PSYCHIATRY

FOR NURSING STUDENTS

Daniel A. (MSc. in ICCMH

MSc. in C. Psychololgy)
Email- dayelegne8@gmail.com 1
How was/is Holiday ?

2
Have you heard about holiday
syndrome/blues ?

3
 Brain storming
• Human brain , main fxn ? Factors that influence it ?
• What makes psychiatry differ from medicinal sciences ?
• What is mental health and mental disorder ?
• What do you think the possible causes of mental disorders ?
• Do you think mental disorder/s are treatable ?
• Which one is your most preference treatment ?
• Religious / cultural treatment

• Medication
• Psychotherapy

• Both 4
 Unit one
Introduction about psychiatry
• Mental Health - is a state of well-being
 the individual realizes his or her own abilities,
 can cope with the normal stresses of life
 can work productively and a fruitfully and is able to make a contribution
to his or her community. (World Health Organization)

• Psychiatry - It is a branch of medicine that deals with the

prevention, diagnosis and treatment of mental illness. 5
 Introduction ……cont….

• Psychiatric Nursing: It is a specialized area of nursing

practice employing theories of human behavior, as a science
and the purposeful use of self as an art in the diagnosis and
response to actual or potential mental health problems.
(American Nurses Association 1994)

6
 Introduction … history cont. . .

History of Psychiatric Nursing :-

• Hildegarde E. Peplau: the Mother of Psychiatric Nursing.

•-She developed the first graduate psychiatric nursing

programmer in 1954 G.C.,

•Her emphasis was on the nurse–patient relationship.

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8
 Unit Two
Therapeutic communication

 The Clinician-Patient Relationship

• The clinician-patient relationship is the core of the practice
of medicine.

• Interpersonal greater than technical skills

• The BIOPSYCHOSOCIAL MODEL (BPS)

9
 Therapeutic com……cont.…

Models of Interaction between

Clinician and Patient

A. Paternalistic model (Autocratic ) Model- guardian

 Circumstances
 Limitation

B. The informative Model- Competent technical expert

C. The interpretative model -Counselor or adviser/ elucidate the pt’s value /
D. Deliberative model- Friend or teacher / health related values and advocate
a particular course of action /
10
 Case

• A 43-year-old premenopausal woman who has recently discovered a breast mass.

Surgery reveals a 3.5-cm ductal carcinoma with no lymph node involvement that is
estrogen receptor positive. Chest roentgenogram, bone scan, and liver function tests
reveal no evidence of metastatic disease. The patient was recently divorced and has
gone back to work as a legal aide to support herself. What should the physician say to
this patient?
1. Paternalistic
2. Informative
3. Interpretative
4. Deliberative
11
 General principles

• Agreement as to Process • Safety and Comfort

• Privacy and Confidentiality • Time and Number of Sessions
• Respect and Consideration • Rapport/Empathy
• Transference and • Interviewing Effectively
Countertransference
(Factors influencing the interview
process)

• The Interview Room

12
 General pri….. Cont.…

• PROCESS OF THE INTERVIEW

 Beginning the interview- privacy, quiet, and lack of interruptions
 Initiation of the Interview
 Specific Techniques (open and closed questions )
 Reflection, Facilitation, Silence, Confrontation, Clarification,
Interpretation, Summation, Explanation, Transition, Self-revelations,
Positive Reinforcement, Reassurance, Advice
 Ending the interview
 Compliance (adherence) 13
 Special Issue in Psychiatry . . .
• Confidentiality
• Supervision
• Missed Appointments and Length of Sessions
• Availability of a Clinician

• Problem Patients and Special Interview Situations

 Histrionic patients - Isolated Patients

 Narcissistic Patients - Suspicious patients

 Demanding patient - Obsessive patients

 Help-rejecting Patients - Demanding patients

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15
 UNIT THREE
Mental health assessment
(Examination and Diagnosis of the
Psychiatric Patient)

16
 MHA…..cont.…

• The TWO overarching elements of the psychiatric

interview are the patient history and the mental
status examination.

17
 HX and MSE
Hx taking
I. Identification
II. Source and reliability
III. Chief complaints
IV. History of presenting illness
• what (symptoms), how much (severity), how long, and associated
factors (alleviate or exacerbate), Rx received for the current episode,
positives and negatives
V. Past psychiatric /medical history
• (when they occurred, how long they lasted, and the frequency and severity of
episodes, dx and Rx and suicidality ,Violence and homicidality )
• Medical illnesses and Medication
18
 Hx . . . Cont . . .
VI. Family history
 (Mental illness, suicide, Substance, communication
(interaction) within the family
VII. Personal history
VIII. Sexual history
X. Forensic history
XI. Premorbid personality

19
 HX and MSE . . . cont. . . .
MSE

1. Appearance and Bhr. 7. Perceptions

2. Attitude toward 8. Sensorium
Examiner • Alertness
3. Motor Activity • Orientation (person, place, time)
4. Speech (fluency, amount, • Concentration
rate, tone, and volume. ) • Memory (immediate, recent,
long term)
5. Mood and affect • Calculations
6. Thinking • Fund of knowledge
• Form • Abstract reasoning
• Content 9. Judgment and Insight
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 UNIT FOUR

SCHIZOPHRENIA SPECTRUM

AND

OTHER PSYCHOTIC DISORDERS

DANIEL A.
5/3/2021 daniaye212@gmail.com 21
 Historical background
For centuries – psychotic states known in every
culture
In the nineteenth century -all mental disorders
described as single entity- unitary psychosis
Benedict Morel 1809 -1873
 French psychiatrist, had used the term demence precoce
Emil kraepelin- 1856 – 1926
 Dementia praecox and affective psychosis
 Course and outcome of psychosis
 .

Eugene Bleuler 1857 – 1939

 Coined the term “Schizophrenia”

 4 “A’s” - Attention, Affect, Ambivalence, Autism

Kurt Schneider 1887 - 1967

 First rank symptoms - characteristic hallucination and delusion

Operational diagnostic criteria – since1952 DSM

 DSM I-DSM IV; also ICD-10
Clinical picture

..
 .

DSM 5 criteria
A. Two (or more) of the following(symptoms), each present
for a significant portion of time during a 1 -month
period (or less if successfully treated).
At least one of these must be (1 ), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional
expression or avolition).
 .

B. Social/occupational dysfunction:
• For a significant portion of the time since the onset of
the disturbance,
• one or more major areas of functioning such as
• work, interpersonal relations, or self-care
• are markedly below the level achieved prior to the
onset
• when the onset is in childhood or adolescence,
failure to achieve expected level of interpersonal,
academic, or occupational achievement
.

C. Duration
• Continuous signs of the disturbance persist for at least
6 months.
• This 6-month period must include at least
• 1 month of symptoms (or less if successfully treated) that
meet Criterion A (i.e., active-phase symptoms) and
• may include periods of prodromal or residual symptoms
 Schizophrenia - Clinical picture
Positive symptoms
Delusions –persecutory, religious, somatic,, bizarre
Hallucination – auditory, visual
Disorganized speech – derailment, tangentially,
circumstantiality, perseveration, etc . . .

Disorganized or catatonic motor behavior – stupor,

mannerism, posturing, echopraxia, etc.

Incongruity of affect - smile, giggle for no reason

Schizophrenia - Clinical picture cont’d . . .

Negative symptoms
Alogia – poverty of speech – amount, content
Affective flattening
Anhedonia – inability to experience pleasure
Asociality – few social contact
Avoliton/Apathy – lack of energy, decreased
motivation
Attentional impairment - absentmindedness
 Schizophrenia - Clinical picture cont’d
Social and occupational deterioration

Work inhibition
Poor interpersonal relationship, social withdrawal
Poor self care – unkempt, bizarre clothing
Decreased level of achievement –academic etc.
Breaking social rules – table manner, obscenities,
collecting garbage
 Hummm… for general k’dge

5. Subtypes of schizophrenia (DSM IV-TR)

1. Paranoid
2. Disorganized
3. Catatonic
4. Undifferentiated
5. Residual
 Courses of schizophrenia

1. First episode, currently in acute episode

2. “ “ “ “ partial remission

3. “ “ “ “ full remission

4. Multiple episode, currently in acute episode . . .

 Outcome of schizophrenia
Devastating illness
 >50% of patients- long-term incapacity
 >10% of patients commit suicide
 (RF SUCIDE: being male, socially isolated, depressive illness
,previous history of suicidal attempt, unemployment, high
level of psychopathology, functional impairment)
Bad prognostic signs
 Insidious onset
 Long duration of episode
 Childhood behavioral problem
 Family history of schizophrenia
 Unmarried, male
 Low social class
Epidemiology

..
 Epidemiology -schizophrenia

 Prevalence: point prevalence ~3.2/1000

o Butajira life-time prevalence – 4.7/1000
 Incidence: 20/10000
 Sex ratio: male-to-female = 1:1
 Marital status: unmarried (more in male)
 Socioeconomic status: low social class
 Ethnicity and race: relatively similar world-wide
 Mortality: high death rates –suicide/accidents
 Gender Difference
Men Women
Prevalence No difference No difference
onset Early 15-25 Late -25-35
Unimodal Bimodal- second
peak in middle ages

Negative symptoms More Less

social functioning Worse Better

Etiology
Multifactorial causation
 Biologic
 Non-biologic
1. BIOLOGIC
 Genetic
 Biochemical Factors
 Structural changes
 Physiological changes
 Psychoneuroendocrinology/immunology
.

Genetic -Twin studies-Adoption studies - Family studies

Prevalence of Schizophrenia in Specific Populations
Population Prevalence (%)
General population 1
Non-twin sibling of a schizophrenia patient 8
Child with one parent with schizophrenia 12
Dizygotic twin of a schizophrenia patient 12
Child of two parents with schizophrenia 40
Monozygotic twin of a schizophrenia patient 47
.

Biochemical Factors

- Dopamine Hypothesis
• Schizophrenia results from too much dopaminergic
activity
• Revised Dopamine hypothesis – increased dopamine at
mesolimbic, and decreased dopamine at mesocortical
pathway
• Other neurotransmitters- Glutamate, GABA, Serotonin,
norepinephrine, neuropeptides
 DA path ways and fxn.
• Nigrostriatal - Sensory stimuli and movement
• Mesolimbic - Emotion and reward
• Mesocortical - Cognitive and emotional behavior
• Tuberoinfundibular- Control of the hypothalamic
and pituitary endocrine system

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 .

Structural changes
- Neuro-pathological basis for schizophrenia,
• the limbic system and the basal ganglia
• neuropathological or neurochemical abnormalities in the
cerebral cortex, the thalamus, and the brainstem
• Lateral and third ventricular enlargement
• Some reduction in cortical volume
• Reduced symmetry in schizophrenia
• the temporal, frontal, and occipital lobes
 .

Neural Circuits - schizophrenia as a disorder of brain

neural circuits
 The basal ganglia and cerebellum are reciprocally
connected to the frontal lobes
 Neural circuit linking the prefrontal cortex and limbic
system

 Neurodevelopmental
 Congenital brain anomalies
 .

Physiological changes
EEG
• Increased sensitivity to activation procedures (e.g., frequent
spike activity after sleep deprivation),
• Decreased alpha activity, increased theta and delta activity,
• More left-sided abnormalities than usual
Evoked Potentials
 The P300 has been reported to be statistically smaller than
comparison groups
Magnetic resonance spectroscopy- decreased brain
metabolism
.

Other biologic factors

Psychoneuroimmunology
Immunological abnormalities
• Decreased T-cell interleukin-2 production
• Reduced number and responsiveness of peripheral
lymphocytes,
• Abnormal cellular and humoral reactivity to neurons
• Presence of brain-directed (antibrain) antibodies
.

Psychoneuroendocrinology

 Abnormal dexamethasone-suppression test

 Decreased concentrations of luteinizing
hormone/follicle-stimulating hormone
 A blunted release of prolactin and growth hormone,
on gonadotropin-releasing hormone or thyrotropin-
releasing hormone stimulation
 A blunted release of growth hormone on
apomorphine stimulation.
2. Non-Biologic
Psychoanalytic Theories
Learning theories
Family Dynamics
Psychosocial

.
.

Psychoanalytic Theories
 Schizophrenia resulted from developmental fixations
that occurred earlier than those culminating in the
development of neuroses
o These fixations produce defects in ego development(poor early object
relations)
o Interpretation of reality and the control of inner drives(sex and
aggression)are impaired

 A disturbance in interpersonal relatedness

**Various symptoms of schizophrenia have symbolic

meaning for individual patients
 .

Learning Theories

 Children who later have schizophrenia learn irrational

reactions and ways of thinking by imitating parents
who have their own significant emotional problems

 The poor interpersonal relationships of persons with

schizophrenia develop because of poor models for
learning during childhood
 .

Family Dynamics
 A poor mother-child relationship - increase in the risk of
developing schizophrenia
 A specific family pattern plays a causative role in the
development of schizophrenia
 Pathological family behavior that can significantly increase the emotional
stress

Psychosocial–
 Low social class -Drift/Breed hypothesis
 Immigration
 Social isolation
 Treatment
of schizophrenia

..
Pharmacologic treatment
Antipsychotic medication
 Control acute psychosis
 Do little for negative symptoms
 Provide long term maintenance
 Two major types- typical and atypical
Adjunctive pharmacologic agents
 Benzodiazepine
 Propranolol
 Lithium carbonate
 Antidepressants
 Carbamzepine and sodium valproate
Electroconvulsive therapy ( ECT)
.

Non-pharmacologic treatment
 Social intervention – residence, work, etc.
 Individual Psychotherapy
o Psychoanalysis and Psychodynamic Psychotherapy
o Supportive Psychotherapy
o Personal Therapy
o Compliance Therapy
 Group Psychotherapy
 Family intervention- expressed emotion
 .

Good out patient clinic

 Monitoring of patients for relapse detection
 Careful medication management
 Family intervention
 Educate family about illness
 Improve communication with in the family
 Realistic appraisal of patients illness
• Other schizo – like disorders
 RECUP…
• A 35-year-old women patient come to your OPD, she was relatively healthy 3 month ago,
but currently she comes with a complaint of talking alone in a conversation manner,
assault people physically and verbally, she believed that ‘someone is following and want to
harm her ’she has also unable to do her day to day activity.

• Your possible dx? _______________

• If she has a Mood symptom that presented for a significant portion of the illness, what is
your possible dx?________________
• If the symptoms presented greater than 6 month, what was your possible
dx?_______________
• If the symptoms presented less than 1 month, what was your possible
dx?________________
• If the symptoms presented less than 1 month after she gave birth, what was your possible
dx ? _____________________________
• List the positive signs that she manifested?____________________________
• List possible general treatment for her?

55
MOOD DISORDERS

• Daniel A. (MSc in ICCMH

MSc. In C.P)
Email- dayelegne8@gmail.com

56
 Hummm . . . Summery

• Just write what you think about schizophrenia and

other psychotic disorder ?

57
 Question
• A patient was relatively healthy a month ago, but currently he
comes with a complaint of talking alone in a conversation
manner , assault people physically and verbally , he believed that
‘someone is following him and want to harm him’, he has also
poor social interaction with his relatives . This all symptoms are
happened without any apparent reasons .
• what is your possible Dx ?
• Also what are your possible DDx ?
• Rx ?

58
 Definition

• Mood and Affect ?

• Adjectives used to describe mood
- for depressed and elated mood ?

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 Historical background

• 4th century B.C.: Hippocrates – melancholie, mania

• 1854:French physicians Falret, Ballinger – folie
circulaire and folie a double form
• 1921: Kraepline – manic depressive psychosis
• 1952: DSM diagnostic and statistical manual
• 1968 up to now: DSM II – DSM IV ( also ICD-
international classification of diseases)
 Mood Disorders
Unipolar mood disorders Bipolar mood disorders
1. Major depressive 1. Bipolar I mood disorder
disorders 2. Bipolar II mood
2. Dysthymia disorders
3. PMDD 3. Cyclothymia
Bipolar Disorders

.
 Definition

• Patients with both manic and depressive episodes or

patients with manic episodes alone are said to have
bipolar disorder.

• The terms “unipolar mania” and “pure mania” are

sometimes used for patients who are bipolar but who do
not have depressive episodes.
63
 Categories
• Based on DSM V, it includes :
 bipolar I disorder,
 bipolar II disorder,
 cyclothymic disorder,
 substance/medication-induced bipolar and related disorder,
 bipolar and related disorder due to another medical condition,
 other specified and unspecified bipolar and related disorder.
64
 Mania

A. Abnormally and persistently elevated, expansive, or

irritable mood and abnormally and persistently
increased goal-directed activity or energy, lasting at
least 1 week and present most of the day, nearly
every day (or any duration if hospitalization is
necessary).
• Mood in a manic episode - euphoric, excessively
cheerful, high, or "feeling on top of the world."
 .

B. During the period - three (or more) of the following

symptoms (four if the mood is only irritable)
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep
3. More talkative -pressure to keep talking. eg, feels rested
after only 3 hrs of sleep
4. Flight of ideas -thoughts are racing.
5. Distractibility i.e., attention too easily drawn
6. Increase in goal-directed activity (either socially, at work or
school, or sexually) or psychomotor agitation (i.e.,
purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high
potential for painful consequences (e.g., buying sprees,
sexual indiscretions, etc).
 .

Cont . . .

C. Marked impairment in social or occupational

functioning or necessitate hospitalization to prevent
harm to self or others, or there are psychotic
features.
 Hypomania

A. Abnormally and persistently elevated, expansive, or

irritable mood and abnormally and persistently
increased goal-directed activity or energy, lasting at least
4 consecutive days and present most of the day,
nearly every day
 .

B. During the period - three (or more) of the following symptoms

(four if the mood is only irritable)
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep
3. More talkative -pressure to keep talking.
4. Flight of ideas -thoughts are racing.
5. Distractibility i.e., attention too easily drawn
6. Increase in goal-directed activity (either socially, at work or
school, or sexually) or psychomotor agitation (i.e., purposeless
non-goal-directed activity).
7. Excessive involvement in activities that have a high potential
for painful consequences (e.g., buying sprees, sexual
indiscretions, etc).
 .

C. The episode is associated with an unequivocal change in

functioning that is uncharacteristic of the individual when
not symptomatic.

D. The disturbance in mood and the change in functioning

are observable by others.

E. The episode is not severe enough to cause marked

impairment in social or occupational functioning or to
necessitate hospitalization.

**If there are psychotic features, the episode is, by definition,

manic.
.

I- Bipolar I Disorder

A. Criteria have been met for at least one manic episode

B. The occurrence of the manic and major depressive
episode(s) is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder,
delusional disorder, or other specified or unspecified
schizophrenia spectrum and other psychotic disorder.
**Life time prevalence(butajira) 6/1000 male; 3/1000
female
 Current or most recent episode

• Manic • Mild
• Depressed • Moderate
• Unspecified • Severe
Subtypes
Bipolar I disorder, single manic episode
Bipolar I disorder, recurrent
*Manic episodes are considered distinct when they are
separated by at least 2 months without significant symptoms of
mania or hypomania 72
.

Bipolar II Disorder
A. Criteria have been met for at least one hypomanic episode and
at least one major depressive episode
B. There has never been a manic episode.
C. The occurrence of the hypomanic episode(s) and major
depressive episode(s) is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional
disorder, etc.
D. The symptoms of depression or the unpredictability caused
by frequent alternation between periods of depression and
hypomania causes clinically significant distress or impairment
in social, occupational, or other important areas of
functioning.
 .

Cychlothymic disorder
A. For at least 2 years (at least 1 year in children and adolescents) there have
been numerous periods with hypomanic symptoms that do not meet criteria
for a hypomania episode and numerous periods with depressive symptoms
that do not meet criteria for a major depressive episode.
B. During the above period - not been without the symptoms for more than 2
months at a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never
been met.
D. Not better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, etc.
E. The symptoms are not attributable to the physiological effects of a
substance or another medical condition
F. Clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
•
Unipolar disorders

.
 .

Major Depressive Episode

A. Five (or more) of the following symptoms -during the same 2-
week period; and represent a change from previous
functioning: at least one - either (1) depressed mood or (2) loss
of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated
by either subjective report (e.g., feels sad, empty, hopeless) or
observation made by others (e.g., appears tearful-In children
and adolescents-irritable mood.)
2. Markedly diminished interest or pleasure -as indicated by either
subjective account or observation
3. Significant weight loss when not dieting or weight gain (e.g., a
change of >5% of body weight in a month), or decrease or
increase in appetite nearly every day; in children-failure to make
expected gain
 .

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings of
restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt
(which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness,
nearly every day (either by subjective account or as observed by
others).
9. Recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt or
a specific plan for committing suicide.
 .

B. Clinically significant distress or impairment in social,

occupational, or other important areas of functioning

C. Not attributable to the physiological effects of a substance or

to another medical condition.

Major depressive Disorder- additionally

D. The occurrence of the major depressive episode is not better

explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, etc.

E. There has never been a manic episode or a hypomanic episode.

Specifiers for Bipolar and Related Disorders/MDD
A. With anxious distress
• The presence of at least 2 of the following
 Feeling keyed up or tense
 Feeling unusually restless
 Difficulty concentrating because of worry
 Fear that something awful may happen
 Feeling that the individual might lose control of himself or
herself

5/3/2021 79
B. With mixed features

i. Manic or hypomanic episode, with mixed features:

- full criteria of Mani/hypomanic + 3 depressive/DAY
ii. Depressive episode, with mixed features
• Full criteria of a MDD + three manic/ hypomanic symptoms
/days

5/3/2021 80
C. With rapid cycling (applicable for bipolar I or II)
• Presence of at least 4 mood episodes in the previous 12
months
 Episodes are demarcated by either partial or full remissions
for at least 2 months or a switch to an opposite polarity
D. With peripartum onset
• If onset of mood symptoms occurs during pregnancy or in
the 4 weeks following delivery

5/3/2021 81
E. With melancholic features
One of the following
• Loss of pleasure in all, or almost all, activities
 Lack of reactivity to pleasurable stimuli
At least 3 of the following
 Distinct quality of depressed mood
 Symptoms worse in the morning
 Early morning awakening (2 hrs earlier)
 Marked psychomotor agitation or retardation
 Significant anorexia or weight loss
 Excessive or inappropriate guilt
5/3/2021 82
F. With atypical features

i. Mood reactivity
ii. At least 2 of the following:
 Significant weight gain or increase in appetite
 Hypersomnia
 Leaden paralysis (heavy feeling in limbs)
 Long-standing pattern of interpersonal rejection
sensitivity
5/3/2021 83
G. With psychotic features

• Delusions or hallucinations are present at any time in the episode

Mood-congruent: the content of all delusions and hallucinations
is consistent with the typical themes of mania or depression

Mood-incongruent: the content of delusions and hallucinations is

inconsistent with the episode polarity themes, or is mixture of
congruent and incongruent
5/3/2021 84
H. With catatonia
• Clinical picture dominated by at least 3 of :
 Stupor ( no psychomotor activity, not actively relating to
environment)
 Catalepsy( passive induction of a posture held against gravity)
 Waxy flexibility (slight resistance to positioning by examiner)
 Mutism ( no, or very little,verbal response)
 Negativism ( opposition or no response to instructions or
external stimuli)

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• Posturing (spontaneous and active maintenance of a posture
against gravity)
• Mannerism
• Stereotypy (repetitive, abnormally frequent non-goal-directed
mov’ts)
• Agitation (not influenced by external stimuli)
• Grimacing
• Echolalia (mimicking another’s speech)
• Echopraxia (mimicking another’s movements)

5/3/2021 86
I. With seasonal pattern
• Applies to the lifetime pattern of at least one type of episode
• Characterized by:
Presence of regular temporal relationship between onset of
particular mood episode and a particular time of the year
Full remission or switch occurs at a characteristic time of the
year
The last 2 years episodes were seasonal, and no non-seasonal
episodes occurred in those years

5/3/2021 87
.

Persistent Depressive Disorder (Dysthymia)

A. Depressed mood for most of the day, for more days than not,
as indicated by either subjective account or observation by
others, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
 .

C. Never been without the symptoms for greater than 2 months

at a time.
D. Criteria for a major depressive disorder may be continuously
present for 2 years.
E. Never been a manic episode or a hypomanie episode, and
criteria have never been met for cyclothymic disorder.
F. Not better explained by a persistent schizoaffective disorder,
schizophrenia, delusional disorder, etc.
G. The symptoms are not due to a substance or another medical
condition
H. Clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
 .

Dysthymia Major depressive episode

2 years in duration 2 weeks in duration

Depressed mood Depressed mood
2 additional 4 additional symptom
symptom
More cognitive More vegetative
symptom symptom
Onset mild Onset may be severe
 Premenstrual dysphoric disorder

• In the majority of menstrual cycles, at least five symptoms

must be present in the final week before the onset of
menses, start to improve within a few days after the onset of
menses, and become minimal or absent in the week post
menses
• At least one of the following symptoms must be present:
Marked affective lability
Marked irritability or anger or increased interpersonal
conflicts . . .
91
 Recap…

• DSM V of BP I, BP II and MDD

92
Epidemiology

93
Type Lifetime Prevalence (%)
Major depressive episode 5-17

Dysthymic disorder 3-6

Minor depressive disorder 10

Full uni-polar spectrum 20-25

In Ethiopia – depression(MDD)- 5.0 %

 Lifetime Prevalence
(%)
Bipolar I disorder 0-2.4

Bipolar II disorder 0.3-4.8

Cyclothymia 0.5-6.3

Hypomania 2.6-7.8

Full bipolar spectrum 2.6-7.8

In Ethiopia – Bipolar disorder - 0.5%

 .

Gender differences

• The mean age of onset for bipolar disorders 30 years

(childhood to 50 years) and for Major Depression disorders is
about 40 years (between childhood & 50 years).
• Twofold greater prevalence of major depressive disorder in
women than in men

• Bipolar I disorder has an equal prevalence among men and

women

• Manic episodes are more common in men, and depressive

episodes are more common in women
 .

• Major depressive disorder occurs most often in persons

without close interpersonal relationships or in those who
are divorced or separated
• No correlation has been found between socioeconomic
status and major depressive disorder
• Depression is more common in rural areas than in urban
areas.
• A higher than average incidence of bipolar I disorder in
upper socioeconomic groups
• The prevalence of mood disorder does not differ among
races.
Etiology

.
 .

1. Biologic factors

A.Genetic
B.Neurotransmitters
C.Alterations of Hormonal Regulation
D.Alterations of Sleep Neurophysiology
E.Immunological Disturbance
F.Structural and Functional Brain changes
G.Genetic Factors
 .

A. Genetic Factors

1. Family studies –
2. Adoption studies
3. Twin studies
4. Linkage Studies
Identify specific susceptibility genes using
molecular genetic methods.

 Genes explain ~50 to 70 percent of the etiology of mood disorders

 .

Family Studies

• If one parent has a mood disorder, a child will have a

risk of between 10 and 25 percent for mood disorder.

• If both parents are affected, this risk roughly doubles

• A family history of bipolar disorder conveys a greater

risk for mood disorders in general and, specifically, a
much greater risk for bipolar disorder
 .

Adoption Studies – one study

 A threefold increase in the rate of unipolar disorder
 A sixfold increase in the rate of completed suicide
Twin Studies
 A concordance rate in the monozygotic (MZ) twins of
70 to 90 percent; the same-sex dizygotic (DZ) twins of
16 to 35 percent

*Environment or other non-heritable factors must explain

the remainder
.

B. Neurotransmitters
1- Biogenic Amines

• Norepinephrine and serotonin are the two

neurotransmitters most implicated in the
pathophysiology of mood disorders

• A relative depletion of the monoamines, especially NE

and 5-HT
 .

2-Other neurotransmitters
 Dopamine
o The mesolimbic dopamine pathway may be dysfunctional in depression
and that the dopamine D1 receptor may be hypoactive in depression.

 Acetylcholine (ACh)
 Gama Aminobutyric acid (GABA)
o Reductions of GABA
 Glutamate and glycine
B. Alterations of Hormonal Regulation
.

• 1- Neuroendocrine Regulation:
• The Hypothalamus is a central to regulation of the
neuroendocrine- the adrenaline, Thyroid and Growth
hormones axes.
C. Structural and Functional Brain changes
1-Computed axial tomography (CAT) and magnetic
resonance imaging (MRI)
 Increased frequency of abnormal hyperintensities in
subcortical regions
 Ventricular enlargement, cortical atrophy, and sulcal
 Reduced hippocampal or caudate nucleus volumes, or
both
 Diffuse and focal areas of atrophy have been associated
with increased illness severity, bipolarity, and increased
cortisol levels.
2.Non-biologic
a. Psychosocial Factors
b. Psychological factors
.
 .

a. Psychosocial Factors
Life Events and Environmental Stress
 more often precede first, rather than subsequent, episodes of mood
disorders.- for both major depressive disorder and patients with bipolar
I disorder
 stress accompanying long-lasting changes in the brain's biology- high
risk of undergoing subsequent episodes of a mood disorder, even
without an external stressor
 life event most often associated with development of depression is
losing a parent before age 11.
• The environmental stressor most often associated with the onset of
an episode of depression the loss of a spouse. Another risk factor is
unemployment;
 Interpersonal theory
1) unresolved grief,
2) dispute b/n partner,
3) transition to new role,
 Personality factors

• No single personality trait or type uniquely predisposes a

person to depression.
• Persons with certain personality disorders— OCD,
histrionic, and borderline—may be at greater risk for
depression than persons with antisocial or paranoid
personality disorder.

109
.

Cognitive theory – negative thinking,

depressive schemata
 .

Cognitive theory – negative thinking, depressive

schemata

Learned helplessness theory – previous experience

with uncontrollable situation

Behavior theory - loss of reinforcement for non

depressive behavior, non-contingent reinforcement

 Theories of Mania – defense against depression

Secondary mood disorders

.
 .

Mood disorders due to medical illnesses

 Neurologic –e.g Parkinson’s disease, brain tumor

 Endocronological –e.g. hypo/hyperthyroidism, Cushing’s disease,

diabetes

 Metabolic –e.g. avitaminosis, renal failure

 Cardiovascular –e.g. myocardial infarction, cadiomyopathies

 Pulmonary –e.g. obstructive lung disease

 Various - brain injury, anemias, SLE, rheumatoid arthritis

 .

Mood disorder due to drugs/psychoactive substance

 Drugs –e.g.thiazide, corticosteroids, anticonvulsants, INH anti-TB
drugs,, methyldopa, theophylline, nifedipine, etc.

 Psychoactive substances – e.g. alcohol, hashish, etc.

Course of mood
disorder

.
 Course of unipolar depression
1. Chronically ill without remission – 5-27% of patients with
MDD
2. Recurrent MDD with full inter-episode recovery, without
dysthymia
3. Recurrent MDD without full inter-episode recovery,
without dysthymia
4. Recurrent MDD with full inter-episode recovery,
superimposed on dysthymia (double depression)
5. Recurrent MDD without full inter-episode recovery
superimposed on Dysthymia (double depression)
 .

Course of Bipolar Disorder

 Median length of
o Mania – 5-10 weeks
o Depressive phase – 19 weeks
o Mixed episode – 36 weeks

 ~20% of patients take chronic course

 Usually 1-2 episodes per year; roughly same frequency

of mania and depression

 Cycle length shortens for the first 3-6 episodes and then
stabilizes
 Prognostic signs
• MDD- Mild episodes, the absence of psychotic symptoms, and a
short hospital stay, a history of solid friendships during
adolescence, stable family functioning, and generally sound social
functioning for the 5 years preceding the illness. are good
prognostic indicators.

• Bp I- Short duration of manic episodes, advanced age of onset, few

suicidal thoughts, and few coexisting psychiatric or medical
problems predict a better outcome. 118
Treatment of mood
disorders

.
 .

BIOLOGICAL
Drugs
Antidepressant drugs- tricyclic and tetracyclic,SSRI,
others
Antimanic drugs or mood stabilizers- lithium,
carbamazepine, valproate, etc.
Antipsychotics
Benzodiazepine
Calcium channel blockers
Thyroid hormone
Electroconvulsive therapy (ECT)
Phototherapy
 .

PSYCHOTHERAPY
 Cognitive therapy (cognitive behavior therapy)
o Correcting automatic negative thinking
o Counteract errors of information processing
 Interpersonal therapy –deals with
o Unresolved grief
o Role disputes
o Transition to new role
o Social skill deficit
 Behavior therapy
o Education & guided practice – social skill training, structured problem-
solving therapy, self control therapy
 Psychodynamic psychotherapy -
 QUIZ
1. A 52-year old university teacher presented to a psychiatric clinic with pathological
guilt of letting down his colleagues, loss of interest in everything, morning
worsening of his condition, early morning awakening 2-3 hours prior to his usual
time of awakening, that predominated his presenting complaints for the last 1
month. The most likely diagnosis is?

A. MDD with anxious distress

B. MDD With atypical features

C. MDD with melancholic features

D. MDD with catatonic featureS

122
 QUIZ …CONT’D
2. W/ro. X presents to a psychiatric clinic with cheerful mood, singing, high self-esteem
with exceptional beauty and wealth and increased sexual desire, presented for the
duration of 3 days. She had a history of hopelessness, worthlessness, loss of pleasure
and suicidal ideation with strong intent to end her life and frequent tearfulness, of three
weeks duration, before a year. The most likely diagnosis is ?
A. BP I, currently with manic episode
B. BP II, currently with hypomanic episode
C. BP II, currently with depressed
D. Dysthymia

123
Anxiety Disorders

Daniel A.
MSc in ICCMH
daniaye212@gmail.com
124
 objectives

List the prevalence of anxiety and related

disorders
Identify comorbid psychiatric diagnoses
Apply general pharmacologic approaches to
the treatment of anxiety disorders

5/3/2021 125
 Anxiety disorders

Include disorders that share features of

excessive fear and anxiety and related
behavioral disturbances.

5/3/2021 126
 CRITERIA FOR PATHOLOGICAL NORMAL
DIFFERENTIATION ANXIETY ANXIETY

Intensity Relatively high and/or out Relatively low and/or proportionate

of proportion to the situation or circumstances

Duration Generally longer lasting Generally shorter lasting

or recurrent

Preoccupation with Yes No

anxiety

Quality of the experience Distressing, Unpleasant, but not too distressing

overwhelming, or not distressing for a long time
incapacitating
Effects on behaviour and impairs functioning Generally does not affect behaviour
functioning more than temporarily, does not
127

impair functioning
 Fear, Anxiety, and Stress

 Anxiety: Future-oriented “diffuse apprehension”

 Fear: Present-oriented defensive response to observable threat.

 Stress: Perceived environmental demands exceed one’s perceived

ability to meet them

5/3/2021 128
 Anxiety vs. Fear
Anxiety Fear

Threat
Threat

Response to a threat is unknown, Response to a threat is known,

internal, vague or confilictual external, definite threat
5/3/2021 129
 When Does Anxiety Become
Disordered?
Distress

Avoidance

Interference

Functional impairment
5/3/2021 130
 Anxiety
Overestimated

Likelihood x Harm
Anxiety =
Ability to cope

Underestimated
5/3/2021 131
Beck et al. 1985
Clinical features

132

.
 Clinical features

General remarks
• Anxiety occur in all people regardless of culture,
race, age, religion, gender, level of education or
economic background.
• Characterized by
– excessive fear and/ or inappropriate feelings of nervousness
– very general (applied to nearly all aspects of life)
– very focused on a particular situation.
• Often chronic, unremitting, and disabling
133
.

Two groups of symptoms

a. Psychological
• Inability to relax
• Nervousness, irritability
• Excessive worry
• Disturbance of concentration
• Panic
• Feelings of unreality
• Fear of losing control
• Fear of going crazy
• Fear of dying 134
.

b. Autonomic/Somatic Symptoms

• Chest pain • Hyperventilation

.

• Choking sensation • Muscle tension

• Diarrhea • Nausea
• Diaphoresis • Palpitations
• Dyspnea • Parasthesias
• Fatigue • Vertigo
• Flushing • Vomiting
• Headache
135
Clinical features cont'd

Classified into
1. Generalized Anxiety Disorder (GAD):
2. Panic disorder
3. Phobic disorder

136
 Clinical features cont'd
1. Generalized Anxiety Disorder (GAD)
• Excessive anxiety or worry– about work, school, etc. ; 6 month duration
• Difficult to control the worry
• Associated symptoms ≥ 3
 Restlessness or feeling keyed
 Hypervigillance - Inability to relax
 Easily fatigued - Difficulty to concentrate
 Irritability - Muscle tension
 Sleep disturbance - Tremor
• Significant distress or impairment of functioning
• Not attributable to the physiological effects of a substance/Med.
137
 DDx
• Anxiety disorder due to another medical condition
• Substance/medication-induced anxiety disorder
• Social anxiety d/o
• OCD . . .

138
Clinical features cont'd
2. Panic Disorder

• Recurrent unexpected panic attacks

Attacks last 5-20 minutes
At least 1 attack followed by 1month of
 Persistent concern of having another attack
 Worrying about the implication of the attack
 Change in behavior related to the attack
139
Clinical features cont'd
During panic attacks ≥ 4
• Palpitation - Feeling of choking
• Sweating - Fear of dying
• Trembling, shaking - Fear of going crazy
• Shortness of breath - Nausea
• Derealization/depersonalization
• Chest pain or discomfort - Numbness, tingling
• Dizzy, light headed - Chills or hot flushes
Symptom develop abruptly; Reach peak in 10 minutes
140
 Clinical features cont'd
3. Phobic Disorders
• Persistent and irrational fear of a specific object or situation
• Compelling desire to avoid the dreaded condition – object,
situation
• Fear recognized as excessive, and unreasonable - three major
types
a. Agoraphobia
b. Social phobia
c. Specific phobia
141
 Clinical features cont'd
A. Agoraphobia

A. Marked fear or anxiety about two (or more) of the

following five situations:
1. Using public transportation (e.g., automobiles, buses,
trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces,
bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
142
 .

B. Social phobia(Social Anxiety Disorder)

• Marked fear or anxiety about one or more social situations -

scrutiny by others.
• Examples include social interactions (e.g., having a conversation,
meeting unfamiliar people), being observed (e.g., eating or
drinking) and performing in front of others (e.g., giving a speech).

• Fear of acting in embarrassing or humiliating way in public

• Avoid situation where expected to interact with others –

e.g. perform a task in front of others like Speaking, eating, writing in

public
 Clinical features cont'd
C. Specific phobia

• Circumscribed fears of specific objects, situations or

activities; fear is excessive, unreasonable, enduring
• Develop anticipatory anxiety and avoidance
behavior
• Common situations or objects - Snake phobia, claustrophobia – being
suffocated/trapped, acrophobia – falling down

144
 Specific cont’d . . .
A. Marked fear or anxiety about a specific object or situation (e.g., flying,
heights, animals, receiving an injection, seeing blood)

B. The phobic object or situation almost always provokes immediate fear

or anxiety

C. The phobic object or situation is actively avoided or endured with

intense anxiety

D. The fear or anxiety is out of proportion to the actual danger posed by

the specific object or situation and to the sociocultural context
145
 Specific cont’d . . .

E. The fear, anxiety, or avoidance is persistent, typically lasting for

6 months or more

F. The fear, anxiety or avoidance causes clinically significant distress or

impairment in social, occupational, or other important areas of functioning

G. The disturbance is not better explained by the symptoms of another

mental disorder

Specifies- Animal, Natural, Situational …

146
147
 Humm… quiz
• A 40 year old woman presented with complaints of not
being able to leave her house. For the past 5 years, She had
increasing difficulty travelling far from home. She
constantly worries that she will not be able to get help if
she ‘’freaks out’’.
• So your dx ? And ddx ?
• A 40 year old woman presented with complaints of
difficulty travelling far from home by airplane.
• Also your dx and ddx ?
148
 Quiz
• A 40 year old woman presented with complaints of not being able to go
to church because of scrutinized by others
Your dx ?
A 23-year-old woman presents to clinic with a chief complaint of ripped by
\"difficulty concentrating because I worry about my child.\" She had
recently gone back to teaching after having her third child. The patient states
she is constantly wondering about other things as well. For example, she is
going to help her sister-in-law throw a goodbye party and finds herself
constantly going over what she needs to do to prepare for the party. At the
end of the day, her husband claims she is irritable and tired. At night, she is
unable to sleep and keeps thinking about her tasks for the next day. What is
the most likely diagnosis?
Your dx ?
149
Epidemiology
 Epidemiology of anxiety disorders

• Generalized Anxiety Disorder

* 12 month prevalence
Adoleccent 0.9%
Adult Ranges from0.4%-3.6%
*Life time morbid risk 9%
*F>M …..2X
* peaks Middle age
5/3/2021 151
 Panic Disorder

• The lifetime - 1 to 4 %

• 6-month - 0.5 to 1.0 percent.

• Women are two to three times more likely to be affected than men

• The only social factors - a recent history of divorce or separation.

• most commonly develops in young adulthood

• the mean age of presentation is about 25 years

5/3/2021 152
 Specific Phobia

 12 month prevalence - US 7%-9%

 European 6%
 Asian African 2%-4%
Children 5%
Adolescent (13-17)16%
Older Adult 3-5%
 Generally F>M 2:1
 Female Animal, natural environment, Situation
 M=F blood injection Phobia
5/3/2021 153
 Social Anxiety Disorder (Social
Phobia)
o 12 month prevalence - US 7%
o European 2-3%
o Children and adolescent comparable
o Prevalence decrease with age
o Older adults 2-5%
o *F>M …..OR 1.5-2.2

5/3/2021 154
 Agoraphobia

o Adolescent 1.7%
o Peaks in late adolescent and early adult hood
o 12 months prevalence >65 0.4%
o No statically significant culture and race
difference

5/3/2021 155
1. Biologic

.
 .

Change in Neurotransmitters
The three major neurotransmitters NT
A. Norepinephrine (NE),
B. Serotonin, and
C. Gamma amino butyric acid (GABA)

A- Increased noradrenergic function.

 A poorly regulated noradrenergic system with
occasional bursts of activity
o primarily localized to the locus ceruleus
o project their axons to the cerebral cortex, the limbic system, the
brainstem, and the spinal cord
 .

B-Serotonin

 Different types of acute stress result in increased 5-

hydroxytryptamine (5-HT) turnover in the prefrontal
cortex, nucleus accumbens, amygdala, and lateral
hypothalamus

 Serotonergic antidepressants have therapeutic effects in

some anxiety
 .

GABA

 A role of GABA in anxiety disorders - undisputed

efficacy of benzodiazepines
 A benzodiazepine antagonist, flumazenil (Romazicon),
causes frequent severe panic attacks in patients with
panic disorder.
 .

Endocrinological
 Dysfunctional Hypothalamic-Pituitary-Adrenal Axis
 Abnormality in Corticotropin-Releasing Hormone
(CRH)
o Psychological stress increase the synthesis and
release of cortisol
o Cortisol serves to mobilize and to replenish
energy stores and contributes to increased
arousal, vigilance, focused attention, and memory
formation
 Alterations in hypothalamic-pituitary-adrenal (HPA)
axis function - in PTSD
 .

Brain-Imaging Studies
Structural studies – CT- MRI
 occasionally show some increase in the size of cerebral ventricles
 a specific defect in the right temporal lobe was noted in patients
with panic disorder. abnormal findings in the right hemisphere but
not the left hemisphere
Functional brain-imaging –fMRI, PET, SPECT, EEG
 abnormalities in the frontal cortex, the occipital and temporal areas
 panic disorder-the parahippocampal gyrus
 OCD- the caudate nucleus is implicated
 In PTSD - amygdala
 ,

Neuroanatomical Considerations
 Locus ceruleus and the raphe nuclei - neuroanatomical
substrates of anxiety disorders.
 Limbic System -in the generation of anxiety and fear
responses
o Amygdala
o Septo-hippocampal pathway
o The cingulate gyrus
 Cerebral Cortex
o Frontal cerebral cortex
o Temporal cortex
 .

Genetic Studies
Heredity has been recognized as a predisposing factor
for anxiety disorders

 Half of all patients with panic disorder have at least

one affected relative
 Higher frequency of the illness in first-degree relatives of affected
patients than in the relatives of non-affected persons

 Twin registers also support the hypothesis that anxiety

disorders are at least partially genetical
Medical illnesses associated with Anxiety

• Symptoms can include panic attacks,

generalized anxiety, obsessions and
compulsions, and other signs of distress
• Signs and symptoms will be due to the direct
physiological effects of the medical condition
• The symptoms of anxiety disorder due to a
general medical condition can be identical to
those of the primary anxiety disorders
164
.

• Migraine • Hypoglycemia
• Endocrine - Pituitary • Premenstrual syndrome
dysfunction, Thyroid • Febrile illnesses and chronic
dysfunction infections
• Vitamin B12deficiency • Cerebral trauma and
postconcussive syndromes
• Toxic condition - Alcohol
and drug withdrawal; Caffeine • Cerebrovascular diseases
• Anemia
• Drugs-amphetamine, etc.

165
 2. Non-biologic

a. Psychosocial
b. Psychological
 .

a. Psychosocial
Stress and Anxiety
• The nature of the stressful event
• The person's resources, psychological defenses, and
coping mechanisms
• A person whose ego is functioning properly is in
adaptive balance with both external and internal worlds
• If the ego is defective and the resulting imbalance
continues sufficiently long, the person experiences
chronic anxiety.
 .

b. Psychological causes
Three major schools of psychological theory

 Psychoanalytic
 Behavioral
 Existential
 .

Psychoanalytic Theories
• Anxiety stemmed from a physiological buildup of libido
• Anxiety as a signal of the presence of danger in the
unconscious
• Result of psychic conflict between unconscious sexual
or aggressive wishes and corresponding threats from
the superego or external reality
• The ego mobilized defense mechanisms to prevent
unacceptable thoughts and feelings from emerging into
conscious awareness.
 .

Behavioral Theories
• Anxiety is a conditioned response to a specific
environmental stimulus
• In the social learning model, a child may develop an
anxiety response by imitating the anxiety in the
environment, such as in anxious parents.
Existential Theories
• Persons experience feelings of living in a purposeless
universe
• Anxiety is their response to the perceived void in
existence and meaning
Treatment

171

.
 Non-pharmacologic treatment

Many forms of psychotherapy

CBT
Interpersonal therapy
Supportive psychotherapy
Psychodynamic psychotherapy
 .

Psycho-education

Relaxation methods

Graded exposure or flooding - phobia

Exposure and response prevention; Desensitization –

OCD

Structured problem-solving
Pharmacologic treatment
Benzodiazepines
• Best used for time-limited treatment
• Dependence/withdrawal possible
SSRI’s - May be helpful for several syndromes
• Social phobia, panic disorder, OCD, PTSD,
GAD
Tricyclic agents- sedating antidepressants

174
 Summery
1. Define anxiety, fear and stress
2. When Does Anxiety Become Disordered? describe at least
three examples Distress, Avoidance, Interference, Functional
impairment
3. Discuss Normal versus Pathologic Anxiety
Is adaptive inborn response to the threat BUT Pathological one
is excessive and impairs functioning.
4. Discuss three neurotransmitters involved in anxiety
Norepinephrine, Serotonin, Dopamine

175
 Answer key

1. B 11. D 21. D
2. B 12. C 22. D
3. B 13. B 23. D
4. C 14. A 24. Antipsychotic
5. A 15. A 25. Schizopherniform
6. B 16. C 26. BPS
7. B 17. A
8. A 18. B
9. A 19. C
10. C 20. D 176
 Trauma- and Stressor-Related
Disorders
• Exposure to a traumatic or stressful
• It include
 Reactive attachment disorder
 Disinhibited social engagement disorder
 PTSD
 Acute stress disorder
 Adjustment disorders.

177
 PTSD

A. Exposure to actual or threatened death, serious injury, or

sexual violence
 Directly experiencing

 Witnessing ONE

 Learning

 Repeated or extreme exposure

178
 PTSD ….CON’D

B. Intrusion symptoms ≥ ONE

 Distressing Memories

 Distressing Dreams

 Dissociative reactions (e.g., flashbacks)

 Psychological distress (internal or external cues)

 Physiological reactions (internal or external cues)

179
 PTSD ….CON’D
C. Persistent avoidance of stimuli
 To distressing memories, thoughts, or feelings
 To external reminders
Negative alterations in cognitions and mood – 2 or more
 To remember an important aspect TE
 Persistent and exaggerated negative beliefs – Future
 Persistent, distorted cognitions
 Negative emotional state, diminished interest, Feelings of
detachment …
180
 PTSD ….CON’D
D. Alterations in arousal and reactivity
 .Irritable behavior and angry outbursts
 Reckless or self-destructive behavior
 Hypervigilance
 Exaggerated startle response
 Problems with concentration
 Sleep disturbance
E. ≥ ONE month and Factional impairment
181
Treatment

182
 SOMATIC SYMPTOM
AND
RELATED DISORDERS
Learning objective
After accomplishing this chapter the student will be able to ?
1. Define SSD ?
2. Identify the common feature of SSD
3. List different disorders under this category ?
4. Explain disorders under this category ?
5. Identify possible pharmacological and non-pharmachological
treatments ?
183
 Common features

• Somatic Sx - Significant distress and impairment

184
 Etiology

• Biological
• Early traumatic exposure
- violence , abuse …
• Learning

185
 Disorders

1. SSD
2. IAD
3. CD
4. PF
5. FD

186
 1. Somatic Symptom Disorder
A. ≥ 1 SS – distressing
B. Excessive and persistent thought, feeling or behavior- ONE
1. Thoughts about the seriousness of one’s symptoms.
2. High level of anxiety about health or symptoms.
3. Excessive time and energy devoted
C. More than 6 months
 Specify if… Predominant pain , Persistent, with severity 187
 2. IAD
A. Preoccupation – serious disease
B. SS – NOT present /minimal
C. High level of anxiety about health
D. Excessive health-related behaviors
E. Duration – 6 months
F. Not better explained by another mental disorder
- Care-seeking type
- Care-avoidant type 188
 3. Functional Neurological Symptom
Disorder
(Conversion Disorder)
A. ≥ 1 altered voluntary motor or sensory function
B. Clinical findings – incompatibility
C. Not better explained by another medical/mental disorder
D. Significant distress or impairment
• With weakness or paralysis, With abnormal movement , With swallowing
symptoms
• With speech symptom , With special sensory symptom (e.g., visual, olfactory,
or hearing disturbance)
• With mixed symptoms
189
 Psychological Factors Affecting Other
Medical Conditions
A. A medical symptom or condition (other than a mental
disorder) is present
B. Psychological or behavioral affect medical conditions
C. Not better explained by another mental disorder

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 Factitious Disorder

A. Factitious Disorder Imposed on Self

B. Factitious Disorder Imposed on other

191
 Quiz

• Mr. K is a 28-year-old single man brought to an emergency

department by his father, complaining that he had lost his
vision while going to stadium. As was usual for this man,
he had been reluctant to play volleyball because of his lack
athletic skills, and he was placed on a team at the last
moment. What is the most likely diagnosis?

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 SEXUAL
DYSFUNCTION

193
 Essential features

- Inability to respond to sexual stimulation or

- The experience of pain during the sexual act
- Inability to participate in a sexual relationship
as he or she would wish

194
 Sexual dysfunctions can be

Lifelong or
Acquired
Generalized or
Situational

195
 Etiology

Psychological factors
Physiological factors
Combined factors,
Numerous stressors including prohibitive cultural
mores, health and partner issues, and relationship
conflicts. 196
 Psychosexual factors

1- sexual identity

2- Gender identity

3- sexual orientation

3- sexual behavior

197
 Phase of sexual response

• Excitement
• Plateau
• Orgasm
• Resolution
198
 Gender difference

Male Female
• a wish to reinforce the
• Desire - sexual thoughts pair bond,

• Interest - sexual activity • feeling of closeness,

• a way of preventing the
• Alertness to sexual cues man from straying,
• or a desire to please the
partner.
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 Masturbation

• Object related sexual behavior

200
 I. DESIRE, INTEREST, AND
AROUSAL DISORDERS

1- Male Hypoactive Sexual Desire Disorder

2- Female Sexual Interest/Arousal Disorder

3- Male Erectile Disorder

201
 II- ORGASM DISORDERS

1- Female organismic disorder

2- Delayed ejaculation

3- premature (early) ejaculation

202
III. SEXUAL PAIN DISORDERS

1- Genito-Pelvic Pain/Penetration Disorder

203
 Treatment

Psychotherapy
• Desire /male erectile disorder- Masturbate
• Delayed ejaculation- Extra-vaginal ejaculation
• Premature ejaculation- Squeeze/stop–start technique
• Vaginismus- fingers or with size-graduated dilators
• lifelong female orgasmic disorder- Masturbate
Biologicaltreatments
204
 Exercise
• A- 45 year old male comes to the clinic with a problem of
marked difficulty in maintaining an erection until the completion
of sexual activity for the last 7 months in every situation and he
has a significant distress because of the problem. The most likely
diagnosis is?
• Mr. A is a 27 year old men, employed in ICT center came to
psychiatry clinic with a complaints of decrease sexual desire
towards his girlfriend even he don’t have a sexual fantasy towards
her for the last 1 year. He has a significant fear of divorce with
her because of the problem. The most likely diagnosis is?
205