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PSYCHIATRY COMPREHENSIVE REVISION NOTES

SCHIZOPHRENIA
Definition

Schizophrenia is a severe brain disorder in which people interpret reality abnormally
...
Contrary to popular belief, schizophrenia isn't a split
personality or multiple personality
...

Schizophrenia is a chronic condition, requiring lifelong treatment
...
In women,
symptoms typically begin in the late teens
...

Schizophrenia involves a range of problems with thinking (cognitive), behavior or emotions
...

Symptoms may include:
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Delusions
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For example, you're being
harmed or harassed; certain gestures or comments are directed at you; you have exceptional
ability or fame; another person is in love with you; a major catastrophe is about to occur; or
your body is not functioning properly
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Hallucinations
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Yet for the
person with schizophrenia, they have the full force and impact of a normal experience
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Disorganized thinking (speech)
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Effective communication can be impaired, and answers to questions may be partially or
completely unrelated
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Extremely disorganized or abnormal motor behavior
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Behavior is not focused on a goal,
which makes it hard to perform tasks
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Negative symptoms
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For
example, the person appears to lack emotion, such as not making eye contact, not changing
facial expressions, speaking without inflection or monotone, or not adding hand or head
movements that normally provide the emotional emphasis in speech
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Symptoms in teenagers
Schizophrenia symptoms in teenagers are similar to those in adults, but the condition may be
more difficult to recognize in this age group
...

Problems with certain naturally occurring brain chemicals, including
neurotransmitters called dopamine and glutamate, also may contribute to
schizophrenia
...
While researchers aren't certain

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about the significance of these changes, they support evidence that schizophrenia is a
brain disease
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Complications that
schizophrenia may cause or be associated with include:

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Suicide
Any type of self-injury
Anxiety and phobias
Depression
Abuse of alcohol, drugs or prescription medications
Poverty
Homelessness
Family conflicts
Inability to work or attend school
Social isolation
Health problems, including those associated with antipsychotic medications, smoking and poor
lifestyle choices
Being a victim of aggressive behavior
Aggressive behavior, although it's uncommon and typically related to lack of treatment,
substance misuse or a history of violence
When doctors suspect someone has schizophrenia, they typically ask for medical and psychiatric
histories, conduct a physical exam, and run medical and psychological tests, including:

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Tests and screenings
...
The doctor may also request imaging studies, such as an MRI or CT scan
...
A doctor or mental health provider will check mental status by
observing appearance and demeanor and asking about thoughts, moods, delusions,
hallucinations, substance abuse, and potential for violence or suicide
...
This manual, published by the American
Psychiatric Association, is used by mental health providers to diagnose mental conditions
...
In addition, a
person must have at least two of the following symptoms most of the time during a one-month
period, with some level of disturbance being present over six months:


Delusions
 Hallucinations
 Disorganized speech (indicating disorganized thinking)
 Extremely disorganized behavior
 Catatonic behavior, which can ranges from a coma-like daze to bizarre, hyperactive behavior
 Negative symptoms, which relate to reduced ability or lack of ability to function normally
At least one of the symptoms must be delusions, hallucinations or disorganized speech
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The American Psychiatric Association eliminated the previous subtypes of schizophrenia —
paranoid, disorganized, catatonic, undifferentiated and residual — because of poor reliability
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Treatments and drugs

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Schizophrenia requires lifelong treatment, even when symptoms have subsided
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During crisis periods or
times of severe symptoms, hospitalization may be necessary to ensure safety, proper nutrition,
adequate sleep and basic hygiene
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The treatment
team also may include a psychologist, social worker, psychiatric nurse and possibly a case
manager to coordinate care
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Medications
Medications are the cornerstone of schizophrenia treatment
...

Antipsychotic medications are the most commonly prescribed drugs to treat schizophrenia
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Willingness to cooperate with treatment may affect medication choice
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Someone who is agitated may need to be calmed initially with a benzodiazepine such as
lorazepam (Ativan), which may be combined with an antipsychotic
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They include:
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Aripiprazole (Abilify)
Clozapine (Clozaril)
Lurasidone (Latuda)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)

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Conventional, or typical, antipsychotics
These first-generation medications have frequent and potentially significant neurological side
effects, including the possibility of developing a movement disorder (tardive dyskinesia) that
may or may not be reversible
...

It can take several weeks after first starting a medication to notice an improvement in symptoms
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The psychiatrist may try different medications,
different dosages or combinations over time to achieve the desired result
...

Psychosocial interventions
Once psychosis recedes, psychological and social (psychosocial) interventions are important —
in addition to continuing on medication
...
Learning to cope with stress and identify early warning signs of relapse
can help people with schizophrenia manage their illness
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This focuses on improving communication and social interactions
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This provides support and education to families dealing with schizophrenia
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This focuses on helping people with
schizophrenia prepare for, find and keep jobs
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Many
communities have programs to help people with schizophrenia with jobs, housing, self-help
groups and crisis situations
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With appropriate treatment, most people with schizophrenia can manage their
condition
...
Here are some ways to cope:

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Learn about schizophrenia
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Education can help friends and family understand the
condition and be more compassionate with the person who has it
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Support groups for people with schizophrenia can help them reach out to
others facing similar challenges
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Stay focused on goals
...
Keeping treatment
goals in mind can help the person with schizophrenia stay motivated
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Learn relaxation and stress management
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Prevention




There's no sure way to prevent schizophrenia
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Sticking with the treatment plan can help prevent relapses or worsening of
schizophrenia symptoms
...


SEXUAL DYSFUNCTION
Sexual dysfunction refers to a problem during any phase of the sexual response cycle that
prevents the individual or couple from experiencing satisfaction from the sexual activity
...

In our set up studies are hard to come by that will show the prevalence of this condition as this
topic is one that many people are hesitant to discuss, but it thought to be prevalent more so
among the women than men (43% of women and 31% of men report some degree of difficulty),
Aetiology
Sexual dysfunction can be a result of a physical or psychological condition
...
These conditions include diabetes, heart and vascular disease,
neurological disorders, hormonal imbalances, chronic diseases such as kidney, liver
failure, alcoholism and substance abuse e
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Miraa
...


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Psychological causes: These include work-related stress and anxiety more so,
performance anxiety, marital or relationship problems, depression, feelings of guilt, and
the effects of a past sexual trauma
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Dysfunction can occur in adults of all
ages
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Men
The most common sexual problems in men are ejaculation disorders, erectile dysfunction, and
inhibited sexual desire
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There are different types of ejaculation disorders, including:
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Premature ejaculation -- This refers to ejaculation that occurs before or very soon after
penetration
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 Retrograde ejaculation -- This occurs when, at orgasm, the ejaculate is forced back into
the bladder rather than through the urethra and out the end of the urethra
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In some cases, premature and inhibited
ejaculation is caused by a lack of attraction for a partner, past traumatic events, and
psychological factors, including a strict religious background that causes the person to view sex
as sinful
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Retrograde ejaculation is common in males with diabetes who suffer from diabetic neuropathy
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In other men, retrograde ejaculation occurs after
operations on the bladder neck or prostate, or after certain abdominal operations
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This generally does not require treatment unless it impairs fertility
...

Causes of erectile dysfunction include diseases affecting blood flow, such as atherosclerosis;
nerve disorders; psychological factors, such as stress, depression, and performance anxiety; and
injury to the penis
...
) can also cause erectile dysfunction
...

Reduced libido can result from physical or psychological factors
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It also may be caused by psychological problems, such as
anxiety and depression; medical illnesses, such as diabetes and high blood pressure; certain
medications, including some antidepressants; and relationship difficulties
...
Tests may be ordered to rule out any medical problems that may be contributing to
the dysfunction
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Tests done to Evaluate Sexual Problems
Several tests can be used to evaluate the causes and extent of male sexual problems
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 Vascular assessment -- This involves an evaluation of the blood flow to the penis
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 Sensory testing -- Particularly useful in evaluating the effects of diabetic neuropathy,
sensory testing measures the strength of nerve impulses in a particular area of the body
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This test can help determine if a man's erectile problems
are due to physical or psychological causes
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Treatment strategies may include the following:
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Medical treatment -- This involves treatment of any physical problem that may be
contributing to a man's sexual dysfunction
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Promescent is a drug used topically to treat premature ejaculation
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Hormones -- Men with low levels of testosterone may benefit from hormone
supplementation (testosterone replacement therapy)
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Mechanical aids -- Aids such as vacuum devices and penile implants may help men with
erectile dysfunction
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Please bring the
partner on board so as to address all needs and concerns; it also helps to overcome many
barriers to a healthy sex life
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The outlook is
good for dysfunction that is related to a treatable or reversible physical condition
...

Prevention
While sexual problems cannot be prevented, dealing with the underlying causes of the
dysfunction can help a patient better understand and cope with the problem when it occurs
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Limit alcohol intake
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Deal with any emotional or psychological issues such as stress, depression, and anxiety
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Increase communication with your partner
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ICD-10 records over 80 sleep disorders, but essentially, there
are three types of problem:
1 Too little sleep (insomnias)
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3 Unusual sleep behaviours (parasomnias), e
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sleep-walking, sleep-talking
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4 Physical exam and investigations, including sleep diary, electroencephalography (EEG)
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• Weekend ‘catch-up’ sleep, although common, indicates sleep curtailment
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• Shift work
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• Psychiatric or neurological illness
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6 h)
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3 Awakening
• At night: Are you having difficulty sleeping through the night? What awakens you? How long
111are you awake for? What keeps you from falling7 back asleep?’
• Early-morning wakening: ‘Are you having any difficulty sleeping until the morning? What is
your mood like in the morning?’
4 Regularity and duration
• ‘Do you usually go to sleep at the same time? What time do you typically fall asleep? And what
time do you wake? What’s the earliest you go to sleep? And the latest?’
• ‘Do you work odd hours or shifts?’
• ‘Do you give yourself restrictions on how much you let yourself sleep?’
5 Snoring: Have you or anyone else noticed you snore loudly/stop breathing in your sleep?

Other important questions:
• Quantify and discuss their caffeine and alcohol intake
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• Prescribed and over-the-counter medications
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• Medical conditions
...


Further assessment
The physical exam should include BMI, blood pressure, neck circumference, examination of the
oral cavity, pupils (for stimulant use), assessment of thyroid status and a neurological exam (if
suspicious of restless leg syndrome or periodic limb movement disorder)
...
Onethird of adults complain of it but it is highly subjective and although a typical adult sleeps 7–9
hours per night this varies widely from night to night as well as varying greatly between different
people
...
Most of the rest are secondary to medical disease
(e
...
it is common in Parkinson’s disease), chronic pain and substance misuse
...

To distinguish these cases, exclude the presence of an underlying eating, sleep and sexual
disorders psychiatric or medical disorder (e
...
restless legs syndrome, lymphoma)
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A sleep
diary and corroboration from the sleeping partner are helpful
...


Treatment of insomnia
Treat any associated disorder (e
...
use a sedative antidepressant if insomnia is due to
depression)
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An effective method to restore a good sleep routine
...

• Sleep hygiene –this approach pays attention to health practices (e
...
use of caffeine and
alcohol) and stimuli (e
...
noise, light) that affect sleep
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The
patient should wind down 90 minutes before bedtime and practice relaxation when in bed
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Effective in the short term and
widely used, but may cause daytime drowsiness, and long-term use should be avoided because of
dependence
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At present it is
licensed only for short-term treatment of insomnia in those over the age of 55
...


Excessive daytime sleepiness
Excessive daytime sleepiness can be caused by:
1 insufficient sleep;
2 fragmented sleep;
3 primary disorder of excessive daytime sleepiness – the hypersomnias

The diagnosis of hypersomnia can only be made if the excessive daytime sleepiness is not due to
other sleep disorders
...
It usually begins in the second decade and is associated with
cataplexy (abrupt loss of muscle tone), hypnagogic hallucinations (on falling asleep) and sleep
paralysis (the patient wakes but is unable to move)
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Pathologically, there is a loss of hypothalamic hypocretinproducing neurons
...


Parasomnias

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Parasomnias are abnormal episodic events during sleep – sleepwalking, nightmares, etc
...

• Distinguish parasomnias from other causes of odd nocturnal behaviour, such as epilepsy
...

The pain and other symptoms patients with this disorder feel are real, and are not created or
faked on purpose (malingering)
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The
disorder is more common in patients with irritable bowel syndrome and chronic pain
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The pain was dismissed as
being "all in their head
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Pain and worry create a cycle that is hard to break
...

However, not everyone with a somatization disorder has a history of abuse
...

Symptoms
Patients with this disorder have many physical complaints that last for years
...

The symptoms often interfere with work and relationships, and lead to many visits to different
health care providers
...

Some of the many symptoms that can occur with somatization disorder include:
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Abdominal pain

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Amnesia
Back pain
Bloating
Chest pain
Diarrhea
Difficulty swallowing
Dizziness
Headaches
Impotence
Joint pain
Nausea and sometimes vomiting
Pain during intercourse
Pain during urination
Painful menstruation
Pain in the legs or arms
Palpitations
Paralysis or muscle weakness
Sexual activity
Shortness of breath
Vision changes

Exams and Tests
A thorough physical examination and diagnostic tests are performed to identify physical causes
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A psychological evaluation is performed to identify related disorders
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Treatment
The goal of treatment is to help the patient learn to control his/her symptoms
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One should have only one primary care provider, to avoid having too many tests and
procedures
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The health care provider should explain any test results
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Cognitive behavioral therapy (CBT)
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Never advise a patient that his/her symptoms are imaginary
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Possible Complications
A patient can become dependent on pain relievers or sedatives
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This may help reduce the intensity of the symptoms
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The movements consist of
uncontrollable grimacing movements of face, tongue or upper body
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TD occurs in about 5% of patients taking long-term antipsychotics every year
...
At the inception of antipsychotic treatment, it is difficult to predict which
patients are likely to develop the syndrome
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However, the syndrome can develop, although much
less commonly, after relatively brief treatment periods at low doses
...
Antipsychotic
treatment, itself, however, may suppress (or partially suppress) the signs and symptoms of the
syndrome and thereby may possibly mask the underlying disease process
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Chronic antipsychotic treatment should generally be reserved
for patients who suffer from a chronic illness that,

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1) is known to respond to antipsychotic drugs, and
2) for whom alternative, equally effective, drugs are not available or appropriate
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The need for continued
treatment should be reassessed periodically
...
However, some patients may require treatment despite the
presence of the syndrome
...
Sometimes called suicide gestures, most
mental health professionals see these acts as a means for a disturbed person to express a need for
help
...

Women between the ages of 15 and 25 are most likely to make a parasuicide act
...
It is most common among
married teen women, divorced women, and single women
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Following young
women, the second most likely group to make a suicide gesture are unmarried men in their 30s
...

Other mental health issues, such as depression or alcoholism, are usually present in someone
who makes a suicide gesture
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Difficult life circumstances are also often a factor
...

When someone makes a suicide gesture, she doesn’t necessarily want to take her own life;
however, a parasuicide attempt is the most common factor in the history of those who eventually
do kill themselves
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Suicidal ideation is thinking about and talking about suicide
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If suicidal ideation doesn’t result
in the person receiving the help he seeks, the next step may be parasuicide or actual suicide
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These people can call one of these hotlines, such as 1-800-SUICIDE
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Do not leave the
person alone and remove anything from the home, such as medications and firearms that the
person could use to inflict self-harm
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Seek help
from outside professionals
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Psychiatric assessment of such patients is mandatory once their medical condition allows
...
This represents a mortality by suicide 50–100 times that of the general population
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Studies examining completed suicides in patients with
mental illness show inadequate doses of therapeutic drug treatment, increased dropout
rate from follow-up and increased presence of untreated comorbidity
...
However, the absolute
risk is low and estimate of the risk in a particular case relies on assessment of the
individual act and the mental state
...
Early psychiatric
assessment may be required for advice regarding detainability, behavioural disturbance,
drug/alcohol withdrawal, or delirium, but assessment of the parasuicide itself should be deferred
until conscious level is full
...
It may be easier to assess these in
reverse order, moving from the factual history towards the emotive descriptions of the
parasuicidal act itself after building rapport
...
Use of method likely to be fatal (e
...
jumping, hanging) is indicative of
clear intent to die
...
Did the patient believe that that
combination of tablets was likely to be fatal? Serious suicidal intent is associated with
medically trivial overdoses—and vice versa
...
Was the act impulsive—‘on the spur of the moment’, or planned in
advance—and for how long?
 Triggers Was there a clear precipitant (e
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row with partner)? Were they intoxicated at
the time? Was there any direct ‘gain’ (e
...
patient in custody at the time of act)?
 Final acts: Was there a suicide note? Did they make any other ‘acts of closure’ (e
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setting affairs in order, arranging for the care of children)?

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Precautions to avoid discovery
...
What did they do after the act? How did they end up coming to
hospital?
Mental state
 Attitude now to survival Are they relieved or disappointed to be alive? Do they have
ongoing wish to die? How do they feel about the future and what plans (if any) do they
have?
 Affective symptoms Current affective symptoms
...
Biological depressive features
...

 Other mental disorder Enquire directly about other symptoms of mental disorder as
directed by the history
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Is there any evidence of intent to harm anyone else? Did the parasuicidal
act put anyone else at risk?
Personal and past medical/psychiatric history
 Recent life events Describe recent events involving loss or change (e
...
bereavements,
job loss, relationship break-up)
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Type and security of job
and accommodation
...

 Previous or current psychiatric diagnoses Clarify with hospital records if further details
required or if significant history
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Again clarify with records or e
...
ED if required
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 Elderly
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 Living alone, poor social support
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Personal/mental health factors
 Previous parasuicide
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 Dependence on alcohol or drugs
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 Concurrent physical disorder
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Liaison psychiatry
Management after parasuicide
Reasons for act Only a minority of patients presenting after parasuicide have evidence of clear
intent to die
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 Those who were ambivalent whether they lived or died, ‘letting the chips fall as they
may’
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 Those whose actions were designed to communicate distress—the
 Classical ‘cry for help’
...

 Those attempting to escape from intolerable symptoms or an intolerable situation
...

There may initially be diagnostic confusion with the following groups:
 deliberate overdoses of drugs taken for intoxicating effect;
 deliberate self-harm (e
...
wrist cutting) which is a repetitive, ritualistic action whose
intent is to relieve tension, not to kill or seriously injure;
 Accidental overdoses of prescribed or OTC medication
...

 Is there evidence of mental illness? Diagnosed in the normal way
...
Be alert to comorbid substance
misuse and to the combination of an acute stressor on the background of a chronic
condition
...
They can be usefully directed to appropriate local
services
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In many cases this will be managed by admission to a
psychiatric ward, on a compulsory basis if necessary
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New diagnoses Here the focus should be on integrating with an appropriate service for
follow-up, rather than necessarily starting new treatments
...
g
...
Short-term community outreach from liaison psychiatry can
‘bridge’ the patient to the general services
...

 Admission required For both new and established mental illnesses, admission will
sometimes be indicated after parasuicide even where there is no ongoing suicidal intent
...
g
...
It should not simply be in order to defer or
devolve the decision about discharge—ask yourself what will have changed to mean
discharge in a few days will be safer than now
...
g
...
Clarify the appropriateness of the
referral and referral method and feed these back to the patient
...

Frequent attenders A small minority of patients attend emergency services repeatedly with
parasuicidal acts or deliberate self-harm without suicidal intent
...
The aim should be to avoid ‘rewarding’
maladaptive behaviours (e
...
by repeated admissions providing ‘time-out’ from stressful
situations), while providing appropriate support and treatment
...
Symptoms may include flashbacks,
nightmares and severe anxiety, as well as uncontrollable/ impulsive thoughts about the event
...
But if the
symptoms get worse or last for months or even years and interfere with ones functioning, one
should consider PTSD
...

Symptoms

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Post-traumatic stress disorder symptoms may start within three months of a traumatic event, but
sometimes symptoms may not appear until years after the event
...

PTSD symptoms are generally grouped into four types: intrusive memories, avoidance,
negative changes in thinking and mood, or changes in emotional reactions
...
Patients may have more PTSD symptoms when
they are stressed in general, or when they run into reminders of what they went through
...
Or one may see a report on
the news about a sexual assault and feel overcome by memories of their own assault
...

PTSD is probably caused by a complex mix of:
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Inherited mental health risks, such as an increased risk of anxiety and depression
Life experiences, including the amount and severity of trauma patients go through since
early childhood
Inherited aspects of one's personality — often called 'temperament'
The way one's brain regulates the chemicals and hormones one's body releases in
response to stress

Predisposing factors
Individuals of all ages can have post-traumatic stress disorder
...

Complications
Post-traumatic stress disorder can disrupt a patient's whole life: job, relationships, health and
enjoyment of everyday activities
...
A physical exam to check for medical problems is mandatory
...
This manual is
used by mental health providers to diagnose mental conditions
...
Patient's exposure can happen in one or more of these ways:
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Experiencing the traumatic event
Witnessing, in person, the traumatic event
Learning that someone close experienced or was threatened by the traumatic event
Repeatedly exposed to graphic details of traumatic events (for example, if a patient is a
first responder to the scene of traumatic events)

Experiencing one or more of the following signs or symptoms after the traumatic event:
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Reliving experiences of the traumatic event, such as having distressing images and
memories
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Experiencing flashbacks as if one were experiencing the traumatic event again
...


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In addition, for more than one month after the traumatic event the patient may:
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Try to avoid situations or things that remind one of the traumatic event
Not remember important parts of the traumatic event
View self, others and the world in a negative way
Lose interest in activities patient used to enjoy and feel detached from family and friends
Feel a sense of emotional numbness, feel irritable or have angry or violent outbursts
Engage in dangerous or self-destructive behavior
Feel as if one is constantly on guard or alert for signs of danger and startle easily
Have trouble sleeping or concentrating

For children younger than 6 years old, signs and symptoms may include:
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Reenacting the traumatic event or aspects of the traumatic event through play
Frightening dreams that may or may not include aspects of the traumatic event

Treatments and drugs
Post-traumatic stress disorder treatment can help a patient regain a sense of control over their
life
...
Combining these
treatments can help improve symptoms, teach coping skills to address symptoms, help one feel
better about self and learn ways to cope if any symptoms arise again
...

Psychotherapy
Several types of psychotherapy, also called talk therapy, may be used to treat children and adults
with PTSD
...
This type of talk therapy helps patients recognize the ways of
thinking (cognitive patterns) that are keeping them stuck — for example, negative or
inaccurate ways of perceiving normal situations
...

Exposure therapy
...
One approach to exposure
therapy uses "virtual reality" programs that allow one to re-enter the setting in which you
experienced trauma
...

Medications
Several types of medications can help improve symptoms of PTSD:

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Antidepressants
...
They
can also help improve sleep problems and concentration
...

Anti-anxiety medications
...
Because
these medications have the potential for abuse, they are not usually taken long term
...
If symptoms include insomnia or recurrent nightmares, a drug called prazosin
(Minipress) may help
...


Prevention
After surviving a traumatic event, many people have PTSD-like symptoms at first, such
as being unable to stop thinking about what's happened
...
However, the majority of individuals
exposed to trauma do not develop long-term post-traumatic stress disorder
...
This may mean turning to family and friends
who will listen and offer comfort
...
Some patients may also find it helpful to turn to their faith
community
...
Support from others may also help prevent one from turning
to unhealthy coping methods, such as misuse of alcohol or drugs

PSYCHOTHERAPY
Definition
Psychotherapy is a general term for treating mental health problems by talking with a
psychiatrist, psychologist or other mental health provider
...
Psychotherapy helps patients to learn how to take control of their lives and
respond to challenging situations with healthy coping skills
...
The type of
psychotherapy that's right for a patient depends on individual patient’s situation
...

Indications:
Psychotherapy can be helpful in treating most mental health problems, including:

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Anxiety disorders, such as obsessive-compulsive disorder (OCD), phobias, panic disorder or
post-traumatic stress disorder (PTSD)
Mood disorders, such as depression or bipolar disorder
Addictions, such as alcoholism, drug dependence or compulsive gambling
Eating disorders, such as anorexia or bulimia
Personality disorders, such as borderline personality disorder or dependent personality
disorder
Schizophrenia or other disorders that cause detachment from reality (psychotic disorders)

Not everyone who benefits from psychotherapy is diagnosed with a mental illness
...
For
example, it may help patients:


Resolve conflicts with their partner or someone else in their life
 Relieve anxiety or stress due to work or other situations
 Cope with major life changes, such as divorce, the death of a loved one or the loss of a job
 Learn to manage unhealthy reactions, such as road rage or passive-aggressive behavior
 Come to terms with an ongoing or serious physical health problem, such as diabetes, cancer or
ongoing (chronic) pain
 Recover from physical or sexual abuse or witnessing violence
 Cope with sexual problems, whether they're due to a physical or psychological cause
 Sleep better, if one has trouble getting to sleep or staying asleep (insomnia)
In some cases, psychotherapy can be as effective as medications, such as antidepressants
...
Patients may also need medications or other
treatments
...
Some work better than others in treating
certain disorders and conditions
...
A
therapist will consider a specific particular situation and preferences to determine which
approach may be best
...

During psychotherapy
For most types of psychotherapy, do encourage the patient to talk about his/her thoughts and
feelings and what's troubling them
...
Clinicians can help patients gain more confidence and comfort as time goes on
...
Some patients may feel physically
exhausted after a session
...

Ask the patient to do "homework" — activities or practices that build on what the patient learn
during the regular therapy sessions
...

Confidentiality
Except in very specific circumstances, conversations with the therapist are confidential
...
These situations include:



Threatening to immediately or soon (imminently) harm themselves or commit suicide
Threatening to immediately or soon (imminently) harm or take the life of another person

30



Abusing a child or a vulnerable adult (someone older than age 18 who is hospitalized or made
vulnerable by a disability)
Being unable to safely care for themselves
Length of psychotherapy
The number of psychotherapy sessions one needs — and how frequently one needs to see one’s
therapist — depends on such factors as:



Ones particular mental illness or situation
 Severity of symptoms
 How long one has had symptoms or have been dealing with ones situation
 How quickly one make progress
 How much stress a patient is experiencing
 How much patients mental health concerns interfere with day-to-day life
 How much support one receives from family members and others
 Cost limitations
It may take only weeks to help one cope with a short-term situation
...

Results
Psychotherapy may not cure patient’s condition or make an unpleasant situation go away
...

Getting the most out of psychotherapy
Take steps to get the most out of one’s therapy and help make it a success
...
If not, look for another therapist with
whom one feels more at ease
...
Therapy is most effective when patients are active
participant and share in decision making
...
Together, one can set goals and measure progress over
time
...
Success with psychotherapy depends on willingness to share thoughts,
feelings and experiences
...
If one is reluctant to talk about certain things because of painful
emotions, embarrassment or fears about the therapist's reaction, let the therapist know
...
If one feel down or lack motivation, it may be tempting to skip
psychotherapy sessions
...
Try to attend all sessions and to give
some thought to what one wants to discuss
...
Working on emotional issues can be painful and may require hard
work
...
One may need several sessions before one begin to see
improvement
...
If the therapist asks a patient to document their thoughts in a
journal or do other activities outside of the therapy sessions, follow through
...

If psychotherapy isn't helping, talk to the therapist
...
A patient and the therapist
may decide to make some changes or try a different approach that may be more effective
...
But because it can explore painful feelings
and experiences, a patient may feel emotionally uncomfortable at times
...
The coping skills one learns can help one manage and conquer
negative feelings and fears
...

Schizoaffective disorder is not as well understood or well defined as other mental health conditions
...

Untreated, patients with schizoaffective disorder may lead lonely lives and have trouble holding down a
job or attending school
...
Treatment can help manage symptoms and improve the quality of life for patients
with schizoaffective disorder
...
Patients who have the condition
experience psychotic symptoms — such as hallucinations or delusions — as well as a mood disorder
...

Psychotic features and mood disturbances may occur at the same time or may appear on and off
interchangeably
...

Signs and symptoms of schizoaffective disorder may include, among others:








Delusions — having false, fixed beliefs
Hallucinations, such as hearing voices
Major depressed mood episodes
Possible periods of manic mood or a sudden increase in energy and behavioral displays that are out of
character
Impaired occupational and social functioning
Problems with cleanliness and physical appearance
Paranoid thoughts and ideas
...
A combination of factors may contribute to
its development, such as:



Genetic links
Brain chemistry
Brain development delays or variations



Exposure in the womb to toxins or viral illness, or even birth complications



Risk factors
Factors that increase the risk of developing schizoaffective disorder include having a close biological
(blood) relative who has:




Schizophrenia
Bipolar disorder
Schizoaffective disorder

Complications
Patients with schizoaffective disorder are at an increased risk of:

33


Social isolation



Unemployment
Anxiety disorders





Developing alcohol or other substance abuse problems
Significant health problems



Suicide

Tests and diagnosis

When psychiatrist suspects someone has schizoaffective disorder, they typically ask for medical
and psychiatric histories, conduct a physical exam, and run medical and psychological tests, such
as:




Blood tests, drug screening and imaging studies
...
The doctor may also request imaging studies, such as an MRI or
CT scan
...
A doctor or mental health provider will check mental status by observing
appearance and demeanor and asking about thoughts, moods, delusions, hallucinations, substance
abuse, and potential for violence or suicide
...
This manual, published by the American Psychiatric
Association, is used by mental health providers to diagnose mental conditions
...
Treatment varies depending on the type and severity of symptoms, and whether the disorder
is depressive-type or bipolar-type
...
However, a number of medications approved for the treatment of other mental health
conditions also may be helpful for schizoaffective disorder
...
Medications to treat psychotic symptoms, such as delusions, paranoia and
hallucinations
...




Mood-stabilizing medications
...
Patients with



bipolar disorder have episodes of mania and depressed mood
...

Antidepressants
...
Common medications include
fluoxetine (Prozac)
...




Psychotherapy and counseling
...
Effective
sessions focus on real-life plans, problems and relationships
...

Family or group therapy
...
Supportive group settings can also help decrease
social isolation and provide a reality check during periods of psychosis
...
Patients with schizoaffective disorder
may benefit from:


Family support groups



Peer and social connections and support
Social skills training for work and school
Assistance with maintaining a healthy lifestyle, including self-care, regular physical activity and
healthy eating




35

MACNAGHTEN TEST
Insanity Defense
Defendants with mental impairments who are found competent to stand trial may seek acquittal
on the claim of insanity, alleging that they were not criminally responsible for their actions at the
time the offense was committed
...

The MNaghten test of insanity was used in the vast majority of states until the 1960s
...
In a celebrated murder trial, Daniel MNaghten was found to be insane and, thus,
not guilty
...
MNaghten experienced the delusion that Peel and the Pope were conspiring against
him
...
The judicial response to a
parliamentary inquiry into the case produced the official MNaghten test
...
Some offenders are so mentally disturbed that they are found to be incapable of acting
rationally
...

A person is not responsible for criminal conduct if, at the time of such conduct, as a result of
mental disease or defect, he or she lacks substantial capacity to appreciate the criminality
(wrongfulness) of his or her conduct or to conform his or her conduct to the requirements of law
...

Classification
According to the DSM-IV-TR, Mental retardation is defined as significantly sub average
general intellectual functioning resulting in, impairment in adaptive behavior and
manifested during the developmental period, before the age of 18
...
The adaptive functions of mildly retarded persons
are effective in several areas, such as communications, self-care, social skills, work, leisure, and
safety
...

Degrees of Severity of Mental Retardation
The degrees, or levels, of mental retardation are expressed in various terms
...

Mild mental retardation (IQ range, 50 to 70) represents approximately 85 percent of persons
with mental retardation
...
By late adolescence, they often
acquire academic skills at approximately a sixth grade level
...
Many adults with mild mental retardation can
live independently with appropriate support and raise their own families
...
Most children with moderate mental retardation acquire language and can
communicate adequately during early childhood
...
During adolescence,
socialization difficulties often set these persons apart, and a great deal of social and vocational
support is beneficial
...

Severe mental retardation (IQ range, 20–35) comprises about 4 percent of individuals with
mental retardation
...
In this group, the
cause for the mental retardation is more likely to be identified than it is in milder forms of mental
retardation
...

Profound mental retardation (IQ range below 20) constitutes approximately 1 to 2 percent of
persons with mental retardation
...
Children with profound mental retardation may be taught
some self-care skills and learn to communicate their needs given the appropriate training
...
This type may be applicable
to infants whose significantly sub average intellectual functioning is clinically judged but for
whom the available tests (e
...
Bayley Scales of Infant Development and Cattell Infant Scale) do
not yield numerical IQ values
...


37

Etiology
Etiological factors in mental retardation can be primarily genetic, developmental, acquired, or a
combination
...
g
...
The severity of the resulting mental
retardation is related to the timing and duration of the trauma as well as to the degree of exposure
to the central nervous system (CNS)
...
In about 75% of persons with severe mental retardation, the cause is
known, whereas the cause is apparent in only 50% of those with mild mental retardation
Down syndrome
The description of Down syndrome, first made by the English physician Langdon Down in 1866,
was based on the physical characteristics associated with subnormal mental functioning
...
Children with this syndrome were originally called mongoloid because of their
physical characteristics of slanted eyes, epicanthal folds, and flat nose
...

The problem of cause is complicated even further by the recent recognition of three types of
chromosomal aberrations in Down syndrome:





Patients with trisomy 21 (three chromosomes 21, instead of the usual two) represent the
overwhelming majority; they have 47 chromosomes, with an extra chromosome 21
...
A nondisjunction during meiosis, occurring for unknown
reasons, is held responsible for the disorder
...

In translocation, a fusion occurs of two chromosomes, usually 21 and 15, resulting in a
total of 46 chromosomes, despite the presence of an extra chromosome 21
...
The asymptomatic carriers have only 45 chromosomes
...
disorders may share some pathophysiology

Fragile X Syndrome
Fragile X syndrome is the second most common single cause of mental retardation
...
3)
...
Much variability is present in both genetic and phenotypic expression
...
The typical phenotype includes a large, long head and ears, short stature,
hyperextensible joints, and post pubertal macroorchidism
...
The behavioral profile of persons with the syndrome includes a high rate of

38

ADHD, learning disorders, and pervasive developmental disorders, such as autism
...
Persons with fragile X syndrome seem to have relatively strong skills in
communication and socialization; their intellectual functions seem to decline in the pubertal
period
...

Cat's Cry (Cri-du-Chat) Syndrome
Children with cat's cry syndrome lack part of chromosome 5
...
The characteristic cat-like cry
caused by laryngeal abnormalities that gave the syndrome its name gradually changes and
disappears with increasing age
...
The basic metabolic defect in PKU is an inability to convert phenylalanine, an essential
amino acid, to paratyrosine because of the absence or inactivity of the liver enzyme
phenylalanine hydroxylase, which catalyzes the conversion
...
Eczema, vomiting, and
convulsions occur in about a third of all patients
...
They frequently have temper tantrums and
often display bizarre movements of their bodies and upper extremities, including twisting hand
mannerisms; their behavior sometimes resembles that of children with autism or schizophrenia
...
The children's
coordination is poor, and they have many perceptual difficulties
...
The disorder occurs in about 1 of 5,000 births and is characterized by cafau lait
spots on the skin and by neurofibromas, including optic gliomas and acoustic neuromas, caused
by abnormal cell migration
...


Tuberous Sclerosis
Tuberous sclerosis is the second most common of the neurocutaneous syndromes; a progressive
mental retardation occurs in up to two thirds of all affected persons
...
Seizures are present in all
those who are mentally retarded and in two thirds of those who are not
...
The phenotypic presentation includes adenoma sebaceum and
ash-leaf spots that can be identified with a slit lamp
...
The
infant deteriorates rapidly and has decerebrate rigidity, seizures, respiratory irregularity, and
hypoglycemia
...
Some variants have been reported with transient ataxia and only mild
retardation
...

Acquired and Developmental Factors
Prenatal Period
Important prerequisites for the overall development of the fetus include the mother's physical,
psychological, and nutritional health during pregnancy
...
Maternal
infections during pregnancy, especially viral infections, have been known to cause fetal damage
and mental retardation
...
Although numerous
infectious diseases have been reported to affect the fetus's CNS, the following medical disorders
have been definitely identified as high-risk conditions for mental retardation
...
The children of affected mothers may show several
abnormalities, including congenital heart disease, mental retardation, cataracts, deafness,
microcephaly, and microphthalmia
...
When mothers are infected in the first trimester of pregnancy, 10 to 15 percent of the
children are affected, but the incidence rises to almost 50 percent when the infection occurs in
the first month of pregnancy
...
Maternal rubella can be prevented by immunization
...
Some children are
stillborn, and others have jaundice, microcephaly, hepatosplenomegaly, and radiographic
findings of intracerebral calcification
...
The diagnosis is
confirmed by positive findings of the virus in throat and urine cultures and the recovery of
inclusion-bearing cells in the urine
...
Today, the incidence of syphilitic complications of
pregnancy fluctuates with the incidence of syphilis in the general population
...


40

Toxoplasmosis
Toxoplasmosis can be transmitted by the mother to the fetus
...

Herpes Simplex
The herpes simplex virus can be transmitted transplacentally, although the most common mode
of infection is during birth
...

Acquired Immune Deficiency Syndrome (AIDS)
Many fetuses of mothers with AIDS never come to term because of stillbirth or spontaneous
abortion
...

Children born with HIV infection often live only a few years; however, most babies born to
HIV-infected mothers are not infected with the virus
...
Often, the affected children have learning disorders
and ADHD
...
The entire syndrome occurs in up to 15 percent of
babies born to women who regularly ingest large amounts of alcohol
...

Prenatal Drug Exposure
Prenatal exposure to opioids, such as heroin, often results in infants who are small for their
gestational age, with a head circumference below the tenth percentile and withdrawal symptoms
that appear within the first 2 days of life
...

Seizures are unusual, but the withdrawal syndrome can be life threatening to infants if it is
untreated
...
The long-term sequelae of prenatal
opioid exposure are not fully known; the children's developmental milestones and intellectual
functions may be within the normal range, but they have an increased risk for impulsivity and
behavioral problems
...
In the early neonatal period, they may have transient neurological and
behavioral abnormalities, including abnormal results on EEGs, tachycardia, poor feeding
patterns, irritability, and excessive drowsiness
...


Complications of Pregnancy
Toxemia of pregnancy and uncontrolled maternal diabetes present hazards to the fetus and
sometimes result in mental retardation
...
Vaginal hemorrhage, placenta previa, premature
separation of the placenta, and prolapse of the cord can damage the fetal brain by causing anoxia
...
So far, with the exception of metabolites used
in cancer chemotherapy, no usual dosages of medications are known to damage the fetus's CNS,
but caution and restraint in prescribing drugs to pregnant women are certainly indicated
...
g
...

Perinatal Period
Some evidence indicates that premature infants and infants with low birth weight are at high risk
for neurological and intellectual impairments that appear during their school years
...
The degree of neurodevelopmental impairment generally correlates
with the severity of the intracranial hemorrhage
...
Very premature children and those who suffered intrauterine growth retardation were
found to be at high risk for developing both social problems and academic difficulties
...

Early intervention may improve their cognitive, language, and perceptual abilities
...
In retrospect, it is sometimes difficult to ascertain the full picture of the
child's developmental progress before the insult, but the adverse effects on the child's
development or skills are apparent afterward
...
Measles
encephalitis has been virtually eliminated by the universal use of measles vaccine, and the
incidence of other bacterial infections of the CNS has been markedly reduced with antibacterial
agents
...
Sometimes a clinician must
retrospectively consider a probable encephalitic component in a previous obscure illness with
high fever
...
Thrombotic and purulent intracranial
phenomena secondary to septicemia are rarely seen today except in small infants
...
Child abuse is also a
cause of head injury
...
In some ways it reflects a "snapshot" of a person's
psychological functioning at a given point in time
...
Most of us intuitively perform many parts of a MSE every
time we interact with or observe others
...
Judgements about mental state should always consider the developmental
level of the person and age-appropriateness of the noted behaviour(s)
...

A typical MSE includes consideration of the following domains:

Appearance
A person's appearance can provide useful clues into their quality of self-care, lifestyle and
daily living skills
...
g
...

These can reveal much about a person's emotional state and attitude
...
g
...
g
...
Affect refers to
immediate expressions of emotion, while mood refers to emotional experience over a
more prolonged period of time
...
g
...
g
...

Unusual speech is sometimes associated with mood and anxiety problems, schizophrenia,
and organic pathology
...
g
...
g
...
g
...

o
o
o
o
o
o

o
o
o

level of consciousness (e
...
alert, drowsy, intoxicated, stuporose)
orientation to reality (often expressed in regard to time/place/person - e
...

awareness of the time/day/date, where they are, ability to provide personal details)
memory functioning (including immediate or short-term memory, and memory
for recent and remote information or events)
literacy and arithmetic skills
visuospatial processing (e
...
copying a diagram, drawing a bicycle)
attention and concentration (e
...
observations about level of distractibility, or
performance on a mentally effortful task - e
...
counting backwards by 7's from
100)
general knowledge
language (e
...
naming objects, following instructions)
ability to deal with abstract concepts (e
...
describing conceptual similarity
between two things or ability to interpret a proverb or 'see beyond')
...
g
...

Content:












delusions (rigidly held false beliefs not consistent with the person's background)
overvalued ideas (unreasonable belief, e
...
a person with anorexia believing they
are overweight)
Ideas of reference preoccupations Paranoid ideation
Depressive cognition (guilt, worthlessness, hopelessness)
Self-harm, suicidal, aggressive or homicidal ideation

Obsessions (preoccupying and repetitive thoughts about a feared or catastrophic outcome,
often indicated by associated compulsive behaviour)
Phobias (strong, persistent, fear of object or situation)
Ruminations
anxiety (generalised, i
...
heightened anxiety with no specific referent; or specific, e
...

phobias) Magical ideation
Process:

Thought process refers to the formation and coherence of thoughts and is inferred very much
through the person's speech and expression of ideas
...
It is also
important in trauma or substance abuse
...


Dissociative symptoms:



derealisation (feeling that the world or one's surroundings are not real)
depersonalisation (feeling detached from oneself)

Illusions:



the person perceives things as different to usual, but accepts that they are not real,
or that (misinterpretation of actual external stimuli)
things are perceived differently by others

Hallucinations:


Hallucinations (auditory, visual, olfactory [smelling], gustatory [taste], tactile)







probably the most widely known form of perceptual disturbance
hallucinations are indistinguishable by the sufferer from reality
can affect all sensory modalities, although auditory hallucinations are the most
common
in children it is common to experience self-talk or commentary as an internal
"voice"command hallucinations (voices telling the person to do something)
should be investigated
important to note the degree of fear and/or distress associated with the
hallucinations

Insight & Judgement
Insight and judgement is particularly important in triaging psychiatric presentations and
making decisions about safety
...
g
...
Clinical
manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status and evidence
of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and
cardiac dysrhythmias)
...
In arriving at a
diagnosis, it is important to identify cases:
Differential diagnosis


Where the clinical presentation includes both serious medical illness (e
...
, pneumonia,
systemic infection, etc
...

 Other important considerations in the differential diagnosis include central
anticholinergic toxicity
 heat stroke
 drug fever and
 Primary central nervous system (CNS) pathology
...
There is no general agreement about specific pharmacological treatment
regimens for uncomplicated NMS
...
The patient should be carefully
monitored, since recurrences of NMS have been reported
...

To understand the basic elements of a crime are (1) the mental state or level of intent to commit
the act (known as the mens rea or 'guilty mind'), (2) the act itself or conduct associated with
committing the crime (known as actus reus or 'guilty act'), and (3) a concurrence in time between
the guilty act and the guilty mental state
...
g
...

The scale is presented and described in the DSM-IV-TR on page 34
...

Development, history and exclusion from DSM-5
The DSM-IV records the development of the GAF scale
...
in the paper "Clinician's Judgements of Mental Health"
...

This was further modified and published as the Global Assessment of Functioning Scale in the
DSM-III-R and DSM-IV
...
in 1992 in the paper 'Revising Axis V for DSM-IV: A
review of measures of social functioning' by Goldman et al
...
The SOFAS
scale is similar to the GAF but only looks at social and occupational functioning rather than
symptoms, and the SOFAS is usually used to rate the current period
...
However for a measure of global disability the
WHO Disability Assessment Schedule (WHODAS 2
...

GAF Scale
91 - 100 No symptoms
...


49

81 - 90 Absent or minimal symptoms (e
...
, mild anxiety before an exam), good
functioning in all areas, interested and involved in a wide range of activities, socially
effective, generally satisfied with life, no more than everyday problems or concerns
...
g
...
g
...

61 - 70 Some mild symptoms (e
...
, depressed mood and mild insomnia) or some
difficulty in social, occupational, or school functioning (e
...
, occasional truancy, or theft
within the household), but generally functioning pretty well, has some meaningful
interpersonal relationships
...
g
...
g
...

41 - 50 Serious symptoms (e
...
, suicidal ideation, severe obsessional rituals, frequent
shoplifting) or any serious impairment in social, occupational, or school functioning (e
...
,
no friends, unable to keep a job, cannot work)
...
g
...
g
...

21 - 30 Behavior is considerably influenced by delusions or hallucinations or serious
impairment, in communication or judgment (e
...
, sometimes incoherent, acts grossly
inappropriately, suicidal preoccupation) or inability to function in almost all areas (e
...
,
stays in bed all day, no job, home, or friends)
11 - 20 Some danger of hurting self or others (e
...
, suicide attempts without clear
expectation of death; frequently violent; manic excitement) or occasionally fails to
maintain minimal personal hygiene (e
...
, smears feces) or gross impairment in
communication (e
...
, largely incoherent or mute)
...
g
...

0 Inadequate information

50

DEPRESSION (MAJOR DEPRESSIVE DISORDER) MDD
Definition
Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest
...
Patients may have trouble doing
normal day-to-day activities, and depression may make one feel as if life isn't worth living
...
During these episodes, symptoms occur most of the day, nearly every day and may include:








Feelings of sadness, emptiness or unhappiness
Angry outbursts, irritability or frustration, even over small matters
Loss of interest or pleasure in normal activities, such as sex
Sleep disturbances, including insomnia or sleeping too much
Tiredness and lack of energy, so that even small tasks take extra effort
Changes in appetite — often reduced appetite and weight loss, but increased cravings for food and
weight gain in some patients
Anxiety, agitation or restlessness — for example, excessive worrying, pacing, hand-wringing or an

inability to sit still
 Slowed thinking, speaking or body movements
 Feelings of worthlessness or guilt, fixating on past failures or blaming yourself for things that are not
your responsibility
 Trouble thinking, concentrating, making decisions and remembering things
 Frequent thoughts of death, suicidal thoughts, suicide attempts or suicide
 Unexplained physical problems, such as back pain or headaches
For some patients, depression symptoms are so severe that it's obvious something isn't right
...

Types of depression
Depression affects each individuals in different ways, so symptoms caused by depression vary from
patient to patient
...
Specifiers include having depression with specific features, such
as:


Anxious distress — unusual restlessness or worry about possible events or loss of control

51


Mixed features — simultaneous depression and mania, which includes elevated self-esteem, talking



too much, and racing thoughts and ideas
Melancholic features — severe depression with a profound lack of response to something that used to
bring pleasure, associated with early morning awakening, worsened mood in the morning, significant
changes in appetite, and feelings of guilt, agitation or sluggishness



Atypical features — ability to be cheered by happy events, increased appetite, little need for sleep,
sensitivity to rejection, and a heavy feeling in arms or legs



Psychotic features — depression accompanied by delusions or hallucinations, which may involve
themes of personal inadequacy or negative themes



Catatonia — includes motor activity that involves either uncontrollable and purposeless movement or
fixed and inflexible posture



Peripartum onset — occurs during pregnancy or in the weeks or months after delivery (postpartum)
Seasonal pattern — related to changes in seasons and diminished exposure to sunlight



Depression symptoms in children and teens
Common symptoms of depression in children and teens are similar to those of adults, but there can be
some differences
...

In teens, symptoms may include sadness, irritability, feeling negative and worthless, anger, poor
performance or poor attendance at school, feeling misunderstood and extremely sensitive, using drugs
or alcohol, eating or sleeping too much, self-harm, loss of interest in normal activities, and avoidance
of social interaction
...

Depression symptoms in older adults
Depression is not a normal part of growing older and it should never be taken lightly
...

Symptoms of depression may be different or less obvious in older adults, including:






Memory difficulties or personality changes
Fatigue, loss of appetite, sleep problems, aches or loss of interest in sex, which are not caused by a
medical condition or medication
Often wanting to stay at home, rather than going out to socialize or doing new things
Suicidal thinking or feelings, especially in older men

52

Causes
It's not known exactly what causes depression
...
Patients with depression appear to have physical changes in their brains
...

Brain chemistry
...
When these chemicals are out of balance, it may be associated with depressive symptoms
...
Changes in the body's balance of hormones may be involved in causing or triggering




depression
...

Inherited traits
...
Researchers are trying to find genes that may be involved in causing depression
...
Traumatic events such as the death or loss of a loved one, financial problems, high stress,
or childhood trauma can trigger depression in some people
...
More women are diagnosed
with depression than men, but this may be due in part because women are more likely to seek treatment
...
Untreated depression
can result in emotional, behavioral and health problems that affect every area of ones life
...
The doctor may do a physical exam and ask in-depth questions about ones health
...

Lab tests
...

Psychological evaluation
...

Diagnostic criteria for depression
To be diagnosed with major depression, one must meet the symptom criteria in the Diagnostic and
Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association
...

For major depression, a patient must have five or more of the following symptoms over a two-week
period, most of the day, nearly every day
...
Other symptoms may include:



Depressed mood, such as feeling sad, empty or tearful (in children and teens, depressed mood can
appear as constant irritability)

54


Significantly diminished interest or feeling no pleasure in all — or almost all — activities



Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children,
failure to gain weight as expected)



Insomnia or increased desire to sleep
Either restlessness or slowed behavior that can be observed by others







Fatigue or loss of energy
Feelings of worthlessness, or excessive or inappropriate guilt
Trouble making decisions, or trouble thinking or concentrating
Recurrent thoughts of death or suicide, or a suicide attempt
A patients symptoms must be severe enough to cause noticeable problems in day-to-day activities, such as
work, school, social activities or relationships with others
...

Other conditions that cause depression symptoms
There are several other conditions with symptoms that can include depression
...
The doctor or mental health provider's evaluation
will help determine if one symptoms of depression are caused by a specific type of depression or another
condition, such as:











Adjustment disorder
...
It's a type of stress-related mental illness that may affect ones feelings, thoughts and
behavior
...
This mood disorder is characterized by mood swings that range from highs to lows
...

Cyclothymic disorder
...

Persistent depressive disorder
...
While it's usually not disabling, persistent depressive disorder can prevent a patient from
functioning normally in his/her daily routine and from living life to its fullest
...
This involves depression symptoms associated with hormone changes
that begin a week before and improve within a few days after the onset of ones period, and are minimal
or gone after completion of the period
...
Children with ADHD can demonstrate irritability
without sadness or loss of interest
...

Treatments and drugs
Numerous depression treatments are available
...


55

A psychiatrist can prescribe medications to relieve depression symptoms
...

If one has severe depression, one may need a hospital stay, or one may need to participate in an outpatient
treatment program until symptoms improve
...

Medications
Many types of antidepressant medications are available to treat depression, including those below
...
Doctors often start by prescribing an SSRI
...
SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram
(Celexa) and escitalopram (Lexapro)
...
Examples of SNRI medications include
duloxetine (Cymbalta), venlafaxine (Effexor XR) and desvenlafaxine (Pristiq)
...
Bupropion (Wellbutrin) falls into this
category
...

Atypical antidepressants
...
They include trazodone and mirtazapine (Remeron)
...
A newer medication called vilazodone (Viibryd) is thought to have a low risk of sexual
side effects
...
Tricyclic antidepressants — such as imipramine (Tofranil) and nortriptyline
(Pamelor) — tend to cause more severe side effects than do newer antidepressants
...

Monoamine oxidase inhibitors (MAOIs)
...
Using MAOIs requires a strict diet because of dangerous (or even deadly)
interactions with foods ― such as certain cheeses, pickles and wines ― and some medications
including birth control pills, decongestants and certain herbal supplements
...

These medications can't be combined with SSRIs
...
Other medications may be added to an antidepressant to enhance antidepressant
effects
...
Anti-anxiety and stimulant medications might also be added for short-term
use
...
Or one may need to try several medications before one find one that works
...

Stopping taking an antidepressant unilaterally is not recommended
...
Stopping
treatment abruptly or missing several doses can cause withdrawal-like symptoms, and quitting suddenly
may cause a sudden worsening of depression
...
In some cases, where available, results
of genetic tests (done by blood test or cheek swab) may offer clues about how a patients body may
respond to a particular antidepressant
...
However, other variables besides genetics can affect ones response to medication
...

Antidepressants and increased suicide risk
Most antidepressants are generally safe
...

Anyone taking an antidepressant should be watched closely for worsening depression or unusual
behavior
...

Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving
mood
...
Psychotherapy is also known as talk therapy, counseling or psychosocial
therapy
...
These therapies can help a patient:






Adjust to a crisis or other current difficulty
Identify negative beliefs and behaviors and replace them with healthy, positive ones
Explore relationships and experiences, and develop positive interactions with others
Find better ways to cope and solve problems
Identify issues that contribute to depression and change behaviors that make it worse



Regain a sense of satisfaction and control in ones life and help ease depression symptoms, such as
hopelessness and anger



Learn to set realistic goals for a patients life
Develop the ability to tolerate and accept distress using healthier behaviors



Hospitalization and residential treatment programs
In some patients, depression is so severe that a hospital stay is needed
...
Psychiatric treatment at a hospital can help one keep calm and safe until mood improves
...
These programs provide
the outpatient support and counseling one need while getting symptoms under control
...
In ECT, electrical currents are passed through the brain
...
Physical side effects, such as
headache, are tolerable
...
ECT is
usually used for patients who don't get better with medications, can't take antidepressants for health
reasons or are at high risk of suicide
...
TMS may be an option for those who haven't responded to
antidepressants
...
The coil sends brief magnetic pulses to stimulate nerve cells in the brain that are involved in
mood regulation and depression
...


Coping and support

58



Simplify life
...




Don't become isolated
...




Take care of self
...




Learn ways to relax and manage your stress
...
Plan your day
...




Don't make important decisions when you're down
...


Prevention
There's no sure way to prevent depression
...






Take steps to control stress
Reach out to family and friends, especially in times of crisis, to help one weather rough spells
...

Consider getting long-term maintenance treatment to help prevent a relapse of symptoms
...
Disinhibition is classical to the
diagnostic criteria for mania
...
Disinhibition is a common symptom following brain
injury, or lesions, particularly to the frontal lobe and primarily to the orbitofrontal
cortex
...
In association
with the typical cognitive deficits, these sequelae characterize the frequently noted
"personality changes" in TBI (Traumatic Brain Injury) patients
...
Disinhibited behaviours
have also been reported with mania-like manifestations in old age with lesions to the
orbito-frontal and basotemporal cortex involving limbic and frontal connections
(orbitofrontal circuit), especially in the right hemisphere
...
g
...


EPILEPSY
Epilepsy is a central nervous system disorder (neurological disorder) in which nerve cell activity
in the brain becomes disrupted, causing seizures or periods of unusual behavior, sensations and
sometimes loss of consciousness
...
Some patients with epilepsy simply stare blankly for a few
seconds during a seizure, while others repeatedly twitch their arms or legs
...
At least two unprovoked seizures are generally required
for an epilepsy diagnosis
...
Seizure signs and symptoms may include:






Temporary confusion
A staring spell
Uncontrollable jerking movements of the arms and legs
Loss of consciousness or awareness
Psychic symptoms

Symptoms vary depending on the type of seizure
...

Seizures are generally classified as either focal or generalized, based on how the abnormal brain
activity begins
...
These seizures fall into two categories
...
These seizures
don't cause a loss of consciousness
...
They may also result in involuntary jerking of a body
part, such as an arm or leg, and spontaneous sensory symptoms such as tingling,
dizziness and flashing lights
...
During these seizures there is a
change or loss of consciousness or awareness
...


Symptoms of focal seizures may be confused with other neurological disorders, such as
migraine, narcolepsy or mental illness
...

Generalized seizures
Seizures that appear to involve all areas of the brain are called generalized seizures
...









Absence seizures
...
These seizures may occur in clusters and cause a brief loss
of awareness
...
Tonic seizures cause stiffening of your muscles
...

Atonic seizures
...

Clonic seizures
...
These seizures usually affect the neck, face and arms
...
Myoclonic seizures usually appear as sudden brief jerks or twitches
of the arms and legs
...
Tonic-clonic seizures, previously known as grand mal seizures,
are the most dramatic type of epileptic seizure and can cause an abrupt loss of
consciousness, body stiffening and shaking, and sometimes loss of bladder control or
biting the tongue
...
Several
tests may be ordered to diagnose epilepsy and determine the cause of seizures
...
The doctor may test behavior, motor abilities, mental
function and other areas to diagnose this condition and determine the type of epilepsy the
patient may have
...
The doctor may take a blood sample to check for signs of infections, genetic
conditions or other conditions that may be associated with seizures
...
This is the most common test used to diagnose
epilepsy
...


61













The electrodes record the electrical activity of the brain
...

Computerized tomography (CT) scan
...
CT scans can reveal abnormalities in the brain that might be causing
seizures, such as tumors, bleeding and cysts
...
An MRI uses powerful magnets and radio waves
to create a detailed view of the brain
...

Functional MRI (fMRI)
...
Doctors may use an fMRI before
surgery to identify the exact locations of critical functions, such as speech and movement,
so that surgeons can avoid injuring those places while operating
...
PET scans use a small amount of low-dose
radioactive material that's injected into a vein to help visualize active areas of the brain
and detect abnormalities
...
This type of test is used
primarily if the patient had an MRI and EEG that didn't pinpoint the location in the brain
where the seizures are originating
...

Neuropsychological tests
...
The test results help doctors determine which areas of the brain are
affected
...
Treatment with medications can control seizures for about 80 percent of
people with epilepsy
...

Doctors generally begin by treating epilepsy with medication
...

Medication
Most patients with epilepsy can become seizure-free by taking one anti-seizure medication,
called anti-epileptic medication
...
Other
patients may have to take a combination of medications be able to decrease the frequency and
intensity of their seizures
...
Many adults also can discontinue
medications after two or more years without seizures
...
Factors that clinicians may consider
are condition, frequency of seizures, patient’s age and other factors when choosing which

62

medication to prescribe
...

The doctor likely will first prescribe a single medication at a relatively low dosage and may
increase the dosage gradually until seizures are well-controlled
...
Mild side effects include:









Fatigue
Dizziness
Weight gain
Loss of bone density
Skin rashes
Loss of coordination
Speech problems
Memory and thinking problems

More severe but rare side effects include:





Depression
Suicidal thoughts and behaviors
Severe rash
Inflammation of certain organs, such as the liver

At least half of all patients newly diagnosed with epilepsy will become seizure-free with their
first medication
...
Some children with epilepsy have been able to reduce their seizures by
following a strict diet that's high in fats and low in carbohydrates
...
After a few years, some children may be able to stop the ketogenic diet and
remain seizure-free
...
These side effects are uncommon if the diet is properly
and medically supervised
...
Its bad press reflects understandable fears, misinformation and

63
its past misuse
...

• Mode of action
...
ECT has many effects in the brain
...

• Clinical indications
...
The response is often better than drug therapy and may be
dramatic
...

• Practical usage
...

Always do a physical examination, and obtain an ECG and routine blood tests first in addition to testing
cognitive function
...

Treatment can be bilateral, with one electrode on each temple, or unilateral into the non-dominant
hemisphere
...

ECT is usually given on alternate days for 6–12 treatments (doses)
...

• Side effects
...

Memory loss occurs for the hours surrounding the seizure
...
Nonetheless, it should be discussed when obtaining consent
...

• Cautions and contraindications
...
Avoid if the patient has a suspected intracranial lesion (as
intracranial pressure rises during seizure)
...

ECT is extremely safe, with a mortality rate of 5 per 100 000 treatments
...
ADHD includes a combination of problems, such as
difficulty sustaining attention, hyperactivity and impulsive behavior
...
Symptoms sometimes lessen with age
...
But they can learn strategies to be successful
...
But ADHD is now the preferred term because it describes both of the primary
features of this condition: inattention and hyperactive-impulsive behavior
...


Signs and symptoms of ADHD may include:


Difficulty paying attention



Frequently daydreaming



Difficulty following through on instructions and apparently not listening



Frequently has problems organizing tasks or activities



Frequently forgetful and loses needed items, such as books, pencils or toys



Frequently fails to finish schoolwork, chores or other tasks



Easily distracted



Frequently fidgets or squirms



Difficulty remaining seated and seemly in constant motion



Excessively talkative



Frequently interrupts or intrudes on others' conversations or games



Frequently has trouble waiting for his or her turn
ADHD occurs more often in males than in females, and behaviors can be different in boys and
girls
...

Normal behavior vs
...
It's normal
for preschoolers to have short attention spans and be unable to stick with one activity for long
...


65

The same is true of hyperactivity
...
In addition, some children just naturally have a higher
activity level than others do
...

Children who have problems in school but get along well at home or with friends are likely
struggling with something other than ADHD
...

Aetiology
While the exact cause of ADHD is not clear, research efforts continue
...
It can run in families, and
studies indicate that genes may play a role
...

Risk factors
Risk factors for ADHD may include:


Blood relatives (such as a parent or sibling) with ADHD or another mental health disorder



Exposure to environmental toxins — such as lead, found mainly in paint and pipes in older
buildings



Maternal drug use, alcohol use or smoking during pregnancy



Maternal exposure to environmental poisons — such as polychlorinated biphenyls (PCBs) —
during pregnancy



Premature birth
Although sugar is a popular suspect in causing hyperactivity, there's no reliable proof of this
...

Complications



Often struggle in the classroom, which can lead to academic failure and judgment by other
children and adults

66



Tend to have more accidents and injuries of all kinds than children who don't have the
disorder



Have poor self-esteem



Are more likely to have trouble interacting with and being accepted by peers and adults



Are at increased risk of alcohol and drug abuse and other delinquent behavior
Coexisting conditions
ADHD doesn't cause other psychological or developmental problems
...




ADHD rating scales to help collect and evaluate information about the patient
Diagnostic criteria for ADHD
To be diagnosed with ADHD, a child must meet the criteria in the Diagnostic and Statistical
Manual of Mental Disorders published by the American Psychiatric Association
...


67

Inattention


Often fails to give close attention to details or makes careless mistakes in schoolwork and
other activities



Often has difficulty sustaining attention in tasks or play activities



Often doesn't seem to listen when spoken to directly



Often doesn't follow through on instructions and fails to finish schoolwork or chores



Often has difficulty organizing tasks and activities



Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort,
such as schoolwork or homework



Often loses items necessary for tasks or activities (for example, toys, school assignments,
pencils, books)



Is often easily distracted



Is often forgetful in daily activities
Hyperactivity and impulsivity



Often fidgets with hands or feet or squirms in seat



Often leaves seat in classroom or in other situations when remaining seated is expected



Often runs about or climbs excessively in situations when it's inappropriate



Often has difficulty playing or engaging in leisure activities quietly



Is often "on the go" or often acts as if "driven by a motor"



Often talks too much



Often blurts out answers before questions have been completed



Often has difficulty awaiting turn



Often interrupts or intrudes on others' conversations or games
In addition to having at least six signs or symptoms from these two categories, a child with
ADHD:



Has inattentive or hyperactive-impulsive signs and symptoms that cause impairment



Has behaviors that aren't normal for children the same age who don't have ADHD



Has symptoms for at least six months



Has symptoms that affect school, home life or relationships in more than one setting (such as
at home and at school)
A child diagnosed with ADHD is often given a more specific diagnosis (a subtype), such as:

68



Predominantly inattentive type ADHD
...
This child may sit quietly and appear to get along with others, but he
or she is not paying attention
...
A child has at least six signs and
symptoms from the hyperactivity and impulsivity list above
...




Combined-type ADHD
...

Other conditions that resemble ADHD
A number of medical conditions or their treatments may cause signs and symptoms similar to
those of ADHD, or exist along with ADHD
...
That's because developmental
problems such as language delays can be mistaken for ADHD
...


Treatments and drugs

69

Standard treatments for ADHD in children include medications, education, training and
counseling
...

It may take some time to determine what works best for the child
...
Stimulants appear to boost and balance levels of brain chemicals called
neurotransmitters
...

Examples include methylphenidate (Ritalin) and dextroamphetamine
...
A long-acting patch is
available that can be worn on the hip
...
And
the dose may need to be adjusted if significant side effects occur or as your child matures
...

Stimulant medications and heart problems
Although rare, several heart-related deaths occurred in children and teenagers taking stimulant
medications
...
The
clinician should make sure the child doesn't have any signs of a heart condition and should ask
about family risk factors for heart disease before prescribing a stimulant medication
...
Clonidine and guanfacine have also been shown to be effective
...
These may be good options if the child can't take stimulants because
of health problems or if stimulants cause severe side effects
...
Watch out for any signs of suicidal thinking or other signs of depression
...
Children and teens shouldn't be in charge of their own
ADHD medication without proper supervision
...
An overdose of stimulant
drugs is serious and potentially fatal
...

Some children with ADHD may also have other conditions such as anxiety disorder or
depression
...

Examples of therapy include:



Behavior therapy
...
These strategies may include token reward systems and timeouts
...
This allows older children with ADHD to talk about issues that bother them,
explore negative behavioral patterns and learn ways to deal with their symptoms
...
This can help parents develop ways to understand and guide their
child's behavior
...
Family therapy can help parents and siblings deal with the stress of living
with someone who has ADHD
...
This can help children learn appropriate social behaviors
...

Coping and support
Caring for a child with ADHD can be challenging for the whole family
...
The stress of dealing with
ADHD can lead to marital conflict
...

Siblings of a child with ADHD also may have special difficulties
...

Techniques for coping

71

Many parents notice patterns in their child's behavior as well as in their own responses to that
behavior
...
It takes a lot of hard work
...
Set small goals for both the parent and the child and
don't try to make a lot of changes all at once
...
Structure doesn't mean rigidity or iron discipline
...

Children with ADHD don't handle change well, and having predictable routines can make
them feel safe as well as help improve behavior
...




Provide positive discipline
...
Also, children with ADHD usually
respond well to positive reinforcement, as long as it's earned
...




Stay calm and learning stress management techniques can help the parent deal with ones
frustrations
...
The relationship among all family members plays a
large part in managing or changing the behavior of a child with ADHD
...
That's one reason it's important for partners to take time to nurture their own
relationship
...
If ones child has ADHD, give oneself a break now and then
...
One will be a better parent if one is
rested and relaxed
...
Make sure that
baby sitters or other caretakers are knowledgeable about ADHD and mature enough for the
task
...
Don't drink alcohol,
smoke cigarettes or use drugs
...




Protect the child from exposure to pollutants and toxins, including cigarette smoke,
agricultural or industrial chemicals, and lead paint (found in some old buildings)
...
Although still unproved, it may be prudent for children to avoid excessive
exposure to TV and video games in the first five years of life
...




Put together a daily routine for the child with clear expectations that include such things
as bedtime, morning time, mealtime, simple chores and TV
...




Work with teachers and caregivers to identify problems early, to decrease the impact of
the condition on the child's life
...
Genetic
Heritable component to vulnerability, and to subjective experiences of the substance
...
Psychological
Personality factors
Learned behaviour
Positive reinforcement – the drugs lead to behaviours that increase their use
4
...
Legal
Restrictions on sale
Penalties for possession or dealing,

73

• Hazardous drinking: 24% of the population drink more than the recommended limits (21 units
per week for men and 14 for women)
...

• Dependent drinking: 9% of men and 4% had features of alcohol dependency
...
As intake increases, however,
there is an escalating morbidity and mortality
...

• Primacy of drinking over other activities – for example, eating, family life, work, health
...

• Relief drinking – drinking to stop or prevent withdrawal symptoms
...

• Reinstatement after abstinence – unable to give up alcohol for long
...

• Withdrawal symptoms
Withdrawal and delirium tremens
The main features of alcohol withdrawal are:
• Tremulousness (‘the shakes’)
...

• Nausea and retching
...

• Overwhelming desire to drink (craving)
...
If untreated, the symptoms may last for several
days
...

• Withdrawal symptoms often occur on waking as the blood alcohol concentration falls during
sleep
...

Wernicke’s syndrome
An acute encephalopathy presenting with delirium, ataxia, nystagmus and ophthalmoplegia,
occurring in the severely alcohol dependent, usually in the context of withdrawal
...
It may progress to Korsakoff’s syndrome,
which presents with cognitive deficits and confabulation
...
e
...

Detection can be improved by:
• Asking about alcohol intake during all medical and psychiatric assessments, including use of
FAST, CAGE or AUDIT questionnaires
...
The AUDIT (Alcohol Use Disorders Identification Test) has 10
questions and takes 2 minutes; its strength is that it would assess hazardous, harmful and

75

dependent drinking
...

• Following up on comments suggesting that a patient thinks he or she drinks too much
...

• Noting the presence of one or more of the psychiatric or social consequences of harmful
alcohol use
Associated medical disorders
If alcohol misuse has led to a medical disorder, then psychiatric or social impairments are likely
...
If an alcohol-related psychiatric disorder is present, check for
physical symptoms and signs of alcohol dependency
...

• In alcoholic hallucinosis, a heavy drinker experiences
recurrent auditory hallucinations, usually of a threatening or derogatory nature
...
withdrawal hallucinations)
...

• About 10% of people who are alcohol dependent commit suicide
...

Features of delirium tremens
Onset 24–48 hours after stopping heavy, prolonged drinking
Delirium
Visual hallucinations
Delusions, usually persecutory and transient
Fear and agitation, sometimes aggression
Coarse tremor
Seizures
Autonomic disturbance (sweating, fever, tachycardia, hypertension)
Insomnia
Dehydration and electrolyte disturbance
Lasts 3–4 days, followed by exhaustion and patchy amnesia for the episode
Management of hazardous and harmful
alcohol use
A brief intervention in primary care is usually sufficient if someone is drinking more than the
safe limits but is not dependent and has no specific medical or psychiatric disorder
...

• Assess the nature and extent of harm (e
...
liver function tests, work record)
...
Tailor advice to the individual, and
reinforce with written information
...

• Review progress
...

The FRAMES acronym covers the main approach to giving advice about drinking:
• Structured Feedback on risk and harm
...

• Clear Advice to make a change in drinking
...

• Express Empathy and be non-judgmental
...

Treatment of alcohol dependence
The first requirement is detoxification (‘detox’, - ‘drying out’), which is controlled withdrawal,
using a reducing course of a benzodiazepine in place of alcohol
...

• Mild dependence – withdraw at home without drugs or with small doses of benzodiazepines
...
g
...
Advise the patient to drink plenty of nonalcoholic liquids
...
Consider parenteral thiamine if risk of Wernicke’s syndrome
is judged to be high as oral thiamine has limited bioavailability
...
– may need higher doses of chlordiazepoxide, and/or inpatient treatment
...

Maintaining abstinence
Various strategies are used to prevent relapse following withdrawal from alcohol
...

• Aim for abstinence where possible – it has a better long-term outcome than controlled drinking
...

• Encourage attendance at groups run by local community alcohol services or Alcoholics
Anonymous
...
Disulfiram works through
negative reinforcement as it causes undesirable symptoms when alcohol is consumed alongside
it; acamprosate leads to a reduction of craving, and opioid antagonists work via the autonomic
nervous system
...

• About 50% of patients will return to drinking again within 6 months of abstinence
...
g
...

Look out for withdrawal symptoms occurring during hospitalization
...

• Treat the psychiatric disorder in the standard manner
...
g
...


ANXIETY DISORDERS
Anxiety disorders are among the most prevalent mental disorders in the general population,
women affected nearly twice as frequently as men
...
Anxiety disorders can be
viewed as a family of related but distinct mental disorders, which include the following as
classified in the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR): (1) panic disorder with or without agoraphobia; (2) agoraphobia with
or without panic disorder; (3) specific phobia; (4) social phobia; (5) obsessive-compulsive
disorder (OCD); and (6) generalized anxiety disorder
...


78

Normal Anxiety
Everyone experiences anxiety
...
The particular constellation of symptoms
present during anxiety tends to vary among persons
...
Fear is a similar alerting signal, but should be differentiated from
anxiety
...

Key Features of Major Anxiety Disorders As Defined by DSM-IV-TR
Panic disorder
Recurrent unexpected panic attacks characterized by four or more of the following:
Palpitations
Sweating
Trembling or shaking
Shortness of breath
Feeling of choking (also known as air hunger)
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, lightheaded, or faint
Derealization or depersonalization
Fear of losing control or going crazy
Fear of dying
Numbness or tingling
Chills or hot flashes
Persistent concern of future attacks
Worry about the meaning of or consequences of the attacks (e
...
, heart attack or stroke)
Significant change in behavior related to the attacks (e
...
, avoiding places at which panic
attacks have occurred)
Agoraphobia
Fear of being in places or situations from which escape might be difficult, embarrassing, or in
which help may be unavailable in the event of having a panic attack
Often results in avoidance of the feared places or situations, for example:
Crowds
Stores
Bridges
Tunnels
Traveling on a bus, train, or airplane
Theaters
Standing in a line

79

Small enclosed rooms
Social phobia
Marked and persistent fear of one or more social or performance situations in which the person
is concerned about negative evaluation or scrutiny by others, for example:
Public speaking
Writing, eating, or drinking in public
Initiating or maintaining conversations
Fears humiliation or embarrassment, perhaps by manifesting anxiety symptoms (e
...
,
blushing or sweating)
Feared social or performance situations are avoided or endured with intense anxiety or distress
Specific phobia
Marked and persistent fear that is excessive, unreasonable, due to the presence or anticipation
of a specific object or situation, for example:
Flying
Enclosed spaces
Heights
Storms
Animals (e
...
, snakes or spiders)
Receiving an injection
Blood
Provokes an immediate anxiety response
Recognition that the fear is excessive or unreasonable
Avoidance, anticipatory anxiety, or distress is significantly impairing
Obsessive-compulsive disorder
Has obsessions or compulsions
Obsessions are defined as recurrent and persistent thoughts, impulses, or images that are
experienced as intrusive and inappropriate, for example:
Contamination
Repeated doubts
Order
Impulses
Sexual images
Compulsions are defined as repetitive behaviors or mental acts whose goal is to prevent or
to reduce anxiety or distress, for example:
Hand washing
Ordering
Checking
Praying
Counting
Repeating words
Recognition that the fear is excessive or unreasonable
Obsessions cause marked distress, are time-consuming (more than 1 hour per day), or cause
significant impairment in social, occupational or other daily functioning

80

Generalized anxiety disorder
...
Characterized by three or more of the following:
Recurrent and excessive distress when separation from home or major attachment figure
occurs or is anticipated
Persistent and excessive worry that major attachment figure will be lost or harmed
Persistent and excessive worry that an event will lead to separation from major attachment
figure (e
...
, getting kidnapped)
Persistent and recurring fear of being alone or without attachment figure at home
Reluctance or refusal to sleep away from home or without being near major attachment
figure
Duration of at least 4 weeks
Age of onset before 18 years of age
Causes distress or impairment in functioning
Physical symptoms (e
...
, headaches, stomachaches, nausea, and vomiting) when separation
occurs or is anticipated

Peripheral Manifestations of Anxiety
Diarrhea
Dizziness, light-headedness
Hyperhidrosis
Hyperreflexia
Hypertension
Palpitations
Pupillary mydriasis
Restlessness (e
...
, pacing)
Syncope

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Tachycardia
Tingling in the extremities
Tremors
Upset stomach (butter flies•)
Urinary frequency, hesitancy, urgency
Stress and Anxiety
Whether an event is perceived as stressful depends on the nature of the event and on the person's
resources, psychological defenses, and coping mechanisms
...
the awareness of the physiological sensations (e
...
, palpitations and sweating) and the
awareness of being nervous or frightened
...

2 anxiety affects thinking, perception, and learning
...

Epidemiology
The anxiety disorders make up one of the most common groups of psychiatric disorders
...
7 percent
...
5
percent lifetime prevalence) are more likely to have an anxiety disorder than are men (19
...
The prevalence of anxiety disorders decreases with higher
socioeconomic status
...

Symptoms of mania
A
...

B
...

2
...


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3 Flight of ideas or the subjective experience of thoughts racing
...

5 Decreased need for sleep
...

7 Distractibility or constant changes in activity or plans
...
g
...

9 Marked sexual energy or sexual indiscretions
...
The degree of
functional impairment is variable
...
g
...
Though
subjectively productivity may be increased, tasks are rarely done well or completed
...
The infectious gaiety easily switches to
irritability
...

• Note that there is no satisfactory category or term for manic symptoms lasting less than 4 days
• Patients whose elated mood never goes beyond hypomania are described as having bipolar-2
disorder
...
Thought processes become disordered and jumpy (flight of ideas),
accompanied by pressure of speech
...
These are mood
congruent and grandiose: a patient may believe themselves blessed with special powers (e
...
that
they can fly or have been sent to save the world)
...

Unfortunately, reality or gravity supervene, and people with mania do things they later regret
...

Bipolar disorder is strongly inheritable (80%)
...
Relatives of someone with bipolar disorder have an increased incidence
of both bipolar and unipolar depressive disorder

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• Many chromosomal loci and genes are implicated, and overlap with those for schizophrenia
Current leading bipolar disorder candidate genes include the HLA (human leucocyte antigen)
complex, ANK3 and CACN1C
...

• No childhood risk factors are known
...

• Most of the neurobiological abnormalities described for depressive disorder are also implicated
in bipolar disorder, although there may be differences in the abnormalities in emotional
processing
...
In someone first presenting in middle age, exclude
cerebrovascular disease, tumours and medication side effects
Management of bipolar disorder
Treatment of mania and mixed episodes
Patients with mild manic symptoms can be successfully treated as out-patients, if the patient has
insight that they need treatment
...

• Antipsychotics (e
...
risperidone, olanzapine) or valproate and lithium are effective antimanics
...

Benzodiazepines are used, as required, for sedation
...
4%
Sex ratio (M: F) 1:1
Mean age of onset Early 20s
Risk to first-degree relatives of a patient with bipolar disorder:
• The choice of drug is influenced by the patient’s existing medication – they may already be on
a mood stabilizer
...
g
...
If the patient is on
lithium, check the blood level to assess recent adherence
...
g
...
If so, a short course of antipsychotic or valproate may successfully treat the
episode
...

Mania can last for months if untreated
...

Treatment of depressive episodes
Depressive episodes and symptoms in bipolar disorder (‘bipolar depression’) can cause severe
dysfunction and can be difficult to treat
...

• Quetiapine, an atypical antipsychotic, is the treatment with the best evidence and can be highly
effective, with a rapid onset of action
...

• Antidepressants may be less effective than in unipolar depression and they should be used in
combination with an effective antimanic drug because antidepressants used alone can precipitate
mood destabilization or mania
...

• For severe depression, antipsychotics, ECT and psychiatric admission may all be necessary
...

• Long-term mood monitoring by the patient can be extremely helpful
...
g
...
Some patients become adept at recognizing and responding to these
warning signs
...
However, the effective early treatment
of bipolar disorder may improve its long-term outcome, and increasingly the trend is to start
long-term treatment after one serious episode, especially when there is a family history of bipolar

85

disorder
...

• Long-term lithium treatment is the standard prophylaxis for bipolar disorder and is supported
by the most robust evidence
...
Long-term lithium treatment should not be initiated unless both patient and doctor
intend to continue it for at least 2 years
...
Lamotrigine reduces the risk of
depressive relapse
...

• Psychological approaches such as CBT or family therapy may also help in preventing relapses
...
Such activities that appear to be neglected usually include routine activities, including
hobbies, going to work and/or school, and most notably, engaging in social activities
...

Psychopathology
Most often identified as a negative symptom of the psychotic disorder Schizophrenia, Substance
Abuse as well as Depression
...

Anhedonia is the absence of experiencing pleasure
...

Alogia is the significant decrease or reduction in speech output
...
It may be difficult to engage an
individual experiencing avolition in active participation of any form of therapy
...

Treatment

86

Treating negative symptoms is notoriously difficult
...
Firstgeneration antipsychotics are called such because they came out of the first wave of empirically
supported medication treatments
...
Unfortunately, these are not effective in treating negative symptoms
...
These include
Zyprexa (olanzepine) and Risperidol
...
As a result, psychosocial interventions show more
promise
...
CBT is a type of psychotherapy that helps individuals understand how
thoughts and feelings influence behavior
...

Social skills treatment focuses on teaching the individual how to successfully manage
interpersonal situations
...


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