Psychiatry Methodical

State Educational Establishment of Higher Professional
Education Kursk State Medical University

Federal Agency of Public Health
and Social Development
Psychiatry department
L.I. Zakharova
Methodological recommendations
for students to be used in the course of psychiatry
https://lookaside.fbsbx.com/file/psychiatry-methodical.doc-E8NnBuszPt0b_rD5RD0pZHCTAo7aodeKtUK2mGGnCS_wasI 02/03/17 12U50

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Kursk - 2007
L.I. Zakharova. Methodological recommendations for students to be used in

the course of psychiatry. - Kursk: SEE HPE KSMU, 2007. - 96 pages.
The methodological recommendations are recommended for the foreign medical

faculty students, preparing for the practical sessions in the course of psychiatry.
The methodological recommendations contain the necessary minimum of the
theoretical information and the data about the signs, symptoms, syndromes of mental
disorders, methods of their practical diagnostics and treatment.
L.I. Zakharova, 2007

SEE HPE KSMU, 2007


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Lesson 1
Theme: Definition of psychiatry. Classifications in psychiatry.

(ICD-10, DSM-IV). Interviewing, clinical examination, clinical laboratory
studies in psychiatry
Plan
1. Psychiatry as a subject. Definition of psychiatry.
An importance of psychiatry for doctors of all specialities.
2. Connections with other sciences.
3. Classifications in psychiatry: organic, functional disorders; neurosis and

psychosis. Chronological classification. ICD-10, DSM-IV.
4. Interviewing, clinical examination. The scheme of history taken. Mental state

examination.
5. Clinical laboratory studies in psychiatry.
1. Psychiatry is that branch of medicine dealing with mental disorder and its
treatment. The word derived from psyche, the Greek word for soul or mind, and
iatros, which is Greek for healer.
Mental disease is the disease of the brain, characterized by positive & negative
symptoms & global changes of behavior & personality.
Positive symptoms are those symptoms that are added to the clinical picture,
including delusions, hallucinations, agitation...
Negative symptoms are characteristics of the patient that are subtracted from the
clinical picture, including such as poverty of thought & content of speech, social
withdrawal & others.

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Psychology A non-medical discipline; a science which
investigates behaviour, experience and the normal
functioning of the mind (e.g. memory, learning,
development)
Psychotherapy The treatment of psychological issues by non-physical

means. This usually refers to the "talking therapies" but
in the wider sense of the word can include art, drama,
music therapies etc. Practitioners do not need to be
medically qualified.
Psychoanalysis A particular sort of psychotherapy, or means of
exploring the unconscious mind, derived by Sigmund
Freud, but elaborated by many others since. A
psychoanalyst must undergo a training analysis and is
not necessary a psychiatrist.
Psychodynamics The study of the way in which past experiences and
current ways of relating result in present symptoms
(sometimes shortened to "dynamics")
Psychiatric A specialist nursing training (also known as "mental
nursing nursing" for those professional nurses caring for people
with mental health problems on a day-to-day basis,
both in hospital and (increasingly) in the community.
Common confusions associated with psychiatry are summarized in the table:
A substantial proportion of patient, seen by a doctor suffers from psychiatric

illness rather than organic disease. Physical and psychiatric problems often coincide
because:
Patient with psychiatric problems can present physical manifestation
Chronic or severe physical ill-health can result in psychiatric disorder
Psychiatric symptoms can be the part of complex physical disease
The patient with established psychiatric disorders can also develop a
physical disease.
2. Other sciences influence the development of psychiatry. Psychology (psychological
testing) may - help localize organic pathology; -contribute to the identification of
borderline or psychotic states; - help with differential diagnosis among psychiatric
conditions. Biochemistry: great focus has been on the tissue of "chemical imbalance"
in the brain being aetiologic in pathologic behaviours (imbalance of biogenic amines,
aminoacids and peptides). Genetics reveals that behavioral conditions have some
suggestions of genetic involvement (e.g. schizophrenia,
mood disorders, primary degenerative dementias, and different forms of chemical
dependence, anxiety disorders and others).

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3. Classification in psychiatry is currently based primarily on symptomatology rather
than pathology or aetiology.
Most psychiatric disorders can be divided into organic, which are secondary to
known physical causes, and "functional". Organic psychiatric disorders include such
as cerebral tumors, endocrine disorders. Psychiatric symptoms can result from the
abuse of alcohol and drugs. Functional disorders include psychosis in that there is
loss of contact with reality. Symptoms of psychosis are the following:
hallucinations,
delusions,
several abnormalities of behaviour, such as gross excitement and
overactivity, marked psychomotor retardation, catatonic behaviour
lack of insight
Psychosis states can arise in organic illnesses and in functional disorders.
In neurosis the symptoms that occur are understandable and can be empathized
with, and differ from normal in a quantitative but not qualitative way (anxiety as a
part of normal experience - anxiety disorders).
Chronological classification of aetiology.
A psychiatric disorder in a single patient can have multiple causes. These can
usefully be classified chronologically into the following:
Predisposing factors are those that predispose a person to vulnerability to
psychiatric disorders (person's genetic make up, obstetric complications, personality)
Precipitating factors are those that arise just before a psychiatric disorder starts, and
which appear to have precipitated it (e.g. life events).
Perpetuating factors are those that cause an existing psychiatric disorder to

continue (social withdrawal).
Individual causes include: genetic, biochemical and neurotransmitter
changes, psychoneuroendocrinological, psychoimmunological,
electrophysiological, neuropathological and neuroanatomical, prenatal and perinatal
factors, infections, psychosocial stressors, personality, psychological, psychodinamic.
The International Classification of Disease (ICD) of the World Health
Organization (WHO) contains clinical descriptions and diagnostic guidelines for
psychiatric disorders. In 1992 the WHO published the 10th revision of the ICD. For
each psychiatric disorders, ICD-10 provides a description of the main clinical

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features, their associated features, and usually also diagnostic guidelines. A
supplement for providing diagnostic criteria for research is also available, which
gives more structured criteria ("operationally defined") for psychiatric diagnoses.
Reference is made to ICD-10 diagnoses throughout this book, and Appendix I
contains a summary of the ICD-10 classification.
th
DSM-IV refers to the 4 edition of the Diagnostic and Statistical Manual of
Mental Disorders, published by the American Psychiatric Association in 1994.
Unlike ICD-10, DSM-IV is a multiaxial classification system. A multiaxial
evaluation entails the assessment of each patient on several axes, each of which refers
to different class of information.
4. Clinical examination. Communication between doctor and patient can be viewed at
different levels, from the details of non-verbal interactions to the sociocultural
significance of the encounter. It is best not to make assumptions if the maximum is to
be gained for both parties.
Doctors should pay attention to their appearance, to the setting, to their own
behaviour, and to the function of contact with the patient.
The structure of the relationship is modulated by boundaries, confidentiality and
individual responsibility. These may be matters of negotiation.
Transference and countertransference are important concepts that refer to those
illusory feelings, behaviours and attitudes evoked in a relationship as a result of the
unconscious interaction of current perception and previous experience.
The most important aims of psychiatric interviewing are:
To obtain information
To assess the emotions and attitudes of the patient
To supply a supportive role and allow an understanding of the patient.
This is the basis of the subsequent working relationship with the patient.
It is important to allow the patient to feel as relaxed and uninhibited about
talking as possible by fostering a trusting relationship.
At the beginning of the interview open questions (e.g. "How are you in your
spirits?") should be used in preference to closed questions (e.g. "Are you feeling
low?"); it is often helpful to allow the patients to talk about their problems for the
first 5 minutes of the interview without being interrupted.
Psychiatric history.
Reason for referral (How and why the patient was referred)
Complaints (These are the patient's complaints given in his or her own
words.)
History of presenting illness (A chronological account of the
development of each symptom should be given, together with any
precipitating factors. Associated impairments should also be given.
The effects of the patient's condition on social functioning should be
noted.)
Family psychiatric history (Any family history of psychiatric or
neurological disorder should be detailed, including the nature of the
disorder and any treatment. Any history of suicide in the family should be
enquired about.).
Personal history:
1. Childhood. This should include details of:
- date of birth
- place of birth
- abnormalities prior to or at birth, and whether the birth

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was premature
- early developmental milestones
- childhood health, including any history of "nervous
problems)
- any early emotional stresses, including separation from
close relatives such as siblings or parents.
2. ducation. This requires details of:
E
- age on beginning schooling
- types of school attended
- relationship with peers and teachers
- any history of truancy or other trouble or difficulties at
school
- qualifications achieved
- age on leaving school
- higher education
3. Occupational history. Summarize the occupational history, giving details of

promotion/demotion. Reasons for being sacked repeatedly (e.g. problem
drinking) should be explored. Any other difficulties at work should be given.
4. Psychosexual history. For women, ask about the age of menarche, any
menstrual abnormalities, history of pregnancies and the age of menopause, if
relevant. The sexual orientation should also be given. Any history of sexual or
physical abuse should be detailed, together with sexual and marital history
(including any history of infidelity) and any sexual difficulties.
5. Children. Details of any children should be given, including any
disturbances they suffer from.
6. Current social situation. Give the patient's current:
- social situation, stating with whom they live
- marital status
- occupation and financial status
- nature and stability of accommodation
- hobbies and social interests
Past medical history: (Chronological account of the past medical
history, including the nature of physical disorders and injuries, where they were
treated and the types of treatment administered. Any
medication, and its side-effects, should also be enquired about, as
should any history of hypersensitivity to drugs.)
Past psychiatric history: This involves details of

- the nature of any illness
- their duration
- hospital and outpatient department attended
- treatment received
- any current psychotropic medication being taken, and
any side-effects from this.

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Psychoactive substance use: Alcohol (amount of alcohol the patient is currently
drinking, including the history of any withdrawal symptoms, physical illnesses,
injuries, legal problems as a result of alcohol intake); tobacco (the type and number
of nicotine-containing products); illicit drug abuse (the types of drugs, the quantities
taken, the methods of administration and consequences). Forensic history: Describe
details of any history of delinquency and criminal offences, including a history of the
punishments received. Premorbid personality: patient's lifelong persistent and
enduring characteristics and attitudes changing of it after the onset of disease. This is
summarized under the following headings:
- attitudes to others in social, family and sexual
relationships
- attitude to self and character
- moral and religious beliefs and standards
- predominant mood
- leisure activities and interests
- fantasy life - daydreams and nightmares
- r eaction pattern to stress
Mental state : Appearance and behaviour:
- general appearance; facial appearance; posture and
movements; social behaviour; rapport
Speech:
- rate and quantity; neologisms; accent; form; record a
sample if abnormal
Mood:
- objective; subjective
Thought content:
- preoccupations; obsessions; phobias; suicidal and
homicidal thoughts.
Abnormal beliefs and interpretation of events:
- referred to the environment - persecutory delusion,
delusions of reference
- referred to the body - hypochondrical and nihilistic
delusion
- referred to the self - passivity phenomena, delusions of
poverty.
Abnormal experiences:
- referred to the environment - hallucinations, illusions,
derealization
- referred to the body - alterations in somatic sensations,
somatic hallucinations
- referred to the self- depersonalizations

Cognitive state:
- orientation in time, place and person
- memory - immediate recall, registration, short-term
memory, memory for recent events, long-term memory
- general knowledge and intelligence
Insight

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8. Laboratory investigations: screening of the patient for any underlying medical
condition; monitoring blood levels of psychotropic medications; identifying
biologic markers in the diagnoses and treatment process.
Practical skills
Student should be able

- to establish relationship with the patient;
- to describe mental status
Questions for control
1. Definition of psychiatry.
2. The importance of psychiatry for doctors of all specialities.
3. The relationship of psychiatry with other sciences (psychology,
biochemistry, genetics).
4. Classification of organic and functional mental disorders.
5. Definitions of psychosis and neurosis, their specific features.
6. Classifications of mental disorder - ICD-10, DSM-IV.
7. Requirements to the psychiatric interview. Doctor-patient relationship.
8. Name main parts of psychiatric case history.
9. Name main parts of mental status.
10. Name three approaches of laboratory investigations
Lesson 2
Theme: Disorders of perception, thinking, sensory synthesis
Plan
1. Disorders of perception (illusions, hallucinations, pseudohallucinations).
2. Disorder of the form of thought (disorders of the stream of thought,

associations).
3. Disorders of the thought content (overvalued ideas, obsessional ideas,

delusional ideas).
4. Disorders of sensory synthesis.

1. An illusion is a false perception of a real external stimulus. A hallucination is
a false sensory perception in the absence of a real external stimulus. A hallucination
is perceived as being located in objective space and as having the same realistic
qualities as normal perceptions. It is not subject to conscious manipulation and only
indicates a psychotic disturbance when there is also impaired reality testing.
Hallucinations may occur in the auditory, visual olfactory, gustatory or somatic
modalities. Auditory hallucinations may occur in depression (particularly second-
person hallucinations of a derogatory nature) and in schizophrenia (particularly third-
person hallucinations and running commentaries). Somatic hallucinations can be
divided into:

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-Tactile hallucinations ( also called haptic hallucinations) are
superficial and usually involve sensations on or just under the skin in the
absence of a real stimulus. These include the sensation of insect crawling
under the skin (called formication).
-Visceral hallucinations of deep sensations.
Other special types of hallucinations include:
- Reflex. A stimulus in one sensory field leads to an hallucination in
another;
- Functional. The stimulus causing the hallucination is experienced in
addition to the hallucination itself;
- Autoscopy (phantom mirror image). The patient sees himself and knows
that it is he.
- Extracampine. The hallucination occurs outside the patient's sensory
field;
- Trailing phenomenon. Moving objects are seen as a series of discrete

discontinuous images, usually as a result of taking hallucinogens.
- Hypnopompic. The hallucination occurs while waking from sleep; it can
occur in normal people.
- Hvpnogogic. The hallucination occurs while falling asleep; it can occur
in normal people.
- A pseudohallucination is a form of imagery arising in the subjective inner
space of the mind. It lacks the substantiality of normal perceptions and occupies
subjective rather than objective space.
An eidetic image is a vivid and detailed reproduction of a previous perception, as
in a "photographic memory".
In pareidolia, vivid image occurs without conscious effort while looking at a

poorly structured background, such as a fire or plain wallpaper.
2. Rate, quantity and articulation. There is an increase in both the quantity and
rate of speech in pressure of speech, seen in mania; it is difficult to interrupt such
speech. In logorrhoea, also called volubility, the speech is fluent and rambling, with
the use of many words.
In poverty of speech there is a restricted amount of speech and any replies to
questions may be monosyllabic. Mutism is the complete loss of speech.
The patient's accent may cause words to be pronounced in such a way as to be
mistaken for neologisms by the interviewer. It should also be borne in mind that
some people may normally speak in a way which could cause an incorrect
psychiatric diagnosis to be made.
Dysarthria is difficulty in the articulation of speech; dysprosody is the loss of its
normal melody. In stammering the flow of speech is broken by pauses and the
repetition of parts of words.

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Form of speech. In flight of ideas the speech consists of a stream of thoughts,
which abrupt changes from topic to topic and no central direction. The connection
between the thoughts may be based on:
-chance relationship; - verbal associations; - clang associations; -distracting
stimuli. In circumstantiality thinking appears slow, with the incorporation of
unnecessary trivial details, but the goal of the thought is finally reached.
In passing by the point (vorbeigehen) the answers to questions, although clearly
incorrect, demonstrate that the patient understands the question.
A neologism is a new word constructed by the patient or an everyday word used
in a special way.
In perseveration mental operations are continued beyond the point at which they
are relevant. In palilalia the patient repeats a word with increasing frequency; in
logoclonia the patient repeats the last syllable of the last word. Echolalia is the
automatic imitation by the patient of another person's speech, even when they do not
understand.
In thought blocking there is a sudden interruption in the train of thought, before
it is completed, leaving a "blank". After a period of silence, the patient cannot recall
what he has been saying.
Loosening of association (knight's move) thinking, in which there are odd
tangential associations between ideas, leading to disruptions in the smooth
continuity of speech. Word salad is incomprehensible mixture of words or
phrases.
3. Overvalued ideas. They are unreasonable and
sustained intense preoccupation maintained with less
than delusional intensity. The idea or belief held is
demonstrably false and not one that is normally held
by others of the patient's subculture. There is a marked
associated emotional investment. Obsessions. They are
repetitive senseless thoughts which are recognized as
irrational by the patient and which are unsuccessfully
resisted. Themes include:
- Fear of causing harm
- Dirt and contamination
- Aggression
- Sexual
- Religious
They may be accompanied by compulsions (compulsive rituals).

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Delusions. It is "a false personal belief based on incorrect inference about
external reality and firmly sustained in spite of what almost everyone else
believes and in spite of what constitutes incontrovertible and obvious proof or
evidence to the contrary. The main types of delusion are shown in the table.
Delusional syndromes
I. Paranoiac
1) Primary delusion ( jelosy, invention and others )

2) Abscense of the disorders of perception, mood
II. Paranoid (syndrome of psychical automatisms)
1) Persecutory delusion (secondary)

2) Hallucinations (pseudo-)
3) Psychical automatisms (associative, motor, senesthopathic)
with mainly with mainly

disorders of perception disorders of thinking
4) Confabulations
III. Paraphrenic
1) Symptoms of paranoid syndrome
2) Grandious delusion
IV. Cotards syndrome

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1) Depressed mood
2) Nihilistic delusion
V. Dysmorphomania Dysmorphophobia
1) Delusion of ugliness
2) Delusion of reference
3) Depressed mood (with suicidal tendencies)
4. Disorders of sensory synthesis. Autometamorphopsia. The patient complains of

change of normal size or forms of body parts. Exametamorphopsia. The patient
notes distortion of normal perception of size, forms, and proportions of real
objects parts and space. The real objects can be perceived as proportionally or
unproportionally large or small, distorted.
Derealization is the feeling that the external environment has become unreal
and remote. In some psychiatric disorders, the patients have a peculiar
disturbance of recall either failing to recognize events that have been encountered
before (jamais vu) or reporting the recognition of events that are in fact novel
(dej'a vu).
A change in self-awareness in a such way that the person concerned feels
unreal is termed depersonalization. It may be: a). Autopsychical (patients
complain of change of their perception, mental functioning, thinking, impairment
of emotions). b) Somatopsychical (the patients feel their own body as somebody's
else.
Practical skills
-to reveal disorders of perception and thinking in a patient
- to describe the disorders in special terms
- to assess the severity of the disorders (psychotic or neurotic levels)
1. Definition of illusions.
2. Definition of hallucination and pseudohallucinations. Different
features of them.
3. Description of special types of hallucinations.
4. Name different kinds of formal disorders of thoughts.
5. Definition of delusion.
6. Differential criteria of overvalued ideas and delusional ideas.
7. Differential criteria of obsessional ideas and delusional ideas.
8. Name main kinds of delusions.
9. escribe the phenomena which occur in disorders of sensory synthesis.
D
10. Definition of derealization and depersonalization.
Lesson 3
Theme: Disorders of memory, attention and concentration,

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emotions and mood, will-activity
Plan
1. Disorders of memory (amnesia, hypermnesia, paramnesia).
2. Disorders of attention and concentration.
3. Disorders of emotions and mood.
4. Disorders of will-activity (hypo- and hyperbulia, parabulia).
5. Disorders of insight.
1. There are a number of components to memory which should be assessed.
Immediate recall can be assessed by asking the patient to repeat immediately a
sequence of digits. Registration can be assessed by giving the patient a name and
address and asking him to repeat them. The patient is asked to repeat this name and
address 5 minutes later, and mistakes are again recorded; this is a test of short-term
memory. Memory for recent events can be assessed by asking the patient to recall
important news items from the previous 2 days. Long-term memory is assessed more
formally by asking the patient to recall his date and place of birth.
Amnesia is the inability to recall past experiences, whereas in Hypermnesia the
degree of retention and recall is exaggerated.
Paramnesia is a distorted recall leading to falsification of memory. E.g.
confabulation - gaps in the memory which are unconsciously filled with false
memories, as occurs in amnesic (Korsakov's) syndrome. Pseudoreminiscence is a
wrong memory of real events which took place in past. In this case patient recallects
events in the wrong way. Criptomnesia is a disorder of a such
memory process as recognition/ A person has no the feeling of familiarity indicating
that some persons, events and objects have been encountered before. This memories
seem quite new to him.
2. Attention and concentration can be checked by the serial sevens test, in
which the patient is asked to subtract 7 from 100 and repeatedly subtract 7
from the remainder as fast as possible, giving the answer at each stage. The
time taken to reach a remainder less than 7 is noted. (The correct answers are
93, 86, 79, 72, 65...). if this proves too difficult, perhaps because of poor
arithmetical skills, a similar test using 3 instead of 7 (serial threes) can be
given. If this also proves too difficult, the patient can be asked to recite the
days of week or months of the year backwards. Since concentration is
sustained attention the serial sevens can be administered first, and if the patient
copes adequately there is no need to check attention separately. Disorders of
attention include distractability, in which the attention is drawn too frequently
to unimportant or irrelevant external stimuli. If the patient is unable to attend to
the task at hand, this should be noted, together with how easily he or she is
aroused. In selective inattention anxiety-provoking stimuli are blocked out.
3. Mood is defined as "a pervasive and sustained emotion that, in the
extreme, markedly colors the person's perception of the world". An objective
assessment should be made of the quality of the mood, based on the history,
appearance, behaviour and posture of the patient. A subjective assessment of
the quality of the mood as described by the patient can be obtained by asking a
question such as :How do you feel in yourself?", or "How do you feel in your
spirits?".
A dysphoric mood is an unpleasant mood. In depression the patient has low or
depressed mood. This may be accompanied by anhedonia, in which the patient loses
the ability to enjoy regular and pleasurable activities and no longer has any interest in
them. In normal grief or mourning, the sadness is appropriate to the loss. If the
patient appears depressed, the presence of depressive thoughts should be probed

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further, including asking whether he has any suicidal thoughts.
Euphoria is a personal and subjective feeling of unconcern and contentment,
usually seen after taking opiates or as sequel to head injury. Elation is an elevated
mood or exaggerated feeling of well-being which is pathological, which is seen in
mania.
A patient with irritable mood is easily annoyed and provoked to anger. A patient
with alexithymia has difficulty in being aware of or describing the emotions he feels.
In apathy there is a loss of emotional tone and the ability to feel pleasure, associated
with detachment or indifference.
Anxiety is a feeling of apprehension, tension or uneasiness owing to the
anticipation of an external or internal danger. Types of anxiety include:
Phobic anxiety - in which the focus of the anxiety is avoided
Free-floating anxiety - the anxiety is pervasive and unfocused
Panic attacks - anxiety is experienced in acute intense episodic attacks,
and may be accompanied by physiological symptoms.
Fear is anxiety caused by realistic danger.
Affect is "a pattern of observable behaviours that is the expression of a
Ritualsexperienced
subjectively characteristic of Affect is variable over time, in response to
feeling state.
obsessive-compulsive
changing emotional states, whereas mood refers to a pervasive and sustained
emotion".
behaviour
Inappropriate affect is an affect that is inappropriate to the thought or speech it
accompanies. The externalized feeling tone is severely reduced in a patient with a
blunted affect. A flat affect consists of a total or almost total absence of signs of
expression of affect. A patient with labile affect has a labile externalized feeling tone
which is not related to environmental stimuli.
4. Disorders of will. Feebleness of will (hypobulia) is a condition, characterized
by few motives to activities, inertia, inactivities, and low level of
moving activity. Absence of will (abulia) is characterized by the absence of motives
to activities; the patients are apathetic to environment, absolutely inactive. Excessive
willfulness (hyperbulia) is intensification of motives rising of activities, agility.
Parabulia is perversion of will activity, manifesting itself in negativism, impulsive
behaviour.
Disorders of attraction (drives). Anorexia is diminished food instinct or its
absence. Nervous anorexia (anorexia nervosa) is characterized by the patient's
persistent striving for sliming, it is realized by long self-restriction to food, intensive
physical exercises, taking of laxative, self-provoking vomit. Mental anorexia is
refusal of food, caused by unhealthy mental condition. The main reasons are: -
depressed mood with tendency to suicide; - delusion of poisoning; - nihilistic
delusion; - olfactory, gustatory, and imperative hallucination; - stupor and substupor
conditions.
Bulimia - pathological enhance of food, which leads to fattening.
Perversion of appetite - eating of uneatable things.
Polydipsia - is unquenchable thirst.
Suicidal tendencies are characterized by striving for death.
Impulsive actions are made without any control of consciousness due to deep
disorder of mental activity. They are sudden, immotive, and senseless.
Impulsive drive suddenly arising strivings which seize the patient's mind. The
patient realizes his strivings without awareing of them. They are: dromomania
(impulsive drive for roaming); dipsomania (impulsive drive for alcoholic drink);
pyromania (impulsive drive for arsons); kleptomania (impulsive drive for stealing
things).
5. Insight. If the patient has a psychiatric disorder, the degree of insight he or she
has into this can be assessed by enquiring into the fallowing three areas:

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Does the patient recognize that he or she is ill?
Does the patient accept that he or she has psychiatric illness?
Does the patient accept that psychiatric treatment is necessary?
The insight should not be recorded simply as being absent or present. Rather,
reference should be made to the above three questions.
Practical skills
-to reveal disorders of memory, will, and emotion in a patient
- to describe the disorders in special terms
- to assess the severity of the disorders
1. Description of normal memory processes.

2. Definition of amnesia, hypermnesia, paramnesia.
3. Description of special types of affect.

4. Name different kinds of the disorders of mood.
5. Definition of mood and affect.
6. Differential criteria of manic and depressive syndrome.
7. Differential criteria of .pathological affect.
8. Name main kinds of the disorders of will.
9. Definition and description of impulsive drives

10. Describe the phenomena of eating disorders
Lesson 4
Theme: Disorders of consciousness, orientation, and psychomotor activity.
Disorders of intelligence (IQ)
1. Disorders of consciousness.
2. Kinds of orientation and their disorders.
3. Disorders of psychomotor activity.
4. Disorders of intelligence (IQ).
1. Consciousness is awareness of the self and the environment. Terms, using for
description of impaired consciousness:
- Coma is the most extreme form. The patient shows no external evidence of
mental activity and little motor activity other than breathing. He does not
respond even to strong stimuli.
- Sopor is a state in which the person can be aroused only by strong
stimulation.
- clouding of consciousness is a state, in which the person is drowsy and reacts
incompletely to stimuli. Attention, concentration, and memory are impaired

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and orientation is disturbed. Thinking seems slow and muddled, and events
may be interpreted inaccurately.
- confusion means inability to think clearly.
- oneiroid (dream-like) state is a condition in which the patient, although not
asleep, describes experiences of vivid imagery akin to that of a dream. When
such a state is prolonged it is called a twilight state.
2. Checking orientation for person (Name? Age? When born?); place (What place is
this? What is your home address?); time (Today's date? Day of week? Time?
Season?); situation (Why are you here?). Time sense is usually the first
lost. Major disorientation suggests organicity. Minor loss may reflect temporary
stress.
3. Motor symptoms include:
Tics (irregular repeated movements involving a group of muscles;
Mannerisms (repeated movements that appear to have some functional
significance);
Stereotvpies (repeated movements that are regular and without obvious
significance);
Posturing (adoption of unusual bodily postures continuously for a long

time; the posture may appear to have a symbolic meaning);
Negativism is a condition when persons do the opposite of what is asked
and actively resist efforts to persuade them to comply;
Echopraxia is the imitation of the interviewer's movement automatically
even when asked not to do so;
Ambitendence is a condition when patients alternate between opposite
movements;
Waxy flexibility is detected when a patient's limbs can be placed in a
position in which they then remain for a long periods whilst at the same
time muscle tone is uniformly increased.
4. Intelligence is the ability to understand, recall, mobilize, and constructively
integrate previous learning in meeting new situations.
Mental retardation: lack of intelligence to a degree in which there is interference
with social and vocational performance: mild (IQ of 50 or 55 to approximately 70);
moderate (IQ of 35 or 40 to 50 or 55); severe (IQ of 20 or 25 to 35 or 40) or profound
(IQ below 20 or 25); obsolete terms are idiot (mental age less than 3 years), imbecile
(mental age of 3 to 7 years), and moron (mental age is about 8).
Dementia: organic and global deterioration of intellectual functioning without
clouding of consciousness
- dyscalculia (acalculia): loss of ability to do calculations not caused by
anxiety or impairment of concentration.
- dysgraphia (agraphia): loss of ability to write in cursive style; loss of
word structure;
- alexia: loss of previously possessed reading facility; not explained by
defective visual acuity.
Pseudodementia: clinical features resembling a dementianot caused by an
organic condition; most often caused by depression.
Judgment: ability to assess a situation correctly and to act appropriately within
that situation.
Critical judgment: ability to assess, discern, and choose among various options

Pgina 19 de 65
in a situation
Impaired judgment: diminished ability to understand a situation correctly and
act appropriately.
Practical skills
-to reveal disorders of consciousness, orientation psychomotor activity and
intelligence in a patient;
- to describe the disorders in special terms;
- to assess the severity of the disorders.
1. Definition of consciousness.
2. Kinds of the disorders of the quantity of consciousness.
3. Kinds of the disorders of the quality of consciousness.
4. Name criteria of coma, sopor, clouding of consciousness.
5. What kinds of orientation do you know?
6. What motor symptoms can occur in schizophrenia?
7. What motor symptoms can occur in organic brain syndrome?
8. Definition of intelligence.
9. Name congenital disorders of intelligence.
10. Name acquired disorders of intelligence.
Lesson 5
Theme: Organic, including symptomatic mental disorders. Dementia
Plan
1. Organic, including symptomatic mental disorders. Definition according to
the ICD-10.
2. Primary degenerative dementia in Alzheimer's disease. Macroscopical,
histological, biochemical and microscopical changes; clinical features.
3. Primary degenerative dementia in Parkinson's disease. Macroscopical,
4. Primary degenerative dementia in Pick's disease. Macroscopical,
5. Primary degenerative dementia in Huntington's chorea. Macroscopical,
6. Primary degenerative dementia in Creutzfeldt-Jacob disease.
Macroscopical, histological, biochemical and microscopical changes;
clinical features.
7. Vascular dementia. Macroscopical, histological, biochemical and
microscopical changes; clinical features.
8. HIV disease dementia.

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1. In ICD-10 organic mental disorders are grouped on the basis of a common
demonstrable aetiology being present in the form of cerebral disorder, injury of the
brain, or other insult leading to cerebral dysfunction. Cerebral dysfunction may be:
Primary - disorders, injuries or insults affecting the brain directly or with
predilection.
Secondary - systemic disorders affecting the brain only if so far as it is one of
the multiple organs or body systems involved.
The disorders result in psychological dysfunction in one or more of the
following areas:
Cognitive functioning, e.g. disorders of memory and intelligence
The sensorium, e.g. disorders of consciousness and attention
Thinking, e.g. delusions
Perception, e.g. illusions and hallucinations
Emotions / mood, e.g. anxiety, depression and elation
Behaviour and personality, e.g. altered sexual behaviour Organic psychiatric
disorders are classified according to whether they cause generalized
psychological dysfunction or specific impairment in one or two areas.
2. Dementia is characterized by generalized psychological dysfunction of higher

cortical functions without impairment of consciousness. In fully developed dementia
the higher cortical functions affected include memory, thinking, orientation
comprehension, calculation, learning capacity, language and judgment. Dementia is
acquired and usually chronic or progressive disorder.
Alzheimer's disease is the commonest cause of dementia in people over the age
of 65. The same pathological changes take place in both the senile (onset over the age
of 65) and the presenile form (onset under the age of 65). Macroscopically there is
global atrophy of the brain, which is shrunken with widened sulci and ventricular
enlargement. The atrophy is usually most marked in the frontal and temporal lobes.
Hystologically there is neuronal loss, shinkage of dendritic branching and a reactive
astrocytosis in the cerebral cortex. Other features include the presence, particularly in
the cerebral cortex, of neurofibrillary tangles; the presence mainly in the cortex, of

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silver-staining neuritic plaques; granulovacuolar degeneration, particularly in the
middle pyramidal layer of the hippocampus; and eosinophilic rod-shaped filamentous
intracytoplasmic neuronal inclusion bodies known as Hirano bodies.
Electron microscopy reveals that each neuritic plaque contains an amyloid core
made of a protein known as A4 or P-amyloid. The gene coding for the A4 or [3-
amyloid has been cloned and localized to the long arm of chromosome 21.
Biochemically, in the post mortem brain there is reduced activity of both
acetylcholinesterase and choline acetyltransferase.
Clinical features. The disease is usually begins with memory loss. Other clinical
features may include: apathy or lability of mood; progressive impairment of
intellectual functioning; progressive deterioration of personality; features typical of
parietal lobe dysfunction; paranoid features; parkinsonism; the mirror sign, in which
individuals may fail to recognize their own reflection; disorders of speech such as
logoclonia and echolalia; epilepsy; and aspects of the Kluver-Bucy syndrome, which
includes hyperorality, hypersexuality, hyperphagia and placidity.
3. In Parkinson's disease there is a substantial loss of pigmented

catecholaminergic neurons in the substantia nigra and locus coeruleus, with Lewy
bodies being found in remaining neurons. Parkinson's disease patients may also have
Lewy bodies in other subcortical nuclei, such as the cholinergic cells of the basal
nucleus of Meynert, and in cortical areas, particularly the cingulate and
parahippocampal gyri.
Clinical features. The disease is associated with the following features: Marked
fluctuating cognitive impairment over weeks or months affecting memory and higher

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cortical functions (language, visuospatal ability, praxis and reasoning.), with
intervening episidic lucid intervals;
Mild or variable loss of short-term memory
Visual and / or auditory hallucinations, delusions, and depressed mood;
Mild spontaneous extrapyramidal symptoms (Motor symptoms and signs);
Neuroleptic sensitivity syndrome (in which marked extrapyramidal
symptoms, particularly parkinsonism, occur in response to standard doses of
antypsychotic drugs).
4. Pick's disease is a rare cause of dementia. Some cases are transmitted as an

autosomal dominant disorder. Pathological features: Macroscopically there is
selective asymmetrical atrophy of the frontal and temporal lobes which, because of
its severity, causes the gyri to become very thin - knifeblade atrophy of the gyri.
A characteristic histological feature of Pick's disease is the presence of argirophilic
intracytoplasmic neuronal inclusion bodies known as Pick's bodies, which consist of
neurofilaments, paired helical filaments and endoplasmic reticulum. Other
histological features include loss of neurons, most marked in the outer layers of the
cerebral cortex, and a reactive astrocytosis. These changes may also occur in the
basal ganglia, locus coeruleus and substantia nigra.
Clinical features. Pick's disease is slightly more common in women, with a peak
age of onset between 50 and 60. Clinical features include: personality deterioration,
with features of frontal lobe dysfunction; nominal aphasia; memory impairment;
perseveration; and aspects of the Kliiver-Bucy syndrome.
5. Huntington's disease (Huntington's chorea) is an autosomal dominant disorder

caused by a gene which has been localized to the most distal band of the short arm of
chromosome 4.
Macroscopically the brain is usually small, with reduced mass, and there is
marked atrophy of the corpus striatum of the basal ganglia, particularly the caudate
nucleus, and of the cerebral cortex, particularly the gyri of frontal lobes. Histological
changes include: neuronal loss in the cerebral cortex, particularly affecting the frontal
lobes, and in the corpus striatum, particularly affecting GABA neurons with relative
sparing of large neurons; and astrocytosis in the affected regions. Biochemical
changes include reduced levels of GABA and glutamic acid decarboxylase.
Clinical features. The causes an insidious onset of involuntary choreiform
movements which , early in the course of the disorder, typically affect the face, hands
and shoulders or the gait (ataxia). These motor abnormalities usually begin before the
onset of progressive dementia, which in turn usually involves impairment of frontal
lobe functions relatively early on; memory is usually not affected to any major degree
until later. Other features include slurring of speech, extrapyramidal rigidity and
epilepsy. Psychiatric features include depression, increased risk of suicide and
schizophreniform and delusional disorders. Insight tends to be retained until a late
stage. Death usually occurs within 15 years of the onset of symptoms.
6. Creutzfeldt-Jakob disease is a rare progressive dementia. It is believed to be
caused by infection with either a prior - a glicoprotein viral subparticle lacking
ribonucleic acid - or a slow virus. These are similar to the viral infective agents
believed to be responsible for the now extremely rare neurodegenerative human
disorder kuru, which was reported as occuring in New Guinea following
cannibalism. Nowadays there is no evidence that any cases of human Creutzfeldt-
Jakob disease have arisen from eating beef, mutton or lamb. There is evidence that
Creutzfeldt-Jakob disease may be transmitted from infected humans through
procedures such as corneal transplantation, depth EEG with contaminated electrodes,
and neurosurgery using contaminated instruments.

Pgina 23 de 65
Pathological features. There may be little or no gross atrophy of the cerebral cortex
evident in rapidly developing cases. In those who survive longest, gross
neuropathological changes seen may include selective cerebellar atrophy and
ventricular dilatation. Histologically there is evidence of neuronal degeneration
without inflammation. Astrocytic proliferation occurs particularly in the cerebral
cortex, basal ganglia, brain stem motor nuclei and spinal cord anterior horn cells. A
characteristic feature of the grey matter of the cerebral cortex is the presence of
multiple vacuoles. Degeneration also occurs in spinal cord. Clinical features.
Creutzfeldt-Jakob disease clinical picture depends on the parts of the brain most
affected, the most important being: a rapidly progressing devastating dementia,
leading to memory impairment and personality change with slowing, fatigue and
depressed mood; and motor abnormalities that usually follow the onset of the
dementia and consist of a progressive spastic paralysis of the limbs, accompanied by
extrapyramidal signs with tremor, rigidity and choreoathetoid movements. Other
clinical features include: features typical of parietal-lobe dysfunction, epileptic fits;
myoclonic jerks; psychotic symptoms; cerebellar ataxia; visual failure; muscle
fibrillation; dysarthria. Death usually occurs within 2 years.
7. Vascular (multi-infarct) dementia caused by multiple cerebral infarcts, with

the extent of cerebral infarction being related to the degree of cognitive impairment.
It is associated with chronic hypertension and arteriosclerosis. Pathological features.
Macroscopically there are multiple cerebral infarcts, local or general atrophy of the
brain with secondary ventricular dilatation, and evidence of arteriosclerotic changes
in major arteries.
Clinical features. Multi-infarct dementia is more common in men. The onset is
usually acute, peaks in the 60s and 70s, and may be associated with a cerebrovascular
accident. Other clinical feature include: stepwise deterioration; focal neurological
features; nocturnal confusion; fits; fluctuating cognitive impairment; and emotional
incontinence and low mood. Death tends to occur on average between 4 and 5 years
after diagnosis.
8. A case of AIDS is a reliably diagnosed disease indicative of a defect in cell-

mediated immunity occuring in a person who has serum antibodies to the human
immunodeficiency virus (HIV) and no other known cause. A wide range of
neurological and neuropsychiatric complications can occur. Subacute encephalitis can
cause insidious cognitive impairment and, with a superimposed opportunistic
infection, a confusional state. The clinical picture may gradually progress to one of
AIDS dementia, with loss of cognitive functioning. Motor and behavioural
functioning are also affected, and patients may manifest pyramidal signs and ataxia.
Features typical of meningitis are also seen in AIDS; the cranial nerves most often
affected are the fifth, seventh, and eighth. If it occurs, primary cerebral lymphoma
may be presented with headache, seizures and focal neurological deficits, or with a
progressive dementia. Macroscopical, histological, and microscopical changes of
primary degenerative dementia and vascular dementia are seen at the following
pictures (reproduced from Adams J.H., Graham D.I., 1994. An introduction to
nd
Neuropathology, 2 edn. Churchill Livingstone, Edinburgh):

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Pgina 26 de 65
A - Alzheimer's disease; B - Vascular (multi-infarct) dementia
Practical skills
-to reveal organic brain disorders in a patient;
- to differentiate dementias with different aetiological factors;
- to assess the severity of the disorders;
- to describe mental status in patients with dementia.
1. Definition of dementia. Primary and secondary dementia.

2. General clinical features of dementia.
3. Clinical features of Alzheimer's disease.Its classification.
Organic changes in the brain.
4. Clinical features of Parkinson's disease. Its classification.
Organic changes in the brain.
5. Differential features of Alzheimer's disease and Pick's disease.
6. Biochemical and histological changes in the brain in Huntington's chorea.
7. Etiology and clinical picture of Creutzfeldt-Jakob disease.
8. Differential diagnostics between Alzheimer's disease and cerebrovascular
dementia.
9. Psychiatric disorders in AIDS.
10. Treatment and prognosis of primary degenerative dementia.
Lesson 6
Theme: Organic amnesic syndrome, delirium, other mental disorders due to brain
damage or dysfunction: organic hallucinosis, organic delusional disorder, organic
mood disorder, organic anxiety disorder). Personality and behavioural
disorder due to the brain disease

Pgina 27 de 65
Plan
1. Organic amnesic syndrome. Clinical pictures, differential diagnosis, course
and prognosis. Treatment.
2. Delirium (other than alcoholic). Clinical pictures, differential diagnosis,
course and prognosis. Treatment.
3. Organic hallucinosis Clinical pictures, differential diagnosis, course and
prognosis. Treatment.
4. Organic delusional disorder. Clinical pictures, differential diagnosis, course
and prognosis. Treatment.
5. Organic mood disorder. Clinical pictures, differential diagnosis, course and
6. Organic anxiety disorder. Clinical pictures, differential diagnosis, course and
7. Personality and behavioural disorder due to brain disease. Clinical pictures,
differential diagnosis, course and prognosis. Treatment.
1. The amnesic (Korsakov's) syndrome is characterized by prominent impairment of

recent and remote memory with preservation of immediate recall in the absence of
generalized cognitive impairment. The following two types of amnesia occur:
Retrograde amnesia - pathological inability to recall events that occurred
prior to the onset of the illness.
Anterograde amnesia - pathological inability to lay down new memories
after the onset of the illness.
Etiology.
Thiamine (vitamin 1) Chronic alcohol abuse; Malabsorption -lesions

deficiency of the stomach (e.g. gastric
carcinoma),duodenum or jejunum;
Hyperemesis; Stravation.
Intoxication Heavy metals - lead, arsenic; Carbon

monoxide;

Pgina 28 de 65
Intracranial causes Head injury; Brain tumors affecting the third
ventricle or hippocampal formations; Bilateral
hippocampal damage; Subarachnoid
haemorrhage; Infections - herpes simplex
encephalitis, tuberculous meningitis; Epilepsy
Hypoxia Anaesthetic accidents; Asphyxiation
Alzheimer's disease.
Pathology. The causes typically affect either or both of the hypothalamic -

diencephalic system and the bilateral hippocampal region of the brain.
Clinical features. The anterograde amnesia is associated with an impaired
ability to learn and disorientation for time. Confabulation, whereby gaps in memory
are unconsciously filled with false memories, is often a feature. The course and
prognosis are those of the primary pathology.
2. Delirium is characterized by acute generalized psychological
dysfunction
that usually fluctuates in degree. There is impairment of consciousness, often
accompanied by abnormal perceptions (illusions, hallucinations) and mood
changes (anxiety, lability or depressed mood).
Clinical features consist of prodromal symptoms (hypersensitivity to light sound;
agitation) and delirium (anxiety, agitation, depression; fluctuation in the level of
consciousness, illusions, hallucinations: visual auditory, tactile; delusions;
disorientation in time, place; impaired memory: new learning, registration, retention,
recall.).
Epidemiology. Delirium can occur in patients, suffering from physical illness,
particularly hospital inpatients:
General medical and surgical wards (10 %)

Surgical intensive care units: 20-30 %
Severely burned patients: 20%
Causes: Drugs and alcohol, intracranial causes, metabolic and endocrine disorders,
systemic infections, postoperative states. Management.
Good calming nursing care
Oral or intramascular haloperidol
benzodiazepines
3. I n ICD-10 organic hallucinosis is defined as being a disorder of
persistent or recurrent hallucinations, in any modality but usually visual or oditory,
which occur in clear consciousness without any significant intellectual decline and
which may or may not be recognized by the subject as such; delusional
elaboration of the hallucination may occur, but often insight is preserved.
Causes: psychoactive substance use; intoxication; intracranial causes; sensory
deprivation; endocrine; Huntington's disease.

Pgina 29 de 65
4. Organic delusional disorder is defined as being a disorder in which the
clinical picture is dominated by persistent or recurrent delusions with or
without hallucinations. The delusions are most often persecutory, but grandiose
delusions or delusion of bodily change, jealousy, disease, or death may occur.
Memory and consciousness are not affected.
The most common cause is psychoactive substance use, particularly
amphetamine and related substances, cocaine and hallucinogens. Intracranial causes,
such as tumours and epilepsy, are particularly important if they affect the temporal
lobe of the brain. Huntington's disease can also be a cause.
5. Organic mood disorder is characterized by a change in mood
(depressive or manic), usually accompanied by a change in the overall level of
activity, which is caused by organic pathology (psychoactive substance use;
medication; endocrine disorders; other systemic disorders: pernicious anaemia,
hepatic failure, renal failure and others; intracranial causes, Parkinson's disease).
6. Organic anxiety disorder is characterized by the features of generalized

anxiety disorder and panic disorder, caused by organic pathology. The
symptoms include tremor, paraesthesia, choking, palpitations, chest pain, dry
mouth, nausea, abdominal pain, loose motions and increased frequency of
micturition. Some of these symptoms, such as paraesthesia, are related to
associated hyperventilation. There may be secondary cognitive impairment.
The most important causes are hyperthyroidism, phaeochromocytoma and
hypoglycaemia.
7. ICD-10 defines organic personality disorders as being characterized by a
significant alteration in the habitual patterns of behaviour displayed by the subject
premorbidly. Such alteration always involves more profoundly the expression of
emotions, needs and impulses. Cognition may be defective, mostly or exclusively in
the areas of planning actions and anticipating their likely consequences.
The most common cause is head injury. Other intracranial causes include brain
tumors brain abscesses, subarachnoid haemorrhage, neurosyphilis and epilepsy,
particularly when the frontal or temporal lobes are involved. Other causes include:
Huntington's disease, hepatolenticular degeneration, medication such as
corticosteroids, psychoactive substance use and endocrinopathies.
Practical skills
-to reveal organic brain disorders in a patient;
- to differentiate dementias with different etiological factors;
- to assess the severity of the disorders;
- to describe mental status in patients with organic syndromes.
1. Definition of amnesic syndrome.
2. Etiological factors which lead to the development of amnesic syndrome.
3. Definition of delirium.
4. Management of delirium.
5. Definition of organic hallucinosis. Causes of it.
6. Definition of organic mood disorders. Causes of it.
7. Definition of organic anxiety disorders. Causes of it.
8. Clinical picture of organic personality disorders.

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9. Treatment of organic syndromes.
Lesson 7
Theme: Schizophrenia
Plan
1. Schizophrenia. Definition. Epidemiology.
2. Classification (ICD-10).
3. Clinical features. Clinical forms (paranoid, hebephrenic, catatonic,
undifferentiated, residual, postschizophrenic depression, simple
schizophrenia).
4. Etiology (hypotheses).
5. Neurophysiological, neuropsychological, biochemical abnormalities in
schizophrenia.
6. Course and prognosis.
7. Treatment of the disease.
1. Schizophrenia is one of the most debilitating disorders. It is a major psychosis that

can manifest itself in a variety of ways.
The clinical picture of schizophrenia characteristically includes one or more disorders
of the following:
Changes in thinking
Changes in perception
Blunted or inappropriate affect
A reduced level of social functioning
Cognitive functions are usually intact in the early stages.
Schneider's first-rank symptoms of schizophrenia
- Auditory hallucinations: voices repeating thoughts out loud

- Auditory hallucinations: discussing the subject in the third person
- Auditory hallucinations: running commentary
- Thought insertion
- Thought withdrawal
- Thought broadcasting
- Made feelings
- Made impulses
- Made actions
- Somatic passivity
- Delusional perception
**-
: ICD-10 symptoms .:

!>

^
- Other persistent delusions. These include religious or political identity, or

Pgina 31 de 65
superhuman powers and abilities.
- Persistent hallucinations. These are important in any modality, when
accompanied either by fleeting or half-formed delusions without clear affective
content, or by persistent overvalued ideas, or when occurring every day for
weeks. An overvalued idea is an unreasonable and sustained intense
preoccupation maintained with less than delusional intensity; the idea or belief is
demonstrably false and is not normally held by others of the patient's subculture.
There is a marked emotional investment associated with overvalued ideas.
- Breaks or interpolations in the train of thought. These can result in
incoherence or irrelevant speech. They can also cause neologisms, which are
new words constructed by the patient or everyday words used in a special way.
- Catatonic behaviour. The symptoms of catatonia include stupor, in which
the patient is unresponsive, akinetic, mute and fully conscious, and excitement;
the patient may change between these two states. Other symptoms include:
posturing, in which the patient adopts an inappropriate or bizarre bodily
posture continuously for a substantial period of time; waxy flexibility, in which
the patient's limbs can be 'moulded' into a position and remain fixed for long periods
of time; and negativism, in which motiveless resistance occurs to instructions and to
attempts to be moved.
- 'Negative' symptoms. They include marked apathy, poverty of speech,
lack of drive, slowness and blunted or incongruity of affect, and usually result
in social withdrawal and
Alzheimers lowered social performance. In identifying the
disease
presence of negative symptoms other possible causes of such symptomatology,
seen ondepression
such as CT scanand antipsychotic medication, should first be excluded. The
'positive' symptoms typically occur in acute schizophrenia. They include
delusions, hallucinations and thought interference.
- Change in personal behavior. This can be noted as a significant and
consistent change in the overall quality of some aspects of personal behaviour,
manifest as loss of interest, aimless, idleness, a self-absorbed attitude and
social withdrawal. Alzheimers disease.
The incidence of schizophrenia is between 15 and 30 new cases per 100 000 of the
population per year. The point is less than 1 %. There
There is are many
a lifetime silver-
risk of developing
schizophreniaHuntingtons
of approximatelydisease.
1 % in generalstaining
population.neuritic plaques in
TheThe coronal
age of onset is section shows15 andthe
usually between 45 years, with ancortex
cerebral earlier mean age of
which
onset in men than in women.
atrophy of the caudate can be seen to be granular
2. ICD-10 classification.
nucleus and filamentous. Some of
Schizophrenia: the plaques have dense
Picks disease. The coronal cores.
-section shows gross atrophy of
Paranoid schizophrenia
-the temporal lobes (with sparing
Hebephrenic schizophrenia
-ofCatatonic
the superior temporal gyri)
schizophrenia
-and in addition, associated
Undifferentiated schizophrenia
-ventricular enlargement.
Post-schizophrenic depression
- Residual schizophrenia
- Simple schizophrenia
- Other schizophrenia
- Schizophrenia unspecified

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3. Subtypes. Paranoid schizophrenia: the presence of paraniod symptoms, such
as: - delusion of persecution; - delusion of reference; -delusion of exalted
Vascular (multi-infarct)
birth, - delusions of bodily change; - delusions of jealousy; - hallucinatory voices;
dementia
- non-verbal auditory hallucinations; - hallucinations in other
Hebephrenic schizophrenia. - irresponsible and unpredictable behaviour;
Deterioration of -rambling
and incoherent speech; - affective changes; - poorly organized delusions; - fleeting
and fragmentary hallucinations. Catatonic intellectual functioning
schizophrenia, -presence of catatonic
in Aonset;
symptoms. Simple schizophrenia. - an insidious - Alzheimers
'negative' symptoms develop
without the prior occurrence of 'positive' symptoms.
disease and B
Residual or chronic schizophrenia is preceded by one of the above types and is
characterized by 'negative' symptoms.
Vascular dementia
4. Etiology. Predisposing factors include genetic, prenatal, perinatal and
personality factors. Precipitating factors include psychosocial stresses. Perpetuating
factors include patient's family and social factors. Mediating factors may include
neurotransmitters and neurodegeneration, and psychoneuroimmunological and
psychoneuroendocrinological factors.
Genetics. Family studies, twin studies, and adoption studies support the
hypothesis that there is an important genetic component to schizophrenia.
Prenatal factors. Schizophrenia is more common in those born in the late winter
and early spring months. It is particularly common in those exposed prenatally to
influenza epidemic between 3rd and 7th months of gestation (maternal viral infection).
Perinatal factors. Obstetric complications during birth.
Personality. Those with schizotypical personality disorder have peculiarities and
anomalies in ideation, appearance, speech and behaviour, deficits in interpersonal
relationships. There is more common in the first-degree relatives (consider to be part
of a genetic), spectrum of schizophrenia.
Psychosocial stressors. Life events may act as precipitating factors in a person

Pgina 33 de 65
with a predisposition of schizophrenia.
The patient's family. Displaying high expressed emotion.
Social factors. Poverty of the social milieu.
5. Clinical features of schizophrenia are the result of central dopaminergic
hyperactivity in the mesolimbic - mesocortical system. There is some evidence that
central serotonergic (5-HT) dysfunction may be associated with schizophrenia.
CT show the cerebral ventricular enlargement. Post mortem neuropathological studies
have revealed changes in the cytoarchitecure of the temporal lobes and limbic system
in schizophrenia. Abnormalities have also been found in the entorhinal cortex, which
forms the anterior part of the parahippocampal gyrus and lies superficial to the
amygdala and to the uncal and most anterior parts of the body of the hippocampal
formation.
6. Approximately one-quarter of cases of schizophrenia show good clinical
and social recovery. Factors associated with good prognosis include:
Being female
Having a relative who suffers from bipolar mood disorder
Older age of onset
Sudden onset
Rapid resolution
Good response to treatment
Affective loading
Good sexual adjustment
Not showing cognitive impairment
Not having ventricular enlargement.
7. Treatment is neuroleptic medication (antipsychotic drug).
Chlorpromazine, thioridazine (with hypotension side-effects). Haloperidol,
droperidol and trifluoperazine (extrapyramidal side-effects).
Loxapine - mild sedative and extrapyramidal side-effects Clozapine -
for patients who do not respond other neuroleptics.

1. Definition of schizophrenia
2. First-rank symptoms of schizophrenia.
3. ICD-10 criteria of schizophrenia.
4. Classification of schizophrenia.
5. Clinical features of paranoid schizophrenia.
6. Clinical features of hebephrenic schizophrenia.
7. Clinical features of catatonc schizophrenia.
8. Main etiological factors which can lead to the development of
schizophrenia.
9. Epidemiological data of schizophrenia.
lO.Neurotransmitters in schizophrenia. Their changes.
1 l.CT-changes in schizophrenia.
12.Treatment of schizophrenia: main kinds of neuroleptics.
Lesson 8
Theme: Mood disorders

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Plan
1. Mood disorders (definition).
2. Mood and affect (definition).
3. Classification of Mood disorders (ICD- 10).
4. Clinical features (depressive syndrome, .manic syndrome).
5. Differential diagnosis.
6. Course and prognosis of Mood disorders.
7. Epidemiology of the disease.
8. Treatment.
1. The prominent feature of mood disorders is a disturbance of mood along

the happy - sad axis.
2. Mood. A pervasive and sustained emotion that colours the person's
perception of the world. Common examples of mood include depression,
elation and anxiety.
Affect. A pattern of observable behaviours that is the expression of a subjectively
experienced feeling state (emotion). Affect is variable over time, in response to
changing emotional states. 3. - Manic episode
- Bipolar affective disorder The amnesic
- Depressive episode (Korsakov's) syndrome.
- Recurrent depressive disorder There are multiple
- Persistent mood (affective) disorder petechial haemorrhages
- Other mood (affective) disorder in the mammillary
bodies and in the walls
of the third ventricle.
(reproduced from
Adams J.H., Graham
D.I., 1994. An
introduction to
Neuropathology, 2 edn. nd
Churchill Livingstone,
Edinburgh).

Pgina 35 de 65
3. In depressive episode there is depression of mood and - loss of interest and
enjoyment (anhedonia); - reduced energy, reduced activity; - reduced attention and
concentration; - ideas of guilt and worthlessness; - lowered self-esteem. Somatic
changes: reduced appetite; weight loss; constipation. Insomnia: initial; broken sleep;
waking in the morning (terminal insomnia). Diurnal variation of mood. Reduced
libido; amenorrhea.
In mania there is elation of mood, increased energy, overactivity, pressure of

speech, reduced sleep, loss of normal social and sexual inhibitions, and poor attention
and concentration. Patient may overspend, start unrealistic projects, be sexually
promiscuous and, if irritable or angry, be inappropriately aggressive.
Kinds of manic syndrome: hypomania; mania without psychotic symptoms; mania
with psychotic symptoms; manic stupor.
5. Differential diagnosis: organic disorders and psychoactive substance use

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disorder; increased activity and restlessness (and often loss of weight) may
occur in hyperthyroidism and anorexia nervosa. Schizophrenia may present
with symptoms of mania. In agitated depression in the elderly the early
stages may present in a similar way to the irritability of hypomania. In the
obsessive-compulsive disorder patient may stay up at night in order to
perform household rituals. Dissocial personality disorder may present with
hypomania.
6. The prognosis is much better in those who regularly take prophylactic

medication. Patient with mania should be treated as inpatients.
The outcome of depressive disorders varies but in general is better the great the
length of follow-up. The risk of relapse is reduced if antidepressant medication is
continued for 6 months after the end of the depressive episode. Overall, there is a
suicidal rate of around 9%.
7. The sex ratio is equal. The point prevalence of bipolar disorder is between
0.4 and 1% in general population. The life-time risk in general population is
0.6-1.1%.
The average age of onset is around the mid 20s.
The incidence of depressive disorder is between 80 and 200 new cases per 100 000 of
the population per year in men and between 250 and 7800 new cases per 1000 000 of
the population in women. The point prevalence of depressive symptoms is much
higher, at up to 20%. The life-time risk in general population is 5-12% in men and 9-
26% in women. The average age of onset is around the late 30s but it can start at any
age from childhood onwards.
8. Treatment of depressive syndrome.

Antidepressant medications: tricyclic antidepressants (imipramine, amitriptyline);
MAOIs. Side-effects: arhythmias, heart block, convulsions, paralytic ileus and blood
dyscrasias.
- electroconvulsive therapy. It is a first-line of treatment:
- very low fluid intake, resulting in oliguria
- depressive stupor
- a dangerously high risk of suicide
where there is a need for rapid response, e.g. in puerperal depressive psychosis.
Manic disorder. Antypsychotic (neuroleptic) drugs.
Lithium compounds (lithium carbonate) are used in the prophylaxis of mania.

Contraindications of the use of lithium include: renal insufficiency, cardiovascular
insufficiency, Addison's disease, untreated hypothyroidism. is used in the
treatment of manic stupor.

1. Definition of mood.
2. Definition of affect.
3. Definition of affective disorder.
4. Classification of affective disorder according to ICD-10.

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5. Clinical features of depressive syndrome.
6. Name criteria of reactive depression.
7. Name criteria of endogenous depression.

8. Differential features of depressive syndrome in different disease.
9. What does mask depression mean?
10. Clinical features of manic syndrome.
11. Differential diagnosis of manic syndrome in different diseases.
12. Name hypotheses of affective disorder.
13. What is the rate of incidents of disease in women?
14. Kinds of treatment in depressive syndrome.
15. Kinds of treatment in manic syndrome.
Lesson 9
Theme: Neurotic stress-related disorders
Plan
1. Phobic anxiety disorders. Definition.

2. Agoraphobia. Clinical features, criteria for diagnosis.
3. Social phobia. Clinical features, criteria for diagnosis.
4. Specific phobia. Clinical features, criteria for diagnosis, course. Treatment
of anxiety disorders.
5. Other anxiety disorders: (panic disorder, generalized anxiety disorder,
mixed anxiety and depressive disorder). Clinical features, criteria for
diagnosis, course and treatment.
6. Obsessive-compulsive disorder. Clinical features, criteria for diagnosis,
course and treatment.
7. Post-traumatic stress disorder. Clinical features, criteria for diagnosis,
course and treatment.

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1. Anxiety is a mood, usually unpleasant in nature, accompanied by bodily
(somatic)sensations. In phobic anxiety disorder anxiety is evoked only, or
predominantly, by certain well-defined situations or objects external to the
subject, which are not currently dangerous, and these are characteristically
avoided or endured with dread.
2. Agoraphobia. Fear not only of open spaces but also of related aspects, such as the
presence of crowds and difficulty of immediate easy escape back to a safe place,
usually home.
Agoraphobia is the cause of 60% of the phobic patients. Over two-thirds are female.
They are often married and have high incidence of sexual problems. Some
individuals may abuse alcohol or drugs in an effort to overcome their phobia.
3. Social phobia. Fear of scrutiny by other people in comparatively small groups (as
opposed to crowds), leading to avoidance of social situations.
Social phobia occurs in 3-4% of the general population. It is associated with panic
disorder and other anxiety disorder. The age of onset is 20-35 years.
Treatment: behavioural therapy, antidepressants, tranquillizers, J3-blockers.

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modalities.
3. Specific (isolated) phobias. Restricted to highly specific situations such as

proximity to particular animals, heights, thunder, flying, blood, etc.
About 10% of general population suffer from disorder. It develops in childhood.
Thought alienation

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5. Panic disorder. Recurrent attacks of severe anxiety (panic) not restricted
to any particular situation or set of circumstances, and therefore unpredictable
secondary fears of dying, losing control or doing mad. Attacks usually last for
minutes only and patients often experience a crescendo of fear and autonomic
symptoms. Comparative freedom from anxiety symptoms between attacks,
although anticipatory anxiety is common.
It occurs in 1-2% of the general population, more commonly in females. The age of
onset is usually 20-40 years. There is an evidence of a genetic inherited
predisposition. Treatment: - psychological: cognitive-behavioural, exposure
techniques, anxiety management techniques; drugs: antidepressants - selective
serotonine (5-ht) reuptake inhibitors, benzodiazepines.
Generalized anxiety disorder. Generalized and persistent 'free floating' anxiety
symptoms involving elements of:

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Apprehension (worries about future misfortunes, 'feeling on edge',
difficulty in concentration etc.)
Motor tension (restless fidgeting, tension headaches, trembling, inability to

relax, etc.)
Autonomic overactivity (lightheadedness, sweating, tachycardia or

tachypnoea, epigastric discomfort, dizziness, dry mouth etc.).
3-5% of population are suffering from the disorder. It often begins in early adult life,
between the ages of 15 and 25 years. Women are affected more often then men (2:1).
The treatment includes psychological (cognitive therapy, anxiety management

training, relaxation techniques, brief focal therapy, marital or family therapy) and
drug therapies (tranquillizers, mainly benzodiazepines, antidepressants buspirone, (3-
adrenergic antagonists).
Mixed anxiety and depressive disorder. Symptoms of anxiety and depression are both
present but neither clearly predominate. Treatment: cognitive therapy,
antidepressants, minor tranquillizers.
6. Obsessive-compulsive disorder. Recurrent obsessional thoughts or

compulsive acts. At least one thought or act still unsuccessfully resisted.
Thought of carrying out the act is not pleasurable. Thoughts, images or
impulses must be unpleasantly repetitive.
0.5% of the general population; 4% of all neurotic disorders; 1% of the psychiatric

outpatient population.
Treatment: psychological - behavioural therapy, drug: serotonin (5-HT) reuptake
inhibitor antidepressants.

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7. Post-traumatic stress disorder. Delayed and/or prolonged response to
stressful event or situation of threatening or catastrophic nature, likely to cause
distress in anyone. Episodes of repeated reliving of the trauma in intrusive
memories ('flashbacks'), dreams or nightmares. Sense of 'numbness' and detachment
from other people. Avoidance of activities and situations reminiscent of trauma.
Usually autonomic hyperarousal with hypervigilance, an enhanced startle reaction
and insomnia.
The acute stress reaction - transient disorder which develops in an individual with no
other apparent mental disorder in response to exceptional physical and/or mental
stress; when stress continues or cannot be reversed, symptoms usually begin to
diminish after 24-48 hours, and are usually minimal after 3 days.
Treatment: psychotherapy: self-help and mutual support groups; antidepressant

medication (serotonin reuptake inhibitors, MAOIs).
Adjustment disorder is a state of emotional distress and disturbance, usually
interfering with social functioning, arising in a period of adaptation to a
significant life change or stressful life event. There may be a brief or prolonged
Terminology.
depressive reaction,(a) Depressive
a mixed anxiety and episode;
depressive (b) - recurrent
reaction or disturbance of
depressive episode; (c) bipolar disorder in DSM IV,
conduct.
manic episode in ICD 10; (d) to (f) bipolar disorder in
1.both
Definition
DSMofanxiety.
IV and ICD 10.
2. Definition of anxiety disorders.
3. linical features of social phobia.
C
4. Clinical features of agoraphobia.
5. Epidemiolody of phobic anxiety disorders.
6. Principles of treatment of phobic anxiety disorders.
7. What main differential features between generalized anxiety disorder and
depressive disorders?
8. Definition of obsessive-compulsive disorder.
9. What are the main diagnostic criteria of obsessive-compulsive disorder?
10. What is the main kind of treatment of obsessive-compulsive disorder?
11. Definition of posttraumatic stress disorder.
12. Clinical features of posttraumatic stress disorder.
13. Definition of adjustment disorder.
14. Prognosis of posttraumatic stress disorder.
Lesson 10
Theme: Personality disorders
Plan
1. Personality disorders definition.
2. Paranoid personality disorder.
3. Schizoid personality disorder.
4. Dissocial personality disorder.
5. Emotionally unstable personality disorder.
6. Histrionic personality disorder.
7. Anankastik personality disorder.

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8. Anxious (avoidant) personality disorder.
9. Dependent personality disorder.
10. Criteria for diagnosis. Treatment of personality disorders.
1. A personality can be defined as the lifelong persistent and enduring

characteristics and attitudes of an individual, including his or her ways of
thinking (cognition), feeling (affectivity) and behaviour impulse control and
ways of relating to others and handling interpersonal situations).
A personality disorder can be defined as an extreme persistent variation from the
normal range of one or more personality traits, causing the individual and/or his
family and/or society to suffer.
2. Those with the paranoid personality disorder tend to interpret the actions of
others as being deliberately demeaning and threatening. They are oversensitive,
suspicious, jealous; blame their own failures on others (projection) and overvalue
their own abilities. They hold grudge and can be litigious. Those with this personality
disorder have been leaders of cults and fringe groups, fanatics and dictators who
collect 'yes' men around them and attempt to isolate those with whom they do not
agree. It is more common in males. Under extreme stress such individuals can
develop transient paranoid psychotic symptoms (paranoid delusion and
hallucinations).
3. Those with schizoid personality disorder are indifferent to social
relationships. They have a restricted range of emotional expression and
experiences. Reserved, shy, introspective and eccentric, they become loners
and possibly vagrants or hermits. They resent being pushed into social
situations such as parties. They may have an eccentric interest. They may have
a preference for numbers rather than people and may function well as
mathematicians or with computers.
4. Dissocial (antisocial personality disorder is characterized by irresponsible
and antisocial behaviour in individuals at least 18 years of age, who have a
history of conduct disorder such as truancy from the age of 15 years. Such
individuals are prone to drug and alcohol abuse, and are more likely to die
prematurely by violent means.
5. Emotionally unstable personality disorder.
Impulsive type. The impulsive type of emotionally unstable personality disorder
(explosive or aggressive personality disorder) is characterized by episodic loss of
control of aggressive impulses, resulting in serious assaultative acts or destruction of
property disproportionate to any precipitating psychosocial stresses. Such individuals
have a short fuse, with a liability to outbursts of anger and violence under stress.
They may subsequently show genuine regret for and self-reproach about such
behaviour. Such individuals may batter their wives and children, from which they
may at the time derive feelings of power which they counter those of inadequacy.
Borderline type. This type is characterized by instability of self-image,
interpersonal relationship and mood. Such individuals may have chronic feelings of
emptiness and boredom, and their liability to become involved in intense and
unstable relationships may cause repeated emotional crises and

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may even be associated with a series of suicidal threats or acts of self-harm. Primitive
defence mechanisms, such as splitting and projective identification are seen.
6. Histrionic personality disorder is characterized by excessive emotionality,
attention-seeking and overdramatic behaviour. Such individual may act out the role of
victim or princess, but can be entertaining and the centre of the party. They are often
empathic and sexually flirtatious, although sometimes frigid. Histrionic personality
traits may be useful in acting and may explain the stereotype descriptions of
actresses. Interpersonal relationships are often stormy and ungatifying for such
individuals. The behaviour is conscious in histrionic personality disorder and should
be distinguished from dissociative disorder (symptoms are unconsciously produced).

1. What is the definition of Personality disorders?
2. What are the main features of Schizoid personality disorder?
3. What are the main features of Paranoid personality disorder?

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4. Criteria for diagnosis of Dissocial personality disorder.
5. Criteria for the differential diagnosis of Anankastik personality disorder and
obsessive-compulsive disorder.
6. Criteria for the differential diagnosis of Histrionic personality disorder and
dissociative (conversion) disorder.
7. What are the main methods of treatment of personality disorders?
Lesson 11
Theme: Sleep disorders
Plan
1. Definition of sleep
2. Classification of sleep disorders.
3. Nonorganic insomnia. Aetiology, epidemiology, clinical picture, differential
diagnosis.
4. Nonorganic hypersomnia. Aetiology, epidemiology, clinical picture, differential
diagnosis.
5. Nonorganic disorder of the sleep wake schedule. Aetiology, epidemiology,
clinical picture, differential diagnosis.
6. Heepwalking. Aetiology, epidemiology, clinical picture, differential diagnosis.
7. Sleep terrors. Aetiology, epidemiology, clinical picture, differential diagnosis.
8. Nightmares. Aetiology, epidemiology, clinical picture, differential diagnosis.
Sleep is usually described as a series of phases characterized by changes in

physiological variables, most notably the EEG. There is usually a typical body
posture (associated with good thermoregulation); physical inactivity; more
stimulation required to arouse than during wakefulness, a specific site or nest for this
behaviour; and regular daily occurrence.
With less than 3 hours sleep in 24 hours humans usually show increased irritability
and a decreased attention span long period if sleep deprivation result in poor
concentration, deterioration in general performance, increased suggestibility and,
later, hallucinations, paranoid and even seizures.
Human being spends, on average, 25% of their lives asleep. There is a variation in
sleep time, both in individuals during the course of development and the life cycle
and, also, between individuals.
Classification of sleep disorders.

Sleep disorders may be devided into those primarily of emotional origin and
those with an organic basis.
The ICD-10 categorization of sleep disorders:
Nonorganic sleep disorders
F 51.0 Nonorganic insomnia
F 51.1 Nonorganic hypersomnia
F 51.2 Nonorganic disorder of the sleep wake schedule
F 51.3 Heepwalking
F 51.4 Sleep terrors
F 51.5 Nightmares.
Insomnia.

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Insomnia is a disorder in which there is insufficient quantity or quality of sleep.
The diagnosis may be used at any age. Insomnia may be transient (a history of only a
few days or weeks) or chronic (an unremitting history over months or years).
Epidemiology.
Prevalence estimates in adults vary from 15% to over 40% and increase in the
elderly.
In childhood 14% of children have sleep difficulties at 3 years of age. Sleep
problems occur in many as 50-80 per cent of children with learning difficulties.
Clinical features.
True insomnia results in tiredness throughout the day. It is important to distinguish
lack of sleep from difficulty settling, although this may also reduce the length of time
asleep. Insufficient sleep due to late bedtimes will most often result in morning
tiredness, with difficulty rising, daytime sleepiness and unscheduled napping. Other
persons may show irritability, increased activity and impairment of concentration
when tired.
Insomnia is a prominent feature of both depression and mania and can also occur
in anxiety disorders. Where history and examination, show other symptoms of there
disorders then the predominant diagnosis must be of the mood or neurotic disorder
rather than the sleep disorder. Insomnia may be secondary to may organic disorders.
In schizophrenia there may be a day\night reversal in sleeping pattern.
Aetiology.
Predisposing factors.
The complaint is more common in lower socioeconomic groups. Individual
differences in body temperature, shin resistance and corticosteroid excretion have
been associated with variation in frequency the degree to which an individual
complains of insomnia.
Precipitating factors.
Transient insomnia is usually the result of:The1) treatment of
some environmental changes or a
change in the work rest pattern (poor sleep hygiene, change
arachnophobia by in time zone, change in
sleeping habits, shift work); 2) emotional crisis (bereavement, exams, house move
etc). systematic desensitization.
There are individual preferences in noise Atlevel,
eachlight
stage
and of the
temperature levels for
sleep. Generally sleep is likely to be disturbedhierarchy
at a temperature of more
of stimulus than 24 C. A
change in temperature may also evoke an episode of insomnia.
causing
Ingestion of pharmacologically active foods increasing
and drinks, especially caffeine and
anxiety,
alcohol, may disrupt sleep. Some drugs, particularly the subject
stimulants, may cause insomnia
either directly or as a result of ride-effects (akathisia
practices -restless legs of with
the techniques
phenothiazines).
Withdrawal from alcohol or hypnoticsrelaxationmay also training
reduce sleep or produce
alterations that increase waking. The use of very short acting hypnotics may
produce rebound waking in the middle of the night.
Although most chronic insomnias are related to medical, psychiatric or
behavioral problems, some people experience prolonged poor sleep without any
obvious disturbance in any of these areas (primary chronic insomnia) and can occur
with daytime sleepiness and\or impairment of mood and well being. It is though
that this is either associated with as yet undetected changes in sleep architecture, or is
part of the range of individual differences (chronic insomnia secondary to organic
factors is any condition that involves pain).
Perpetuating factors.
Transient insomnia may progresses to chronic insomnia if there is poor sleep hygiene
or if a vicious cycle is set up of worry about the lack of sleep leading to anxiety
symptoms which lead to further waking and difficulty settling.
Management.
1) Sleep hygiene is the basis of a preventive strategy.

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Sleep conditioning:
-use bed only for sleep
-only go to bed when sleepy
-get up if awake after 10 minutes.
*When anxiety associated, learn progressive muscle relaxation techniques.
*Low light and noise levels.
*Moderate intake of easily digested warm food (not a large meal nor caffeine).
2) Hypnotics - especially benzodiazepines have been prescribed in large quantities
over recent years (problems of dependence!!!). Tolerance develops withing 3-14
days. They should only be prescribed rarely, for short periods (less than a month), and
intermittently.
Longer-acting benzodiazepines such as diazepam or nitrazepam may be helpful
where the insomnia is associated with daytime anxiety. They are contraindicated in
the elderly as they can build up over a relatively short time to produce dangerous
levels of drowsiness, unsteadiness and confusion.
Shorter acting benzodiazepines are preferred in order to avoid the morning
hangover effects.
3) Behavioural approaches are the treatment of choice with children. Drugs are
rarely indicated, although they can be used sometimes for a very few days in order (to
break a cycle of night time waking or provide rest for exhausted parents).
The keys to successful treatment are:
- a thorough assessment of the settling sleep wake pattern;
- a clear understanding of the wishes and views of corers in order that a partner
ship to management may be achieved.
Combination of careful history taking and the carers keeping a diary of
settling, sleeping and waking with their responses.
Course and prognosis.
Transient insomnia can become chronic if various perpetuating factors are in
place, if measures are not taken to manage it appropriately or if cause is a chronic
condition. Chronic insomnia may be lifelong.
Hypersomnia.
Hypersomnia is a condition of excessive daytime sleepiness and sleep attacks
which occurs on a regular basis or recurrently for short periods, and causes a
disturbance of social or occupational functioning.
Epidemiology.
Daytime drowsiness has been found to occur in between 0,3 and 4% of the
population.
Hypersomnia must be distinguished from narcolepsy (consist of sleep attacks
only), or such symptoms as cataplexy (sudden loss of muscle tone when arousal
abruptly increased, e.g. when surprised).
- day-time sleepiness associated with sleep apnoea:
- organic; clouding of consciousness, fatigue states ( either normal, eras in chronic
fatigue syndrome) and circadian rhythm disturbances.
Kleine Levin syndrome is a rare disorder of hypothalamic activity with onset in
adolescence, a male preponderance, excessive eating and episodic hypersomnia.
Aetiology.
1) Hypersomnia may be an early symptom of depression.
2) Associations between attacks of sleepiness and unpleasant or unwanted
daytime experiences.
3) Idiopathic (no specific emotional psychological or psychiatric factors can be
identified).

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Management.
If there is an association with psychiatric disorder must be dreaded in the
normal way.
Stimulants (amphetamines) have been used to good effect in idiopathic
hypersomnia.
(Psychiatric condition courses determined by the primary disorder).
Idiopathic h. may change during development, and can improve with age.
Disorders of the sleep wake cycle are defined as sleep occurring at out of synchrony
with the environmental and social cues, or zeitgebers circadian rhythm disturbances
include entrainment failure, loss of central rhythmicity, delayed sleep phase
syndrome, advanced sleep phase syndrome, and sleep wake irregularity.
It may be diagnosed if there is no identifiable psychiatric or physical cause for
the disorder.
Entrainment failure means that there is an independent running of the
individuals sleep wake eyed (as occurs experimentally when subjects are kept in
isolation without zeitgebers), may occur because of damage to sight. Delayed sleep
phase syndrome and advanced sleep phase syndrome are diagnosed when sleep
occurs later or earlier, respectively.
It can be distinguished from organic pathology:
Dementia, delirium, head injury, withdrawal from intoxication.
Epidemiology.
Entrainment failure and primary delayed sleep phase syndrome are rare.
Irregularity of sleep pattern is common because of the many possible associations.
Management.
1) Entrainment failure due to lack of sleep-wake cues in one modality (light dark)
can be helped by attention to routine and cues in other sensory modalities.
2) Delayed sleep phase syndrome can be helped by advice to the patient to
advance his sleep time by a small amount in each 24 hours.
Parasomnias.
Parasomnias are those phenomena which occur as part of or alongside sleep. They
include:
- Sleepwalking (somnambulism);
- Night terrors (pavor nocturns);
- Nightmares or dream anxiety;
- Bruxism (teeth grinding);
- Nocturnal enuresis;
- Headbanging (jacatio capitis nocturns);
- Sleep paralysis;
- Nocturnal painful erections;
- Cluster headache;
- Physical symptomatology occuring at night (paroxysmal nocturnal dyspnoea,
sleep epilepsy);
- Sleep myoclonus.
Sleepwalking.
Somnambulism is a state of altered consciousness in which an individual gets up
from bed while asleep and walks. He may simply walk around the bedroom, but may
also walk outside. The individual is difficult to rouse, but usually returns to bed with
or with out gentle guidance. Often the person may sit up making purposeless
movements and mumbling. There is a close relation ship between sleepwalking and
night terrors. There is a risk of injury.

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Epidemiology.
Male: female radio is 3:4.
Over half the cases occur between the ages of 4 and 6; 15% of children aged
5-12 sleepwalk at least once 0.5% of adults. Differentiate from psychomotor epilepsy
during sleep (they can coexist).
Aetiology.
Sleepwalking occurs in stages 3 and 4 sleep. EEG activity does not differ from
the normal pattern. The general conclusion is that SW is due to physiological
immaturity. It is familial in 10-20% of cases.
Management:
- make the room and surrounding area safe,
- reassurance to the family is also important in view of the number of sinister
implications attributed to sleepwalking in novels and films,
- Anxiety reduction techniques,
- Small dose of a hypnotic medication.
Night terrors and nightmares
Involve the experience of fear and its physiological concomitants.
Comparison.
Nightmares Sleep terrors
Sleep stage RCM (oc 1-2) Stage 3-4
Time of night Middle and late sleep Mostly 1-2 hours after
sleep starts
Associations Hypnotic withdrawal Stress

Alcohol Previous sleep loss
b-blokers
Reserpine M>F
Depression
Other features Also occur in day haps Usually in deep sleep
Some relationship to anxiety Can accompany
Sompambulism
Occurs with enuresis
A night terror, occurring as it does in stage 3-4 sleep usually happens 1-2 hours
after going to sleep.
Typically a child will sit up in bed with a loud cry or scream and will continue to
cry, cream or chatter incoherently. The is usually pale clammy has dilated pupils and
may thrash around. There is hypertension during an attack. As little is usually
remembered the next day, the experience is more disturbing for the observer than for
the individual.
Nightmares, in contrast, are more clearly remembered. The waking may have
occurred at a time of motor activity in the dream.
Epidemiology.
1-4% of children, much less common in adulthood.
Aetiology.
Night terrors are sometimes familial. They can be reproduced by some
benzodiazepines antagonists.
They can be associated with upper airway obstruction and can disappear with
adenoidectomy.
Nightmares may be negative dreams (depression, stress anxiety).
Management.

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Nightmares no treatment in themselves. Night terrors usually an individual
can be helped to settle in 5-10 min; changing the settling routine (hot drink, have a
bath) stop it.
Making a careful diary of the terrors over the course of the week (note time).
The following week the child should be completely awoken such night for 5-10
minutes before the derior would have occurred, and then resettled.
Night terrors resolve spontaneously.

1. What are main predisposing factors of sleep disorders?
2. What main kinds of sleep disorders do you know?
3. What are main differential features of night terror and nightmares do you know?
4. What is aetiology of Sleepwalking?
5. What are main kinds of sleeplessness?
6. What are main kinds of Parasomnias?
7. Hypersomnia must be distinguished from narcolepsy. What are main differential
features?
Lesson 12
Theme: Epilepsy
Plan
1. Definitions.
2. International classification of epileptic seizures.
3. Preictal and ictal symptoms.
4. Personality disturbances in epilepsy
5. EEG changes in epilepsy
Epilepsy is the most common chronic neurological disease in the general
population, affecting about 1% of the population. For psychiatrists the major
concerns regarding epilepsy are consideration of an epileptic diagnosis in psychiatric
patients, psychological and cognitive effects of commonly used antiepileptic drugs.
30-50% of all epileptic persons have psychiatric difficulties sometime during the
course of their illness. The most common behavioural symptom of epilepsy is a
change in personality; psychosis, violence and depression are much less common
symptoms of an epileptic disorder.
Definitions
A seizure is a transient paroxysmal pathological disturbance of cerebral function that
is caused by a spontaneous, excessive discharge of neurons. Epilepsy is a chronic
condition characterized by recurrent seizures. The ictus or ictal event of seizure is the
seizure itself. The nonictal time periods can be categorized as preictal, posictal and
interictal. The symptoms present during the ictal event are primarily determined by
the site of origin in the brain for the seizure and by the pattern of the spread of the
seizure activity through the brain.
Classification
The two major categories of seizures are partial and generalized. Partial seizures
involve epileptiform activity in localized brain regions; generalized seizures involve
the entire brain.
International classification of epileptic seizures.
I. Partial seizures (seizures beginning locally)
A. Partial seizures with elementary symptoms generally without
impairment of consciousness

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1. with motor symptoms
2. with sensory symptoms
3. with autonomic symptoms
4. compound forms
B. Partial seizures with complex symptoms (generally with impairment of
consciousness; temporal lobe or psychomotor seizures)
1. with impairment of consciousness only
2. with cognitive symptoms
3. with affective symptoms
4. with psychosensory symptoms
5. with psychosensory symptoms (automatisms)
6. compound forms
C. Partial seizures secondary generalized
II. Generalized seizures (bilaterally symmetrical and without local onset)
A. Absences (petit mal)
B. Myoclonus
C. Infantile spasms
D. Clonic seizures
E. Tonic seizures
F. Tonic-clonic seizures
G. Atonic seizures
H. Akinetic seizures
III. Unilateral seizures
IIII. Unclassified seizures (because of incomplete data)
Generalized seizures
Generalized tonic-clonic seizures have the classic symptoms of loss of consciousness,
generalized tonic-clonic movements of the limbs, tongue biting and incontinence.
The period of recovery from a generalized tonic-clonic seizure ranges from a few
minutes to many hours. The clinical picture is that of a gradually clearing delirium.
Absences (petit mal)
The epileptic nature of the episodes may go unrecognized, because the characteristic
motor or sensory manifestations of epilepsy may be absent. Petit mal epilepsy usually
begins in childhood between the ages of 5 and 7 years. Brief disruptions of
consciousness, during which the patient suddenly loses contact with the environment,
are characteristic of petit mal. The EEG produces a characteristic pattern of three-per-
second spike and wave-activity.
Adult onset petit mal epilepsy is characterized by sudden, recurrent psychotic
episodes or deliriums that appear and disappear abruptly. The symptoms may be
accompanied by a history of falling or fainting spells.
Partial seizures
are classified as either simple (without alterations in consciousness) or complex (with
alterations in consciousness).
Symptoms
1. Preictal symptoms. Preictal events (auras) in complex partial epilepsy include
automatic sensations (e.g. fullness of stomach, blushing, changing in
respirations), cognitive sensations (e.g. dj vu, jamais vu, forced thinking and

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dreamy states), affective states (fear, panic, depression, and elation), and
classically, automatisms (e.g. lip smacking, subbing and chewing).
2. Ictal symptoms. Brief, disorganized, and uninhibited behaviour characterizes
the ictal event. The cognitive symptoms include amnesia for the time during
the seizure and a period of resolving delirium after the seizure. Normal EEG
are often obtained from a patient with complex partial epilepsy; normal EEG
cannot be used to exclude a diagnosis of complex partial epilepsy. The use of
long-term EEG recordings (usually 24 to 72 hours) can help the clinician detect
a seizure focus.
Personality disturbances
The most frequent psychiatric abnormalities reported in epileptic patients are
personality disorders, and they are especially likely to occur in patients with epilepsy
of temporal lobe origin. The most common features are changes in sexual behaviour,
a quality usually called viscosity of personality, religiosity and a heightened
experience of emotions.
Changes in sexual behaviour may be manifested by hypersexuality; deviations in
sexual interest, such as fetishism and transvestism; and, most commonly,
hyposexuality. The hyposexuality is characterized both by lack of interest in sexual
matters and by reduced sexual arousal. Some patients with the onset of complex
partial epilepsy before puberty may fail to reach a normal level of sexual interest after
puberty.
The symptoms of viscosity is usually most noticeable in a patients conversation,
which is likely to be slow, serious, ponderous, pedantic, overly replete with
nonessential details, and often circumstantial. The listener may grow bored but be
unable to find a courteous and successful way to disengage from the conversation.
The speech tendencies are often mirrored in the patients writing, resulting in a
symptom known as hypergraphia.
Religiosity may be sticking and may be manifested not only by increased
participation in overly religious activities, but also by unusual concern for moral and
ethical issues, preoccupation with right and wrong and heightened interest in global
and philosophical concerns.
Violence. Episodic violence has been a problem in some patients with epilepsy,
especially epilepsy of temporal and frontal lobe origin.
Violence may be a manifestation of the seizure itself or interictal psychopathology.
Mood disorders. Depression, mania are seen less often in epilepsy than in
schizophrenic disorder.
The mood disorder symptoms that do occur tend to be episodic and occur most often
when the epileptic foci affect the temporal lobe of the nondominant cerebral
hemisphere.
Increased incidence of attempted suicide.
Psychotic symptoms
Schizophrenia like interictal episodes can occur in patients with epilepsy,
particularly those with temporal lobe origins.

Pgina 53 de 65
1. International classification of epileptic seizures.
2. Definition of epilepsy.
3. What is the most common behavioural symptom of epilepsy?
4. How can the nonictal time periods be categorized?
5. What kinds of seizures are partial?
6. What kinds of seizures are generalized?
7. What main kinds of EEG changes in epilepsy do you know?
8. What kinds of mood disorders in epilepsy do you know?
9. What kinds of absences (petit mal) do you know?

Pgina 54 de 65
10. What kinds of partial seizures (seizures beginning locally) do you know?
11. Main methods of treatment in epilepsy.
Lesson 13
Theme: Non-organic eating disorders
Plan
1. Definition of Eating disorders.

2. Definition of Anorexia nervosa.
3. The diagnostic criteria for anorexia nervosa.
4. Epidemiology and Etiology of anorexia nervosa.
5. Clinical features of anorexia nervosa.
6. Treatment and prognosis of anorexia nervosa.
7. Definition and diagnostic criteria of bulimia nervosa.
8. Clinical features of bulimia nervosa.
9. Treatment and prognosis of bulimia nervosa.
Eating disorders
Eating disorders are behavioral syndromes that develop in individuals who
manifest a broad spectrum of psychological, biological & sociocultural
characteristics. They include anorexia nervosa & bulimia nervosa.
Anorexia nervosa
Anorexia nervosa is characterized by a profound disturbance of body image &
relentless pursuit of thinness.
The disorder is much more prevalent in females than in males & usually has its
onset in adolescence. Hypotheses of it in young women with the disorder include
conflicts surrounding in the transition from a girl to a woman.
The diagnostic criteria for anorexia nervosa
1. Refusal to maintain body weight at or above a minimally normal weight for age &
height (e.g. weight loss leading to maintenance of body weight less than 85% of
that expected; or failure to make expected weight gain during period of growth,
leading to body weight less than 85% of expected)
2. Intensive fear of gaining weight or becoming fat, even though underweight
3. Disturbance in the way in which ones body weight or shape is experienced; undue
influence of body weight or shape on self-evaluation; or denial of the seriousness
of current low body weight
4. In postmenarchal females amenorrhea, i.e. the absence of at least three
(consecutive) menstrual cycles. A women is considered to have amenorrhea if her
periods occur only following hormone, e.g. estrogen, administration
Specify types
Restricting type: During the episode of anorexia nervosa the person does not
regularly engage in binge eating or purging behavior (i.e. self-induced
vomiting or the misuse of laxatives or diuretics)

Pgina 55 de 65
Binge eating/Purging type: During the episode of anorexia nervosa the
person regularly engages in binge eating or purging behavior (i.e. self-
induced vomiting or the misuse of laxatives or diuretics)

pidemiology
E
Bulimia nervosa is more prevalent than anorexia nervosa. Estimates of bulimia
nervosa range from 1 to 3% of young women. Like anorexia nervosa, bulimia
nervosa is significantly more common in females, than in males, but its onset is often
later in adolescence than the onset of anorexia nervosa or in early adulthood
occasional symptoms of bulimia nervosa such as isolated episodes of binge eating &
purging, have been reported in up to 40% of college women. Although bulimia
nervosa is often present in normal weight young women, they sometimes have a
history of obesity.
Etiology
1. Biological factors: Some investigations have attempted to associate cycles of
binging & purging with various neurotransmitters. Because antidepressants
often benefit patients with bulimia nervosa, serotonin & norepinephrine have
been implicated.
Plasma endorphin levels are raised in some bulimia nervosa patients who
vomit, leading to the possibility that the feelings of well-being experienced by
some of those patients after vomiting may be mediated by raised endorphin
levels.
2. Social factors: Patients with bulimia nervosa like those with anorexia nervosa
tend to be high achievers & to respond to societal pressures to be thin. As
which anorexia nervosa patients many bulimia nervosa patients are depressed
& have increased familial depression. However, the families of such patients
are generally different from those of anorexia nervosa patients. Families of
bulimia nervosa patients are less close & more conflictual than the families of
anorexia nervosa patients. Bulimia nervosa patients describe their parents as
neglectful & rejecting.
3. Psychological factors: Patients with bulimia nervosa like those with anorexia
nervosa have difficulties with adolescent demands, but bulimia nervosa
patients are more outgoing, angry & impulsive than a. n. patients. Alcohol
dependence, shoplifting & emotional lability (including suicide attempts) are
associated with bulimia nervosa. Bulimia nervosa patients difficulties in
controlling their impulses are often manifested by substance dependence &
self-destructive sexual relationships in addition to the binge eating & the
purging that are the hallmarks of the disorder.
Diagnosis & clinical features
The essential features of bulimia nervosa are recurrent episodes of binge eating;
a tense of each of control over eating during the eating binges; self-induced vomiting,
the misuse of laxatives & diuretics, fasting or excessive exercise to prevent weight
gain; persistent self-evaluation unduly influenced by body shape & weight.
Vomiting is common & is usually induced by sticking a finger down the throat,
although some patients are able to vomit at will. Vomiting decreases the abdominal
pain & the feeling of being bloated & allows the patients to continue eating without
fear of gaining weight. Depression often follows the episode & has been called
postbinge angaish.
The food is eating secretly & rapidly & is sometimes not even chewed. Bulimia

Pgina 56 de 65
nervosa patients are concerned about their body image & their appearance, worry
about have others see them & are concerned about their sexual at attractiveness. Most
bulimia nervosa patients are sexually active, compared with anorexia nervosa
patients, who are not interested in sex.
Patients with the purging behavior may be at risk for certain medical
complications such as hypokaliemia from vomiting or laxative abuse &
hypochloremic alkalosis.
Those who vomit repeatedly are at risk for gastric & esophageal tears.
Bulimia nervosa occurs in persons with high rates of mood disorders & impulse
control disorders. They have increased rates of anxiety disorders, dissociative
disorders.
Laboratory examination
Bulimia nervosa can result in electrolyte abnormalities & various degrees of
starvation. Thus even with normal-weight patients with bulimia nervosa the clinician
should obtain laboratory tests of electrolytes & metabolism. In general thyroid
function remains intact in bulimia nervosa but the patients may show non-supression
on the dexamethasone supression test. Degidratation & electrolyte disturbances are
likely to occur in bulimia nervosa patients who regularly purge. Hypomagnesemia &
hyperamylasemia. Patient may have menstrual disturbances. Hypotension &
bradicardia occur in some patients.
Differential diagnosis
The diagnosis can not be made if the binge eating & purging behaviors occur
exclusively during episodes of anorexia nervosa, binge eating/purging type.
The clinician must ascertain that the patient has no neurological disease such as
epileptic-equivalent seizures, central nervous system tumors.
Kliver-Bucy syndrome tortures are visual agnosia compulsive licking & biting,
the examination of objects by the mouth, inability to ignore & stimulus, placidity,
altered sexual behavior (hypersexuality) & altered dietary habits, especially
hyperphagia.
Kleine-Levin syndrome consists of periodic hypersomnia lasting for two to three
weeks & hyperphagia. The syndrome is more common in men. The onset is usually
during adolescence. Bordline personality disorder patients sometimes binge eat but
the eating is associated with the other signs of the disorder.
Course & prognosis
Bulimia nervosa seems to have a better prognosis than does anorexia nervosa.
The patients are not symptom free during period of improvement. It is a chronic
disorder with a waxing & waning course.
Less than one third of patient are doing well on a three year follow-up more than
one third have some improvement in their symptoms & about one third have a poor
outcome with chronic symptoms.
The prognosis depends on the severity of the purging sequel that is whether the
patient has electrolyte imbalance & to what degree the frequent vomiting requests in
esophagitis, amylasemia, salivary gland enlargement & dental caries.
Treatment
Includes individual therapy with a cognitive behavioral approach, group therapy,
family therapy & pharmacotherapy. Patients with bulimia nervosa are not as secretive
about their symptoms as patients with anorexia nervosa therefore treatment is usually
not difficult.
Pharmacotherapy: antidepressant medication can seduce binge eating & purging
independent of the presence of a mood disorder. Imipramine (Tofranis), desipramine

Pgina 57 de 65
(Norpramin), trazodone (Desipel) & MAO inhibitors have been helpful. Prozac is
also promising as an effective treatment (but dose of it may be higher (60 mg/day)
than those used in depressive disorders).
Carbomazepine & lithium in bipolar disorder.
Bulimia nervosa
Bulimia nervosa, which is more common than anorexia nervosa, consist of
recurrent episodes of eating large amounts of food accompanied by a feeling of being
out of control. Social interruption or physical discomfort that is abdominal pain or
nausea terminates the binge eating which is often followed by feelings of quiet,
depression or self disgust. The person also has recurrent compensatory behaviors
such as purging (self-induced vomiting, repeated laxative or diuretic use), excessive
exercise to prevent weight gain. Unlike anorexia nervosa patients those with
bulimia nervosa may maintain a normal body weight.
Diagnostic criteria for bulimia nervosa
1. Recurrent episodes of binge eating. An episode of binge eating is characterized
by both of the following
a. eating, in a discrete period of time (e.g. within any 2 hour period), an
amount of food that is definitely larger than most people would eat
during a similar period of time & under similar circumstances
b. a sense of lack of control over eating during the episode (e.g. a feeling
that one cannot stop eating or control what or how much one is eating)
2. Recurrent inappropriate compensatory behavior in order to prevent weight
gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas or
other medications, for fasting or excessive exercise
3. The binge eating & inappropriate compensatory behaviors both occur on
average at least twice a week for 3 month
4. Self-evaluation is unduly influenced by body shape & weight
5. The disturbance does not occur exclusively during episodes of anorexia
nervosa
Specify types:
Purging type: during the current episode of bulimia nervosa the person has
regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics
or enemas
Nonpurging type: during the current episode of bulimia nervosa such as fasting
or excessive exercise but has not regularly engaged in self-induced vomiting or
the misuse of laxatives, diuretics or enemas
Diagnosis & clinical features
The onset of anorexia nervosa usually occurs between the age of 10 & 30 years.
After the age of 13 years the frequency of onset increases rapidly with the maximum
frequency at 17 to 18 years of age.
Anorexia nervosa patients usually refuse to eat with their families or in public
places. They lose weight by a drastic reduction in their total food intake, with a
disproportional decrease in high-carbohydrate & fatty foods.
The term of anorexia meaning loss of appetite, is a misnomer, because the loss
of appetite is usually rare until late in the disorder. Evidence that the patient are
constantly thinking about food in their passion for collecting recipies & preparing

Pgina 58 de 65
elaborate meals for others. Some patients cannot continuously control their voluntary
restriction of food intake & they have eating binges. Those binges usually occur
secretly & often at night. Self-induced vomiting frequently follows the eating binge.
Patients abuse laxatives & even diuretics to loss weight. Ritualistic exercising,
extensive cycling, walking, jogging & sunning are common activities.
Patients with the disorder exhibit peculiar behavior regarding food. They hide
food & over the house & frequently carry large quantities of candies in their pockets
& purses.
They cut their meat into very small pieces & spend a great deal of time
rearranging the food pieces on their plates. If the patients are confronted about their
peculiar behavior they often deny that their behavior is unusual of flatly refuse to
discuss it.
An intense fear of gaining weight is present in all patients with the disorder &
contributes to their lack of interest in therapy & even resistance to it.
Obsessive-compulsive behavior, depression & anxiety are the other psychiatric
symptoms in anorexia nervosa. Poor sexual adjustment is frequently described in
patients.
Patients usually come to medical attention when their weight loss become
apparent. As the weight loss becomes profound, physical signs such as hypothermia
(as low as 35C), dependent edema, bradicardia, hypotension, lanugo (the appearance
of neonatal-like hair) apper & the patient presents a variety of metabolic changes.
Some female anorexia nervosa patients come to medical attention because of
amenorrhea which often appears before their weight loss is noticeable.
Some anorexia nervosa patients induce vomiting or abuse purgatives &
diuretics, causing concern about hypokaliemi alkalosis. Impaired water diuresis may
be noted on ECG.
Electrocardiographic (ECG) changes such as flattening r inversion of the T-
waves, ST segment depression & lengthening of the QT- interval - have been noted
in the emaciated stage. ECG changes may also occur as a result of potassium loss,
which may lead to death.
Other medical complications of anorexia nervosa are:
1. Related to weight loss:
a. Cachexia: loss of fat, muscle mass, reduced thyroid metabolism (low T 3
syndrome), cold intolerance & difficulty in maintaining core body
temperature
b. Cardiac: loss of cardiac muscle; small heart; cardiac arrhythmias,
including atrial & ventricular premature contractions, prolonged His
bundle transmission (prolonged QT-interval), bradicardia, ventricular
tachycardia; sudden death
c. Digestive-gastrointestinal. Delayed gastric emptying, bloating,
constipation, abdominal pain
d. Reproductive: Amenorrhea, low levels of luteinizing hormone (LH) &
follicle-stimulating hormone (FSH)
e. Dermatological: lanugo (fine baby-like hair over body), edema
f. Hematological: leucopenia
g. Neuropsychiatric: abnormal taste sensation, apathetic depression, mild
cognitive disorders

Pgina 59 de 65
h. Skeletal: osteoporosis
2. Related to purging (vomiting & laxatives abuse)
a. Metabolic: Electrolyte abnormalities, particulary hypokaliemic,
hypochloremic alkalosis, hypomagnesemia
b. Digestive-gastrointestinal: Salivary gland & pancreating inflammation &
enlargement with increase in serum amylase, esophageal & gastric
erosion, dysfunctional bowel with haustral dilation
c. Dental: Erosion of dental enamel, particularly of front teeth with
corresponding decay
d. Neuropsychiatric: Seizures (related to large fluid shifts & electrolyte
disturbances), mild neuropathies, fatigue, weakness, mild cognition
disorder
e.
Patients with anorexia nervosa are often secretive, deny their symptoms
& resist treatment
Epidemiology
Eating disorders of various kind have been reported in up to 4% of adolescent &
young adult students. Anorexia nervosa is estimating to occur in about 0,5 to 1% of
adolescent girls. It occurs 10 to 20 times more often in females than in males. It
seems to be most frequent in developed countries & it may be seen with greatest
frequency among young women in progressions that require thinness such as
modeling & ballet.
Etiology
1. Biological factor: some evidence points to higher concordance rates in
monozygotic twins than in dizigotic twins. Systems of anorexia nervosa
patients are likely to be afflicted. Major mood disorders are more common in
females members than in the general populations. Neurochemically diminished
norepinephrine turnover & activity are suggested by the reduced 3-methoxy-4-
hydroxyphenylglycol (MHPG) in the urine & the cerebrospinal fluid (CSF) of
some anorexia nervosa patients. An inverse relation is seen between MHPG &
the depression in patients with anorexia nervosa: an increase in MHPG is
associated with a decrease in depression
Endogenous opiates may contribute to the denial of hunger in anorexia nervosa
patients.
Several computed tomographic (CT) investigations reveal enlarged CSF spaces
(enlarged sulci & ventricles) in anorexia nervosa patients during starvation & finding
that is reversed by weight gain. In one positrone emission tomography (PET) scan
study, caudate nucleus metabolism was higher in the anorectic state than after
realimentation. Patients with Anorexia nervosa have family histories of depression,
alcohol dependence or eating disorders.
2.Social factor: Anorexia nervosa patients find support for their practices in
societys emphasis on thinness & exercise
Anorexia nervosa patients have close but troubled relationships with their parents.
3. Psychological factor: Anorexia nervosa appears to be a reaction to the
demands on adolescents for more independence & increased social & sexual
functioning. Patients with Anorexia nervosa typically lack a sense of autonomy
& selfhood. Many patients with the disorder experience their bodies as
something under the control of their parents.

Pgina 60 de 65
Only through acts of extraordinary self-discipline the anorectic patient can
develop a sense of autonomy & selfhood
4. Psychodinamic factor: Young patients have been unable to separate
psychologically from their mothers
The body may be perceived as through it were inhabited by an introject of an
intrusive & unempathic mother. Starvation may have the unconscious meaning of
arresting the growth of that intrusive internal object & there by destroying it.
Laboratory examination
The tests include serum electrolytes with renal function tests, thyroid function
tests, glucose, amylase & hematological tests; an electrocardiogram; cholesterol
level; dexamethasone suppression test & carotene level.
The clinician may find decreased thyroid hormone, increased serum glucose,
nonsupression of cortisole after dexamethasone, hypokaliemia, increased blood urea
nitrogen & hypercholesterolemia. Cardiovascular complications are common &
include hypotension & bradicardia.
Differential diagnosis
a. Medical illness that can account for the weight loss (for example, a brain
tumor or cancer)
b. Depressive disorder: patient with a depressive disorder has a decreased
appetite whereas an anorexia nervosa patient claims to have a normal
appetite & to feel hungry. Only in the sever stages of anorexia nervosa
does the patient actually have a decreased appetite. The preoccupation
with the caloric content of food, recipes & preparation of gourmet feasts
is typical of the anorexia nervosa patients. And in depressive disorders
the patient has no intense fear of obesity or disturbance of body image
c. Weight fluctuations, vomiting & peculiar food handling may occur in
somatization disorder. Generally the weight loss in somatization disorder
is not as severe as that in anorexia nervosa; not does the patient with
somatization disorder express a morbid fear of becoming overweight.
Amenorrhea for three month or longer is unusual in somatization
disorder.
d. Delusions about food in schizophrenia. are seldom concerned with the
caloric content of food, patient is rarely preoccupied with a fear of
becoming obese & does not have the hyperactivity that is seen in
anorexia nervosa. They have bizarre eating habits
e. Bulimia nervosa, a disorder with episodic binge eating followed by
depressive moods, self-deprecating thoughts & often self-induced
vomiting. Patient seldom has a 15% weight loss (the two conditions
frequently coexist)

Course & prognosis
The course of anorexia nervosa varies greatly-spontaneous recovery without
treatment, recovery after a variety of treatment, a fluctuating course of weight gain
followed by relapses a gradually deteriorating course resulting in death caused by
complications of starvation. In general the prognosis is not good, because social
relationships are poor, many patients are depressed. Mortality rates from 5 to 18%.
Treatment
The decision to hospitalize the patient is based on the patients medical

Pgina 61 de 65
condition. In patient psychiatric programs for anorexia nervosa patients generally use
a combination of a behavioral management approach, individual psychotherapy,
family education & therapy psychotropic medications
Most patients are resistant to treatment. They rarely accept the recommendation of
hospitalization.
Restore nutritional balance through normal eating & encourage weight gain.
Low-dose neuroleptics or benzodiazepine-class anxiolytics may be used if fear
of weight gain is excessive. Cyproheptadine, an appetite stimulator, &
serotonin antagonist
Diagnose & treat psychiatric comorbidity (affective disorder may be treated
with antidepressants). Personality disorders should be addressed in
psychotherapy
Assess the family
Provide ongoing support (support heallhydict & exercise habits, constructive
approaches to self, family & interception problems, sense of autonomy with
ongoing psychotherapy)
1. What is the definition of Eating disorders?
2. What is the definition of Anorexia nervosa?
3. What kind of the diagnostic criteria for anorexia nervosa do you know?
4. What do you know about the epidemiology and aetiology of anorexia nervosa?
5. What are the main clinical features of anorexia nervosa?
6. Treatment and prognosis of anorexia nervosa.
7. What is the definition and diagnostic criteria of bulimia nervosa?
8. What are the main clinical features of bulimia nervosa?
9. Treatment and prognosis of bulimia nervosa.
Petit mal epilepsy characterized by bilaterally

synchronous, 3-Hz spike
-and-wave activity.

Pgina 62 de 65
Literature
EEG M.,
1. Gelder recording during generalized tonic-clonic seizure,
Gath D., Mayou R., Cowen P.: Oxford Textbook of psychiatry.
showing
Third rhythmic
edition, 1996. - P. 994.sharp waves and muscle artifact during
tonic I.phase,
2. Kaplan spike-and-wave
H., Sadock discharges
. J., Grebb J. A., Synopsis of during clonic phase,
psychiatry.
and attenuation of activity during postictal state.
Seventh edition, 1994. - P. 1257.
3. Puri . ., Laking P. J.: Textbook of psychiatry, 1996. - P. 546.
4. Scully J. H., Bechtold D. W., Bell J. A., Dubovsky L. D., Gordon L. N. et al.
The National Medical Series for independent study. Psychiatry.
The third edition, 1994. - P. 335.
5. Tomb A. D. Psychiatry. Forth edition, 1999. - P. 234.
Additional literature
1. Early detection and management of mental disorders / Edited by Mario Maj[et

al.], 2005. - 306 p.
2. Manual of clinical psychopharmacology / Alan F. Schatzburg [et al.] 5th edition,
2005. - 636 p.
3. Comprehensive handbook of psychopathology / Edited by Henry E. Adams and
rd
Patricia B. Sutker. 3 edition, 2004. - 970 p.
4. .. :
. 2- ., . . .: ,
, 1997. 436 .
Content

Pgina 63 de 65
Lesson 1. Definition of psychiatry. Classifications in psychiatry. (ICD-
10, DSM-IV). Interviewing, clinical examination, clinical laboratory
studies in psychiatry.. 5
Lesson 2. Disorders of perception, thinking, sensory synthesis... 14
Lesson 3.Disorders of memory, attention and concentration, emotions

and mood, will-activity 21
Lesson 4. Disorders of consciousness, orientation, and psychomotor

activity. Disorders of intelligence (IQ) 25
Lesson 5. Organic, including symptomatic mental disorders. The

syndrome of Dementia. 28
Lesson 6. Organic amnesic syndrome, delirium, other mental disorders

due to brain damage or dysfunction: organic hallucinosis, organic
delusional disorder, organic mood disorder, organic anxiety disorder).
Personality and behavioural disorder due to the brain disease 39
Lesson 7. Schizophrenia... 44
Lesson 8. Mood disorders. 50
Lesson 9. Neurotic stress-related disorders... 54
Lesson 10. Personality disorders... 61
Lesson 11. Sleep disorders 65
Lesson 12. Epilepsy 73
Lesson 13. Non-organic eating disorder.. 79
Literature.. 93

Pgina 64 de 65

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44

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Psychiatry Methodical

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State Educational Establishment of Higher Professional

Education Kursk State Medical University

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L.I. Zakharova. Methodological recommendations for students to be used in

The methodological recommendations are recommended for the foreign medical

L.I. Zakharova, 2007

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ISBN 978-5-7487-1195-1 56.14:81.2 7

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Theme: Definition of psychiatry. Classifications in psychiatry.

2. Connections with other sciences.

3. Classifications in psychiatry: organic, functional disorders; neurosis and

4. Interviewing, clinical examination. The scheme of history taken. Mental state

5. Clinical laboratory studies in psychiatry.

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Psychotherapy The treatment of psychological issues by non-physical

Common confusions associated with psychiatry are summarized in the table:

A substantial proportion of patient, seen by a doctor suffers from psychiatric

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Perpetuating factors are those that cause an existing psychiatric disorder to

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3. Occupational history. Summarize the occupational history, giving details of

Past psychiatric history: This involves details of

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- referred to the self- depersonalizations

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Student should be able

1. Disorders of perception (illusions, hallucinations, pseudohallucinations).

2. Disorder of the form of thought (disorders of the stream of thought,

3. Disorders of the thought content (overvalued ideas, obsessional ideas,

4. Disorders of sensory synthesis.

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- Trailing phenomenon. Moving objects are seen as a series of discrete

In pareidolia, vivid image occurs without conscious effort while looking at a

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1) Primary delusion ( jelosy, invention and others )

II. Paranoid (syndrome of psychical automatisms)

1) Persecutory delusion (secondary)

with mainly with mainly

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4. Disorders of sensory synthesis. Autometamorphopsia. The patient complains of

Questions for control

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Questions for control

1. Description of normal memory processes.

3. Description of special types of affect.

9. Definition and description of impulsive drives

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Posturing (adoption of unusual bodily postures continuously for a long

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Questions for control

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2. Dementia is characterized by generalized psychological dysfunction of higher

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3. In Parkinson's disease there is a substantial loss of pigmented

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4. Pick's disease is a rare cause of dementia. Some cases are transmitted as an

5. Huntington's disease (Huntington's chorea) is an autosomal dominant disorder

https://lookaside.fbsbx.com/file/psychiatry-methodical.doc-E8NnBuszPt0b_rD5RD0pZHCTAo7aodeKtUK2mGGnCS_wasI 02/03/17 12U50