PSYCHIATRY

NOTES
PZ4M
COMPILED BY E. ZIUMBWA

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HISTORY TAKING AND
MENTAL STATE
EXAMINATION
Michelle Dube
Psychiatrist

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 2

Myths About Mental Illness

• People who need psychiatric care should be
placed in institutions.
• A person with a mental illness can never be
normal.
• An individual with mental illness is dangerous.
• People with mental illness aren’t suited for
important, responsible positions.

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• An IMPORTANT diagnostic tool

• From the time a patient enters until they leave

• To assess the patient to identify any mental health

difficulties.

• Can be therapeutic.

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Set the scene
• Ensure Privacy &
Confidentiality

• Try to avoid
interruptions

• Safety- Seating
arrangement

• Note taking

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General principles
• Put the patient at ease

• Introduce yourself & anyone accompanying you &

explain their role

• Length of interview (50minutes)

• Interview patients in first language where

possible. May need interpreter

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Interview style
• Keep relaxed & in control

• Appropriate eye contact, be interested

• Begin with a general question eg “tell me about your

problem”

• Have a systematic but flexible approach

• May need to interrupt

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Interview techniques
• Open questions as much as possible

• Closed questions can be helpful especially for ……?

• Avoid leading questions eg “You have a poor appetite,

don’t you?”

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Interview techniques
• You may have to explain the rationale of certain questions, eg
abuse, criminal record etc.

• Summarise to check understanding

• Don’t take words at face value eg “paranoid”

• Pick up non-verbal cues

• Encourage patient by using encouragers such as leaning

forward, nodding, saying “go on” “tell me more about…..”

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 Collateral information
• Always useful particularly if patient is cognitively
impaired, patient is concealing information

• Often best to see patient alone first and then with

informant
• Ascertain informants concerns as well as gather
information.

• Symptomatology, cultural beliefs & treatment

expectations may vary

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History
• Presenting Complaint
• History of presenting complaint
• Past Psychiatric History
• Past Medical History
• Family History
• Personal History
• Substance Use
• Drug History
• Forensic History
• Personality
• Current Social Situation

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Presenting Complaint(s)
• Mode of referral
• Where is patient being seen.
• What is their problem, in their own words
• Why now?

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History of presenting complaint
• Nature of problem
• Chronology of each symptom
• Onset & duration
• Severity of symptoms & Degree of functional impairment
Precipitating factors
• Perpetuating factors
Protective factors
• Factors worsening or improving
• Treatments trialled

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Past psychiatric history
• Similar or other symptoms in the past
• Psychiatric diagnosis
• Psychiatric admission
• Any treatments (drugs, psychotherapy, psychosocial
interventions, from primary care, counselling
• Outcomes of treatment, any recovery, remission etc
• Suicide, DSH attempts

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Past medical history
• Full medical history
• Endocrine, CNS, systemic illness,
• History of Head Injury – duration of loss of consciousness is
very important prognostic factor
• Chronic medical conditions: diabetes, ischemic heart disease,
epilepsy, asthma (use of steroids), CCF, stroke,
• HIV status – Date and result of last test
• Chronology of illnesses, hospitalizations
• Recovery

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Medications history
• Current medications
• All drugs taken for psychiatric or medical illness: dose,
duration and outcome
• Drugs that may precipitate psychiatric disorders
• Side effects of psychiatric medication
• Allergies
• May need to check with the GP

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Family history
• Family tree to include patient’s siblings and
parents eg adoptees, biological etc, separation,
divorce, steps
• Pt’s nature of relationship with the family &
among family
• Nature of death if any one not alive

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Family Psychiatric History
• Known or suspected Hx of mental illness

• Suicides, suicidal behaviours

• Hx of DSH in relatives

• Hx of substance misuse

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Personal history
• Mother’s pregnancy
• Neuro-developmental milestones – birth,
walking, talking, sitting & socializing age
• Childhood separation or emotional problems
• Home & school environment (Bullying, school
refusal, shyness, conduct disorders)
• Schooling and academic achievements
• Relationships with friends and family

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Personal Hx continued
• Occupation: Profession and employment record,
Current employment
• Financial situation in general
• Current and past debt problems, spending etc
• Psychosexual: Age at sexual debut, sexual orientation.
Marital status – single, married, divorced, widowed
• Children – ages if dependent, parental responsibility
• Housing situation, past and present-living alone

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Drug History
• Alcohol Use debut: age, where, with who, why
• ? Increasing use
• ?Last drink
•C A G E

• ANY OTHER DRUG OF ABUSE

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Forensic history

• Past and present charges, penalties, arrests and convictions

(Violence/Anger, sexual offences etc)
• Pending court cases
• Unrecorded offences
• Relationship to symptoms & substance misuse

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Pre morbid personality
• Life long persistent characteristics prior to
illness
• Moral and religious beliefs
• Leisure activities and hobbies
• How would others eg relatives/friends describe
them

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Mental state examination
• Here and now
• More reliant on observation & skilful
exploration
• History should guide you in making certain
observations

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Appearance and behaviour
• Body language & appropriateness of dress
• Evidence of self neglect
• Under or over psychomotor activity – excitation
or retardation
• Facial expression – dilated pupils, rigidity
• Abnormal movements or posture
• Rapport & eye contact
• Distractibility
• Disinhibition
Preoccupation
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Speech
• Rate, tone & volume
• Level of coherence
• Rate: slow in depression; pressured in
mania.
• Quantity: poverty in depression & chronic
schizophrenia
• Pattern: spontaneous, coherence,
circumstantial, trivial details eg
obsessional traits, perseveration
• Neologisms, word salad, loosening of
associations
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Mood
• Subjective description-Sad, happy, top of the
world, worried, up & down.
• Range: depression – euthymic – euphoria
• Inability to enjoy activities (anhedonia)
• Inability to describe one’s emotion
(alexithymia)

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Affect
• Your objective description of emotion
• Depressed, anxious, fearful, irritable,
suspicious, perplexed, elated, angry
• Fluctuations: reactivity, lability (mania),
blunting (chronic schizophrenia)
• Congruent with mood, thoughts/behaviour?

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Thought
• Has 2 aspects: Form & Content

• Pre-occupations: thoughts that recur frequently but can be

put out of mind

• Delusion ....out of keeping with the patient’s social & cultural

background.

• Delusional perception: eg traffic light change means pt has

been chosen to be President.

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Thought Content continued
• Delusions can be of:
• persecution e.g Schizophrenia
• infidelity – Othello Syndrome
• grandiose – B.M. D
• hypochondriacal,
• Love -
• guilt, nihilistic, poverty e.g. Depression
• Reference - Schizophrenia
• infestation.

• Thought insertion, withdrawal, broadcast

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Perceptions
• Illusions
• Hallucinations
• Auditory (2nd, 3rd) visual gustatory, olfactory
(organic, TLE), tactile (cocaine addiction, drug
withdrawals)
• Voices- echo, running commentary & 3rd PAH
• Passivity phenomena
• Derealisation & depersonalization
• déjà vu, Jamias Vu

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Cognition
• Level of Consciousness
• Orientation to time, place & person
• Attention and concentration (serial 7 subtraction)
• Memory – Registration, short term and long term memory
• Separate poor concentration from memory problems
• Abstract thinking
• Judgement
• Intelligence

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Insight
• Awareness of abnormal state of mind
• Insight rests on a continuum

• Ask the patient if they think they are ill

• Mentally or physically
• Ask the patient if they are willing to accept help
• Ask the patient if they will take treatment

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Multiaxial System
• Axis I: Clinical Disorders and Other Conditions That May Be a
Focus of Clinical Attention
• Axis II: Personality Disorders and Mental Retardation
• Axis III: General Medical Conditions
• Axis IV: Psychosocial and Environmental Problems
• Axis V: Global Assessment of Functioning

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 DR FT Muchirahondo

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Psychiatry
 Defined as the division of medicine that deals
with the diagnosis, treatment and prevention of
mental, emotional and behavioral disorders.
 It entails development of the capacity to collect
data to collect data objectively and accurately by
history taking and examination of the mental
state, and to organize the data in a systematic
and balanced way.
 Also entails the capacity of intuitive
understanding of each patient as an individual.

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 WHO defines mental health as a state of
complete mental and social being not just the
absence of disease.
 Psychiatry is therefore related to the
promotion of mental wellbeing i.e. the
prevention of mental disorders and the
treatment and rehabilitation of people
affected by mental disorders.

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Signs and symptoms consist of
 Disorders of speech
 Disorders of mood
 Disorders of thought
 Disorders of perception
 Disorders of memory
 Disorders of personality
 Other such as physical symptoms e.g.
anxiety, motor symptoms of mental illness,
somatization; Phobias

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Disorders of speech

 Pressure of speech :-Rapid speech that is

increased in amount & difficult to interpret
 Poverty of speech :Restriction in the amount of
speech
 Dysprosody: Loss of normal speech melody
 Dysarthria: Difficulty in articulation
 Stuttering :Frequent repetition/ prolongation of
a sound/syllable leading to markedly impaired
speech fluency
 Neologisms- words that a patient makes up.

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Clinical implications
 Speech expressive problems Brain
involvement, developmental problems
 Pressure of speech :Mania
 Poverty of speech: depression, schizophrenia
 Mutism/Alogia :-Depressive Sx/Catatonia

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 Objective  Objective( Noted by the
 Pervasive and examiner)
sustained emotion, not
influenced by will
 Classified as blunted,
flattened, broad, labile,
 Sadness, elation,
appropriate &
aggression
congruent

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Disorders of mood and affect
 Depressed or low mood [ depression]
 Elated mood; : Mood consists of feelings of joy,
euphoria, and intense optimism (mania)
 Incongruity of affect: affect does not reflect
reported mood
 Disorders of mood found in many psychiatric
conditions. They are central to mood disorders.
 Apathy of mood ; total loss of emotion and
inability to feel pleasure.
 Blunted affect associated with reduced ability to
variation of mood.[often associated with
schizophrenia]

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Clinical implications

 Elation, Euphoria : Mania, intoxication

 Anxious/restlessness: Anxiety
 Sad, /depressed: Depression( Irritability,
anger in children)
 Blunted, indifferent, restricted, inappropriate:
Schizophrenia
 Anhedonia: Depression

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Perception
 Complex process Of screening of physical
signals by sense organs by processing these
data to represent reality.
Imagery:
 Awareness of a percept that has been
generated within the mind. Imagery can be
called up and terminated by an effort of
will(voluntary).

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Disorders of perception
 Illusion: Misperceptions of external stimuli
(anxiety and delirium)
 Hallucination
 A true hallucination will be perceived as in
external space, distinct from imagined
images, outside conscious control, and as
possessing relative permanence

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Hallucinations
 a percept experienced in absence of an
external stimulus to the sense organs and
with similar qualities to a true percept.[
experienced as originating in the outside
world.
 Can occur in all sensory modalities i.e.
visual, auditory, olfactory, gustatory, tactile,
can also be deep sensation.

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Types of hallucinations
 Auditory hallucinations—false perceptions of sounds
(2nd person, 3rd person, thought echo, running
commentary)
 Gustatory hallucinations—false perceptions of taste.
 Olfactory hallucinations—false perceptions of smell.
 Visual hallucinations—false visual perceptions with
eyes open in a lighted environment. Can be
microscopic or macroscopic, extracampine( outside
visual field), autoscopic ( seeing one’s body projected
in space)

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 Olfactory and gustatory hallucinations; are
often experienced together often as
unpleasant smells and taste. Can occur in
conditions such as schizophrenia but are
suggestive of temporal lobe epilepsy.
 Tactile hallucinations; maybe experienced as
sensations of being touched, pricked, or
strangled, or as insects crawling under the
skin[ often experienced in abuse of cocaine].

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Clinical implications
 3rd person auditory hallucinations: suggestive of
schizophrenia
 Thought echo, running commentary;
schizophrenia
 Visual hallucinations :-Suggestive of organic
mental disorders but are seen in functional
disorders.

 Gustatory, olfactory, and tactile hallucinations:

Strongly suggest organic mental disorders.
 Tactile hallucinations: Common in drug and
alcohol withdrawal and intoxication states.

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Thoughts
 Disorders of thought form
 Disorders of stream
 Types of abnormal thinking Delusion,
Overvalued idea, depressive cognition,
suicidal idea, obsessions

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Disorders of stream of thought;
 Both amount and speed of are changed.
 Flight of ideas( pressure of thought) reflected in speech
as pressure of speech common in mania]; ideas arise with
unusual abundance and variety, as if they are racing in
one’s mind.
 Poverty of speech, patient has a few thoughts with lack of
variety and richness, and which seem to move through
one’s mind slowly[ occur in depressive states and
schizophrenia].
 Thought blocking -Stream of thought can be interrupted
suddenly by an experience in which the patient’s mind
goes blank, noticed by an observer as interruption in flow
of conversation, highly suggestive of schizophrenia

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Disorders of thought form
 Circumstantiality-: exhibits lack of goal
directedness, incorporates tedious and
unnecessary details and has difficulty in arriving
at an end point.
 Tangentiality – Pt digresses from subject under
discussion and introduces thoughts that seem
unrelated, oblique, and irrelevant.
 Loosening of associations- jumping from one
topic to another with no apparent connection
between the topics.( common in schizophrenia)

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Thought form cont.

 Word salad –incomprehensible mixing of many

words and phrases( severe form of loosening of
associations)
 Clang associations- a form of loosening of
associations in which the association between
words can be tenuous and patient uses rhyming
and punning.
 Perseveration- pt. repeats the same response to
a variety of questions and topics, found in
dementia

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Clinical implications
 Poverty of thought: schizophrenia
 Thought block: schizophrenia
 Flight of ideas : mania
 Circumstantiality, tangentiality: Schizophrenia
 Loosening of association : Schizophrenia
 Perseveration Dementia
 Word salad: Severe form of thought
disintegration as in schizophrenia

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Types of abnormal thinking

 Delusions,
 Suicidal thoughts
 Obsessions

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Delusion;
 A belief that is firmly held on inadequate
grounds, is not affected by rational argument or
evidence to the contrary, and is not in keeping
with the person’s educational cultural or religious
background. It is usually a false belief.
 Can be primary or secondary. A primary delusion
appears suddenly with no mental events leading
to it. A secondary delusion is derived from some
preceding morbid experience e.g. someone
hearing voices may come think he is being
followed.

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Types of delusions
 Delusions of persecution: being followed,
harassed, threatened, or plotted against.
 Delusions of grandeur: being influential and
important, perhaps having occult powers, or
actually being some powerful figure out of
history (Napoleonic complex).
 Delusions of reference: external events or
“portents” have personal significance, such as
special messages or commands

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Types of delusions cont.

 Delusions of love characterized by the

patient's conviction that another person is in
love with him or her ( De-Clerembauldt)
 Delusions of guilt :A delusional belief that
one has committed a crime or other
reprehensible act. (psychotic Depression)
 Delusions of control: (passivity)The core
feature is the delusional belief that one is no
longer in sole control of one's own body.

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 Hypochondriacal delusions founded on the
conviction of having a serious disease.
 Delusional jealousy: A delusional belief that
one's partner is being unfaithful (Othello
syndrome)
 Delusional misidentification: A delusional belief
that certain individuals are not who they
externally appear to be.
 The delusion may be that familiar people have
been replaced with outwardly identical strangers
(Capgras syndrome) or that strangers are (really)
familiar people (Fraegoli syndrome).

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 Delusions of thought interference:. A group of
delusions which are considered first-rank
symptoms of schizophrenia:-thought , thought
insertion withdrawal, and thought broadcasting
 Nihilistic delusion: A delusional belief that the
patient has died or no longer exists or that the
world has ended or is no longer real. Nothing
matters any longer and continued effort is
pointless. A feature of psychotic depressive
illness

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Obsessions
 It is a thought, idea, imagery or impulse which is
repetitive , intrusive, irrational, recognized as
ones own thought .
 Contamination obsessions
 Aggressive obsessions
 Pathological doubts
 Sexual obsessions
 Blasphemous obsessions
 Obsessive ruminations
 miscellaneous

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 Delusional perception-
 Attribution of new meaning in the sense of
self reference to a normally perceived object
 The new meaning cannot be understood as
arising from the patient’s affective state or
previous attitudes

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 Phobias
 Persistent irrational fear of and a wish to avoid a specific object,
activity, or situation. Fear is out of proportion with the real
danger and is recognized as such by the subject. Often patient
finds it difficult to control fear and often avoids the feared object
or situation. Phobic patients feel anxious when confronted with
the feared object or situation.

Depersonalization and derealization

 Depersonalization; a change in self awareness such that the
person feels unreal.
 Derealization; objects and people around appear unreal.
 Often associated with changes in body image such as the feeling
that a limb has changed in size or shape or feeling of being
outside one’s body.[ often found in temporal lobe epilepsy]

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 Motor symptoms and signs
 Tics; irregular repeated movements of muscles.
 Mannerisms repeated movements that appear to
be of functional significance.
 Stereotypes; repeated that are regular and
without obvious significance, e.g. rocking.
 Posturing; adoption of abnormal bodily postures.
 Echopraxia; imitation the interviewer’s
movements.
 Waxy flexibility; when a patient’s limbs can be
placed in a position in which they can remain for
hours.

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 Disorders of memory
 Failure of memory is. amnesia

 Memory is affected by several kinds of psychiatric

conditions. Organic brain disorder generally affects all
aspects of memory.
 Following a period of unconsciousness, there is a poor
memory for interval between ending of complete
unconsciousness and restoration of full consciousness;-
anterograde amnesia.
 Inability to recall events just before period of
unconsciousness is called retrograde amnesia. This is
found in some causes of unconsciousness e.g. head injury
and E.C.T.

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 Concentration-reflects patient’s ability to focus and
maintain attention on a particular task. Pt shows
inability to pay attention to questions asked by
examiner. Formal testing of attention should however
be done.
 Abstract thinking-refers to the capacity to formulate
concepts and to generalize e.g. similarities
interpretation of proverbs.
 Concrete thinking refers to literal translation of
abstract concepts.
 Judgment – pt’s capacity to make appropriate
decisions ; impaired in many psychiatric conditions
 Insight- the capacity of a pt to be aware and to
understand that he or she has a problem or an
illness.

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Disorders of body image
 Unilateral unawareness and neglect – arises often in
lesions of the parietal lobe[ supramarginal and
angular gyri]. Patient may neglect to wash one side of
the body
 Anosognosia- lack of awareness of disease, often
manifest on the left. Maybe denial of blindness
[Anton syndrome.]
 Distorted awareness of size and shape e.g. feelings
that a limp is enlarging, becoming smaller, or
distorted- may occur as part of the aura of epilepsy or
after taking some drugs . May also occur in
schizophrenia.
 Reduplication phenomena- feeling that part of one’s
body has been duplicated e.g. having feeling one has
2 heads can occur in temporal lobe epilepsy and
schizophrenia

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SCHIZOPHRENIA

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 What is Psychosis?
• Generic term
• “Break with Reality”
• Psychosis is a symptom, not a diagnosis
• Caused by a variety of conditions that affect the
functioning of the brain.
• Has the following symptoms:
• hallucinations,
• delusions and
• Disorganized behaviour/thought disorder

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Psychosis can occur in different
conditions

P
Mood disorders S
Y Substance
C induced
“organic” mental
H disorders
“Functional” O
disorders S Delirium
Schizophrenia
I Dementia
“spectrum”
S Amnestic d/o
disorders

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Differential Diagnoses: (Cont)
• Personality disorders • Miscellaneous
Schizoid PTSD
Schizotypal Dissociative disorders
Malingering
Paranoid
Culturally specific phenomena:
Borderline
Antisocial Religious experiences
Meditative states
Belief in UFO’s, etc

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Workup of New-Onset Psychosis:
“Round up the usual suspects”
• Good clinical history
• Physical exam
• Labs/Diagnostic tests:

U+E, LFT URINE DRUG SCREEN!!!

FBC
RPR, VDRL CSF/LP
Serum Alcohol HIV serology
Urinalysis CT or MRI
Thyroid profile EEG

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 Schizophrenia
• Is a syndrome
• A psychotic disorder with major disturbances in
thought, emotion, and behavior
• Disordered thinking
• Ideas not logically related
• Faulty perception and attention
• Lack of emotional expressiveness
• Incongruent or flat emotions
• Disturbances in movement or behavior
• Unkempt appearance
• Disrupts interpersonal relationships, diminish
capacity to work or live independently
• Significantly increased rates of suicide and death

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 Schizophrenia
• Lifetime prevalence ~1%
• M=F
• Onset typically late adolescence or early adulthood
• Peak age of onset is 10 to 25 years for men and 25 to 35 years for
women.
• About 90 percent of patients in treatment for schizophrenia are
between 15 and 55 years old.
• Onset of schizophrenia before age 10 years or after age 60 years
is extremely rare.
• Some studies have indicated that men are more likely to be
impaired by negative symptoms than women.
• Women are more likely to have better social functioning than are
men before disease onset.
• In general, the outcome for female schizophrenia patients is better
than that for male schizophrenia patients.

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 History
• Emil Kraepelin: This illness develops relatively early in life, and
its course is likely deteriorating and chronic; deterioration
reminded of dementia (Dementia praecox), but was not followed
by any organic changes of the brain, detectable at that time.
• Eugen Bleuler: He renamed Kraepelin’s dementia praecox as
schizophrenia (1911); he recognized the cognitive impairment in
this illness, which he named as a „splitting“ of mind.
• Bleuler described the following 4 fundamental symptoms:
• affective blunting
• disturbance of association (fragmented thinking)
• autism
• ambivalence (fragmented emotional response)
• Kurt Schneider: He emphasized the role of psychotic
symptoms, as hallucinations, delusions and gave them the
privilege of „the first rank symptoms” even in the concept of the
diagnosis of schizophrenia.
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Course of Illness

• Course of schizophrenia:
• continuous without temporary improvement
• episodic with progressive or stable deficit
• episodic with complete or incomplete remission

• Typical stages of schizophrenia:

• prodromal phase
• active phase
• residual phase

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 DSM5 criteria for schizophrenia
A. Characteristic Symptoms
B. Social/occupational dysfunction
C. Duration of 6 months
D. Schizoaffective and mood disorder exclusion
E. Substance/general medical exclusion
F. Relationship to pervasive developmental disorder

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DSM-5 Criteria for Schizophrenia
A. Two or more symptoms lasting for at least 1 month; one
symptom should be 1, 2, or 3:
1) Delusions
2) Hallucinations
3) Disorganized speech
4) Abnormal psychomotor behavior (catatonia)
5) Negative symptoms (blunted affect, avolition, asociality)
B. Functioning in work, relationships, or self-care have
declined since onset
C. Signs of disorder for at least 6 months; at least 1 month
of the symptoms above; or, if during a prodromal or
residual phase, negative symptoms or two or more of
symptoms 1-4 in less severe form

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Symptom dimensions in schizophrenia
• Psychotic • Neurocognitive –
• Hallucinations Impairments
• Suspiciousness • Memory
• Delusions • Attention
• Negative • Motor skills
• Impoverished speech • Social cognition
• Lack of motivation • Executive skills
• Asociality • Disorganized speech
• Decreased Affect

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Clinical Description of
Schizophrenia
• Three major clusters of symptoms:
• Positive
• Negative
• Disorganized

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 © 2012 John Wiley & Sons, Inc. All rights reserved.

Positive Symptoms:
Behavioral Excesses and Distortions
• Delusions • Hallucinations
• Firmly held beliefs • Sensory experiences in the
• Contrary to reality absence of sensory
stimulation
• Resistant to disconfirming
evidence
• Types of delusions:
• Types of hallucinations:
• Persecutory delusions
• Auditory – 3rd person
• Thought insertion • Running Commentary
• Thought broadcasting • 74% have this symptom
• Outside control • Visual
• Grandiose delusions • Hearing voices
• Ideas of reference

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Negative Symptoms: Behavioral
Deficits
• Avolition
• Lack of interest; apathy
• Asociality
• Inability to form close personal relationships
• Anhendonia
• Inability to experience pleasure
• Consummatory pleasure
• Anticipatory pleasure

• Alogia/ Attentional Impairment

• Reduction in speech
• Affective blunting/flattening
• Exhibits little or no affect in face or voice

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Disorganized Symptoms
• Disorganized speech (Formal thought disorder)
• Incoherence
• Inability to organize ideas
• Neologisms
• Loose associations (derailment)
• Word salad
• Rambles, difficulty sticking to one topic
• Disorganized behavior
• Odd or peculiar behavior
• Silliness, agitation, unusual dress
• e.g., wearing several heavy coats in hot weather

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Movement Symptoms
• Catatonia
• Motor abnormalities
• Repetitive, complex
gestures
• Usually of the fingers or
hands
• Excitable, wild flailing of
limbs
• Catatonic immobility
• Maintain unusual posture
for long periods of time
• e.g., stand on one leg,
psychological pillow
• Waxy flexibility
• Limbs can be manipulated
and posed by another
person
Page 84 of 1077
Schneider's first rank symptoms

Page 85 of 1077
Paranoid Schizophrenia

• Paranoid schizophrenia is characterized mainly

by delusions of persecution, feelings of passive or
active control, feelings of intrusion, and often by
megalomanic tendencies also. The delusions are
not usually systemized too much, without tight
logical connections and are often combined with
hallucinations of different senses, mostly with
hearing voices.
• Disturbances of affect, volition and speech, and
catatonic symptoms, are either absent or
relatively inconspicuous.

Page 86 of 1077
Hebephrenic Schizophrenia
• Hebephrenic schizophrenia is characterized by
disorganized thinking with blunted and inappropriate
emotions. It begins mostly in adolescent age, the behavior
is often bizarre. There could appear mannerisms, grimacing,
inappropriate laugh and joking, pseudophilosophical
brooding and sudden impulsive reactions without external
stimulation. There is a tendency to social isolation.

• Usually the prognosis is poor because of the rapid

development of "negative" symptoms, particularly flattening
of affect and loss of volition. Hebephrenia should normally
be diagnosed only in adolescents or young adults.

• Denoted also as disorganized schizophrenia

Page 87 of 1077
Catatonic Schizophrenia
• Catatonic schizophrenia is characterized mainly by
motoric activity, which might be strongly increased
(hypekinesis) or decreased (stupor), or automatic
obedience and negativism.
• We recognize two forms:
• productive form — which shows catatonic excitement,
extreme and often aggressive activity. Treatment by
neuroleptics or by electroconvulsive therapy.
• stuporose form — characterized by general inhibition of
patient’s behavior or at least by retardation and slowness,
followed often by mutism, negativism, fexibilitas cerea or
by stupor. The consciousness is not absent.

Page 88 of 1077
Undifferentiated Schizophrenia
• Psychotic conditions meeting the general
diagnostic criteria for schizophrenia but not
conforming to any of the subtypes in F20.0-F20.2,
or exhibiting the features of more than one of
them without a clear predominance of a particular
set of diagnostic characteristics.

• This subgroup represents also the former

diagnosis of atypical schizophrenia.

Page 89 of 1077
Simple Schizophrenia

• Simple schizophrenia is characterized by early

and slowly developing initial stage with growing
social isolation, withdrawal, small activity,
passivity, avolition and dependence on the
others.
• The patients are indifferent, without any initiative
and volition. There is not expressed the presence
of hallucinations and delusions.

Page 90 of 1077
 Etiology of Schizophrenia:
Genetic Factors
• Genetically heterogeneous
• Not likely that disorder caused by single gene

• Evidence for a genetic causation comes from:

• Family studies
• Relatives at increased risk- likelihood of having schizophrenia is
correlated with the closeness of the relationship to an affected
relative (e.g., first- or second-degree relative)
• Twin studies show concordance rates of:
• 44% risk for MZ twins vs. 12% risk for DZ twins
• Adoption studies
• Increased likelihood of developing psychotic disorders

Page 91 of 1077
 Etiology of Schizophrenia:Genetic
Factors
• The modes of genetic transmission in
schizophrenia are unknown, but several genes
appear to make a contribution to schizophrenia
vulnerability
• Two genes associated with cognitive deficits
• COMT
• BDNF
• Genome-wide scans
• Identification of gene mutations
• Several identified but results need to be replicated

Page 92 of 1077
Etiology of Schizophrenia:
Neurotransmitters
• Dopamine Theory
• SCN due to excess levels of dopamine
• Drugs that alleviate symptoms reduce dopamine activity
• Amphetamines, which increase dopamine levels, can induce a
psychosis
• Theory was revised as it did not fully explain
why some patients continue to have negative
symptoms despite treatment with anti-
psychotics

Page 93 of 1077
Dopamine Theory of Schizophrenia

Page 94 of 1077
Etiology of Schizophrenia:
Evaluation of Dopamine Theory
• Dopamine theory doesn’t completely explain
disorder
• Antipsychotics block dopamine rapidly but symptom
relief takes several weeks
• To be effective, antipsychotics must reduce dopamine
activity to below normal levels
• Other neurotransmitters involved:
• Serotonin
• GABA
• Glutamate
• Medication that targets glutamate shows promise

Page 95 of 1077
Page 96 of 1077
 .

Etiology of Schizophrenia:
Brain Structure and Function
• Enlarged ventricles
• Implies loss of brain cells
• Correlate with
• Poor performance on cognitive tests
• Poor premorbid adjustment
• Poor response to treatment

Page 97 of 1077
 Etiology of Schizophrenia:
Brain Structure and Function
• Prefrontal Cortex
• Many behaviors disrupted by schizophrenia
(e.g., speech, decision making) are governed
by prefrontal cortex.

• Individuals with schizophrenia show

impairments on neuropsychological tests of
prefrontal cortex (e.g., memory).

• Individuals with schizophrenia show low

metabolic rates in prefrontal cortex
• Failure of frontal activation related to negative
symptoms
Page 98 of 1077
Etiology of Schizophrenia:
Environmental factors
• Damage during gestation or birth such as:
• Obstetric complications rates high in patients
with schizophrenia
• Reduced supply of oxygen during delivery may
result in loss of cortical matter
• Viral damage to fetal brain
• Presence of parasite, toxoplasma gondii,
associated with 2.5x greater risk of
developing schizophrenia
• mother had flu in second trimester of
pregnancy and winter births
Page 99 of 1077
Etiology of Schizophrenia:
Brain Structure and Function
• Developmental factors
• Prefrontal cortex matures in adolescence or early adulthood
• Dopamine activity also peaks in adolescence
• Excessive pruning of synaptic connections
• Use of cannabis during adolescence associated with
increased risk – high levels of cannabis use (more than 50
occasions) were at sixfold increased risk of schizophrenia
compared with nonusers.
• The use of amphetamines, cocaine, and similar drugs
should raise particular concern because of their marked
ability to increase psychotic symptoms

• May explain why symptoms appear in late

adolescence but brain damage occurs early in life

Page 100 of 1077

 .

Etiology of Schizophrenia:
Psychological Stress
• Socioeconomic status
• Highest rates of schizophrenia among urban poor
• Stress of poverty causes disorder -
social stressors in urban settings may
affect the development of
schizophrenia in persons at risk.
• Downward drift in socioeconomic status – more
likely.
• schizophrenia begins early in life; causes significant
and long-lasting impairments stopping affected
persons achieving the socio-ecomonic status
expected
Page 101 of 1077
Etiology of Schizophrenia:
Family Factors that have been
disproved
• Schizophrenogenic mother
• Cold, domineering, conflict inducing
• No support for this theory

• Communication deviance (CD)

• Hostility and poor communication
• Inconclusive at this time

Page 102 of 1077

Etiology of Schizophrenia:
Families and Relapse
• Family environment impacts relapse
• High Expressed Emotion (EE)
• Hostility, critical comments, emotional overinvolvement

Page 103 of 1077

 Etiology of Schizophrenia:
Developmental Studies
• Use of retrospective or “follow-back” studies
• Developmental histories of children who later developed
schizophrenia
• Lower IQ
• More often delinquent (boys) and withdrawn (girls)
• Coding of home movies
• Poorer motor skills
• More expression of negative emotion

Page 104 of 1077

Treatment of Schizophrenia:
Medications
• First-generation antipsychotic medications (neuroleptics;
1950s)
• Phenothiazines (Thorazine), butyrophenones (Haldol), thioxanthenes
(Navane)
• Reduce agitation, violent behavior
• Block dopamine receptors
• Little effect on negative symptoms
• Long term maintenance dosages to prevent relapse

Page 105 of 1077

Neuroleptic (typicals):
side effects
• Acute dystonia
• Parkinsonian side effects (EPS)
• Akathisia
• Tardive dyskinesia
• Sedation, orthostasis, QTC prolongation, anticholinergic,
lower seizure threshold, increased prolactin
• Neuroleptic malignant syndrome

Page 106 of 1077

Treatment of Schizophrenia:
Medications
• Second-generation antipsychotics
• Clozapine
• Impacts serotonin receptors
• Fewer motor side effects
• Less treatment noncompliance
• Reduces relapse
• Side effects
• Can result in severe agranulocytosis
• Seizures
• Newer medications may improve cognitive function:
• Olanzapine
• Risperidone
• Quetiapine

Page 107 of 1077

Treatment of Schizophrenia:
Medications
• Second-generation drugs were not more effective than the older,
first-generation drug
• Second-generation drugs did not produce fewer unpleasant side
effects
• Second-generation antipsychotics have serious side effects
• Weight gain, diabetes, pancreatitis
• Disturbing trend for people of color:
• Not prescribed second generation antipsychotics

Page 108 of 1077

Psychological Treatment
Recommendations
• Psychosocial interventions should be given in addition to
medication
• Social skills training
• Teach skills for managing interpersonal situations
• Completing a job application
• Make appointments
• Appropriate non-verbal emotional cues
• Involves role-playing and other practice exercises

Page 109 of 1077

Psychological Treatments
• Family therapy to reduce HEE
• Educate family about causes, symptoms, and signs of
relapse
• Stress importance of medication
• Help family to avoid blaming patient
• Improve family communication and problem-solving
• Encourage expanded support networks
• Instill hope

Page 110 of 1077

 Psychological Treatments
• Cognitive behavioral therapy
• Recognize and challenge expectations associated with
negative symptoms
• e.g., “Nothing will make me feel better so why bother?”

• Cognitive remediation training or cognitive

enhancement therapy (CET)
• Improve attention, memory, problem solving and other
cognitive-based symptoms
• Case management
• Multidisciplinary team to provide comprehensive services
• Vocational rehabilitation

Page 111 of 1077

Clinical Challenges
• Insight can be impaired leading people with
schizophrenia to refuse treatment.

• Adherence to treatments can be irregular

Page 112 of 1077

Clinical Challenges
• Substance use disorders are common in people with schizophrenia
• Lifetime prevalence of any drug abuse (other than tobacco) is
often greater than 50 percent e.g alcohol prevalence was 40%
in one study.
• Drug abuse is associated with poorer function.
• Substance abuse increases risk of hospitalization and may
increase psychotic symptoms.
• The use of amphetamines, cocaine is of particular concern
because of their marked ability to increase psychotic
symptoms.
• Up to 90 percent of schizophrenia patients may be dependent
on nicotine.
• Apart from smoking-associated mortality, nicotine decreases
the blood concentrations of some antipsychotics
Page 113 of 1077
Table 9.2: Diagnoses of Schizophrenia
Spectrum and Other Psychotic Disorders

Page 114 of 1077

Other Psychotic Disorders
• Schizophreniform Disorder
• Same symptoms as schizophrenia
• Symptom duration greater than 1 month but less than 6
months
• Brief Psychotic Disorder
• Symptom duration of 1 day to 1 month
• Often triggered by extreme stress, such as
bereavement
• Schizoaffective Disorder
• Symptoms of both schizophrenia and mood disorder
• DSM-5 likely to require appearance of major depressive or
manic episode
Page 115 of 1077
Other Psychotic Disorders
• Delusional Disorder
• Delusions may include:
• Persecution
• Jealousy
• Being followed
• Erotomania
• Loved by a famous person
• Somatic delusions
• No other symptoms of schizophrenia
• Attenuated Psychosis Syndrome
• Possible new category in DSM-5

Page 116 of 1077

Depression Module
4th Year Psychiatry
UZ- CHS

Page 117 of 1077

 Module components
Lecture 1:
Learning objectives
Definitions
Epidemiology
Neuroscience
Assessment (including diagnosis and MSE/PE)

Lecture 2:
Learning Objectives
Clinical Management (including tests and treatment)
Treatment resistant depression
Questions

Page 118 of 1077

 Learning objectives - you will learn:
1. To describe depression and identify persons with moderate-
severe depression

2. To name differential diagnoses for Depression and be able to rule

them out

3. To list 4 or more epidemiological risk factors for Depression

4. To describe the neurobiology of depression and key areas of

change in the brain

5. To perform an assessment and diagnose a patient with

Depression

6. To identify and assess the risk of suicide and self-harm in a

patient with Depression
Page 119 of 1077 3
Definitions and
Epidemiology

Page 120 of 1077

Open discussion

1. What do local people call depression in day-to-day

language?

2. What do they think are the causes of depression?

3. How do people with Depression present? and to

whom?

Page 121 of 1077 5

 Diagnostic Criteria
Core symptoms of Depression:

• Low mood
• Anhedonia
• Anergia

Page 122 of 1077

 Poor appetite
Weight loss (>5% in last
1/12)

Somatic Symptoms
of Depression

Poor Sleep- early

morning
wakening Reduced Libido
Diurnal variation
of mood Poor concentration
Page 123 of 1077
 Worthlessness
Focus on the negatives
eg. Perceived Failings

Cognitive
Symptoms of
Depression

Sense of
hopelessness Excessive Guilt

Suicidal thoughts
Page 124 of 1077
 ICD-10: Depressive Episode

At least 2 weeks of core symptoms +

•2 other symptoms + slight impact on function =

Mild Depressive Episode

•3-4 other symptoms + considerable impact on

function = Moderate depressive episode

•At least 4 other symptoms + unable to function

normally = Severe Depressive Episode
Page 125 of 1077
Psychotic Depression

Major Depressive Episode + delusions and/or

hallucinations and/or Stupor.

• Delusions/ hallucinations- mood congruent.

• Nihilistic
• Poverty
• Olfactory hallucinations common- rotting flesh etc.

• Treatment: Aggressively treat Depression +

antipsychotics.
Page 126 of 1077
 Differential Diagnosis
Other psychiatric disorders; i.e. BPAD,
Schizophrenia, Dementia etc.

Substance-abuse- drugs/ alcohol

Mood disorders caused by a general medical

condition: Anaemia, Hypothyroidsim, HIV,
stroke, Diabetes etc.

Normal bereavement

Page 127 of 1077

 Investigations
FBC
TFTs
HIV test
U&Es
Syphilis

Can be used to rule out an organic cause

depending on the history.
Page 128 of 1077
 Why do we need to scale up care for
depression?
Annual prevalence
◼ Around 5% in the community
◼ Commoner among primary health care attenders

Lifetime prevalence
◼ About 17% overall across countries and races
◼ Roughly twice as high in women as men

Rate of completed suicide 10-15%

Depression can affect physical disease. E.g.

◼ It predisposes to myocardial infarctions
◼ Reduced adherence to treatment for chronic diseases, incl. HIV and
TB.
Page 129 of 1077
Average prevalence of depression in people
with physical diseases (70 countries)

Tuberculosis

HIV/AIDS

Cancer
Prevelance
Hypertension

Diabetes
Myocardial
infarction

0% 20% 40% 60%

Page 130 of 1077
 Post-partum depression

Prevalence: about 10% of women after delivery

Onset: most common in the first few months after birth

Duration: from months to a year

Impact: may reduce the interaction between mother and

child and delay child development

Page 131 of 1077 15

 Depression Vs. Normal grief
Suicidal thoughts Suicidal thoughts
common- driven by low transient, driven by desire
mood to be with the deceased.
Tend to blame self Tend to blame
others/fate.
Psychomotor retardation No Psychomotor
retardation
Psychotic Symptoms if No psychotic symptoms
severe. Mood-congruent. but may ‘see’/ ‘hear’ the
deceased
Fluctuating symptom
Pervasive symptom course
course
Page 132 of 1077
 Who’s at risk?
Women

Risk in primary care populations twice that for men

16% of mothers and women living in the community in

one study

Severe life events, e.g. Marital crises, violence,

bereavement, infertility and unwanted pregnancy common

Support from close family member protective

Page 133 of 1077
Victims of Trauma and Torture
Experience of violence common both as a
result of war, civil conflict and crime

Rates of depression high amongst those

who had been victims as well as witnesses

Page 134 of 1077

 The Poor
Hunger (due to lack of money) and low income risk
factors for depression

Incidence in those who had experienced hunger due to

lack of money: 30% vs 12%

Persistence in those whose economic problems had

resolved compared to those who had new problems:
31% vs 56%

Page 135 of 1077

 Illness course: a chronic waxing and waning
illness

• 50% will have another episode after 1st.

• Average length of episode is 8-9 months without

treatment or 2-3 months with treatment.

• Psychotic Depression has a poorer prognosis

•Disability and suffering has been shown to be

proportional to number and severity of episodes.

Page 136 of 1077

 The Genetics of Mood
Disorders
Twin Concordance rates (MZ:DZ):
44%: 20% for Unipolar Depression
40%: 5.4% for Bipolar Affective Disorder

No single gene located.

Complex relationship of genetic and environmental interactions.

Serotonin Transporter Gene: Short (S) allele have x3 risk of

Depressive Episode after >3 life events. No increased risk for those with
Long Allele.

Page 137 of 1077

Functional Neuroanatomy
and Neurobiology of
Depression

Page 138 of 1077

*
Neurocircuitry Dysfunction
Each psychiatric illness has uniquely dysregulated circuitry

Commonly implicated neurocircuits in psychiatric illness

1. Prefrontal cortical-striatal-pallidal-thalamic pathways

2. Prefrontal cortical-limbic pathways

3. Prefrontal cortical-aminergic feedback pathways

4. Paralimbic/limbic circuits

5. Diffuse innervation by biogenic amine nuclei in brainstem

Page 139 of 1077
*
Background to understand the neurobiology
of psychiatric illnesses
Neurocircuitry
• Frontal-subcortical circuits
• Frontal-limbic circuits

Prefrontal cortical and limbic structures

• Main prefrontal areas projections from: orbitofrontal, anterior
cingulate, medial prefrontal cortices
• They project to: hippocampus, amygdala, hypothalamus

Neurotransmitters
• GABA
• Glutamate
• Role of monoamines 5HT, NE, DA

Page 140 of 1077

 Monoamine Hypothesis of
Depression

Depression is result of depleted levels of:

Noradrenaline (NA): affects mood and energy

Serotonin (5-HT): affects sleep, appetite,
memory and mood
Dopamine (DA): Affects psychomotor activity

Page 141 of 1077

*
Cortical-striatal-thalamic circuitry simplified

PFC
Glu
PFC

◼ Prefrontal cortex
Glutamatergic neurons project to the striatum
Page 142 of 1077
*
Cortical-striatal-thalamic circuitry simplified

Coronal view

PFC Striatum

GABA
Dorsal Striatum
(Caudate)

Horizontal view

◼ The striatum is made up of GABAergic neurons

◼ There are separate striatal structures: the dorsal striatum
(caudate, putamen), and thePage
ventral striatum (nucleus accumbens)
143 of 1077
*
Cortical-striatal-thalamic circuitry simplified

Coronal view

Glu

Glu
GABA

Thalamus

Horizontal view

◼ The thalamus is the final place prefrontal output is processed before

it returns to back to the prefrontal cortex; it is glutamatergic
Page 144 of 1077
*
Cortical and limbic connections: the
prefrontal cortex inhibits the amygdala
The mPFC, OFC, and AC
Regulate amygdalar activity
mPFC
AC

OFC A

When these structures are dysregulated, amygdalar activity is less modulated

by the prefrontal cortex: anxiety and emotional responses are less
controlled; fear may be more easily aroused.
Page 145 of 1077
 Cortical and limbic connections

mPFC
AC

OFC

GABA

mPFC
AC
Caudate
Thalamus
excitatory
inhibitory Amygdala Hippocampus

When prefrontal-striatal-thalamic processing is dysregulated, prefrontal

inhibition of hippocampus/amygdala will be disconnected resulting in:
• abnormal function in the mPFC, AC, and the OFC
• Page 146 of 1077
anxiety, autonomic arousal, hypothalamic pituitary axis (HPA) activation
*
Cortical and limbic connections: role of monoamines
(serotonin, norepinepherine, dopamine)

All monoamines have nuclei DA ventral tegmental area

substantia nigra
in the brainstem
NE locus ceruleus

5HT dorsal raphe nucleus

median raphe nucleus

All project diffusely to all brain structures

and modulate activity at GABA/glutamate
synapses

midbrain
pons
VTA
LC
DRN

Abbrev: dorsal raphe nucleus DRN; locus ceruleus LC; ventral tegmental
Page 147 areaof
VTA; serotonin 5HT, glutamate glu,
1077
*
Key points: Functional Neuroanatomy
Neurocircuitry important in understanding the neurobiology of
psychiatric illness
• frontal-subcortical circuits
• frontal-limbic circuits

Prefrontal cortical structures regulate limbic areas

• amygdala
• hippocampus

Neurotransmitters found in these circuits

• GABA
• Glutamate

Monoamine neurotransmitters found in these circuits

• 5HT
• NE
• DA
Page 148 of 1077
 Brain Volume Changes in
Depression
Loss of hippocampal volume commonly seen in
Depression.

Degree of atrophy correlates with

duration of current episode and illness
and duration of untreated depression.

Hippocampal atrophy is also correlated

with cognitive deficits of Depression.

Volume loss in PFC and ofPFC and enlarged ventricles

have also been found in depressed patients.
Page 149 of 1077
 Case study
Clinical Assessment of the patient
with Depression

Page 150 of 1077

 Video (Sarah)
http://youtu.be/mWS3fer1IAU

Page 151 of 1077 35

Establish communication and build trust

A person with depression might be reluctant to speak or

share with you
◼ Do not rush the interview

◼ Listen carefully

◼ Show that you understand the person's feelings and

thoughts

People in the community may not take the person's

complaints seriously
◼ Show interest in and respect for the person

◼ Take the person's story seriously

◼ Directly ask about the person's own understanding of their

problems
Page 152 of 1077
 Sarah's symptoms so far
Besides presenting complaints (body aches, fear of cancer)
what additional problems do you notice in Sarah’s case?

• Sarah reported the following issues

◼ She is worried about a social problem (husband

unemployment)

◼ Forgetfulness

◼ Sleep problems

◼ Poor appetite
Page 153 of 1077
 Sarah’s additional symptoms
What else have we learned?
Sarah is describing symptoms of
◼ Self blame
◼ Feelings of sadness /heaviness of heart
◼ Crying a lot
◼ Feelings of hopelessness

With this presentation, what must you assess before Sarah

leaves your office?

RISK OF SUICIDE

Page 154 of 1077

 Assessing suicide risk
‘How do you feel about the future?’
‘Have you ever had thoughts about trying to end
your life?’
‘Have you ever made plans or actually tried to kill
yourself?’

Asking about suicide does not make people

more likely to do it!

Page 155 of 1077

 Factors affecting suicide risk
• Previous self-harm (violent methods- higher risk, eg.
Hanging).
• Presence of Mental Illness, Psychosis, Depression
etc.
• Recent life events, eg. Bereavement, separation,
unemployment.
• Physical health problems.
• Childhood adversity.

Page 156 of 1077

 RECALL: What other condition should you ask
about?
• Ask at least one question about alcohol use!

• “Do you drink alcohol?”

• If yes, ask more questions:

• ‘I’d like to get an idea how much you drink. Can you talk me
through an average day?’
• ‘Do you need to drink more than you used to?’
• ‘How do you feel before your first drink in the morning?’

• ‘How does drinking affect your mood do you think?’

• ‘Have you ever tried to stop drinking?’

Page 157 of 1077

What do you think Sarah has?
Why?

Page 158 of 1077 42

 Recall: Mild versus moderate/severe
depression
Sara has: little pleasure/ interest in activities
Low Mood? (‘heavy heart’)

Plus: Poor sleep

Reduced appetite- 5kg weight loss
Poor concentration/ memory
Feeling tired all the time/ anergia

So: 2 core symptoms + 4 or more other symptoms AND

significant impairment in functioning = Severe
Depressive Episode

Page 159 of 1077

 What is the next step if the person has
moderate severe depression?
• Check for history of mania

•Prescribing antidepressants to a person with a history of

mania can trigger a manic episode!

Page 160 of 1077

 What is a manic episode?
An acute episode with symptoms lasting for at least 1
week
◼ Extremes of mood

◼ Excessive energy, activity and talking

◼ Recklessness

Other features:
◼ Drastic, sudden change from normal state

◼ Person loses control of his her life (e.g., spending too

much money, promiscuity, etc)
◼ Severe impairment of daily function

Page 161 of 1077

 Sarah's case- additional risks to consider

• Sarah is 23 and has a baby at home

• What else do you want to know?

◼ Is she breastfeeding?

◼ Is she pregnant?

◼ Is the baby developing well?

Page 162 of 1077

 What to look for on physical exam?

Sarah needs a full physical exam to rule out underlying

and concurrent medical issues

Look specifically for signs of anaemia and

hypothyroidism

Sarah’s physical exam is NORMAL

Page 163 of 1077 47

 What have we learnt?

How to identify moderate-severe depression

How and why to assess for a history of mania

How to assess for alcohol use problems and imminent

risk of suicide

To check for pregnancy and breastfeeding in women of

child bearing age

Page 164 of 1077

Questions?

Page 165 of 1077

Lecture 2

Page 166 of 1077

 Learning Objectives
1. To demonstrate an understanding of
psychoeducation in Depression and be able to
facilitate 6 to 10 simple steps towards recovery in
Depression (low-intensity CBT).

2. To be able to prescribe antidepressants to adults

with moderate-severe depression

3. To identify treatment resistant depression and

appropriate treatment modalities

Page 167 of 1077

 Treatment Modalities
Psychotherapy/ Psychoeducation

Somatic therapies
◼ Medications
◼ Brain stimulation treatments

Hospitalization

Page 168 of 1077

 Psychoeducation
Explain diagnosis and emphasise that
Depression is common and treatable.

Reassure that you don’t believe they are ‘mad’

or that they are making things up. Explain that it
is very common to have physical symptoms as a
result of stress/ Depression.

Give simple advice: Sleep Hygiene, adequate

diet, regular gentle exercise etc.

Page 169 of 1077

 Psychoeducation
Use low-intensity CBT techniques to:

Encourage pleasurable activities.

Explore social support networks and encourage

activating these.

Think about other social factors which could be

modified eg. Help with childcare, more contact
with friends, family etc.

Page 170 of 1077

Principles of CBT in Depression
Mood

Behaviours Thoughts

• CBT challenges Negative Automatic Thoughts triggered by day to

day situations, which can lead to unhelpful moods and
behaviours.

• Eg. ‘Last time I went to a party everyone ignored me, it’s because
I’m boring and irritating and no one has ever liked me and never
will. I haven’t been out with friends since, I stay at home all day
and feel more and more lonely and depressed.’
Page 171 of 1077
Antidepressants

Antidepressants are not addictive

They are generally safe drugs

2/3 respond to any one antidepressant and 90% will respond

overall.

Continuing treatment reduces relapse risk by 70%.

Page 172 of 1077

 How long to treat
Ist episode: 6-12 months

2nd episode: 12-24 months

3 or more: years? Lifetime

Page 173 of 1077

 When and when not to prescribe
antidepressants
• Mild Depression

• Recent Bereavement

• Physical Cause

• Be cautious! In prescribing an antidepressant if the person is a

child/pregnant/breastfeeding
◼ may require referral. Paroxetine and Sertraline may be used at low

doses.

Page 174 of 1077

SSRIs- Serotonin pathways

Raphe Nucleus

Stahl S M, Essential
Psychopharmacology
Page 175 of 1077 (2000)
 In Depression…
There are depleted Serotonin (5-HT)
levels

Upregulation of 5 - HT autoreceptors
causing abnormal postsynaptic signalling.

Page 176 of 1077

 SSRI mechanism of action

Antidepressant Action: Antidepressant blocks 5HT reuptake both at the

dendrites and at the axon
Stahl S M, Essential
Psychopharmacology
Page 177 of 1077
(2000)
 SSRI mechanism of action

The increase in 5HT causes the autoreceptors to desensitize / down-

regulate Stahl S M, Essential
Psychopharmacology
Page 178 of 1077 (2000)
 How SSRIs work.

Increase Restore
SSRIs block 5 - HT in the normal firing
Downregulate
the 5 - HT synapse and in the neuron
autoreceptors
transporter at the
dendrites.

Page 179 of 1077

 SSRIs: Common Side effects
◼ Restlessness
◼ Nervousness
◼ Insomnia
◼ Anorexia
◼ Gastrointestinal disturbances
◼ Headache
◼ Sexual dysfunction
◼ Hyponatraemia

Avoid in those with a history of GI bleeding or clotting

disorders.
Page 180 of 1077
 Tricyclic Antidepressants
• Inhibit presynaptic NA and 5 – HT
transporters.

• TCAs also block various other receptors,

contributing to their side - effect profile.

Page 181 of 1077

 Tricyclics: Side Effects
Receptor blocked Side - effect produced

Muscarinic-cholinergic Dry mouth, urinary retention,

constipation,
blurred vision, glaucoma,
tachycardia, delirium,
sexual dysfunction
Alpha - 1 adrenergic Postural hypotension,
drowsiness, sexual dysfunction
Histamine H 1 Drowsiness, weight gain

Other or unknown Arrhythmias, seizures

Page 182 of 1077

 Precautions for TCAs

•Avoid use in; the elderly, people with cardiovascular

disease and people with dementia

• If a TCA is the only available antidepressant in these

groups, then consult a specialist

•Avoidlong prescriptions in those with suicidal ideas-

dangerous in OD.

Page 183 of 1077 67

 Other antidepressants
Venlafaxine: selective SNRI
Elevation of BP at high dose
Avoid in heart disease and needs ECG monitoring.

MAO-Inhibitors: Prevent breakdown of monoamines in presynaptic

terminals by the enzyme MAO, thereby increasing transmitter
availability. Dietary precautions necessary- can cause hypertensive
crisis.
S.E’s- Postural hypotension, insomnia, ankle oedema, dry mouth,
dizziness, agitation and headache.

Page 184 of 1077

 Other antidepressants
Mirtazapine: Alpha 2 adrenoreceptor antagonist
and 5HT heteroreceptor antagonist.

Also blocks 5HT 2A, 2C & 3, and H1

drowsiness, weight gain, reversible

agranulocytosis rarely.

Page 185 of 1077

 Monitoring people on antidepressants

• It is expected that people will have a positive response,

but there are some results that will require action

• Symptoms of mania STOP

• Inadequate response CHANGE

• No response CHANGE

Page 186 of 1077 70

 When and how to stop an antidepressant

• If after 9-12 months of therapy the person reports both

• No or minimal symptoms

AND
• Adequate daily function

• Discuss the plan with the person before reducing the

dose

• Describe early symptoms of relapse

• Plan routine and emergency follow up

• Reduce doses gradually over at least 4 weeks

Page 187 of 1077 71
 Antidepressants : Summary
• Time of onset is 4-6 weeks
• Treatment should continue for 9 - 12 months
• Taper slowly if ceasing medication

• Do not prescribe antidepressants to

• A functioning person (not mod-sev depression)
• Use in under 18s, pregnant or breastfeeding women requires
specialist input.

• Avoid TCAs if the person is elderly, has dementia or has

cardiovascular disease Page 188 of 1077 72
Depression not responding to 1st
line treatment
Trial of medication at maximum dose for minimum 4-6
weeks.

Review diagnosis: Perpetuating factors? Eg. Ongoing

martial conflict, endocrine disorder, alcohol misuse.

Psychotherapy if not already tried- CBT + medication is

more effective than either alone.

Assess/ investigate medication adherence

Consider change in class of antidepressant

Page 189 of 1077
 Treatment Resistant Depression
= Failure to respond to 2 or more different classes of antidepressants.

Up to 20% may be treatment resistant.

Refer to specialist.

Treatment options: Add Lithium,

• Combine antidepressants, eg. Mirtazapine + SSRI
• Add low dose antipsychotic
• ECT
Page 190 of 1077
 Electroconvulsive Therapy (ECT)
• An electrical current is passed through the brain, inducing a
short seizure.

• Given with light general anesthetic and muscle relaxant.

• Mechanism of action not fully clear

but theories include an increase in
monoamine levels.

• May also induce neuroangiogenesis

(new blood vessels in the brain).

Page 191 of 1077

Questions

Page 192 of 1077

 Questions
Major depression is best understood as:

1. Primarily due to abnormal function in the noradrenergic and serotonergic

neurotransmitter systems.

2. The result of a systems level dysregulation of multiple cortical,

subcortical, and limbic neurocircuits.

3. Not associated with volumetric abnormalities in any cortical or limbic

structures.

4. The result of clear abnormal structure and function of the mamillary

bodies.

5. All the above.

Page 193 of 1077

 Questions
A 25-year-old man comes to the psychiatrist with a chief
complaint of depressed mood for 1 month. His mother,
to whom he was very close, died 1 month ago, and
since that time he has felt sad and been very tearful.
He has difficulty concentrating, has lost 3 lb, and is not
sleeping soundly through the night. Which of the
following is the most likely diagnosis?

a. Major Depression
b. Dysthymia
c. Posttraumatic stress disorder
d. Adjustment disorder
e. Uncomplicated bereavement

Page 194 of 1077

 Questions
A 30-year-old man comes to the psychiatrist for the evaluation of a
depressed mood. He states that at least since his mid-20s he has
felt depressed. He notes poor self-esteem and low energy, and
feels hopeless about his situation, though he denies suicidal
ideation. He states he does not use drugs or alcohol and has no
medical problems. His last physical examination by his physician 1
month ago was entirely normal. Which of the following treatment
options should be tried first?

a. Hospitalization
b. Psychoanalysis
c. Sertraline
d. ECT
e. Amoxapine

Page 195 of 1077

 By Dr Walter Mangezi

Page 196 of 1077

 Students should be able to describe the
clinical assessment of Bipolar Affective
Disorder Patients
 Students should be able to manage the
patients with Bipolar Affective Disorder

Page 197 of 1077

 Pathological Mood Disturbance
◦ Sadness
◦ Happiness
 Elation/ Elated Mood
 Euphoria

Page 198 of 1077

 The course of Bipolar consists of at least one
mania (Type I) or hypomania (Type II) phases.
 The course in most cases involves the
recurrence of mania, hypomania, and
depressive phases with normal states in-
between.
 A phase normally lasts 2 or more weeks.

Page 199 of 1077

 Depressive phase – reduced monoamines (
especially dopamine, serotonin, adrenaline
and nor-adrenaline) in the brain
 Mania and Hypomania phase increase in
monoamines in the brain.

Page 200 of 1077

Page 201 of 1077
 APPEARANCE

◦ Depression

 Dull clothes
 Unkempt if severe
 Psychomotor Retardation

Page 202 of 1077

◦ Mania

 Bright Coloured clothes

 Unkempt if severe
 Psychomotor Agitation

Page 203 of 1077

 SPEECH

◦ Depression
 Slow
 Hesitant
 Monosyllabic
 Mute
 Often Coherent

Page 204 of 1077

◦ Mania

 Talkative/Pressured
 Coherent to incoherent

Page 205 of 1077

 MOOD
◦ Depression
 Sad for at least 2 weeks
 Lack of reactivity
 Diurnal variation

Page 206 of 1077

◦ Mania
 Pathological happiness
 Euphoria
 Elated mood/elation
 Labile/irritability

Page 207 of 1077

 Affect
◦ Depression
 Congruent to mood
 sad

Page 208 of 1077

◦ Mania
 Congruent to mood happy
 Sometimes labile

Page 209 of 1077

 Biological/Neurovegetative Signs
◦ Depression
 Sleep increased or insomnia
 Appetite increased or decreased
 Weight increased or decreased
 Energy reduced
 Libido reduced

Page 210 of 1077

 Interest reduced
 Pleasure reduced
 Guilt/Self blame
 Feelings of hopelessness
 Suicidal ideation

Page 211 of 1077

◦ Mania
 Sleep insomnia (reduced need)
 Appetite increased ( no time to eat)
 Weight increased or decreased
 Energy increased
 Libido increased

Page 212 of 1077

 Interest increased but distractible
 Pleasure increased
 Suicidal ideation

Page 213 of 1077

 Depression
◦ Thoughts
 Slow
 Morbid & paranoid delusions
 Preoccupation with negative

Page 214 of 1077

 Mania
◦ Thoughts
 Racing & Flight of ideas
 Grandiose delusions

Page 215 of 1077

 Depression
◦ Perception
 Persecutory auditory hallucinations
 Often second person

Page 216 of 1077

 Mania
◦ Perception
 Grandiose auditory hallucinations
 Second person

Page 217 of 1077

 Cognition
◦ Depression
 Consciousness clear
 Orientation Good in T.P.P.
 Memory intact
 Intelligence normal
 Abstract thinking normal

Page 218 of 1077

 Judgment masked with negative
thoughts
 Insight Good

Page 219 of 1077

◦ Mania
 Consciousness clear
 Orientation Poor in time and place
(psychotic)
 Memory intact
 Intelligence normal
 Abstract thinking normal

Page 220 of 1077

 Judgment (irresponsible)
 Insight poor

Page 221 of 1077

 DEPRESSION

◦ Social

 Collateral History
 Home visit

Page 222 of 1077

◦Physical
 Rule out physical causes
 Hypothyroidism
 Substance abuse
 e.g. alcohol MCV , GGT.
 Appropriate test to physical findings

Page 223 of 1077

 MANIA
◦ Social
 Collateral history
 Home visit
 Assess estates Safety from
irresponsibility
 Power of Attorney
 Curator bonis

Page 224 of 1077

 Rule out organic cause

 Thyrotoxicosis
 HIV
 Substance misuse
 Appropriate for patients presentation

Page 225 of 1077

 Preparation for lithium prophylaxis
 Full blood count
 Urea and electrolytes
 Liver function test
 Thyroid function test

 If on lithium
 Lithium levels

Page 226 of 1077

 Bipolar Affective Disorder

◦ Antipsychotics (Mania episode) e.g.

 Haloperidol
 Olanzapine
 Other Antipsychotics e.g. Fluphenazine
Decanoate
 In poor compliance

Page 227 of 1077

 Principles in management
◦ First episode mainly antipsychotic Drugs.
◦ If episodes recur frequently disrupting function
need for Prophylaxis
- Use mood stabilizers

Page 228 of 1077

◦ Mood Stabilizers

 Multiple Episodes Requiring

Prophylaxis

 Lithium Carbonate
 Carbamazepine
 Sodium Valproate
 Lamotrigine(in depressive episodes)

Page 229 of 1077

 Lithium Carbonate
◦ Follow-up Bloods Lithium, TFT,U&E
 Once stable 3 monthly than 6monthly
◦ Monitor Therapeutic Range
 0.8-1.5 Mania phase
 0.6-1.2 prophylaxis
 >1.5 toxicity

Page 230 of 1077

 Psychotherapy
◦ Psycho education to patient and
relatives.
◦ Supportive Psychotherapy

Page 231 of 1077

◦ Social Management
 Due to Irresponsible
 Appoint Power of Attorney or
 Appoint Curator Bonis
 Supervision of Treatment –Poor insight

Page 232 of 1077

 Rehabilitation
◦ Were appropriate

Page 233 of 1077

 Homework
◦ Lithium Toxicity
◦ NICE Guidelines for mood stablizer
◦ Suicide risk assessment

Page 234 of 1077

 THE
END

Page 235 of 1077

Mental Health & HIV/AIDS

Psychiatric Epidemiology

Page 236 of 1077

 Mental Health & HIV/AIDS
Psychiatric Epidemiology
• Depression->2 fold increase
at risk populations high rate

• PTSD-high-risk populations
women/prisoners/minorities

• Dementia-decreased with ART

Prevalence? MCMD?

• Bipolar-primary & secondary

10 x higher

• Schizophrenia at-risk population

2- 10 x higher
Page 237 of 1077
 Mental Health & HIV/AIDS
Depression

• Prevalence estimated at two fold higher

– Meta-analysis 10 studies (Ciesla & Roberts 2001)

• Risk factor for HIV Infection (Regier 1990)

• 2.5 fold increase when CD4 cell <200

cells/mm³ (Lyketsos 1996)

Page 238 of 1077

 Mental Health & HIV/AIDS
Depression
• Negative effects noted
– Adherence to ART (Dimatteo 2000)
– Quality of Life (Lenz & Demal 2000)
– Treatment outcomes (Holmes & House 2000)
– Mortality & disease progression (Ickovics 2001)

• Personal Health Questionnaire 9 (PHQ9)

– Patient completed survey
– Research validated Primary Care Clinics (Spitzer 1999)
– APA advocates implementation

Page 239 of 1077

 Mental Health & HIV/AIDS
Depression
#1 Complexity
– “Patient has a good reason to be..” or
– “Well, you would be to if you were....” or
– “It’s reasonable to be depressed…”

– Fact: The majority of patients with chronic

medical illness are not depressed (prevalence is
never >50%)

Page 240 of 1077

 Mental Health & HIV/AIDS
Depression
#2 Complexity
Overlapping Symptoms - 4 out of 9 Six could be
caused by physical illness:
» Appetite changes
» Sleep disruption
» Energy changes
» Slowed motor movement

Page 241 of 1077

 Mental Health & HIV/AIDS
Depression

Inclusive Model for Diagnosis of Major

Depression

Count all physical symptoms unless they are

clearly and fully caused by physical or medical
illness (positive predictive value 54 – 80%)

Page 242 of 1077

 Mental Health & HIV/AIDS
Depression
• Psychosocial Stress
– High suicide rates
• Initial HIV diagnosis & later stages of illness
– Multiple comorbid factors
• Substance abuse
• Poverty
• Homelessness
• Social isolation
– Physical stigma of ART
• Lipoatrophy, lipodystrophy: disclosure of infection

Page 243 of 1077

 Mental Health & HIV/AIDS
Depression
• Multiple studies indicate almost all
antidepressants are effective
– Concern for P450 interactions with some
antiretroviral medications
– Favor citalopram & sertraline over paroxetine &
fluoxetine (2D6)
– Caution with nefazodone & fluvoxamine (3A4)
– Side effect profile guides choice of agent
– Mirtazipine favored for sedation and appetite
stimulation

Page 244 of 1077

 Mental Health & HIV/AIDS
Depression
• Psychotherapy
– Many studies showing benefit with and without
antidepressants
– Group therapy – prominent modality
– Cognitive Behavioral Therapy (CBT)
– Interpersonal
– Supportive
– Themes of guilt, shame, anger

Page 245 of 1077

 Mental Health & HIV/AIDS
PTSD
• Greatly increased rates
– 42% HIV+ women, County Medical Clinics
(Cottler 2001)

– 30% pts develop in reaction to HIV

diagnosis (Kelley 1998)
– Predicts lower CD4 counts (Lutgendorf 1997)

– Higher levels of pain (Smith 2002)

Page 246 of 1077

 Mental Health & HIV/AIDS
PTSD
• SSRIs show 50% improvement in six
– prefer to use sertraline (Zoloft) or citalopram (Celexa)

• Prazosin often used for intrusive nightmares

– current studies (Raskind SVAMC)

• Psychotherapy effective, using variety of approaches

(CBT, Abreaction, Supportive)

Page 247 of 1077

 Mental Health & HIV/AIDS
Panic Disorder
• Panic Disorder & Generalized Anxiety Disorder > 4
times more prevalent (Bing 2001)

• Affects accessing primary care, adherence to

treatment, and quality of life
– Especially agoraphobic/housebound

• Responds well to treatment

Page 248 of 1077

 Mental Health & HIV/AIDS
Panic Disorder
• First line treatment: SSRIs
– Then consider dual action agents (venlafaxine (Effexor) or
duloxetine (Cymbalta)), mirtazepine (Remeron), or
tricyclics (TCAs)
– Wellbutrin of little benefit
• Responds well to psychotherapy: CBT
• Best outcomes = both meds & psychotherapy
• Use benzodiazepines as last resort
eg, clonazepam preferred (longer half life)

Page 249 of 1077

 Mental Health & HIV/AIDS
Social Phobia
• Fear of social situations, scrutiny and criticism of-
others, unable to eat or speak in public

• Relates to internalized stigma of illness- exacerbated

by lipoatrophy and lipodystrophy caused by ART

• Responds well to psychotherapy & meds- First line:

SSRIs

Page 250 of 1077

 Mental Health & HIV/AIDS
Dementia
• CNS Infection
– 10% AIDS pts present with neurological dx

– 75% AIDS pts: brain pathology at autopsy

• gliosis, white matter pallor & multinucleated giant cells

– HIV-Associated Dementia (HAD) &

Minor Cognitive Motor Disorder (MCMD) predict shorter
survival

Page 251 of 1077

 Mental Health & HIV/AIDS
Dementia
• HIV-infected macrophages directly enter CNS early in
HIV infection

• CNS may be sanctuary for HIV replication

• CSF HIV viral load not correlated with plasma viral

load when CD4 count <200 cells/mm³

• CSF viral load correlates dementia severity

Page 252 of 1077

 Mental Health & HIV/AIDS
Dementia
• With effective ART, incidence of CNS
OIs dropped significantly, since early
1990’s
– 2/3 decreased incidence HAD (Saktor 1999)
– 75% decrease CMV & lymphoma on
autopsy
– However 60% with some evidence of HIV
encephalopathy on autopsy* (Neuenburg 2002)

Page 253 of 1077

 Mental Health & HIV/AIDS
Dementia
• Risk Factors
– Seroconversion illness
– Anemia
– Vitamin deficiencies (B6, B12)
– Low CD4 count
– High CSF HIV viral Load
– ETOH, cocaine & amphetamine
– Depression

Page 254 of 1077

 Mental Health & HIV/AIDS
Dementia

• HIV CNS infection has predilection for

subcortical brain structures
-Basal ganglia:
-Caudate, putamen, nucleus accumbens, globus
pallidus, substantia nigra, subthalamic nucleus
-Leads to unique clinical manifestations

Page 255 of 1077

 Mental Health & HIV/AIDS
Dementia
• Early signs & symptoms
– Decreased attention & concentration
– Psychomotor slowing
– Reduced speed of information processing
– Executive dysfunction
• Abstraction
• Divided attention
• Shifting cognitive sets

Page 256 of 1077

 Mental Health & HIV/AIDS
Dementia

• Later signs & symptoms

– Memory impairment
– Language problems
– Visual-spatial difficulties
– Apraxias

Page 257 of 1077

 Mental Health & HIV/AIDS
Dementia

• Associated behavioral changes

– Apathy
– Depression
– Sleep disturbance
– Agitation & mania
– Psychosis

Page 258 of 1077

 Mental Health & HIV/AIDS
Dementia
• Neurocognitive problems

– 30-50% Subclinical
Neuropsychological testing impaired

---------(threshold clinical significance)------------

– 20% MCMD
Minor Cognitive Motor Disorder

– 2-4% HAD
HIV Associated Dementia

Page 259 of 1077

 Mental Health & HIV/AIDS
Dementia
• Mild Manifestation • Diagnostic Criteria
– MCMD 1) At least 2 of: impaired attention,
Minor Cognitive Motor Disorder concentration, memory, mental &
psychomotor slowing, personality
change
2) Rule out other cause

• Diagnostic Criteria
• Severe Manifestation*
1) Acquired cognitive abn*
– HAD
2) Acquired motor abn*
HIV Associated Dementia
3) No clouded LOC & rule out other
cause
*functional impairment

Page 260 of 1077

 Mental Health & HIV/AIDS
Dementia
• Treatment
– Most effective treatment is ART
• Raises question of lumbar puncture to confirm
effectiveness on CSF HIV viral load…..

– Slows progression of dementia (Ferrando 1998)

– Reversed periventricular white matter changes

seen on MRI scan in some cases

Page 261 of 1077

 Mental Health & HIV/AIDS
Dementia
• Potential neuroprotective agents

– Most promising are memantine (Namenda) & selegeline (L-

Deprenyl)
– Many adjuvant agents commonly used, with some controversy
about use of stimulants
• Improved cognitive performance (Brown 1995, Hinkin
2001)
• Accelerated HAD six’s (Czub 2001, Nath 2001)

Page 262 of 1077

 Mental Health & HIV/AIDS
Dementia
• Adjuvant treatments
– Selegeline (L-Deprenyl)
– Buproprion (Wellbutrin)
– SSRIs (Prozac, Paxil, Celexa, Zoloft, Lexapro)
– Dual-action antidepressants (Effexor, Cymbalta)
– Atomexitine (Strattera)
– Modafinil (Provigil)
– Anabolic steroids
– Atypical or second generation antipsychotics

Page 263 of 1077

 Mental Health & HIV/AIDS
Bipolar - Mania
• Prevalence of bipolar disorder in HIV infection is 10
times higher than in general population
(Lyketsos 1993)

• Stress of HIV infection exacerbates pre-existing

bipolar disorder – complicating adherence
• New-onset or secondary mania
– result of HIV infection, opportunistic infections or due to
antiretroviral medications

Page 264 of 1077

 Mental Health & HIV/AIDS
Bipolar - Mania
• Patients with bipolar disorder (primary) at
increased risk of HIV infection
– Impulsivity, poor judgment, & libido changes all
part of mood episodes
• Secondary mania seen in later stages of HIV
infection
– Harder to treat
– More chronic, less episodic course

Page 265 of 1077

 Mental Health & HIV/AIDS
Bipolar - Mania
• Secondary mania
– Associated with impaired cognition
– Increased risk of dementia
– Different clinical features
• Irritable > elevated mood
• Psychomotor slowing
• More chronic than episodic
• More resistant to treatment

Page 266 of 1077

 Mental Health & HIV/AIDS
Bipolar - Mania
• Treatment
– Not well studied with mostly anecdotal case reports
– Depakote (VPA) well tolerated
• Avoid with impaired hepatic function
• Risk anemia with AZT
– Lithium
• Conflicting reports of good response (increases WBC) versus
intolerable side effects
– Tegretol (carbamazepine)
• Avoid as risks medication interactions (inducer) & bone
marrow suppression

Page 267 of 1077

 Mental Health & HIV/AIDS
Bipolar - Mania
• Treatment
Second generation (atypical) antipsychotics all have
indication as mood stabilizers, well tolerated and effective
for psychotic sx’s

Olanzapine (Zyprexa) > risperidone (Risperdal) & quetiapine (Seroquel)

> ziprasidone (Geodon) & aripiprazole (Abilify)

Risk of metabolic effects: wt gain, DM, hyperlipidemia, etc

*Note: clozapine (Clozaril) contraindicated for several reasons

Page 268 of 1077

 Mental Health & HIV/AIDS
Schizophrenia
• Patients with chronic mental illness at
increased risk for HIV infection
– Prevalence rates 2 to 10%
– Medical providers often do not test for HIV
• Incorrectly assume pts not sexually active
• Substance abuse significant co-morbidity
• Pts do not implement HIV risk behavior knowledge

Page 269 of 1077

 Mental Health & HIV/AIDS
Schizophrenia
• Treatment
– Coordinate between medical & psychiatric providers as
much as possible
– Typical or 1st generation antipsychotics
• Increase risk of EPS & tardive dyskinesia
– Atypical or 2nd generation antipsychotics are preferred but
risk weight gain:
- Olanzapine (Zyprexa) > risperidone (Risperdal) & quetiapine
(Seroquel) > ziprasidone (Geodon) & aripiprazole (Abilify)

*Note: clozapine (Clozaril) contraindicated for several reasons

Page 270 of 1077

 Mental Health & HIV/AIDS
Schizophrenia
• Substance-induced psychosis
– Least studied & most resistant to treatment

– Methamphetamine > cocaine > hallucinogen

– Possibly increased susceptibility in patients with

later stage HIV infection (C3)

Page 271 of 1077

Mental Health & HIV/AIDS

Medication Interactions

Page 272 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
Metabolism & excretion
– Hepatic metabolism
• Phase I – prepare for excretion
• Phase II – conjugation
– Renal metabolism
• Creatinine clearance
• Affects lithium or gabapentin
– P-Glycoproteins
• Present in gut, liver, gonads, kidneys, & brain
• Transport hydrophobic substances

Page 273 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
Hepatic metabolism
– Phase I
• Oxidation – Cytochrome P450
• Reduction
• Hydrolysis
– Phase II
• Glucuronidation - UGT
• Acetylation
• Sulfation

Page 274 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
Drug-drug interactions - metabolism:
– Substrate (goes through the funnel)
• drug metabolized by an enzyme

– Inducer (opens the funnel)

• drug increases activity of metabolic enzyme

– Inhibitor (plugs the funnel)

• drug decreases activity of metabolic enzyme

Page 275 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Induction
– May cause decreased amounts circulating drug,
thereby lowering therapeutic effect
• Funnel is opened wider…
• Inhibition
– May cause increased amounts circulating drug,
thereby creating toxic effect
• Funnel is plugged….

Page 276 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Occur in 3 situations
– Add interacting drug (inhibitor or inducer) to existing
regimen containing a substrate drug

– Withdraw interacting drug (inhibitor or inducer) from

existing regimen containing a substrate drug

– Add substrate drug to a regimen containing an

interacting drug (inhibitor or inducer)

Page 277 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Hepatic cytochrome P450

Enzyme system that catalyzes Phase I reactions

Responsible for most metabolic drug interactions

11 families
• 3 of which are important to humans
• designated by a number e.g. CYP1, CYP2, CYP3

Page 278 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Hepatic cytochrome P450

Families are broken down into subfamilies

• designated by capital letter
• e.g. CYP3A

Sub-families are broken down into isoenzymes

• designated by a number
• e.g. CYP3A4

Page 279 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Hepatic cytochrome P450
Most important cytochrome P450 enzymes:
• 1A2
• 2C9 & 2C19
• 2D6
• 3A4*

Page 280 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Phase II Glucuronidation

H2O-soluble molecules conjugated

= more easily excreted

Uridine Glucuronosyltransferase (UGT)

– 2 clinically significant subfamilies
1A & 2B

Page 281 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Phase II Glucuronidation
eg, UGT 2B7 site of conjugation of benzodiazepines
• Lorazepam (Ativan), temazepam (Restoril) & oxazepam
(Serax) are substrates at UGT 2B7
• Inhibited by NSAIDS
• Induced by ritonavir, phenobarbital, rifampin & oral
contraceptives

Page 282 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Anti-retrovirals

Major culprit: ritonavir

Most potent known inhibitor of 3A4!

Page 283 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Antiretrovirals
– 1A2
• Induction by ritonavir & nelfinavir
– 2C9
• Induction by ritonavir & nelfinavir
• Inhibition by delavirdine
– 2C19
• Induction by efavirenz & nelfinavir
• Inhibition by efavirenz & delavirdine

Page 284 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Antiretrovirals
– 2D6
• Inhibition by ritonavir
– 3A4
• Induction by ritonavir, nelfinavir, efavirenz, nevirapine
• Inhibition by ritonavir, fosamprenavir, indinavir,
nelfinavir, saquinavir, tipranavir, delavirdine

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 Mental Health & HIV/AIDS
Medication Interactions
• Antidepressants
– Most metabolized at 2D6
– Exceptions:
• Fluvoxamine (Luvox)
– AVOID
• Nefazodone (Serzone)
– AVOID or dose cautiously
• Bupropion (Wellbutrin, Zyban)
– @ 400 mg, dose cautiously with ritonavir

Page 286 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Antidepressants
– SSRIs
• Fluoxetine (Prozac) & paroxetine (Paxil):
– some interactions, but not clinically significant for most
antiretrovirals
• Citalopram (Celexa), escitalopram (Lexapro), &
sertraline (Zoloft):
– have fewest interactions

Page 287 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Antidepressants
– Tricyclic antidepressants
• Generally well tolerated with anti-retrovirals
• Nortriptyline & desipramine (secondary amines)
– Narrow metabolism at 2D6
– Levels can be elevated by other medications
– Get a blood level if in doubt

Page 288 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Antidepressants
– Dual-action agents:
• Venlafaxine (Effexor) & duloxetine (Cymbalta)
• Well tolerated without adjusting dose
– Mirtazipine (Remeron)
• Well tolerated

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 Mental Health & HIV/AIDS
Medication Interactions
• Anxiolytics
– Mostly metabolized at 3A4
– Avoid
Alprazolam (Xanax)
Triazolam (Halcion)
Midazolam (Versed)

Page 290 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Anxiolytics
– Safest to use glucuronidated benzodiazepines:
• Lorazepam (Ativan)
• Temazepam (Restoril)
• Oxazepam (Serax)
– Caution with buspirone (Buspar), and dosing of
other benzodiazepines with ART (3A4)

Page 291 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Antipsychotics
– Typicals (first generation = D2 blockers)
– Atypicals (second generation = multiple neurotransmitters)

Both are mostly metabolized at 2D6

Page 292 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
Antipsychotics: for use with ritonavir, start with low dose
1A2 & 2D6
• Haloperidol (Haldol) (risk EPS & TD)
– Avoid chlorpromazine (Thorazine), thioridazine
(Mellaril)
• Olanzapine (Zyprexa) & clozapine (Clozaril)
3A4
• Aripiprazole (Abilify) & clozapine (Clozaril)
– Avoid pimozide (Orap)

Page 293 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Stimulants
– Atomoxetine (Strattera*) * = nonstimulant
• Caution with impaired hepatic function
• Metabolized at 2D6
• Inhibits at 2D6

– Modafinil (Provigil) – be cautious

• Metabolized at 3A4
• Induces at 1A2 & 3A4

Page 294 of 1077

 Mental Health & HIV/AIDS
Medication Interactions
• Herbal remedies
– Kava Kava
• Anxiolytic
• Increases bleeding time
• Risk of hepatotoxicity
– St John’s Wort
• Mild antidepressant effect
• Induces 3A4
• Caution with certain ARV medications- may lead to
regimen failure

Page 295 of 1077

 Mental Health & HIV/AIDS

Challenging Patient Population

Page 296 of 1077

 Mental Health & HIV/AIDS
Challenging Patient Population
• Dual, Triple, & Quadruple Diagnosed:
– HIV-AIDS diagnosis
– Psychiatric diagnoses
• Axis I & Axis II
– Substance abuse & dependence
– Co-morbid medical illness
• Hepatitis C
• Diabetes mellitus….

Page 297 of 1077

 Mental Health & HIV/AIDS
Challenging Patient Population
• Multiple comorbid psychiatric disorders:
– Substance abuse & dependence
– Personality disorders
– Chronic mental illness
• Further challenges
– Poverty, lower SES
– Minorities over represented
– Language and cultural barriers to care

Page 298 of 1077

 Mental Health & HIV/AIDS
Challenging Patient Population
• Personality disorders
– Cluster B traits predominant:
• Borderline, Antisocial, Histrionic, & Narcissistic
– Common features of impulsivity, risk taking,
novelty seeking, self destructive behavior
place themselves and others at risk of HIV
infection
– Added factors exploitative, manipulative,
chaotic, entitled, dramatic, and demanding all
make provision of care more challenging

Page 299 of 1077

 Mental Health & HIV/AIDS
Challenging Patient Population
• Goal as provider to take empathic
approach yet able to set non-punitive limits
– Narcissism – reaction or defense to low self
esteem, need to devalue others, unable to
make empathic connections with others
– Splitting & manipulation – manner in which
patients understand their world (Borderline) or
get their needs met (survival on streets)
– Multidisciplinary team approach: improve
communication, minimize splitting

Page 300 of 1077

 Mental Health & HIV/AIDS
Challenging Patient Population
• Strategy:
– Communicate between providers & systems
• Utilize mental health case managers to assist with
adherence to ART, appointments
– Monitor blood work
• Do not assume other provider is following hepatic
or renal function, electrolytes or blood levels
– Monitor for medication interactions
• Communicate between pharmacies

Page 301 of 1077

 Mental Health & HIV/AIDS
Challenging Patient Population
• Lower Socio-Economic Status
– Most needs
– Fewest resources
– Increased risk of violence
– Increased chaos in daily lives
• Affecting adherence to ART
• Not showing for appointments
– Access to chemical dependency treatment

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Mental Health & HIV/AIDS

Substance Abuse

Page 303 of 1077

 Mental Health & HIV/AIDS
Substance Abuse
Triple Diagnosis
HIV infection, psychiatric diagnosis, &
substance abuse
• Epidemiology
– 30% AIDS patients are Injection Drug Users
– >50% HIV patients have some kind of
substance abuse/dependence
• Madison Clinic ~ 65% psychiatric pts
< 5% self report a problem with drugs or EtOH

Page 304 of 1077

 Mental Health & HIV/AIDS
Substance Abuse
• Substances
– Alcohol
– Amphetamines
– Cocaine
– Heroin
– Club drugs:
• GHB, MDMA (Ecstasy), Ketamine (Special K)

Page 305 of 1077

 Mental Health & HIV/AIDS
Substance Abuse
• Injection drug users (IDU)
– Present later in illness for medical care
– Once in care, do not have accelerated course
• Active use impairs access & complicates
care through non-adherence
• Alcohol, amphetamines, cocaine, & heroin
– suppress immune function or increase HIV
replication (Kibayashi 1996)

Page 306 of 1077

 Mental Health & HIV/AIDS
Substance Abuse
• Characteristics of injection drug users non-
adherent to ART(Moatti 2000)

– Younger age
– Active IDU (5 fold higher)
– Alcohol abuse or use
– Stressful life events

Page 307 of 1077

 Mental Health & HIV/AIDS
Substance Abuse
• Treatment
– Detoxification: complicated by HIV illness &
withdrawal from multiple substances
– Chronic opioid users
• Refer to methadone maintenance programs
• Certain ARV medications may decrease
methadone levels
– Integrated settings most effective
– Directly Observed Therapy (DOT) may assist
ART adherence

Page 308 of 1077

 Mental Health & HIV/AIDS
Summary
• Changing epidemic with significant impact

• Challenging illness & patient population

• Team approach, multidisciplinary care

• Remember to look up medication interactions!

www.madisonclinic.org
http://hivinsite.ucsf.edu/arvdb?page=ar-00-02

Page 309 of 1077

 EPILEPSY

by Dr E.T. Nyamukoho

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 Definition
• Recurrent unprovoked seizures
• A seizure is disorderly discharge of
cerebral neurons

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 Characterised by
• Strange sensation
• Emotion
• Behavior
• Convulsions
• Muscle spasm
• Loss of consciousness

Page 312 of 1077

 Classification: international League
Against Epilepsy
• Partial (Focal) Seizures
• Partial (Focal) to Generalized
• Generalized seizures
• Unclassified epileptic seizures

Page 313 of 1077

 Partial/focal seizures
• Can be simple or complex
• Involve part of the brain but not the whole
brain
• Simple partial seizures do not involve clouding
of consciousness/ loss of awareness
• Complex partial seizures associated with
clouding of consciousness
– Eg temporal lobe epilepsy

Page 314 of 1077

 Temporal lobe epilepsy
• State of clouding of consciousness
• Origin is in the temporal lobe
• Associated with
• Anxiety
• Fear
• Hallucinosis
• Automatism

Page 315 of 1077

 Generalised seizures
• Involve both cerebral hemispheres
• Associated with loss of consciousness
• Eg
– Absence seizures
– Infantile spasm
– Tonic clonic seizures
– Tonic seizures
– Clonic seizures
– Atonic seizures
– Myoclonic seizures

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 Absence seizures
• Interruption of consciousness for short
periods usually 30 seconds
• Slight twitch
• Does not fall
• Patients grow out of it by 12 years
• EEG: 3 Hz spike wave discharges

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 Tonic clonic seizures
– Tonic phase initially (muscle contraction)
– Clonic phase (rhythmic muscle contraction)
– Tongue biting
– Urinary incontinence
– Absence of breathing

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 Myoclonic seizures
• Sporadic muscle contraction

Page 319 of 1077

 Atonic Seizures
– Loss of muscle tone
– Fall to the ground
– Drop attacks
– Differential diagnosis
• Narcolepsy
• cataplexy

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 Unclassified
• Eg pseudoseizures/ psychogenic seizures
– Can co-occur with epilepsy
– Occur when there is an audience
– Post seizure clear consciousness, no
confusion or drowsiness
– Often no
• tongue biting
• Incontinence of urine
• Loss of consciousness

Page 321 of 1077

 Status epilepticus
– Any fit that lasts longer than 5 minutes
– Medical emergency

Page 322 of 1077

 Phases of seizures
• Pre-ictal/ prodrome
• Ictal
• Post- ictal
• Inter-ictal

Page 323 of 1077

 Pre-ictal/ prodrome
• Irritable
• Anxious
• Aggressive
• Depressed
• Labile mood.
• About 30 minutes up to 3 days
• Relieved by the seizure

Page 324 of 1077

 Ictal
• What happens depends on the type of seizure
• Aura
- Auditory hallucinations
- Visual hallucinations
- Gustatory hallucinations
- Déjà vu, jamais vu
- Depersonalisation, derealisation

Page 325 of 1077

• Automatisms occur in temporal lobe epilepsy
• Aggression is very rare
– Undirected or unintentional
– Can be due to poor handling of a patient during a
fit
– Simple violent automatisms such as failing of arms
can occur at the onset of focal seizures
– Secondary violent automatisms can occur as a
response to an unpleasant or emotional aura
Page 326 of 1077
 Post- Ictal
• Confusion- lasts minutes to hours or
occasionally days.
• Awareness is impaired
• Wandering
• Aggression which is undirected or resistive
can occur.
• The patient is usually amnesic for the event.

Page 327 of 1077

• Psychosis -prevalence- 6-10%
• Ass with focal more than generalised epilepsy
• Delusions, hallucinations, thought disorders
and mania are transient
• Last several hrs to wks- usually self limiting

Page 328 of 1077

 Inter-ictal
• Depression is the commonest inter-ictal
psychiatric disorder amongst epileptic patients
• Anxiety disorders are more common than in
the general population
• Bipolar -similar prevalence to the general pop
• Interictal Psychosis- characteristics
indistinguishable from those of schizophrenia

Page 329 of 1077

 Personality disorders
• A high prevalence of personality disorders
among epileptic patients
• Eg Borderline, histrionic and dependent
• Patients are often stigmatised, even feared by
some and have many psychosocial problems
• The above lead to a low self esteem,
dependency and borderline personality traits

Page 330 of 1077

 Cognitive impairment
• Most people with epilepsy have an IQ in the
normal range.
• A small number of patients have slowly
progressive dementia
• Status epilepticus, repeated head injury,
cumulative effect of seizures, underlying
degenerative brain disorder or anti epileptic
medication could be responsible

Page 331 of 1077

 Suicide
• 4-5 times more than the general population
• Reasons
-Paranoid delusions
-Agitated compunction to kill themselves
-Command hallucinations
• Psychosocial stressors are not usually the
reason for committing suicide

Page 332 of 1077

 Causes of Epilepsy
• Genetic
• Brain injury due to antenatal and birth
trauma
• Post cerebral infections eg meningitis,
encephalitis, brain abscess
• Post head injury
• Post cerebrovascular accident

Page 333 of 1077

 Triggers of seizures
• Flashing light.
• Hyperventilation.
• Emotional Stress
• Menses

Page 334 of 1077

 Investigations
• Dx is mainly on clinical ground
– (1 fit is not epilepsy)
• Electroencephalogram (EEG)
– Aids in Diagnosis
– Classification of epilepsy

Page 335 of 1077

• Do a full neurological examination
• CT Scan
• Serum prolactin levels
– markedly elevated after a seizure
– differentiate pseudo seizure and actual
seizures

Page 336 of 1077

 Treatment
• Psychopharmacology
– Psychiatric conditions are managed the
same as in non epileptics
– Note neuroleptics and antidepressants
are epileptogenic i.e. lower seizure
threshold

Page 337 of 1077

• Generalized epilepsy
– Tonic Clonic
• Phenytoin
• Carbamazepine
• Sodium Valproate
• Phenobarbitone

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– Absence
• Ethosuximide
• Sodium valproate

Page 339 of 1077

• Complex Absences and Atonic seizures
– Sodium Valproate
– Clonazepam
– Clobazam

Page 340 of 1077

• Partial seizures
– Phenytoin
– Carbamazepine
– Sodium Valproate

Page 341 of 1077

• Myoclonic seizures
– Sodium Valproate
– clonazepam

Page 342 of 1077

• Newer anti-epileptics
– Topiramate
– Levetiracetam
– etc

Page 343 of 1077

• Psychotherapy
– Supportive Psychotherapy
– Psycho education to patient and family

Page 344 of 1077

• Social Management
– Legal
• No driving unless 2 years seizure free
• Caution heights, swimming etc
• Crimes can occur during a seizure
e.g. aggression
– No alcohol allowed in epilepsy
– Work on developing support system

Page 345 of 1077

– Address problems attached to stigma
– Public awareness
• Target myths e.g. touch froth from
epilepsy patient and you become
epileptic

Page 346 of 1077

• Rehabilitation
– Manage any potential handicap
• Underlying problem
• Secondary problem

Page 347 of 1077

• Surgery: Indication
• Patient is seriously handicapped by
frequent seizures
• Poor response to an adequate
antiepileptic course over 3-5 years
• Clinical or EEG for localized electrical
discharges
• Eg temporal lobectomy, callosotomy
etc
Page 348 of 1077
The End

Page 349 of 1077

alcohol use disorders

[email protected]
Dr. M Madhombiro

Page 350 of 1077

outcomes……
• Discuss and explain the following
• related to the use of alcohol
• Pharmacokinetics
• Safe drinking
• Screening for alcohol use disorders
• Intoxication
• Withdrawal
• Medical and psychiatric complications of alcohol use disorders
• Managing patients with AUD

Page 351 of 1077

 Alcohol history
• “Noah, who was a farmer, was the first man to plant a vineyard.
• After he drank some of the wine, he became drunk…”
• Gen 9: 20-21 (Good News Bible

Page 352 of 1077

Pharmacokinetics
• Mostly taken orally
• Absorbed:
• 20% from stomach
• 80% from small intestines into bloodstream
• Absorption may be slowed by delayed gastric emptying, e.g. through the
presence of food
• Disseminated through body through process of distribution
• Small amount excreted in urine, breath and sweat (less than 10%) -but
mostly metabolised
• Levels in breath mirror blood alcohol concentrations

Page 353 of 1077

pharmacokinetics
• metabolism
• 1st
• bypass metabolism
• Hepatic alcohol dehydrogenase
• metabolise to acetaldehyde
• Hepatic aldehyde
• dehydrogenase to acetate

Page 354 of 1077

pharmacodynamics

• Increases inhibitory activity via GABA(A)

• receptors
• With chronic alcohol use -> reduced GABA sensitivity-> tolerance
• GABA leads to endogenous opioid release, that affects dopamine
reward path, leading to alcohol’s reinforcing effects
• Reduced inhibitory effect-> hyperexcitability-> withdrawal reduce
excitatory activity via NMDA glutamate receptors

Page 355 of 1077

Page 356 of 1077
Page 357 of 1077
Page 358 of 1077
normal effects of alcohol

Page 359 of 1077

Intoxication

• Following recent intake of alcohol, the patient

• presents with problematic behaviour or
• psychological changes (e.g. aggressive,
• inappropriate sexual behaviour, labile mood,
• impaired judgement)

Page 360 of 1077

Intoxication
• Any of the following:
• 1. Slurred speech
• 2. Incoordination
• 3. Unsteady gait
• 4. Nystagmus
• 5. Impaired memory/attention
• 6. Stupor/coma

Page 361 of 1077

alcohol withdrawal syndrome
• Custer of symptoms, following cessation or reduction in alcohol use
that has been heavy and prolonged.
• Usually within 6-8hours
• autonomic hyperactivity (e.g. sweating, tachycardia, hypertension)
• increased hand tremor
• insomnia

Page 362 of 1077

alcohol withdrawal syndrome
• nausea or vomiting
• transient tactile, visual or auditory hallucinations or illusions
• psychomotor agitation
• anxiety
• tonic-clonic seizures – up to 1/3 that stop abruptly,
• max risk 1st 48 hours

Page 363 of 1077

alcohol withdrawal

Page 364 of 1077

screening
• Clinical interview- ask about heavy drinking days, number of drinks
per week

• Screening tools, e.g. AUDIT, CAGE

Page 365 of 1077

Page 366 of 1077
when is alcohol too much?
• When it elevates risk for alcohol-related health or social problems or
complicates the management of other health/social problems

• Male: 5+ standard drinks per day or >15/week

• Female: 4+ per day or 8/week ;nil in pregnancy

Dawson DA, Grant BF, Li TK. Quantifying the risks associated with exceeding recommended drinking limits. Alcohol Clin Exp Res. 2005; 29(5):902-908

Page 367 of 1077

safe drinking
• Men less than 14 Units / week and women less than 8 Units / week
• Not daily (at least 2 alcohol free days/week)
• Not all on one day (avoid binges)
• Men <60y: no more than 4U/day
• Women, men>60y: no more than 3U/day all on one day (avoid
binges)

Page 368 of 1077

safe drinking
• Not during pregnancy
• Never before or during driving, swimming, active
• sport or use of machinery, electrical equipment,
• ladders or in other potentially dangerous
• situations

Page 369 of 1077

A standard drink

Page 370 of 1077

units

Page 371 of 1077

when to anticipate withdrawals
• Severe dependence (extended history of continuous heavy drinking
with high levels of tolerance or severe withdrawal symptoms on
presentation e.g. evidence of marked autonomic over-activity

• Past history of convulsions

• Past history of DT’s
• Older age (>60y) or younger age (<16y)
• Pregnancy

Page 372 of 1077

should you anticipate withdrawals then
arrange in-patient detox
• Significant concomitant medical comorbidity
• (e.g. liver disease, cardiac disease, severe
• infections etc.)
• Significant concomitant psychiatric
• comorbidity (e.g. psychosis, suicidality,
• cognitive impairment)

Page 373 of 1077

should you anticipate withdrawals then
arrange in-patient detox
• Concomitant withdrawal from other
• downer drugs
• Lack of support at home
• Previous failed outpatient detoxification
• attempts

Page 374 of 1077

alcohol detoxification
• Benzodiazepines
• Long acting benzodiazepines – e.g. Diazepam to prevent
• delirium and seizures
• May lead to accumulation with severe liver dysfunction – use
• short acting , like oxazepam
• Either fixed dose or symptom triggered
• General care:
• Correct fluids, electrolytes, nutritional deficiencies
• Thiamine supplementation

Page 375 of 1077

thiamine supplementation
• Healthy uncomplicated alcohol-dependent/
• heavy drinkers (i.e. those at low risk), oral thiamine >300 mg/day
during detoxification
• High risk of WE (e.g. malnourished, unwell) prophylactic parenteral
treatment 200-300 mg thiamine i.m. or i.v. once daily for 3–5 days or
until no further improvement is seen

Page 376 of 1077

Alcohol complications

Page 377 of 1077

some alcohol complications
Liver disease Elevated liver enzyme Fatty liver, alcoholic hepatitis,
levels cirrhosis
Pancreatic Acute pancreatitis, chronic
disease pancreatitis
Cardiovascular Hypertension Cardiomyopathy, arrhythmias,
disease stroke
Gastrointestinal Gastritis, gastro Esophageal varices, Mallory-
problems esophageal reflux Weiss tears
disease, diarrhea, peptic
ulcer disease

Page 378 of 1077

some alcohol complications

Neurological Headaches, blackouts, Alcohol withdrawal

disorders peripheral neuropathy syndrome, seizures,
Wernicke's encephalopathy,
dementia, cerebral atrophy,
peripheral neuropathy,
cognitive deficits, impaired
motor functioning
Reproductive Fetal alcohol effects, fetal Sexual dysfunction,
system alcohol syndrome amenorrhea, anovulation,
disorders early menopause,
spontaneous abortion
Cancers Neoplasm of the liver,
neoplasm of the head and
neck, neoplasm of the
pancreas, neoplasm of the
esophagus
Page 379 of 1077
fetal alcohol syndrome

Page 380 of 1077

wernicke encephalopathy
• Acute thiamine deficiency
• Operational criteria for the diagnosis of WE have been proposed with
only two of the classic triad Ophthalmoplegia
• Ataxia

Page 381 of 1077

wernicke encephalopathy
• Confusion and dietary deficiencies. (Caine et al., 1997)
• significant mortality Up to 80% develop Korsakoffs
• Requires prompt treatment with intravenous thiamine – if treated
early, most symptoms will resolve
• Avoid glucose without thiamine

Page 382 of 1077

korsakoff syndrome
• Korsakoff syndrome is characterized by impaired
• ability to learn new information and
• confabulation
• Strong link with Wernicke's
• May be irreversible
• Some may recover with thiamine, abstinence and
• time

Page 383 of 1077

high risk for W-K
• Drinking that exceeds15 units per day for a month or more evidence
of recent weight loss
• vomiting or diarrhea malnutrition
• peripheral neuropathy
• chronic ill-health

Page 384 of 1077

thiamine for suspected W-K
• If WE is suspected or established, parenteral thiamine (i.m. or i.v.) of
>500 mg should be given for 3–5 days, or longer depending on
response

Page 385 of 1077

delirium tremens
• Up to 5% of alcoholics who stop abruptly
• Onset usually 2-5 days after stopping, often at night.
Present with
• clouded consciousness, disorientation
• Evidence of withdrawal (e.g. high pulse, blood pressure, tremors, fever etc)
• Anxiety, signs of withdrawal, agitation
• Delusions
• Visual +/- auditory hallucinations (“the horrors”)
• Lasts +/- 5 days
• Risk of death: 5-15% with treatment; 35% without
Page 386 of 1077
treatment of DTs
• Pharmacological treatment
▪ Benzodiazepines
▪ +/- Haloperidol
• Nutrition control of fluid balance intensive treatment of concurrent
somatic disorders
• Rest and sleep

Page 387 of 1077

withdrawal seizures
• Generalized tonic-clonic type
• seizures
• Up to 1/3 of alcoholics who stop abruptly
• 8-24 hours after last drink
• Risk peaks at 24 hours

Page 388 of 1077

alcohol and psychiatry
• Mood disorders
• Anxiety disorders
• Psychotic disorders –
• hallucinosis
• Pathological jealousy “Othello
• syndrome”
• Sexual disorders
• Sleep disorders
• Amnesic disorders
• Dementia
• Personality disorders

Page 389 of 1077

alcoholic hallucinosis
• Can occur during intoxication or withdrawal
• Vs DT’s: Clear sensorium
• Only after years of heavy drinking
• Typically 12-24 hours after stopping, lasts for
• days
• auditory and visual hallucinations, most
• commonly accusatory or threatening voices
• 20% of hospitalized alcoholics
• Do not carry a significant mortality

Page 390 of 1077

pathological jealousy
• A strong delusional belief that their
• spouse or sexual partner is being
• unfaithful without any proof
• preoccupation with a partner’s sexual
• infidelity
• Risk of violence, homicide risk

Page 391 of 1077

treatment of alcohol dependence
• Aversion
Disulfiram
• Anti-craving
Acamprosate
Naltrexone
• Other
E.g. SSRI’s, topiramate, baclofen, odansetron etc.

Page 392 of 1077

how disulfiram works
Acetaldehyde
Antabuse dehydrogenase

Acetaldehyde acetate

Flushing, throbbing of head and neck

Shortness of breath
Sweating, thirst, chest pains
Heart palpitations, dizziness, fear, weakness
Page 393 of 1077
disulfiram
• Highly motivated client, who struggles to maintain sobriety, especially
those with risk of significant harm if they relapse (e.g. drivers)
• Use with psychosocial treatment interventions
• Rare episodes of severe hepatotoxicity, monitor of liver functions
• Dose: 200 mg (1/2 tablet) daily or 400 mg alternate days
• Efficacy may be improved by supervising consumption
• Obtain informed consent from patient
• Ensure no contra- indications, drug interactions
• Provide information to patient on side-effects, interactions with “hidden”
sources of alcohol, e.g. aftershave, cough syrups etc. Ensure no alcohol
consumed 24 hours prior to commencement

Page 394 of 1077

acamprosate
• Normalizes the dysregulation of the NMDA
• mediated glutaminergic neurotransmission (a
• physiological mechanism that may prompt relapse)
• ?blocks NMDA-R and activate GABA-A R

Page 395 of 1077

acamprosate
• Adds a modest effect in improving relapse to alcohol use
Who ?:
• individuals who are able to achieve abstinence, but are unable to
remain sober due to severe cravings and who have failed at attempts
of psychosocial rehabilitation
• Agent of choice with severe liver impairment
Use along with psychosocial treatment interventions

Page 396 of 1077

acamprosate
• Initiate as soon as possible after abstinence
• Contra-indicated with severe kidney impairment can cause diarrhoea-
consider impact on patients with disorders associated with diarrhoea.
• The FDA label notes increased “…events of a suicidal nature…” with
acamprosate compared to placebo; patients with suicidal
behaviour/ideation should be monitored

Page 397 of 1077

acamprosate
• Avoid in pregnancy or breastfeeding
• Dose: >60 kg: 666 mg 3x/day; <60 kg: 666 mg am;
• 333 mg midday and pm

Page 398 of 1077

naltrexone
• opioid receptor antagonistblocks
• the endogenous
• opioid reward system

Page 399 of 1077

naltrexone
• Adds a modest effect in improving relapse to alcohol by blocking alcohol
use ? by reducing pleasurable effects (opioids released by alcohol that
release DA in mesolimbic system)
• Avoid in patients receiving opioids for medical reasons/ opioid addicts who
are still using
• Avoid in significant liver dysfunction
• Nausea, headache common
• 50mg/day
• Hepatotoxicity in large doses
• Dysphoria

Page 400 of 1077

other
• SSRI
Co-occurring depression
??? Of value in type 1
Avoid/caution in type 2
• Topiramate:
preliminary data suggest reduce heavy drinking and enhance
abstinent days at a target dose of 300 mg/day
• Ondansetron
Increased abstinent days and reduced drinks/drinking day in
one single-site study.

Page 401 of 1077

other
• Baclofen:
Preliminary data suggest possible enhanced abstinence and
reduced alcohol use in alcoholic patients without serious
liver disease and in alcoholic patients with cirrhosis.

Page 402 of 1077

psychosocial therapies
• Support for:
• Motivational enhancement therapy
• CBT
• 12-step facilitation
• No one of these interventions seem superior to one another
• Supportive counseling and non-specific social work interventions
alone is less effective
• Support for marital or family interventions
• Weak support for matching pnts to interventions

Page 403 of 1077

psychosocial therapies

• For limited problems, limited interventions as effective as intensive

• interventions
• No evidence suggesting superiority for duration of treatment or
setting of
• intervention (in vs outpnt)
• With comorbid mental health problems or homelessness, there is a
need to
• focus on this concurrently

Page 404 of 1077

RESEARCH

Page 405 of 1077

references/reading

Caputo F, et al. Pharmacological management of alcohol dependence: From mono-

therapy to pharmacogenetics and beyond. Euro
Neuropsychopharm (2014) 24: 181-191
Luty J. What works in alcohol use disorders? APT 2006, 12:13-22
Bayard M, McIntyre J, Hill KR, Woodside J. Alcohol Withdrawal Syndrome. American
Family Physician 2004; 69(6):1443-1450
Williams SH. Medications for Treating Alcohol Dependence. American Family
Physician 2005; 72:1775-80
Ries et al. Principles of addiciton medicine 4 ed. Lippencott williams &Wilkens 2009
th

Galanter et al. The American Psychiatric textbook od Substance Abuse Treatment 4 th

ed. American Psychiatric Publishing 2008

LowinsonJH et al. Substance Abuse. A comprehensive Textbook 4 ed. Lippencott
th

williams &Wilkens 2005

Page 406 of 1077

 cannabis use disorders
expectations

Street names
Methods of use
Pharmacokinetics
Intoxication
Withdrawal
Medical and psychiatric complications of use
Medicinal use

Page 407 of 1077

 cannabis street names

Dagga
Marijuana
Hemp
Weed
Dope
Pot
Slow boat
Ganja
Herb
Boom
Bung
Mbanje

Page 408 of 1077

 cannabis epidemiology

From Cannabis Sativa plant

The most potent agent is delta9-
tetrahydrocannabinol (THC) – potency
increased significantly since 1960’s
(from 1-2% to 10-15%)
Worldwide most commonly used
illegal substance
USA: 46% population used at least
once; 1.3% cannabis use disorder
Risk factors: male, younger age,
divorced/separated, lower education,
prison population
High rates comorbid medical,
psychiatric, other substance

Page 409 of 1077

 formulations of cannabis

Dry stalks, flowers, leaves and

seeds (herbal cannabis)
Pressed, dry resin or secretion
(hashish)
Oil (hash oil)
Smoked in joints, pipes or
buckets, baked, or taken as
an extract (“tea”).
Slow boat: cigarette - mixture
of cannabis and tobacco

Page 410 of 1077

cannabis continues…….

Page 411 of 1077

 pattern of use

Experimental
Occasional users
Regular users (3-5x/week)
Heavy daily use
Genetic basis ~60% - strong role to develop use
disorder
Environmental factors ~ 40% (i.e. childhood
trauma, parental divorce) – strong role initial
use
Cannabis use disorder: mild – moderate – severe

Page 412 of 1077

Page 413 of 1077
Page 414 of 1077
 pharmacokinetics

After smoking: effects within 15-30 minutes, lasts 2-6

hours
After ingestion: effects within 30-60 minutes, lasts 5-12
hours
Lipid soluble: accumulates in fatty tissues – leads to long
T1/2 of up to 7 days
Complete elimination may exceed 30 days
Regular users may build up significant levels of THC that can continue to
reach their brains even after prolonged abstinence
Readily crosses BB-barrier
Metabolised in liver – metabolites also psychoactive
Urine excretion, also bile, faeces

Page 415 of 1077

pharmacokinetics…….

Page 416 of 1077

 pharmacodynamics

Agonist at endogenous cannabinoid receptors

CB1 receptors (CNS - diffusely)
CB2 receptors (peripheral tissue, mainly immune system)
THC activates CB1 R in meso-limbic dopamine system – modulate
reinforcing and rewarding effects
Tolerance at CNS level – repeated stimulation CB1 R results in
desensitisation and down-regulation of Receptors
Increases fluidity of cell membranes
Increases dopamine in reward pathway
Modulation of GABA system

Page 417 of 1077

 intoxication

Effects are dose related

Generally, relaxation, euphoria and sense of sharpened
awareness
High doses/potent cannabis may cause hallucinations,
paranoid/grandiose thoughts, depersonalisation
Vasodilatation: red eyes, tachycardia, postural
hypotension
No pupil size change
appetite, dry mouth
REM sleep
estimation of time and distance

Page 418 of 1077

Page 419 of 1077
 intoxication cont……

Perceptual changes i.e. sensation colours brighter,

music more vivid, distorted time perception
Altered information processing so that boring and
repetitive tasks are performed with interest and
concentration
↓ attention/concentration, judgment,
Motor in-coordination, complex tasks (NB – MVA
risk)
Analgesia, anti-emetic, anti-epileptic
Dysphoric reaction: anxiety, panic, dysphoria, social
withdrawal (first time user, anxious, psychologically
vulnerable)

Page 420 of 1077

Page 421 of 1077
Page 422 of 1077
 amotivational syndrome

Amotivational syndrome
Apathy, dullness, diminished goal-directed activities, impaired
concentration, deteriorated personal appearance,
long-term impairment in performance, especially of attention,
memory, ability to process complex information can last
weeks months or even years
? permanent cognitive impairment

Page 423 of 1077

Page 424 of 1077
 dependence

Tolerance (83%) and withdrawal (91%)

thus physically addictive

Continued use despite a health problem (72%)

Great deal time spent obtaining or recovering from
its effects (65%)

Page 425 of 1077

Page 426 of 1077
 dependence

Withdrawal usually mild to moderate – onset 1-2 days

after last use, peak day 3-6 and resolve in 7-14 days
4 to 5 days of fatigue, yawning, insomnia or
hypersomnia, anxiety, depressed mood, irritability,
restlessness, decreased appetite, agitation, tremor,
Usually does not require medical detoxification, but if
client is very uncomfortable so that this discourages
abstinence, withdrawal medication can be given
(diazepam 5mg TDS,
reduced over 3-5 days)

Page 427 of 1077

 complications

Cardiac: Postural hypotension, fainting, acute cardiac

incidents
Lungs: Cannabis smoke contains carbon monoxide,
bronchial irritants, tumour initiators and promoters and
carcinogens as cigarettes, 3x>tar retained, higher
combustion temperature → more bronchitis and
emphysema, lung cancer (3/4 joints=20 cigarettes)
Immunosuppressant
Endocrine effects
Cognitive effects

Page 428 of 1077

Page 429 of 1077
psychiatric complications

Acute “toxic” responses: panic, anxiety, depression,

psychosis
Cannabis induced psychosis
Amotivational syndrome (impaired attention, memory,
learning, drive)
Effects on pre-existing mental illness
Cannabis as risk factor for
mental illness
Withdrawal effects

Page 430 of 1077

 psychiatry comorbidity

Schizophrenia, other psychotic disorders

Bipolar disorder
Major depressive disorder
Anxiety disorders including panic disorder, GAD
Other substance use disorders: nicotine, alcohol,
stimulants, opiates

Typical sequential progression from adolescence to

adulthood: tobacco, alcohol → cannabis → other illegal
substances – “gateway theory”

Page 431 of 1077

 therapeutic uses

1st used in China 5000 years ago for malaria, constipation,

rheumatic pains, childbirth, surgical analgesic
Reynolds (Queen Victoria’s physician) : “Indian hemp … is
one of the most valuable medicines we possess”
Nausea and vomiting in cancer chemotherapy
Weight loss in cancer and AIDS patients
Multiple sclerosis
Pain
Raised intra-ocular pressure
Asthma

Page 432 of 1077

Page 433 of 1077
Page 434 of 1077
 treatment options

No specific pharmacotherapy to address

cannabis use disorder
Medical and psychiatric comorbidity
Psychoeducation
Motivational interviewing
CBT
12-step programs

Page 435 of 1077

Page 436 of 1077
 cocaine

From Erythoxylon coca plant

Cocaine hydrochloride (salt): readily injected, snorted; cannot smoked
readily
coke
Snow
Charlie
dust
Freebase cocaine: smoked, difficult to dissolve for injection
Crack
Rocks
Sugars: mixture of cheap heroin, cocaine or other stimulants used in mostly
in Durban
Speedballing: using heroin and cocaine together

Page 437 of 1077

Page 438 of 1077
Page 439 of 1077
Page 440 of 1077
Page 441 of 1077
Page 442 of 1077
 cocaine
From plant leaves – Andes Mountain South America
Smuggled (not manufactured) – more expensive, variable
availability
T ½ ~ 45 min
Tend more cardiotoxic than amphetamines

Page 443 of 1077

Page 444 of 1077
cocaine and alcohol

Cocaine with alcohol: “liquid lady”

body produces coca ethylene
Cocaine substitute
3-5x longer t½
18-25 x in risk for immediate death
More cardio-toxic, CVA’s, seizures, liver
damage, immune compromise
Alcohol trigger for relapse

Page 445 of 1077

 administration

Route:
Usually snorted or smoked
Smoking it either in a crack pipe or added to tobacco
or marijuana cigarettes
Taken by mouth mixed in a liquid such as coffee or
soft drinks
Intravenous injection

Page 446 of 1077

Page 447 of 1077
 mechanism of action

Cause increase in synapse of monoamine

neurotransmitters including dopamine,
noradrenaline and serotonin.
Dopamine becomes highly concentrated in
synapse and available for postsynaptic
signaling. With repeated use down-regulation
and desensitisation of post-synaptic D2
receptor – tolerance and loss of salience of
normal rewards.
Metamphetamine-induced neurotoxicity incl.
oxidative stress, glutamate excititoxicity,
neuroinflammation, mitochondrial dysfunction,
neurotrophic factor dysfunction, changes BBB.
Long-term serotonin – dysphoria, anhedonia

Page 448 of 1077

Page 449 of 1077
 effects of stimulants

Initial rush
Period of feeling “high”
Subjective feelings of well-being and alertness
Increased energy, activity, libido
Decreased appetite
Agitation or paranoia that can lead to violent
behaviour.

Page 450 of 1077

 highs

Tolerance occurs rapidly – the pleasurable effects

disappear even before the drug concentration in
the blood falls significantly – some users may try
to
maintain the high by “binging” on the
drug.
“runs” of days (3-6 days)
“tweaking”
Toxic

Page 451 of 1077

 physical features

Increases
Pulse
Blood pressure
Pupil size
Respiration
Sensory acuity
Decreases
Sleep
Reaction time

Page 452 of 1077

Page 453 of 1077
“crash”

Agitation, loss of
appetite, depression
(may have suicidal ideas)
and severe craving.
Later: exhaustion with a
desire to sleep, but an
inability to do so.
Late: oversleeping and
often an increased
appetite.
The crash phase can last
hours to several days

Page 454 of 1077

Page 455 of 1077
Page 456 of 1077
stimulant withdrawal

Low energy levels, inability

to enjoy anything
(anhedonia), anxiety and
depression (may have
suicidal thoughts)
Severe cravings
High risk of relapse
Can last for months

Page 457 of 1077

Page 458 of 1077
Page 459 of 1077
 “extinction”

The phase were the mood returns to

normal
Usually episodes of craving brought
on by “conditioned triggers” (things
that are associated with drug use, e.g.
a place, person, object etc.)
Some addicts remain depressed,
fuzzyheaded, and think life is not as
pleasurable without the drug for
months or even years after
withdrawal.

Page 460 of 1077

 health complications

Heart and blood vessels:

Ischemia: coronary blood flow at time of oxygen demand ( pulse,
BP, platelet aggregation, focal vasospasm)
directly cardio toxic
arrythmogenic
CNS:
seizures, status, involuntary movements
cerebral haemorrhages, TIA’s, CVA’s
Hyperpyrexia , rhabdomyolisis, dehydration
Jaw clenching, dental problems, “meth mouth”

Page 461 of 1077

 complications cont….

Twitching, jitteriness, and repetitive behaviour

Movement disorders i.e. chorea, Parkinsonism
Nutritional deficiencies and body wasting
Renal failure
Respiratory problems
Necrosis of nasal septum (snorting)
Endocrinological problems, e.g. impaired sexual
performance and reproductive functioning
Birth abnormalities and pregnancy related
complications, like premature delivery, and altered
neonatal behavioural patterns, such as abnormal
reflexes and extreme irritability
Death

Page 462 of 1077

psychiatric complications

Delirium: confused and

disorientated
Mania
Psychosis: paranoia, visual and
auditory hallucinations,
formication, delusions
Depression with suicide risk
Anxiety disorders
Sleep disorders
Long-term permanent brain
damage
Stimulant use disorder

Page 463 of 1077

 stimulant use disorder

Withdrawal
Tolerance
Cravings
Often larger amounts/longer periods than intended
Strong desire or unsuccessful attempts stop/control use
Great deal time: obtain, use, recover from effects
Results role failures i.e. work, home
Relationship problems caused/exacerbated
Use situations physically hazardous
Continue despite physical/psychological problem
caused/exacerbated
Important activities given up/reduced i.e. social, recreational

Page 464 of 1077

 High HIV risk

Sexually arousing (↑ libido) and disinhibitory

“loss of control”
Unprotected sex
Multiple partners
Injecting stimulants
HIV infection renders the brain vulnerable to
damage from methamphetamine and visa
versa

Page 465 of 1077

 detoxification

No specific detoxification regime

Often irritable, explosive, cravings for about 5-7
days
Support and empathy
Comprehensive assessment for comorbid
medical and psychiatric disorders or squeal to
stimulant use
Symptomatic treatment
Promethazine (insomnia)
Benzodiazepines (with caution) (insomnia, agitation,
restlessness, paranoia)

Page 466 of 1077

management of stimulant psychosis

Paucity of data
No controlled trials
Usually abates rapidly with abstinence,
adequate fluids, diet and restorative
sleep
Benzodiazepines for agitation
If persists, it is managed as for other
psychosis with antipsychotic medication
Monitor for depression and suicide risk
No consistent guidelines for the duration
of treatment
? Low dose treatment beyond psychotic
episode may protect against further
psychotics episodes (sensitisation theory
for psychosis)

Page 467 of 1077

psychosocial stimulant management

Intensive, long term outpatient treatment as

primary approach
+/- initial short-term inpatient treatment
Extended treatment is critically important to
help client through the most difficult period
of protracted abstinence dysphoria,
anhedonia and cognitive disruption
Residential rehabilitation – therapeutic
communities

Page 468 of 1077

 nicotine

Identification
Medical and psychiatric
comorbidity
Nicotine replacement –
patches, gums
Buprenorphine (NDRI)
Varenicline (nicotine partial
agonist)
Psychoeducation
Psychosocial interventions:
motivational interviewing,
CBT, 12-step programs
Other i.e. flooding, hypnosis

Page 469 of 1077

 caffeine

Most widely consumed psychoactive

substance
Psychiatric consequences include caffeine-
induced anxiety and sleep disorders
Heavy caffeine use – associations with
smoking and alcohol use
Caffeine antagonist adenosine receptor –
result in increased dopamine synapse
Low doses: ↓sedation, ↑concentration,
well-being, energy
High doses: anxiety, nervousness
Treatment: generally slowly decrease
consumption i.e. 10% every 5-7 days; avoid
abrupt cessation
Psychoeducation: withdrawal symptoms

Page 470 of 1077

your plants

thank you
siyabonga
danke

Page 471 of 1077

SUICIDE RISK ASSESSMENT
Dr Michelle Dube

Page 472 of 1077

DEFINITION

a fatal act of self-injury (self-harm) undertaken with

more or less conscious self-destructive intent
Suicidal behaviour or suicidality is a continuum ranging
from suicidal ideation and communications to suicide
attempts and completed suicide
Its the fatal outcome of a long-term process shaped by
a number of interacting cultural, social, situational,
psychological, and biological factors

Page 473 of 1077

DYNAMIC AND STATIC RISK
FACTORS
Static Risk Factors Dynamic Risk Factors

History of self-harm Suicidal ideation, communication and intent

• Seriousness of previous suicidality • Hopelessness

• Previous hospitalisation • Active psychological symptoms

• History of mental disorder • Treatment adherence

• History of substance use disorder • Substance use

• Personality disorder/traits • Psychiatric admission and discharge

• Childhood adversity • Psychosocial stress

• Family history of suicide • Problem-solving deficits

• Age, gender and marital status

Page 474 of 1077

Risk Factors

• Access to preferred
method of suicide

• Future service contact

• Future response to drug

treatment

• Future response to
psychosocial intervention

• Future stress

Page 475 of 1077

Remember

• S: Male sex
• A: Age (<19 or >45 years)
• D: Depression
• P: Previous attempt
• E: Excess alcohol or substance
use
• R: Rational thinking loss
• S: Social supports lacking
• O: Organized plan
• N: No spouse
• S: Sickness

Page 476 of 1077

DEPRESSION

•The mortality risk for suicide in major depression is 20 times

that expected, and 15-to 20-fold in all affective disorders.
•
•Every sixth death among depressive people treated as
psychiatric patients is by suicide.

•The risk is highest for depressive inpatients, even during the

postdischarge period, and much lower among psychiatric
outpatients, although clearly lowest for those treated for
depression in primary care.

Page 477 of 1077

ALCOHOL AND DRUGS

•Alcohol and drugs, often combined, are a major risk or a precipitating

factor for suicide.
•They may intensify the suicidal intent, offer a constantly available
suicide method, worsen the somatic status of the victim, and increase
the risk of complications after the attempt.
•Alcohol and drugs impair judgement and lower the threshold to
suicide.
•Alcohol is detected in about every third case at the moment of suicide.
•The lifetime risk of suicide has been estimated at 7 per cent for alcohol
dependence, with only slight variation over the life.
•The suicide rate in heavy drinking is 3.5 times and in alcohol use
disorders ten times higher than that in the general population.
•In drug dependence or abuse it is 15 times higher than expected.

Page 478 of 1077

MENTAL ILLNESS

• The suicide risk in schizophrenia appears to

be almost 10 times higher than in the general
population.(17)
• The lifetime risk of suicide in schizophrenia is
estimated to be 5 per cent.(30,33)
• The great majority of schizophrenic patients
commit suicide in the active phase of the
disorder after having suffered depressive
symptoms.
• Suicide in schizophrenia is typically preceded
by a previous attempt, and suicidal intent has
been communicated at least as often as in
non-schizophrenic suicides
• Undertreatment, comorbidity, treatment non-
compliance, and a high frequency of non-
responders are also common problems
among schizophrenic suicide victims.

Page 479 of 1077

MANAGING THE SUICIDAL
PATIENT

In inpatient settings, levels of observation and supervision and

privileges should “parallel the clients’ potential for suicidal
behaviour e.g. continuous observation/ suicide watch (1:1 or
remaining in sight of staff members) and restricting the client to
an area where he or she can be seen at all times by staff

REMOVING RISKS IN THE ENVIRONMENT

Adequate treatment for medical and Psychiatric Illness

Page 480 of 1077

 Peter is a 45 year old man who presents to HPU because his wife said
she will leave him if doesn’t come.

He is sad, sits alone after work and drinks a bottle of whisky every

Reduced interest and pleasure

Says he feels life is not worth living

QUESTIONS

1. ASK MORE QUESTIONS ABOUT HIS ALCOHOL USE.

2. ASSESS HIM FOR DEPRESSION

3. ASSESS HIM FOR SUICIDE RISK

Page 481 of 1077

 Puerperal disorders

By Dr Patience Mavunganidze

Page 482 of 1077

 classification
• DSM v does not recognize these as separate
diagnosis but adds a specifier to major
depression diagnosis.

• 1.baby blues
• 2post partum psychosis
• 3.post partum depression

Page 483 of 1077

 Baby blues
• Half to two thirds of primigravida
• 3rd to the 10th day post delivery
• Lasts 1 to 2 days
• Aetiology
• 1.drop in hormones post delivery
• 2.sleep deprivation
• 3.milk engorgement
• 4.adjustment to parenthood

Page 484 of 1077

 symptoms
• Labile mood
• Episodes of crying
• Irritability
• Fatigue
• Anxiety
• Loneliness
• sadness

Page 485 of 1077

 Management
• Reassurance
• Empathy
• Support from the spouse and family

Page 486 of 1077

 Post –natal depression
• 10 to 15% of women- within 4weeks of
delivery

Page 487 of 1077

 Risk factors
• Personal or family history of depression
• Age below 20
• Single mother
• Poor relation with own mother
• Unwanted pregnancy
• Poor social support
• Previous post partum psychosis

Page 488 of 1077

 Clinical features
• Preoccupation with babies health and her
perceived failure to look after the baby.
• Other symptoms of depression
• Anxious-fear of losing the baby
-Fear of harming the baby
-fear that baby has stopped breathing
-stressed when baby doesn’t put on
weight
Page 489 of 1077
 management
• Early identification
• Rule out medical causes?
• Antidepressants
• CBT
• Close monitoring[ Edinburg Post natal
Depression Scale]

Page 490 of 1077

 Post partum Psychosis
• Occurs 1.5/1000 births occurs first 1 to
4weeks postpartum
• Onset is rapid
• Aetiology
• Reduction in-oestrogen and cortisol
• Post partum thyroiditis
• Linked to 1st time mothers
• Linked to chromosome 16

Page 491 of 1077

 Risk factors
• Personal or family history of axis 1 diagnosis
• Lack of social support
• Single parenthood
• Previous post –partum psychosis

Page 492 of 1077

 Clinical features
• Prominent affective symptoms 80%
• Schizophreniform disorder 15%
• Acute organic psychosis 5%
• Cognitive impairment
• Grossly disorganized behavior
• Poor insight and judgment

Page 493 of 1077

 management
• Admission
• Medication-antipsychotics
• Repeated assessments
• ECT

Page 494 of 1077

 Treatment challenges
• Feeding on demand led to sleep deprivation
• Medication accumulates in milk; lithium
toxicity in infants
• Carbamazepine and sodium valproate-
hepatotoxicity in the infant

Page 495 of 1077

 The end
• Thank you

Page 496 of 1077

ANXIETY DISORDERS &
TREATMENTS
DR. NEMACHE MAWERE
MBChB, D.M.H, M.Med.(Psych)
(SNR REGISTRAR-ANNEXE-PGH)

Page 497 of 1077

 Outline
• Introduction
• Classification
• Epidemiology
• Aetiology
• Clinical Features
• Differential Diagnosis
• Investigations
• Treatments

Page 498 of 1077

 Introduction
• Universal, normal and necessary emotional
reaction.
• Protection from threats.
• Inspires humans to excel insurmountable tasks.
• Pathological – Increased duration and extent of
symptoms in proportion to stressor, maladaptive
to situation and adverse effect on quality of life.
• Definition: Excessive irrational fear or dread.
• Vernacular terms: non-specific-e.g. kutya, hana
etc

Page 499 of 1077

 Classification
DSM-V ICD-10
Generalized Anxiety Disorder (GAD) Generalized Anxiety Disorder (GAD)
Simple Phobia Specific Phobia
Social Phobia Social Phobia
Panic Anxiety Disorder (PAD) Panic Disorder
Agoraphobia (with or without panic disorder) Agoraphobia (without panic disorder)

Obsessive Compulsive Disorder (OCD) Obsessive Compulsive Disorder(OCD)

Post Traumatic Stress Disorder (PTSD) Post Traumatic Stress Disorder (PTSD)

Page 500 of 1077

 Epidemiology
• Female: Male= 2:1
• Males- More OCD

Page 501 of 1077

 Aetiology
• Stressors- Often in context of stressful event
• Genetics- personality traits and overlap with
depression
• Childhood and Life Events- Adversity and if events
deemed threatening to life and limb.
• Attachment Theories- Quality of attachment of
children and parents affects confidence as adults
hence insecure children develop into anxious
adults [It is easier to build strong children than to
repair broken men-Fredrick Douglas].
Page 502 of 1077
 Aetiology
• Cognitive Theory- Negative automatic thoughts
which develop in a background of adverse prior
experiences.
• Behavioral Theories-
• Classical conditioning (Pavlov; Little Albert and
the rat)
• Negative Reinforcement (Skinner; running away
vs. habituation)
• Personality Disorders- Anxious/avoidant
personality ; obsessive compulsive trait or
personality.
Page 503 of 1077
 Aetiology
• Neurobiological- complex processes involving
dysregulation of neurotransmitters
• Noradrenaline- (from locus cerulean/ adrenal
cortex)- increase anxiety & arousal
• Serotonin (from raphe nucleus) –inhibitory or
anxiogenic effects
• GABA (widespread receptors)-inhibitory
effects

Page 504 of 1077

 Clinical Features
• Generally similar for all types of anxiety.
• Psychological/emotional arousal
• Physical-Autonomic Nervous system
hyperactivity (excess adrenaline in the body)
• Hyperventilation
• Sleep disturbances
• Muscle Tension

Page 505 of 1077

 Psychological/emotional arousal
• Depends on type of anxiety
Fearful anticipation
Irritability
Sensitivity to noise
Restlessness
Poor concentration
Worrying thoughts

Page 506 of 1077

 Physical
• Gastrointestinal
- Dry mouth
- Dysphagia (difficulty swallowing-lump in
throat)
- Epigastric discomfort
- Excess wind/Flatulence/bloated feeling
- Frequent or loose stool
- Boborygmi (butterflies in the stomach))

Page 507 of 1077

 Physical
• Respiratory system
-Constriction of chest
-Difficult inhaling (cf. asthma-exhaling)

Page 508 of 1077

 Physical
• Cardiovascular system
-Palpitations
-Discomfort over the heart area
-Awareness of missed beats
-Throbbing in neck

Page 509 of 1077

 Physical
• Genitourinary
-frequent/urgent micturition
-failure of erection
-reduced libido
-menstrual discomfort
-Ammenorhea !!

Page 510 of 1077

 Physical
• Central Nervous
-tinnitus
-blurring of vision
-dizziness (not due to rotation)
-Pricking sensation

Page 511 of 1077

 Muscle Tension
-Headache
-Aching Muscles
-Stiffness of muscles
Tremors (shaking hands repeatedly-kubvunda)

Page 512 of 1077

 Sleep Disturbances
• Insomnia-lack of sleep (usually initial-Not able
to go to sleep due to worry)
• Intermittent-Unpleasant dreams
-constant waking
-wake up unrefreshed
**NB-Terminal insomnia -Not a feature and if
present most likely depression
***Sleep terror-wake up suddenly feeling
intensely fearful

Page 513 of 1077

 Hyperventilation
Breathlessness-rapid shallow breathing and
have to catch your breath.
Paraesthesia (tingling and numbness over
hands, feet and around mouth)
-oxygen not getting to extremities and
hyperventilation blows off carbon dioxide
***Low PCO2 causes raised pH and thus
hypocalcaemia hence nerve conduction affected
and paraesthesia and in extreme cases
carpopedal spasm occurs.

Page 514 of 1077

 Physical Examination
• Strained face
• Furrowed brow
• Tense posture
• Restless
• Tremulousness
• Sweaty (hands, feet, axillae)
• Pale skin
• Tearfulness-apprehensive
• No abnormalities seen in all systems.(NAD)
Page 515 of 1077
 GAD
• Excessive worry/tension about impending danger
(Life is a worry- health, finances, family, work etc.
-past mistakes and future imagined catastrophes)
• Develop unshakeable concerns even after
realizing that it is irrational.
• Unable to relax
• Poor memory (Due to poor attention and
concentration)
• ANS symptoms occur at different times
• Usually referred from physicians/GPs after
extensive tests etc..

Page 516 of 1077

 GAD
• Female :Male 2:1
• Lifetime prevalence- 5.7%
• Strong genetic correlation with depression
• No specific stimulus triggers symptoms
• Symptoms must be present for 6 months
• Continuous and generalized(cf. PAD-episodic)

Page 517 of 1077

 GAD
• Differential Diagnosis
• Hyperthyroidism
• Substance Misuse-
• Excess Caffeine consumption
• Depression (Mixed state)
• Anxious (Avoidant) Personality Disorder
• Dementia
• Schizophrenia

Page 518 of 1077

 PAD
• Pan- Greek god who surprised travellers in forests
• Sudden onset (no warning signs)
• Intermittent attacks up to 30 minutes.
• Recurrent attacks – several in a month
• Overwhelming (extreme “100%” anxiety) with
mainly cardiovascular and respiratory symptoms
• Pounding heart (fear of impending doom-heart
attack) and “loss of control- losing my mind, on
verge of death ,going nuts”

Page 519 of 1077

 PAD
• Attacks provoke further panic until reassured
or patient engages in safety behaviors to
prevent a catastrophe-(e.g. call ambulance,
take Asprin)
• With time safety zone is reduced and patient
has fear to go to places they would feel
helpless hence develop agoraphobia (fear of
open spaces)

Page 520 of 1077

 PAD
• Differential Diagnoses
• GAD
• Depression
• Substance Misuse- Withdrawal
• Organic causes- Always R/O CVS,RS conditions
and rarely phaeochromocytoma

Page 521 of 1077

 Phobias
• Phobos= fear
• Persistent irrational fear of quite ordinary
object or situation.
• One develops avoidance reaction to the
feared object or situation.
• Seriousness of phobia depends on resultant
disability.

Page 522 of 1077

 Phobias
• AGORAPHOBIA. (fear of the market place)
• Fear of open spaces or of situations that are
confined and difficult to leave and escape to
safety (usually home)
• Common feared areas- bus, train, queues,
parks, supermarket, rallies, middle row.
• No fear of social interactions
• Lifetime prevalance-1.4%

Page 523 of 1077

 Agoraphobia
• Onset- Gradual or precipitated by a sudden
panic attack.
• Prefer safety of home and severity worse with
increasing distance from home.
• If all triggers avoided then there is little or no
anxiety (comfort zone)
• Depression usually comorbid.

Page 524 of 1077

 Agoraphobia
• Differential Diagnosis
• Depression-Social withdrawal
• Social Phobia-
• OCD- Time consuming rituals confine people
at home
• Schizophrenia- especially with paranoia

Page 525 of 1077

 Social Phobia
• Develops in situation where one feels is centre of
attraction e.g. to give speech
• Fears being singled out ,ridiculed, criticized,
embarrassed or belittled in public
• Symptoms related to embarrassment -trembling,
frequency of urine, sweating
• Avoid situations e.g. eating in public, leadership roles
(“Ndinokakama”)
• Develop in childhood/ adolescence
• Tolerate anonymous audiences but small groups may
be intimidating (cf. agoraphobia)
• Self medication with alcohol hence alcohol misuse
disorders.

Page 526 of 1077

 Social Phobia
• Differential Diagnosis
• Shyness/Poor social skills- Discomfort in social
situations
• Agoraphobia-No fear of scrutiny
• Anxious/Avoidant PD-Lifelong
• Autistic Spectrum Disorders- Poor social interaction and
communication
• Benign essential tremor- Familial tremor worse in social
situations-relieved by alcohol.
• Schizophrenia-Paranoid delusions about being
watched.

Page 527 of 1077

 Specific Phobias
• Fear of a restricted, single, specific situation
• Start in childhood usually-worse prognosis
• Onset as adult- after a very frightening
experience-better prognosis
• Patients have avoidance behaviours and
sometimes disability results (conversion)
• Fear of choking, medical, dental procedures
• Fear of blood after injury causes vasovagal
reaction hence hypotension – worsens clinical
state with fainting etc.

Page 528 of 1077

 Aetiology of Phobias
• Psychoanalytical theories(Freud)-Phobia not
related to external stimulus, but internal source
excluded from consciousness by repression&
displaced onto external object.
• Cognitive behavioral theories-Conditioning -
learning in response to stressful experience or
acquired by child via observational learning of a
close other.
• Prepared learning-Predisposition to persistent
fear responses to certain stimuli -occurs in
primates ??? Humans.

Page 529 of 1077

 Obsessive Compulsive Disorder
• Obsession-thoughts/ideas persistent causing
anxiety.
• Compulsion-Motor action/Rituals done to
relieve the anxiety but no pleasure derived
from doing these acts.
• Types
• Washing type-fear of germs, dirt
• Checking type-Doubting so repeat checks

Page 530 of 1077

 OCD
• Male> Female
• Genetics- 3x risk in relatives of patients
• Obsessive compulsive /anankastic personality
• Associated with condition where there is a
basal ganglia lesion- e.g. Syndenham’s chorea,
tic disorders.
• Confirmed lesions in frontal lobe hence
possibility that ritualistic thoughts difficult to
suppress.
Page 531 of 1077
 OCD
• Differential Diagnosis
• Anxiety Disorders
• Depression
• Obsessive compulsive personality
• Schizophrenia- Delusional not obsessive
• Organic Disorder- e.g. Syndenham’s chorea

Page 532 of 1077

 Reactions to Stress
• Acute Stress Disorder
• Adjustment disorder
• Post Traumatic Stress Disorder
• Follow episodes of severe traumatic stress(i.e.
experience or witness an unusually bad event like
rape, car accident, natural disasters e.g. floods,
being involved in combat , torture, terror, etc.
• In DSM V – No longer classified under anxiety but
symptoms of anxiety predominant hence
discussed under anxiety

Page 533 of 1077

 Adjustment Disorder
• ** Adjustment disorder- failure to adjust by
coping with changes in life which are stressors
within realms of normal life situations - e.g .
divorce, job loss, promotion etc.
• Transient symptoms of low mood, insomnia,
irritable and some anxiety symptoms
• Start within a month of the stressor and
resolve within 6 months

Page 534 of 1077

 Acute Stress Disorder
• Common reaction to severe stressors BUT
-transient (minutes to hours-max- 3dys)
-Some symptoms of anxiety
-Derealization and depersonalization
-Amnesia-(retrograde and anterograde)
-Disoriented; panicky; irritable; agitated or
aggressive
**Role of debriefing-good or bad.

Page 535 of 1077

 PTSD
• “Shell shock, combat fatigue, etc.”
• Traumatic event-(suffered or witnessed)
deemed to be life threatening or catastrophic.
• Lifetime prevalence-6.8%
• Civilian life- Female>Male
• Latency period of up to 6 months

Page 536 of 1077

 PTSD
• 10% of trauma victims develop PTSD.
• Determined by degree of exposure, resilience
factors, genetics
• Risk factors- past or family history of mental
illness, childhood abuse, insecure attachment
• Persistence- due to survivor guilt, continued
exposure to same or other trauma
• Neurobiology-Due to traumatic events not being
remembered (atrophied hippocampus-no
memory storage) but being relived(overactive
amygdala-emotional processing).
Page 537 of 1077
 PTSD
• Clinical Features
• Re-experiencing:-flashbacks; nightmares; intrusive thoughts
but poor recollection
• Avoidance- any reminders of the trauma cause multiple
anxiety symptoms and flashbacks.
• Hyper arousal- Can’t relax, hyper alert, increased startle
response; insomnia; irritable; attention and concentration
reduced. Anxiety symptoms.
• Other- derealization with emotional detachment
(numbness)
• Emotional Reactions- anger, loss of control, shame,
• Comorbid substance use-self medication

Page 538 of 1077

 PTSD
• Differential Diagnosis
• Depression
• GAD
• Adjustment disorder

Page 539 of 1077

 Investigations
1.History- focused on anxiety symptoms
• SEDATED
• Symptoms of anxiety
• Episodic or continuous
• Drinks/drugs
• Avoidance and escape
• Timing/Triggers
• Effect on life
• Depression symptoms (comorbid)
• ** Also check on family history; past history; social history
2. Collateral history

Page 540 of 1077

 Investigations
• R/O Organic cause- TFTs; MCV/GGT, Urine
Drug Screen; ECG for- arrythmia;
hypoglycaemia; phaeochromocytoma
• Social and occupational assessments-impact
on quality of life.

Page 541 of 1077

 Management
• Advice and reassurance- psychoeducation
• Counseling-Deals with worries
• Problem solving-how to identify and cope with
stressors
• Encourage family support
• Relaxation techniques/ breathing exercises.-
only when patient is calm

Page 542 of 1077

 Management
• CBT-Reduces expectations of stress and
behaviours which maintain the negative
beliefs.
• E.g. GAD- symptoms due to avoidance and
reassurance seeking hence test the thinking
errors
• PAD- deal with negative thoughts of possible
impending doom

Page 543 of 1077

 Management
• Exposure Therapy-
• Systemic Desensitization –identify goal and
construct a hierarchy of feared situations with
least feared item first and most feared last.
• Need to teach the patient relaxation techniques
before working on program. Helps patient stay in
situation until anxiety is down (habituation).
Repeated attempts at same task results in less
anxiety until it is extinguished
• Use with specific phobias, agoraphobia and social
phobias

Page 544 of 1077

 Management
• Pharmacotherapy
• SSRI- e.g. fluoxetine, sertraline (use higher doses cf.
depression; take longer to start working; marked
anxiety on suddenly stopping medication
• TCA-e.g. Imipramine, clomipramine
• Buspiron-partial agonist of 5HT.
• BZ-(work on GABA receptors- and thus enhance
inhibitory effects) e.g. diazepam, lorazepam- used in
short term before SSRI/TCAs kick in (about 2-4 weeks).
Risk of dependency in long term.
• Treat comorbid depression/ substance misuse

Page 545 of 1077

 Management
• Specific therapies for OCD
• CBT-exposure and response prevention
• SSRI or TCA (Clomipramine best)
• Specific therapies for PTSD
• Risk of retraumatisation during CBT
• Work on new belief systems after trauma
• Exposure therapy as patient works on memories
• EMDR-Eye Movement Desensitisation and
Reprocessing-
Page 546 of 1077
 Prognosis
• Common condition and follows a chronic
course.
• Rule of thirds
• One third- recover completely
• One third-partial recovery
• One third- poor recovery with disability and
poor quality of life.
• Need for early diagnosis & treatment
Page 547 of 1077
 Last Word
• “A brave man is not he who does not feel
afraid, but he who conquers the fear” Nelson
Mandela

Page 548 of 1077

Psychopharmacology 1

Prepared by Dr. C. Rwafa

Page 549 of 1077

 Objectives
• Understand the pharmacological approach to
mental disorders
• Describe the different antipsychotics, know how
to choose an antipsychotic and side effects
• Discuss antidepressants including indications for
use and side effects
• Describe mood stabilizers including indications
for use and side effects
• Discuss antidepressants including indications for
use and side effects
• Identify anxiolytic classes and indications for use
Page 550 of 1077
 Psychopharmocology
• Study of drugs and their effect on the mind
and on behaviour
• Study of the drugs used to treat disorders of
the mind and behaviour

Page 551 of 1077

 Psychiatric conditions
• Psychotic Disorders
– Schizophrenia, Schizoaffective Disorder
• Mood Disorders
– Depression, Bipolar Disorder
• Anxiety Disorders
– Generalized anxiety disorder, panic disorder, PTSD
• Alcohol and Substance Use Disorders
• Personality Disorders
– Cluster A (odd); Cluster B (dramatic); Cluster C (anxious)
• Adjustment Disorders
• Cognitive Disorders
– Delirium, Dementia

Page 552 of 1077

 Psychopharmacological agents
• Antipsychotics
– Conventional
– Atypical
• Antidepressants
– SSRIs
– SNRIs
– Tricyclic Antidepressants
– MAOIs
– Others
• Mood Stabilizers
– Lithium
– Anticonvulsants
– Atypical antipsychotics
Page 553 of 1077
 Psychopharmacological agents
• Anxiolytics
– Antidepressants
– Benzodiazepines
– Other agents
• Medications for dementias/ cognitive enhancers
– Cholinesterase inhibitors
– Memantine
• Medications for substance use disorders
– Alcohol use disorders
– Opioid substitution therapies
– Nicotine dependence
• Others
– Medications used to treat “side effects”
– Medications used for augmentation
– Sleep aids

Page 554 of 1077

 Pharmacological approach to mental
illness
• Indication: Establish a diagnosis
• Choice of agent and dosage:
– Select an agent with an acceptable side effect profile
– use the lowest effective dose.
• Remember drug to drug interactions
• Establish informed consent:
– benefits and risks of the medication.
– Discuss teratogenicity
• Monitoring:
– Track and document compliance
– Monitor side effects
– target symptom response
– Check blood levels and blood tests as appropriate.
– Adjust dosage for optimum benefit, safety and compliance.
• Use adjunctive and combination therapies if needed
however always strive for the simplest regimen.
Page 555 of 1077
 Antipsychotics
• Antipsychotic agents are also known as neuroleptic or
major tranquillizers
• Mainly affect Dopamine function
– Mesolimbic, Mesocortical, Nigrostriatal, Tuberinfundibular
• Indications:
– schizophrenia, schizoaffective disorder,
– bipolar disorder- for mood stabilization and/or when
psychotic features are present, delirium,
– psychotic depression,
– dementia,
– trichotillomania,
– augmenting agent in treatment resistant anxiety disorders.

Page 556 of 1077

Key pathways affected by
dopamine in the Brain

Page 557 of 1077

 Dopamine pathways
• MESOCORTICAL- projects from the ventral
tegmentum (brain stem) to the cerebral cortex.

• This pathway is felt to be where the negative

symptoms and cognitive disorders (lack of executive
function) arise.

• Problem here for a psychotic patient, is too little

dopamine.

Page 558 of 1077

 Dopamine pathways
• MESOLIMBIC-projects from the dopaminergic
cell bodies in the ventral tegmentum to the
limbic system.

• This pathway is where the positive symptoms

come from (hallucinations, delusions, and
thought disorders).

• Problem here in a psychotic patient is there is

too much dopamine.
Page 559 of 1077
 Dopamine pathways
• NIGROSTRIATAL- projects from the
dopaminergic cell bodies in the substantia nigra
to the basal ganglia.

• This pathway is involved in movement

regulation.

• Remember that dopamine suppresses

acetylcholine activity.

• Dopamine hypoactivity can cause

Parkinsonian movements i.e. rigidity,
bradykinesia, tremors), akathisia and dystonia.

Page 560 of 1077

 Dopamine pathways
• TUBEROINFUNDIBULAR-projects from
the hypothalamus to the anterior pituitary.

• Remember that dopamine release

inhibits/regulates prolactin release.

• Blocking dopamine in this pathway will

predispose your patient to
hyperprolactinemia
(gynecomastia/galactorrhea/decreased
libido/menstrual dysfunction).
Page 561 of 1077
 Antipsychotics
• TYPICAL ANTIPSYCHOTICS
– Phenothiazine derivatives
• Aliphatic side chaim: CHLORPROMAZINE
• Piperidine Derivative: THIORIDAZINE
• Piperazine Derivative: FLUPENAZINE, PERPHENAZINE,
TRIFLUOPERAZINE
– Thioxanthene Derivative: THIOTHIXENE
– Butyrophenone: HALOPERIDOL

Page 562 of 1077

 Antipsychotics: Typicals
➢ Are D2 dopamine receptor antagonists
➢ High potency typical antipsychotics bind to the
D2 receptor with high affinity.

➢ As a result they have higher risk of

extrapyramidal side effects.

➢ Examples include Fluphenazine, Haloperidol,

Pimozide

Page 563 of 1077

• Low potency typical antipsychotics have less
affinity for the D2 receptors

• but tend to interact with nondopaminergic

receptors resulting in more cardiotoxic and
anticholinergic adverse effects including
sedation, hypotension.

• Examples include chlorpromazine and

Thioridazine.

Page 564 of 1077

 Antipsychotics
• Atypicals:
– CLOZAPINE
– OLANZAPINE
– QUETIAPINE
– RISPERIDONE
– ARIPIPRAZOLE
– ZIPRASIDONE
– SERTINDOLE
– LOXAPINE

Page 565 of 1077

 Antipsychotics: Atypicals
• The Atypical Antipsychotics - atypical
agents are serotonin-dopamine 2
antagonists (SDAs)
• They are considered atypical in the way
they affect dopamine and serotonin
neurotransmission in the four key
dopamine pathways in the brain.

Page 566 of 1077

 Risperidone (Risperdal)
➢ Available in regular tabs, IM depot forms and rapidly
dissolving tablet
➢ Functions more like a typical antipsychotic at doses
greater than 6mg
➢ Increased extrapyramidal side effects (dose
dependent)
➢ Most likely atypical to induce hyperprolactinemia
➢ Weight gain and sedation (dosage dependent)

Page 567 of 1077

 Olanzapine (Zyprexa)
➢ Available in regular tabs, immediate release IM,
rapidly dissolving tab, depo form
➢ Weight gain (can be as much as 30-50lbs with even
short term use)
➢ May cause hypertriglyceridemia,
hypercholesterolemia, hyperglycemia (even without
weight gain)
➢ May cause hyperprolactinemia (< risperidone)
➢ May cause transaminitis (2% of all patients)

Page 568 of 1077

 Quetiapine (Seroquel)
➢ Available in a regular tablet form only
➢ May cause transaminitis (6% of all patients)
➢ May be associated with weight gain, though less than
seen with olanzapine
➢ May cause hypertriglyceridemia,
hypercholesterolemia, hyperglycemia (even without
weight gain), however less than olanzapine
➢ Most likely to cause orthostatic hypotension

Page 569 of 1077

 Ziprasidone (Geodon)
➢Available regular tabs and IM immediate
release form
➢Clinically significant QT prolongation in
susceptible patients
➢May cause hyperprolactinemia (< risperidone)
➢No associated weight gain
➢Absorption is increased (up to 100%) with
food

Page 570 of 1077

 Aripiprazole (Abilify)
➢ Available in regular tabs, immediate release IM
formulation and depo form
➢ Unique mechanism of action as a D2 partial agonist
➢ Low EPS, no QT prolongation, low sedation
➢ CYP2D6 (fluoxetine and paroxetine), 3A4
(carbamazepine and ketoconazole) interactions that
the manufacturer recommends adjusted dosing.
Could cause potential intolerability due to
akathisia/activation.
➢ Not associated with weight gain

Page 571 of 1077

 Clozapine (Clozaril)
• Available in 1 form- a regular tablet
• Is reserved for treatment resistant patients because of
side effect profile but it is more effective than all other
antipsychotics, effective in treatment resistance
• Associated with life threatening agranulocytosis (0.5-2%)
and therefore requires weekly blood draws x 6 months,
then Q- 2weeks x 6 months)
• Increased risk of seizures (especially if lithium is also on
board)
• Associated with the most sedation, weight gain and
transaminitis
• Increased risk of hypertriglyceridemia,
hypercholesterolemia, hyperglycemia, including
nonketotic hyperosmolar coma and death with and/or
without weight gain
Page 572 of 1077
 Antipsychotic adverse effects
➢ Extrapyramidal side effects (EPS): Acute dystonia,
Parkinson syndrome, Akathisia
➢ Tardive Dyskinesia (TD)-involuntary muscle
movements that may not resolve with drug
discontinuation- risk approx. 5% per year
➢ Neuroleptic Malignant Syndrome (NMS):
Characterized by severe muscle rigidity, fever, altered
mental status, autonomic instability, elevated WBC,
CPK and lfts. Potentially fatal.

Page 573 of 1077

 Extrapyramidal side effects (EPS)
• Acute dystonia
• Parkinsonian syndrome
• Akathisia

Page 574 of 1077

 Managing EPSEs
• Antiparkinsonian agents are the specific drugs to treat
the extrapyramidal sideeffects of antipsychotic agents.
• Anticholinergics, antihistamines & amantidne are used
to treat these side effects.
• Anticholinergic drugs block the function of Ach ,
thereby reducing the symptoms of akathesia & acute
dystonia. They are not effective against tardive
dyskinesia
• Antihistamines have effects like anticholinergic drugs.
Amantadines are dopamine-releasing agents from
central neurons. Studies show that this drug may affect
some clients with tardive dyskinesia
Page 575 of 1077
 Agents for EPS
➢Anticholinergics such as benztropine,
trihexyphenidyl (Benzhexol)
➢Dopamine facilitators such as Amantadine
➢Antihistamines- Ophenadrine,
Diphenhydramine
➢Beta-blockers such as propranolol
➢Need to watch for anticholinergic SE
particularly if taken with other meds with
anticholinergic activity ie TCAs
Page 576 of 1077
 Tardive Dyskinesia (TD)-
• Its define any tardive hyperkinetic movement
disorder, such as stereotypy, akathisia, dystonia,
tremor, tics, chorea, and myoclonus
• Mostly truncal and oro-buccal in nature
• Initially reversible
• Management: avoid anticholinergics
– Change antipsycotics: sulpiride, Clozapine etc
– Propranolol
– Benzodazepine: clonazepam
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC37
09416/pdf/tre-03-161-4138-1.pdf

Page 577 of 1077

 Case 1
• 21 yr old male with symptoms consistent
with schizophrenia is admitted because of
profound psychotic sx. He is treatment
naïve. You plan to start an antipsychotic-
what baseline blood work would you
obtain?

Page 578 of 1077

 Case 1
• Many atypical antipsychotics can cause
dyslipidemia, transaminitis and elevated
blood sugars and there is a class risk of
diabetes unrelated to weight gain so you
need the following:
• Fasting lipid profile
• Fasting blood sugar
• Lfts
• CBC
Page 579 of 1077
 Case 5
• His labs come back and his cholesterol is
slightly elevated

• What agent would you like to start?

Page 580 of 1077

• Pt has mildly elevated total cholesterol and a low
HDL for his age. Olanzapine or Quetiapine are
not good choices given risk of dyslipidemia.
• Risperidone or Aripiprazole are good choices.

Page 581 of 1077

Antidepressants

Page 582 of 1077

 Antidepressants- Indications
• Depression
• Anxiety disorders including OCD, panic,
social phobia, PTSD
• Organic mood disorders,
• Schizoaffective disorder
• Premenstrual dysphoric disorder
• Impulsivity associated with personality
disorders.
Page 583 of 1077
 Antidepressant Classifications
• Tricyclic antidepressants(TCAs)
• Selective Serotonin Reuptake Inhibitors
(SSRIs)
• Serotonin/Norepinephrine Reuptake
Inhibitors (SNRIs)
• Monoamine Oxidase Inhibitors (MAOIs)
• Novel antidepressants

Page 584 of 1077

 General guidelines for antidepressant
use
• Selection is based on past history of a response,
side effect profile and coexisting medical
conditions.

• There is a delay typically of 4-6 weeks after a

therapeutic dose is achieved before symptoms
improve.

• If no improvement is seen after a trial of

adequate length (at least 2 months) and
adequate dose, either switch to another
antidepressant or augment with another agent.
Page 585 of 1077
 Mode of action
• Research studies have shown reduced levels of
noradrenaline (NE) & serotonin (5-HT) in the space
between nerve endings from one nerve cell to another
cause depression

• Antidepressants increase the level of these

neurotransmitters i.e. noradrenaline & serotonin to the
synaptic receptors in the central nervous system.
– Tricyclic inhibitors block the reuptake of NAdr & 5-HT
– SSRIs and SNRIs block reuptake
– MAO inhibitors block the action of monoamine oxidase in
breaking down excess of NAdr & 5-HT at the presynaptic
neuron.
Page 586 of 1077
 TCAs
• They have been employed in drug therapy
since the late 1950s.
• Largest group of drug agents used for the
treatment of depression.
• Referred as “ tri-cyclic ” compounds –three
rings

Page 587 of 1077

 TCAs
• Very effective
• Potentially unacceptable side effect profile
• Lethal in overdose
• Can cause QT lengthening even at a
therapeutic serum level

Page 588 of 1077

 TCAs side effects
• Anti-histaminic (sedation and weight gain),
• Anti-cholinergic (dry mouth, dry eyes,
constipation, memory deficits, delirium),
• Anti-adrenergic (orthostatic hypotension,
sedation, sexual dysfunction)

Page 589 of 1077

 TCA- Classification
• Tertiary TCAs:
– e.g:Imipramine, amitriptyline, doxepin,
clomipramine
– Have tertiary amine side chains
– Side chains are prone to cross react with
other types of receptors which leads to more
side effects
– Act predominantly on serotonin receptors
– Have active metabolites including
desipramine and nortriptyline

Page 590 of 1077

 TCA- Classification
• Secondary TCs
– Are often metabolites of tertiary amines
– Primarily block norepinephrine
– Side effects are the same as tertiary TCAs but
generally are less severe
– E.g: Desipramine, notrtriptyline

Page 591 of 1077

 TCAs- Imipramine
• It is a prototype drug of the TCA class
• Primary indications-
– Major depression
– Phobic and panic anxiety disorders
– Neuropathic pain
– Obsessive compulsive disorder (OCD)
– Nocturnal enuresis; Imipramine has been used to control bed-
wetting in children (older than six years) by causing contraction
of the internal sphincter of the bladder.
• Usual dose 50-150 mg daily at night
• Side effects: Dry mouth; Constipation; Blurred vision;
Mydriasis; Metallic taste; Urine retention; Drowsiness;
Weight gain

Page 592 of 1077

 SSRIs
• Fluoxetine, Citalopram, Escitalopram, Paroxetine,
Sertraline
• Inhibit serotonin reuptake into the presynaptic cell,
increasing the level of serotonin leading to greater post
synaptic neuronal activity
• They do not have significant effect on Noradrenaline &
Dopamine
• Very little risk of cardiotoxicity in overdose
• They typically take 2 to 12 weeks to produce improvement
in mood
• Side effects: anxiety; agitation; insomnia; sexual
dysfunction (30%); weight gain
• Abrupt stopping can result in discontinuation syndrome
with agitation, nausea, disequilibrium and dysphoria
Page 593 of 1077
 Fluoxetine (Prozac)
• Pros
– Long half-life so decreased incidence of discontinuation
syndromes.
– Good for pts with medication noncompliance issues
– Initially activating so may provide increased energy
– Secondary to long half life, can use to taper off other SSRI

• Cons
– Long half life and active metabolite may build up (caution in
hepatic illness)
– Significant P450 interactions so this may not be a good choice in
pts already on a number of meds
– Initial activation may increase anxiety and insomnia
– More likely to induce mania than some of the other SSRIs

Page 594 of 1077

 Citalopram (Celexa)
• Pros
– Low inhibition of P450 enzymes so fewer drug-drug
interactions
– Intermediate ½ life
• Cons
– Dose-dependent QT interval prolongation with doses
of 10-30mg daily- doses of >40mg not recommended!
– Can be sedating (has mild antagonism at H1
histamine receptor)
– GI side effects (less than sertraline)

Page 595 of 1077

 Escitalopram (Lexapro)
• Pros
– Low overall inhibition of P450s enzymes so fewer
drug-drug interactions
– Intermediate 1/2 life
– More effective than Citalopram in acute response
and remission
• Cons
– Dose-dependent QT interval prolongation with
doses of 10-30mg daily
– Nausea, headache

Page 596 of 1077

 Sertraline (Zoloft)
➢ Pros
⚫ Very weak P450 interactions (only slight CYP2D6)
⚫ Short half life with lower build-up of metabolites
⚫ Less sedating when compared to paroxetine

➢ Cons
⚫ Max absorption requires a full stomach
⚫ Increased number of GI adverse drug reactions

Page 597 of 1077

 Paroxetine (Paxil)
➢ Pros
⚫ Short half life with no active metabolite means no build-up
(which is good if hypomania develops)
⚫ Sedating properties (dose at night) offers good initial relief
from anxiety and insomnia
➢ Cons
⚫ Significant CYP2D6 inhibition
⚫ Sedating, wt gain, more anticholinergic effects
⚫ Likely to cause a discontinuation syndrome

Page 598 of 1077

Fluvoxamine (Luvox)
• Pros
– Shortest ½ life
– Found to possess some analgesic properties
– Fewer sexual s/e
• Cons
– Shortest ½ life
– GI distress, headaches, sedation, weakness
– Strong inhibitor of CYP1A2 and CYP2C19

Page 599 of 1077

 Serotonin/Norepinephrine reuptake
inhibitors (SNRIs)
➢Inhibit both 5HT and NA reuptake
➢LikE TCAS but without the antihistamine,
antiadrenergic or anticholinergic side effects
➢Used for depression, anxiety and neuropathic
pain

Page 600 of 1077

 Venlafaxine (Effexor)
➢ Pros
⚫ Minimal drug interactions and almost no P450 activity
⚫ Short half life and fast renal clearance avoids build-up (good for
geriatric populations)
➢ Cons
⚫ Can cause a 10-15 mmHG dose dependent increase in diastolic BP.
⚫ May cause significant nausea, primarily with immediate-release (IR)
tabs
⚫ Can cause a bad discontinuation syndrome, and taper recommended
after 2 weeks of administration
⚫ Noted to cause QT prolongation
⚫ Sexual side effects in >30%

Page 601 of 1077

Duloxetine (Cymbalta)
• Pros
– Efficacy for the physical symptoms of depression
– Thus far less BP increase as compared to
venlafaxine,

• Cons
– CYP2D6 and CYP1A2 inhibitor
– Cannot break capsule, as active ingredient not
stable within the stomach
– In pooled analysis had higher drop out rate

Page 602 of 1077

 Novel antidepressants - Mirtazapine
(Remeron)
➢ Pros
⚫ Different mechanism of action may provide a good augmentation
strategy to SSRIs.
⚫ Is a 5HT2 and 5HT3 receptor antagonist
⚫ Can be utilized as a hypnotic at lower doses secondary to
antihistaminic effects
➢ Cons
⚫ Increases serum cholesterol by 20% in 15% of patients and
triglycerides in 6% of patients
⚫ Very sedating at lower doses. At doses 30mg and above it can become
activating and require change of administration time to the morning.
⚫ Associated with weight gain (particularly at doses below 45mg

Page 603 of 1077

 Buproprion (Wellbutrin)
• Pros
– Good for use as an augmenting agent
– Mechanism of action likely reuptake inhibition of dopamine and
norepinephrine
– No weight gain, sexual side effects, sedation or cardiac interactions
– Low induction of mania
– Is a second line ADHD agent so consider if patient has a co-occurring
diagnosis

• Cons
– May increase seizure risk at high doses (450mg+) and should avoid in
patients with Traumatic Brain Injury, bulimia and anorexia.
– Does not treat anxiety unlike many other antidepressants and can
actually cause anxiety, agitation and insomnia
– Has abuse potential because can induce psychotic sx at high doses

Page 604 of 1077

 MAOIs
• Phenelzine; Isocarboxacid; Tranylcypromin

• Treatment of depression began with the use of MAOIs

in 1950’s.

• Bind irreversibly to monoamine oxidase thereby

preventing inactivation of biogenic amines such as
NE,DA and 5H leading to increased synaptic levels.
• Are very effective for atypical depression
• Side effects include orthostatic hypotension, weight
gain, dry mouth, sedation, sexual dysfunction and
sleep disturbance
• Hypertensive crisis can develop when MAOI’s are
taken with tyramine-rich foods or sympathomimetics.
Page 605 of 1077
 MAOI
• Serotonin Syndrome can develop MAOI + meds
that increase serotonin or have sympathomimetic
actions.

• Symptoms of Serotonin syndrome include

abdominal pain, diarrhea, sweats, tachycardia,
HTN, myoclonus, irritability, delirium, hyperpyrexia,
cardiovascular shock and death.

• 2 weeks wash-out period before switching from an

SSRI to an MAOI

• Wait 5 weeks with flouxetine because of long half-

life.

Page 606 of 1077

 Case 1
• Susan has a nonpsychotic unipolar depression
with no history of hypomania or mania. She has
depressed mood, hyperphagia, psychomotor
retardation and hypersomnolence. What agent
would you like to use for her?

• Establish dx: Major depressive disorder

• Target symptoms: depression, hyperphagia,
psychomotor retardation and hypersomnolence

Page 607 of 1077

 Case 1
• For a treatment naive patient start with an
SSRI.
• Using the side effect profile as a guide
select an SSRI that is less sedating.
• Good choices would be Citalopram,
Fluoxetine or Sertraline.
• Buproprion would also have been a
reasonable choice given her
hypersomnolence, psychomotor
retardation and hyperphagia.

Page 608 of 1077

 Case 2
• Mr. T is a 55 year old diabetic man with mild HTN
and painful diabetic neuropathy who has had
previous depressive episodes and one suicide
attempt.
• He meets criteria currently for a major depressive
episode with some anxiety.
• He has been treated with paroxetine, sertraline and
buproprion.
• His depression was improved slightly with each of
these meds but never remitted.
• What would you like to treat him with?
Page 609 of 1077
 Case 2 continued
• Establish dx: Major depressive disorder with anxious
features
• Depressive sx, anxiety and possibly his neuropathic
pain
• Assuming he received adequate trials previously
would move on to a dual reuptake inhibitor as he
had not achieved remission with two SSRIS or a novel
agent.

Page 610 of 1077

 Case 2 continued
• Given his mild HTN would not choose Venlafaxine.
• TCA’s like AMT or Imipramine can help with
neuropathic pain and depression however may not
be the best choice given the SE profile and lethality
in overdose.
• Duloxetine is a good choice since it has an
indication for neuropathic pain, depression and
anxiety. Three birds with one stone!!
• Keep in mind Duloxetine is a CYP2D6 and CPY1A2
inhibitor and has potential drug-drug interactions.

Page 611 of 1077

Psychopharmacology 2

Prepared by Dr. C. Rwafa

Page 612 of 1077

Mood Stabilizers

Page 613 of 1077

 Mood stabilizers
➢Indications: Bipolar, cyclothymia,
schizoaffective, impulse control and
intermittent explosive disorders.
➢Classes: Lithium, anticonvulsants (Sodium
valporate, Carbamazepine, Lamotrigine),
atypical antipsychotics
➢Selection depends on what you are treating
and again the side effect profile.

Page 614 of 1077

 Lithium
• Lithium is an element with atomic number 3
& atomic weight 7
• It was discovered by FJ Cade in 1949, & is a
most effective & commonly used drug in the
treatment of mania.

Page 615 of 1077

 Lithium
• Effective in long-term prophylaxis of both mania
and depressive episodes in 70+% of BAD I pts
• Factors predicting positive response to lithium
– Prior long-term response or family member with good
response
– Classic pure mania
– Mania is followed by depression
• Only medication to reduce suicide rate.
– Rate of completed suicide in BAD ~15%

Page 616 of 1077

 Lithium- how to use it
• Before starting :Get baseline creatinine, TSH and FBC,
pregnancy test (during the first trimester is associated
with Ebstein’s anomaly 1/1000 -20X greater risk than
the general population)
– Ebstein anomaly: (distortion & downward displacement of
tricuspid value in right ventricle

• Monitoring: Steady state achieved after 5 days- check 12

hours after last dose.
• Once stable check q 3 months and TSH and creatinine
q 6 months.
• Goal:
– Therapeutic levels = 0.8-1.2 mEq/L (for treatment of acute
mania)
– Prophylactic levels = 0.6-1.2 mEq/L (for prevention of relapse in
bipolar disorder)
– Toxic lithium levels>2.0 mEq/L

Page 617 of 1077

 Lithium- Dosing
• Lithium is available as
– Lithium carbonate: 250 to 300mg tablet
– 400mg sustained release tablets
– Lithium citrate: 300mg/5ml liquid
• The usual range of dose per day in acute
mania is 900-2100mg given in 2-3 divided
doses.

Page 618 of 1077

 Lithium side effects
• Most common are GI distress including reduced
appetite, nausea/vomiting, diarrhea
• Thyroid abnormalities
• Leukocytosis
• Polyuria/polydypsia secondary to ADH
antagonism.
• In a small number of patients can cause
interstitial renal fibrosis.
• Hair loss, acne
• Reduces seizure threshold, cognitive slowing,
intention tremor

Page 619 of 1077

 Lithium toxicity
• Mild- levels 1.5-2.0 see vomiting, diarrhea,
ataxia, dizziness, slurred speech, nystagmus.

• Moderate-2.0-2.5 nausea, vomiting, anorexia,

blurred vision, clonic limb movements,
convulsions, delirium, syncope

• Severe- >2.5 generalized convulsions,

oliguria and renal failure

Page 620 of 1077

 Lithium toxicity
• Discontinue the drug immediately.
• For significant short-term ingestions, residual
gastric content should be removed by induction
of emesis, gastric lavage adsorption with
activated charcoal.
• If possible instruct the patient to ingest fluids.
• Assess serum lithium levels, serum electrolytes,
renal functions, ECG as soon as possible.
• Maintenance of fluid & electrolyte balance
• In a patient with serious manifestations of
lithium toxicity, hemodialysis should be initiated.
Page 621 of 1077
 Sodium Valproate
➢ As effective as Lithium in mania prophylaxis but is
not as effective in depression prophylaxis.

➢ Factors predicting a positive response:

⚫ rapid cycling patients (females>males)
⚫ comorbid substance issues
⚫ mixed patients
⚫ Patients with comorbid anxiety disorders

➢ Better tolerated than Lithium

Page 622 of 1077

 Valproic acid
➢Before med is started: baseline liver function
tests (lfts), pregnancy test and FBC
➢Start folic acid supplement in women
➢Monitor FBC and LFTS

Page 623 of 1077

 Valproic acid side effects
• Thrombocytopenia and platelet dysfunction
• Nausea, vomiting, weight gain
• Transaminitis
• Sedation, tremor
• Increased risk of neural tube defect 1-2% vs
0.14-0.2% in general population secondary to
reduction in folic acid
• Increased neurodevelopmental disorders
• Hair loss

Page 624 of 1077

 Carbamazepine
• First line agent for acute mania and mania
prophylaxis
• Indicated for rapid cyclers and mixed patients
• The average daily dose is 600-1800 mg orally,
in divided doses. The therapeutic blood levels
are 6-12 µg/ml

Page 625 of 1077

 Carbamazepine
➢Before med is started: baseline liver function
tests, CBC and an ECG
➢Monitoring: Steady state achieved after 5
days, repeat FBC and LFTS
➢Goal: Target levels 4-12mcg/ml
➢Need to check level and adjust dosing after
around a month because induces own
metabolism.

Page 626 of 1077

 Carbamazepine side effects
• Rash- most common SE seen
• Nausea, vomiting, diarrhea, transaminitis
• Sedation, dizziness, ataxia, confusion
• AV conduction delays
• Aplastic anemia and agranulocytosis (<0.002%)
• Water retention due to vasopressin-like effect
which can result in hyponatremia
• Drug-drug interactions!

Page 627 of 1077

 Drug interactions
• Drugs that increase carbamazepine levels and/or toxicity:
acetazolamide, cimetidine (both can cause rapid toxic reactions),
clozapine (may act synergistically to suppress BM), diltiazem, INH,
fluvoxamine, occasionally fluoxetine, erythromycin, clarithromycin,
fluconazole, itraconazole, ketoconazole, metronidazole,
propoxyphene, verapamil, diltiazem.

• Drugs that decrease carbamazepine levels: neuroleptics,

barbiturates, phenytoin, TCA’s.
• VPA may increase or decrease carbamazepine levels.

• Carbamazepine is a heteroinducer, increasing its own metabolism

and that of many other drugs, including estrogen and progesterone
(contraceptives), warfarin, methadone, many psychotropics
including antidepressants, antipsychotics, BZD’s, in addition to
cyclosporine (and other immunosuppressants), theophylline, etc.

Page 628 of 1077

 Lamotrigine ( Lamictal)
➢ Indications similar to other anticonvulsants- good
in Bipolar depression
➢ Also used for neuropathic/chronic pain
➢ Before med is started: baseline liver function
tests
➢ Initiation/titration: start with 25 mg daily X 2
weeks then increase to 50mg X 2 weeks then
increase to 100mg- faster titration has a higher
incidence of serious rash
➢ If the patient stops the med for 5 days or more
have to start at 25mg again!

Page 629 of 1077

 Lamotrigine: Side effects
• Nausea/vomiting
• Sedation, dizziness, ataxia and confusion
• The most severe are toxic epidermal necrolysis and
Stevens Johnson's Syndrome. The character/severity of
the rash is not a good predictor of severity of reaction.
Therefore, if ANY rash develops, discontinue use
immediately.
• Blood dyscrasias have been seen in rare cases.
• Drugs that increase lamotrigine levels: VPA (doubles
concentration, so use slower dose titration),
sertraline.

Page 630 of 1077

 Mood stabilizing antipsychotics
Generic name Trade name Manic Mixed Maintenance Depressed

Aripiprazole Abilify
x x x
Ziprasidone Geodon
x x X*
Risperdone Risperdal
x x
Asenapine Saphris
x x
Quetiapine Seroquel
x X*
Quetiapine XR Seroquel XR
x X* x
Chlorpromazine Thorazine
x
Olanzapine Zyprexa
x x x
Olanzapine fluoxetine Symbyax
comb
x
Page 631 of 1077
 Case 3
• 33 yr old woman hospitalized with her first
episode of mania. She has no previous
history of a depressive episode.

• She has no drug or alcohol use history

and has no medical issues. What
medication would you like to start?

Page 632 of 1077

 Case 3
• Given her first presentation was a manic
episode statistically she will do better on
lithium.
• You could also opt for a mood stabilizing
antipsychotic
• Make sure to check a pregnancy test, serum
creatinine and TSH prior to initiation of
treatment.
• Discuss with her what she will use for birth
control and document this discussion.
Page 633 of 1077
 Case 3
• You start her at 300mg BID/ 600 nocte
(average starting dose)
• She comes to see you in one week she is
complaining about stomach irritation and
some diarrhea.
• What do you think is going on and what
should you do?

Page 634 of 1077

 Case 3
• GI irritation including diarrhea is common
particularly early in treatment.

• Encourage pt to drink adequate fluid,

leave at current dose and see if side
effects resolve.

Page 635 of 1077

 Case 4
➢27 yr old male is admitted in a manic episode.

➢He has 5 to 6 manic or depressive episodes a

year.

➢He has also struggled on and off with alcohol

abuse. What medication would you like to
start?

Page 636 of 1077

 Case 4
• Sodium Valporate would be a good choice
because pt is a rapid cycler (4 or more
depressive or manic episodes/year) and
because of comorbid alcohol abuse.

• You start 200mg BD and titrate to 400mg BD.

• You check his LFTs and compared to

baseline they have increased as follows:

Page 637 of 1077

 Case 4

➢ALT 48 →115
➢AST 62→140
➢ALK PHOS 32→80

➢What happened and what do you want to

do??

Page 638 of 1077

 Case 4
• It is not unusual for patients on
anticonvulsants to experience an increase
in LFTs and as long as they do not more
than triple no change in therapy is
indicated.
• Continue to monitor over time

Page 639 of 1077

 Anxiolytics
• Used to treat many diagnoses including
panic disorder, generalized Anxiety
disorder, substance-related disorders and
their withdrawal, insomnias and
parasomnias. In anxiety disorders often
use anxiolytics in combination with SSRIS
or SNRIs for treatment.

Page 640 of 1077

 Buspirone (Buspar)
• Pros:
– Good augmentation strategy- Mechanism of action is
5HT1A agonist. It works independent of endogenous
release of serotonin.
– No sedation
• Cons:
– Takes around 2 weeks before patients notice results.
– Will not reduce anxiety in patients that are used to
taking BZDs because there is no sedation effect to
“take the edge off.

Page 641 of 1077

 Benzodiazapines
➢ Used to treat insomnia, parasomnias and anxiety
disorders.
➢ Often used for CNS depressant withdrawal protocols
like alcohol withdrawal.
➢ Side effects/cons
⚫ Somnolence
⚫ Cognitive deficits
⚫ Amnesia
⚫ Dis-inhibition
⚫ Tolerance
⚫ Dependence

Page 642 of 1077

 Dose Elimination
Peak Blood
Equiva Half-
Level
Drug lency Life1 Comments
(hours)
(mg) (hours)
Alprazolam 0.5
1-2 12-15 Rapid oral absorption
(Xanax)
10.0 Active metabolites;
erratic
Chlordiaze
2-4 15-40 bioavailability
poxide
from IM
(Librium)
injection
Clonazepam 0.25 Can have layering
1-4 18-50
(Klonopin) effect
5.0 Active metabolites;
erratic
Diazepam
1-2 20-80 bioavailability
(Valium)
from IM
injection
30.0 Active metabolites
Flurazepam
1-2 40-100 with long half-
(Dalmane)
lives
Lorazepam 1.0
1-6 10-20 No active metabolites
(Ativan)
Oxazepam 15.0
2-4 10-20 No active metabolites
(Serax)
Temazepam 30.0
2-3 10-40 Slow oral absorption
(Restoril)
0.25 Rapid onset; short
Triazolam
1 duration of
(Halcion) 2-3
action
Page 643 of 1077
 Principles of Treatment
Psychosis
Depression
Mood Stabilizers
Substance Misuse
Epilepsy

Page 644 of 1077

 Psychosis
• First Episode:
– Takes 6 weeks to 3 months for symptoms to
resolve on Anti-psychotic medication
– Management with antipsychotic for a least 6
months after symptoms resolution
• (Patients need at least 9 to 12 months treatment)
– Remember:
• Monotherapy
• Insight (Self management & Social support)

Page 645 of 1077

 Schizophrenia
• Diagnosis of Schizophrenia (use criteria)
• No improvement with antipsychotic for 6
weeks Change
• Management different antipsychotic for
another 6 weeks
• Management with Clozapine
• Subsequent Episode: 2 to 4 years symptom
free

Page 646 of 1077

 Depression
• Mild Depression Psychotherapy
• Moderate and Severe Depression
– Anti-depressant medication
• First episode 12 months
• Subsequent episodes 2 to 4 years
– Psychotherapy – e.g. Cognitive Behavioural
Therapy (CBT) 6 to 8 session
– Remember: Psychotherapy is essential.

Page 647 of 1077

 Mood Stabilizers

Prevents a depressive, manic or mixed phase

Gold standard: Lithium Carbonate (Compliance important)

Anticonvulsant: Antipsychotics:
– Sodium Valproate – Olanzapine
– Lamotrigine – Aripiprazole
– Carbamazepine

Page 648 of 1077

 Substance Misuse
• Detoxification
– Substitution
• Nutrients and hydration
– Thiamine
• Anti-crave
– Naltrexone
– Acamprosate
• Aversive medication
– Disulfiram

Page 649 of 1077

Epilepsy

• Raise Seizure threshold

• Titrate dose to seizures
• Switching: Cross tapper
• Monotherapy
• Optimal dose before
adding Second drug
• Stop: 2 years Seizure
free

Page 650 of 1077

THANK YOU
Page 651 of 1077
ECT AND PHYSICAL
TREATMENTS IN
PSYCHIATRY
Michelle Dube

Page 652 of 1077

Electroconvulsive therapy (ECT
• Involves the induction of a grand mal
seizure in a patient by passing electricity
through the brain.

• Patients with any of several conditions

often show dramatic short-term
improvement after the procedure.

Page 653 of 1077

 ECT
• ECT was introduced as a treatment for schizophrenia
in the 1930s, and soon became a common treatment
for neurologically based disorders affecting mood.
• In the early days of use, ECT was administered
without anaesthesia or muscle relaxants.
• Patients were frequently injured as a side effect of
the induced seizure.
• ECT without anaesthesia is referred to as
"unmodified ECT", or "direct ECT", and is illegal in
most countries.

Page 654 of 1077

ECT
• Currently, in most countries, patients are first administered
an anesthetic agent as well as a paralytic agent

• Short acting barbiturates and ultra-short acting

depolarizing agents are used in the anaesthesia

• The anaesthetic is to allay anxiety and to modify the force

of the convulsion thus preventing injury

Page 655 of 1077

Electrode placement
• Bilateral – electrodes are placed 4cm above a line joining
the tragus and the lateral canthus of the eye

• Unilateral is on one side of the head

• Voltage is 70 – 12 Volts for .7- 1.5 sec

Page 656 of 1077

• ECT was a common psychiatric treatment until
the late 20th century, when it fell into disuse as
better drug therapies became available for more
conditions.

• ECT is reserved for severe cases of refractory

depression in such illnesses as clinical
depression (unipolar depression) and the
depression associated with bipolar disorder

Page 657 of 1077

Electrophysiological Principles
• Ohm’s Law: I=E/R (I=current, E=voltage, and
R=resistance)
• Dose of electricity in ECT= 100-500 milliCoulombs
• Brain has low impedance (resistance), skull has very high
impedance. Only 20% of applied charge actually enters
the brain.
• Seizure involves propagation of action potentials in a
large percentage of neurons.

Page 658 of 1077

Mechanism of Action
• Neurotransmitter levels all increased in CSF after seizure.
Results in down regulation of Beta adrenergic receptors.

• During seizure- PET studies show an increase in BBB

permeability and in cerebral blood flow and metabolism.

• After seizure, blood flow and metabolism is decreased

especially in the frontal lobes. Research shows this
correlated w/ response.
• desensitizes autoreceptors and sensitizes serotonin
receptors on nuerones.

Page 659 of 1077

Indications
• Major Depressive Episode (arising from unipolar
depression, as part of bipolar depression
• ECT should be strongly considered, especially when
associated with one of the following features:
• a) acute suicidality with high risk of acting out suicidal
thought
• b) psychosis
• c) rapidly deteriorating physical status due to
complications from the depression e.g. poor oral intake;
• d) history of poor response to pharmacological
interventions;
• e) history of good response to ECT;
• F) patient preference;
• g) catatonia.
Page 660 of 1077
Indications

• Bipolar disorder - manic or depressed

phase
• Acute or Catatonic Schizophrenia
• Some studies have shown efficacy in
treating OCD, Delirium, NMS, Chronic pain
syndromes,Neuroloeptic malignant
Syndrome and intractable seizure disorders

Page 661 of 1077

Major Depression
• Efficacy vs antidepressants
• Length of Antidepressant effect
• Maintenance ECT
• Pregnancy and Postpartum Period
• ECT is considered a low-risk and effective treatment in all stages of
pregnancy
• Anaesthesia consultation should be obtained well ahead of time
because of potential differences in technique, monitoring,
• and positioning
• Obstetrical consultation is also required, particularly with high-risk
pregnancies and those near term. Resources should be readily
accessible in the event of a neonatal or obstetric emergency.
• ECT is also considered a low-risk and effective treatment in the
postpartum period. Anaesthetic agents pose little risk to the breast-fed
infant.
Page 662 of 1077
Bipolar Mania
• Efficacy vs Lithium
• Pregnancy w/ Acute mania

Page 663 of 1077

Pre ECT Workup
• Physical Exam
• Head CT
• CXR
• FBC, U+E
• ECG
• ? Spinal Films

Page 664 of 1077

Contraindications?

• Relative Contraindications: Recent MI,

Berry Aneurysm, Brain Mass, Increased
Intracranial Pressure
• Anaesthetic contraindications

Page 665 of 1077

Treatments
• Premedicate consider short acting Beta blocker
• Patient not intubated
• Bite block
• Cuff leg to monitor seizurez
• EEG and EMG
• Length of seizure- 20 sec to 1 min.

Page 666 of 1077

Number and Spacing of ECT
• 2-3x/wk- efficacy vs less memory
impairment
• 5-12 sessions/ treatment (although up to
20 is possible)
• Effect gradually wears off so should be
maintained with pharmacotherapy if
possible

Page 667 of 1077

Adverse Effects
• Mortality rate: .002% per treatment session,
.01% per patient. (usually due to anaesthetic
complications)
• Sore Muscles
• Head ache
• Short term confusion/ delirium in post-ictal period
• Memory loss – usually with bilateral electrode
placement
• Fracture/ Dislocation

Page 668 of 1077

Transcranial magnetic stimulation TMS
• A noninvasive method to excite neurons in the brain.

• The excitation is caused by weak electric currents induced in the

tissue by rapidly changing magnetic fields (electromagnetic
induction).

• This way, brain activity can be triggered or modulated without the

need for surgery or external electrodes.

• TMS has shown promise for noninvasive treatment of a host of

disorders, including depression and auditory hallucinations .

Page 669 of 1077

• TMS is currently under study as a treatment for severe
• Depression
• mania,
• auditory hallucinations (e.g., associated with schizophrenia),
• posttraumatic stress disorder,
• obsessive-compulsive disorder,
• generalized anxiety disorder,
• migraine headaches and
• tinnitus.
• May provide a viable alternative to electroconvulsive therapy.

• TMS is also under investigation for the treatment of drug-resistant

epilepsy and tinnitus

• rTMS therapy for drug-resistant depression has been approved by

Health Canada for clinical delivery since 2002.
Page 670 of 1077
• Although research in this area is in its infancy, there is
now some evidence that TMS is an effective treatment for
depression, obsessive-compulsive disorder, generalized
anxiety disorder, and auditory hallucinations, with more
symptoms and disorders being researched. Additionally,
in June 2006, US medical researchers published
evidence indicating that TMS is more successul at treating
migraines in patients than current medications. A larger
research study involving more patients and better controls
is planned to confirm the validity of these results.

Page 671 of 1077

• Several TMS/rTMS devices are approved by the US Food and Drug Administration
(FDA) for stimulation of peripheral nerve and, therefore, can be used "off label" by
individual physicians to treat brain disorders, essentially in any way they believe
appropriate, analogous to the off label use of medications. However, most legitimate
use of TMS in the US and elsewhere is currently being done under research protocols
approved by hospital ethics boards and, in the US, often under Investigational Device
Exemption from the FDA. The requirement for FDA approval for research use of TMS is
determined by the degree of risk as assessed by the investigators, the FDA, and the
local ethics authority. The FDA is expected to approve TMS as a treatment for
depression in early 2007. As regulated medical devices, TMS devices are not sold to
the general public. They are also expensive (25,000-100,000 USD; together with state-
of-the-art targeting and recording instruments, up to about 500,000 USD). In Europe,
TMS devices that have been manufactured according to the Medical Device Directive
have been granted the CE mark and can thus be freely marketed within the EU.

Page 672 of 1077

Transcranial Magnetic Stimulation (TMS)
• Rt Frontal lobe- TMS pulses suppress activity and causes
happiness and increased energy
• Left Frontal lobe- TMS pulses suppress activity and leads
to sadness
• 4/250 had seizure
• 10Hz stimulation 20x/day, 11/17 patients w/ Major
Depression showed significant improvement.

Page 673 of 1077

TMS continued
• So far positive effects have not lasted as long as positive
effects from ECT
• Handful of case reports show efficacy w/ anxiety
disorders.

Page 674 of 1077

Vagus Nerve Stimulation
• The vagus nerve is associated with many
different functions and brain regions,

• Research is being done to determine its

usefulness in treating illnesses such as
anxiety disorders, Alzheimer's disease ,and
migraines.
• Vagus nerve stimulation (VNS) is an
adjunctive treatment for certain types of
intractable epilepsy and clinical depression.
Page 675 of 1077
Vagus nerve stimulation (VNS)
•
• VNS uses an implanted stimulator that sends electric
impulses to the left vagus nerve in the neck via a lead
implanted under the skin.

• The VNS device consists of a titanium encased generator

about the size of a pocket watch; a lithium battery to fuel
the generator, with a battery life of ~6-8 years; a lead
system with electrodes; and an anchor tether to secure
leads to the vagus nerve.

Page 676 of 1077

Page 677 of 1077
“Big” Names associated with Cognitive Behavioral
Therapy

1. Epictetus, Greek philosopher. Observed that

people are not disturbed by things that happen
but by the view they take of things that
happen.
2. Albert Ellis, “grandfather of cognitive
behavioral therapy.”
3. Aaron Beck, MD, a psychiatrist (University of
Pennsylvania)

Page 678 of 1077

Mental health problems - can have both
psychological, social and somatic
dimensions. These issues often make it
hard for people to manage their lives and
achieve their goals.

Therapists/mental health professionals

are expected and legally bound to respect
client privacy and client confidentiality.

Page 679 of 1077

Definitons of Terms
Psychotherapy - set of clinical techniques use to improve mental health.
Behavior Therapy (Behavior Modification Therapy) - changing
somebody's behavior
Classical Conditioning - creation of response to stimulus (Pavlov's dogs)
Operant Conditioning - learning through positive and negative
reinforcement
Cognitive Therapy - psychotherapy aimed at changing way of
thinking. Several approaches to cognitive-behavioral therapy

Page 680 of 1077

 Characteristics of
Cognitive-Behavioral Therapies:

1. Thoughts cause Feelings and Behaviors.

2. Brief and Time-Limited.

Average # of sessions = 16 VS
psychoanalysis = several years

3. Emphasis placed on current behavior.

Page 681 of 1077

4. CBT is a collaborative effort between the
therapist and the client.
Client role - define goals, express concerns,
learn & implement learning
Therapist role - help client define goals, listen,
teach, encourage.

5. Teaches the benefit of remaining calm or

at least neutral when faced with difficult
situations. (If you are upset by your
problems, you now have 2 problems: 1) the
problem, and 2) your upsetness.

Page 682 of 1077

6. Based on "rational thought." - Fact not
assumptions.
7. CBT is structured and directive. Based on
notion that maladaptive behaviors are the
result of skill deficits.
8. Based on assumption that most emotional
and behavioral reactions are
learned. Therefore, the goal of therapy is to
help clients unlearn their unwanted reactions
and to learn a new way of reacting.
9. Homework is a central feature of CBT.

Page 683 of 1077

 PERSONALITY
DISORDERS

NSC 304- DR V MAWEREWERE

Page 684 of 1077

 PERSONALITY DISORDERS

• Personality trait: An enduring pattern of perceiving,

relating to, and thinking about the environment and
others.

• Personality disorders: Ingrained patterns of relating

to other people, situations, and events with a rigid
and maladaptive pattern of inner experience and
behavior.

Page 685 of 1077

PERSONALITY DISORDER CLUSTERS

• Cluster A - The odd and eccentric behaviors

• Cluster B - The dramatic and emotional behaviors
• Cluster C - The anxious and fearful behaviors

Page 686 of 1077

CLUSTER A PERSONALITY DISORDERS

• Cluster A of the personality disorders include those

disorders characterized by eccentric behavior.

• In other words, individuals with these disorders show

characteristics that might lead others to view them
as slightly odd, unusual, or peculiar.

Page 687 of 1077

 PARANOID PERSONALITY
DISORDER
• Suspects, without sufficient basis, that others are
exploiting, harming, or deceiving him or her
• Is preoccupied with unjustified doubts about the
loyalty or trustworthiness of friends or associates
• Is reluctant to confide in others because of
unwarranted fear that the information will be used
maliciously against him or her
• Reads hidden demeaning or threatening meanings
into benign remarks or events

Page 688 of 1077

 CONT..

• Persistently bears grudges (i.e., is unforgiving of

insults, injuries, or slights)
• Perceives attacks on his or her character or
reputation that are not apparent to others, and is
quick to react angrily or to counterattack
• Has recurrent suspicions, without justification,
regarding fidelity of spouse or sexual partner

Page 689 of 1077

SCHIZOID PERSONALITY DISORDER

• Takes pleasure in few, if any, activities

• Does not desire or enjoy close relationships,
including family
• Appears aloof and detached
• Avoids social activities that involve significant
contact with other people
• Almost always chooses solitary activities

Page 690 of 1077

 CONT…

• Little or no interest in sexual experiences with

another person
• Lacks close relationships other than with immediate
relatives
• Indifferent to praise or criticism
• Shows emotional coldness, detachment or
flattened affect
• Exhibits little observable change in mood

Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior
written consent of McGraw-Hill
Page 691 of 1077 Education
SCHIZOTYPAL PERSONALITY DISORDER

• Odd beliefs or magical thinking that influences

behavior and is inconsistent with subcultural norms
(e.g., superstitiousness, belief in clairvoyance,
telepathy, or “sixth sense”;
• Unusual perceptual experiences, including bodily
illusions
• Odd thinking and speech (e.g., vague,
circumstantial, metaphorical, over-elaborate, or
stereotyped)
• Suspiciousness or paranoid ideation

Page 692 of 1077

 CONT…

• Inappropriate or constricted affect

• Behaviour or appearance that is odd,
eccentric, or peculiar
• Lack of close friends or confidants other
than first-degree relatives
• Excessive social anxiety that does not
diminish with familiarity and tends to be
associated with paranoid fears rather than
negative judgments about self

Page 693 of 1077

 TREATMENT FOR CLUSTER A

• Parallels interventions commonly used in treating

schizophrenia

Page 694 of 1077

 CLUSTER B PERSONALITY
DISORDERS
THESE BEHAVIORS INCLUDE IMPULSIVITY, AN INFLATED
SENSE OF SELF, AND A TENDENCY TO SEEK STIMULATION.

Page 695 of 1077

ANTISOCIAL PERSONALITY DISORDER

• The diagnostic criteria require that an individual

show a pervasive pattern of three out of seven
possible behaviors:

1. Failure to conform to social norms

2. Deceitfulness-violation of emotional rights of others
3. Lack of stability in job and home life
4. Aggressiveness
5. Disregard for safety of self or others
6. Consistent irresponsibility
7. Lack of remorse

Page 696 of 1077

 TREATMENT OF ANTISOCIAL
PERSONALITY DISORDER
• Problems of working with these individuals
• Seeming lack of motivation to change
• Tendency toward deception and manipulation
• Lack of deep or lasting emotion

• Is the most difficult personality disorders to treat. Individuals

rarely seek treatment on their own and may initiate therapy
only when mandated to do so by a court

Page 697 of 1077

BORDERLINE PERSONALITY DISORDER

• may experience mood swings and display

uncertainty about how they see themselves and
their role in the world.
• As a result, their interests and values can change
quickly.
• tend to view things in extremes, such as all good or
all bad.
• Their opinions of other people can also change
quickly. An individual who is seen as a friend one
day may be considered an enemy or traitor the
next.

Page 698 of 1077

 BPD CONT…

• Efforts to avoid real or imagined abandonment,

such as rapidly initiating intimate (physical or
emotional) relationships or cutting off
communication with someone in anticipation of
being abandoned

Page 699 of 1077

 TREATMENT FOR CLIENTS WITH BPD

Dialectical Behavior Therapy (DBT):

• teaches skills that can help:
• Control intense emotions
• Reduce self-destructive behaviors
• Improve relationships
Cognitive Behavioral Therapy (CBT):
• identify and change core beliefs and behaviors that
underlie inaccurate perceptions of themselves and others,
and problems interacting with others.

Page 700 of 1077

 HISTRIONIC PERSONALITY DISORDER

• Exaggerated emotional reactions, approaching

theatricality, in everyday behavior.

• Show extreme pleasure as the center of attention and

who behave in whatever way necessary to ensure
that this happens.

• They are excessively concerned with their physical

appearance, often trying to draw attention to
themselves in such extreme ways that their behavior
seems ludicrous.

Page 701 of 1077

HISTRIONIC PERSONALITY DISORDER

• Flirtatious and seductive

• Demand reassurance, praise, approval
of others
• Need for immediate gratification
• Easily influenced by others
• Lack analytical ability

Page 702 of 1077

 TREATMENT OF HPD

No treatment yet

Page 703 of 1077

NARCISSISTIC PERSONALITY DISORDER

• Have an exaggerated sense of self-importance

• Have a sense of entitlement and require constant,
excessive admiration
• Expect to be recognized as superior even without
achievements that warrant it
• Exaggerate achievements and talents
• Be preoccupied with fantasies about success,
power, brilliance, beauty or the perfect mate
• Believe they are superior and can only associate
with equally special people

Page 704 of 1077

 CONT..

• Monopolize conversations and belittle or look down

on people they perceive as inferior
• Expect special favours and unquestioning
compliance with their expectations
• Take advantage of others to get what they want
• Have an inability or unwillingness to recognize the
needs and feelings of others
• Be envious of others and believe others envy them

Page 705 of 1077

 CONT..

• Behave in an arrogant or haughty manner, coming

across as conceited, boastful and pretentious
• Insist on having the best of everything — for
instance, the best car or office

• React with rage or contempt and try to belittle the

other person to make themselves appear superior

Page 706 of 1077

 TREATMENT OF NARCISSISTIC
PERSONALITY
• Most effective approach
• Provide reassurance and develop a more realistic view of
themselves and other people

• People with NPD are difficult to treat

• Tend not to have insight into their disorder
• Extreme perfectionism can obstruct treatment

Page 707 of 1077

 CLUSTER C
PERSONALITY DISORDERS
DISORDERS THAT INVOLVE
PEOPLE WHO APPEAR ANXIOUS OR FEARFUL AND MAY SEEM HIGHLY
RESTRICTED

Page 708 of 1077

 AVOIDANT PERSONALITY DISORDER

• Easily hurt by criticism or disapproval

• No close friends
• Reluctance to become involved with
people
• Avoidance of activities or occupations that
involve contact with others
• Shyness in social situations out of fear of
doing something wrong

Page 709 of 1077

 CONT…

• Exaggeration of potential difficulties

• Showing excessive restraint in intimate
relationships
• Feeling socially inept, inferior, or
unappealing to other people
• Unwilling to take risks or try new things
because they may prove embarrassing

Page 710 of 1077

 TREATMENT OF AVOIDANT
PERSONALITY

Cognitive-behavioral
• Break negative cycle of avoidance
• Confront and correct dysfunctional
attitudes and thoughts
• Graduated exposure to social
situations
• Learn skills to improve chance of
intimacy
Page 711 of 1077
DEPENDENT PERSONALITY DISORDER

• Difficulty making decisions without

reassurance from others
• Extreme passivity
• Problems expressing disagreements with
others
• Avoiding personal responsibility
• Avoiding being alone
• Devastation or helplessness when
relationships end
Page 712 of 1077
 CONT..

• Unable to meet ordinary demands of

life
• Preoccupied with fears of being
abandoned
• Easily hurt by criticism or disapproval
• Willingness to tolerate mistreatment
and abuse from others

Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior
written consent of McGraw-Hill
Page 713 of 1077 Education
 TREATMENT

Cognitive-behavioral therapy focuses on patterns of

thinking that are maladaptive, the beliefs that
underlie such thinking, and resolving symptoms or
traits that are characteristic of the disorder

Page 714 of 1077

 OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
• Is preoccupied with details, rules, lists, order,
organization, or schedules to the extent that the major
point of the activity is lost
• Shows perfectionism that interferes with task
completion (e.g., is unable to complete a project
because his or her own overly strict standards are not
met)
• Is excessively devoted to work and productivity to the
exclusion of leisure activities and friendships (not
accounted for by obvious economic necessity)

Page 715 of 1077

 CONT..

• Is over conscientious, scrupulous, and inflexible

about matters of morality, ethics, or values (not
accounted for by cultural or religious identification)
• Is unable to discard worn-out or worthless objects
even when they have no sentimental value
• Is reluctant to delegate tasks or to work with others
unless they submit to exactly his or her way of doing
things
• Adopts a miserly spending style toward both self
and others; money is viewed as something to be
hoarded for future catastrophes
• Shows significant rigidity and stubbornness
Page 716 of 1077
 TREATMENT

• long-term psychotherapy

Page 717 of 1077

Psychiatric evaluation of children
and adolescents
MBChB IV

Page 718 of 1077

 Outline
• Introduction
• Parental interview
• Child interview
• Physical examination
• Investigations
• Rating scales and psychometric assessment
• Formulation
• Communicating findings and recommendations

Page 719 of 1077

 Introduction
• There are distinctive aspects of the
psychiatric interview of children and
adolescents compared to adults

Page 720 of 1077

 Introduction
• Children rarely initiate psychiatric
assessment
• Following referral the aim is to:
1. identify the stated reasons Parents
and factors leading to
referral;
2. obtain an accurate picture of
the child's developmental Primary
Courts
functioning and of the nature Care
and extent of the child's Referrals
behavioural difficulties,
functional impairment,
and/or subjective distress;
3. to identify potential Teachers Paediatrician
individual, family, or
environmental factors that
may account for, influence, or
ameliorate these difficulties
Page 721 of 1077
 Introduction
• Children need to be
evaluated in the
context of the family,
the school, the
community and the
culture
• No child can be
assessed in isolation

Page 722 of 1077

 Introduction
• The presenting
problems must be
considered in a
developmental context
• Children’s ability to
reflect and discuss
their feelings or
experiences is
influenced by
maturational factors
Page 723 of 1077
 Introduction
• The clinical assessment of children typically
requires more time than adults

Page 724 of 1077

 Introduction
• The purpose of the psychiatric evaluation of
children and adolescents is to :
1. determine whether psychopathology is present
and, if so, establish a differential diagnosis;
2. determine whether treatment is indicated and,
develop treatment recommendations and plans
3. create a good therapeutic relationship to
facilitate the family and child's cooperation to
therapy.

Page 725 of 1077

• The full diagnostic assessment of the child
usually requires gathering data from different
sources
Parents

Psychologist School

Nursing staff
Child Primary Physician

Previous medical
Justice system
records

Social workers
Page 726 of 1077
 Parental Interview
• The parent interview has the dual goal of
gathering information and establishing rapport.
• Following the parental interview the clinician
should be able to understand
– The presenting symptoms
– The impact of the symptoms
– The risk factors contributing
– The strengths of the patient
• The clinician should also be able to give
explanations to the parents
Page 727 of 1077
 Parental interview
• The • Conception, Pregnancy and Delivery
developmental • Neonatal hx
history should • Development of milestones
provide a detailed
• Cognitive and School Functioning
history of the
child's physical, • Peer Relations
cognitive, • Family relationships
linguistic, social, • Emotional Development, Temperament,
and emotional and Mental State
development • Development of Conscience and Values
• Interests, Hobbies, Talents, and
Avocations
• Prior Psychiatric Treatment History
Page 728 of 1077
 Parental Interview
• The parental interview
also encompasses
assessment of family
and community
– Parents or Caretakers
(relations, education,
occupation, and
financial resources)
– Family medical and
psychiatric history
– Religion
– Cultural practices Page 729 of 1077
 Child interview
• The clinical interview of the child provides
the setting for the direct exploration of the
child's own perceptions of the presenting
problem and the assessment of the child's
overall developmental and mental status
• It provides information on:-
– the degree of the child's personal suffering,
– information concerning affects and mental
phenomena which may not be observable
(e.g., anxiety, suicidal thoughts, obsessional
thoughts, hallucinations),
– secrets such as antisocial activities or sexual
abuse.
Page 730 of 1077
 Child Interview
• The aims of the child interview are to:
– Establish a therapeutic relationship and gain the
child’s trust.
– Obtain the child’s perception of the problem
– Get a good understanding of the child’s current
developmental stage
– Obtain information about emotional symptoms,
traumatic events, delinquent acts, drug use, sexual
problems
– Collect data for the mental status examination
– Provide explanations

Page 731 of 1077

Child Interview

Page 732 of 1077

 Child Interview
• There is no fixed order or manner of conducting
the child interview;
• The interview style differs based on:-
– the nature of the chief complaint and presenting
pathology
– the child's age and development status
– the interviewer's personal style,
– the clinical setting and context (e.g., emergency
room, hospital ward, school-based consultation,
private office, outpatient mental health clinic).
Page 733 of 1077
 Child Interview
• Specific Child Interview Techniques
– Interactive Play Techniques
– Projective Techniques
– Direct Questioning

Page 734 of 1077

 Child Interview
• The assessment of infants and preverbal
toddlers requires specialized techniques,
including careful developmental assessment
and direct observation of parent-child
interaction

Page 735 of 1077

 Child Interview
• Special areas of interest for the interview with
adolescence patients include :-
– antisocial or delinquent behaviour
– Sexual identity and preference
– Alcohol and substance abuse
– Suicidal ideation or behaviour, including deliberate
self harm

Page 736 of 1077

 Physical Examination
• All children and adolescents require a physical
examination and appropriate physical tests
• These include:-
– General examination; (include height and weight
and head circumference )
– Neurological evaluation
– Metabolic, endocrinological, or genetic evaluation
– Evaluation of vision or hearing.

Page 737 of 1077

 Investigations
• Blood tests
• Urine tests (toxicology screen, pregnancy
testing)
• Brain imaging
• Genetic screening
• Electroencephalography (EEG)

Page 738 of 1077

 Consultation
• Where indicated, the child may need to be
referred for additional evaluation which
includes:-
– psychological,
– educational,
– speech and language assessment,
– paediatric or neurological consultation.
– Social service or agency evaluation of home
environment.

Page 739 of 1077

 Rating scales and psychometric
assessment
• Rating scales are instruments (paper and pencil or
computer-based) used to collect qualitative and
quantitative data
• Rating scales can be used :-
– as screening tools to ascertain whether a child should
be evaluated more thoroughly for mental health
disorders
– as a source of additional diagnostic information,
– to monitor and measure the effectiveness of
treatment (outcome),
– as research tools.

Page 740 of 1077

 Rating scales and psychometric
assessment
• Psychometric tests are standardized
instruments for systematically recording and
assessing the development of children with
respect to various realms of functioning
• They however cannot take the place of an
individualized child psychiatric interview, nor
can they be relied upon as the sole basis for
establishing diagnoses or planning treatment

Page 741 of 1077

 Diagnostic Formulation
• The diagnostic formulation represents the
clinician's conclusions based on the data gathered
• It provides an account of the potential nature of
the child's difficulties and the factors that may
have predisposed the child to develop such a
problem,
• It also indicates the concomitants and
consequences of the problem, and the factors
that maintain the problem or might ameliorate it.

Page 742 of 1077

 Communicating findings and
recommendations
• Communication of the clinician’s findings and
recommendations to the parents and child is
an essential part of the assessment
• It may require one or more sessions
• Depending on the nature of the problem and
the child's age and level of comprehension,
this may entail meeting with the child and
parents separately or together

Page 743 of 1077

 Communicating findings and
recommendations
For an effective conclusion:-
• Use comprehensible terms;
• Place the findings in the context of the child's overall strengths and
vulnerabilities;
• Indicate remaining areas of uncertainty and nature of the additional
assessment(s) needed;
• Assess the parents' and child's understanding of the clinician's
findings and recommendations;
• With the necessary consent, communicate the findings and
recommendations in appropriate terms to the referring clinician or
agency
• Where treatment or additional assessment are best done by
someone other than the assessing clinician, assist parents with
finding a suitable referral.

Page 744 of 1077

INTELLECTUAL DISABILITY

2017
DEPARTMENT OF PSYCHIATRY

Page 745 of 1077

 OBJECTIVES

By the end of the session students should be able to:

1. Define intellectual disability
2. Classify ID
3. Identify the causes of ID
4. Assess and manage a child with ID

Page 746 of 1077

 Introduction

 Intellectual disability (ID) is a condition of arrested mental

development characterized by below-average intelligence
or mental ability and a lack of skills necessary for day-to-
day living. The disability originates before the age of 18.

Page 747 of 1077

 Diagnostic and Statistical Manual of Mental Disorders
(DSM-5, APA 2013).

Someone with intellectual disability has limitations in two

areas which are:

1. Intellectual functioning
 Also known as IQ- person’s ability to learn through trial and error,
reason, make decisions, and solve problems.
 Reasoning and Problem solving
 Planning
 Judgment
 Academic learning (ability to learn in school via traditional teaching
methods)

Page 748 of 1077

 Cont.

2. Adaptive functioning
This includes skills needed to live in an independent and responsible
manner/skills for daily living such as:

 Communication-Inability to understand others, and to express one's self

through words or actions.

 Social skills- The ability to understand and comply with/ obey social rules,
customs, and standards of public behaviour.

 Practical skills- Activities of daily living- Personal care, shopping and

accessing public transportation, safety, use of money

Page 749 of 1077

 Cont.

 School or work functioning

➢ ability to conform to the social standards at work or school.

➢ ability to learn new knowledge, skills, and abilities.

➢ Cannot apply this information in a practical, adaptive manner without excessive

direction or guidance.

These limitations should occur in the developmental period

Page 750 of 1077

 ICD-10

A condition of arrested or incomplete development of the

mind which is characterized by impairment of skills. This is
manifested during the developmental period which
contributes to the overall level of intelligence i.e.

 cognitive
 language
 motor
 social abilities.

Page 751 of 1077

 Common signs of ID

 Delayed milestones
 Behaviour problems such as explosive tantrums
 Difficulty with problem-solving or logical thinking
 Slow to master things like potty training, dressing, and
feeding himself or herself
 Difficulty remembering things
 Inability to connect actions with consequences

Page 752 of 1077

 Classification of ID

SUB-TYPE IQ RANGE

 Mild ID 55-69
 Moderate ID 40- 54
 Severe ID 25-39
 Profound ID < 25

Page 753 of 1077

 Mild ID

School Age

 Can learn academic skills to +/- 6th grade level by late teens
 Can be guided towards social conformity

Adults

 Can usually achieve social skills adequate to minimum self-support

 may need guidance and assistance when under unusual social or

economic stress

Page 754 of 1077

 Moderate

School Age
 Can profit from training in social and occupational skills
 Unlikely to progress beyond 2nd grade level in academic subjects
 May learn to travel alone to familiar places

Adult
 May achieve self-maintenance in unskilled or semi-skilled work under
sheltered conditions

Page 755 of 1077

 Severe ID

School Age
 Can talk or learn to communicate
 Can be trained toilet trained
 Profits from systematic habit training
 Unable to profit from vocational training

Adult
 May contribute partially to self-maintenance under complete
supervision

Page 756 of 1077

 Profound ID

School Age
 Some motor development present
 May respond to minimal or limited training in self-help

Adult
 Some motor & speech development
 May achieve very limited self-care
 Needs nursing care

Page 757 of 1077

 Epidemiology

1. Severe impairment has a prevalence of 3.5 per 1000

population

2. More common in males who have a larger variance in IQ

Page 758 of 1077

 CAUSES

They can be congenital or acquired

 Prenatal

 Perinatal

 Postnatal

 Socio- cultural

Page 759 of 1077

 Prenatal

1.Chromosomal abnormalities
• Trisomy 17-18: Edward’s syndrome

• Trisomy 21: Down’s syndrome or mongolism

• Deletion of short arm of 5 : cri du chat syndrome

• Deletion of short arm of 4: Wolf’s syndrome

 XXY: Klinefelter’s syndrome: Poor muscle coordination

 Fragile X syndrome: Associated with X chromosome in the 23rd pair of

chromosome

Page 760 of 1077

 Cont.

 Prader- Willi syndrome: leading cause of obesity

 Cornelia de Lange Syndrome: abnormal fingers and hands, aggression

 Turner’s syndrome: webbing of neck and puffiness

 William’s syndrome: absence of material in the 7th pair of chromosomes

Page 761 of 1077

 Cont.

2. Inborn errors of metabolism

 Phenylketonuria: Inability of the body to convert phenylalanine to

tyrosine leading to build up of phenylalanine in the blood

 Galactosaemia: inability of body to use simple sugar galactose

 Hypothyroidism (cretinism)

 Nephrogenic diabetes insipidus—X linked recessive.

Page 762 of 1077

 Cont.

3. Developmental disorders of the brain

 Hydrocephalus

 microcephalus

Page 763 of 1077

 Cont.

4. Environmental influences

• Placental insufficiency

• Maternal Malnutrition

• Infantile hypoglycaemia

• Foetal alcoholism (20% risk with alcoholic mother)

• Lead encephalopathy

• Exposure to radiation

Page 764 of 1077

 cont.

5. INFECTIONS

 Rubella (German measles) at up to 16 weeks of pregnancy.

 Cytomegalovirus

 Syphilis

 Toxoplasmosis

Page 765 of 1077

 Perinatal causes

 Prematurity and low birth weight

 Intrauterine growth retardation

 Birth injury

 Birth asphyxia/ Anoxia

 Assisted deliveries.

Page 766 of 1077

 Postnatal causes

• Encephalitis

• meningitis
• Lead poisoning
• trauma/accidental injury
• febrile convulsions

• Malnutrition

• cerebral palsy

Page 767 of 1077

 Environmental and psychosocial factors

 ID associated with dependent/ illiterate members of certain

communities

 Malnutrition

 Inadequate health care

 Environmental health hazards

 Poverty/ Adverse living conditions

Page 768 of 1077

 Cont.

 Child abuse and neglect

 Lead poisoning

 Low SES, under-nutrition, maternal infection or alcohol

intake in pregnancy all operate more frequently in lower
SES groups. Therefore effects may be erroneously
attributed purely to psychosocial mechanisms

Page 769 of 1077

 Management

ASSESSMENT
Medical
• Neurological and general examination, family hx, pathological
screening, EEG, Serological tests for syphilis, etc.

Developmental assessment
• Includes tests of general IQ and tests of special functions as well as
assessment of developmental milestones.

Page 770 of 1077

 Cont.

General assessment

• Must be made of the child and his or her family and social
circumstances by the multidisciplinary team.

• All assessments must be repeated as the child grows as his or her

needs and abilities change.

Page 771 of 1077

 Mx cont

• Psychotropic medication may be required for agitation, depression etc.

• Individual educational programs and family psychotherapy may be

appropriate

• Behavioural therapy/ modification involves detailed analysis of

unwanted behaviour and the supplying of immediate rewards for
required behaviour

Page 772 of 1077

 Guidance for Parents

• Supply factual information about the disorder, cause, prognosis and

management.

• Reassure and give advice concerning the prognosis, likely

disabilities and ways of helping the child.

• Genetic counselling may be appropriate

• special education

Page 773 of 1077

 Placement programs

 Special education/Individualised Education programmes- Designed to

cater for their special educational needs

 Alternative programs- vocational training, physical education, theatre,

music

 Specialised homes

 Behaviour Therapy programs

Page 774 of 1077

 Prevention

Primary
 Improving the nutritional status of the community as a whole especially
the girl child
 Universal immunization of children
 Genetic counselling

Secondary
 Early detection and treatment of any condition that might predispose to
ID

Page 775 of 1077

 Prevention Cont.

Tertiary
• Genetic counselling

• Prenatal screening-PKU, Galactosaemia

• Rubella immunization in adolescent girls.

• Maternal syphilis screening and treatment

Page 776 of 1077

 Prevention cont.
• Folate supplements in pregnancy

• Avoidance of maternal drug and alcohol abuse (foetal alcohol

syndrome)

• Improvement in obstetric care

• Prevention of malnutrition

• Improved social and educational standards

Page 777 of 1077

THE END

Page 778 of 1077

 CHILD ABUSE

This is any child rearing technique that results in physical

harm, death or emotionally deprives the child of self esteem
through avoidable acts of omission or commission

Page 779 of 1077

Types of abuse

• Neglect

• Physical abuse

• Sexual abuse

• Emotional/psychological abuse

Page 780 of 1077

Who are the abusers?

Not just strangers

95% of children calling Childline know the abuser
Abusers include:
• Parents, Uncles
• Aunts, Grandparents
• Teachers
• Family friends
• Brothers, Sisters.
• Most men from all classes
• Health Professionals
• Some young people.

Page 781 of 1077

THEORETICAL PERSPECTIVES ON CHILD
ABUSE
MENTAL ILLNESS MODEL
• Parents who abuse their children are mentally ill.

ENVIRONMENTAL STRESS MODEL

• In this model, two factors interact to precipitate abuse ie. a violent
environment and stress- society or the family.

• Abusive parents are assumed to belong to that segment of society that

approves of physical violence against children in certain circumstances.

Page 782 of 1077

Cont.

SOCIAL LEARNING MODEL

• This model too explains that behavior is learned through observation as
well as through behavioral reinforcement. This model of abuse is useful
because it includes cultural and family influences by Bandura (1973).
SOCIAL PSYCHOLOGIC MODEL
• having unrealistic expectations of the child and failing to recognize and
respect the child as a unique individual.
• physically or mentally disabled child different from the other children in
the family
• Many parents who abuse their children were themselves victims of child
abuse because they were unable to meet their parents needs.

Page 783 of 1077

NEGLECT

Failure of a parent or other person legally responsible for the

child’s welfare to provide for the child’s basic needs and an
adequate level of care.

Neglect, is the chronic failure of adults to protect the child from

obvious physical danger or to provide the care needed.

Page 784 of 1077

 TYPES OF NEGLECT

PHYSICAL NEGLECT:
Lack of appropriate supervision
Inappropriate child hygiene
Lack of education as required by law
Lack of medical treatment or medication for a serious illness
Lack of basic food and clothing
Residing in an inappropriate/dangerous living environment

EMOTIONAL NEGLECT
Failure to meet the child’s needs for love/affection, attention and
emotional nurturance.

Page 785 of 1077

Suggestive statement

• “My mum and dad both have drinking problems. Sometimes

there's nothing to eat in the house. And I'm often left alone
to look after my brothers and sisters.”

Page 786 of 1077

Physical manifestations of neglect
• Failure to Thrive/ Signs of malnutrition
• Poor personal hygiene
• Unclean and in appropriate dressing
• Evidence of poor health such as delayed immunization,
untreated infections, frequent colds,
• Frequent injuries from lack of supervision.

Page 787 of 1077

Suggestive behaviors
• Dull and inactive
• excessively passive or sleepy
• Self - stimulatory behaviors, such as finger sucking
• Begging or stealing food
• Absenteeism from school
• Drug or alcohol addiction
• Vandalism or shoplifting

Page 788 of 1077

PHYSICAL ABUSE
Non accidental physical injury to the child. Even if the person who
inflicts the injury had no intension to hurt the child its still abuse
• beating/slapping
• Chocking
• Punching
• shaking

Page 789 of 1077

Predisposing factors
Parental characteristics
• Violence

• Poverty

• Parental history of abuse

• Socially isolated

• Low self esteem

Page 790 of 1077

Characteristics of the child
• Number of children

• Child's character

• Position in the family

• additional physical needs if ill or disabled

• Activity level or degree of sensitivity to parental needs.

• Occasionally the abused child is ill e.g. brain damaged, hyper

active or physically disabled

Page 791 of 1077

Environmental characteristics
• Chronic stress
• divorce
• Poverty
• Unemployment
• Poor housing
• Frequent relocation
• Alcoholism
• Drug addiction

Page 792 of 1077

Suggestive physical findings
• Bruises on lips, mouth, back, buttocks, thighs
• regular patterns descriptive of object used such as belt
buckle, hand, chain, wooden spoon, squeeze or pinch mark
• Burns- on soles of feet, palms of hand, back or buttocks
Patterns descriptive of object used, such as cigarette
burns, immersion in scalding water, rope burns on
wrists.
Absence of ' splash' marks and presence of symmetric
burns

Page 793 of 1077

Cont.

• Fractures and dislocations- Multiple new or old fractures in

various stages of healing

• Lacerations and abrasions on back of arms , face or external

genitalia

• Descriptive marks such as from human bites or pulling hair

out

Page 794 of 1077

Suggestive behaviour
• They avoid physical contact with adults
• Apparent fear of parents or going home
• In appropriate reaction to injury, such as failure to cry from
pain
• Withdrawal behavior/isolation
• Superficial relationship
• Lack of reaction to frightening events

Page 795 of 1077

EMOTIONAL ABUSE
Lack of love, Approval, Acceptance

Being constantly:
• Criticised
• Blamed
• Shouting at the child
• Told that other people are better than them
• Rejected by those they look to for affection.
• Calling the child names

Page 796 of 1077

Suggestive Physical findings
• Failure to thrive.
• Feeding disorders
• Enuresis
Suggestive behaviours
• Self-stimulatory behavior such as nail biting, rocking.
• During infancy, lack of social smile and stranger anxiety.
• Withdrawal and fearfulness
• Antisocial behavior, such as destructiveness, stealing, cruelty
• Lags in emotional and intellectual development, especially language
• Suicide attempts

Page 797 of 1077

MANAGEMENT OF ABUSED CHILDREN
CHILD AND FAMILY ASSESSMENT
• History taking and physical exam
• Use age - appropriate methods to assess development; young
children respond to play therapy with people that represent family
members.
• Provide age - appropriate support for the child during radiologic and
other diagnostic tests.
• Document physical injuries.
• Document observations of child behavior that indicate psychological
and emotional status.
• With other health care team members, complete the family
assessment.

Page 798 of 1077

INTER DISCIPLINARY PARTICIPATION IN CARE
• Provide positive reinforcement for family / parent strengths.

• Model healthy communication and parenting behavior

• Inform parents that the case will be reported to social welfare and the police

• Explain that the objective of involvement is to strengthen family functioning

and prevent future harm to children

• Assist parents in identifying strategies necessary to prevent future abuse

Page 799 of 1077

SEXUAL ABUSE
Involvement of dependent developmentally immature children in sexual
activities they do not fully comprehend and to which they are unable to
give informed consent for the sexual gratification of the
perpetrator/adult

• Physical and emotional power over the child

• Gratification of the perpetrator at the expense of the child

• The child does not know the perpetrator knows

Page 800 of 1077

 Types of sexual abuse
• SEXUAL PLAY – viewing or touching of the genitals, buttocks of children
with no force or coercion

• INCEST –Any physical sexual activity between family members including

step parents, siblings, grand parents, aunts and uncles (chiramu)

• MOLESTATION -touching, foundling, kissing, single or mutual

masturbations, or oral- genital contact

Page 801 of 1077

 CONT……..

• EXHIBITIONISM –Indecent exposure, usually exposure of the genitals by an

adult to children

• CHILD PORNOGRAPHY –Arranging and photography in any media sexual acts

involving children, either alone or with adults or animals, regardless of
consent by the child's legal guardian and distribution of such material in any
form with or with out profit

• CHILD PROSTITUTION – Involving children in sex acts for profit and usually
with different sex partners

• PEDOPHILIA – Laterally means “Love of child” - the preference for pre

pubertal children as the means of achieving sexual excitement
Page 802 of 1077
Suggestive statements

'I thought for a long time that what was happening was OK because Dad
said it was a game that all fathers played with their sons, a secret game
that only the men knew about.'

Page 803 of 1077

Who is at risk
• Orphans, destitute
• Children with disabilities

• Children left unattended

• Step children
• Children with ill parents

• Children with parents in the diaspora

Page 804 of 1077

 CLINICAL MANIFESTATONS
• Bruises bleeding, lacerations or irritation of external genitalia, anus,
mouth or throat
• Torn, blood stained under clothing
• Pain on urination
• swelling and itching of genital area
• Penile/vaginal discharge
• Sexually transmitted disease,
• non specific vaginitis or genital warts
• Difficulty in walking or sitting
• Pregnancy in young adolescent
• Recurrent urinary tract infection

Page 805 of 1077

 Suggestive behaviours
• Sudden emergence of sexually related problems, including
excessive or public masturbation,
• age - in appropriate sexual play

• promiscuity or overly seductive behavior

• Withdrawn or excessive day dreaming

• Poor relationships with peers

• Preoccupied with fantasies, especially in play

Page 806 of 1077

Cont.

• Regressive behavior, such as bed- wetting or thumb sucking

• Sudden onset of phobias or fears, particularly fears of the
dark, men, strangers or particular settings or situations
• Running away from home

• Substance abuse

• Rapidly declining school performance

• Suicidal attempts or ideation.

Page 807 of 1077

 Management
• History taking from child and parents

• Physical exam/genital exam

• Forensic evidence

• Investigations/Treatment

• Victim friendly court/police

• Counseling of victims and parents

• Support groups

• Long term care

Page 808 of 1077

What is the extent of child abuse

All studies indicate under reporting;

• Children unable to verbalize abuse

• Difficulty in reporting parents

• Cultural/ family privacy
• Fear of investigations

• Threats by offenders
• Stigma and social problems after reporting
• Lack of time and awareness in people in contact with children.

Page 809 of 1077

DISRUPTIVE BEHAVIOUR
DISORDERS

Page 810 of 1077

•
`
Consist of disorders manifesting mainly with antisocial
behavior.
• Consist of two subgroups
1]Conduct disorder
2]Oppositional defiant disorder

OPPOSITIONAL DEFIANT DISORDER

• Consists of negativistic, hostile or defiant behavior,
creating disruption in 3 domains of
functioning[academic, social and occupational] lasting
at least 6 months.
• Also involves angry and vindictive behavior.
• Most of behavior directed at an authority figure.

Page 811 of 1077

• However no major antisocial violations.
• Most commonly emerges in late preschool-early school age
children.
• Occurs on average 2-3 yrs earlier than conduct disorder.
• Included under conduct disorders in ICD 10.
D.S.M IV criteria
A] A pattern of negativistic, hostile, and defiant behavior
lasting at least 6 months, during which 4 or more of the
following are present.
• Often loses temper
• Often argues with adults.
• Often actively defies or refuses to comply with adult
requests or rules.

Page 812 of 1077

• Often deliberately annoys people.
• Often blames others for his or her mistakes.
• Often touchy or is easily annoyed. By others.
• Often angry and resentful.
• Often spiteful and vindictive.
B] Disruptive behavior causes significant impairment in
social, academic, or occupational functioning.
C]Behaviors do not occur exclusively during the course of
a psychotic or mood disorder
C]Criteria not met for conduct disorder, or antisocial
personality disorder if over 18 yrs.

Page 813 of 1077

Epidemiology
• Point prevalence reported ranges from 1,7%-9,9%, with
an average of 5,7%.
• Average age of onset is 6 years.
• Boys outnumber girls in the prepubertal age range
after which the two genders are equal.
• Occurs mostly in lower socioeconomic class.
Differential diagnosis and comorbidity
• Delineation from normative oppositional behavior,
transient antisocial acts, conduct disorder.
• Oppositional defiant disorder not transient, leads to
significant impairment, but does not involve major
violation of the law and rights of others.

Page 814 of 1077

• Attention deficit hyperactivity disorder is the
most common comorbidity, between 25-60% of
children with O.D.D also fulfill criteria for
A.D.H.D., and 50% of children with A.D.H.D, have
O.D.D.
• The association confers poor prognosis.
• Also separation anxiety and pervasive
developmental disorders.

Page 815 of 1077

CONDUCT DISORDER

Page 816 of 1077

Definition
• A repetitive pattern of behavior in the basic
rights of others or major age appropriate
societal norms are violated.

• Symptoms clustered in four areas, aggression

to people and animals, destruction of
property, deceitfulness and theft, and serious
violation of rules.

Page 817 of 1077

Epidemiology
• Among the most frequent diagnosed and treated
psychiatric problems in western countries.
• Affects about 1,5 to 3,4% of the children and
adolescents.
• Male: female ratio ranges between3:1 and
5:1,depending on age.
• In adolescents the gap between boys and girls begins
to close.
• Peak age of onset is late childhood and early
adolescence.

Page 818 of 1077

DIAGNOSIS AND CLINICAL FETURES
3 or more of the following;

A] Aggression to people and animals.

• Often bullies, threatens, or intimidates others.
• Often initiates physical fights.
• Has used a weapon that can cause serious physical harm to others[
e.g. knife, gun, bat].
• Physical cruelty to people/and animals.
• Has stolen while confronting a victim[e.g. mugging, purse snatching,
armed robbery]
• Has forced someone into sexual activity.

Page 819 of 1077

B]Destruction of property
• Has deliberately engaged in fire setting with intention
to cause serious damage.
• Has deliberately destroyed other people’s property.
C] Deceitfulness or theft
• Has broken into someone else’s house, building, or ca
• Often lies to obtain goods or favors or to avoid
obligations [cons others]
• Has stolen items of nontrivial value without
confronting.[e.g. shop lifting]

Page 820 of 1077

Serious violation of rules
• Often stays out at night despite parental prohibitions
before age 13.
• Has run away from home over night at least twice,
while living in parental, or parental surrogate home.
• Often is truant from school, beginning before the age
of 13 yrs.
Subtypes
• Childhood onset; before age 10
• Adolescent type; 10 years or older.

Page 821 of 1077

B] The disturbance in behavior causes clinically significant
impairment in social, academic or occupational functioning.
C]If individual is 18 yrs or older criteria for antisocial
personality disorder are not met.
Subtypes
• Childhood onset-onset of at least one criterion before age
of 10 yrs.
• Adolescent onset- absence of criteria before the age of 10
yrs.
• Unspecified type.
Mild, moderate and severe.

Page 822 of 1077

AETIOLOGY
• Heterogeneous disorder.
• Final common pathway for several divergent
trajectories.
Risk resilience model
• Postulates gradual accumulation of risk as well as
absence or weak presence of protective factors;
peer factors, parenting factors, personality
factors, constitutional factors[e.g. difficult
temperament],ecological factors such as poverty.

Page 823 of 1077

 Biological factors
• Familial aggregation of the disorder has suggested a genetic
risk.
• Supported by twin and adoptive studies.
• Hereditary estimates mostly based on adult criminal
populations, which represent the most serious cases.
• Complex interactions between constitutional risk and
environmental adversity better explains aetiological
variance than any single factor.
• Physiological abnormalities postulated e.g. low baseline
autonomic activity and reactivity on a variety of parameters
in the early onset group.
• Gender differences led to postulation of involvement of
testosterone, not substantiated .

Page 824 of 1077

 Social factors
• Poor family functioning.
• Familial drug and alcohol abuse, psychiatric problems,
marital discord and poor parenting all associated with
conduct disorder.
• Abusive, neglectful parenting and child maltreatment, are
highly specific risk factors.
• Fairly substantiated evidence points to the fact that
televised or media violence contributes, especially in high
risk children.
• Socioeconomic disadvantages, such as crowding, poor
housing and poverty all exert consistently negative
influence.

Page 825 of 1077

 TREATMENT
• Modest evidence to show treatment of conduct disorders is
effective.
• Treatment options show only modest effectiveness.
• Consensus among expects; early intervention is better.
• Prevention more effective than treatment.
• Treatment packages should reflect developmental needs of child.
No one intervention is effective across all ages.
Preschool
• Conduct disorder rare, intervention may prevent future cases.
• Programs like` Head Start’ aimed at prevention of future
delinquency, consist of special stimulation packages for children,
parent education about normal child development and maturation,
parental support in times of crisis.

Page 826 of 1077

School –Age
• Parent training and social skills training aimed at
improving peer relationships and child’s ability to
comply with demands from authorities as well as
improving academic skills.
• Primary target of intervention should the child, the
family and school environment i.e. teachers and peers.
• Behavioral techniques targeted at prosocial functioning
and antisocial behavior.
• Family therapy is one of the mainstays of intervention
in this age group, can primarily explore conflicts and
parenting problems.

Page 827 of 1077

Adolescents
• Increasingly beyond parental control, rely on internal
psychological structures and peers to guide their daily
conduct.
• Substances and alcohol play an increasingly prominent part
in patient’s symptoms.
• Most kids with conduct disorder in this age have charges
pending or assessed against them. A lot abuse substances.
Treatment should should reflect these factors.
• Multisystem psychotherapy; coordinating family and
multisystem interventions., targeting social skills, conflict
resolution, and anger management.

Page 828 of 1077

Psychopharmacology
• Of limited use except in cormorbid psychiatric
conditions.
• Double blind placebo controlled trials show
lithium, selected S.S.R.Is, stimulants might be
effective against aggression.
• Antipsychotics, Carbamazepine ,clonidine and
propranolol have all been studied; limited
supportive data.
• Psychopharmacological approaches indicated for
cormorbid conditions.
Page 829 of 1077
Prognosis
• Childhood onset associated with more aggression, higher
likelihood of neuropsychiatric impairment and poorer
prognosis.
• Pervasive lack of relationships and the isolated predatory
nature of acts implies a poorer prognosis than crimes
committed in consort or under influence of dyssocial peers.
• Several studies showing stability of conduct disorders over
time.
• 40% go on to develop antisocial personality disorder.
• The majority of remainder also lead a problematic life
• In which several domains in their lives continue to be
affected.

Page 830 of 1077

 PERVASIVE DEVELOPMENTAL
DISORDERS
Definition
• Early onset conditions characterized by delay and
deviance in the development of social,
communicative and other skills.
• The individual lacks interest in the social
environment; mannerisms, resistance to change,
and idiosyncratic interests and preoccupations
are typical.
• Disorders include, autistic disorder, Rett’s
disorder, Asperger’s syndrome and childhood
disintegrative disorder.

Page 831 of 1077

 AUTISTIC DISORDER
• Also known as childhood autism; by far the best
known pervasive developmental disorder.
• Characterized by marked and sustained
impairment in social interaction and
communication, and restricted or stereotyped
patterns of behavior and interests. Abnormalities
in each area must be present by age 3 yrs.
• Usually associated with mental retardation[70%].

Page 832 of 1077

Epidemiology
• Prevalence; 4-5 per 10000.
• More recent studies have reported higher prevalence
possibly because of broader definition of autism.
• Male predominance; M:F ratio of 3:1 to 4:1.
• Females may show more severe symptoms.
• Earlier studies showed an association between autism
and upper social class .More recent studies failed to
show this.
Aetiology.
• Biological theories; suggested by high rate of
association with mental retardation and seizure
disorder and recognition that various genetic and
medical conditions are associated with the syndrome.
Page 833 of 1077
Genetic factors
• Twin studies demonstrated a higher concordance in
monozygotic twins than dizygotic twins.
• Evidence also suggested high rates of cognitive difficulties
in the unaffected cotwin, suggesting a perinatal insult
related to autism in the face of some inherited liability for
the disorder.
• In general family studies have shown a rate of 2-3% of
autism among siblings[50-100 times that in general
population].
• Parents given to earlier diagnosis may decide not to have
kids [stoppage]. Taking this into account the risk may even
be higher.
• Unaffected siblings have a higher risk of various
developmental difficulties including problems with
language and cognitive development.

Page 834 of 1077

Age of onset
• Onset is almost always before age 3 yrs.
• Parents typically become concerned between the
age of 12 and 18 months as language fails to
develop.
• May be concern that child is deaf, but child may
respond dramatically to sound.
• Occasionally retrospectively parents may report
child was `too good’; made few demands, and had
little interest in social interaction.
• Parents almost always report being worried by
age 2.
• Onset after age 3 is atypical autism.

Page 835 of 1077

Clinical presentation
1] Qualitative impairment of social interaction
• Autistic children show little interest in the human face,
while normal children have marked interest social
interaction and social environment from birth
• Disturbances are shown in development of joint
attention, attachment and other aspects of social
interaction e.g. child may not engage in games of
infancy or may have difficulty in imitative play and lack
usual play skills.
• Social interest may increase over time.
• This lack of desire for social interaction is commonly
known as autistic aloofness.

Page 836 of 1077

 2] Qualitative impairment in verbal and nonverbal
communication
• As many as 50% of individuals with autistic disorder never
speak.
• Delays in acquisition of language is the most frequent
presenting complaint.
• Usual patterns of language acquisition e.g. playing with
sounds, and babbling are absent or infrequent.
• In contrast to children with a language disorder these
children have apparent motivation to engage in
communication or attempt to communicate via nonverbal
means.
• When they do speak, their language may show echolalia,
be inflexible, e.g. no change in tone for different emotions.
• There may be pronoun reversal
• Vocabulary and semantic skills may be slow to develop.

Page 837 of 1077

• Markedly restricted repertoire of activities and
interest
• Difficulty in tolerating change [autistic desire
for sameness];e.g. attempts to change the
sequence of activities may be met with
catastrophic distress on the part of the child.
• Child may develop an interest in a repetive
activity. E.g. repeating certain words or
numbers.

Page 838 of 1077

• Abnormalities in motor activity
• Motor stereotypes; hand flapping, body rocking,
waving e.tc., often emerge by age 3yrs.
• May have echopraxia
• Clumsiness and poor coordination.
• Overactivity is common, particularly in preschool
age; hypoactivity can also be observed, or the
two can alternate in the same individual.
• Less frequent in adolescence and in higher
intellectually functioning individuals.

Page 839 of 1077

Abnormal response to sensory stimuli
• Hyper or hyposensitivity to sensory stimuli are typical
e.g. hyperacusis [may cover ears when hearing a dog
bark].
• There may be excessive sensitivity to touch [tactile
defensiveness], including major sensitivity to certain
fabrics and social or affectionate touch.
Sleep and eating disorders
• Child may display erratic sleep pattern, with recurrent
awakening at night.
• Eating disturbance include aversion to certain foods
because of their texture, colour or smell, or insistence
on eating only a certain type of food.
• In severely retarded children pica may be present.
Page 840 of 1077
Mood and affect disturbances
• Poor affect modulation and display of
emotions inappropriate for a given social
situation.
• Sudden mood changes are common.
• Higher functioning individuals may show
intense anxiety in social situations.
• Depression common in adolesence.

Page 841 of 1077

• Self injurious behavior and physical aggression to
others
• Lower functioning children may bite their hands,
often causing bleeding and callous formation.
• Head banging may occur particularly in severely
mentally retarded children; may necessitate
wearing helmets.
• May pick their skin or pull their hair or hit
themselves.
• Lack of understanding or inability to
communicate may lead to aggressive outbursts.

Page 842 of 1077

 .
Seizure disorder
• 10-35% develop epilepsy.
• Lower functioning individuals are at increased risk.
• Peak is in adolescence; onset may be associated with
deterioration of symptoms.
Physical characteristics
• Higher incidence of minor physical anomalies, e.g. ear
malformations.
• Anomalies may reflect embryological period in which
factors responsible for autism act [ears are formed at
about the same time older regions of the brain].

Page 843 of 1077

D.S.M IV CRITERIA
• Diagnosis requires 6 or more items from 1, 2, and 3, with at
least two from 1, and one each from2 and 3.
1] Qualitative impairment in social interaction, as manifested
by at least two of the following;
a] marked impairment in use of multiple non verbal behaviors
such as eye to eye gaze, facial expression, body postures
and gestures to regulate social interaction.
b] failure to develop peer relationships appropriate for
developmental stage.
C] Lack of spontaneous seeking to share enjoyment. Interests,
or achievement with other people.
D] Lack of social reciprocity.

Page 844 of 1077

2]Qualitative impairments in communication as
manifested by;
a] Delay or total lack of development of spoken
language[not accompanied by an attempt to
compensate through gestures or mime.]
b] In individuals with adequate speech, marked
impairment in ability to sustain a conversation.
c] Stereotyped and repetitive use of language or
idiosyncratic language.
d] Lack of varied, spontaneous make believe play or
social imitative play appropriate to
developmental level.

Page 845 of 1077

3] Restricted or repetitive and stereotyped movements
a]] Encompassing preoccupation with one or more
stereotyped patterns of behavior interests and
activities that is abnormal in intensity and focus.
b] Inflexible adherence to specific nonfunctional routines
or rituals.
c] Stereotyped repetitive movements[ e.g. rocking, hand
flapping]
c] Persistent preoccupation with parts of an object.
B Delays or abnormal functioning in at least one of the
following prior to 3 yrs; social functioning, language,
symbolic or imaginative play.
C] Not better accounted for by other autistic spectrum
disorders.

Page 846 of 1077

Course and prognosis
• Lifelong disability, most individuals remain unable
to live independently, for life.
• However most children with autism show
improvement in social relatedness,
communication and self help skills, with
increasing age.
• During adolescence, some children may display
deterioration in behavior; in a minority decline
may be associated with onset of a seizural
disorder.

Page 847 of 1077

TREATMENT
• Goal is to reduce disruptive behavior and promote
learning, particularly language acquisition and
communication and self help skills.
• Best achieved after a comprehensive assessment of
strengths and needs
• A highly structured and individualized program should
be put into place that maximizes child’s strengths and
minimizes weaknesses
• Program should take place in special educational
setting by professionals with experience.

Page 848 of 1077

Educational approaches
• Intensive highly specialized education.
• Special speech and language therapy.
• Use of non vocal communication.
• Social and communication skills-eye gaze,
voice modulation, gestural communication,
rules of conversation, posture, greeting
behaviors.

Page 849 of 1077

• Behavioral therapy
• Behavior modification techniques to establish
desired behavior, and eliminate problem
behavior.
• Most educational programs for autistic children
use behavioral management techniques.
Psychotherapy
• Individual psychotherapy in high achieving
individuals.
• Should focus on problem solving skills.

Page 850 of 1077

Psychopharmacology
• No pharmacological agent proven curative,
but certain medications can be of benefit to
specific symptoms such as self injury,
aggression, stereotyped movement and
overactivity.
• Baseline tests prior to commencement of
treatment, E.E.G, B.P, weight, F.B.C.

Page 851 of 1077

Antipsychotics
• Low doses decrease stereotyped behavior and
agitation.
S.S.R.I.s
• Several studies suggest potential usefulness of
S.S.R.Is in autistic behavior and other related
disorders.
Other drugs
• Include clonidine, naltrexone and propranolol.
Page 852 of 1077
• RETT’S SYNDROME [seen only in girls]
• Progressive condition that develops after some months of
apparently normal development. Head circumference at
birth is normal but head growth begins to decelerate
between 6 months and 48 months.
• Purposeful movements are lost.
• Characteristic hand wringing or hand washing develops.
• Expressive and receptive language skills severely impaired.
• Gait and truncal ataxia develop.
• Loss of social interactional skills usually observed.

Page 853 of 1077

D.S.M IV criteria
A] All of the following;
1] Apparently normal pre and perinatal development.
2] Normal head circumference at birth.
3] Apparently normal psychomotor development through the first 5 months
after birth.
B] Onset of all of the following after the period of normal development.
1] Deceleration of head growth between the ages of 5 and 48 months.
2]Loss of previously acquired purposeful hand skills between the ages of 5
and 30 months with subsequent development of stereotyped hand
movements.
3]Loss of social engagement early in the course.
4] poorly coordinated gait or trunk movements.
5]Severely impaired expressive and receptive language delopment with
psychomotor retardation.

Page 854 of 1077

Asperger’s syndrome
• Clinical symptoms resemble autistic disorder,
but early development is marked by lack of any
clinically significant delay in spoken or receptive
language, cognitive development, self help skills
or curiosity about the environment.
• Epidemiology; 1 in 10000, more prevalent in
males ; M:F -9 TO 1.
• Aetiology; Stronger genetic component than
autistic disorder.
Page 855 of 1077
Childhood disintegrative disorder
• Rare condition characterized by regression in
multiple areas of development after several years
of normal development[up to 2 yrs].
• Occurs in 1 in 100000.
• Significant loss in expressive language, social skills
,bowel and bladder control, play, motor skills.
• Restricted repetitive stereotyped patterns of
behavior.

Page 856 of 1077

 D.S.M. IV criteria
• A] Apparently normal development for at least 2 yrs
after birth as manifested by presence of age
appropriate verbal and non verbal communication,
social relationships, play, and adaptive behavior.
• B] Clinically significant loss of previously acquired skills[
before the age of 10 years] in at least two of the
following areas;
• 1] Expressive or receptive language
• 2]Social skills or adaptive behavior.
• 3]Bowel or bladder control.
• 4]Play
• 5] Motor skills.

Page 857 of 1077

C] Abnormalities of functioning in at least two of the
following;
• 1] Qualitative impairment in social interaction.
• 2]Qualitative impairment in communication[ delay or
lack of spoken language, inability to initiate or sustain a
conversation, stereotyped or repetitive use of
language]
• 3]Restricted, repetitive, and stereotyped pattern of
behavior, interests, and activities, including motor
stereotypes and mannerisms.
• D] Disturbance is not better accounted for by another
specific pervasive developmental disorder.

Page 858 of 1077

 ATTENTION DEFICIT
HYPERACTIVITY DISORDER
ADHD

Page 859 of 1077

 Learning objectives
Students are expected to
• Describe epidemiology of ADHD
• List the clinical features of ADHD
• Give an account of the aetiological factors
associated with ADHD
• Give an account of pharmacological and non
pharmacological management of ADHD.

Page 860 of 1077

• Most common psychiatric condition among school age
children.
• Symptoms consist of developmentally inappropriate
overactivity, inattention and impulsive behavior( hence
DSMIV primary categories)
• Usually accompanied by academic under achievement.
• Need for treatment highlighted by associated risk for
delinquency, accidents and substance abuse, though
disruptive behavior is usually the reason for referral for
treatment.

Page 861 of 1077

Epidemiology
• Affects 3 to 5% of children and adolescents.
• Strong male predominance, about 2-3 times
more common in males than females.
Diagnostic criteria
Either 1or 2
• 6 or more of the following symptoms of
inattention have persisted for more than 6
months. To a degree that is maladaptive and
inconsistent with level of development.

Page 862 of 1077

Inattention
[a] often fails to give close attention to detail or makes
careless mistakes in school work or other activities.
[b]often has difficulty sustaining in tasks and play
activities.
[c]often does not seem to listen when spoken to.
[d]often does not follow through on instructions and fails
to finish homework, chores or duties at work.
[e]often has difficult organizing tasks or activities.

Page 863 of 1077

[f]often dislikes, avoids or is reluctant to be involved in
activities that require sustained mental activities.
[g]often loses things necessary for task or toys [e.g. toys,
school assignments, pencils].
[h]easily distracted by extraneous stimuli.
[i]often forgetful in daily activities.
2 six or more of the following symptoms of hyperactivity
[a]often fidgets with hands or feet or squirms in seat.
[b]often leaves seat in classroom or in other situations in
which remaining seated is expected.

Page 864 of 1077

[c]often runs about or climbs in inappropriate situations
[in adolescents and adults ,may be a subjective feeling
of restlessness].
[d]often has difficulty in playing or engaging in leisure
activities quietly.
[e]often ‘on the go’ or acts as if driven by a motor.
[f]often talks excessively.
Impulsivity
[g]often blurts out answers before questions have been
completed.
[h]often has difficulty awaiting turn.

Page 865 of 1077

[i] often interrupts or intrudes on others.
B. Some hyperactivity or inattention symptoms that
caused impairment where present before the age
of 7.
C. Some impairment from symptoms are present in
two or more situations [e.g. school, and home]
D. Clear evidence of clinically significant impairment
in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during a
pervasive developmental disorder, schizophrenia
or other psychotic disorder.
Page 866 of 1077
Subtypes
• Attention deficit/ hyperactivity disorder,
combined type: if criteria for 1 and 2 are met for
same 6 months.
• Attention deficit/ hyperactivity disorder
predominantly inattentive type: if criterion a1 is
met but A 2 is not met for same 6 months.
• Attention deficit/ hyperactivity disorder,
predominantly active-impulsive type: if criterion
A2 is met and A1 is not met for same 6 months.
Page 867 of 1077
Diagnosis
• Variability of clinical features depends on age and
,symptom subtype, cognitive deficit, and comorbidity.
• Inconsistent behavior and poor academic performance
are hallmarks of A.D.H.D.
• Symptoms depend on context, with greater supervision
and reduced stimulation, and support, child’s behavior
and functioning can improve.
• Detailed description of child’s school history is
important, also direct observation of child in school
environment.

Page 868 of 1077

Comorbidity
• Significant rate of mood disorders anxiety
symptoms.
• Commonly associated with conduct disorder
[seen in 40-70% of patients with A.D.H.D]
• Also associated with learning disorders,
substance abuse, mental retardation, and
pervasive developmental disorders.

Page 869 of 1077

Aetiology
1]Familial disorder, largely genetic.
2Acquired conditions: low birth weight, traumatic brain
injury, and prenatal substance exposure [e.g. alcohol
and nicotine].
3]Neuroimaging; consistent with the hypothesis that
functioning of the frontal lobes is impaired in some
children with A.D.H.D.
• Reduced perfusion in bilateral frontal areas, the
caudate nuclei and basal ganglia, initially increased by
methylphenidate has been reported.

Page 870 of 1077

• Apparent reduction in perfusion of frontal and basal
ganglia regions consistent with emerging view that self
regulation difficulties found in A.D.H.D resembled
behavior seen in classic frontal lobe damage.
• Neurochemistry
• Benefit of psychostimulants on hyperactive and
impulsive behavior resulted in research into
involvement of neurotransmitters in the aetiology of
A.D.H.D.
• Significant evidence exists supporting involvement of
dopaminergic and catecholaminergic systems to
A.D.H.D.

Page 871 of 1077

• Treatment
• Consists of psychopharmacology and psychosocial
measures.
• Psychopharmacology: short acting psychostimulants remain
first line pharmacotherapy for A.D.H.D, principally because
of their ability to improve both behavioral and cognitive
aspects of the disorder.
• Safety profile is good.
• Examples of psychostimulants include, methylphenidate
[ritalin]; 0,3-1mg t.d.s, D-amphetamine[not used in most
setups because of addictive properties], magnesium
pemoline

Page 872 of 1077

Second line
• Clonidine
• Buproprion[ Zyban]
• Tricyclic antidepressants
• Carbamazepine commonly used in England.
• Antipsychotics such as haloperidol

Page 873 of 1077

• Psychosocial therapy
• Cognitive behavioral therapy: used for
teaching problem solving strategies, self
monitoring.
• Psychoeducation and support for parents, can
be provided through programmed group
training sessions.
• School interventions e.g. remedial education.

Page 874 of 1077

 TIC DISORDERS
• Comprise a group of disorders that appear in childhood
or adolescence sharing the primary symptom of
persistent and interfering tics.
• Most widely recognized and severest is Gilles de la
Tourrete syndrome or Tourrete’s disorder
• Tics are defined as rapid repetitive muscle contractions
or sounds that are usually experienced as out volitional
control and which often resemble normal movement
or behavior.
• Classified as simple or complex; simple motor tics
involve one or a small group of muscles e.g. eye
blinking, facial grimacing, or shoulder shrug.

Page 875 of 1077

• Simple tics can be further subdivided into; tonic,
clonic or dystonic types.
• Clonic tics are very brisk movements.
• Complex motor tics come close to mimicking
normal movements e.g. hoping, obscene
gesturing and copropraxia.
• Phonic tics can be simple or complex.
• Simple phonic tics include grunting, sniffing.
• Complex phonic tics include intelligible syllables
or even phrases such as `hi’ or `I love you’ or
obscene utterances.[coprolalia]
• Complex tics can be mistaken for volitional acts.
Page 876 of 1077
 TOURETTE’S DISORDER
• Involves multiple motor tics and at least one vocal tic.
• According to D.S.M.IV and I.C.D 10, tics must occur
nearly every day or intermittently for at least one year
and cause impairment or distress.
• Average age of onset of tics is 7 yrs, but tics may occur
as early as 2 yrs.
• Onset must occur before the age of 18 yrs.
• Initial tics are of the face and neck.
• Over time tics occur in downward progression or
involve more complex movements of several muscle
groups.

Page 877 of 1077

• Most commonly described tics involve the face and
head, arms and hands, the body and lower extremities.
• Tics can take the form of grimacing, puckering the
forehead, raising eye brows, winking, wrinkling the
nose, biting lips, head rolling e.t.c.
• Typically prodromal behavior symptoms-such as
hyperactivity, attention difficulties, and poor
frustration tolerance are evident before or coincide
with onset of tics.
• Most frequent initial tic is the eye blink followed by a
head tic or facial grimace.
• Complex motor tics and vocal tics emerge several years
after initial tic.

Page 878 of 1077

• Coprolalia usually begins in early adolescence and
occurs in about 15% of all cases.
Chronic motor or vocal tic disorder
• Onset in early childhood
• Symptoms involve simple or complex motor or vocal
tics but not both.
• Tics occur many times a day, nearly every day or
intermittently for a period of more than a year with no
tic free period of more than 3 months during this time.
• Onset before the age of 18 yrs.

Page 879 of 1077

Transient tic disorder
• Single or multiple motor or vocal tics.
• Tics occur many times a day nearly every day
for at least 4 weeks, but no longer than 1 yr.
• Onset before age of 18 years.
Tic disorder not otherwise classified
• Disorders characterized by tics but not
otherwise meeting criteria for a specific tic
disorder.

Page 880 of 1077

Aetilogy
• Converging data supports the notion that tic disorders
are genetic disorders involving dopaminergic-excitatory
amino acid interactions in neural circuits bridging
frontal lobes, basal ganglia and the thalamus.
• Familiality in Tourette’s disorder; twin and family
studies demonstrate patterns of inheritance in many
families consistent with an autosomal dominant
disorder with incomplete penetrance.
• A relationship has been demonstrated between
Tourette’s disorder, other tic disorders and O.C.D.
• High rate of comorbidity of tic disorders and A.D.H.D.

Page 881 of 1077

Neurochemistry
• Potent tic suppressing effects of antipsychotics
such as haloperidol that possess high affinity for
D2 receptors have long been inferred to support
involvement of abnormal dopamine
neurotransmission in Tourette’s disorder,
suspected to involve dopamine hypersensitivity.
• More subtle benefits clonidine have led to the
postulation of the role of other monoamines.

Page 882 of 1077

TREATMENT
• Treatment should be guided by patient’s
overall functioning, associated
psychopathology, developmental challenges,
and family and social adjustment rather than a
narrow focus on tic suppression.
• Clinicians should be prepared to use a variety
of treatment modalities, depending on
individual needs, including pharmacotherapy,
behavioral treatments, educational
interventions, and family therapy.
Page 883 of 1077
• Psychoeducation to patient and family is required.
• Identifying sources of symptom exacerbation can aid
efforts to reduce stressors.
Pharmacotherapy
• High potency neuroleptics such as haloperidol,
pimozide and trifluoperazine possess potent tic
suppressing effects and significantly reduce tic
frequency and severity in 70-80% of patients on daily
doses.
• Atypical antipsychotics such as olanzapine and
risperidone have been shown to be also effective.
• Clonidine also used.

Page 884 of 1077

CLINICAL FEATURES OF AUTISTIC
SPECTRUM DISORDERS

DR FT MUCHIRAHONDO

Page 885 of 1077

Definition
• A group of early onset disorders characterized by delay and
deviance in the development of social, communicative and
other skills, often associated with stereotyped behaviors.
DSMIV Classification
• Autistic disorder
• Asperger's disorder[ ?Considered as a mild form of autism
in DSMV]
• Rett’s disorder[ No longer classified under autism spectrum
disorders]
• Childhood disintegrative disorder
• Pervasive developmental disorder not otherwise classified

Page 886 of 1077

 CORE FEATURES OF AUTISTIC
DISORDER
[DSMIV]-triad
• Social deficits
• Impaired communication
• Restricted, repetitive interests and behaviors
DSMIV- dyad not triad
• Social and communication deficits
• Restricted and repetitive behaviors;-now includes
restricted repetitive use of language. Hypo/ hyper
sensory difficulties now regarded as part of this

Page 887 of 1077

 Social deficits
• Inability ton form social relationships
• Difficulty in reciprocal interactions, including
social imitative play - tendency towards engaging
in parallel play[ if engaged in play at all]
• Marked impairment in use of nonverbal
behaviors e.g. eye to eye gaze, facial expression,
body postures, gestures to regulate social
interaction[ Includes difficulty in reading other
people’s body language]

Page 888 of 1077

 Social deficits continued
• Little interest in developing peer relationships
• Lack of sharing of enjoyment
• Lack of interaction will result in poor acquisition of
social skills.
Qualitative impairment in communication
• Delay in or total lack of development of spoken
language[ 50% of children never acquire functional
language]
• Marked impairment of in ability to initiate
conversations among those who do develop adequate
language.

Page 889 of 1077

 Impairment of communication contd
• Pronoun reversal e.g. referring to self in 2nd or 3rd
• Echolalia
Restricted repetitive interests, behavior
• Inflexible adherence to specific non functional
routines.
• Stereotyped and repetitive motor mannerisms e.g.
rocking, finger flapping.
• Preoccupation with one or more stereotyped and
restricted patterns of interest that is abnormal in focus
or intensity- e.g. unusual preoccupation with parts of a
toy

Page 890 of 1077

 Stereotypes continued
• Unusual reaction to change- autistic desire for
sameness.
• Unusual reaction to sensory stimuli- hyper/
hypo acusis,

Page 891 of 1077

 Course of autism
1st year
• Little babbling – “no baby talk”
• No pointing
• Difficult to comfort – does not like being cuddled
• No pick boo
Preschool and early school going age
• Echolalia
• Monotonous speech
Adolescence
• Language generally improves but may regress
• Odd social behavior
• Often bullied or may bully others to compensate.

Page 892 of 1077

Adolescence
• Difficulties in relating to peers – often regarded
eccentric, ‘uncool’
• May develop depression or anxiety especially
high functioning individuals
• Epilepsy may first manifest at this stage.
Adulthood
• Social withdrawal- aloof, eccentric, active odd,
passive odd.
• Difficulty in finding meaningful employment.

Page 893 of 1077

 Associated features
• 75-80% are mentally retarded- with 30-40% being
mildly to moderately mentally retarded.
• Cormorbid ADHD is common
• Anxiety symptoms
• Depressive symptoms especially in high functioning
adolescents.
• Abnormal response to sensory stimuli- hyper/
hyposensitivity, tactile defensiveness
• Sleep and eating disturbances- erratic sleep, aversion
to certain foods because of texture or colour or
insistence on eating the same type of food.

Page 894 of 1077

 Associated features contd
• Mood and affect disturbances- poor affect
modulation, display of inappropriate emotions,
sudden mood changes, intense anxiety in social
situations.
• Self injurious behavior- head banging, hand
biting, skin picking
• Seizure disorders- Epilepsy develops in 10-35% of
the autistic population
• Physical characteristics-higher incidence of ear
malformations.- may reflect embryological period
during which factors responsible for autism act.

Page 895 of 1077

Pathway to care in autism
• For early recognition, referral, diagnostic
assessment and management of autism
• Early recognition-? Routine screening for autism
in well baby clinics.
• Need for multi disciplinary integrated pathway to
care –parents, primary care physicians and
nurses, paeditricians, psychiatrists, occupational
therapists, clinical and educational psychologists,
special education teachers, social workers.
Page 896 of 1077
Hollywood and autism- Sheldon in The big
bang theory

THANK YOU, TATENDA, SIYABONGA, ZIKOMO,

DANKE

Page 897 of 1077

ENURESIS & ENCOPRESIS

DrWalter Mangezi

Page 898 of 1077

LEARNING OBJECTIVE
 To be able to describe the definition of Enuresis and
Encopresis
 To be able to manage Enuresis and Encopresis

Page 899 of 1077

ENURESIS

 DEFINITION:
• The involuntary passage of urine
• in the absence of physical abnormalities
• after the age of 5 years old.

Page 900 of 1077

TYPES:

1) Nocturnal – Bedwetting

2) Diurnal - Daytime incontinence.

Page 901 of 1077

1) Primary Enuresis –
Bedwetting continuous since
birth Usually every night.

Page 902 of 1077

 2) Secondary Enuresis –
• Since birth there has been at least 6 months in which the
patient was dry.

Page 903 of 1077

 EPIDEMIOLOGY:
- 5Years old – 10%

- 10Years old – 5%

- 15Years old – 1%

Page 904 of 1077

 AETIOLOGY:
1) Positive Family History
2) Small bladder capacity
3) Low intelligence

Page 905 of 1077

4) Environmental factors
- Recent stressful life events
- Large family size Social disadvantage.

Page 906 of 1077

MANAGEMENT:
1. Rule out an organic cause through:

a) History
b) Physical examination
c) Renal Tract Investigations
Micturating-Cysto-Urethro-Gram (MCUG)
Schistosomiasis , Urinary Tract infection

Page 907 of 1077

 Objective of Treatment
 Reducing anxiety
 Increase Bladder Capacity
 Strengthening bladder outlet valve
 Conditioning waking-up with full bladder

Page 908 of 1077

2)Reassurance of patient and caregiver:
a) Avoid blame
b) Reduce anxiety

Page 909 of 1077

 Physiotherapist
 Pelvic muscle exercises
 Delaying in emptying bladder

Page 910 of 1077

 3) Diary:a)Record of dry periods and
enuresis.
b) Positive Reinforcement.

.
4) Buzzer or Bell and Pad. (Older children).

Page 911 of 1077

Bed Time 10 pm
Wake-up 6 am
1st Alarm 2 am ( Mid-point between Bed-time & Wake-up)
DATE 1st ALARM 2nd ALARM
Mon 24 May Dry Wet
Tues 25 May Dry Wet
Wed 26 May Dry Wet
Thurs 27 May Wet Wet
Friday 28 May Dry Wet
Sat 29 May Dry Dry
Sun 30 May Dry Dry

Page 912 of 1077

5) Tricycles Antidepressants:
a) Imipramine 25 –50 mg PO Nocte
(problem Rebound)

Page 913 of 1077

ENCOPRESIS

DEFINITION:
 The inappropriate passage of formed faeces
 onto the underclothes
 in the absence of physical pathology
 after 4 years of age.

Page 914 of 1077

Symptoms vary:

• Slight staining
• to smearing of faeces onto the wall.

Page 915 of 1077

Encopresis uncommon:

• 8 year olds - 1.8% for boys

- 0.7% for girls

Page 916 of 1077

CLINICAL FEATURES
Aggressive toilet training:

Encopresis
-Retentive:
Emotional (i.e. aggressive)

Page 917 of 1077

Non-Retentive:
Continuous (primary)
Discontinuous (secondary)

Page 918 of 1077

 Retentive:

1) Coercive and obsessed toilet training.

2) Continuous non-extensive encopresis in
disorganized families.
3) In response to stressful situations.

Page 919 of 1077

 Psychotic disturbance is common among children
with encopresis.

Page 920 of 1077

 TREATMENT

-Exclude organic:
• Hirshsprung’s disease.

Page 921 of 1077

-Assess attitude

of parents and child problem.

Page 922 of 1077

Objective : Acquire normal bowel habit.
: Improvement of parent-child
relationship.

Page 923 of 1077

Initially bowel washouts or enemas to
clear bowels
-Bowel smooth muscle stimulants
-Stool softener
-Bulk agents (lactulose)
-Suppositories

Page 924 of 1077

Dietary education – parent and child

Psychological components –
behavioral e.g. Keeping Diaries.

Page 925 of 1077

Individual psychotherapy

Page 926 of 1077

THE
END

Page 927 of 1077

Psychosexual Disorders

Dr. C. Rwafa

Page 928 of 1077

 Sexuality and psychiatry
• Why is it difficult to talk to patients about
sexuality?
• Why is it important to ask about sexual issues?

Page 929 of 1077

 Normal Sexual Function
• Normal sexual behaviour serves to:
– Preserve the species (reproduction)
– Emotional/ relational bonding
– Pleasure

Page 930 of 1077

 Normal sexual cycle
• Psycho-physiological experience with 4 phases
– Desire
– Excitement
– Orgasm
– Resolution

Page 931 of 1077

Normal Sexual Cycle Males

Page 932 of 1077

Normal Sexual Cycle Females

Page 933 of 1077

Page 934 of 1077
Page 935 of 1077
 Psychosexual Disorders
• Sexual Dysfunction
• Paraphilias
• Gender Identity Disorders

Page 936 of 1077

 Sexual Dysfunction
• Disturbance in one or more of the sexual response
cycle or pain associated with sexual arousal or
intercourse affecting an individual’s inability to
participate in a sexual relationship
• The dysfunction can be:
• Lifelong or acquired
• Generalized or situational
• Consequence of physiologic factors, psychologic factors
or combined.

Page 937 of 1077

 Sexual Dysfunction Classification
1. Sexual desire disorders
a. Hypoactive sexual desire disorder
b. Sexual aversion disorder
2. Sexual arousal disorders
a. Female sexual arousal disorder
b. Male erectile disorder
3. Orgasmic disorders
a. Female orgasmic disorder
b. Male orgasmic disorder
c. Premature ejaculation
4. Sexual pain disorders
a. Dyspareunia
b. Vaginismus
5. Sexual dysfunction due by GMC
6. Substance induced sexual dysfunction
7. Sexual dysfunction not otherwise specified
Page 938 of 1077
 Hypoactive Sexual desire disorder
• Characterized by a deficiency or absence of sexual fantasies
and the desire of sexual activity.
• F>M
• The lifelong form : traumatic events in childhood or
adolescent, occasionally deficient level of androgens
• The acquired: boredom or unhappiness in the longstanding
relationship, depression or chronic anxiety, use of alcohol,
psychotropic drugs and prescription drugs
(antihypertensive, antidepressants).
• Diagnosis: Obtain more History to exclude psychiatric
problem (depression) or physical condition,
endocrinopathies) or discover marital conflicts.
• Management: Identify and treat underlying cause, address
relationship problems, Behavioural approach- ‘Sensate
focus’ Page 939 of 1077
 Sexual Aversion Disorder
• Characterized by an aversion to and avoidance of genital sexual
intercourse. They usually display anticipatory fear or anxiety of sexual
activity.

• The lifelong form:

• sexual trauma (abuse, rape)
• repressive atmosphere in the family, religious training
• initial attempts of intercourse that resulted in dyspareunia (painful
memories)

• The acquired form: situational or interpersonal (partner related).

• Management:
• Behavioral psychotherapy
• Marital therapy is indicated if the cause is interpersonal or marital
difficulties
Page 940 of 1077
 Female Sexual Arousal Disorder
• Characterized by inability to maintain sufficient
degree of vaginal lubrication in the excitement
phase and till the completion of sexual act.
• The dryness of the vagina main cause pain
during intercourse
• To make the diagnosis you should exclude
psychological causes (anxiety, guilt, fear) or
physiologic changes( Alteration in levels of
testosterone, estrogen, prolactin, dopamine,
thyroxin and serotonin) sexual or substance
abuse.
• Mx: Identify and treat any underlying factors,
address relationship problems, Sensate Focus to
improve arousal, vaginal lubricants
Page 941 of 1077
Male Sexual Arousal Disorder- Erectile
Dysfunction
• Characterized by failure to attain or maintain an
erection until the completion of sexual act. It is
known an impotence.
• Leading cause for attendance in sexual disorder
clinic.
• It can be primary:
– psychological factors (sexual guilt, fear of intimacy, feeling
of inadequacy, depression and severe anxiety)
– biological factors ( testosterone deficiency).
• It can be secondary:
– organic causes and physiologic changes (atherosclerosis of
penis, hormonal disturbances, smoking, MS, Spinal cord
injuries, prostatic surgeries).

Page 942 of 1077

 Erectile Dysfunction
• To distinguish between the psychological and
organic impotence:
– Nocturnal penile tumescence studies: penile erection
during sleep are monitored
– Penile plethysmography: measure penile blood supply
– Doppler flow meter studies
– Cystometric studies
– Biochemical studies: glucose levels, prolactin, FSH,
LFT, TFT.
– Invasive studies: penile arteriography,
cavernosonography

Page 943 of 1077

Erectile Dysfunction- Management
• Reassurance and Education
• Medical options: A constriction ring in case of
venous leak in penis, PGE injections, Viagra.
• Behavioral therapy for the anxiety and
depression.
• Counseling for the dysfunctional relationships
should be part of the therapy

Page 944 of 1077

 Female Orgasmic Disorder-
Anorgasmia
• Characterized by recurrent or persistent delay in or
absence of orgasm following a normal sexual excitement
phase.
• There are many reasons for anorgasmia:
– Fear of becoming pregnant
– Guilt or shame of sexual act
– Socio-cultural & religious beliefs that sexual activity if sinful
– Various Psychiatric or medical conditions.
– Substance abuse
• Management: directed masturbation, Sensate focus,
Kegel exercises

Page 945 of 1077

 Male Orgasmic Disorder
• It is characterized by inhibited male orgasm,
so the men achieves ejaculation during
coitus with great difficulty.
• The lifelong form is reflects more severe
psychopathology, whereas the acquired form
indicates interpersonal difficulties, and use
of substance (alcohol, opoids,
antipsychotic).
• Situational: performance anxiety
• It is rather uncommon compared to female
orgasmic disorder

Page 946 of 1077

 Premature Ejaculation
• Inability to control ejaculation adequately for both
partners to enjoy sexual interaction
• Ejaculation can occur with minimal stimulation or in
the absence of an erection
• More common in younger, inexperienced males
• Mx:
– Seman’s technique: effective in 90% of cases. Stimulation
to high arousal then cessation of stimulation for some min
then repeat 4-5 times before permitting ejaculation
– Squeeze technique: stimulation to high arousal then firm
squeeze to the head of the penis at the base of the glans

Page 947 of 1077

 Dyspareunia- Sexual Pain Disorder
• It is recurrent or persistent genital pain occurring before,
during and after intercourse.
• It affects both males and females but it is more common
in females.
• This should be diagnosed if there was no evidence of
medical cause (endometriosis, vaginitis, prostatitis,
urethral infection, pelvic inflammatory disease, tight
foreskin).
• In women it is related to vaginismus
• Management:
– Identify and treat underlying causes
– Reassuarance- dispel myths, address negative attitudes
– Relaxaion techniques
– Sensate focus to improve arousal
– Use of vaginal dilators

Page 948 of 1077

 Paraphilias
• Disorders characterized by intense, repetitive sexual
impulses, fantasies or practices that are unusual,
deviant or bizarre and where the sexual goal is an
unusual situation, activity or object.

• The fantasies, behaviors and/or urges:

– involve non-human sexual objects
– require suffering or humiliation of self or partner
– involve children or other non-consenting partners

Page 949 of 1077

 Aetiology
• Psychodynamic theory – postulates that
paraphilia is due to failure of normal
psychosexual development and a successful
heterosexual orientation and adjustment
• Learning theory – importance of early
experience. There is an association of the act
with sexual arousal during childhood that leads
to conditioned learning.
• Biological Predisposition – abnormal hormone
levels, chromosomal abnormalities, EEG
abnormalities

Page 950 of 1077

 Types of Paraphilias
• Paedophilia
• Exhibitionism
• Fetishism
• Transvestic fetishism
• Frotteurism
• Sexual machoism
• Sexual sadism
• Voyeurism
• Zoophilia

Page 951 of 1077

 Paedophilia
•Characterized by sexual activity with a child, usually
age 13 or younger.
•Most common paraphilia.
•95% heterosexuals, 5% homosexuals.
•Pedophilia is much more common among men than
among women.
•Both boys and girls can be victims, although more
reported cases involve girls.
•Pedophiles may focus only on children within their
families (incest), or they may prey on children in the
community.
•Force may be used to engage children sexually, and
threats may be invoked to prevent disclosure by the
victim.

Page 952 of 1077

 Exhibitionism
• Characterized by sexual fantasies, urges, or
behaviors involving surprise exposure of the
individual's genitals to a stranger.
• This produces sexual arousal.
• Rare in females.
• Further sexual contact is almost never sought,
so exhibitionists rarely commit rape.
• Most exhibitionists are younger than 40 and
may or may not be married.

Page 953 of 1077

 Fetishism
• Characterized by sexual fantasies, urges, or
behaviors involving use of non-human
inanimate objects to produce or enhance
sexual arousal with or in the absence of a
partner.
• People with fetishes may become sexually
stimulated and gratified by wearing rubber or
leather, or holding, rubbing, or smelling
objects, such as high-heeled shoes, clothing.

Page 954 of 1077

 Transvestic fetishism
•Heterosexual males with this paraphilia dress
in female clothes (cross-dressing) to produce
or enhance sexual arousal, usually without a
real partner, but with the fantasy that they are
the female partner as well.
•Patients typically are heterosexual married
males.
•Far less commonly, a woman prefers to wear
men's clothing. In neither case does the
person wish to change his or her sex, as
transsexuals do
Page 955 of 1077
 Frotteurism
•Characterized by sexual fantasies, urges, or
behaviors involving touching or rubbing one's
genitals against the body of a non-consenting
person.
• Patients typically practice this behavior in
crowded places.

Page 956 of 1077

 Sexual machoism and sadism
• Machoism: Individuals enhance or achieve
sexual excitement by being abused physically
or mentally or being humiliated.

• Sadism: Individuals enhance or achieve sexual

excitement by causing mental or physical
suffering to another person.

Page 957 of 1077

 Voyeurism
• From the French word "watcher“

• Characterized by sexual fantasies, urges, or

behaviors involving observing an unknowing
and non-consenting person, usually
unclothed and/or engaged in sexual activity,
to produce sexual excitement.

Page 958 of 1077

 Zoophilia
• Individuals enhance or achieve sexual
excitement by performing sexual acts with
animals.

Page 959 of 1077

 Other Paraphilias
•Scatologia involves making obscene phone
calls.
•Necrophilia involves an erotic attraction or
sexual interest in corpses.
•Partialism is sexual interest exclusively focused
on a particular body part.
•Coprophilia is sexual activity involving feces.
•Klismaphilia is sexual activity involving
enemas.
•Urophilia is sexual activity involving urine.

Page 960 of 1077

 Other paraphilias
• Autogynephilia describes being sexually aroused
by thoughts or images of himself as a woman.
• Asphyxiophilia or hypoxyphilia is when a patient
uses hypoxia to achieve sexual excitement; this
can be complicated by asphyxiation.
• Video voyeurs derive sexual gratification from
videos, usually of women doing natural acts or
women involved in sexual activity.
• Infantophilia is a new subcategory of pedophilia
in which the victims are younger than 5 years.

Page 961 of 1077

 Prognosis
•Poor prognostic factors: early age of
onset, co-morbid substance abuse and
high frequency of behavior.

• Good prognostic factors: self-referral

for treatment, sense of guilt associated
with behavior, history of otherwise normal
sexual activity in addition to the paraphilia

Page 962 of 1077

 Management
• The management of these conditions is quite difficult
and challenging
• There are no effective drugs for the treatment of
specific paraphilias
• Psychotherapy remains the best option
• Cognitive behaviour therapy and individual insight-
oriented psychotherapy have been tried and have
shown beneficial results.
• Comorbid depression and anxiety should be treated
with appropriate psychopharmacological agents
• Antiandrogens have been used to dampen sexual drive
with limited success.

Page 963 of 1077

 Gender Identity Disorders
• A group of disorders that have as their main symptoms a
persistent preference for the role of the opposite sex and
the feeling that one was born into the wrong sex.
-Associated with life long distress, depression and increased risk of
suicide.

• Gender dysphoria: the feeling of discontent with one’s

biological sex.

• Transsexualism: distress with one’s biological sex and a

desire to eliminate one’s primary and secondary sex
characteristics and acquire those of the other sex.

• Associated mental disorders are common.

Page 964 of 1077

 Gender Identity Disorders
• Overall prevalence is unknown.
• More common in men.
• Can often be diagnosed in childhood.
• Prevalence rate for transsexualism is1/10,000 males,
1/30,000 females

Page 965 of 1077

 Diagnostic Criteria
A strong and persistent cross-gender identification
(not merely a desire for any perceived cultural
advantages of being the other sex).
In children, the disturbance is manifested by 4(or
more) of the following:
(1)Repeatedly stated desire to be, or insistence that
she or he is, the other sex.
(2)In boys, preference of cross-dressing or
simulating female attire; in girls insistence on
wearing only stereotypical masculine clothing.
(3)Strong preference for playmates of the other sex.
Page 966 of 1077
 Diagnostic Criteria
• In adolescents and adults, the disturbance is
manifested by symptoms such as
– stated desire to be the other sex
– frequent passing as the other sex
– desire to live or be treated as the other sex
– or the conviction that he or she has the typical
feelings and reactions of the other sex.

Page 967 of 1077

 Diagnostic Criteria
Persistent discomfort with his or her sex or sense of
inappropriateness in the gender role of that sex.
• In children, the disturbance is manifested by any of the
following:
– in boys, assertion that his penis or testes are disgusting or will
disappear or assertion that it would be better not to have a
penis
– or aversion toward rough- and tumble play and rejection of the
male stereotypical toys, games and activities.
– In girls, rejection of urinating in a sitting position, assertion that
she has or will grow a penis, or
– assertion that she does not want to grow breasts or menstruate,
or marked aversion toward normative feminine clothing.
• In adolescents and adults, the disturbance is manifested by
symptoms such as preoccupation with getting rid of
primary and secondary sex characteristics. Or belief that
she or he was born the wrong sex.

Page 968 of 1077

 Diagnostic Criteria
• The disturbance is not concurrent with a
physical intersex condition.

• The disturbance causes clinically significant

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

Page 969 of 1077

 Aetiology
Biological:
– Testosterone (controversial)

Psychosocial:
– Absence of same-sex role models.
– Inborn temperamental traits, may result in sensitive,
delicate boys and energetic, aggressive girls.
– Physical and sexual abuse may predispose.

Page 970 of 1077

 Differential diagnosis
• Transvestic fetishism:
– Cross dressing for purpose of sexual excitement.
• Intersex conditions, such as:
• Turner’s syndrome.
• Virilizing adrenal hyperplasia.(andrenogenital
syndrome).
• Androgen insensitivity syndrome.
• Schizophrenia:
– delusions of being other sex.

Page 971 of 1077

 Management
Children:
-Improve existing role models, or provide one from the family or
elsewhere.
-any associated mental disorder is addressed.
-caregivers help to encourage sex-appropriate behavior and attitudes.
Adolescents:
-difficult due to coexistence of normal identity crises and gender
identity confusion.
- Rarely have strong motivation to alter their stereotypic cross-
gender roles.
Adults:
Psychotherapy:
not to create a person with a conventional sexual identity.
Sex-reassignment surgery: (rarely)
- Definitive and irreversible.
- Must go 3-12 months trail of cross-dressing and receive hormone
therapy.
- 70% satisfied.
- 2% commit siucide.
Hormonal treatments
Page 972 of 1077
 Prognosis
Children:
• may Diminish spontaneously.
• Depends on the age of onset and intensity of
symptoms.
• Begins in boys before age of 4 and peers conflict
develops at about age of 7 or 8.
• In girls the age of onset is also early, but most
give up masculine behavior by adolescence.
Adults: tends to be chronic.

Page 973 of 1077

Page 974 of 1077
 Management of psychiatric patients in
the custody of the judiciary system
 Care of Ministry of Justice
 Assessment of victim and perpetrator
of crime
 Report writing for judiciary system
 Treatment of inmates

Page 975 of 1077

 Mlondlozi Special Institution
 Harare Central Prison
 Chikurubi Special Institution

 All the other prison facilities hold

patients stable on medication
◦ ABOVE: Only enter with court order
 Police cells hold patients before trial

Page 976 of 1077

 Function of the Forensic Facilities
◦ Safe custody of patients with
diminished responsibility
◦ Treatment of Inmates
◦ Rehabilitation of Patients
◦ Containing of Dangerous patients
with failed treatment

Page 977 of 1077

 Before Court
◦ Custody of police
◦ Assessment before appear before court
◦ Minor offences decision by Investigating
officer and Attorney General Office
 After Court
◦ Remand – Assessment before trial
concluded
◦ Those being considered for death role
◦ Inmate – fall ill during prison sentence
Page 978 of 1077
 Be thorough especially in murder cases
 See patient over minimum one month
 Examine
◦ Charge/Alleged offence
◦ State outline – summary of accused crime
◦ Interview significant others for collateral history
Record full names on ID
◦ All old medical records/Test results
◦ If serious offence easier if you admit the patient

Page 979 of 1077

 Assessment
◦ Capacity - Responsibility
◦ Think: Will the offence be committed
again?-risk assessment.
◦ Fitness to stand trial
◦ Recommendation

Page 980 of 1077

◦ At time of alleged offence what was
the mental state?
◦ Was there diminished responsibility?
 Mental disorder
 Mental subnormal
◦ Mostly from the history

Page 981 of 1077

◦ This is the legal term for psychosis
◦ The legal fraternity understands is:
 Hearing voices in ones head
 Seeing visions others do not see
 Detailed description of disorganized
behaviour
 Speech others do not understand
 AVOID technical terms non-health
personal cannot understand

Page 982 of 1077

◦ Peri-natal history
◦ Chores
◦ Educational history
◦ Cognition
◦ Physical age

Page 983 of 1077

 Babies heart slowing (Risk of brain
damage)
 Delivery difficulties
 Delay in crying after birth (indicator of
brain damage)

Page 984 of 1077

 Dressing self
 Bathing self
 Cooking
 Laundry
 Sweeping

Page 985 of 1077

 Age started school – Why started late
 Class repeated
 School reports
 Special class
 Why stopped school

Page 986 of 1077

 Drawings
 Patterns
 Simple arithmetic's
 Identifying money and purchasing
problems
 Formal clinical psychologist
assessment/Wechsler Adult Intelligence
Scale test

Page 987 of 1077

 Assessment
◦ Informed Consent
 Sexual knowledge – consequences

◦ Fitness to stand Trial

 Ability to narrate what happened/name
people/consistent
 In camera/Victim friendly court (with no
cross examination).

Page 988 of 1077

◦ Often written as a sworn
statement/Affidavit
◦ Identify self full legal names
◦ State your qualifications &
registration/license
◦ State What you had access to during the
assessment
 Whom you interviewed
 Site of any medical records
 Site of any medical results

Page 989 of 1077

◦ Information from
 history
 examination
 investigations
Which lead to conclusion

Page 990 of 1077

 Give opinion depending on what was asked
for by magistrate or judge
◦ Mental state of patient at time of alleged
offence
◦ Ability to give informed consent
◦ Ability to stand trial/Give evidence
◦ Recommendations

Page 991 of 1077

 Often want clarity of discrepancies in report.
 Subpoena – invitation to court for cross
examination.
 Answer questions with utmost clarity
 Remember cross examiner will deliberately
irritate you
 Stick to medical evidence avoid determining
verdict

Page 992 of 1077

 Police pardon
 Normal sentencing with reduced sentence if
diminished responsibility
 Dangerous e.g. Murder/Malicious Damage to
property/Grievous Bodily Harm
◦ Special verdict committed to Forensic Institution
subject to tribunal assessment
◦ If treated safe low risk of offence recurring charges
may be dropped.

Page 993 of 1077

 The Act is there to safe guard the patients
and publics safety and rights.
 Often at time of admission the patient is not
able to make a sound decision.
 A second party makes the decision for the
admission contrary to patients wishes.
 This therefore is an instrument of potential
abuse thus the act aims to prevent this.

Page 994 of 1077

 Reception of a certified patients
 Provision of mentally disordered and mentally
handicapped
 Patients residing in private dwelling
 Mental Hospital boards and Special boards

Page 995 of 1077

 Mental Health Tribunal
 Care and administration of estate and
property
 Offences and penalties

Page 996 of 1077

 Main objective is to provide a comprehensive
report for the court
 Do not allow the judiciary system to rush you
 Final report only after last assessment when
patient has been optimally treated
 Assess the possibility of the crime recurring
 Remember the Mental Health Act which is for
all of us

Page 997 of 1077

 The
End

Page 998 of 1077

Community Psychiatry

Page 999 of 1077

 History of Psychiatric Care
• Mental health care was originally offered in
asylum institutions
• From around 1800s to 1950s large asylums,
‘mad houses’ were constructed in many
countries to house the mentally ill in places far
removed from their families and communities
• Initially no formal psychiatry profession and
no effective treatments

Page 1000 of 1077

History

Page 1001 of 1077

History

Page 1002 of 1077

History

Page 1003 of 1077

 Deinstitutionalisation
• Came about due to increasingly inhumane
conditions in these asylums
• In the 1950s typical antipsychotics were
discovered leading to effective treatment of
psychosis
• Formal psychiatric hospitals such as the Bedlam
hospital in the UK were opened
• Also due to increasing evidence that short
hospital stays or outpatient care was effective in
managing mental illness
Page 1004 of 1077
 Deinstitutionalisation
• As asylums closed, length of hospital stay
declined and patients were discharged to the
community.
• During this period some patients were
prematurely or inappropriately discharged
leading to the increased destitution among
the mentally ill that gave deinstitutionalisation
a bad reputation

Page 1005 of 1077

 Thus....Community Psychiatry

• Most services are provided in the community

close to the population being served
• Hospitalization being provided in general
hospitals and hospital stay being reduced as
far as possible

Page 1006 of 1077

WHAT IS COMMUNITY
PSYCHIATRY?

Page 1007 of 1077

 Community Psychiatry
• Involves the provision of care to patients with
mental illness in or close to their homes.
• It is an extension of hospital psychiatric care
and allows continuation of care beyond the
hospital.
• Community Psychiatry is a key component in
treatment and recovery for psychiatric
patients

Page 1008 of 1077

WHY DO COMMUNITY
PSYCHIATRY?

Page 1009 of 1077

 PRINCIPLES OF COMMUNITY
PSYCHIATRY
• Community oriented care
• Active case finding and screening within the
community
• Locally accessible services with tasking
shifting
• Supervision and support of the primary care
staff by specialist staff
• Community participation, empowerment and
collaboration
Page 1010 of 1077
 Principles
• Use of peer support and peer facilitated
interventions
• Networking and collaboration with other
stakeholders
• Individualization of care with a focus on the
recovery as the patient sees it
• Stop the revolving door syndrome
• Social reintegration and inclusion
• Prevention and early intervention
Page 1011 of 1077
Advantages of community based care
• Cost effective
• Developed in collaboration with the
community therefore more acceptable
• Reduces stigma
• Accessible
• Empowers the community

Page 1012 of 1077

How are Community Psychiatric
services carried out?

Page 1013 of 1077

 HOW ?
• In low resource settings the focus is on
establishing and improving capacity of existing
primary health care workers in delivering basic
mental healthcare.
• Community health care workers are trained in
screening and basic management of common
mental health problems
• The few specialists act both as clinicians and
as public health specialists to empower and
support the primary health care providers.
Page 1014 of 1077
• In better resourced areas specialised
community mental health teams can provide
care in the community through:
– General and specialised outpatient clinics
– Multidisciplinary community treatment teams
– Early intervention teams and crisis resolution
teams
– Community residential teams and community
residential care
– Day hospitals and crisis housing
– Recovery/ occupational and rehabilitation services

Page 1015 of 1077

 Community Engagement
• Multi-sectoral stakeholder meetings
• Community involvement in service
development
• Training and supervision of community health
workers- ‘Friendship Bench’
• Community education on common mental
health problems

Page 1016 of 1077

Training of Primary Healthcare workers
• Is done using the WHO mhGAP resources

• The Mental Health Gap Action Program

(mhGAP)was developed to assist countries,
particularly low and middle income countries
to scale up services for mental, neurological
and substance use disorders

Page 1017 of 1077

Training of Primary Healthcare workers
• The mhGAP can be used in training primary
healthcare staff as well as all cadres along the
referral line.
• This enables most cases of mental health
disorders to be managed at lower levels of the
referral line with only complex cases being
managed at specialist centres.
• Training can be pre service as part of basic
training curricula of the different health
cadres or in service.
Page 1018 of 1077
 Challenges in Community Mental
Healthcare
• Lack of appropriate policies and poor
implementation of existing policies
• Poor organisation of services
• Limited human resources
• Anxiety and opposition from staff
• Lack of structure and support of community
services
• Anxiety and opposition from the
community
• Financial challenges
Page 1019 of 1077
Social Psychiatry

◼Concerned with the relationship between

disorders of the mind and the human
environment.
◼ It studies the forces which act at the
interface between individuals and those around
them which may contribute to the onset of, or
which influence the course of mental disorders
(Henderson 1988)

Page 1020 of 1077

Focus of Social Psychiatry
◼Socialization and other developmental
influences that lead to differentials in;
- Vulnerability
- Resilience
◼Psychosocial determinants of psychiatric
disorders such as social adversity/risk
factors

Page 1021 of 1077

Socialization
Human beings are born into several groups:
◼families
◼Social class
◼race
◼Religion
These group’s cultures determine the nature
and type of experiences the individual is
exposed to from then on:

Page 1022 of 1077

 Socialization (cont)
◼The learning of one’s culture (way of life, beliefs, etc.)
is termed socialization
◼Socialization is integral to the development of socially
relevant and acceptable behaviours
◼It is an active social process that involves cognitive
processing of societal norms and not merely a passive
transmission of culture from one’s generation to the next
◼Socialization denotes 2 processes;
- Imitation (in terms of behavior, as with children)
- identification (in terms of values, as with adults)

Page 1023 of 1077

 Socialization ( cont)
◼Thus, in adults, socialization does not imply mere
compliance with stereotyped patterns of behaviour but
consists of acceptance of values which may be expressed in
diverse ways.
◼Hence an element of choice in most instances except
maybe in total institutions (prison, even hospital)
◼Socialization therefore depends on learning and not heredity
and helps us to fit into society and form relationships with
others.
◼Social deviancy and relationship failures may be seen as
portending psychopathology.

Page 1024 of 1077

Risk factors

Social Class:
◼Those from the lower socio-economic strata
tend to be over-represented among state
mental hospital admissions
◼Most likely related to such factors as
- Labelling,
- Diagnostic bias
- downward drift.

Page 1025 of 1077

Risk Factors (cont)

Acculturation
◼Was found to be a significant source of social stress
among migrants.
◼West Indians who had migrated to England were found
to be at a higher risk for developing mental illness than
their counterparts back home.
◼There is anecdotal evidence that those of our own in
the Diaspora might be experiencing greater levels of
stress and distress than us at home despite their being
better off financially.

Page 1026 of 1077

Risk Factors (cont)
Community attitudes towards mental illness
Labelling and stigma
◼Society may, at any given time, deem certain
behaviours as inappropriate e.g. Homosexuality.
◼To the average person, a person becomes a mental
patient once he enters a psychiatric hospital.
◼The label then applies for an indefinite period after
discharge
◼With regards to stigma, being an ex-mental patient is
often more of a liability than being an ex-criminal vis-a-
vis jobs, housing, friends, etc.
Page 1027 of 1077
Risk Factors (cont)

Life Events
◼Negative events e.g. Wars, natural disasters,
◼Positive events - e.g. Weddings, holidays
◼Normal life-cycle developmental stages such
as adolescence, marriage, birth of a child,
deaths )

Page 1028 of 1077

Cross-Cultural Psychiatry

e.g. of Schizophrenia

Page 1029 of 1077

Cross-cultural similarities
Ubiquitousness
◼Schizophrenia appears to be present in virtually every
culture in which it has been studied.
◼Prevalence also appears to be remarkably similar
across cultures (except for a few notable exceptions
with higher rates such as among the Irish in Ireland, the
Southwest Croatians, the Northern Swedish, the
Caribbean Immigrants in England, and the
Scandinavian Immigrants in the USA.

Page 1030 of 1077

Cross-cultural similarities
Ubiquitousness
Schizophrenia appears to be present in virtually every
culture in which it has been studied.
Prevalence also appears to be remarkably similar
across cultures (except for a few notable exceptions
with higher rates such as among the Irish in Ireland, the
Southwest Croatians, the Northern Swedish, the
Caribbean Immigrants in England, and the
Scandinavian Immigrants in the USA.

Page 1031 of 1077

Cross-cultural similarities
Symptom presentation
◼In terms of symptom presentation, cross-cultural
similarities far outweigh differences.
◼There are core symptoms that seem to cluster into
more or less the same syndrome pattern in the West
and elsewhere
◼Evidence exists showing cross-cultural universality in
the categories that constitute psychosis e.g.
hallucinations, delusions, inability to test reality,
inappropriate/violent behaviours (even though the
content of delusions may vary across cultures).
Page 1032 of 1077
Cross cultural variability
Cultural Signifiers
◼Determining whether certain experiences should be
considered delusional, hallucinatory, bizarre or
otherwise psychotic in nature should be informed by an
understanding of socio-cultural context and background.
◼Different societies may have their own unique cultural
signifiers of psychopathology.
◼What may signify psychopathology in one culture e.g.
“being controlled by a dead person” or “hearing the
voice of a recently deceased relative calling from the
afterworld” may be quite normal in another.

Page 1033 of 1077

Cross cultural variability (cont)

Subtyping
◼The prevalence of catatonic schizophrenia and
to some extent hebephrenic has progressively
declined in most societies (except India for
catatonic (20%) and Japan for hebephrenic
(50%)
◼While the undifferentiated and paranoid
subtypes have become more prevalent.

Page 1034 of 1077

Cross cultural variability (cont)
Course and outcome
◼There appears to be variation in the course
and outcome of schizophrenia across cultures
◼Acute onset and good outcome appear to be
more common in developing than in developed
countries
◼Put another way, outcome seems to be
inversely related to social development in the
country.
Page 1035 of 1077
The bottom line
◼The theory and practice of psychiatry is
embedded in the social context and cultural
reality that obtains wherever one is practicing
psychiatry.
◼A comprehensive problem formulation
focussing on the 3 Ps (predisposing,
precipitating and perpetuating) helps the
clinician articulate the role of the psychosocial
and cultural determinants in the presenting
psychopathology.

Page 1036 of 1077

 Principles of Cognitive
Behavioural Therapy (CBT)

Lecture by Primrose Nyamayaro

15/02/17
Page 1037 of 1077
 Outline
• Definition of CBT
• History of CBT
• The CBT Model
• Key Features of CBT
• Objectives of CBT
• Efficacy of CBT
• Video of CBT Summary and Clinician using CBT
• Conclusion

Page 1038 of 1077

 Learning Objectives
• To be able to:
1. Define CBT
2. Explain the CBT model
3. Explain Cognitive Distortions
4. Explain the key features in the practice of CBT
5. Explain the aims of therapy in CBT

Page 1039 of 1077

 Definition

• Cognitive Behavioural Therapy (CBT) is a time

sensitive, structured, present oriented
psychotherapy directed towards solving
current problems and teaching clients skills to
modify dysfunctional thinking and behaviour

Page 1040 of 1077

Beck Institute, 2016
 Definition
• Cognitive Behaviour Therapy is a therapy
that explores problems by focusing on and
exploring the Cognitions (thoughts, beliefs,
meanings) and Behaviours that contribute to
the development and maintenance of those
problems, and the emotions associated with
them.

Page 1041 of 1077

 CBT

• ‘hypothesises that people’s emotions and

behaviours are influenced by their perceptions
of events. It is not a situation in and of itself
that determines what people feel but rather
the way in which they construe a situation’

Page 1042 of 1077

Fenn & Bryne (2013)
 CBT

• how people feel is determined by the way in

which they interpret situations rather than by
the situations per se. For example, depressed
patients are considered to be excessively
negative in their interpretations of events

Page 1043 of 1077

 Normal Process

What emotion will If he thinks “it is a thief”

he feel?

If he thinks “Its that dog next

door
A man wakes up in the
knocking over the bin again”
middle of the night and
hears a noise

If he thinks: “Oh dear that’s

my garden gate banging again.
It will wake up the neighbours”

Page 1044 of 1077

 Normal Process
If he thinks “it is a thief”
might get up and go downstairs or
What will the man phone the police

do?
If he thinks “Its that dog next door
knocking over
the bin again”
might turn over and go to sleep
but speak to his neighbour the
How might he behave? next day about moving the bin

If he thinks: “Oh dear that’s my

garden gate banging again. It will
wake up the neighbours”
might write a reminder to himself
to fix the hinge on the garden
Page 1045 of 1077 gate
 Conclusion
• What we think affects how we feel.
• What we think and how we feel affects what
we do.
• It is the personal meaning of events that
determines emotional and behavioural
reactions, not the events themselves

Page 1046 of 1077

CBT Model

Page 1047 of 1077

 CBT Model
• CBT is based on a cognitive theory of
psychopathology

• The cognitive model describes how people’s

perceptions of, or spontaneous thoughts
about situations influence their emotions,
behavioural and often physiological reactions

Page 2016
1048 ofBeck
1077 Institute for Cognitive Behavior Therapy
CBT Model

Page 1049 of 1077

CBT Model

Page 1050 of 1077

 History

Born 1921
Aaron Beck is considered the pioneer of CBT
Psychiatrist at the University of Pennsylvania

Page 1051 of 1077

 History of CBT
• Beck found that depressed patients had
negative thoughts that seemed to arise
spontaneously. He called these automatic
thoughts.
• The automatic thoughts fell into three
categories
• Self
• The world
• future
Page 1052 of 1077
 History of CBT
• Beck began to identify and evaluate these
automatic thoughts

• As a result, patients were able to think more

realistically resulting in them feeling better
emotionally and they were able to behave
more functionally

Page 1053 of 1077

Levels of Cognition

Automatic
Thoughts

Intermediate
Beliefs

Core
Beliefs/Schemas

Page 1054 of 1077

 Core Beliefs
• Everyone looks at the world differently. Two
people can have the same experience, yet have
very different interpretations of what happened.
• Core beliefs are the deeply held beliefs that
influence how we interpret our experiences.
• They develop early on in life
• Think of core beliefs like a pair of sunglasses.
Everyone has a different “shade” that causes
them to see things differently.
Page 1055 of 1077
Core Beliefs

Page 1056 of 1077

Cognitive Triad of Core Beliefs

Page 1057 of 1077

 Intermediate Beliefs
• expectations and assumptions about ourselves,
relationships and situations around us

• Rules and guidelines we follow

• “ Meeting new people is something to avoid”

• “ Always look for danger and expect it to be

there”

Page 1058 of 1077

 Negative Automatic Thoughts
• Those immediate, first, quick thoughts that go
through our mind in response to a situation.

• They are our initial thinking reactions that go on

to affect emotions and behaviors.
• Examples:

• “ She thinks I’m weird”

“ I won’t pass that test”

Page 1059 of 1077

 Automatic Thoughts
• Negative and irrational

• Identifying them and replacing them with new

rational thoughts can improve our mood

“I messed up but
“I’m probably mistakes happen. I am
going to be going to work through
fired. I always this like I always do.
Trigger probably going to be
mess up. This is
it. I’m no good fired. I always mess up.
at this job”. This is it. I’m no good at
Page 1060 of 1077
this job”.
 Cognitive Distortions
• Are irrational thought patterns that affect a
person’s perception of reality in a negative
way

• Reinforce negative thinking and emotions

Page 1061 of 1077

 Cognitive Distortions
Cognitive Distortion Description Example
All or nothing thinking You look at things in If I am not perfect, I have
absolute black and white failed
categories

Overgeneralizing You view a negative event Nothing good ever happens

as never-ending pattern of
defeat

Mental Filter Only paying attention to Noticing our failures but

certain types of evidence not seeing our successes
Discounting the positive You insist that your I know I am going to get in
accomplishments or trouble because why else
positive qualities don’t would my boss want to talk
count. to me

Jumping to conclusions Interpreting the meaning of Doing this job is pointless

a situation with little or no noone will appreciate my
evidence
Page 1062 of 1077 efforts
 Cognitive Distortions
Cognitive Distortion Description Example
Magnification or minimisation You blow things way out of Getting good grades does not
proportion or you shrink their mean I am smart. Others may
importance get better grades than mine

Labelling Assigning labels to ourselves I am a loser

or other people

Should statements Only paying attention to Noticing our failures but not
certain types of evidence seeing our successes
Personalisation You blame yourself for This is my fault
something you weren’t
entirely responsible for, or
you blame other people and
deny your role in the problem
Emotional Reasoning Assuming that because we I feel embarrassed so I must
feel a certain way what we be an idiot
think must be true
Page 1063 of 1077
CBT Model

Page 1064 of 1077

 Example 1 Physiology
Heart racing
Lump in throat
Situation Automatic Thoughts Feelings
Partner says: Automatic response:
Sadness
“I need time to “Oh no, he’s losing interest
Worry
be with my friends” and is going to break up
Anger
with me….”
Behavior
Seek reassurance
Withdraw
Cry

Underlying Assumptions & .

Core Beliefs
“I’m flawed in numerous ways,
which means I’m not worthy of
consistent attention and care.
People only care when they want
something.”Page 1065 of 1077
 Example 2 Physiology
Automatic Thoughts Pit in stomach
“I am not going to get Dry mouth
through this program -
Situation Feelings
I’m not as smart
Disappointing Worry, shame,
as everyone else.
exam result Disappointment
People will
discover this and I Humiliation.
will be humiliated.”
Behavior
Use alcohol,
Procrastinate
with homework

Underlying Assumptions
and Core Beliefs
“If I don’t excel in school, I’m a
total failure”
I am a failure
Page 1066 of 1077
 Objectives of CBT

To help people
evaluate their To change unhelpful To deal with emotion
thinking objectively behaviour patterns differently
to correct biases

To re-evaluate past
To understand how experiences and
their problems arise beliefs that
developed from them

Page 1067 of 1077

 Objectives of CBT
• The overall goals of treatment are

✓ symptom reduction,
✓ improvement in functioning,
✓ and remission of the disorder.

• In order to achieve this goal, the patient becomes an

active participant in a collaborative problem-solving
process to test and challenge the validity of
maladaptive cognitions and to modify maladaptive
behavioral patterns.

Page 1068 of 1077

(Hoffman et al, 2012)
 Key Features of CBT
CBT is educational and
collaborative A sound therapeutic relationship
is a necessary condition of
CBT is brief and time limited
therapy and is used to produce
CBT is structured and problem change
oriented

Homework is an essential feature CBT aims to convey a process

of CBT that arms the patient with lifelong
CBT uses the past to inform the skills to deal with emotional
present difficulty

Page 1069 of 1077

 Individual differences
• It is the personal meaning of events that
determines emotional and behavioural
reactions, not the events themselves
• So what determines personal meaning ?
• Previous experiences which then flavour
interpretation of subsequent events

Page 1070 of 1077

Page 1071 of 1077
Page 1072 of 1077
 How to evaluate and challenge the
negative thoughts?

What is the effect of telling What could be the effect of

myself this thought? changing my thinking?

What would I tell ___ (a

friend/family member) if s/he
What can I do now?
viewed this situation in this
way?

Page 1073 of 1077

 Efficacy of CBT
• Cognitive and behavioral approaches are
effective

• CBT is most effective in

✓Mood Disorders e.g Depression

✓Anxiety disorders, e.g Social Phobia

Page 1074 of 1077

Anxiety Disorders: Example

Page 1075 of 1077

CONCLUSION

Page 1076 of 1077

 References
• The Beck Institute for Cognitive Behavior Therapy.
www.beckinstitute.org
• Fenn & Bryne (2013). The key Principles of
Cognitive behavioural therapy. InnovAiT, 6(9),
579–585 DOI: 10.1177/1755738012471029
• Hofmann, et al (2016). The Efficacy of Cognitive
Behavioral Therapy: A Review of Meta- analyses.
36(5): 427–440. doi:10.1007/s10608-012-9476-1
• Worksheets and Tools for Mental Health
Professionals. Therapistaid.com
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