Psychiatry Made Easy

Table of contents :
Cover
Content
Introduction
Etiology of Psychiatric Disorders
Psychiatric Symptoms and Signs
Organic Mental Disorders
Psychosomatic Disorders
Substance Abuse and Dependence
Anxiety Disorders
Somatoform Disorders
Dissociative Disorders
Adjustment Disorders
Mood Disorders
Schizophrenia
Delusional Disorders
Psychosexual Disorders
Eating Disorders
Child Psychiatry
Mental Retardation
Personality Disorders
Psychopharmacology
Electro Convulsive Therapy
Psychotherapies
Psychiatric Emergencies
Questions

Citation preview

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7'x,":\-;

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Including

Cases, MCQs Previous

Exam Q,u^stion

Mahmoud Sewilam Kasr Al-Ainy School of Medicine Cairo University

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

Psychiatry Made Easy By:

Mahmoud Sewilam

Kasr Al-Ainy School of Medicine

Cairo University

Second Edition

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

All thanks to Allah and special thanks for

all those people who are always encouraging me to do more than my best and who have never stopped believing in me,

1

Thanks for:

V My father, you are the greatest gift I have ever taken from Allah, you gave me the greatest gift anyone could wish; you believed in me. V My mother, the most beautiful woman I ever saw. All I am I owe to my mother. I attribute all my success in life to the moral,intellectual and physical education I received from her. V My brothers; ♦ Mohammed, when I talk about love I talk about you.

Thanks for all of your advices to me & for the attracting design. ♦ Ahmed,thanks for supporting me every time. V My little beautiful sister. Reman: you are a gift to my heart, a friend to my spirit & a golden thread to the meaning of life. V My friends, I love you all, and special thanks for Mohammed Hassan, without your efforts this book would have never seen the light. V For my students: you should always do more than your best, be yourself, be the change that you want, don't let anyone break you, you are the future, make it always full of whatever you want. V For her!

I would like to tell you that I love you so much! You are the only one who deserves my feelings, time, effort and everything I have, that's for you! Finally I dedicate you my success.

Mahmoud Sewilam Email: [email protected] Mobile No.: 01008855731

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

‫‪.v-‬‬

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

Table of Contents

Chapter number

Name

Page

1.

1.

Introduction

1

2.

II.

2

3.

III.

4.

IV.

Etiology of Psychiatric Disorders Psychiatric Symptoms and Signs Organic Mental Disorders

5.

V.

6.

VI.

7.

3 17

VII.

Psychosomatic Disorders Substance Abuse and Dependence Anxiety Disorders

31

8.

VIII.

Somatoform Disorders

38

9.

IX.

Dissociative Disorders

10.

X.

Adjustment Disorders

11.

XI.

Mood Disorders

42

12.

XII.

Schizophrenia

45

13.

XIII.

Delusional Disorders

48

14.

XIV.

Psychosexual Disorders

49

15.

XV.

Eating Disorders

52

16.

XVI.

Child Psychiatry

54

17.

XVII.

Mental Retardation

57

18.

XVIII.

Personality Disorders

58

19.

XIX.

60

20.

XX.

Psychopharmacology Electro Convulsive Therapy

21.

XXI.

67

22.

XXII.

Psychotherapies Psychiatric Emergencies

22

23

40

66

72

Questions

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

CHAPTER I: Introduction IJ Psvchiatrv & Psycholo

❖ Psychology: Jj®!' liljLu o-jJjj

❖ Psychiatry

❖ [)efinition •

Branch of Medicine that deals with the

diagnosis and treatment of psychiatric disorders.

• Psychiatric disorders are disorders in mental or psychological functions e.g. disorders ofthinking.

• The scientific study ofindividual human behavior e.g. thinking • Human behavior in groups is the domain of sociology. • It is NOT concerned with the diagnosis and treatment of disorders of these functions.

• Psychology is NOT a branch of medicine.

I.

Psychiatric disorders are widely spread, may be more prevalent than most other medical disorders.

II.

In October 2001, the WHO Yearly Report cited Four Psychiatric Disorders among the top ten diseases that caused worldwide disability in all age groups ;

1. Unipolar Depression (ranked 1st). 2. Alcohol Use Disorders(ranked 5th).

3. Schizophrenia (ranked 7th).

A!

4. Bipolar Mood disorder(ranked 2th).

s.

The Mind-Brain Relationship ;

da ^

A. The mind and brain are understood as one and the same. B.

Mind is the product of biological processes in the hrain visualized by special neuroimaging techniques.

C.

For example, Consolidation of memory is now believed to be the product of long term potentiation inside the neuron.

uCD.

Brain plasticity:

• The ability of brain synapse to alter its configuration in response to experience, y.. 4. Evaluation of Normality and Abnormality :

❖ In psychiatry, a person is considered abnormal (disordered) if he displays two major characteristics:

1. Clear psychiatric symptoms and signs: > Leading to significant distress to the patient or suffering to others > Should not occur in normal life, such as hallucinations and delusions. 2. Manifest decline in social and vocational adjnstment:

> Psychiatric patients always perform at a lower level than expected making them a great economic burden and a source of lots offamilial and social problems.

1

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

CHAPTER II: Etiology of Psychiatric Disorders ❖ The complexity of Psychiatric Disorders arise from:

1. Interaction of combined factors together to develop psyehiatrie disorders i.e.

the Bio — Psycho-Social Model of Etiology

uy '"

fj

1. Separation of time between the cause & effect. ■£

❖ Etiology of Psychiatric Disorders:

v

1. Biological Factors

A. Genetic Factors : ^ ii^ • Evidenced by genetic studies_e.g. Adoption studies • Mode of inheritance is £olygenic

• Interaction of Combined factors may be necessary to develop psychiatric disorders e.g. genetic factors with environmental factors or psvehosoeial

• The Degree of genetic contribution to disorder Differs in relation to Different psychiatric disorders. B. ^turochemical and neuroendocrine factors: > Dvsregulation in neurotransmitters

> Dvsflmction in neuroendocrine sv.stems

e.g. Schizophrenia —»• dysfunctions in dopamine & serotonin

e.g. Depressive Disorders hypothalamopituitary-adrenal axis over activity.

C. Neuronhvsioloeical and neuronatholoeical factors: > Neuronhvsiological fi e. functionab changes

e.g. changes in cerebral blood flow —>■ psychiatric disorders.

> Neuronathological changes in brain anatomical structures —»• psychiatric disorders.

NB: 'Neurochemical. neuroendocrine. neuvophysioloeical & neuropatholopical represent the biological mechanisms mediating the disease process i.e. they are Intermt^diatp. Cau\fis rather than being the original causes of disorder. 2. Psychological Factors

> A. B. C. 3.

Start since early stages of child development: Traumatic psychological experiences e.g. sexual abuse Defective development of personality e.g. defective needs by caregivers. Pathological patterns of relationships e.g. conflicts with parents Social Factors

A. Stressful life events, e.g. death of loved people

B. ^tresses of^pcial milieu, e.g. stresses related to social class C. Society nature e.g. rural versus urban

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

Psychiatric disorders can be classified in terms of: 2. Precipitating Factor

1. Predisposing Factors

3. Perpetuating (Maintaining)Factors

© Definition

Factors and events that occur

• Factors that prolong the

early life and determine the person's vulnerability to the

shortly before the onset of a disorder and appear to have

course of illness and

disorder

induced it

• Factors which operate from

•

counteract therapeutic efforts

e.g.

• Genetic factors, intrauterine

factors, physical, psychological and social

• Biological or psychosocial in • Physical e.g. Trauma, or nature. Psychological e.g. Conflicts or social factors.

factors. N.B.

• Predisposing Factors & Constitutional factors

(physical and mental factors) form together the type ofthe individual's personality

• They do not influence the pattern ofthe illness or its intensity.

CHAPTER III: Psychiatric Symptoms and Signs 1. Disorders of Attention

2. Insight 3. Judgment 4. Disorder of Orientation

5. Disorders of Perception 6. Disorders of Consciousness

7. Disorders of Motor Behavior(Conation)

8. Disorders of Speech 9. Disorders of Memory 10. Disorders of Emotions

11. Disorders of Thinking

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

1. Disorders of Attention 1. Attention

2. Concentration

• The ability to focus awareness on certain important task.

• The ability to sustain or maintain that focus.

Disorders of Attention

1. Distractibillty

3. Hypervigilance (hyperprosexia)

2. Selective inattention

aLjIIVI aJbj

• Inability to focus and maintain attention.

• Blocking out stimuli that generate anxiety.

•

Excessive attention and focus on all stimuli.

• It is found in mania and paranoid patients.

2. Insight 2efinition : refers to the patient's conscious recognition of his condition, i.e., awareness that: I.

II. III. IV.

He is disturbed or ill

His illness is psychiatric in nature He should seek professional help He should cooperate with the offered treatment

3. Judgment j>»Vt^jvSaJll: iirartiTfiTiBT

• The ability to assess a situation rationally and to act appropriately within that situation.

4. Disorder of Orientation

• Orientation is awareness of time, place and persons. • Disorientation: disturbed orientation to time, place or persons. It is usually related to disturbed consciousness.

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

5. Disorders of Perception neural causes

Definition of Perception :

a CAT Bs-percewed bv S

and correlates Ol consciousness

The process by which sensory stimuli (physical stimulation)

apresentation

are transferred into a meaning (psychological information) CAT n perceived by

Disorders of Perception : Illusions

:

Misinterpretation of REAL external sensory stimuli e.g. mistaking a rope for a snake. May affect any sensory modality (visual, auditory, etc...). May occur in normal OR pathological conditions (e.g., delirium). 2. Depersonalization and Derealization

C* Definition : Disturbed perception of oneself or the surrounding environment

B. Dereallization

A. Depersonalization

'

H:m r>

a

^

J

i

The person perceives himself, his body or parts • The person perceives the external world, objects or people as different, unreal or unfamiliar. of his body as different, unreal or unfamiliar.

•NB: Depersonalization and Derealization :

• Mav occur in normal people (during stress),

^^

• In anxiety disorders, mood disorders, schizophrenia, and in organic conditions (e.g., temporal lobe

- HQl .ir-mQtir,n k p PAlSF nprp ntin in tho sihsence ofanv external st.imu^^^^^^^^^^^^^^^ • Tvpes of hallucinations classified according to:

HUV

A. Sensory modalities

B. Complexity

> Auditory Hallucinations

> Elementary (e.g., noises, Hashes of light).

>

Visual Hallucinations

> Complex (voices, music, faces, scenes).

>

Tactile Hallucinations

> Olfactory (smell) and Gustatory (taste) Hallucinations >

Somatic Hallucinations

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

^

intoxication and withdrawal.

under the skin in COCAINE

Crawling sensation on or

amputated limb

Phantom limb from

E.g.:

False perception oftouch.

1. Tactile Hallucinations

VARIETIES:

thoughts(echo de nenseei

• Voices repeating patient's

on his thoughts or actions

(3*^ nersont. e.g., commenting

commanding B. Voices talking about the patient

12"'* nersoni. i.e., addressing or

A. Voices talking to the patient

•

• Occur in psychotic disorders especially schizpphrenja

hallucinations.

• The most common type of

2. Auditory Hallucinations

(Mostly visceral). • They usually occur in psychotic disorders, particularly schlzophr^enia^^

the body

things occurring in

• False sensation of

Hallucinations

3. Somatic

mood disorders.

scbizpph renia or severe

May occur in

rubber car

Most common in organic conditions, e.g. temporal lobe epilepsy e.g. burned

Hallucinations

4. Olfactory (smell) and Gustatory (taste)

Types of hallucinations according to Sensory modalities

dissociative disorders.

mood disorders or

.schjzpp.hrenja, severe

May occur in

withdrawal).

intoxication or

organic mental conditions,(e.g., delirium, substance

Most common in

Uyiill t n.-k-ilsii

5. Visual Hallucinations

6. Disorders of Consciousness Definition of Consciousness:

The general state of awareness of the self and the environment. Disorders of Consciousness:

2. Clouding of Consciousness:

1. Somnolence

It is excessive drowsiness.

• It is INcomplete clear-mindedness in which the person is NOTfully alert. • Attention, memory and thinking are impaired to varying degrees.

3. Stupor JjAill

4. Coma:

' ■ -trsi. Sr-is'- ■ V,

State of lack of reactivity to stimuli and awareness ofthe surroundings (partial or semi-coma) The patient is immobile, mute and unresponsive but appears to be conscious and aware of his surroundings, e.g., catatonic and depressive stupors.

State of profound unconsciousness from which the

person cannot be aroused by painful stimulation.

N.B.: Most symptoms indicating disturbances in consciousness, orientation, memory, and attention highly suggest an Organic Mental Disorder.

5. Dream-like state (oneroid or twilight state):

State of disturbed consciousness associated with dream like imagery or hallucinations.

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

7. Disorders of Motor Behavior (Conation) 1. Tics

V

,5-»JV

Involuntary, Irregular, repeated simple movements involving a group of mus e.g. turning the head

jiV

(>

In stress or anxiety, rarely organic disease 3. Stereotypy

2. Mannerisms

J*i jIjSj

jIjSj

IjIjIjj

(JjU dl


JS Jxiu 1

Pathological repetition of the words or phrases of one person by another.

Pathological imitation of the movement of one person by another.

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

8. Disorders of Speech Volubility

:

Volubility is excessive but coherent and logical speech. It typically occurs in mania and hypomania. 2.

Poverty of speech

^:

It is restriction in the amount of speech. It typically occurs in depression. 3. Mutism

4.

5.

:

It is organic or flinctional MARKED reduction in the amount of speech. Poverty of content of speech (poverty of thought) ulJai: Speech is normal in amount but conveys little meaningful information (Because of vagueness, emptiness or stereotyped phrases). Stuttering and stammering : Stuttering is frequent repetition of syllables. Stammering is prolongation of consonants, especially letter "m".

6. Dvsarthria

o-O-oo

:

It is difficulty in articulation.

It is seen in organic disorders (peripheral upper or lower motor diseases)^ 7.

Aphasia

SjJaII 0'-^:

It is disturbance in language output caused by brain lesion. Types:

A. Motor aphasia (expressive)

> The patient can understand spoken and written language but cannot express himself in proper words.

B. Sensory aphasia (receptive)

> The patient cannot

C. Nominal aphasia

> It is difficulty in finding

understand the

the correct name for an

meaning of words.

object.

9. Disordersof Memory the psychological function by which information stored in the brain is later recalled in consciousness.

Clinicallv, 4 levels of memory are described 1. Immediate

2. Recent (short-term)

3. Recent Past

4. Remote (Long-term) I— /-—

Extended Hours

pEQQnjj pKESMIIIj I

oo -JR. OO 3k

/—oo^

/-~ Thought broadcastiiip jtilj

(> ji

Aj

:

• This is a delusion that one's thoughts can be heard by others, as if they were being broadcast into the air. 16

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

CHAPTER IV: Organic Mental Disorders Definition:

• Group of disorders caused by "demonstrable" organic pathological

conditions affecting the brain. There are two major categories of O.M.D. A. Cognitive disorders

They may be secondarv to general systemic medical diseases e.g. metabolic. Organic mental disorders in which clinical

These conditions may affect the brain directlv e.g., trauma.

Organic mental disorders in which the most prominent features are disturbances of cognitive functions which may be associated with

manifestations resemble those offunctional

nsvchiatric disorders (e.g., anxiety, mood, delusional or personality disorders) but are caused by a specific organic factor or medical

disturbed consciousness.

Cognition is a elohal term which implies a group of psychological functions including attention, perception , prientation, memory, and thinking. Cognitive disorders

condition.

❖ Medical disorders include such syndromes:

include

such syndromes: Too Much hormone

1. Delirium

^

Produced ^

Ta

2. Dementia

St?

3. Amnestic disorders

1.

Organic anxiety disorder e.g. with pheochromocytoma and hyperthyroidism

2.

Organic behavioral and personalil^ disorders e.g. following brain surgery and

postconcussional states

3.

f\, "

MlJt

Organic mood disorders e.g., due to hypo- or hyperthyroidism, and Gushing and Addison's disease

4.

Organic hallucinosis e.g. substance-related hallucinosis

5, Organic delusional disorder e.g. alcohol-relatqd disorder

Etiology of Organic Mental Disorders: 1. Head Trauma

2. 3. 4. 5. 6.

Brain Tumors, infections, ,cerebrovascular or degenerative diseases Metabolic disorders (e.g., Tyrosinemia, hypoxia, uremia, hypoglycemia, etc...) Endocrine disorders (e.g. Thyroid, adrenal, etc...) Nutritional deficiencies (e.g., deficiency of Thiamine, niacin, etc...) J' jomRS (e.g., lead, organic phosphorous, etc...)

7. SKbstmm-rdated disorders (e.g., alcohol, opium, sedatives,

delta-9- Tetrahydrocannbinol(THC), etc...)

17

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

Delirium

Dementia

Amnestic Disorders

^Liuuitl KMiratfiTftrmff" Delirium is an acute reversible

•

state of global cortical dysfunction. It is characterized by Mood & Memory disturbance behavioral changes & Multiple i^ognitive defects

state of global cortical dysfunction. • It is characterized by - Mood & Memory disturbance - behavioral changes & -

They are isolated

Dementia is a chronic nropressive

disturbances of

ppss without significant impairment of other cognitive functions.

Multiple Cognitive defects kMllili[HMl disturbance of

Q3l3lJ disturbance of

Consciousness.

Consciousness.

Epidemiology: 10% of hosnitalized surgical or • 2^ of elderly over 65 years medical patients • 20% of elderly over^ years 20% ofICU patients are reversible if the cause is Elderlv and voung children

treatable

more susceptible, i-*! Equal prevalence in males and females

❖ Onset, Course and Prognosis: •

ONSET:

ONSET:

-

Acute or rapid (over hours or days).

years.

•

COURSE:

Usually insidious, over months or Tr^lamus

'-islA

May be acute after severe head trauma or vascular lesions of the

Shows typical diurnal fluctuations ofsymptoms with

brain. COURSE:

resolves within days to few

Usually chronic and progressive (over years) ending in death. May be remittent (e.g., vascular dementia).

weeks ifthe cause isJreated.

PROGNOSIS:

I

nocturnal worsenin •

Hypothslamus

PROGNOSIS:

It is a transient condition that

They are due to pathological conditions causing damage ofcertain diencephalic (thalamic) and midtemporal structures,(e.g.,

May be reversible(15%), if the cause is treatable (e.g., endocrine causes).

❖ Pathogenesis: •

Brain neuronal loss due to neuronal

hippocampus, mamillary bodies and

degeneration or cell death secondary

fornix).

Causes are acute conditions

affecting the brain primarily or secondary to systemic disease.

•

to organic diseases ofthe brain. lAmnestic Disorders!

Deliriu

1. Epilepsv (ictal and postictal) 2. Multifactorial: A combination of

1. Degenerative diseases:

1. Korsakoff s

jiyiBlrping;

al Alzheimer's disease

minor illnesses and

M bick's disease (frontal lobe dementia)

-

minor metabolic disturbances

b) £arkinson's disease

-

(especially in the elderly)

Wilson's disease

(Copper accumulates in tissues)

2. Demyelinating disease, e.g. bisseminated (multiple) sclerosis

It is the most

It is caused by thiamine deficiency usually associated

common cause.

with alcohol

dependence.

3. Hereditary Dementia, e.g. Huntington's disease 18

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

>

Head trauma.

> Cerebrovascular disease e.g. strokes > Meta ?olic, endocrine & nutritional disorders:

Fluid imbalance e.g. Heart

Chronic anoxic or Hvpoxic states Chronic metabolic disturbances (e.g., renal or Hepatic- failure) Vitamin deficiency (e.g., tJiiamine,

failure.

folate, B12)

Electrolyte imbalance (e.g., Hvponatremia, Hvpokalemia, hyperealeemia)

Hypoxia e.g._Heart failure. Hepatic or renal failure (encephalopathy)

•. „ f V

V"*

Severe anemia and vitamin

deficiency (e.g., tliiamin, niacin) Substance related (intoxication or withdrawal), e.g.. Alcohol and Henzodiazepines Toxins (e.g., £0, organophosphorus compounds) Medication induced (e.g., anesthesia, anticholinergic drugs, Hopaminergics, antibiotics,).

> Substance related (chronic exposure): Alcohol

> Toxins e.g. Heavy metal £oisoning, £0 poisoning >

Medications and irradiation.

> Brain Tumor

> Postsnrgical conditions > Infections (e.g., meningitis, sepsis, urinary tract infection, etc ...)

1. 2.

orientation

b) Memory impairment Inability to learn new information or recall previously learned information. 1. Initially involves |H3cent memory followed later by

3. T/emory: disturbed immediate and recent memory. 3. Other manifestations:

disturbed conscious level.

Global disturbance of cognitive functions including: a) Disturbed attention, perception and

focus attention.

persons.

1. Memory impairment Inability to learn new information or recall

previously learned information.

They involve

O^cent memory and

[mote memory imediate recall remains

2. Other manifestations: A. Emotional disturbances:

^athy and/or emotional

-

Anxiety, depression. Agitation, £erplexity & fear.

> Brain tumor

jmote memory.

Emotional disturbances!

lability

e.g. Alcohol and £enzodiazepines > iMins e.g.(£0 poisoning).

Amnestic Disorders

2. Global disturbance of

b) Perception: prominent illusions and hallucinations (mainly visual). c) Orientation: disorientation for time, followed by place and

Substance related:

> Chronic Infections e.g. a) aids dementia (virus) b) £rion causing £reutzfeldt-Jacob Hisease

Delirium

a) /Ittention: reduced ability to

>

> Brain surgery

1. Disturbance of consciousness.

cognitive functions including:

Hypoglycemia Hypoxia

Apathy and/or emotional lability Anxiety & Depression(40-50% of patients)

A. Aphasia A. Apjifixia finability to carry out motor activities) A. AsnQsia (inability to recognize objects) 19

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

B.

£sychomotor Behavior: Hypo- or Hyperactivity(may alternate).

Sleep-wake Cycle: Insomnia, fragmented sleep or Reversal of sleep-wake cycle.

Esychotic symptoms:

B

-

Delusions and hallucinations(20-40% of patients). C. CNS manifestations: Usually late - Various sensory and motor manifestations

Irregular periods

of sleep

-

Ultimately the patient becomes incontinent and bedridden.

D. nisturbance of Executive Eunctions (planning and organizing thoughts and actions).

J. Impairment of Judgment leads to impaired social behavior (inappropriate or bizarre behavior).

kM,»JIHIlHMlHllHl

❖ Most common type(50-60% of all dementias)

❖ The second most common type (15-30% of all dementias) ❖ More common in males Onset earlier than Alzheimer's disease

Onset, Course & Prognosis: ONSET:

ONSET:

Gradual onset,

Acute.

May be late (after age 65)or Early (before 65). COURSE:Progressive

COURSE:

Stepwise as it reflects recurrent infarcts.

PROGNOSIS:

Death within 2- 8 years from onset

Degenerative changes, predominantly in parietal ♦> Cerebral infarction and multiple areas of and temporal lobes (diffuse cortical atrophy, amyloid plaques and neurofibrillary tangles)

neuronal loss

Decreased acetylcholine metabolism and Slioke

Degeneration ofchoiinergic neurons ❖ Etiology: Genetic factors nlav a maior role:

Risk factors include:

Familial in 40"/o of cases

CerebroXascular disease (atherosclerosis,

Significantly more in monozwo^ than dizygotic twins

embolic or thrombotic occlusion^emorrhage) Cardiovascular disease j

Related to Down syndrome

(/fypertension, /zeart disease)

4

1. Focal neurological(CNS) manifestation^

1. Condition starts with gradual memory impairment followed by deterioration of other cognitive aspects.

2. Patchy Cognitive impairment

2. Aphasia, agnosia and apraxia develop after several years.

3. Motor and gait disturbances develop later. 4. Finally, the patient becomes incontinent &

0)

bedridden.

20

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

Dementia

Delirium

Treatment of the cause in REVERSIBLE

Treatment of the cause.

TYPES (e.g.. vitamin deficiency.

No specific treatment for IRREVERSIBLE TYPES

Anticholine-esterase (inhibitors) may help

delay memory and cognitive decline.

•

Siinnortive measures: tREDt

a) b) c) d)

Rehabilitation (physical and psychological) Emotional support for the patient and his family Safe, calm and orienting Environment

Maintaining proper Diet, exercise and activities

e) Maintaining physical health and treatment of associated medical Diseases (e.g., diabetes, heart disease, etc...) 05 mg

HAimmooL IfV-Ofcc.

Rj5P®;STablets FillD'CO Q20tabJ Most of substances known to be amenable for abuse and dependence (addiction) can be grouped into the following classes:

1. Alcohol.

2. Amphetamines and other stimulants. 3. Anxiolytics, sedatives & hypnotics. 4. Phencyclidine [e.g. Ketamine] 5. Caffeine. 6. Cocaine.

7. Cannabinoids [e.g. Bango - hashish - marijuana]. 8. Cigarette smoking (Tobacco)

9. Opioids [e.g. Heroin, opium, morphine. Codeine and Codeine-Containing Cough sedatives]. 10. Hallucinogens [e.g. LSD,anticholinergics, mescaline ...] 11. Volatile solvents. >

N.B:

-

Poly-substance abuse and dependence is common.

Substances may be mixed with others.

24

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

Ol

N)

^ Is there dependence?

^ How are taken?

What are the examples?

How does it exert their effects?

What is the effect in CNS?

ASKvoursell?

compulsive taking behavior are easily established in the daily smoker

- The criteria of tolerance, withdrawal, and

❖ Nicotine addiction:

cholinergic receptors.

INHIBITORY effect on PERIPHERAL

♦♦♦ Nicotine, in LARGE toxic doses is

> Nor epinephrine, epinephrine, and serotonin.

DEPENDENCE effect.

> DOPAMINE which is responsible for the

• Nicotine increases:

widely used of all habit forming substances ♦♦♦ Nicotine, in mild to moderate doses^ is STIMULANT effect on CNS by enhancing CENTRAL cholinergic receptors activated by acetyl Choline.

• In the United States nicotine is the FIRST

Nicotine

Stimulant.

system STIMULANTS.

nervous system Stimulants.

♦> They are central

Hallucinogens

DEPENDENCE

• Causing abuse and

mixed with tea or food.

hashish, marijuana & bango. ❖ Taken by: - Cigarette Smoking, orally &

cannabinoids include

❖ Common forms of

❖ Cannabinoids exert their

Single use.

develop after a

on cocaine can

DANGER

9

X

♦♦♦ NO physical dependence.

Smalfdoses. ❖ DEPENDENCE

effective even in substances

♦♦♦ It is extremely dangerous

addictive &

❖ Its action by is

❖ They have both an antagonist and an competitive effects by increasing : agonist effect on bloekade of > Acetvlcholine. DOPAMINE, Serotonergic^systems. dopamine reuptake gamma-amino-butyric acid ^ elevation of histamine, serotonin, ❖ Examples are DOPAMINE in norepinephrine, opioid lysergic acid synaptic clefts. peptides, and prostaglandins. diethylamide(LSD) N.B.

Decreased heart rate

Increased reaction time (reaction is slowed down).

Insomnia^

Signs:

to one week.

Symptoms persist for a few days up

Suicidal ideations

Strong Craving

animals or humans

been demonstrated in

reinforcing properties Neither physical dependence nor a withdrawal syndrome

Have weak

frequency of use. They are NOT highly

doses or increased

Tolerance quickly develops, leading to ingestion of larger

Hallucinogens

Desire for nicotine.

Fatigue, HyperSofMolence

- Depressed mood - Dysphoria

symptoms:

withdrawal

Heightened excitement lasts 30 seconds to several minutes.

o It starts with penile insertion into the vagina, o It immediately precedes orgasm. 3. Phase III; Orgasm

• The peak of sexual pleasure, with release of sexual tension and rhythmic contraction ofthe pcrincal muscles and pelvic reproductive organs. • Oreasm lasts from 3 to 25 seconds and is associated with a slight clouding of consciousness.

o

It is characterized by ;

■

■

In males :

In females :

Voluntary and involuntary movements ofthe large muscle groups, including facial grimacing and carpopedal spasm.

Blood pressure rises 20 to 40 mm (both systolic and diastolic), and the heart rate increases up to 160 beats a minute.

-

Subjective sense of ejaeulatory inevitability triggers the man's orgasm

3 to 15 involuntary contractions ofthe lower

Forceful emission ofsemen follows.

contractions ofthe uterus.

third ofthe vagina and by strong sustained

4. Phase IV: Resolution

• Disgorgement of blood from the genitalia fdetumescence), which brings the body back to its resting state.

• If orgasm occurs, resolution is rapid:

• If it does not occur, resolution mav take 2 to 6 hours and be associated with irritability and discomfort o Resolution through orgasm is characterized by : ■

-

•

■

In males :

In females:

Subjective sense of well-being, general relaxation, and muscular relaxation. Men have a refractory period that may last from The refractory period does NOT exist in several minutes to many hours; in that period they women, who are capable of multiple and cannot be stimulated to further orgasm. successive orgasms.

Non-organicallv sexual disorders in which the individual is unable to participate in a sexual relationship because of difficulties in normal sequences ofthe sexual cycle. I. Erectile dysfunction (impotence)

2. Premature Ejaculation

• It is the persistent inability to obtain an erection sufficient for vaginal insertion

• The man recurrently achieves orgasm and ejaculates before he

Or to maintain it until completion ofthe sexual activity. • It may be due to organic or psychological causes or a

•

combination of both.

wishes to do so.

There is no definite time frame within which to define the

• If a man reports having spontaneous erections or morning erections, organic causes ARE EXCLUDED. • The condition may accompany some other psychiatric disorders e.g. depression and schizophrenia Or may occur due to a pharmacological substance or psychoactive substance abuse. 3. Female orgasmic disorder

dysfunction. • The diagnosis is made when the man regularly ejaculates before or immediately after entering the vagina or following minimal sexual stimulation.

4. Dyspareunia

• Inhibited female orgasm or anorgasmia is manifested by the

• Recurrent and persistent pain recurrent delay in, or absenee of, orgasm after a normal sexual related to intercourse. excitement phase judged to be adequate in foeus, intensity, and • It is usually a disorder of women duration. presented by vaginismus. • May be due to psychological factors as: • Caused by anxiety about sexual Guilt concerning sexual impulses. intercourse, and history of rape or - Fear of rejection by a sex partner. childhood sexual abuse. Hostility toward men.

50

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

5. Paraphilias This a group of sexual deviations in which sexual arousing fantasies involve: Nonhuman objects; or Children or other-non-consenting persons; or suffering of oneself or one's partner. Paraphilias are diagnosed if the deviant behavior replaces normal sexual behavior. Thev include the following examples: 2. Exhibitionism

1. Fetishism

t^tAKeO IN

Sexual arousal is achieved by using inanimate objects or a non-genital body part.

RUaLICi

Sexual arousal and orgasm are associated by public Exposure of one's own genitals to a stranger.

3. Vo;^nrism

4. Frottenrism

It is characterized by male's rubbing his penis against the body of a Fully clothed woman to achieve orgasm. These acts usually occur in

it involves seeking out or observing (evel people who are naked or are engaged in sexual activity

crowded places.

6. Sexual Masochism

5. Sexual Sadism

It involves the act of being humiliated, or physically suffering (beaten, bound, etc...) to achieve sexual excitement and orgasm to the

It involves acts causing psychological or physical suffering of the victim to produce sexual excitement to the Sadistic person.

victim.

7. Eedophilia Sexual excitement and orgasm involve sexual ai iiMties with Prepubescent children. 6. Homosexuality Some authors consider homosexuality as pathological if only accompanied with distress, dissatisfaction.

Authors from other cultures still consider homosexuality as a pathological deviation. Management of Psychosexual Disorders 1. Prppgr To diagnose a psychosexual disorder, the abnormal sexual behavior should be : Medical causes and substance-induced disorders should be excluded. Recurrent or persistent, Replacing normal sexual behaviors Causing problems to Self or to others. 2. Psvchotherapv: Sexual education to the couple is enough to solve the problem. Behavioral and cognitive behavioral psychotherapies are the most widely used techniques. 3. Pharmacological treatment:

Sildenafil (Viagra) for erectile dysfunction Local anesthetic Sprays for premature ejaculation SSRls are used for premature ejaculations Pharmacological treatment of any underlying pS.vchiatric disorders e.g. depression.

51

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

• They are a group of disorders where there is excessive preoccupation with weight,food, and body shape. • Two main types are recognized : A. Anorexia Nervosa

B. Bulimia Nervosa

•

Much higher nrevalence in females

•

•

Age at onset is in the early adolescence.

• Age at onset is in late adolescence or early

Much higher nrevalence in females

adulthood (later than anorexia nervosa) •

Four times more common than anorexia nervosa

1. Biological Factors

• Diminished norepinephrine turnover. • Diminished norepinephrine & serotonin turnover. • Higher concordance rate in monozygotic than in dizygotic twins • Genetically related to major depression 2. Psychodynamic Factors

• Self- discipline over eating in an attempt to gain • Self- discipline over eating in an attempt to gain autonomyfrom the mother. • Fears concerning acquisition offeminine shape ofbody

autonomyfrom the mother. • They are more out-going, angry leading to bouts of binge-eating as ego-dystonic

3. Social Factors

• Common in societies with emphasis on thinness • Patients respond to societal pressures to be slim. and exercise

>■

Ten-vear outcome studv in the United States:

•

The Ions-term outcome is still under studv.

• • •

Complete recovery : 25% Partial improvement: 50 % Poorly fimctioning: 25%, including 7 % mortality rate.

•

Without treatment, nersists for at least several years.

• •

With treatment: Up to 70% benefit from it: fiill recovery is achieved in 50 % of cases. Mortality rate is 1%.

-i |UJ 1 iireiiatgnna Miilfinpntimiip

A. General changes 1.

Weight loss «&Amenorrhea in females

2.

Intense fear of weight gain.

3.

Intense disturbance of bodv image

2.

(the patient perceives herself as overweight despite the clear evidence of her thinness)

3.

4. Anorexia is NOT an essential feature.

1.

The natient is within normal weight & normal menses.

Recurrent Behavior to nrevent weight gain, such

as self-induced vomiting, purgatives or laxatives. Recurrent enisodes of Binge-eating & lack of

control over eating 4. At least twice a week for 3 months

B. Physical Changes • • • •

dizziness or fainting decreased vital signs. diarrhea or Constipation dysplastic Changes in the quality of skin

|

•

dehydration, fatigue, swollen salivary glands

•

Loss of dental enamel

• •

Esophageal or gastric tears Side effects of Emetics, or purgatives.

52

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

|

C. Behavioral Changes

C. Psychological Changes

• Anxiety, Fatigue • Depressed mood, social withdrawal •

•

Secretive behavior e.s. snendine lone neriods in the bathroom.

• Over-concern with dieting and nutrition

Loss of interest in usual activities

EWWiffi

•

•

Due to chronic severe malnutrition and marked

Medical & Social Problems :

reduction in caloric intake.

1. Muscle cramping due to electrolyte imbalance 2. Cardiac complications (e.g. arrhythmia) 3. Gastro-esophageal bleeding

. 1. Nervous: neuropathies, cognitive impairment, seizures

2. Endocrine: /owT3,LH and FSH

3. Electrolytes: Aypokalemia, /jy/xsmagnesaemia 4. Cardiological: arrhythmias, Ararfycardia prolonged QT interval, loss of cardiac muscle,

4. Renal failure 5. Social isolation

6. Impairment in family relationships due to lying.

sudden death.

5. Hepatic: fatty degeneration 6. Hematological: anemia, leucopenia 1. Skeletal: osteoporosis

• It has one ofthe highest mortality rates for young females • Mortality rate 5 - 15 % • With comorbid medical conditions, mortality approaches 50%

• Anxiety disorders, major Depression & psychotic

• Anxiety disorders, major depression & psychotic disorders.

Disorders.

• Deliberate gelf-harm, e.g. reckless driving • Alcohol and substance misuse n

1. Hospitalization is indicated in severe cases, with marked weight loss and with medical complications.

2. Psychotherapy e.g. behavioral, cognitive behavioral psychotherapy in addition to pharmacotherapy. 3. Pharmacotherapy to the underlying or co-

1. Psychotherapy:

-

Cognitive-Behavioral Therapy

-

Group Therapy Family Therapy

2. Pharmacotherapy: - antidepressants e.g. SSRIs

morbid psychiatric disorder e.g.

antidepressants, anxiolytics & antipsychotics

53

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

CHAPTER XVI CHILD PSYCHIATRY

p«mf7iTirTTgfl!ff

w

Child psychiatric disorders as are first diagnosed in infancy, childhood or adolescence. 2. Attention Deficit

Pervasive Developmental

Hyperactivity Disorder (ADHD)

Disorders

1. Conduct Disorder

iaji.4 sLiljyi

Disruptive behavior in whieh the basic rights of others and society rules are violated.

•

(Autistic Disorder)

uljlxual

It is a triad of;

1. Inattention

2. Hyperactivity 3. Impulsivity

• Expected social skills, language behavior are either not developed or are lost in early childhood before the age of 3 years. • The most common type is Autistic Disorder.

Epidemiology It usually starts in early

• It usually starts in early

• It usually starts in early

childhood.

childhood.

childhood.

More prevalent in males.

More prevalent in males.

More prevalent in males.

❖ Etiology *1* It is a multifactorial disorder:

❖ The exact e cause ofthe

• Evident by positive family history. 2. Organic factors: •

Increased incidence of BEG

changes. 3. Family factors: • Neglecting mother • Frequent punishment •

Marital conflicts, divorce.

4. Environmental factors: •

Increased incidence in low socioeconomic.

5. Social Modeling: •

Effect of mass media as TV.

♦♦♦ It is a multifactorial

disorder is UNKNOWN,

1. Genetic factors:

however the following factors are implicated : 1. Genetic factors:

•

Evident by high concordance in monozygotic than dizygotic twins

disorder:

1. Genetic factors:

•

High concordance in monozygotic twins, compared to dizygotic twins. • Translocation of fragile X chromosome in 15% of autistic children.

2. The frontal lobe in children of ADHD does not exert its

2. Biochemical factors: inhibitory mechanisms on lower structures, leading to disinhibition. • Increased plasma serotonin

3. Perinatal complications. 4. Food additives and colorings

•

Increased CSF homovanillic

5. Exposure to Toxins, heavy metals, aleohol (pre- or postnatal)

•

Increased incidenee of EEG

acid (metabolite of dopamine) ehanges

3. Perinatal complications 4. Psychogenic factors parental rejection. KMnmrnniiigBHr The disorder is either conducted

solitary or in a group (gang). ❖ Aggression may be : 1. Direct(Overt) aggression is directed to people, animals with

the aim of destruction e.g. using weapons, initiating fights.

2. Indirect aggression e.g. lying, and staying out late at night

V It includes three main criteria:

I. Inattention = Disturbed attention or concentration:

A. Easily distractible B. Difficulty to sustain attention in tasks

C. Child does not listen to what is said

despite of parental prohibition.

1. Inability to develop relationship with people

e.g. defect in eye to eye contact.

2. Delayed development of language skill, e.g. repetitive use of words. 3. Repetitive or stereotyped movements, e.g. twisting. 4. Insistence on sameness i.e.

54

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

2, Hyperactivity: A. Difficulty in sitting still

Marked rigidity and distress when trying to change the

B. Excessive movement

child's behavior.

C. Talks excessively 3. Impulsivity A. Answers before question is completed B. Difficulty waiting turns in games

C. Engages in dangerous without caring. ❖ For a diagnosis of ADHD, symptoms must be present for at least 6 months in at least

two settings. Managemen Pharmacotherapy: V^YCHOSTIMULANTS, e.g., dextroamphetamine, methylphenidate Antipsychotics Antidepressants

1. For the Child :

A. Behavioral therapy B. Group therapy C. Pharmacotherapy •

Lithium carbonate & clonidine

to control aggression •

Anticonvulsants for treatment of

underlying epilepsy. 2. Family therapy to resolve family conflicts. 3. Parental education programs to change the destructive pattern

Lithium carbonate

Family therapy Special education programs

1. Pharmacotherapy: • High potency neuroleptics •

Selective Serotonin

Reuptake Inhibitors (SSRJ) 2. Parental &family education programs education programs to provide a supportive home environment

3. Special education programs to each child to promote linguistic skills

of behavior.

and social interactions.

4. Institutionalization in severe eases.

FM

❖ Developmental Learning Disorders

SMiramrnTim • These disorders are termed academic skills disorders .

f*—

i

• They are psychological problems in understanding or in using spoken or written language. nmg

1.

Neocortical deficits in cognitive processing e.g. visual problems. Clinical picture Poor scholastic achievement despite their average 3. It may be associated with:

intelligence 2. Impairment in : • Reading, written expression, mathematics.

A. Anxiety and other emotional problems. B. Behavioral problems e.g. alienation or rebellion.

C. Delayed speech 1. Special assessment including IQ, EEG, plain X ray skull, and CT scan brain 2. Special educational programs for the family & the teacher. 3. Special scholastic placements.

4. Psychotherapy for the patient and family.

55

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

❖ Elimination Disorders I.

II.

Functional EnuresiS

Functional Encopresis

miliHilFiTfl

• Repeated voiding of urine into the child's

• Fecal soiling of clothes.

• R^^^^^^^untary or intentior^^^^^^^ the most common form.

• N.B. Daytime control usually precedes nocturnal control by 1-2 years.

•

^■ann In United States 7 % of 5 year olds are enuretic. •

1. Primary: •

If bladder control has never been achieved

More common in males than females

1. Primary : •

If no bowel control has never been achieved.

2. Secondary:

2. Secondary:

•

•

If the child has learned control for I year.

•

Other classification

If the child has learned control for 1 year.

A. With constipation and overflow:

•

75 % of encopretic children have constipation

•

There is fecal concretion with overflow offluid fecal mailer.

B. Without constipation: • Incontinence without constipation results in intermittent production offormed stools. (HBlJ 1. The child is at least 4 years old. 1. The child must be at least 5 years old 2. Wetting is repetitive 2. Encopresis occurs at least once a month for at least 3 months. 3. Medical causes should be excluded e.g. urinary tract infection.

^■1 1. Restricting fluids before bedtime and waking the child during the night. 2. Rewarding successful dry nights. 3. Bladder training during the day. 4. Medications: before bedtime e.g. • Imipramine • Desmopressin (synthetic anti- diuretic hormone) • Anticholinergic drugs.

3.

Medical causes should be excluded.

1.

For children with severe retention or

impaction: • Cleaning out the bowel e.g. enema followed by retraining the bowel e.g. high roughage diet. 2. For encopresis without constipation: • Behavioral program. 3. In resistant cases individual and family psychotherapy

56

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

Chapter XVTI; Mental Retardation I.

Biological Causes:

1. Genetic Factors:

Autosomal dominant e.g. phakomatoses as tuberous sclerosis. Autosomal recessive e.g. inborn errors of metabolism as phenyl ketonuria. Chromosomal abnormalities e.g. Down sjmdrome and Fragile X Syndrome. 2. Prenatal Factors:

Maternal illness e.g. intrauterine infection & Brain malformations 3. Perinatal Factors:

Brain trauma & Blood group incompatibility. 4. During Infancy or childhood:

Brain infections (encephalitis or meningitis or postimmunization)& Lead intoxication & malnutrition. II.

Psychosocial Causes:

Psychiatric disorders (living with psychotic parents)& Drug abuse > Classification & Clinical Description:

1 • The Intelligence iiuotient was calculated from the following formula: ■ IQ = mental age / chronological age x 100

1

1

1. Severity: Mild M.R.

Moderate M.R. 2.

50-69

|

Severe M.R.

Profound M.R.

20 - 34

below 20

IQ:

35- 49

3. Incidence: 85%

1

10%

4%

1

1%

4. Self-care and living skills: • No difficulty. • Retarded & can be trained • Need help with • Find difficulty in paying a budget. calculating the change

• Markedly impaired. • Need constant help and supervision. • Dependent on others for money arrangement

due.

5. Language and communication skills: •

Able to use

•

Educable.

• Slow in developing. • Very limited. 6. Education and occupation: •

Limited.

•

I

Not trainable.

• Severely limited • Extremely limited

Diagnosis requires both

A. Low intelligence (IQ less than 70) and B. Deficits in adaptive functions during the developmental period (before the age of 18 years).

1

Co-morbidity

• Mentally retarded children are four to five times at a higher risk to have a psychiatric disorder than normal children.

•

The most common symptoms suggestive of Co-morbiditv includes:

A. Irritability, B. Impulsivity & hyperactivity,, C. Short attention span and language delay. D. Frustration may lead to aggressive temper outbursts. ❖ Managemen 1. Early detection oftreatable Causes e.g. hypothyroidism. 2. Treatment of Co-morbid conditions e.g. depression or ADHD.

3. Proper evaluation of the Case to manage the Complications. 4. 5. 6. 7.

Monitoring speed of progress. Specialists for speech therapy. Parental support. Psychotherapy (mild MR)to enhance self-esteem

8. Behavior modification e.g. self-injury. 57

‫اﺷﺗري ﻧﺳﺧﺗك إذا ﻧﻔﻌك اﻟﻛﺗﺎب وادﻋم ﺗﺣدﯾﺛﮫ ﺑﻧﯾﺔ ﻧﺷر اﻟﻌﻠم‬

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CHAPTER XVIII: Personality Disorders

E• Definition of personality • Personality describes the characteristic cognitive, behavioral and emotional traits. *X* Definition of personality disorders: 1. It cannot be diagnosed before the age of 18 years. 2. It has an onset in Adolescence or early Adulthood

3. It is an Extreme set of characteristics beyond the range found in most people. 4. An Enduring pattern of maladantive behavior i.e. deviates markedly from the Expectations of the individual's culture. 5. Pervasive and inflexible. 6. It is Stable over time.

7. It leads to distress or impairment of functioning. 1. Biological Factors:

Expressed through the actions of a key neurotransmitter e.g. dopamine, serotonin, and norepinephrine. 2. Psychological Factors:

Personality becomes disordered by the maladaptive use of ego defenses (Defense Mechanisms). 3. Social Factors:

Character of a person is developed through socialization and experience 1. Schizoid Personality Disorder

2. Paranoid Personality Disorder ilLu y

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