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Psychiatry Lecture Notes
Psychiatry Lecture Notes
Psychiatry Lecture Notes
2
Have you heard about holiday
syndrome/blues ?
3
Brain storming
• Human brain , main fxn ? Factors that influence it ?
• What makes psychiatry differ from medicinal sciences ?
• What is mental health and mental disorder ?
• What do you think the possible causes of mental disorders ?
• Do you think mental disorder/s are treatable ?
• Which one is your most preference treatment ?
• Religious / cultural treatment
• Medication
• Psychotherapy
• Both 4
Unit one
Introduction about psychiatry
• Mental Health - is a state of well-being
the individual realizes his or her own abilities,
can cope with the normal stresses of life
can work productively and a fruitfully and is able to make a contribution
to his or her community. (World Health Organization)
6
Introduction … history cont. . .
7
8
Unit Two
Therapeutic communication
9
Therapeutic com……cont.…
16
MHA…..cont.…
17
HX and MSE
Hx taking
I. Identification
II. Source and reliability
III. Chief complaints
IV. History of presenting illness
• what (symptoms), how much (severity), how long, and associated
factors (alleviate or exacerbate), Rx received for the current episode,
positives and negatives
V. Past psychiatric /medical history
• (when they occurred, how long they lasted, and the frequency and severity of
episodes, dx and Rx and suicidality ,Violence and homicidality )
• Medical illnesses and Medication
18
Hx . . . Cont . . .
VI. Family history
(Mental illness, suicide, Substance, communication
(interaction) within the family
VII. Personal history
VIII. Sexual history
X. Forensic history
XI. Premorbid personality
19
HX and MSE . . . cont. . . .
MSE
SCHIZOPHRENIA SPECTRUM
AND
DANIEL A.
5/3/2021 daniaye212@gmail.com 21
Historical background
For centuries – psychotic states known in every
culture
In the nineteenth century -all mental disorders
described as single entity- unitary psychosis
Benedict Morel 1809 -1873
French psychiatrist, had used the term demence precoce
Emil kraepelin- 1856 – 1926
Dementia praecox and affective psychosis
Course and outcome of psychosis
.
..
.
DSM 5 criteria
A. Two (or more) of the following(symptoms), each present
for a significant portion of time during a 1 -month
period (or less if successfully treated).
At least one of these must be (1 ), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional
expression or avolition).
.
B. Social/occupational dysfunction:
• For a significant portion of the time since the onset of
the disturbance,
• one or more major areas of functioning such as
• work, interpersonal relations, or self-care
• are markedly below the level achieved prior to the
onset
• when the onset is in childhood or adolescence,
failure to achieve expected level of interpersonal,
academic, or occupational achievement
.
C. Duration
• Continuous signs of the disturbance persist for at least
6 months.
• This 6-month period must include at least
• 1 month of symptoms (or less if successfully treated) that
meet Criterion A (i.e., active-phase symptoms) and
• may include periods of prodromal or residual symptoms
Schizophrenia - Clinical picture
Positive symptoms
Delusions –persecutory, religious, somatic,, bizarre
Hallucination – auditory, visual
Disorganized speech – derailment, tangentially,
circumstantiality, perseveration, etc . . .
Negative symptoms
Alogia – poverty of speech – amount, content
Affective flattening
Anhedonia – inability to experience pleasure
Asociality – few social contact
Avoliton/Apathy – lack of energy, decreased
motivation
Attentional impairment - absentmindedness
Schizophrenia - Clinical picture cont’d
Social and occupational deterioration
Work inhibition
Poor interpersonal relationship, social withdrawal
Poor self care – unkempt, bizarre clothing
Decreased level of achievement –academic etc.
Breaking social rules – table manner, obscenities,
collecting garbage
Hummm… for general k’dge
3. “ “ “ “ full remission
..
Epidemiology -schizophrenia
Biochemical Factors
- Dopamine Hypothesis
• Schizophrenia results from too much dopaminergic
activity
• Revised Dopamine hypothesis – increased dopamine at
mesolimbic, and decreased dopamine at mesocortical
pathway
• Other neurotransmitters- Glutamate, GABA, Serotonin,
norepinephrine, neuropeptides
DA path ways and fxn.
• Nigrostriatal - Sensory stimuli and movement
• Mesolimbic - Emotion and reward
• Mesocortical - Cognitive and emotional behavior
• Tuberoinfundibular- Control of the hypothalamic
and pituitary endocrine system
41
.
Structural changes
- Neuro-pathological basis for schizophrenia,
• the limbic system and the basal ganglia
• neuropathological or neurochemical abnormalities in the
cerebral cortex, the thalamus, and the brainstem
• Lateral and third ventricular enlargement
• Some reduction in cortical volume
• Reduced symmetry in schizophrenia
• the temporal, frontal, and occipital lobes
.
Neurodevelopmental
Congenital brain anomalies
.
Physiological changes
EEG
• Increased sensitivity to activation procedures (e.g., frequent
spike activity after sleep deprivation),
• Decreased alpha activity, increased theta and delta activity,
• More left-sided abnormalities than usual
Evoked Potentials
The P300 has been reported to be statistically smaller than
comparison groups
Magnetic resonance spectroscopy- decreased brain
metabolism
.
Psychoneuroendocrinology
.
.
Psychoanalytic Theories
Schizophrenia resulted from developmental fixations
that occurred earlier than those culminating in the
development of neuroses
o These fixations produce defects in ego development(poor early object
relations)
o Interpretation of reality and the control of inner drives(sex and
aggression)are impaired
Learning Theories
Family Dynamics
A poor mother-child relationship - increase in the risk of
developing schizophrenia
A specific family pattern plays a causative role in the
development of schizophrenia
Pathological family behavior that can significantly increase the emotional
stress
Psychosocial–
Low social class -Drift/Breed hypothesis
Immigration
Social isolation
Treatment
of schizophrenia
..
Pharmacologic treatment
Antipsychotic medication
Control acute psychosis
Do little for negative symptoms
Provide long term maintenance
Two major types- typical and atypical
Adjunctive pharmacologic agents
Benzodiazepine
Propranolol
Lithium carbonate
Antidepressants
Carbamzepine and sodium valproate
Electroconvulsive therapy ( ECT)
.
Non-pharmacologic treatment
Social intervention – residence, work, etc.
Individual Psychotherapy
o Psychoanalysis and Psychodynamic Psychotherapy
o Supportive Psychotherapy
o Personal Therapy
o Compliance Therapy
Group Psychotherapy
Family intervention- expressed emotion
.
55
MOOD DISORDERS
56
Hummm . . . Summery
57
Question
• A patient was relatively healthy a month ago, but currently he
comes with a complaint of talking alone in a conversation
manner , assault people physically and verbally , he believed that
‘someone is following him and want to harm him’, he has also
poor social interaction with his relatives . This all symptoms are
happened without any apparent reasons .
• what is your possible Dx ?
• Also what are your possible DDx ?
• Rx ?
58
Definition
59
Historical background
.
Definition
Cont . . .
I- Bipolar I Disorder
• Manic • Mild
• Depressed • Moderate
• Unspecified • Severe
Subtypes
Bipolar I disorder, single manic episode
Bipolar I disorder, recurrent
*Manic episodes are considered distinct when they are
separated by at least 2 months without significant symptoms of
mania or hypomania 72
.
Bipolar II Disorder
A. Criteria have been met for at least one hypomanic episode and
at least one major depressive episode
B. There has never been a manic episode.
C. The occurrence of the hypomanic episode(s) and major
depressive episode(s) is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional
disorder, etc.
D. The symptoms of depression or the unpredictability caused
by frequent alternation between periods of depression and
hypomania causes clinically significant distress or impairment
in social, occupational, or other important areas of
functioning.
.
Cychlothymic disorder
A. For at least 2 years (at least 1 year in children and adolescents) there have
been numerous periods with hypomanic symptoms that do not meet criteria
for a hypomania episode and numerous periods with depressive symptoms
that do not meet criteria for a major depressive episode.
B. During the above period - not been without the symptoms for more than 2
months at a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never
been met.
D. Not better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, etc.
E. The symptoms are not attributable to the physiological effects of a
substance or another medical condition
F. Clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
•
Unipolar disorders
.
.
5/3/2021 79
B. With mixed features
5/3/2021 80
C. With rapid cycling (applicable for bipolar I or II)
• Presence of at least 4 mood episodes in the previous 12
months
Episodes are demarcated by either partial or full remissions
for at least 2 months or a switch to an opposite polarity
D. With peripartum onset
• If onset of mood symptoms occurs during pregnancy or in
the 4 weeks following delivery
5/3/2021 81
E. With melancholic features
One of the following
• Loss of pleasure in all, or almost all, activities
Lack of reactivity to pleasurable stimuli
At least 3 of the following
Distinct quality of depressed mood
Symptoms worse in the morning
Early morning awakening (2 hrs earlier)
Marked psychomotor agitation or retardation
Significant anorexia or weight loss
Excessive or inappropriate guilt
5/3/2021 82
F. With atypical features
i. Mood reactivity
ii. At least 2 of the following:
Significant weight gain or increase in appetite
Hypersomnia
Leaden paralysis (heavy feeling in limbs)
Long-standing pattern of interpersonal rejection
sensitivity
5/3/2021 83
G. With psychotic features
5/3/2021 85
• Posturing (spontaneous and active maintenance of a posture
against gravity)
• Mannerism
• Stereotypy (repetitive, abnormally frequent non-goal-directed
mov’ts)
• Agitation (not influenced by external stimuli)
• Grimacing
• Echolalia (mimicking another’s speech)
• Echopraxia (mimicking another’s movements)
5/3/2021 86
I. With seasonal pattern
• Applies to the lifetime pattern of at least one type of episode
• Characterized by:
Presence of regular temporal relationship between onset of
particular mood episode and a particular time of the year
Full remission or switch occurs at a characteristic time of the
year
The last 2 years episodes were seasonal, and no non-seasonal
episodes occurred in those years
5/3/2021 87
.
A. Depressed mood for most of the day, for more days than not,
as indicated by either subjective account or observation by
others, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
.
92
Epidemiology
93
Type Lifetime Prevalence (%)
Major depressive episode 5-17
Cyclothymia 0.5-6.3
Hypomania 2.6-7.8
Gender differences
.
.
1. Biologic factors
A.Genetic
B.Neurotransmitters
C.Alterations of Hormonal Regulation
D.Alterations of Sleep Neurophysiology
E.Immunological Disturbance
F.Structural and Functional Brain changes
G.Genetic Factors
.
A. Genetic Factors
1. Family studies –
2. Adoption studies
3. Twin studies
4. Linkage Studies
Identify specific susceptibility genes using
molecular genetic methods.
Family Studies
B. Neurotransmitters
1- Biogenic Amines
2-Other neurotransmitters
Dopamine
o The mesolimbic dopamine pathway may be dysfunctional in depression
and that the dopamine D1 receptor may be hypoactive in depression.
Acetylcholine (ACh)
Gama Aminobutyric acid (GABA)
o Reductions of GABA
Glutamate and glycine
B. Alterations of Hormonal Regulation
.
• 1- Neuroendocrine Regulation:
• The Hypothalamus is a central to regulation of the
neuroendocrine- the adrenaline, Thyroid and Growth
hormones axes.
C. Structural and Functional Brain changes
1-Computed axial tomography (CAT) and magnetic
resonance imaging (MRI)
Increased frequency of abnormal hyperintensities in
subcortical regions
Ventricular enlargement, cortical atrophy, and sulcal
Reduced hippocampal or caudate nucleus volumes, or
both
Diffuse and focal areas of atrophy have been associated
with increased illness severity, bipolarity, and increased
cortisol levels.
2.Non-biologic
a. Psychosocial Factors
b. Psychological factors
.
.
a. Psychosocial Factors
Life Events and Environmental Stress
more often precede first, rather than subsequent, episodes of mood
disorders.- for both major depressive disorder and patients with bipolar
I disorder
stress accompanying long-lasting changes in the brain's biology- high
risk of undergoing subsequent episodes of a mood disorder, even
without an external stressor
life event most often associated with development of depression is
losing a parent before age 11.
• The environmental stressor most often associated with the onset of
an episode of depression the loss of a spouse. Another risk factor is
unemployment;
Interpersonal theory
1) unresolved grief,
2) dispute b/n partner,
3) transition to new role,
Personality factors
109
.
.
.
.
Course of unipolar depression
1. Chronically ill without remission – 5-27% of patients with
MDD
2. Recurrent MDD with full inter-episode recovery, without
dysthymia
3. Recurrent MDD without full inter-episode recovery,
without dysthymia
4. Recurrent MDD with full inter-episode recovery,
superimposed on dysthymia (double depression)
5. Recurrent MDD without full inter-episode recovery
superimposed on Dysthymia (double depression)
.
Cycle length shortens for the first 3-6 episodes and then
stabilizes
Prognostic signs
• MDD- Mild episodes, the absence of psychotic symptoms, and a
short hospital stay, a history of solid friendships during
adolescence, stable family functioning, and generally sound social
functioning for the 5 years preceding the illness. are good
prognostic indicators.
.
.
BIOLOGICAL
Drugs
Antidepressant drugs- tricyclic and tetracyclic,SSRI,
others
Antimanic drugs or mood stabilizers- lithium,
carbamazepine, valproate, etc.
Antipsychotics
Benzodiazepine
Calcium channel blockers
Thyroid hormone
Electroconvulsive therapy (ECT)
Phototherapy
.
PSYCHOTHERAPY
Cognitive therapy (cognitive behavior therapy)
o Correcting automatic negative thinking
o Counteract errors of information processing
Interpersonal therapy –deals with
o Unresolved grief
o Role disputes
o Transition to new role
o Social skill deficit
Behavior therapy
o Education & guided practice – social skill training, structured problem-
solving therapy, self control therapy
Psychodynamic psychotherapy -
QUIZ
1. A 52-year old university teacher presented to a psychiatric clinic with pathological
guilt of letting down his colleagues, loss of interest in everything, morning
worsening of his condition, early morning awakening 2-3 hours prior to his usual
time of awakening, that predominated his presenting complaints for the last 1
month. The most likely diagnosis is?
123
Anxiety Disorders
Daniel A.
MSc in ICCMH
daniaye212@gmail.com
124
objectives
5/3/2021 125
Anxiety disorders
5/3/2021 126
CRITERIA FOR PATHOLOGICAL NORMAL
DIFFERENTIATION ANXIETY ANXIETY
impair functioning
Fear, Anxiety, and Stress
5/3/2021 128
Anxiety vs. Fear
Anxiety Fear
Threat
Threat
Avoidance
Interference
Functional impairment
5/3/2021 130
Anxiety
Overestimated
Likelihood x Harm
Anxiety =
Ability to cope
Underestimated
5/3/2021 131
Beck et al. 1985
Clinical features
132
.
Clinical features
General remarks
• Anxiety occur in all people regardless of culture,
race, age, religion, gender, level of education or
economic background.
• Characterized by
– excessive fear and/ or inappropriate feelings of nervousness
– very general (applied to nearly all aspects of life)
– very focused on a particular situation.
• Often chronic, unremitting, and disabling
133
.
b. Autonomic/Somatic Symptoms
Classified into
1. Generalized Anxiety Disorder (GAD):
2. Panic disorder
3. Phobic disorder
136
Clinical features cont'd
1. Generalized Anxiety Disorder (GAD)
• Excessive anxiety or worry– about work, school, etc. ; 6 month duration
• Difficult to control the worry
• Associated symptoms ≥ 3
Restlessness or feeling keyed
Hypervigillance - Inability to relax
Easily fatigued - Difficulty to concentrate
Irritability - Muscle tension
Sleep disturbance - Tremor
• Significant distress or impairment of functioning
• Not attributable to the physiological effects of a substance/Med.
137
DDx
• Anxiety disorder due to another medical condition
• Substance/medication-induced anxiety disorder
• Social anxiety d/o
• OCD . . .
138
Clinical features cont'd
2. Panic Disorder
144
Specific cont’d . . .
A. Marked fear or anxiety about a specific object or situation (e.g., flying,
heights, animals, receiving an injection, seeing blood)
• The lifetime - 1 to 4 %
• Women are two to three times more likely to be affected than men
5/3/2021 154
Agoraphobia
o Adolescent 1.7%
o Peaks in late adolescent and early adult hood
o 12 months prevalence >65 0.4%
o No statically significant culture and race
difference
5/3/2021 155
1. Biologic
.
.
Change in Neurotransmitters
The three major neurotransmitters NT
A. Norepinephrine (NE),
B. Serotonin, and
C. Gamma amino butyric acid (GABA)
B-Serotonin
GABA
Endocrinological
Dysfunctional Hypothalamic-Pituitary-Adrenal Axis
Abnormality in Corticotropin-Releasing Hormone
(CRH)
o Psychological stress increase the synthesis and
release of cortisol
o Cortisol serves to mobilize and to replenish
energy stores and contributes to increased
arousal, vigilance, focused attention, and memory
formation
Alterations in hypothalamic-pituitary-adrenal (HPA)
axis function - in PTSD
.
Brain-Imaging Studies
Structural studies – CT- MRI
occasionally show some increase in the size of cerebral ventricles
a specific defect in the right temporal lobe was noted in patients
with panic disorder. abnormal findings in the right hemisphere but
not the left hemisphere
Functional brain-imaging –fMRI, PET, SPECT, EEG
abnormalities in the frontal cortex, the occipital and temporal areas
panic disorder-the parahippocampal gyrus
OCD- the caudate nucleus is implicated
In PTSD - amygdala
,
Neuroanatomical Considerations
Locus ceruleus and the raphe nuclei - neuroanatomical
substrates of anxiety disorders.
Limbic System -in the generation of anxiety and fear
responses
o Amygdala
o Septo-hippocampal pathway
o The cingulate gyrus
Cerebral Cortex
o Frontal cerebral cortex
o Temporal cortex
.
Genetic Studies
Heredity has been recognized as a predisposing factor
for anxiety disorders
• Migraine • Hypoglycemia
• Endocrine - Pituitary • Premenstrual syndrome
dysfunction, Thyroid • Febrile illnesses and chronic
dysfunction infections
• Vitamin B12deficiency • Cerebral trauma and
postconcussive syndromes
• Toxic condition - Alcohol
and drug withdrawal; Caffeine • Cerebrovascular diseases
• Anemia
• Drugs-amphetamine, etc.
165
2. Non-biologic
a. Psychosocial
b. Psychological
.
a. Psychosocial
Stress and Anxiety
• The nature of the stressful event
• The person's resources, psychological defenses, and
coping mechanisms
• A person whose ego is functioning properly is in
adaptive balance with both external and internal worlds
• If the ego is defective and the resulting imbalance
continues sufficiently long, the person experiences
chronic anxiety.
.
b. Psychological causes
Three major schools of psychological theory
Psychoanalytic
Behavioral
Existential
.
Psychoanalytic Theories
• Anxiety stemmed from a physiological buildup of libido
• Anxiety as a signal of the presence of danger in the
unconscious
• Result of psychic conflict between unconscious sexual
or aggressive wishes and corresponding threats from
the superego or external reality
• The ego mobilized defense mechanisms to prevent
unacceptable thoughts and feelings from emerging into
conscious awareness.
.
Behavioral Theories
• Anxiety is a conditioned response to a specific
environmental stimulus
• In the social learning model, a child may develop an
anxiety response by imitating the anxiety in the
environment, such as in anxious parents.
Existential Theories
• Persons experience feelings of living in a purposeless
universe
• Anxiety is their response to the perceived void in
existence and meaning
Treatment
171
.
Non-pharmacologic treatment
CBT
Interpersonal therapy
Supportive psychotherapy
Psychodynamic psychotherapy
.
Psycho-education
Relaxation methods
Structured problem-solving
Pharmacologic treatment
Benzodiazepines
• Best used for time-limited treatment
• Dependence/withdrawal possible
SSRI’s - May be helpful for several syndromes
• Social phobia, panic disorder, OCD, PTSD,
GAD
Tricyclic agents- sedating antidepressants
174
Summery
1. Define anxiety, fear and stress
2. When Does Anxiety Become Disordered? describe at least
three examples Distress, Avoidance, Interference, Functional
impairment
3. Discuss Normal versus Pathologic Anxiety
Is adaptive inborn response to the threat BUT Pathological one
is excessive and impairs functioning.
4. Discuss three neurotransmitters involved in anxiety
Norepinephrine, Serotonin, Dopamine
175
Answer key
1. B 11. D 21. D
2. B 12. C 22. D
3. B 13. B 23. D
4. C 14. A 24. Antipsychotic
5. A 15. A 25. Schizopherniform
6. B 16. C 26. BPS
7. B 17. A
8. A 18. B
9. A 19. C
10. C 20. D 176
Trauma- and Stressor-Related
Disorders
• Exposure to a traumatic or stressful
• It include
Reactive attachment disorder
Disinhibited social engagement disorder
PTSD
Acute stress disorder
Adjustment disorders.
177
PTSD
Witnessing ONE
Learning
178
PTSD ….CON’D
Distressing Memories
Distressing Dreams
182
SOMATIC SYMPTOM
AND
RELATED DISORDERS
Learning objective
After accomplishing this chapter the student will be able to ?
1. Define SSD ?
2. Identify the common feature of SSD
3. List different disorders under this category ?
4. Explain disorders under this category ?
5. Identify possible pharmacological and non-pharmachological
treatments ?
183
Common features
184
Etiology
• Biological
• Early traumatic exposure
- violence , abuse …
• Learning
185
Disorders
1. SSD
2. IAD
3. CD
4. PF
5. FD
186
1. Somatic Symptom Disorder
A. ≥ 1 SS – distressing
B. Excessive and persistent thought, feeling or behavior- ONE
1. Thoughts about the seriousness of one’s symptoms.
2. High level of anxiety about health or symptoms.
3. Excessive time and energy devoted
C. More than 6 months
Specify if… Predominant pain , Persistent, with severity 187
2. IAD
A. Preoccupation – serious disease
B. SS – NOT present /minimal
C. High level of anxiety about health
D. Excessive health-related behaviors
E. Duration – 6 months
F. Not better explained by another mental disorder
- Care-seeking type
- Care-avoidant type 188
3. Functional Neurological Symptom
Disorder
(Conversion Disorder)
A. ≥ 1 altered voluntary motor or sensory function
B. Clinical findings – incompatibility
C. Not better explained by another medical/mental disorder
D. Significant distress or impairment
• With weakness or paralysis, With abnormal movement , With swallowing
symptoms
• With speech symptom , With special sensory symptom (e.g., visual, olfactory,
or hearing disturbance)
• With mixed symptoms
189
Psychological Factors Affecting Other
Medical Conditions
A. A medical symptom or condition (other than a mental
disorder) is present
B. Psychological or behavioral affect medical conditions
C. Not better explained by another mental disorder
190
Factitious Disorder
191
Quiz
192
SEXUAL
DYSFUNCTION
193
Essential features
194
Sexual dysfunctions can be
Lifelong or
Acquired
Generalized or
Situational
195
Etiology
Psychological factors
Physiological factors
Combined factors,
Numerous stressors including prohibitive cultural
mores, health and partner issues, and relationship
conflicts. 196
Psychosexual factors
1- sexual identity
2- Gender identity
3- sexual orientation
3- sexual behavior
197
Phase of sexual response
• Excitement
• Plateau
• Orgasm
• Resolution
198
Gender difference
Male Female
• a wish to reinforce the
• Desire - sexual thoughts pair bond,
200
I. DESIRE, INTEREST, AND
AROUSAL DISORDERS
201
II- ORGASM DISORDERS
2- Delayed ejaculation
202
III. SEXUAL PAIN DISORDERS
203
Treatment
Psychotherapy
• Desire /male erectile disorder- Masturbate
• Delayed ejaculation- Extra-vaginal ejaculation
• Premature ejaculation- Squeeze/stop–start technique
• Vaginismus- fingers or with size-graduated dilators
• lifelong female orgasmic disorder- Masturbate
Biologicaltreatments
204
Exercise
• A- 45 year old male comes to the clinic with a problem of
marked difficulty in maintaining an erection until the completion
of sexual activity for the last 7 months in every situation and he
has a significant distress because of the problem. The most likely
diagnosis is?
• Mr. A is a 27 year old men, employed in ICT center came to
psychiatry clinic with a complaints of decrease sexual desire
towards his girlfriend even he don’t have a sexual fantasy towards
her for the last 1 year. He has a significant fear of divorce with
her because of the problem. The most likely diagnosis is?
205