Psychiatry- Classification of Mental Disorders, Symtoms and Treatment

An introduction to Psychiatry, Mental or psychiatric Disorders and Treatment. and also discuss about mental status examinationand psychaitric History

1. A n I n t rod u cti o n to Psychiatry A n I ntroduction t o P sychiatry - Binu chungath

2. A branch of medicine that deals with the etiology, diagnosis and treatment of mental and emotional disorders Etiology- The study of causation, or origination Diagnosis- The process of identification of the nature and cause of a certain phenomenon Treatment- The method of handling, or dealing with someone or something Psychiatry

3. Affect- External Experience of Emotions. Anxiety- State of uneasiness and apprehension, as about future uncertainties. Cognition- mental action or process of acquiring knowledge through thought, experience and the senses. Delusion- False unshakable belief. Which not out of keeping with the socio-cultural, economical and educational background. Feelings- An emotional state or reaction. Hallucination- False belief without stimulus. Insight- Ability to understand one’s own behavior and emotions. Illusion- False beliefs with stimulus. Mood-Sustained state of feeling. Orientation- Familiarization with something. Perception- Ability to see, hear, or become aware of something through the senses. Thought- An idea or opinion produced by thinking, or occurring suddenly in mind. Thinking- Process of considering or reasoning about something. General terms

4. Normal mental health , much like normal health, is a rather difficult concept to define . normality is not an easy concept to define , some of the following traits are more commonly found in ‘normal’ individuals. 1. Reality orientation. 2. Self-awareness and self-knowledge. 3. Self-esteem and self-acceptance. 4. Ability to exercise voluntary control over their behaviour . 5. Ability to form affectionate relationships. 6. Pursuance of productive and goal-directive activities. Normal mental health

5. Mental Disorder An illness of the mind that can affect the thoughts, feelings, and behaviors of a person, preventing him or her from leading a happy, healthful, and productive life. a psychiatric disorder is a disturbance of Cognition (i.e. Thought), Conation (i.e. Action), or Affect (i.e. Feeling), or any disequilibrium between the three domains. M e n t a l D i s o r d e r s

6. Bio-Psycho-Social Approach TO MENTAL HEALTH

7. DSM-IV American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) a widely used system for classifying psychological disorders presently distributed as DSM-IV-TR (text revision) Classifying Psychological Disorders (medical approach dominates)

8. ICD-10 ICD-10 (International Classification of Diseases, 10th Revision, 1992) is World Health Organisation’s classification for all diseases and related health problems (and not only psychiatric disorders ). ICD-10 is easy to follow , has been tested extensively all over the world (51 countries; 195 clinical centres), and has been found to be generally applicable across the globe Classifying Psychological Disorders (medical approach dominates ) cont ….

9. IDENTIFICATION DATA- Basic Details about the patient INFORMANTS - Name & relation PRESENTING (CHIEF) COMPLAINTS Onset of present illness/symptom. Duration of present illness/symptom. Course of symptoms/illness. Predisposing factors. Precipitating factors (include life stressors). 4. HISTORY OF PRESENT ILLNESS 5. PAST PSYCHIATRIC AND MEDICAL HISTORY 6. TREATMENT HISTORY 7. FAMILY HISTORY Psychiatric History and Examination

10. 8. PERSONAL AND SOCIAL HISTORY Perinatal History Childhood History Educational History Play History Puberty Menstrual and Obstetric History Occupational History Sexual and Marital History Premorbid Personality (PMP) 9. ALCOHOL AND SUBSTANCE HISTORY 10. PHYSICAL EXAMINATION Psychiatric History and Examination cont ……

11. Mental status examination is a standardised format in which the clinician records the psychiatric signs and symptoms present at the time of the interview. 1. General Appearance and Behaviour Hygiene- Maintained/or not Grooming- Adequate/ or not Eye-to- eye contact- established/ maintained or not Attitude towards Examiner- cooperative/ or not Psycho-motor activates 2. Speech- Relevant/ or irrelevant Rate and Quantity- Decreased, normal or High Volume and Tone- Low, Normal or High MENTAL STATUS EXAMINATION (MSE)*

12. 3. Mood -Subjective (Feed back) / or Objective (Observation) Euphoria- Mailed Elevation Elation- Moderate Elevation Exaltation- Severe Elevation Dysphoria- Euphoria + Irritable Labile – Immediate Change 4. Affect- Appropriate/ or Inappropriate Restricted- Sadness Blended- Extreme Sadness MENTAL STATUS EXAMINATION (MSE )* cont ….

13. 5. Thought Stream and Form of Thought Flight of ideas Circumstantiality Pressure of speech Perseveration Echolalia Neologism Loosing of association Possession of Thought Thought Broadcasting Thought withdrawal Thought Insertion MENTAL STATUS EXAMINATION (MSE)* cont ….

14. Content of Thought Delusions Delusion of Persecution- stalked, spied upon, obstructed, poisoned etc.. Delusion of Reference- talking about me Delusion of Love- Infatuation Delusion of Grandiosity- Supreme powers Delusion of Poverty- Begging Money Delusion of Guilt- Thought about sin (Suicidal tendency) Somatic Delusions- somatic thoughts Hypochondriacal Delusion- Infected Diseases Delusion of Infidelity- External marital affairs (paranoid) Delusion of Nihility- Brain is empty/ end of the world MENTAL STATUS EXAMINATION (MSE)* cont ….

15. Bizarre Delusions- Do not derive from ordinary life experience Bizarre Delusions- Stranger has removed his internal organs Delusion of Control- somebody trying to control my mind and body Delusion of Body dysmorphic- Enlarged body parts Pseudo-cies- Am pregnant Delusion of Couvadu- Pregnancy sickness for Husband Delusion of Capgras- Familiar person as a stranger Delusion of Misidentification- Misidentify others Delusion of Doubles- Doubles the person Delusion of Fregoly- Stranger as a familiar person Delusion of Negation- Living peoples are dead MENTAL STATUS EXAMINATION (MSE)* cont ….

16. 6. Perception Illusion- False believes with stimulus Hallucination- False believes without stimulus Auditory- First, Second/or Third person Visual- Unrealistic Visuals Olfactory- Unrealistic Smell Gustatory- Unrealistic Taste Tactile- senses Unrealistic touch Lilliputian- Macropsia (s=B) / Micropsia ( B=s) [AWLS] Reflex- Inappropriate meaning of sound [ Hallucinatory Behavior- response to internal/ external factors] MENTAL STATUS EXAMINATION (MSE)* cont ….

17. 7. Cognitive Functions Attention and concentration Abstract Thinking Memory- (Recent and Remote)intact/ or impaired Orientation Intelligence Insight Judgment 8. Diagnose/ Judgment MENTAL STATUS EXAMINATION (MSE)* cont ….

18. Neurotic Disorder usually distressing but that allows one to think rationally and function socially Psychotic Disorder person loses contact with reality experiences irrational ideas and distorted perceptions Classifying Psychological Disorders

19. Organic ( Including Symptomatic) Mental Disorders Schizophrenia Mood Disorders Neurotic , Stress-related and Somatoform Disorders Disorders of Adult Personality and Behaviour Sexual Disorders Sleep Disorders Psychosomatic Disorders Child Psychiatry Types of Mental Disorders

20. Delirium, Dementia, Organic amnestic syndrome, etc. Organic Mental Disorders

21. Delirium is a complex neuropsychiatric syndrome characterized by disturbances in consciousness, orientation, memory, thought, perception, and behaviour due to one or more structural and/or physiological abnormalities directly or indirectly affecting the brain. Delirium is the most appropriate substitute for a variety of names used in the past such as acute confusional states , acute brain syndrome , acute organic reaction , toxic psychosis, and metabolic (and other acute ) encephalopathies . Delirium

22. Clinical Features Fluctuating level of consciousness Inattention Disorientation Memory impairment (especially recent events) Speech & Language disturbance Sleep disturbance Perceptual disturbances Thought process abnormalities Agitation Apathy and withdrawal Emotional (affective) disturbances Delirium conte …

23. Predisposing Factors in Delirium Pre-existing brain damage or dementia Extremes of age (very old or very young) Previous history of delirium Alcohol or drug dependence Chronic medical illness Surgical procedure and postoperative period Present or past history of head injury Treatment with psychotropic medicines Delirium conte …

24. Dementia is a chronic organic mental disorder, characterised by the following main clinical features : Impairment of intellectual functions , Impairment of memory (predominantly of recent memory , especially in early stages ), Deterioration of personality with lack of personal care. Impairment of all these functions occurs globally , causing interference with day-to-day activities and interpersonal relationships. There is impairment of judgement and impulse control, and also impairment of abstract thinking. There is however usually no impairment of consciousness DEMENTIA

25. Additional features may also be present. These include: Emotional liability (marked variation in emotional expression). Catastrophic reaction (when confronted with an assignment which is beyond the residual intellectual capacity , patient may go into a sudden rage ). Thought abnormalities, e.g. perseveration, delusions. Urinary and faecal incontinence may develop in later stages. Disorientation in time; disorientation in place and person may also develop in later stages . DEMENTIA conten …..

26. Medical Risk Factors Atherosclerosis Cholesterol Homocysteine Diabetes Psychological and Experimental factors Down syndrome Genetics and Life style Risk factors Age Genetics Smoking Alcohol use Risk factors for dementia

27. Organic amnestic syndrome is characterised by the following clinical features: 1. Impairment of memory due to an underlying organic cause, 2. No severe disturbance of consciousness and attention (unlike delirium), and 3. No global disturbance of intellectual function, abstract thinking and personality (unlike dementia ). The impairment of memory is characterised by a severe impairment of recent memory or short-term memory (inability to learn new material). This is associated with impaired remote memory or long-term memory ( inability to recall previously learned material ). There is however no impairment of immediate memory (i.e. immediate retention and recall). ORGANIC AMNESTIC SYNDROME

28. According to ICD-10, the following features are required for the diagnosis: recent memory impairment (anterograde and retrograde amnesia), no impairment of immediate retention and recall, attention, consciousness , and global intellectual functioning, Historical or objective evidence of brain disease or injury (occurs particularly with bilateral involvement of diencephalic and medial temporal structures). Diagnosis

29. Schizophrenia is defined by “Schizophrenia is characterized by Disturbance in thought, Perception, Affect, Motor behavior and Relationship to the External World” a group of characteristic positive and negative symptoms deterioration in social, occupational, or interpersonal relationships continuous signs of the disturbance for at least 6 months Schizophrenia

30. First Rank Symptoms (SFRS) of Schizophrenia Audible thoughts : Voices speaking out thoughts aloud or ‘ thought echo ’. Voices heard arguing : Two or more hallucinatory voices discussing the subject in third person. Voices commenting on one’s action . Thought withdrawal : Thoughts cease and subject experiences them as removed by an external force. Thought insertion : Experience of thoughts imposed by some external force on person’s passive mind. Thought diffusion or broadcasting : Experience of thoughts escaping the confines of self and as being experienced by others around. Schizophrenia cont ….

31. Positive and Negative Symptoms Hallucinations Alogia Delusions Affective flattening Bizarre behavior Avolition-apathy Positive formal thought disorder Anhedonia-asociality Attentional impairment Schizophrenia cont ….

32. Manic episode Depressive episode Bipolar mood (affective) disorder Recurrent depressive disorder Persistent mood disorder (including cyclothymia and dysthymia) Other mood disorders. Mood Disorders

33. The life-time risk of manic episode is about 0.8- 1 %. This disorder tends to occur in episodes lasting usually 3-4 months, followed by complete clinical recovery . The future episodes can be manic, depressive or mixed . A manic episode is typically characterised by the following features (which should last for at least one week and cause disruption in occupational and social activities). Manic episode

34. Clinical Features Talkative Over activeness Restlessness Over happiness Irritable behavior High level Food intake Irrelevant investments Expansive ideas Over confidence Religiosity Violent and destructive Reckless driving Low Sleep rate Manic episode conti ..

35. Stages a . Euphoria (mild elevation of mood): An increased sense of psychological well-being and happiness, not in keeping with ongoing events. This is usually seen in hypomania (Stage I). b. Elation (moderate elevation of mood): A feeling of confidence and enjoyment, along with an increased psychomotor activity. Elation is classically seen in mania (Stage II). c. Exaltation (severe elevation of mood): Intense elation with delusions of grandeur; seen in severe mania (Stage III). d. Ecstasy (very severe elevation of mood): Intense sense of rapture or blissfulness; typically seen in delirious or stuporous mania (Stage IV). Manic episode conti ..

36. The life-time risk of depression in males is 8-12% and in females is 20-26%. However, the life-time risk of major depression (or depressive episode) is about 8 %. The typical depressive episode is characterised by the following features (which should last for at least two weeks for a diagnosis to be made): Depressive Episode

37. Clinical Features The lowered mood varies little from day to day, is unresponsive to circumstances symptoms : loss of interest or pleasure in activities that are normally enjoyable (anhedonia ) & Depressed mood lack of emotional reactivity to normally pleasurable surroundings and events Less amount of Talk & Social withdrawal High rate of Sleep & lack of Energy loss of appetite weight loss loss of libido Poor Hygiene Depressive Episode cont..

38. Stages 1. Mild Depressive Episode For mild depressive episode are typical depressed mood, anhedonia and increased fatigability. The afflicted person is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely . Duration <1 week 2. Moderate Depressive Episode An individual with moderate depressive episode suffers from more symptoms (f our or more of the above symptoms are usually present ) of greater severity and will usually have considerable difficulty in continuing with social, work or domestic activities . Duration 1> week Depressive Episode cont..

39. 3. Severe Depressive Episode In a severe depressive episode , the sufferer usually shows considerable distress or agitation. Loss of self-esteem or feelings of uselessness or guilt are likely to be prominent, and suicide is a distinct danger in particularly severe cases Duration 1>6 months

40. Bipolar affective disorder is characterized by repeated, at least two episodes in which the patient’s mood and activity levels are significantly disturbed (manic or depressive syndromes, patients who suffer only from repeated episodes of mania are comparatively rare). The first episode may occur at any age from childhood to old age. The frequency of episodes and the pattern of remissions and relapses are both very variable. The lifetime prevalence is between 0,5 an 1 %. Suicidality – about 19%. Comorbidity with alcohol and drug abuse Bipolar mood (affective) disorder

41. Recurrent depressive disorder is characterized by repeated episodes of depression without any history of independent episodes of mood elevation and over activity. Recovery is usually complete between episodes, but a substantial part of patients will have a recurrence and about 30% may develop a persistent depression. The lifetime prevalence - about 10—20 %; women: men 2:1. The risk of suicide (approximately 10—15%. Recurrent depressive disorder

42. Persistent mood disorders are persistent and usually fluctuating disorders of mood in which individual episodes are not sufficiently severe to warrant being described as hypomanic or even mild depressive episodes. Dysthymia . An adult person with depressive symptoms up to 2 years. cyclothymia persistent instability of mood, involving periods of mild depression and mild elation is typical Persistent mood disorder

43. Seasonal affective disorder - onset of mood symptoms is connected with changes of seasons, with depression typically occurring during the winter months and remissions or changes from depression to mania occurring during the spring. R apid-cycling - identifies those patients who have had at least four episodes of a major depressive, manic, or mixed episode during the past 12 months . Post partum Psychosis Other mood disorders

44. anxiety disorder, Phobic anxiety disorder Obsessive compulsive disorder . Neurotic, Stress-related and Somatoform Disorders

45. Anxiety is the commonest psychiatric symptom in clinical practice and anxiety disorders are one of the commonest psychiatric disorders in general population . Anxiety is a ‘normal’ phenomenon, which is characterised by a state of apprehension or unease arising out of anticipation of danger. Anxiety is often differentiated from fear, as fear is an apprehension in response to an external danger while in anxiety the danger is largely unknown (or internal) anxiety disorder

46. 1. Physical Symptoms A. Motoric Symptoms: Tremors; Restlessness; Muscle twitches; Fearful facial expression B. Autonomic and Visceral Symptoms: Palpitations; Tachycardia ; Sweating; Flushes; Dyspnoea; Hyperventilation ; Constriction in the chest; Dry mouth ; Frequency and hesitancy of micturition; Dizziness ; Diarrhoea; Mydriasis 2. Psychological Symptoms A. Cognitive Symptoms: Poor concentration; Distractibility; Hyper arousal; Vigilance or scanning; Negative automatic thoughts B. Perceptuel Symptoms: Déréalisation; Dépersonnalisation C. Affective Symptoms: Diffuse, unpleasant, and vague sense of apprehension ; Fearfulness; Inability to relax; Irritability; Feeling of impending doom (when severe) D. Other Symptoms: Insomnia (initial); Increased sensitivity to noise; Exaggerated startle response. Symptoms of Anxiety

47. Panic Disorder is characterised by discrete episodes of acute anxiety . The essential features are recurrent attacks of severe anxiety (panic attacks) which are not restricted to any particular situation or set of circumstances. Typical symptoms are palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or decrealization). Individual attacks usually last for minutes only. The frequency of attacks varies substantially. Frequent and predictable panic attacks produce fear of being alone or going into public places. The afflicted persons used to think that they got a serious somatic disease. The course of panic disorder is long-lasting and is complicated with various comorbidities, in half of the cases with agoraphobia . Panic Disorder

48. Phobia is defined as an irrational fear of a specific object , situation or activity, often leading to persistent avoidance of the feared object, situation or activity . The common types of phobias are: Agoraphobia , Social phobia, and Specific ( Simple) phobia . Phobic anxiety disorder

49. Presence of the fear of an object, situation or activity. The fear is out of proportion to the dangerousness perceived . Patient recognises the fear as irrational and unjustified ( Insight is present ). Patient is unable to control the fear and is very distressed by it. This leads to persistent avoidance of the particular object , situation or activity. Gradually , the phobia and the phobic object become a preoccupation with the patient, resulting in marked distress and restriction of the freedom of mobility (afraid to encounter the phobic object; phobic avoidance ). Phobia: Some Characteristic Features

50. Agoraphobia : - the fear from marketplace. Agoraphobia includes various phobias embracing fears of leaving home: fears of entering shops, crowds, and public places, or of traveling alone in trains, buses, underground or planes. The lack of an immediately available exit is one of the key features of many agoraphobic situations. The avoidance behavior causes sometimes that the sufferer becomes completely housebound . Phobia : types

51. Social Phobias : irrational fear of activities or social interaction, characterised by an irrational fear of performing activities in the presence of other people or interacting with others. The patient is afraid of his own actions being viewed by others critically, resulting in embarrassment or humiliation. Direct eye-to-eye confrontation may be stressful. Low self-esteem and fear of criticism. Symptoms may progress to panic attacks. Avoidance - almost complete social isolation. Usually start in childhood or adolescence. It is equally common in both sexes. Phobia: types

52. Specific (Isolated) Phobias: Fears of proximity to particular animals spiders ( arachnophobia ) insects ( entomophobia ) snakes ( ophidiophobia) Fears of specific situations such as heights (acrophobia) thunder (keraunophobia) darkness (nyctophobia) closed spaces (claustrophobia) Fears of diseases, injuries or medical examinations visiting a dentist the sight of blood (hemophobia) or injury (pain —odynophobia) the fear of exposure to venereal diseases (syphilidophobia) or AIDS-phobia. Phobia: types

53. Obsessional thought are ideas, images or impulses that enter the individual’s mind again and again in a stereotyped form. They are recognized as the individual’s own thoughts, even though they are involuntary and often repugnant. Common obsessions include fears of contamination, of harming other persons or sinning against God. Compulsions are repetitive, purposeful, and intentional behaviors or mental acts performed in response to obsessions or according to certain rule that must be applied rigidly. Compulsions are meant to neutralize or reduce discomfort or to prevent a dreaded event or situation. Autonomic anxiety symptoms are often present. Obsessive-compulsory symptoms may appear in early stages of schizophrenia. The life time prevalence : 2 - 3%. E qually common in men and women. OBSESSIVE-COMPULSIVE DISORDER

54. The neurobiological model has received widespread support in the past decade. OCD occurs more often in persons who have various neurological disorders, including cases of head trauma, epilepsy, birth injury, abno rm al EEG findings, abnormal auditory evoked potentials, growth delays, and abnormalities in neuropsychological test results. The most widely studied biochemical model has focused on the neurotransmitter serotonin because SRIs are effective in treating patients with OCD . . Pharmacotherapy Cognitive - behavior therapy Family therapy Patient support groups Psychosurgery ETIOLOGY & Clinical Management

55. Personality is defined as a deeply ingrained pattern of behaviour that includes modes of perception , relating to and thinking about oneself and the surrounding environment . Personality traits are normal, prominent aspects of personality. Personality disorders result when these personality traits become abnormal, i.e. become inflexible and maladaptive, and cause significant social or occupational impairment, or significant subjective distress. Disorders of Adult Personality and Behaviour

56. In DSM-IV-TR, the personality disorders ( and traits ) are divided into three clusters. Cluster A contains disorders which are thought to be “odd and eccentric” and on a “ schizophrenic continuum”. These include Paranoid, Schizoid and Schizotypal personality disorders . Cluster B consists of disorders considered “ dramatic, emotional and erratic” and on a “ psychopathic continuum ”. These include Antisocial (or Dissocial ), Histrionic , Narcissistic and Borderline (or Emotionally Unstable ) personality disorders . Cluster C has disorders considered “anxious and fearful ” and characterised by “introversion”. These include Anxious (Avoidant), Dependent and Obsessive Compulsive (or Anankastic) personality disorders.

57. Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal (Personality) Disorder Antisocial or Dissocial Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Emotionally Unstable (Borderline) Personality Disorder Anxious (Avoidant) Personality Disorder Dependent Personality Disorder Obsessive-Compulsive ( Anankastic) Personality Disorder Clinical Subtypes

58. Paranoid personality disorder is characterized by a distrust of others and a constant suspicion that people around you have sinister motives. They search for hidden meanings in everything and read hostile intentions into the actions of others. They are quick to challenge the loyalties of friends and loved ones and often appear cold and distant to others. They usually shift blame to others and tend to carry long grudges . They search for hidden meanings in everything and read hostile intentions into the actions of others. Recurrent suspicions regarding fidelity of spouse or sexual partner Paranoid Personality Disorder

59. People with schizoid personality disorder avoid relationships and do not show much emotion They genuinely prefer to be alone and do not secretly wish for popularity. They tend to seek jobs that require little social contact Their social skills are often weak and they do not show a need for attention or acceptance They are perceived as humorless and distant and often are termed "loners." Schizoid Personality Disorder

60. A pervasive pattern of social and interpersonal deficits with reduced capacity for close relationships as well as cognitive or perceptual distortions and eccentricities of behavior with 5 or more of the following: Ideas of reference Odd beliefs or magical thinking Unusual perceptual experiences including bodily illusions Odd thinking and speech Suspiciousness or paranoid ideation Inappropriate or constricted affect Behavior or appearance that is odd or eccentric Lack of close friends other than first-degree relatives Excessive social anxiety that does not diminish with familiarity Schizotypal (Personality) Disorder

61. A pervasive pattern of disregard for and violation of the rights of others occurring since the age of 15 years as indicated by 3 or more of the following : Failure to conform to social norms with respect to lawful behaviors Deceitfulness and conning others for personal profit or pleasure Impulsivity or failure to plan ahead Irritability or aggressiveness as indicated by repeated fights or assaults Reckless disregard for safety of self or others Consistent irresponsibility Lack of remorse There is evidence of Conduct Disorder with onset before age 15 Antisocial Personality Disorder

62. Pervasive pattern of excessive emotionality and attention seeking indicated by > 5 of the following: Uncomfortable in situations in which he is not the center of attention Interaction with others often characterized by inappropriate sexually seductive behavior Displays rapidly shifting and shallow expression of emotion Consistently uses physical appearance to draw attention to self Has a style of speech that is excessively impressionistic and lacking in detail Shows self-dramatization and exaggerated emotion Is suggestible Considers relationships to be more intimate than they are Histrionic Personality Disorder

63. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, lack of empathy as indicated by > 5 of the following: Grandiose sense of self-importance preoccupied with fantasies of unlimited success, power, brilliance or beauty Believes he is special and can only be understood or should associate with other special or high status people Requires excessive admiration Has a sense of entitlement Is interpersonally exploitive Lacks empathy Is often envious of others and believes others are envious of him Shows arrogant, haughty behaviors or attitudes Narcissistic Personality Disorder

64. Pervasive pattern on instability of interpersonal relationships, self image and affects and marked impulsivity as indicated by 5 or more of the following: Frantic efforts to avoid abandonment Unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation Identity disturbance Impulsivity in at least two areas that are potentially self-damaging Recurrent suicidal behaviors, gestures or threats or self-mutilating behaviors Affective instability due to a marked reactivity of mood Chronic feelings of emptiness Inappropriate anger Transient, stress-related paranoia Emotionally Unstable (BOrDERLINE)Personality Disorder

65. A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation as indicated by > 4 of the following: Avoids social occupations that involve significant interpersonal contact Is unwilling to get involved with people unless certain of being liked Is preoccupied with being criticized in social situations Shows restraint in intimate relationships because of fear of being shamed or ridiculed Inhibited in new interpersonal situations because of feeling inadequate Views self as socially inept and unappealing Is unusually reluctant to take personal risks or engage in any new activities because they may prove embarrassing Anxious (Avoidant) Personality Disorder

66. A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviors and fears of separation as indicated by > 5 of the following: Has difficulty making everyday decisions without an excessive amount of reassurance Needs others to assume responsibility for most major areas of his life Has difficulty expressing disagreement with others because of fear of loss of approval Difficulty initiating projects on his own because of lack of self confidence Goes to excessive lengths to obtain nurturance and support from others Feels uncomfortable or helpless when alone Urgently seeks another relationship as a source of care and support when a relationship ends Is unrealistically preoccupied with fears of being left to take care of himself Dependent Personality Disorder

67. A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness as indicated by > 4 of the following: Preoccupied with details, rules, lists, order or schedules to the extent that the major point of the activity is lost Shows rigidity and stubbornness Perfectionism that interferes with task completion Excessively devoted to work and productivity to the exclusion of leisure activity and friends Over conscientious and inflexible about matters of morals or ethics Is unable to discard worn or worthless objects even those without sentimental value Reluctant to delegate tasks Adopts miserly spending style toward self and others Obsessive-Compulsive (Anankastic) Personality Disorder

68. The sexual disorders can be classified into four main types : Gender identity disorders. Paraphilia's (disorders of sexual preference). Sexual dysfunctions . Sexual Disorders Sex refers to biological differences; chromosomes, hormonal profiles, internal and external sex organs. Gender describes the characteristics that a society or culture delineates as masculine or feminine. Sex = male and female Gender = masculine and feminine

69. “ Gender identity refers to one’s sense of oneself as male, female, or transgender” Gender identity disorders are characterised by disturbance in gender identity, i.e. the sense of one’s masculinity or femininity is disturbed. This group includes : Features:- Man or Woman? Trapped in the Body of the Wrong Sex Transexualism Transgendered Rare Gender identity disorders

70. Nature: Goal is Not Sexual No Physical Abnormalities Independent of Sexual Arousal Patterns May be Attracted to People With Desired Identity Causes: No Specific Biological Link, but… Probably Developed Early in Life Gender identity disorders cont …..

71. Types: Transexualism. Gender identity disorder of childhood. Dual-role transvestism. Intersexuality Gender identity disorders cont …..

72. Para - “ Beyond” or “ Amiss” Philia - “ Love ” Sexual Stimulation Requiring Bizarre or Unusual Acts, Imagery, or Objects Paraphilias ( sexual déviations; perversions) are disorders of sexual preference in which sexual arousal occurs persistently and significantly in response to Sexual Disorders 125 objects which are not a part of normal sexual arousal (e.g . nonhuman objects; suffering or humiliation of self and/or sexual partner; children or non consenting person) Paraphilia's (disorders of sexual preference )

73. Fetishism Sexual Attraction to: Inanimate Objects Tactile Stimulation Parts of the Body Exhibitionist Expose Genitals to Unsuspecting Strangers Element of Risk is Important May Not Be “Harmless” (Many Rape / Molest ) Voyeurism Watching Unsuspecting Strangers Naked or Undressing Paraphilia's types

74. Transvestic Fetishism “Cross Dresser” Sexual Arousal by Dressing in Clothes of the Opposite Sex Most are Male Heterosexuals Most are Married Sexual Sadism and Masochism The “ Sadist ” Sexual Arousal by Inflicting Pain / Humiliation, Domination , Beatings The “ Masochist ” Suffers the Pain / Humiliation Helps the Sadist Paraphilia's types

75. Pedophilia and Incest Pedophilia- Sexual Attraction to Children More Aroused to Young Children Incest- Children Related to Perpetrator Other Forms of Paraphilia Frotteurism -- Rubbing Necrophilia -- Corpses Klismaphilia -- Enemas Coprophilia -- Feces Zoophilia -- Animals Scatologia -- Obscene Calls Urophilia -- Urine Paraphilia's types

76. Sexual dysfunction is a significant disturbance in the sexual response cycle, which is not due to an underlying organic cause . Sexual dysfunctions

77. The common dysfunctions include the following: Sexual Desire Disorders Sexual Arousal Disorders Orgasm Disorders Sexual Pain Disorders Types

78. Hypoactive Sexual Desire Disorder Little or no interest in any type of sexual activity Masturbation, sexual fantasies, and intercourse are rare in this disorder Accounts for half of all complaints at sexuality clinics 22% of women and 5% of men suffer from this disorder Sexual Aversion Disorder Little interest in sex Extreme fear, panic, or disgust related to physical or sexual contact 10% of males report panic attacks during attempted sexual activity Sexual Desire Disorders

79. Male Erectile Disorder Difficulty achieving and maintaining an erection Female Sexual Arousal Disorder Difficulty achieving and maintaining adequate lubrication Associated Features of Sexual Arousal Disorders Problem is arousal, not desire Problem affects about 5% of males, 14% of females Males are more troubled by the problem than females Erectile problems are the main reason males seek help Sexual Arousal Disorders

80. Inhibited Orgasm: Female and Male Orgasmic Disorder Inability to achieve orgasm despite adequate sexual desire and arousal Rare condition in adult males, but is the most common complaint of adult females 25% of adult females report significant difficulty reaching orgasm 50% of adult females report experiencing regular orgasms during intercourse Premature Ejaculation Ejaculation occurring before the man or partner wishes it to 21% of all adult males meeting criteria for premature ejaculation Most prevalent sexual dysfunction in adult males Most common in younger, inexperienced males, but declines with age Orgasmic Disorders

81. Dyspareunia Extreme pain during intercourse Adequate sexual desire, and ability to attain arousal and orgasm Must rule out medical reasons for pain Affects 1% to 5% of men and about 10% to 15% of women Vaginismus Limited to females Outer third of the vagina undergoes involuntary spasms Complaints include feeling of ripping, burning, or tearing Affects over 5% of women seeking treatment in the United States Prevalence rates are higher in more conservative countries and subgroups Sexual Pain Disorders

82. There are several types of sleep disorders known. The ASDC (Association for Sleep Disorders Centre) has done a lot of work in classifying the various sleep disorders and their classification has been adapted for use both by DSM-IV-TR and ICD-10. The sleep disorders are known as non-organic sleep disorders in ICD-10. The various sleep disorders are divided in 2 subtypes: I. Dyssomnias Insomnia Hypersomnia Disorders of sleep-wake schedule. II . Parasomnias Stage 4 sleep disorders Other sleep disorders. SLEEP Disorders

83. The sleep itself is pretty normal. But the client sleeps too little, too much, or at the wrong time. So , the problem is with the amount (quantity), or with its timing, and sometimes with the quality of sleep . Insomnia- too little sleep Difficulty initiating or maintaining sleep Persists for 1 month or longer Often due to: Major Depressive Episode, Manic Episode, or anxiety disorder Commonly misused substances, as well as some prescription medicines. Breathing-related problems The cause sometimes can not be identified. Dyssomnias : types

84. Hypersomnia - sleeping too much Excessive sleepiness Persists for 1 month or longer Often due to : Major Depressive Episode, Dysthymic Disorder with atypical features Use of substances is less likely to produce hyersomnia than insomnia, but it can happen (e.g., sleeping pills overdose) The cause sometimes can not be identified. Treatmen t: Exercise when becoming sleepy Dyssomnias : types

85. Narcolepsy - (Sleeping at the wrong time) Sleep intrudes into wakefulness, causing clients to fall asleep almost instantly Sleep is brief but refreshing May also have sleep paralysis, sudden loss of strength, and hallucinations as fall asleep or awaken . Treatment : Stimulants, sometimes antidepressants, with less success. Dyssomnias : types

86. Something abnormal occurs during sleep itself, or during the times when the client is falling asleep or waking up (e.g., bad dreams .) The quality, quantity, and timing of the sleep are essentially normal . Nightmare Disorder- Repeated awakenings from bad dreams When awakened client becomes oriented and alert The same nightmare may recur repeatedly or different ones may pop up three times a week. Stress may induce 60% of nightmares. Half of the cases of nightmare disorder appear before age 10; 2/3 before age 20. Dreams are clearly remembered Drugs can trigger nightmares. Parasomnias types

87. Sleep Terror Disorder- Abrupt awakening from sleep, usually beginning with a panicky scream or cry. Intense fear and signs of autonomic arousal Unresponsive to efforts from other to calm client No detailed dream recalled Usually only children have sleep terror disorder. The client is not having a nightmare. The eyes are open, screams erupt. Usually happens in early evening. Parasomnias types

88. Sleepwalking Disorder- Rising from bed during sleep and walking about. Usually occurs early in the night. On awakening, the person has amnesia for episode Most sleepwalking children are psychologically normal. Runs in families. Begins between ages 6 and 12 and may be stress-related. Customarily sleepwalkers exhibit other delta-sleep interruptions. Adult sleepwalking is far less common, usually worse and more chronic. Parasomnias types

89. Psyche (Mind) + soma (Body) A psychosomatic disorder is a diseases which involves both mind and body. It mainly used to mean… “ a physical disease that is thought to be caused, or made worse, by mental factors”. Some physical diseases are thought to be particularly prone to be made worse by mental factors such like stress and anxiety…psoriasis, eczema, high blood pressure and heart disease There is a mental aspect for every physical disease There can be physical effects from mental illness The mind can cause physical symptoms (Release of adrenaline) PSYCHOSOMATIC DISORDERS

90. Different Somatizations; Nervous system- headache, twitchings… Digestive system- gastric ulcer, constipation… Cancers Rheumatism and osteo- musles disorders- arthritis, lumbago.. Cardiovascular system- arterial hypertension, throbbing of heart… Immunologic disorders- allergy; asthma… Endocrine diseases- hyperthyroidism, diabetes… Lungs disorders- cough, dyspnea… Nutritive function disorders- anorexia, boulimy…. Gynecology Sexology Dermatology- psoriasis, eczema... PSYCHOSOMATIC DISORDERS cont ……

91. Causes of Psychosomatic disorders Genetics Social or Environmental Factors Nervous system Treatment Acupuncture Homeopathy Plants Stress management Communication Self Assurance PSYCHOSOMATIC DISORDERS cont ……

92. T h a n k y o u