For 3rd Year Nursing students

By Abera A.

January , 2024
Bonga , Ethiopia
2/17/2024 1
 Course Title: Mental health nursing
 Course Code: Nurs 3063
 Mode of delivery: Block

 Course instructor: Abera A.

 Gmail: abebeabera542@gmail.com

2/17/2024 2
v Continuous assessment=60%

 Mid-exam 30%

 Quizzes/tests/assignments 30%

 Final written examination 40%

v NB: Attendance should be 100%.

2/17/2024 3
 This course is designed to prepare nursing
students to assess, diagnose, plan and manage
common psychiatric disorders.
 It also will help students to develop skills in
therapeutic communication and developing
nurse patient relation- ship to manage, support,
and rehabilitate patient with mental illness in
hospital and community.
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Introduction to mental health

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v By the end of this session, students will be able
to:
v Define, mental health, mental illness psychiatry,
v Identify characteristics of mentally health person
v Identify common misconceptions towards
mental illness
v Identify impacts of mental illness

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What is health?
v Health State of complete physical, mental, &
social well being.

v It is not only the absence of disease or infirmity

but also a sense of satisfaction with and enjoyment
of self & environment
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7
Mental health is a state of well-being in
which an individual:
v realizes his or her own abilities
v can cope with the normal stresses of life;
v can work productively and fruitfully:
vIs able to make a contribution to his or her
community
vCan maintain a meaningful relationship with
others
(WHO, 2009)
2/17/2024 8
Mental illness: maladjustment in living that
interferes with:

v individual’s thinking,

v perception of the environment,

v social relationship and

v the ability to adapt to changing living conditions

and ability to function optimally

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v Is specific diagnosis of a condition or type of
mental illness that is made by a trained
professional after formal psychiatric
assessment or interview.
v Psychiatric disorder is a clinically significant
psychological or behavioral syndrome that
causes
v Distress (subjective symptomatology)
v Disability(objective symptomatology)
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v Is the branch of medicine concerned with the
prevention, diagnosis and treatment of mental
disorders/illness which manifestations are
primarily behavioral and psychological.

2/17/2024 11
v Based on majority behavior

v Absence of pathological behavior such as behavior

causing distress to himself and to the people
around.

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MENTAL HEALTH MENTAL ILLNESS
 Accepts self & others Feels inadequate and
 Coping w/ stress
has poor self concept
 Can return to normal
Is unable to cope
functioning if temp Exhibits maladaptive
disturbed behavior
 Relationship builder No meaningful
 Sound judgment relationships
 Accepts Poor judgment
responsibility Irresponsible

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MENTAL HEALTH MENTAL ILLNESS
 Optimistic Pessimistic
 Recognizes Does not recognize
limitations limitations
 Function
Exhibits dependency
needs
effectively &
independently Avoids problems
Desires immediate
 Solve problems
gratification
 Can delay
gratification

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Mental health is not influenced by single factors but
by combinations of the following.

v Biologic

v Psychological and

v Socio cultural Influences

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15
2/17/2024 16
v Substance
v Genetic make up
v Neurotransmitters
v Prenatal, perinatal, neonatal events
v Neuro anatomy
v History of injuries
v Nutrition
v Physical Health Status
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17
v Internal and external
v Emotional developmental level
v Interactions
v Self concept
v Creativity
v Skills

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18
vunemployment,
vthe death of a loved one
veconomic problems
vloneliness,
vinfertility, marital conflict,
vFamily stability

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19
v People who have had a mental illness are
viewed with suspicion and as dangerous
persons.

v Mental illness is something to be ashamed of

v Mental illness is caused by evil spirits (black

magic),Cursing, evil eye, or satan, Digimit,
etc…

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v Punishment by God or Allah

v Dangerous and violent

v Incurable

v Contagious

v Professionals are believed to be mentally

disturbed

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v More common in those who are single rather
than married.
v More in cities than rural areas and the prevalence
increase with the size of the city
v More severe with increasing age.
v Less severe mental disorders are common in high
social classes and more severe mental disorders
are found in low social class

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Three major purposes of classification:
v To enable communication, regarding the
diagnosis.
v To facilitate comprehension of the underlying
cause.
v To aid prediction of the prognosis.
Consensus by many national and international
experts
v ICD & DSM system

2/17/2024 23
v Providing therapeutic environment

v Helping patients learn positive coping skills

concerning real problems that they face daily.

v Providing care for physical symptoms

v Acting as a social agent.

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v Participating in psychotherapy

v Providing leadership for member of the health

care team.

v Participating in patient education.

v Participating in research and education.

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 Psychiatric disorders are prevalent and often go
untreated.

 lifetime prevalence in Ethiopia : 20%

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 Nearly 940 million people suffer from a mental
disorders world wide.
 301 million suffer from anxiety disorder
 Over 280 million people suffer from depression
 24 million people from schizophrenia
 40 million people suffer bipolar disorder
 Billions abuse substances
 700,000 people die from suicide each year

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 Mental disorders represent one of the 10 leading
causes of disability worldwide.

 Mental and behavioral disorders account for 12%

of the global burden of disease.

 There is an increasing burden of mental disorders,

and a widening “treatment gap”.

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 About 25% of the world’s population will
develop mental illness at some stage in their
lives.

 Most of these live in developing countries

 In developing countries, most individuals

with severe mental disorders are left to cope
with their illness on their own.

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 66% of psychiatric patient receive no treatment

 half the patients who commit suicide

sought treatment in a primary care setting
within 1 month of dying

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 Mental and behavioral disorders have a large
impact on:
vIndividuals
vFamilies and

vCommunities.

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v Distressing symptoms of disorders

v Inability to participate in work and leisure activities

v Worry about not being able to shoulder their

responsibilities towards family and friends

v Being fearful of becoming a burden for others

v Stigma and discrimination

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v Providing physical and emotional support to the
mentally ill member
v Bearing the negative impact of stigma and
discrimination
v The stress of coping with disturbed behavior
v Disruption of household routine
v Expenses for the treatment of mental illness
v Prevent other members of the family from
achieving their full potential

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 The cost of providing care

 Lost productivity

 Some legal problems

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Can be both:-

v Traditional

v Modern

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v Holy Water: Bathing in or drinking holy water ,
sprinkling on the walls and floor of one's home.

v Herbal : to chew or drink or sewn in a piece of clothing

and then be worn around the neck.

v Exorcism by prayer: God for His mercy upon the

mentally ill.

v Exorcism by fumigation: to release the possession of

evil eye or "Buda“.

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v Psychopharmacology
v Psychotherapy
v Psychosurgery
v Electroconvulsive therapy

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v Negative attitude

v Inaccessibility of service centers (scarcity)

v Limited knowledge of the spectrum of mental

disorders

v Centralization

v Shortage of trained human power

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v Limited scope of management skills

v Lack of proper planning, monitoring and

evaluation

v Lack of basic statistics on the prevalence of

major mental health problems

v Shortage of essential drugs

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v Be physically active for at least 30 min/day
v Eat a balanced and healthy diet
v enough sleep and rest
v Reduce alcohol consumption and avoid illicit
drug use
v Make social connection a priority
v Facing emotion by crying,, communication,
religion

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Tankyou

2/17/2024 41
Psychopathology
For Nursing students

Bonga university

Compiled by Abera A.

1
v At the end students are expected to|:

v Define major psychopathological terminologies

v Differentiate different areas of

psychopathological disturbances

2
vPsychopathol ogy: the study of sign and
symptoms of mental illness
v Signs: are objective findings observed by the
clinicians.
Examples- affect, and psychomotor activities, etc
v Symptoms: are subjective experiences described
by the patient.
Examples- depressed mood and decreased
energy
v Syndrome: is a group of signs and symptoms
that occur together and delineate a recognizable
clinical condition
3
Disturbance of perception

Disturbances of thought

Disturbances of Speech

Disturbances of Emotion

Disturbance of motor behavior

Disturbance of attention

Disturbances of memory
4
Perception

v process of transferring physical stimulation into

psychological information

v Mental process by which sensory stimuli are

brought to awareness.

5
Illusion

v Misperception or misinterpretation of real

external sensory stimuli.

v can occur in “normal individuals”

Hallucinations

v sensory perception occurring in the absence of

any relevant external sensory stimuli

v Can be auditory, Visual, Olfactory, Gustatory,

6
v Depersonalization: loss of contact with one
own personal reality accompanied by feelings
of unreality and strangeness

v Derealization The psychological symptom in

which the world appears to be unreal, and the
patient has a sense of detachment from it

7
v Thinking is defined as the mental activity and
processes used to imagine ,forecast plan and
create

8
v Is essentially what thoughts are occurring to the
patient and is Inferred from what the patient
spontaneously expresses
vDelusion is fixed false belief which is difficult
to change by reason, logic, or proof
vOvervalued idea An unreasonable and
sustained belief that is maintained with less than
delusional intensity
9
Major types of Delusion

v Persecutory delusion: False/fixed belief that one is being

harassed, conspired, or persecuted by others

v Delusion of grandeur: delusional belief of having special

power ,talent, abilities or identity

v Somatic Delusion: Delusional belief involving functioning of

one’s body

10
v Delusion of infidelity (delusional jealousy):
false belief derived from pathological jealousy
that one’s lover is unfaithful
v Erotomania: delusional belief that someone
(usually famous/high ranked) is deeply in love
with them. more common in women than in
men
v Thought insertion: delusion that thoughts are
being inserted in one’s mind by other people or
forces
v Thought withdrawal: delusion that one’s
thought are being removed from one’s mind by
other people or forces 11
v Thought broadcasting: delusion that one’s
thoughts can be heard by others

v Thought reading: delusional belief that people

can read one’s mind or know one’s thought

v Obsessions:- are recurrent and persistent

thoughts, impulses, or images that enter one’s
mind despite efforts to exclude them.

v Phobias:- are irrational fear & avoidance of

objects, events or situations
12
v Is disturbance of how the thoughts are
formulated, organized, and expressed

v Circumstantiality :Unnecessary
digression, which eventually reaches the
point.

v Tangentiality: Thought which wanders

from the original point.

13
v Perseveration: repetitive response to a prior stimulus after a new

stimulus has been presented.

v Verbigeration: meaningless repetition of specific words or phrases

v Echolalia: repeating of words or phrases another person, tends to be

repetitive and persistent

v Clang associations: Word connections due with words similar in

sound rather than actual e.g. “My car is red. I’ve been in bed. It hurts

my head.”

14
v Neologism: Invention of new word

v Loosening of association: flow of thought in

which ideas shift from one subject to another in a
completely unrelated way

v Flights of ideas: rapid, continuous

verbalizations or constant shifting from one idea
to another, in which the ideas tend to be
connected

v Blocking: abrupt interruption in train of thinking 15

Our speech tells other people about our inner
world

v Speed: fast, slow and normal

v Volume: Loud, Low, Normal

v Quantity: Too little, too much or normal

16
v Pressured speech Rapid speech, typical of patients
with manic disorder

v Poverty of speech Minimal responses, such as

answering just “yes or no.”

v Aphasia: disturbance in language output and can be

expressive or receptive

17
v Mood: pervasive and sustained emotion
subjectively experienced and reported by the
patient
v Dysphoria-Feeling of unpleasantness or
discomfort

v Anhedonia- lack of the ability to experience

pleasure with previously enjoyable activities

v Euphoria-Exaggerated feeling of well-being that

is inappropriate to real events. Can occur with
drugs such as opiates, amphetamines 18
v Irritable mood-State in which one is easily
annoyed and provoked to anger

v Labile mood-Multiple abrupt changes

in mood between euphoria and depression

v Apathy Dulled emotional tone associated with

detachment or indifference

19
v Affect: the patient's present emotional responsiveness
which inferred from the patient's facial expression
v Constricted affect – mildly Limited range of expressed
emotion
v Blunted affect - Emotional expression is further reduced
and only few physical gestures of emotion
v Flat affect - Virtually no signs of affective expression

20
v Inappropriate affect: is not matching to the
present situation
v Incongruent affect: In which the patient's affect
is not in line with what the patient is saying
v Labile affect: refers to abrupt ,rapid, and
repeated shifts of type and intensity of emotion

21
v Psychomotor retardation: Diminished or
absent bodily movements, including gestures

v Psychomotor agitation: restless and agitated,

motor activity

v Cataplexy: temporarily sudden loss of muscle

tone causing weakness and immobilization

v Posturing: is the adoption of unusual bodily

postures continuously for a long time
22
v Mannerism - repeated movements that appear to
be goal directed (eg. saluting )

v Stereotypy: repeated movements that are non

goal directed

v Waxy flexibility: retaining one’s body part in an

uncomfortable position

23
v Echopraxia: is the imitation of the interviewer’s
movements automatically
v Tics: are involuntary, regular and repeated
movements involving small groups of muscles.
v Negativism : Doing the opposite of what is asked
and actively resists efforts to persuade them to
comply

24
Level of memory

v Immediate : recall of perceived material within

seconds to minutes

v Recent: Recall over past few hours to days

v Remote: recall of events in distant past

25
Disturbances of memory
v Amnesia: partial or total inability to recall past
experiences
v Anterograde amnesia: amnesia for events
occurring after a point in time or inability to learn
new information
v Retrograde amnesia: amnesia for events occurring
before a point in time inability to recall previously
learned material
v Blackout amnesia: Amnesia experienced by
alcoholics about behavior during drinking bouts

26
v Manifested by impairments in the person's ability
to deploy, focus, and sustain attention.
v Orientation: a person's awareness of self with
regard to time and place.
v Disorientation :Any impairment that affect
person’s awareness to time, place and person.

27
Thankyou

28
29
Mental Health Assessment
For nursing students

Bonga University
Compiled by Abera A.

1
v Able to describe about:

v Communication and therapeutic communication

v The goal and principles of psychiatric assessment

v Psychiatric history taking

v Mental state examination

v Biopsychosocial formulation and treatment plan

2
v Communication is a process of sending and
receiving verbal and nonverbal messages.

v Allows for exchange of information, feelings,

needs, and preferences

v The process of sharing information

v The process of generating and transmitting

meanings

3
Essential components of communication are:
v Sender– the originator or source of the idea
v Message-- the idea being communicated
v Channel--the means of transmitting (either
verbally or nonverbally) the idea
v Receiver-- someone to receive and interpret the
message
v Feedback-- the response to the message

4
v Is the face to face process of interacting that focuses
on advancing the physical and emotional wellbeing of
the patient
v When your patient asks you a question or
discusses something with you, be careful to
respond in a helpful and caring manner.
v By encouraging the patient to speak up, you are
helping him/her to decrease his level of stress
and thereby his recovery time.
v When your patient communicates with you, you
must be able to correctly observe, evaluate,
and respond.

5
v Be able to interpret the patient's message; get to know
the patient well enough to discover the underlying meaning
(intent) of his/her communication.

v Be realistic in your relationships with people; avoid

making assumptions or judgments about your patients'
behavior. you will accept him for what he is; you will allow
him his own identity.

v Be emotionally mature enough to postpone the satisfaction

of your own needs in deference to the patient's.
6
v Goals of Psychiatric interview is:

v To obtain information that will establish a

criteria-based diagnosis

v Essential part of the treatment process

7
v Psychiatric inpatient units
v Medical non psychiatric inpatient units
v Emergency rooms
v Outpatient offices
v Nursing homes, other
v Correctional facilities.

8
v Greet the person warmly and with respect

v Introduce yourself by name and position

v Maintain confidentiality and privacy

v Respect and Consideration

9
v Show interest
v Empathic interventions (“that must have
been very difficult for you” or “I'm beginning
to understand how awful that felt”)
v Empathy is understanding what the patient
is thinking and feeling while at the same time
maintaining objectivity

10
v The Patient clinician relationship is the foundation on
which psychiatric interview is established
v From the start, the patient's willingness to share is
increased or decreased depending on the verbal and
often the nonverbal interventions of the physician
Unconditional positive regard
v Nonjudgmental attitude and behavior of the
physician
v Demonstration by the physician that he or she
understands what the patient is stating
v Recognition by the patient that the examiner cares

11
v Inappropriate boundaries (r/p becomes social or
intimate)

v Feelings of sympathy and encouraging dependency

v You want to be empathetic and not sympathetic

v Non acceptance of the patient as a person because of

his or her behaviors, leading to avoidance of the
client, negative verbal responses or facial expressions
of annoyance

12
v Interview in a quiet, well illuminated, and private ro

v Welcome him by name and by handshake

v Observe how the patient respond and tell him your

name and welcome the attendant too.

v Both the health professional and the patient should

have access to exits

v Length of the interview is usually 30min to one hour

13
v Adopt a relaxed posture and appear unhurried
even the time is short

v Maintain appropriate eye contact with the

patient and not appear engrossed in note taking.

v Be alert to verbal and non-verbal cues of distress.

v Diagonal sitting arrangement is preferred, chair

should not be lower than the interviewer

14
v Begin with broad open-ended questions
v Allow the patient to speak as much as possible
v At the beginning of the interview the examiner
encourages the patient to speak as spontaneously
and openly as possible
E.g can you tell me please what troubles that bring
you today?

15
 Open Questions Closed Questions

1. "How are you feeling 1. "Are you sad?"

today?"

2. "How would you describe 2. "Are you having problems

your sleep?" falling asleep?"

3. "Are you still going to

3. "Can you tell me how your
work?"
problem impacts your life?”

16
v To ask specific information ( age, address, name)

v In eliciting information about the absence or presence

of certain symptoms (hallucination ,delusion,suicidal
ideation)

v Do not use closed ended question at the beginning of

the interview it does not allow the patient to have the
option.

17
A. Psychiatric history

B. Mental status examination

C. Physical examination

D. Diagnosis

E. Formulation

F. Treatment plan

18
v Is the record of the patient's life

v It allows health worker to understand in detail

about who the patient is

19
I. Identification
II. Chief complaint
III. History of presenting illness
IV. Past psychiatric history
V. Substance history
VI. Past medical history
VII. Family history
VIII. Developmental and social history
VIII. Legal history

20
Provides a succinct demographic summary of
patient by
vName, age, sex, marital status,
vEducational status, occupation
vPatient's current living circumstances,
vWhether the patient came in On his or her
own or Brought in/ escorted by someone
else/police.
vThe source(s) of the information, reliability
vWhether the current disorder is the first
episode

21
v Patient's problem or reason for the visit with
duration

v What brought you to the hospital?

v Record verbatim or patients own word

v E.g. “I don’t have problem my brother brings

me here by force”

22
vTake a detailed account of the illness from the
earliest time at which a change was noted
vWhat : is the problem?
vWhen: did the problem start?

vHow: did it develop?

vTriggers: precipitating and relieving factors

vWhy now?
23
vImpact of illness: associated impairment due to
illness (physical, psychological & social)
vPredisposing, precipitating, aggravating,
relieving factors
vRisk assessment (suicide, homicide, substance
use)
vPositive-negative statements
vTreatments and its effect.

Onset Course
Acute Continuous
Insidious Episodic

24
v In the past have you ever had problems with your
mental health

v What were the symptoms?

v Have you ever been admitted to a psychiatric

hospital?

v What treatments have you had?

v Suicidal and homicidality history?

25
v Type of substances, amount, duration, frequency?

v Impact of use on social interactions, work, school,

legal consequences?

v Any periods of sobriety (abstinence)?

v History of treatment ?

26
v Do you have any problems with your physical
health?
v What medications do you take regularly?
v What medications have you had in the past?
v patient's reaction to these illnesses and coping
skills?
v In women, a reproductive and menstrual
history?

27
v Any psychiatric illness, hospitalization, and
treatment of the patient's immediate family
members

v Family history of suicide

v Family history of alcohol and other substance

abuse

v The family's attitude toward, and insight into, the

patient's illness
28
v Prenatal and perinatal
v Childhood history
§ childhood home environment
§ school history
v Work history
v Marriage and relationship
v patient's capacity to develop stable
relationships
v Current relationships with parents
v hobbies, interests, pets, and leisure time
activities
29
vList of charges & legal outcome.
vHave you ever been in trouble with the police?
vAny violent/sexual crimes and persistent
offending.

30
Mental Status Examination(MSE)

31
v MSE describes the mental state and behavior of
the person being seen at the time of examination

v Like a physical examination , a mental state

examination should be orderly and systematic.

v It includes both objective observations of the

clinician and subjective descriptions given by
the patient.

32
1. Appearance and Behavior
2. Psychomotor Activity
3. Speech
4. Mood and affect
5. Thinking
6. Perceptions (hallucination, illusion
7. Sensorium /cognition
8. Judgment and Insight

33
v Does the patient appear to be their stated age,
younger or older?

v Style of dress, physical features, or style of

interaction?

v Grooming (putting on all cloth) and hygiene ?

v Behavior

v cooperative, agitated, disinterested, etc

34
v Speed: fast, slow ,and normal

v Volume: Loud, Low, Normal

v Quantity: Too little,too much or normal

35
v Mood: evaluate the mood by asking the feeling
of the patient:

v Sadness, elation (very happy and

excited),anxious, labile, euthymic,

v Affect: what the interviewer observing during

the interview and read it from facial expression
of the patient :

v Flat, constricted, appropriate, inappropriate,

normal range,labile
36
Form:

v Flight of ideas, Circumstantiality, Tangentiality,

Loosing of association, Clang association,
Perseveration, Thought blocking, Neologism

Content:

v Delusion, idea of reference, worthlessness

(valueless), Suicidal ideation, obsession

v Thought: insertion, withdrawal, Broadcasting,

Control, reading 37
v Hallucination

v Illusions

v Depersonalization

v Derealization

38
v Consciousness: alert and not alert

v Orientation: to time, place ,person.

v Memory: Remote, Recent, Immediate

v Concentration and attention serial 7s,

v Abstract thinking: the ability to deal with

concepts

39
v General knowledge; depend on patient’s
educational level

v Insight; the patient's degree of awareness and

understanding about being ill

v Judgment ; Can he/she understand the likely

outcome of his or her behavior

40
v Physical examination

v Investigation: laboratory

v Diagnosis

v Treatment planning

41
v Formulation tells us the interplay of factors
which have brought about the syndrome to take
place the how and why

v It tries to show possible scientific explanation

for the syndrome based on bio- psycho -social
model of etiology for mental disorders.

42
Factors involved PHYSICAL SOCIAL PSYCHOLOGICAL

PREDISPOSING

PRECIPITATING

PERPETUATING

PROTECTIVE

43
v Medication recommendations

v Review & revise existing treatment

v Indication, optimal dose and duration

v Compliance & tolerability

v Addition of psychotropic (medications that have

an effect on how mind works) medications

44
45
 10 Q
Above all don’t give up!!!

46
Psychotic Disorders
For nursing students

Bonga University
Compiled by Abera A.

1
v Able to describe about psychosis

v Differentiate about different disorders presenting with

psychosis

v Describe about schizophrenia

v Identify diagnostic criteria of schizophrenia

v understand the different DDX of schizophrenia

v Understand and describe the different types of other

psychotic disorders
2
Mental disorder that is characterized by impairment in
v thoughts, feelings, affective response,
v ability to recognise reality and
v ability to communicate and relate to others
The characteristics of psychosis are:
v impaired reality testing,
v hallucinations, delusions and illusions.

3
v Schizophrenia
v Schizophreniform disorder
v Schizoaffective disorder
v Brief psychotic disorder
v Delusional disorder
v Psychotic Disorder Due to Another Medical
Condition
v Substance-induced psychotic disorder
v Other Specified and unspecified Schizophrenia
Spectrum and Other Psychotic Disorder
4
v Schizophrenia is the most severe and
debilitating form of the psychotic disorders
characterized by Major disturbances in:

v Thought

v Emotion

v Behavior

v perception and attention

v Disturbances in movement or behavior 5

v Symptoms of schizophrenia are broken up
into three categories:
1. Positive symptoms
a. Hallucinations are most commonly auditory
or visual, but hallucinations can occur in any
sensory modality.
b. Delusions
c. Disorganized behavior
d. Thought disorder

6
7
2.Negative symptoms
a. Poverty of speech (alogia) or poverty of
thought content
b. Anhedonia
c. Flat affect
d. Loss of motivation (avolition)
e. Attentional deficits
f. Loss of social interest
8
3.Cognitive symptoms
v Difficulties in concentration and memory:
v Disorganized thinking
v Slow thinking
v Difficulty understanding
v Poor concentration
v Poor memory
v Difficulty expressing thoughts
v Difficulty integrating thoughts, feelings,
behaviors
9
v The presence of tactile, olfactory or gustatory
hallucinations may indicate an organic etiology such as
complex partial seizures.

v Sensorium is intact.

v Insight and judgment are frequently impaired.

v No sign or symptom is pathognomonic of schizophrenia.

10
The typical findings in schizophrenic
patients
vDisheveled appearance
v Flat affect
v Disorganized thought process
vAuditory hallucinations
vParanoid delusions
v Ideas of reference
v Lack of insight into their disease
11
Symptoms of schizophrenia often present in three
phases:
1. Prodromal: Decline in functioning that
precedes the first psychotic episode.
The patient may become socially withdrawn and
irritable or show declining school/work
performance
2. Active phase: Perceptual disturbances,
delusions, and disordered thought
process/content.
3. Residual: Occurs following an episode of
active psychosis and marked by
mild hallucinations or delusions, social
withdrawal, and negative symptoms
12
A. Two or more of the following must be present
for at least 1 month:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

Note: At least one must be 1, 2, or 3. 13

B. Must cause significant social, occupational, or self-care functional

deterioration.

C. The total duration of the illness must be at least 6 months including

prodromal or residual periods.

D. Symptoms not due to effects of a substance or another medical

condition

E. Exclude other mental disorders with psychotic futures

14
v First episode, currently in acute episode: First
manifestation of the disorder meeting the defining
diagnostic symptom
v First episode, currently in partial remission
v First episode, currently in full remission:
v Multiple episodes, currently in acute episode:
v Multiple episodes, currently in partial remission
v Multiple episodes, currently in full remission
v Continuous:

v Unspecified

v With catatonia
15
v The lifetime prevalence of schizophrenia is one
percent.
v Onset of psychosis usually occurs in the late teens
or early twenties.
v Males and females are equally affected, but the
mean age of onset is later in females, and females
frequently have a milder course of illness.
v The suicide rate is 10-13%
v More than 90% of patients are smokers, and the
incidence of substance abuse is increased
(especially alcohol, cocaine, and marijuana)

16
v Genetics

v Neurochemistry

v Neuropathology - mainly temporal lobe

v Neuroimaging -ventricular enlargement,

v Environmental factors

17
v Of all known risk factors for schizophrenia,
family history is the most powerful

v The most important risk factor for

schizophrenia is having an affected relative

v increased rate among the biological relatives

of patients with schizophrenia.

18
v Non-twin sibling of a schizophrenia patient 8 %

v Child with one parent with schizophrenia 12 %

v Dizygotic twin of a schizophrenia patient 12 %

v Child of two parents with schizophrenia 40 %

v Monozygotic twin of a schizophrenia patient 50 %

19
v Dopamine Theory of schizophrenia

v Disorder due to excess levels of dopamine

over activity in mesolimbic pathway causing
positive symptoms

v And negative symptoms of schizophrenia are

due to decrease dopamine in mesocotical
pathways

20
v The investigators found three main categories
of obstetric complication to have significant
estimates:

(1) abnormal fetal growth and development:

Low birth weight, congenital malformations, and
small head circumference;

21
(2) complications of pregnancy: Bleeding, pre-
eclampsia, diabetes,

(3) complications of delivery: Asphyxia, uterine-

atony, and emergency cesarean section. Taken
together, they seem to implicate an increased
risk of hypoxia.

22
vThere is a higher risk of schizophrenia
(around three to four times) in the
offspring of fathers who are older than 50,
at the time of conception, compared to the
offspring of fathers in their early 20s

23
v Many studies report an excess of stressful life
events in the few weeks prior to the onset of
psychotic and affective disorders.
v Early childhood trauma studies describe a range
of severe adverse experiences including sexual,
physical and emotional abuse, and neglect.
v studies suggesting that the risk of psychotic
experiences is increased in those exposed to
early childhood trauma

24
v children who later have schizophrenia learn
irrational reactions and ways of thinking by
imitating parents who have their own
significant emotional problems.

v poor interpersonal relationships of persons with

schizophrenia develop because of poor models
for learning during childhood

25
v Schizophrenia is equally prevalent in men and
women however Men have an earlier onset of
schizophrenia than do women.
v Men are more likely than are women to be
impaired by negative symptoms and that
women are more likely to have better social
functioning.
v The peak ages of onset for men 15-25 for
women 25-35.
v The onset of schizophrenia before the age of 10
or after the age of 50 is extremely rare. 26
v About 50% have suicidal ideations and 10-15%
patient with schizophrenia die of suicide

v Depression - occurs in 50% of cases, often after

an acute episode

v Homelessness – 30-35% of homeless

v Crime: 4-fold increase in acts of violence

compared with the general population

v Substance abuse
27
Associated with good Prognosis
v Later onset
v Good social support
v Positive symptoms
v Mood symptoms
v Acute onset
v Female gender
v Few relapses
v Good premorbid functioning

28
v Associated with Worse Prognosis
v Early onset
v Poor social support
v Negative symptoms
v Family history
v Gradual onset
v Male gender
v Many relapses
v Poor premorbid functioning (social isolation,
etc.)
v Comorbid substance use
29
 Medical Psychiatric
v Epilepsy (TLE) v Schizophreniform
disorder
v CNS neoplasm
v Delusional disorder
v CVA
v Schizoaffective disorder
v CNS trauma v Drug-induced psychosis
v HIV-AIDS v Mania
v Herpes encephalitis v MDD with psychotic
feature
v Personality disorder
v Factitisious disorder

30
A. Psychotic disorder due to a general medical
condition, delirium, or dementia. Included would
be CNS infections, thyrotoxicosis, multiple strokes,
HIV, hepatic encephalopathy, and others.
B. Substance-induced psychotic disorder.
Amphetamines and cocaine frequently cause
hallucinations, paranoia, or delusions. Phencyclidine
(PCP) may lead to both positive and negative
symptoms.
C. Schizoaffective disorder. Mood symptoms are
present for a significant portion of the illness. In
schizophrenia, the duration of mood symptoms is
brief compared to the entire duration of the illness.
.

31
D. Mood disorder with psychotic features
1. Psychotic symptoms occur only during major mood
disturbance (mania or major depression).
2. Disturbances of mood are frequent in all phases of
schizophrenia
E. Delusional disorder. Non-bizarre delusions are present in
the absence of other psychotic symptoms.
F. Schizotypal, paranoid, schizoid or borderline
personality disorders
1. Psychotic symptoms are generally mild and brief in
duration.
2. Patterns of behavior are life-long, with no identifiable
time of onset.
G. Brief psychotic disorder. Duration of symptoms is
between one day to one month.
H. Schizophreniform disorder. The criteria for
schizophrenia is met, but the duration of illness is less
than six months.
32
Types of Treatment
v Pharmacotherapy
v psychosocial/psychotherapeutic

33
Therapeutic Goals
v minimize symptoms
v minimize medication side effects
v prevent relapse
v maximize function
v “recovery”

34
Addressing :

v positive psychotic symptoms .

v negative symptoms.

v cognitive symptoms.

v disorganized symptoms.

35
1. Assess symptoms and establish a diagnosis.
2. Formulate and implement a treatment plan.
3. Develop a therapeutic alliance and promote
treatment Adherence.
4. Treat comorbid conditions, especially major
depression, substance use disorders, and
posttraumatic stress disorder.
5. Integrate treatments from multiple clinicians
6. Investigations –urine screen for drugs of abuse,
Electrolytes ,CBC, glucose RFT,LFT ,TFT
7. pregnancy tests in women of reproductive age.

36
Antipsychotic medication
vControl acute psychosis
vProvide long term maintenance

Two major groups of antipsychotics

vConventional antipsychotics (first generations)

vAtypical antipsychotics( second generations)

37
v First-generation (or typical) antipsychotic
medications These are primarily dopamine
(mostly D2) antagonists.
v Treat positive symptoms with minimal impact
on negative symptoms.
v High Potent (2-20 mg/day)/(haloperidol,
fluphenazine)
v Mid Potent10-100 mg/day)/(perphenazine)
v Low Potent (300-800+
mg/day)/(chlorpromazine)

38
Treatment
v 2ndgeneration Atypical antipsychotics
(risperidone, olanzapine, clozapine)Lower
propensity to cause extrapyramidal side effects
vFirst-line drugs of choice - 70% of patients
respond
vAtypicals are better for negative symptoms
vClozapine is effective in 35-50% of patients
who do not respond to other antipsychotics
(80-85% of all patients)

39
 Side effects of antipsychotic medications
1.Extrapyramidal symptoms (especially high-
potency first generation antipsychotics):
v Dystonia: sustained contraction of the muscles of
neck, eyes, tongue, jaw and other muscle groups,
typically occurring within 3-5 days after initiation
of the neuroleptic.
v Dystonias are often very painful and frightening
to patients.
v Parkinsonism (resting tremor, rigidity,
bradykinesia)
v Akathisia characterized by strong feelings of
inner restlessness, which are manifest by
difficulty remaining still and excessive walking 40
2. Anticholinergic symptoms (especially low-
potency first-generation antipsychotics and
atypical antipsychotics):resulting in dry mouth,
tachycardia, urinary retention, blurry vision,
constipation

 Treatment: As per symptom (eye drops, stool

softeners, etc.)

41
3.Tardive dyskinesia is an involuntary movement
disorder involving the tongue, mouth, fingers, toes,
and other body parts.
v It is characterized by chewing movements,
smacking and licking of the lips, sucking
movements, tongue protrusion, blinking,
grimaces and spastic facial distortions. (more
likely with first-generation antipsychotics):

42
4. Neuroleptic malignant syndrome (typically
high-potency first-generation antipsychotics):
v A medical emergency that requires prompt
withdrawal of all antipsychotic medications
and immediate medical assessment and
treatment
v Change in mental status, autonomic instability
(high fever, labile blood pressure, tachycardia,
tachypnea, diaphoresis elevated creatine
phosphokinase (CPK) levels, leukocytosis.

43
ACUTE- more than 60% of
patients with FGAs.
q EPS - occur within hours to weeks
Ø Dystonia- muscular contraction
with sudden in onset
Ø Pseudo‐parkinsonism -rigidity,
tremor & bradykinesia
Ø Akathisia-restlessness

44
5.Metabolic syndrome (second-generation
antipsychotics): A constellation of conditions that
↑ blood pressure, ↑ blood sugar levels, excess
body fat abnormal cholesterol levels—that occur
together, ↑ the risk for developing cardiovascular
disease, stroke, and diabetes.
v Treatment: Consider switching to a first-
generation antipsychotic
v Monitor lipids and blood glucose measurements.
v Refer the patient to primary care for appropriate
treatment of hyperlipidemia, diabetes, etc.
v Encourage appropriate diet, exercise, and
smoking cessation
45
 Weight Gain
Ø High –Clozapine,
Olanzapine
Ø Moderate -
Chlorpromazine,
-Risperidone
Ø Low-Haloperidol,
-Trifluoperazine
Dyslipidaemia
vClozapine
vOlanzapine
Hypertension
Ø Clozapine, Olanzapine
and Risperidone

46
v Anti-HAM effects: Caused by actions on
Histaminic, Adrenergic, and Muscarinic
receptors:

v Antihistaminic: results in sedation, weight gain.

v Anti adrenergic: results in orthostatic

hypotension, cardiac abnormalities

v Hyperprolactinemia:↓ libido, galactorrhea,

gynecomastia, impotence, amenorrhea.
47
Special points
vNo conventional drug is superior to another
conventional drug
vNo specific antipsychotic for specific type of
schizophrenia
vNo benefit of prescribing more than a single
antipsychotic at a time
vSmokers need higher dose

48
v Lowest effective antipsychotic dose
vLow dose 100mg – high dose 500-600mg
CPZ equivalent
vIM depot medication - for non compliant
patients
v Drug tapering slowly over weeks to months

49
Continue treatment for:
vAfter first episode: for 1-2 years
vMultiple episodes: for at least 5 years
vLife long treatment: for patients who are
dangerous to themselves or others

50
Extrapyramidal Side Effects
vSome individuals are highly sensitive to
extrapyramidal side effects at the dose that is
necessary to control their psychosis
vProvide SDA because these agents result in
substantially fewer extrapyramidal side effects
than the DRAs
vDrug-induced Parkinsonism is treated by
adding an anticholinergic agent such as
benztropine (Cogentin) or trihexyphenidyl
(Artane).
vProphylactic anti-Parkinson medications may
also be indicated when high-potency drugs are
prescribed for young men who tend to have an
increased vulnerability
51
v Dystonias (other than laryngospasm) should be
treated with 1-2 mg of benztropine (Cogentin) IM
v Akathisia frequently does not improve with
anticholinergic medication, but may respond to a
beta-blocker such as propranolol in the dose
range of 10-40 mg tid or qid.
v Benzodiazepines such as diazepam are used for
refractory cases.

52
v Tardive Dyskinesia 20 to 30 percent of
patients on long-term treatment with a
conventional DRA;
v risk of tardive dyskinesia is not absent
with SDAs.
vTreatment: Discontinue or reduce the
medication and consider substituting
an atypical antipsychotic
vBenzodiazepines and vitamin E may
be used.

53
v Acute phase
Goal-
v immediate control of psychosis
4 -8wks.
v Stabilization phase
Goal-
v Consolidation of the therapeutic gains.
v To decrease the rate of relapse .
v Same agents as in the acute phase .
v As long as 6 months .

54
v Stable/maintenance phase

starts when the patient is in relative remission .

Goals

v prevention of psychotic relapse

v assist patients in improving their level of

functioning .

55
Rapid loading – no advantage
vStart low, go slow- slowly increase dosage
vIf no response in 3-8 weeks change to another
drug
Highly agitated patient
vHaloperidol parenteral Q 30- 120 min, until
agitation subsides OR
vHaloperidol + Benzodiazepine – parenteral Q
30 min until agitation subsides
vPRN dose not recommended

56
Choice of antipsychotic depends on:

A. Clinical factors

1. patient’s prior experience

v clinical response

v subjective response.

2.Sensitivity to EPS ------SDA.

3. Tardive dyskinesia ---- clozapine , SDA

57
4. Poor medication compliance :Depot
preparations (Haldol, Modicate)
5. Pregnancy ------------Haldol
6. Presence of cognitive symptoms -SDA
( atypicals)
7. Presence of negative symptoms - SDA
(atypicals )

58
B. Non-clinical factors
v Cost

v availability

v uniformity of supply
v Atypicals –higher cost but fewer hospital days
v Comorbidities and Polypharmacy.
v Patient Preferences and Expectations

59
Management of Agitation in Schizophrenia
1. Part of the psychotic process in response to
delusions and hallucination
2. EPS Akathisia.
3. stimulant abuse.
NB. Patient’s description of subjective state and a
trial of anticholinergic or propranolol can
differentiate b/n psychotic agitation and
akathisia.
v Psychotic agitation responds to high potency
antipsychotic plus benzodiazepines

.
60
 Treatment-resistant schizophrenia
v The persistence of symptoms despite ≥2 trials
of antipsychotic medications of adequate
dose and duration with documented adherence.
Look for:
v Compliance
v Substance abuse specially tobacco
v Drug drug interaction
v Wrong diagnosis
v Chronicity of the illness

61
vPatients not responding to antipsychotic
medications
vSevere catatonic symptoms – stupor,
extreme agitation
vSevere depression secondary to
schizophrenia

62
v Support
v Education
v Family therapy (expressed emotions)
v Housing

v Finances

v Employment / occupational therapy

63
1. Psychotic symptoms prevent the patient from
caring for his basic needs.
2. Suicidal ideation, often secondary to
psychosis, usually requires hospitalization.
3. Patients who are a danger to themselves or
others require hospitalization.
4. Patients with command hallucinations to
harm self or others should be evaluated for
hospitalization, especially with a history of
acting on hallucinations.

64
1. Medication Management: Administer
prescribed medications as prescribed and the
patient for any side effects or adverse reactions to
medications.
2. Therapeutic Communication: Establish a
trusting and supportive nurse-patient relationship.
3. Structured Routine: Create a structured
environment that helps reduce anxiety and
agitation.
4. Safety Measures: Ensure the safety of the
patient and others by Monitoring for signs of self-
harm or harm to others.
5. Psychoeducation: Educate the patient and
their family about schizophrenia, its symptoms,
and treatment options.
65
 6. Encourage Self-Care: Assist the patient in
maintaining personal hygiene and self-care activities.
Encourage participation in activities that promote a
sense of accomplishment.
7. Social Support: Facilitate social interactions and
support from family and friends.
8. Monitoring and Assessment: Regularly assess the
patient's mental status, including mood, thoughts, and
behaviors and Monitor vital signs and physical health
to address any potential medical concerns.
9.Collaboration with Multidisciplinary Team: Work
closely with psychiatrists, psychologists, social workers,
and other healthcare professionals to provide
comprehensive care.
10. Participate in treatment planning and regular
team meetings to discuss the patient's progress.
66
v Main stigma surrounds issue of violence
v Public perception 70% believe that people with
schizophrenia are dangerous
v Media coverage of mental illness 77% associated
with aggression
v Facts: aggression more common than in
general population but much less than that due
to alcohol/drug intoxication.
v Serious violence rare (<5%) and >95%
homicides committed by people without
schizophrenia

67
v Increase use of treatment strategies that control
symptoms and avoiding side effects.
v Initiate community educational activities aimed at
changing attitudes.
v Improve psycho education of patients and families
about ways living with the disease.
v Involve patients and families in identifying
discriminatory practices.
v Emphasize developing medications that improve
quality of life & minimize stigmatizing side effects.
68
Other psychotic disorders

69
 Schizophreniform Disorder

v Patients with schizophreniform disorder meet

full criteria for schizophrenia, but the duration
of illness is between one to six months

70
v With Good Prognostic Features –as
evidenced by 2 or more of the following:
v Acute onset of symptoms
v Confusion or perplexity during peak of the
illness
v Good premorbid social and occupational
functioning
v Absence of blunted or flat affect
v Without Good Prognostic Features- 2 or
more of the above features have not been
present
v With catatonia

71
Epidemiology of Schizophreniform
Disorder

v Lifetime prevalence of schizophreniform

disorder is approximately 0.2%.

v Prevalence is the same in males and females.

v Depressive symptoms commonly coexist and

are associated with an increased suicide risk

72
v effective assessment, treatment, and supervision of a
patient’s behavior.
v Antipsychotic medication in conjunction with
psychotherapy is best
v Hospitalization may be required if the patient is unable
to care for himself or if suicidal or homicidal ideation
is present.
v APs:(e.g., risperidone)-3-6-month (Maintenance APs)
v Mood Stabilizers- prophylaxis if recurrent episode
v ECT: for catatonic or depressed features
73
v Antipsychotic medication in conjunction
with psychotherapy is best

v Hospitalization may be required if the patient

is unable to care for himself or if suicidal or
homicidal ideation is present.

74
Brief Psychotic Disorder

v Brief psychotic disorder is a disorder

characterized by hallucinations, delusions,
disorganized speech or behavior and the
duration of symptoms is between one day and
one month

v Onset is usually sudden

75
Classification of Brief Psychotic Disorder

A. Brief Psychotic Disorder with Marked

Stressors is present if symptoms occur in relation
to severe stressors (ie, death of a loved one,
divorce).
B. Brief Psychotic Disorder without Marked
Stressors is present if symptoms occur without
identifiable stressors.
C. Brief Psychotic Disorder with Postpartum
Onset: occurs within four weeks of giving birth

76
Treatment of Brief Psychotic Disorder

A. Brief hospitalization may be necessary,

especially if suicidal or homicidal ideation is
present.

B. A brief course of antipsychotics is often

indicated

77
Schizoaffective disorder

A. Schizoaffective disorder is an illness which

concurrently meets the criteria for schizophrenia
and major mood disorders
B. The illness must also be associated with
delusions or hallucinations for two weeks,
without significant mood symptoms.
C. Mood symptoms must be present for a
significant portion of the illness

78
D. The disturbance is not attributable to the
effects of a substance (e.g., a drug of abuse,
medication) or AMC.
v Specify whether:
Ø Bipolar type: manic episode
Ø Depressive type: only MDE part of the
presentation.
v Specify if:
Ø With catatonia (criteria for catatonia
associated with another mental disorder) 79
v LTP less than 1%

v Bipolar subtype: M:F=1:1

v Depressed subtype: two fold in female to

male

v The age of onset for women is later than that

for men

80
Treatment of Schizoaffective Disorder

v Psychotic symptoms are treated with antipsychotic

v The depressed and bipolar phase of schizoaffective
disorder is treated with antidepressant and mood
stabilizers respectively medications
v Prognosis: better than schizophrenia but worse than
mood

81
Delusional disorder
v Non-bizarre delusions have lasted for at least one month.

v This disorder is characterized by the absence of

hallucinations, disorganized speech, grossly
disorganized behavior symptoms of schizophrenia

v Behavior and functioning are not significantly bizarre

or impaired.

v If mood episodes have occurred, the total duration of

mood pathology is brief compared to the duration of
the delusions

82
v Erotomanic type

v Grandiose type

v Jealous type

v Persecutory type: most common type

v Somatic type

v Mixed type

65

83
v Prevalence of delusional disorders, 0.2-0.3%

v There are no major gender differences in the

overall frequency of delusional disorder.

v Men are more likely to develop paranoid

delusions than women

v Women are more likely than men to develop

delusion of erotomania 64

84
Treatment of Delusional Disorder

A. Delusional disorders are often refractory to

antipsychotic medication.

B. Psychotherapy, including family or couples

therapy, may offer some benefit.

85
v Delusion develops in an individual in the context
of a close relationship with another individual
who has already existing delusions

v DSM-5: “Delusional Symptoms in Partner of

Individual with Delusional Disorder,”

v The content of the delusion is similar or the same

as the primary case
68

86
v Has the potential to spread to entire family
v It is more common in women than men.
v Individual with shared psychotic disorder
commonly less impaired than “primary case”
v Complete remission commonly occurs once
separated

69

87
88
v Postpartum psychosis (PPP), also known
as puerperal psychosis or peripartum
psychosis, involves the abrupt onset
of psychotic symptoms shortly following
childbirth, typically within two weeks of
delivery but less than 4 weeks postpartum

89
v Postpartum psychosis (PPP) is a reversible but
severe mental health condition that affects
people after they give birth.
v This condition is rare, but it’s also dangerous.
v IMPORTANT: People with postpartum
psychosis have a much higher risk of harming
themselves, dying by suicide or harming their
children.
v Because of this, PPP is a mental health
emergency.

90
 Hospitalization may be necessitated if the
patient is suicidal and infanticidal
 Treatment plans are made up of a combination
of education, medication, and close follow-up
care and support;
 the major goals of care include improving sleep
and psychotic symptoms while helping to
minimize major shifts in mood
 Medical treatment typically
involves ECT, antipsychotics

91
Psychotic disorder Due to Another Medical Condition

A. Prominent hallucinations or delusions.

B. There is evidence from the history, physical

examination, or laboratory findings that the
disturbance is the direct physiological
consequence of a general medical condition.

C. The disturbance is not better accounted for by

another mental disorder.

92
A. Prominent hallucinations or delusions.
B. There is evidence from the history, PE, laboratory
findings of either (1) or (2)
1. The symptom in Criterion A developed during, or
within month of substance intoxication or
withdrawal
2.medication use is etiologically related to the
disturbance

93
v presentations in which symptoms characteristic of a
schizophrenia spectrum and other psychotic disorder that
cause clinically significant distress or impairment
predominate but do not meet the full criteria
v used in situations in which the clinician chooses to
communicate the specific reason that the presentation does
not meet the criteria
v e.g. Persistent auditory Hallucinations:

v Delusions with significant overlapping mood episodes

94

v Attenuated psychosis syndrome: less severe and persistent

v presentations in which symptoms characteristic of a
schizophrenia spectrum and other psychotic
disorder that cause clinically significant distress or
impairment predominate but do not meet the full
criteria
v used in situations in which the clinician chooses not
to specify the reason that the criteria are not met for
a specific schizophrenia spectrum and other
psychotic disorder and includes presentations in
which there is insufficient information to make a
more specific diagnosis (e.g., in emergency room
settings).

95
96
Mood disorders
For Nursing students

Bonga university
By Abera A.

1
 Patients with mood disorders (also called affective
disorders) experience an abnormal range of
moods and lose some level of control over them.

 Distress may be caused by the severity of their

moods and the resulting impairment in social and
occupational functioning.

2
 Mood episodes are distinct periods of time in
which mood disturbance is present. They
include depression, mania, and hypomania
 Mood disorders are defined by their patterns of
mood episodes include major depressive
disorder (MDD), bipolar I and II disorder,
persistent depressive disorder, and cyclothymic
 may have psychotic features (delusions or
hallucinations).

3
 MDD
Depressive
disorder
Dysthymia

Bipolar
Mood Disorder
disorder I
Bipolar Bipolar
disorder disorder II

Cyclothymia

4
 MDD is marked by episodes of depressed
mood associated with loss of interest in daily
activities.
 Patients may not acknowledge their depressed
mood or may express vague, somatic
complaints (fatigue, headache, abdominal pain,
muscle tension, etc.)

5
Diagnosis and DSM-5 Criteria

 At least one major depressive episode

 No history of manic or hypomanic episode.

6
 Must have at least five of the
following symptoms (must include
either number 1 or 2) for at least a 2-
week period:
1. Depressed mood most of the time
2. Anhedonia (loss of interest in
pleasurable activities)
3. Change in appetite or weight (↑ or ↓)
4. Feelings of worthlessness or
excessive guilt
5. Insomnia or hypersomnia
6. Diminished concentration
7. Psychomotor agitation or retardation 7
B. Clinically significant distress or impairment in
social, occupational, or other important areas of
functioning.

C. Not attributable to the physiological effects of a

substance or another medical condition.

8
ü Melancholic
ü Atypical
ü Catatonic
ü Psychotic
ü With post partum onset
§ Anhedonia,
 Early morning awakenings
 Psychomotor disturbance
 Excessive guilt, and anorexia
ü hypersomnia,
ü hyperphagia,
ü reactive mood, and
 Purposeless motor activity
 Extreme negativism or
 Mutism
 Echolalia
 Echopraxia
 Hallucinations
 Delusions
 10–25% of hospitalized patients with
depression.
With peripartum onset
§ Applied if onset of mood symptoms occurs
during pregnancy or in the 4 weeks following
delivery.
Rapid Cycling
>4 episode/year
Biological factors
 Down regulation or decreased sensitivity of β-
adrenergic receptors
 Depletion of serotonin
 Reduced dopamine activity
Alterations of Hormonal Regulation
 Elevated HPA activity
 Thyroid axis activity
14
Genetic factors
 If one parent has a mood disorder, a child will
have a risk of between 10 and 25 percent for
mood disorder.

 If both parents are affected, this risk roughly

doubles.

15
Psychosocial factors

 Losing a parent before age 11 years

 Loss of a spouse

 Unemployment, 3 x risk

 Recent stressful events

16
 Lifetime 17%
 M:F 1:2, due to
üHormonal differences, the effects of
childbirth, differing psychosocial stressors for
women and for men, and behavioral models
of learned helplessness.
 Mean age of onset 40 years,
 50% between 20 and 50 years
 Most often in persons without close
interpersonal relationships, divorced or
separated.
17
◦ 10-15% commit suicide
◦ 2/3rd have suicidal ideation
◦ risk of suicide increased as they begin to
improve and regain the energy needed to plan
and carry out a suicide (paradoxical suicide).

18
 Medical Disorders
 Other mood disorders
 Substance related disorders
 Psychotic disorders

19
Course
 In about 50% of patients the first
depressive episode occurs before age 40
years
 Untreated depressive episode lasts 6 to
13 months
 As course progresses, episodes become
more frequent and lasts longer

20
 Indicators of good prognosis
ØAbsence of psychotic symptoms,
ØAbsence of comorbid psychiatric disorders
No more than one previous hospitalization
ØAdvanced age of onset

21
Goal
• Patient’s safety
• Complete diagnostic evaluation
• Treatment plan should address the immediate
symptoms and patient’s prospective well-
being

22
 Hospitalization
◦ Suicide or homicide,
◦ Reduced ability to get food and shelter
◦ Need for diagnostic procedures

23
 Pharmacotherapy
ØDoubles the chance of recover with in 1
month
ØAntidepressants:
ØGuideline: ‘Start Low Go Slow’ and when
stopping taper over 1 to 2 weeks

24
SSRI TCA MAOI SNRI
Fluoxetine Amitriptyline Stelazine Bupropion
Fluvoxamine Imipramine Tranylcypromine venlafaxine
Sertraline Nortriptyline Isocarboxazid Nevazodone
paroxetine Desipramine
mirtazapine
 Selective serotonin reuptake inhibitors
(SSRIs): Safer and better tolerated than other
classes of antidepressants;
 side effects are mild but include headache,
gastrointestinal disturbance, sexual dysfunction
 Tricyclic antidepressants (TCAs) side effects
include sedation, weight gain, orthostatic
hypotension, and anticholinergic effects

26
 Fluoxetine
ü Initial dose of 20 mg in the
morning.
ü Older started at a dose of 10
mg.
ü Standard dose range is 20 to 40
mg once per day.
ü The dose can be titrated up in
increments of 10 or 20 mg per
day, every four weeks.
ü Doses up to 80 mg per day
have been used.
Sertraline
ü An initial dose of 50 mg in
the morning.
ü Older patients started at a
dose of 25 mg.
ü Standard dose range is 50 to
150 or 200 mg once per day.
ü The dose can be titrated up
in increments of 25 or 50
mg per day, every one to
four weeks.
ü Doses up to 300 mg per day
have been used.
2/17/2024 27
28
 All antidepressant medications are equally
effective but differ in side-effect profiles.
 Medications usually take 4–6 weeks to fully
work.
 Patient may not respond due to:
ØThey cannot tolerate the side effects,
ØNon-adherence ;
ØSub-therapeutic dose ;
ØWrong diagnosis


29
Persistent depressive disorder (dysthymia)

 Patients with persistent depressive disorder

(dysthymia) have chronic depression most of
the time, and they may have discrete major
depressive episodes.

30
1.Depressed mood for the majority of time for at least 2
years
2. At least two of the following:
 Poor concentration or difficulty making decisions
 Feelings of hopelessness
 Poor appetite or overeating
 Insomnia or hypersomnia
 Low energy or fatigue
 Low self-esteem
 3. During the 2-year period:
 The person has not been without the above symptoms
for >2 months at a time.
31
Treatment

 Combination treatment with psychotherapy

and pharmacotherapy is more efficacious
than either alone
 Antidepressants found to be beneficial
include SSRIs, TCAs, and MAOIs

32
A. At least five symptoms must be present in the
final week before the onset of menses, start to
improve within a few days after the onset of
menses, and become minimal or absent in the
week post menses
B. At least one of the following symptoms is
present: affective lability, irritability/anger,
depressed mood, anxiety/tension.

33
c. At least one of the following symptoms is
present (for total of at least five
 symptoms when combined with above):
anhedonia, problems concentrating, anergia,
appetite changes, hypersomnia/insomnia,
feeling overwhelmed/out of control, physical
symptoms (e.g., breast tenderness/swelling,
joint/muscle pain
34
Treatment
q SSRIs are first-line treatment

35
Bereavement
 Bereavement, also known as simple grief, is a
reaction to a major loss, usually of a loved
one, and it is not a mental illness.
 While symptoms are usually self-limited and
only last for several months, if an individual
meets criteria for a depressive episode, he/she
would be diagnosed with MDD.
 Normal bereavement should not include gross
psychotic symptoms, disorganization, or
active suicidality.

36
Bipolar disorders

37
 Diagnosis – DSM 5

 For a diagnosis of bipolar I disorder, it is

necessary to meet the criteria for a manic
episode.

 The manic episode may have been preceded by

and may be followed by hypomanic or major

depressive episodes.

38
Ø A distinct period of abnormally and persistently
elevated, expansive, or irritable mood, and
increased goal-directed activity or energy,
lasting at least 1 week (or any duration if
hospitalization is necessary), and including at
least three of the following (four if mood is
only irritable):
1. Distractibility
2. Inflated self-esteem or grandiosity
3. ↑ in goal-directed activity (socially, at work, or
sexually) or psychomotor agitation
39
4.↓ need for sleep
5. Flight of ideas or racing thoughts
6. More talkative than usual or pressured speech
(rapid and uninterruptible)
7. Excessive involvement in pleasurable activities
that have a high risk of negative consequences
(e.g., shopping sprees, sexual indiscretions)

40
 Biological, environmental, psychosocial, and
genetic factors are all important.
 First-degree relatives of patients with bipolar
disorder are 10 times more likely to develop
the illness.
 Bipolar I has the highest genetic link of all
major psychiatric disorders

41
A. The lifetime prevalence of bipolar disorder is
approximately 0.5-1.5%.

B. The male-to-female ratio is 1:1

C. The first episode in males tends to be a manic

episode, while the first episode in females tends
to be a depressive episode.

42
 Requiring the lifetime experience of at
least one episode of major depression and
at least one hypomania episode
 Hypomanic episode lasts at least 4 consecutive
days, that includes at least three of the
symptoms listed for the manic episode criteria
(four if mood is only irritable).
 can be hypomanic or depressive

43
 Mood stabilizers such as lithium and
 anticonvulsants such as sodium valproate and
carbamazepine are effective for acute
treatment as well as the prophylaxis of mood
episodes
 Second generation antipsychotics such as
olanzapine approved by FDA

44
Treatment Of Acute Mania
v Lithium Carbonate
v300 mg 2–3 times/day and can go up to 1800mg/day
Therapeutic lithium levels is between 0.6 and 1.2
mEq/L.
v Sodium Valproate
v750 to 2,500 mg per day, achieving blood levels
between 50 and 120 μg/mL.
v Carbamazepine
v 600 and 1,800 mg per day associated with blood levels
of between 4 and 12 μg/mL
1. Lithium: Vomiting, Abdominal pain ,Dryness
of mouth, Ataxia, Dizziness, Slurred speech,
Nystagmus, Lethargy
Ø Severe intoxication: (lithium level >2.5
mEq/L) Generalized convulsions ,Oliguria and
renal failure, Death
2. sodium valproate: Alopecia,
thrombocytopenia, Gastrointestinal symptoms,
Neurological effects- tremor, Weight gain,
menstrual irregularity, Hirsutism
3. Carbamazepine: agranulocytosis,
thrombocytopenia, skin rash, aplastic anemia-rare,
Dermatitis or Stevens-Johnson syndrome
46
 Mild form of bipolar II disorder

 “chronic, fluctuating mood disturbance”

with many periods of hypomanic symptoms and
periods of depressive symptoms

47
A.For at least 2 years there have been numerous
periods with hypomania 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 2-year period the individual
has not been without the symptoms for more
than 2 months at a time.

48
 Biological therapy
üMood stabilizers and antimanic drugs – 1st
line
üAntidepressant – should be with caution
 Psychosocial therapy
üDirected toward increasing patients’
awareness of their condition and helping them
develop coping mechanisms for their mood
swings
üFamily and group therapies
üPatients often require lifelong treatment
because of long term nature of the disorder
49
ü Mood disorder due to another medical
condition.
ü Substance/Medication-induced mood
disorder.
ü Other Specified depressive/bipolar disorder
ü Unspecified depressive/bipolar disorder

50
51
10 q 4 ur
attention!

52
For Nursing students
By Abera A.

Bonga University

1
 Expected to :

 Differentiate normal anxiety from pathological

anxiety

 Understand different types of anxiety disorders

its diagnosis and treatment

2
Anxiety
ü Feelings of worry or unease about something
with an uncertain outcome.
ü State of intense apprehension, uncertainty, and
fear
Ø Usually resulted in the disruptions of normal
physical and psychological functioning
Ø Anticipation of future threat
Fear
o Emotional response to real or perceived threat
o physical , emotional and behavioral responses
to perceived threats 3
Normal Anxiety

o Unpleasant and vague transient sense of

apprehension

o Can occur in normal life situations

o Symptoms such as headache, palpitations,

and mild stomach discomfort can occur

4
5
vphysiological symptoms
*Palpitation
*A feeling of suffocation
*Dizziness
*Trembling
*Headaches

6
§ Avoiding situation that give rise to anxiety
(e.g public transport, market places)
§ Poor sleep
§ Angry outburst
v Thoughts and emotion symptoms
*Fear
*Worrying
*Thought that she/he going to die

7
1. If it is greater in severity and duration than
expected

2. If it leads to impairment of functioning in social

life, work and relationships.

3. If it resulted in unexplained medical symptoms

and unwanted thoughts

8
 Most prevalent mental disorders in the general
population (10.4% to 28.8%)
 Women are more likely to have an anxiety
disorder than men (nearly twice)
 Prevalence decreases with higher socioeconomic
status
 Have fluctuating course
 Functional impairment
 Decreases quality of life

9
Biological
ü Stimulation of autonomic Nervous System.
ü Disruptions in neurotransmitters mainly
norepinephrine, serotonin, and γ-aminobutyric acid
(GABA).
ü Increased synthesis and release of neurochemical
called cortisol
Genetic Studies
ü Some genetic component contributes to the
development of anxiety disorders

10
 Family history of anxiety or other mental disorders

 Personal history of anxiety in childhood or

adolescence, including marked shyness

 Stressful life event and (or) traumatic event,

including abuse

 Being female

 Comorbid psychiatric disorder (particularly

depression)
11
q Excessive anxiety and worry about several events
q The worry is difficult to control
q Associated with somatic symptoms, such as
muscle tension, irritability, disturbed sleep, and
restlessness
q Prevalence range from 3 to 8 percent
q Ratio of women to men = 2 to 1
q Covers about 25 percent of all anxiety disorders
q Onset is usually in late adolescence or early
adulthood

12
A. Excessive anxiety and worry (apprehensive
expectation) about a number of events in most days
for at least 6 months.
B. Difficulty to control the worry.
C. Three (or more) of the following six symptoms
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance
D. Clinically significant distress or impairment
13
Ø Most often coexists with another mental disorders;
mainly
1. Social phobia
2. Specific phobia
3. Panic disorder
4. Depressive disorder.
Ø About 50 to 90 percent of patients - with another
mental disorder.

14
§ Clinical course and prognosis are difficult to predict
because of high incidence of comorbidities

§ Only one-third of patients seek psychiatric

treatment.

§ Many go to medical specialties other than

psychiatry

§ Chronic condition that may be lifelong.

15
q Psychotherapy

q Pharmacotherapy

q Supportive approaches

Ø The most effective treatment is the combination

Ø Because of the long-term nature of the disorder,

a treatment plan must be carefully thought out

16
Ø The decision to prescribe medications should be
made rarely on the first visit
Ø Most commonly prescribed medication groups are
antidepressants and benzodiazepines
Ø Drug treatment – for 6 to 12-months
v Drug choice depends on :
qPatient’s ability to tolerate side effect
qDrug effectiveness in reducing symptoms and
qPatient prior response

17
SSRI
 SSRIs are effective, especially for patients with
comorbid depression.
 The prominent disadvantage of SSRIs, especially
fluoxetine (Prozac), is that they can transiently
increase anxiety and cause agitated states.
ü sertraline , citalopram , or paroxetine are better
choices in patients with high anxiety disorder.
v It is better to start SSRI in combination with
benzodiazepine, then to taper benzodiazepine use
after 2 to 3 weeks..
 Though it is general believed that all antidepressant
drugs significantly improve symptom
18
 Benzodiazepines have been the drugs of choice
for generalized anxiety disorder.
 Alprazolam
 Clonazepam
 Diazepam
 Lorazepam
 Chlordiazepoxide
 The problem with long term use of
benzodiazepines are amnesia, dependence
tolerance and withdrawal (rebound insomnia,
rebound anxiety ).
19
ü Panic disorder is characterized by spontaneous,
recurrent panic attacks.
ü These attacks occur suddenly, “out of the blue.”
Patients may also experience panic attacks with a
clear trigger.
ü Recurrent and unexpected
ü The attack reaches peak within minutes
ü Accelerated heart rate, sweating, dizziness,
trembling, and chest pain are common symptoms
ü Prevalence ranges =1 to 4 percent
ü Women are 2 to 3 times more likely to be affected
than men
ü It is a chronic condition 20
Four (or more) of the following symptoms
1. Palpitations, pounding heart, or accelerated
heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort

21
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed, or faint
9. Chills or heat sensations
10. Paresthesia (tingling sensations)
11. Derealization (feelings of unreality) or
depersonalization (being detached from oneself)
12. Fear of losing control or “going crazy.”
13. Fear of dying

22
 One or more of panic attacks followed by >1
month of continuous worry about experiencing
subsequent attacks or their consequences,
and/or a maladaptive change in behaviors (e.g.,
avoidance of possible triggers)

 Not caused by the direct effects of a substance,

another mental disorder, or another medical
condition
23
1. Unexpected : Occur at any time and are not
associated with any identifiable situational
stimulus.
2. Situational : situation in which an individual
always has an attack.
3. Situationally predisposed: situation in which an
individual is likely to have an attack, but doesn’t
always have one .
E.g. an individual who sometimes have an attacks
while driving

24
ü Pharmacotherapy and cognitive-behavioral therapy.
ü The best model is combination of both
ü All SSRIs are effective for panic disorder
ü Benzodiazepines for rapid onset of action
ü Pharmacological treatment for 8 to 12 months

25
Trauma and stress related
disorders

26
 Is characterized by the development of
multiple symptoms after exposure to one or
more traumatic events
 Includes PTSD, ASD
The stressors causing both acute stress disorder
and PTSD are sufficiently overwhelming to
affect almost anyone.
 They can arise from experiences in:
war, torture, natural catastrophes, rape, and
serious accidents, for example, in cars and in
burning buildings.

27
 Posttraumatic stress disorder (PTSD) is a
condition marked by the development of
symptoms after exposure to traumatic life
events.
 The person reacts to this experience with:
◦ fear and helplessness,
◦ persistently relives the event, and
◦ tries to avoid being reminded of it.

28
 prevalence of PTSD is estimated to be about 8
percent of the general population, although an
additional 5 to 15 percent may experience
subclinical forms of the disorder.
 The lifetime prevalence ranges from about 10 to 12
percent among women and 5 to 6 percent among
men.
 Although PTSD can appear at any age, it is most
prevalent in young adults, because they tend be
more exposed to precipitating situations.

29
 Stressor
 stressor is the prime causative factor in the
development of PTSD.
 Not everyone experiences the disorder after a
traumatic event, however The stressor alone
does not suffice to cause the disorder.
 The response to the traumatic event must
involve intense fear or horror.

30
ü Presence of childhood trauma.

ü Inadequate family or peer support system.

ü Being female.

ü Genetic vulnerability to psychiatric illness.

ü Recent stressful life changes.

31
 Exposure to actual or threatened death, serious
injury, or sexual violence by directly
experiencing or witnessing the trauma.
1. Recurrent intrusions of reexperiencing the
event via memories, nightmares,
or dissociative reactions (e.g., flashbacks);
intense distress at exposure to cues relating to the
trauma; or physiological reactions to cues relating
to the trauma
2. Active avoidance of triggering stimuli (e.g.,
memories, feelings, people, places, objects)
associated with the trauma.
32
3. At least two of the following negative
cognitions/mood: dissociative amnesia,
negative feelings of self/others/world, self-
blame, negative emotions (e.g., fear, horror,
anger, guilt), anhedonia, feelings of
detachment/ estrangement, inability to
experience positive emotions.
4. At least two of the following symptoms of ↑
arousal/reactivity: hypervigilance,
irritability/angry outbursts, impaired
concentration, insomnia.
5. Symptoms not caused by the direct effects
of a substance or another medical condition.
6. Duration of the disturbance is more than 1
month
33
34
Acute Stress Disorder

 Acute Stress Disorder is diagnosed in patients who

experience a major traumatic event and suffer from
similar symptoms as PTSD but for a shorter
duration.
 The onset of symptoms occurs within 1 month of
the trauma and symptoms last for less than 1
month

35
36
Pharmacotherapy
Selective serotonin reuptake inhibitors
ü sertraline (Zoloft) and paroxetine are
considered first-line treatments for PTSD,
owing to their efficacy, tolerability, and safety
ratings. SSRIs reduce symptoms from all
PTSD symptom.
Psychotherapy
übehavior therapy,
ü cognitive therapy,

37
Phobia - an excessive and irrational fear of
object, circumstance, or situation.

38
1. Agoraphobia

2. Social phobia

3. Specific phobia

39
ü Fear of or anxiety regarding places from
which escape might be difficult.

ü Avoiding situations in which it would be

difficult to obtain help.

ü Most disabling of the phobias

ü Females likely affected twice as males

ü Peaks of occurrence is late adolescence and

early adulthood
40
A. Marked fear or anxiety about two (or more) of
the following five situations:
1. Using public transportation
2. Being in open spaces
3. Being in enclosed places
4. Standing in line or being in a crowd
5. Being outside of the home alone
B. Avoidance of feared situations
C. Situations almost always provoke anxiety
D. Symptoms last ≥ 6 months

41
Ø Pharmacotherapy

Benzodiazepine

Selective Serotonin Reuptake Inhibitors

Tricycle Antidepressants

Ø Psychotherapy

Supportive Therapy

Behavioral Therapy

42
q A marked and persistent fear of one or more social
or performance situations in which the person is
exposed to unfamiliar people or to possible scrutiny
by others.

q Fears about performing specific activities such as:

eating or speaking in front of others

q Prevalence ranging from 3 to 13 percent

q Females are affected more often than males

43
 1. A marked and persistent fear of social or
performance situations in which the person is
exposed to unfamiliar people
2.Exposure to the feared situation almost
invariably provokes anxiety, which may take the
form of a panic attack.
3.The feared situations are avoided or endured
with intense distress.
4.The avoidance, anxious anticipation, or distress
in the feared situations interferes with normal
functioning or causes marked distress.
5. The duration of symptoms is at least six months.
44
Ø Both psychotherapy and pharmacotherapy

Ø Combination of both is better than either

Ø SSRIs and benzodiazepines are effective drugs

Ø Cognitive, behavioral, and exposure techniques

are also useful in performance situations

45
 A specific phobia is an intense fear of a
specific object or situation (i.e., the phobic
stimulus)
§ Prevalence is about 10 percent
§ Most common disorder among women
§ Second most common among men
§ Duration ≥ 6 months

46
q The DSM-5 includes distinctive types of
specific phobia:
I. Animal type,
II. Natural environment type (e.g., Storms),
III. Blood-injection-injury type (e.g.,
Needles),
IV. Situational type (e.g., Cars, elevators,
planes),

47
q Acrophobia ___________ fear of heights
q Ailurophobia __________ fear of cats
q Hydrophobia _________ fear of water
q Claustrophobia ________fear of closed spaces
q Cynophobia ____________fear of dogs
q Mysophobia ____________ fear of dirt and germs
q Pyrophobia ____________ fear of fire
q Xenophobia ____________fear of strangers
q Zoophobia ____________ fear of animals
q Algophobia ____________fear of pain
q Gynophobia ____________fear of women/sex
q Thanatophobia________ fear of death
48
q Behavioral Therapy

ü The most studied and most effective

ü Systematic desensitization is best behavioral

technique

49
 OCD AND
RELATED
DISORDERS

50
 OCD is characterized by obsessions and/or
compulsions that are time consuming,
distressing, and impairing.

 Obsessions are recurrent, intrusive, undesired

thoughts that ↑ anxiety.

 Compulsion: action response of obsession to

relieve this anxiety of obsession

51
1. Contamination: cleaning or avoidance of
contaminant

2. Doubt : checking multiple times

3. Symmetry: ordering

4. Intrusive taboo or thought: with or without

compulsion

52
Treatment
 Utilize a combination of psychopharmacology
and CBT
 Exposure and response prevention is the best
non pharmacological approach
 First-line medication: SSRIs (e.g., sertraline,
fluoxetine), typically at higher doses
 Can also use the most serotonin selective TCAs
 Clomipramine approved by FDA as
treatment of OCD.

53
 Patients with body dysmorphic disorder are
preoccupied with body parts that they perceive
as flawed or defective, having unattractive or
repulsive.
 Though their physical imperfections are
minimal or not observable by others patients
view them as severe.
 They spend significant time trying to correct
perceived flaws with make up, dermatological
procedures, or plastic surgery.
Treatment: SSRIs and CBT 54
 Persistent difficulty discarding possessions,
regardless of value.
 Difficulty is due to need to save the items and
distress associated with discarding them.
 Results in accumulation of possessions that
congest/clutter living
 Hoarding causes clinically significant distress
or impairment in social, occupational, or other
areas of functioning
 Treatment
 CBT
 SSRIs can be used, but not as beneficial unless
OCD symptoms are present.
55
 Reading assignment
 Excoriation and Trichotillomania
disorders

56
 End
Thank you!!

57
Personality disorders
For nursing students
Bonga University

By Abera A.

1
 Personality is one’s set of stable, predictable, emotional,
and behavioral traits.
 Personality disorders involve enduring, pervasive,
maladaptive patterns of inner experience and behavior that
deviate markedly from expectations of an individual’s
culture.
 Patients with personality disorders often lack insight about
their problems
 their symptoms are either ego-syntonic or viewed as
immutable.
 Patients with personality disorders are vulnerable to
developing symptoms of other mental disorders during
stress
2
1. Enduring pattern of behavior/inner experience that
deviates from the person’s culture and is manifested in two
or more of the following ways:
 Cognition
 Affect
 Interpersonal functioning
 Impulse control
2. The pattern:
 Is pervasive and inflexible in a broad range of situations
 Is stable and has an onset no later than adolescence or
early adulthood
 Leads to significant distress in functioning
 Not due to another mental/medical illness or substance 3
 The international prevalence of personality disorders is 6%.

 Personality disorders vary by gender.

 Many patients with personality disorders will meet the

criteria for more than one disorder;

 they should be classified as having all of the disorders for

which they qualify

4
 lusters
 Personality disorders are divided into three clusters:
Cluster A schizoid, schizotypal, and paranoid:
 Patients seem eccentric, peculiar, or withdrawn.
 Familial association with psychotic disorders.
Cluster B antisocial, borderline, histrionic, and
narcissistic:
 Patients seem emotional, dramatic, or inconsistent.
 Familial association with mood disorders.
Cluster C avoidant, dependent, and obsessive-
compulsive personality disorder:
 Patients seem anxious or fearful.
 Familial association with anxiety disorders

5
 Biological, genetic, and psychosocial factors during
childhood and adolescence contribute to the
development of personality disorders.

 The prevalence of some personality disorders in

monozygotic twins is several times higher than in
dizygotic twins.

6
 Personality disorders are generally very difficult to treat,
especially since few patients are aware that they need help

 The disorders tend to be chronic and lifelong.

 In general, pharmacologic treatment has limited usefulness

except in treating comorbid mental conditions (e.g. major
depressive disorder).

 Psychotherapy is usually the most helpful

7
 uster
 These patients are perceived as eccentric or odd by
others and can have psychotic symptoms :

 schizoid,

 schizotypal, and

 paranoid

8
 Patients with PPD have a pervasive distrust and
suspiciousness of others and often interpret motives as
malevolent (evil)

 They tend to blame their own problems on others and

seem angry and hostile.

 They are often characterized as being pathologically

jealous, which leads them to think that their sexual
partners or spouses are cheating on them

9
Clinical Features of PPD

A. The patient is often hypervigilant and constantly

looking for data to support his paranoia.
B. Patients are often argumentative and hostile.
C. Patients have a high need for control and autonomy
in relationships to avoid betrayal and the need to trust
others.
D. Pathological jealousy is common.
E. Patients are quick to counterattack and are
frequently involved in legal disputes.
F. These patients rarely seek treatment.

10
 Epidemiology
 Prevalence: 2–4%.

 More commonly diagnosed in men than in

women.

 Higher incidence in family members of

schizophrenics.

11
Treatment
§ Psychotherapy is the treatment of choice.

§ Group psychotherapy should be avoided due to

mistrust and misinterpretation of others’ statements.

§ Patients may also benefit from a short course of

antipsychotics for transient psychosis.

12
 Patients with schizoid personality disorder have a
lifelong pattern of social withdrawal.

 They are often perceived as eccentric and reclusive.

 They are quiet and unsociable and have a constricted

affect.

 They have no desire for close relationships and prefer

to be alone.

13
Epidemiology
§ Prevalence: 3–5%.

 Diagnosed more often in men than women.

 May be ↑ prevalence of schizoid personality disorder in

relatives of individuals with schizophrenia.

14
 Individual psychotherapy is the treatment of
choice.
 Group therapy is not recommended because other
patients will find the patient's silence difficult to
tolerate
 The use of antidepressants, antipsychotics and
psychostimulants to treat comorbid conditions

15
3. Schizotypal personality disorder
 condition marked by a consistent pattern of intense
discomfort with relationships and social interactions.

 Patients with schizotypal personality disorder have a

pervasive pattern of eccentric behavior and peculiar
thought patterns.

 People with STPD have unusual thoughts, speech and

behaviors, which usually hinder their ability to form and
maintain relationships.

 They are often perceived as strange and odd.

16
 Schizoid personality disorder (ScPD) is marked by a
consistent pattern of detachment from and general
disinterest in social relationships.
 This is distinct from schizotypal personality disorder
(STPD) because people with STPD have an intense
discomfort with personal relationships, not a lack
of interest in them.
 People with STPD also have peculiar thoughts and
behaviors, like magical thinking, whereas people
with ScPD generally don’t

17
 Psychotherapy is the treatment of choice to help
develop social skills training.

 Short course of low-dose antipsychotics if

necessary (for transient psychosis). Antipsychotics
may help decrease social anxiety and suspicion in
interpersonal relationships

18
 Includes antisocial, borderline, histrionic, and
narcissistic personality disorders.

 These patients are often emotional, impulsive,

and dramatic

19
1. Antisocial personality disorder
 Patients diagnosed with antisocial personality disorder
are exploitive of others and break rules to meet their
own needs.
 They lack empathy, compassion, and remorse for
their actions.
 They are impulsive, deceitful, and often violate the
law.
 They are frequently skilled at reading social cues and
can appear charming and normal to others who meet
them for the first time and do not know their history.
 Prevalence: 3% in men and 1% in women

20
 Psychotherapy is generally ineffective because these
patients will try to destroy or avoid the therapeutic
relationship.

 Psychotropic medication is used in patients whose

symptoms interfere with functioning or who meet criteria
for another psychiatric disorder.

21
 Patients with BPD have unstable moods, behaviors,
and interpersonal relationships.
 Relationships begin with intense attachments and end
with the slightest conflict.
 They are impulsive and may have a history of
repeated suicide attempts/gestures or episodes of self-
mutilation.
 They swing from being excessively dependent to
being hostile to persons close to them.
 Hence, they have a history of unstable relationships
 Finally, these patient excessively use the defense
mechanism of splitting (where in they consider each
person to be either “all good” or “all bad”) 22
 Epidemiology
 Prevalence: Up to 6%.

 Diagnosed three times more often in women than

men.

 Suicide rate: 10%.

23
 Treatment
 Psychotherapy Dialectical Behavior Therapy is the
treatment of choice.

 Pharmacotherapy is frequently used for coexisting

mood disorders, eating disorders, and anxiety disorders.

 Valproate (Depakote) or SSRIs may be helpful for

impulsive-aggressive behavior

24
 Histrionic personality disorder
 These patients are excitable and overtly emotional
and behave in a dramatic and extroverted way.
 They want to be the center of attention and exaggerate
everything, making it sound more important than it
really is.
 They tend to behave in a sexually seductive manner
and use physical appearance to draw attention
towards self.
 The patient is not comfortable unless he is the center
of attention.
 The patient consistently uses physical appearance to
attract attention.
 Speech is excessively impressionistic and lacking in
detail.

25
Epidemiology

 Prevalence: 2%.

 Women are more likely to have HPD than men.

26
 Treatment
 Psychotherapy (e.g., supportive, problem-solving,
interpersonal, group) is the treatment of choice.

 Pharmacotherapy to treat associated depressive or

anxious symptoms as necessary

27
4.Narcissistic personality disorder
 These patients have a heightened sense of self
importance.
 They believe that they are special and very talented.
 They are preoccupied with fantasies of unlimited
success and power.
 They want to be admired by others.
 If condemned, they may become very angry or they
may show complete indifference to criticism.
 They have a fragile self esteem and are susceptible to
development of depression, when faced with rejection
 The patient is often envious of others or believes
that others are envious of him .

28
 The prevalence of NPD is less than 1% in the general
population and up to 16% in clinical populations.
 The disorder is more common in men than women.
 Studies have shown a steady increase in the incidence
of narcissistic

29
 Psychotherapy is the treatment of choice, but the
therapeutic relationship can be difficult since envy
often becomes an issue.
 Coexisting substance abuse may complicate
treatment.
 Depression frequently coexists with NPD; therefore,
antidepressants are useful for adjunctive therapy.

30
 Includes Avoidant, dependent and obsessive-
compulsive personality disorders

 These patients tend to be anxious and their personality

pathology is a maladaptive attempt to bind anxiety.

31
 Patients with avoidant personality disorder have a
pervasive pattern of social inhibition and an
intense fear of rejection.
 They will avoid situations in which they may be
rejected.
 Their fear of rejection is so overwhelming that it
affects all aspects of their lives.
 They avoid social interactions and seek jobs in
which there is little interpersonal contact.
 These patients desire companionship but are
extremely shy

32
 Prevalence: 2.4%.

 Equally frequent in males and females

33
 Individual psychotherapy, group psychotherapy and
behavioral techniques may all be useful.
 Group therapy may assist in dealing with social
anxiety.
 Behavioral techniques, such as systematic
desensitization, may help the patient to overcome
anxiety and shyness.
 Beta-blockers can be useful for situational anxiety.
 Since many of these patients will meet criteria for
Social Phobia (generalized) a trial of SSRI
medication may prove beneficial.
 Patients are prone to other mood and anxiety
disorders, and these disorders should be treated with
antidepressants or anxiolytics.
34
• Patients with DPD have poor self-confidence and
fear of separation.
• They have an excessive need to be taken care of
and allow others to make decisions for them.
• difficulty making everyday decisions without input
from others
• submissiveness, meaning a person allows others to
take the lead
• frequent need for reassurance, approval, or validation
• difficulty expressing disagreement
• feeling uncomfortable or anxious when alone
• intense fear of abandonment

35
 Prevalence: Approximately <1%.
 Women are more likely to be diagnosed with DPD
than men

36
 Group psychotherapy , and behavioral therapies
such as social skills training have all been used
with success.
 Family therapy may also be helpful in supporting
new needs of the dependent patient in treatment.
 Dependent patients are at increased risk for mood
disorders and anxiety disorders.
 Appropriate pharmacological interventions may
be used if the patient has these disorders

37
 Patients with OCPD have a pervasive pattern of
perfectionism, inflexibility, and orderliness.
 They become so preoccupied with unimportant
details that they are often unable to complete
simple tasks in a timely fashion.
 They appear stiff, serious, and formal, with
constricted affect.
 They are often successful professionally but have
poor interpersonal skills.

38
 Epidemiology

§ Prevalence: 1–2%.

§ Men are two times more likely to have OCPD

than women

39
 Differential Diagnosis
 Obsessive-compulsive disorder (OCD): Patients with
OCPD do not have the recurrent obsessions or
compulsions that are present in OCD.

 In addition, the symptoms of OCPD are ego-syntonic

rather than ego-dystonic (as in OCD);

 OCD patients are aware that they have a problem and

wish that their thoughts and behaviors would go away.

40
Treatment
 Psychotherapy is the treatment of choice.
Cognitive-behavior therapy may be particularly
useful.
 Pharmacotherapy may be used to treat associated
symptoms as necessary
 SSRIs are useful to treat associated intrusive
thoughts

41
 10 q
Failing to plan is planning to fail!

42
For Nursing students

By Abera A.
Bonga University

1
 At the end u are expected to:
 Understand terminologies in substance
use disorder
 Know effect of substance on patients life
 Define diagnostic criteria of substance
use disorder
 Understand all about alcohol and khat use
disorder

2
v What are psychoactive substances?
“…Any chemical substance which, when taken
into the body, alters its function physically,
socially and/or psychologically...”
(World Health Organization, 1989)
v Some of the psychoactive substances are used
as medicines to relieve pain and for their
calming effect.
v Some people also take substances to relieve
themselves from anxiety or other feelings of
discomfort in life.
3
 Substance use disorder is Cognitive,
behavioral, and physiological symptoms
indicating continuous use of a substance despite
significant substance-related problems

4
v To feel good: Most abused drugs produce intense
feelings of pleasure. This initial sensation of euphoria is
followed by other effects, which differ with the type of
drug used.
v To feel better: Some people who suffer from social
anxiety, stress-related disorders, and depression begin
abusing drugs in an attempt to lessen feelings of
distress.
v To do better: The increasing pressure that some
individuals feel to chemically enhance or improve their
athletic or cognitive performance.
v Curiosity and “because others are doing it.”
In this respect adolescents are particularly vulnerable
because of the strong influence of peer pressure; they
are more likely, for example, to engage in “thrilling”
and “daring” behaviours.
5
 Dependence: It is defined as a pattern in which
the use of a substance or a class of substances
takes on a much higher priority for a given
individual than other behaviors that once had a
greater value
 Intoxication: A transient condition that
develops following administration of a
substance, in which various mental functions
such as consciousness, thinking, perception or
behavior are altered.
 Withdrawal: Specific symptoms that occur
after stopping or reducing the amount of
substance that has been used regularly over a
prolonged period
6
 Addiction :The repeated and increased use of a
substance, the deprivation of which gives rise to
symptoms of distress and an irresistible urge
to use the agent again and which leads also to
physical and mental deterioration.
 Tolerance: Phenomenon in which, after
repeated administration, a given dose of drug
produces a decreased effect or increasingly
larger doses must be administered to obtain
the effect observed with the original dose

7
v Substance use disorder is manifested by at
least two of the following within a 12-month
period (note that these criteria are the same
regardless of the substance):
1. the substance is often taken in larger amounts
or over a longer period than was intended
2. Persistent desire or unsuccessful efforts to cut
down on use
3. Significant time spent in obtaining, using, or
recovering from substance
4. Craving to use substance
5. Failure to fulfill obligations at work, school, or
home 8
6. Continued use despite social or interpersonal
problems due to the substance use
7. ↓ social, occupational, or recreational activities
because of substance use
8. Use in dangerous situations (e.g., driving a car)
9. Continued use despite subsequent physical or
psychological problem (e.g., drinking alcohol
despite worsening liver problems)
10. Tolerance
11. Withdrawal

9
Effects of Substance Use on the Patient's Life
1. Family Manifestations. Family dysfunction, marital
problems, divorce physical abuse and violence.
2. Social Manifestations. loss of friends, gravitation
toward others with similar lifestyle.
3. Work or School Manifestations. Decline in work
school performance, frequent job changes, frequent
absences,
4. Legal Manifestations. Arrests for disturbing the peace
or driving while intoxicated, stealing, drug dealing,
prostitution
5. Financial Manifestations. Irresponsible borrowing or
selling of possessions

10
 Alcohol
 Tobacco (Nicotine)
 Cannabis
 Khat
 Heroin
 Cocaine
 Solvents
 Caffeine (e.g. tea, coffee)
 Benzodiazepines (e.g. Diazepam)
 LSD (Lysergic Acid Diethylamide)
11
v CNS Stimulants
(Uppers) v CNS Depressants (Downers)
•Cocaine / crack •Alcohol
•Khat •Benzodiazepines (Tranquilisers,
•Tobacco (Nicotine) e.g. Diazepam)
•Caffeine •Solvents
•Amphetamines •Barbiturates
•methamphetamines •Cannabis(low dose)
•Alkyl nitrates
[Anabolic steroids]
v Hallucinogens v Opiates (Pain killers)
•Cannabis(high dose) •Heroin
•LSD(lysergic acid •Morphine
diethylamide) •Opium
•Magic mushrooms •Codeine
•Dissociative anaesthetics •Methadone
(e.g. Ketamine) •Pethedine
12
Substance: Number of users
 Alcohol: 2 billion
 Tobacco smoker: 1.3 billion
 Illicit drug: 185 million
Death and Disability
ü Death- 12.4% of all deaths
ü DALYs- 8.9% of DALYs lost

13
Alcohol related disorders

14
 The term alcohol refers to a large group of
organic molecules that have a hydroxyl group (-
OH) attached to a saturated carbon atom.

 Ethyl alcohol (ethanol) is substance present in

varying amounts in beer, wine, tella, tej, areki
and liquors.

15
 Route of administration – oral

 Its absorption is 10% by stomach and 90% by

small intestine.

 It takes 5 minutes to affect brain.

 Peak blood concentration of alcohol is reached

in 30 to 90 minutes and usually in 45 to 60
minutes.

16
 Lifetime prevalence is 14%
 Male predominance of 5:1
 About 200,000 deaths each year are directly related
to alcohol abuse.
 Cause of death include suicide, cancer, heart
disease and hepatic disease
 High fatality also occurs due to automotive accident
and homicide.
 Alcohol dependence decreases life span by 10 to 15
years.

17
A. Recent ingestion of alcohol.
B. Clinically significant maladaptive behavioral
or psychological changes (e.g., inappropriate
sexual or aggressive behavior, mood lability,
impaired judgment, impaired social or
occupational functioning) that developed during,
or shortly after, alcohol ingestion.
C. One (or more) of the following signs,
developing during, or shortly after, alcohol use:
◦ slurred speech
◦ incoordination
◦ unsteady gait
◦ Nystagmus
◦ impairment in attention or memory
◦ stupor or coma
18
v Assess vital signs and manage respiratory
depression, cardiac arrhythmia or blood
pressure instability.
v The possibility of intoxication with other drugs
should be considered by obtaining toxicology
screens
v Aggressive behavior should be handled by offering
reassurance
v If the aggressive behavior continues, relatively low
doses of short-acting benzodiazepine such as
lorazepam (e.g., 1–2 mg PO or IV) and
alternative use of antipsychotic medication (e.g.,
0.5–5 mg of haloperidol PO or IM or 2.5–10 mg
of olanzapine) is considered. 19
 Is a condition characterized by sign and
symptoms that develops following the
cessation or reduction of alcohol use that was
heavy and prolonged.
 Conditions that may aggravate, withdrawal
symptoms include fatigue, malnutrition,
physical illness( hepatitis, pancreatitis), and
depression.
 Tremulousness (commonly called the shakes
or the jitters) develops 6 to 8 hours after the
cessation of drinking,
 the psychotic and perceptual symptoms begin in
8 to 12 hours,
 seizures in 12 to 24 hours, and
 DTs during 72 hours.
20
Stage 1: which occurs within about 8 hours of a cut
back in alcohol, is characterized by nausea,
insomnia, sweating, and tremors.
Stage 2: which starts to occurs within 8 to 12 hours,
is characterized by a worsening of Stage 1
symptoms, plus vomiting and illusions or
hallucinations.
Stage 3: which usually occurs within 48 hours, is
characterized by major seizures.
Stage 4: is characterized by Delirium tremens can
appear suddenly, but usually it occurs gradually 2-3
days after cessation of drinking and reaches its
peak intensity on day 4 or 5.
21
A. Cessation or reduction of alcohol use that has been
heavy and prolonged.
B. >2 or more of the ff developing within several hours
to a few days after Criterion A:
◦ autonomic hyperactivity (e.g., sweating or pulse >100)
◦ increased hand tremor
◦ insomnia
◦ nausea or vomiting
◦ transient visual, tactile, or auditory hallucinations or
illusions
◦ psychomotor agitation
◦ anxiety
◦ grand mal seizures
22
vStabilization:- fluid and electrolytes
vSupplementation:- nutrition, Thiamine 50 -
100mg/d for 1-5 days, vitamin B complex etc.
vTreatment of Comorbid illnesses:- pneumonia,
UTI, etc.
v Detoxification:- To prevent serious withdrawal
state (delirium tremens)
 E.g. E.g. Diazepam 5-20 mg p.o. qid and reduce the dose
by 20% every day
 Antiemetic if necessary

23
 Detoxification is a process where individuals
are treated for withdrawal symptoms upon
discontinuation of addictive drugs.
 Detoxification treatment is conducted under the
care of physician in an inpatient or out patient
setting.
 Alcohol detoxification using diazepam
ü day 1and 2: diazepam 10mg tid,
ü day 3 and 4: diazepam 10mg bid,
ü day 5 and 6: diazepam 5mg bid,
ü day 7: diazepam 5mg at bed time.
@ Is severe manifestation of alcohol withdrawal
and occurs 3-10 days following the last drink.

@ Is a medical emergency that can result in

significant morbidity and mortality

@ Untreated, DTs has a mortality rate of 20

percent, usually as a result of an intercurrent
medical illness such as pneumonia, renal disease,
hepatic insufficiency, or heart failure
25
@ include agitation, global confusion,
disorientation, hallucinations, fever,
hypertension, diaphoresis, and autonomic
hyperactivity (tachycardia and hypertension).
@ Profound global confusion is the hallmark of
delirium tremens.
 Psychomotor agitation
 Dehydration with electrolyte imbalance
 Insomnia, Nausea, Diarrhea

26
 The best treatment for DTs is prevention by
giving low dose prophylaxis benzodiazepine
(i.e. chlordiazepoxide).
 Use high dose once the delirium appeared.
 A high-calorie, high-carbohydrate diet
supplemented by multivitamins is also
important.
 Dehydration, often exacerbated by diaphoresis
and fever, can be corrected with fluids given by
mouth or IV.

27
• Is a disturbance in short-term memory caused
by prolonged heavy use of alcohol.
• Because the disorder usually occurs in persons
who have been drinking heavily for many years.
• The disorder is rare in persons younger than age
35.
Two types:
A, Wernicke's encephalopathy (a set of acute
symptoms, reversible with treatment)
B, Korsakoff's syndrome (a chronic condition,
only about 20 percent reversible ).

28
Wernicke's encephalopathy (alcoholic
encephalopathy) is characterized by :
Ø ataxia (affecting primarily the gait),
Ø vestibular dysfunction,
Ø confusion, and
Ø a variety of ocular motility abnormalities like
nystagmus

29
 Responds rapidly to large doses of parenteral
thiamine
 Thiamine is effective in preventing the
progression into Korsakoff's syndrome.
 The dosage of thiamine is usually initiated at
100 mg po two to three times daily and is
continued for 1 to 2 weeks.

30
 Is the chronic amnestic syndrome that can
follow Wernicke's encephalopathy.

 The cardinal features of Korsakoff's syndrome

are impaired mental syndrome (especially
recent memory) and anterograde amnesia in an
alert and responsive patient.

 The patient may have the symptom of

confabulation.

31
 Thiamine given 100 mg by mouth two to three times
daily;
 The treatment regimen should continue for 3 to
12 months.
 Few patients who progress to Korsakoff's syndrome
ever fully recover, although many have some
improvement in their cognitive abilities with
thiamine and nutritional support.

32
 A condition that occur to a child bc of mother
drinking during pregnancy
 Symptoms includes abnormal appearance,
low body weight, small head size, poor
coordination, learning difficulties, prblm
with hearing and sight,
 Those who affected are more likely to have
trouble with school, and legal system

33
Khat

34
 Khat also called Catha edulis.
 A bush native to East Africa, have been used as
a stimulant in the Middle East, Africa, and the
Arabian Peninsula for at least 1,000 years.
 People chew fresh leaves of Catha edulis.
§ Most often it is chewed but can be made into a
tea, dried and smoked.
§ The leaves loss their potency after 24-48 hours.
 Khat is still widely used in Ethiopia, Kenya,
Somalia, and Yemen.

35
 Is active ingredient ,explains why only the
fresh leaves of the plant are valued for their
stimulant effects.
 Has most of the CNS and peripheral actions of
amphetamine and appears to have the same
mechanism of action.

36
 Elevates mood, decreases
hunger, and alleviates
fatigue.
 At high doses, it can
induce an amphetamine-
like psychosis .
 it is typically absorbed
buccally after chewing
the leaf

37
ü The stimulant effect of Khat is through the
release of monoamine neurotransmitter
system.

ü Cathinone causes the release of dopamine

esp. in the striatum and nucleus accumbens
in the brain.

ü The result is very similar to amphetamines.

38
v There is evidence that if some people have
enough khat that they can develop symptoms of
psychosis.

v In those people who already are prone to

psychosis such as Schizophrenia may use khat
(along with other drugs – cannabis, alcohol) and
it can make the symptoms worse.

39
 Two types:

 Manic -grandiose delusions

 Paranoid - persecutory delusions &/or

- auditory hallucinations

 Sometimes accompanied with depression &

violent reactions

40
Ø Psychosis is infrequent but may occur because of
excessive use of khat
Ø For Khat induced Psychosis, often drug
abstinence is enough to resolve the problem.
Ø However, when it is acute and possibly
dangerous, anti-psychotic drugs or
benzodiazepines have been used.

41
ü People who are prone to depression may use
khat which may initially help lift their mood
but when withdrawals begin it can make the
depression worse.
ü Khat may interact with anti-depressants such as
monoamine oxidase inhibitors (MAOIs) such as
phenelzine (Nardil) and produce a hypertensive
crisis.

42
 ü Increased confidence
< Like all drugs, it varies from individual
ü euphoria & elation
to individual though some effects are
common to most of those who use it. ü increased alertness & excited
mood
ü Increased blood pressure (diastolic &

systolic ü Flight of ideas

ü Tachycardia ü appetite loss

ü Insomnia ü Psychosis (hallucinations, delusions
ü Blurred vision often grandiose, paranoia)
ü Dry mouth

ü Constipation

43
v Cardiovascular problems
(including tachycardia,
hypertension, arrhythmias, üamphetamine use
leads to severe tooth
myocardium infarction (heavy
decay
users may have 39X greater
chance of MI), cerebral
haemorrhage, pulmonary edema .
v Gastro-intestinal
@ Polydipsia (excessive thirst),
teeth problems, gastritis
(inflammation of the stomach
lining), constipation, ulcers,
weight loss.

44
ü Genito-urinary system- urinary retention, impotence
libido change
ü Oral Cancer
ü Obstetric effects – low birth weight, stillbirths,
impaired lactation
ü CNS effects – dizziness, impaired cognitive
functioning, fine tremor, insomnia, headaches
ü Psychiatric – depression, anxiety, psychosis

45
o Possible slight trembling
o Loss of energy
o Lethargy(fatigue)
o Depression
Ø Most of these symptoms are mild compared
to other drugs and resolve within a short time
– usually several days or a week

46
 Scarce income being spent on khat.

 Some authors report that up to ¼ of family

income.

 Loss of interest in work is common.

 Aggressive or violent behaviour may result

from intoxication or withdrawal from khat.

47
1. Helping them to stop
@ Finding other things to do
@ Changing friends
2. Helping them to reduce how much they use
@ Reduce quantity that is chewed
@ Avoid late nights
@ Clean teeth after Khat use
@ Avoid using it with other drugs/alcohol
@ Avoid tea and cola

48
v Antipsychotics may be prescribed for the first
few days. In the absence of psychosis,
diazepam (Valium) is useful to treat patients'
agitation and hyperactivity.

49
50
 !
AT
K H
L &
H O
C O
A L
” 2
N O
“
Y
SA

51
52
1
Outline

ü Normal sleep

ü Electrophysiology of Sleep/Sleep pattern

ü Sleep Regulation

ü Sleep Requirements

ü Sleep-Wake Disorders
2
Normal Sleep

o Most significant human behaviors

o Associated with a high degree of brain activation

o Occupying roughly one-third of human life

o Prolonged sleep deprivation leads to severe

physical and cognitive impairment and, finally to
death

3
ELECTROPHYSIOLOGY OF SLEEP/SLEEP
PATTERN


Ø Sleep is made up of two physiological states: non-
rapid eye movement (NREM) and rapid eye
movement (REM) sleep
Ø Stages of sleep defined by the visual scoring of three
parameters:
o Electroencephalogram (EEG)-brain activity
o Electro-oculogram (EOG)- eye movements
o Electromyogram (EMG)-muscles tone
4
NREM sleep

o Composed of stages 1 through 4
o Most physiological functions are lowered
o Pulse rate, respiration and blood pressure
are tend to be low
o Episodic and involuntary body movements
o Few, if any, rare penile erections
o Blood flow including cerebral blood is
slightly reduced
5
NREM sleep…

o The deepest portions of NREM sleep are stages
3 and 4
o Most stage 4 sleep occurs in the first third of
the night
o When persons are aroused 30 minutes to 1hour
after sleep – disorientation and disorganized
thinking that may result in specific problems
including enuresis, somnambulism, and stage 4
nightmares or night terrors

6
REM sleep

§ High level of brain activity and physiological
activity levels similar to those in wakefulness
§ In normal adults - About 90 minutes after sleep
onset, first REM episode
§ Pulse, respiration, and blood pressure in
humans are all high during REM sleep—much
higher than during NREM sleep

7
Sleep patterns change over a
person’s life span

Ø Neonatal period
 REM sleep represents more than 50 percent
Ø Newborns
 sleep about 16 hours a day
 brief periods of wakefulness
Ø By 4 months age
 REM sleep drops to less than 40 percent
 entry into sleep occurs with an initial period of
NREM sleep

8
SLEEP REGULATION

Ø By interconnecting systems which are located
chiefly in the brainstem
q Serotonin
§ Prevention of serotonin synthesis reduces sleep for a
considerable time
q Norepinephrine
§ Increased noradrenergic neurons markedly reduce
REM sleep and increase wakefulness
q Acetylcholine
§ Involved in the production of REM sleep
9
SLEEP REGULATION…

q Melatonin

§ Enhance sleepiness

§ Inhibited by bright light, so the lowest serum

melatonin concentrations occur during the day

q Dopamine

§ Drugs that increase dopamine concentrations in the

brain tend to produce arousal and wakefulness
10
FUNCTIONS OF SLEEP

§ Restore homeostatic function

§ Crucial for normal thermoregulation and

energy conservation

§ Satisfying metabolic needs

11
Sleep Requirements

v Short sleepers

§ Require fewer than 6 hours of sleep each

night

§ They are generally efficient, ambitious

and socially adept

12
Sleep Requirements…

v Long sleepers

§ Sleep more than 9 hours each night to

function adequately

§ They have more REM periods

§ Tend to be mildly depressed, anxious, and

socially withdrawn
13
Sleep-wake disorders-DSM5

 DSM Classifies sleep disorders on the basis of
clinical diagnostic criteria and etiology
Primary Sleep disorders – Dyssomnia and
parasomnia
Sleep d/o 2° to another mental d/o and
substance abuse

14
Dyssomnias

 Heterogeneous group of sleep disorders which
cause the individual an inability to sleep or
complications with sleeping and includes:-

Insomnia disorder
Hypersomnolence disorder
Breathing-related sleep disorders, etc

15
Parasomnias

Are sleep disorders that cause abnormal

behaviors related with sleep

16
1. Insomnia disorder

 A predominant complaint of dissatisfaction with
sleep quantity or quality, associated with one
(or more) of the following symptoms:
Initial insomnia - Difficulty initiating
Middle insomnia - Difficulty maintaining sleep
Late insomnia – Early morning awakening with
inability to return to sleep
17
Insomnia disorder…

§ Causes clinically significant distress or impairment

§ At least 3 nights /week and present for at least 3

months

§ Occurs despite adequate opportunity for sleep

§ Most prevalent of all sleep disorders- 6%-10%.

§ More prevalent complaint among females than

among males
18
Treatment

q Cognitive-Behavioral Therapy
§ To overcome dysfunctional sleep behaviors,
misperceptions and disruptive thoughts about
sleep
q Behavioral techniques
• Universal sleep hygiene
• Stimulus control therapy
• Sleep restriction therapy
• Relaxation therapies
q Pharmacotherapy
19
Universal Sleep hygiene

 Do's and Don'ts for Good Sleep Hygiene

Ø DO’s

Maintain regular hours of bedtime and arising

If you are hungry, have a light snack before

bedtime

Maintain a regular exercise schedule

20
DO’s…

If you are preoccupied or worried about
something at bedtime, write it down and deal
with it in the morning

Keep the bedroom cool

Keep the bedroom dark

Keep the bedroom quiet

21
DON’Ts

Take naps
Watch the clock so you know how bad your
insomnia actually is
Exercise right before going to bed in order wear
yourself out
Watch television in bed when you cannot sleep
Eat a heavy meal before bedtime to help you
sleep
Drink coffee in the afternoon and evening
22
DON’Ts…


If you cannot sleep, smoke a cigarette
Use alcohol to help in going to sleep
Read in bed when you cannot sleep
Eat in bed
Exercise in bed
Talk on the phone in bed
23
Pharmacological Treatment


Ø Primary insomnia is commonly treated with
benzodiazepines

Ø Sleep medications should not be prescribed for more

than 2 weeks because of tolerance and withdrawal

 Long acting (e.g flurazepam) - for middle insomnia

 Short-acting (e.g, zolpidem)- difficulty falling asleep

 Sedating antidepressants - as sleep aids

24
2. HYPERSOMNOLENCE DISORDER


 Self-reported excessive sleepiness despite a main
sleep period lasting at least 7 hours

§ Nonrestorative prolonged sleep episode of more than

9 hours per day

§ Difficulty being fully awake after abrupt awakening

§ At least 3 times/week, for at least 3 months

§ Significant distress or impairment

25
HYPERSOMNOLENCE DISORDER…


 Individuals with this disorder fall asleep
quickly

 Prolonged impairment of alertness at the

sleep-wake transition which referred to as
sleep inertia or sleep drunkenness

26
Treatment of hypersomnia


 Wake-promoting substance like modafinil

 Stimulant drugs, such as amphetamines

 Non sedating antidepressant drugs, such as SSRIs

 Scheduled naps

 Lifestyle adjustment

 Psychological counseling

27
Breathing-Related Sleep Disorder


1. Obstructive Sleep Apnea (OSA)

 Periods of functional obstruction of the

upper airway during sleep, resulting in a
transient arousal

 Usually in overweight patients

28
Cont…

Episodes of OSA in adults are
characterized by multiple periods of at
least 10 seconds in duration in which
nasal and oral airflow ceases completely
(an apnea) or partially (a hypopnea)
l%-2% of children
2%-15% of middle-age adults
more than 20% of older individuals

29
Predisposing factors for OSA


Being male
Middle age
Being obese
Nasopharyngeal abnormalities
Hypothyroidism

30
Clinical features of OSA

 Excessive sleepiness, snoring, obesity, restless
sleep, nocturnal awakenings with choking or
gasping for breath
 Morning dry mouth, morning headaches, and
heavy nocturnal sweating
 Nocturia, hypertension, heart failure and
polycythemia
 Depression and memory impairment
 Erectile failure in men
31
Treatment

 Weight loss

 Avoid sleeping in the supine position

 Continuous Positive Airway Pressure (CPAP)

 Only drug therapy approved for use in patients

with OSA is the wake-promoting substance
modafinil with PAP

32
NREM Sleep Arousal Disorders


1. Sleep-walking (Somnambulism)

 Repeated episodes of rising from bed during sleep

and walking

 The individual has a blank, staring face

 Amnesia for the episodes is present

 Sleep-related eating and sexual behavior (sexsomnia)

33
NREM Sleep Arousal Disorders…


2. Sleep terrors
 Recurrent episodes of abrupt terror arousals
from sleep, usually beginning with a panicky
scream
 There is intense fear and signs of autonomic
arousal
 There is relative unresponsiveness
 Amnesia for the episodes is present

34
Treatment for NREM Sleep Arousal Disorders


Investigation of stressful family situations

When medication is required, diazepam in

small doses at bedtime improves the
condition and sometimes completely
eliminates the attacks

35
REM Sleep Behavior Disorders


1. Nightmare Disorder
 Repeated awakenings from the major sleep period
with detailed recall of extremely frightening dreams
 The person rapidly becomes oriented and alert
v Treatment
 Tricyclic drugs
 Benzodiazepines

36
Reference

 DSM 5

 KAPLAN & SADOCK’S Synopsis of Psychiatry:

Behavioral Sciences/Clinical Psychiatry, 11th
edition

37
 

10q!
Stay focused!
38
Psychiatric Emergency
For Nursing Students

By Abera A.

1
 Psychiatric emergency is a condition where in the
patient has disturbances of thought, affect and
psychomotor activity leading to a threat to his
existence (suicide), or threat to the people in the
environment.

 Conditions in which there is alteration in behaviors,

emotion or thought, presenting in an acute form, in
need of immediate attention and care.

2
3
 Suicide-self-inflicted death with evidence that the person
intended to die.

 Suicidal ideation- thoughts about or an unusual

preoccupation with suicide.

 Suicidal intent-subjective expectation and desire for a

self- destructive act to end in death.

 Suicide gesture - an act that is indicative of self

destructiveness, but the level of lethality is so low that it
could not cause death. 4
 Aborted suicide attempt-stopped the attempt
before physical damage occurred.
 Suicidal attempt-An action has taken to kill
oneself but, the person was survived.

 Completed suicide-An attempt to oneself has

succeeded and ended in death.

 Deliberate self-harm-willful self-inflicting of

painful, destructive, or injurious acts without
intent to die. 5
 It is the primary emergency for the mental health
professional

 It is a major public health problem

 In the United States

o More than 30,000 persons commit suicide each year

o with more than 600,000 suicide attempts

6
 In Ethiopia

 Suicide complete = 7.7/100,000/year

 Suicide attempt = 3.2%

o It is almost always the result of a mental

illness

o Usually depression and

o Is amenable to psychological and
pharmacological treatment.
7
 Hanging(Globally, the most common method)
 Ingesting poison or inhaling poisonous
substance
 Jumping from height
 Drowning
 Using guns

8
Gender Differences
v Men commit suicide more than four times as often
as women
v Women attempt suicide or have suicidal thoughts
three times as often as men
v Disparity remains unclear but it may be related
to the methods used.

9
 Men are more likely than women to commit suicide
using firearms, hanging or jumping from high
places

 Women more commonly take an overdose of

psychoactive substances or poison.

 Globally, the most common method of suicide is

hanging.
 The choice of a hard method points to a highrisk of
successfulsuicide
10
Marital Status
 Single, never-married persons register an overall rate
nearly double that of married persons.

 Divorce increases suicide risk

 Widows and widowers also have high rates.

 With divorced men three times more likely to

kill themselves as divorced women.

11
 The relation of physical health and illness to
suicide is significant.
 Previous medical care appears to be a
positively correlated risk indicator of suicide:

 About one third of all persons who commit suicide

have had medical attention within 6 months of death

 Physical illness is estimated to be an important

contributing factor in about half of all suicides.

12
 Loss of mobility

 Disfigurement particularly among women

 Chronic, intractable pain

 Patients on hemodialysis are at high risk.

13
 Almost 95 percent of all persons who commit or
attempt suicide have a diagnosed mental disorder.
Depressive disorders account for 80 percent of this
figure

 Schizophrenia accounts for 10 percent

 Dementia or delirium for 5 percent.

14
SAD PERSONS SCALE
Rational thinking loss
 Sex: Male 

 Age: >60  Suicide in family

 Depressive disorder  Organized plan

 Previous attempt  No spouse
 Ethanol abuse  Sickness

15
 Hospitalize (forced)

 5-6 strongly consider Hospitalization

 3-4 Close follow up, consider Hospitalization

 0-2 consider sending him home with family

16
 Most suicides among psychiatric patients are preventable

 Detect suicide behavior in every patient with clinical

interview.
 Detect the presence of psychiatric disorder

o Depression

o Chronic general medical illness

o Psychosocial stressors.
17
 Remove or treat risk factors
o Underlying medical problems (delirium 20 treatable

conditions, alcohol and substance abuse/withdrawal)

o Chemical restraint -anxiolytic, antidepressants,

antipsychotics

o Psychotherapy (supportive, family therapies)

o Electroconvulsive therapy (ECT)

18
Serotonin Syndrome:
v Precipitated by use of two drugs with serotonin-
enhancing properties
v (e.g., MAOI + SSRI).
v Altered mental status, fever, agitation, tremor,
myoclonus, hyperreflexia, ataxia,
incoordination, diaphoresis, shivering, diarrhea.
v Management: Discontinue offending agents,
benzodiazepines, consider cyproheptadine

19
Lithium Toxicity:
• May occur at any Li level (usually >1.5).
• Nausea, vomiting, slurred speech, ataxia,
incoordination, myoclonus, hyperreflexia,
seizures, nephrogenic diabetes insipidus,
delirium, coma
• Management: Discontinue Li, hydrate
aggressively, consider hemodialysis

20
vNeurolepticmalignantsyndrome
vdeliriumtremens
vPostpartumpsychosis
vAggressiveandagitatedpatient

21
 Child psychiatry for Nursing students

By Abera A.

1
 A branch of Psychiatry that deals with
behavioral and emotional disorders of
childhood
 Intellectual disability , learning problems,
ADHD, Conduct disorders, communication
disorder, elimination disorder, …etc.

2
Intellectual disability
• Intellectual disability (ID, intellectual
developmental disorder) replaces the term
mental retardation with the intention of
decreasing stigmatization.
• ID is characterized by severely impaired
cognitive and adaptive/social functioning.
• Severity level is currently based on adaptive
functioning, indicating degree of support required.

3
• Deficits in intellectual functioning, such as
reasoning, problem solving, planning, abstract
thinking, judgment, and learning
• Deficits in adaptive functioning, such as
communication, social participation, and independent
living
• Deficits affect multiple domains: conceptual,
practical, and social
• Onset during the developmental period
• Intellectual deficits confirmed by clinical assessment
and standardized intelligence testing
• Adaptive functioning deficits require ongoing
support for activities of daily life
• Severity levels: mild, moderate, severe, profound

4
 IQ range, 50-70

 85% of all ID

 Developmental milestone delay

 able to communicate and learn basic skills

 Able to care for themselves

 Can read & compute (grade 6)

 Able to perform semi-skilled works

 Usually need support

5
 IQ is 35 -49
 accounting for about 12% of all cases
 slow intellectual developmental milestones
 learning and thinking logically impaired
 able to communicate and look after
themselves with some support
 With supervision, they can perform unskilled or semiskilled
work and can attend up to 2nd to 3rd grade level. 6
 IQ is 20 -34

 3% to 4% of all cases

 Early years development is typically delayed

 They have difficulty pronouncing words

 Very limited vocabulary

 Can have basic self-help skills but need considerable

practice, time and supervision.

7
 IQ is usually below 20
 accounts for 1% to 2% of all cases
 No self-care and language they need appropriate
training.
 Their capacity to express emotions is limited and
poorly understood
 Physical disabilities, and reduced life expectancy are
common.

8
 Genetic and physiological
 Prenatal etiologies (genetic syndromes, inborn
errors of metabolism, brain malformations,
maternal disease (including placental disease),
and environmental influences (e.g., alcohol, other
drugs, toxins, teratogens).
 Perinatal causes (labor and delivery-related
events leading to neonatal encephalopathy)
 Postnatal causes (hypoxic ischemic injury,
traumatic brain injury, infections, demyelinating
disorders, seizure disorders (e.g., infantile spasms),
severe and chronic social deprivation, and toxic
metabolic syndromes and intoxications (e.g., lead,
mercury)..
9
 based on an assessment of social,
educational, psychiatric, and
environmental needs.

10
Attention Deficit Hyperactivity disorder
ADHD

 ADHD is characterized by persistent:

 Inattention,

 Hyperactivity, and

 Impulsivity which is inconsistent with the

patient’s developmental stage.

11
 Pattern of diminished sustained attention and
higher levels of impulsivity in a child or
adolescent than expected for someone of that
age and developmental level
 Affects 5-8 % of school-aged children, with 60-
85% continuing in adolescence, and up to 60%
continuing in adulthood.
 Family Hx – 2-8x at risk than general
population
 Boys than girls (2:1 – 9:1)
 Etiology – 75% hereditability

12
A. A persistent pattern of inattention and/or hyperactivity-
impulsivity that interferes with functioning or development,
as characterized by (1) and/or (2):
1. Inattention Symptoms (at least 6 symptoms for at least six
months)
a.Fails to give close attention to details or makes careless
mistakes in schoolwork, work, etc.
b.Difficulty sustaining attention
c.Does not seem to listen when spoken to directly
d.Does not follow through on instructions and fails to finish
schoolwork, chores, etc.
e.Difficulty organizing tasks and activities
f. Avoids tasks requiring sustained mental effort
g.Loses things necessary for tasks or activities
h.Easily distracted by extraneous stimuli
i. Forgetful in daily activities
13
2. Hyperactivity/Impulsivity Symptoms (at least 6
symptoms for at least six months);
a.Difficulty playing or engaging in activities quietly
b.Always "on the go" or acts as if "driven by a
motor”
c.Talks excessively
d.Blurts out answers
e.Difficulty waiting in lines or awaiting turn
f. Interrupts or intrudes on others
g.Runs about or climbs inappropriately
h.Fidgets with hands or feet or squirms in seat
i. Leaves seat in classroom or in other situations in
which remaining seated is expected

14
Ø Combined presentation:
üIf both Criterion A1 (inattention) and Criterion
A2 (hyperactivity-impulsivity) are met for the
past 6 months.(most common)
Ø Predominantly inattentive presentation:
üIf Criterion A1 (inattention) is met but Criterion
A2 (hyperactivity-impulsivity) is not met for the
past 6 months.
Ø Predominantly hyperactive/impulsive presentation:
üIf Criterion A2 (hyperactivity-impulsivity) is
met and Criterion A1 (inattention) is not met for
the past 6 months.
15
 The etiology of ADHD is multifactorial and may
include:
 Genetic factors: ↑ rate in first-degree relatives
of affected individuals
 Environmental factors: low birth weight,
smoking during pregnancy,
 childhood abuse/neglect, neurotoxin/alcohol
exposure

16
 Multimodal treatment plan: decreasing core
symptoms
Pharmacological treatments:
 First-line: Stimulants methylphenidate compounds,
dextroamphetamine, and amphetamine
 Second-line choice: atomoxetine a norepinephrine
reuptake inhibitor
Nonpharmacological treatments:
 Behavior modification techniques and social skills
training
 Educational interventions (i.e., classroom
modifications)
 Parent psychoeducation

17
üsocial interaction
ücommunication
ürepetitive behavior

18
19
 child spends time alone rather than with
others (
 shows little interest in making friends
 less responsive to social cues such as eye
contact or smiles

20
 language develops slowly or not at all

 uses words without attaching the usual

meaning to them
 communicates with gestures instead of words
 lack of spontaneous or imaginative play, no
game „as if“

21
 stereotyped body movements
 persistent preoccupation with parts of objects
 needs of routines - distress with changes in
trivial aspects of environment
 restricted range of interests and a
preoccupation with one narrow interest

22
 Educational approaches and support for
families can improve the lives of persons
with ASD and their families.
 Information, training and support, always
within the context of family values and
culture

23
 To improve longer-term outcome:
Education, as early as possible, with
special attention to social, communication,
academic and behavioral development is
vital.
 Establishing clear short and long-term
goals, defining the ways in which these
goals can be met and monitoring
outcomes.

24
 Psychopharmacological interventions in
autism spectrum disorder help ameliorate
behavioral symptoms rather than core
features of autism spectrum disorder.
 Target symptoms include irritability,
broadly including aggression, temper
tantrums, and self-injurious behaviors,
hyperactivity, impulsivity, and inattention.

25
 Two second-generation antipsychotics,
risperidone, and aripiprazole, have been
approved by the Food and Drug
Administration
(FDA for treatment of irritability in
individuals with autism spectrum disorder.
 Typical doses of resperidone range from
0.5 to 1.5 mg for treatment of irritability
in individuals with autism spectrum
disorder.

26
 the treatment of tantrums, aggression, and self-
injury in children and adolescents with autism
spectrum disorder found that aripiprazole was
both efficacious and safe. Doses ranged from 5
to 15 mg/day.
 The main side effects included sedation,
dizziness, insomnia, akathisia, nausea, and
vomiting.

27
 Thank you!
አ መሰ ግ ና ለ ሁ !
Galatoomaa!
Be well!
"Together we can make a difference "

28
Epilepsy for nursing students

Bonga University

By Abera A.

1
 Define seizure
 Epilepsy
 Different types of seizure disorder
 Management of seizure disorders

2
Epilepsy is a group of non
communicable neurological disorders characterized
by recurrent epileptic seizures.

seizure is the clinical manifestation of an abnormal,

excessive, and synchronized electrical discharge in
the brain cells called neurons.

 Epilepsy is The occurrence of two or more

unprovoked seizures
3
ØAlteration of consciousness
üAwareness of ongoing activities
üMemory for time during the event
üResponsiveness to verbal or nonverbal stimuli
üSense of self
Motor and sensory symptoms
üconvulsion, muscle spasm, jerks; numbness
Ø Psychic events/dyscognitive
üperceptual distortions like hallucinations,
illusions

4
 Prevalence
Ø~10/1000 globally
Ø5-8/1000 in Ethiopia
 Prognosis
Ø ~70% full control with medication
Ø5-10% refractory seizure
 Epilepsy – overall mortality 2-3 times that of
general population
 SUDEP: 2-18% of deaths in patients with
epilepsy.

5
1) Underlying condition e.g. tumor

2) Frequent or uncontrolled seizure

3) Accidents e.g. drowning

4) Increased risk of suicide

6
1. Poverty - inaccessibility to medical care, low
health awareness, poor sanitation

2. Higher rate of brain injuries - birth trauma, traffic

accidents

7
1. Perinatal brain damage
2. Head injuries
3. Cerebrovascular diseases
4. Neoplasm
5. Central nervous system infections
6. metabolic disorders
7. Chronic alcohol abuse
8. Genetics

8
1. Sleep deprivation

2. Starvation or hypoglycemia

3. Emotional disturbance

4. Drugs – psychotropic medications

5. Alcohol

9
1) Bacterial meningitis
2) Uremia
3) Hyponatremia, hypoglycemia
4) Thyrotoxicosis
7) Alcohol withdrawal

10
 Seizures

Focal Generalized
seizure seizure

Simple
Absence seizure(typical and atypical)
Partial

Complex Myoclonic seizure

Partial

Secondarily
Atonic seizure
Generalized

Tonic seizure

Tonic-Clonic seizure

11
 Occurs when the abnormal electrical
activity causing a seizure begins in both
halves (hemispheres) of the brain at the
same time.

12
13
14
a. Burn accidents

b. Injuries - head injury, subdural hematoma,

vertebral fractures etc.

c. Transient neurologic deficit - paralysis of

extremities, aphasia, hemianopsia, etc.

15
Ø Also known as Petit mal Epilepsy
Ø Characteristic epilepsy of childhood
Ø Usually begins in the first decade of life.
Ø Clinical manifestations
1. No aura symptom
2. Sudden interruption of consciousness -
patients become motionless, stop talking,
stare blankly, cease to respond
3. Clonic movements- eye lids, facial
muscles, fingers
4. Simple automatism - lip smacking,
chewing, etc.
16
Ø Very short in duration – less than 11 seconds

Ø Occur many times a day – even up to 100

times

Ø Can be elicited by hyperventilation

o 3 minutes of hyperventilation in the

examination room

17
18
19
1. Disappear in adolescence

2. Give way to grand mal/tonic clonic seizures

3. Petit mal persist into adulthood

20
Ø Are brief jerking spasm of muscles or group of
muscle
Ø Myoclonic epilepsy of early childhood
o Between 6months - 4 years
Ø Juvenile myoclonic epilepsy
o Between 12 years – 14 years
v Clinical presentation
o Frequent upper extremity and upper trunk
myoclonic jerks
üFlexor muscles of the neck and shoulders
üIf forceful jerk –sudden drop to the ground
o Additional grand mal seizures or absence seizures
are possible 21
 Atonic Seizures
◦ Sudden loss of postural muscle tone or
voluntary muscle control lasting 1–2 s
◦ Consciousness is briefly impaired
◦ No postictal confusion
◦ When brief, a quick head drop or nodding
movement
◦ A longer seizure will cause the patient to
collapse/fall down/

22
A tonic seizure causes a sudden stiffness or
tension in the muscles of the arms, legs or trunk.
 Unlike atonic seizure which is characterized
b y l o s s o f m u s c l e t o n e t o n i c s e i z u re i s
characterized by sustained increase of muscle
tone
 The stiffness lasts about 20 second
 Tonic seizures that occur while the person is
standing may cause them to fall.
23
Ø History taking
1. Complete description of the seizure itself
2. Specific precipitating factors
3. Familial predisposition
4. Perinatal and developmental history
5. Past medial history – head injury, CNS
infections, etc.
Ø Physical examination –Neurological, renal,
cardiovascular, etc
Ø Ancillary investigation – laboratory, EEG, Skull
X-ray, CT-Scan
24
25
main Goals:

 Controlling seizures,
 Avoiding or minimizing treatment side effects,
and
 Maintaining or restoring quality of life.

26
A) Non-drug measures
B) Drug treatment
C) Surgery

27
1) Physical and mental hygiene
Ø Regular hours of sleep
Ø Avoid substances – alcohol, hashish,
cigarettes
Ø Avoid dangerous situations
Ø Moderate physical exercise
1) Removal of precipitating factors-e.g.. TV
watching
2) Supportive psychotherapy – education about
the illness, avoid overprotection in children

28
1. Move patient away from water, fire, traffic,

2. Take away any object that could harm the patient

3. Loosen tight cloths, remove eye-glasses

4. Put something soft under the head

5. Turn patient to his side

6. Remain with the patient until he regains

consciousness
29
1. Do not put anything( e.g. tongue plate) into the
mouth

2. Do not light matches

3. Do not give anything to drink

4. Do not try to stop the convulsion

5. Do not give diazepam

30
A. General remark
ANTIEPILEPTIC DRUGS - AEDs
Ø Decrease the frequency/severity of seizures in
patients with epilepsy
Ø AEDs treat the symptoms, not the underlying
condition
Ø Goal: maximize quality of life by minimizing
seizures and adverse drug effects

31
B. Steps of drug treatment
1. Start drug treatment with one drug
2. Select the appropriate drug
3. Start drug treatment with a small dose
4. Gradually increase dosage until complete
control of seizure
5. Aim to achieve lowest maintenance dose

32
6. Watch for presence of marked side effects
7. If initial drug is not well tolerated, substitute
with another
8. If initial drug cannot control seizure,
substitute with another
9.Gradually withdraw first drug while gradually
introducing the new drug

33
Type of seizure Drugs
Focal motor epilepsy, Carbamazepine, phenytoin,
complex partial Phenobarbital, NA
epilepsy valporate

Grandmal epilepsy Carbamazepine, phenytoin,

Phenobarbital, sodium
valproate

Petit mal epilepsy Sodium valproate,

ethosuximide
Myoclonic epilepsy Clonazepam, Valproate
34
35
36
Ø Grand mal epilepsy, partial epilepsy (2-5) years

Ø Petit mal epilepsy: 2 years

Ø Juvenile myoclonic epilepsy: for life

37
Definition
v Status epilepticus is diagnosed when two or more
seizure occurs in close succession with out
consciousness being regained OR a single seizure
lasting 30 minutes or longer

38
ØSudden discontinuation of antiepileptic drugs
ØAlcohol withdrawal in chronic alcoholics
ØIntracranial infection

ØHead trauma

39
1. General supportive measures for the
unconscious
Ø Side positioning
Ø Secure IV line
Ø Control input-output
Ø Frequent check-up of vital signs
2. Drug treatment
Ø Diazepam 10 mg IV slowly stat , if no
response anther 10 mg IV slowly; for
children 0.2-0.5 mg/kg body weight .
Ø If no response refer to ICU for further
management

40
Ø Age related seizure disorder occurring during
febrile illnesses
üCommon between 6 months and 6 years of age
üSeizure occur in association with high fever-
usually above 390 C
üCommon child hood illnesses- URTI, otitis,
gastroenteritis
Ø Management of febrile convulsion
üIdentify and treat the primary illness
üControl fever - antipyretics, cold sponges
üTerminate seizure – diazepam 0.2-0.5mg/kg IV
slowly; rectal diazepam 0.5mg/kg 41
Ø Contraception

Ø Fertility

Ø Seizure during pregnancy

Ø Obstetrical risk

Ø Teratogenicity

Ø Breast feeding

42
ØSeizure tend to frequent in the premenstrual
period

ØSome anti-epileptic drugs lead to

contraceptive failure – phenobarbital, phenytoin,
carbamazepine

ØOral contraceptives do not increase seizure

risk

ØFertility is lower in epileptic women

43
Possible causes of low fertility
 Direct effect of seizures on the hypothalamus,
disrupting ovulation as well as causing the elevation
of prolactin
 AEDs
◦ Interfere with the hypothalamic-pituitary axis,
leading to menstrual irregularities, anovulatory
cycles,
◦ Diminished libido

44
Ø~ 30% of pregnant epileptic women have
increased seizure frequency
Ø There is increased obstetric complications
o bleeding tendency during delivery
o Low infant birth weight, preterm delivery,
still births
o Labor induction, operative delivery-cesarean
section, forceps
Ø There is increased risk of congenital
malformation in children born to epileptic
women ( ~ twice as high as the general
population)
45
 The occurrence of seizures in the first trimester
poses the greatest risk of congenital
malformation and developmental delay in the
offspring.

46
Ø contraceptive failure
Ø Overall, intrauterine devices (IUDs) are preferred
for women with epilepsy who are not intending to
become pregnant
Ø Never stop medication during pregnancy, labor or
breast-feeding
Ø Avoid polydrug therapy during pregnancy
Ø Do not use carbamazepine and sodium valproate
during pregnancy

47
Ø Give fefol tab (4mg folic acid/day) during the
whole pregnancy
Ø Delivery should be in a health institution
Ø Give vitamin K for the mother – 10mg/day orally,
from the 36th week of gestation until delivery
Ø Give vitamin K for the new born - 1mg IM stat
at birth
Ø Weaning should be gradual to avoid withdrawal
symptom in the baby

48
 Thank you!
Galatoomaa!
አ መሰ ግ ና ለ ሁ !
Be well!
"Together we will make a difference "

49
Psychiatric aspect of HIV AIDS
For nursing students

By Abera A.

1
 Outline
 HIV and Mental illness  an overview

 Milestones of HIV disease and psychiatric disorders

 Major psychiatric disorders in HIV

A) Psychosis

B) Mood disorders- mania, depression

C) Anxiety disorders

CLINICAL NEUROPSYCHIATRY 2
Why is mental health important to caring for people with HIV/AIDS?
1. Psychiatric illness increases risk for HIV

2. HIV increases risk for psychiatric illness

3. Mental illness can affect management of HIV disease

3
 . 1. Psychiatric illness increases risk for HIV
 Poor judgment and decision making.

 Poor assertiveness skills and low self-esteem may lead to sexual

exploitation.

 Difficulty maintaining relationships and poor relationship quality

may lead to non-monogamous relationships.

4
 . 2. HIV increases risk for psychiatric illness
 Primary – due to direct effect of HIV virus or immune reaction to it

 Secondary to compromised immunity  Infections and neoplasms

 Due to psychosocial factors

 Treatment related- drug side effects and interactions

5
 . 3. Effect of psychiatric disorders on HIV/AIDS management
 Delayed initiation of ARV drug treatment
 Poor adherence to ARV
 Limit the choice of ARV
 Neuropsychiatric side effects of ARV drugs
 Drug interactions between psychotropic and HIV medications
 Stigma on the part of the health care worker

6
 Milestones of HIV Disease
 HIV testing and news of HIV positive status
 Disclosure of HIV status
 Appearance of first illness symptoms
 Declining CD4 counts and increasing viral load
 Onset of AIDS defining illness
 Initiation of multidrug regimen
 Bereavement
 Onset of functional disabilities
 Onset of cognitive disorders

7
 Milestones of HIV Disease…
 Decision to test for HIV – fear-denial
 News of HIV positive status
 Initially reaction
 Anger, shock, or denial,
 Guilty feeling
 Feelings of loneliness and isolation
 Feelings of grief and loss
• Adjustment disorder
• Depression
• Anxiety
CLINICAL NEUROPSYCHIATRY 8
 Milestones of HIV Disease…
 Disclosure of HIV status

 Fear of telling others about HIV diagnosis - greatest burdens

HIV - very misunderstood condition - Can only be acquired in immoral
ways??

 Fear of stigma and rejection

Can lead to unprotected sexual activity

Decision who to tell, how and when to tell

CLINICAL NEUROPSYCHIATRY 9
 Milestones of HIV Disease…
 Appearance of first illness symptoms and initiation of ART
 Psychological disturbances are relatively absent during asymptomatic stage

Early symptomatic phase- uncertainty about the future – somatization, anxiety,

intrusive worries

 Onset of ART medication – worries about adverse effects of drugs

 Development of AIDs – dysphoric mood, helplessness, anhedonia, rejection

sensitivity, suicidality

CLINICAL NEUROPSYCHIATRY 10
 Milestones of HIV Disease…
 Loss
 Bereavement – HIV related death  Partner, friend

 Onset of functional disabilities  Cognitive impairment, Loss of job

CLINICAL NEUROPSYCHIATRY 11
Major psychiatric disorders in HIV
 Psychosis

 Depression

 Anxiety disorders

 Neurocognitive disorders

 Delirium

CLINICAL NEUROPSYCHIATRY 12
 HIV and Psychosis
 Rate of psychosis in HIV: 0.5 – 15%

 Psychotic symptoms - independent of HIV

 Past history or family history of psychosis.

 Substance use/withdrawal syndromes

 Psychotic symptoms secondary to HIV effect

 Psychosis is usually a later stage

 Complications of HIV/AIDS
 Towards the end of the middle stage and in the late stage of HIV

CLINICAL NEUROPSYCHIATRY 13
 HIV and Psychosis…
 Psychosis contributes to behaviors that may lead to HIV infection
 Injection drug use  unprotected sex, multiple sex partners, trading
sex for money or other goods, and sex while intoxicated.

 Positive symptoms and impulse control problems  increased risk of

high-risk sexual behavior.

CLINICAL NEUROPSYCHIATRY 14
 HIV and Psychosis…
 Clinical Features
 Usually rapid onset – over hours or days
 Change of level of consciousness – arousal is suppressed or fluctuating
 Hallucination: more Visual than auditory
 Delusion: Less fixed, fleeting
 Mood symptoms -tended to occur prominently and frequently (depression, euphoria, mixed)
 Cognitive impairment has also been consistently described as a feature of HIV associated
psychosis.

CLINICAL NEUROPSYCHIATRY 15
 Treatment of psychosis in HIV
 Pharmacological treatment of HIV patients
 Does not differ much from that of other populations

 Increased propensity to develop EPS and to have drug-drug

interactions

 Atypical antipsychotics have a lesser risk of side effects (EPS)

than the typical antipsychotics

CLINICAL NEUROPSYCHIATRY 16
 HIV and Depression
 Depression

 Major cause of distress in patients with HIV and AIDS

 Frequently underdiagnosed and undertreated

 The most frequently occurring psychiatric disorder in HIV patients

 Prevalence

 HIV Exceed rates in the general population  50% to 80%.

CLINICAL NEUROPSYCHIATRY 17
 HIV and Depression…
 Depression has a negative impact

 on adherence with medical treatments,

 quality of life, and

 treatment outcome.

 Two fold increase in the prevalence of major depression in patients

infected with HIV.

CLINICAL NEUROPSYCHIATRY 18
 HIV and Depression…
 Major depression is a risk factor for HIV infection by virtue of its
 Impact on behavior,

 Intensification of substance abuse,

 Exacerbation of self-destructive behaviors, and

 Promotion of poor partner choice in relationships.

 Depression can be seen as a vector of HIV transmission.

CLINICAL NEUROPSYCHIATRY 19
 HIV and Depression…
 HIV increases the risk of developing major depression through
 Direct injury to subcortical areas of brain,
 Chronic stress,
 Worsening social isolation, and
 Intense demoralization.

 A two and a half fold increase in rates of depression as patient CD4 cells fall
below 200.

CLINICAL NEUROPSYCHIATRY 20
 HIV and Depression…
 Common ways of presentation of depression include:
 Irritability
 Prefer to be lonely (bichegninet)
 Feeling low (medebet)

 Somatic concerns (aches and pains, feeling that something is not right in the body)
are the most common symptoms of depression.
◦ Head-related
◦ Stomach –related
◦ Elsewhere in the body
212
1
 HIV and Depression…
 AFFECTIVE  SOMATIC

 Loss of appetite
 Depressed mood
 Weight loss
 Loss of interest
 loss of libido

 Guilt, worthlessness  Sleep disturbance

 Hopelessness  Thoughts of death

 Suicidal ideation

 Fatigue, anergia

 Loss of concentration

CLINICAL NEUROPSYCHIATRY 22
 HIV and Depression…
 Detecting Depression could be hard

 The somatic symptoms of depression may be confused with opportunistic infections

 Physical illness produces vegetative symptoms, similar to depression.

 Psychological distress is a normal feature of being physically ill or in the dying process.

 Stigma of psychiatric issues could cause patient’s reluctance to talk about it.

 Determining whether depression is primary or secondary to HIV infection or the

antiretroviral agents.

CLINICAL NEUROPSYCHIATRY 23
 Cause and Risk Factors for Depression in HIV
 Personal history of prior mood disorder
 Personal history of alcoholism, substance use, suicide attempt, anxiety disorders
 Family history of the above
 Current alcohol or drug use
 Stigma and inadequate social support
 Non-disclosure of status
 Multiple losses
 Advancing illness- opportunistic infection, etc.
 Drugs, drug-drug interactions

242
4
 HIV/AIDS and Suicide
 Suicide is the most feared result of depression, and suicidal ideation and
suicide attempts are more common in HIV-infected individuals than in the
general population.

 The advent of ART has resulted in a decline in suicides among HIV-infected

individuals.

 Suicide is still three times higher in the HIV-infected population than in the
general population.

8/3/2021 CLINICAL NEUROPSYCHIATRY 252

5
 Risk Factors for Suicide
.

 Acute mental disorder, suicidal ideation, and expression of intent.

 Poor response to HIV treatment.
 Current substance use or abuse.
 Social isolation - Major loss or separation from family and community
 Loss of job
 Access to means to end life.

26
 Predictable times with increased risk for Suicide
 When they are first diagnosed with HIV

 When their medical condition deteriorates

 A drop in CD4 counts,
 An opportunistic infection,
 Hospitalization
 Onset of treatment with HAART
 In times of pain
27
 Predictable times with increased risk for Suicide…
..

 When there are losses, especially when cumulative

 Death of friends, death of a partner

 Loss of employment

 Rejection

 Meets the criteria for major depression.

28
 HIV and Depression…
Treatment

 Antidepressants:

 Selective Serotonin Reuptake Inhibitors (SSRIs)

 Tricyclic Antidepressants (TCA)

 Any medication must be carefully monitored: CNS effects likely

 Consider drug-drug interactions

 Psychoeducation/ psychotherapy
8/3/2021 292
9
 Anti-depressants and ART drug s interaction
Protease Inhibitors NNRTIs Integrase Inhibitor

Amitryptyline Possible TCA concentrations Possible  TCA concentrations Potential for TCA
Elavil Etravirine: Possible or ¯ concentrations with
amitriptyline concentrations. elvitegravir/cobicistat.
Imipramine Possible TCA concentrations Possible TCA concentrations
Tofranil Etravirine: Possible or  imipramine
concentrations. Monitor for response
Fluoxetine No anticipated effect of unboosted PIs on No anticipated effect on fluoxetine or and adjust
Prozac fluoxetine. NNRTIs. Monitor closely for the clinical antidepressant dose
Potential for SSRI concentrations with response to fluoxetine; possible dose accordingly.
higher doses of ritonavir. increases may be required. Delavirdine:
Cautious use of combination is warranted.

Sertraline Potential or  sertraline concentrations Potential for  sertraline

Zoloft due to complex metabolism of sertraline. Efavirenz kinetics not affected.
Darunavir/r :  sertraline Etravirine: Possible or  sertraline
Monitor for antidepressant efficacy and concentrations.
sertraline dose if required.

303
0
 AIDS Mania
 AIDS mania has been described in late HIV infection.

 AIDS mania occurred in 8 percent of all AIDS patients (more than ten times the general
population prevalence).

 AIDS mania have different clinical profile than bipolar mania.

 They were less likely to have a personal or a family history of mania and late
age at onset.

 Patients tend to have cognitive slowing or dementia.

 Irritable mood is more characteristic than euphoria.

31
 AIDS mania…
 AIDS mania is usually quite severe in its presentation and malignant in its course.

 AIDS mania seems to be more characteristically chronic than episodic.

 In late-stage disease patients are very sensitive to extra-pyramidal side effects.

 So the dose of antipsychotic needed is much lower than customarily used.

 The atypical antipsychotics, such as risperidone, olanzapine are now first-line

treatment in most advanced cases.

32
 AIDS mania…
 Lithium use has been problematic.
 The major problem with lithium in AIDS patients has been rapid fluctuations in
blood level, causing lithium intoxication.
 Valproic acid has been used with success.
 Monitoring of liver function tests is essential, but hepatic toxicity is not often a
problem.
 Carbamazepine may also be effective but more poorly tolerated because of the
presumed synergistic bone marrow suppression in combination with antiviral
medications.
 Protease inhibitors may lower levels of Valproic acid and lamotrigine.
33
 HIV and Anxiety Disorder
 Anxiety disorder is more prevalent in HIV-infected individuals.

 Prevalence estimates, from 4% to 40%

1. Generalized Anxiety Disorder (GAD)
2. Panic disorder
3. Phobias
4. Obsessive-compulsive disorder (OCD)
5. PTSD
6. Adjustment disorder with anxiety
CLINICAL NEUROPSYCHIATRY 34
 HIV and Anxiety Disorder…
Clinical Features: Autonomic/Somatic Symptoms
 Chest pain  Palpitations
 Choking sensation  Parasthesias
 Diarrhea  Fatigue
 Diaphoresis  Flushing
 Dyspnea  Headache
 Hyperventilation  Tachycardia
 Muscle tension  Vertigo
 Nausea  Vomiting

**Symptoms specific to each type of anxiety disorder – e.g. Phobic disorder

CLINICAL NEUROPSYCHIATRY 35
 HIV and Anxiety Disorder…
◦ Treatment - two modes of treatment
1. Non-pharmacologic treatment
a. Psychoeducation
b. Psychotherapy
2. Drug treatment
– Benzodiazepines
– SSRI’s
– Tricyclic agents
CLINICAL NEUROPSYCHIATRY 36
Thanks!

3
7
Post partum psychiatric
disorders
For Nursing students

Bonga university
By Abera A.

1
 Post partum psychiatric disorders are the type
of psychiatric disorders that can occur after
child birth

Can be:

 Post partum blue

 Post partum depression

 Postpartum psychosis
2
 Postpartum blues also known as baby
blues and maternity blues is a very common
but self-limited condition that begins shortly
after childbirth .

3
• Tearfulness or crying "for no reason"
• Mood swings
• Irritability
• Anxiety
• Questioning one's ability to care for the baby
• Loss of appetite
• Fatigue
• Difficulty sleeping
• Difficulty concentrating

4
 Symptoms of postpartum blues generally
begin within a few days of childbirth and
often peak by day four or five.
 Postpartum blues may last a few days up
to two weeks.
 If symptoms last more than two weeks,
the individual must be evaluated for
postpartum depression.

5
 Most hypotheses regarding the etiology of
postpartum blues center on the intersection of
the significant biological and psychosocial
changes that occur with childbirth.

6
• Caring for a newborn that requires 24/7 attention
• Sleep deprivation
• Lack of support from family and friends
• Marital or relationship strain
• Financial stress
• Unrealistic expectations of self
• Societal or cultural pressure to "bounce back"
quickly after pregnancy and childbirth
• questioning ability to care for baby
• Anger, loss, or guilt, especially for parents of
premature or sick infants

7
Estrogen and progesterone

v After delivery of the placenta, mothers

experience an abrupt decline of gonadal
hormones, namely estrogen and progesterone.

v Major hormonal changes in the early

postpartum period may trigger mood symptoms

8
 Factors most consistently shown to be
predictive of postpartum blues are personal and
family history of depression.
 a history of postpartum depression appears to
be a risk factor for developing postpartum blues,
and postpartum blues confers a higher risk of
developing subsequent postpartum depression

9
 Treatment

 Postpartum blues is a self-limited condition.

Signs and symptoms are expected to resolve
within two weeks without any treatment.
Nevertheless, there are a number of
recommendations to help relieve symptoms
• Getting enough sleep
• Taking time to relax
• Asking for help from family and friends
• Avoiding alcohol and other drugs that may
worsen mood symptoms
• Reassurance that symptoms are very
common and will resolve on their own
10
 Postpartum depression (PPD), also
called postnatal depression, is a type of mood
disorder experienced after childbirth

11
• Persistent sadness, anxiousness
• Severe mood swings
• Frustration, irritability, restlessness, anger
• Feelings of hopelessness or helplessness
• Guilt, shame, worthlessness
• Low self-esteem
• Inability to be comforted
• Trouble bonding with the baby
• Feeling inadequate in taking care of the baby
• Thoughts of self-harm or suicide

12
• Lack of interest or pleasure in usual
activities
• Low libido
• Changes in appetite
• Fatigue, decreased energy and motivation
• Poor self-care
• Social withdrawal
• Insomnia or excessive sleep
• Worry about harming self, baby, or partner

13
 The cause of PPD is unknown. Hormonal and
physical changes, personal and family history
of depression, and the stress of caring for a new
baby all may contribute

14
• Genetic history of PPD
• Caring for 24/7 baby
• Chronic illnesses caused by neuroendocrine
irregularities
• Hormone irregularities
• Low social support
• Poor marital relationship or single marital status
• Low socioeconomic status
• A lack of strong emotional support from spouse,
partner, family, or friends
• Infant temperament problems
15
 Postpartum depression in the DSM-5 is known
as "depressive disorder with peripartum onset".
 Peripartum onset is defined as starting
anytime during pregnancy or within the four
weeks following delivery.
 The criteria required for the diagnosis of
postpartum depression are the same as those
required to make a diagnosis of non-childbirth
related major depression.

16
Treatment
 Treatment for mild to moderate PPD includes
psychological interventions or antidepressants.
 Women with moderate to severe PPD would likely
experience a greater benefit with a combination of
psychological and medical interventions
 Both individual social and psychological interventions
appear effective in the treatment of PPD.
 Social interventions include individual counseling and
peer support, while psychological interventions
include cognitive behavioral therapy (CBT)
and interpersonal therapy (IPT)
 Interpersonal therapy (IPT) has shown to be effective in
focusing specifically on the mother and infant bond
17
 Some evidence suggests that mothers
with PPD will respond similarly to people
with major depressive disorder.
 There is low-certainty evidence which
suggests that selective serotonin
reuptake inhibitors (SSRIs) are effective
treatment for PPD.
 The first-line anti-depressant medication
of choice is sertraline, an SSRI, very
little passes into the breast milk.

18
 Electroconvulsive therapy (ECT) is a safe and
highly effective method for treating PPD.
 This treatment uses a mild electrical current,
passed through your brain, to induce a
mild seizure.
 The effects of that seizure cause changes in
brain activity that reduce or resolve the effects
of PPP.

19
 Postpartum psychosis (PPP), also known
as puerperal psychosis or peripartum
psychosis, involves the abrupt onset
of psychotic symptoms shortly following
childbirth, typically within two weeks of
delivery but less than 4 weeks postpartum

20
 Postpartum psychosis (PPP) is a reversible but
severe mental health condition that affects
people after they give birth.
 This condition is rare, but it’s also dangerous.
 IMPORTANT: People with postpartum
psychosis have a much higher risk of harming
themselves, dying by suicide or harming their
children.
 Because of this, PPP is a mental health
emergency.

21
• Delusions and hallucinations.
• Depression.
• Feelings of guilt.
• Loss of appetite.
• Loss of enjoyment related to things they
usually enjoy (anhedonia).
• Thoughts of self-harm, suicide or of
harming their child

22
Risk factors

 Childbirth is the primary cause of PPP

 The largest known risks for the
occurrence of PPP include
 a history of PPP in a previous pregnancy,
 personal or family history of bipolar
disorder.
 hormonal changes
 genetics and circadian rhythm disruption
 sleep loss, first pregnancies (primiparity)

23
 By its diagnostic definition (under the name
"brief psychotic disorder with peripartum
onset") PPP occurs either during pregnancy
or within 4 weeks of delivering the infant.
 Generally, PPP symptoms have been observed
within 3–10 days of childbirth, though women
with a past history of bipolar disorder may
experience symptoms even sooner.
24
 Hospitalization may be necessitated if the
patient is suicidal and infanticidal
 Treatment plans are made up of a combination
of education, medication, and close follow-up
care and support;
 the major goals of care include improving sleep
and psychotic symptoms while helping to
minimize major shifts in mood
 Medical treatment typically
involves ECT, antipsychotics

25
 First-generation antipsychotics have a longer
history of use, efficacy and safety in pregnancy,
particularly chlorpromazine and haloperidol.
 Still, second-generation antipsychotics may
be preferred over first-generation antipsychotics
due to the reduced risk for extrapyramidal
symptoms
 Chlorpromazine and olanzapine demonstrates
minimal transference to the infant through
breastmilk

26