חוברת פסיכיאטריה 2014 תל אביב עם תוכן

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3 ...............................................................................................
9 .......................................................................................
20 ....................... Diagnostic and Statistical Manual of Mental Disorder (DSM)
26 ............................................ (PSYCHOTIC DISORDERS)
28 ................................................................. ( )SCHIZOPHRENIA .1
38 .................................... ( ) schizophreniform disorder .2
39 ......................................... ( ) Schizoaffective disorder .3
40 ........................................................ ( ) Delusional disorder .4
44 ........................................ ( ) Brief psychotic disorder .5
48 ....................................... (AFFECTIVE DISORDERS) .II
50 ........................................................ (Depressive disorders)
56 ........................................................ (- ) Bipolar disorders .2
61 .......................................................................... DYSTHYMIC DISORDER
65 .................................................... ANXIETY DISORDERS .III
75 ................................................ Obsessive-compulsive disorder (OCD)
3.
81 ................................................................. (- ) PTSD .4
88 ........................................ PERSONALITY DISORDERS .IV
100 ......................................................... Adjustment disorder
104 ....................................... Impulse control disorders
109 .................................................................................. Somatiform disorders
118 ..................................................................................
122 ................................................Pervasive Divelopemental Disorders (PDD)
126 ........................................................................................................ ADHD
131 ..............................................................................................
137 ...........................................................................................
141 ................................................................................................
142 .......................................................................................................
146 ............................................................................................................ ECT
150 ........................................................... ()
151 ....................................... ANTIPSYCHOTIC DRUGS (NEUROLEPTICS;
158 ...................................................................... Atypical anti-psychotic drugs
162 ................................... ( ) ANTIDEPRESSANT DRUGS
163 ............................................ (SSRI) Serotonin Specific Reuptake Inhibitors
165 ................................................. ( ) cyclic Antidepressants
168 ..................................................... Monoamine Oxidase Inhibitors (MAOI)
169 ........................................................................................................SNRI'S
174 ................................................... ( ) MOOD STABILIZERS
174 .......................................................................................... ( )Lithium
177 ................................................................................. -
181 .......................................................... ( )BENZODIAZEPINES
187 .................................. Anticholicholinergic drugs (Antiparkinsonian drugs)
187 ........................................ (-( ) -)
188 ........................................................ ALCOHOL & SUBSTANCE ABUSE
198 ..................................................................................................... Delirium
200 .................................................................................................... Dementia
201 ..................................................................................... Alzheimer's disease
2
208 ...................................................................................
212 .........................................................
215 ............................................................
) PARAPHILIAS ( 217 ...........................................................
220 .......................................................................
)224 .................................... (BEHAVIORAL THERAPIES
226 ......................................................................................
227 .................................................................................................
234 ...........................................................................................
236 ...........................................................................................................

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11
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19
(Diagnostic and Statistical Manual of Mental Disorder (DSM 20
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21 (Diagnostic and Statistical Manual of Mental Disorder (DSM

:DSM- ,
1) Axis I:
Major depressive disorder

Alcohol Abuse
Axis II:
Dependent personality disorder
Axis III: Glaucoma

Axis IV: Threat of job loss
Axis V:
GAF- Highest Past Year = 60, Current= 35
2) Axis I:
Mood disorder with depressive features due to hypothyroidism
Axis II:
No diagnosis
Axis III: Hypothyroidism

Asthma
Axis IV:
Death of brother
Axis V:
GAF = 83
21

:I
(PSYCHOTIC DISORDERS) .I
(Schizophrenia) .1
(Schizophreniform disorder) .2
(Schizoaffective disorder) .3
(Delusional disorders) .4
' .5
(Major affective episodes with psychotic features)
' 5.1
(major depressive episode with psychotic features)
5.2
(Manic episode with psychotic features)
(Brief reactive psychosis) .6
.7
(Psychotic disorder due to a general medical condition)
.8
(Substance-induced psychotic disorder)
(AFFECTIVE DISORDERS) .II
(Major depressive disorder) '.1
(Dysthymic disorder) .2
(Bipolar affective disorder) .3
Bipolar I disorder 3.1
Bipolar II disorder 3.2
.(Cyclothymic disorder) .4
(ANXIETY DISORDERS) .III

(Generalized anxiety disorder) .1
(Panic disorder & Agoraphobia) & .2
(Phobia) .3
(Simple phobia) 3.1
(Social phobia) 3.2
(Posttraumatic stress disorder) - .4
(Obsessive-compulsive disorder) .5

2
(PERSONALITY DISORDERS) .IV
Cluster A
(Paranoid personality disorder) .1
(Schizoid personality disorder) .2
(Schizotypal personality disorder) .3
Cluster B
(Antisocial personality disorder) - .1
(Borderline personality disorder) .2
(Histrionic personality disorder) .3
(Narcissistic personality disorder) .4
Cluster C
(Avoidant personality disorder) .1
(Dependent personality disorder) .2
(Obsessive-compulsive personality disorder) .3
(Passive-aggressive personality disorder) - .4
23

DSM5 .
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26 )(PSYCHOTIC DISORDERS
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27
) SCHIZOPHRENIA .1 28(

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.1 ,
.2 , , .VDRL ,CBC ,B12 ,TSH ,
.dsDNA ,ANA ,
.3 .
.4 CT - .EEG-
.
) SCHIZOPHRENIA .1(
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.
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.
- Social Causation Hypothesis

.
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) SCHIZOPHRENIA .1( 29
:
- Stress diathesis hypothesis .1 ,
) ,( ) ,( .
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.4 :Expressed Emotion -
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Subtypes of schizophrenia DSM5
DSM IV- , :
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. ) - (DSM IV ) ( /
. , , .
.
) (hebephrenic) disorganized type .2-( : )> (25y
. -
. DSM IV -
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) residual type .5( : , /
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DSM - -
) simplex schizophrenia ( :
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postpsychotic depressive disorder
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.
35
( )SCHIZOPHRENIA .1 36
Good Prognosis
Poor Prognosis
Late onset
Young onset
Obvious precipitating factors
No precipitating factors
Acute onset
Insidious onset
Good premorbid social, sexual, and work
Poor premorbid social, sexual, and work
histories
histories
Mood disorder symptoms (especially depressive

disorders)
Withdrawn, autistic behavior
Married
Single, divorced, or widowed
Family history of mood disorders
Family history of schizophrenia
Good support systems
Poor support systems

Negative symptoms
Neurological signs and symptoms
Positive symptoms
History of perinatal trauma

No remissions in 3 years
Many relapses
History of assaultiveness
, ,10 :early onset SZP-

. ,
: DD
amphetamine, hallucinogens, belladonna alkaloids, alcohol
: .1
hallucinosis, barbiturate withdrawal, cocaine, phencyclidine (PSP)

. .2
( ) , .3
,- , ,B12 , , .4
.' SLE
,brief psychotic disorder , ,- - .5
,OCD , , ,malingering ,factitious ,delusional disorder
,- , ,
.
:
, , , , .1
. ,
, " . - - .2
, .' ,
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) Perphenan- EPS ( .
.
60-70%- . ,
" 80%-.30%-
" 6-8 . 4
/ .
** " , ".
** , " .
' - ) ( , )
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.3 - , ,
.
: , , ,
, , / .
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: .
) ( ;
, .
. .
, ;
, .
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, .
. , , ,
, ,
. ,
, - ,
, .

37
) schizophreniform disorder .2 38 (
) schizophreniform disorder .2 (
) (
6- . 6-
, .
) ( .
. .0.2% - .
:DSM IV - Schizophreniform disorder
.A E ,D,A .
.B ) , (
6- , .
With/without good prognostic factors : 2:
) 4
(

) (
-
, , )
( . .
= .
: , inf. frontal region- .

:
60-80% . .
. .
, .
, 6.
:D.D
-
Substance induced psychosis
- 3-6 .
.
ECT-
) Schizoaffective disorder .3 ( 39
) Schizoaffective disorder .3 (
, ,
. .0.5-0.8% - ,
.M<F .

.
' ) (.
, ) mood congruent (
) mood incongruent (.

) ( .
: DSM IV - Schozoaffective
.A - ' , ,
A .
.B
- /
.
.C )= (15-20%) (DSM5 )
(.
.D .GMC/
*** Bipolar : Depressive
:DD , , , ,
.
:
:
- ) /( , " .
.

ECT
SSRI-
- - , .
39
) Delusional disorder .4 40 (
) Delusional disorder .4 (
) . (DSM5
. : 0.03% -
) 40y 18 (F>M ,
"
- ,
- 1/4-
; 10%- .
)(/
. .
: .
.
- :
, -
: ,/ ) ,( , ,
, , ) -(,
.
- .
) ,(Othello syn ,conjugal paranoya , , ,.
) Delusional disorder .4 ( 41
- Dilluzional disorder :DSM IV
.A .
.B A . .
.C , .
.D ,
.
.E .
:
. . , , ,,
, , ,.
. , .
. ) -( ," , .
. " ,
, , , .
Paradoxical Conduct "
. , F "
.M , ,
. -
" ," .
. )( .
. , , )
( , , ) (.
.
. , )
-( , )
() Lyncathropy , () Heutoscopy , (,
/ ) -
, , , (
41
) Delusional disorder .4 42 (
) (
.1
.2
.3 !!!! " " , .
projection ,denial ,reaction-formation :
:D.D
-
, ,sympathomimetics ,L-DOPA ,'.
][BPSD
Somatiform disorder

OCD
Paranoid PD .
Factitious or Malingering
50% ; 20% 30%- .
: // ,F ,>
,30y , , , ,
) (.
:
:
o
o
o
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6
"
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. ,
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.
.

) Delusional disorder .4 ( 43
) Folie a' deux ( DSM5
2 ; .
. . :
, , , .
, , . "
. " )
(.
: -
" " .
.
43
) Brief psychotic disorder .5 44 (
) Brief psychotic disorder .5 (

, ,
. -.
- , ,
.
,
, . .
: , ) ,F ,(20-30 , -
.

- Brief psychotic disorder :DSM IV
.A (1) : (2) , (3), (4) , .
.B , .
.C " , ,
, ) ,( , .
,brief reactive psychosis .postpartum ,
: , , ,,
.
:DD
: , ,,
.
mood disorders
NOS
Factitious or malingering

:
" , ) ( 50-80% -
' .
, , .
50%- ) ,SZP (.
) Brief psychotic disorder .5 ( 45

- - , -
, , , ,
, , , .
- .postpsychotic
" ) high potency ( .BDZ-

.
-
, , .
45
) Brief psychotic disorder .5 46 (
.6 ) NOS Not Otherwise Specified DSM5

:(Not Elsewhere Classified NEC
IV DSM ) , , ,
( contradictions
.
:NOS
Post partum psycosis ." .
. DD- )!(.
. 1-2/1000 .
) MDD .(BIP- .
- , .
. ,
.
.
. Brief psychotic
.
.
. ,
, .
Post-partum depression
Baby Blues
-
30-75%
10-15%
3-5
3-6
/?
'
"
.II )47 (AFFECTIVE DISORDERS

.7

,SLE ,HIV : ) ,(CPS .
, )
( .
: ) ,LSD , ,PCP ,(.
)(
, ,
, ,
"
"
47
.II 48 )(AFFECTIVE DISORDERS
.II )(AFFECTIVE DISORDERS

(MDD) Major depressive disorder
dysthymia.cyclothymia-
MDD -:
.1 :
. NA- NA- NA . , .
down regulation-
)
(.
. NT- . .
.
) ( ,
.
. ) ( ,
, ,GH ) ( , .
Kindling . -
. ,
Kindling - . "
.
.
Circadian rhythm
.
.2 50-70% " . mood disorder

10-25% 2 . " .
.
2-10 , MZ - .50%
- ) 2 BIP I - 1
,MDD 3 BP- 2 MDD- .(BP
- ) (
8-18 , MDD - 50%- Bipolar I - )" (MDD MZ - 33-90% ) MDD : " ( , ,- , ) 21q ( .3 -:
.
- . ,
, '.
.II )49 (AFFECTIVE DISORDERS

: )
( .11
. ,OCPD ,(.
.
Learned helplessness . .
" -"
.
" "
.
. : ,
; ; .
.
.4 - " " .
;oral phase- . Abraham
) tyrannical superego(
.euphoric self satisfaction-
.
- ,
.
Episode Disorder :
, , "
.DSM- , :
.A Moderate ,Mild .Severe
.B ) Psychotic features , , , '(.
.C Mood congruent .Incongruent
.D .
,Disorder 3:
.MDD .1
.Bipolar I .2
.Bipolar II .3
49
50 )(Depressive disorders
)(Depressive disorders
) Depression( - (1 :
) ((2 ,
. , , .
DSM IV- - 2- :
.1 '
.2
) MAJOR DEPRESSIVE DISORDER .1 '(:

) (major depressive episodes
] )
( , ) ( , , ,
[; ) ,
, , , (;
) , ( .
) vegetative symptoms (
.
: ,17% 25% ,1.59% - .F- 2.F-
,20-50y .40 20
. , .
, . ,
.
:DSM IV Major depressive disorder
.A 5 9 , 1 ;2
) : DSM5 (1-2
.1 , .
.2/ , , .
.3 ) (5% . .
.4 )( ) ( .
, . .
*** 80%-.
.5/ .
.6 *** 97%-.
.7 .
.8 /.
.9 ) ( , , *** .
2/3 , 10-15%- .
.B ) .Mixed episode - specifier(DSM5
.C /.
.D ) ( )(.
.E ,
, , . DSM5
)51 (Depressive disorders

DSM :
.1 +
.2
.3 , +
/
.4 , /
) , , , ,( ) , ,
(.
:
) melancholic( : / + (1 :3
(2 , (3 ,/ (4 ,
) ((5 , /(6 , .
" -.
) atypical( = :hysteroid dysphoria ) /(
+ (1 :2 / (2 ,(3 , /
)(4 ,(leaden paralysis .
** . ' : ,
, / / .
.
, ,BP1- .
: - / ,/ ,
/ ,/.
-
2 Recurrent depression ' ,

. .
Chronic depression
) Postpartum onset -( - ' 4

." .
: , , , .
MDD
o
50%- .
2/3 10-15% , .
) (97% ,
. .
90% .
51
o
50% Diurnal variation

, ) ( .
.
50-75%- = :Pseudo-dementia
, . .
** ,school phobia-
, ,substance abuse , , ,
,.
** .underrecognition
" ,"Raising like a fog

,
, , ,
. " " "" ,
, .
: ) (slow wave) increased nocturnal arrousal-

, , ,REM ' (
REM latency
:
o
-Alcohol abuse/dependence OCD ,panic disorder ,social -

anxiety disorder .
mixed anxiety depressive disorder
* M-
* F-
** ' - M- , , ADHD-
** ' - F- , , - -
- -
- .
.
: ,MI , , , ) (
DD :
.1 , .
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.2 :
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.SSRI- , ,
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o
= ,
= , TMS ,ECT ,
:
.1 , / , . .
.2 .
: ," ) 3-4( . 6
) (.
- Anti-depressants :
SSRIs . " , / ."
) 5HT2 ,
,( GIT) 5HT3 , , ,(** .
53
SSRI- , , ,
.
TCA . " : )
,(1 ) ,(M1 ) .(H1
, .
.
SNRI
MAOI . . 2
MAOI) Phenelzine ( MAOI) Moclobemide - RIMA/
(.
" : , , , ,
** - " ) MAO(.
.(DNRI) Bupropion (Zyban) .
.
- (SNRI) Venlafaxine/Effexor :
- Nefazodone , ,(NaSSA) Mirtazapine ,
- (NRI) Reboxetine/Edronax .
SSRI- TCA .'1 "

SSRI .
, 4-5 .
. .
" SSRI- TCA- "" . ) ( - 4-6 .

:
o
- ) 7-14-( ,,
.
MAOI + TCA ; " ,

'1 '2 .'3
- ECT .3 / ,
) ( -
.4 -
.5 - -CBT , , ,
, .
** :CBT , ,
.
** : ,
) (depressogenic schemata
" . - (1 :
(2 , - (3 , -
. .
:
-
: , , ,
50%-
, -
4- ) (+ , 3
5-10% =
20 - 5-6
5-10% MDD 6-10

. Switch - .32
MDD , 25%
" , ,30-50% 5- .50-75%
1-2.
70%- , 30% 30% .

.
, , ,
, , ,
/ , ,
.
55
) Bipolar disorders .2 56 -(
-
, , ,
) M , (.
) Bipolar disorders .2 -(
) I (II- 1%
onset- - ) 30y (5-50
BP ,11
BP .
,F=M M-
- ,
.
) (84%
75% - ; 75%
BIPOLAR I
) .(manic episodes
.
! , ,
. - .MDD-
Manic episode" :DSM IV
.A , ) (.
.B - 3 4) 7 (:
. ) (.
. .
. .
Flight of ideas . ; .
. - .
. ) , ," ,( .
. , ,.
.C ) Mixed episode , '
, . .(GMC
.D / .
.E )(.
DSM IV :
.1
.2
.3 , "
.4 , /
) , , (.
) Bipolar disorders .2 -( 57
= .
2 ) = (BIP I disorder, recurrent
. :
Rapid cycling .1 ,BIP I/II - ,F- . 4
, , .Mixed 2
.
' " BP" . "
.
Seasonal pattern .2 )" (
BP - DSM4 :
, .
: ;
, / , , , ,
,OCD ,
.
, .BP1-
:MDD-
: , , , , -,
SAD ,
:
-
Relapse -
.1 .MDD
.2 " ) ( .
.3 .MDD-
) ( . "
-.
.4
) Lithium .i ( - , .
, .
- Valproate/Depalept .ii ;'1 ".
.Carbamzepine /Tegretol .iii
* Rapid cycling Bupropion - (CCB) Nimodipine
57
ECT .5 .
.6 /.
Guidelines )(:
:
// .
- ,
.
/ + ) -(.
, .
CI : ,
.
:
- ) (
.TMS ,ECT
+
. " STEP-BD
. .
Switch.
- -
.
/ .ECT
:
-
) 70%- 67%-(.
, 10-20% .
: ' . - 3-.
. 5- 6-
9.
" 9 ).(2-30
BIP I .MDD 7%- 50% .

40% . .
15% - 45% , 30% ,

10% , 1/3 .
.
50-60% .
) Bipolar disorders .2 -( 59
-
, ,
, )/(.
- , ,
, , ,mixed .M ,
BIPOLAR II
Bipolar II - ' , ,
. .0.5% - BIP -
,I ) .(MDD-
, .
Hypomanic episode" :DSM IV
.A 4 .
) ( .
.B - 3 7 ) 4 7
(.
.C , ) , (.
.D /.
.E / , .
.F .GMC
:
.
. BIP I .BIP II

.1 ,
. ." .
.
.2 , 50% .
.
.3 .MDD with psychotic features-
.4 ) mood congruent , , , ,
( . MDD with psychotic features-
) ( .
.5 "" . 50-75%-
.depressive pseudodementia
.6 , .
.
.7 .
.8 .
," .
59

.1 , , .
.
.2 , " ,
. . .
.3 ,loud , . . ,
, . ,clanging ,flight of ideas
.
.4 75%-.
.5 ) mood congruent , , '(.
.6 .
.7 - 75% . .
.8 , .
.9 , .
:Mixed episode
.
) ( .
, F-
2 :DSM-
- Bi polar 3
- Bi polar 4 ' -
- )(bipolar I / II disorder
:
. , ,
".
severe mania/ . ) /( +".
less severe mania / . .
" , "
".
-:
) (manic switch " . , " ,
.
'1 ) Lamotrigine ( . .
".
61 DYSTHYMIC DISORDER
):(relapse
) ,( ," .self medication -

4) rapid cycling - (.
) ,(stressful life events' - , .
) :(maintenance 1/2 relapse -

.
DYSTHYMIC DISORDER
' , . ) inadequacy/(,
, . .
(1) : < (3) insidious onset (2) ;2y /.
: .5-6% ,F- , .
.MDD
- late onset .20 ," .
DSM IV Dysthymic disorder
.A , , - " .
) (.
.B 2 :
.1 .
.2
.3 .
.4 .
.5
.6
.C .B A
.D ,MDD MDD ) (
.E ,mixed , . .cyclothimia
.F
.G
.H , .
" : ,
.inadequacy-
-:
-
) MDD ( double depression
substance abuse
61
DYSTHYMIC DISORDER 62
:DD
o
Minor depressive disorder .

.MDD
: ] , SSRIs ,[insight-oriented ,interpersonal ,
.
Recurrent brief depressive disorder )

( , , .MDD
Double depression :MDD + 40%- MDD

. MDD- . : 2-,
MDD .
:
-
.
50% . .25
20% .bipolar 1 - 5%> ,bipolar 2 - 15% ,MDD
10-15% 25% , recovery.
:
,CBT .1 .
.2 ) ,SSRI (MAOI
.
.3 ,
.
) CYCLOTHYMIC DISORDER .4(
- ,2 " mild -
.depression DSM-IV-TR- ,
. ,BP2- "
'.
, , .BP1-
.
lifetime 1% -
3:2 = F:M
63 DYSTHYMIC DISORDER
-
50-75% onset 15-25y
30% - .BP1
BP2 " 3(1 :1/3-
'(2 ,
-(3 , 60%- .
-
.
- .
- .
.
"
.
:
: , .
.
DSM IV CYCLOTHYMIC DISORDER

.A ,
,MDD ** .
.
.B A- ) (
.C ' , mixed
.D
.E
.F , .
:D.D
- , ,
-
,- ,
ADHD Trial .
ADHD .

-
, moody-.
onset- 20- .
.
63
DYSTHYMIC DISORDER 64
-
1/3- ' , .BP2
: - '1 - ,
carbamazepine .valporate- - , 40--
50% - .
- :
. ,
. .
.III 65 ANXIETY DISORDERS
.III ANXIETY DISORDERS

) Normal anxiety ( : ,
, ) ,,
(.
.
: ,
, .
) Pathological anxiety ( :
, ) ( .

.
- .
, , .
- , , .
:
.
) coitus interruptus-
( . , ) (signal .
-
. , - ] ) (repression [ .,
. ,
) (
.
.
,
.
)
(.
15- , , .
- ,
, .
: - GABA
NA ) Limbic system & Cerebral cortex - -
, , " ( .
.
65

, .' -
, ,
.
.
;
,
.PTSD , .
, ,
) CNS- ( PNS .
-
. ,
) ;(anxiety tolerance
.
,
, ,
.
,
. )" (:
. ) - (disintegration . ) (self
)
(.
. ) - (persecutory "
). (Annihilation
.
. .
. - , ," ,
.
. - , "
.
" .
.

, :
.1
.2
.3
.4 " , ,
.5
.6 ,
.7 ,
" .8"
** -
) PANIC DISORDER & AGORAPHOBIA .1 & (

: ,1-4% - Panic disorder .3-5.6% - panic attacks
) F- 2-3 ,(M- ) 25y (.
: ) ( ,
) .(4-8
- 50%- .PD-
+PD - PD .
.2-6% -
EEG : 25%-
:
.1 ,
, GABA // , 2
.Locus ceruleus
panicogenic substances) THC :( "
, ; ,
.CO2 , -
.
.
.2 - )
" ( )
(.
67
Panic attack DSM IV

, 4
10 ] - DSM- 20-30
[:
o ,
o
o )(trembling or shaking
o
o
o
o/
o/ /
o
o
o
Derealization o depersonalization
o ,
spontaneous .situational
,Panic disorder - ) (!!!
:DSM IV Panic disorder with/without Agoraphobia
DSM5
.A :2 + 1
.1 .
.2 1 ) ( ) ( :
. . ) , ( .B ) ".("Panic disorder with or without agoraphobia
.C .
.D , ,PTSD ,OCD ,
Panic disorder - " , ,

.
, ,
, .
) (
.PD
) Mental status- , ( .
) ( 20% .
. -.
.
.
Panic disorder - Agoraphobia
) No escape- , , , ,( .
) (safe person ,

, . .
.
, ;Panic disorder Panic
disorder .
3/4 ;0.6-6% - .Panic disorder -
.
.
DD : ) ( , )
(.
PD ;
.
: ;
.OCD
,sepatarion anxiety ,IBS :Panic disorder- chronic ,
.fatigue syndrome
DD :Panic disorder
.1 ) CVS , ,( , )( , ,,
.
.2 ) ,( .
.3 ,BZD ,.
.4 B12 .
.5 ,PTSD , )
) Malingering ,(30-90%- () Factitious , ( ,.
:
-35% -50% , -10-20% , .
: - , , , .
,
, .
:
.1 91%- 84%- - .
10-15% .2 1/3 . "
.MDD 40-80%- . .
.3 /
) ,(30% ) ) PTSD ,(20% ) OCD ,(10% .(30%
.4 , ) 20-40%
(.
69

.CBT + SSRI :
: " paroxetine FDA -alprazolam-
) SSRI ( .BZD
paroxetine ) fluoxetine ''

( BZD . - '1 SSRI .
Relapse 30-90%- .
) '2 () TCA : () MAOI , SSRI
TCA (
) ( . .Effexor
, , CCB ,.
, .
: .
) (
) (.
,
, in vivo )
(
: ,insight oriented ,
) (:
.1 - , :
SSRI . 2-3 .
. .
.(TCA) Clomipramine/Anafranil . )
(OCD-
.
BDZ . Clonex . '1-

PD SSRI- . 4-12
BZD- .SSRI -
.BZD
" : , , )(.
." OCD) PTSD- ""(.

(SNRI) Venlafaxine/Effexor . .GAD- PD -
.
.
) Buspiron( ; 5HT1A .
.GAD-
, 8-12.
.2 )( : CBT :
2:
o
- False believes ,
.
.
, , , .
,
. .
-
,
- .
Systemic desensitization
.
. -
BDZ .
habituation
. .
12 :
"" 1-2-
" .
o
.
. .
. .
. .
.3 OCD ,PTSD- panic ,.
) PHOBIA .2(
- , .
- , .
, , .
2-:
) simple phobia ( - ; -:
- acrophobia
-ailurophobia ,agoraphobia , ,
-algophobia -androphobia , -claustrophobia , ,

-cynophobia -gynophobia , -pedophobia , .
) social phobia ( - -
. ,
, ' .
.
71

:
.1
Provoked .2
Ego-dystonic .3 . .
.4 safety behavior-
Anticipation .5 .
: ) 5-20%
( . F-
:
.
Conditioned Emotional Reactions " "

,
)
(.
.
,

.
- .
:
o
)(
: , , ,
.
Specific phobias
.11% - : ) (5-9 natural environment
,type 25 situational type

:DSM IV Specific phobia
.A , , / .
.B ) (.
.C ) (.
.D .
.E// .
.F 18 6.
.G ,PTSD ,OCD , ,
.
*** . " " , , ,
, ,/ , ) , , ( , .
:
.
. )
( / )
(.
, - ) 60-75%-
(.
** //
- )
" ( .
.F=M
:DD) OCD , ( , )
( , ) -(.
:
-
-50-80% , .
.
, .
: ) CBT - -" systemic desensitization

) -( flooding ,.intensive exposure ,
: , ,
) (.
-insight oriented .
) (BZD ,BB .
- , .
Social phobia
.3-13% - social phobia ,
. ,F- M
73

) ,
( . interaction-/
performance- .
- Generalized social phobia
, .
. .
' , .
: ) ( ,
) / NA- , (
) 3 (.
:DSM IV Social phobia

.A
. .
.B-G .
, ' ,
, , .
*** ) Generalized ( .
,(!!!) blushing : , , , , '.

: , ) 1/3- ,(MDD
) - (..
.Generalized social phobia
:DD) Cluster A , ,( , .
- - :
.1 .social skill training ,CBT
.2 SSRI - ,'1 Efexor ,BZD ) Buspirone
.(SSRI- .(MAOI) Phenelzine BB
.
SSRI 12-14
performance SSRI-
) BB-( (short/intermediate acting) BZD ,
CBT.
75 (Obsessive-compulsive disorder (OCD
Obsessive-compulsive disorder (OCD) .3

) -( DSM5 .
2:
) obsessions( : , , , ,
. " - ) ( .
.
) compulsions( : ) (
," )( . ,
.
OCD - ) ( , ;
- . .
.
: 2-3% - .M=F , .20y
19) M- 22 .(F- .
4- , , .MDD-
:
.1 , , ' ,
) 35% (.
.2 .
.3 .
4 :
.1 ) , '( -
) (
" " .
, .
.2 . :
.
.3 , .
. :
.
.4 . .
DSM5 Hoarding disorder
.5 )" (
. : ,
.
75
(Obsessive-compulsive disorder (OCD 76

: < < < < < < <
: < < < < / < <
: ) ,(67% ) ,(25% ) ,(20-30% ) (5-7%

- ,GAD , , , OCD .-
OCPD 2 . .HIV
OC spectrum :OCD-
.1 ) Tourette syndrome AD M-
F- .(OCD- .chorea
.2 .Hypochondriasis ,Anorexia nervosa ,BDD :
.3 ) Trichotillomania DSM5 ,(impulse control
.sexual compulsions ,pathological gambling DSM5 Excoriation
) (
:DSM IV OCD
.A :
1 :4
.1 ,
.
.2 , .
.3 ,
.
.4 , )
(.
1:2-
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" .
.2 ,
.
.B ] .
![
.C , ) (
, .
.D ,1 )
, ,
'(.
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*** With poor insight

:
-
50%- , 50-70% - ,
. 5-10
.

-
" ;
-20-30% . -40-50% , -20-40% , /
.
1/3- '.
, .
- ,
, .
- , , ,
MDD ," , , " ) ( ,
) Overvalued (.
** !
" : -
, , , , , -
, OCD - Sydhenham's -
,Chorea - " " , -
.
: , - .
.1 .
. - . - , ,
, .
.2 :
o
SSRI - '1 3-4 , 6-8

(TCA) Anafranil/Clomipramine .
-'2 ) , ,(
" - ) ( - SNRI ,buspirone ,MAOI ,
50-70% . psycosurgery/ ECT

. / . .
- )(OCD
,SSRI .
) Clomipramine (Anafranil) TCA

(.
" )
-(.
..........................
77

:OCS-
, .
:
NT- .
,
.OCD
.SSRI - CSF- OCD - 5HIAA
. OCD- -
" .
- ,caudate-
:
o
OCD- ) Caudate nucleus-

.(Putamen-
.
OCD
. OCD- ,Caudate-
) PET (.
- Orbitofrontal cortex ,
Cingulate gyrus- , .PET-
.cingulum-
.
OCD.Temporal Lobe Epilepsy -
Thalamus
OCD -
.
40% - . OCD- 3-5

,GAD) OCD-,
,BDD , , ( . "
.DSM 5-
EEG - ) REM Latency -

REM REM(.
Pediatric AI neuropsychiatric disorder associated ) PANDAS AI

(with streptococcal infection 1-3 GAS,
OCD- . .
10 ,OCD 10 .
,
. 7 X
7 .
) 7-'( , .
, ' ,
.
OCD )
( , ,
.Doing & Undoing
OCD
OCD-
) X Y ( .
, -
.
OCD - OCPD- ,
. OCD
-
.OCD 15-35% OCD
-.
) GENERALIZED ANXIETY DISORDER (GAD) .4 (

-,
, ' . ) ""(
- , , ,- , , , , ,
, , , - .
, .
5% :' , 2 25% .F- . 6 25% .
1 .
: 50-90% - "
PD , ) % ,(MDD .
25% PD GAD PD- .
:
.1 ,GABA- ,NE , .CCK-
79

.2 2 : -
GAD- .
,
.

.3
: GAD (1 (2 ,
) , ((3 , )" , , ,(GI
(4 ) ( .
.
:DSM IV GAD
.A 6 .
.B .
.C 3:
.1 .
.2 )(easily fatigued
.3 .
.4 )(
.5 )(muscle tension
.6 , .restless
.D 1.
.E , .
.F , ,Mood.PDD ,
:D.D
: , ) , , '( , , ) ,MS , ( , - . PD
: ,PD,MDD ,OCD , .PTSD GAD -
" . GAD
, /
. - , , ,
, ADHD ,.
: 20- - 1/3 ,
. .
--:
) PTSD .4 -( 81
.1 ) insight oriented -CBT ( .
.
.2 3 :GAD-
BZD .a . 75% .
2-6 . .
] - SSRI .b ' .[SNRI
. ) -fluoxetine (
.BZD BZD BZD-
60-80% . .
6-12 ,
, .
) Buspirone .c ( )
,(BZD- 2-3
BZD .
-Effexor .d , ,
) PTSD .4 -(
.
. ,
. ,
.
, - M- , - F- ,.
DSM IV Acute Stress Disorder
.A
- 2-:
.1
,
, .
.2
.B
, )(horror
- , 3 :
.1
, , .
.2
)" "(
.3
.4
.5
) (
.C - : ,,
, , , ;
.
.D - ) , , , , ,
(.
81
) PTSD .4 82 -(
.E - ) , , , ,
, (.
.F , , -
, "
.
.G 4 , 4 .
.H GMC/ " brief psycotic disorder
1 .2
DSM IV PTSD
.A , ) . DSM5
, ( 2 :
. , , .
.
.
, ) (.
- DSM5
: , , , , )(.
*** , Acute stress reaction
.
.B/ ) ( :
. , , )
( . .
, , .
.
) (.
,
, , /
. .
. .
.
18 6 . - . DSM5
.C ) (Numbing )
( 3- :
.1
, . .
.2
, .
.3
.4
.5
.6
) (.
.7
, , .
) PTSD .4 -( 83
.D ) ( 2-
:
. .
.
.Hyper vigilance
. .Startle response
.E . " :
. 48h- .
.
ASD 4 ) . 4 (
Acute PTSD 3.
Chronic PTSD 3.
Late onset PTSD . 6 .

DSM5
.F ,
.
PTSD - " .
PTSD .
-
: ) ( ) (.
" : Acting out) Traumatic play ,

" ( , /.
: , , .
: PTSD .9-15% - 8% -'

, 5-15% PTSD ) (.
.(5-6%) M < (10-12%) F
- .
, , , , .
: , . .PTSD -
2/3 : 2 : , ,
, PTSD .BP .
83
) PTSD .4 84 -(
:
.1 PTSD- ,
) , , ( , / ,F ,
, , "
" , .
.2 .
.3 -
;
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2 (1 ) (
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. )
,( .
.4 NA , , HPA-
.CRF
:PTSD-
= ,
, .
o
. PTSD
) PTSD
(.
, , -
,
.PTSD

.
,
.
.
.

,
.
) PTSD .4 -( 85
.PTSD-
: , ,
** . .100% -
.
o
, ,
.
-

) " , " ""
(.
.
= .
: PTSD- ; ,
. PTSD- :
.1 PTSD- - Prolonged exposure(1 :

) ) (re experiencing In
.vivo , ,impolsive therapy- , systemic -
.(desensitization - ; (2
stress
-management )
( - .
(eye movement desensitization and relaxation) EMDR ;

).(mental image
.
- "
. .
-" .
,
.
.2 :
.sertraline ,fluoxetine ,paroxetine SSRI . '1
.PTSD" ) TCA , ,(MAOI ,trazodone ,
)(phenelzine
. , , .
.
/ , .
85
) PTSD .4 86 -(
." - ""-
.
Topiramate . ; .
* BZD vivid -
dreams . .
BZD .PTSD -
)( /" .
PTSD : ; 30 .
.
-
-
30%
40%
20%
10%
50% - .
: , )> 6( , -
, , ,
/ ) (.
, .
* PTSD 90%.
* 80% PTSD 1-2- ) 30%(.

. ,
. ,
, ' ' ) CV- , ,
(.
:Complex PTSD .
75% . .complex PTSD
) PTSD .4 -( 87
SSRI ,'1 BZD

) /S- /NE-(.
,SSRI - ,
.
BZD " ,
, .SSRI -
BZD 3 . - ,
,BZD - .
BZD - t1/2 , ,
.
87
.IV 88 PERSONALITY DISORDERS
.IV PERSONALITY DISORDERS

, ,
. , ,
.
- .
10-20% . ,
.
, .
, )-
(.
)
3- - , ( .

.
, , ,
, .,
,
.
3-:
Cluster A .1 : , ,.
Cluster B .2 : , , , .
Cluster C .3 : ,.NOS ,OCPD ,
:
.1 :
. .MZ-
. Cluster A- ) (.
.
B - C- .
.2 :
. , .
. MAO- ) (.
.
Smooth pursuit eye movements /

.
. .D ,5HT ,
EEG . .
.3 " .
; , .

" ,
, .
; , , , ,
-
.
.4 ,
** : , , , ,
, , , ,/.
:
Fantasy .1 , . eccentric
ways . Dissociation .2 .
; "" ,
. .
- Isolation .3 ,
.obsessive compulsive personalities-
Projection .4 unacknowledged .

.
Splitting .5 . .
.
" " . .
Passive aggression .6 .
,self-demeaning , '.
Acting out .7 , , ,child abuse , .
Projective identification .8 .
First, an aspect of the self is projected onto someone else. The projector then tries to
coerce (force) the other person into identifying with what has been projected. Finally,
the recipient of the projection and the projector feel a sense of oneness or union
89

Personality disorder :DSM IV
.A .
2 :
.1 ,
.
.2 , ,.appropriateness ,
.3
.4
.B ,
.C ,
.
.D .
.E
.F .
CLUSTER A
.
)(A
:DSM ,
.0.5-2.5%
:
) (1 ,
,
'.
,M-,

,
.
; ) (2
; ) (3
; )(4
,
; )(5
; ) (6
; )(7
.
.1
.2

.
.3
BNZ :
)( ,
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/
-
,
, )
, ,(.
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.
)(A
,.
.
-

:DSM

-
:
) (1 ,
; ) (2
; ) (3 )
( ;
) (4 , ; )(5

;
) (6 / ;
.7.5%
) (7 , .
2.M-

!

.

.
.1 :
.
.2 :

.

.

.
:
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.

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)
( .
.
.

.
.

; "".
91
.
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,
,
,
-
.

.
3%.

.
33% MZ -
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:DSM

.:
) (1 ) (;
) (2

,

.
) , ,
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) (4 ) ,
, (; )(5
; ) (6
; ) (7 ,
; ) (8
;
) (9
, "
.
.2 :"

."
) (SSRI
/ ; ) (3
, ;
.1 :
.

10%.

.

.
- Cluster B ,
) (B

.

.

.
> 1%; 2-
16%
.
:
Mirroring

,

.
:DSM ,
,
:
) (1 ;
) (2 ,
, , , ; )(3
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) ( ; )(4
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.

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.
!

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-

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,

.
.
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; ) (8 .
.

)
.(mirroring ,
.2:
:Don-Juanism .sex addiction
)( -
.
- SSRI's
) (B
.
!!!
,
.
2-3%.
10-15%
.
.F-
:DSM
,
:
) (1 ;
) (2
; ) (3
; )(4

; ) (5
.1 :
-
.

,
,
.
; ) (6 ,
; ) (7 "
.2"
-
:
" ,
; ) (8
.
"
,
.
'
.
.

, ,
.
.
: ,
) (B

.
, ,
:DSM ,
,
:
"stable
object ,
"instability
,relations
) (1
;
) (2
:
;
) (3 :
;
) (4
1-2%.
: ,,
, , )
2 ,F-
.40
75%
(;
) (5 ,
, ;
,
.
.1 :
.
.
MDD
!!!
.

.
-DBT 24/7

.

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/
93
) (6 ; ) (7
; ) (8 ;
,MDD :
) (9
, .

)/ '(,

.

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,projective identification -
- ,

,
,
(
.
.
.
,Latency of REM :
,
TRH .MDD-
: ,
, .
,
,
,

,

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)
2(
,
".
,
,
,
.
.2 .
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,
;
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- Alprazolam/xanax
)
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)( -
.
-
)(B

,
.

:DSM
, ,15
:
) (1
.

.
.1 :
:
.

, ;
) (2
:
-

) ( .
;
) (3 , ;
) (4 : ,
;
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; ) (6 ,
- /
.15
.
,
; ) (7
/.
5%
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,

.
) , '(.
75% -
-.
+ 18
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conduct .15
-
-
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,
. .
:abuse
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)
(
/
,

) (.
EEG.
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, .
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) (C
,
,

,

.
:DSM ,
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, :
) (1
;
) (2
;
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;
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.
.1 :
insight
.

.
,oriented
.

.

95
;
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MDD

) ,
,
;

( .
2.5% .
) (6

,F-
,

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) (8
.

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,

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.
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.
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.
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.
:DSM ,
, ,
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) (1
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;
) (2
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.

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.

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,
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M-
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, ,
:
.

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.
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.

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) (1 , , , ,
;
) (2
;
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;
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;
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; ) (8 .

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,
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.

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) (SSRI
97
.OCD
.
:NOS
- - : . .
, .
. .
, . :"
/ . , BZD-
.
- : +.
,insight oriented - . .

. . .:
) ( .
- - insight oriented .

.
- .
. /
.
. .
.
-DSM-:
SOL
MS

,
.
:
" "
" "
" "
" "
" , "
99
100 Adjustment disorder
.V
Adjustment disorder
) (
. 3
6 .
2-8% - , 2.F-
) 10% ,5%( . .
) " , /
( . , - , ,
. .
:
. ) ,
(.
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o
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) : ,68% ,13%
,( 8%
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) ( ) (
.
.
" 3 :
.1 .
.2
.
.3 , ,
,
) (.
: MZ-

:
.
-
,good enough mother - winnicott

.
** Inanimate objects, such as a teddy bear and a blanket (transitional object), also serve as
a secure base, that often accompanies them as they investigate the world.
Attachment ,
. -
.
,
, ,Attachment ." ""
,
.
- Adjustment disorder " :DSM IV

.A / / 3 .
.B 1-:
.1 ) (Distress .
.2 .
.C 1 .2
.D .
.E , 6-.
*** ) Acute 6-( ) Chronic 6-(.
: , .
.
. DSM- :
- Adjustment disorder with depressed mood

, . MDD
. MDD .
Adjustment disorder with anxiety

, , . .
- Adjustment disorder with mixed anxiety and depressed mood

, ' .
- Adjustment disorder with disturbance of conduct

" . :
, , ,
, , , , ,
.
.Adjustment disorder with mixed disturbance of emotions and conduct
101
Adjustment disorder unspecified ,
, , '.
* , .
**
*** ) (.
DD:adjustment disorder-
.1 /
.MDD .2
Brief psychotic disorder .3
.GAD .4
.Somatization disorder .5
Substance disorder .6
.Conduct disorder .7
PTSD .8 PTSD-
. PTSD .
.9 / , .
:" , 3 . " .
:
.1 ," " ) Crisis intervention ,suggestion ,
,reassurance ( .
.2 , BZD ) ( ,
) SSRI ( " ) (.
,
) :(Elizabeth Kubler Ross
.1 ) (denial ,
.
.2 ) (anger , , . " ?"" ,
?".
.3 ) (bargaining X,Y,Z " .
.4 ) (depression .
.5 ) (acceptance .
.

" , ,
, . , ,
.
5 .
)(Mourning
4 :
.1 , .
. " -
) ( .
.
.2 .
.
-
) ( . .
.3 . , , ,
. .
.
.
.4 .
.
.
.
.
, .

,
) (
.
. .
103
104 Impulse control disorders

" " .

.
':

' . .
, .
, .
,
.
, .
, ,
.
'.
' .
' ,
.
- '.
Impulse control disorders

, . .
" , //.
Ego-syntonic ;
) .(Ego-dystonic , ) Impulse -
( .
.
: . :
.1 ,
) , ,(.
.2 )
( , , , '.
.3 - ) ( , ,
, . .
Intermittent
,,
,
/.
DD
Explosive
Disorder

.

)
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) M- ( F-
)
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.

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.
.
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, ,,
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-; -;
.
.
.
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.
;
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F ;50
.35

-:
105
DD
, .
insight oriented (1
.OCD
psycotherapy
.

)
(
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,,
social
contingencies
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ECT .4
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+ (CBT-
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Pyromania
.
.
/
.
.
)
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:;
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.
.
.

)
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-

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.
.
DD
Pathological
gambling
,
.
.1
5
,M-
:
.1 .
;F-
- .3%
.2
.
.3 .
.4
.
M-
:
, ,
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, ,
,.
.5
.
.6 ,
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.7
.
.8
.
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.
.10
.
.2 .

.
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:
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.
,
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.
GA .1 .AA

.
.2
.insight oriented

3
.
.3 .
CBT .4
.
.5
.,
.
:
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,
.
107
Trichotillomania
DD
.
.
.
>.1%
, -
;F .
"
.
.
: ,
, ,
,
) ,(OCPD-.
/.
"
.2-
(;
-
)(;
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)
(13
.
.Malingering : .
.1
.
.2
, ,
covert
desensitization,
.habit reversal
.3
.insight oriented
.4:
,
hydroxyzinie
) hydrochloride

(.
SSRI

.
SSRI-

.
.5 -
.
Impulse control
disorder NOS

Oniomania .1 ) (.
.Internet compulsion .2
109 Somatiform disorders

.Mobile phone compulsion .3
Repetitive self mutilation .4 , .
.Compulsive sexual behavior .5
Somatiform disorders
Somatization disorder .1
"
/ .
0.2-2% : 0.2% ,F- .M- .
,30" .
.
:
.1 . :
. ) (.
. ) / (.
. ) (.
** - , , . .
.2 .
.
:DSM IV Somatization disorder

.A 30 '
.
.B :
.1 4 ) . , , , ,,
, ,(.
.2 2 ) () . , , ,
(.
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, (
.4 ) , ,
, , , , , , ,
, , , , , (
1 .C 2:
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.2 ,
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.
; .
: , , , )
( , .
109
Somatiform disorders 110

. .
.
, .
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.
: 50%- ,MDD ,GAD ,,
.
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o

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.
.
: , , .
-
- .
20 .
80% 5
:
; , ,
. ) ( .
.
50%- .
.
) (.
-
) Conversion disorder .2(Functional Neurological Symptom Disorder DSM5

, CNS- .PNS-" .
:
(!) 1/3 .
11-300/100,000 . .F-

. 10 ) 35
( . , , .
: - .
,1 : , .
:2 ) " , ,( .
:
.1
. ) (
. .
.2 ;
, .
.3 / /
.
:DSM IV Conversion disorder
.A "
, .
.B
.
.C , "
.
.D " , .
.E
.F " / .
:
.mixed seizures or convulsions ,sensory symptom or deficit ,motor symptom or deficit
: , .
, :
Primary gain " .
Secondary gain ) , ,(.
La belle indifference . .
.
Identification conversion disorder
.
:DD
25-50% . !
: , ,MG ,Guillain-Barre ,MS ,
HIV ,CJD.
Somatization disorder
Hypochondriasis
111

Malingering or factitious
:" ) ( ,"
.95%- 6
50%- . .20-25%
: , , IQ , , ,
.
: - .
:" . - .
, .
.
Hypochondriasis .3 DSM5
.
.
,4-6% : ,M=F .15% , .20-30
:
.1 - 1
.
.2 - / .
.3 3 , .80%-
.
.4 4 .
:
, )
( .
) .(BDD-
.
6 , . 6-

.
- With poor insight .
" , /.
:DD

o
, ,
,MG ,MS ,.SLE ,
Somatization disorder
; " 30 ,F-
.
BDD ,
.
Delusional hypochondrial beliefs

. .
Factitious or malingering
:" - .
: , ,
, , .
.
:
" ; .
.
.MDD
113

Body dysmorphic disorder (BDD) .4
. .

.
-/ . "
, .
DSM5 .somatiform disorders

: ,15-30y .F- .
: ; .
DSM IV Body Dysmorphic Disorder
.A .
.B
.C " ) (
: )( , ) ( , ,.
/ , /
. 1/3-
; 1/5 .
:
< 90% MDD , 70%- 30%- .
,OCD .
:DD
o
)(Neglect
: " .
.
" .
: // .
-
: ) -SSRI's -(clomipramine TCA ,

50%- MAOI ,TCA . .
SSRI ,clomipramine , , "
/ .
CBT :
Pain disorder .5 DSM5

.
.
: 2 ;F- 4 .5- .
: ,
.
DSM IV - Pain Disorder
.A
.
.B .
.C , , .
.D , .
.E " ,
.dyspareunia
:

> 6
< 6
3-:
Associated with psychological factors o
Both psychological and general medical factors o
:Only general medical factors o !
:
.1 ; ;
; ;
, .
.2 .
.3 ;
.
.4 , " .
: " -.
-:
:
-
50% MDD
60-100% -.
115

:DD
-
/ - . - .
)Tension headache (not pain disorder
Factitious; malingering
:
) ,( .
: , , ) (.
:
-
- - .
- , , ,.
Biofeedback, hypnosis, exercise
: ) (TCA ,SSRI
Undifferentiated somatoform disorder

6
. 2 (1
(2 , .
Somatoform disorder NOS
;
) Pseudocyesus ( , 6-,
6-.
. - -
- . .
.
: , , ,
, / , .
) (.
Demographic and
Management
Epidemiological
Clinical Presentation Feat res
Diagnostic Features Strategy
Diagnosis
Somatization
disorder
- Polysymptomatic - Young age

- Recurrent & chronic - F:M = 20:1
- Familial pattern
- Sickly by history
5%
- Review of systems
profusely positive
- Multiple clinical
contacts
- Polysurgical
Prognosis
- Monosymptomatic - Highly prevalent - Simulation

incompatible with
- F>M
known physiological
- Young age
- Mostly acute
mechanisms or
- Simulates disease - Rural and low
anatomy
social class
- Little-educated
and psychologically
unsophisticated
Hypochondriasis - Disease concern or - Previous physical - Disease conviction

amplifies symptoms
preoccupation
disease
- Middle or old age - Obsessional
- M=F
- Histrionic PD - Physical disease

- Depression
- Antisocial PD
- Alcohol and
substance abuse
- Many life
problems
- Conversion
disorder
- Unconscious
- Cultural &
developmental
Unconscious
psychological
factors
Suggestion and
persuasion
Multiple
techniques
- Alcohol and - Depression

- Schizophrenia
substance
- Neurological disease
dependence
- Antisocial PD
- Somatization
disorder
- Histrionic PD
- Unconscious
- Psychological
stress or conflict
may be present
Unconscious
psychological
factors
Excellent
except in
chronic
conversion
disorder
Document
Fair to good
symptoms
Waxes and
Psychosocial
wanes
review
Psychotherapeutic
- OCPD
- Depressive
and anxiety
disorders
- Depression
- Physical disease
- PD
- Delusional disorder
- Delusional disorder - Unconscious

- Depressive disorders - Self-esteem
- Somatization
factors
disorder
Body dysmorphic - Subjective feelings - Adolescence/

disorder
of ugliness or concern young adult
with body defect
- F>M
- Pervasive bodily
concerns
Guarded
Therapeutic
alliance
Stress management
Psychotherapies
Antidepressant
medications
- Anorexia
nervosa
- Psychosocial
distress
- Plastic
surgery
addiction
Pain disorder
- Simulation or
intensity incompatible
with known
physiological
mechanisms or
anatomy
Therapeutic
Guarded,
alliance
variable
Redefine goals of
treatment
Antidepressant
medications
- Depression
- Depressive
- Psychophysiological
disorders
- Alcohol and - Physical disease
substance abuse - Malingering and
- Dependent or disability syndrome
histrionic PD
117
- Pain syndrome
simulated
- F:M=2:1
- Older: 4th-5th
decade
- Familial pattern
- Up to 40% of pain
populations
Motivation for
Symptom
Production
Therapeutic
Poor to fair
alliance
Regular
appointments
Crisis intervention
- 10% incidence in
primary care
populations
Conversion
disorder
Associated
Disturbances
Psychological
Processes
Primary Differential Contributing to
Presentation
Symptoms
- Unconscious
Unconscious
- Stress &
psychological
bereavement ( )factors
- Developmental
factors
Unconscious
psychological
factors
- Unconscious
Unconscious
- Acute stressor and psychological
developmental
factors
- Physical trauma
may predispose
118

.
.

.multiple personality disorder- ,
, .
,
.

, .
, " .
2 :
.i
- : .
.ii
- : . " ".
: complex partial DID fugue

.poly-fragmented DID DID
119
Dissociative
Amnesia
, " ,
" ,
.GMC
-
6%.
,F-
.

, .

.
:
- Localized ;
.

) (,

.
Generalized

"
Selective/Systemized
.
.

.
:

/BZD +

.

.
,
.
:

.CBT -
, ) ( ,
, , , ,
.
- .
:D.D
: ,,
:Post trauma ) 30-( .
- :Trans global amnesia , ,50
,
. ,
.
ASD/PTSD Factitious, MalingeringDissociative
Fugue
0.2%

"
-;

-.

DID-
) , '( . "
119
120
,
. ,
,
.
,
.
, .
.
:
.

) ,( ,PTSD
.
:D.D
MPD Malingering Dissociative
Identity
Disorder
)(DID
2
.
" ,
.
100%-

,
.

multiple
personality
"
.
SZP , .Rapid cycling
,5-10 2-3
.
:
.1
.2
.3
disorder
)(MPD
, , ,
' .
altered .
.
.4

.
- 3%
:
(1
Onset,
(2
.
,M-
5-9.F-
.3
.30y

.
66%
.
.

.
:
PTSD-
.
.
"" "".
.
+
/.
.
,PTSD ," .OCD -
:D.D
Depersonaliza
tion Disorder

. ,
.
- .
2 .
:D.D- :
2 .F-
" 40
) .(16
121
, /
/ / /
/ :
)( , / /
- ,CNS ,
, . -
.
'
-
NMDA-r

,,
.
) (LSD-

-
.SSRI-

/
'
)" ," '(
:
.
/ .
,
.
.
, .
:
,
,
,

.

).(SZP
Ganser syndrome
, .factitious disorder-
/ .
/ ,
,fugue , - , ,
, .
,balderdash syndrome ,nonsense syndrome :
syndrome of approximate
hysterical pseudodementia ,answers ) prison psychosis

, (.
: , ,,
, .factitious disorders ,
EEG - .
121
.(Pervasive Divelopemental Disorders (PDD 122
).Pervasive Divelopemental Disorders (PDD

DSM5 . Autism Spectrum Disorder
.1 .2 .
, .
PDD :
.1
.2
.3
.4
DSM-IV 5(3) ,Rett's disorder (2) ,Autistic disorder (1) :
.PDD NOS (5) ; Asperger's disorder (4) ;childhood disintegrative disorder
Autistic disorder

.
: .8:10,000 .3 3-5 ,M-
F- . .
4- : , , .
- Aiutistic disorder :DSM
.A 6 3- , ,1- 2- :3-
.1 2:
, , . . , . . .2 :
/ ) , (.
, . . . .3 , ,
:
. . ) (. . .B :3
.1 .
.2
.3 .
Rett's disorder - childhood disintegrative disorder
.C
123 .(Pervasive Divelopemental Disorders (PDD

, . ,URTI : , , , . , , .
:
o
: ,
, .
, . "
, .
,
. , .
: .
.
.
. . 50%-
. - ,
. .
: .
, , .
. ) ( .
. -
.
:
.
: .
. :
. .
: .
. , , . .,
.
:
mild-) 50-70 - 30% ,(severe-profound) 50-55 > IQ - 45-50%
.70< - 25-30% ,(moderate
1/5- .

.
islets of precocity
:Splinter functioning
D.D :
.1
.2
.3 :
.
.
.
.4 - D.D
:
.
.
.
.
.5
.6
123
.(Pervasive Divelopemental Disorders (PDD 124

, .Autistic savant -
) (.
70-75%- . ,
"" .
. ,
) ,( ' .

.
- DD :
o
) (
38
):(
2-510,000-
3-4:1
,
1.67:1 M-
)(
, ,
Echolalia .

, 70%

) > 15%(70-
)> .(70
grand mal
4-32%
2/3 : .
70 < IQ 5-7 .
: --:
.1 )( - - ;
Risperidal , ; SSRI
. Lithium .
.
.2 )(CBT
.3 , ,
125 .(Pervasive Divelopemental Disorders (PDD

Aspergers disorder
,
. - ,
, .
.high functioning autism
: .
:DSM Asperger's disorder
.A :
.1 , ,
.
.2
.3 , .
.4 .
.B , ,
:
.1 .
.2 .
.3 ) : , (.
.4
.C , .
.D ) : .(3
.E , )
( .
.F Specific PDD- .SZP-
:DD PDD , , - .
:
, ,
.
IQ : , .
: .
. - .
.
. .
Self- .
-sufficiency and problem-solving techniques
. .
Childhood disintegrative disorder

: " , ,
, ) "(.
125
ADHD 126
: ) ( + .
, .
Facilitated communication , , , .
.
: , , , , .
." , - ) - ( , ) "(,
,escitalopram , ,'.
Tetrahydrobiopterin- . ) ( 6
.
: '1 +.
Rette syndrome
a
is
)hyperammonemia
cerebroatrophic
terme
(originally
syndrome
Rett
neurodevelopmental disorder of the grey matter of the brain that almost exclusively affects
females but has also been found in male patients. The clinical features include small hands
and feet and a deceleration of the rate of head growth (including microcephaly in some).
Repetitive stereotyped hand movements, such as wringing and/or repeatedly putting hands
into the mouth, are also noted. People with Rett syndrome are prone to GI disorders and up
to 80% have seizures. They typically have no verbal skills, and about 50% of individuals
affected do not walk. Scoliosis, growth failure, and constipation are very common and can
be problematic.
: )
( , .
) breathing disorganization- ,
. (
PDD NOS
: . " . "
.
ADHD
/
. 6 ,
.7
3-5% - , 3-5.M-
: , ) (,
.conversion ,
127 ADHD
:
-
) Inattentive = ADD (
)(Hyperactive impulsive
)(combined
. - . .

Abuse- .
.
% ADHD
: -
,
, .
/ . ,
, , .
.
)
( - , .
, , .
" .
, ,
. .
"
. , ,
. .
,
.
127
ADHD 128
) ( : , , ,
, , , , ,
, .EEG-
AD/HD " :DSM
(1) .A ):(2
6 .1 6
) : DSM5 5(.
. . . , , . . / . . " . . 6 .2 / 6
:
:
. . . . . .:
. . ) /(. .B " .7 DSM5 .12
.C 2- ) , ,(.
.D , .
.E SZP , , .DSM5
.
30%- ADHD
11% C/I
14% conduct
34%
4%
:DD
-
Conduct
129 ADHD
EEG :ADHD-
: .
- - 15-20% .12y .
.
ADHD - .
:
CNS ) Methylphenidate(.Dextroamphetamine,
- Re uptake ,D D
)( - 3-4-
. .
SR 4-6- . "
. .
LA 8-10- , .
) (.
Concerta 10-12- .
.
10" ) 6 0.5" ( . 70--
90" 90" )" (.
: ," , , ,.
) ( . LA
- .
, , .
:Non stimulant
) (Strattera ,Edronax- Edronax.
) Clonidine (2
":
, , , , , ,
.
. -
, .
" , , , .. , .
- , , " .7-10d
,5%- .
.
129
ADHD 130
.
,
- D , .Prone
.
.ADHD-
.
0.2" ,
. .
, Abuse ,Upper-
ADHD .
, .
SSRI" .
!!! - :
, , .
)( : ,conduct ,25% -ADHD : ,.
131

Anorexia nervosa
" .
50% " .
.
F- .
: 10-20 ,F- 1% . 5%- .
.
" ,2- .10-18
: ) ( ,.
) ,(65% ).(26%) OCD ,(34%
: ) ( , .
- Anorexia nervosa " :DSM
85%- .
18 > BMI -.
.A .
.B / .
, .
.C- 3 , .
.DSM5
DSM5
.
:
o
) restrictive type (
) Binge eating/Purging /(.
: , ,
, ) ( , , ,
, ) Binge & Purge / (,
. .
, , , , .
/ /.
) ;(10% ) , " ,( ,
) ,ST-T - QT ( , ,GI-
, , , ,
, ) ( , , ) Purging
131
132
( CRH , , / ,,
) (.
:DD
.1 :
. - , , )
(.
.
.a )
( , .
.b , .
.c - ,
, .
.
.2 .
:
, )( .
.
. .
.
- 5-18%- .
30-50% 1-3.
" 25% . .
.
: , , .
: , , , , ,
) ,Obsessive-compulsive , , ,(,
.
: .
o
) ( .
, ' .
: 20% . 30% 2-
6.
- CBT - ,
. : ,
, ,
.
.Dynamic expressive-supportive psychotherapy
BL-/ . .
133
Families of children who present with eating disorders, especially binge eating or purging
subtypes, may exhibit high levels of hostility, chaos, and isolation and low levels of nurturance
and empathy. An adolescent with a severe eating disorder may tend to draw attention away
from strained marital relationships.
" "
" " .
: - . ;
. . " " TCA . ",
. .
: , , .
Bulimia nervosa
,
.
: 2-4% , F-.
" - .20
.
, )( , ,
,cluster B , .
133
134
,NA ,.
:DSM Bulimia nervosa

,A ":
.1 , )>( .
.
.2 ) (
.B ) , , ,; Non
purging (;
.C ) DSM5 ( 3
) 1-2(;
.D ;
.E .
" ) : ,,
, . ( . ) (10,000Kcal
. .
, , ) .(postbinge anguish
- , '.
) (.
- " , .
:
o
(80%) Purging ,
Non-purging
) ,( , ,GI
, ," /.
) , , (.
: .
5-10 50% . : , .
:
) CBT + ('1 ,
.1 / , ) "" ) (
. projection :CBT /(introjection-
.2
135
, , , - SSRI - " ) : .3
bringe-purge cycles- . .( MAOI
. /
.
, , :
/ ,( )
.
. ) ( - Binge eating disorder
- BED 30%
. 3 DSM5 .
DSM-IV-TR Research Criteria for Binge-Eating Disorder
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by
both of the following:
1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount
of food that is definitely larger than what most people would eat in a similar
period of time under similar circumstances
2. a sense of lack of control over eating during the episode (e.g., a feeling that
one cannot stop eating or control what or how much one is eating)
B. The binge-eating episodes are associated with three (or more) of the following:
1. eating much more rapidly than normal
2. eating until feeling uncomfortably full
3. eating large amounts of food when not feeling physically hungry
4. eating alone because of being embarrassed by how much one is eating
5. feeling disgusted with oneself, depressed, or very guilty after overeating
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least 2 days a week for 6 months.
The binge eating is not associated with the regular use of inappropriate compensatory
behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively
during the course of anorexia nervosa or bulimia nervosa.
:Night-eating syndrome
. .
. ,
( zolpidem )
.
135
136
:
) pica .1( - , , ' .
18 .
.
) rumination disorder .2( - ) ( .
.
.
:
137

Oppositional disorder
, ) ,(
. .
" . .
: ,2-16% ,M- .(M=F) F-
10" , .
" , .
: ,ADHD , ,
Oppositional disorder - DSM

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6
months, during which 4 (or more) of the following are present:
1. often loses temper
2. often argues with adults
3. often actively defies or refuses to comply with adults' requests or rules
4. often deliberately annoys people
5. often blames others for his or her mistakes or misbehavior
6. is often touchy or easily annoyed by others
7. is often angry and resentful
8. is often spiteful or vindictive
Note: Consider a criterion met only if the behavior occurs more frequently than is typically
observed in individuals of comparable age and developmental level.
B. The disturbance in behavior causes clinically significant impairment in social,
academic, or occupational functioning.
C. The behaviors do not occur exclusively during the course of a psychotic or
mood disorder.
D. Criteria are not met for conduct disorder, and, if the individual is age 18
years or older, criteria are not met for antisocial personality disorder.
, , ,.
- , , , .
- , , , ) ,
( . .
, , .
:
, '
,HD/ADHD ,Conduct disorder :DD ,
137
138
- , .
- .
25% : , , .Conduct disorder-
Conduct disorder
, ) (
. .
.
: Group type ,Solitary aggressive- .
) (DSM 10 +
.
ICD- :
)(
: .5%- .M-
9-16% M- 2-9% ,18 F- .18
F Acting out- M , .
:
- ,
, , .
, , ) (.
, .
ADHD- ADHD .
HIAA5 , CSF-
:
M F ,10-12 .14-16
, .
:
139
, , "

"
139
140
Conduct disorder - DSM

A. A repetitive and persistent pattern of behavior in which the basic rights of
others or major age-appropriate societal norms or rules are violated, as
manifested by the presence of 3 (or more) of the following criteria in the past 12
months, with at least one criterion present in the past 6 months:
Aggression to people and animals
1. often bullies, threatens, or intimidates others
2. often initiates physical fights
3. has used a weapon that can cause serious physical harm to others (e.g., a
bat, brick, broken bottle, knife, gun)
4. has been physically cruel to people
5. has been physically cruel to animals
6. has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery)
7. has forced someone into sexual activity
Destruction of property
8. has deliberately engaged in fire setting with the intention of causing
serious damage
9. has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or theft
10. has broken into someone else's house, building, or car
11. often lies to obtain goods or favors or to avoid obligations (i.e.,
cons others)
12. has stolen items of nontrivial value without confronting a victim (e.g.,
shoplifting, but without breaking and entering; forgery)
Serious violations of rules
13. often stays out at night despite parental prohibitions, beginning before age
13 years
14. has run away from home overnight at least twice while living in parental or
parental surrogate home (or once without returning for a lengthy period)
15. is often truant from school, beginning before age 13 years
B. The disturbance in behavior causes clinically significant impairment in social,
academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial
personality disorder
:
, , , :
. IQ ,
. , , , :
:
,
.
. ,
. ,
. , "
. ,
141

""
. "
.
.
TD .
. ,7
.11
- AD 99% - M- 70- .F- 10%
.
3.M-
: ) caudate nucleus- OCD-(
40% OCD- 2 )
(.
50%- ADHD- . "
.
.
.
TD :DSM-
. 1 +
, .
. )" (
, 3-
.
. 18.
. ) (
) -(.
Tic disorder NOS ) , (.
, ) , (
/ .

) , ,'( .
) , '( ] , , ,
[
) , '( )
) coprolalia-( - = -"
1/3 (** . ) ( .
.
141
142
:
,
. , .
: .MDD
.
:
o
" .
+ ) (.
o
- premonitory urge "

,Massed (negative) practice . habbit reversal ,
) "" (,
incompatible
,response training ,.
o
:" ) ( .
- ) ,( '1 " . 20-30%
" . .
:) guanfacine/ -(2-
)/ SSRI .(ADHD .OCD
)/( ) (.
-
. ,
) , (
.Equivalent
, .
Ideation Attempt Suicide
o
- Ideation ,
. .
MDD- .
Attempt .
, )
( .
2- :
143
.1 - . 1-
10 4 . .
.2 -
.
" ) (aborted " ) .(interrupted

.
o
Suicide
) :(Self mutilation
. , .
, , )
, ,
(.
,
,
.
: . 450 1/3- .
2- 24 .
M F- 3.5:1 , F .
, ) (
.
, .
, 8
) " , (.
-
) 60 ( , 85 .
, , .
, .
Risk management
:
M
. ) self disclosure -
( M- .
) 3- (
potential lethality-.

143
144
:

/
24-
) ,(
??
??
:
.
, , , .
) (
.
.
/ :
:

) , (

-
:
)/(

7% ) .(15%
145
:
(.
.
" Hopelessness "" , ".

, .
,
. .
.

, ).(10%-
:

, .
.
, MDD- , .
.

) (Panic disorder ,5-7% .
.

. .
.

- .
, ,-.

: , , )( , ,
, , ) , , '( ,
, , ,
.
145
ECT 146
!!!
!!!!!!!!
!!!!!!
) ,(
40%
2/3 , 72-
.

!!!!! 90%-
) 1 - (2 .

2 -
ECT
" , .
1:25,000 - .
:
Major depression .1 unipolar .
.a ) = Trials
(
.b MDD ,
.
,Waxy flexibility , , )
,
( , ,.
.c
.d
.2
.a
.b " NMS
.c 1 , ) Epstein
(anomaly . )
(.
147 ECT
.3 "
. ECT ) :
, , , (.
.4
-Intractable seizure disorders .5 ECT-
.
:
ECT NE , .
.
.
) (
.
. 3 ,
.
+ + )
(.
..
"
, )( , )
"(.
: 2- ;
. ,
,
) ( .
)
(.
:C/I
ICP C/I ! .
High risk patients C/I:
COPD ) (
147
ECT 148
MS
ECT- - " ,
SOL , ,CVA ) recent acute MI 3-
( - .
" )" 3 ,
"( . 12-15 , 20-
.
2 :
, Midbrain-
.
.

" . "
) ( .
":
. ,
. 6 . ECT
) ,(Users
.
149 ECT
ECT :
BZD ECT C/I 2 , ECT-

BZD- . 50) Prolonged
20( . BZD-
.ECT BZD
.
Clozapine , SVT**) . -2008

(.
ECT
MAOI ,TCA-"
:
ECT . :
Acute treatment ECT/ 4-8

.
Continuation treatment :
o
) 20-30 78% .(35
8-14 - , 3 -.
25%
.
6 - .ECT/
149
) 150 (
MEDICATIONS FOR TREATMENT OF

PSYCHIATRIC DISORDERS
) (
:NT-
-
. - ,GABA , , ,
,NA - , , ,Ach ,
,VP - , , ,substance P ,
-CAMP ,
,CO ,NO - )(NH3
PG
Biogenic amines
) ( - :
) catecholamines .1( - , .
.2.

.

Epinephrine
Noreepinephrine
Dopamine
3
DOPA
Tyrosine
1
1- tyrosine hydroxylase
2- DOPA decarboxylase
3- dopamine--hydroxylase
4- phenylethanolamine-N-methyltransferase
Melatonin
Serotonin
5-Hydroxytryptophan
2
Tryptophan
1
1- tryptophan hydroxylase
2- amino acid decarboxylase
Biogenic amines' major metabolites:

)dopamine homovalinic acid (HVA
151 ;ANTIPSYCHOTIC DRUGS (NEUROLEPTICS

)noreepinephrine 3-methoxy-4-hdroxyphenethyleneglycol (MHPG
)epinephrine metanephrine (MET
)serotonin 5- hydroxyindolacetic acid (5-HIAA
;ANTIPSYCHOTIC DRUGS (NEUROLEPTICS

)(DOPAMINE RECEPTOR ANTAGONISTS

" , major tranquilizers
. .
:
.1 - )(midbrain
)
(.
.2 - )(midbrain
) (.
.3 - substantia nigra- midbrain-
.corpus striatum-
.substantia nigra-
.4 - ) -(tuberoinfundibular pathways -
arcuate nucleus -
. ,
) .(PIF= Prolactin Inhibiting Factor
2 ) (D1 & D2 3
).(D3-D5
-chemoreceptor trigger zone .

-.
) Dopamine Hypothesis ( -
.
) (D2 .
.
** :
151
;ANTIPSYCHOTIC DRUGS (NEUROLEPTICS 152

.1 )( .

D2 .
.2 ) , reuptke
( .
.3 ) HVA ( CSF-
2 : ,
. HVA .
.
** :
.1 -
6.
.2 ,
.
) Basal ganglia (
. :
.1 -corpus striatum- putamen-) globus pallidus-
,(lentiform nucleus-.caudate nucleus-
.substantia nigra .2
.subthalamic nucleus .3

, , ' .
- ) .(extrapyramidal symptoms
:
- Typical anti psychotic , .
Atypical anti psychotic
Typical anti psychotic drugs

:
D2 .
5- " :
) Phenotiazines (azine 3- :
o
Levopromazine (Nozinan) ,Cloropromazine (Largactil) Aliphatic
Thioridazine (Millaril) , Pericyazine Piperidines
Perhpenazine (Perphenan), fluphenazine (Moditen) Piperazines
) Thioxanthines (thixol )Zuclopenthixol (Clopixol
)(Halopperidol) Halidol Butyrophenones (dol
Diphenylbutylpiperidine )Pimozide, Penfluridol (Semap
) Benzamides (ride ) Sulpirized (Modal

D2 " ,
2- :
Halidol
= High affinity .
. .
"
"
.
" : , ,,
- )M
Cloropromazinezine
F ,
(.
Low affinity - " "

) ,(1
) (M1 ).(H1
* ,Medium potency Prephenan ".

" .
.1 - -
. -
.
Delusional disorder .2
Brief psychotic disorder .3
Affective disorder with psychotic features .4
Schizoaffective disorder .5
.6 / ) , ,'(.
.7 ) \PDD(
.8
.9 ) , ,,
(.
Delirium & Dementia .10 "
high
.potency .
" / = )Extrapyramidal syndrome (EPS
153

.
. - !EPS
:
Parkinsonism .1 ) (15%" ) F ;(5-90
. :
o - " " ) -rabbit syndrome (
o - " / "" , "
o )/( - ) (shuffling
: , )( , - , .
) SZP '(
:-/ ) D2
(/ )( . - 4-6
. 50%-
.
, 3 -
.
:rabbit syndrome- / class- .) Orphenodrine -
( ,Diphenhydramine ,
(10%) Acute dystonia .2 )- ( ,
. M- .
, )( , , ) , ( , ,
)( , ) Occulogyric crisis "" -
( , )( )( . :
/ )( - / . ,
" . : .IM/IV .
, )( , . .
, .
Acute akathisia .3 -
.
) ,-( .
) 50% - 10-15% , .
, (.
(.
, ) BB( . ,BZD
) ( .
. .

Tardive dyskinesia .4 6 15%-
. : , , , ,F-
, .
- . "" )-(
, .
contortion) grimacing , ( ,
' . , , )
Pill rolling ( . .
50%- )
5-40% 50-90%- ( . Tardive
.
: .AIMS
: " . - .
.
: / - Tardive-
/leponex . " )(
/BZD/ .TD - ketancerin
) ( . .
Neuroleptic malignant syndrome (NMS) .5 !!!
.25% / . .
(1 : ) (2 ;(41C ) EPS , , ,,
,
(,
(3
)/(,
(4
)/ ," / , , ((5 . :
, CPK ,.
:
, " ;
) ,(.
M- . " 24-72 10-14.
:" - ) (,
- , //./ /
)( . ) (.
) Amantidine ,Bromocryptine ( , ).(Dantrolene
5-10 - . -
** ECT / , 3.

- .by exclusion
-

155

) BB (
:
Nocturrnal myoclonus
.
,Levodopa , BZD : , .
Restless leg syndrome (RLS)/ Ekbom syndrome

," ,
. , " .
slep initiation insomnia- ,
. , , B12/ .
:
-(REQUIP) Ropinirole ) ( - -.
,carbidopa ,L-dopa : .pergolide , -.
, , ,
" ) (
.
, ) ,(M , ).(F
. ,
) (osteoporosis )!( . D.D-
.
** : ) ( , ,
)*.(thioridazine
** , ) (.
) (CNS- ,
, , , , , .
) R( - )
( , , , ,
) ,(retrograde ejaculation , .
Orthostatic hypotension TCA- . 1 adrenergic R

. .IM/IV .
" " :TCA - , )

(H1 (thioridazine*) retrograde ejaculation*-
) ( . -
) - ( , PR-
QT ) /(ms 450<QT
/ , ,T.
**" ) retinitis pigmentosa - thioridazine- -

(benign pigmentation of ** .
the eye ** anterior subcapsular cataract** .chlorpromazine
) (
** -
chlorpromazine - ,
- / ) ,RUQ , , ,B- .(
** low potency
, - QT
: " ,EPS ,CNS ,mydriasis , , , ",

. - , , , ,.
: . .
.
Extrapyra
Anticholinergic
midal Side-
+ Hypotensive
Effects
+ Sedative
Potency
Trade
Class
Drug
Name
Effects
1-Phenothiazines
Aliphatics
Low
Largactil
Chloropromazine
Low
High
Other
Nosinan
Levomepromazine
Mellaril
Thioridazine
Piperidines
Low
High
Low
Fluphenazine
Piperazines
High
Low
High
Moditen
High
High/medium Low
Perphenan
Perphenazine
High
Low
High
Stelazine
Trifluperazine
High
Low
High
Halidol
Haloperidol
2-Butyrophenones
Low
High
Low
Taractan
Chlorprothixene
3-Thioxanthenes
medium
Clopixol
Zulopenthixol
157
Atypical anti-psychotic drugs 158

High
Low
very low
very low
High
Orap
Pimozide
4-Diphenylbutylpi-
Other
Semap
Penfluridol
peridine
very low
Modal
*Sulpiride
5-Benzamides
* - D2 " - .
Atypical anti-psychotic drugs

,
, ) .(5HT2A
:
)Ziprasidon (Geodon
)Resperidone (Resperidal
)Amisulpiride (Solian
)Olanzepine (Zyprexa
)Sertindole (Sedrolect
)Clozapine (Leponex
)Paliperidone(Invega
)Quetiapine (Seroquel
RIDE .PINE + DONE + RIDE + AZOLE A A.

.EPS-
EPS- . " , . " ,
.
" , R.
)( -
D
) " ,(.
.
, ) Clozapine (leponex
.
":
.1 -
, :
; LDL- TG- ;HDL- .Fasting glucose- :
, ) DKA , - ,
, , , , , , (.
** < 5% .
, , ," , .
.2 - Clozapine (Leponex) : " Neutropenic
fever , 1%- .
18 )
) eos ,neut : ( .(PLT- 18
.
159 Atypical anti-psychotic drugs

. 18 .
.
.3 )( : .
: ) /(2 .
.4- - , , ) (.
OCD .5
:
) Clozapine .1( .
, .
'2 , .Tardive dyskinesia - '1

) "( . 30%
.
" ) -
( , ) ,(TG -
, ) ( . QT
**" ,1-2% , .
- ".
C/I ,3500>WBC : , ,
) (** .
.
** .TD- TD .
/ ,,PTU ,
sulfonamides BZD .captopril- ) (.
**" EEG . -
.
**" ) .
" ( -
.. ( , , ,OCD ".
:" ,.. , ,.
(Risperdal) Risperidone .2 ; ": ) 3-4( ,
- .EPS - , , . .'1
(Zyprexa) Olanzapine .3 " , H1 ,
; . . .'1
(Seroquell) Quetiapine .4 " ; .
300 -" )
(.
(Geodon) Ziprezidone .5 .
QT
/long QT ( .
." : ,.
159
Atypical anti-psychotic drugs 160

- (Solian) Amisulpiride .6 ,D2- "
. ) ( .Pure D2 Blocker
** : ,.
** , : < < < .
** " , " .60% 80% EPS-
.
,Long acting 5
, , ,.
Halidol decanoate .1 .
Modecate (Fluphenazine) decanoate .2 .
- Clopixol depo (Zuclopenthixol) .3 .
Risperdal consta .4 ; .
) SEMAP .5 (PO ; .
:LA -
-
; ;
.
; first pass ) ( ,
.
; ; ;
.
, .
- )" "( :
Halidol .1
Zyprexa .2
Geodon .3
Clopixol acu-phase .4 3; .
:
" : , ) 50%( , ) (,
/ / pectin/kaolin/) cimetidine- "(
" TCA ,disulfiram : SSRI- paroxetine, ) CYP2D6
) (fluoxetine, fluvoxamine () Risperidone , (
-
161 Atypical anti-psychotic drugs

, ) ( - ) ,
(; . ,
.Low potency " " .
SEMAP/DEPO .
, .IM Short acting
" Brief ,
, .
- / .
C/I

) CNS ,,
BZD ,'(.
Severe cardiac abnormality

Narrow angle glaucoma BPH .
tardive dyskinesia

" 2/3 - . )(,
80% -.
, ) (,
) (.
- 3 - , .
, 4-10 , .
:2 -
primary .
secondary .
.
, EPS- ,' ,
- . , ,
.
, .
/ /
. , )' , depot
( . " " , "
.
161
) ANTIDEPRESSANT DRUGS 162 (
) (acute phase .
):(relapse
.1
" ,EPS-
.2
.3
.stressful life events
) (stabilization phase )* .(relapse

" 1/2 , " .
* , .
) (chronic / stable phase "

.
* 2- " 2 / 5,
. , ,
.relapse
* ' ,'EPS -
.EPS- "
.
)(:
.tardive dyskinesia -
) ANTIDEPRESSANT DRUGS (
2 .
NA .CNS- NA- , Raphe -
.nucleus ,
) , , .(Sequential
, Pseudo
.dementia , .
Impulsivity (and suicide) Serotonin
: ) (5-HT -
) .(reuptake inhibition,
'' .
-.
: " , ).(NE
163 (Serotonin Specific Reuptake Inhibitors (SSRI

) (neurogenesis
)' ,(.
(SSRI) Serotonin Specific Reuptake Inhibitors

: reuptake- .
Trade Name
Generic Name
Prozac,Flutine,Prizma
Fluoxetine
Favoxil
Fluvoxamine
Seroxat,Paxxet
Paroxetine
Zoloft, Lustral
Sertraline
) ,26hr < (35hr) citalopram < (3-5d
Cipralex
Escitalopram
< (21hr) paroxetime < (27-32hr) escitalopram
Celexa,Cipramil
Citalopram
SSRI- clomipramine -
/-/
adrenergic
. receptors
:T1/2
,4-6d) Fluoxetime sertaline < (7-9d
.(15hr) fluvoxamine
:
.1 SSRI . ,BIP I
, ) SSRI-
( . 4.
.2 :
OCD .i .'1 3-4 ,

6-8.
Panic disorder .ii ) Seroxat (.
GAD ,Social phobia .iii
PTSD .iv , .
.3 , ) 60"(.
.4 , , ,,
, , ,ADHD , , ,
,BDD , , ,,Tension headache ,
.
-Premenstrual dysphoric disorder (PMDD) .5 ,
, . SSRI : ) sertaline-
/ ( . - , )(alprazolam
, - . .
163
(Serotonin Specific Reuptake Inhibitors (SSRI 164
:SSRI
) " (
"

!
50%- ":
. ) GI ( , , . "
90%- .GI-
. ." GI -
" .Sertraline PUD .NSAIDS
. ) -(50-80% )"
( , ) ,(F- ) (
).(M-
** : / /bupropion . -
" ).(bupropion ,mirtazapine
.
CNS . ) REM ( , )( , .
/ - .
.0.02% CNS " )
(.
) EPS , ,( , .
. ;
.
) SIADH( ; .
) ( -/ -
. - , , , . ) Seroxat
(.
. .4%-
.
.
. ) (
SSRI Discontinuation syndrome . ) SSRI t1/2(

) , ,( , ) (,
, , , , ,
) , , , , , , ,
( , ) ( , .
) cyclic Antidepressants ( 165

1/3- . .
T1/2 " , 2-3
.
Serotonin syndrome . .MAOI
) ((1 :(2 , (3 , ,
, ) ,((4 ,,
, , , (5 , , ,SE , CV.
:
: , ,methysergide , , , ,BZD , , .
75% " . " . .

10-15%
SSRI/ .
: ] ) ( ,
) , , , ([ , .
:
.1 -L , MAOI .
.2 .
.3 , ,
) Paroxetime .4( - ,SSRI-
.
-Citalopram .5 : , , , .imipramine
.6 :CYP450 . CYP2D6
) "( ,Sertaline . cipramil-
.
) cyclic Antidepressants (
.
) (TCA -.
: reuptake serotonin NA-"
. - )
( ,- ) (H1- . 2 & 1 -
Imipramine .
) ( )-( ,
) " t1/2 , (.
165
) cyclic Antidepressants 166 (
Anticholin.
Generic Name
Trade Name
SE
!!! SSRI reuptake
++
Tofranil; Primonil
)Imipramine (3
+++
Elatrol
)Amitriptyline (3
Anafranil; Maronil
)Clomipramine (3
,NA
TCA

Norpramin; Deprexan
)Desipramine (2
Nortyline
)Nortriptyline (2
Ludiomil; Melodil
)Maprotiline (4
Asendin
)Amoxapine (4
Bonserin
)Mianserin (4
: ,
: , , .
:
MDD .1 ,'1
.2
.3
Panic disorder .i
GAD .ii
OCD .iii TCA- OCD ) Clomipramine SSRI
,OCD- (NA
) Pain .4 ( - , .
.5 , ADHD ,PTSD ,.
* ] , [
":
.1 switch ,BIP
.
.2 , .
) cyclic Antidepressants ( 167
: ) CNS ,(
/ ) < ,(300ng/ml
.
: , , , , ,
, , ) -
( , , ,.
.3 ) orthostatism , / "
( , , , ".
.4 ) (quinidine- ,
,T QT ,PR- ) ST ( .
. TCA- SSRI-" .
.
.5 ." ,
.
.6 !!! . .
.7 ,twitching- ) Clomipramine( .
,.peroneal palsies ,speech blockage ,
.8 ) ,(5% )( , ,
)( . .
.9" )* -amitriptiline , -
amoxapine( , , ,SIADH , , , . )" ,
(

) /( : 10 TCA
. : hyperactive deep ,
,tendon reflexes , , " ' .
, " ,
.CNS
:
TCA .
/ - ,
) ( , .
.
" ) ( +".
.
C/I : 450 < QT.
167
(Monoamine Oxidase Inhibitors (MAOI 168

TCA " CYP450 :
.1 " .
.2 " " TCA- .
.3 CNS ,.BZD ,
.4 TCA .
.5 TCA : , , , ,.
.6 TCA : ) ( , ,,
, , , .
)Monoamine Oxidase Inhibitors (MAOI

.(Nardil) Phenelzine
" ) " (
.
: MAO
, - ,
) ,NA (
MAO-A , MAO B .NA- .

:
MAO-I .1 ) t1/2(.
),Phenelzine (Nardil
.Tranylcypromine ,Isocarboxazid
Selective MAO-A-I .2 A- ).Moclobemide (Mobemide) .(RIMA
;Selegiline Selective MAO-B-I .3 " .
:MAOI -
.1
.2 Social phobia - ; .PTSD ;Panic disorder
.Bulimia nervosa .3
.Pain disorder .4
.5 , .
" :MAOI
.1 " ) -(NA
- .
.2 , , , ,.
.3 .
.4 .
169 SNRI'S
.5 )** selegiline D(NA-
.6 , ,.
("Cheese effect") Tyramine induced hypertensive crisis .7
. , , )
(/ .(dextomethorphan ,pseudoephedrine ,ephedrine
" MAO . MAOI
" , , , , .
/
) .(MAO
: BB ,.
** selective MAO-A inhibitor (RIMA) Moclobemide -
, ) (
.
:MAOI" , , , , , .
: , ) ( ".
:C/I
, . MAOI , . .** , .
** .
:
- SSRI ,Serotonine syndrome- . - .
SNRI'S
Reuptake ) NA ,(TCA-
) TCA- TCA , (
,Duloxetine (Cymbalta) ,Venlafaxine (Efexor, Viepax) :
)Milnacipram (Ixel
:
.1 - ,SSRI-
. -
.
169
SNRI'S 170
GAD .2 '1 GAD- SSRI SNRI .SNRI
.3 ) ( ,OCD , ,.
" - SSRI-:
.1 ,
.
.2 / , , , , , , , ,
, .
** , ) - ,
, , , , ( 2-4
.
.3" ) Effexor ( " , .
" ".
serotonin syndrome : ,/" , ,.
: / ) (.
:
Cimetidine .1 " / .
.2 .Halidol
.3 !!! MAOI serotonine syndrome-
.4 .CNS-
171 SNRI'S
)NaSSA (Mirtazapine
;SNRI- ) Mirtazapine (Remeron
- ) NA ,(5HT2,3 - ,2 .H1
:
; ; .
- ) ( .
" : )< ,(50% ) ,(25% ) ,(13% , ,,
,/ ) ,(2% ,TG- ,ALT,
)>/(500 ) (0.3% , .
: .
.
: (serotonine syndrome) MAOI
NRI'S
: reuptake NA.
. (Edronax) Reboxetine
- ,
/SSRI- .
" : , , ,
/ ;
, , .
)NDRI'S (Buproprion
: Reuptake NA . .(Zyban) Bupropion
, .
- SSRI- , " /
SSRI ) , , ,
D (NA- .
, , .
:
.1 " . .SSRI
.2 BIP I- .TCA
) ADHD .3 ( '2
.4
.5 . .
.6
171
SNRI'S 172
" SSRI " ] : [

.1 : ) ( , , , URT , , .
: , , .
.2 ,
C/I .3 ,0.05% )< 450"( /
) , , ,BZD- , ,
(.
.4 /.
.5 " .
.6 , , , ,
. .
:
.1 MAOI .
.2 .
.3 .
.4 ; .
:
.1 , .CBT
ECT .2 .
TMS .3 .
.4 - .
:
3 ) ( 2 : ; ; > 2 ;20 ) //(.
- Major Depressive Disorder

2/3 '1 .
- '1 '2
2-4.
" ,'
)' ,(.
.
173 SNRI'S
-:
,SSRI )' , , 20"( , 3-4
. , )' , , 40"( 3-4
.
/
) 1/3 -(
.SSRI
.SNRI
NRI )' .(Mirtazapine

, , + SSRI .
4-6 , ,
SSRI - .
T3 -
" ) SSRI ?( !
- ,' ) ECT 80% -(.
-:
,SNRI .

.ECT-
,':
-" +" , .ECT-
) , , , (
SSRI - (bupropion???) DRI TCA .NRI
) ,(acute phase ) ,(complete remission

) .(partial response
.
, ) (continuation phase ,
.
relapse 1/2 . ,
60% .
reaccurance 1/2 .
, 30% .
173
) MOOD STABILIZERS 174 (

).(recovery / maintenance
/ :
, , .
. , 50-85% -
.
,50 .
- ' ,.
".
.
.
,
) .(relapse , .relapse -
, 3 .
) MOOD STABILIZERS (
) Lithium(
- , .
80%- ; .
BBB , BBB .
" ) (.
, .
) ( -
.
) ( .
" +
,. ," , ) ( ,. ,BHCG ,...
) 300mgX3/d 300" (.
5 .
2-6 ) 12 (.
, -
) 1-1.5 mEq/L : ( ) 0.4-0.8 - (

!
) Lithium( 175
:
BIP I disorder .1 , ; 70-80%- .
- 1-3 BD-
" . - ;
. " , SSRI Bupropion
.
Schizoaffective disorder .2 .
.
MDD .3 " .
.4 ".
.5 ,SZP , Conduct ,.
.6 , , .
: , ,
,BIP , , , .
" ) ( - :
** GI .1 : , , , ,
** . - ) ( ,
)( , , .
** CNS .2 : ) postural , " (,
,** . ) : , , ,
, (**." , ICP ),(IIH
,MG neuron-toxic syndrome . ) acute
,(confusional states , .
.3 ** , ) ADH
nephrogenic DI1/3-
( interstitial Fibrosis** ,NS , - Cr- " )(.

.4 ** , ] ) ,30% -(TSH- ) .15% -(T3,4-
,F- : - [
)(.
.5 ** )( ,.
.6 ** " ) ** ,(T SA node -
) ** ,(sick sinus ) CHF-(
.7 ** ) , /(** , ** ,
.
.8 ** - )" ( - ** , )
(.
175
) Lithium 176(
: , ,ECT
..interstitial fibrosis -
:
.1 - , , .
.2" ) nephrogenic DI- ( -
" .
) :(1.5-2 - GI , , , -
, , , ,/ , .
) :(2-2.5 GI , .
, , , ,,
, , , , ) ",
( - .. , ,.
) < :(2.5 , " ,.
: , , , ,.
:
, ;Mental status , , .; .. ) ( - GI-" Kayexalate polyethylene glycol " . - ) < /4mEq/L ( .BBB-
!!!:
- 1 ,
,CV Ebstein's anomaly 20' )

( . 4-12% 2-3%' ,
.
: ,
.0.6 mEq/L ) 3
( - . TSH
. . .
) , ( , ,
.
.
.
- 177
:
.1" .
.2 ,NSAIDS ,ACEI : ) (.
.3 : , , , CA
.4 CCB
-
) " ( BP I disorder / " / .rapid cycling
.
/ /SZP. . ,
.
(Orfiril ,Valporal ,Depalept ) Valproic acid

:
.1 Rapid cycling) Mixed-
( " .
.
- schizoaffective disorder .2
.3 ,PTSD , ,OCD , , ,
/.
":
.1 GI , , , . ,
.
CNS .2 , , , . .BB-
.3 , .
.4
(!5-10%) Alopecia o
o ,5-40%- . 3.
, , .
Fetal
hepatotoxicity , .
o
o
) SIADH o (
177
178 -
.5 ) ( ) (
- )/( , , ,

: . : , ,.
X; ,3%- .NTD
NTD-" (1-4mg/d) FA .
.
:
) (SJS-
) +(
) (
) (;
" ) ;(EPS-
) (
) Clonazepam -(
/ ) (
:'///TCA/ ;
/.
. .
250" 3 X 250 - . .
. .50-100 g%
(Tegretol) Carbamezapine
:
- Bipolar disorder .1 '1 , '2 .
.2 - .
PTSD .3 .
.4 .intermittent explosive behavior ,
.5 BZD- .
.6 -.Trigeminal neuralgia ,
:
.1 ) " < .(3K
) ,1-2% ( "
.
- 179
.2 -SIADH ) VP (DI-
) , ( . .
.
.3 .
CVS .4 .
.5 .
.6.
.7 SLE.
" )" (:
blood dyskresia .1 .1:125,000 .
, , , brsuing , .
" 3 ) (.
.2 ) ( ) B + (ALP- -"
. .
.3 3 ) ,Exfoliative dermatitis
SJS , .(toxic epydernal necrolysis TEN- )-(10-15%
.
.4.
.5 GI" ; , , , , , .
. .
CNS .6 ) -(acute confusional state" .
:CNS-,
,- , , , ,.
.7 , C/I . .AVB
:C/I , .
: BPH ,.
: ,1% - cranial facial ) NTD
.abnormalities, fingernail hypoplasia, spina bifida
.K .
200" ) 1000-1200 -" .(600
4-12g% -
) flumazenil- .(BNZ-
179
180 -
:
.1
: ,.
.2 - ," CCB- " .CNS- ,

.CNS
.3 MAOI.
(Lamictal) Lemotrigine
.
) BP- (rapid cycling- )(
.
+.
":
- , , , , , ,.,
) .(8% -"
toxic epidermal necrolysis - Stevens-Johnson syndrome"
,

: , .
.16
- - !
.
(Topamax) Topiramate
: . ) binge eating -
.self mutilation ,PTSD ,(top models
":
: , ),(word-finding
, , ,.
: , , , , ,
, , .
" ) ( , '
200mgX2/d
) BENZODIAZEPINES( 181

) BENZODIAZEPINES(
BZD .
) ( ,
. , .
: .GABA-R
. GABA.
) (BZD -/:
.1 ).(Buspiron
) BB .2 ( - , .
.3 - , ) (.
:
- Insomnia .1 - REM- 3 4- .
.2 ) ( BZD .
SSRI/SNRI
.
Adjustment disorder .3
- Mixed anxiety depressive disorder .4 SSRI-
, Alprazolam (Xanax)- .
.5 , , , .
IM . ) .Lorazepam (
.6 .
.7
.8 - .
.9 ) (.
.10 .
BZD Long acting - .Short acting - .
- , ,- Panic disorder ,.
- , PTSD ,.
- PTSD- ) ( '.
BZD , ) , (.
.
181
) BENZODIAZEPINES 182(
)(.
** (Zolpidem/Stilnox) Z drugs ;
.
. .
, .
,
(Halcion) TRIAZOLAM
6>) Ultra short(
T1/2
-
Midazolam - IV
* -
(Dormicum) MIDAZOLAM
/Short
2.5h
(Stilnox) ZOLPIDEM
4) Ultra short(
<6h
* BZD R
*
(Lorivan) LORAZEPAM
8-12) Short/Medium
15h
(Vaben) OXAZEPAM
8h
TEMAZEPAM
LOMETAZEPAM
(Bondormin) BROTIZOLAM
(Xanax) ALPRAZOLAM
(24h) Medium
12h
- " FDA-
(Numbon) NITRAZEPAM
(24-30h) Medium/Long
(Valium,Assival) DIAZEPAM
(24-48h) Long
24-30h
CHLORDIAZEPOXIDE
70h
100h
- - IVStatus Epilepticus-
FLURAZEPAM
Long
(Clonex) CLONAZEPAM
Long
34h
) ( -' "
T1/2 ) (hypnotics t1/2 ,

) (anxiolytics t1/2 . , t1/2.
)(
.
.
":
- - , " .
" CNS- : .
, / CNS
.
, ,
.1" : ) -(10% t1/2
/ .
** residual daytime sedation BZD

. , .
)> (2% )> (1% .
.2 ) , -
() paradoxical agitation , ,
- ( ,.
) - ( : , ,,
, ,; " * .
. .
Flumazenil (Anexate) :BZD- ;GABA- IV
;t1/2=10min .BZD
)
/TCA -"( ." ,N/V , , , ,
, , , . "
. Zolpidem.Zolpiclone-
* BZD ,topamax ,gabapentin :
Levetiracetam
)Zonisamide ,tiagebin ,(keppra

:
: .
,cleft lip & palate . BZD ,
) ( . 3
. , , . ,
. , /
. .

.
:
BZD- )(.
.
t1/2- , . - )<(.
**) Zolpidem (stilnox Zolpiclone (Nocturno)- BZD1 -
, .
.
- discontinuation/ :
, ) ( , .t1/2-
183
: , , , , , , , , ,
, , .
) -Alprazolam ( - ,
) , , ,( , , , , ,.
BZD 25% , rebound/ .
) , T1/2(.
** BZD-
, , . .BZD-
**
.
BZD- .
BZD
. .
BZD .
" .
:
+ (Zaleplon ,Zolpidem) BZD CNS : ,,TCA ,
, )"( , , .

" C/I-
Clonidine
.ADHD -
NA
" : ,
- .
, ,,
- ,
" ,.
, ",
0.1*2" ,
- .PTSD-
0.1-
-.
" ,
:C/I"> ,90/60
"
) ( ,
: , ,
1.2"
, , ,
'2".
, ,
" .

.
.
:
" :;
Diphenhydramine
,H1
" , , ,
Hydroxizime
) '2
)"(,
CNS.
,N/V .
- "
Promethazide
Cyproheptadine
(;
-
) BZD(.
Cypro -
",
C/I :
, ,
".
,
)(.
Nefazodone
-.
Reuptake
) CVS,
( ,,
-(Trazodone
.MAOI
/ .
+ NA
) -
:,
.OCD -
TCA .(1.6%
,,
Halcion -
.PMS -
, ,
.CP450
:C/I .
/ .
) - (Serzonil
Trazodone

, ,
".
- "
) (.
Trazodone
- .
reuptake
(Trazodil,Depyrel
; ;
MAOI
.OCD-
.ECT-
) ,
" "
)( -
TCA--
.MAOI
) -TCA (
R(;
.
":
"
, )
" .
"
( , ,
, , ,
, ,
.
:C/I/ , /
.
185
Buspirone
GAD -
R-
" : , ,,
BZD-
- .SSRI-
, , ,,
.MAOI
- -
, ,
2-11 = T1/2.
.PTSD ,ADHD
) (.
:C/I / ,
- GABA
* -
/NA-
,GI-
.
.
187 (Anticholicholinergic drugs (Antiparkinsonian drugs
)Anticholicholinergic drugs (Antiparkinsonian drugs

) -( ) -(
:
.antimuscarinic drugs
+ .
\ .
:
Ach
- Ach .
, ) (EPS"
.
3 Biperiden (Dekinet) ,Trihexyphenidyl (Artane) :, Disipal-
Benztropine
":
CNS , /.
PNS , , , , ,
,mydriasis , , , ,.
,BPH , .
, abuse- .
: ,- ,Tiagabine , , , ,,
.MAOIs
NTDs - .
:
-
GFR
," TCA-
** t1/2
-
187
ALCOHOL & SUBSTANCE ABUSE 188
ALCOHOL & SUBSTANCE ABUSE

) Intoxication (1( - ""
-
.CNS ,,
, .
. .
) Withdrawal syndrome (2 ( -
.
. )" (
. " / .
.
) Tolerance (3( - .
, ,
)( .
) Dependence (4() Addiction /( - 2-:
(a -
.
(b ) habituation -( -
. , .
- , ,
.
Substance abuse - :DSM IV
.A , )
( 12:
.1 , , .
.2 ) , (.
.3 ) ( . DSM5
""
.4 .
.B .
) (Substance dependence :DSM
, , 3- ,
12:
.1 , " :
189 ALCOHOL & SUBSTANCE ABUSE

. .
. .
.2 , :
. .
. .
.3 .
.4 / .
.5 , .
.6 , .
.7 / .
:
) (. .***) Course specifiers , Abuse- (:
Early full remission . Abuse - , )3 DSM5
( .
Early partial remission . Abuse - ,
, .
.
Sustained full remission , .
Sustained partial remission . Abuse - ,

, .
On agonist therapy .
Abuse , .
.
In a controlled environment ,
Abuse - .
.
,
, .
Binge using ,
. - .
-
)
( .
)
(.
189
) ( ,
, ) - Panic attack (.
:
o
, , .
,
"" , .
: ,
" binges
/.
:
, .
,
.
.

.
.
,
.
Bias-

.
.
. DSM-
.
.
D.D- .
:
, LSD ,
"" ,
,.
, ' )
(.
"" " "

.
o
' , THC
' -
'
LSD-
191
.1 CNS -
ALCOHOL 1.1
10% abuse : F- 20%- ,M- 5% F- 10%- .M- ,,
. .
: ; -; ;
) ( ;25-50% - ' ).(10-15%
: R 5-HT3 ,-
.GABAa
) .(BZD , , ,
, , " . .
REM ) (4 ) (.
, ,GI .MI/CVA-
: , , , , ,.
** delayed ejaculation-
- :
.1 - ) ,(slurred speech , , ,
.
.2 - ) ,(labile
.
- CV-.
** Alcohol-related blackouts DSM4 " ."
TGA
.
/ .
,BZD :CNS- ,
) .(major tranquilizers CNS-
. 2 , BZD- ,
.
: , ,' -.
) Alcohol Withdrawal Syndrome ( -
,
.
: ) 6( , , ,,
, , , , , .grand mal
--// ) 10(.

- Delirium tremens - 72
.
""
) (38
" -
"" ) (formication
-
4 .20%
: " )BZD/( - IM
. . -'2 .
/BB .abuse- - .DT-
.BZD DT ;
, ; . )
(; ; IV/PO , ;
" , -
/ .
- Alcohol Hallucinosis" .
" 48 .
.delirium tremens-
- Wernicke-Korsakoff Syndrome
) " < .(35 ) B1(
.
(Wernicke
) encephlopathy (1 :(2 ,
) , gait(3 ,(gaze palsy ,lateral orbital palsy ,,
vestibular
.dysfunction
-/ :(Korsakoff Syndrome) Alcohol amnestic syndrome
.
.
: IV ) B1(
- Alcoholic Dementia .
.
- Alcoholism & Alcohol Dependence .
: )( ,- ) " (BZD-.
193

Disulfiram-
aldehide
) dehydrogenase ( . Disulfiram-
.
EEG : .
) SEDATIVE-HYPNOTIC-ANXIOLYTIC DRUGS 1.2/(

:
:BZD - ,.
* .GABA-A -
* BZD1 ,.
* BZD2 , , .
).Buspiron :(5HT1A agonists
: .
:Barbiturates ,
" . : .Grand mal :
.
) :BZD (
) STIMULANTS .2 (
) AMPHETAMINES 2.1 , ,Ice , ,(
) (- ) NA (
- . .reuptake-
) (MDMA - NA
) ( . :MDMA , , , ,
, .
3 ,(Dexedrine) dextroamphetamine :
,methamphetamine
- Ritalil) methylphenidate- (.
: - ADHD -
)( . .
- : , , ) (,
- , , , , , .
" - : , , , , ,
) ,(insomnia , )
** . - -
/"( , )

,ADHD -(.
, ) ,( ,GI-
) ,CVA ,MI ,( . - ," , ,CV
, / ,.
/
rebound effect ADHD
.
:abuse ) ( ,
) ( .
: :" , , , , )
,( , , , . 2-48.
: ) -DD ( , , ,
, , , . .
:" , .
: , , , , , , , ,
, 2-4 .
) (.
rebound effect .
, . :
.
:
o
"
(Valium) BZD/
Bupropion
: ,1- .
COCAINE 2.2
reuptake .
reuptake- .
.
: , , , . .
- (1 :2/9 -/ (2 , (3 ,/
"(4 , (5 ,/(6 , (7 ,/ (8 ,
, , (9 , , , , .
, , , . - , ) ( ,,
, ,MI ,CVA , .
.
50% , .SZP
195

:
BZD
" /
BB
- (1 :2/5 +(2 , ),(vivid dreams
(3/(4 , (5 ,/ .
- - , ),(formication
.
50%- .
HALLUCINOGENS .3
psychedelics psychotomimetics-
.
,Mescaline ,PCP ,LSD : ,
LSD 3.1
: . LSD-
. .
LSD . .
12-.
: ) , ,
( . ) synesthesia -(
'.
- .
. .
, , .
) ( ," , , ,,
,.
* - PCP , , , , , .
" . '
.
: " ) ,
, ( . ),
( ) BZD , ( .
-Mescaline -trailing phenomenon
) (.
.4
- OPIATES , ,.
) morphine -(.
3 .
.
, , , , ,
, " , ' , ,.
" / ' 1 HIV-
. ,
. "
.
, , , , , " ,,
, ,.
:
-
, .airway
)( IV .
) , ( .
.
.
.
- , , . , , , ,
," , .
, t1/2- .
: - . :
t1/2 (1 .
(2 .
(3 ) PO ( .
Clonidine )
(.
,
. -
) (10-40mg/d .
) INHALANTS .5 (
: ) ( , ,.
CNS-
.
: , .
197
Delirium 198
, , .
.
, ,
,'.
) ( : -" .
) CANNABIS .6(
.Cannabis sativa- .
.
: , . .GABA
" .
:
: ,.
-.
.

/ , .
.
- ) ,(GABA- .
.
: , )"'"(.
.amotivation syndrome-

:
. ,CNS- )
( , NA , , vasopressinACTH ,
.
:
: , , ,.
Delirium
3- . .
, .
" :DSM-
199 Delirium
.B )( , , ,,
.
.C - , )
(.
.D ,. .
:
, ,
) ,( , ,
, ,ABX ,
NOS
-
) ( ,
) , (.
// ) (
: , .
.
. , / . .
)-( , .lucid intervals
.
:
- , ,
- .
: . .
% . PTSD- .
:
199
Dementia 200
, ,
'.
underline cause -
2 :
(1 / . " .
- ) ''( .
/.
(2 BZD/ . .
.
.
ECT ,
Delirium
Dementia
-
Dementia
)
( , )( , ,visuospatial , ,
, ) , , , ,,
, , - ( , .
. -
) ,(.
** : , , ,
.
5% : ,65 20-40%- ,85 . .
:
(1 ) 60% - (
201 Alzheimer's disease

) Vascular dementia (2 (.15-30% -
mixed (3 .
: ) , ( ) ( ) , ,B12 (Lewy body disease ,
) (.
Cortical Dementia
Subcortical Dementia
-
DLBD ,
visuospatial skills
<
) (
/"
,tremor-tics ,
] [
Alzheimer's disease
50% . .65 presenile = 65
.dementia .F-
.
-.
-
,senile plaques-
) neurofiibrillary tangle (.
: . .
.ApoE-
.PM .
201
Alzheimer's disease 202

" :DSM-
.A :
.1 )(
.2 :
, ,
.
) ( ) (.

.
- Impaired Executive functions , , , .
, . .
.B / , .
.C
.D ) CNS (
.E
.F 1
) Subjective cognitive impairment (SCI

, . . SCI-
.MCI" 90% , SCI- 7 ) 10%-
,(SCI 71% MCI- .
SCI- Mild cognitive impairment (MCI)-

" / - .
. .
MCI 6-25% : ) 1-2%-' (.
MCI- .
Vascular dementia
20%- " , " CV
. .M-

- - .
: , / ) CT
( .
) ( :
, ) '( , .
: .

Diffused Lewy body dementia
25%- PM Lewy bodies
. ,-synuclein ,PD-tau -
) AD -(.
,AD " ,
.
: ) -(fluctuating
, ) ,
( ) (.
) (.
,AchEI- EPS- ".
DOPA ) / (.
" Levodopa )/(.
Binswanger's Disease/ subcortical arteriosclerotic encephalopathy
" sparing .
, MRI .
Pick's Disease
5% . ,M-
. parietal-temporal distribution- ,
- , ,
) ( . PM-
. : .
,
, ,
.75 , 50% .
) kluver-bucy syndrome , ,(
.
Huntington's disease
- ,
) ( . -
, . ,
.
, , -
.
203

HIV related dementia
HIV- = . HIV dementia/(AIDS) dementia complex
.14% -HIV
75%- CNS.PM-
.MRI-
:HIV- ) ,(Treponema pallidum ,Cryptococcus"
.
: ) HIV- HIV-( + 2 +
/ ) , ,( . ,
.
) (:
, .
.
, .
) (20-30% ) ,30-40% (
)(40-50%
) ( /
) "
, , ( .
. .
, ) sundowning (
40
ADL
) (MMSE > .24-25 .

, .FN
.X ,
, . .
Mini COG 2 "
//
NPH
SOL
Chronic subdural hematoma
,SLE
,B12 ) B1( ,
,CHF ,COPD ,
:Mild 20-24
11-20 :Moderate
6-10 :Severe
3 .
) 8-10( : , "
:
:
o
BZD ,"
) ( . "
, . )
- (TCA- .
-trazodone , ,"
205

o

AchE-I
.Donepezil, rivastigmine
. - . - .
, , ,.
NMDA- . - .
, , ,.
E .
-C/I ) (
Pseudodementia
Dementia

,
- /

,

<

**
**

" "

**
**
: )!( ,
.
.

.
,
. ,
.
D.D :
: , ]
[.
] [ : ][ , ]/[ , = "
" ][ , ][ , ][.
Complications of dialysis treatment: psychiatric problems, such as depression, and suicide is

not rare. Sexual problems can be neurogenic, psychogenic, or related to gonadal dysfunction
and testicular atrophy. Dialysis dementia is a rare condition that evidences loss of memory,
disorientation, dystonias, and seizures. The disorder occurs in patients who have been
receiving dialysis treatment for many years. The cause is unknown.
207
208

) PSYCHOSEXUAL DEVELOPMENT .1 ( -
" .
. , ,
)( .
) fixation-( .
.
:
(1 )) :(oral 0-1( - ,
.
. " .
) ( .
, ,
, , ) ( . ,
, .
(2 ) 1-3) :(anal stage( .
.
. ,
, ) ( "
. ,
)
, ,( .
(3 ) -(oedipal ) 3-6) :(phallic(
)( - .
. ) .(penis envy

.
.
) - ( .
.
- , ,
. -
. -
, , .
(4 ) 6-12) :(latency(
)( . .
, ) , ,( .
, .
209
) COGNITIVE DEVELOPMENT .2 ( -' '

' ' 4
)( )
(:
(1 - )) -(sensorimotor stage 0-2(
" )( " .
)
2( . ) (Object permanence
.
.
(2 - )) :(preoperational thinking 2-7(

- , , , ) 10 ( )
(.

, ) (deffered imitation
.
(3 )) :(concrete operations 7-11(
)(.

) -(conservation , ,

' . ) (reversibility
. ,
.
(4 )) :(formal operations 11(
.
.

.
) PSYCHOSOCIAL DEVELOPMENT .3 ( -
.
.
,
. )(
"" )(
"" ) ( .
. ,
209
210
, .
)( )(
.

, , ,
. ,
.
) Basic trust vs. basic mistrust (1 () : 0-1(
.
.

. ,
.
) Autonomy vs. shame and doubt (2 () : 1-3(
.
) """ ," '( .
- , , ,
. ,
- .
) Initiative vs. guilt (3 () : 3-6( -
.
.
- . ,
- .
) (Industry vs. inferiority) (4 () : 6-11(
. )
, , '( .
- . ,
- .
) Identity vs. role diffusion (5 () : 11-20(
. .
.
.

.
. ,
, ,
.
) Intimacy vs. isolation (6 () : 20-40(
. - . -
211
. , ) (,
.
) Generativity vs. stagnation (7 () : 40-65(
. . ,
, .
. ,
.
" , '.
) Integrity vs. despair (8 () : (65 .
.
. ,
, .
) SEPARATION-INDIVIDUATION PROCESS .4 -( -

. .
Separation-
.Individuation-
, 5 .
Separation-Individuation- 5 , 3 4-(1 :
) : 6-9( "
." " 8
.
(2 )) :(practicing 10-16( -
.
.
.
).(separation anxiety
(3 )) :(rapprochement 16-24( -
.
- ,
.
(4 )) :(consolidation 24-36( -
. , -
. ,
, .
211
212
) ANACLITIC DEPRESSION (
. "
.
= 1 ) - (protest .
= 2 ) - (despair .
) 3 ( = ) -(detachment
. .
) ELIMINATION DISORDERS (
) Functional enuresis (
.3
/ 5 )/(
. .
, ,M- - -
, '.
, )
( , , "" .
.
,ADHD :
:
-
% .
1 . ) (Star chart .
.BL
: ) (bell or pad apparatus

50%.
: //" " .
, 6 .
relapse . " TCA .
ADHD .desipramine
) (DDAVP relapse .10-90% . ."

, , , .
213
) Functional encopresis(
) , ,(
4 .
.
,
. .M-
- ; ,
, . "
, .overflow impaction- 75%-
.
-
-
.
.
) ( "
- .9
, " , .
, .
) SELECTIVE MUTISM (
)
( . ,
. ,
.
) (SLEEP TERROR DISORDER) NIGHT TERROR ( -

) ( , )( , ) (
) , , ,(.
.
" 1/3- ) 4 ,3 .(slow wave sleep-
,M- .
,
, 1- .
** ) nightmare disorder , (
,
213
214
. REM -
.
- .
: . / . .
) SEPARATION ANXIETY DISORDER (
)( , " , ) 7-8
" .M=F ,(4% - 8
. 4 .18
, , - ) (school phobia
, ,
.
, .
** -(3%) GAD : < ) < (2.4% )(1%
215

) FACTITIOUS DISORDERS ( -

. " " ) (sick role
. , ""
. malingering
) , '( .
2-:
) with physical symptoms (Munchausen's syndrome) .1 " (:
" -" - ,
' . " , )
( , .
) ( .
.
:with psychological symptoms .2 -
, , ' -.
) MALINGERING ( -
, .
, ,
'.
MENTAL DISORDERS DUE TO A GENERAL MEDICAL CONDITION
) (
.
.
DSM IV- 2-:
) cognitive disorders .1 ( : 3-
1.1
1.2
amnestic syndrome 1.3
:due to a general medical condition .2 DSM IV-
. :
depression due to pancreatic cancer
anxiety due to hyperthyroidism' .

.
215
216
DSM IV-
.DSM III-R-
) organic mental disorder ( organic brain syndrome
)) (OBS ( .
(psycho-active
) .substance-induced mental disorders DSM IV-
) substance related disorders (substance related personality disorders
.
) (
) ( . , ,
) , , '(
) , '(
, - . ,
) (
. "" .
:
.1 : , , )(.
.2 : CPS .
) , ( , .
:CPS- ) , , ( , ),deja vu
,jamais vu , ( , ) , , (elation ,
) // (.
- , .
) Temporal lobe syndrome ( - ,
,
. (1 : - )
( ,,
(2 (3 , .
.3 CVA -
.4
.5 ) MS : -(ALS ,
.6 : , , subacute sclerosing ,
.CJD ,panencephalitis
.7 : )( , , ,.
.8 , hepatic/uremic encephalopathy : , )
, , ( , ) B12 , , , -
// . -// = // =
(megaloblastic madness ,(pellagra) B3 ) B1 -(.
.9 ,CO :.
) PARAPHILIAS ( 217
,

" .
),
( .
Pseudoseizure
"
//

"
EEG
) PARAPHILIAS (
, .
. .
.
.M-
, .
217
) PARAPHILIAS 218 (
:
) exhibitionism .1 ( : .
- ) -
(.
) fetishism .2( : ) '(
.
:frotteurism .3 )"
- '(.
) pedophilia .4( : .
) sexual masochism .5 ( : )"
, ( . , 6.
) sexual sadism .6 ( :
.
) transvestism .7( : " .
] ) Transsexualism(gender identity disorder/
M F- .
, .
, .
.[M-
) voyeurism .8( : )(
.
) zoophilia .9( : .
:Sexual disorder NOS / /
. -
;
" ; .
) SUICIDE(
.
:
.1 : 95%-
80%- . :,
, -.
.2 : , ) CNS- ,MS ,( , .
.3 M : 3 F- F 4 .M- M-
) , ,'( .
.4 : .
) PARAPHILIAS ( 219
** 10% , 25%- .
) : , , ( . - )
(.
.5 : < < <
.6 :
.
.7 : ""
) , '( .
, , .
.8 :
) , (.
:
.5-HIAA
. ,
.
219
220

) (
, . .
" , .
** WHO- well being , ,
well being .DSM-
, , .
, , 2- :
) conscious .1( - .
) unconscious .2 ( - .-

.
3-:
) id .1( - . 2 : )(
)( )( . .
) superego .2 ( - .
) ( .
, , .

) ego ideal (.
) ego .3( )( - ) ,,
'(
.
. , , " " , .
.
) ( )4-5
( .
.
, - , , ,
.
) (Psychodynamic psychiatry) Dynamics ( -

. "" : ,
.
.
.interpetation-
221
) DEFENSE MECHANISMS (
.
, .
.
. , , )(
) ( . ,
, .
.
.
, , .
.
:
) repression( - , , - .
. .
: .
-suppresion / / .
, . .
) denial( - , .
: .
/ .
) projection( - .
: .
.
. .
) reaction formation ( - ,
.
: ;
"".
) displacement( - )(
.
: )
( . " " " )(
. .
) rationalization( -
.
: " "
. .
) sublimation(- )/( .
: ; )
(.
221
222
) compensation( - "
.
: ;
.
) undoing-( - -
.
: .
) regression( - .
)""( .
: , .
. ,
, : -
.
) isolation( - )( )( " .
"" , .
: .
) splitting( - ""
"" .
)""( , ) (devaluation
)""( .
) intellectualization( -
.
: ;
" .
) Acting out-( - , ",

.
) Comedy( -
. . -
) wit( - .
. ,
. - )"-
"( )( , , ,- .acting out , ,
, , , - )(** .,
, - .
:
-OCD .1 3- ) isolation :() undoing ,-(,

) reaction-formation- (.
223
.2 - , , :
" " " - " " "
" - ".
.3 - , ,
) (splitting .
** :asceticism ,
.
) NARCISSISM(
. , ,
. .
.
, - ,
. ,
:
(1 : ) ,
'( - - ) .(auto-erotism 6-18
,
)( ) ( .
) , '(.
(2 : ,
.
,SZP,
.
(3 .
.
) NEUROSIS(

) (.
: , , ,
, .
- ) (neurotic process
.
.
: , .
223
224 )(BEHAVIORAL THERAPIES
)(BEHAVIORAL THERAPIES
,
" " .
" " . .
, -
. ,
(unlearning
) /unconditioning - .
, .
) , ,
( ) (.
:
) Systemic desensitization .1 ( :
. . 3:
1.1 .
1.2 )
( . : ,
.
1.3 , ,
.
" .
.reciprocal inhibition
, -
, .
) Flooding .2( :
) (
. .
.
. .
) Aversive therapy .3 ( :
) ( .
'.
,
.
" ".
) Positive reinforcement .4 ( ) Token economy ( :
. " )
, '( .
. .
)225 (BEHAVIORAL THERAPIES

) Biofeedback .5( : ,
)" , , ( .
.
-" , , .-
"
. .
) Response prevention .6 ( : .
- , .
) Modeling .7( : .
225
226
11

) Abreaction( -
. " .
.
) Automatism( -
. .
) Biological psychiatry ( -
, ,
.
) Counterphobia ( - ,
. : .
) Ego-dystonic/Ego-syntonic- ,-( -
. -
, . :
- ,
- . , -
. :
- , -
.
) Empathy( - " " ,
, .
) Existential psychiatry ( -
) (
.
) Neurobiology( -
, '
.
) Nosology( - .
. DSM-
, , ,
.
) Psychopathology( - 3:
.1 .
227
.2 . :
.
.2 .
) (.
) Psychosurgery ( -
.
) lobotomy( .
30- .50- .

-.
, ,
) (PET,SPECT
. ,

) ( . - .cingulotomy

.
) Symbiosis( -
. 2 .

-Primary insomnia
/ .
.
.
-
) deconditioning .
, 5 - , / (.
// ) (.
- , ,
, , )
(.
- .M-
: BZDs - .BZDs, Zolpidem, Zaleplon - GABA-A

, . .
227
228
Primary hypersomnia
/ ) (
.
. , /
, , 3 -recurrent :
.
. - ( ):
.( SSRI )
. , :Kleine-Levin syndrome
./
-Psycophysiological/Conditioned insomnia
Typically presents as a primary complaint of difficulty in going to sleep. A patient may describe
this as having gone on for years and usually denies that it is associated with stressful periods
in his or her life. Objects associated with sleep (the bed, the bedroom) likewise become
conditioned stimuli that evoke insomnia.
Often occurs in combination with other causes of insomnia: episodes of stress and anxiety
disorders, delayed sleep phase syndrome, hypnotic drug use and withdrawal. In
contrast to the insomnia in patients with psychiatric disorders, daytime adaptation is generally
good. Work and relationships are satisfying; however, extreme tiredness can exist.
Other features include: (1) excessive worry about not being able to sleep; (2) trying too
hard to sleep; (3) rumination, inability to clear one's mind while trying to sleep; (4)
increased muscle tension when attempting to sleep; (5) other somatic manifestations of
anxiety; (6) being able to sleep better away from one's own bedroom; (7) being able to
fall asleep when not trying.
The sleep complaint becomes fixed over time. Interestingly, many patients with
psychophysiological insomnia sleep well in the laboratory.
.
)
.(
Stimulus control therapy
.
.
229
-Sleep state misperception/ subjective insomia

A dissociation between the patient's experience of sleeping and the objective polygraphic
measures of sleep. The ultimate cause of this dissociation is not yet understood, although it
appears to be a specific case of a general phenomenon seen in many areas of medicine.
Sleep state misperception is diagnosed when a patient complains of difficulty initiating or
maintaining sleep and no objective evidence of sleep disruption is found. Sleep state
misperception can occur in individuals who are apparently free from psychopathology or it can
represent a somatic delusion or hypochondriasis. Some patients have obsessional features
concerning somatic functions. Short-term sleep state misperception can occur during periods
of stress, and some clinicians believe it can result from latent or ineffectively treated
anxiety or depressive disorders.
. / ,Cognitive relabeling
-
Typically starts early in life, sometimes at birth, and continues throughout life. its cause
is unknown; suspected causes include neurochemical imbalance in brainstem RF, impaired
regulation of brainstem sleep generators (raphe nuclei, locus ceruleus), basal forebrain
dysfunction.
. , , -
-
. 3 , .A
: .B
,/ " ) - .1
, ( ,
, REM .2
/
GMC/ .C
:( , )
,FDA- ) " Modafinil (provigil) . -
. , , .("
229
. SSRI ,TCA
. , , ,
230
-Circadian rhythm sleep disorder

delayed sleep type (1
The circadian system is operating in a delayed, but stable, relationship to the day-night cues of
the external world. It is marked by sleep and wake times that are intractably later than
desired, actual sleep times at virtually the same daily clock hour, no reported difficulty in
maintaining sleep once begun, and an inability to advance the sleep phase by enforcing
conventional sleep and wake times. The patients' major complaint is often the difficulty of
falling asleep at a desired conventional time, and their disorder may appear to be similar to
sleep onset insomnia. Daytime sleepiness often occurs secondary to sleep loss.
- . :
.
- jet lag (2
Depending on the length of the east-to-west trip and individual sensitivity, jet lag sleep
disorder usually disappears spontaneously in 2-7 days.
. : .
. ' ' -
, , , , , , , :"
,- , - F- ), ,
.( ,
COPD ,severe sleep apnea , :C\I
shift work (3
Shift work can induce sleep disturbances, as well as other difficulties, including accidents
because of sleepiness during nighttime working hours and, in more extreme cases, a shiftwork syndrome GI and CV disorders. A common experience among night shift workers is to
come home in the early morning, to go to bed feeling exhausted, to sleep only 2 to 3
hours, and to awaken feeling unrefreshed but unable to continue sleeping.
. / . "
)
- . .(
.
-Central alveolar hypoventilation
Several conditions marked by impaired ventilation in which the respiratory abnormality
appears or greatly worsens only during sleep and in which no significant apneic episodes are
present. The ventilatory dysfunction is characterized by inadequate tidal volume or
respiratory rate during sleep. Death may occur during sleep (Ondine's curse).
( )
231
-(somnambulism) Sleepwalking
A. The predominant symptom is repeated (two or more) episodes of rising from bed,
usually during the first third of nocturnal sleep, and walking about for between several
minutes and half an hour.
B. During an episode, the individual has a blank, staring face, is relatively unresponsive
to the efforts of others to influence the event or to communicate with him or her, and
can be awakened only with considerable difficulty.
C. Upon awakening (either from an episode or the next morning), the individual has
amnesia for the episode.
D. Within several minutes of awakening from the episode, there is no impairment of
mental activity or behavior, although there may initially be a short period of some
confusion and disorientation.
E. There is no evidence of an organic mental disorder, such as dementia, or a
physical disorder, such as epilepsy.
.BZD- . .
-(somniloquy) sleeptalking
. .
, .
.
.
. - :
231
232
)Sleep-Related Head Banging (Jactatio Capitis Nocturna
) - (
/ )" immediate presleep period- (.
/ .NREM
: .
-Nightmare disorder
- , .
, ,REM" REM
. ,
/ 50% . .
: . ) REM (TCA
. .BZD , .
)Obstructive Sleep Apnea Syndrome (OSA

URT , ,
) (.
, ,OSA . ,
, / ,
. , .
: ," , / .
OSA ," . " ,OSA- OSA-"
, .
" , ,M- , .
: 10 /
)( / )( , .
, , .PVC
, .EEG- )
-(the breakthrough .
. ) NREM ( ) REM (.
):Central sleep apnea (CSA
" , .CNS-
OSA- , CSA- ,
.
: ,OSA-
.
OSA :CSA- , , , -
) (.
233
, OSA ,
. OSA -
.ventilatory measurements
, OSA- ,
.
.
:D.D
-
- 1/3- ,
. .
- paradoxical vocal cord movement ," /
.
-nocturnal laryngospasm / ' .
:
-
nCPAP .OSA-
, ,uvulopalatoplasty ,
SSRI :" ) REM

( . - ' . ,
.
/ ,sleep apnea ) (
, .
** , REM-.slow wave sleep-
, .
, - ,'
, , .sleep apnea
BZD .zolpidem (stilnox) / zolpiclon (nocturno) -

.BZD -
233
234

-
Expressive language disorder is diagnosed when a child demonstrates a selective deficit in
expressive language development relative to receptive language skills and nonverbal
intelligence. Thus, a child with expressive language disorder may be identified using the
Wechsler Intelligence Scale for Children III (WISC-III) in that verbal intellectual level may
appear to be depressed compared with the child's overall intelligence quotient (IQ). A child is
likely to function below the expected levels of acquired vocabulary, correct tense usage,
complex sentence constructions, and word recall. Children often present verbally as younger
than their age.
Expressive language disturbance often appears in the absence of comprehension difficulties,
whereas receptive dysfunction generally diminishes proficiency in the expression of language.
Prevalence 15% under age 3, 6% in ages 5-11, 3-5% above 11. M:F=2-3:1
Most prevalent among children whose relatives have a family history of phonological
disorder or other communication disorders.
Children with expressive language disorders may be ostracized by peers because of their poor
ability to explain what they are talking about. They may appear vague when telling a story and
use many filler words (stuff, things) instead of naming specific objects. The essential feature
is marked impairment in the development of age-appropriate expressive language,
which results in the use of verbal or sign language markedly below the expected level
in view of a child's nonverbal intellectual capacity. Language understanding (decoding)
skills remain relatively intact. When severe, the disorder becomes recognizable by about the
age of 18 months, when a child fails to utter spontaneously or even echo single words or
sounds. Even simple words, such as Mama and Dada are absent from the child's active
vocabulary, and the child points or uses gestures to indicate desires. The child seems to
want to communicate, maintains eye contact, relates well to the mother, and enjoys
games such as pat-a-cake and peek-a-boo. The child's vocabulary is severely limited. At 18
months, the child may be limited to pointing to common objects when they are named.
When the child begins to speak, the language impairment gradually becomes apparent.
Articulation is often immature; numerous articulation errors occur but are inconsistent,
particularly with such sounds as th, r, s, z, y, and l, which are either omitted or are substituted
for other sounds.
By age 4, most children with expressive language disorder can speak in short phrases,
but may have difficulty retaining new words. After beginning to speak, they acquire
language more slowly than do most children. Their use of various grammatical structures is
also markedly below the age-expected level, and their developmental milestones may be
slightly delayed. Emotional problems involving poor self-image, frustration, and depression
may develop in school-age children.
.- :
.
235
- / ".
.
, .
- -
- - .
preschool , .
Kindergarten .

.
.
.
, , .
.
.

-
- ,
" .
.
" /.
/ .
" .
.
.
.
.
" ' .
-
- 2 .:
.1 .
.2 .
" . . )( -
.
+ + .
, , .
.
.
235
236
-
'1 .
'1 , ,.
'1
, ," .
- , , .
: '' , .
-Chronic fatigue syndrome
-
.
" .
,
)(.
) NSAIDS
( . .
).graded exercise therapy (GET
, . CBT - .
" Nefazodone .bupropion (Wellbutrin), .

) (Serzone , .
-
/ ,
.
: , , , ) -
,(.
: ) ,(62% ) ,(18% ) ,(10% )(7%
:
" 10 1/3 9 , , .
2-8% : , ) adequacy
, , ( ,
- .
237
- Neglect
A maltreated child often shows no obvious signs of being battered, but has multiple minor
physical evidences of emotional and, at times, nutritional deprivation, neglect, and abuse. A
maltreated child, often brought to a hospital or to a private physician, has a history of FTT,
malnutrition, poor skin hygiene, irritability, withdrawal, and other signs of psychological
and physical neglect.
Children with this disorder exhibit bizarre eating behaviors and disturbed social
relationships. Binge eating, ingestion of garbage or inedible substances, drinking of toilet
water, and induced vomiting have been reported.
:
, ) - , :
, . ,
- . ,delayed PTSD ,(
.( )
-Motor skills disorder
Motor skills disorder (motor coordination disorder, Developmental coordination
disorder) is a human developmental disorder that impairs motor coordination in daily
activities. It is neurological in origin. Many children with autismor Asperger syndrome
experience deficits in motor skills development, which often manifests as abnormal
clumsiness, but is not major enough to be considered a disorder in and of itself.
The disorder has its basis in the brain, a network of neural connections that allow humans to
process the information received. Developmental coordination disorder is a result of weak or
disorganised connections in the brain, which then translates to trouble with motor coordination.
Movements are performed because the brain sends messages to the area requiring action.
The Developmental coordination disorder is a result of weak or poorly structured neural
pathways to the moving parts of the body.
,ADHD ,// , :
.( ),( )
-
, , , , :
.vivid sensory imagery , , ,
Reactive Attachment Disorder (RAD)
normal ,
.5 . .attachment behavior
.
237
238
/ )
( . .social relatedness-
- inhibited type (1 : .
social relatedness - disinhibited type (2 .
,pathogenic caregiving
.
) FTT ,malnutrition- (.
1%> :.
: - , , .
, .RAD
: RAD .normal attachment behaviors
.RAD-
RAD , , .
: ,MR , ,
, ) ( , , .
attachment- : , , .
: .5
: " " .
, ,
. , malnurtrition.
FTT .
, , .
, . , .
, .
FTT RAD- malnurished , .
. - .marasmus
> %3 HC ." . .
"".
: , , .
. GH/ ) (.
, .
:ZAR
, , , , ,
.
, , , . ,
, .
.
: - .
:Sibling rivalry disorder
.A
239
.B - :2 , , , ,

.C 6
.D 4
239

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...

(1-3y) Toddler , ,temper tantrums , ),

) <(flight of ideas ) <(pressured<

) Loose associations ( = Derailment

) Incoherence - Word salad ( -

) Clang associations ( - "

: < < ,somnolence, stupor, alert ,

)((1) :(2) ,(3) , ) ? ? ?

) .thinking ) (primary process thinking

(Diagnostic and Statistical Manual of Mental Disorder (DSM 20

)Diagnostic and Statistical Manual of Mental Disorder (DSM

21 (Diagnostic and Statistical Manual of Mental Disorder (DSM

Major depressive disorder

Dependent personality disorder

Axis III: Glaucoma

GAF- Highest Past Year = 60, Current= 35

Mood disorder with depressive features due to hypothyroidism

Axis III: Hypothyroidism

(Diagnostic and Statistical Manual of Mental Disorder (DSM 22

(ANXIETY DISORDERS) .III

23 (Diagnostic and Statistical Manual of Mental Disorder (DSM

(Diagnostic and Statistical Manual of Mental Disorder (DSM 24

25 (Diagnostic and Statistical Manual of Mental Disorder (DSM

Substance induced psychosis ) ,( , ,

)27 (PSYCHOTIC DISORDERS

CNS- . , .MS ,"

Dementia (Behavioral & Psychiatric Signs of Dementia) BPSD-

- Downward Drift Hypothesis

- Social Causation Hypothesis

. ) ,>50% ( 75% ) "

Obvious precipitating factors

Good premorbid social, sexual, and work

Poor premorbid social, sexual, and work

Mood disorder symptoms (especially depressive

Withdrawn, autistic behavior

Single, divorced, or widowed

Family history of mood disorders

Family history of schizophrenia

Good support systems

Poor support systems

History of perinatal trauma

, ,10 :early onset SZP-

hallucinosis, barbiturate withdrawal, cocaine, phencyclidine (PSP)

: , inf. frontal region- .

Substance induced psychosis

, ,sympathomimetics ,L-DOPA ,'.

50% ; 20% 30%- .

) Folie a' deux ( DSM5

) Brief psychotic disorder .5 44 (

) Brief psychotic disorder .5 (

) Brief psychotic disorder .5 ( 45

" ) high potency ( .BDZ-

) Brief psychotic disorder .5 46 (

.6 ) NOS Not Otherwise Specified DSM5

.II )47 (AFFECTIVE DISORDERS

.II 48 )(AFFECTIVE DISORDERS

.II )(AFFECTIVE DISORDERS

.2 50-70% " . mood disorder

.II )49 (AFFECTIVE DISORDERS

) MAJOR DEPRESSIVE DISORDER .1 '(:

)51 (Depressive disorders

2 Recurrent depression ' ,

) Postpartum onset -( - ' 4