PSYCHIATRY

PYUZA,MD
What is health???
OVERVIEW
• Psychiatry is the medical specialty devoted to the diagnosis,
prevention, and treatment of mental conditions.
• It have a lot of condition but according to our curriculum we are
going to discuss the following condition
• SCHIZOPHRENIA
• BIPOLAR DISORDER
• GENERALISED ANXIETY DISORDER
• SUBSTANCE USE DISORDER
Revision
• Hallucination ????
• Hallucinations are perception-like experiences that
occur without an external stimulus.
• They are vivid and clear, with the full force and impact
of normal perceptions, and not under voluntary
control..
• It can be visual, auditory(most common ), olfactory,
Tactile, Gustatory(tastes)
• Delusion ?
 a false belief or judgment about external reality
• Erotomanie type: This subtype applies when the central theme of the
delusion is that another person is in love with the individual.
• Grandiose type: This subtype applies when the central theme of the delusion is
the conviction of having some great (but unrecognized) talent or insight or
having made some important discovery.
• Jealous type: This subtype applies when the central theme of the individual’s
delusion is that his or her spouse or lover is unfaithful.
• Persecutory type: This subtype applies when the central theme of the delusion
involves the individual’s belief that he or she is being conspired against,
cheated, spied on, followed, poisoned or drugged, harassed, or obstructed in
the pursuit of long-term goals.
• Somatic type: This subtype applies when the central theme of the
delusion involves bodily functions or sensations.
• Mixed type: This subtype applies when no one delusional theme
predominates.
• Unspecified type: This subtype applies when the dominant delusional
belief cannot be clearly determined or is not described in the specific
types (e.g., referential delusions without a prominent persecutory or
grandiose component).
• Specify if:
• With bizarre content: Delusions are deemed bizarre if they are clearly
implausible, not understandable, and not derived from ordinary life
experiences (e.g., an individual’s belief that a stranger has removed his or
her internal organs and replaced them with someone else’s organs
without leaving any wounds or scars)
• Thought
 an idea or opinion produced by thinking, or occurring suddenly in the mind
• Affect
ability to influence your mind in a way that is linked to your body
• Insomnia
is when you aren't sleeping as you should(lack of sleep VS no need to sleep)
Grossly Disorganized
• Negative Symptoms- Two negative symptoms are particularly prominent in
schizophrenia: diminished emotional expression and avolition. Diminished
emotional expression includes reductions in the expression of emotions in the
face, eye contact, intonation of speech (prosody), and movements of the hand,
head, and face that normally give an emotional emphasis to speech. Avolition is a
decreasein motivated self-initiated purposeful activities.
OTHER SYMPTOM YOU WILL GO AND READ (DSM V)
History
•Patients profile
•Presenting Complaint
•History of presenting complaint
•Past Psychiatric History
•Past Medical History
•Medications history
•Family History
•Personal History
•Substance Use
•Forensic History
•Premorbid personality
Examination
• Mental status examination
• General and systemic examination
Appearance and behaviour
•Body language & appropriateness of
dressing, grooming, gait.
•Evidence of self neglect-unkempt/kempt
•Under or over psychomotor activity –
excitation or retardation
•Facial expression – dilated pupils, rigidity
•Abnormal movements or posture
•Rapport & eye contact
Speech
•Rate, tone & volume
•Level of coherence
•Rate: slow in depression;
pressured in mania.
•Quantity: poverty in
depression & chronic
schizophrenia
•Neologisms, word salad,
loosening of associations,
etc.
Mood and Affect
• Mood :Subjective emotional state in the patients
own words
• Affect : Objective Emotional state in terms of
quality
• Range; depressed ,elevated ,anxious
Inability to enjoy activities (anhedonia)
Inability to describe one’s emotion (alexithymia)
Stability ;fixed ,labile
• Intensity : flat ,blunted
Fluctuations: reactivity, lability (mania), blunting (chronic
Thought
•Form - circumstantiality, tangentiality,
flight of thoughts, thought
block/poverty/pressure etc
•Content
•Pre-occupations: obsessions, phobias &
rituals
•Delusion ....out of keeping with the
patient’s social & cultural background.
•Delusional perception: eg traffic light 13

change means chosen to be Messiah.

Perceptions
Illusions
Hallucinations
Auditory (2nd, 3rd) visual gustatory,
olfactory (organic, TLE), tactile
(cocaine addiction, drug
withdrawals)
Cognitive functioning
• Consciousness
• Orientation - time, place & person
• Memory - registration, short/long term
memory
• Concentration/attention
• Abstract reasoning and Judgement
Insight
• Awareness of abnormal state of mind
• Insight rests on a continuum from being partially
insightful to having insight
• Ask the patient if they think they are ill
• Mentally or physically
• Ask the patient if they are willing to accept help
• Ask the patient if they will take treatment
Schizophrenia

17
Learning tasks
• Define Schizophrenia
• Explain aetiology and risk factors of Schizophrenia
• Outline the epidemiology of Schizophrenia
• Explain clinical features of Schizophrenia
• Establish provisional and differential diagnosis of Schizophrenia
• Describe the Pre referral treatment of Schizophrenia
• Provide follow-up services of Schizophrenia

18
Schizophrenia
• Schizophrenia is a group of major functional psychotic
disorders characterized by disturbances in thinking,
perception, mood and behavior
Or -A spectrum of disorders characterized by
severely impaired cognitive processes, personality
disintegration, affective disturbances and social
withdrawal.
• It is characterized by impaired ability to monitor reality,
resulting in altered mood, thinking, language, perceptions,
behavior, and interpersonal interactions.
Aetiology
Risk factors
• Genetic – Family history of schizophrenia
• Environmental risk like various perinatal
problems including pre term labour and fetal
hypoxia
• Cannabis use is also a risk factor
• Imbalances in neurotransmitters (Excess in
dopamine)
Epidemiology
• Schizophrenia occurs throughout the world.
• The prevalence of schizophrenia (ie, the
number of cases in a population approaches
1%
• Slightly more men are diagnosed with
schizophrenia than women
Types of Schizophrenia
• There are several types of
schizophrenia
• Paranoid type: Where delusions and
hallucinations are present but
thought disorder, disorganized
behavior, and affective flattening are
absent.
• characterized mainly by delusions of
persecution, feelings of passive or
active control and feelings of
interference.
Types of Schizophrenia…
• Disorganized
(hebephrenic) type:
Where thought
disorder and flat
affect are present
together.
Types of Schizophrenia…
• Catatonic type: The
subject may be almost
immobile or exhibit
agitated purposeless
movement.
• Symptoms can
include catatonic
stupor and waxy
flexibility.
Types of Schizophrenia…
• Undifferentiated type: Psychotic symptoms
are present but the criteria for paranoid,
disorganized, or catatonic types have not
been met.
• Residual type: Where positive symptoms are
present at a low intensity only.
Clinical Features
• At least two of the following core psychotic features
should be present for ≥ 6 months
Positive symptoms:
• Hallucinations - Sensory experiences that occur in the
absence of environmental stimulation
o Hallucinations are commonly auditory
• Delusions - beliefs that are contrary to reality
o Persecutory delusions are common
• Disorganized speech
• Grossly disorganized or catatonic behavior
Diagnostic criteria (DSM V)
A. Two (or more) of the following, each present for a
significant portion of time during 1 month period. At
least one of these must be (1),(2) or (3) :-

Active – phase symptoms

1. Hallucinations.
2. Delusions.
3. Disorganized speech (e.g. frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms – passivity , a volition ,
Diagnostic criteria (DSM V)
B.For a significant portion of the time since the onset of the disturbance,
level of functioning in one or more major areas, such as work,
interpersonal relations, or self-care, is markedly below the level
achieved prior to the onset (or when the onset is in childhood or
adolescence, there is failure to achieve expected level of interpersonal,
academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This
6-month period must include at least 1 month of symptoms (or less if
successfully treated) that meet Criterion A (i.e., active-phase symptoms)
Diagnostic criteria (DSM V)
• D. Schizoaffective disorder and depressive or bipolar disorder with
psychotic features have been ruled out because either 1 ) no major
depressive or manic episodes have occurred concurrently with the active-
phase symptoms, or 2) if mood episodes have occurred during active-
phase symptoms, they have been present for a minority of the total
duration of the active and residual periods of the illness.
• E. The disturbance is not attributable to the physiological effects of a
substance (e.g., adrug of abuse, a medication) or another medical
condition.
• F. If there is a history of autism spectrum disorder or a communication
disorder of childhood onset, the additional diagnosis of schizophrenia is
made only if prominent delusions or hallucinations, in addition to the
other required symptoms of schizophrenia, are also present for at least 1
month (or less if successfully treated).
Diagnosis

• A diagnosis of schizophrenia is based on the

presence of above mentioned symptoms, coupled
with social or occupational dysfunction for at least
six months in the absence of another diagnosis
that would better account for the presentation.
Differential Diagnosis

• Infections like HIV, neuropsyphilis, cerebral abscess

• Brief psychotic disorder- delusions lasts for less 1 month
• Delirium due to medical conditions like sepsis, endocrine
disorders
• Space occupying lesions like Brain tumors and subdural
hematoma
• Major depressive or bipolar disorder with psychotic or
catatonic features.
• Schizoaffective disorder.
• Delusional disorder.
Differential Diagnosis…
• Alcoholic hallucinosis
• Drug abuse – Stimulants and hallucinogens like
Amphetamine/ khat (miraa, mirungi)/ cocaine
• Metabolic diseases like electrolyte imbalances e.g
hyponatremia
• Mood disorders like mania
• Obsessive-compulsive disorder and body dimorphic
disorder.
• Posttraumatic stress disorder.
Investigations
• No laboratory investigations can confirm schizophrenia,
but the following can be done as routine and for ruling
out organic causes of symptoms
• Hemoglobin
• Widal test
• Blood slide for malaria
• Urinalysis
• HIV Test
• Syphilis test
• Lumbar puncture for CSF analysis
Treatment
• Anti –psychotic drug treatment
• Chlorpromazine 50 – 100mg IM in acute phase
followed by maintenance dose of up to 400mg
orally in divided dose per day.
• Haloperidol 5-15mg/day IM in acute phase
followed by maintenance dose of up to 5-15 mg
orally in divided dose per day.
• Injection Diazepam 10 – 20mg IV stat to calm the
patient.
Treatment
• Anti-psychotics give side effects of extra pyramidal
system such as
• Tremors
• Tongue protrusion
• Stiffness of the neck and rigidity
• These side effects are controlled by
• Tablet Artane / Benzhexol (trihexyphenidyl) 5-
10mg OD
• Refer to hospital whereby patient is observed in a
special secured ward
Treatment
Non pharmacological
• Psychotherapy is also widely recommended and
used in the treatment of schizophrenia
• Cognitive behavioral therapy (CBT) is used to
target specific symptoms and improve related
issues such as self-esteem, social functioning,
and insight.
Treatment …
• Another approach is cognitive remediation, a
technique aimed at remediating the
neurocognitive deficits sometimes present in
schizophrenia.
• Rehabilitation is mandatory if the patient is in
danger to himself or to his family or to the
community at large.
Treatment …
• Family therapy or education, which
addresses the whole family system of an
individual with a diagnosis of schizophrenia,
has been consistently found to be beneficial,
at least if the duration of intervention is
longer-term.
Follow-up
• Patient on Schizophrenia treatment should be
followed up for side effects of antipsychotics
including extra pyramidal side effects such as
tremors
• Patients should be counseled on adherence to
non pharmacological management
Prognosis
•Good prognostic indicator:

 Female
 Older age of onset
 Married
 Living in a developing (as opposed to developed) country
 Good premorbid personality
 No previous psych history
 Good education and employment record
 Acute onset, affective symptoms, good compliance with meds
prognosis
•Poor prognostic indicators:

 Early age of onset

 Male sex
 Lower educational achievements
 More prominent negative symptoms
 More prominent cognitive impairments
BIPOLAR DISORDER

44
Learning tasks
• Define Bipolar disorder
• Explain aetiology and risk factors of Bipolar disorder
• Outline the epidemiology of Bipolar disorder
• Explain clinical features of Bipolar disorder
• Establish provisional and differential diagnosis of Bipolar
disorder
• Describe the Pre referral treatment of Bipolar disorder
• Provide follow-up services of Bipolar disorder

45
Bipolar disorder
• Bipolar disorder is an illness characterized by periods of
mood elevation (mania) interspersed by episodes of
depression
• It is one of the mood disorders, others being major
depressive disorder, substance induced mood disorders
etc.
• Most patients initially present with manic episode but 20%
present with major depression
• Mania is marked by periods of great excitement, euphoria,
delusions, and over activity.
MOOD DISORDERS
•Mood:
 Sustained feeling tone that is expressed internally,
that influences a person’s behavior and perception of
the world.
Distinguished from affect-the external expression of
mood.
Mood Disorders are a group of clinical conditions
• characterized by loss of sense of control and
subjective experiences of great distress
 Elevated mood-expansiveness flight of ideas, lack of
sleep, grandiose ideas
 Depressed mood- lack of energy , feeling guilty,
difficulty in concentration, loss of appetite, thought of
AETIOLOGY
Risk factors
• Genetic – Family history of Bipolar
disorder
• Imbalances in CNS neurotransmitters
(Excess in dopamine)
• Hormonal imbalance has also been
implicated
• Psychosocial factors such as abuse
Epidemiology
• Bipolar disorder occurs throughout the world.
• The true prevalence of bipolar disorder is uncertain but it is
estimated to be approximately 1%
• Female more affected than males
• Age of onset is between 15 and 30 years
Manic episode are more common in men and
depressive episodes are more common in women.
 Women are rapid cyclers i.e. can have 4 or more
manic episode in a 1year period
Age
• -bipolar 1 disorder (commonly in 30yrs)
• -MDD commonly around 40yrs (50% btn 20-50yrs)
 Clinical Features of mania
• Persistent elevated expansive mood
• Excessive spending or gambling
• Impulsive travel
• Hyper-sexuality, promiscuity
• Low frustration tolerance with irritability
and outbursts of anger
• Grandiosity-reflects inflated self esteem
Clinical Features…
• Flight of ideas-racing thoughts
• Increased goal oriented activities
• Pressured speech or increased talkativeness
• Vegetative signs
• Increased libido
• Weight loss and anorexia
• Insomnia (expressed as decreased need for sleep)
• Excessive energy
 Diagnosis
• Diagnosis of BPD requires presence of at least one manic or
hypomanic episode and one depressive episode
• Mania diagnosis criteria
• Persistently elevated, expansive, or irritable mood,
lasting at least one week with at least three of the
following symptoms
Inflated self esteem or grandiosity
Decreased need for sleep
More talkative than usual
Racing thoughts or flight of ideas
Increase in goal-directed activity
Differential Diagnosis
• Psychiatric conditions including schizophrenia, abuse of
alcohol, cocaine, or amphetamines;
• Thyrotoxicosis,
• Partial complex seizures,
• Systemic lupus erythematosus,
• Cerebrovascular accident,
• Human immunodeficiency virus,
• Tertiary syphilis
Investigations
• Patients should be evaluated for signs of neurological,
endocrine abnormalities and signs of substance/alcohol
abuses
• Evaluation may include
• Thyroid stimulating hormone (TSH)
• FBP
• Serum electrolytes
• HIV
• Imaging studies such as Brain CT scan
Treatment
• Chlorpromazine 50 – 100mg IM in acute phase followed with
maintenance dose of up to 400mg orally in divided dose per
day, or:
• Haloperidol 5 – 15mg/day IM in acute phase followed with
maintenance dose of up to 5 – 20mg orally in divided dose per
day.
• Lithium carbonate – in mania, 0.6-1.8g daily (elderly (300 –
400mg daily
Major Depressive Disorder

• It is a mood disorder characterized by at least 2 weeks of

depressed mood and/or diminished interest and pleasure in
activities. It is associated with impairment in level of functioning in
differentareas including social and occupational.
• Diagnostic Criteria
• Psychological symptoms
Depressed mood
 Feeling of worthlessness
 Guilt
 Diminished concentration
 Thoughts of death and suicide
• Somatic symptoms
Change in appetite
 Sleep disturbances (lack of sleep)
 Agitation
 Retardation
 Loss of energy
• Non-Pharmacological Treatment
Effective psychotherapies include:
Cognitive Behavioral Therapy
 Interpersonal psychotherapy
 Stress management / coping skills
 Marital and family issues
 Sleep hygiene advice
• Pharmacological Treatment
• A: amitriptyline (PO) 12.5–75mg 24hourly at night,
increase gradually to a maximum of 150mg
24hourly. {Elderly: Initially 12.5–50 mg. Max. 75mg)
OR
• D: citalopram (PO) 10-60mg 24hourly
OR
• S: fluoxetine (PO) 20-60mg 24hourly (morning)
Treatment
Psychosocial interventions aiming at
• Addressing immediate social problems as a result of illness;
• addressing precipitating factors;
• Education for future adherence
• Social skills training to improve intrapersonal relationships
Follow-up
• Patient on Bipolar disorder treatment should be followed up for
side effects of mood stabilizers including extra pyramidal side
effects such as tremors
• Patients should be counseled on adherence to psychosocial
interventions
GENERALISED ANXIETY
DISORDER
 ANXIET
Y

DEFINITION:-
• A FEELING OF WORRY, NERVOUSNESS, OR
UNEASE ABOUT SOMETHING WITH AN
UNCERTAIN OUTCOME.
ANXIETY
DISORDER

•Anxiety disorder: A chronic condition characterized by

an excessive and persistent sense of apprehension,
with physical symptoms such as sweating, palpitation,
and feelings of stress.
CLASSIFICATION OF ANXIETY
DISORDER
1.Panic disorders
2.Generalised anxiety disorders
3.Phobic disorders
4.Obsessive-compulsive
disorders
5.Post-traumatic stress
disorders
•Generalised anxiety disorder (GAD) is usually characterised by
chronic anxiety unrealistic and excessive anxiety and worry, that is
uncomfortable to the point of interfering with daily life.
•A person with GAD worries excessively and feels highly anxious at
least 50 per cent of the time for six months or more.
ETIOLOGY OF GAD
•As with many mental health conditions, the exact cause of generalized anxiety
disorder isn't fully understood, but it may include genetics as well as other risk
factors.

RISK FACTORS-
•These factors may increase the risk of developing generalized anxiety disorder:
•Personality. A person whose temperament is timid or negative or who avoids
anything dangerous may be more prone to generalized anxiety disorder than
others are.
•Genetics. Generalized anxiety disorder may run in families.
•Being female. Women are diagnosed with generalized anxiety disorder
somewhat more often than men are.
MEDICAL CONDITION:-
The following medical conditions have been associated to a greater
degree with individuals who suffer from GAD than in general
population:
•Abnormalities in the hypothalamic-pituitary-adrenal and
hypothalamic-pituitary-thyroid axes.
•Acute myocardial infarction.
•Phenochromocytomas.
•Substance intoxication and withdrawal (cocaine, alcohol, marijuana,
opioids).
•Hypoglycaemia.
•Caffeine intoxication.
•Mitral valve prolapses.
•Complex partial seizures.
SIGN AND SYMPTOMS OF
GAD
The symptoms of generalized anxiety disorder
fluctuate. You may notice better and worse times of
the day.
Not everyone with generalized anxiety disorder has
the same symptoms. But most people with GAD
experience a combination of a number of the
following emotional, behavioural, and physical
symptoms.
EMOTIONAL SYMPTOMS
OF GENERALIZED
ANXIETY DISORDER
• Constant worries running through your head

• Feeling like your anxiety is uncontrollable; there is nothing

you can do to stop the worrying

• Intrusive thoughts about things that make you anxious; you

try to avoid thinking about them, but you can’t

• An inability to tolerate uncertainty; you need to know what’s

going to happen in the future

• A pervasive feeling of apprehension or dread

BEHAVIOURAL SYMPTOMS OF
GENERALIZED ANXIETY DISORDER

• Inability to relax, enjoy quiet time, or be by

yourself

• Difficulty concentrating or focusing on things

• Putting things off because you feel overwhelmed

• Avoiding situations that make you anxious

PHYSICAL SYMPTOMS OF
GENERALIZED ANXIETY DISORDER

• Feeling tense; having muscle tightness or body aches

• Having trouble falling asleep or staying asleep because

your mind won’t quit

• Feeling edgy, restless, or jumpy

• Stomach problems, nausea, diarrhoea

 ICD-10
criteria
• ICD-10 Generalized anxiety disorder "F41.1"
Note: For children different criteria may be
applied (see F93.80).

A period of at least six months with prominent

tension, worry and feelings of apprehension, about
everyday events and problems.

B. At least four symptoms out of the following list of

items must be present, of which at least one from
items (1) to (4).
• Autonomic arousal symptoms

• (1) Palpitations or pounding heart, or

accelerated heart rate.

• (2) Sweating.

• (3) Trembling or shaking.

• (4) Dry mouth (not due to medication or

dehydration).
• Symptoms concerning chest and abdomen

• (5) Difficulty breathing.

• (6) Feeling of choking.

• (7) Chest pain or discomfort.

• (8) Nausea or abdominal distress (e.g.

churning in stomach).
• Symptoms concerning brain and mind

• (9) Feeling dizzy, unsteady, faint or light-headed.

• (10) Feelings that objects are unreal (derealisation),

or that one's self is distant or "not really here"
(depersonalization).

• (11) Fear of losing control, going crazy, or passing

out.

• 12) Fear of dying.

• General symptoms
• (13) Hot flushes or cold chills.
• Symptoms of tension

• (15) Muscle tension or aches and pains.

• (16) Restlessness and inability to relax.

• (17) Feeling keyed up, or on edge, or of mental

tension.

• (18) A sensation of a lump in the throat, or

difficulty with swallowing.
• Other non-specific symptoms

• (19) Exaggerated response to minor surprises

or being startled.

• (20) Difficulty in concentrating, or mind going

blank,
because of worrying or anxiety.

• (21) Persistent irritability.

• (22) Difficulty getting to sleep because of

worrying.
DIFFERENCE B/W NORMAL WORRY AND GAD
• GENERALISED ANXIETY • NORMAL “WORRY”
DISORDER
•Your worrying doesn’t get in the way of
•Your worrying significantly
disrupts your job, activities, or your daily activities and responsibilities.
social life. •You’re able to control your
•Your worrying is worrying.
uncontrollable. •Your worries, while unpleasant, don’t
•Your worries are extremely cause significant distress.
upsetting and stressful. •Your worries are limited to a specific,
•You worry about all sorts of small number of realistic concerns.
things, and tend to expect the •Your bouts of worrying last for
worst. • only a short time period.
•You’ve been worrying almost
DIAGNOSTIC CRITERIA FOR
GAD
To help diagnose generalized anxiety disorder, your health
provider may:-

• Do a physical exam to look for signs that your anxiety might be linked to an
underlying medical condition
• Order blood or urine tests or other tests, if a medical condition is suspected
• Ask detailed questions about your symptoms and medical
history
• Use psychological questionnaires to help determine a diagnosis
DSM-5 criteria for
generalized anxiety disorder
include:
• Excessive anxiety and worry about several events or
activities most days of the week for at least six months

• Difficulty controlling your feelings of worry

• Anxiety or worry that causes you significant distress or

interferes with your daily life
• At least three of the following symptoms in adults and one of
the following in children:
1. Restlessness,
2. Fatigue,
3. Trouble concentrating,
4. Irritability,
5. Muscle tension or
6. Sleep problems

• Anxiety that isn't related to another mental health condition,

such as panic attacks or post-traumatic stress disorder (PTSD),
substance abuse, or a medical condition
• Generalized anxiety disorder often occurs along with other
mental health problems, which can make diagnosis and
treatment more challenging. Some disorders that
commonly occur with generalized anxiety disorder
include:

• Phobias
• Panic disorder
• Depression
• Substance abuse
• PTSD
TREATMENT AND DRUGS:-
• The two main treatments for
generalized anxiety disorder are
psychotherapy and medications. You
may benefit most from a
combination of the two. It may take
some trial and error to discover
which treatments work best for you.
PSYCHOTHERAPY
• Also known as talk therapy or psychological counselling,
psychotherapy involves working with a therapist to reduce your
anxiety symptoms. It can be an effective treatment for
generalized anxiety disorder.

• Cognitive behavioural therapy is one of the most effective

forms of psychotherapy for generalized anxiety disorder.
Generally a short-term treatment, cognitive behavioural therapy
focuses on teaching you specific skills to gradually return to
the activities you've avoided because of anxiety. Through this
process, your symptoms improve as you build on your initial
success.
MEDICATIONS
The drugs used for GAD will be:

• Benzodiazepines

• Buspirone (anti-anxiety medication)

• Alpidem (Alpidem (Ananxyl) is an anxiolytic drug from the

imidazopyridine family, related to the more well-known
sleeping medication zolpidem)

• Tricyclic drug or beta-adrenergic antigens (e.g.,

propranolol).
 A CASE OF
GAD
A case of 50 years old man, MR. RP was admitted to the Psychiatric
Hospital for treatment of a generalised anxiety disorder.
On clinical initial assessment, the student nurse noted that Mr RP was
• 1. Quite restless
• 2. Sitting on the edge of the bed.
• 3. Fidgeting with his gown.
• 4. He constantly rearranged his personal items on the bedside stand.
• 5. Complaints of dizziness, an upset stomach, insomnia and frequency
of urination noted.
• 6. Mr.RP appears to be easily distracted as people walk into the room.
• 7. He was impatient with the student nurse taking vitals signs. His
hands are cold and clammy and the radial pulse was 120 beats/min.
• During post clinical conference, the students nurse shared
her feelings of irritation about RP. She also state that the
client’s anxiety was “infectious” and that she found herself
becoming tense although she tried to remain calm during the
admission procedure. Another student stated that she would
have given RP a sedative first to allow him to settle down and
then would have attempted to carry out initial assessment. The
group discuss interpersonal reaction with persons who exhibit
clinical symptoms or GA. And how easy it would be to
avoid contact with the patient.
Substance use disorder

96
Learning tasks
• Define Substance use disorder
• Explain aetiology and risk factors of Substance use disorder
• Outline the epidemiology of Substance use disorder
• Explain clinical features of Substance use disorder
• Establish provisional and differential diagnosis of Substance
use disorder
• Describe the Pre referral treatment of Substance use disorder
• Provide follow-up services of Substance use disorder

97
Introduction
• Substance use disorder is refer to conditions arising from the
abuse of alcohol and/or psychoactive drugs
• Alcohol and other substances can have varied physiological
and psychological effects.
• In the short term, the individual may perceive these effects as
quite desirable.
Epidemiology
• The World Health Organization estimated that more than 5
percent of adults had a current (past 12-month) alcohol use
disorder worldwide
• Nearly 5 percent of all deaths worldwide have been attributed to
alcohol use
• Substance use is endemic among adolescents
Alcohol related psychiatric disorders
Alcohol dependence
• The term dependence refers to certain physiological and
psychological phenomena induced by the repeated taking of a
substance.
• Alcohol dependence syndrome is characterized by the
presence of three or more of the following: ·
Alcohol dependence…
• A strong desire or compulsion to drink
• Difficulty in controlling the onset or termination of drinking or the
levels of alcohol use
• A physiological withdrawal state on cessation of alcohol or its
use
• Progressive neglect of other interests
Alcohol dependence…
• Increasing tolerance to alcohol (Tolerance is the need to
consume more alcohol to achieve the same effect produced
originally by smaller amounts)
• Persisting use of alcohol despite awareness and clear evidence
of the harm it is causing.
Intoxication phenomena

• This includes phenomena such as lability of mood,

• Cognitive impairment
• memory black outs.
Withdrawal
• Withdrawal symptoms occur in people who have been drinking
heavily for years and who maintain a high intake of alcohol for
weeks at a time.
• They occur when alcohol consumption is abruptly discontinued
or substantially reduced.
Withdrawal…
• The first symptoms usually appear within 8-12 hours of the last
drink and progression to a state of delirium may occur within 2-3
days.
• The withdrawal symptoms may be: mild such as tremor,
nausea, sweating, insomnia, mood disturbances, restless,
agitation or severe with seizures, disorientation and delirium
tremens
Depression
• Alcohol is a CNS depressant and the biological changes
induced by it can mimic those seen in depressive disorders.
• In some patients alcohol misuse is a symptom of underlying
depressive illness.
• Suicide and deliberate self-harm are significant risks in patients
with serious alcohol problems
Anxiety
• Alcohol can be used as a means of coping with anxiety.
In addition, symptoms of alcohol withdrawal state may mimic an
anxiety state.
Morbid jealousy
The excessive drinker develops the delusion that his or her
partner is unfaithful which may result in domiciliary violence and
death of the partner.
Alcoholic dementia
• Specific cognitive deficits are demonstrable in problem drinkers
that may or may not be accompanied by non-progressive
impairment of intellectual capacity.
Wernicke's encephalopathy and
Korsakoff's syndrome
• This is caused by thiamine deficiency resulting in haemorrhage
in the mammilary bodies of the posterior hypothalamus and
nearby midline structures.
• Wernicke's encephalopathy is characterised by
ophthalmoplegia, ataxia and a confusional state, which
can be reversed to a large extent by administration of
thiamine.
Wernicke's encephalopathy and
Korsakoff's syndrome
• Korsakoff's dysmnestic syndrome is characterised by profound
short term memory loss with relative preservation of other
intellectual abilities.
• The gaps in short term memory are filled in by confabulation. Its
resolution is less predictable.
Physical disorders
• Physical risks to health can be due to intoxication, e.g.
accidents or long term physical disorders resulting from heavy
alcohol usage. These relate to organ systems as follows:
• GI : Hepatitis; hepatic cirrhosis and its complications;
pancreatitis; Mallory-Weiss tears;
Physical disorders…
• CVS : Hypertension; alcohol cardiomyopathy
CNS : Seizures, peripheral neuropathy; cerebellar
degeneration; dementia; myopathy.
Others: Malnutrition and vitamin deficiency; damage to foetus in
pregnant mother
Social disorders…
• These are multifactorial and relate partly to several of the
physical and psychiatric consequences of alcohol misuse, listed
above. In addition other factors such as poverty, poor
performance at work and difficulties in interpersonal
relationships, domestic violence, poor parenting,
unemployment, and involvement in crime
Cannabis
Cannabis (Dope, Hash, Weed, Skunk)
• The active element is tetrahydrocannabinol.
• It is usually smoked, producing a profound sense of relaxation
and mild euphoria.
• Its use is widespread and subject to controversy about whether
it should be legalised.
Cannabis…
• It may produce mild paranoid ideation.
• There are some suggestions that it can produce an acute
confusional state with delusions and hallucinations.
• It is now being used increasingly by those suffering chronic
disorders such as multiple sclerosis allegedly for pain relief.
Stimulants
Stimulants (Amphetamine, )
• When ingested they produce an elevation of mood,
increased alertness and physical activity.
• They may be taken orally or injected intravenously
(amphetamine). Rapid tolerance is common.
• Amphetamine can cause what is known as
Amphetamine Psychosis - a florid, schizophrenia like
illness. The condition usually subsides in about a
week though it can occasionally persist for months.
Hallucinogens
Hallucinogens (LSD), Phencyclidine (Angel Dust)
• These have been known and used for many years.
• They are usually taken orally, giving rise to heightened
perceptions, vivid imagery, illusions and hallucinations and
often a state of euphoria.
• Sometimes a terrifying hallucinations and delusional thinking.
• Those who use the drug regularly may experience 'flash
backs' to a 'bad trip'.
• Neurological damage can occur.
Cocaine
• This stimulant is derived from the leaves of the Coca plant.
• It is usually smoked or snorted although it can also be
injected intravenously. In the North East of England, its use
has been limited by its very high price but this is changing.
• It rapidly produces CNS stimulation and a sense of euphoria.
Persons often develop a craving for cocaine, tolerance and
psychological dependency. Chronic usage can lead to
paranoid psychosis. Cocaine abusers sometimes experience
Formication (Cocaine bugs), a feeling as if insects are
crawling under the skin.
Opiates
(Heroin) being the most commonly abused among them. They
are frequently inhaled (smoked) but may be taken
intravenously. They produce a sense of euphoria, detachment
and well being in addition to analgesia. They are rapidly fatal in
overdose - often by respiratory depression, which leads to
cardiac arrest.
Opiates
• Prolonged use leads to the development of tolerance and
dependency. Cessation of use leads to an unpleasant though
not life-threatening (c.f. alcohol) withdrawal state ('Cold Turkey')
characterized by:
• Restlessness, insomnia, piloerection, pupillary dilatation, nasal
discharge, sweating, vomiting, diarrhoea, abdominal pain,
hyperaesthesia, paraesthesia and cramps.
Investigations
• Several laboratory findings may suggest the presence of
substance abuse.
• The mean corpuscular volume is elevated with long-term
alcohol use.
• Liver enzymes can be elevated with alcohol use and infectious
hepatitis acquired from sharing needles.
• Positive serology for hepatitis B or C can suggest drug abuse.
• Drug testing can also be performed
Treatment – Alcohol related disorders
Drinking Assessment
• Many individuals are unaware of how much they drink and its
potential impact on their health.
• It is there fore important to obtain an alcohol history from all
patients, during the first encounter and periodically thereafter
Treatment…
A quick screening questionnaire such as the CAGE questionnaire
is a useful tool:
• Cut down on drinking - do you need to?
• Annoyed by anybody criticising your drinking?
• Guilty about drinking too much?
• Eye opener - do you need a drink first thing in the morning?
Treatment…
• Discuss Costs/Benefits of Alcohol use from patients'
perspective (Motivational interviewing)
• Enlist support of family and friends
• Focus on the reasons that the person drinks.
• Situation of drinking
• The expected results from drinking
Treatment …
Medication
- Disulfirm (antabuse):
- Side effects: flushing in face, hypotension, malaise, dizziness
Naltrexone  decrease alcohol craving by blocking
Treatment of SUDs
• Use of multiple therapeutic modalities like individual, family, group
etc in amphetamine and cannabis abuse
• For some SUDs like cocaine treatment is abstinent longer enough for
the system to recover.
• For opiod related SUDs, methadone assisted therapy is available in
zonal consultant hospitals
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