Psychiatry lecture note

Unit one
Introduction

1
 CON
• Psychiatry: is a branch of medicine which deals with
mental disorder and their treatment.

• Psychiatric nursing: is the branch of nursing concerned

the prevention and cure of mental disorders .

• It employs theories of human behavior as its scientific

frame work and requires the use of self as its art or
expression in nursing practice.

2
 Con
Mental health as suggested by the World Health Organization (WHO)
in 2001, is a state of well being in which the individual

realizes his/her own abilities

can cope with the normal stresses of life

can work productively and fruitfully, and

is able to make a contribution to his or her community

3
 Con…
Mental illness;- IS defined as an

• illness with psychological or behavioral

manifestation and/ or

• impairment in functioning due to

– social,
– psychological,
– spiritual,
– physiological disturbance

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Comparative characteristics of a mentally healthy and
a mentally ill person

• MENTAL HEALTH
1. Accepts self and others
2. Ability to cope or tolerate stress. Can
return to normal functioning if temporarily
disturbed
3. Ability to form close and lasting relationships
4. Uses sound judgment to make decisions
5. Accepts responsibility for actions
6. Optimistic
7. Recognizes limitations (abilities and deficiencies)
5
 Con…

8. Can function effectively and independently

9. Able to perceive imagined circumstances from

reality
10. Able to develop potential and talents to fullest extent
11. Able to solve problems
12. Can delay immediate gratification

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 MENTAL ILLNESS

1- Feelings of inadequacy Poor self-concept

2. - Inability to cope
• Maladaptive behavior
3. Inability to establish a meaningful relationship
4. Displays poor judgment
5. Irresponsibility or inability to accept responsibility for
actions
6. Pessimistic
7. Does not recognize limitations (abilities and
deficiencies)

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 Con…
8. Exhibits dependency needs because of
feelings of inadequacy
9. Inability to perceive reality
10. Does not recognize potential and talents
due to a poor self-concept
11. Avoids problems rather than handling
them or attempting to solve them
12. Desires or demands immediate
gratification

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 Causes of mental illness

• is no clear understanding , but different etiological

models are considered.

• These factors include

• Biological factors

• Psychological factors

• Social factors

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 Biological factors

Genetic factors: family study, twins study, adoption study

Neuro-developmental study: perinatal infection, hypoxia, Rh

incompatibility, maternal starvation

Functional anatomy: abnormality of certain brain structure may

leads to psychiatric disorder. the system of special interest to
psychiatry are
– Prefrontal cortex

– Limbic system

– Basal ganglia

Neuro-chemistry: dysregulation of neurotransmitters dopamine,

serotonin, nor-epinepherine etc

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11
12
 Con…

• Psychological factors: psychochlogic factors,

behavioral and cognitive factors.

• Social factors: cultural, environmental, and familial

influence

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 Factors influencing mental health can be generalized in to
three categories .
1. predisposing factors:- appear early in life

 genetic factors

 environment in the uterus

 physical psychological and social factors

during child hood

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 Con…

2. Precipitating factors:- occur shortly before the on set of

the disorder
– Physical e.g. substance abuse alcohol, khat,
hashish…
– Loss e.g. person, job, property…

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 Con….

3. Perpetuating factors: - factors those prolong course of

mental disorder after it’s on set

– Demoralization

– Social withdrawal

– Poor social or family support

– Loss of job etc

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 History and Trends of Psychiatric Nursing

– Mental illness began in the primitive age as human

existence began. There is evidence that it did exist
and attempts were made to treat it.
– It was thought to be caused by evil sprits entering
and take over the body. People were attempted to
drive these evil sprits from the body through the use
of incantations and magic.
– Some primitive tribes rejected their mentally ill and

drove them from the community.

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In the ancient civilization,
• Greeks, Romans and Arabs viewed mental deviations as natural
phenomena and treated the mentally ill humanely. Care consists
of
Sedation with opium
Music
Good physical hygiene
Nutrition and activity

• The Greek philosopher Plato (429-348 BC) and the Greek

physician Hypocrites (460-377 BC, known as the father of

medicine), were concerned about the treatment of the mentally ill.
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 Con…

In the middle age

• the humanitarian ideas concerning the mentally ill
were forgotten.
• They would revert to mysticism, witchcraft and
magic the results of mental illness.
• Mentally ill were usually locked in where flogging,
starvation, torture, and blood letting were
common.

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20
 Con…
 A French physician Philip Pineal (1745 - 1826), began
the movement toward more human treatment of the
mentally ill when he removed the chains from twelve
male patients at Bicker hospital near Paris in 1792.
 Pineal disavowed punitive treatment of mental patients.
 He recognized the need for medical care and advocated
freedom, useful work, and kindness for patients.
 The first hospital in America to admit mental patients
was the Pennsylvania hospital located in Philadelphia
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 Con…
 The first American textbook on psychiatry was written by
Benjamin Rush (1745-1813) was a physician who used a
humanistic approach in the treatment of mental illness,
 he is considered by many to be the father of American
psychiatry.
 In 19th century Dorothea Lynde Dix, who contributed much
effort for the establishment of American hospitals for the care of
the mentally ill.
 As a result of her efforts, many hospitals were built in
United States, Canada, and in other countries.

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 Cont…
 The first psychiatric training school for nursing in United States
was established in 1882 at Mclean hospital. Linda Richared:
first graduate nurse and American psychiatry nurse.
 In the 20th century an Austrian neurologist, Sigmund Freud
made a significant contribution to the understanding and
treatment of mental illness..
 In Ethiopia the first mental hospital (Emanuel Hospital) was
established after the end of Ethio - Italian war that is to protect
the royal family from mentally ill patients.
 The patients were collected and taken to jails to the corner of the
town which is now known as Emanuel Hospital.

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 Cont…

 Slow and gradually humanitarian type of care was started by one

psychiatrist Dr. Fikire workineh.
 The first psychiatric nursing school was established in Emanuel
hospital in 1991 and 12 nurses was graduated for the first time.
 The service was started to be decentralized to other corners of
the country
 By now some of hospitals in Ethiopia have psychiatric units even
though the Quality is not to the expected level

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Principles of psychiatric nursing
• Realizing that every patient is unique.
• Try to discover and remove or alleviate the psychosocial problem
of the patients
• Realizing that a patients illness behavior can be perpetuated by the
environment to which he live and the attitude of other people.
• people who are new to psychiatric unit tend to be afraid of
psychiatric patient. So always approach your patients in a calm,
friendly and confident manner and talk to him/her with out fear or
sense of superiority.

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• realize that what ever the patient does or say to you is due to his
illness. Accept each one of them regardless of their behavior.
• Recovery of psychiatric patients tend to be quicker if they are kept
occupied
• Physical care
• Teaching self-care and specific social skills

• Planning activities for patient right and plan for things they can

actually do and achieve after they have left the Hospital.

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 Assessments of mental illness.

• The best method of collecting data in mental illness

includes.

• History taking.

• Mental status examination

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 Psychiatric history taking

• The single most important method of arriving to

diagnose in psychiatry is very good psychiatric

interview.

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 Cont…
• Preliminary requirements.
– Room: sound proof, free from interruption, privacy, confrontation
and safety of the patient.
– Observe the patient from waiting area
– Seating position is not opposite to the interviewer.
– No leading question and comment.
– Record only some verbatim statement only
– Time not more than one hour.
– Do not use closed ended question at the beginning of the
interview

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 Psychiatric history includes.

• Biographic data; - include

• Chief complaint
• History of the present
• Past psychiatric hx
• Past medical hx
• Family hx
• Personal history
• Forensic hx

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 Mental status examination

Mental status examination is carried out orderly and

systematically.
It Includes examination of.
• General description;
• Appearance: dress: color, cleanness, inadequacy for
the weather.
• self care (neglect): unshaven, uncombed hair,
• Unusual combination of clothing;
• Unusual accessory.

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 Cont..

Motor activity:
• Gait: unusual fast, slow or unusual characteristics.
• Abnormal motor activity: tic, stereotypes etc.
• Speech: speed, volume, quantity, tone or non social speech.
• Emotion: mood and affect
• Perception: hallucination, illusion, depersonalization and
derealization.
• Thought: stream, content, control, and form.

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 Cont..

• sensorium and cognition

– Alertness and level of consciousness.
– Orientation to time place and person.
– Memory: remote ask life events that happen in this country 10
years or 20 years back, recent what he had for break fast and
immediate you tell your name and addresses and then ask
him after some time
– Concentration and attention: subtract serial 7 from 100 for
concentration test and ask the patient to call days of the week
forward and back ward for attention

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 Cont..

• Judgment: ask some general knowledge the patient

to evaluate the general knowledge.
• Insight: is the patient belief that he is ill?. If so he
need treatment or not
• Diagnose
• Differential diagnoses.

• plan of managements

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SIGN AND SYMPTOMS
IN PSYCHIATRY
Mohammed y

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 Learning Objectives
• To help you understand
– What sign and symptoms are
– Sign and symptom of
• Emotion
• Perception
• Thought
• Speech
• Motor activity
• Cognition

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 General points
Signs: are objective findings observed by the clinicians.
Example- constricted affect, and psychomotor
agitation or retardation.
Symptoms: are subjective experiences described by the
patient.
Example- depressed mood and decreased energy
Syndrome: is a group of signs and symptoms that
occur together as a recognizable.

37
 General points
• Most commonly affected areas in mental disorders are:-
– Speech
– Mood
– Thinking
– Perception
– Memory

• Symptoms are more likely to indicate mental disorder if

they occur together, are persistent and interfere with the
function of the individual.
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 Major groups of symptoms

1. Disorders of perception
2. Disorder of thought
3. Disorder of Speech
4. Disturbance of affect/mood
5. Disturbance of motor behavior
6. Disturbance of consciousness

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 1.Disorders of perception
• Perception: Process of transferring physical stimulation
into psychological information
• Mental process by which sensory stimuli are brought to
awareness.

• Two forms
– Sensory distortions - there is a constant real perceptual
object, which is perceived in a distorted way
– Sensory deceptions - a new perception occurs that
may or may not be in response to an external stimulus
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 Sensory Distortions

• Change in the intensity and quality of the

stimulus or the spatial form of the perception
– Changes in intensity (hyper- or hypo-
aesthesia)
– Change in quality
– Change in spatial form – micropsia,
macropsia & dysmegalopsia
• Distortions of the experience of time - very
slowly and even stands still or time speeds

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 Changes in intensity (hyper- or hypo-
aesthesia)

• Increased intensity of sensations (hyper

aesthesia) may be the result of intense emotions
or a lowering of the physiological threshold.
• Thus a person may hear the noise of a door
closing like a clap of thunder(hyper acusis) .
Eg. Anxiety and depressive disorders
hangover from alcohol
migraine

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 Cont…
• Hypoacusis occurs in delirium, where the
threshold for all sensations is raised.
• This highlights the importance of speaking to the
delirious patient more slowly and louder than
usual.
• Hypoacusis is also a feature of other disorders
associated with attentional deficits such as
depression and attention-deficit disorder.

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 Changes in quality

• It is mainly visual perceptions that are affected

by this, brought about by toxic substances.
• Colouring of yellow, green and red have been
named xanthopsia, chloropsia and erythropsia.
• These are mainly the result of drugs (for
example, santonin, poisoning with mescaline or
digitalis) used in the past to treat various
disorders.

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 Changes in spatial form (dysmegalopsia)

• This refers to a change in the perceived shape

of an object.
• Micropsia is a visual disorder in which the
patient sees objects as smaller than they really
are.
• The opposite kind of visual experience is known
as macropsia or megalopsia.

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 Sensory Deception

Two forms
1. Illusions - misinterpretations of stimuli arising from an
external object.
– Stimuli from a perceived object are combined with a
mental image to produce a false perception e.g. grieved
person momentarily see diseased once, misinterpreting
shadows as threatening

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2. Hallucinations –is a false perception
experienced in the absence of actual stimuli,
- a false perception which is not a sensory
distortion or a misinterpretation, but which occurs
at the same time as real perceptions.
– Come from ‘within’, but subject reacts to them as
true perceptions coming from ‘without’

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 Forms of hallucination
• Hearing (auditory)
– Different explanation of origin & different effect on
the patient
– Is false perception of hearing. Second or third
person hallucination. Common in schizophrenia
• Visual
• Olfactory – uncommon
• Gustatory- uncommon
• Tactile
– Heat, electrical shocks and sexual sensations
• Visual and tactile hallucination are common in
delirium, alcohol withdrawal or other medical
condition.
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 Special hallucinations

Functional hallucination
• An auditory stimulus causes a hallucination but
the stimulus is experienced as well as the
hallucination.
• In other words the hallucination requires the
presence of another real sensation.
• For example, a patient with schizophrenia first
heard the voice of God as her clock ticked;
hearing a voices coming from the running tap
which stops when the tap is closed

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 Cont…
– Extracampine hallucinations - a
hallucination that is outside the limits of the
sensory field e.g. a patient sees somebody
standing behind them when they are looking
straight ahead or hear voices talking in London
when they are in Addis
– Hypnagogic and hypnopompic
hallucinations - during sleep onset & offset
respectively

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 Disturbance of perception cont.

Depersonalization: a subjective sense of being

unreal, strange, or unfamiliar to one self

Derealization: a subjective sense that the

environment is strange or unreal; a feeling of
changed reality

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 Thought disorder
• Thinking is goal-directed flow of ideas, symbols
and associations initiated by a problem or task
and leading toward a reality oriented conclusion.
• When a logical sequence occurs thinking is
normal.

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 Disturbance of thinking

• The two thought disorders are:-

– Disorder of form of thought
– Disorder of content of thought

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 Formal thought disorder
– Disturbance in the form of thought rather than
the content of thought; thought process is
disordered and the person is mostly defined as
psychotic.

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Specific disturbances in form of thought
• Flight of ideas:- rapid continuous verbalizations
or plays on words produce constant shifting from
one idea to another; ideas tend to be connected.

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Specific disturbances in form of thought
• Circumstantialities:- when thinking proceeds
slowly with many unnecessary and trivial details,
but finally the point is reached.
• Tangentiality:- inability to have goal-directed
associations of thought; speaker never gets from
desired point to desired goal.

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Specific disturbances in form of thought
• Loosening of association:-flow of thought in

which ideas shift from one subject to another in

completely unrelated way; when severe speech
may be incoherent.
• Echolalia:- psycpathological repeating of words of

one person by another; tends to be repetitive and

persistent.
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Specific disturbances in form of thought
• Clang association:- association of words similar
in sound but not in meaning; words have no
logical connection.
• Thought Blocking:- occurs when there is a
sudden arrest of the train of thought, leaving a
‘blank’. An entirely new thought may then begin.

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 Cont….
• Perseveration: Perseveration occurs when
mental operations persist beyond the point at
which they are relevant and thus prevent
progress of thinking.
• Verbigeration: meaningless repetition of
specific words or phrases

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 Disorders of content of thought

Delusion
a belief that is pathological and is held
despite evidence to the contrary.
False belief / fixed belief
Incorrigible - by reason, logic, or proof
Immense preoccupying power
Not shared by his cultural group
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 Types of delusion
• Delusion - false, unshakeable belief that is
out of keeping with the patient’s social and
cultural background
– Bizarre =totally implausible Vs non-bizarre
– mood congruent
– Mood incongruent

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 Content/types of delusion

• Persecutory delusion
• Delusion of infidelity
• Delusion of love /erotomania
• Grandiose delusion
• Delusion of guilt
• Delusion of poverty
• Nihilistic delusion
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 Disturbance of thought content cont.
 Persecutory delusion: False belief that one is being
harassed, conspired, or persecuted
 Delusion of reference: False belief that ordinary,
insignificant comments, objects, or events refer to or
have special meaning for the patient.
 Delusion of grandeus: delusional; belief of special
power, talent, abilities or identity
 Somatic Delusion: false belief involving functioning of
one’s body 63
 Delusion of control

• Thought alienation - thoughts are under the control of an outside

agency
– Thought insertion:- thoughts are being implanted in a person’s mind
by other people or force.
– Thought withdrawal:- Outside force removing one’s thought
– Thought broadcasting:- One’s thought is heard aloud.
– Mind reading:- Other people can know one’s thoughts.

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 Disturbance of thought content cont.
 Delusion of infidelity (delusional jealousy):
false belief derived from pathological jealousy
that one’s lover is unfaithful
 Delusion of Erotomania: delusional belief,
more common in women than in men, that
someone is deeply in love with them
 Nihilistic delusion: false feeling that self,
others, or the world is nonexistent or ending.
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 Cont…
• Obsessions – repetitive & intrusive mental
activity (thought or image)
• Compulsion – repeated acting in a ritualistic way,
usually aimed to alleviate anxiety due to
obsession

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 Disorders of speech

Disturbance of speech
• Rate or speed of speech- slow, hesitant, long
pauses before answering, pressurized speech
• Rhythm: monotonous, exaggerated inflection
• Volume of voice: soft, barely audible, loud
• Amount: monosyllabic, hyper talkative , mute

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 Speech disorders

Stammering and stuttering

• In stammering the normal flow of speech is
interrupted by pauses or by the repetition of
fragments of the word.
• Grimacing and tic-like movements of the body
are often associated with stammer.
• Stuttering usually begins at about the age of 4
years and is more common in boys than girls.

68
 Cont…
Mutism
• Mutism is the complete loss of speech and may
occur in children with a range of emotional or
psychiatric disorders and
• in adults with hysteria, depression,
schizophrenia or organic brain disorders.
• Elective mutism may occur in children who
refuse to speak to certain people; for example,
the child may be mute at school but speak at
home.

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 Cont..
Neologisms
• Neologisms may be new words that are
constructed by the patient or ordinary words that
are used in a new way.
• The term ‘neologism’ is usually applied to new
word formations produced by individuals with
schizophrenia.

70
 Disorders of Emotion
Emotion: stirred up state due to physiological
changes which occurs as a response to some
event and which tends to maintain or abolish the
causative event.
• Emotion has two parts
– Mood is the inside feeling of a person and is
relatively long lasting.
• positive or negative reaction to some
experience
• Subjective experience of emotion
– Affect is the outward and observed
expression of one’s feeling and is mostly short
lived. 71
Affect
 Inferred from the patient's facial expression
 The amount and the range of expressive behavior
 Is observed expression of emotion possibly
inconsistent with patient’s description of emotion.
 May or may not be congruent with mood

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• Appropriate affect
– Condition in which the emotional tone is in
harmony with the accompanying idea, thought
or speech.
– It is also described as broad or full affect in
which a full range of emotions is appropriately
expressed.

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• Inappropriate affect
– Disharmony between the emotional feeling tone
and the idea, thought or speech.
– E.g. laughing when discussing the death of a
loved one.
– Mostly seen in severe psychiatric disorder.

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• Restricted or constricted affect
– Reduction in intensity of feeling tone
– Less severe than blunted affect but clearly
reduced.
– Limited range of expressed emotion
– Little variability of expression during the
interview.

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• Blunted affect
– Disturbance in affect manifested by severe
reduction in intensity of externalized feeling tone.
– Minimal expression in intensity of emotion.
– The individual’s facial expression varies little.
– There are few physical gestures of emotion.
– Eye contact is either minimal or the patient seems
to stare at the interviewer.
– The patient speaks in monotonous tone with little
vocal inflection.
– The person’s face seems to have little muscle
tone.
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• Flat affect
– Is more severe form of blunted affect with
essentially no affective expression.
– The interviewer may feel as if he is conversing
with inanimate object.
– If he is told that his mother died or if he is told that
he win lottery the response will be the same.
– No expression of sadness at the news of the
death of his mother.
77
• Labile affect
– Refer to abrupt, rapid and repeated shifts of type
and intensity of emotion
– Unrelated to external stimuli.
– Individual’s emotional response is exaggerated.
– It is not proportionate to the expected response.
– There is emotional incontinence.

78
 Mood
• A pervasive and sustained emotion subjectively
experienced and reported by a patient
E.g. depression, elation, anger

79
 Mood
• Euthemic mood:- normal range of mood, implying
absence of depression or elevated mood.
• Alexythymia:- a person’s inability to describe or
difficulty in describing or being aware of emotions
or mood.

80
• Irritable mood:- a state in which a person is easily
annoyed and provoked to anger.
• Mood swings(labile mood):- oscillations between
euphoria and depression or anxiety.
• Expansive mood:- a person’s expression of feeling
without restraint, frequently with an overestimation
of their significance or importance.

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• Elevated mood:- air of confidence and enjoyment,
a mood more cheerful than usual.
• Euphoria:- intense elation with feeling of grandeur.
• Elation:- feeling of joy, euphoria, intense self-
satisfaction or optimism.

82
• Anhedonia:- loss of interest in and withdrawal from
all regular and pleasurable activities, often
associated with depression.
• Grief or mourning:- sadness appropriate to a real
loss.
• Dysphoric mood:- an unpleasant mood.
• Guilt:- emotion secondary to doing what is
perceived as wrong.
83
 Motor disorders
• Tics - irregular, involuntary & repeated
movements involving a group of muscles
• Mannerism - repeated movements that appear
to have some functional significance to a given
person, but used out of context & inappropriately
e.g. saluting
• Stereotypes - repeated movements that are
regular and without obvious significance e.g.
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rocking to and fro
• Posturing - adoption of unusual body posture for a
long period of time
• Negativism - doing the opposite of what was
asked to do
• Echopraxia - imitation of the others act
• Waxy flexibility - maintenance of a position for a
long time(can be molded like a wax)

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• Psychomotor agitation - excessive motor activity
associated with feelings of inner tension
• Catatonic rigidity - maintenance of a rigid posture
against all efforts to be moved
• Akinesia - lack of physical movement
• Catalepsy - a general term for an immobile position
• Cataplexy - sudden loss of motor tone, associated
with narcolepsy

86
Disturbances of Consciousness
• Consciousness is awareness of self in the
environment.
• The abnormality in consciousness can be
manifested at various levels.
• Disorder(disturbance) of conscious are most
often associated with brain pathology.

87
 Disturbances of Consciousness
• Clouding of consciousness
– Conscious is explained as being cloudy when
a person is in state of drowsiness.
– Attention, concentration and memory is
impaired.
– Reaction to stimuli is incomplete.

88
Disturbances of Consciousness
• Confusion
– Confusion is a stage where thinking is muddled;
consciousness may be impaired; reaction to
environmental stimuli is inappropriate.
• Stupor
– Lack of reaction to and awareness of
surroundings.
• Coma
– Profound degree of unconsciousness
89
 Disturbances of Consciousness

• Drowsiness
– A state of impaired awareness associated with a
desire or inclination to sleep

• Disorientation
– Disturbance of orientation in time, place or
person

90
Disturbance of attention and concentration

• Attention is the ability to focus on something.

• Concentration is the ability to maintain that focus.
• Attention and concentration can be impaired in
many of psychiatric conditions, physical illness
and anxiety stage.

91
 Disturbance of attention
• Distractibility
– Inability to concentrate
– Attention is drawn to unimportant or irrelevant
external stimuli
• Selective inattention
– Blocking out only those things that generate anxiety

• Hyper vigilance
– Excessive attention and focus on all internal and
external stimuli
92
Memory

Levels of memory:
immediate: recall of perceived material
within seconds to minutes
Recent: recall over past few days
Remote: recall of events in distant past

93
Disturbances of memory

• Amnesia: Partial or total inability to recall past

experiences
 Anterograde Amnesia: amnesia for events
occurring after a point in time
 Retrograde Amnesia: amnesia for events
occurring before a point in time.
 Common in trauma
 Blackout amnesia: experience by alcoholics
about behavior during drinking bouts. 94
• Déjà vu:- refers to recognition of events as if
the person is familiar with it though the person
may not have encountered the event at all in the
past.
• Jamais vu:- It is the opposite of déjà vu, where
the person is fails to recognize the events that
had been experienced before.
• Confabulation:- when a person does not
remember the events of certain period, he tries
to fill in that gap with unrealistic stories or events
that had never occurred.
95
 Summary

• It is important to know the main sign and

symptoms in psychiatry.
• There is no pathognomonic symptoms in
psychiatry.
• Some signs and symptoms are more common in
certain disorder than other disorder.

96
Thank you

97
• Psychiatric disorder
• Mental illness can be classified by using decision tree
• C
• Phobia
• L Normal Non psychotic Anx. Dis Anxiety
• Obss. comp
• PTSD
• I
• Personality disorder
• E
• Abnormal acute (delirium)
• Cognitive
• N
• Chronic(dementia) (amnesia)

• Psychotic Affective bipolar I

• T functional bipolar II
• Schizophrenia
• Non affect
• Delusion. D
• Characteristic feature of psychosis
• 1. Bizarre behavior
• 2. Abnormal experience
• 3. Loss of reality contact
• 4. Lack of insight.
98
 Unit two
Anxiety Disorders
Anxiety:- is a response to a threat that is unknown, internal vague, or
conflict.
– It is characterized most commonly as a diffuse, unpleasant,
vague sense of apprehension,
– often accompanied by autonomic symptoms such as
– head ache
– perspiration
– palpitation
– tightness in the chest
– mild stomach discomfort, and restlessness.

– Every one experience anxiety.

99
Fear:-
 is a response to a known, external, definite, or non
conflict threat.

 Both anxiety and fear are an alerting signal;

 are warns of impending danger and

 enable a person to take measure to deal with a threat

100
• The anxiety disorders are the most common, or frequently
occurring, mental disorders.

Types of Anxiety Disorders

• Generalized anxiety disorder.
• Panic disorder.
• Phobia.
• Obsessive-compulsive disorder.
• Acute stress disorder.
• Post-traumatic stress disorder.

101
Contribution to the cause of anxiety.

1. Theories for the cause of anxiety.

– Psychoanalytic theory:- anxiety as a signal of the

presence of danger in unconsciousness.

– behavioral theories: - anxiety is a conditioned

response to a specific environmental response

102
2. contribution of biological science
• Stimulation of autonomic nervous system.
• Neuron transmitters
– Increased nor adrenaline functions
– Stimulation of serotonin receptors
– GABA
• Genetic study
• Neuro anatomical consideration: limbic system
and cerebral cortex.
103
Epidemiology
• The anxiety disorders are the most
common, or frequently occurring, mental
disorders.
• More common in female than male

104
1. Generalized Anxiety Disorder

 is defined as excessive anxiety and worry

about several events or activities for most

day during at least 6 months of period.

 The worry is difficult to control and

accompanied by multiple associated

symptoms (DSM-IV).
.
105
 Cont…
These symptoms include
• Muscle tension (shaking, restlessness and head ache)
• Autonomic hyperactivity SOB, excessive sweating,
palpitation and varies gastro intestinal symptoms
• poor concentration.
• Easy fatigability
• Insomnia and irritability

106
• The excessive worries often pertain to many areas, including
 Work
 Relationships
 Finances
 The well-being of one’s family
 Potential misfortunes, and
 Impending deadlines.
 Patient with GAD usually seek the health institution for help with
somatic symptoms

107
Treatment:-
Psychotherapy

– Cognitive-behavioral
• Supportive : comforting, reassuring
• Insight oriented: focus on uncovering unconscious
conflict
• pharmacotherapy
• Benzodiazepines
• Buspirone ;serotonin receptors partial agnost
• Antidepressant
• Propranolol: beta adrenergic receptor antagonest

108
2. Phobia
• Is an excessive irrational fear.

• The patient recognizes that the fear is excessive or

unreasonable.
• The phobic situation is avoided or else is endured

with intense anxiety or distress.

• Impairment in social occupational condition.

109
 Types
A. Agoraphobia
• Severe and pervasive anxiety about being in
situations from which escape might be difficult or
• Avoidance of situations such as being alone
outside of the home, traveling in a car, bus, or
airplane, or being in a crowded area

110
B. Specific Phobias
These common conditions are characterized by

marked fear of specific objects or situations.

Exposure to the object in real life or via imagination or

video
The specific phobias generally do not result from

exposure to a single traumatic event

111
Example
• Androphobia _fear of men

• Astraphobia – fear of storms, lightning, thunder

• Claustrophobia – fear of enclosed place

• Hydrophobia – fear of water

• Nyctophobia – fear of night

• Zoophobia – fear of animal

• Acrophobia- fear of heights

112
C. Social Phobia
• Marked and persistent anxiety in social situations, including
performances and public speaking.
• Like specific phobias, the fear is recognized by adults as
excessive or unreasonable, but the dreaded social situation
is avoided or is tolerated with great discomfort
Treatment: systemic desensitization
anti anxiety

Anti depressant

113
 Panic Disorder
• A discrete period of intense fear or discomfort, in which four (or
more) of the following developed symptoms abruptly and
• reached a peak within 10 minutes:
– palpitations, pounding heart, or accelerated heart rate
– sweating
– trembling or shaking
– sensations of shortness of breath or smothering
– feeling of choking
– chest pain or discomfort

114
 Cont…
– nausea or abdominal distress
– feeling dizzy, unsteady, lightheaded, or faint
– derealization (feelings of unreality) or
depersonalization (being detached from oneself)
– fear of losing control or going crazy
– fear of dying
– paresthesias (numbness or tingling sensations)

– chills or hot flushes

115
At least one of the attacks has been followed by 1 month (or more)
of one (or more) of the following:
– persistent concern about having additional attacks
– worry about the implications of the attack or its
consequences (e.g., losing control, having a heart attack,
"going crazy")
– a significant change in behavior related to the attacks
The Panic Attacks are not due to the direct physiological effects of
a substance (e.g., a drug of abuse, a medication) or a
general medical condition (e.g., hyperthyroidism).

116
Treatment

• Anti depressant e.g. clomipramine 25 mg,

fluoxetine 20 mg

• Benzodiazepines

• Behavioral therapy

117
 Obsessions – compulsions disorder
Obsessions as defined by
– Recurrent and persistent thoughts, impulses, or images that are
experienced,
– intrusive and inappropriate and that cause marked anxiety or distress

– The thoughts, impulses, or images are not simply excessive worries

about real-life problems
– The person attempts to ignore or suppress

– The person recognizes that the obsessional thoughts, impulses, or

images are a product of his or her own mind

118
• Compulsions as defined:
– Repetitive behaviors = hand washing, ordering, checking or
mental acts = praying, counting, repeating words silently
– person feels driven to perform in response to an obsession
– The behaviors or mental acts are aimed at preventing or
reducing distress
– are not connected in a realistic clearly excessive
– person has recognized that the obsessions or compulsions
are excessive or unreasonable.

119
 – Note: This does not apply to children.
– The obsessions or compulsions cause
marked distress, are time consuming (take
more than 1 hour a day)
Treatment
• Anti depressant e.g. clomopramine

120
 Acute Stress Disorders
 Refers to the anxiety and behavioral disturbances that
develop within the first month after exposure to an
extreme trauma.
 Generally, the symptoms of an acute stress disorder
begin during or shortly following the trauma. Such
extreme traumatic events include
– Rape or other severe physical assault,
– near-death experiences in accidents,
– Witnessing a murder, and combat.
121
Symptoms of an acute stress disorder include
– symptoms of generalized anxiety and hyper arousal
– avoidance of situations or stimuli that elicit memories of the
trauma
– Persistent, intrusive recollections of the event via flashbacks,
dreams, or recurrent thoughts or visual images.
– The symptom of dissociation
– Dissociation also is characterized by a sense of the world as a
dreamlike or unreal place and may be accompanied by poor
memory of the specific events,

122
Post-Traumatic Stress Disorders
• If the symptoms and behavioral disturbances of the acute stress disorder
persist for more than 1 month,
• These features are associated with functional impairment or significant
distress to the sufferer
• Post-traumatic stress disorder is further defined in DSM-IV as having
three sub forms:
• Acute (< 3 months’ duration).
• Chronic (> 3 months’ duration).
• Delayed onset (symptoms began at least 6 months after exposure to the
trauma).

123
Sign and symptoms including
• Person re-experiences the event.

• Person involves intense fear helplessness or horror.

• The traumatic event is persistently re-experienced in

one or more of the following ways.

– Recurrent and intrusive (disturbing) distressing

recollection of the event including image, thought,

or perception.

124
 Cont..
– Recurrent distressing dream of the events.
– Acting or feeling as if the traumatic event were
recurring (including sense of revealing the experience
illusion, hallucination)
– Intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic events.

125
• Decreased self-esteem.
• Loss of sustained beliefs about people or society.
• Hopelessness.
• A sense of being permanently damaged.
• Difficulties in previously established relationships are
typically observed.
• Substance abuse often develops especially involving
alcohol, marijuana, and sedative-hypnotic drugs.

126
 Cont….
• About 50 percent of cases of post-traumatic stress
disorder remit within 6 months.
• For the remainder, the disorder typically persists for
years and can dominate the sufferer’s life.
• A longitudinal study of Vietnam veterans, for
example, found 15 percent of veterans to be
suffering from post-traumatic stress disorder 19
years after combat exposure

127
Treatment
pharmacotherapy
• anti depressant SSRI e.g sertraline and paroxetine
are first line : tricyclic antidepressant
• Anti convulsant: carbamazepine, valporate
• Antipsychotic e.g haloperidol to control sever
agitation and aggression
• Antiadrenergic agent

128
Psychotherapy
• Behavioral, Cognitive, hypnosis
• Follow model of crisis intervention with support , education,
and development of coping mechanism and acceptance of
the events
• Exposure therapy in which the patient re-experience the
traumatic event through imagination or vivo experience.
• Group and family therapy

129
 Unit three
somatoform and related disorder

Somatoform disorder
• Expressing emotional conflict through physical symptoms.

• not under voluntary control

• is not explained as a known physical disorder.

• Physical complaint that occur in the absence of medical examination.

130
Classification

1. Somatization disorder

2. Conversion disorder

3. Hypochondriasis

4. Body dysmorphic disorder

5. Pain disorder

131
1. Somatization disorder
• is chronically and persistently complain of varied
physical symptoms
• have no identifiable physical origin.
• etiologic explanation is that internal psychological
conflicts are unconsciously expressed as physical
signs.
• Patients visit many doctors trying to get the
treatment they think they need

132
DSM-IV Criteria
• a history of somatic symptoms prior to the age of 30
• pain in at least four different sites on the body
• two gastrointestinal problems other than pain such
as vomiting or diarrhea
• one sexual symptom such as lack of interest or
erectile dysfunction
• one pseudoneurological symptom such as fainting or
blindness.

133
• Such symptoms cannot be related to any medical
condition.

• The symptoms do not all have to be occurring at the

same time

• But may occur over the course of the disorder

134
2. Conversion disorder
• is a condition in which an anxiety provoking impulse is
converted unconsciously in to functional symptoms.
• Although the disturbance is not under voluntary control the
symptoms occur in organs under voluntary control.
• Patient benefit by primary gain is obtaining relief from anxiety by
keeping an internal need or conflict out of awareness.
• Secondary gain benefit or support from the environment that a
person obtains as a result of being sick e.g. gain attention, love,
financial reward and sympathy

135
Common symptoms complexes in conversion disorder

Neurological symptoms
• involuntary movement
• seizure
• abnormal gait and paralysis
• numbness
• blindness
• deafness
• paraesthesia
• tics
Visceral symptoms
• psycholenic vomiting
• diarrhea
• urine retaintion

136
3. Hypochondriasis
• Refers to an excessive preoccupation or worry about
having a serious illness.

• persists even after a physician has evaluated and

reassured

• do not have an underlying medical basis or,

• if there is a medical illness, the concerns are far in

excess of what is appropriate for the level of disease.
137
4. Body dysmorphic disorder
• Is excessively concerned about and preoccupied by an
imagined or minor defect in his or her physical features.
• The sufferer may complain of
– several specific features or
– a single feature, or
– a vague feature or
– general appearance,
• causing psychological distress that impairs occupational and/or
social functioning

138
5.Pain disorder
• is when a patient experiences chronic pain in one or more
areas
• is thought to be caused by psychological stress.
• The pain is often so severe that it disables the patient from
proper functioning.
• It can last as short as a few days, to as long as many years.
• This disorder often occurs after an accident or during an illness
that has caused genuine pain, which then takes a life of its
own.

139
Factitious Disorder - Munchausen Syndrome
• Patients knowingly experience fake symptoms, but do so for
psychological reasons
• They usually prefer the sick role
• move from hospital to hospital in order to receive care.
• They are usually loners
• Unlike many malingering, they follow through with medical procedures
and
• are at risk for drug addiction and for the complications of multiple
operations
• a patient with a factitious disorder intentionally produces physical

symptoms without external incentives

140
Malingering
• Manifest with intentional production of false or
grossly exaggerated physical or psychological
symptoms

• motivated by external incentive such as

– obtaining financial compensation or
– avoiding employment, or
– avoiding prison
141
 Unit Four

Dissociative disorder

• Characterized by disturbance or alteration in the

normally integrative functions of
Identity
Memory
consciousness
Perception

142
Classification
1. Dissociative identity disorder

2. Depersonalization disorder

3. Psychogenic amnesia

4. Dissociative fuge

143
1. Dissociative identity disorder
• Dissociative Identity Disorder (multiple personality
disorder)
• Is defined as a psychiatric disorder that describes a
condition in which a single person displays multiple
distinct identity or personality.
• In ability to recall important personal information that
is to extensive to be explained by ordinary
forgetfulness

144
2. Depersonalization disorder
• Is a feeling of detachment or estrangement from one
self
• Feeling as if living in a dream or a movie.
• Is an 'alteration' in the perception or experience of
the self
• One feels 'detached' from and as if one is an
'outside' observer of, one's mental processes or
body

145
3. Psychogenic amnesia
• Also known as functional or dissociative amnesia
• Is a disorder characterized by abnormal memory functioning in
the absence of structural brain damage or a known
neurobiological cause;
• Severe cases are very rare.
• It is defined by the presence of retrograde amnesia or the
inability to retrieve stored memories and events leading up to
the onset of amnesia and anterograde amnesia or the inability
to form new long term memories.

146
 Cont…
• In most cases, patients lose their autobiographical
memory and personal identity even though they are
able to learn new information and perform everyday
functions normally.

• Other times, there may be a loss of basic semantic

knowledge and procedural skills such as reading and
writing.

147
4. dissociative fuge
– Is the assumption of a new identity or confusion
about personal identity.
– It also involve an expected travels away from ones
home or customary place or work

148
 Unit FIVE
Mood Disorders
• The Mood Disorders section includes disorders that have a disturbance
in mood as the predominant feature
• Characterized a disturbance in emotion and feeling, manifests itself as
either elation or unhappiness.
• Are very common and usually responding well to treatment
• About 7 percent of Americans suffer from mood disorders, a cluster of
mental disorders best recognized by depression or mania.
• They have potentially severe consequences for morbidity and mortality

149
Classification

Major depressive disorder

Mania episode.
Bipolar disorder.
Dysthymia.
cyclothymia

150
Major Depressive Disorders.
• The cardinal symptoms of major depressive disorder are
• Depressed mood and
• loss of interest or pleasure.
• Insomnia and weight loss are considered to be classic signs,
even though many depressed patients gain weight and sleep
excessively.
• A more severe depressive syndrome characterized by a
constellation (group) of classical signs and symptoms, called
melancholia, is more common.
• Suicide is the most dreaded complication of major depressive
disorders.

151
DSM-IV criteria for major depressive episode
• Five (or more) of the following symptoms have been present
during the same 2-week period
• At least one of the symptoms is either (1) depressed mood or
(2) loss of interest or pleasure.
– Depressed mood most of the day, nearly every day
– Markedly diminished interest or pleasure in all, or almost all,
activities
– Significant weight loss or weight gain
– Decrease or increase in appetite

152
– Insomnia or hypersomnia nearly every day.
– Psychomotor agitation or retardation.
– Fatigue or loss of energy nearly every day.
– Feelings of worthlessness or excessive or inappropriate guilt
(which may be delusional)
– Diminished ability to think or concentrate
– Recurrent thoughts of death (not just fear of dying),
– recurrent suicidal ideation without a specific plan, or a suicide
attempt or a specific plan for committing suicide

153
• The symptoms do not meet criteria for a mixed
episode.
• Impairment in social, occupational, or other
important areas of functioning.
• The symptoms are not due to the direct
physiological effects of a substance (e.g., a drug
of abuse, a medication) or a general medical

condition (e.g., hypothyroidism

154
 Associated descriptive features and mental
disorders
• Depressive Episode frequently present with tearfulness,

irritability, obsessive rumination, anxiety, phobias, excessive

worry over physical health
• complaints of pain (e.g., headaches or joint, abdominal, or other

pains). During a Major Depressive

• Episode, some individuals have Panic Attacks

• Some individuals note difficulty in intimate relationships, less

satisfying social interactions

155
 Cont…
• difficulties in sexual functioning

• There may be marital problems (e.g., divorce),

occupational problems (e.g., loss of job),

• academic problems (e.g., truancy (absenteeism),

school failure),
• Alcohol or Other Substance Abuse, or

• increased utilization of medical services

156
Course and outcome of depression
• Most depressive episodes clear spontaneously
within about 6 months
• Most patient experience a recurrence of
depression.
• Suicide is the most serious complication 15%

157
Treatment
Hospitalization the first and most critical decision
Psychotherapy: cognitive, behavioral, family therapy
Pharmacotherapy: Antidepressant
• Amitriptyline
• Imipramine
• Fluoxetine
• Clomipramine
• ECT is effective way of therapy for sever depression.
• Close observation especially in case of suicidal ideations

158
Dysthymia
– Is a chronic form of depression.
– Defined by its sub-syndromes nature
– Duration of at least 2 years for adults and 1 year
for children.
– Impairment in social, occupational, or other
important areas of functioning
– Management similar with major depression

159
Manic episode
• Mania is derived from a French word that literally means crazed
or frenzied.
• The mood disturbance can range from pure euphoria or elation
to irritability to a labile that also includes dysphoria.
• Thought content is usually grandiose but also can be paranoid.
• Grandiosity usually takes the form both of overvalued ideas
• Auditory and visual hallucinations complicate more severe
episodes.

160
DSM IV Criteria for manic episode
• Persistently elevated, expansive, or irritable mood, lasting at

least 1 week
• During the period of mood disturbance, three (or more) of the

following symptoms have persisted.

– Inflated self-esteem or grandiosity

– Decreased need for sleep

– More talkative than usual or pressure to keep talking

161
– Flight of ideas
– distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli)
– increase in goal-directed activity (either socially, at work or
school, or sexually) or psychomotor agitation
– excessive involvement in pleasurable activities that have a high
potential for painful consequences
• engaging in unrestrained buying sprees
• sexual indiscretions
• foolish business investments

162
• The symptoms do not meet criteria for a mixed
episode.
• Impairment in occupational functioning
• The symptoms are not due to the direct physiological
effects of a substance

163
Associated descriptive features and mental
disorders Individuals with a Manic
• Episode frequently do not recognize that they are ill and
resist efforts to be treated.
• They may travel impulsively to other cities, losing contact with
relatives and caretakers.
• They may change their dress, makeup, or personal appearance
to a more sexually suggestive
• They may engage in activities that have a disorganized or
bizarre quality (e.g., distributing candy, money, or advice to
passing strangers).
• Gambling and antisocial behaviors may accompany
• The person may be hostile and physically threatening to others.
• When no longer in the Manic Episode, most individuals are
regretful for behaviors engaged in during the Manic Episode.

164
• Treatment:
– Antipsychotic

– Lithium therapy

– Valprote

– Carbamazepine

– ECT, and close observation

165
Cyclothymic Disorder
• For at least 2 years, the presence of numerous

periods with hypomanic symptoms and numerous

periods with depressive symptoms that do not meet
criteria for a major depressive episode.
• Note: In children and adolescents, the duration

must be at least 1 year.

166
• Note: After the initial 2 years (1 year in children and
adolescents) of cyclothymic disorder, there may be
superimposed manic or mixed episodes (in which case both
bipolar I disorder and cyclothymic disorder may be diagnosed)
• or major depressive episodes (in which case both bipolar II
disorder and cyclothymic disorder may be diagnosed).
• The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning

167
Bipolar Disorder
• Bipolar I disorder:
– Is a recurrent mood disorder featuring one or more episodes
of mania or mixed episodes of mania and major depression.
– Characterized by recurrent episode of both manic and major
depression.
• Bipolar II
– Characterized by one or more major depressive episode and
at least one hypomanic episode.

168
• Hypomania, as suggested above, is the sub
syndromal counterpart of mania

• Hypomanic are not associated with marked

impairments in judgment or performance

169
 Unit SIX
Schizophrenia and Other Psychotic Disorders

• These include psychotic symptoms as a prominent

aspect of their presentation

– Delusions

– Hallucinations

– Disorganized speech, grossly disorganized behavior

170
The disorders in this section include

• Schizophrenia
• Schizophreniform Disorder
• Schizoaffective Disorder
• Delusional Disorder
• Brief Psychotic Disorder

171
 Schizophrenia

Schizophrenia is characterized by profound disruption in the most

fundamental human attributes
• Cognition

• Emotion

 Language
 Thought
 Perception
 Affect
 Sense of self

172
Diagnostic criteria for schizophrenia
• Two (or more) of the following, each present for a significant portion of
time during a 1-month period (or less if successfully treated):
• Delusions

• Hallucinations

• Disorganized speech

• Grossly disorganized or catatonic behavior

• Negative symptoms i.e., affective flattening, alogia, or avolition

173
Note: Only one Criterion A symptom is required if

– Delusions are bizarre or

– Hallucinations

• Commentary

• Conversing

– Social/occupational dysfunction

– Duration: persist for at least 6 months.

174
Classification of schizophrenia
1. paranoid schizophrenia
– Stable and persecutory delusion which are usually
accompanied by auditory hallucination
– Disturbance of volition, affect, and speech are not
prominent
– There is relatively litter deteriorations of personality
– The patient may able to live independently in the society

175
2. Hebephrenic schizophrenia
• Characterized by disturbance of volition and affect is

common
• Early on set

• Lack of systematic delusion

• Inappropriate mood

• Poor prognoses

• Rapid development of negative symptoms

176
3. Catatonic schizophrenia
• characterized by psychomotor symptoms such as
– stupor
– excitement
– posturing
– negativism
– rigidity and waxy flexibility and
– command automatism

177
4. Residual schizophrenia
– characterized by current lack of schizophrenic
symptoms but definite experience of at least one
schizophrenia episode in the past
5. Undifferentiated type difficult to categorized in to
one of group

178
Management
• Antipsychotic
• Chlorpromazine initial 50 mg – 100mg/d
• Thioridazine 50- 800mg/d
• Haloperidol 2.5 – 80mg/d
• Flufenazine
• Keep the patient from hazard

Poor prognostic factors are related with

• family history of schizophrenia
• early on set
• pronounced negative symptoms
179
 Delusional disorder
• primary or only manifestation is a delusion
• non bizarre delusion
• Functioning is not markedly impaired and behavior is not
obviously odd or bizarre
• The patient emotional response to the delusions system is
congruent with and appropriate with the content of the delusion
• The personality remain intact or deteriorate minimally

180
• Specific types – based on predominant delusion theme
– Ertromanic: delusion that another person. Usually of higher
status, is in love with the individual
– Grandious type: delusion of inflated worth, power
knowledge, or identity or special relation ship to a deity of the
famous person
– Jelousy type: delusion that the individual sexual partner is
unfaithful
– Pesecutary type: delusion that the person is being
malevolently treated in some way
– Somatic: delusion that the person has some physical defect
or general medical condition

181
Treatment
• Drug therapy = antipsychotic
– chlorpromazine
– haloperidol

Brief psychosis:
• is characterized a symptoms like schizophrenia
duration of the episode of the disturbance at least
one day but less than one month
• Treatment similar with schizophrenia

182
Schizophreniform:
– symptoms identical to those of schizophrenia except that
they resolve within six month and normal functioning
return
– treatment similar with schizophrenia

Scizoaffective:
• A disorder with concurrent feature of both
schizophrenias and mood disorder that can not be
diagnosed as either one separately.
• Treatment anti depressant and antipsychotic

183
 Unit seven
Cognitive disorder

 Cognition is a process of gathering, retaining, relating to

previous experience and retrieving information.
 It is the process of knowledge that involve one’s capacity of
orientation, attention, concentration and memory.
 When we say cognitive disorder we mean disorder of
orientation, attention, concentration, memory, forming abstract
concepts and learning from experiences

184
• The cardinal symptoms of the disease are impairment in

• Consciousness

• Memory

• Judgment

• Orientation

• Occur due to damage to the brain

185
• Cognitive disorder includes:

• Delirium.

• Dementia.

• Amnesia

186
Delirium
• A delirium is characterized by a disturbance of consciousness and a
change in cognition that develop over a short period of time.
• The hallmark symptoms of delirium is an impairment of consciousness,
usually seen in association with global impairment of cognitive
functioning
• Has sudden on set
• A brief and fluctuating course and a rapid improvement
• Loss orientation to time place person the response is reveres
• The most common psychiatric syndrome found in general medical
hospital.
• It is common in elderly hospitalized patients.
• Death in 25% of cases.

187
Causes
• Disease or injury of central nervous system
(meningitis, head injury)
• Systemic illness (liver, kidney)
• Drug abuse
• Drug with drawl
• Substance intoxication and withdrawal

188
• Patients high risk for developing
delirium.

– Elderly patient.

– Post cardiotomy pts.

– Burning patients.

– Patient with AIDS

189
• Sign and symptoms.
• The key features are an impairment of consciousness
and concentration.
• Orientation
• Restlessness, anxiety, irritability, and sleep disruption
before the on set of delirium.
• Visual and auditory hallucinations are common.
• Impaired memory.
• Impaired thinking.
• Impaired judgments.
• Incoherent speech and lack of insight.

190
Treatment:
– Treating the Underlying cause:.
– Pharmacological treatment.
– Agitated delirium – haloperidol

191
• Appreciate the mortality and morbidity of delirium.

• Frequent record of V/S.

• Close observation.

• Monitoring fluid input and out put.

• Ensure good oxygenation.

• Discontinue all non essential medication.

• Environmental intervention: Orient patient to time place and

person

• Psychosocial support.

192
Dementia
• A dementia is characterized by multiple cognitive deficits that
include impairment in memory
• Is a form of global or diffused brain dysfunction that is
characterized by
– gradual
– progressive
– chronic deterioration of intellectual functioning, judgment,
orientation, memory, affect, and attention.
• commonly seen in elderly person’s.

193
Causes
• Common causes

– Alzheimer’s disease approximately = 50%

– Vascular disease approximately 15- 30%. The

most common after age 60.

– combination of the two 15-20%

194
Other causes:

– Neurological disease

– HIV/AIDS

– Metabolic disturbance

– Endocrine disorder

– Pernicious anemia.

195
DSM IV diagnostic criteria.
• The development of multiple cognitive deficits manifestation
by both.
– Memory impairment.
– One or more of the following cognitive disturbances.
• Aphasia=Deterioration of language function
• Apraxia.= impaired ability to execute motor activities
despite intact motor abilities
• Agnosia. = failure to recognize or identify objects
despite intact sensory function
• Disturbance in executive functioning.

196
• Cause social or occupational function impairment.

• Gradual onset and continuing cognitive decline.

• The deficits do not occur during the course of

delirium.
• The disturbance is not better accounted for by

another axis I disorder e.g. schizophrenia,

depression.

197
Clinical features:
• Memory impairment is typically an early and prominent
feature in dementia.
• Impairment in orientation.
• Agitation, insomnia, wandering, suspiciousness, hallucination,
hostility.
• Poor self care
• Soil garments
• Super imposed infection.
• In case of vascular dementia it is characterized by abrupt on
set, stepwise progression, fluctuating course, depression,
history of hypertension, history of strokes and evidence of
atheriosclerosis

198
Treatment
• Underlying cause
• Agitated delirium – haloperidol with low dose 0.5 – 2 mg/d
• A medication must be scheduled properly to produce the
desired effect e.g. 1 hr before bed time to improve sleep.
• Management of risk factors
• Incase of vascular dementia aspirin therapy to inhabit platelet
aggregation.
• Orient patient to time place and person

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Amnestic disorder
• Characterized by an inability to learn new information
despite normal attention, and an inability to recall
extremely remote information with no other cognitive
deficit

200
 Unit SEVEN

Psychopharmacology
• Psychopharmacology is the study of

drug used to treat psychiatric disorder

201
Psychotherapeutic drug in current use are
• Antipsychotic agent
• Antidepressant
• Anti manic
• Anti anxiety agent and hypnotic
• Anti convulsant
• Anti cholinergic (anti parkinsonism drugs)

202
 Antipsychotic agent

• Antipsychotic are drug used for the treatment of

psychosis such as
• Schizophrenia
• Mania
• Delusional
• Organic disorder

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 Classification
I. First generation typical antipsychotic
1. Phenothiazine
• Aliphatic e.g. chlorpromazine dosage 50 –
1500mg/d
• Piperidine e.g. thioridazine dosage range 50 –
800mg/d
• Piperazine e.g. fluphenazine dosage range 2 – 60
mg/d
2. butyrophenone e.g. haloperidol dosage range 2 – 60mg/d

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II. Atypical antipsychotic medications

– Olanzapine 10–30 mg/d Available in oral

tablets and dissolving tablets
– Risperidone 2-8mg/d Available in oral tablets,

dissolving tablets, liquid form

– Clozapine (Clozaril)150–600

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 Mechanism of action of
antipsychotic
• Dopamine pathway in the brain
• nigrostrial = nigra to the basal ganglion
part of extra pyramidal nerve system
related with movement.
• Mesolimbic = mid brain to limbic system

206
Action of antipsychotic
• Excessive dopamine activist is believed to be important

factors in developing schizophrenia.

• Antipsychotic drugs are act primarily by occupying

dopamine receptors in brain tissue there by decreasing the

effect of dopamine neurotransmitters.
• The drugs act in hours to alleviate manifestation of hyper

arousal: anxiety, agitation, insomnia, aggressive behavior,

hallucination and delusion

207
 Cont…
• Conventional neuroleptics differ in their potency and side-effect
profile. Older agents, such as chlorpromazine and thioridazine,
are more sedating and anticholinergic and more likely to cause
orthostatic hypotension,
• while higher potency antipsychotics, such as haloperidol,
perphenazine, and thiothixene, are more likely to induce
extrapyramidal side effects

208
Adverse effect
• General adverse effect
– drowsiness
– lethargic
– dry mouth
– blurred vision
– dermatitis
– photosensitivity
– urine retain ion
– orthostatic hypotension
– diminished sex derive
– weight gain
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2. Extra pyramidal syndrome
– Result from blockage of dopamine receptors in the basal
ganglion
– Occur more commonly with the high potency neuroleptics
• parkinsonism: characterized by rigidity, tremor, motor
retardations, salivation

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• Akathisia:
– restlessness, difficulty of sitting, or stronger urge to
move.
– Generally occur 2 weeks after treatment begins
• Acute dystonic reaction:
– irregular involuntary spastic muscle movement,
wryneck or torticollis facial grimacing, abnormal eye
movement, back ward rolling of eye in the socket
– may occur any time from a minute to several time

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Tardive dyskinesia:
• repetitive, involuntary, purposeless movements.
• grimacing,
• tongue protrusion,
• lip smacking,
• puckering and pursing of the lips, and rapid eye blinking.
• Rapid movements of the arms, legs, and trunk may also occur.
• Impaired movements of the fingers may appear as though the
patient is playing an invisible guitar or piano.
• For comparison, patients with parkinsons disease have
difficulty moving, while patients with tardive dyskinesia have
difficulty not moving.

212
Neuroleptic malignant syndrome.
• Muscular rigidity
• Followed by high fever, symptoms of instability of the
autonomic nervous system such as
• Unstable blood pressure
• Changes in cognition, including agitation, delirium and coma.
• Other symptoms may include muscle tremors and

pharyngitis.

213
 Antidepressants:
• Drugs used for the treatment of
depression

214
Types of Antidepressants
1. Selective serotonin reuptake inhibitors (SSRIs)
• It is thought that one cause of depression is an inadequate
amount of serotonin
• SSRIs are said to work by preventing the reuptake of
serotonin by the presynaptic neuron, thus maintaining higher
levels of 5-HT in the synapse.
• This family of drugs includes fluoxetine (Prozac) 10-80 mg/d,

and sertraline 50-200mg/d, Paroxetine (Paxil)20–60.

• These antidepressants typically have fewer adverse events
and side effects than the tricyclics or the MAOIs,

215
2. Tricyclic antidepressants (TCAs)
• The oldest class of antidepressant drugs and
include such medications as amitriptyline and
imipramine.
• Tricyclics block the reuptake of certain
neurotransmitters such as nor epinephrine and
serotonin.
• They are used less commonly now due to the
development of more selective and safer drugs...

216
7. Monoamine oxidase inhibitor (MAOIs)
• Monoamine oxidase inhibitors such as phenelzine
may be used if other antidepressant medications are
ineffective.
• Because there are potentially fatal interactions
between this class of medication and certain foods
(particularly those containing Tyramine
• Phenelzine (Nardil)45–90, Tranylcypromine (Parnate)20–50

217
• Side effect
– increased heart rate,
– drowsiness,
– dry mouth,
– constipation,
– urinary retention,
– blurred vision,
– dizziness,
– confusion, and
– sexual dysfunction

218
• Indication
• Depression
• anxiety disorders
• bipolar disorder
• obsessive compulsive disorder
• eating disorders and
• Chronic pain

219
Anxiety agents and sedative – hypnotics

• Are used to relieve moderate to severe anxiety and

tension
• Classification

– Benzodiazepine

– Non benzodiazepines

220
1. Benzodiazepines
• hypnotic, sedative, anxiolytic, anticonvulsant, muscle relaxant
and amnesic properties
• Indication in treating
• Anxiety
• Insomnia
• Agitation
• Seizures
• Muscle spasms

221
 Cont…
• Alcohol withdrawal.
• Prior to some unpleasant medical procedures in order to
induce sedation and amnesia for the procedure.
• Another use is to counteract anxiety-related symptoms upon
initial use of SSRIs and other antidepressants, or as an
adjunctive treatment
• The long-term use of benzodiazepines can cause physical
dependence

222
Types of benzodiazepine
– Long acting e.g. diazepam 5mg/d, chlordiazepoxide
10mg/d, clonazepam 0.5mg/d
– Intermidiate acting: e.g. lorazepam
– Short acting e.g. triazolam

Mechanism of action
– modulating the GABA receptors, the most prevalent
inhibitory receptor within the brain

Side effect: nausea, vomiting, hypotension, sleep disturbance,

fever, delirium,

223
2. Non benzodiazepine anti-anxiety agents

• Buspirone 7.5mg/d

• Its mechanism of action is unclear, but it

apparently interacts with serotonin and
dopamine receptors in the brain.

• Compared to others it causes less sedation

224
 Anticonvulsant
used
• in prevention of the occurrence of epileptic seizures.
• the treatment of bipolar disorder
Mechanism of action
• The precise and site of action are unclear. However, it is taught
this drug act in two ways to control seizure activities
• First suppress the rapid and excessive firing of neurons that
start a seizure. Consequently, the seizure threshold is raised
and seizure activities are decreased
• Second, and more common, they prevent the spread of
impulse in to the normal neurons that surround the abnormal
one.
225
Classification
• barbiturates e.g. phenobarbitone
• benzodiazepines
• carbamate
• carboxamide e.g. carbamazepines
• Fatty acid e.g. valvoric acid
• hydantoins e.g. phenotoine
• succinimides e.g. ethusaximide

226
Anti manic
• Lithium is the primary drug of choice in client with

bipolar disorder.
• lithium is effective in controlling mania in about 80 %

of clients.
• When used prophylactically the drug decrease the

frequency and intensity of manic cycles

227
Mechanism of action
• Lithium is thought to maintain a constant sodium concentration
in the brain, regulating impulse along the nerve cell as well as
mood swings
• It believes to level out the activities of neuron transmitters in the
area of brain that controls emotions
• Lithium toxicity occur when serum lithium level exceed 1.5 – 2
MEq/little
• Patient going lithium therapy should be given the drug during or

after meals to decrease gastric irritation

228
• Anticholinergic/anti Parkinsonism
– Are drug to treat extrapyramidal effect
including akathisia, acute dystonia, and
parkinsonism
• E.g.- trihyexyphenidyl (artane) 2mg- 15mg/d
• Diphenhydramine 25 – 200mg/d

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 Unit EIGHT
Personality Disorders
• Personality
– The totality of somebody's attitudes, interests, behavioral
patterns, emotional responses, social roles, and other
individual traits that endure over long periods of time.
– Are enduring patterns of perceiving, relating to, and thinking
about the environment and oneself that are exhibited in a
wide range of social and personal contexts

230
 Personality disorder is
– Is an enduring pattern of inner experience and
behavior that
– Deviates markedly from the expectations of the
individual's culture
– Is pervasive (persistent) and inflexible
– Has an onset in adolescence or early adulthood
– Is stable over time
– Leads to distress or impairment

231
• The Personality Disorders are grouped into three

clusters based on descriptive similarities.

Cluster A includes
• Individuals with these disorders often appear odd or

eccentric
– Paranoid

– Schizoid

– Schizotypal Personality Disorders

232
Paranoid Personality Disorder
• Is a pattern of pervasive distrust and suspiciousness of others
such that their motives are interpreted as malevolent.
• Assume that other people will exploit, harm, or deceive them,
even if no evidence exists to support this expectation.
• They suspect on the basis of little or no evidence
• They are preoccupied with unjustified doubts about the loyalty
or trustworthiness of their friends and associates, whose actions
are minutely scrutinized for evidence of hostile intentions

233
Schizoid Personality Disorder
• A pervasive pattern of detachment from social relationships
• Neither desires nor enjoys close relationships, including being
part of a family
• Almost always chooses solitary activities
• Has little, if any, interest in having sexual experiences with
another person
• Takes pleasure in few, if any, activities
• Lacks close friends or confidants other than first-degree relatives
• Appears indifferent to the praise or criticism of others
• Shows emotional coldness, detachment, or flattened affectivity

234
Schizotypal Personality Disorder
• A pervasive pattern of social and interpersonal deficits marked by acute
discomfort with
• reduced capacity for, close relationships as well as by cognitive or
perceptual distortions
• Ideas of reference (excluding delusions of reference)
• Odd beliefs or magical thinking
• Unusual perceptual experiences, including bodily illusions
• Odd thinking and speech
• Suspiciousness or paranoid ideation
• Inappropriate or constricted affect
• Lack of close friends or confidants other than first-degree relatives

235
Cluster B includes
– Antisocial
– Borderline
– Histrionic
– Narcissistic Personality Disorders.
• Individuals with these disorders often appear
dramatic, emotional, or erratic

236
Antisocial Personality Disorder
• There is a pervasive pattern of disregard for and violation of
the rights of others
• Failure to conform to social norms
• Deceitfulness (distrust)
• impulsivity or failure to plan ahead
• irritability and aggressiveness, as indicated by repeated
physical fights or assaults
• reckless (careless) disregard for safety of self or others
• lack of remorse (sorrow), as indicated by being indifferent to or
rationalizing having hurt, mistreated, or stolen from another
• The individual is at least age 18 years

237
Borderline Personality Disorder
• A pervasive pattern of instability of interpersonal relationships,
self-image, and affects, and marked impulsivity
• Frantic (anxious) efforts to avoid real or imagined abandonment.
• unstable and intense interpersonal relationships
• Identity disturbance:
• Impulsivity in at least two areas that are potentially self-
damaging (e.g., spending, sex, substance abuse, reckless
driving, binge eating).
• Recurrent suicidal behavior
• affective instability

238
Histrionic Personality Disorder
• A pervasive pattern of excessive emotionality and attention
seeking
• Is uncomfortable in situations in which he or she is not the
center of attention
• Displays rapidly shifting and shallow expression of emotions
• Consistently uses physical appearance to draw attention to self

• Has a style of speech that is excessively impressionistic and

lacking in detail

239
Narcissistic Personality Disorder
• A pervasive pattern of grandiosity (in fantasy or behavior),
need for admiration, and lack of empathy
• Is preoccupied with fantasies of unlimited success, power,
brilliance, beauty, or ideal love
• Believes that he or she is "special" and unique and can only
be understood by, or should associate with, other special or
high-status people (or institutions)
• Is interpersonally exploitative, i.e., takes advantage of others
to achieve his or her own ends
• Lacks empathy

240
Cluster C includes the

– Avoidant

– Dependent

– Obsessive-Compulsive Personality Disorders.

• Individuals with these disorders often appear anxious or fearful.

241
Avoidant Personality Disorder
• A pervasive pattern of social inhibition, feelings of inadequacy,
and hypersensitivity to negative evaluation
• Avoids occupational activities that involve significant
interpersonal contact, because of fears of criticism,
disapproval, or rejection
• Is preoccupied with being criticized or rejected in social
situations
• Views self as socially inept (incompetent), personally

unappealing, or inferior to others

242
Dependent Personality Disorder
• A pervasive and excessive need to be taken care of that leads to
submissive and clinging behavior and fears of separation,
• Has difficulty making everyday decisions without an excessive amount
of advice and reassurance from others
• needs others to assume responsibility for most major areas of his or
her life
• has difficulty expressing disagreement with others because of fear of
loss of support or approval.
• has difficulty initiating projects or doing things on his or her own
• goes to excessive lengths to obtain nurturance and support from
others
• feels uncomfortable or helpless when alone
• urgently seeks another relationship as a source of care and support
when a close relationship ends

243
Obsessive-Compulsive Personality Disorder
• A pervasive pattern of preoccupation with orderliness, perfectionism,
and mental and interpersonal control, at the expense of flexibility,
openness, and efficiency,
• Is preoccupied with details, rules, lists, order, organization, or
schedules
• shows perfectionism that interferes with task completion
• is excessively devoted to work and productivity to the exclusion of
leisure activities and friendships
• is unable to discard worn-out or worthless objects even when they have
no sentimental value
• is reluctant to delegate tasks or to work with others unless they submit
to exactly his or her way of doing things
• adopts a miserly spending style toward both self and others; money is
viewed as something to be hoarded for future catastrophes
• shows rigidity and stubbornness

244
Management of personality disorder

• Psychotherapy
• Symptomatic

245
 Unit NINE

• Disorder of infancy, child hood and

adolescent

246
 Autistic disorder
• Is an illness in which the child is relatively unresponsive to other
human beings
• Demonstrate bizarre behavior response to environment
• Unusual language development
• Most begins before 3 years
• Social interaction deficit such as impairment in
– Non verbal communicative behavior
– Peer relation ship
– Taking initiative in social interaction

247
 Con…
• Communication deficit such as
• impairment in language development
• impaired in conversation skills
• use of repetitive or idiosyncratic language

• Behavioral deficit
• impairment in imitative behavior
• pre occupation with one or few area of interest

248
 Attention deficit hyperactivity disorder
• is characterized by
• Short attention span
• Difficulty of concentration
• Impulsivity
• Distractibility
• Excitability
• Hyperactivity (increase motor activity to level that
interfere with the child functioning at school, at home or
socially)

249
Separation anxiety disorder
• Is characterized by inappropriate and excessive
anxiety concerning separations from home or from
those to whom the individual is attached as evidenced
by the following
• Excessive distress and impairment in functioning
• Persistent and excessive worry about losing

• Persistent reluctant of refusal to go to school or else

where because fear of separation

250
 Con…
• Persistent and excessive fear full to be alone
• Refusal to go to sleep with out being near home or major
attachment and repeated night mare involving separation
• Physical symptoms such as head ache, stomachache, nausea,
vomiting
• Duration of disturbance is at least 4 weeks
• The on set is before age 18 years

251
 Enuresis:
• is characterized by the child continue to urinate at inappropirate time
and place after the time when he should have been toilet trained (5
years)
– nocturnal enuresis occur during night time

• etiology can be
– physical disorder : e.g. small bladder, UTI, diabets

– psychological factors ( acute stress, regression, adjustment

reaction,and psychosis)
• treatment
– conditioning by pad and bell

– imipramine 25 – 50 mg at night time

252
 Encopresis:
• is fecal incontinence beyond the period
when bowel control should normally have
developed (after 4 years of age)
• treatment
– unrewarding, but 50% spontaneously recover
in two years, all over recovery before adult life

253
 Eating disorder:
• Anorexia nervosa: is an eating disorder characterized by
– Obsess ional weight loss with out an identifiable organic cause
– Refusal to maintain weight at or above minimal weight for age and
height
– Fear of gaining weight or become obese even when significant
under weight
– Disturbed body image, such that appropriate body weight is
perceived as excessive or low body weight is perceived as
appropriate
– Restricting weight maintained largely by caloric restriction
– Bingeing/ purging ( vomiting, laxative, diuretic and enema)

254
 Electro convulsive therapy
• Is a treatment in which a grand mal seizure is
artificially induced in an anesthesia patient by passing
an electrical current through electrode applied to the
patient head
Indication
– Major depression
– Mania
– Catatonic and Paranoid types of schizophrenia
–

255
 Nursing care
Before procedure
• Emotional support and education
• Informed consent
• Pretreatment nursing care
• Lab test
• Check equipment
• NPO for 8 hrs
• Wear comfortable clothe

• Should void immediately before receiving ECT

256
During procedure
• Assist in stretcher
• Ask to remove shoes and socks
• Cleaning area of the patient head with mild soap
• Muscle relaxant – succinylcholine
• Anesthesia, oxygen administration
• Insertion of padded spatula in oral cavity
• Recording the time at which seizure start and end stopped
commonly in 20 sec

257
Post treatment
• Vital sign monitoring
• When the patient awaken discuss with patient
• Most patient do not remember receiving the treatment and
may be confused and disoriented.
• The nurse should provide
• Frequent reassurance
• Reorientation
• Convey information to staff nurse

258
 Crisis interventions
• Crisis is a serious interruption or disturbance of one’s
• biological
• Physiological
• social integrity
• results in unharmonious in their thought whishes,
feeling and physical needs is in ability to cope result
in attempt to refine the problem.

259
 Crisis intervention –
• Aimed at helping the person resolve the situation
quickly by supportive technique, suggestion,
reassurance environmental modification and
hospitalization if necessary

260
 The intervention includes
• Display acceptance and concern attempt to establish a positive
relationship
• Encourage the person to discuss present feelings such as denial guilt
grief or anger
• Help the person to confront the reality
• Explain that the persons emotion are a normal reaction to crisis
• Avoid giving false reassurance
• Clarify fantasies contrasting them with facts
• Do not encourage the person to place the blame for the crisis on other
• set limits on destructive behavior
• emphasis the persons responsibility for behavior and decision
• assist the persons in seeking hello with every day activities of daily living
until resolution occur

261
• intervene in any plans for suicide or homicide by
• Taking warning signs seriously
• Removing dangerous and potentially lethal materials or objects where
possible
• Place the patient in safe, protective environment and monitoring closely
and consistently
• Encourage the patient to talk about stressors feeling of pain anger and
suicide or homicide plan
• Listening emphatically
• Reinforcing the patient desire to resolve problems to live
• Referring the patient for follow up treatment

262
• raise the patient self esteem by
• Acknowledging his or her strength
• Empathizing with the patient and his or her situation
• Mobilizing the patient to constructive action
• Mobilizing the patients support system by
• Helping him or her contact family or friend who will be
supportive
• Referring him or her to appropriate social or community
service
• Promote express of feeling

263
The End !

264