Course outline

 Module Title: Mental health

 Course Title: Psychiatric HO
 Credit hour: 2
1.Introduction
2. Sign and symptoms in psychiatry (psychopathology)
3. Clinical examination of psychiatric patient
4. Psychotic disorder
5. Mood disorders
6. Cognitive disorder
7.Anxiety disorder
8.Obsessive-Compulsive and Related Disorders
9.Trauma and stress related d/o
10.Somatic symptom and Related disorders
11. personality disorder
12. Substance use problems/Alcohol

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Learning objectives: At the end of the training, you will be able to:
 identify and manage major psychotic conditions

 identify and manage depression and anxiety

 identify other prevailing non-psychotic psychiatric disorders and take

action

 council or give appropriate advice and guidance for the emotionally

disturbed

 Follow up psychiatric patients who have on treatment

 refer difficult cases to central or regional levels

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 References:
 Kaplan & Sadock's Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry, 11th Edition
 Kaplan and Sadock's Comprehensive Textbook of
Psychiatry, 9th Edition
 Lewis's Child and Adolescent Psychiatry: A Comprehensive
textbook, 4th Edition
 Stephen M. Stahl, Essential Psychopharmacology: The
Prescriber’s Guide, 1 st Edition

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  Assessment:
Assignment,quize and presentation=10
 Mid exam…………………………50%

 Prepared by Asmamaw Getnet

BSc, MSc in ICCMH

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 UNIT ONE: INTRODUCTION
 Definition of Health
 Definition of Mental health
 Definition of Mental illness
 Definition of Mental disorder
 Definition of Psychiatry
 Classification of mental disorders
 Causes of mental Disorders
 prevalence of mental disorders
 Historical View of Mental Illness

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 WHAT IS HEALTH?
Health is a state of complete physical, mental and social

wellbeing and not merely the absence of disease or

infirmity (WHO, 1948)

Mental health: is a state of well-being in which

 individual can realize his/her own abilities,

 interact positively with others,

 cope with the stressors of life and study,

 work productively and fruitfully,

 and contribute to his/her family and community. (WHO)

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Mentally healthy person shows growth and maturity in

three areas:

 Cognitive,

 Emotional, and

 Social processes.

A mind is a terrible thing to waste...and there is no

health without mental health!!!

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Mental illness: is a state of disturbance in which an

individual:

 can not realize his/her own abilities

 interact negatively with others

 can not cope with the stressors of life and study

 not work productively and fruitfully, and

 not contribute to his/her family and community.

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 WHAT IS MENTAL DISORDER?
Mentally ill person acts in ways that deviate from

socially and culturally acceptable manners.

Mental disorders: Is specific diagnosis of a condition

or type of mental illness that is made by a trained

mental health professional after formal psychiatric
assessment.

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  Psychiatry is a branch of medicine that deals with
identification, diagnosis, treatment and prevention of mental
disorders
 . CLSSIFICATION OF MENTAL DISORDERS

 TRADITIONAL CLSSIFICATION

 MODERN CLASSIFICATION

 DSM 5 ------APA[USA,many africa country including

Ethiopia]
 ICD -10th Edition-------WHO [many European

country&India]
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 CAUSES OF MENTAL ILLNESS
Although the exact cause of most mental illnesses is

not known, it is becoming clear through research that

many of these conditions are caused by a combination
of :
biological,
psychological and
environmental factors.
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BIOLOGICAL CAUSES:

 Genetic make up

 Substance abuse

 Illness of mothers during pregnancy, infections

 Neurotransmitters abnormality

 Defects in or injury to certain areas of the brain

 Exposure to toxins, such as lead, etc

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PSYCHOLOGICAL CAUSES:

 Traumatic and abusive past or current experiences,

 Significant life events like bereavement or divorce, or

 If you have self-destructive thought patterns and

perceptions, etc

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 SOCIAL AND ENVIRONMENTAL CAUSES:

 Are those factors around us such as where we live, war,

disaster, etc

 Whether we have strong support networks

 Our work place

 Physical environments such as the neighborhood

e.g crime

 Unable to find employment

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 PREVALENCE OF MENTAL DISORDERS
GLOBALLY

Mental, neurological and behavioural disorders are common to

all countries and causes immense suffering.

People with these disorders are often subjected to social

isolation, poor qualities of life and social costs.

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 WHO (2002) Study showed that Globally:
 154 million people suffer from depression

 25 million people suffer from schizophrenia

 91 million people suffer from alcohol use disorders and 15

million by drug use disorders

 50 million people suffer from Epilepsy (neurological disorder)

 24 million people suffer from Alzheimer dementia and other

dementias

 326 million people suffer from migraine headache

 877,000 people commit suicide every year.

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 PREVALENCE IN ETHIOPIA

Over 13 million people suffer from different kinds

of mental illness.

Mental health problem prevalence (%)

 Common mental disorders 12-17%

 Schizophrenia 0.6-0.7%

 Mood disorders 3.8-5%

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 Child hood disorders 12-24%
 Substance dependence 4%
 Alcohol use disorders 2.7-7%
 Khat abuse 22-64%
 Suicide attempt 0.9-3.2%
 Completed suicide 7.7/100,000/year

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 Historical View of Mental Illness
 Mental illness began in the primitive age as human existence
began:
 It was thought to be caused by evil sprits entering and take
over the body.
 In ancient civilization, Greeks, Romans and Arabs viewed mental
deviations as natural phenomena and treated the mentally ill
humanely.
 Care consisted of sedation with opium, music, good physical
hygiene, nutrition and activity
 The Greek philosopher Plato (429-348 BC) and the Greek
physician Hypocrites (460-377 BC,
known as the father of medicine), were concerned about the
treatment of the mentally ill.

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  In the middle ages (500 - 1450 AD) the Roman Empire
fell (476 AD) the humanitarian ideas concerning the
mentally ill were forgotten.
 During (14th- 17th) Century:
 Mental illness was considered irreversible.
 mental patients were viewed as incompetent,
defective, and potentially dangerous.
 They had no rights and were left in social isolation to
communicate primarily with other mentally ill
patients.
 In the 20th Century an Austrian neurologist,
Sigmund Freud made a significant contribution to
the understanding and treatment of mental
illness.
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  In Ethiopia the first mental hospital was established after the
end of the Ethio-Italian war to protect the royal family from
mentally ill patients.

 The patients were collected and taken to jails to the corner of

the town that is now known as Amanuel Hospital.

 Slowly and gradually a more humanitarian type of care was

introduced by one psychiatrist. Dr. Fikire Workineh

 The first psychiatric nursing school was established in

Amanuel Hospital in 1991 and twelve nurses graduated for
the first time.

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 Treatment approaches:
Assistance – giving food and money, which enable
the family to maintain integrity.
punishment – wandering bands of “lunatics”
Confinement
 lunatics were chained
 mixed the old with the young, men and women,
insane with criminals
 They were thought to be immune to biologic
stresses such as cold, heat, and hunger

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  Psychotropic Drugs (1950)
◦ Use of chlorpromazine and imipramine.
◦ Mental illness is caused by chemical imbalance in the
brain.

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 UNIT TWO: SIGNS &SYMPTOMS
IN PSYCHIATRY
Speech

Emotion

Perception

Thought: form &content

Memory

Motor disturbances

Characteristics of psychosis

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Speech

 Muteness - refers to the absence of speech as in severe

depression, severe schizophrenia or disease of the brain

system (mid brain).

 Pressured speech:-rapid, loud & usually excessive

speech seen in classic mania

 Aphasia :Any disturbance in the comprehension or

expression of language caused by a brain lesion

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 EMOTION: is a state feeling
MOOD: Sustained & pervasive emotional states
• It is experienced & reported by pt
• Reported feelings when asked
Elated Mood:- is characterized by excessive happiness as
in mania

Depressed mood: - refers to unusual and persistent

sadness or unhappiness as in depressive illness.

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 Irritable mood: - refers to easily being annoyed as in
mania or depressive illness.

Labile mood: - is characterized by fluctuation of

mood without warning, say from extreme happiness to
anger or depression and weeping, as in mania.

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 ABNORMALITIES OF MOOD:

The emotions displayed are,

top row, left to right, anger, fear,
disgust,&

bottom row, surprise, happiness,

and sadness

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 AFFECT: is a short term emotional state or feeling tone

as perceived by the clinician during the interview.

It is the outward manifestation of internal feeling.

Incongruent affect: if emotional externalized feeling

tone is not harmonious with one’s thoughts, actions and
circumstances.

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 Blunted affect:-Disturbance of affect manifested by a
severe reduction in the intensity of externalized feeling
tone; one of the fundamental symptoms of schizophrenia.

Flat affect:-Absence or near absence of any signs of

affective expression.

Labile affect: excessive, rapid and abrupt change of

emotional feeling tone.

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 ANHEDONIA is loss of interest in, and withdrawal

from, all regular and pleasurable activities. Often

associated with depression.

PERCEPTION: is the process of becoming aware of

what is presented through sense organs.

Hallucinations: is perception in the absence of an

external stimulus and may occur in all the sensory

modalities.

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  Types of hallucinations

 Auditory hallucination

 Visual hallucination

 Olfactory hallucination

 Tactile hallucination

 Gustatory (taste) hallucination

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 Auditory hallucination is hearing a voice which does not

exist.

 Running commentary refers to the experience of the

patient that strange people comment on his/her every

action, thought and feelings.

 Example one patient complained that even when he went

to toilet, his/her enemies commented on this act of

opening bowels and laughed at him/her.

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 Command hallucination: False perception of orders that
a person may feel obliged to obey or unable to resist.
 Visual hallucination: is seeing things which don’t exist.
 Tactile hallucination: is sense of touch without existing
stimulus, e.g. insect crawling on the body.

 Olfactory hallucination: smelling things which don’t

exist.
 Gustatory hallucination: is the experience of strange
taste in the mouth.

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 Illusion: is the misinterpretation of real external stimulus.

De realization: refers to the experience of the patient that

everything in his surrounding appears to have changed and

is strange.

De personalization: Sensation of unreality concerning

oneself, or parts of oneself.

Dejavu: Illusion of visual recognition in which a new
situation is incorrectly regarded as a repetition of a
previous experience .

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JAMAIS VU: a false feeling of unfamiliarity with a real
situation that one has previously experienced.
THINKING: the ability to process information in once

mind in both content and form.

Disturbance of thinking occur in the following two forms:

 Thought form abnormality

 Thought content abnormality

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 Form of thought: refers to how ideas are connected and

related to each other.

 The following are the disorders thought form:

Circumstantiality: patient digresses into unnecessary details

and inappropriate thoughts before communicating the central idea

Tangentiality:Oblique, digressive, or even irrelevant manner of

speech in which the central idea is not communicated

Pressure of thought: When patients thoughts are rich in variety

and pass quickly through his mind

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  Thought blocking: Sudden interruption of the flow of
thoughts for seconds or minutes in which the patient
experiences as his mind
going blank or his mind is empty
 Clang association: An abnormality of speech where the
connection between words is their sound rather than their
meaning
 Flight of ideas: Subjective experience of one's thoughts
being more rapid than normal with each thought having a
greater range of consequent thoughts than normal.
Meaningful connections between thoughts are maintained.

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  Loosening of associations: lack of meaningful connection
between sequential ideas
unrelated and unconnected ideas shift from one subject to
another
 Word salad: Incoherent mixture of words and phrases seen
in schizophrenia
 Perseveration: The patient may give the correct answer to
the first questions but continue to give the same answer
inappropriately to subsequent questions
 mainly seen in organic brain disorders

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 Verbigration: meaningless repetition of specific words or
phrases in a stereotypic way
Also called cataphasia
 seen in schizophrenia
 Neologism: A made-up word or normal word used in an
idiosyncratic way.
found in schizophrenic speech

 Echolalia: Psychopathological repeating of words or phrases

of one person by another; tends to be repetitive and
persistent.
Seen in certain kinds of schizophrenia

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 Content of thought: refers to the quality of message

being transmitted.

 Delusion: is a false belief or conviction that cannot be

changed by rational arguments or evidence.

Grandiose delusions

Delusions of jealousy (infidelity):delusions that the

individual’s sexual partner is unfaithful

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 Persecutory delusions: delusions that the person (or

someone to whom the person is close) is being malevolently

treated in some way
Somatic delusion: delusions that the person has

some physical defect or general medical condition

Erotomanic delusion:delusions that another person,

usually of higher status, is in love with the individual

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  Delusion of reference :A person false belief that the
behavior of others refer to oneself as article read in
newspaper, or remark heard on TV is believed to be directed
specifically to himself
 Delusion of being controlled:False feeling ,in which the
patient believes that his actions ,impulses and thoughts are
controlled by others.
 Thought withdrawal:Delusion that one's thoughts are
being removed from one's mind by other people or forces
 Thought broadcasting:Feeling that one's thoughts are
being broadcast or projected into the environment
 Thought insertion:Delusion that thoughts are being

43 implanted
1 in one's mind by other people or forces
 Obsessions: Persistent and recurrent idea,thought, or

impulse that cannot be eliminated from consciousness by

logic or reasoning
obsessions are involuntary and ego-dystonic
Compulsion: A behaviour or action which is recognised

by the patient as unnecessary and purposeless but which

he cannot resist performing repeatedly.

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 Phobia: Persistent, pathological,unrealistic,

intense fear of an object or situation

The phobic person may realize that the fear is
irrational but, cannot dispel it

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 Memory: is the ability to remember past events and
general knowledge
These can be: immediate, short term and long term
memory.
 Immediate memory: refers to events that have just
occurred as when one asks the patient to recite seconds to
minutes.
 Recent memory: Recall of events over the past few days.

 Long term memory: refers to the recall of events that

46
occurred
1 long time ago.
 Memory Disturbances

 Amnesia: partial or total inability to recall past

experiences.

 Anterograde amnesia: Loss of memory for events

subsequent to the onset of the amnesia; common after

trauma.

 Retrograde amnesia: is loss of memory for events

before the onset of amnesia.

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 Disturbances of Motor function
Motor functions: Comprises of movement, posturing

and mannerisms

 Tics: are involuntary, regular and repeated

movements involving small groups of muscles. E.g.

raising shoulder.

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  Mannerism: repeated, involuntary movements that

appear to have some functional significance. E.g.

saluting.

 Stereotypes: repeated movements that are irregular

(unlike tics) and without obvious significance (unlike

mannerism). E.g. rocking to and from.

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  Negativism : patient does the opposite of what is
asked and actively resists efforts to persuade them
to comply
 Abnormal posturing and positioning: adaptation
of unusual bodily posture continuously for a long
time. E.g. standing on one leg.
 Waxy flexibility: Condition in which a person
maintains the body position into which they are
placed.
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  Cataplexy: an attack of muscular flaccidity.

 Ecopraxia: pathological imitation of movement of one

person by another even when asked not to do so.

 Echolalia: pathological repeating of words or phrases

of one person by another.

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 Judgment: the ability to make sound decisions in the interest
of self and others.
Insight: is a correct awareness of one’s own mental and
physical condition.
Characteristics of psychosis

 Impairment in reality testing/ego defect

 Abnormal experiences e.g. delusion, hallucination

 Bizarre behaviours

 Lack of insight

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UNIT THREE: PSYCHIATRIC ASSESSMENT
FORMAT
A. Psychiatric History

B. Mental Status examination

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 A. Psychiatric History
Psychiatric history is the record of the patient's life
It allows to understand
Who the patient is
Where the patient has come from
Where the patient is likely to go in the future
It includes information about the patient obtained from other
sources
Parent
Spouse
Colleagues
A psychiatric history differs slightly from histories
54 taken
1 in medicine or surgery.
 Components psychiatric history
I. Identification
II. Chief complaints
III. History of presenting illness
IV.Past psychiatric history
V. Past medical history
VI. Family history
VII. Personal history
VIII.Sexual history
IX. Forensic history
X. Premorbid personality

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 I. Identification
Provide a succinct demographic summary of the patient by
 Name, age, sex, marital status
 Ethnic background, and religion
 Educational status, occupation
 Patient's current living circumstances
 Whether the patient came
On his or her own
 Referred by someone else
 Brought in by someone else
 The source of information, the reliability of the source
Whether the current disorder is the first episode for the patient
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E.g. Ato zerihun is a 25-year-old single,Amhara,
Protestant male who works as a department store clerk.
He is a college graduate living with his parents from
Kolfe sub-city. He was referred by his internist for
psychiatric evaluation.
II. Chief Complaints:
The patient’s main problem?
What brought the patient to the hospital?
Record verbatim!

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 III. History of Present Illness:
Is chronological description of pt’s signs & symptoms in

current episode.

Ask:

 How the symptom emerged/How was the onset (abrupt,

insidious)?

 How they progressed?

 Is1there any precipitating factor? Relieving factor?

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 Any help sought?

 Ask pertinent positives e.g. delusion, hallucination

 Ask pertinent negatives e.g. anhedonia, alogia, avolution,

asociality

 Impact of illness

 Ask about risks E.g. suicide, homicides, legal issues

 Substance use history: amount used, frequency,…

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 IV. Past Psychiatric History:
 In the past have your patient ever had problems with his/her
mental health
What were the symptoms?

 Have the patient ever seen a psychiatrist before?

 Previous admission to psychiatric hospital

 Previous treatments?

 Has there ever been a time that the patient felt completely well?
Diagnosis, treatment and response
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 V. Past Medical History:
 Do the patient has any problems with his physical health?

 What about in the past?

 Have the patient ever had any operations or been in hospital?

 Medications taken regularly?

 Medications in the past

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 VI. Family History:
 Any psychiatric illness, hospitalization, and treatment of the
patient's immediate family members
 Family history of suicide
 Family history of alcohol and other substance abuse
 The family's attitude toward, and insight into, the patient's
illness
 Patient's attitude toward each of his parents and siblings
 Source of family income
 Impact of illness on the family

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 VII. Personal History
 Prenatal and perinatal
Early childhood (through age 3)
 Middle childhood (age 3- 11)
Late childhood puberty through adolescence
Adulthood

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Prenatal and perinatal
 Full-term pregnancy or premature
 Vaginal delivery or caesarian
Drugs taken by mother during pregnancy (prescription and
recreational)
 Birth complications
Infancy and early childhood[birth-3 years]
 Infant-mother relationship
 Problems with feeding and sleep
Significant milestones
 Standing/walking
 First words/two-word sentences
Bowel and bladder control

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 Middle childhood [3-11 years]
 Preschool and school experiences
 Separations from caregivers
 Friendships/play
 Methods of discipline
Illness, surgery, or trauma
Adolescence [11-19 years]
 Onset of puberty & Academic achievement
 Organized activities (sports, clubs)
 Areas of special interest
 Romantic involvements and sexual experience
Work experience
 Drug/alcohol use
 Symptoms (moodiness, irregularity of sleeping or eating,
65
fights
1 and arguments)
 Young adulthood[19-35 years]
Meaningful long-term relationship
 Academic and career decisions
 Military experience
 Work history
Prison experience
 Intellectual pursuits and leisure activities
 Middle adulthood and old age [35 & above]
Changing family constellation
 Social activities
Work and career changes
 Major losses
66  Retirement
1 and aging
 VIII. Sexual History
Screening questions
Are you sexually active?
 Have you noticed any changes or problems with sex
recently?
 Developmental
Onset of puberty/menarche
 Development of sexual identity and orientation
 First sexual experiences
Sex in romantic relationship
 Changing experiences or preferences over time
Sex and advancing age
Clarification of sexual problems

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Desire phase
Presence of sexual thoughts or fantasies
 When do they occur?
 Who initiates sex and how?
Excitement phase
 Difficulty in sexual arousal (achieving or maintaining
erections, lubrication), during foreplay and preceding orgasm
Orgasm phase
 Does orgasm occur?
Does it occur too soon or too late?
How often and under what circumstances does orgasm
occur?

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 If orgasm does not occur, is it because of not being excited or
lack of orgasm despite being aroused?
Resolution phase
What happens after sex is over (e.g., contentment,
frustration, continued arousal)?
IX.Forensic History:
List of offences/charges & legal outcome.
 History of being in trouble with the police?
 any violent/sexual crimes and persistent offending

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 X. Premorbid personality
 How would you describe yourself?
 How would other people describe you?
 When you find yourself in difficult situations, what do
you do to cope?
 What sort of things do you like to do to relax?
Do you have any hobbies?
 Do you like to be around other people or do you
prefer your own company?

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 B.Mental Status Examination
It is the description of the patient's appearance,
speech, actions, and thoughts during the
interview.
 Like a physical examination , a mental state
examination should be orderly and systematic.
 As with a physical examination the examiner should
carry out a complete MSE for every patient

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 Outline for the Mental Status
Examination
1.General description(Appearance, Attitude toward Examiner, Overt Behavior and
Psychomotor Activity
2. Speech
3. Mood and affect
4.Thinking
Form and Content
5. Perceptions
6. Sensorium /cognition
Alertness
Orientation (person, place, time)
Concentration
Memory (immediate, recent, long term)
Calculations, Fund of knowledge Abstract reasoning
7. Judgment
8. Insight
1 examinatio
9.Physical
72
 1.General description(1.1.Appearance:)
Dress might be untidy ,with buttons undone, or done
incorrectly, worn torn or it might in adequate for the weather.
Self neglect: Men may appear unshaven, the face may be
unwashed, hair uncombed.
Women may wear no makeup or they may apply their
makeup carelessly
 Unusual accessories: patient sometimes pack there pockets
with there belonging
 carry a large holders of personal possessions or paper
manuscripts
Finger nails might be long and dirty
 Gait: Unusually slow, fast, unusual character of gait

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 1.2.Attitude towards the examiner
Attitude towards examiner can be described as
 Cooperative
 Attentive, interested
Frank, seductive
Defensive, hostile
 playful, evasive, guarded
Contemplative
1.3.Overt Behavior and Psychomotor Activity
Tic, Tardive Dyskinesia
 Stereotypes, Mannerism
Posturing, Negativism
Echopraxia
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Waxy flexibility
 2. Speech
Speed: fast, slow ,and normal
Volume: Loud, Low, Normal
 Quantity: Too little, too much or normal
 Tone: Low pitched, high pitched

3. Emotion
Mood: you evaluate the mood by asking the feeling of the
patient:
 Sadness ,elation, anxious,
 labile, euthimic, expansive
 Affect: what the interviewer observing during the interview
read it from facial expression of the patient :
 Blunted, flat, constricted, appropriate, inappropriate,
75 normal
1
range, labile
 4. Thought
 FORM:
 flight of ideas
 circumstantialities,
Tangentiallity, loosing of association
 Clang association
 Perseveration
 Word salad, Neologism
thought blocking
pressure of thought
 CONTENT:
Delusion, compulsion, obsession
 hopelessness, worthlessness,
 Suicidal ideation, preoccupation
Thought---
1
insertion, withdrawal, Broadcasting, reading
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 5. Perception
 Hallucination
 Illusions
 Depersonalization
 Derealization

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 6. Sensorium and Cognition
6.1. Alertness and level of consciousness
 Some terms used to describe the patient's level of
consciousness are clouding, somnolence, stupor, coma,
lethargy, or alert
6.2. Orientation: to time, place ,person.
Any impairment usually appears in this order (i.e., sense of
time is impaired before sense of place); similarly, as the
patient improves, the impairment clears in the reverse order.
6.3.Memory: Remote, Recent, Immediate

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 Immediate memory
 Repeat these numbers after me: 1, 4, 9, 2, 5.
 Recent memory
 I want you to remember these three things: a yellow pencil,
a white paper, and a black coat.
After a few minutes I'll ask you to repeat them.
 Also memories of past few days
 Long term memory
What was your address when you were in the third grade/
married?
 Who was your teacher/?
What did you do during the summer between high school
and college/when the EPRDF took power

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 6.4. Concentration and attention
Attention is the ability to focus

 Concentration is the ability to maintain attention

 Concentration can be assessed by serial seven

Attention can be assessed by calculations or by asking the

patient to spell words backward or name five things start with
particular letter.
6.5. Abstract thinking: the ability to deal with concepts
6.6. General knowledge: depend on patient’s educational
80 level
1
 7. Judgment
 The patient's capability for social judgment
Can he/she understand the likely outcome of his or her
behavior
 Can the patient predict what he or she would do in imaginary
situations
8. Insight
The patient's degree of awareness and understanding about
being ill

81 1
 9. Physical examination
vital signs
 HEENT
 Chest
 CVS
 Abdomen
 GUS
integumentary ……
10. Diagnosis

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 UNIT 4: PSYCHOTIC DISORDERS
 Brief psychotic disorder-1 day to 1 month history of illness

 Schizophreniform disorder-1 month but <6 month history

 Schizophrenia --->6 months history of psychotic illness

 Schizoaffective disorder----both psychotic and mood

symptoms

 Delusional disorder----non-bizarre delusion >1 month history

 Psychotic disorder secondary to substance use

 Psychotic disorder secondary to another Medical Condition

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 Schizophernia
 History of schizophrenia

 Etiology

 Symptoms dimension in schizophrenia

 Sub-types of schizophrenia

 DSM 5 criterion for diagnosis of schizophrenia

 Management

84 1
 Schizophrenia

 Eugen Bleuler, a Swiss psychiatrist, coined the term

Schizophrenia

 ‘Schiz’-broken; ‘Phrenos’: -soul or heart  Splitting of the

mind.

 Schizophrenia is Psychotic disorder.

 External behavior of schizophrenic pts seems bizarre to observers

 Internal mental experiences are incomprehensible and frightening

to the1 patient
85
 Schizophrenia is a clinical syndrome of variable, but

profoundly disruptive, psychopathology that involves

cognition, emotion, perception, and other aspects of
behavior.

The diagnosis of schizophrenia is based entirely on the

psychiatric history and mental status examination.

There is no laboratory test for schizophrenia.

86 1
 Etiology
A. Stress diathesis model:
 A person may have a specific vulnerability (diathesis) that
when acted by a stressful influence, allows the symptoms of
schizophrenia to develop.

Stressful influence includes:

 Infection

 Stressful family environment

 Death of close relatives

 Substance abuse, etc

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 B.Genetics
 Prevalence in General population = 1%

 Non twin siblings of schizophrenia patient = 8%

 Child with one parent with schizophrenia = 12%

 Di zygotic twin of a schizophrenia patient = 12%

 Child with two parent with schizophrenia = 40%

 Mono zygotic twin of schizophrenia patient = 47%

88 1
 C. Biochemical Factors
Dopamine Hypothesis:

 The dopamine hypothesis of schizophrenia states that

schizophrenia results from too much dopaminergic

activity in the msolimbic pathway

The theory evolved from two observations:

 The efficacy and the potency of many antipsychotic drugs

89 (i.e.,
1 the dopamine receptor antagonists )
  Drugs that increase dopaminergic activity, notably

cocaine and amphetamine, are psychotomimetic.

 Up to 75% of patients with schizophrenia have

increased signs and symptoms of their psychosis upon

challenge with moderate doses of methylphenidate or

amphetamine or other dopamine-like compounds.

90 1
 DOPAMINE PATHWAYS IN THE BRAIN
1.Nigrostrial Pathway: Substantia Nigra to Basal Ganglia
(movement)
2.Mesolimbic Pathway: Venteral Tegmental Area (VTA) of the
Brainstem to Limbic Systems of the Brain (Positive
schizophrenia symptoms
3.Mesocortical Pathway: VTA to Frontal Cortex (Negative
&Cognitive schizophrenia symptoms)
4.Tuberoinfundibular Pathway: Hypothalamus to Anterior
Pituitary Gland (Prolactin secretion)
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92 1
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 Five Symptoms dimension in schizophrenia
1.Positive symptoms of Schizophrenia
 Delusion
Hallucination
Disorganized Speech and Behavior
Catatonic Behavior

2. Negative symptoms of Schizophrenia [4 A'S]

Asocialia

Avolition

Anhedonia

Affective flattening
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 Negative symptoms are:

 More refractory to treatment

 Atypical antipsychotics better than typical ones

3. Cognitive symptoms of Schizophrenia

 Impaired attention
Impaired information processing

Impaired learning

Impaired thought

Impaired memory

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 4. Aggressive symptoms of Schizophrenia
 Hostility

 Verbal abusiveness

 Physical Assault

 Self-injurious behavior including suicide

 Arson/property damage

 Impulsiveness

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5. Depressive/Anxious symptoms of Schizophrenia

 Depressed mood

 Anxious mood

 Guilt

 Tension

 Irritability

 Depression develops in 25-50% of individuals with

schizophrenia and can be associated with suicidal

behaviour
1
99
 Sub-Types of Schizophrenia
1.Paranoid Subtype

 Pre-occupation with one or more delusions of persecutions or

grandeur

 Frequent auditory hallucinations

 First episode of illness at an older age

 Show less regressions of their mental faculties, emotional

responses and behaviors than the other types d/o.

 Comparing to other sub-types paranoid type show better outcome

100 1
 2. Disorganized Subtype

 Disorganized thought, speech, and behaviour

 Affective flattening

 Marked regression to primitive /childhood state

 Onset before the age of 25

 Poor outcome

101 1
 3. Catatonic Subtype
 Marked disturbance of motor activity that is apparently

purposeless and not influenced by external stimuli

 Motoric immobility evidenced by stupor, waxy flexibility

Negativism, rigidity, excitement

 Peculiarities of voluntary movement e.g. mannerisms

 Echolalia or echopraxia

Two of the above symptoms are required.

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 4. Undifferentiated Subtype
Criterion A symptoms are present, but the criteria are
not met for the paranoid, disorganized, or catatonic
behavior.
5. Residual Subtype
Presence of continuing evidence of schizophrenia
symptoms in the absence of active symptoms.
Presence of Emotional blunting, social withdrawal,
anhedonia, odd beliefs.

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DSM 5 diagnostic criteria for Schizophrenia
A. Two or more of the following each present for a
significant portion of time during a 1 month period(or
less if successfully treated) .At least one of these must be
1,2 or 3
1.Delusion
2.Hallucination
3.Disorganised speech
4.Grossly disorganized or catatonic behaviour

104
5.Negative
1 symptoms
 B. Social or occupational impairment

C. Duration: Continuous sign of disturbance for 6

months

D. Exclusion: Schizoaffective and mood disorder

E. The disturbance is not due to Substance/General

Medical Condition

F. Relationship to a pervasive developmental disorder

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 Management
Therapeutic principle

Define the target symptoms to be treated

An antipsychotic that has worked well in the past for a

patient may be used

The minimum length of an antipsychotic trial is 4-6

weeks at adequate dosages

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 If trial is unsuccessful a different antipsychotic drug,

usually from different class can be tried

In Treatment resistance cases, combination of

antipsychotics with other drugs e.g. carbamazepine,

lithium, valproate is recommended

Maintain on the lowest possible effective dosage of

1
medication
107
 Pharmacological therapy
Typical antipsychotics

 Low potent : Chlorpromazine, Thioridazine

 Medium potent: Stelazine, Perphenazine

 High potent: Haloperidol, Fluphenazine

deconate/Modicate injection

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Atypical antipsychotics

e.g. Clozapine, Risperidone, Olanzapine

Similar efficacy with typical ones except for side effect

profile
Clozapine is effective in severely ill, refractory cases &

pts With Tardive Dyskinesia/TD/

Associated with Agranulcytosis in 1-2%

Weekly monitoring of CBC is required

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 Duration of therapy
1st episode- maintenance therapy for 1-2 years

Multi-episode- maintenance therapy for 3- 5 years

Several severe episodes ,suicidality, violence,

aggression may require indefinite maintenance therapy

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Old generation /dopamine antagonist/conventional antipsychotic
that are used to Rx psychotic d/o and available in Ethiopia
Generic name Dose/mg/day rout

Chlorpromazine 100-1000 PO/IV

Fluphenazine 2-20 PO

Haloperidol 2-20 PO/IM

Thiorizadine 100-800 PO

Trifluoperazine 5-50 PO

Fluphenazine 12.5-75 IM
deconate(medicate)
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 New generation /dopamine –serotonine antagonist that are used to
Rx psychotic d/o and available in Ethiopia
Generic name Dose/mg/day rout

Risperidone 2-8 po

Olanzapine 5-20 po

Clozapine 25-450 po

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 Psychological therapy
 Psychosocial support

Psychosocial support
 Psycho education

 Addressing current psychosocial stressors

 Reactivating social networks

• Communicating well can be a form of support in itself

• Be genuine and respectful
• Listen well and show your understanding
• Offer regular follow-up
•

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 UNIT FIVE: MOOD DISORDERS
Mood disorders are heterogeneous groups of psychiatric

disorders in which :
Pathological moods,

Vegetative symptoms &

Psychomotor disturbances dominate the clinical

pictures.

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 Magnitude of mood disorders
Mood disorders are one of the most common mankind
illnesses.
WHO has ranked major depression the fourth among
the list of the most urgent health problems worldwide.
Depressive disorder affects one out of five women &

one out of ten men during their lives.

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 Bipolar disorders constitute at least 5% in general population.

People affected by mood disorders are at high risk for suicide

Furthermore, many people with mood disorders are disabled.

Thus, mood disorders are truly public health problems

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 Etiology
Biological Factors

 Monoamine neurotransmitters: nor epinephrine,

dopamine, & serotonin were the main focus of theories

and research about the etiology of these disorders;
serotonin and
nor epinephrine being the most implicated.

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 Genetic Factors

 Numerous family, adoption, and twin studies have long

documented the heritability of mood disorders.

Psychosocial Factors

 Life Events and Environmental Stresses

The most compelling data indicate that the life event

most often associated with development of depression is

losing a parent before age 11.

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  The environmental stressor most often associated with

the onset of an episode of depression is the loss of a

spouse.

 Another risk factor is unemployment; persons out of

work are three times more likely to report symptoms of

an episode of major depression than those who are
employed.

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 Classification of Mood Disorders
I. Unipolar mood disorders
Major depressive disorder
Dysthymia
II. Bipolar mood disorders
Bipolar I disorder

Bipolar II disorder

Cyclothymia

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 Major Depressive Disorders (MDD)
DSM 5 Criteria for Major Depressive Episode
A. Five (or more) of the following symptoms have been

present during the same 2-week period and represent a

change from previous functioning; at least one of the
symptoms is either

 depressed mood or

 loss of interest or pleasure.

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1. Depressed mood most of the day, nearly every day, as
indicated by either subjective report (e.g., feels sad or
empty) or observation made by others (e.g., appears
tearful). Note: In children and adolescents, can be irritable
mood

2. Markedly diminished interest or pleasure in all, or almost

all, activities most of the day, nearly every day

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 3. Significant weight loss when not dieting or weight
gain

4. Insomnia or Hypersomnia nearly every day

5. Psychomotor agitation or retardation nearly every day

6. Fatigue or loss of energy nearly every day

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 7. Feelings of worthlessness or excessive or inappropriate
guilt
8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day
9. Recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing suicide

124 1
 B. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
C. The episodes are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication)
or another medical condition (e.g., hypothyroidism).
D. Exclusion of schizoaffective d/o,schizophrenia,& other
psyhiatric d/o
E. They has never been a manic and hypomanic episode.
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 Dysthymia
Is low grade, intermittent & protracted depression

The essential features of dysthymic disorder include:

Habitual gloom/brooding,

Lack of joy in life, and

Preoccupation with inadequacy .

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 Dysthymia disorder characterized as:

 Long-standing,

Fluctuating,

Low-grade depression,

Experienced as part of the habitual self and

Representing an accentuation of traits observed in the

depressive temperament

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 DSM 5 Diagnostic Criteria for Dysthymia Disorder

A. Depressed mood for most of the day, for at least 2

years.

Note: In children and adolescents, mood can be irritable

and duration must be at least 1 year.

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 B. Presence, of two (or more) of the following: in

addition to depressed.

1. Poor appetite or over eating

2. Insomnia or hypersomnia

3. Low energy or fatigue

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 4. Low self-esteem

5. Poor concentration or difficulty making decisions

6. Feelings of hopelessness.

C. During the 2-year period (1 year for children or

adolescents) of the disturbance, the person has never been
without the symptoms in Criteria A and B for more than 2
months at a time.

D. Criteria for major depressive disorder may be continuously

130 present
1 for 2 years.
 E. There has never been a manic or a hypomanic episode,
and criteria have never been met for cyclothymic d/o

F. The disturbance does not occur exclusively during the

course of a chronic psychotic disorder, such as
schizophrenia or delusional disorder.

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 G. The symptoms are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g.,
hypothyroidism).

H. The symptoms cause clinically significant distress or

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

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 Bipolar I Disorder
 defined as having a clinical course of one or more manic, or
mixed episodes and, sometimes, major depressive episodes.
 DSM 5 Criteria for Manic Episode

A. A distinct period of abnormally and persistently elevated,

expansive, or irritable mood, lasting at least 1 week (or any
duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of

the following symptoms have persisted (four if the mood is
only irritable) and have been present to a significant degree:

133 1
 1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (e.g., feels rested after only 3

hours of sleep)
3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts

are racing
5. Distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external stimuli)
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 6. Increase in goal-directed activity (either socially, at

work or school, or sexually) or psychomotor agitation

7. Excessive involvement in pleasurable activities that

have a high potential for painful consequences (e.g.,

engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)

C. The mood disturbance is sufficiently severe to cause

marked impairment in occupational functioning.
135
 D. The symptoms are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication, or other treatment) or another medical
condition (e.g., hyperthyroidism).

136 1
 Bipolar II Disorders

DSM 5 Diagnostic Criteria for Bipolar II Disorder

A. Presence history of one or more major depressive

episodes.
B. Presence history of at least one hippomanic episode.
C. There has never been a manic episode .
D. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important

137
areas
1
of functioning.
 DSM 5 Criteria for Hypo manic Episode

A. A distinct period of persistently elevated, expansive, or

irritable mood, lasting throughout at least 4 days

B. During the period of mood disturbance, three (or more)

of the following symptoms have persisted (four if the

mood is only irritable)

138 1
 1. Inflated self-esteem or grandiosity

2. Decreased need for sleep

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility

6. Increase in goal-directed activity

7. Excessive involvement in pleasurable activities

139 1
C. The episode is associated with an unequivocal change in
functioning that is uncharacteristic of the person when not
symptomatic.

D. The disturbance in mood and the change in functioning

are observable by others.

E. The episode is not severe enough to cause marked

impairment in social or occupational functioning, or to
necessitate hospitalization, and there are no psychotic
features.
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 Cyclothymic Disorder
DSM 5 Diagnostic Criteria for Cyclothymic Disorder

A. For at least 2 years, the presence of numerous periods

with hypo manic symptoms and numerous periods with
depressive symptoms that do not meet criteria for a major
depressive episode.

141 1
 B. During the above 2-year period, the person has not
been without the symptoms in Criterion A for more
than 2 months at a time.

C. No major depressive episode, manic episode has been

present during the first 2 years of the disturbance.

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D. The symptoms in Criterion ‘A’ are not better accounted for
by schizoaffective disorder and are not superimposed on
schizophrenia, schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise specified.

E. The symptoms are not due to the direct physiological effects

of a substance (e.g., a drug of abuse, a medication) or a
general medical condition (e.g., hyperthyroidism).

F. The symptoms cause clinically significant distress or

impairment in social, occupational, or other important areas
143 1
of functioning.
 MANAGEMENT OF MOOD DISORDERS

Accurate diagnosis is crucial, because unipolar and

bipolar spectrum disorders require different

treatment regimens.

144 1
 Major Depressive Disorder
Psychotherapy

Low social dysfunction suggested a good

response to interpersonal therapy;
Low cognitive dysfunction suggested a good
response to cognitive-behavioral therapy
and pharmacotherapy.

145 1
 High work dysfunction suggested a good response to
pharmacotherapy; and

High depression severity suggested a good response to

interpersonal therapy and pharmacotherapy.

146 1
 Pharmacotherapy
All currently available antidepressants may take up to 3

to 4 weeks to exert significant therapeutic effects,

 Although antidepressant drugs,

 Tricyclic Antidepressants (TCAs),

Selective Sretonin Re uptake Inhibtors (SSRIs) have

made the treatment of choice for depression that

more clinician and patient friendly.•

147 1
 General Clinical Guidelines
 The most common clinical mistake leading to an unsuccessful trial of

an antidepressant drug is

 the use of too low a dosage for too short time.

 Unless adverse events prevent it, the dosage of an antidepressant

should be raised to the maximum recommended level and

maintained at that level for at least 4 or 5 weeks before a drug trial

is considered unsuccessful.

 Antidepressant treatment should be maintained for at least 6 months

or the length of a previous episode, whichever is greater.

148 1
 ANTIDEPRESSANT DRUGS INCLUDE:

TCA e.g. Amitriptyline, imipramine, Chlomipramine…

SSRI e.g. Fluoxetine, Sertraline…

Electro Convulsive Therapy (ECT) is effective in

psychotic and non psychotic forms of depression, but is
recommended generally only for repeatedly nonresponsive
cases or in patients with very severe disorders.

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 Bipolar Disorders
1. Lithium Carbonate
Lithium carbonate is considered the first line mood

stabilizer
Yet, because the onset of anti-manic action with

lithium can be slow,

150 1
 It usually is supplemented in the early phases of
treatment by Atypical Antipsychotics, Mood-
Stabilizing Anticonvulsants, or High-Potency
Benzodiazepines.
Therapeutic lithium levels are between 0.6

and 1.2 mEq/L.

 Dose level is 300 mg up to 1800 mg

151 1
 2. Na -Valporate
 Valporate (valproic acid ) has surpassed lithium in use for

acute mania.

 Typical dose levels of valproic acid are 750 to 2,500 mg

per day.

152 1
 3. Carbamazepine

 Carbamazepine has been used worldwide for

decades as a second line treatment for acute mania,
but has only gained approval in the United States in
2004.
 Typical doses of carbamazepine to treat acute mania
range between 600 and 1,800 mg per day associated
with blood levels of between 4 and 12 µg/mL.

153 1
 4. Clonazepam and Lorazepam
The high-potency benzodiazepine anticonvulsants

used in acute mania include clonazepam (Klonopin)

and lorazepam (Ativan).

Both may be effective and are widely used for

adjunctive treatment of acute manic agitation,

insomnia, aggression, and dysphoria, as well as panic.

154 1
 5. Atypical Antipsychotics

 All of the atypical antipsychotics olanzapine & risperidone

have demonstrated antimanic efficacy.

155 1
 NE & 5-HT reuptake inhibitors/TCAs

Generic name Dose/mg/day rout

Amitriptyline 75-300 po
Imipramine 50-150 po

 Mood stabilizers used to Rx bipolar I,II and cyclothymia which

are available in Ethiopia
Generic name Dose/mg/day rout

Lithium 300-1800 po

Carbamazepine 300-1800 po

Valproate 750-2500 po
156 1
157 1