Psychiatry PDF

PSYCHIATRY  Psychiatry Contents Lecture: 1. Introduction to Human Behavior and psychology. 2. Stress and psychosomatic disorder. 3. Anxiety disorders. 4. Emotion & emotional disorder. 5. Psychosis & Psychotic disorder...

PSYCHIATRY  Psychiatry Contents Lecture: 1. Introduction to Human Behavior and psychology. 2. Stress and psychosomatic disorder. 3. Anxiety disorders. 4. Emotion & emotional disorder. 5. Psychosis & Psychotic disorder. 6. Child development and behavioral disorders in children. A+ KEEPERS TEAM 1  Psychiatry 1.Introduction to Human Behavior and psychology Definition of Behavioral Science: Any course concerned with Human Action: Psychology. Psychiatry. Sociology. Anthropology. Compare psychiatry versus Psychology Psychology versus Psychiatry psychology psychiatry o Is the study of human cognition, emotion o Is the science of diagnosing, treating and behavior that will help to understand and preventing mental disorder? how people behave in specific situation and o Psychiatry dealing with abnormal why? behavior. o Psychology study range of normal behavior. o Psychiatry is a misnomer? Issue psychology psychiatry field Deal with normal behavior Deal with abnormal behavior Cognitive, behavioral, General and special (child, addiction, Subcategories psychodynamic, etc. etc.) Type of study Basic medical study Clinical medical study Psychiatry As a study of mental disorders: General psychiatry. Addiction medicine (Substance use disorder). Child and Adolescent psychiatry. Geriatric (old age) Psychiatry. Forensic psychiatry. Liaison psychiatry. Sleep medicine, Sexology. A+ KEEPERS TEAM 2  Psychiatry Psychology perspectives relation to human brain and Behavior: Perspectives (Schools) are different strategy or approaches that try to interpret, analyze and predict human behavior. 1. Behavioral perspectives: Concerned with how environmental factors (Stimulus) affect observable behavior (response) (consequences of behavior). 2. Cognitive perspectives: It is a scientific approach that view people like a computer. It is concerned with mental function as attention, perception, memory and learning. 3. Biological: Study different biological factors that have significant influence on behavior as Genetics, Neurotransmitter, hormones. 4. Humanistic: How inner feeling and self-image affect behavior. They belief that each individual is unique and has the free will to choose or change. 5. Psychodynamic: Sigismund Freud (1856-1936) who was the founder of psychodynamic believe that events occurred early in childhood may have significant impact on our behavior and choices later on in life so we don’t have free will. A+ KEEPERS TEAM 3  Psychiatry 2.Stress and psychosomatic disorder Stress Definitions: It is unpleasant situation or events which considered to be stressful. Stress as a response: o Every person under stress has a yielding point. o Any person can withstand stress up to certain limit at which his defenses will be broken. Sources of stress: 1- Changes. 2- Losses. 3- Interpersonal. Genetic of stress (Etiology): o Every individual had his own biological response to stress according to genetic vulnerability. o Chronic stress could modulate gene structure (telomeres) that protect chromosomes from damage even as young as 9 years (increase vulnerability to all illnesses). Factors affecting response to stress: 1. Personal: If we provide the person with sufficient information about stressful event, he will o Prior experience. tolerate it better. o Information. o Personal factors (personality style- defensive mechanisms- locus of control). 2. Stress: o Lack of control over stress. 3. Circumstances: o Social support. A+ KEEPERS TEAM 4  Psychiatry General adaptation syndrome (GAS) (Selley, 1956): It is general physiological reaction to all forms of stress. 1- Alarm stage (sympathetic and adrenal medulla): increased heart rate, cardiac output and blood pressure, tremors, piloerection, mydriasis etc. 2- Resistance stage (corticosteroids from suprarenal cortex): increased blood glucose level To restore function to level superior to pre-stress level 3- Exhaustion stage ( occurs if the stress continued): General adaptation syndrome Alarm reaction Resistant Parasympathetic activity Stimulation of sympathetic nervous balances sympathetic Exhaustion system. activity. Increased release of hormones from: Hormonal level return to o Hypothalamus (CRH). normal. o Posterior pituitary (endorphins, ADH). Alarm reaction recurs or o Anterior pituitary (ACTH). continues until energy is o Adrenal cortex (cortisol, aldosterone). depleted. o Adrenal medulla (epinephrine, The person cannot adapt norepinephrine). and subsequently dies. Adaptation Recovery Fight or flight A+ KEEPERS TEAM 5  Psychiatry Physiological responses to stress: 1) Increased HR and CO (cardiac output) and BMR (basal metabolic rate) due to: a) Increased activity of sympathetic nervous system. b) Increased catecholamines release from the medulla. 2) Increased activity of limbic-hypothalamic- pituitary--adrenal axis (LHPAA) which lead to increased glucose level. Physiological responses to stress Initial response Prolonged response (resistant stage) Due to sympathetic stimulation Stimulation of Hypothalamus secretes ++ Adrenal medulla CA(catecholamine) corticotropin releasing factor(CRF) secretion and Cardiovascular stimulation ++ stimulation of Pituitary secretes (++ Heart rate (HR) and blood pressure adrenocorticotrophic hormone(ACTH) (BP), vasoconstriction) ++ stimulation of Adrenal cortex ++ Glycogen release from liver + glucose (Mineralocorticoid, glucocorticoid and level. Androgen) Increase Glucose level, Prepare body for fight or flight To restore function Early Late Short duration Longer duration Reaction to Stressors: Fight or Flight A+ KEEPERS TEAM 6  Psychiatry Psychological response: o Alarm stage: Feeling anxious and threatened. o Coping strategy to deal with situations. o Success of strategy end the anxiety stage. o Failure of strategy------Illness. Stress and illness Alarm stage Feeling anxious, threatened Coping strategies Unhealthy Healthy coping Illness Coping with stress: 1. Direct coping: o Confrontation. o Compromise. o Withdrawal. 2. Indirect coping (palliative coping): o It has analgesic action. o Defensive mechanisms (denial, intellectualization). o Drug abuse (alcohol, benzodiazepines, etc.). Failure of coping (Stress and illness): 1. Psychiatric disorder: o Adjustment disorder. o Acute stress reaction. o PTSD (Post traumatic stress disorder). o Any psychiatric disorder. A+ KEEPERS TEAM 7  Psychiatry 2. Medical illness (psychosomatic disorder) o DM (Diabetes Mellitus). o Peptic ulcer. o Hypertension. o Eczema. Psychosomatic disorder Psych = Mind, soma= body Definition: It means any physical disorder that caused, or worsens by psychological factors, as Hypertension, Diabetes, Allergy, Eczema, Peptic Ulcer, Irritable colon. Patho-physiology: Stressor stimulation of autonomic nervous system (body regulatory function) release of epinephrine, norepinephrine and cortisol affect major body system (heart, GIT, renal,) physical symptoms and signs disorder. Management of psychosomatic disorder (Coping with stress): 1. Education about relation between body and mind. 2. Identification of stressor. 3. Coping strategies with stressor. o Relaxation exercise. o Anger management. o Activity. 4. Cognitive behavioral therapy. 5. Psychological coping with stress. 6. Medication? Psychological coping with stress: 1. Controlling source of stress. 2. Learning to set limits and to say No to some demands. 3. A person’s capacity to tolerate stress may increase by thinking about something else (vacation- movie- music). 4. Problem focused strategies: Think about the problem and different ways to solve it. A+ KEEPERS TEAM 8  Psychiatry 5. Appraisal focused strategies: To see the problem in another way (it is not that important, humor, it is good and not threatening. Stress and illness: ❖ Not-uncommonly, medical and surgical patients have concurrent psychological problems. These difficulties cause psychological stress, which can exacerbate the patient’s physical disorder. ❖ Common psychological complaints in hospitalized patients include anxiety, depression sleep disorders, and disorientation, secondary to delirium. ❖ Patients with chronic pain usually suffer from depressive symptoms. ❖ Psychological and medical risk can be reduced by enhancing sensory and social input (e.g., placing the patient’s bed near a window, encouraging the patient to talk), providing information on what the patient can expect during and after a procedure, and allowing the patient to control the environment (e.g., lighting, pain medication) as much as possible. A+ KEEPERS TEAM 1  Psychiatry 3.Anxiety disorders Definition: it is a diffuse highly unpleasant vague feeling of fear and apprehension accompanied by somatic symptoms. ❖ Patterns of somatic symptoms varies widely from one to other. ❖ Normal Anxiety: anxiety is a normal response when it is related to definite threat and proportionate to its severity. Adaptive functions of Anxiety: ❖ It warns the body to take care from internal or external threat, so it pushes the organism to take the necessary precautions or to take actions to reduce this stress. ❖ We need physiological anxiety to improve creativity and performance. Physiological Pathological Normal Abnormal Improve performance Hinder performance Adaptive response Maladaptive No suffering Suffering Clinical presentation: Typically: ❖ Present with physical symptoms. ❖ May not discuss psychic complaints. ❖ Have clusters of symptoms. Psychological symptoms Somatic symptoms (physical) Cognitive symptoms o Worry, apprehensian, o ANS (Autonomic nervous o Decrease concentration, fear. system) over activity decrease ability to learn o Irritable, restless. Dry mouth – sweating o Decrease ability to o Hypersensitive. tachycardia- pallor- ordinary work, tachypnea- tremors. performance, difficulty o Sleep : difficulty in to memorizing and recall ✓ Initiation. o Distractibility, ✓ Continuation. ✓ Unsatisfactory. A+ KEEPERS TEAM 2  Psychiatry Classification of anxiety disorders: 1. Generalized anxiety disorder. 2. Panic disorder with or without agoraphobia. 3. Phobic disorders. 4. Post-traumatic stress disorder. 5. Obsessive compulsive disorder. 6. Adjustment disorder with anxious mood. 1. Generalized Anxiety disorder: Persistent anxiety symptoms every day for at least 6 months: o Psychological. o Somatic (Physiological). o Cognitive. 2. Panic disorder: Recurrent panic attack which include: Acute onset of intense fear or uncomfortable with one or more of the following o Dyspnea. o Dizziness, unsteadiness, or faintness. o Trembling or shaking. o Palpitations or tachycardia. o Chest pain or discomfort. o Fear of losing control. o May last from few minutes to ½ hour. 3. Phobic Anxiety: o Agoraphobia. o Social phobia. Main symptoms o Animal phobia. Un-proptional, irrational fear from specific o Death phobia. target (animal, situation) lead to avoidance o Illness phobia 4. Post-traumatic Stress Disorder (PTSD): o Flash back. o Nightmares. o Depression. o Repeated reliving of the trauma. o Avoidance of cues of the trauma. A+ KEEPERS TEAM 3  Psychiatry 5. Obsessive Compulsive Disorder (OCD): ❖ Undesired………Ideas. ❖ Unwanted………Images. ❖ Uncontrolled….Impulses. ❖ Unacceptable….Fears. ❖ Rumination. Medical Causes of Anxiety: ❖ Hyperthyroidism. ❖ Pheochromocytoma (noradrenaline producing tumor). ❖ Cardiac dysrhythmias and failure. ❖ Hypoglycemia. ❖ Respiratory dysfunction (chronic obstructive airway disease, asthma). ❖ Neurological Disorders. ❖ Premenstrual. ❖ Drug induced. ❖ Autoimmune. ❖ Head Injuries. Management of anxiety disorders Pharmacological Non pharmacological o BZD: benzodiazepine drugs. o Psychotherapy (cognitive behavioral o Non-BZD. psychotherapy). o B blockers: to calm heart rate. o Relaxation technique. o Neuroleptics (antipsychotic: small dose o Stress management techniques. for sedative effect). o Coping strategies techniques o Antidepressants. A+ KEEPERS TEAM 4  Psychiatry 4.Emotion & emotional disorder Emotion Emotion is: ❖ How we react and interpret the world around us constitute who we are. ❖ A complex reaction pattern, involving experiential, cognitive, behavioral and physiological elements.” A mood is “any short-lived emotional state Component of emotion: 1. Subjective (affective) experience (arousal, pleasure, displeasure) = Stimulus. 2. Cognitive processes (thoughts – emotionally relevant perceptual processes). 3. Physiological adjustments response (Autonomic) (wide spread). 4. Behavioral responses (changes). 1. Subjective (affective) experience: ❖ While basic emotions are expressed by all individuals regardless of culture or upbringing, the experience that produces them can be highly subjective. ❖ Seeing a colour, losing a loved one or getting married. ❖ No matter how intense the experience is, it can provoke many emotions in a single individual and the emotions each individual feel may be different. 2. Cognitive processes: a) Schachter-Singer Theory(2 factor theory): o The physiological arousal occurs first, and then the individual must identify the reason for this arousal to experience and label it as an emotion. o A stimulus leads to a physiological response that is then cognitively interpreted and labelled, resulting in an emotion. b) Lazarus theory of emotion (Cognitive Appraisal Theory): o Thinking must occur first before experiencing emotion. o Stimulus---Thought--- both physiological response and the emotion. A+ KEEPERS TEAM 5  Psychiatry 3. Physiological adjustments response: o Fear lead to palpitation. o This physiological response is the result of the autonomic nervous system’s reaction to the emotion we’re experiencing 4. Behavioral responses (expression, changes): o The behavioral response aspect of the emotional response is the actual expression of the emotion. Smile, grimace, laugh depend on societal norms and personality. o Behavioral responses are important to signal to others how we’re feeling, but research shows that they’re also vital to individuals’ wellbeing. o Suppression of behavioral responses to emotion had physical effects on the participants. (Psychosomatic). o Understanding other emotion is part of our emotional intelligence. Example (all components of emotion) As an example when you hear a strange sound which awakens you at night you may feel the following 1. Subjective feeling------Fear. 2. Cognitive processes: o Labeling the emotion. o How to deal with the situation. o Identifying the source. 3. Physiological changes: o Bounding heart. o Perspiration. o Hyperventilation. 4. Behavioral-------Escape or attack. The neurophysiology of emotions: 1. The autonomic nervous system: o Sympathetic system facilitate arousal of major systems of the body increases readiness to act to fight or flight. o Parasympathetic dominant during periods of relaxation produces calmness and rest. 2. Hypothalamus: o Stimulates pituitary ACTH Adrenal cortex Glucocorticoids increase blood glucose level. o Adrenal medulla Epinephrine and Norepinephrine →Heighten body functions of fight, flight. A+ KEEPERS TEAM 6  Psychiatry o There are Neuro-transmitter (NT) responsible for certain emotion e.g. Serotonin related to Depression, Dopamine to pleasure. Mood disorder ❖ For nearly 2500 years mood disorders have been described as the most common diseases of mankind. ❖ Hippocrates (460–357 BC) described melancholia ("black bile"). ❖ The World Health Organization has ranked depression fourth in a list of the most urgent health problems worldwide. 1- Depressive disorders Types: 1. Bipolar depression & Unipolar. 2. Major depression (Mild, Moderate, Severe) Melancholic, psychotic. 3. Minor Depression (reactive, brief, premenstrual). 4. Adjustment Disorder with depressed mood. 5. Mixed anxiety Depression. 6. Postpartum Depression. 7. Dysthymia. 8. 2ry to general medical condition. Etiology: Psycho-socio-biological: 1. Biological: o Biogenic amines imbalance. o Neuro-endocrine. o Genetic. 2. Psycho-Social: o Thinking that one is helpless, unworthy, or useless. o Loss of self-esteem. o Loss of loved object. o Learned helplessness. A+ KEEPERS TEAM 1  Psychiatry Clinical Picture of Major Depression: 1. Psychological symptoms: a) Depressed mood and sadness (usually there is diurnal variation, which means that the symptoms are more severe in the morning). b) Loss of interest and lack of enjoyment. c) Sense of emptiness, helplessness, hopelessness, worthlessness, pessimism, death wishes, suicidal thoughts, loss of self-esteem, self-blame and guilt. d) Psychotic symptoms may be found in severe as: o Delusions of guilt, nihilism, poverty, hypochondriasis. o Hallucinations: auditory, visual etc. (All delusions or hallucination are mood congruent). 2. Physiological (somatic symptoms): a) Loss of appetite, fatigue and loss of energy. b) Weight loss. c) Loss of libido. d) Sleep disturbances: insomnia, early morning awakening interrupted sleep. e) Pains (headache, back pain). f) Digestive upsets, loss of appetite, loss of weight. g) (Sometimes-atypical symptoms occur e.g. (increased appetite, hypersomnia). 3. Behavioral symptoms: a) Negligence of self-care. b) Social withdrawal, suicidal attempts. 4. Motor, cognitive symptoms: a) Difficulty in attention and concentration. b) Slow thinking. c) Psychomotor retardation or agitation. 5. Impaired social and occupational functioning. Diagnosis according to ICD10: ❖ 2 weeks of: Category A o Depressed mood. o Loss of interest. A+ KEEPERS TEAM 2 o Decrease energy.  Psychiatry For severe depression need all criteria of category A and 5 of category B to be (8). For moderate depression 2 of category A and 4 of B to complete (6). For mild depression 2 of A and 2 of B to form (4). Management: 1. Identify current life problems or social stresses. 2. Involve the patient in discussing the advantages and disadvantages of available treatments. 3. Most depressive illnesses can be managed in the primary care setting. 4. Psychiatric referral is indicated if: Suicide risk is high, severe depression or psychotic depression, Nonresponse to treatment. Treatment: ❖ Management starts with risk assessment, in terms of self-neglect and suicide. 1. Pharmaco-Therapy: Hospitalization a. Tricyclic Antidepressants (TCAs). Indications: b. Selective Serotonin Reuptake 1. Suicidal risk. Inhibitors (SSRIs). 2. Refusal of food or medication. c. Selective Serotonin Norepinephrine 3. Severe agitation or retardation. Inhibitors (SNRIs). 4. Psychotic symptoms. 2. Electro-Convulsive Therapy (ECT). 5. Severe depression. 3. Psycho-social therapy. Explain to the patient and relatives that: ❖ Expected side effects. ❖ Improvement will build up over two or three weeks. ❖ ECT is very safe and is reserved for severe cases and suicidal patient. 2- Bipolar disorder ❖ Patients may have a period of depressive symptoms alternating with episodes of mania or excitement with the pattern described below. A+ KEEPERS TEAM 3  Psychiatry ❖ So bipolar disorder is either Bipolar Depression or Bipolar mania. Clinical Picture (Manic episode): 1. Psychological: a) Mood: elation, euphoria, and irritability. b) Thinking: May be mood related psychotic symptoms e.g. delusion of grandiosity and power. c) Speech: hyper-talkative in a loud and rapid voice. d) Impaired judgment. 2. Behavioral: a) Hyperactivity, restlessness. b) Grandiose attitude and inflated self-esteem. c) Increased sociability, aggression and excitement. d) Enthusiasm, multiple projects. e) Sexual and social disinhibition. f) Wearing bright colors and excessive cosmetics. g) Over spending of money. 3. Physiological: a) Increased energy and lack of sense of exhaustion. b) Decreased need to sleep. c) Increased sexual activity. d) Excessive eating. 4. Cognitive and psychomotor: Differential diagnosis a) Hyperactive. Alcohol misuse and Drug use disorder, b) Psychomotor agitation. Can cause similar symptoms. c) Distractibility. Diagnosis: According to ICD10: a) 1 Week (may be less if severe) of Disturbed mood. A+ KEEPERS TEAM 4  Psychiatry b) 3 of the previous symptoms. c) With impairment of function. Characteristics of Bipolar Depression: a) Depressive symptoms, the same as unipolar. b) Short duration. c) Patient may shift to manic episode rapidly. d) More psychotic symptoms, irritability, and cognitive impairment. A+ KEEPERS TEAM 5  Psychiatry 5.Psychosis & Psychotic disorder What is psychosis? ❖ Distortion of reality. ❖ Disturbance of thinking, emotion and behavior. ❖ Delusions and Hallucinations. What are psychotic disorders? Types: A. Schizophrenia. B. Acute Psychotic Episode. C. Schizophreniform. D. Other psychotic Disorders: Differences between them may be in duration and- or severity of symptoms. E. Delusional disorder. F. Schizoaffective disorder. Schizophrenia Etiology: Bio-psycho-social. Epidemiology: o Prevalence: up to 1-1.5 % in USA. o Sex incidence: equal (although different course and prognosis). o Age of onset: 15-25 in males 25-35 in females. o Suicide: 10%. o Life span: 20% shorter. A+ KEEPERS TEAM 6  Psychiatry Diagnosis, Clinical picture: 1. Disturbance of thinking: o Content: Delusion (persecution- infidelity- grandiosity poverty-somatic) o Thought control disturbance. o Disturbance in form of thinking. 2. Disturbance of emotion: o Flat- blunted- incongruent-perplexed- any mood disturbance. 3. Disturbance of behavior: o (disorganized behavior, aggressive,retarded, catatonic) 4. Disturbance of perception (Hallucination): o Auditory, visual, tactile, Kinesthetic, olfactory, gustatory. 5. Disturbance of volition: Passivity phenomenon. 6. Deterioration of function. 7. Duration: symptoms should continuo for 6 months. Clinical picture of schizophrenia Positive symptoms Negative symptoms o Delusion. o Social withdrawal. o Hallucination. o Negligence of self-hygiene. o Disturbed behavior. o Flat affect. o Inappropriate affect. Cognitive dysfunction o Impaired attention and concentration and memory. Management: ❖ Diagnosis made clinically (history & Examination). ❖ Investigation done to: Exclude organicity, substance or prior to certain drugs ❖ Treatment: bio-psycho-social: o +/- Hospitalization. o APD (Antipsychotic drugs). o Family counseling. o CBT (cognitive behavioral therapy). o Rehabilitation. Prognosis: A+ KEEPERS TEAM 7  Psychiatry o 1/3 of cases has good (remission). o 1/3 of cases has intermediate (remission and exacerbation). o 1/3 of cases has deteriorating course. 6.Child development and behavioral disorders in children Epidemiology and classification: ❖ It is estimated that between 12% and 15% of children have a mental disorder. ❖ About 10% of boys and 6% of girls aged 5–10 years have an emotional or behavioral disorder. ❖ Boys were more likely than girls to have ADHD, behavioral or conduct problems, autism spectrum disorder, anxiety, and Tourette syndrome. ❖ Girls were more likely to be diagnosed with depression. ❖ Suicide is the second leading cause of death among children ages 12-17. Normal development: ❖ In order to understand the behavioral and psychological problems of childhood, it is essential to know the normal patterns of child development. Normal childhood development 3 months Follows the moving objects, converges and focuses Adaptive 4-5 months Grasps objects crudely behavior 6 months Transfer objects from one hand to other (includes 9-10 months Claps hands fine motor 1 year Gives hand-held objects to mother movements) 1.5 years Makes a tower of 3-4 cubes A+ KEEPERS TEAM 8  Psychiatry Normal childhood development 4 weeks Turns head and responds to sound of a bell; vocalizes (apart from crying) 3 months Laughs aloud Language 9 months Speaks mama, dada, ; responds to name and 1-1.5 years Uses 3-5 words meaningfully emotion 18 months About 10 words spoken including name 2 years Combines 2 different words; Simple sentences made 3 years Uses plurals; Has a fairly good vocabulary 5 years Color naming accurately (primary colors); Defines words Intellectual disability (MENTAL RETARDATION) Definition: Mental retardation (MR) is defined as significantly sub-average general intellectual functioning, (usually an IQ of below 70), associated with significant deficit or impairment in adaptive functioning, which manifests during the developmental period (before18 years of age). ❖ General intellectual functioning is usually assessed on a standardized intelligence test. ❖ While adaptive behavior is the person’s ability to meet responsibilities of social, personal, occupational and interpersonal areas of life, appropriate to age, and educational background. ❖ 1-2% of the general population has mental retardation. Classification of Mental Retardation by IQ Types IQ Percentage Capabilities 50-70 85-90% o Can achieve vocational and social self-sufficiency Mild MR with a little support. o “Educable”. 35-50 10% o Trainable”. Moderate o They can be trained to support themselves by MR performing semiskilled or unskilled work under supervision. A+ KEEPERS TEAM 9  Psychiatry 20-35 3% o Recognized early in life with poor motor development (significantly delayed developmental severs MR milestones) and absent or markedly delayed speech and other communication skills. o “Dependent”