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Khaled khalilia

Psychiatry
Khaled khalilia
IMLE

2016

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Personality disorders
Narcissistic personality disorder ‫خالد‬

‫ ابراهيم‬Borderline personality disorder

Antisocial personality disorder (Dr
...

 Associate with high-status people
...

Violate the law
Charming on first impression
Lying and manipulate others
Irritable, aggressive
Lack of remorse

 Impulsive, fails to plan ahead

Paranoid personality disorder ‫اميرة‬

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excessively emotional
Attention-seeking behavior
Dramatic
Theatrical and exaggerated expression of
emotion
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2
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Paranoid
Schizotypal
Schizoid

1
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3
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Borderline
Narcissistic
Antisocial
Histrionic

1
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3
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2
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4
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6
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8
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10
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 Symptoms > 2years

15% suicide

 Tx: antidepressant + psychotherapy

Cyclothymic Disorder

Bereavement (Grief) ‫שכול‬

 Presence of hypomanic episode and mild
depression
...

 Usually starts during adolescence or early
adulthood and tends to have a chronic course
...

 decreased mood over a period of 2 years
 poor appetite ↓ / over eating ↑
 sleep problems
 fatigue
 low self esteem
 poor concentration
 Hopelessness
...

 Elevated mood
 Increased self-esteem
 Pressured speech
 ↓ need for sleep

Within 8 weeks
50% first child (primapara)
Associated with Mood disorder (bipolar)
Perinatal complication
Delusion + Hallucination

 Begin shortly after childbirth
 Normal condition  50% after child birth
 No Anhedonia
 Self-limited
 Last few days  disappear spontaneously
Fatigue/Anxiety/Irritability, tearfulness (reduced in 1
week)

Hypomania
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X < 1 week
Don’t affect functioning
Not severe enough to hospitalize
No psychotic features

 colorful clothes that are bizarre

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mania
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X > 1 week
Affect functioning
Severe  hospitalization
Psychosis
Can be triggered by antidepressants
Depression and mania share Anger
elation, agitation, hyperactivity, irritability and
hyper excitability
...

 Anxiety is out of proportion to the event
 X > 6 months
 F > M (2:1)
 50 % recurrence after recovery
 ↑ increased rate of comorbidity with other disease
 Fatigue, ↓concentration, sleep problems, restlessness
 GAD is probably the disorder that most (not least) often coexist with
another mental disorder, usually social phobia, specific phobia, panic
disorder, or a depressive disorder
...

 Specific phobia: fear of an object, such as animals ,heights ,cars
...

 blood-injection-injury phobia:
 Bradycardia and hypertension often follow initial tachycardia
 F=M
 ↑high familial inheritance
 difficult to treat
 Tx: cognitive behavioral therapy (in vivo and virtual exposure therapy)

 Experience of intense anxiety along with feeling of dread and doom
...

associated with mood disorder
Tx: SSRI (sertraline), benzodiazepine (combination of both)

Panic attack: patient is presenting with autonomic hyperactivity  Benzodiazepine
Panic disorder: patient is telling the doctor a story about panic attacks  SSRI

Obsessive Compulsive Disorder (OCD)

Posttraumatic Stress Disorder (PTSD)

Obsession: recurrent and persistent thoughts, urges, or images that are
intrusive and unwanted, and that cause marked anxiety or distress
...
g
...
g
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 Obsession  thoughts
 Compulsion  acts
 Fear of infection (contamination)  wash Hands (most common
example)
 Anxiety increases when patient try to resist
...

 SSRI maintenance dose of OCD > Depression
 Tourette's disorder have a familial and genetic relationship with OCD
...

 Symptoms occur within 3 months of stressor
 Symptoms must remit within 6 months of removal of stressor
 Symptoms: Anxiety, Depression, impairment of functioning
...

 Tx: SSRI

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Schizophrenia
Defenition: thought disorder that impairs judgment, behavior and the ability to interpret reality
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Positive symptoms (added to the state) +

Negative Symptoms -

1
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3
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Delusion
Hallucination
Bizarre behavior
Disorganized speech (thoughts)

1
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3
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5
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Suicide 10%
prevalence worldwide  1%
risk of schizophrenia for a child of a schizophrenic patient  10 %
Monozygotic Twins  40-50% risk
20-30% of patients continue to have moderate intensity of active symptoms all the time

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Affected Blunting (lack of facial expression)
Anhedonia ( lack of ability to enjoy)
Avolition ( lack of motivation, Drive)
Alogia ( lack of speech)
Asocial
Attentional impairment

Resistent schizophrenia  Clozapine
Critical course  first 5 Years ( maybe wrong et2kad)
MRI  enlarged ventricle (lateral + 3rd)
CT  enlarged ventricle + 33% atrophy
Good prognosis  mood symptoms (depression), family history of mood disorder, + socioeconomic status, Suddenly, F
Bad prognosis  Family history, poor social history, disorganized features, insidious
...

Phencyclidine  associated with the full range of symptoms as seen in patients with schizophrenia
...

positive symptoms  Are more responsive to medication than negative symptoms
diagnosed at a very young age  Prominent positive signs
January – April  ↑ Schizophrenia

Brief Psychotic Disorder

Schizofreniform Disorder

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Schizoaffective Disorder

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Delusion disorder
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Dementia

Fixed, false beliefs  being followed or poisoned etc
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Hopelessness  most accurate indicators of long-term suicidal risk
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Genetic basis
Associated disorders:
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Male = ↑die
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Female = ↑ attempt
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Mood disorders ( Depression, Bipolar)
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Aids = ↑ suicide risk
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Anxiety
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Married = ↓ risk
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Schizophrenia (10%) **
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Summer, spring = ↑
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Substance abuse (alcohol,cocaine)
Risk factors:
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Eating disorder
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Prior suicide attempt ***
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Adjustment disorder
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Age > 65**
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Conduct disorder
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Psychiatric Disorder **
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Personality disorder ( borderline *,
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Male
Antisocial)
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Family history
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AIDS  epilepsy spinal cord injury 
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Genetics
brain injury Huntington's chorea  cancer
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AIDS
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 The

occurrence of DT increased
significantly the complication of alcohol
withdrawal

Notes

Hopelessness
A feeling of a loss of control
History of admission to a psychiatric hospital
...

 cause significant distress or impairment in functioning
 Primary gain: somatic symptom represents a symbolic resolution of an unconscious psychological conflict; serves to reduce anxiety and conflict with no external
incentive
...
g
...
( interrupt interposal relationship)
 Patient must be diagnosed X > 6 months to be diagnosed
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 An individual fakes an illness in order to get attention and emotional support in the
patient role
...

 Behavior may be compulsive
...

 Patient’s goal  admission to the hospital
 Tx: focus on management rather than cure
...


Hypochondriasis
 Patients believe that they have some specific disease despite
constant reassurance
...


Pain Disorder
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Most common somatoform disorder
↑ risk  first degree relatives
Peak age  40-50
Most common in Blue collar occupation
F>M

Malingering
 Conscious production of signs and symptoms for an obvious gain such as: avoiding
work, financial gain, avoid school, avoid exam etc
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 Lack of cooperation from patient
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Tourette Disorder
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Onset of multiple tics  Head shaking and blinking
Initial tics  Face + Neck
Initial symptoms  eye Tics (Blinking)
X > 1 year
Before age of 18
Genetic relationship with OCD
Tx: Antipsychotics  Haloperidol, Clonidine (mild)

Body dysmorphic disorder
 Patient believe that some body part is abnormal, defective or misshapen, although
others don’t see these defects
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Inattention, short attention span or hyperactivity that is severe enough to interfere
with daily functioning in school, home, or work
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 Hyperactivity  most likely to remit
 ↑ increase risk in siblings
 Ritalin side effects  insomnia, ↓apetite, ↑anxiety, headache, GI disturb
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Poor eye contact
Problems with language
Problem with relationship
Problem with understanding others
Restrictive Stereotyped/repetitive movements
Inflexibility
Unusual interest in sensory aspects of the environment
Disruptive reaction intensity to sensual stimulus

Tx: Methylphenidate (Ritalin), Dextroamphetamine

Inattention

 Good prognosis  reciprocal conversion
Tx: speech and language therapy + family education + school programming
use antipsychotics/ Risperidone (aggression) and SSRI (Anxiety)
...

Conduct Disorder Diagnosis (TRAP)
 Theft: breaking and entering, deceiving, non-confrontational stealing
 Rule breaking: running away, skipping school, out late
 Aggression: people, animals, weapons, forced sex
 Property destruction, vandalism, fire setting
 Early age onset  poor prognosis
 Familial factors (parent)  antisocial personality, substance abuse,

child abuse, low socio economic state, family violence
...

 ODD kids “ARE BRATS”
- Annoying
- Resentful
- Easily annoyed
- Blames others
- Rule breaker
- Argues with adults
- Temper

- Spiteful/vindictive

 Coexist with ADHD

 Onset < 8 years old

 Diagnosis: age < 18

 May progress to CD

Separation Anxiety Disorder

Disruptive Mood Dysregulation Disorder (DMDD)

Excessive and developmentally inappropriate anxiety on separation from
primary caregiver with physical or emotional distress for at least 4 wk
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 Occur almost every day

 School refusal (75%)

 Noticeable by others

 Worry about something happening to parent or themselves if

 Out of proportion to the situation
...

 Persistent worry, refusal to sleep, clinging, nightmares, somatic
symptoms
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Eating Disorders
Anorexia Nervosa

Bulimia Nervosa

 Failure to maintain a normal body weight, fear of and preoccupation with
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gaining weight, and body image disturbance
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tend to deny their emaciated condition
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lose weight by  maintaining strict caloric control, excessive exercise,
purging and fasting
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- Psychotherapy

 ↓ ESR
 ↓ WBC

(Leukopenia)
 ↓K
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Hypokalemia
↓ BP
↓ CRH
↓ Mg
↓ Muscle mass
↓ height than
expected
↓ HR (
Bradycardia)
↓ Hypoglycemia

 ↑ cholesterol
 ECG changes :
 ST-segment
 T-wave

Athletic Triade:
1
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Amenorrhea
3
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 No control of overeating
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 At least once a week for 3 months
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 Vomiting (purging)  gastric juice  Erosion of teeth + parotid gland swilling
 Normal weight with history of obesity
...
incipidus
Pancytopenia
Seizure
Tremor

 Definition: recurrent episodes of binge-eating (as defined by criteria A of BN)

that are associated with eating much more rapidly than normal, eating until
feeling uncomfortably full, eating large amounts when not physically hungry,
eating alone because embarrassed by how much one is eating, feeling disgusted
with oneself/depressed/very guilty afterwards at least once/wk x 3 mo
 not associated with any compensatory behaviors
 Tx: Cognitive behavioral therapy

Sexuality and Gender
Gender Identity Disorder (Dysphoria)
 persistent discomfort and sense of

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Inappropriateness regarding the
patient’s assigned sex
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 M>F
Treatment
 Begin in childhood  increase with Age
 ƒ anti-androgen drugs
 Fetishism  Recurrent use of nonliving objects to achieve sexual pleasure
 ƒ behavior modification
 Pedophilia  Recurrent urges or arousal toward prepubescent children
 ƒ psychotherapy
 Masochism  Recurrent urge or behavior involving the act of humiliation
 Sadism  Recurrent urge/ behavior involving acts in which physical/ psychological suffering of victim is exciting
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2
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4
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2
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4
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6
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8
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Olanzaoine
Clozapine
Quetiapine
Asenapine
Aripiprazole

Antidepressant
SSRIs
1
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3
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5
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Fluxetine
Paroxetine
Fluvoxamine
Sertraline
Citalopram
Ecitalopram

SNRI

NDRI

1
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Duloxetine

1
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Amitriptyline
2
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Nortriptyline
2
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Phenelzine
2
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Mitrazapine

Anxiolytics
Benzodiazepine
Long acting
3
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5
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Clonazepam
Diazepam (valium)
Flurazepam
chloridiazepoxide

Mood stabilizer
1
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3
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5
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2
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4
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1
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Eszopiclone

alprazolam (Xanax)
lorazepam
oxazepam
temazepam
triazolam

Elecroconvulsive Therapy (ECT)

Biofeedback

Lithium
Valproic acid
Lamotrigine
Divalproex
Carbamazepine

Notes
 Clomipramine  tricyclic  most potent serotonin reuptake
inhibitor
 Burpropion (NDRI)  block dopamine reuptake
 MAOI  don’t eat cheese, wine, aged meat
 TCA  not the best choice for a patient with suicide history
 Suicide patient  SSRI or MAOI
 Fluoxetine  Bruxism
 Paroxetine  ↑↑ withdrawal syndrome
 Fluoxetine  ↓↓ withdrawal syndrome
 Paroxetine  least likely to induce seizure
 Benzodiazepine  GABA – receptor
 Imipramine  dry mouth , dizziness, urinary incontinence
 Opiod withdrawal  clonidine
 Valproic acid  ↑↑ risk for fetus
 Sildenafil/trazodone  + priapism
 D2-receptors  found in limbic system
 Cimetidine  ↑↑ increase level of Benzodiazepine
 Flumazenil  benzodiazepine rec
...

 Typical and atypical antipsychotics  same efficacy
 Acute delirium  haloperidol
 antipsychotic medication  Acute dystonia  difficulty speaking, eating and
drinking, agitation, anxiety, tongue twisting and can’t move mouth
...
incipidus
 Cardiac teratogenicity
 nephrotoxic
 Hypothyroidism
 Psoriasis flares
 Epstein anomaly

 Contraindication: Pregnancy (Teratogenic)
 Aspirin  ↑ valproate
 IV, Oral

Before administration do:
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BUN
Creatinine
Electrolytes
ECG
Pregnancy test
Thyroid test

Side effect:
 Birth defects
 Spina befidia
 Hepatotoxic
 Nausea/vomiting
 Dizziness
 Bleeding
 ↓platelet
 Encephalopathy
 Pancreatitis
 Mydriasis

Indication:
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Bipolar
Mania
Schizoaffective disorder
Recurrent depression

Haloperidol
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Typical antipsychotic
SSRI  increase level of haloperidol
↓ Anticholinergic side effects
Good for patient with orthostatic hypotension

Indication:
 Schizophrenia
 Tourette syndrome
 Delirium
 Psychosis
 Aggression
 Hyperactivity
 Hallucination in alcohol withdrawal

clozapine
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Side effects:
 Tradive dyskinesia
 Neuroleptic
malignant syndrome
 QT-Prolongation
 Parkinsonism
 Dry mouth
 Blurred vision
 Acute dystonic
reaction
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effective for refractory psychosis
best for  resistant schizophrenia
↓ extrapyramidal side effects
Side effects:
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Agranulocytosis 1% (weekly monitoring)
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↑ weight gain
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Neuroleptic malignant syndrome
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Myocarditis
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Seizure
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Tachycardia
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↑ Salivation
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Drooling
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Anticholinergic phenomen

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Contraindication:
 Pregnancy
 Parkinson

Metabolic syndrome

Antidepressant
SSRI (selective serotonin reuptake inhibitor) side effects
Fluoxetine
Paroxetine
Fluvoxamine
Sertraline
Citalopram

SNRI (serotonin + Norepinephrine reuptake inhibitor)

The least to cause serotonin syndrome
Nausea (most common) *, grandly teeth, long half life
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Side effects:
Serotonin syndrome
SIADH
Sexual dysfunction
Impotence
Anorgasmia
↓ weightless
Diarrhea
Tremor
Headache

NDRI (Norepinephrine + Dopamine reuptake inhibitor)
 Seizure
 ↓ Appetite
 ↑ Libido

 ↑ BP

Escitalopram

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TCA

(3 Amine)

Amitriptyline
Imipramine
...
(Tyramin) 
may cause orthostatic
hypotension
...

 medication combinations such as:
 SSRI+MAOI
 SSRI+tryptophan
 MAOI+tryptophan
 Fluoxetine  least likely to cause Serotonin syndrome
...

Fever  must be
mental status changes (usually occur first), fever, autonomic reactivity, rigidity
Adverse reaction to neuroleptic or antipsychotic drugs
...

develops over 24-72 h
No GIT Symptoms *
Muscle cramp
Tremor
Muscle Rigidity *
Altered mental status
Fever
Myoglobinuria
Delirium
Agitation
Rhabdomyolysis
Diaphoresis
Metabolic acidosis
Seizure
↑ WBC
↑ CPK
↑↓ BP
↑ increased creatine phosphokinase
Treatment:
 discontinue drug, hydration, cooling blankets, dantrolene (hydrantoin derivative,
used as a muscle relaxant), bromocriptine (DA agonist)

Electroconvulsive Therapy (ECT)

Biofeedback Tx

 Induction of a grand mal seizure using an electrical pulse through the

brain while the patient is under general anesthesia with a muscle relaxant
...

 Control of: Brainwaves, HR, Muscle Tone, Pain, skin…
 Indication:
 ADHD
 Migraine
 Urinary incontinence
 EEG
 Pain
 Stress
 Raynaud syndrome
 Panic
 Depression
 Epilepsy
 Vaginismus
 ↑ BP

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 side effects:

risk of anesthesia
memory loss (may be retrograde and/or anterograde)
Headaches
Myalgia
 Contraindication:
 Increased intracranial pressure
 Space occupying lesion in brain
 Aneurysm
 Bleeding disorder
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Thought of content
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Obsession
Delusion
Ideas of reference
Phobia
Suicidal thought
Derealization
depersonalization

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Thought of content
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word salad
flight of ideas
circumstantiality
Tangintiality
Clang association
Preservation
Goal directed ideas

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General Psychiatry 2
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Drug induced psychosis  classic vival hallucination
Mood disorder associated with  panic disorder
I don’t know, I don’t remember  Depression
Cause of Priapism  Sildenafil, Trazodone
Seizure  Alcohol, Bupropion, clozapine, clozapam
Most common somatoform disorder  Pain disorder
Fire setter  have ↓ low IQ than average, Enuresis
(Bedwetting)
 Count backwards by 7 starting at 100  test concentration
 Delusion  seen in 90% of all terminal patients
 Antipsychotics (Perphenazine )  + Tradive Dyskinesia 
involuntary choria movements of face, trunk,

 Trichotillomania: pulling of hair
 Pyromania: sitting of fire
 Onionmania: compulsive buying
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 Selective mutism: consistent refusal to speak in specific social situation but speak freely at
home, at least 1 month
...

 Fregoli Delusion: Delusion of double
 Childhood disintegrative disorder: normal development first 2 years of life  then lose skills,
verbal, bowel control
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 Cataplexy: sudden attack of generalized muscle weakness
 Narcolepsy: sudden attacks of sleepiness
 Twilight state: disturbed conscious + hallucination
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 Cotard Syndrome: nihilistic delusional context (lost intestine, Heart) patient believe he lost
everything
...

 Clerambault syndrome: patient believes that a person is erotically attached to him
...

 Restless leg syndrome: worse at night and relieved by walking and moving
...
Loxapine Hcl
4
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Ziprasidone
4
...
Quetiapine
8
...
Aripiprazole

1
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5
...


2
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Antidepressant
SSRIs

SNRI

1
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Paroxetine
3
...
Sertraline
5
...
Ecitalopram

NDRI

1
...
Duloxetine

TCA (3 Amine)

3
...
Amitriptyline
2
...
Nortriptyline
2
...
Phenelzine
2
...


1
...
Diazepam (valium)
3
...
chloridiazepoxide

Mood stabilizer

alprazolam (Xanax)
lorazepam
3
...
temazepam
5
...


2
...


Elecroconvulsive Therapy (ECT)

Lithium
Valproic acid
3
...
Divalproex
5
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2
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Mitrazapine

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