment of mania:

1- Antipsychotic drugs, particularly chlorpromazine and haloperidol are

widely used to treat mania. The current trend in the management of mania is
to use lower doses of antipsychotic drugs, such as:
CPZ (Largactil) 300-500 mg daily
Halidol 6-20 mg daily

If addition sedation is needed, adjunctive treatment with a benzodiazepine

such as Lorazepan can be given.

2-Lithium Carbonate also can be used in the treatment of mania, alone or

adjunctive treatment with antipsychotic drugs, the main affect to decrease the
elevated mood.

3- Anticonvulsant drugs: Carbamazepine is effective in the treatment of acute

mania, and has earlier onset of action. The same Sodium Valporate in doses of
20 mg/kg body is effective in treatment of acute mania without psychoses.

4- ECT: ECT is superior to Lithium and anticonvulsant drugs in treatment of

mania. There is a tendency to give ECT to patients who are unresponsive to
drug treatment, with life threatening, extreme over activity and physical
exhaustion.
Prevention of relapse:

Unipolar depression:

For depression continuation of treatment for six months with

antidepressants has been shown to reduce the relapse rate. If antidepressants
are continued for longer period of time as prophylactic treatment they reduce
the risk of new episode of depression. Lithium in doses 0.6-0.8 mEg/L is also
effective in the prevention of depression.

Bipolar disorders:

There is substantial evidence for the efficacy of Lithium, Carbamazepine,

and Sodium Valporate in the prevention of mood disturbance in patients with
bipolar disorders.

To reduce the rate of relapses the duration of treatment is two years for one
episode, five years for two episodes and long life for more than three
episodes.

Further readings: - Oxford textbook of psychiatry

-Comprehensive textbook of psychiatry
 Anxiety Disorders
Dr. Issam Bannoura, MD, JBpsychiatry
Clinical tutor, Bethlehem mental hospital

When evaluating a patient with anxiety, the clinician must distinguish

between normal and pathological anxiety.

Anxiety is normal for the infant who is threatened by separation from

parents, or by loss of love, for children on their first day in school, for
adolescents on their first date, for adults when they contemplate old age and
death, and for any one who is faced with illness.

Pathological anxiety by contrast, is an inappropriate response to given

stimulus. The feeling is characterized by a defuse, unpleasant, vague sense of
apprehension, often accompanied by autonomic symptoms, such as headache,
perspiration, palpitation, tightness in the chest, and stomach discomfort. An
anxious patient also feels restless, unable to sit or stand still for long.
The distinction between fear and anxiety may be difficult. Fear is a
response to a threat that is known, external, nonconflictual in origin, anxiety is
a response to a threat that is unknown, internal, vague or conflictual in origin.

Etiology of anxiety disorders

Psychological theories:
-Psychoanalytic theories: Freud proposed that anxiety is a signal to the ego
that an unacceptable drive is pressing. As a result to the signal, anxiety
arouses the ego to take defense action. If repression alone results, the result
is without symptom formation, if repression is unsuccessful as a defense,
other defense mechanisms(such as conversion, displacement, and repression)
may result in symptom formation, this can produce the picture of classic
neurotic disorder such as hysteria, phobia and obsessive compulsive
disorder.
Anxiety is seen as falling into four major categories, depending on its
nature: id or impulse anxiety, separation anxiety, castration anxiety, and
superego anxiety.

-Behavioral theories: Those state that anxiety is a conditioned response to

specific environmental stimulus.

-Cognitive theories: according to cognitive model patients suffering from

anxiety disorder tend to overestimate the degree of danger and harm, and
underestimate their ability to cope with perceived threat.
Biological theories:
-Autonomic nervous system: Simulation of the autonomic nervous system
causes certain symptoms, cardiac (tachycardia), muscular (headache),
gastrointestinal (diarrhea), and respiratory (dyspnoea). These symptoms are
associated with the adrenal release of epinephrine.
-Neurotransmitters: Three major neurotransmitters are associated with
anxiety and have responses to drug treatment, they are nor epinephrine,
serotonin, and GABA.
-neuroanatomical considerations: The neuroanatomical substrates of anxiety
disorders are the locus ceruleus and the raphe nuclei project primarily to the
limbic system and the cerebral cortex.
-Genetic studies: Genetic studies have produced data that at least there are
some genetic components contribute to the development of anxiety disorders.
Also indicate a higher frequency of the illness in first degree relatives of
affected patients than of the relatives of non affected persons.
-Other personal family social and environmental factors: these factors
play a major roll in the etiology of anxiety disorders.

Generalized anxiety disorder (GAD)

Clinical picture and diagnoses:
The symptoms of GAD are persistent and not restricted to any particular
set of circumstances, and they should have been present for most days, for at
least several weeks at a time, as usually several months, at least six moths
durations (DSMIVcriteria)
Symptoms of GAD:
1-Psychological- fearful anticipation,
- irritability
- sensitivity to noise
- restlessness
- poor concentration
- worrying thoughts.
2-Autonomic:sweating, palpitation, dry mouth, epigastric discomfort, and
dizziness.
3- Physical: Gastrointestinal: dry mouth, epigastric pain, difficulty in
swallowing, excessive wind, loose motion.
Respiratory: constriction in the chest, difficulty inhaling,
over breathing.
Cardiovascular: palpitation, discomfort in the chest, awareness of
missed beats.
Genitourinary: urgent micturation, failure of erection, menstrual
discomfort, amenorrhea.
Neuromuscular: tremor, tinnitus, dizziness, headache, aching
muscles.
4-Sleep disturbances: insomnia and night terrors
5- Other symptoms: depression, obsession, depersonalization.

Differential diagnosis :
-depressive disorders.
-schizophrenia.
-presenile and senile dementia.
-drugs and alcohol addiction.
-some physical illness, thyrotoxicoses, phaechromacytoma, and
hypoglicemia.
Epidemiology:
GAD is a common condition. The prevalence ranges from 3-6 percent.
Perhaps 50% of patients with GAD have another mental disorder.
The ratio of women to men is about 2:1.
Etiology:
GAD appears to be caused by stressors acting on a personality, predisposed
by a combination of genetic, biological, psychological and environmental
factors.
Prognoses:
Many anxiety disorders improve within six months, of these lasting longer
80% persist for three years. Poorer prognoses is associated with severe
symptoms, with syncope episodes, agitation, derealization, hysterical features,
and suicidal ideas. On follow up episodes of depression occur frequently
among many patients with anxiety disorders.

Treatment:
Counseling: In the early stages of anxiety, simple methods of counseling are
often effective. First, the nature of the disorder is explained and
reassurance about any fears of physical symptoms. Second, the
patient is helped to deal with social problems.

Cognitive behavioral treatments:

Relaxation training may be helpful, anxiety management training combines
relaxation with cognitive procedure, to help patients to control worrying
thoughts.

Treatment with drugs:

-Benzodiazepines: they are appropriate for short term treatment of GAD: for
example diazepam 5 mg twice a day or 10 mg three times a day in the most
severe cases. Anxiolitic drugs should seldom be prescribed for more than
three weeks, because of the risk of dependence, and it is better to use the long
acting preparations.
-Barbiturates: they were used to treat GAD, but they have risk of dependence.
-Buspirone: Buspirone is as effective as benzodiazepine in the short term
management of GAD, and less likely to cause dependence.
-Beta-blockers: they have some use for patients with GAD especially for
controlling severe palpitation.
-Tricyclic antidepressants: they are less likely to cause dependence, they can
be given in low doses and for long time.
-MAOI: also in low doses they are Anxiolitic.
-Antipsychotic drugs: they have Anxiolitic effect in low doses.

Panic disorder
The central feature of panic disorder is the occurrence of panic attacks.
Panic attacks are sudden attacks of severe anxiety with physical symptoms
and excessive fear.

Symptoms of panic attack( at least four symptoms needed for the diagnosis
of panic attack):-shortness of breath
-chocking
-palpitation and acceleration of heart beats
-chest discomfort and pain
-sweating
-dizziness, faintness
-nausea and abdominal pain
-depersonalization and derealization
-numbness
-flushes and chills
-trembling or shaking
-fear of dying
-fear of going crazy, uncontrolled
-hyperventilation: that may be the main feature that characterize
panic disorder, it is breathing in a rapid and shallow way with
fall in the concentration of carbon dioxide in the blood, the
resulting hypnocapnea may cause dizziness, tinnitus,
headache, weakness, faintness, numbness, tingling in the
hands, feat, and face, carpopedal spasm and chest discomfort.

DSM 5 Diagnoses of panic disorder:

The diagnoses of panic disorder is made when more than four attacks have
occurred in four weeks, or one attack has been followed by four weeks of fear
of having another attack.

Differential diagnoses:
Panic attacks occur in generalized anxiety disorder, phobic anxiety
disorders, depressive disorders, and acute organic disorders.
 Epidemiology:
The prevalence of panic disorder is about 6-10% . the prevalence in
women is about twice that in men.
Etiology :
-the biochemical hypotheses: many theories reflect the roll of serotonin and
noradrenalin in panic disorder.
-some evidence prove that panic disorder occur more often among relatives,
suggesting a genetic component, and possible biochemical basis for the
disorder.
-the hyperventilation hypotheses: based in the observation that in some people
voluntary over breathing produces symptoms like those of panic attacks.
-cognitive theory: patients generally have fear of serious physical or mental illness
secondary to misunderstanding and exaggeration of physical signs and symptoms.

Cause and prognoses:

panic disorder in general is a chronic disorder, nevertheless:
30-40% seem to have good outcome
50% still have symptoms that are mild
10-20% continue to have significant symptoms

Treatment:
Apart from supportive measures and attention to any causative personal or social
problems, treatment is mainly with either drugs or cognitive therapy.
-Benzodiazepine: especially alprazolam (xanax) , in high doses
-Antidepressant drugs: Imipramin (tofranil) in dose of 150-250 mg daily
Clomipramin (anafranil) in dose of 150-250 mg daily
SSRIs -Flouxetine (prozac) = 20-60 mg daily
-Paroxetine (seroxat) = 20-60 mg daily

Panic disorder with agoraphobia

Some patients , in the course of their panic disorder, develop fear of going outside
home or they prevent to be alone, or they stay at home, when they are outside home they
are anxious and afraid of having panic attacks. Treatment of these cases is directed to the
panic disorder, which is the primary cause of agoraphobia.

Agoraphobia
Clinical picture:
Agoraphobic patients are anxious when they are away from home, in crowds, or in
situations that they cannot leave easily. Many situations provoke anxiety, avoidance, and
irrational fear, such as distance from home, overcrowding, buses, trains, shops, and
supermarkets. Most patients are less anxious when accompanied by a trusted companion,
and some are helped presence of a child or a dog.
 Anticipatory anxiety is a common symptom. In severe cases this anxiety appears hours
before the person enters the feared situation.
Other symptoms may be present, include depressive symptoms, depersonalization, and
obsessional thoughts.
Epidemiology:
Most cases begin in the early or mid twenties, or mid thirties( adults). Usually starts
with panic attack. The prevalence is about 6-10%, more common for female, about 2:1

Etiology:
Environmental factors:-stress,
-serious problems(worry about a sick child)
-worry about physical illness
-child birth.
Cognitive theory: agoraphobia develop to people who are afraid of minor physical
symptoms, and they misinterpret their body symptoms.
Behavior theory: the symptoms appear secondary to unconditioned stressful events.
Psychodynamic: unacceptable sexual or aggressive impulses.
Personal causes: agoraphobic patients are often described as dependent, and prone to
Avoid rather than confront problems.
Prognoses:
Agoraphobia lasting for one year changes little in the next five years.
Differential diagnoses:
Agoraphobia may be differentiated with:
-social phobia
-generalized anxiety disorder
-panic disorder
-depressive disorder
-paranoid disorders
Treatment:
The treatment of choice is a form of behavior therapy:
-relaxation
-training in coping with phobic situation
-desensitization in imagination ( gradually )
-desensitization in practice ( gradually )
Drug treatment may be needed for short time
- Anxiolitic drugs (Xanax)
- Antidepressants (clomipramin, MAOIs, SSRIs)

Agoraphobia with panic attacks

Some patients who have agoraphobia, they develop panic attacks, especially when
they are away from home or outside home. The treatment is directed to the agoraphobia,
which is the primary cause of the panic attacks.
Simple or specific phobia
Simple phobia is an irrational, exaggerated fear and anxiety in the presence of one or
more particular objects or situations, such as animals, high places, dark, phobia of dental
treatment, of flying, phobia of illness.
Prevalence: usually starts in adolescents and children, the prevalence is 4% for men
13% for woman.
Etiology: Most simple phobias of adult life are a continuation of childhood phobias.
Genetic and psychological factors play a roll in the etiology.
Differential diagnoses: -Depressive disorders.
-Other phobias.
- Generalized anxiety disorder.
-Obsessional disorder.
Prognoses: Simple phobia originates in childhood continue for many years, whilst those
starting in adult life after stressful events have a better prognoses.
Treatment: Exposure form of behavior therapy.

Social phobia 0r generalized anxiety disorder

Irrational and inappropriate fear and anxiety experienced in situations in which the
person observed and could be criticized. Anxiety is also experienced in anticipation of
entering situations. Flushing and trembling are frequent. Alcohol abuse is more common
in social phobia than in other phobias.
Epidemiology: Social phobias are about equally in men and woman, the prevalence is
about 7-9%.
Prognoses: The condition usually begins between ages of 17 and 30( adolescent).
Without treatment the condition often lasts for many years.
Differential diagnoses:- Agoraphobia
-Panic disorder
-Generalized anxiety disorder
-Depressive disorder
-Schizophrenia
-Avoidant personality disorder
Etiology: -minor genetic factors
-environmental factors
- conditioning and cognitive factors.
Treatment:
Psychological treatment: -social skill training
-relaxation training
-cognitive behavior therapy.
Drug treatment: -Benzodiazepines
-Beta-blockers
-MAOIs
-SSRIs.
 Obsessive compulsive and related disorders(OCD)

Obsessive compulsive disorder(OCD)

Obsessive compulsive disorders are characterized by obsessional thinking, compulsive

behavior and varying degree of anxiety, depression and depersonalization. Obsessional
thoughts are words, ideas, beliefs recognized by the patient as his own, they are
unpleasant and attempts are made to exclude them.
Also the patient may experience obsessional thoughts, ruminations, doubts, impulses
and obsessional rituals(compulsion) include cleaning, counting, checking, and dressing.
Anxiety is an important component of the obsessive compulsive disorder.

Diagnoses:
Diagnoses is made when obsessions or compulsions cause marked distress, and
interfere with the persons normal routine occupational functioning, and the patient knows
that they are excessive and unreasonable. the symptoms must be disruptive to everyday
functioning and present for enough period of time.

Differential diagnoses:
OCD can be distinguished from:
 Generalized anxiety disorder
 Panic disorder
Phobic disorders
 Depressive disorders
 Schizophrenia
 Torette’s disorder
 Organic cerebral disorders

Epidemiology:
The lifetime prevalence is estimated as 2-3%. Men and women are equally affected.

Etiology:
Genetic: OCD have been found about 5-7% among the parents of patients with OCD.

Biological factors: Neurotransmitters. Deregulation of serotonin is involved in symptom

formation of obsessions and compulsions.

Brain imaging. Studies showed increased activity in the frontal lobes,

basal ganglia and the cingulum of patient with OCD.

Behavioral factors: According to this theory obsessions are secondary to conditioned

Stimuli.
Early experience and learning: Mothers with the disorder might be expected to transmit
symptoms to their children by imitative leaning.

Psychoanalytic theories: Freud suggested that obsessional symptoms result from

unconscious defense of an aggressive or sexual impulses, these
impulses cause anxiety which is reduced by the action of serial
of defense mechanisms of isolation, undoing and reaction
. formation

Freud also proposed that obsessional symptoms occur when

there is a regression to the anal stage of development.

Prognoses of OCD: 66%

About two-third of cases improve by the end of a year. Cases lasting for more than a
year usually run a fluctuating course. Prognoses is worse when the personality is
obsessional and symptoms are severe.

Treatment: Major depression among 70% over lifetime

Depressive disorder often accompanies OCD, and in such cases effective treatment of
the depressive disorder often leads to improvement in the obsessional symptoms.
Counseling: Treatment should begin with an explanation of the symptoms, reassurance
that these symptoms are not an early sign of madness.

Drugs:- Anxiolitic drugs in small doses not for more 2-3 weeks.
-Small doses of Tricyclic antidepressants or an antipsychotic drug may be used
TCA -Clomipramin(Anafranil) is a potent 5HT uptake inhibitor in doses 200-250 mg
daily is the drug of choice, and more effective than other antidepressant drugs.
-SSRIs
-MAOIs

Behavior therapy: Obsessional rituals often improve with a combination of

desensitization, response prevention, and exposure therapy.

Psychotherapy: supportive interviewers and joint therapy with spouse and family are
indicated.

ECT: ECT is indicated fore severe cases resistant to treatment for at least one year.

Psychosurgery: There is an immediate results of psychosurgery for severe obsessive

compulsive disorders. It should be only for the most chronic cases that have
resisted day patient or inpatient treatment including drugs, behavioral methods
and ECT for at least one year.
Several types of operations have been used:
 Bimedial leucotomy
 Cinguloctomy
 Tracheotomy
 Sub caudate tracheotomy

Contraindication of psychosurgery:-history of seizures

-premorbid personality disorder

Side effects of psychosurgery:- personality change

- seizures, tremors.
- apathy and social withdrawal
- urine incontinence.
Body dysmorphic disorder

the typical patient with compulsive dysmorphophobia is convinced that some

part of his body is too large, too small, or misshapen. The common complaints
are generally about the nose, ears, mouth, breasts, buttocks and penis, but any
part of the body maybe involved.

Treatment: when dysmorphophobia is secondary to a psychiatric disorder such as

schizophrenia or major depression the primary illness should be treated. It should
be explained that no real deformity, and that some people develop mistaken beliefs
about their appearance, some people can be helped by reassurance and continued
support.

Cosmetic surgery is usually successful for patients who have clear reasons for
requesting operation, and followed by improvement of self esteem and confidence.
There is some evidence of beneficial effects from antidepressant medications,
especially in patients with prominent depressive symptoms.

Hoarding disorder
Compulsive hoarding is a common phenomena associated with impairment in
some functions as eating sleeping and grooming. The disorder characterized by
hoarding things that are with little or no value, and obsessive fear of losing items
that the person believes may be of use at some point in the future.

Hoarding may be associated with compulsive buying, dependent, avoidant,

schizotypal, and paranoid type of personality . hoarding may resemble ADHD, and
common among schizophrenic patients , and may associated with eating disorders,
depression, anxiety disorders, and substance use disorders.
Treatment is similar to OCD. Medications and CBT
Hair pulling disorder(trichotilomania)

The essential features of Trichotilomania is the recurrent and

compulsive pulling out of one’s hair, resulting in noticeable hair loss.
Other clinical symptoms include an increasing sense of tension before
pulling the hair and sense of compulsive pleasure, gratification or release
when pulling the hair, then feeling of guilt.

Epidemiology: more common in females than males. Associated

disorders are OCD, obsessive compulsive personality disorder, borderline
personality disorder and depressive disorder.

Etiology: biological substrate, substance abuse and stress factors pay

major roll.

Treatment: Usually involve psychiatrists and dermatologists

Psychiatric treatment include anxiolitic drugs. Antidepressants, SSRIs,
and antipsychotic drugs. Hypnotherapy and behavioral therapy such as
biofeedback have been reported to be successful.

Excoriation (skin picking) disorder

Excoriation or skin picking disorder is characterized by the
compulsive and repetitive picking of the skin. It can lead to severe tissue
damage. It has prevalence 1-5 % in the general population, and associated
with OCD, body dimorphic disorder, substance use disorder and
factitious disorder.

Treatment: Usually involve psychiatrists and dermatologists

Psychiatric treatment includes anxiolitic drugs. Antidepressants, SSRIs,
and antipsychotic drugs. Hypnotherapy and behavioral therapy such as
biofeedback have been reported to be successful.

Further readings: - Oxford textbook of psychiatry

-Comprehensive textbook of psychiatry
 Trauma and stress related disorders
Dr.Issam Bannoura MD JB psychiatry
Clinical tutor: Bethlehem mental hospital

Stressful events frequently provoke psychiatric disorders, such events can also provoke
emotional reactions that are distressing.
Responses to stressful events have three components, an emotional response, somatic
response and psychological response.
Various syndromes are described as responses to stressful events:
- Acute stress reaction
- Acute stress disorder
- Post traumatic stress disorder
- Adjustment disorders

Acute stress reaction:

Acute stress reaction is a brief response lasting several hours to about three days, to
severely stressful events.
Etiology: Many kinds of events, such as motor accidents, fire, physical assault, rape,
discovery of serious illness, battle fatigue of military staff.
Clinical picture: The core symptoms of acute stress reaction are: anxiety, depression, other
symptoms include: numbness, dazing, insomnia, restlessness, poor concentration,
and autonomic physical symptoms.
3days - 1month
Acute stress disorder: <1 month if more then PTSD

Acute stress disorder is a response to severe stress lasting from at least two days to at
most four weeks.
Diagnoses: the diagnoses requires fear, helplessness, horror, and five dissociative
symptoms:1- sense of numbness and detachment
2- dazing
3- derealization
4- depersonalization
5- dissociative amnesia.
The clinical picture is usually mixed and changing, including anxiety, depression, and
anger.
Etiology: the same as acute stress reaction.
Treatment: for both acute stress reaction and disorder the following measures are needed:
1- reducing the emotional response.
2- Encouraging recall
3- Learning effective coping skills
4- Treatment for anxiety and depression.

1
Post-traumatic stress disorder (PTSD):
This term denotes an intense prolonged and sometimes delayed reaction to an intensely
stressful event.
Clinical picture: The essential features of PTSD are:
Hyper arousal - persisted anxiety
- irritability
- insomnia
- poor concentration
Reexperiencing - difficulty in recalling stressful events.
- intense intrusive imagination (flashbacks)
- distressing dreams
- depressive symptoms
Avoidance : - avoidance of reminders of the event
- detachment
- numbness
- diminished interest in social activities
Maladaptive coping mechanism include:
- aggressive behavior
- excessive use of alcohol
- deliberate self harm
- suicide
Diagnoses: May begin very soon after the stressful event, or after an interval, usually days,
months, rarely more than six months. Most cases resolve within three months, but some may
persist for years.
PTSD can be diagnosed in people who have a history of mental disorder before the
stressful events. In contrast the acute stress reaction and disorder, these terms can not be
used only when the person was free from psychiatric disorder at the time of the impact of the
stressful event.
Epidemiology: prevalence of PTSD is 1-3%. and equal for males and females and occur to
children
Etiology: the necessary cause is an exceptionally stressful event, examples of extreme
stresses are
-natural disasters such as floods and earthquakes
-man-made calamities such as fires
-serious transport accidents
-the circumstances of war
-rape
-serious physical assault
-victims of torture.

2
Treatment of PTSD:
Immediate measures:
-reducing the emotional response
-encouraging recall
-few doses of benzodiazepine or hypnotic drugs
later treatment:
-counseling to facilitate working through the associated emotions
-behavior therapy
-psychodynamic psychotherapy
Drug treatment:-Anxiolitic drugs
-anti depressants
- SSRI
-MAOI
-Tricyclic drugs
Adjustment disorders:
This term refers to the psychological reaction involved in adapting to new circumstances,
they are commonly provoked by life changes such as:
-divorce and separation
-change of work
-transition from school to university
-migration
-birth of handicapped child
-bereavement
-onset of terminal illness
-sexual abuse
Clinical picture: the symptoms of an adjustment disorder include anxiety, worry, poor
concentration, depression, irritability, together with physical and autonomic symptoms such
as palpitation and tremors. These symptoms may be dramatic or associated with aggressive
behavior, episodes of deliberate self harm or the abuse of alcohol or drugs. The onset is
gradual, the course is prolonged, usually functioning is impaired
Adjustment disorder can be specified as:
-adjustment disorder with depressed mood
-adjustment disorder with anxiety
-adjustment disorder with mixed anxiety and depressed mood
-adjustment disorder with disturbance of conduct
-adjustment disorder with mixed disturbance of emotions and conduct
The disorder usually starts within 1-3 months after the life change.
Treatment: treatment is designed to help a resolution of the stressful problems if possible,
encouraging problem solving, and discouraging maladaptive responses. Also, to treat the
underling symptoms anxiety or depression.

3
Normal grief reaction:
Grief reaction has three stages:
1. Stage I hours to days: denial, numbness, disbelief
2. Stage II weeks to 6 months- sadness weeping, waves of grief
- somatic symptoms of anxiety
- restlessness
-poor sleep and appetite
- guilt and blame of others
-experience of presence
- illusion and vivid imagery
- hallucinations of dead persons life
- preoccupation with memories of deceased .
- social withdrawal.

3. Stage III weeks to months – acceptance and readjustment

- symptoms resolved
- social activity resumed
- memories of good time with deceased.

Pathological grief 1- intense grief (Adjustment disorder)

2- prolonged grief; less than six months
3- delayed grief; after two weeks of death
4- inhibited grief
5- distorted grief

Dissociative disorders:
They are conditions in which certain mental symptoms occur without physical
pathology, with which they are associated with psychological causes. The term of
dissociative disorder until recently is known as Hysteria.
Epidemiology: the lifetime prevalence is 3-6 per thousand, more in women than in men,
most cases begin before the age of 35.

Etiology:
Genetics: more dissociative patients found among relatives.
Organic causes: they are sometimes associated with organic disease of the CNS.
Psychological causes: it is the immediate cause of dissociative disorders, especially when
the patient is subjected to severely stressful events, and the person has tendency to
dissociate.

4
 Five points are taken into account for Diagnoses:
 Dissociative disorders seldom appear for the first time after the age of 40.
 They are provoked by stressors
 Primary gain is generally unconscious to reduce anxiety
 Secondary gain usually presents, and means that the patient may gain advantage
from dissociation.
 The patient shows hysterical indifference, he shows less distress and concern than
would be expected.
Dissociative amnesia:
Dissociative amnesia starts suddenly after stress, patients are unable to recall long
periods of their lives, and deny any knowledge of their previous life or identity.
Among patients who present in this way, some have concurrent organic disease,
especially epilepsy, multiple scleroses, or head injury.

Dissociative fugue:
In a dissociative fugue patients not only lose their memory but also wonder away from
their usual surroundings, also they deny memory of their previous life. Fugues also occur
in epilepsy, sever depressive disorder, alcoholism, and sometimes associated with
suicidal attempts.

Dissociative identity disorder:

Also known as multiple personality, there are sudden attenuation between two pattern
of behavior, each of which is forgotten by the patient when the other is present. In some
cases more than to personalities may appear.
The causes are uncertain, many of these patients report physical and sexual abuse
during childhood, many have premorbid antisocial personality disorder, and alcohol or
drug abuse, they also have symptoms of anxiety and depression.

Depersonalization disorder:
It is characterized by persistent or recurrent alteration in perception of the self, to the
extent that the sense of one’s own reality is lost. The patient feels that he is unreal
mechanical, in a dream detached from his body. It must be differentiated from depressive
disorder and schizophrenia.

Other dissociative disorder:

Dissociative trance: the condition is referred to as trance and possession disorder, they
are characterized by a temporary loss of the sense of personal identity, and of full
awareness of the person’s surroundings, and occur outside religious or cultural
experiences.

5
 Dissociative stupor: patients show the characteristic features of stupor, patients are
motionless, mute, immobile, but aware of surroundings.

Dissociative pseudo dementia: patients are with extensive impairment of memory and
behavior that suggest intellectual impairment.

Ganser syndrome: It is a rare condition, appears during military experience, among

prisoners or wartime, with five features; approximate answers to questions, pseudo
hallucinations, cloudening of consciousness, talk past the point and conversion
symptoms.It is characterized by nonsensical or wrong answers to questions or doing things incorrectly,

Dissociative states: certain degrees of dissociation may occur in persons who have been
subjected to periods of prolonged stress, and left hopeless, helpless for long time, they
experience coercive persuasion, such dissociation also called brain washing.

Prognoses:
Most patients of recent onset recover quickly, those cases that last longer than a year
are likely to persist for many years.

Treatment:
Medications do not play important part in the treatment of dissociative disorders.
Treatment by reassurance and suggestion is usually appropriate, together with immediate
efforts to resolve any stressful circumstances that provoke the action.

Somatic symptom and related disorders

The somatic symptom and related disorders are a group of disorders that include
physical symptoms (for example pain, nausea and dizziness), for which an adequate
medical explanation cannot be found.

Somatic symptom disorder: the essential feature of somatic symptom disorder is some
or multiple somatic complaints of long duration, beginning before the age of 30 . It was
known before as hysteria, it is common for women and may coexist with other mental
Must be present >6 months
disorders Onset age <30
Diagnoses: requires that the onset of symptoms before the age of 30, the patient must
have few or more than 13 symptoms; pain symptoms, gastro-intestinal, sexual, and
pseudo neurological symptom none of which is explained by physical cause.
Treatment: single doctor must see the patient, regular visits, assurance of the patient
and periodic lab investigations if necessary.
Somatoform disorders include the following diagnoses:
1) Conversion Disorder - Neurological symptoms without a neurological explanation. This diagnosis is restricted to motor and sensory symptoms. Include Numbness,
paralysis, seizure, blindness, etc. May be preceded by an acute stressor. Also cannot be part of a somatization disorder (see below).
2) Somatization disorder - A patient who consistently complains of a variety of physical symptoms without a physiological explanation. The DSM requires that the onset
must be before age 30, that there is pain in at least 4 different parts of the body, 2 GI problems (not including pain), one sexual symptom, and one neurological
symptom.
3) Hypochondriasis - Excessive preoccupation or worry about illness that persists even after evaluation by a physician is negative. Fears that minor symptoms are
indicative of a serious condition.
6
4) Body Dysmorphic Disorder - Excessive concern and preoccupation with physical flaws - either imagined or extremely minor - that cause significant psychological
distress (and cannot be accounted for by another disorder, such as anorexia nervosa)
5) Pain Disorder - chronic pain in one or more area that cannot be otherwise explained.
Functional neurological symptom disorder(conversion disorder) they were
previously known as hysteria, and are characterized by the presence of one or more
neurological symptoms, that cannot be explained a known neurological or medical
disorder.
Epidemiology: the prevalence is 3-6 per 1000, the ratio of woman to men among
adults at least 2:1 and as much 5:1 it is more common in adolescents and young
adults.
Etiology: is the same as dissociative disorders

Conversion disorders are divided as follows

With motor symptoms such as paralysis, gait disorder, tremors and mutism
With sensory symptoms such as anesthesia, paraesthezia, pain, deafness, blindness
With seizures and convulsions.

The course of the condition is very variable, most episodes are transient and a
minority has a chronic course, reoccurrence is common. The treatment follows general
principles outlined in the treatment of dissociative disorders.
‫ﯾﻌﻧﻲ ﺷﻐﻠﮭم اﻟﺷﺎﻏل‬

Illness anxiety disorder or hypochondriasis is defined in terms of disease

conviction and disease phobia. DSM 5 requires a preoccupation with fear or belief
of having a serious disease based on the individuals’ interpretation of physical
signs and sensations as evidence of physical illness. The patient is in need for
reassurance as treatment, regular follow up, anxiety management and intensive
cognitive behavior therapy
Pain disorder: a pain disorder is characterized by the presence of, and focus on
pain in one or more body sites, and is sufficiently severe to come to clinical
attention. Patients often visit many doctors, usually complaining of low back pain,
headache, atypical facial pain, chronic pelvic pain, and other kinds of pain.
Treatment: single doctor must see the patient, regular visits, assurance of the
patient and periodic lab investigations if necessary.

Psychological factors affecting other medical conditions

Stress can be described as a circumstance that disturbs or is likely to disturb, the
normal physiological and psychological functioning of a person.
The body reacts to stress with responses , there are neurotransmitter, immune and
endocrinal responses to stress.
Life events and other stress factors may provoke stress responses, such as death,
divorce, separation, jail, illness, marriage, marital problems, family problems,
pregnancy and sexual difficulties.

7
Functional gastrointestinal disorders:
-peptic ulcer
-ulcerative colitis
-Crohn’s disease
Functional cardiovascular disorders
-cardiac arrhythmias and sudden death
-hypertension
-myocardial infarction
Functional respiratory system disorders
-bronchial asthma
-hyperventilation syndrome
-chronic obstructive pulmonary disease
Functional endocrinal system disorders
-hyperthyroidism
-hypothyroidism
-diabetes mellitus
-Cushing’s syndrome
-hypercortisolism
-hyperprolactinemia
Functional skin disorders
-atopic dermatitis
-psoriasis
-psychogenic excoriation
-localized pruritus
-urticaria
Functional musculoskeletal system disorders
-rheumatoid arthritis
-systemic lupus erythematosus
-low back pain
-fibromyalgia
Functional headaches
-Migraine (vascular )and cluster headaches
-tension ( muscle contraction ) headaches
Treatment of psychosomatic disorders:
The main goal is mobilizing the patient to change behavior ,change in
lifestyles. CBT with stress management and relaxation therapy are increasingly
used. Medication depend on the presence of anxiety, depressive or OCD features

8
 primary and secondary gain in malingering only secondary gain
Factitious disorders.
In factitious disorders patients intentionally produce signs or symptoms of
medical or mental disorders and mispresent their history and symptoms.
Etiology: - childhood abuse and deprivation
- escape from traumatic home situation.
- Rejecting mothers.
- Absent father
- Masochistic and borderline personality disorder.
Diagnoses: depend on three factors:
1. Intentional self producing or feigning physical or
psychological signs or symptoms.
2. The motivation for the behavior is to assume sick roll
3. External incentives are absent.

Types of factitious disorders:

1. FD with predominantly psychological signs and symptoms.
2. FD with predominantly physical signs and symptoms .also called
Munchausen’s syndrome or hospital addiction.
3. FD with combined physical and psychological signs and symptoms.
Treatment : is very difficult:
 Early recognition of the disorder.
 Treatment of any psychological cause.
 Legal intervention.
 Help of other medical surgical staff

Differential diagnoses:
 Somatoform disorders.
 Personality disorders.
 Schizophrenia.
 Substance abuse.
 Gancer syndrome.
 Malingering: Malingering patients are self producing or feigning
physical or psychological signs and symptoms to play sick roll, but
the patients have external incentives such as financial compensation,
evade the police, avoid work, or obtain free bed for the night.

Somatoform disorders not other wise specified: it include other nonspecific

disorders such as pseudocysis or a disorder with unexplained physical complaints
(fatigue).

9
 Eating and Sleeping Disorders
Dr. Issam Bannoura MD JBpsych.
Clinical tutor, Bethlehem Mental Hospital
Eating disorders: binge means eating a lot excessively

Anorexia Nervosa:
The condition usually begins in adolescents, most often between the age of 16 and 17,
with intense wish to be thin, fear of being fat, and the patient has distorted body image.
Some try to achieve weight loss by induced vomiting, excessive exercise and misusing
laxatives. Amenorrhea is one of the several physical features of the disorder, but
depressive symptoms, liability of mood and social withdrawal are all common.

Diagnoses: (DSM 5 criteria)

1. body weight is less than of the expected(loss 15% of body weight)
2. Intense fear of fatness.
3. disturbance of body image
4. amenorrhea, the absence of at least three consecutive menstrual cycles
was removed from DSM 5

Two types can be specified:

a) restrictive type: with reducing food intake and prolonged fasting
b) binge eating type-purging type: with episodes of taking big amounts of food
(binge eating ) then self induced vomiting (purging ).

Epidemiology
Anorexia Nervosa is estimated about 1% of adolescent girls, it occurs 10-20 times
more often in females than in males. The disorder reported among the upper social
classes, in developed countries and among young women in professions that require
thinness, such as modeling and ballet.

Physical consequences:
A number of important signs and symptoms of anorexia nervosa are secondary to
starvation, including sensitivity to cold, delayed gastric emptying, constipation, low
blood pressure, bradycardia, and hypothermia.
In most cases amenorrhea is secondary to weight loss. Vomiting and abuse of
laxatives may lead to electrolyte disturbance and hypokalemia that may cause seizures
and cardiac arrhythmias.
Hormonal abnormalities also occur, growth hormone levels and plasma cortisol
increased, and levels of gonadotrophines are reduced. Thyroxin and TSH are usually
normal, but T3 may be reduced.
Etiology:
Genetic causes: there is some low genetic component.
Hypothalamic dysfunction: suggested a primary disorder of hypothalamus
Social causes: most cases appear in school girls, female college students who have
concern about their body shape and weight, especially in the middle and upper
social class. There is a higher prevalence in occupational groups such as ballet
students, fashion and gymnastic interested girls.
Psychological and family causes:
 patients are engaged in struggle for sense of identity
 dietary problems in early life
 fixation at oral stage of development
 regression to childhood stage
 escape from emotional problem of adolescent
 disturbance relationships with family
 parents who are mostly preoccupied with food
 families who leave the child without sense of identity
 families are overprotective, rigid, and lack of conflict resolution
 family members have an unusual interest in food and physical appearance

Course and prognoses:
Long term outcome: - 20% die
- 20% recover
- 20% severe disturbance
- 40% fluctuating disturbance
-
Treatment:
 First establish a good relationship with the patient in order to inverse the
physical and psychological effects of starvation
 Admission is needed if weight loss is more than 45%
 Restoring weight at least three thousand calories daily
 Behavior principles are used
 Family therapy
 Cognitive therapy
 Self help groups
 Antidepressant drugs
Bulimia Nervosa:
Bulimia Nervosa is more common than anorexia nervosa, it consists of recurrent
episodes of eating large amounts of food accompanied by being out of control.
Diagnoses (DSM 5 criteria)
1. episodes of binge eating binge eating followed by compensatory behaviour
2. behavior is taken in order to prevent weight gain, such as self induced vomiting,
misuse of laxatives, diuretics, enemas, fasting and excessive exercise.
3. the binge eating occur at least twice a week for three months
4. overvalued ideas about body shape and weight
5. the disturbance is not due to anorexia nervosa
Epidemiology:
Bulimia nervosa is more common than anorexia nervosa; it is about 1-3% of young
women more common in women 10 times than men.
Etiology:
The same as anorexia nervosa
Treatment:
 antidepressant drugs
 cognitive behavior therapy
 family therapy
 interpersonal therapy

binge eating disorder

Unlike bulimia nervosa patients with binge eating disorder do not compensate in any way
after a binge episode
The cause is unknown, more likely to impulsive personality stile, during periods of stress
or to alleviate depressive mood
Management is CBT, self help groups and pharmacotherapy

Obesity and the metabolic syndrome

Obesity is diagnosed when body mass index exceeds 25%.
Most causes are social factors, with predisposing genetic influences. Emotional, low
self esteem and lack of confidence also play a roll.
Treatment:
- Change in eating habits and exercise.
- Appetite suppressing drugs and behavior methods
- Gastric restrictions (surgical)
- Intestinal by-pass
- Jaw wiring
- Pharmacotherapy
Normal sleep and sleeping disorders
Sleep is associated with a variety of physiological change, including respiration,
cardiac function, muscle tone, temperature, hormonal, and blood pressure.
Sleep has two haemostatic functions:
- thermoregulation
- energy conservation
Sleep is regulated by a small number of interconnecting systems located in the
brainstem, many studies support the roll of serotonin, noradrenalin, and acetylcholine in
sleep. Melatonin play the major roll in regulating the circadian rhythm, melatonin is
secreted by the pineal gland when the eye receives darkness and inhibited by bright light.

Sleep patterns:
Sleep usually has regular recurrent NONREM and REM stages:
NONREM sleep occupies 75% of total sleep, and has four stages
- Stage I about 5% of sleep, the lightest sleep, EEG shows low
voltage theta activity.
- Stage II about 45% of sleep, appear sleep spindles in EEG (12 -
14 cycles ) and K complex waves (triphasic waves)
- Stage III in which theta activity occupy about 50% of tracing.
- Stage IV theta activity occupy more than 50% of tracing.
Stages III and IV are deep sleep
REM sleep occupies 25% of total sleep, known as paradoxical sleep, in which pulse,
respiration and blood pressure are all high during REM sleep, it also
accompanied with penile erection.

REM latency is the period between onset of sleep and onset of REM, with duration of
about 90 minutes. REM period duration is between 10-20 minutes.
Sleep disorders:
A- Sleep wake 1- primary insomnia
disorders 2- primary hypersomnia
3- narcolepsy
4- breathing related sleep disorders
5- circadian rhythm sleep disorders
B- parasomnias 1- night mares
2- night terrors
3- sleep walking and talking
C- drug induced sleeping disorders
D- sleep disorders due to mental or physical condition
Sleep wake disorders:
Primary insomnia:
Primary insomnia is diagnosed when there is difficulty in initiating or maintaining
sleep, and the complaint is continuous for at least one month, and the insomnia occurs in
the absence of any other physical or mental condition.
The patients are asked to do sleep hygiene, to use bed for sleeping only, if not fall
asleep after five minutes to get up and to do anything else, or changing bed.
Primary insomnia is commonly treated with benzodiazepines, chloral hydrate, or other
sedative or hypnotic drugs.

Primary hypersomnia:
Primary hypersomnia is diagnosed when there is no other cause for excessive sleep,
for duration of at least one month. The treatment consists mainly of behavioral methods,
drug treatment with stimulant drugs such as amphetamine, SSRIs may be of value in
some cases.

Narcolepsy:
Narcolepsy consists of excessive daytime sleepiness and abnormal manifestations of
REM sleep. Narcolepsy is characterized by the following features:
 It occurs daily for at least three months
 Rapid and early onset of sleep
 Appearance of REM sleep within 10 minutes of sleep onset
 Hypnogogic and hypnpombic hallucinations
 Cataplexy ; a sudden loss of muscle tone such as jaw or head drop whilst the
patient remains awake
 Sleep paralyses; on awakening usually in the morning, the patient is awake and
conscious but unable to move a muscle
Treatment of Narcolepsy consists of regimen of forced naps at a regular time of day
may be helpful.
When medications are needed, Amphetamine, such as Methylphenidate (RITALIN) or
Pemolin (Nitan), sometimes combined with antidepressant drugs.

Breathing related sleep disorder:

Breathing related sleep disorders are group of sleep disruptions leading to excessive
sleep or insomnia due to breathing disturbance. Sleep apnea can be dangerous condition,
it is responsible for a large number of pulmonary and cardiovascular deaths. Sleep apnea
can lead to arrhythmias and attenuation of blood pressure.
Nasal continuous positive airway pressure (nCPAP) is the treatment of choice for
sleep apnea, other procedures include weight loss, nasal surgery, or tracheotomy may be
considered.
Circadian rhythm sleeps disorders:
Include many conditions such as:
 Jet lag type: usually disappears spontaneously in two to seven days
 Shift work type: usually associated with night shift work or changing shift work

Parasomnias:

Night mare disorder

Night mare disorder is characterized by awakening from REM sleep to full
consciousness with detailed dream recall.
Night mares may be stimulated by repeated frightening experiences during the
day, especially in children who are anxious; other causes include PTSD, fever and
drugs.

Night terror disorder:

It is sometimes familial, a few hours after the child is going to sleep in stage
NREM sleep, he sits and appears terrified, he may screams and usually appears
confused, with increased of heart and respiratory rates. There is little or no dream
recall.
Benzodiazepines or trycyclic drugs may be useful in treating nightmares and night
terrors.

Sleep walking or talking disorders:

Sleep walking and talking are automatism occurring during deep NONREM sleep.

Most common between the ages 5-12 years and may be familial.

Sleep walkers need to be protected from injury, sometimes trycyclic drugs may be
useful.
 Sexual disorders
Dr. Issam Bannoura MD. JB psychiatry
Clinical tutor, Bethlehem mental hospital
Psychosexual factors:
A person’s sexuality depends on four psychosexual factors; sexual identity, gender
identity, sexual orientation and sexual behavior.

Sexual identity:
The differentiation of the male from the female results from the action of fetal
androgen, which begins in the sixth week of embryogenic life and is completed by the
end of the third month.

Gender identity:
By the age of 2-3 years, almost every one has to confirm that he is male or she is
female.

Sexual orientation:
This describes the person’s sexual impulses, which may be directed to the opposite
sex (heterosexual), or to the same sex (homosexual), or to both sexes (bisexual).

Sexual behavior:
Sex responses to a true psycho-physiological experience, there are four phase
responses; desire, excitement, orgasm, and resolution phase.

Masturbation:
Masturbation is usually a normal precursor of object-related sexual behavior, nearly
all men and three fourth of women masturbate sometimes during their lives. Adolescents
are physically capable of coitus and orgasm, but are inhibited by social restrains. The
result is a great deal of physiological sexual tension, that demands release, and
masturbation is a normal way of reduction sexual tension.

Homosexuality:
Homosexuality is an alternative life style, rather than pathological process; it is the
result of sexual orientation to the same sex. The prevalence is about 10% for men and 5%
for women. 35% of all persons were reported a homosexual experience at sometime in
their lives, including adolescent sexual activity.
Theoretical causes:
- Psychological factors; castration fears, unresolved oedipal complex, fixation on
narcissism.
- Biological factors; low levels of circulatory androgens for men, atypical estrogen
feedback.
- Genetic factors; high incidence of homosexuality among families, high concordance
among monozygotic twins than dizygotc twins.
- Sexual behavior patterns are abnormal from early life.
- Psychopathological causes; adjustment disorder, depressive disorder.

Sexual disorders include three categories:

1- sexual dysfunctions
2- abnormalities of sexual preference (paraphilias )
3- gender identity disorder

Sexual dysfunctions:
1- Sexual desire disorders:
a- Hypoactive sexual desire disorder; characterized of absence of sexual
fantasies and desire for sexual activity, which cause distress or interpersonal
difficulties, and not accounted for another cause.
b- Sexual aversion disorder; characterized by an aversion and avoidance of
sexual contact, which cause marked distress or interpersonal difficulties, but not
caused by another condition
2- Sexual arousal disorders:
a- Female sexual arousal disorder; characterized by the partial or complete
failure to attain or maintain the vaginal lubrication which cause marked distress
to the sexual life
b- Male erectile disorder; characterized by partial or complete failure to attain or
maintain an erection until the completion of sexual act.
3- Orgasmic disorders:
a- Female orgasmic disorder; characterized by an inhibition of the women to
achieve orgasm. It is related to the man’s inexperience and the woman’s
capacity to reach orgasm.
b- Male orgasmic disorder; characterized by delay or absence of ejaculation, it
may be caused by drugs including antipsychotic drugs, MAOIs and SSRIs
c- Premature ejaculation; refers to habitual ejaculation before penetration, or so
soon afterwards that the woman has not gained pleasure. It is more common
among younger than older men, sexually inexperienced, in their first sexual
relationships, and have fear of failure
4- Sexual pain disorders:
a- Dyspareunia: refers to pain on intercourse that pain may result from impaired
vaginal lubrication or from scars or any other organic cause such as;
endometrioses, ovarian cyst, tumors, or pelvic infection.
b- Vaginismus: refers to the spasm of the vaginal muscles which causes pain when
intercourse is attempted, and there is no physical lesion causing pain.
Vaginismus may be part of the phobic response to fear of sex.
C- Pain on ejaculation: the usual causes are urethritis or proststitis but sometimes
no cause is found.
5- Sexual disorders due to general medical condition
6- Substance induced sexual dysfunctions.

Etiology of sexual dysfunction:

 Psychological causes: - unconscious fear about sex
- unacceptable homosexual impulses
- unresolved oedipal complex
- fixation at the phallic stage of development, that produce
fear of vagina (vagina dentate)
- fear of penis
 Poor general relationships with partner
 Low sexual desire
 Ignorance about sexual technique
 Anxiety about sexual performance
 Physical and psychiatric illness - depressive and anxiety disorders
- pregnancy
- child birth
- diabetes mellitus
- myocardial infarction
 Medication and alcohol or drug abuse; antihypertensive, major tranquilizers,
tricycles drugs, MAOIs, SSRIs and others.

Treatment of sexual dysfunctions:

Generally if there is any physical or drug cause the treatment is directed to the
primary cause. Most causes are psychological or related to the relationships between the
couple, it is important to consider if the couple need marital therapy, if they need advice
and education about sex, if they need specific sexual therapy.
Masters and Johnson approach is advised in some cases and has four characteristic
features:
1. The partners are treated together, both can discuss their difficulties to overcome
social inhibition.
2. Communication; and the ability to talk freely about specific sexual problems, and
concerned with increasing understanding, besides helping the partners to express
their own desire more frankly.
3. Education; mainly about sex, also about anatomy and physiology of sex, for
example the time needed for a woman to reach sexual arousal and orgasm, the
importance of foreplay including clitoral stimulation and vaginal lubrication.
4. Graded tasks: begins with simple tender physical contact, the couples are
encouraged to caress any part of the body except genitalia which remain to later
stages (sensate focus), to reach mutual masturbation at the final stages and each
couple to discover the most enjoyment method by the other person, they give
homework gradually until complete sexual penetration achieved.

Premature ejaculation can be treated with squeeze technique or start stop technique, when
the man indicates that he will soon have an orgasm the woman grips the penis for a few
seconds and then release it suddenly.

Oral medications:
 Benefits have been reported from Naltroxon, Bromcriptine, Yohimbine,
Cyproheptadine, especially for drug induced sexual disorders.
 Viagra and simulated drugs.
 Intracavernal injection of the smooth muscle relaxant papaverine
 Vacuum devices.
 Surgical methods, microsurgery, and penile prosthesis

Abnormalities of sexual preference ( paraphilic disorders )

1- Fetishism: In sexual fetishism the preferred methods to evoke sexual arousal and
excitement are objects or parts of the human body, usually begins in adolescents
among men and the more frequent objects are rubber garments, women’s
underclothes, shoes, women’s hair or foot. The experience may be followed by
masturbation or sexual intercourse
2- Transvestic fetishism: The preferred method to evoke sexual arousal is wearing
clothes of the opposite sex, followed by masturbation or complete sexual intercourse.
3- pedophilia: The preferred method for obtaining sexual arousal, excitement or
behavior is directed to children, usually under the age of 13, most common in men
above the age of 16and may be attracted to both sexes.
4- Zoophilia: Also called bestiality, and characterized by the use of an animal as a
preferred method to achieve sexual excitement.
5- Necrophilia: Sexual arousal is obtained through intercourse with dead bodies.
6- Exhibitionism: It is the repeated exposing of the genitalia to strangers for the purpose
of achieving sexual excitement.
7- Voyeurism: Obtaining sexual excitement by watching and observing others engaged
in intercourse.
8- Frotteurism: Obtaining sexual excitement by rubbing the penis against the buttocks
or other parts of the fully clothed woman.
9- Sexual sadism: Obtaining sexual arousal and excitement by inflicting pain or
humiliation to the partner.
10- Sexual masochism: Obtaining sexual arousal or excitement from the experience of
suffering or humiliation to oneself by another person.
. Hypoxyphilia : Autoerotic asphyxiation, poppers, amyl nitrate,
nitric oxide
Other abnormalities:
 Auto-erotic asphyxia: is the practice of inducing cerebral anoxia to evoke sexual
arousal while masturbating.
 Coprophilia: sexual arousal is induced by thinking or watching the act of
defecation.
 Coprophagia: arousal is followed the eating of faeces.
 Urophilia: arousal is obtained by thinking or watching the act of urination.

Etiology of sexual dysfunction:
Psychological causes:
- Failure to resolve oedipal complex.
- Anxiety about castration
- Faulty imprinting
- Association learning by abnormal fantasy.
Organic causes:
- Soft neurological dysfunctions
- Some have evidence of temporal lobe epilepsy.
- Seizures.

Treatment of sexual dysfunctions:

- Insight oriented therapy.
- Psychoanalyses.
- Sexual therapy.
- Behavioral therapy (noxious stimuli)
- Drug therapy: antidepressants, antyandrogens such as cyproterone acetate to
prevent sexual arousal.
Gender identity disorder:(DSM5 Gender dysphoria )
Transsexualism:
Transsexual people are convinced that they are of gender opposite to that indicated by
their external genitalia.
Among men: patients report a strong conviction of belonging to the other sex, by the time
the hair is arranged, make up is worn, facial and body hair is removed, they enjoy
cooking and sewing.

Transsexuals often ask help to change their appearance, they use estrogens to enlarge
the breasts, or they demand surgery to the breasts and surgical castration or removal of
the penis, they create artificial vagina. Depression is common and 16% made suicidal
attempt.

Among women: they are convinced that they occupy body of the wrong sex, some seek
surgery for mastectomy or hysterectomy or create artificial penis. They behave like men
in dress, voice and social behavior.

Etiology:
- There is no convincing evidence of genetic cause.
- No endocrinal disorders.
- Most have psychological causes.

Differential diagnoses:
Transsexuality has to be differentiated with intersex conditions:
Intersex conditions are not transsexual disorders; they include a variety of syndromes
that produce persons with gross anatomical or physiological aspects of the opposite sex.
- Turner’s syndrome: (XO) the result of the absence of one sex chromosome is
absence of gonads, they have female looking genitalia, which are not complete,
they have web neck, and short stature.
- Klinefelter’s syndrome: (XXY) although the patient is born with penis and
tests, they are small and infertile. The patient develops gynecomastia, and other
feminine appearance with weak sexual desire and emotional instability or
mental retardation.
- Congenital virilizing adrenal hyperplasia: (adrenogenital syndrome) results
from an excess of androgen acting on the fetus, the result is hermaphroidism.

Treatment of gender identity disorders

Mainly psychological treatment. If failed after two years

Sex reassignment surgery, treatment is mainly directed to the body not to the mind.
 Child Psychiatry
Dr. Issam Bannoura MD JBpsychiatry
Clinical tutor Bethlehem mental hospital
(1)
Intellectual disability
Formerly known as Mental retardation is defined as sub average
general intellectual functioning and impairment of adaptive behavior. IQ
is below 70, the age is before 18.
Normal IQ = 85-110
Borderline IQ = 70-84 ( limited IQ)

Intellectual disability ( ID ) is classified upon severity and IQ:

1. mild: (IQ50-70), they account about 85% of all mentally retarded,
usually their appearance is unremarkable, most develop normal
language, they are educable and good trainable.
2. moderate: (IQ 35-49), they account 10% of all mentally retarded,
most can talk and can learn to communicate.
3. severe: ( IQ 20-34), they account 3-4% of all mentally retarded,
they have slow development, need close supervision and clear
structure to their lives.
4. profound: (IQ < 20), they account about 1-2%of all mentally
retarded, difficult to care for themselves.

Epidemiology: The prevalence of ID at one time is about 1% of the

population. The highest incidence is in the school age children, with peak
at the age of 10-15. ID is about 1,5 times more common among boys than
among girls.

Etiology: Causative factors in ID include genetic, prenatal, perinatal,

postnatal, and social cultural factors.

Genetic causes: include - chromosomal abnormalities

- metabolic disorders.
Chromosomal abnormalities:
-Downs syndrome: the children were called mongoloid. The cause is
mainly trisomy 21, most patients have moderate and severe MR, the most
important signs of downs syndrome are; general hypotonia, oblique
palpebral fissure, abundant neck skin, flat nose, flat occiput, single
palmar crease, short hands, and small fingers. They are often associated
with congenital heart disease, intestinal abnormalities, hearing problems,
and immunological defect. In middle life they develop Alzheimer like
change in the brain.
- Fragile X chromosome: caused by mutation of X chromosome at site
(Xg27.3). the syndrome occurs in about one in every 1000males and
1/2000females, the causes are deficiency of folic acid. The syndrome
characterized by large long head and ears, short stature, hyper extensible
joints, flat feet, and hyperactivity.

- Prader-Willi syndrome: Results from deletion of chromosome 15, it is

less 1/10000, persons often have over eating behavior. Obesity, small
stature, small hands, small feet, and hypotonia.
- Cat cry (Cri du chat) syndrome: they have missing part of chromosome
5, they have microcephaly, low set ears, oblique palpebral fissure and cat
like cry.

- Other syndromes - Turner syndrome (XO)

- Klienfilter syndrome (XXY)

Metabolic disorders(inborn error of metabolism):

- Phenylketonuria (PKU):
Transmitted autosomal recessive, occurs 1/10000 population, the basic
defect is an inability to convert phenylalanine due to deficiency of
phenylalanine hydroxilase enzyme, and secondary to enzyme deficiency
the child develops eczema, vomiting, and convulsions with mild and
moderate mental retardation.
- Neurofibromatosis:
Transmitted autosomal dominant, affecting 1/5000 births,
characterized by café-au-lait spots on the skin, and neurofibromatos,
including optic gliomas, and acustic neuromas.
- Tuberous scleroses:
Transmitted autosomal dominant, about 1/15000 births, seizures are
present with infantile spasms.
- Lesh-Nyhan syndrome:
Transmitted autosomal recessive, characterized by microcephaly,
seizures, and spasticity.
- Maple syrup urine disease, transmitted autosomal recessive
- Hartnup disease, transmitted autosomal recessive.
- Homocystinuria, transmitted autosomal recessive.
- Galactosemia, transmitted autosomal recessive.
Prenatal factors:
-infectious; rubella, cytomegalovirus, syphilis, toxoplasmosis, HIV.
-intoxication; lead, drugs, alcohol.
-physical damage; injury, radiation, hypoxia.
-placental dysfunction; toxemia, nutritional growth, radiation.
-endocrinal; hypothyroidism, hypoparathyroidism
Perinatal factors:
-birth asphyxia.
-complication of prematurity.
-kernicterus.
-intraventricular hemorrhage.

Post-natal factors;
-injury; accidental, child abuse
-intoxication; lead, mercury.
-infectious; encephalitis, meningitis.
-autism.

Social factors:
May account in IQ variation as much as 20 points, it is related to:
-low social class
-poverty
-poor housing
-unstable family environment.
-deprived children in special residential care.

Physical disorders among the ID :

-sensory and motor disabilities.
-epilepsy about 25% of MR
-incontinence.

Psychiatric disorders among ID :

ID persons may develop any mental disorder, but the symptoms are
not well elaborated, symptoms may be difficult to detect, because patients
have minimal verbal fluency, and they cannot describe themselves. They
may develop schizophrenia, affective disorders, emotional disturbances,
and personality disorders.

Treatment for ID :
Generally MR patients are in need for education, training and
occupation at special services.
Treatment of psychiatric disorders follows the general principles
described elsewhere. Behavior problems are treated by behavioral
modification therapy, which include training in washing, toilet training,
and dressing. Drugs of Thioridazine (Melleril) or Haloperidol or
Risperdal may be needed to control the abnormal behavior.
 (2)
Specific Learning disorders of children
1- specific reading disorder
Reading disorder is characterized by an impaired ability to read and
poor comprehension in the absence of low intelligence or sensory
deficits. Three or four times as many boys as girls are reported, reading
disorder is more among family members, and has correlations with left
handedness. A high incidence among children with cerebral palsy,
epilepsy, prematurity, low birth weight, and malnutrition.
Treatment is remedial education and teaching . Other psychotherapies
such as counseling, support, or cognitive behavior may be needed

2- mathematics disorder
mathematics disorder is a disability in performing arithmetic skills that
are expected from the child. The affected child’s performance in number
concepts, such as counting, adding, …etc is below the age expected
norms, but the child shows normal intellectual skills in other areas.
Maturational, cognitive, emotional, educational, and socio-cultural
factors may play a roll in the cause of arithmetic disorder.
Treatment is remedial teaching and education beside needed
psychotherapy.

3- disorder of written expression

It is characterized by writing skills are significantly below the
expected level for the child’s age, the disorder is not due to a neurological
or sensory deficit.
Hereditary predisposing and temperamental factors may play some
roll in specific writing disorder.
Treatment is psychotherapy and remedial education.
 (3)
Motor disorders

Developmental Coordination disorder

The disorder is characterized by markedly lower than expected
performance requiring motor coordination. The patient usually has
clumsy in gross and the fine motor skills, such as hopping, jumping,
standing, or he may have delay in motor milestones such as sitting,
crawling standing up, and walking.

Clumsiness in children has been associated with learning disorders,

attention deficit disorders, and disruptive disorders.

Etiology: - organic and developmental factors, risk factors include

prematurity, hypoxia, perinatal malnutrition, and low birth weight.

The treatment include:

- perceptual motor training.
- Physical education.
-
Stereotypic movement disorder

Stereotypic movement disorder is characterized by repetitive, seemingly

driven, and apparently purposeless behavior and movement that
interferes with social academic or other activities and may result in self
harm. These movements are rhythmic, such as hand flapping, body
rocking, hand waving, skin picking, or self harming. They occur in
children with autism and intellectual disability. Nail biting , thumb
sucking, and nose picking are often not included.
Treatment is psychological and behavioral

Tourette disorder:

The main clinical features are multiple tics( motor and vocal)
beginning before the age of 18, associated with stereotyped movements
such as jumping, snoring, coprolalia( telling obscenities) . associated
features include over activity, difficulty in learning, emotional
disturbance, and social problems.
The life time prevalence is 4-5 per 10000, the onset of motor tics
occur by the age of 7, vocal tics by the age of 11, Tourette disorder
occurs about three times more often in boys than in girls.
Etiology:
Genetic it is transmitted autosomal dominant, and in relation to OCD and
ADHD.
Evidence of neurochemical dysfunction of Dopamine and Noradrenalin
Evidence of neuroanatomical abnormalities of basal ganglia

Treatment:
Behavioral treatments may give some benefits, but pharmacological
treatment is more effective, the drugs used are; Halidol, Pimozide,
Risperdal, Clonidine.

Chronic motor or vocal tic disorder:

In chronic vocal or motor disorders the tics are sudden, rapid,

recurrent that may be multiple motor or vocal but not both at the same
time, must be present for more than one year.

Treatment: - psychotherapy which is behavioral

- drug treatment with Halidol

Transient tic disorder:

They are single or multiple vocal or motor tics that occur many times a
day for at least 4 months but less than a year. Treatment is behavioral, tics
may disappear spontaneously
 (4)
Autism spectrum disorders
1-Autistic disorder:
Described by Kanner 1943 and was called infantile autism,
characterized by abnormalities in communication and social interaction,
developed after 36 months of normal development.
Clinical features and diagnoses:
The condition develops after a period of 36 months of normal
psychomotor development, the condition characterized by:
 Autistic aloneness; the child unable to make emotional relationships
with people, dislike being picked up or kissed, and absence eye to eye
contact.
 Speech and language deterioration; lack of speech is a manifestation
of severe cognitive defect.
 Obsessive desire for the sameness; they have distress if they face any
change in the environment, usually they like same food, same clothes,
repetitive games and fascinated by spinning toys.
 Impairment of communication and social interaction.
 Bizarre behavior and mannerisms; such as odd motor behavior,
whirling round and round, or rocking.
 Other features such as over activity, bad sleep and 25% develop
seizures and epilepsy.
 No delusions or hallucinations in the clinical picture of autism.
Etiology:
 Genetic factors of major importance.
 Organic brain disorders increased frequency of autistic disorder in
pregnancy with complication and soft neurological signs.
 Abnormal parenting; parents are cold detached and obsessive.
Epidemiology:
the rate of autistic disorder is 2-5/10000 children, most cases begin
within 36 months. 3 to 5 more boys than girls are affected.
Differential diagnoses:
 schizophrenia with childhood onset.
 Mixed receptive expressive language disorder.
 Congenital deafness or hearing problem.
 Psychosocial deprivation.
Treatment:
 Insight oriented individual psychotherapy.
 Educational and behavioral methods.
 Low doses of Haloperidol or risperdal reduces behavioral
symptoms and accelerates learning.
2- Retts disorder
Retts disorder is a rare condition which has been reported only in girls.
After a period of normal development in the first 6 months up to 2 years,
there is deterioration of cognitive development and loss of purposive
motor skills, with microcephaly stereotypic movements, ataxia
psychomotor retardation, severe mental retardation, and seizures.
Treatment is symptomatic intervention, behavior therapy and
anticonvulsants.

3- Childhood disintegrative disorder

The condition begins after a period of normal development, usually
36 months, and has the same characteristics as autistic disorder, it differs
from autistic disorder, in the loss of motor skills and of bowel or bladder
control, with progress to severe neurological condition.

4- Asperger disorder
also called autistic psychopathic, the condition has the same features
as autistic disorder, it differs that in Asperger disorder there is no speech
and language deterioration. The condition develop normally until about
the third year when they begin to lack warmth in their relationships and
speak in monotonous ways, usually it persists into adult life.
 (5)
Attention deficit hyperactivity disorder
( ADHD )
The cardinal features of this disorder are persistent restlessness
prolonged over activity and difficulty in maintaining attention. Children
with this disorder are often impulsive, reckless, and prone to accidents.
There are learning difficulties as a result of the condition.

Diagnoses:
The main features are impaired attention and hyperactivity, one of
them or both for at least six months, and should be started before the age
of seven.

Epidemiology:
The prevalence of ADHD is 3-5% in school boys, rates are about four
times higher in boys than girls.

Etiology:
 Genetic factors.
 Social factors such as poor social condition.
 Lead intoxication.
 Food additives.

Treatment:
Remedial teaching is very important, patients are in need for
stimulant drugs to control their hyperactivity, such as:
 Methylphenidate (Ritalin) in doze of 20-40 mg daily.
 Pemolin (Nitan) in doze of 40-80 mg daily.
 Dextroamphetamin (dextran) 2.5-10 mg daily.

The side effect of the drugs are irritability, depression, insomnia, poor
appetite, and slowness of growth. The drug may be needed for several
months or years.
 (6)
Mood disorders and suicide in children and
adolescents
Depressive disorders in children and adolescents:
Children and adolescents may develop depressive disorders, that may be
with serious clinical attention, depressed children may have thoughts of
death , or suicidal thoughts, and some have suicidal attempts and they
may commit suicide.

Children and adolescents may develop:

-major depressive disorder
-persistent depressive disorder ( dysthymia )
-cyclothymic disorder
-bereavement
Treatment is psychological and pharmacological

Early onset bipolar disorder

Early onset bipolar disorder is often characterized by extreme irritability
that is severe and persistent , and may include aggressive and violent
behavior, in between outbursts, children may continue to be angry or
dysphoric. The condition may complicated by comorbidity with ADHD,
or anxiety disorder.

Treatment is multimodal including pharmacotherapy, psycho education,

and psychological intervention with the family and the child.

Disruptive mood dysregulation disorder(DMDD)

Disruptive mood dysregulation disorder is characterized by severe,
inappropriate , and recurrent temper outbursts at least three times a week
by the age of 12, along with persistent irritability and angry mood
between temper outbursts.

DMDD often co-occurs with other psychiatric disorders, such as, ADHD,
ODD, MDD, and must be differentiated with Bipolar disorder, ADHD,
and ODD.
Treatment is pharmacological and psychological.
Oppositional defiant disorder

Oppositional defiant disorder is an enduring pattern of negativistic,

hostile and defiant behaviors in the absence of serious violation of social
norms or the rights of others.
The most common symptoms of the disorder include: often loses
temper, argues with adults, refuses to comply with others, annoy people,
easily annoyed by others, touchy, angry, resentful, makes mistakes and
blame others for his mistakes.

Conduct disorder
The essential features of conduct disorder is a repetitive and persistent
pattern of behavior in which the basic rights of others or social normal
rules are violated. The behavior must be presented at least six months for
the diagnoses.
Conduct disorder has one of the following:
 Aggression to people and animals.
 Destruction of property.
 Deceitfulness and theft.
 Violation of rules.
Conduct disorder is more common during childhood and adolescents,
the prevalence is 6-16% for boys, and 2-9% for girls, the ratio is 4-1 more
in boys than girls.

Etiology:
-parental factors;- faulty child rearing practices
- child abuse and negligence
- sociopathy of parents
- alcohol and substance dependence in family
-socio-cultural factors; socio-economical deprived children
-psychological factors; inability to develop tolerance for frustration
-neurobiological factors; disturbance levels of Serotonin, Dopamine, and
Noradrenalin.
-child abuse and maltreatment
-CNS dysfunction and severe psychopathology

Treatment:
 School settings use behavior techniques
 Drug treatment for aggression such as; Haloperidol, Lithium
carbonate, Carbamazepine, and Clonidine.
 (7)
Feeding and eating disorders of
Infancy and Early childhood

1- Pica: pica is a pattern of eating nonnutritive substances for at least

one month.
Etiology: - nutritional deficiencies, iron, Zink, calcium
- parental neglect and deprivation
- accepted cultural rituals
Treatment: Psychosocial, environmental, behavioral, and family
guidance approaches.

2- Rumination disorder of infancy and early childhood:

Rumination disorder is the repeated regurgitation of food usually in
infants occurs after three months of age, it sometimes associated with
hiatus hernia that results in esophageal reflux.

Etiology: mental retardation, impairment mother child relationship,

Immature child, marital conflict, gastro esophageal reflux, or
Hiatus hernia.

Treatment: - improvement the child’s social environments

- increased tender loving care
- psychotherapy for mother and both parents
- surgical repair for hiatus hernia or esophageal reflux if
present

Avoidant or restrictive food intake disorder

It is characterized by a lack of interest in food or its avoidance based on
the sensory features of the food , and can result weight loss and
nutritional deficiency.
 (8)
Communication disorders

1- Expressive language disorder:

In this disorder the ability to use expressive spoken language is
markedly below the level appropriate for the child’s mental ag
Other behavioral symptoms that may appear in children with
expressive language disorder include hyperactivity, short attention span,
withdrawing behavior, thumb sucking, temper tantrum, bed wetting,
disobedience, and conduct disorder.
Treatment; language therapy should started.

2- Mixed receptive expressive language disorder:

In this disorder the child is impaired in both the understanding and
the expression of language, associated disorders are reading disorder,
mathematic disorder, and disorder of written expression.
The condition must be differentiated from hearing problem, mental
retardation, and pervasive developmental disorder.
Treatment; speech and language therapy.

3- speech sound disorder:

It is also called speech articulation disorder, in this condition use of
speech sounds is below the level for the child’s mental age. Children
usually make errors of articulation, but in this disorder speech sounds
may be omitted, distorted, or substituted. The most sounds affected are L.
R. S. Z. th. And ch.
Treatment is speech therapy.

4- Stuttering:(child onset fluency disorder)

Stuttering is a disturbance in the normal fluency of speech that is
inappropriate for the patient’s age
Etiology: - response to conflict, fears and neuroses
- stressful situations.
- abnormal cerebral dominance.
- environmental factors.
Treatment: - classic psychotherapy.
- insight oriented psychotherapy.
- group therapy.
- family therapy.
- behavioral therapy including suggestion, relaxation and
Distraction.
5-Social ( pragmatic ) communication disorder.
It is characterized by persistent deficit in using verbal and nonverbal
communication for social purposes. Deficits may be exhibited by
difficulty in understanding and following social rules of language.
Behavior therapy and social skill training can treat the disorder, with DD
of ADHD and anxiety disorder

6-Othe communication disorders (Cluttering):

Cluttering is disturbance of the rate and the rhythm of speech, usually
associated with learning and communication disorders. Treatment is the
same as stuttering.

(9)
Elimination disorders
1- Enuresis:
Enuresis is the repeated involuntary voiding of urine into the clothes or
bed after the age of five. Enuresis may be nocturnal or diurnal, nocturnal
enuresis may be primary, if there has been no preceding period of urine
continence, it is called secondary if there has been previous period of
urinary continence.
Nocturnal enuresis can cause great unhappiness and distress,
particularly if the parents blame or punish the child.

Epidemiology: - it is about 10% at five years old

4% at eight years old
1% at 14 years old
- occurs more in boys.

Etiology: - occasional results from physical conditions

- may be as a result of delay in maturation of nervous system
- familial genetic factors
- rigid toilet training
- negative attitude of parents
- stressful events leading to anxiety

On assessment a careful history and appropriate physical examination to

exclude urinary infections, small bladder, diabetes or epilepsy.
Treatment:
Appropriate toilet training
- Explanation to the child
- Assurance the child and family
- Avoidance punishment
- Advice about restricting fluids before bedtime
- Lifting the child during the night
- Using of star charts to reward success
Behavior therapy: classical conditioning with pad and bell method is the
most effective. Other methods is bladder training by
encouragement for delaying micturation.
Pharmacotherapy: drugs should rarely used;
- Imipramin( Tofranil) at bedtime, with relapse on
discontinuation the drug always happened
- Desmopressin; is an antidiabetic compound is available as
intranasal spray
2- Encopresis:
Encopresis is the repeated voluntary or involuntary passing of faeces
into clothes after the age of four. Encopresis may be present since birth
( primary) or after a period of continence ( secondary )

Epidemiology: - it is about 8% at the age of four

1% at the age of eight
- more common in boys.
Etiology:
- may be secondary to chronic constipation
- may associated with mental retardation
- may associated with conditions that cause pain on defecation
such as anal fissure and Hirsh spring’s disease
- emotional disorder is common
- poor relationships with parents
- harsh toilet training
Treatment;
- exclusion of physical cause
- assessment of parental attitudes and emotional factors in the
family
- finding that the child thinks and feels about the problem
- explanation of the disorder and reassurance
- exclusion of punishment
- behavioral program in which the child encouraged to sit on the
toilet for about 10 minutes after each meal and rewarded for
doing this
- individual and family therapy
 (10)
Gender identity disorder of children
1- Effeminacy in boys:
Some boys prefer dress of girls, prefer playing with girls, they usually
have effeminate manner and say that they want to be girls.
Etiology: - encouragement of feminine behavior by parents
- lack of boys as companion to play
- a girlish appearance
- lack of older male child
Treatment: - individual and family therapy
- reassurance to the parents

2- Tomboyish ness in girls:

Some girls prefer to dress as boys, and play with boys rather than girls
and say they want to be boys.
Etiology and treatment the same as effeminacy

(11)
Other disorders of infancy ,childhood and adolescent
1- Separation anxiety disorder:
Fear of separation from people to whom the child is attached, the
onset is before the age of six years.
Clinical picture:
Anxiety symptoms, they may refuse to sleep, may have disturbed
sleep with night mares, physical symptoms as stomach ache headache,
nausea, and vomiting, associates with crying, tantrum, or social
withdrawal. Separation anxiety disorder is one of the causes of school
refusal.
Etiology:
- frightening experience of the child
- conflict between parents
- overprotective parents
Treatment:
- stressors should be reduced
- children should talk about their worries
- family therapy
2- Selective mutism:
The condition in which the child is fluent with language and fails to
speak in specific social situations such as school.
3- Social anxiety disorder of childhood:
The term used to describe anxiety of the child with strangers and fear
of strangers that lead to avoidance of strangers.

4- Phobic anxiety disorders:

The same as specific or simple phobia in adults, they usually concern
about animals, insects, the dark, school and death.

5- Sibling rivalry disorder:

The child shows extreme jealousy or other signs of rivalry of siblings
following the birth of that sibling. The child may regress in behavior such
as urine incontinence, temper tantrum, and sleep disturbance.

6- Reactive attachment disorder of infancy or early

childhood:
It is the disturbance of social interaction and grossly inappropriate
caretaking, such as neglect of the child, abuse the child, and changes of
caretakers.
The disorder may result in a picture of failure to thrive ( psychosocial
short stature ). If the child has been deprived by parents he will develop
deprivation dwarfism.
Etiology:
 defect on bonding
 parents mental retardation
 lack of parental skills
 social isolation
 premature parenthood
Treatment:
 assurance of child’s safety
 psychosocial support
 family therapy

7-Early onset schizophrenia

8-PTSD for children and adolescents
9-OCD for children and adolescents
10-Adulescents substance abuse
11-Attenuated psychoses
12-Academic problem
13-identity problem.
 (12)
Conditions associated with children

1- Juvenile delinquency:
Juvenile delinquency in not a psychiatric disorder, it is an offence; A
young person who has been found guilty of an offence, however it may
be associated with psychiatric disorder especially conduct disorder.

Etiology:
 low social class.
 Bad neighborhood
 Crime may run in families.
 Prolonged parental separation.
 Broken homes.
 Child neglect and abuse.
 Low IQ child.
 Child with reading and education difficulties.
 Frustration.
 Brain damage and epilepsy.

2- School refusal :
School refusal is not psychiatric disorder, but a pattern of behavior.
The condition characterized by sudden and complete refusal to attend
school, these children complain of somatic symptoms of anxiety such as
headache abdominal pain diarrhea and sickness.

Etiology:
 Separation anxiety disorder.
 Social anxiety disorder.
 School phobia.
 Travel phobia.
 Buses phobia.
 Bulling by other children or teachers.
 Failure to do well at school.
 Depression.

Treatment is directed to the cause.

Further reading - oxford textbook of psychiatry

- synopses of psychiatry
 Impulse control disorders and
Other mental disorders
Dr. Issam Bannoura MD JB Psychiatry
Clinical tutor Bethlehem mental hospital
Patients with impulse control disorders share the following features:
1. before committing the act they feel an increasing sense of tension
and arousal.
2. they fail to resist an impulse drive .
3. while committing the act they feel pleasure, gratification or release
4. after committing the act they feel remorse and guilt.

1- intermittent explosive disorder:

It is found in persons who have episodes of loosing control of
aggressive impulses, resulting in serious assault or the destruction of
property. The symptoms appear within minutes or hours and remit
quickly. Each episode is usually followed by genuine regret or self
reproach.
It appears more common in men, and must be differentiated from
schizophrenia, antisocial and borderline personality disorders, attention
deficit hyperactivity disorder, conduct disorder, substance intoxication,
and epilepsy.
Etiology:
Disordered brain pathology, particularly in the limbic system may play
a major roll in the etiology, perinatal trauma, infantile seizures, head
trauma, encephalitis, minimal brain dysfunction and hyperactivity, and
some evidence of serotonin decrease.
Treatment:
Group psychotherapy may be of some help, anticonvulsants have long
been used in treating explosive patients, Phenothiazines, antidepressants,
lithium, and propranolol have been used .

2- kleptomania:
The essential features of kleptomania is a recurrent failure to resist
impulses to steal objects not needed for personal use. Like other impulse
control disorders kleptomania is characterized by mounting tension
before the act followed by gratification during the act, and they feel guilt
after the theft. Kleptomania is more common in women.
Kleptomania may be associated with anxiety, depression, mood
disorders, OCD, and eating disorders.
Treatment: insight oriented psychotherapy, behavior therapy including
systemic desensitization have been made successfully. Flouxetine may be
helpful.
3- pyromania:
The essential features of pyromania are deliberate and purposeful fire
setting, tension or arousal before setting the fire pleasure and gratification
on setting the fire may be followed by feeling of quilt.
Common associated features include alcohol intoxication, sexual
dysfunction, low IQ, and frustration.
Etiology: Freud saw fire as a symbol of sexuality, frustration caused by a
sense of social, physical or sexual inferiority . the absence of father.
Significance low CSF levels of 5HIAA and 3.4 MHFG.
Treatment: incarceration may be the only method. Behavior methods
can be administered.

4- other impulse disorders :

-internet compulsion
-mobile compulsion
-repetitive self mutilation
-compulsive sexual behavior

Post partum mental disorders

These disorders can be divided into maternity blues, puerperal
psychoses and depressive disorders of moderate severity.

Maternity blues:
Among women delivered of a normal child, between 50-75%
experience brief episodes of irritability, liability of mood and crying. The
symptoms reach their peak on the third or fourth day post partum
Maternity blues is more common among primigravida, patients have
experienced anxiety and depressive symptoms in the last trimester of
pregnancy, or women who are more likely to give history of premenstrual
tension, fear of labor, and poor social adjustment. Readjustment of
hormones besides the emotional state may be the cause. No treatment
except social support is required because the condition resolves
spontaneously in few days.

Puerperal psychoses:
The onset of puerperal psychoses is usually within the first one or two
weeks after delivery, but rarely in the first two days. It is reported one per
500 births and more frequent in primigravidas women who have suffered
from previous major psychiatric illness, and unmarried women.
 Three types of clinical picture are observed; acute organic, affective
and schizophrenic. The cause may be hormonal change and dopamine
super sensitivity.
Severely depressed patients may have delusional ideas that the child
is abnormal or malformed, these false ideas may lead to attempts to kill
the child. Depressed or schizophrenic patients may also make suicidal
attempts.
Treatment is given according to the clinical picture, there should be
special baby mother units, ECT is usually the best treatment for patients
with depressive or manic episodes. Antidepressants or antipsychotic
drugs may be needed according to the clinical picture of the patient.

Puerperal depression of mild or moderate severity:

These depressive disorders usually begin after the first tow three
weeks of delivery, tiredness, irritability and anxiety are more prominent.
The rates are between 10-15%.
The main causes are stressful life events, previous history of
psychiatric disorder, younger age, early post partum blues, poor marital
relationships, and absence of social support.
Psychological and social measures, antidepressants needed treatment.

Premenstrual syndrome
Also called premenstrual dysphoric disorder, and the term denotes a
group of distressing psychological and physical symptoms starting few
days after ovulation and ending after the onset of menstruation.
The psychological symptoms include anxiety, irritability and
depression. The physical symptoms include breast tenderness, abdominal
discomfort and feeling of distention.
The syndrome varies from 30-80% of women, and the explanation
have been based on ovarian hormones( excess estrogens, lack of
progesterone) pituitary hormones, disturbed fluids and electrolytes
imbalance.
The syndrome has been widely treated with progesterone, oral
contraceptive drugs, bromcriptine, diuretics, SSRIs, and cognitive
behavior therapy

The menopause:
In addition to the physical symptoms of flushing, sweating and
vaginal dryness, menopausal woman often complain of headache,
dizziness and depression.
Estrogen deficiency may be the main cause, and antidepressant
medications may be helpful.
 Neurocognitive Disorders
( Organic mental disorders )
Dr. Issam Bannoura
Clinical tutor: Bethlehem Mental Hospital

The term is used most often to denote psychiatric disorders that arise
from demonstrable structural disease of the brain, such as brain tumors,
injuries, or degenerations. It is also applied to psychiatric disorders
arising from brain dysfunction that is clearly caused by disease outside
the brain, such as myxoedema. The term also includes epilepsy, which is
sometimes associated with psychiatric disorder, but excludes mental
retardation .
Delirium
Delirium is characterized by impairment of consciousness, with global
impairment of cognitive functioning. In the past the word delirium was
used to denote a disorder of thinking, or organic brain disorder, or
confusion state, or acute brain failure. Both DSM IV and ICD10 it is used
as a general term for the acute cognitive impairment syndrome.

Clinical picture: the most important features is impairment of

consciousness, as reduced clarity of awareness of the environment, it is
usually worse at night. It is recognized by slowness poor concentration,
and uncertainty about the time of day. It has impairment of thinking,
attending, perceiving and remembering, in other words as mild
impairment of cognitive processes in association with reduced awareness
of the environment. The patients behavior may take the form of over
activity, irritability, and noisiness or else of inactivity, slowness or
reduced speech.
Thinking is slow and muddled, but is often rich in content, ideas of
reference and delusions are common but poorly elaborated. Visual
hallucination are common and may be distorted, tactile and auditory
hallucinations also occur.
Change in mood such as anxiety, depression, or lability are common,
some patients are agitated and perplexed, experiences of
depersonalization and derealization are also reported to some patients.
The patient is disoriented by place person and time, memory is impaired,
also insight is impaired.

Etiology: the main causes of delirium are:

1- drug intoxication, anticholinergics, anxiolitic-hypnotic drugs,
anticonvulsants, digitalis, opiates, L-Dopa, also some industrial
poisons.
2- withdrawal of alcohol and anxiolitic drugs.
3- Metabolic failure, such as uremia, liver failure, respiratory failure,
disorders of electrolytes,
4- Endocrine causes, such as hypoglycemia.
5- Systemic infection, such as exanthemata, septicemia, pneumonia.
6- Intracranial infection, such as encephalitis, meningitis, HIV, cerebral
malaria.
7- Other intracranial causes, space occupying lesions, raised intracranial
pressure.
8- Head injury.
9- Nutritional and vitamin deficiency, thiamin, nicotinic acid, and
vitamin B12
10- Epileptic, status epilepticus, and post ictal states .

Epidemiology: It is a common disorder, accompanied of physical illness,

occurring in about 5-15% of patients in general medical or surgical
wards, and in about 20-30 % of patients in surgical intensive care units.
Most cases recover quickly, few are seen by physicians.

Diagnoses of delirium: diagnoses is important to know the cause of

delirium, so the patient needs special investigations, EEG, Brain CT scan,
and psychological testing.
DSM 5 criteria of diagnoses:
A- Disturbance of consciousness.
B- A change in cognition
C- The disturbance develops over a short period of time
D- There is evidence from history, physical examination, or lab
findings that there is a cause of the disturbance.

Treatment: the primary goal is to treat the underling condition that is

causing delirium, general measures are necessary to relieve distress, and
prevent accidents, reduce disorientation important for sensory
stimulation. The patient needs good nursing care to be given repeated
explanation. There are many advantages in nursing the patient in a quiet,
single room with enough light, and to ensure adequate sleep.

It is important to give few drugs to avoid impairment of

consciousness and to control distress and prevent accidents. Halidol and
resperidone are the most used with less side effects. Chlorpromazine and
benzodiazepine have to be avoided because of side effects. Although
short acting benzodiazepines may be appropriate at night to promote
sleep.
Prognoses : the symptoms of delirium usually last as long the primary
cause is present, after the identification of the cause some symptoms
usually recede within few days. Generally the condition is reversible and
has good prognostic features.

Dementia
Dementia is a generalized impairment of intellect, memory, and
personality, with no impairment of consciousness. Although most cases
are irreversible, a small but important group are remediable.

Clinical picture:
Dementia usually presents with impairment of memory, other features
include change in personality, mood, hallucinations, and delusions.
Dementia generally develops gradually and determined by the patients
premorbid personality.
Behavior is often disorganized, inappropriate, distractible, and restless.
Change in personality may includes sexual disinhibition, sudden anger, or
shop lifting.
Thinking slows with poverty and concrete with perseveration, and
becomes fragmented and incoherent. Speech becomes with errors, may be
associated with meaningless noise or become mute.
Change in mood may include anxiety, irritability, and depression,
progresses to become blunted with sudden mood change.
Forgetfulness is usually early and prominent, memory loss is more
obvious for recent than for remote events. Other cognitive defects include
impairment of attention and concentration. Disorientation for time and
later for place and person is invariable. Insight is lacking.

Epidemiology: dementia is essentially a disease of the aged, over the age

65 about 5% have dementia, over the age 75 about 10% have dementia,
and over the age 80 about 20% have dementia. Alzheimer type is the
most common, risk factors for Alzheimer include being female, having
first degree relative, and a history of head injury. The second common
type is vascular dementia, it is common between the age 60-70 and more
common in men than in women.

Etiology: dementia has many causes, among elderly patients

degenerative and vascular causes predominate. The most important
causes are:
1- Degenerative; Alzheimer disease, Picks disease, other frontal
dementias, Huntington’s chorea, Parkinson’s disease, normal
pressure hydrocephalus, multiple scleroses.
2- Intracranial space occupying lesion, tumor, subdura haematoma.
 3- Traumatic; severe single head trauma, repeated head injuries in
boxers and others.
4- Infectious causes : encephalitis oh any cause, neurosyphilis,
cerebral sarcoidoses, HIV, prion disease.
5- Vascular: vascular dementia, occlusion of carotid artery, cranial
arthritis. Multi-infarct dementia, or thromboemboli from distant
origin.
6- Metabolic: sustained uremia, liver failure, renal dialyses, effects of
carcinoma or lymphoma.
7- Toxic: alcohol, poisoning with heavy metals, lead, arsenic,
thallium.
8- Anoxia: anemia, post anesthesia, carbon monoxide, cardiac arrest,
chronic respiratory failure.
9- Vitamin lack: lack of vitamin B1, B12, folic acid,

Diagnoses: diagnoses is important to know the cause of dementia, so the

patient needs special investigations, EEG, Brain CT scan, and
psychological testing.
DSM 5 criteria as the following:
A-development of multiple cognitive deficits by both;
1- memory impairment.
2- one or more of the following cognitive disturbances:
a- aphasia
b- apraxia.
c- agnosia.
d- disturbance of executive functioning.
B- the cognitive deficit cause significant impairment in social,
occupational, functioning.
C- gradual onset and continuing cognitive decline.
D- There is evidence from history, physical examination, or lab findings
that there is a cause of the disturbance
E- the deficit do not occur during the course of delirium.
F- the disturbance not accounted by another axis 1 disorder (depression,
schizophrenia) .
Treatment: If possible the cause should be treated, the plan should seek
to improve functional ability, and to relieve distress for the patient and
support for the family.
There is no specific drug treatment for dementia, medications mainly
used to alleviate symptoms like anxiety, depression and agitation. the use
of halidol, thioridazin, resperidone may be helpful. Some drugs like
metabolic enhancers, vasodilators, neuropeptides may give some help.
Course and prognoses: Most are irreversible and had bad prognostic
features, few are reversible, data suggest that the early onset of dementia
with family history are likely to have rapid course. The course is variable
with gradual deterioration in 5-12 years. The condition is generally
complicated with delirium, depression and death.

Differential diagnoses between delirium and dementia:

features delirium dementia
Memory impairment +++ +++
Thinking impairment +++ +++
Judgment +++ +++
Consciousness +++ -
Attention deficit +++ +
Fluctuating over day +++ +
Disorientation +++ ++
Nocturnal exacerbation ++ -
Acute onset +++ -
Hallucination +++ +
Incoherent speech ++ +

Amnestic disorder
The amnesic syndrome is characterized by prominent disorder of
recent memory and by disordered time sense, in the absence of
generalized intellectual impairment.

Etiology: Alcohol abuse is the most frequent cause, seems to act by

causing deficiency of thiamin, several factors may cause same deficiency,
for example gastric carcinoma, and dietary problems and hyper emeses.
Such cases generally have hemorrhagic lesions in the mamilliary bodies
around the third ventricle. Other causes not through thiamin deficiency
like vascular lesions, carbon monoxide poisoning, encephalitis, and
tumors of the third ventricle.

Clinical picture: The Russian neuropsychiatrist Korsakov described a

chronic syndrome in which memory deficit` was accompanied by
confabulation and irritability, his patients suffered from peripheral
neuropathy, and they were suffering from thiamin deficiency.
The term Wernicke-korsakov also described by Wernicke as an acute
syndrome, the main features are impairment of consciousness memory
defect, disorientation, ataxia, and ophthalmoplegia.
 The central features of amnesic disorder is a profound impairment of
recent memory, and time sense, the patient can recall events immediately
after they occur, but cannot do so a few minutes or hours afterwards. New
learning is grossly defective, but remote memory is relatively preserved,
the condition associated with disorientation in time, and confabulation.

Treatment: The primary approach is to treat the primary cause by giving

Thiamin treatment 300 mg daily for six weeks then 100 mg daily for six
months. After the resolution of the amnesic syndrome psychotherapy like
cognitive, psychodynamic, and supportive therapy may be helpful.

Course and prognoses: most patients had histories of alcohol abuse,

there was a 17% death rate in acute stage, all except 4% develop
Wernick-korsakove syndrome, once established there was no
improvement in a half, complete recovery in a quarter, and partial
recovery in the rest.

Mental disorders due to general mental condition

The term introduced to eliminate the misleading distinction between
organic disorders and functional disorders. The psychiatric symptoms in
these disorders are part of the syndrome caused by nonpsychiatric
medical condition. An example depression associated with Cushing’s
disease.
Mental disorders due to general medical condition are:
1- Delirium due to GMC
2- Dementia due to GMC
3- Amnesic disorder due to GMC
4- Psychotic disorder due to GMC
5- Mood disorder due to GMC
6- Anxiety disorder due to GMC
7- Sexual dysfunction due to GMC
8- Sleep disorder due to GMC
9- Catatonic disorder due to GMC
10-Personality change due to GMC
11-Other mental nonclasified due to GMC

1-Degenerative disorders:
Degenerative disorders affecting the basal ganglia are commonly
associated not only with movement disorders, but also with
depression, dementia, and psychoses. The most widely known
degenerative disorders are Parkinson’s disease, Huntington’s disease,
Wilson’s disease, and Fahr’s disease.
2-Epilepsy:
Epilepsy is a chronic condition characterized by recurrent seizures.
A seizure is a transient paroxysmal pathophysiological disturbance
of cerebral function caused by abnormal electrical discharge of the
brain.

Classification of epilepsy:
A- Partial seizures or beginning focally: about 65%
1- simple partial
2- complex partial
B- Generalized seizures: about 30%
1- tonic
2- clonic
3- tonic-clonic(Grand mal).
4- atonic
5- myoclonic
6- absence (petit mal)
7- reflex
C- Unclassified: about 5%

Clinical picture:
Simple partial seizure: include Jacksonian motor and other visceral or
sensory seizures, it is usually associated with aura and no loss of
consciousness.

Complex partial seizures: that start focally and may be sensory, motor
or visceral and ends as generalized seizure with loss of consciousness,
usually starts with aura, associated with autonomic symptoms,
disturbance of perception, speech disturbance, fear, anxiety, may also
associated with delusions and hallucinations. This seizure called
psychomotor or temporal lobe epilepsy.

Tonic seizures: sudden onset of tonic phase and loss of consciousness

Clonic seizure: predominate clonic jerks and loss of consciousness

Tonic clonic: onset of seizure with tonic clonic phase, it may starts
with tonic then clonic jerks, with duration of few seconds up to two
minutes, generally associated with loss of consciousness, salivation,
lacrimation, tongue bite, urination, confusion and deep sleep.

Atonic seizure: associated with sudden drop attack with loss of

consciousness.
 Myoclonic seizure : have motor jerk movements for group of muscles
with loss of consciousness.

Absence seizures: the cardinal feature is loss of consciousness without

convulsions, no aura before it, for duration of few seconds, and mostly
for children.

Absence seizures: seizures occur due light stimulation, like TV, sun or
computer.

Epidemiology: about 1% of population have epilepsy most in

children, 20% of subjects are handicapped or mentally retarded.

Diagnoses: Eye witness and clinical description of the seizure is the

most important factor for diagnoses, the patient needs good history
taking with good differential diagnoses. Duration is less than two
minutes. EEG can confirm the diagnoses but cannot exclude it.

EEG: electro-encephalo-graphy is a procedure which can registrate

the electrical potential of the cerebral cortex, it has the following

normal waves – Alpha rhythm at 8-12 c/s mostly at frontal and lateral
- Beta rhythm with more than 12 c/s at central and
occipital area
- Theta rhythm at 4-7 c/s mostly for children well
formed after age of two till 18
- Delta rhythm with waves less than 3 c/s mostly for
children before age of two.
Abnormal waves are – sharp waves.
- spike waves
- slow waves
- theta and delta waves for adults.
Etiology: any cause within the brain or out of brain that may affect the
brain may cause epilepsy. But majority of causes are idiopathic.
In the new born and children – birth injury
- congenital malformation
- metabolic disorders
- infectious ,meningitis
In the adults: - head injury
- vascular disease.
- Degenerative disease
- Space occupying lesion
- Infectious, encephalitis, meningitis.
Any systemic disease: fever, septicemia, uremia, renal failure, hypoxia.
Drug therapy: neuroleptics, and antidepressants.
Drug withdrawal: sedatives , alcohol.
Withdrawal of antiepileptic drugs.

Management: for proper treatment the patient needs proper diagnoses of

the type of seizure, patients have to avoid dangerous work, and avoid
driving. During attack to be sure that the patient on his side, with free
airway, and to prevent patient from self injury. After the attack the patient
is confused and needs care with support.

Drugs of choice:
Partial or focal seizures, simple or complex:
First choice drugs; Carbamazepine ( tegretol )
Second choice drugs; pheytoin (Epanutin )
Sodium valporate ( depalept)

Generalized seizures;
Tonic-clonic seizures first choice Cabamazepine or Sodium valporate
Second is Phenytoin
Myoclonic and atonic first Sodium valporate or Clonazepam (clonix)
Absence seizures; first Sodium valporate or Ethusuxamide (zarontin )
Status epilepticus: it is a hospital emergency manifested by repeated and
prolonged attacks of seizures with loss of consciousness, emergency
treatment with Assival IV or Phenytoin IV

Prognoses: drug treatment has to be continued for at least three years

without seizures, then to reduce drugs gradually if EEG is normal and the
patient is fit free. Some patients need long life drug treatment. Good
prognoses for children and poor for adults. In general 70% of patients
have good prognoses and 30% are resistant.

Psychiatric disorders associated with epilepsy:

-Cognitive dysfunction : It established that few patients develop
cognitive change, they are likely due to brain damage, and adverse effects
of drugs, and may include progressive decline in cognitive function. In
children associated with poor school attendance and social difficulties.

-Personality change: seizures may cause personality change, the patients

may become egocentric, irritable, religious, sticky and quarrelsome.

-Sexual dysfunction.
Depression and another emotional disorder.
-Suicide and deliberate self harm.
-Crime may be more associated with epilepsy.
-Inter-ictal psychoses: some patients with temporal lobe epilepsy
develop chronic paranoid psychoses. The psychoses usually began many
years after the onset epilepsy.

Differential diagnoses of epilepsy:

organic Non organic

Syncope Temper tantrum
Hypoglycemia Breath holding spells
Transient ischemic attack Hyperventilation
Migraine Dissociative disorders
Sleep disorders Conversion disorders
Panic attacks
Schizophrenia
Depression
Night terrors
3- Brain tumors:
About 50% of patients with brain tumors experience mental
symptoms, most likely at frontal and limbic regions, rather than parietal
and temporal regions. Meningiomas and gliomas may cause diffuse
symptoms. If the history and physical examination reveal bowel or
bladder incontinence, a frontal lobe tumor should be suspected.
Patients with such tumors may show impairment in cognition, language
skills, memory, perception and awareness.

4- Head trauma:
Head trauma can cause any mental disorder, it can lead to delirium,
dementia, personality change, and post- concussional disorder.

5- Demyelinating disorders:
The major demyelinating disorder is multiple scleroses(MS), other
disorders include adrenoleukodystrophy, subacute sclerosing pan
encephalitis. All these disorders can be associated with neurological,
cognitive, and behavior symptoms.
6- Infectious diseases:
- Encephalitis
- Neurosyphilis.
- Meningitis
-Subacute sclerosing pan encephalitis.
-Creutzfeldt-Jakob disease.
7-Immune disorders:
The major immune disorders are AIDS, and systemic lupus
erythematous.

8- Endocrine disorders:
Thyroid disorders: ``
Hyperthyroidism is characterized by confusion, anxiety and agitated
depression. Hypothyroidism is characterized bye depression, paranoia,
hypomania.
Para thyroid disorders:
Excessive secretion of Para thyroid hormone causes hyperglycemia,
which can result in delirium, personality change, cognitive impairment,
and apathy.
Hypocalcaemia can occur with hypo parathyroid disorders, and can
result delirium and personality change.
Adrenal disorders:
Patients with chronic adrenocortical insufficiency (Addison’s disease)
exhibit symptoms such as apathy, easy fatigability, irritability, and
depression.
Excessive cortisol secretion,(Cushing’s syndrome) lead to secondary
mood disorder, a syndrome of agitated depression and schizophrenic like
symptoms.
Pituitary disorders:
Patients have combination of symptoms, especially of thyroid and
adrenal disorders, and can present with many psychiatric symptoms.
9- Metabolic disorders:
- Hepatic Encephalopathy:
It can cause alteration of consciousness hyperventilation, and EEG
abnormalities.
- Uremic Encephalopathy:
Can be associated with alteration in memory, orientation, and
consciousness.
- Hypoglycemic Encephalopathy:
Symptoms can mimic anxiety, they include nausea, sweating,
tachycardia, restlessness and feeling of hunger. With progression of
symptoms disorientation, confusion, and hallucination may develop.
-Diabetic Ketoacidoses:
The condition begins with feeling of weakness, easy fatigability,
increasing polyuria, polydipsia, headache, nausea, and vomiting appear.
- Acute intermittent porphyria:
May be associated with anxiety symptoms, with triad of symptoms,
acute colicky abdominal pain, motor polyneuropathy, and psychoses.
10- Nutritional disorders:
- Niacin Deficiency:
Niacin or nicotinic acid deficiency is associated with pellagra.
Pellagra is seen in association with alcohol abuse, vegetarian diet and
starvation. The neuropsychiatric symptoms include apathy, irritability,
insomnia, depression and delirium. The medical symptoms include, 5D’s
dermatitis, diarrhea, delirium, dementia, and death.

- Thiamin deficiency(Vit B 1):

Thiamin deficiency leads to Beriberi associated with cardiovascular
and neurological changes. Also can lead to Wernicke-Korsakoff
syndrome.

- Cobalamin deficiency (Vit B12):

The deficiency can cause megaloblasatic anemia(pernicious anemia) ,
and can cause degenerative change in peripheral nerves, the spinal cord,
and the brain. Mental changes such as apathy, depression, irritability are
common. In few patients is associated with delirium, delusions,
hallucinations, sometimes paranoid features are prominent.

11- Toxins :
Delirium and dementia may be associated with Arsenic and Mercury
poisoning. Sometimes is associated with depression irritability and
psychoses. Associated symptoms are sensory neuropathy, cerebellar
ataxia, dysarthria, paresthesia, and visual field defects.

Further reading - Oxford textbook of psychiatry

- Synopses of psychiatry
 Personality disorders
Dr. Issam Bannoura
Clinical tutor, Bethlehem Mental Hospital
Personality can be defined as the totality of emotional and behavioral
traits that characterize the person in everyday living under ordinary
conditions. When personality traits are inflexible, maladaptive, and cause
significant functional impairment to the person and environment they
constitute personality disorder.

Classification of personality disorders:

The personality disorders are grouped into three clusters(DSM5):
Cluster A ; include, paranoid, schizoid and schizotypal personality
disorders, persons appear to be odd and eccentric.

Cluster B ; include, antisocial, borderline, histrionic, and narcissistic

personality disorders, persons appear to be dramatic,
emotional, and erratic.

Cluster C ; include, avoidant, dependent, and obsessive compulsive

personality disorders, persons appear anxious and fearful.

Other personality disorders are passive aggressive, and depressive, often

appear anxious.

Etiology of personality disorders:

Genetic factors: there is evidence that among monozygotic twins, the

concordance for personality disorders was several times higher than that
among dizygotic twins.

Cluster A personality disorders are more common in the biological

relatives of schizophrenic patients than among control groups.

Cluster B personality disorders have a genetic base, antisocial

personality disorder is associated with alcohol use disorder. Mood
disorders and depression is more common in relatives of borderline
personality disorder. An association is found between histrionic
personality disorder and somatization disorder.

Cluster C personality disorders may have genetic base, they may

associated with anxiety and depression.
Temperamental factors: Temperamental factors identified in childhood
may be associated with personality disorders in adulthood. For example
children who are fearful may go to have avoidant personality disorder.
Also may develop from poor parental fit, and abnormal child rearing
practices. Personality features of shyness, ill-temper, and dependency
may be more persistent.

Family factors: Everyday observation suggests that children resemble

their parents in personality, the behavior may be acquired through
learning.

Social factors: It suggests that there is an association between childhood

experiences and personality, persons can shape other personalities, also
can be acquired through social learning.

Personality disorder and upbringing: considerable attention has been

given to disturbances in child-parent relationships, particularly maternal
deprivation.

Psychological causes: Freud proposed that serious difficulties at the oral,

anal, genital stages may develop abnormal personalities. In the other hand
persons have to develop their defenses, through the conflict between
conscious and unconscious mind

Cerebral pathology and cerebral maturation: while there is fairly

strong evidence for a continuity between behavior disorders in childhood
and antisocial PD in adult life, there is only week evidence that minimal
brain dysfunction is a cause of behavior disorder in childhood, it may
result from delay in the maturation of the brain( more theta activity at
EEG recordings)

Epidemiology : The epidemiology of personality disorders is variable

and it is around 1-3% of population , higher in men and decrease with
age.

Clinical features of abnormal personalities:

Paranoid personality disorder: the main features that persons are

suspicious, sensitive, mistrustful, argumentative, stubborn,
and self importance.

Schizoid PD : they are emotionally cold, seclusive, without friends,

detached, aloof, humourless, and introspective.
Schizotypal PD: they are with social anxiety, inability to make close
friendship, eccentric behavior, odd speech and odd behavior,
suspicious, ideas of reference, and inappropriate affect.

Antisocial PD : - failure to sustain relationships, and disregard of

feelings of others
- impulse actions, with tendency to violence and low
tolerance to frustration
- failure to learn from experience
- lack of guilt.
-
Borderline PD : Borderline personality disorder is characterized by
unstable relationships, impulse behavior, variable mood, lack
of control of anger, suicidal threats and behavior, uncertainty
about personal identity, chronic feeling of emptiness and
boredom, avoid abandonment, with paranoid and dissociative
symptoms.

Histrionic PD : this kind of personality are self dramatization, self

centred, sociable, confident, lively, craving for novelty, and
excitement.

Narcissistic PD : they characterized by a grandiose sense of self-

importance, preoccupation with fantasies of unlimited success,
power, and intellectual brilliance.

Obsessive-compulsive PD : they are more dependable, obstinate,

punctual, inflexible, more cautious, indecisive, more careful,
lost in details, show little emotions, with high standards, and
law abiding.

Avoidant(anxious) PD : they are persistently anxious, ill at ease in

company, fearing disapproval, criticism, or rejection, they are
cautious worried of new experiences and meeting new people.
They crave social relationships that they cannot attain.

Dependent PD : they are weak-willed, compliant with the wishes of

others, avoid responsibility, depend on others, and lack of self
confidence.
Passive-aggressive PD : they have passive resistance for adequate
performance, delay in performance, deliberate inefficiency,
pretended forgetfulness, and unreasonable criticism of people
in authority.

Depressive PD : always seem to be with low spirits.

Hyperthymic PD : always seem to be cheerful and optimistic with high

spirits.

Cycloid PD : they used to have alterations between the extremes of

depression and hyperthymic states described above.

The management of personality disorders:

It has been said that people cannot change their nature but can only
change their situations. The role of treatment for these patients is often to
help patients to avoid adding to their problems.

Psychotherapy:
Good psychiatric assessment
Counseling
Dynamic psychotherapy
Cognitive therapy
Group therapy
Therapeutic community

Drug therapy of personality disorder:

Drugs had little part to play in the management of personality
disorders.

Anti-psychotic drugs have short time beneficial effects for some

patients with borderline PD.

Anxiolytics should be avoided because they may lead to dependence.

Tricyclic antidepressants may help when there is a secondary

depressive disorder., but they generally worsen borderline PD.

SSRIs may be helpful even when there is no associated depressive

disorder.
 Monoamine oxidase inhibitors have been found some beneficial for
borderline PD

Lithium carbonate appear to reduce mood variation and aggression.

Anti-epileptic drugs have been used to treat disturbance of behavior

and violence.

The prognoses of personality disorders:

Just as normal personalities may show small change with increasing

age, so abnormal personalities may become less abnormal.

At follow up , about a third of treated abnormal personalities had

improved, and almost borderline, and antisocial personalities had poor
prognoses, whilst cluster C personality disorders had the best outcome.

Poor prognostic features are associated with personalities who are

complicated with alcohol or drug abuse, also who associated with other
psychiatric disorders, the most psychiatric disorders that may associate
personality disorders are depression, bipolar disorders, anxiety and
schizophrenia.

Further readings: Oxford textbook of psychiatry- Hilgard

Synopses of psychiatry- Kaplan.
 Psychological treatment
Dr.Issm Bannoura. Bethlehem Mental hospital

It is concerned with various kinds of counseling, psychotherapy,

behavioral and cognitive therapy. The most important that logical
psychological treatment cannot be learned by reading alone, they must be
learned by appropriate and adequate supervised experience.

In primary care counseling may be considered for patients with

emotional problems, and of incurable illness, whether physical or mental,
and also provided for special groups such as mothers with postnatal
depression, the bereaved, and people with alcohol problems.
Psychiatrists are likely to use brief psychotherapy for younger patients
with moderately severe recurrent depression or anxiety symptoms, and
patients with low self esteem with phobic, panic, and obsessional
disorders, more likely to use cognitive and behavioral methods. For
depressive disorders brief psychotherapy is often combined
antidepressant drugs and with social measures.

Common factors in psychotherapy:

1- Listening and talking
2- Release of emotion.
3- Giving information.
4- Providing a rationale.
5- Restoring of morale.
6- Suggestion.
7- Guidance and advice.
8- The therapeutic relationship.
Transference and counter-transference:
In all psychological treatment the relationship between the patient and
the therapist may help or hinder the patients progress, helping to sustain
the patient through his difficulties and to motivate him to overcome his
problems.
The relationship has realistic and unrealistic component, the realistic
component is known as the therapeutic alliance; the unrealistic element
results from transference. The patient transfers of his feelings and attitude
towards the therapist, when the therapist is conceived as a good figure,
transference is said to be good figure, when the therapist is conceived as a
bad figure it said to be negative. In contrast the therapist may reflects his
feelings and attitude towards the patient, this process is called counter-
transference. Both transference and counter-transference can turned to
advantage or disadvantage to the process of treatment.
Counseling:
The word counseling denotes the giving of advice, and concerned with
emotions as well as with giving information. The following account
outlines some of these procedures:

1- counseling about risks

2- counseling to relieve distress
3- interpersonal counseling.
4- Marriage guidance counseling.
5- Bereavement counseling
6- Problem-solving counseling

Interpersonal therapy:

Interpersonal therapy was developed as a structured psychological

treatment for problems in relation to personal roles and interpersonal
relationships of depressed patients. They involve bereavement, other loss,
interpersonal disputes, roll transition, and interpersonal deficits, this
therapy to help persons to overcome their difficulties and to find new
ways of coping..

Supportive psychotherapy:
1- Eclectic supportive psychotherapy:
This therapy is used to relieve distress or to help patients to persist
despite difficulties, and for problem solving. It is useful for patients
with chronic mental or physical illness or handicap and suitable for
dying.

2- Psychodynamic supportive psychotherapy:

It is similar but places more on relationship between patient and
therapist, it is useful for patients with severe emotional disorders,
including borderline personality disorder. This therapy includes
reassurance, suggestion, information, advice and emotional release.
Patients are encouraged to accept causes for problems that are
outside their control.
Brief insight oriented psychotherapy:
1- Brief eclectic psychotherapy:

It aims to produce limited changes within a short time, with

duration seldom more than six months. Patients are asked to talk
about their problems, the therapist will help patients to find their
own solutions. They encouraged to talk about emotionally painful
subjects rather to avoid them. Finally they are encouraged to
consider alternative ways of thinking and behaving in situations
that cause difficulties. It is mainly helpful for patients who have
difficulties in personal relationships but are free from serious
disorder of personality. Suitable patients are (YAVISW ); young,
attractive, verbal, intelligent, sociable and well motivated.

2- Brief psychodynamic psychotherapy:

This therapy is intended to examine the effects of past experience

on present behavior, and aims to alter these organizes of behavior.
These methods are supplemented by free association and by
interpretations of defences and transference. Treatment is generally
once a week for six or nine months. When links with past and
present have been identified, patients are encouraged to use their
new knowledge to change their current behavior and feelings and
to deal more adaptively in relationship with others.

Psychoanalyses:
Psychoanalyses is the most intensive and prolonged form of long term
psychotherapy, and needs long training which includes personal analyses
as well as supervised experience in treating patients.

The basic psychoanalytic techniques are free association and

interpretation. The psychoanalyst also uses dream analyses to allow
access to unconscious process. The analyst ask questions to make the
material clearer, confronts the patient with contradictions, the patient
usually avoid some topics, or may show other forms of resistance, the
patient is examined for the evidence about the patients use of
mechanisms of defence.
Clinical experience suggests that long term therapy is more
appropriate than shorter treatment for patients who have long standing
and complicated emotional difficulties. The use of these methods for
schizophrenia or bipolar disorders is not recommended. Histrionic and
schizoid personality disorders , while not contraindicated, are particularly
difficult to treat.
Group therapy:
Small group psychotherapy:
this kind of therapy is concerned with a group of patients, usually
about eight in numbers. Small group can be used with the intention of
bringing substantial change in symptoms , personal problems, difficulties
in interpersonal relationships, as a form of supportive treatment, or to
encourage limited adjustments to specific problems including those with
disabling physical or mental illness.

Other small groups are sensitivity groups, encounter groups, and

psychodrama.
Therapeutic factors are sharing experience, support to and from group
members, socialization, imitation, and interpersonal learning.

Large group therapy:

Large groups usually include all the patients in a treatment unit
together with some or all of the staff, with total membership varying from
20-50. large groups allow patients to express problems of living together
through social learning, or attempt to change their abnormal behavior,
they share similar problems and allow themselves to learn to overcome
their difficulties.

Supportive groups:
Groups led by a professional therapist to support patients with chronic
psychiatric or physical illness, or people with shared problems such as the
parents of handicapped children.

Self help groups:

They are organized for groups who share same problems, to learn ways
of overcoming or adjusting their difficulties. The group have benefits
from their experience, have the opportunity to talk about their own
problems and express feelings, also have mutual support. They are for
people who suffer from many kinds of disorders; such as alcoholics (
alcoholics anonymous ), or to help people to loss weight ( weight
watchers ), or other groups who share some physical or need professional
adviser.

Marital therapy:
Marital therapy implies treatment for husband and wife, sometimes
called couple therapy for couples who are living together. This kind of
treatment given because marital conflict appears to be the cause of
emotional disorder in one of the parents, and the marriage appears likely
to break up and both parents wish to save it.
 An important issue that the problem is not confined to one person but
shared between the two. The aim of treatment is to find balance, and to
share decision making.
There are many types of marital therapy, such as analytic methods,
transactional methods, behavioral therapy, and eclectic methods.

Family therapy:
Family members take part in this treatment, both parents joint with
children, and by grandparents or others who make part of the family. The
aim to alleviate the problems that led to the disorder, and to improve
family functioning.

Family therapy is used mainly in the treatment of problems presented

by young people living with their parents, when the parents cannot cope
with the behavior of a child or adolescent, or when the family is making
one member scapegoat for shared problems.

Many types of family therapy is used, such as psychodynamic

methods, structural methods, systemic family therapies, and eclectic
methods.

Cognitive therapy:

In cognitive treatment, the therapist attempts to change one or more of

the disordered ways of thinking that characterize the disorder, like the
irrational fear of phobic patients, or unreasonable pessimistic ideas of a
depressed patient.

First step is to know the irrational ideas, then working to change them
by many methods; by using distraction, or thought stopping, or
reassurance. The techniques to change thoughts including giving
information and questioning the logical bases of the thoughts.

Behavioral therapy:

In behavioral treatment the therapist attempts to alter a prominent

behavioral element in the psychiatric disorder by encouraging the patient
to carry out an incompatible behavior. For example in phobic patients
avoidance behavior is treated by encouraging them to enter situations that
they fear(exposure) , and in depressed patients inactivity and social
withdrawal are treated by participation in enjoyable activities.
 There are several behavioral techniques used in behavior therapy:
- Relaxation training; it is used for anxiety disorders, insomnia,
depression, and other conditions with stressful events.
- Desensitization in imagination: it is used in phobic disorders, other
anxiety disorders, and impulse control disorders.
- Desensitization in practice. It is used in phobic anxiety disorders,
and other anxiety disorders.
- Exposure and flooding; it is used in phobic disorders.
- Exposure and response prevention. It is used mainly in obsessive
compulsive disorders.
- Social skill training. Used in social anxiety disorder and low self
esteem.
- Assertiveness training. Used in social anxiety disorders, it is a
particular kind of social skill training.
- Self-control techniques . used in eating disorders.
- Contingency management. Also called token economy, used to
modify abnormal behavior of schizophrenic patients, or people
with learning difficulties and for autistic children.
- Pad and bell method. For children with enuresis.
- Biofeedback. Used for patients with anxiety disorders.
- Aversion therapy. for sexual disorders to help patients to suppress
abnormal behavior.
- Negative practice. Used to reduce the patients repeated behavior
such as tics, stammering, thumb sucking, and nail biting.
- Techniques for sexual disorders. Such as start stop technique for
premature ejaculation.

Other forms of psychological treatment:

Hypnoses:
Hypnoses is a state in which the person is relaxed and drowsy, and
unusually suggestible. It is used mainly for patients with dissociative and
conversion disorders, the aim is let patients to talk freely about their
stressful events and to find their way of thinking.
Autogenic training:
it is a clinical procedure used to treat physical symptoms caused by
emotional disorder.
Meditation:
Some techniques are used to treat neurotic patients based on
relaxation, and regulation of breathing.
Abreaction:
The method is of most use in acute neuroses caused by extreme stress,
it has been used mainly for war neuroses, prison and military stress
factors.
 Interviewing and history taking
Dr Issam Bannoura
Clinical tutor: Bethlehem hospital

The diagnostic interview:

The aim of the interview for any psychiatric patient is collect data,
the data may be from the patient, relatives, friends files or any other
informants,

In general when we collect data, our main goal to reach proper

diagnoses, by knowing the correct signs and symptoms as well the
etiological factors for these symptoms, then to formulate diagnoses and
arrange proper plan of management.

This kind of interview have to be conducted in systematic and

proper way, to know what information needed, and how these
information’s can help for the diagnoses and management of the patient.

As the interview continues the doctors task is to keep the patient

to relevant topics by bringing him back to the point if he strays from it. In
doing this the interviewer should use a minimum of leading or closed
questions. It is important to give the patient an opportunity talk
spontaneously.

The scheme of history taking

1- the patients profile: Name , age ID number, Occupation, address.

2- Source of information’s: the patient, family, relatives, records

3- Reliability: good acceptable or irrelevant.

4- Source and reasons of referral: referred by whom and why

5- Chief complaining: of the patient and others in their language

6- Present condition: description of the episode in medical terms, and

that include mode of onset of symptoms, duration, severity and
impairment of functioning.

7- Family history: include the family pedigree ages occupations,

relationships, presence of family problems, illnesses, to provide if
there family or genetic causal factor.
8- Personal history: and that include all personal circumstances of the
patient in all his life to date:
- Mothers pregnancy and the birth
- Early development
- Childhood emotional problems
- Schooling and education
- Occupation
- Menstrual history
- Sexual and marital history
- Forensic history
- Social circumstances
- Past medical history
- Past psychiatric history
- Premorbid personality, include- relationships, leisure
activities, prevailing mood, character, attitudes and
standards, habits including alcohol and drug use.
9- Mental state examination: the interviewer will have noted the
patients symptoms up to the time of the consultation. There is a
degree of overlap between the history and the mental state
examination.
The MSE is described in the following paragraphs:
- Behavior and appearance
- Speech
- Mood
- Depersonalization, derealization
- Obsessional phenomena
- Delusions
- Hallucinations and illusions
- Orientation
- Attention and concentration
- Memory
- Judgment
- Insight
10- Physical and neurological investigation
11-Formulation and case summary:
The formulation describe the following
- statement of the problem, in which the aim to describe the
positive findings in the case.
- Differential diagnoses and diagnoses of the problem.
- Etiology, to describe predisposing, precipitating and
maintaining factors.
- Plan of management
- Prognoses.