5 th

5th
Internal
Internal medicine

medicine
First

[ADRENALINE]
PSYCHIATRY IN BRIEF
‫‪Psychiatry In Brief‬‬ ‫‪Take a HINT‬‬

‫‪Take a Hint‬‬

‫‪ -‬بدايه ‪ ..‬كل الشكر لكل اللى تعب و اجتهد عشان يخففوا على زمايلهم ‪ ..‬يستاهلوا كل خير‬

‫‪ -‬وعشان الناس تطمن ‪...‬‬

‫‪ -‬مذكرة الشرح اقرب ما يكون من اللى اتشرح فى الشفت ‪..‬و بنسبه ‪ %09‬كالمها من ‪first aid‬‬
‫‪ -‬يعنى ذاكر المواضيع اللى اتحددت منها وانت متطمن ‪ ...‬ولو مش هتلحق تذاكرتفاصيل هتالقي هنا كل‬
‫االجزاء المهمه ملخصه فى شكل نقط بنفس نظام اسئله االمتحان ( وباذن هللا االسئله مش هتخرج عنها )‬
‫‪ -‬فاضل بس الجرعات لو حددوا حاجه باذن هللا هضيفها‬
‫‪ -‬المواضيع اللى اتحددت بترتيبه مذكرة الشرح‬
‫‪1.‬‬ ‫‪major depressive disorder‬‬
‫‪2.‬‬ ‫‪mood disorder‬‬
‫‪3.‬‬ ‫‪bipolar‬‬
‫‪4.‬‬ ‫‪schizophrenia‬‬
‫‪5.‬‬ ‫‪anxity‬‬
‫‪6.‬‬ ‫‪somatoform‬‬
‫‪7.‬‬ ‫) ‪cognitive disorder ( delirium‬‬
‫‪8.‬‬ ‫) فى الشيت بس ‪(symptomatology & psychiatric history‬‬

‫‪ -‬اسئله السنين اللى جت قبل كدا بدايه من ‪ 6902‬على المواضيع اللى اتحددت وهتالقو اجاباتهم فى قلب‬
‫المواضيع وعلى حسب االهميه هتالقو جنب العنوان "‪"QQQQ‬‬

‫)‪1- Delirium (clinical presentation + causes‬‬

‫)‪2- Severe recurrent depression (lines of ttt + diagnostic symptoms‬‬
‫)‪3- SSRIs (side effects‬‬
‫)‪4- Generalized anxiety disorder (dd‬‬
‫?‪5- DSM 5 diagnostic criteria (criteria A) of schizophrenia‬‬
‫)‪6- Substances dependence (signs‬‬

‫" دعواتكم فضال ‪" ....‬‬

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Psychiatry In Brief Major Depressive D.

Major Depressive Disorder ( M D D )

3 ‫لو مش هتقرأ الموضوع خالص ذاكر اول جزء تحت و ص‬
( D S M - 5 C R I T E R I A )QQQQ
 Must five of the following symptoms (must include either number 1 or 2) for at least a
2-week period:
KEY FACT
1. Depressed mood most of the time Symptoms of major depression—
2. Anhedonia SIG E. CAPS (Prescribe Energy
Capsules)
3. Change in appetite or weight (↑ or ↓) - Sleep - Interest
4. Feelings worthlessness or guilt - Guilt - Energy
- Concentration - Appetite
5. Insomnia or hypersomnia - Psychomotor activity - Suicidal
6. Diminished concentration ideation

7. Psychomotor agitation restlessness or slowness)

8. Fatigue
9. Recurrent thoughts of death or suicide

Epidemiology
 Lifetime prevalence: 12% worldwide.
 age of onset peaks in the 20s.
 1.5 - 2 times in women than men during reproductive years.

Sleep Problems Associated with MDD

 Multiple awakenings.
 Initial and terminal insomnia
 Hypersomnia is less common.
 Rapid eye movement (REM) with reduced stages 3 and 4 (slow wave) sleep.

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Psychiatry In Brief Major Depressive D.

Etiology
The cause is unknown, but MDD believed to be heterogeneous disease, with biological,
genetic, environmental, and psychosocial factors contributing.
 High cortisol.
 Abnormal thyroid axis
 Gamma-aminobutyric acid (GABA), glutamate have a role.
 Psychosocial/life events:
 Genetics: First-degree relatives are two to four times more likely to have MDD.
 Medication-Induced Depressive Disorder Levodopa Antipsychotics Barbiturates

Subtypes of depression:

1-with anxious distress

2-with mixed features
3-with melancholic feature
a) Diminished enjoyment b) Unable to react to joy stimuli with excess guilt
4-with atypical features 5-with catatonia:
6-with peripartum onset 7-with seasonal pattern

Recurrent depressive disorder:

at least 2 separate major depressive episodes, at least 2 months of healthy interval

in between these episodes.
Cyclothymia:
numerous episodes for 2 years at least, but not meet full diagnostic criteria for Dep.
Dysthymia: Persistent mild depressive disorder for at least 2 years.

Good prognostic factors: Bad prognostic factors:

-acute onset -insidious onset
-early age of onset -old age of onset
-reactive depression -neurotic depression
-low self-esteem

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Psychiatry In Brief Major Depressive D.

Treatment QQQQ
All medications equally effective but differ in side-effect. & take 4–6 weeks to work

1. Hospitalization
2. Pharmacotherapy
1. Antidepressant medications:
1-Selective Serotonin Reuptake Inhibitors(SSRI) 2-Selective serotonin and noradrenaline
 Examples: - Sertraline reuptake inhibitors (SNRI):
 Side Effects: (GIT&sexual) QQQQ  Examples: - duloxetine
 Nausea , diarrhea  S.E: as SSRI
 Sexual dysfunction
 GIT bleeding and hyponatremia
 increase suicidal thoughts
3. noradrenaline and serotonin specific 4- Tricyclic Antidepressants (TCA)
antidepressants (NASSA)  Examples: Amitriptyline
 Example: Mirtazapine  S.E: sedation, drowsiness
 S.E: sedation& weight gain. Overdose: tachyarrhythmia,
seizures, coma, Death
5-Monoamine oxidase inhibitors( MAOIs )
1. Examples: phenelzine
2. S.E: postural hypotension-insomnia -agitation-ankle edema -dry mouth
2. Adjunct medications:
 Atypical antipsychotics prescribed in resistant MDD without psychotic features.
 Triiodothyronine (T3), levothyroxine (T4) , lithium & methylphenidate.

3. Psychotherapy (supportive, cognitive, dynamic, family and marital therapy)

4. Electroconvulsive Therapy (ECT)

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Psychiatry In Brief Mood Disorder

Mood Disorders

Classification of Mood Disorders

1. depressive disorders:
a- Major depressive episode (unipolar) b- Dysthymic disorder
2. Bipolar disorders: B1 , B2
3. Cyclothymic disorders: mild depression and intermittent hypomanic periods .
4. Mood disorders due to: general medical conditions or substance abuse.

Etiology of Mood Disorders

A. BIOLOGICAL:
1. Genetic factors 2. Neuro chemical factors :
B. PSYCHOLOGICAL:
1. Psychoanalytic theory 2. Cognitive theory: - ve view of self
3. Learned helplessness
4. Personality: there is association between cyclothymic with bipolar and
obsessional traits , neuroticism with depression.
C. ENVIRONMENTAL & SOCIAL:
1. Childhood deprivation of maternal affection
2. Stressful life events 3. Medical illness

(Depression)
....‫تكمله للى فوق مش مهمه اوى‬
CLINICAL VARIABLES OF DEPRESSIVE DISORDERS
1. Masked depression 5. Seasonal affective disorders
2. Atypical depression 6. Melanchonia
3. Agitated depression 7. Depressive stupor
4. Post partum depression

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Psychiatry In Brief Mood Disorder

DEFFERENTIAL DIAGNOSIS Probability for further episodes

1. Schizophrenia 2. Dementia
3. Dysthyma 4. Anxiety disorder  50% After 1st episode
5. Substance induced mood disorder  70% After 2nd episode
6. Mood disorder due to medical condition  90% After 3rd episode

Bipolar Disorder
Diagnosis and DSM-5 Criteria

 occurrence of a manic episode (5% of patients experience only manic episodes).

Symptoms:
 Elevated or irritable mood.
 Talkativeness,flight of ideas, distratbility.
 Decreased need for sleep, increased libido,
 excessive energy, over spending of money.
 Over eating , hyper sexuality and execessive involvement in pleasure activity

( Mania )
1.  Though racing - Flight of ideas – Grandiosity - Attention - Insomnia
2.  Elation – Excitement
3. Talkativeness – Hyperactivity – expenditure - Hyper sexuality - Destructiveness
Symptoms:

1. elevated or irritable mood, 2. talkative, flight of ideas, distractbility,

3. decreased need for sleep , 4. increased libido,
5. excessive energy, 6. spending of money,
7. over eating 8. hyper sexuality
9. and excessive involvement in pleasure activity.
Treatment Of Bipolar Disorder Antimanic drugs (mood stabilizers)
1. Lithium carbonate – carbamazibine valporic acid
2. Antipsychotic 3. ECT

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Psychiatry In Brief Mood Disorder

Schizophrenia
Def : psychotic disorder marked by severe impairment of thinking, emotion, behavior

symptomsQQ :

Positive symptoms: - Hallucinations, - delusions,

- bizarre behavior - disorganized speech.
Negative symptoms: - Flat or blunted affect - anhedonia,
- apathy, - alogia&lack of interest.
Cognitive symptoms: - Impairments in attention
- executive function,& working memory.

DSM-5 Criteria QQQQ

- Two or more of the following must be present for at least 1 month:

Note: At least
1. Delusions 2. Hallucinations
one must be
3. Disorganized speech 1, 2, or 3.

4. Grossly disorganized or catatonic behavior

5. Negative symptoms
- Must cause signifcant social , occupational, or self-care functional deterioration.
- for at least 6 months

Prognosis:
 40–60% remain impaired after diagnosis,
 20–30% function fairly well in society.
 20% with schizophrenia attempt suicide .
Associated with Better Prognosis Associated with Worse Prognosis
- Later onset - Good social support - Early onset - Poor social support
- Positive symptoms - Mood symptoms - Negative symptoms - Family history
- Acute onset - Female gender - Gradual onset - Male gender
- Few relapses - Many relapses
- Good premorbid functioning - Poor premorbid functioning
- Comorbid substance use

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Psychiatry In Brief Mood Disorder

treatement QQ:
1. Typical antipsychotic medications (e.g., chlorpromazine, fluphenazine)
2. Atypical antipsychotic medications (e.g., aripiprazole, asenapine, clozapine)
3. Psychotherapy (supportive, cognitive, dynamic, family and marital therapy)
4. Electroconvulsive Therapy (ECT)
5. Hospitalization: (indicated if) - Excitement, difficulty taking drugs
- Suicidal/Homicidal ideation - Severe psychological stress

Other psychotic disorders

1- Schizoaffective disorder

Diagnosis and DSM-5 Criteria:

Meet criteria for major depressive or manic episode with schizophrenia also met.
Delusions or hallucinations for 2 weeks
Mood symptoms present for a majority of the psychotic illness.
Symptoms not due to the effects of a drug or medication or medical condition.
Treatment
1. Typical antipsychotic medications (e.g., chlorpromazine, fluphenazine)
2. Atypical antipsychotic medications (e.g., aripiprazole, asenapine, clozapine)
3. Electroconvulsive Therapy (ECT)
4. Hospitalization:

2- Brief psychotic Disorder

Diagnosis and DSM-5 Criteria

Patient with psychotic symptoms as in schizophrenia with symptomslast from 1 day to
1 month, and there must full return to premorbid level of functioning.
Symptoms not due to the effects of a drug or medication or medical condition.
This is a reaction to extreme stress such as bereavement, sexual assault, etc.
Treatment ‫نفس الكالم ز ى اللى فوق‬

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Psychiatry In Brief Mood Disorder

3-Delusional disorders

Diagnosis and DSM-5 Criteria QQ

One or more delusions for at least 1 month.
Does not meet criteria for schizophrenia.
Functioning in life not impaired, and behavior not obviously bizarre.
there are important differences () delusions present in delusional disorder and
schizophrenia.
Types of Delusions
Erotomanic type: Delusion that another person is in love with the individual.
Grandiose type: Delusions of having great talent.
Somatic type: Physical delusions.
Persecutory type: Delusions of being persecuted
QQQ
Schizophrenia Delusional Disorder
 Bizarre or nonbizarre delusions  Usually nonbizarre delusions
 Daily functioning signifcantly impaired  Daily functioning not signifcantly
 Must have two or more of the impaired
following:  Does not meet the criteria for
Delusions schizophrenia as described in the left
Hallucinations column
Disorganized speech
Disorganized behavior
Negative symptoms

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Psychiatry In Brief ANXITY Disorder

ANXIETY Disorders
Panic Disorder
spontaneous, recurrent panic attacks.
occur suddenly, “out of the blue.”
The frequency of attacks ranges from multiple times per day to a few monthly.
Patients develop debilitating anxiety about having future attacks —“fear of the fear.”
can lead to avoidance behaviors (i.e., agoraphobia).
Diagnosis and DSM-5 Criteria
 Recurrent, unexpected panic attacks without an identifiable trigger
 One or more of panic attacks followed by >1 month of continuous worry about
experiencing subsequent attacks or (e.g., avoidance of possible triggers)
 Symptoms not due to the effects of a drug or medication or medical condition.
Treatment
- Pharmacotherapy and CBT - most effective
 First-line: SSRIs (e.g., sertraline, citalopram, escitalopram)
 TCAs (clomipramine, imipramine)
 benzodiazepines (clonazepam, lorazepam) as scheduled or PRN
Agoraphobia
intense fear of being in public places
The course of the disorder is usually chronic. Avoidance behaviors may become as
extreme as complete confinement to the home.
Diagnosis and DSM-5 Criteria
Intense fear/anxiety about >2 situations or other humiliating symptoms:
 outside of the home alone  public transportation (e.g., trains)
 open spaces (e.g., bridges)  crowds/lines
 enclosed places (e.g., stores)
The triggering situations cause intense anxiety, avoidance, or requiring a companion.
cause social or occupational dysfunction
last ≥ 6 months & not better explained by another mental disorder
Treatment : as panic disorder: CBT and SSRIs (for panic symptoms)

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Psychiatry In Brief ANXITY Disorder

SPECIFIC PHOBIAS/SOCIAL ANXIETY DISORDER

A phobia is an irrational fear that leads to endurance of the anxiety and/or avoidance
of the feared object or situation.
A specific phobia is an intense fear of a specific object or situation
social phobia: or fear of acting in a humiliating or embarrassing way.
Diagnosis and DSM-5 Criteria
 Persistent, excessive fear
 Exposure to the situation triggers an immediate fear response
 Situation is avoided when tolerated with intense anxiety
 Symptoms cause significant social or occupational dysfunction
 Duration ≥ 6 months
 Symptoms not due to the effects of a drug or medication or medical condition.
Treatment
Specific phobia:
 Treatment of choice: CBT
Social anxiety disorder (social phobia):
 CBT
 SSRIs (e.g., sertraline, fluoxetine)
 SNRI (e.g., venlafaxine)
 Benzodiazepines (e.g., clonazepam, lorazepam) or PRN
 Beta-blockers (e.g., atenolol, propranolol) for performance anxiety/public speaking

Generalized Anxiety Disorder (GAD) QQQQ

persistent, excessive anxiety about many aspects of their daily lives.
DD of ( GAD QQQQ ) ‫ وجه قبل كدا‬FA‫مش موجود ف‬
1- Withdrawal from drugs or alcohol, 2- Excessive caffeine consumption,
3- Depression, 4- Psychotic disorders,
5- Organic causes “ thyrotocisosis , parathyroid disease , hypoglycaemia ”

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Psychiatry In Brief Cognitive Disorder

Diagnosis and DSM-5 Criteria

 Excessive, anxiety/worry about various daily events/activities > 6 months
 Difficulty controlling the worry
 Associated > 3 symptoms: restlessness, fatigue, impaired concentration, irritability,
muscle tension, insomnia
 Symptoms not due to the effects of a drug or medication or medical condition.
 Symptoms cause significant social or occupational dysfunction
Treatment ‫نفس العالج اللى قبلها‬

Cognitive Disorders
Delirium
DEF : acute organic brain dysfunction Characterized by disturbance of consciousness.

Causes of deliriumQQQQ:

A- Delirium due to a general medical condition

Local brain pathology Systemic causes
Traumatic brain injury Liver failure
Inflammatory brain diseases. e.g. Renal failures
encephalitis, meningitis Hypoxia and respiratory failure
Vascular e.g. stroke or hemorrhage. Diabetic ketoacidosis or hypoglycemia.
Late stage of increased intracranial Endocrinopathies.
pressure e.g. cases of brain tumor Dehydration and electrolyte
imbalance
Systemic infection, and septicaemia
B- substance intoxication or substance withdrawal (specify which substance).
C- a multiple etiologies (specify which conditions).
D- Delirium not other causes e.g. sensory deprivation.
Affect Fear, Rage
Disturbed consciousness Behavior Intellect
1. Drowsiness 1. Agitation 1. Disorientation
2. Inattention
2. Confusion 2. sleep disturbance
3. Hallucination
4. Illusions
5. Lack of insight and judgment

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Psychiatry In Brief Cognitive Disorder

DSM-IV Diagnostic Criteria

A. Disturbance of consciousness with reduced ability to focus, sustain or shift attention.
B. The change in cognition or perceptual disturbance is not due to dementia.
C. The disturbance develops over a short period of time and fluctuates during the day.
D. clinical evidence OF disturbance caused by medical condition &/or substance use or
withdrawal.
Differential Diagnosis of Delirium

A. Dementia
1. The major difference between dementia and delirium is that demented patients are
alert without the disturbance of consciousness characteristic of delirious patients.
2. Information from family or caretakers is helpful
B. Psychotic Disorders and Mood Disorders with Psychotic Features.
Delirium can be distinguished from psychotic symptoms by the abrupt development of
cognitive deficits including disturbance of consciousness.
In delirium, there should be some evidence of an underlying medical or substance-
related condition.
a. Malingering. Patients with malingering lack objective evidence of a medical or
substance-related condition.
Treatment of Delirium
1. Treatment of the underlying condition.
2. A quiet environment with clear environmental cues
3. close observation of vital signs, state of consciousness and behaviour
4. Physical restraints necessary to prevent injury to self or others.
5. Medication to control agitation,confusion, and perceptual disturbances:
 Haloperidol (Haldol)
 small doses of quetiapine (Seroquel)
 Lorazepam (Ativan),
2- Dementia

see Neurology book

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Psychiatry In Brief Somatoform Disorder

Somatic Symptom Related Disorders (Somatoform & Dis.)

Subtypes of “somatic symptom and related disorders” :

1. Somatization 5. Factitious disorder.

2. Hypochondriasis 6. specified somatic disorder.
3. Conversion disorder. 7. Unspecified
4. (Psychosomatic)

1. Somatic symptom disorder (Somatization D.)

Diagnosis according to DSM-5 criteria :

1. One or more somatic symptoms that result in significant disruption.

2. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or
associated health concerns.
3. Lasts at least 6 months.
Etiology: risk factors include:

 older age  History of childhood abuse.

 unemployment  Chronic stress
 Low threshold to physical discomfort
Differential Diagnosis QQ:

1. Medical illness as immune deficiency diseases

2. conversion disorder, illness anxiety dis.
3. Malingering and factitious disorder
Good prognostic factors include:

 Good socioeconomic status

 Better education
 Good responsiveness to drug therapy
 Absence of co-morbid medical, psychiatric or personality dis,
Treatment:

1. regularly scheduled visits with a single primary care physician.

2. Address psychological issues slowly.
3. Psychological treatment:
Psychotherapy whether individual or group (directed to stress management)
Pharmacotherapy: mainly antidepressants (SSRIs)

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Psychiatry In Brief Somatoform Disorder

2. Illness anxiety disorder (Hypochondriasis)

Diagnosis according to DSM-5 criteria :

 Preoccupation with having or acquiring a serious illness

 Somatic symptoms not present
 High level of anxiety about health
 Performs excessive health-related behaviors
 Persists for 6 months
 Not better explained by another mental disorder
Differential Diagnosis:

 Medical illness with symptoms similar to patient’s complaint

 conversion disorder, somatic symptom dis., OCD
 Malingering and factitious disorder
 Delusional disorder
Treatment:
1. Regularly scheduled visits to one primary care physician.
2. Psychotherapy: CBT most useful.
3. SSRIs

3. Conversion disorder

Etiology:
 Usually following acute stress
 Histrionic or avoidant personality disorders
 High incidence of comorbid neurological, depressive, or anxiety disorders

Treatment:
 Resolution is commonly spontaneous.
 Education about the illness is essential.
 Psychotherapy: Insight oriented, supportive, behavioral or Cognitive- behavioral.
 Drug therapy if there is associated anxiety and/or depression.

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Psychiatry In Brief Cognitive Disorder

4. Psychological factors affecting other medical conditions

Psychosomatic dis.

Diagnosis according to DSM-5 criteria :

A medical symptom is present.

Psychological factors adversely affect medical condition in at least one way.
Precipitating, or exacerbating symptoms or necessitating medical attention.
Psychological or behavioral factors not better explained by another mental disorder.
Treatment:

education and frequent contact with a primary care physician.

SSRIs and/or psychotherapy (especially CBT)

5. Factitious Disorder

Diagnosis according to DSM-5 criteria :

 Falsification of physical or psychological signs or symptoms, or induction of injury.

 The deceptive behavior is evident even in the absence of obvious external rewards .
 Behavior is not explained by another mental disorder,or another psychotic disorder.
 Individual can present him/herself, or another individual .
 Commonly feigned symptoms:
Psychiatric—hallucinations, depression
Medical—fever (by heating the thermometer), infection, hypoglycemia

Treatment & Prognosis:

Collect collateral information from medical treaters and family. Collaborate with
primary care physician and treatment team to avoid unnecessary procedures.
require confrontation in a nonthreatening manner.

6. Malingering

malingering is not considered to be a mental illness.

Epidemiology

Not uncommon in hospitalized patients

Significantly more common in men than women

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Psychiatry In Brief Substance Use D.

Presentation

 Patients present with multiple complaints that do not conform to a known medical
condition.
 They are uncooperative and refuse to accept good prognosis
 Their symptoms improve once their desired objective is obtained.

Substance Use Disorder

‫هكتفى بالسؤال دا النه الوحيد اللى بيجى فى الموضوع‬
Enumerate signs of dependence ?
CANT STOP
Compultion to take substances Stopping causes withdrawal
Aware of harms but persist Time preoccupied with
substances increase
Neglect of other activity Out of control of use
Tolerance Persistent, wish to cut down

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