Nahda collage

Medical program

Lecture note in

Psychiatry

Dr Hassan Ali Khalid, MD

Consultant of psychiatry
Mood disorder
sometimes called affective disorders. They include the following:
1. Major depressive disorder
2. Persistent depressive disorder (Dysthymia)
3. Cyclothymic disorder
4. Disruptive mood dysregulation disorder
5. Premenstrual dysphoric disorder
6. Bipolar(I and II)and related disorders
7. Mood disorders (depressive and bipolar related) due to another medical
condition
8. Substance/Medication-induced mood (depressive and bipolar related)
disorder
9. The general category of unspecified depressive and bipolar and related
disorders
Mood is a pervasive and sustained feeling tone that is experienced
internally and that influences a person’s behavior and perception of the world. Affect
is the external expression of mood.
II. Epidemiology
A. major depressive disorder has the highest lifetime prevalence (almost 17%) of any
psychiatric disorder. The annual incidence (number of new cases) of a major
depressive episode is 1.59% (women, 1.89%; men, 1.10%). The annual incidence of
bipolar illness is less than 1% .
B. Sex. Major depression is more common in women; bipolar I disorder is equal in
women and men. Manic episodes are more common in women .
C. Age. The age of onset for bipolar I disorder is usually about age 30.
D. Sociocultural. Depressive disorders are more common among single and divorced
persons compared to married persons.

III. Etiology
A. Neurotransmitters
1.Serotonin. biogenic amine neurotransmitter. Serotonin depletion occurs in
depression; Some patients with suicidal impulses have low cerebrospinal
fluid (CSF) concentrations of serotonin metabolites (5- hydroxyindole acetic acid [5-
HIAA]) and low concentrations of serotonin uptake sites on platelets.
2. Norepinephrine. Abnormal levels (usually low) of norepinephrine metabolites in
blood, urine, and CSF of depressed patients.
3. Dopamine. Dopamine activity may be reduced in depression and increased in
mania. Drugs that reduce dopamine concentrations (e.g., reserpine [Serpasil]) and
diseases that reduce dopamine concentrations (e.g., Parkinson’s disease) are
associated with depressive symptoms. Drugs that increase dopamine concentrations,
such as tyrosine, amphetamine, and bupropion (Wellbutrin), reduce the symptoms of
depression.

B. Psychosocial
1. Psychoanalytic. Freud described internalized ambivalence toward a
love object (person), which can produce a pathologic form of mourning if the object is
lost or perceived as lost. Mania and elation are viewed as defense against underlying
depression. Rigid superego serves to punish person with feelings of guilt about
unconscious sexual or aggressive impulses.
2. Psychodynamics. In depression, introjection of ambivalently viewed lost objects
leads to an inner sense of conflict, guilt, rage, pain,
3. Cognitive. negative self-view (“things are bad because I’m bad”).
4. Learned helplessness. A theory that attributes depression to a person’s inability to
control events.
5. Stressful life events. Losing a parent before age 11 is the life event most associated
with later development of depression.

V. BipolarDisorder
There are two types of bipolar disorder:
1-bipolar I characterized by the occurrence of manic episodes with or without a major
depressive episode
2-bipolar II characterized by at least one depressive episode with or without a
hypomanic episode.
A. Depression(major depressive episode).

1-Information obtained from history

a. Depressed mood: subjective sense of sadness, feeling “blue” or “down in the
dumps” for a prolonged period of time.
b. Anhedonia:inability to experienced pleasure
c. Social withdrawal.
d. Lack of motivation,little tolerance of frustration.
-Signs and Symptoms of Major Depressive Episode
1. A depressed mood and a loss of interest .
2. Trouble sleeping.
3. Decreased appetite and weight loss, or increased appetite and weight gain
4. Inability to concentrate and impairments in thinking
5. Psychomotor agitation or retardation
6. Fatigue and decreased energy
7. Feeling worthless with guilt
8. Suicidal thoughts
-e. Vegetative signs.
(1) Loss of libido.
(2) Weight loss and anorexia.
(3) Weight gain and hyperphagia.
(4) Low-energy level; fatigability.
(5) Abnormal menses.
(6) Early morning awakening
(7) Diurnal variation (symptoms worse in morning).
(8) Constipation.
(9) Dry mouth.
(10) Headache.

2. Information obtained from mental status examination

a. General appearance and behavior. Psychomotor retardation or agitation, poor eye
contact.
b. Affect.Constrictedorlabile.
c. Mood.Depressed,irritable,frustrated,sad.
d. Speech. Little or no spontaneity; long pauses; soft, low monotone.
e. Thought content. Suicidal ideation affects 60% of depressed
patients, and 15% commit suicide; poverty of thought hallucinations and delusions.
f. Cognition. Distractible, difficulty concentrating, complaints of poor memory,
g. Insight and judgment. Impaired.

3. Associated features
a. Somatic complaints may mask depression:e.g cardiac,
gastrointestinal, and genitourinary symptoms .
b. Content of delusions and hallucinations, when present, tends to be
congruent with depressed mood;e.g guilt, poverty, Mood-incongruent delusions are
those with content not apparently related to the predominant mood (e.g., thought
insertion, broadcasting,).

4. Age-specific features.
Depression can present differently at different ages.
a. Prepubertal. Somatic complaints, agitation, phobias.
b. Adolescence. Substance abuse, antisocial behaviour .
c. Elderly. Cognitive deficits (memory loss, apathy).

B. Mania (manic episode).

Persistent elevated expansive mood.
1. Information obtained from history
a. Erratic and disinhibited behaviour.
(1) Excessive spending or gambling.
(2) Impulsive travel.
(3) Hyper-sexuality .
b. Overextended in activities and responsibilities.
c. Low frustration tolerance.
d. Vegetative signs.
(1) Increased libido.
(2) Weight loss.
(3) Insomnia .
(4) Excessive energy.
2. Information obtained from mental status examination
a. General appearance and behavior. Psychomotor agitation; seductive, colorful
clothing; excessive makeup; bizarre combinations of clothes .
b. Affect.Labile.
c. Mood.Euphoric ,irritable.
d. Speech. Pressured, loud, dramatic .
e. Thought content. Highly elevated self-esteem, grandiose

Signs and Symptoms of Manic Episode

An elevated, expansive, or irritable mood .1
Increased self-esteem or grandiosity .2
Less need for sleep .3
Very talkative .4
Racing thoughts .5
Easily distracted and unable to focus .6
(sex and gambling) Excessive spending and engaging in pleasurable activities .7
Severe impairment in occupational and social functioning .8

Signs and Symptoms of Hypomanic Episode

An expansive, elevated, or irritable mood, but of lesser duration than mania .1
Increased self-esteem or grandiosity .2
Less need for sleep .3
Very talkative .4
Racing thoughts .5
Easily distracted .6
Excessive spending and engaging in pleasurable activities .7
Less severe than mania and with no significant change in daily functioning .8

. f. Thought process. Flight of ideas; racing thoughts, neologisms

. g. Sensorium. Highly distractible, difficulty concentrating

h. Insight and judgment. Extremely impaired; often total denial of illness

C. Other types of bipolar disorders
Rapid-cycling bipolar disorder. Four or more depressive, manic, or .1
.mixed episodes within 12 months
. Hypomania. Less severe than mania with no psychotic features .2

D. Depressivedisorders
Major depressive disorder. Can occur alone or as part of bipolar disorder. When it .1
occurs alone it is also known as unipolar depression. Symptoms must be present for at
.:1least 2 weeks. More common in women than in men by 2
Other types of major depressive disorder .2
.a. Melancholic
Melancholic Features Specifier :Signs and Symptoms
Lack of interest and pleasure in usual and all activities .1
Poor response to enjoyable activities .2
Depressed mood is different than usual reaction to stressful events .3
Mood is worse in the morning .4
Disturbed sleep with early morning arousal .5
Loss of appetite and weight loss .6
Inappropriate self-blame and remorse .7

c. Permpartum onset.Severe depression beginning within 4weeks of giving birth.

Symptoms range from marked insomnia, liability, and fatigue to suicide. Homicidal
and delusional beliefs about the baby may be present. Also applies to manic or mixed
.episodes or to brief psychotic disorder

d. Atypical features. characterized by weight gain and hypersomnia rather than weight
.:1to 3 :1loss and insomnia. More common in women than in men by 2

e. Catatonic. Stuporous, blunted affect, extreme withdrawal, negativism, pyschomotor

retardation with posturing and waxy flexibility. Responds to electroconvulsive
.(ECT) therapy
f. Pseudodementia. cognitive dysfunction resembling dementia. Occurs in elderly
persons, and more often in patients with previous history of mood disorder.
.Responsive to ECT or antidepressant medication

g. Depression in children. Signs and symptoms similar to those in adults. Masked

depression seen in somatic symptoms, running away from home, school phobia, and
.substance abuse. Suicide may occur

h. Double depression. Development of superimposed major depressive disorder in

dysthymic patients

.(Dysthymia) Persistent depressive disorder .3

Less severe than major depressive disorder. More common and chronic in women
than in men. Insidious onset. Occurs more often in persons with history of long-term
e.g., substance ) stress or sudden losses; often coexists with other psychiatric disorders
.(abuse, personality disorders, obsessive-compulsive disorder
(Dysthymia) Signs and Symptoms of Persistent Depressive Disorder
Easily depressed .1
Low self-esteem .2
Fearful .3
May be suspicious of others .4

Cyclothymic disorder. Less severe disorder, with alternating periods of hypomania .4

and moderate depression. Symptoms must be present for at least 2 years. Equally
common in men and women. Onset usually is insidious and occurs in late adolescence
.or early adulthood

Disruptive mood dysregulation disorder . The pertinent symptoms include; acute .5

and recurrent angry outbursts and occur frequently three or more times a week.
.diagnosis should not be made before age 6 or after 18 years

Premenstrual dysphoric disorder. It occurs about 1 week before the onset of menses .6
and is characterised by irritability,emotional , lability, headache, anxiety, and
depression. Somatic symptoms include wight gain breast pain and syncope

VI. Differential Diagnosis

.A. Mood disorder resulting from general medical condition
.Myxedema madness. Hypothyroidism associated with fatigability, depression .1
produces (poisoning) Mad hatter’s syndrome. Chronic mercury intoxication .2
.symptoms (and sometimes depressive) manic
.B. Substance-induced mood disorder
.(e.g., cocaine, amphetamine,steroids) Mood disorders caused by a drug or toxin
C. Schizophrenia. Schizophrenia Thought insertion and broadcasting, loose
associations, poor reality testing, or bizarre behaviour. Bipolar disorder with
depression or mania more often is associated with mood-congruent hallucinations or
.delusions
Differentiated from major depressive D. Grief. sadness secondary to major loss
disorder by absence of suicidal ideation or profound feelings of hopelessness and
worthlessness. Usually resolves within a year. May develop into major depressive
.episode in predisposed persons
VII. Course and prognosis
Fifteen percent of depressed patients eventually commit suicide. At least 75% of
affected patients have a second episode of depression, usually within the first 6
recover, 30% %50 :months after the initial episode. The prognosis generally is good
.partially recover, 20% have a chronic course

VIII. Treatment
.A. Depressive disorders
.Psychopharmacologic .1
.(SSRI) a. selective serotonin reuptake inhibitor
Early transient side effects include anxiety, gastrointestinal upset, and headache.
Educating patients about the self-limited nature of these effects can enhance
.compliance
Sexual dysfunction is often a persistent, common side effect that may respond to a
change in drug or dosage, or adjunctive therapy with an agent such as
.(BuSpar) or buspirone (Wellbutrin) bupropion
SSRIs may aggravate suicidal ideation and can be managed by clonazepam. Insomnia
can be managed with a benzodiazepine, zolpidem , trazodone
b. Bupropion is a noradrenergic, dopaminergic useful for depression marked by
anergy and psychomotor retardation. It is also devoid of sexual side effects. The
.average dose is 150 to 300 mg/day
c. Venlafaxine, desvenlafaxine, and duloxetine are serotonin– norepinephrine
reuptake inhibitors ,venlafaxine is 75 to 375 mg/day, desvenlafaxine is 50 to 100 mg,
.and of duloxetine is 20 to 60 mg/day
d. Mirtazapine has antihistamine, noradrenergic, and serotoninergic
actions. It specifically blocks 5-HT2 and 5-HT3 receptors, At low doses, it can be
highly sedating and cause weight gain. At higher dosages, it becomes more
noradrenergic relative to its antihistamine effects and so a more activating drug.
.Average dose is 15 to 30 mg/day
f. The tricyclics. Side effects include anticholinergic effects in addition to potential
cardiac conduction delay and orthostasis. The secondary amines, such as nortriptyline,
.are often better tolerated than the tertiary amines, such as amitriptyline
g. Augmentation strategies in treatment-resistant or partially responsive patients
.include liothyronine ,lithium, amphetamines, buspirone
h. If symptoms still do not improve, try an MAOI. An MAOI is safe with reasonable
dietary restriction of tyramine-containing substances. MAOIs must not be
administered for 2 to 5 weeks after discontinuation of an SSRI or other serotoninergic
.e.g., 5 weeks for fluoxetine) drugs
j. ECT is useful in refractory major depressive disorder and major depressive episodes
with psychotic features; or when side effects of antidepressant medications must be
.avoided
k. Lithium can be a first-line antidepressant in treating the depression of bipolar
.disorder

.Psychological .2
a. Cognitive. based on correcting chronic distortions in thinking that lead to
depression, in particular the cognitive triad of feelings of helplessness and
.hopelessness about one’s self, one’s future, and one’s past
positive reinforcement may be an ) b. Behavioral. Based on learning theory
. (effective

B. Bipolar disorder
Biologic .1
and olanzapine are first-line treatments for the ,(Depakote) a. Lithium, divalproex
is also a well- (Tegretol) manic phase of bipolar disorder, but carbamazepine
established treatment. Gabapentin and lamotrigine are also of use. ECT is highly
.effective in all phases of bipolar disorder
b. Treatment of acute manic episodes often requires adjunctive use of potent sedative
mg every 1) drugs. Drugs commonly used at the start of treatment include clonazepam
.(mg every 4 to 6 hours 2) (Ativan) and lorazepam (4 to 6 hours
and ,(to 10 mg/day 2.5) olanzapine ,(to 10 mg/day 2) (Haldol) Haloperidol
.(to 6 mg/day 0.5) (Risperdal) risperidone
c. Lithium remains a mainstay of treatment in bipolar disorders. A
.blood level of 0.8 to 1.2 mEq/L is usually needed to control acute symptoms
Realated Disorder & Somatic Symptoms
-:I. Somatic Symptoms Disorder
known as hypochondriasis, requires 6 or more months of a nondelusional preoccupation with fears -
.of having, or that one has, a serious disease based on the misinterpretation of bodily symptoms
-:Epidemiology
,In medical clinics, the 6-month prevalence is 4% to 6%-
.women have more somatic complaints than men-
Onset can occur at any age, but commonly appears at 20 to 30 years of age, 3% of medical students, -
.usually in the first 2 years
-:Etiology
.Persons augment and amplify their somatic sensations-
-:Diagnosis
the diagnostic criteria for somatic symptom preoccupied with the false ,)DSM-5( According to the-
belief that they have a serious disease, based on their misinterpretation of physical signs or
sensations the belief must last at least 6 months, despite the absence of pathologic findings on
.medical and neurologic examinations
must be sufficiently intense to cause emotional distress or impair the patient’s The symptoms-
.ability to function
-:Clinical Features
Patients believe that they have a serious disease that has not yet been detected and they cannot be -
persuaded to the contrary. They may maintain a belief that they have a particular disease despite
.negative laboratory results
-:Diagnosis
Somatic symptom disorder must be differentiated from nonpsychiatric medical conditions with -
myasthenia gravis, multiple sclerosis, degenerative diseases of the ,)AIDS( vague symptoms like
.nervous system, systemic lupus erythematosus, and occult neoplastic disorders
differentiated from illness anxiety disorder, which is fear of having a disease rather than a concern -
.about many symptoms
.Conversion disorder is acute and transient, and involves a symptom rather than a particular disease-
panic disorder-
dellusional disorder-
-:Treatment
Group psychotherapy often benefits because it provides the social support and social interaction that -
.reduce anxiety
behavior therapy-
congentive therapy-
regularly scheduled physical examination
Schizophrenia Spectrum and Other Psychotic Disorders
I. Introduction
-Schizophrenia is a group of disorders along a spectrum with heterogeneous etiologies and is
characterized by disturbances in cognition, emotion, perception, thinking, and behavior.
-Schizophrenia is well established as a brain disorder, with structural and functional abnormalities
visible in neuroimaging studies and a genetic component as seen in twin studies.
-The disorder is usually chronic :
a-prodromal phase.
b-an active phase.
c-a residual phase.
-The active phase has symptoms such as hallucinations, delusions, and disorganized thinking.
-The prodromal and residual phases are characterized by attenuated forms of active phase .

II. Epidemiology
A. Incidence and prevalence. In the United States, the lifetime prevalence
of the disease is about 1%, will develop the disorder during his or her lifetime. Worldwide, 2 million
new cases appear each year. In the United States.
B. Gender and age. Equally prevalent between men and women; usually onset is earlier in men. Peak
age of onset between 15 and 35 .
C. Infection and birth season. Persons born in winter are more likely to develop the disease than
those born in spring or summer ,Increased in babies born to
mothers who have influenza during pregnancy.
D. Race and religion. Jews are affected less often than Protestants and
Catholics, and prevalence is higher in non-white populations.
E. Medical and mental illness. Higher mortality rate from accidents and natural causes than in
general population. Leading cause of death in schizophrenic patients is suicide 10% and 40% abuse
drugs and alcohol. The prevalence of diabetes mellitus type II and metabolic abnormalities is higher
and treatment with atypical antipsychotics agent .
F. Socioeconomics. More common among lower rather than higher socioeconomic groups; high
prevalence among recent immigrants .

III. Etiology
- no single factor is considered causative.
- person has specific biologic vulnerability.
- triggered by stress ) schiz symptoms (.

IV. Diagnosis,Signs,andSymptoms :
- Diagnosis is based on observation and description .
-There are no pathognomonic signs or symptoms. According to the fifth edition of the Diagnostic
Statistical Manual of Mental Disorders )DSM-5( at least two of the following five signs or symptoms
must be present for at least 1 month.
)1( Hallucinations; )2( delusions; )3( disorganized speech; )4( disorganized behavior; or )5( negative
symptoms )e.g., flat affect, abulia(.
A. Overall functioning. function declines or fails to achieve the expected level.
B. Thought content. Abnormal )e.g., delusions, ideas of reference, poverty of content(.
C. Form of thought. Illogical )e.g., loosening of associations, incoherence,neologisms, echolalia(.
D. Perception. Distorted )e.g., hallucinations: visual, olfactory, tactile, and, most frequently,
auditory(.
E. Affect.Abnormal)e.g.,flat,blunted,silly,labile,inappropriate(.
F. Sense of self. Impaired )e.g., loss of ego boundaries, gender confusion(.
G. Volition. Altered )e.g., inadequate drive or motivation and marked
ambivalence(.
H. Interpersonal functioning. Impaired )e.g., social withdrawal and
emotional detachment, aggressiveness (.
I. Psychomotor behavior. Abnormal or changed )e.g., agitation vs.
withdrawal, grimacing, posturing, catatonia(.
J. Cognition. Impaired )e.g., concreteness, inattention, impaired
information processing(.

V. Types:
A. Paranoid
1. delusions of persecution or grandeur.
2. Frequent auditory hallucinations.
3. Patients tense, suspicious, guarded, and sometimes hostile or aggressive.
B. Disorganized)hebephrenia(
1. regression to primitive, disinhibited, and chaotic behavior.
2. Incoherence, marked loosening of associations
3. grimacing.
4. usually before age 25.
C. Catatonic
1. disturbance in motor function called waxy flexibility.
2.rigidity,stupor, echopraxia; Workward positions for long periods of time.
3. Purposeless excitement with risk of injury to self or others.
4. Speech echolalia or mutism.
D. Undifferentiated type
1. Prominent delusions, hallucinations, incoherence .
2. Does not meet the criteria for paranoid, catatonic .
E. Residual type
1. Absence of prominent delusions, hallucinations, incoherence .

VII. Pathophysiology
A. Neuropathology. No consistent structural defects; changes noted
include decreased number of neurons, increased gliosis, and disorganization of neuronal architecture.
There is degeneration in the limbic system, especially the amygdala, hippocampus, and the cingulate
cortex. The basal ganglia, including the substantia nigra and dorsolateral prefrontal cortex are also
involved.
B. Brainimaging
1. Computed tomography )CT(. Cortical atrophy in 10% to 35% of
patients; enlargement of the lateral and third ventricle in 10% to 50%.
2. Magnetic resonance imaging )MRI(. Ventricles in MZ twins with schizophrenia are larger than
those of unaffected siblings.
3. Magnetic resonance spectroscopy. Decreased metabolism of the dorsolateral prefrontal cortex.
4. Positron emission tomography )PET(. In some patients, decreased frontal and parietal lobe
metabolism .
5. Cerebral blood flow )CBF(. In some patients, decreased resting levels of frontal blood flow,
increased parietal blood flow, and decreased whole-brain blood flow.

IX. Differential Diagnosis

A. Medical and neurologic disorders. Present with impaired memory,
orientation, and cognition; visual hallucinations; signs of CNS damage. substance intoxication )e.g.,
cocaine (.CNS infections )e.g., herpes encephalitis( .temporal lobe epilepsy .
B. Schizophreniform disorder. last for less than 6 months.
C. Brief psychotic disorder. Symptoms last less than 1 month.
D. Mood disorders mood symptom in schizo must be brief .
E. Schizoaffective disorder. Mood symptoms develop concurrently with symptoms of schizophrenia.
F. Delusional disorders. Nonbizarre, systematized delusions that last at least 6 months in the context
of an intact, relatively well-functioning personality in the absence of prominent hallucinations .

X. Course and Prognosis

A. Course. Prodromal symptoms of anxiety, perplexity, terror, or
depression generally precede the onset of schizophrenia. Precipitating events )e.g., emotional trauma,
use of drugs, a separation(.
B. Prognosis. 1-one- third of patients lead somewhat normal lives, 2-one-third continue to experience
significant symptoms but can function within society, 3-and the remaining one-third are markedly
impaired and require frequent hospitalization.

IX. Treatment
Clinical management of the schizophrenic patient may include hospitalization and antipsychotic
medication in addition to psychosocial treatments, such as behavioral, family, group, individual, and
social skills and rehabilitation therapies.

A. Pharmacologic. The antipsychotics include the first-generation dopamine receptor antagonists and
the second-generation agents such as serotonin–dopamine antagonists )SDAs(, such as risperidone
)Risperdal( and clozapine )Clozaril(.

a. First-generation antipsychotics
)also known as typical antipsychotics, or dopamine receptor antagonists( High-potency agents )e.g.,
haloperidol( are more likely to cause extrapyramidal side effects such as akathisia, acute dystonia,
and pseudoparkinsonism. Low- potency agents )e.g., chlorpromazine [Thorazine]( are more sedating,
hypotensive, and anticholinergic. These agents can cause tardive dyskinesia .
First generation:
1-Chlorpromazine tab
2-Fluphenazine Decanoate inj Long active 5-30 mg
3-Trifluoperazine)stelazine(
4-Haloperidol 5-20 mg

b. Second-generation antipsychotics :
Second-generation agents :
1-Aripiprazole )10-30(
2-Clozapine )150-600(
3-Olanzapine )10-30(
4-Quetiapine )300-800(
5-Risperidone )2-8(
)also known as atypical, novel, or SDAs(—the newer-generation antipsychotic drugs that provide
potent 5-HT2 receptor blockade and varying degrees of D2 receptor blockade, these drugs improve
two classes of disabilities: )1( positive symptoms such as hallucinations, delusions, disordered
thought, and agitation, and )2( negative symptoms such as withdrawal, flat affect, poverty of speech,
and cognitive impairment. They cause tardive dyskinesia.

B. Electroconvulsive therapy )ECT(. Can be effective for acute psychosis and catatonic subtype.
Also for refractory positive symptoms .

C. Psychosocial.
1. Behavior therapy. Desired behaviors are positively reinforced by
rewarding them with specific tokens,
2. Group therapy helpful in decreasing social isolation and increasing reality testing.
3. Family therapy. decrease relapse rates
4. Supportive psychotherapy include advice, reassurance, education, modeling .
personality disorder
I. General Introduction
A. Definition. Personality disorder is an enduring pattern of behavior and
inner experiences that deviates significantly from the individual’s cultural standards; is rigidly
pervasive; has an onset in adolescence or early adulthood;
manifests in at least two of the following four areas: cognition, affectivity, interpersonal function, or
impulse control.
B. Classification.
1. Cluster A. The odd and eccentric cluster consists of the paranoid, schizoid, and schizotypal
personality disorder. These disorders involve the use of fantasy and projection and are associated
with a tendency toward psychotic thinking.
2. Cluster B. The dramatic, emotional, and erratic cluster includes the histrionic, narcissistic,
antisocial, and borderline personality disorders. These disorders involve the use of dissociation,
denial, splitting, and acting out.
3. Cluster C. The anxious or fearful cluster includes the avoidant, dependent, and obsessive-
compulsive personality disorders. These disorders involve the use of isolation, passive aggression,
and hypochondriasis.

II. Odd and Eccentric Cluster

A. Paranoid personality disorder
1. Definition. Characterized by their intense distrust and suspiciousness
of others, patients with paranoid personality disorder are often hostile, irritable, hypersensitive,
envious, or angry,
2. Epidemiology
a. The prevalence is 0.5% to 2.5% in the general population; 10% to
30% for inpatients; and 2% to 10% for outpatients.
b. The prevalence is higher among minorities, immigrants, and the
deaf.
3. Etiology
a. A genetic component is established.
b. . Histories of childhood abuse .
4. Psychodynamics
a. The classic defenses are projection ,denial,and rationalization.
5. Diagnosis.
The critical feature of such patients is a pervasive and unwarranted tendency to perceive the actions
of others as deliberately demeaning or threatening. This tendency begins by early adulthood
Paranoid Personality Disorder
A pattern of skepticism toward others and paranoid suspicion of their motives, as evidenced by ≥4
of:
-Suspicion that others are out to trick
-Obsession with friends’ infidelity
-Refusal to trust others
-Constant detection of covert and damaging interpretations of innocuous matters
7. Course and prognosis.
In some patients the disorder is lifelong, while in others it is schizophrenia. In general, patients with
paranoid personality disorder have problems working and living with others.
8. Treatment
a. Psychotherapy. improving social skills and diminishing suspiciousness.
b. Pharmacotherapy. antianxiety agent such as diazepam )Valium( or clonazepam )Klonopin( is
sufficient. antipsychotic, such as olanzapine )Zyprexa( or haloperidol )Haldol(,
Schizoid personality disorder
Definition.
characterized by their isolated lifestyles and their lack of interest in social interaction. .1
2. Epidemiology
a. Thisdisordermayaffect7.5%ofthegeneralpopulation.
b. The incidence is increased among family members of
schizophrenic and schizotypal personality disorder probands.
c. The incidence is greater among men than among women,
3. Etiology
a. Genetic factors
b. disturbed family.

5. Diagnosis.
poor eye contact.
Their affect is often constricted, aloof,
avoid spontaneous speech,
Habitual pefernce
Lack of hobbies
Abssence of freinds
6. Differential diagnosis
a. Paranoid personality disorder. has a history of aggressive behavior, and projects his or her
feelings onto others.
b. Schizotypal personality disorder. The patient exhibits oddities
and eccentricities of manners, has schizophrenic relatives, and may
not have a successful work history.
Course and prognosis.
course is long lasting, but not necessarily lifelong.
8. Treatment
a. Psychotherapy. Group therpy
b. Pharmacotherapy. Small dosages of antipsychotics, antidepressants, and psychostimulants .
Serotonergic agents may make patients less sensitive to rejection. Benzodiazepines may be of use to
diminish interpersonal anxiety.
C. Schizotypal personality disorder
1. Definition.
characterized by magical thinking, peculiar notations, ideas of reference, illusions, and derealization.
2. Epidemiology
a. Theprevalenceofthisdisorderis3%.
b. The prevalence is increased in families of schizophrenic probands.
3. Etiology.
Etiologic models of schizophrenia may apply.
5. Diagnosis,
oddities of thinking, behavior, and appearance. Taking the history of such patients may be difficult
due to their bizarre way of communicating. These patients may be superstitious or claim powers of
clairvoyance and may believe that they have other special powers of thought and insight. They may
be isolated and have few friends due to their inability to maintain interpersonal relationships and
their inappropriate actions. While under stress, patients may decompensate and show psychotic
symptoms.
Course and prognosis.
Up to 10% of patients commit suicide.
Schizophrenia can develop in some patients. Prognosis is guarded.
8. Treatment
Pharmacotherapy. In dealing with ideas of reference, illusions, and other symptoms, antipsychotic
agents may be useful and can be combined with psychotherapy. Antidepressants may be used when
depression is present. Dramatic,Impulsive,andErraticCluster
A. Antisocial personality disorder
1. Definition.
Persons with antisocial personality disorder are characterized by their inability to conform to the
social norms which govern individual behavior. Such persons are impulsive, egocentric,
irresponsible, and cannot tolerate frustration. Patients with antisocial personality disorder reject
discipline and authority and have an underdeveloped conscience.
2. Epidemiology
a. The prevalence is 3% in men and 1% in women in the general population. .
b. The disorderis more common in lower socioeconomic groups.
d. Predisposing conditions include attention-deficit/hyperactivity disorder )ADHD( and conduct
disorder.
3. Etiology
a. genetic factors .
b. Brain damage or dysfunction
c. Histories of parental abandonment or abuse
5. Diagnosis.
hostility, irritability, and rage. A stress interview, one where patients are vigorously confronted with
inconsistencies in their histories, may be needed to reveal the pathology. A diagnostic workup should
include a thorough neurologic examination. Patients often show abnormal
electroencephalogram )EEG(results and soft neurologic signs suggestive of minimal brain damage in
childhood. Typical experiences beginning in childhood include lying, truancy, running away from
home, thefts, fights, substance abuse, and illegal activities. Promiscuity, spouse abuse, child abuse,
and drunk driving are common. Patients lack remorse for their actions and appear to lack a
conscience.
6. Differentialdiagnosis
a. Substance use disorders. The patient may exhibit antisocial
behavior as a consequence of substance abuse and dependence.
c. Mental retardation. The patient may demonstrate antisocial
behavior as a consequence of impaired intellect and judgment.
d. Psychoses. The patient may engage in antisocial behavior as a
consequence of psychotic delusions.
e. Adhd cognitive difficultis impulse dyscontrol are present
7. Course and prognosis. The condition often significantly improves after early or middle adulthood.
Complications include death by violence, substance abuse, suicide, physical injury, legal and
financial difficulties, and depressive disorders.
8. Treatment
a. Psychotherapy.
b. Pharmacotherapy. Pharmacotherapy is used to deal with symptoms such as anxiety, anger, and
depression, but drugs must be used judiciously due to the risk of substance abuse. If the patient
exhibits evidence of ADHD, psychostimulants such as methylphenidate )Ritalin( may be useful.
B. Border line personality disorder
1. Definition.
Patients with borderline personality disorder are literally
on the border between neurosis and psychosis. They exhibit extraordinarily unstable mood, affect,
behavior, object relations, and self-image. Suicide attempts and acts of self-mutilation are common
occurrences among borderline patients. These individuals are very impulsive, and suffer from
identity problems as well as feelings of emptiness and boredom. Borderline personality disorder has
also been called ambulatory schizophrenia,
2. Epidemiology
a. The prevalence of borderline personality disorder is about 2%
b. Itismorecommoninwomenthaninmen.
c. Of these patients, 90% have one other psychiatric diagnosis, and 40% have two.
d. The disorder is five times more common among relatives , borderline personality disorder is
increased in the mothers of borderline patients.
3. Etiology
a. Brain damage may be present and represent perinatal brain injury,
encephalitis, head injury, and other brain disorders.
b. Histories of physical and sexual abuse, abandonment,
5. Diagnosis.
Patients with borderline personality disorder are marked by their pervasive and excessive instability
of affects, self-image, and interpersonal relationships and their distinct impulsivity. They tend to
have micropsychotic episodes, often with paranoia or transient dissociative symptoms. Self-
destructive, self-mutilating, or suicidal gestures, threats, or acts occur frequently.
6. Differential diagnosis
a. Psychoticdisorder.Impairedrealitytestingpersists.
b. Mood disorders. sustained episodes of depression,
c. Personality change secondary to a general medical condition.
Results of testing for medical illness are positive.
d. Schizotypal personality disorder. The affective features are less
severe.
e. Antisocial personality disorder. The defects in conscience and
attachment ability are more severe.
f. Histrionic personality disorder. Suicide and self-mutilation are
less common. The patient tends to have more stable interpersonal
relationships.
g. Narcissistic personality disorder. Identity formation is more
stable.
h. Dependentpersonalitydisorder.Attachmentsarestable.
i. Paranoid personality disorder. Suspiciousness is more extreme and consistent.
Course and prognosis. .7
; some improvement may occur in later years. Suicide, self-injury, mood disorders, somatoform .8
disorders, psychoses, substance abuse, and sexual disorders are possible complications.
8. Treatment.
a. Psychotherapy. Behavior therapy may be useful to control impulses and angry outbursts and to
reduce sensitivity to criticism and rejection. Social skills training is useful to improve their
interpersonal behavior. Dialectical behavior therapy may be used in cases of parasuicidal behavior
such as frequent cutting.
b. Pharmacotherapy. Antipsychotics are useful in controlling anger, hostility, and brief psychotic
episodes. Antidepressants are useful in improving depressed mood. Monoamine oxidase
inhibitors )MAOIs( may be effective in modulating impulse behavior. Benzodiazepines, particularly
alprazolam )Xanax(, can be helpful with anxiety .
C. Histrionic personality disorder
1. Definition.
Characterized by the flamboyant, dramatic, excitable and
overreactive behavior, persons with histrionic person personality disorder are intent on gaining
attention. They tend to be immature, dependent, and are often seductive.
2. Epidemiology
a. The prevalence of histrionic personality disorder is 2% to 3%.
b. The prevalence is greater in women than in men,
c. This disorder may be associated with somatization disorder, mood
disorders, and alcohol use.
3. Etiology
a. Early interpersonal difficulties may have been resolved by
dramatic behavior.
b. Distant or stern father with aseductive mother may be apattern.
4. Psychodynamics
a. Fantasy in “playing a role,” with emotionality and a dramatic style,
b. Fixation at the early genital level
c. Fear of sexuality, despite overt seductiveness.
Diagnosis.
Patients with histrionic personality disorder are often cooperative and eager to be helped. Gestures .5
and dramatic punctuation in their conversation are common and their language is colorful. Cognitive
test results are usually normal; however, a lack of perseverance may be shown on arithmetic or
concentration tasks. Emotionality may also be shallow or insincere and patients may be forgetful of
affect-laden material. They tend to exaggerate thoughts and feelings to get attention,
IV. Anxiousor Fearful Cluster
A. Obsessive- compulsive personality disorder
1. Definition.
Characterized by perfectionism, orderliness, inflexibility, stubbornness, emotional constriction, and
indecisiveness. Also called anancastic personality disorder.
2. Epidemiology
a. The prevalence is 1% in the general population
b. The prevalence is greater in men than in women.
c. Familialtransmissionislikely.
d. Theconcordanceisincreasedinmonozygotictwins.
3. Etiology.
Patients may have backgrounds characterized by harsh
discipline.
Diagnosis .6
. Patients with obsessive-compulsive personality disorder have a stiff, formal, and rigid demeanor. .7
In an interview, patients may be anxious about not being in control and their answers to questions are
unusually detailed.
B. Avoidance personality disorder
1. Definition.
Patients have a shy or timid personality and show an intense sensitivity to rejection. They are not
asocial and show a great desire for companionship; however, they have a strong need for reassurance
and a guarantee of uncritical acceptance. They are sometimes described as having an inferiority
complex.

C. Dependent personality disorder

1. Definition.
Patients are predominantly dependent and submissive.
They lack self-confidence and get others to assume responsibility for
major areas of their lives.
Diagnosis.\ .5
Persons with dependent personality disorder have an intense need to be taken care of, which leads .6
to clinging behavior, submissiveness, fear of separation, and interpersonal dependency. In
interviews, they appear rather compliant; they try to cooperate, welcome specific questions, and look
for guidance. They are passive and have difficulty expressing disagreement. Patients are pessimistic,
passive, indecisive, and fear expressing sexual or aggressive feelings .
V. Other Specified Personality Disorders
A. Passive-aggressive personality
1. Definition.
Patients with this disorder show aggression in passive
ways characterized by obstructionism, procrastination, stubbornness,
and inefficiency. It is also called negativistic personality disorder.
B. Depressive personality
1. Definition.
Patients are characterized by depressive traits that last
that have been prevalent throughout their lives, such as pessimism, self-doubt, and chronic
unhappiness. They are introverted passive and duty bound.
Diagnosis .5
. Patients with depressive personality disorder often complain of chronic feelings of unhappiness. .6
They admit to low self- esteem and have difficulty finding anything joyful, hopeful, or optimistic in
their lives.
C. Sadomasochistic personality
. It is characterized by elements of sadism, the desire to cause others pain sexually, physically, or
psychologically, and masochism, inflicting pain on oneself either sexually or morally. Treatment
with insight-oriented psychotherapy, including psychoanalysis, can be effective.
Sadistic personality. .D
Patients show a pervasive pattern of cruel, demeaning, and aggressive behavior toward others. .E
Anxiety Disorder
I/Introduction:
*Include:-
1(Panic Disorder. 2(Agoraphobia. 3(Specific Phobia
4(Social Phobia. 4(Social Anxiety or phobia.
5(Generalised Anxiety Disorder
*Differentiated from FEAR)which is response to known threat(but
ANXIETY)is response to unknown threat(
II)Classification:
Those are two diagnostic type according to )DSM5(:-
1(SEPARATION ANXIETY DISORDER:-
*Fear of :
-Separation from loved one or home
-Worry about harm to loved one
-Fear about isolation from loved one
*Including:-
I(nightmares
II(physical symptoms
2(SELECTIVE MUTISM:-
-Inability to speak in certain social situation despite the ability to speak in other

-SPECIFIC PHOBIA:-e.g:horses-height-needles
*about 25% of population has specific phobia
*more common in females

-Sign &symptoms of Anxiety Disorder:-

I(PHYSICAl SIGNS:- II(PSYCHOLOGICAL SYMPTOMS:-
1(Backache,Headache 1(Feeling of dread
2(Muscle tension. 2(Difficulty concentrating
3(Shortness of breathe. 3(Hypervigilance
4(Fatigability. 4(Insomnia
5( Autonomic hyperactivity. 5(Decreased libido
6( Flushing and pallor. 6(Lump in the throat
7(Tachycardia ,Palpitation. 7( Upset stomach
8(Sweating
9( Cold hand
10(Diarrhoea
11(Dry mouth
12( Urinary frequency
13(Parasthesia
14(Difficulty swallowing

-SOCIAL PHOBIA:-
*Irrational fear of public situation e,g: speaking -eating
*Occur during teens but can develop during childhood
*Affect about 13%of population
*Equal in females and males

-PANIC DISORDER:-
*Characterised by spontaneous panic attack
*It may occur alone or associated with Agoraphobia
*Sign & symptoms:-
1(Palpable heart pulsation. 6(Upset stomach
2(Diaphoresis. 7(Hot flushes
3(Sensation of shortness of breath. 8(Numbness
4(Suffocating feeling 9(Detachment from oneself or reality
5(Chest pain 10(Worries about death

-AGORAPHOBIA:-
*Anxiety about being in place or situation such as in crowd or in open space outside home

-GENERALISED ANXIETY DISORDER:-

*Involved excessive worry about everyday life circumstances,event,or conflict
*Difficult to control in subjectively distressing
*Ration)woman to men2:1(
*Sign & symptoms:-
1(Fidgetiness 3(Inattention 5(Muscle stiffness
2(Exhaustion 4(Moodiness

Substance /medication induced Anxiety Disorder:-

*Panic attack or Anxiety Disorder develop during or soon after intoxication of or withdrawal from
substance / medication
*Most common contributing drug include:-
1(Amphetamine. 2(Coccaine 3(Caffeine
4(Theophylline. 5(Antihypertensive

Anxiety Disorder due to another medical condition:-

*Many medical disorder are associated with Anxiety e,g:-
1(Neurological disorder e,g:-cerebral neoplasm
2(Systemic condition
3(Endocrine disturbance

Epidemiology:-
*There is a 12month prevalence rate of about 17%. Woman>men

Etiology:-
I(Biologic:-
1(Excessive autonomic reaction with increased sympathetic tone
2( release of catecholamine is increased with the production of norepinephrine
3( decrease level of Aminobutyric Acid )GABA( cause CNS Hyperactivity
4(increase in the activity of Temporal Cerebral Cortex
II(According to Freud:-
*Unconscious impulses
III(Learning theory:-
*produced by continued or severe frustration or stress
IV(Course and prognosis:-
*good prognosis with treatment
Treatment:-
1(Pharmacologic:-
I(Benzodiazepines:-
*Not used by physician because of physical dependence
*Include:-
1(Alprazolam)Xanax(
2( Clonazepam
3(Diazepam
II(Selective Serotonin Reuptake Inhibitors )SSRIs(:-
1(Fluoxetine )Prozac(. 4(Paroxetine
2(Citalopram. 5(Sertraline
3(Escitalopram. 6(Venlafaxine)Effexor(
*)SSRIs( is safer than Tricyclic drug because they:-
1(lack anticholinergic effect
2( Not lethal if taken overdose
*Most common side effect:-
1( Transient nausea 2(Headache. 3( Sexual dysfunction
*SSRIs are used with extreme caution in children and adolescents because of report of agitation
and impulsive suicidal act
III(Tricyclics:-
*Reduce the intensity of Anxiety
*Side effect:-
)Anticholinergic effect.-Cardiotoxicity -Potential lethality ( IN OVERDOSE
*Include:-
1(Imipramine)Tofranil(. 2(Nortryptaline 3( Clomipramine)Anafranil(

2(Psychological:-
I(Supportive Psychotherapy
II(Insight-oriented psychotherapy
III(Behavior therapy
*Technique include:-
1( Positive &negative reinforcement. 2(Flooding. 3(Graded exposure
4( Stop thought. 5(Relaxation technique
IV( Cognitive therapy:-
*Maladaptive behavior is secondary to distortion in how people perceive themselves &how others
perceive the
Substance -Related &Addictive Disorder
The signs and symptoms of substance use disorder according to DSM-5 are listed below:
1. A maladaptive pattern of substance use leading to clinically significant
impairment or distress
2. Recurrent substance use in situations in which it is physically hazardous
)e.g., driving an automobile or operating a machine when impaired by
substance use(
3. Continued use leading to impairment in school or work
4. Development of tolerance
5. Characteristic withdrawal syndrome depending on substance
6. Persistent desire to cut down or decrease substance
7. Drug-seeking behavior
II. Terminology:-
A. Dependence. :-
Diagnosis of Substance Dependence
1. A need for markedly increased amounts of the substance
2. Diminished effect
3. Characteristic withdrawal syndrome
4. Taken in larger amounts or over a longer period
5. Unable to cut down or control substance use
6. Significant amount of time is spent in activities necessary to obtain the substance 7. Important
activities are sacrificed because of substance abuse
B. Abuse:-
Diagnosis of Substance Abuse
1. Recurrent drug use and inability to fulfill obligations
2. Engaging in physically hazardous activities
3. Legal problems
4. Interpersonal problems
C. Misuse:-
Similar to abuse but usually applies to drugs prescribed by physicians that are not used properly.
D. Addiction. :-
The repeated and increased use of a substance, the deprivation of which gives rise to symptoms of
distress and an irresistible urge to use the agent again and which leads also to physical and mental
deterioration.
E. Intoxication:-
A reversible syndrome caused by a specific substance )e.g., alcohol( that effects one or more of the
following mental functions: memory, orientation, mood, judgment, and behavioral, social, or
occupational function
Diagnosis of Substance Intoxication
1. Slurred speech
2. Dizziness
3. Incoordination
4. Unsteady gait
5. Nystagmus
6. Impairment in attention or memory
7. Stupor or coma
8. Double vision
F. Withdrawal:-
A substance-specific syndrome that occurs after stopping or reducing the amount of the drug or
substance that has been used regularly over a prolonged period of time. The syndrome is
characterized by physiologic signs and symptoms in addition to psychological changes such as
disturbances in thinking, feeling, and behavior.
Diagnosis of Substance Withdrawal:-
1. Substance-specific syndrome develops after stopping or decreasing prolonged use
2. Syndrome leads to impaired functioning.
3. Not caused by a known general medical condition
G. Tolerance.:-
Phenomenon in which, after repeated administration, a given dose of a drug produces a decreased
effect or increasingly larger doses must be administered to obtain the effect observed with the
original dose.
IV. Specific Substance-Related Disorders:-
A. Alcohol-related disorders:-
the disorders associated with alcoholism generally can be divided into three groups: )1( disorders
related to the direct effects of alcohol on the brain )intoxication, withdrawal, withdrawal delirium,
and hallucinosis(
)2( disorders related to behavior associated with alcohol ) )alcohol abuse and dependence(
)3( disorders with persisting effects )persisting amnestic disorder, dementia, Wernicke’s
encephalopathy, and Korsakoff’s syndrome(
6. Diagnosis,signs,andsymptoms:-
a. Alcohol dependence:-
. Tolerance is a phenomenon in the drinker, who with time requires greater amounts of alcohol to
obtain the same effect. The development of tolerance, especially marked tolerance, usually indicates
dependence.
b. Alcohol abuse:-
Chronic use of alcohol that leads to dependence, tolerance, or withdrawal.
C. Alcohol intoxication:-
1. Definition:-
Alcohol intoxication, also called simple drunkenness, is the recent ingestion of a sufficient amount of
alcohol to produce acute maladaptive behavioral changes.
2. Diagnosis, signs, and symptoms:-
-Whereas mild intoxication may produce a relaxed, talkative, euphoric, or disinhibited person,
-severe intoxication often leads to more maladaptive changes, such a aggressiveness, irritability,
labile mood, impaired judgment, and impaired social or work functioning, among others.
-Persons exhibit at least one of the following: slurred speech, incoordination, unsteady gait,
nystagmus, memory impairment, stupor. Severe intoxication can lead to withdrawn behavior,
psychomotor retardation, blackouts, and eventually obtundation, coma, and death.
-Common complications of alcohol intoxication include motor vehicle accidents, head injury, rib
fracture, criminal acts, homicide, and suicide.
4. Treatment:-
a. Usually only supportive.
b. May give nutrients)especially thiamine,vitaminB12,folate(.
c. Observation for complications )e.g., combativeness, coma, head injury, falling( may be required.
d. Alcoholic idiosyncratic intoxication is a medical emergency that requires steps to prevent the
patient from harming others or self. Lorazepam )Ativan( 1 to 2 mg by mouth or intramuscularly or
haloperidol )2 to 5 mg by mouth or intramuscularly( can be used for agitation. Physical restraints
may be necessary.
Alcohol withdrawal:-
. Begins within several hours after cessation of, or reduction in, prolonged )at least days( heavy
alcohol consumption. At least two of the following must be present: autonomic hyperactivity, hand
tremor, insomnia, nausea or vomiting, transient illusions or hallucinations, anxiety, grand mal
seizures, and psychomotor agitation.
F. Alcohol withdrawal delirium )delirium tremens :-
Usually occurs only after recent cessation of or reduction in severe, heavy alcohol use in medically
compromised patients with a long history of dependence.
2. Medical workup:-
a. Complete history and physical.
b. Laboratory tests—complete blood cell count with differential;
measurement of electrolytes, including calcium and magnesium; blood chemistry panel; liver
function tests; measurement of bilirubin, blood urea nitrogen, creatinine, fasting glucose,
Treatment:-
a. Take vital signs every 6hours.
b. Observe the patient constantly.
c. Decrease stimulation.
d. Correct electrolyte imbalances
e. If the patient is dehydrated,hydrate.
f. Chlordiazepoxide )Librium(: 25 to 100 mg orally every 6 hours
in the geriatric patient, lorazepam )Ativan( 1 to 2 mg by mouth, intravenously, or intramuscularly
every 4 hours
g. Thiamine:100mg orally one to three times a day.
h. Folicacid
i. multivitamin
j. Magnesium sulfate: 1 g intramuscularly every 6 hours for 2 days
I.antipsychotics
Alcohol-induced persisting amnestic disorder:-
1. Wernicke’s encephalopathy:-)also known as alcoholic encephalopathy(.
-An acute syndrome caused by thiamine deficiency. Characterized by nystagmus, abducens and
conjugate gaze palsies, ataxia, and global confusion. Other symptoms may include confabulation,
lethargy, indifference, mild delirium, anxious insomnia, and fear of the dark.
-Treat with 100 to 300 mg of thiamine per day until ophthalmoplegia resolves.
-The syndrome may clear in a few days or weeks or progress to Korsakoff’s syndrome.
2. Korsakoff’s syndrome )also known as Korsakoff’s psychosis(:-
-A chronic condition, Characterized by retrograde and anterograde amnesia. The patient also often
exhibits confabulation, disorientation, and polyneuritis.
In addition Twenty-five percent of patients recover fully, and 50% recover partially with long-term
oral administration of 50 to 100 mg of thiamine per day
Stimulant-related disorders:-
-Amphetamines and amphetamine-like substances effect by releasing catecholamines, primarily
dopamine, from presynaptic stores, from the ventral tegmentum to the cortex and the limbic areas.
Legitimate indications include attention-deficit disorders, and narcolepsy, but are also used in the
treatment of obesity, dementia, fibromyalgia, and depression.
-Methylphenidate )Ritalin( less addictive than other amphetamines, possibly because it has a
different mechanism of action )inhibits dopamine reuptake(.
-Amphetamines are usually taken orally a less rapid euphoria and consequently is less addictive
Amphetamines can induce a paranoid psychosis similar to paranoid schizophrenia.
-Intoxication usually resolves in 24 to 48 hours. Amphetamine abuse can cause severe hypertension,
cerebrovascular disease, and myocardial infarction and ischemia
-Neurologic symptoms range from twitching to tetany to seizures, coma, and death as doses escalate.
Tremor, ataxia, bruxism, shortness of breath, headache, fever, and flushing are common but less
severe physical effects.
2. Drugs:-
a. Major amphetamines:Amphetamine, dextroamphetamine
)Dexedrine(, methamphetamine )Desoxyn, “speed” (, and methylphenidate )Ritalin(.
b. Related substances:-. Ephedrine, phenylpropanolamine )PPA(, khat, and methcathinone
)“crank” (.
c. Substituted )designer( amphetamines )also classified as
hallucinogens(. These have neurochemical effects on both serotonergic and dopaminergic systems
D.Ice:-Pure form of methamphetamine )inhaled, smoked, or injected(
Diagnostic Criteria for Stimulant Intoxication:- A. Behavioral and physical signs and symptoms of
stimulant use. B. Characteristic effects of elation and euphoria. C. Perceived improvement in mental
and physical tasks. D. Agitation and irritability.
E. Dangerous sexual behavior and. aggression.
F. Tachycardia, hypertension, andmydriasis.
Stimulant intoxication delirium:-
In general, result from high doses and sustained use.
c. Stimulant-induced psychotic disorder. Presence of paranoid delusions and hallucinations.
Formication )sensation of bugs crawling under the skin(
d. Stimulant-induced mood disorder. This includes the stimulant- induced bipolar and depressive
disorders.
e. Stimulant-induced anxiety disorder.
g. Stimulant-induced sexual dysfunction. Amphetamines can be used to reverse sexual side effects of
serotonergic agents like fluoxetine )Prozac(. They are often misused to enhance sexual experience
and high and long-term use may lead to erectile and sexual dysfunction
4. Treatment. Symptomatic. Benzodiazepines for agitation. Fluoxetine )Prozac( or bupropion
)Wellbutrin( has been used for maintenance therapy after detoxification.
Cannabis-related disorders:-
Cannabis is the most widely used illegal drug in the world, with an estimated 19 million users in
2012. Cannabis sativa is a plant from which cannabis or marijuana is derived. All parts of the plant
contain psychoactive cannabinoids of which Δ-9- tetrahydrocannabinol )THC( is the main active
euphoriant )many other active cannabinoids are probably responsible for the other varied effects(.
Sometimes, purified THC also is abused. Cannabinoids usually are smoked but also can be eaten
a. Cannabis use disorder:-
. People who use cannabis daily over weeks to months are most likely to become dependent.
b. Cannabis intoxication:-
When cannabis is smoked, euphoric effects appear within minutes, peak in 30 minutes, and last 2 to
4 hours. Motor and cognitive effects can last 5 to 12 hours. -Symptoms include euphoria or
dysphoria, anxiety, suspiciousness, inappropriate laughter, time distortion, social withdrawal,
impaired judgment, and the following objective signs:
1(conjunctival injection, increased appetite, dry mouth, and tachycardia. It also causes a dose-
dependent hypothermia and mild sedation. Often used with alcohol, cocaine, and other drugs. Can
cause depersonalization and, rarely, hallucinations. More commonly causes mild persecutory
delusions, which seldom require medication. In very high doses, can cause mild delirium with panic
symptoms or a prolonged cannabis psychosis )may last up to 6 weeks(. Long-term use can lead to
anxiety or depression
. Chronic respiratory disease and lung cancer are long-term risks secondary to inhalation of
carcinogenic hydrocarbons. Results of urinary testing for THC are positive for up to 4 weeks after
intoxication.
c. Cannabis intoxication delirium:-It is characterized by marked impairment on cognition and
performance tasks.
d. Cannabis withdrawal:-Cessation of daily cannabis use results in withdrawal symptoms within 1 to
2 weeks of cessation. These include irritability, nervousness, anxiety, insomnia, disturbed or vivid
dreaming, decreased appetite, weight loss, depressed mood, restlessness, headache, chills, stomach
pain, sweating, and tremors.
e. Cannabis-induced psychotic disorder:-Cannabis-induced psychotic disorder is rare; transient
paranoid ideation is more common.
f. Cannabis-induced anxiety disorder:-. This disorder is a common diagnosis for acute cannabis
intoxication.
4. Treatment:-
-Treatment abstinence and support.
-Treatment of intoxication usually is not required.
-Anxiolytics may be useful for anxiety
-antipsychotics for hallucinations or delusion
Obsessive Compulsive Of Related Disorder
1)Obsessive Compulsive Disorder:-
*represented by a diverse group of symptoms
* includes:-
A(intrusive thoughts B(rituals. C( preoccupations. D(compulsions
*Obsession is a recurrent and intrusive thought, feeling, idea, or sensation.
*Compulsion is a conscious recurrent behavior, such as counting checking, or avoiding.
A)Epidemiology:-
*Life time prevalence 1-3%
*fourth most common psychiatric diagnosis
*men to woman1:1
*boys are more common than girls
*The mean age of onset is about 20 years
B)Etiology:-
a.Neurotransmitters:-
support the hypothesis that dysregulation of serotonin
b. Brain-imagingstudies:-
increased activity in the frontal lobes, the basal ganglia and the cingulum of patients with OCD.
*)CT(& )MRI( studies have found bilaterally smaller caudates in patients with OCD.
c. Genetics:-
High in ralative with OCD than control probands
C)Psychsocial Factors:-
OCD differs from Obsessive Compulsive Personality which is concern for details, perfectionism
D)Diagnosis and clinical features:-
*Sign and symptoms:-
1(Must have obsessions, compulsions, or both.
2(Obsessions are thoughts or urges that are so pervasive and undesirable they prompt some
suppressive thought or action
3(Compulsions are behaviors that an individual feels he or she must perform in a particular manner
to reduce stress
*OCD symptoms in adult:
A(Contamination:- obsession of contamination followed by washing or avoidance
B( pathological doubt:-obsession and doubt followed by compulsion of checking
C( Intrusive thought:-there are intrusive obsessional thought without compulsion e.g suicidal idea
D(Symmetry:-symmetry or precision lead to compulsionof slowness)pts:take hours to eat meal and
shave their face(
E( Other symptoms:-compulsive hair pulling and nail biting are behavioral patterns related to
OCD )masturbation may also be compulsive(
E)Differential Diagnosis:-
1.Medical condition:-
OCD frequently develops before age 30 years, and new-onset OCD in an older individual should
raise questions about potential neurologic contributions and basal ganglia diseases, such as
Sydenham’s chorea and Huntington’s disease
2. Tourette’s disorder:-
About 90% of persons with Tourette’s disorder have compulsive symptoms
3. Other psychiatric conditions
OCD resemblance to obsessive–compulsive personality disorder
Psychotic symptoms :-often lead to obsessive thoughts and compulsive behaviors.
4.Course and prognosis:-
More than half of patients with OCD have a sudden onset of symptoms. 50% to 70% occurs after a
stressful event, such as a pregnancy, a sexual problem, or the death of a relative.
The course is usually long but variable; some patients experience a fluctuating course, and others
experience a constant one.
*SUICIDE IS RISK FOR OCD pt
F) Treatment:-
1. Pharmacotherapy
Initial effects are generally seen after 4 to 6 weeks of treatment, although 8 to 16 weeks are usually
needed to obtain maximal therapeutic benefit.
**** )SSRI( or clomipramine
A. Selectiveserotoninreuptakeinhibitors
1(fluoxetine )Prozac(, 2(fluvoxamine 3(paroxetine 4(sertraline 5(citalopram
-Higher dosages have often been necessary for a beneficial effect, such as 80 mg a day of fluoxetine.
-SSRIs can cause sleep disturbance, nausea and diarrhea, headache.
-these adverse effects are often transient
B. Clomipramine
-Of all the tricyclic and tetracyclic drugs, clomipramine is the most selective for serotonin reuptake
versus norepinephrine reuptake.
-Dose must be titrated upward over 2 to 3 weeks to avoid gastrointestinal adverse effects and
orthostatic hypotension.
c. Otherdrugs
1(clomipramine or an SSRI:- unsuccessful, many therapists augment the first drug by the addition
of :-
1(valproate 2(lithium 3(carbamazepine )Tegretol(
4(atypical antipsychotic such as risperidone
2. Behaviortherapy
Desensitization, thought-stopping, flooding.
3. Othertherapies
Family therapy reduce marital discord resulting from the disorder
group therapy For extreme cases, electroconvulsive therapy
Other Specified Obsessive Compulsive or Related Disorder:-
A. Olfactoryreferencesyndrome
Olfactory reference syndrome is characterized by a false belief by the patient that he or she has a foul
body odor that is not perceived by others. The preoccupation leads to repetitive behaviors such as
washing the body or changing clothes
B. Body dysmorphic disorder:-
1. Definition:-Imagined belief )not of delusional proportions( that a
defect in the appearance of all or a part of the body is present.
2. Epidemiology:-Onset from adolescence through early adulthood.
*Men and women are affected equally.
3. Etiology:-Unknown
4.Diagnosis, signs, and symptoms:-Patient complain)e.g., wrinkles, hair loss, small breasts or penis,
age spots, stature(.
-Complaint is out of proportion to objective abnormality. If a slight physical anomaly is present, the
person’s concern is grossly excessive.
5.Differential diagnosis:-Distorted body image can also occur in schizophrenia, mood disorders,
anorexia nervosa, OCD, gender identity disorder.
6.Course and prognosis:-Chronic course with repeated visits to doctors, plastic surgeons, or
dermatologists. Secondary depression may occur.
-In some cases, imagined body distortion progresses to delusional belief.
7.Treatment:-
a. Pharmacologic:-Serotoninergic drugs )e.g., fluoxetine ,clomipramine )effectively reduce
symptoms in at least 50% of pts(
b. Psychological
Hair-PullingDisorder(Trichotillomania)
a chronic disorder characterized by repetitive hair pulling that leads to variable hair loss
-The lifetime prevalence ranges from 0.6% to as high as 3.4% in general population
-A childhood type of hair-pulling disorder occurs approximately equally in girls and boys.
Excoriation(Skin-Picking)Disorder
characterized by the compulsive and repetitive picking of the skin.
-It can lead to severe tissue damage
. It was also known , emotional excoriation, epidermotillomania
Clinical features:-
-The face is the most common site of skin picking.
-Other common sites are legs, arms, hands, fingers, and scalp.
-Many report picking as a means to relieve stress, tension, and other negative feelings
-15% report suicidal ideation due to their behavior and about 12% have attempted suicide
Treatment:-
SSRIs. fluoxetine )Prozac( , naltrexone , lamotrigine )Lamictal( ,CBT)Cogentive Behavior Therapy
Psychopharmacological Treatment
V. Antipsychotic Drugs:-
These are classified into first-generation )conventional( antipsychotics or second-generation
antipsychotics )SDAs, novel or atypical( antipsychotics. Historically, conventional antipsychotics
were efficacious for treating the positive symptoms of schizophrenia with worsening of negative,
cognitive, and mood symptoms. Atypical antipsychotics have been suggested to show improvement
in )1( positive symptoms such as hallucinations, delusions,disordered thoughts, and agitation and )2(
negative symptoms such as withdrawal, flat affect, anhedonia, poverty of speech, catatonia, and
cognitive impairment
Second-generation antipsychotic drugs )SDAs, atypical antipsychotic drugs(:-
-include risperidone )Risperdal(, risperidone consta olanzapine, quetiapine ,ziprasidone,aripiprazole
)Abilify(, paliperidone )Invega(, and clozapine.
-lower risk of extrapyramidal symptoms and eliminate the need for anticholinergic drugs. Second-
generation drugs are also effective for the treatment of bipolar disorder and mood disorders with
psychotic or manic features. A few are also approved for the treatment of bipolar depression, major
depressive disorder )MDD(, and will also have an indication in generalized anxiety disorder.
1. Pharmacologic actions:-
a. Risperidone:-About 80% of risperidone is absorbed from the GI tract, and the combined half-life
of risperidone averages 20 hours
so that it is effective in once-daily dosing.
b. Olanzapine:-Approximately 85% of olanzapine is absorbed from the GI tract, and its half-life
averages 30 hours.in a once daily dose
e. Clozapine:-Clozapine is absorbed from the GI tract. Its half-life is 10 to 16 hours and is taken
twice daily.
f. Aripiprazole:-It has a long half-life of about 75 hours and can be given as a single daily dose.
g. Paliperidone:-Paliperidone has a peak plasma concentration of approximately 24 hours after
dosing.
*Sustenna( reaches higher concentration in the deltoid muscle with a half-life of 25 to 49 days.
*Trinza( has even longer duration of action and is given once every 3 months.
a. Baseline monitoring:-
)1( Personal and family history of obesity, diabetes, dyslipidemia,
hypertension, and cardiovascular disease.
)2( Weight and height
)3( Waist circumference
)4( Blood pressure.
)5( Fasting plasma glucose.
)6( Fasting lipid profile.
Clozapine risk evaluation and mitigation strategy)REMS(:-
-Patients will be monitored for neutropenia using the absolute neutrophil count )ANC( and WBC.
-Treatment will be interrupted if the ANC drops below 1,000 cells/μL
-During the first 6 months, weekly ANC counts are indicated to monitor for the development of
agranulocytosis. If the ANC count remains normal, the frequency of testing can be decreased to
every 2 weeks.Patients exhibiting symptoms of chest pain, shortness of breath, fever, or tachypnea
should be immediately evaluated for myocarditis or cardiomyopathy, an infrequent but serious
adverse effect ending in death. Serial CPK-MB )creatine phosphokinase with myocardial band
fractions(, troponin levels, and EKG studies are recommended, with immediate discontinuation of
clozapine.
All second-generation drugs:-
)1( Neuroleptic malignant syndrome:-
-The development of neuroleptic malignant syndrome is considerably rare with second-generation
drugs than with dopamine receptor antagonists. This syndrome consists of muscular rigidity, fever,
dystonia, akinesia, mutism, oscillation between obtundation and agitation, diaphoresis, dysphagia,
tremor, incontinence, labile blood pressure, leukocytosis, and elevated creatine phosphokinase.
Clozapine, especially if combined with lithium, and risperidone have been associated with
neuroleptic malignant syndrome.
)2( Tardive dyskinesias:-
Second-generation drugs are significantly less likely than dopamine receptor antagonists to be
associated with treatment-emergent tardive dyskinesias.
Dopamine receptor antagonists:-
The dopamine receptor antagonists are presently second-line agents for the treatment of
schizophrenia and other psychotic disorders. Because of their immediate calming effects, however,
dopamine receptor antagonists are often used for the management of acute psychotic episodes

Drug Name:- Chemical name:- Dose:- Sedatives:-

1(Chlorpromazine Phenothiazine: 100mg. +++
2(Fluphenazine. ,, 2mg. +.
3(Haloperidol . Butyrophenone. 2mg. +
4(Loxapine)Loxitane(. Dibenzoxazepine. 10mg. ++
5(Thioridazine)Mellaril( Phenothiazine. 100mg. +++
6(Trifluoperazine )Stelazine( . Phenothiazine. 5mg. ++

Antidepressants:-
a. Pharmacokinetics:-
-All SSRIs are well absorbed after oral administration and reach their peak concentrations in 4 to 8
hours.
-Fluoxetine has the longest half-life, 2 to 3 days.
-The half-life of sertraline is 26 hours.
- citalopram )2-3days(and escitalopram)35hours(, fluvoxamine. )15hours(
B.Pharmacodynamics:-
The clinical benefits of SSRIs are attributed to the relatively selective inhibition of serotonin
reuptake, with little effect on the reuptake of norepinephrine and dopamine.
1( Choice of drug.:-
-. A number of reports indicate that more than 50% of people who respond poorly to one SSRI will
respond favorably to another.
)2( Comparison with tricyclic antidepressants:-
-Some degree of nervousness or agitation, sleep disturbances, GI symptoms, and perhaps sexual
adverse effects are more common in persons treated with SSRIs than in those treated with tricyclic
drugs.
b. Suicide:-
-SSRIs reduce the risk. Some persons become especially anxious and agitated when given fluoxetine.
The appearance of these symptoms in a suicidal person could conceivably aggravate the seriousness
of their suicidal ideation.
c. Depression during and after pregnancy:-
The use of fluoxetine during pregnancy is not associated with increases in perinatal complications,
congenital fetal anomalies, learning disabilities, language delays, or specific behavioral problems.
Emerging data for sertraline, paroxetine, and fluvoxamine indicate that these agents are probably
similarly safe when taken during pregnancy.
d. Depression in the elderly and medically ill:-
All SSRIs are useful for elderly.
e. Chronic depression:-
Because discontinuation of SSRIs within 6 months after a depressive episode is associated with a
high rate of relapse, a person with chronic depression should remain on SSRI therapy for several
years.
Premenstrual dysphoric disorder:-
-SSRIs reduce the debilitating mood and behavioral changes that occur in the week preceding
menstruation in women with premenstrual dysphoric disorder. Scheduled administration of SSRIs
either throughout the cycle or only during the luteal phase )the 2-week period between ovulation and
menstruation(.

SSRs dose:-
Starting dose. Maintaince. High
Paroxetine 5-10. 20-60 760
CR Fluoxetine. 2-5 20-60. 780
Sertraline 12.5-25. 50-200. 7300
Citalopram. 10mg 20-40. 760
Escitalopram 5mg 10-30. 730
Fluvoxamine. 25mg. 500-100. 7300

Venlafaxine )Effexor( and desvenlafaxine )Pristiq(.:-

-Venlafaxine and desvenlafaxine are effective antidepressant drugs with a rapid onset of action.
Venlafaxine is among the most efficacious drugs for the treatment of severe depression with
melancholic features.
Mirtazapine:-
-It is approved for the treatment of major depression. It is rapidly and completely absorbed and has a
half-life of about 30 hours. It lacks the anticholinergic effects of tricyclic antidepressants and the GI
and anxiogenic effects of SSRIs. Somnolence, the most common adverse effect of mirtazapine,
occurs in more than 50% of persons and increases appetite in about one-third of patients leading to
weight gain. It may increase hepatic enzymes and cause neutropenia in 0.3% of patients. The
recommended doe range is 15 to 45 mg. Mirtazapine is excreted in breast milk and should not be
taken by nursing mothers.

Generic name Trade Name Adult dose Range Therapeutic plasma.

1(Imipramine Tofranil. 150-300mg/day 150-300mg/ml
2(Desipramine. Norpramine. 150-300. 150-300
3(Trimipramine Surmentil. 150-300. 150-300
4(Amitriptyline Elavil. 150-300. 100-250
5(Nortriptyline. Palmelor. 50-150. 150-150
6(Amoxapine Asendin. 150-400. 150-250
7(Maprotilive. Ludomil. 150-230. 150-250
8(Clomipramine. Anafranil. 130-250. 150-300
Main adverse effect:-
1(Sedation. 2(Postural hypotension. 3(Tachycardia. 4(Arrythmia
5(Dry mouth. 6(Blurring of vision. 7(Constipation. 8(Urinary retension
Dissociative Disorder
General Introduction:-
-Dissociation is defined as an unconscious defense mechanism involving the segregation of any
group of mental or behavioral processes from the rest of the person’s psychic activity.
-Dissociative disorders involve this mechanism so that there is a disruption in one or more mental
functions, such as memory, identity, perception, consciousness, or motor behavior.
-The disturbance may be sudden or gradual, transient or chronic.
-signs and symptoms often caused by psychological trauma.
-There are four specific dissociative disorders:
1(dissociative amnesia, 2(dissociative fugue, 3(dissociative identity disorder
4(depersonalization/derealization disorder
A(Dissociative Amnesia:-
A. Definition:-
-the patient is unable to recall an important memory which is usually traumatic or stressful, but
retains the capacity to learn new material.
B. Diagnosis:-
-The DSM-5 diagnostic criteria.
-The forgotten memories are usually related to day-to-day information that is a routine part of
conscious awareness.
-Patients are capable of learning and remembering new information, and their general cognitive
functioning and language capacity are usually intact.
-Patients are aware that they have lost their memories, and while some may be upset at the loss,
others appear to be unconcerned or indifferent.
*localized amnesia )loss of memory for the events over a short time(.
*generalized amnesia )loss of memory for a whole lifetime of experiences(.
*selective or systematized amnesia )inability to recall some but not all events over a short time(.
C. Epidemiology:-
1. Most common dissociative disorder)2%to6%(.
2. Occurs more often in women than in men.
3. Occurs more often in adolescents and young adults than in older
adults.
4. Incidence increases during times of war and natural disasters.
D. Etiology:-
1. Precipitating emotion altrauma.
2. Physical and sexual abuse.
3. Rule out medical causes.
E. Psychodynamics:-
1. Defenses include repression,denial,and dissociation.
2. Memory loss is secondary to painful psychological conflict.
F. Differential diagnosis:-
1. Dementia or delirium:-Amnesia is associated with many cognitive symptoms.
2. Epilepsy. Sudden memory impairment associated with motor or
electroencephalogram )EEG(abnormalities
3. Transient global amnesia:-
-Associated with anterograde amnesia during episode; patients tend to be more upset and concerned
about the symptoms and are able to retain personal identity; memory loss is generalized, and remote
events are recalled better than recent events.
H. Treatment:-
1. Psychotherapy:-
-Hypnosis is used primarily as a means to relax the patient sufficiently to recall forgotten information.
2. Pharmacotherapy:-
-short-acting barbiturates, such as:-
1(thiopental
2(benzodiazepines :-may be used to help patients recover their forgotten memories.
4(Dissociative Fugue:-
A. Definition:-
-now diagnosed on a subtype of dissociative amnesia. It is characterized by sudden, unexpected
travel away from home, with the inability to recall some or all of one’s past. This is accompanied by
confusion about identity.
B. Diagnosis:-
-Memory loss is sudden and is associated with purposeful unconfused travel, often for extended
periods of time. Patients lose part or complete memory of their past life and are often unaware of the
memory loss. They assume an apparently normal, nonbizarre new identity. However, perplexity and
disorientation may occur. Once they suddenly return to their former selves, they recall the time
antedating the fugue, but they are amnestic for the period of the fugue itself.
C. Epidemiology:-
1.Occurs most often during times of war, during natural disasters.
2.Prevalence rate 0.2% of general population
D. Etiology:-
1. Precipitating emotional trauma.
2. Psychosocial factors include marital, financial, occupational, and war-time stressors.
3. Predisposing factors include borderline, histrionic, schizoid personality disorders
E. Differential diagnosis:-
1. Cognitive disorder.:-Wandering is not as purposeful or complex.
2. Temporal lobe epilepsy :-.no new identity is assumed.
3. Dissociative amnesia:-No purposeful travel or new identity.
4. Malingering:- secondary gain.
6. Bipolar disorder:-Patients are able to recall behavior during depressed or manic state.
7. Schizophrenia:-Memory loss of events during wandering episodes is due to psychosis.
F. Course and prognosis:-
-Fugues appear to be brief, lasting from hours to days. . Recovery is spontaneous and rapid.
G. Treatment:-
-hypnosis help reveal to the clinician and the patient the psychological stressors that precipitated the
fugue episode.
Dissociative Identity Disorder:-
A. Definition.
Formerly known as multiples personality disorder, dissociative identity disorder is usually the result
of a traumatic event, often physical or sexual abuse in childhood. This disorder involves the
manifestation of two or more distinct personalities, which, when present, will dominate the person’s
behaviors and attitudes as if no other personality existed.
B. Diagnosis.
Diagnosis requires the presence of two distinct personality states. Original personality is generally
amnestic for and unaware of other personalities. The median number of personalities ranges from 5
to 10, although data suggest an average of 8 personalities for men and 15 for women. Usually two or
three identities are evident at diagnosis and others are recognized during the course of treatment
Transition from one personality to another tends to be abrupt. During a personality state, patients are
amnestic about other states and events that took place when another personality was dominant. Some
personalities may be aware of aspects of other personalities; each personality may have its own set of
memories and associations, and each generally has its own name or description. Different
personalities may have different physiologic characteristics )e.g., different eyeglass
prescriptions( and different responses to psychometric testing )e.g., different IQ scores(. Personalities
may be of different sexes, ages, or races. One or more of the personalities may exhibit signs of a
coexisting psychiatric disorder )e.g., mood disorder, personality disorder(. Signs of dissociative
identity disorder are listed in Table 15-6.
C. Epidemiology
1. Occurs in 5%of psychiatric patients.
2. More common in females than males.
3. Most common in late adolescence and young adulthood.
4. two-thirds of patients attempt suicide.
D. Etiology:-
1. Severe sexual and psychological abuse in childhood.
E. Differential diagnosis:-
1. Schizophrenia:-
-delusional belief and patients have formal thought disorder.
2. Malingering:-
- clear secondary gain
3. Borderline personality disorder:-
-Erratic mood, behavior, and interpersonal instability.
4. Bipolar disorder with rapid cycling:-
-. Discrete personalities are absent.
5. Neurologic disorders:-
- complex partial epilepsy.
F.Course and prognosis:-
-The earlier the onset of dissociative identity disorder, the worse is the prognosis.
G. Treatment:-
1. Psychotherapy:-
-Insight-oriented psychotherapy often with hypotherapy.
2. Pharmacotherapy:-
- Antidepressant and antianxiety medications can be useful as adjuvants to psychotherapy.
Depersonalization /DerealizationDisorder:-
A. Definition:-
-persistent or recurrent feeling of detachment or estrangement from one’s self. The individual may
report feeling like an automaton or watching himself or herself in a movie.
B. Diagnosis:-
-depersonalization, including :-
)1( bodily changes, )2( duality of self as observer and actor, )3( being cut
off from others, )4( being cut off from one’s own emotions.
C. Epidemiology:-
1. Occasional isolated depersonalization episodes are common and
occur in 70% of a given population.
*Pathologic depersonalization is rare
2. Occurs more often in women than in men.
3. Mean age of occurrence is 16 years.
D. Etiology :-
1. Predisposing factors include anxiety,depression,and severe stress.
2. May be caused by apsychological,neurologic,orsystemic disease.
3. Associated with an array of substances including alcohol, barbiturates, benzodiazepines,
scopolamine, β-adrenergic antagonists, marijuana.
4. Frequently associated with anxiety disorders, depressive disorders, and schizophrenia
G. Treatment :-
-Usually responds to anxiolytics and to both supportive and insight-oriented therapy.
Functional Neurologic Symptom Disorder
Conversion Disorder:-
-is an illness that affects voluntary motor or sensory functions, suggesting a medical condition, but is
caused by psychological factors because it is preceded by conflicts or other stressors. The symptoms
are not intentionally produced, are not caused by substance use, are not limited to pain or sexual
symptoms, and the gain is primarily psychological and not social, monetary, or legal.
Epidemiology:-
-The incidence and prevalence are 10% of hospital inpatients and 5% to 15% of all psychiatric
outpatients.
-Onset is in early adulthood, but can occur in middle or old age. It is more common in females,low
socioeconomic status, less educated persons, rural population.
Etiology:-
1. Biologic factors. The symptoms may be caused by an excessive cortical arousal that sets off
negative feedback loops between the cerebral cortex and the brainstem reticular formation. Elevated
levels of corticofugal output, in turn, inhibit the patient’s awareness of bodily sensation.
2. Psychological factors. According to psychoanalytic theory, conversion disorder is caused by
repression of unconscious intrapsychic conflict and conversion of anxiety into a physical symptom.
Diagnosis:-
-Symptoms that affect a voluntary motor or sensory function.
-DSM-5 describes several types of symptoms or deficits include weakness or paralysis; abnormal
movements.
-Common Symptoms of Conversion Disorder:-
1(Motor symptoms:-
A(Involuntary movements B(Tics. C(Seizures
D(Paralysis E(Weakness F(Aphonia
2(Sensory deficits:-
A(Anesthesia, especially of extremities Midline anesthesia
B(Blindness. C(Deafness
3(Visceral symptoms:-
A(Psychogenic vomiting. B(Urinary retention Diarrhea
Clinical Features:-
-Paralysis, blindness, and mutism are the most common conversion disorder Conversion disorder
may bemost commonly associated with passive dependent, antisocial, and histrionic personality
disorders.
Diagnosis:-
1. Paralysis:-. It is inconsistent and does not follow motor pathways.Spastic paralysis, clonus, and
cogwheel rigidity are also absent in conversion disorder.
2. Ataxia:-Movements are bizarre in conversion disorder. In organic lesions leg may be dragged and
circumduction not possible.
3. Blindness:-No pupillary response is seen in true neurologic blindness )except note that occipital
lobe lesions can produce cortical blindness with intact pupillary response(. Tracking movements are
also absent in true blindness.
4. Deafness:-Loud noise will awaken sleeping patient with conversion disorder.
5. Sensory:-On examination, sensory loss does not follow anatomic distribution of dermatomes
glove-and-stocking anesthesia in conversion disorder.
Course & prognosis:-
-Tends to be recurrent. Major concern is not to dismiss early neurologic symptom
-)multiple sclerosis may begin with spontaneously remitting diplopia or hemiparesis(.
Treatment:-
-Resolution of the conversion disorder symptom is usually spontaneous
1. Pharmacologic:-
1(benzodiazepines for anxiety and muscular tension;
2(antidepressants or serotonergic agents for obsessive rumination about symptoms.
2.Psychological:-
1(Insight-oriented therapy
2(behavior therapy
Suicide ,violence&Emergency psychotic medicine
A. Definition:-
The word suicide is derived from Latin, meaning “self-murder.
B. Incidence and prevalence:-
1. About40,000 persons commit suicide per year in the United States.
2. The rate is 12.5 persons per 100,000.
3. About 250,000persons attempt suicide per year.
C. Associated risk factors:-
1. Gender:-Men commit suicide three times more often than women.
Women attempt suicide four times more often than men.
2. Method:-Men’s higher rate of successful suicide is related to the methods they use while
women more commonly take an overdose of psychoactive substances or a poison.
3. Age:-Rates increase with age.
a. Among men, the suicide rate peaks after age 45; among women, it peaks after age 65.
b. Older persons attempt suicide less often but are more successful.
4. Race:-In the United States, two of every three suicides are committed by male white persons. The
risk is lower in non-whites.
Religion:-Rate is the highest in Protestants; the lowest in Catholics, Jews, and Muslims.
6. Marital status:-Rate is twice as high in single persons than in married persons. Divorced,
separated, or widowed persons have rates four to five times higher than married persons.
Physical health:-Medical or surgical illness is a high-risk factor, especially if associated with pain or
chronic or terminal illness
8. Mentalillness
a. Depressive disorders:-Mood disorders are the diagnoses most commonly associated with suicide.
Fifty percent of all persons who commit suicide are depressed. Fifteen percent of depressed patients
kill themselves.
b. Schizophrenia:-Ten percent of persons who commit suicide are schizophrenic with prominent
delusions. Patients who have command hallucinations telling them to harm themselves are at
increased risk.
c. Alcohol and other substance dependence:-
-Alcohol dependence increases the risk of suicide, especially if the person is also depressed.
- heroin dependent or dependent on other drugs is approximately 20 times the rate for the general
population.
d. Personality disorders:-Borderline personality disorder is associated with a high rate of para-
suicidal behavior.
e. Dementia and delirium:-Increased risk in patients with dementia and delirium
f. Anxiety disorder:-Unsuccessful suicide attempts are made by almost 20% of patients with a panic
disorder and social phobia.
9.Other risk factors:-
1(Unemployment.
2(Sense of hopelessness.
3(Hoarding pills.
4(Family history of suicide or depression.
6(Previous suicide attempt.
7(History of childhood physical or sexual abuse.
8(History of impulsive or aggressive behavior.
D. Management:-
1. Do not leave a suicidal patient alone; remove any potentially
dangerous objects from the room.
2. Assess whether the attempt was planned or impulsive.
3. Patients with severe depression may be treated on an outpatient basis if their families can
supervise them closely and if treatment can be initiated rapidly. Otherwise, hospitalization is
necessary.
4. Suicidal ideas in schizophrenic patients must be taken seriously
6. Patients with personality disorders benefit mostly from empathic confrontation and assistance in
solving the problem that precipitated the suicide attempt
7. Long-term hospitalization is recommended for conditions that contribute to self mutilation
II. Violence:-
A. Definition:-
1. Intentional act of doing bodily harm to an other person.
2. Includes assault, rape, robbery, and homicide.
3. Physical and sexual abuse
B. Incidence and prevalence:-
Men are victim of violence more often tham woman
C. Disorders associated with violence:-
The psychiatric conditions most commonly associated with violence include such psychotic
disorders as schizophrenia and mania )particularly if the patient is paranoid or is experiencing
command hallucinations(, intoxication with alcohol and drugs, withdrawal from alcohol and
sedative–hypnotics, catatonic excitement, agitated depression, personality disorders characterized
by rage and poor impulse control )e.g., borderline and antisocial personality disorders(, and cognitive
disorders )especially those associated with frontal and temporal lobe involvement(.
E. Evaluation and management:-
-Never interview a potentially violent patient alone or in an office with the door closed. Consider
removing neckties, necklaces, and other articles of clothing or jewelry you are wearing that the
patient can grab or pull. Stay within sight of other staff members. Leave physical restraint to staff
members who are trained in that. Do not give the patient access to areas where weapons may be
available )e.g., a crash cart or a treatment room(. Do not sit close to a paranoid patient, who may feel
threatened. Keep yourself at least an arm’s length away from any potentially violent patient. Do
not challenge or confront a psychotic patient. Be alert to the signs of impending violence. Always
leave yourself a route of rapid escape in case the pt attack you.
-Signs of impending violence include :-
1(recent violent acts against people or property,
2(clenched teeth
3(verbal threats
4(possession of weapons or
5)psychomotor agitation
6(alcohol or drug intoxication, paranoid delusions, and command hallucinations.
- Physical restraint should be applied only by persons with appropriate training.
-Perform a definitive diagnostic evaluation. The patient’s vital signs should be assessed, a
physical examination performed, and a psychotic history obtained
-Explore possible psychosocial interventions to reduce the risk for violence.
-Hospitalization
-If psychiatric treatment is not appropriate,you may involve the police and the legal system.
G. Drug treatment:-
1(Drug treatment depends on the specific diagnosis.
2(Benzodiazepines and antipsychotics are used most often to tranquilize a patient. Haloperidol
)Haldol( given at a dose of 5 mg by mouth or intramuscularly.
3(If the patient’s agitation has not decreased in 20 to 30 minutes, repeat the dose.
4(Avoid antipsychotics in patients who are at risk for seizures.
5(Benzodiazepines may be ineffective in patients who are tolerant, and they may cause disinhibition,
which can potentially exacerbate violence.
6(For patients with epilepsy, first try an anticonvulsant )e.g., carbamazepine [Tegretol] or gabapentin
[Neurontin]( and then a benzodiazepine )e.g., clonazepam [Klonopin](. Chronically violent patients
sometimes respond to beta-blockers )e.g., propranolol(
III. Other Psychiatric Emergencies:-
A psychiatric emergency is a disturbance in thoughts, feelings, or actions that requires immediate
treatment. It may be caused or accompanied by a medical or surgical condition that requires timely
evaluation and treatment. Emergencies can occur in any location—home, office, street, and medical,
surgical, and psychiatric units. Under ideal conditions, the patient will be brought to the psychiatric
emergency unit.
Mental status :

A- Appearance :
1- Describe patient’s appearance and behavior , e.g cooperative , attentive , interested , hostile ,
playful and guarded .
2- Behavior and psychomotor activity, e.g gait , tics , gestures , stereotypes , and echopraxia .
3- General description, e.g posture,clothes, hair , nail, healthy ,angry , frightened, apathetic ,
perplexed .
B- Speech : rapid, slow, pressure,hesitate,emotional,monotonous,loud , whispered, slurred,
mumbled , stuttering , and echolalia .
C- Mood and affect :
1- Mood : a pervasive and sustained emotion , how dose patient say he or she feels - depressed,
irritable, anxious, angry, euphoric ,empty ,guilty.
2- Affect : the outward expression of Pt inner expression, how the examiner evaluates the Pt affects -
blunted or flat , restricted .
D- Thinking and perception
1- Form of thinking:
A- Productive ; flight of ideas rapid thinking, slow thinking, hesitant thinking when Pt speak
spontaneously or only when ask questions.
B- Continuity of thought ; Pt replies answer questions and are goal directed,relevant or irrelevant,loss
associations, illogical , blocking or distractibility .
C - language impairments ; reflect disordered mentation e.g incoherent or incomprehensible speech,
clang association, neologism.
2- Content of thinking :
A- preoccupations about illness .
B- obsession, compulsions , phobias.
C- obsession or plans about suicide , homicide .
D- hypochondriacal symptoms.
3- Thought disturbances :
A- Delusions e.g persecutory delusions .
B- Ideas of reference and idea of influence.
C- Thought broadcasting.
D- Thought insertion.
4- Perceptual disturbances :
A- Hallucinations and illusions; Pt hears voices or see visions, olfactory or taste, hypnagogic
hallucination ) occurring as person fall asleep( ,hypnopompic hallucination )occurring as person
awakens(
B- Depersonalization and derealization ; extreme feelings of detachment from self or from the
environment.

E- Sensorium :
1- Alertness ; awareness of environment, attention span , clouding of consciousness, fluctuation in
levels of awareness, somnolence , stupor , lethargy , fugue state and coma .
2- Orientation :
A- Time ; whether the Pt know the day .
B- Place ; whether the pt know where he is she .
C- Person; whether the pt know who is the examiner .
3- concentration and calculation :
Whether the pt can subtract 7 from 100 or 4*9
4- Memory :
A- Remote memory ; childhood data ,important events, know to have occurred when the pt was
younger.
B- Recent past memory ,past few months .
C- Recent memory , past few days .
D- Immediate retention and recall , ability to repeat six figures first forward then backward .
5- Fund of knowledge:
A- Estimate of the pt intellectual capability .
B- General knowledge.
6- Abstract thinking: Disturbance in concept formation , e.g similarities between apple and pears .
7- Insight : the recognition of having a mental disorder and degree of personal awareness and
understanding of illness.
A- complete denial of illness.
B- Slight awareness of being sick and need help but denying it at the same time .
C- Awareness of being sick but blaming it on others .
8- Judgment : what pt would do with a stamped , addressed letter found in streets or if medication
was lost .
Psychiatric History
A. Identification
1. Name, age, marital status, sex, occupation, language if other than English; race, nationality,
religion, if pertinent.
2. Previous admissions to a hospital for the same or a different condition.
3. Persons with whom the patient lives.

B. Chief complaint

C. History of present illness

1. Chronologic background and development of the symptoms or
behavioral change.
2. Patient’s life circumstances at the time of onset.
3. Personality when well; how illness has affected life activities and
personal relations
4. Psychophysiological symptoms—nature and detail of dysfunction
5. Level of anxiety
6. How anxieties are handled
7. Use of drugs or other activities for alleviation.

D. Past psychiatric and medical history

1. Emotional or mental disturbances
2. Psychosomatic disorders
3. Medical conditions
4. Neurologic disorders
.
E. Family history
1. Elicited from patient and from someone else
2. Ethnic, national, and religious traditions.
3. List other people in the home and descriptions of them
4. Role of illness in the family and family history of mental illness.
5. Where does the patient live
6. Sources of family income

F. Personal history
1. Early childhood )through 3 years of age(
a. Prenatal history and mother’s pregnancy and delivery: length of
pregnancy, spontaneity and normality of delivery, birth trauma,
b. Feeding habits : breast fed or bottle fed ,eating problems.
c. Early development: language development, motor development, , sleep pattern, separation anxiety.
d. Toilet training.
e. Symptoms of behavior problems: thumb sucking, temper tantrums ,night terrors, fears, bedwetting

f. Personality and temperament as a child: shy, restless, overactive,

withdrawn

2. Middle childhood )3to11years of age(

a. Early school history— feelings about going to school.
b. Early adjustment ,gender identification.
c. Conscience development ,punishment.
d. Social relationships.
e. Attitudes toward siblings and playmates.

3. Later childhood )prepuberty through adolescence(

a. Peer relationships: number and closeness of friends, leader or
follower,
b. School history: relationships with teachers and classmates
c. Cognitive and motor development: learning to read and other intellectual and motor skills
d. emotional or physical problems: nightmares, phobias, bedwetting, running away , smoking, drug
or alcohol use
e. Psychosexual history.
Onset of puberty, feelings about it feelings about menstruation
f. Adolescent sexual activity: crushes, parties, dating masturbation,
g. Attitudes toward same and opposite sex
h. Sexual practices: sexual problems, homosexual and
heterosexual experiences.
i. Religious background: strict, liberal, mixed )possible conflicts(,
relationship of background to current religious practices.

4. Adulthood
a. Occupational history
b. Social activity: whether patient has friends; whether he or she is withdrawn or socializing well.
)1( Marital history.
)2( Sexual symptoms.
)3( Attitudes toward pregnancy and having children; contraceptive practices and feelings about them.