SULTANATE OF OMAN MINISTRY OF HEALTH

MANUAL FOR THE MANAGEMENT OF MENTAL ILLNESS IN PRIMARY HEALTH CARE

SECOND EDITION-2011

DEPARTMENT OF NON COMMUNICABLE DISEASES SURVEILLANCE &CONTROL IBN-SINA HOSPITAL DEPARTMENT OF PRIMARY HEALTH CARE.

MR - 414 PREFACE

Health is “the complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organisation Constitution 1948). Thus mental health is an integral part of health and plays an important role in the overall health of individuals, families, communities and nations. Indeed, there is no health without mental health. It is therefore important to include mental health in preventive, curative and rehabilitative health care services in every stage of development in the human life cycle. Despite there being no doubt that mental health is as important as physical health to overall well being of individuals, societies and countries, only a small minority of the 450 million people in the world suffering from a mental or behavioural disorder are receiving treatment, and this is also true of Oman as well as other countries .

Prevention of all illnesses and disabilities is the policy of the Ministry of Health in Sultanate of Oman. There is a need to provide easily accessible, effective and early recognition of mental disabilities because delay produces adverse effects not only on the patients and their families but also on the whole economy and overall well being of society. Early recognition leads to early intervention resulting in better prognosis. Given the prevalence of mental disorders , and the desire to achieve equitable population access to mental health promotion, prevention, and treatment, it is essential , as in other countries, to integrate mental health into primary health care. Therefore this manual forms part of a systematic and comprehensive program to integrate mental health into Oman's primary health care system. As well as this manual, other components of the program include training of primary health care doctors and nurses in mental health, inclusion of mental disorders in the primary care IT system, provision of medicines in primary care, and other supportive issues. Thus it is intended that primary care staff will be empowered with the necessary knowledge, skills, competence and attitude to recognize and manage mental health problems both in the community and Primary Health Care facilities.

Advances in neuroscience and behavioural medicine have shown that, like many physical illnesses, mental disorders are the result of complex interaction between biological, psychological and social factors. Therefore the approach taken throughout our programme is a biopsychsocial approach: biopsychosocial assessment and biopsychosocial management.

This manual therefore provides a set of standardised methods and guidelines to identify and evaluate psychological disorders in all health care facilities in Oman, especially in primary health care, along side any physical conditions and social issues which the patient may have.

The preparation and publication of this manual is the culmination of the efforts of numerous people who are concerned with caring for the mentally ill, in supporting their families and in planning the provision of psychiatric care in Oman. The Ministry of Health would like to thank them for their commendable efforts in producing this manual.

The World Health Organization office in Oman has also been closely involved in the publication of this manual and in providing all kinds of assistance, advice and support. Their role is highly appreciated.

Dr. Mohammed bin Said bin Sultan Al-Hosani Undersecretary of Health affairs

2 Editor: Dr.Hashim Zainy Specialist psychiatrist In charge of Mental Health Department - non-communicable diseases Surveillance & Control

Main contributors

1. Dr. Hashim Zainy Specialist psychiatrist 2. Dr. Nasser Al-Sibani Consultant psychiatrist 3. Dr. Jamila Tufail Al-Rahman Senior specialist psychiatrist 4. Dr. Mahmood Al-Abri Senior specialist psychiatrist Director of Ibn- Sina Mental hospital

List of contributors

1- Dr. Sosamma John Consultant psychiatrist

2- Dr.Badrya Al-Rashdi Senior specialist FAMCO

3- Dr.Ahmed Al-Wahaibi Senior specialist FAMCO

4- Dr. Asad Al-Mousawi Senior specialist psychiatrist

5- Dr. Jawad Al- Lawati Director of non-communicable diseases Surveillance & Control

12 - Dr. Said Al- Lamki Director of primary health care department

3 Acknowledgement:

The contributors wish to extend their thanks and gratitude to his Excellency the Minister of Health Dr.Ahmed bin Mohammed bin obaid Al-Saidi for his continuous support and encouragement as well as adoption of the program of integrating Mental Health in Primary Health care.

Thanks also extended to His Excellency the undersecretary of Health affairs Dr. Mohammed bin Saif bin Sultan Al-Hosani for his help and support. Contributors are also grateful for the continuous support provided by His Excellency Dr. Ali bin Jaffer bin Mohammed, Advisor of health affairs and supervising DGHA

Thanks and appreciation offered to Prof. Rachel Jenkins, Consultant psychiatrist, director of WHO Collaborating Centre, Institute of Psychiatry, Kings College London and Dr. Jihane Tawila WR of WHO Oman office for their valuable guidance, suggestions and continuous support.

4 Contents

Preface………………………………………………………………………………………………………2 List of contributors………………………………………………………………………………………..3

Acknowledgement………………………………………………………………………………………...4

Introduction……………………………………………………………………………...... 7

Section1. General management issues Prevention of mental health problems………………………….……………….….…….11 Management of psychiatric disorders …………………………….……….…….……….12 Assessment of patients in primary health care units………………………….………...12 Roles and responsibilities of health centers……………………………………………...15 Classification of mental disorders………………………………………………………….16

Section 2: Specific mental disorders ………………………………..………………………………………………....19 Anxiety…………………………………………………………………………..…………...22 Post traumatic disorder……………………………………………………………..28 ……………………...…………………………………….….……...30 …………………………………………………………………………31 Acute ……………………………….………………………………………….....32 ……………………...... 33 Bipolar affective disorder..……………………………………………………….………….35 Mental and behavioral disorders due to psychoactive substance use…………………37 ……………………………………………………………………………………...48 Mental disorders in women and reproductive psychiatry…………………………..……50 Mental retardation……………………………………………………………………………52 Hyperkinetic disorder………………………………………………………………………...54 ……………………………………………………………………………..55 Childhood emotional disorder……………………………………………………………….56 Reading disorder (Dyslexia)………………………………………………………………...57 Pervasive developmental disorder…………………………………………………………59

5 Section 3: Psychiatric emergencies Managing violent patient …………………………………………….……………………..61 Intentional self harm (suicide)………………………………………..……….…………....65 Main medical/ drug related emergencies in psychiatry…………………………………..69

Section 4: Medication guidelines General principles…………….……………………………………….……………………..76 Antipsychotic medications…………………………………………………………………..77 Antidepressant medications…………………………………………………………………81 Mood stabilizing medications………………………………………………………………..83 Anticholinergic drugs………………………………………………………………………....86 Anxiolytics, sedatives and hypnotics……………………………………………………….87

ANNEXURE 1: Other useful materials Checklists and screening tests for use by professionals in PHC …………………...88

ANNEXURE 2: Medications in PHC Medications approved to use in PHC……………………………………………….………92 Suggested medications for approval to use in PHC………………………………………93 ANNEXURE 3: Glossary of psychiatric signs and Symptoms……………………94

6 Introduction:

Global situation:

Mental and behavioural disorders are common, affecting more than 25% of all people at some time of their lives. They are also universal affecting people from all countries and societies, individuals at all ages, women and men, the rich and the poor, from urban and rural environments. They have an economic impact on societies and on the quality of life of individuals and families. Mental and behavioural disorders are present at any point in time in about 10% of the adult population. Around 30% of all patients seen by primary health care professionals are diagnosed with mental disorders. One in four families is likely to have at least one member with behavioural or . These families not only provide physical and emotional support, but also bear the negative impact of stigma and discrimination. It was estimated that, in 1990, mental and neurological disorders accounted for 10% of the total DALYs lost due to all disease and injuries. This was 12% in 2000.By 2020; it is projected that the burden of these disorders will have increased to 15%.

Situation in Oman: An epidemiological survey of school children has been conducted in 2006 showing prevalence rates of mental disorders is 16% which is similar to elsewhere in the world. A similar study on adults has not yet been conducted. As yet there are no prevalence studies of mental disorders in primary care, but international WHO studies have indicated that around 1 in 3 primary care attendees have a psychological disorder. In Oman, until now, the majority of people with identified mental disorders are initially treated by specialist services, and some are followed up by primary care.

Specialist services in Oman currently consist of outpatient clinics and hospital beds. There are 26 outpatients mental health facilities available in the country, of which 2 are for children and adolescents .In 2006 these facilities, treated 386 users per 100,000 general populations (WHO- AIMS Report on Mental Health System in Oman 2008).

Psychotropic drugs are most widely available in the mental hospital, followed by outpatient clinics. Most of the specialist mental health facilities are present in or near large cities, with a dearth of provision in rural areas. In order to promote equity of access to mental health specialist services, Oman is encouraging the development of community – based psychiatric units and inpatient wards in reference hospitals at regions throughout the country.

Mental Health Policy Vision: To make Oman the leading country in the region in provision of quality mental health care services.

Mission: To provide quality promotive, preventive, curative and rehabilitative mental health care services to all Omani people. Ministry of health will aim to achieve:  Promotion of mental health in the general population, schools, and workplaces, with special attention to prevention in vulnerable groups , and to linkages with physical health.

7  Treatment of people with mental disorders quickly and effectively, in local primary care services where possible, and with attention to comorbidity with physical illnesses.  Community mobilization through media, families, NGOs to support people with mental disorders to participate in normal life with their families and friends, and return to work, to tackle stigma and discrimination, and to protect human rights and dignity. Ministry of health will lead the implementation of the mental health program, through the following program components:  Enhance the capability of the ministry to implement the mental health program.  Integrate mental health into primary care services  Further decentralization and strengthening of the secondary mental health care system.  Strengthened links between primary and specialist care.  Ensuring basic supply of medications for PHCs, regional psychiatric clinics and inpatient units.  Good practice guidelines for PHCs, regional psychiatric clinics and inpatient units.  Intersectoral liaison between health , education, social development, police and prisons, NGOs etc at national, governorate/ regional and willayet levels  Community mobilization through media, support to families and NGOs, health education in schools.

Defining mental health and mental illness

Positive mental health includes

 a positive sense of well-being

 individual resources including self esteem, optimism, and sense of mastery and coherence

 the ability to initiate, develop and sustain mutually satisfying personal relationships

 the ability to cope with adversity (resilience) These will enhance the person's capacity to contribute to family and other social networks, the local community and society at large

Mental health problems include:

 Psychological distress usually connected with various life situations, events and problems; prevalence: most of us!

 common mental disorders (e.g. depression, anxiety disorders in adults and emotional and conduct disorders in children); prevalence: 10-20% of adults in general population (but up to 40-50% in highly vulnerable populations), 30% of primary care attendees, 10% of children in general population

 severe mental disorders with disturbances in perception, beliefs, and thought processes (psychoses); prevalence: 0.5% of general population

8  disorders (excess consumption and dependency on alcohol, drugs and tobacco); prevalence: very country specific.5% and above, growing

 abnormal personality traits which are handicapping to the individual and/or others; prevalence: not known

 Progressive organic diseases of the brain (dementia); prevalence of senile dementia: 5% of over 65s and 20% of over 80s.

Mental health problems constitute a heavy burden;

 suffering

 disability

 mortality

 loss of economic productivity

 poverty

 family burden

 intellectual and emotional consequences for children

Causes of mental illness:

Risk factors for mental disorders:

Social  life events (e.g. bereavement, job loss)  chronic social adversity (unemployment, poverty, illiteracy, child labour, violence, war)  lack of social supports  Marital discord Psychological  poor coping skills  low self esteem

Physical  nutrition  infection  trauma  endocrine & metabolic  genetic  Toxins  Drugs

Consequences of mental illness:  unemployment

 poverty

 marital breakdown

 intellectual, physical and cognitive damage to children

 physical illness

 death from physical illness

 Suicide

9 National mental health programme:

 A central component of Oman's mental health strategy is the integration of mental health into primary health care in order to provide population access to mental health care  Therefore mental health should be one of the major constituents of primary health care in the Sultanate of Oman.  Cases that cannot be managed at the primary level will need referral to the secondary and tertiary care.  Oman's mental health strategy also includes the progressive establishment of a school mental health program, child guidance clinics and schools for the children with special needs, so close liaison between the school mental health program and the primary care mental health program is essential.

Integration of mental health in Primary Health Care (PHC):

The program of integrating mental health in primary health care is planned for the following reasons:  High burden of mental disorders on affected individuals and their families.  Mental and physical health problems are interwoven.  The treatment gap for mental disorders is enormous.  Primary care for mental health problems enhance access (people can access mental health services closer to their homes) thus keeping their families together and maintaining their daily activities.  Primary care for mental health promotes respect to human rights by minimizing stigma.  Primary care for mental health is affordable and cost effective.  Primary care for mental health generates good health outcome by enhancing early recognition, management and referral.

Objectives of the programme: 1. Early recognition of common mental disorders. 2. Standardization of management of common mental disorders. 3. Defining safe and adequate referral criteria for patients suffering from mental disorders to secondary and tertiary care. 4. Prevention, early recognition and management of relapses of mental disorders. 5. Maintaining continuity of care. 6. Minimizing stigma and discrimination toward the mentally ill. 7. Recognition, assessment and management of psychiatric emergencies. 8. Recognition and screening for childhood &adolescence mental disorders. 9. Recognition and screening for mental disorders related to old age.

Strategies:  Providing easily accessible primary mental health care to the whole population of the Sultanate.  To integrate mental health into primary health care services.  To strengthen, expand and render the existing specialist services more effective through early recognition and intervention at primary level.  Use good practice guidelines  Ensure availability of antidepressants, anti-psychotics and anxiolytic medications in the primary care clinics

10 Section 1: General management issues

Prevention of Mental health problems

Primary Prevention  support vulnerable people to stop them from getting ill  health workers and community health workers (CHWs) can consider who is vulnerable and give/mobilise support e.g. to carers  Strengthen individuals, families and communities

Secondary Prevention  treat ill people quickly to reduce length of illness  health workers and CHWs can be alert to symptoms of illness

Tertiary Prevention  rehabilitate back to normal functioning  Health workers and CHWs can organize opportunities for rehabilitation

Vulnerable groups

Carers are very important and need support.  adult carers  child carers and children heading households

Women and Children  children are a nation's most precious resource but services for children and adolescents need to be developed and resourced  children's cognitive and emotional development is greatly influenced by the mental health of their parents, especially mother, and particularly when mother is main carer  in addition to general rates of adult illness, women experience higher rates of depression in adulthood and higher rates of illness around time of childbirth. if untreated, these disorders severely affect mother's relationship with children, which in turn damages child's cognitive and emotional development and physical growth.  particular childhood disorders for consideration include emotional and conduct disorders, epilepsy, mental retardation, specific learning problems e.g. dyslexia

Intellectual handicap Children and adults with intellectual handicap should be able, encouraged and supported to lead as normal a life as possible. They have  special educational needs  social, physical and psychological needs  specific neurological problems e.g. cerebral palsy, epilepsy. Essential medicines are needed to ensure that intellectual deficit is not aggravated by these associated conditions

Older people  risk of dementia increases exponentially with age over 65  people with dementia are at risk of neglect (starvation, abuse, hypothermia, neglect of physical illness). Sensory impairment

11  deafness is particularly associated with psychological symptoms  profound early deafness interferes with speech and language development, emotional development and educational attainment  blindness causes difficulty and physical hazard  In previously sighted people, blindness causes considerable distress and depression

Management of psychiatric disorders: The general physician should be able to recognize and screen for most psychiatric disorders and he should be capable of managing the common psychiatric disorders identified in general practice, whether with or without accompanying physical illness.

Approach all patients using biopsychosocial multiaxial assessment and management.

1-Assessment: a) Recognize the existence of psychiatric disorder by asking the following questions.  Is there a psychiatric disorder or is this an understandable reaction to the circumstances? If there is a psychiatric disorder, what is it? What are the etiological factors of the disorder? In particular, what psychological, physical and social factors may be relevant?  Is there a need to treat the disorder? What kind of treatment would be indicated (psychological, physical, and social)? Who should be involved? Is referral to psychiatrist indicated? b) Collateral history is essential to establish diagnosis and treatment plans.

2-Treatment: Treatment depends on the nature of the condition and should include a variety of psychological, physical and social measures.  Give a basic explanation and advice about the nature of symptoms, their causes.  Establish a therapeutic relationship  Communicate effectively by being specific ,avoiding jargon and ambiguity  Provide advice and instil hope

Assessment of patient in primary health care units:

 An interview/history(including collateral history from relatives or acquaintances)  A complete mental state examination  A complete physical and neurological examination  All relevant lab tests  Observation reports History is a crucial tool for diagnosis and management. Maximum information can be obtained if the interview is conducted in a warm, concerned and direct way by a confident physician.

History:  Identifying information: Name, age, gender, marital status, address, educational level, occupation, source of referral and reason for referral  Presenting complaints  History of presenting complaints  Past psychiatric and medical histories  Drug history  Family history  Personal history: Childhood, adolescence, adulthood, education, employment and relationships

12  Social history  Forensic history  Premorbid personality

Mental state examination: 1. General appearance and Behaviour,  Apparent age, dress, grooming  Movement , gait and posture  Facial expression and eye to eye contact  Psychomotor activity(agitated or retarded)  Overt social behaviour and attitude toward examiner (cooperative, friendly, evasive, hostile or aggressive). 2. Speech: .  Rate: Rapid, pressure of speech, slow  Tone: Monotonous, loud , whispered,  Quantity : overtalkative, reduced in amount  Quality: Spontaneous, hesitant, slurred, (stammering) ,  Abnormal features: Neologism (invention of new strange words), echolalia ( parrot like repetition of words or statements) . 3. Mood and affect: Mood: Pervasive and sustained emotion that colours patient’s perception of the world (depressed/anxious/elated etc).Affect: The outward expression of patient’s inner experience (blunted/flat/inappropriate).  Quality: Depressed, anxious, euphoric  Quantity: Restricted, blunted, flat  Appropriateness : Congruent, incongruent  Stability: Emotional lability (mood swings)  Depressive Ideas :worthlessness, hopelessness , low self esteem and guilt  Suicidal risk: Suicidal ideas, plans and previous attempts. 4. Perception: Awareness of the significance and meaning of sensory stimulus.  Hallucinations: perception without external stimulus (auditory, visual, olfactory, tactile and gustatory).  Illusions: misperception of external stimulus (faulty perception of external stimulus) it can occur in normal people.  Depersonalisation and derealization: Extreme feeling as if one’s self or external world is unreal.

5. Thought: Thought disorders are divided into:  Disorders of form: o Productivity: Overabundance of ideas, paucity of ideas, flight of ideas ,retardation(slowness) of thinking

13 o Continuity: loose associations, illogical thinking, tangential thinking, perseveration, thought block, circumstantialities, derailment. o Language impairment: Incoherent or incomprehensible speech (word salad), clang associations, neologisms.  Disorders of content: o Preoccupations: Obsessions, , suicidal or homicidal ideas, hypochondriacal ideas (about illness). o Thought disturbances: Delusions (false unshakeable, fixed beliefs which can not be dispelled by logical reasoning and not corresponding with sociocultural background) eg.persecutory delusions, grandiose delusions, delusions of reference, delusions of guilt, hypochondriacal delusions.

6. Cognitive functions:  Consciousness and awareness: .Clarity of awareness to the environment (drowsiness, stupor, coma).  Attention and concentration: ability to focus on the task on hand. o Serial sevens( subtract 7 out of 100 serially several times) o Enumerate days of the week backward.  Orientation o Time: Year, season, month, day, date o Place: Country, region, city, hospital , ward o Person: Attendants, interviewer  Memory: o Immediate retention and recall: Ability to repeat names of 3 objects after the examiner dictates them, then after a few minutes of interruption by a distracting question, the patient asked to repeat the figures again. o Recent memory: Past few days events(what did the patient have for breakfast, lunch or dinner) o Recent past memory: Past few weeks or months events. o Remote memory: Childhood data, important events.  Intelligence: General knowledge.  Abstract thinking: Proverb test (understand the aim and abstract meaning of a given proverb).  Visio -spatial abilities: Draw shapes and copy designs.

7. Insight and judgement:  Insight: Does the patient notice a change? Does he recognize that this change is abnormal? Does he acknowledge that his problem is psychiatric? Does he realize the need for some form of treatment?  Judgement: Patient’s predictions of what he would do in imaginary situations(what he would do if he found an addressed letter in the street)

Physical and neurological examination: A full physical and neurological examination should be performed (especially in cases of acute psychosis or ).

14 Investigations:  Basic laboratory tests should be obtained as early as possible. These should include complete blood count, random blood glucose, urea and electrolytes, liver function test, renal functions and drug screen (if available). Further tests should be conducted depending on the indications such as thyroid function test, ECG, EEG, sexually transmitted diseases screen(including test for HIV) and radiological examinations.

Effective measures are available to treat mental illness:

 Counselling :( individual/ family counselling…)

 Psychotherapy :( e.g. supportive therapy, cognitive therapy….)

 Medicines :( e.g. antidepressants, antipsychotics…)

 Rehabilitation (social, vocational…)

Roles and responsibilities at Health Centers: Clinical roles  identification, diagnosis, treatment, follow up, referral  address physical, psychological and social axes simultaneously  use good practice guidelines  use psychosocial skills  rational prescribing of psychotropics  reduce use of benzodiazepines  conduct outreach and home visits  liaise with community health workers  liaise with families

Registering a case

Statistics are vital for planning including determining drug supply, service required, staff continuing education needs in order to improve the quality of mental health care at different levels of service delivery. Statistics are also useful in evaluation of services provided. Statistical information can be accessed from the electronically computerized system using ICD-10 classification as installed in all PHC institutes.)

Referral and follow up procedures for psychiatric cases: o The referring doctor should complete referral form in PHC centers.It should include: . Diagnosis or provisional diagnosis. . Salient findings and special precautions (if any) . Medicines given to the patient.(type, dosage, frequency and duration )

15 . Reason for referral o Referral to psychiatric hospitals should be through secondary care psychiatrists. o In order to collect effective data and required statistics, the PHC centres, secondary care centres and hospitals should send monthly statistical reports which will reflect number of patients treated, socio-demographic data and diagnostic categories.

Classification of mental disorders:

ICD 10 classification of mental disorders: F 00-F 09 Organic, including symptomatic, mental disorders  Dementia: Dementia in Alzheimer’s disease, , dementia in pick’s disease, dementia in Creutzfeldt – Jackob disease, dementia in Huntington’s disease, dementia in Parkinson’s disease, dementia in HIV disease, dementia in other specified diseases, unspecified dementia.  Organic amnesic syndrome, not induced by alcohol and other psychoactive substances.  Delirium  Other mental disorders due to brain damage, dysfunction, and physical disease.  Personality and behavioural disorders due to brain disease, damage or dysfunction.  Unspecified organic or symptomatic mental disorders

F 10-F 19 Mental and behavioural disorders due to psychoactive substance use: Alcohol, opioids, cannabinoids, sedatives and hypnotics, cocaine, other stimulants, hallucinogens, tobacco and solvents.

F 20-F 29 Schizophrenia, schizotypal and delusional disorders: Schizophrenia, and non-organic related disorders such as acute and transient psychotic disorders and persistent delusional disorders.

F 30-F 39 Mood (affective) disorders: Manic episodes, depressive episodes, bipolar affective disorders, recurrent depressive disorders and persistent mood (affective) disorders

F 40-F 48 Neurotic, stress related and somatoform disorders:  Phobic anxiety disorders: with or without , social ,

16  Other : panic disorder, generalised anxiety disorder, mixed anxiety and depressive disorder  Obsessive-compulsive disorder  Reaction to severe stress and adjustment disorders  Dissociative (conversion) disorders  Somatoform disorders

F 50-F 59 Behavioural syndromes associated with physiological disturbances and physical factors: Eating disorders, non - organic sleep disorders, (not caused by organic disorder or disease), puerperal mental and behavioural disorders and abuse of non dependence- producing substances (e.g. antidepressants, laxatives, analgesics etc.)

F 60-F 69 Disorders of adult personality and behaviour:  Specific personality disorders: paranoid, schizoid, dissocial, emotionally unstable(impulsive and borderline), histrionic, anankastic, anxious, dependent  Habit and impulse disorders: pathological gambling, pathological fire setting(pyromania),pathological stealing (),  Gender identity disorders  Disorders of sexual preference  Psychological and behavioural disorders associated with sexual development and orientation F 70-F 79 Mental retardation:  Mild mental retardation  Moderate mental retardation  Severe mental retardation  Profound mental retardation

F 80-F 89 Disorders of psychological development:  Specific developmental disorders of speech, and language, Specific developmental disorders scholastic skills and Specific developmental disorders of motor functions  Pervasive developmental disorders: childhood , atypical autism, Rett’s syndrome etc. F 90-F 98 Behavioural and emotional disorders with onset usually occurring in childhood and adolescence:  Hyperkinetic disorders  Conduct disorders  Mixed disorders of conduct and emotions  Emotional disorders with onset specific to childhood  Disorders of social functioning with onset specific to childhood and adolescence

17  Tic disorders What diagnostic categories should be recorded in the patient’s register (simplified form)?

 Depression - F32  Phobia – F40  Panic disorder – F41.0  Generalized anxiety disorder - F41.1  Somatization disorder- F45.0  Conversion disorder – F44  Obsessive – Compulsive disorder- F42  Acute psychosis – F 23  Post traumatic stress disorder - F43.1  Schizophrenia - F20  Bipolar affective disorder – F31  Drug abuse or dependence – F11…..F19  Alcohol abuse or dependence – F 10  Mental retardation – F70 …F79  Hyperkinetic disorder – F90  Childhood emotional disorder-F 93  Specific reading disorder –F81.0  Pervasive developmental disorders –F84  Conduct disorder - F91  Dementia – F 00  Suicide –X 60-84 combined Y10-34 excluding Y33.9  Others

18 Section 2: Specific mental disorders

Depression – F 32 Presenting complaints:  the patient may present with one or more physical symptoms, such as headache or ‘tiredness all the time’  irritability  anxiety, , worries about social problems such as financial or marital difficulties, increased or alcohol use, or (in a new mother) constant worries about her baby or fear of drug harming the baby

 Depressed mood for most of the day, nearly everyday Diagnostic features for at least 2 weeks.  Markedly diminished interest or pleasure in all or almost all activities.  Significant loss of appetite and weight or sometimes increase in appetite and weight.  Insomnia or .  agitation or slowing of movement or speech (psychomotor retardation or agitation)  fatigue or loss of energy  Guilt or worthlessness.  poor concentration  suicidal thoughts , plans or acts  pessimism or hopelessness about the future  decreased libido(impaired sexual desire)  Duration should be for more than 2 weeks  Bipolar affective disorder should be excluded from history(no history of manic episodes )  These symptoms should cause significant distress or impairment in social and occupational functioning.

Differential  General medical conditions diagnosis  Substance related disorders (alcohol, opioids, stimulants…)  Grief reaction  Somatization disorder   Schizophrenia

19 Information, advice,  Assess risk of suicide support and other measures for patient o What do you think about life? and family o Do you ever feel that life is not worth living? o Do you ever feel hopeless? o Do you ever feel you would rather be dead o Have you thought of killing yourself? o Have you thought how you would do it? o Have you tried to kill yourself before? o Have you given away any of your possessions? o Is the patient likely to act on the plan? If patient is making active plans to kill himself, this patient is at high risk and will need close supervision, from family, friends and health professionals. If possible, refer to a specialist.

 Assess risk of harm to others(homicide, infanticide)  Psychoeducation: informing the patient that depression is a common and treatable condition)  Identify past and current life problems or social stressors.  Advise to stop alcohol /drug use.  Support the patient and family.  Structured program of physical activities.

Medication  Selective Serotonin reuptake inhibitors (SSRIs) : o Fluoxetine: oral; 20 mg od, if no response after 4- 6 weeks then increase the dose to 40 mg daily. Therapeutic dose range is 20-60 mg / day in divided dose OR o Citalopram: oral; start 20 mg od, if no response after 4-6 weeks increase to 40 mg daily. Therapeutic dose range is 20-60mg/day.  If SSRIs are not available ,use tricyclic antidepressants: o Amitriptyline: oral; start with 25mg Hs, slow build up (over 2-4weeks). Therapeutic dose range is 75-200 mg/day in divided doses OR o Maprotiline: oral; start with 25 mg Hs, slow build up to the minimum effective dose (2-4 weeks). Therapeutic dose range 100-200mg /day in divided doses  Follow up every two weeks for the initial 8 weeks then every month(once therapeutic dose reached)

 In elderly patients and children: Use half of the recommended adult dose.

 Patients with cardiac disease, narrow angle

20 glaucoma and prostate problems, caution is advised (avoid tricyclic antidepressants).  Continue full dose of antidepressants for at least 6-24 months after remission to prevent relapse.  Withdraw antidepressants slowly (4-6 weeks)

Referral Refer to specialist psychiatrist if:  Significant suicidal /homicidal risk.  Severe depression with or without psychotic features (delusions and hallucinations)  Depressive stupor.  Depressive episode in Bipolar affective disorder  Refusal to eat and/or drink.  No response/partial response to treatment after 6-8 weeks from the use of full effective dose.

21 Anxiety

Anxiety is a widespread phenomenon in which the subject experiences a feeling of tension and apprehension accompanied by autonomic disturbances manifested by sympathetic overactivity. Anxiety can occur as: 1. Feeling of restlessness and tension under conditions of stress, which may be adaptive (enhance performance) or maladaptive (causing distress and hesitancy). 2. Anxiety can occur in many psychiatric disorders such as depression, schizophrenia, delirium, drug intoxication and withdrawal. 3. Anxiety may accompany medical disorders such as thyrotoxicosis, hypoglycemia, epilepsy, pheochromocytoma etc. 4. Some drugs may induce anxiety symptoms: caffeine, stimulants (cocaine, amphetamines), cannabis and others.

Anxiety disorders:

1. Phobias: Intense fear from certain object, situation or activity that lead to avoidance. Types of phobias;

Specific phobia- F 40.2

 Marked and persistent Fear that is Diagnostic features excessive and unreasonable from certain object or situation e.g. insects, dogs, heights, flying, darkness, injections etc.  Exposure to phobic stimulus almost invariably provokes immediate anxiety response.  The person recognizes fear as excessive and unreasonable  The phobic situation is avoided or endured with intense anxiety or distress.  Interference with social, occupational functioning.

 Appropriate fear Differential diagnosis  Reaction to severe stress  Posttraumatic stress disorder Explain to the patient that; Information, advice,  Phobias are common and treatable support and other measures for patient and problems. family  Mechanism of development anxiety in phobias.  Anxiety has both physical and mental symptoms.  Encourage patient to use relaxation methods.  Advice to avoid using alcohol, smoking and reduce caffeine intake.  Psychotherapeutic intervention (if accessible) is the gold standard of treatment

 Medications usually reserved for severe Medication incapacitating cases during the course of behavioural therapy (if patient needs behavioural therapy refer to psychiatrist).

22  Follow up as needed.

 Severe incapacitating conditions should Referral be referred to psychiatrist for further management.

Social phobia- F 40.1

 A marked and persistent fear of social or Diagnostic features performance situations and activities which include fear from speaking, writing or eating in public.  Exposure to feared social situation almost invariably provokes immediate anxiety response.  The person recognizes fear as excessive and unreasonable.  The feared social situation is avoided on endured with intense anxiety or distress.  Interferes with social, academic and occupational functioning.

Differential diagnosis  General medical conditions  Substance induced (stimulants, hallucinogens...).  Excessive shyness  Reaction to severe stress  Schizophrenia. Information, advice, Explain to patients that; support and other  Social phobia is common and treatable measures for patient and family problem.  Mechanism of development of anxiety in phobias.  Anxiety has both physical and mental symptoms.  Encourage patient to use relaxation methods.  Avoid using alcohol, smoking and reduce caffeine intake  Psychotherapeutic intervention (if accessible) is the gold standard of treatment

 SSRI: Paroxetine or Fluoxetine: oral; start Medication with 20mg od if no response after 4-6 weeks increase to 20mg bid. Therapeutic dose range is 20-60mg/day

 Beta blockers: (propranolol): oral; 20-40mg, one hour before performance (in performance anxiety).  Follow up every 2 weeks for 8 weeks, then for every month.  Continue treatment for 6-24 months.

 Slowly taper medications (4-8 weeks)

23 Referral  Severe and incapacitating conditions.  Need for psychotherapeutic intervention  Poor response to treatment.

Agoraphobia- F 40.00

Diagnostic features  Fear from situations in which escape is embarrassing or difficult (being in a crowd, standing in a line, being on a bridge, travelling in a bus or train).  These situations are avoided or endured with marked distress

 Reaction to severe stress. Differential diagnosis  Substance induced (stimulants, hallucinogens...).  General medical condition (thyrotoxicosis…)  Schizophrenia.

Information, advice, support  Explain to the patient that: and other measures for o Phobias are common and patient and family treatable problems. o Mechanism of development of panic attacks in agoraphobia. o Anxiety has both physical and mental symptoms.  Reassurance  Encourage patient to use relaxation methods.  Avoid using alcohol, smoking and reduce caffeine intake  Psychotherapeutic intervention if accessible

 See panic disorder treatment Medication  Follow up every 2 weeks for 8 weeks, then every month  Treat for 6-24months after stability.  Taper gradually. Referral  Poor response to treatment after 12 weeks.  Severe condition that cause marked distress or impairment of functioning.

24 2. Panic disorder- F41.0

Panic attacks: Discrete periods of intense fear and discomfort with the following symptoms which develop abruptly and reaches peak within 10 minutes.

 Palpitation  Sweating  Trembling, tremor  Shortness of breath  Choking sensation  Chest discomfort  Nausea  dizziness ,light headedness  derealization,depersonalisation  parethesia, numbness  chills and hot flushes  fear of dying, loosing control or going mad

Panic disorder:

Diagnostic features Recurrent unexpected panic attacks with or without Agoraphobia.  At least one followed by one month or more of persistent concern of having additional attacks.  Marked distress or impairment of functioning

 General medical conditions: Differential diagnosis (Epilepsy, hypoglycaemia, thyrotoxicosis..)  Substance induced (stimulants, hallucinogens...)  Reaction to severe stress  Schizophrenia

Information, advice,  Explain to patient that: support and other measures o Panic disorder is common and for patient and family treatable problem. o Mechanism of development of anxiety in panic. o Anxiety has both physical and mental symptoms.  Encourage patient to use relaxation methods.  Avoid using alcohol, smoking and reduce caffeine intake

 SSRI (Paroxetine, Citalopram): oral; Medication start with 10mg od then build slowly to effective dose. Therapeutic dose range is 20-60 mg/day in divided dose. if no/partial response, add

25  Benzodiazepines( clonazepam): oral; 0.5-2mg od (should be used for no more than 2 weeks and after discussion with psychiatrist).  Follow up every 2 weeks for 8 weeks, then every month  Treatment continued for 6-24months after stability.  In stable conditions taper medications slowly) Referral  Poor response to treatment after 12 weeks.  Severe condition that cause marked distress or impairment of functioning.

3. Generalized anxiety disorder- F41.1

Diagnostic features  Excessive worry (generalised, free- floating persistent anxiety) for more than 6 months  Difficulties to control the worry  Restlessness  Irritability  Easy fatigability  Difficulties in concentration  Muscle tension  Sleep disturbances  Causing significant distress or impairment in social and occupational functioning

Differential diagnosis:  General medical conditions  Substance induced  Reaction to stress  Depressive disorder Information, advice,  Explain to the patient that: support and other measures o Anxiety has both physical and mental for patient and family symptoms. o Mechanism of development of anxiety.  Encourage patient to use relaxation methods  Avoid using alcohol, smoking and reduce caffeine intake Medication  SSRI (Paroxetine or Citalopram): oral; start with 10mg od build up slowly to effective dose. Therapeutic dose range 20-60 mg/day in divided dose.  Benzodiazepines( Diazepam): oral; 2-5mg od in severe cases and for a short time (should not be used for more than 2 weeks in PHC practice)  Follow up every 2 weeks for 8 weeks, then every one month.

26  Treatment for 6-24months, if the patient is stable then taper gradually.

Referral  Poor response to treatment after 12 weeks.  Severe condition that cause marked distress or impairment of functioning.

4. Obsessive compulsive disorder- F42

Diagnostic features:  Obsessions: are recurrent thoughts, impulses or images which are intrusive and inappropriate and causing marked anxiety or distress.  The thoughts, impulses or images are not simply excessive worries about real life problems.  The person attempts to ignore or suppress such thoughts, impulses or images, or neutralize them with some other thoughts or actions  The person recognizes that these thoughts, impulses or images are products of his own mind.

 Compulsions: are repetitive behaviours (hand washing, checking...) or mental acts (counting, praying, repeating words silently) that the person feels driven to perform in response to an obsession.  Obsessions and compulsions cause marked distress, or significant impairment of social and occupational functioning. Differential diagnosis:  General medical conditions (Sydenham’s chorea, Huntington’s disease, Tourette’s syndrome)  Other anxiety disorders  Schizophrenia Information, advice,  Reassurance and support. support and other measures  Psychoeducation. for patient and family  Behavioural therapy if accessible

Medications  SSRI (Fluoxetine): oral; start with 20 mg od then gradual increase to effective dose. Therapeutic dose range is 20-80 mg/day in divided dose. or  Clomipramine: oral; start with 25 mg od, increase gradually (2-4 weeks) to effective dose. Dose range is 75-200 mg in divided doses.  Follow up every two weeks for 8 weeks then every month.  Use medications for 6-24 months after improvement then taper gradually. Referral  Severe conditions  Poor response to treatment Post traumatic stress disorder- F43.1

27 Diagnostic features:  The person experienced, witnessed , or was confronted with an event or events that involved actual or threatened death or serious injury , or a threat to the physical integrity of self or others  The person's response involved intense fear, helplessness, or horror  The traumatic event is persistently reexperienced as: o Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions o Recurrent distressing dreams of the event o Acting or feeling as if the traumatic events were recurring (sense of reliving the experience, illusions, hallucinations, flashbacks) o Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event o Psychological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event  Persistent avoidance of stimuli associated with trauma, as indicated by: o Efforts to avoid thoughts, feelings, or conversations associated with trauma. o Efforts to avoid activities, places, or people that arouse recollections of trauma. o Inability to recall an important aspects of trauma. o Markedly diminished interest or participation in significant activities o Feeling of detachment or estrangement from others o Restricted range of affect  Persistent symptoms of increased arousal o Sleep difficulties o Irritability o Difficulty in concentration o Hypervigilance o Exaggerated startle response  Duration of symptoms is more than one month  The disturbance cause significant impairment of social, occupational functioning  PTSD may be : o Acute: if duration of symptoms is less than 3 months

28 o Chronic: if duration of symptoms is more than 3 months o Delayed : if the onset of symptoms is at least 6 months after the stressor

Differential diagnosis:  Panic disorder  Generalized anxiety disorder  Obsessive Compulsive disorder  Depressive disorder Information, advice, support  Psychoeducation and other measures for  Psychological support patient and family  Relaxation training

Medications  SSRI (Fluoxetine): oral; start with 20 mg od then gradual increase to effective dose. Therapeutic dose range is 20-60mg/day in divided dose.  Benzodiazepines (Diazepam): oral; 2-5mg od in severe acute cases and for a short time (should not be used for more than 2 weeks in PHC practice)  Use medications for12-24 months after improvement then taper gradually. Referral  Poor response to treatment after 12 weeks.  Severe condition that cause marked distress or impairment of functioning.

29 Somatization disorder- F 45.0

A history of many physical complaints usually beginning before age of 30 years and occur over a period of several years . Presenting complaints  any physical symptom may be present  symptoms may vary widely  complaints may be single or multiple and may change over time

Diagnostic features:  Four pain symptoms; history of pain related to at least 4 different sites or functions (head, abdomen, back, limbs, chest, during menstruation, during urination or intercourse)

 Two GIT symptoms (nausea, bloating, vomiting, diarrhoea).

 One sexual symptom; One sexual or reproductive symptom other than pain(, ejaculatory problems, irregular menses, excessive menstrual bleeding)

 One pseudoneurological symptom;(incoordination, localized weakness, difficulty in swallowing, blindness, deafness)

 After appropriate examination and investigations, these symptoms can not be explained by a known general medical condition or direct effects of a substance (drug of abuse or medication). Differential diagnosis:  Depressive disorder  Generalized anxiety disorder  Drug abuse  Other somatoform disorders (conversion disorder, ...) Information, advice, support  Regular short visit schedule(by single named doctor) and other measures for  Avoid unnecessary investigations. patient and family  Acknowledge symptoms severity and experience of distress as real but emphasis negative investigations and lack of structural abnormality.  Reassure the patient of continuing care.  Treat psychiatric comorbidity.  Psychoeducation for patient and family.  Psychotherapeutic intervention if accessible.

Medication  Limited role  SSRI if associated with depression or anxiety disorder (see depression and anxiety treatment). Referral  Patients are best treated in health centres.  Refer to psychiatrist if poor response to treatment.

30 Conversion disorder (formerly Hysteria)- F44

Diagnostic features:  One or more symptoms or deficits affecting voluntary motor or sensory function that suggest neurological or other medical condition.  Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.  The symptom or deficit is not intentionally produced or feigned (as in or malingering).  The symptoms or deficit cannot after appropriate investigations, be fully explained by a general medical condition, or by the direct effect of a drug.  These symptoms or deficits cause clinically significant distress or impairment of functioning.  Motor symptoms (incoordination, paralysis, weakness, dysphasia...)  Sensory symptoms (loss of touch or pain sensation ,deafness, blindness)  Pseudoseizures Differential diagnosis  General medical condition  Malingering  Factitious disorder  Depressive disorder

Information, advice,  Encourage the patient to acknowledge recent support and other stresses or difficulties. measures for patient and  Encourage emotional ventilation family  Give positive reinforcement for improvement; try not to reinforce symptoms.  Advise the patient to take a brief rest and relief from stress, and then return to usual activities.  advise against prolonged rest or withdrawal from activities  Psychotherapeutic intervention if accessible.

Medication  Limited role.  Treat psychiatric comorbidity. Referral  Poor response to treatment.  Need of psychotherapeutic interventions.

31 Acute psychotic disorder- F23

Diagnostic features The following symptoms should be present for a significant portion of time during a 1-30 days period.  Delusions; False, fixed, unshakeable beliefs that are held with complete conviction (can not be dispelled by adequate reasoning) and are inappropriate with the sociocultural background.  Hallucinations; False perceptions without external stimulus.  Disorganized speech ;( derailment, incoherence, irrelevance).  Grossly disorganized behaviour.

Differential diagnosis  Delirium (acute confusional state).  General medical conditions.  Drug induced  Schizophrenia: if psychotic symptoms are recurrent or chronic  Bipolar disorder  Depression with psychotic features

Information, advice,  Duration of untreated psychosis correlates adversely with support and other prognosis. measures for patient  Ensure the safety of the patient and his contacts. and family  Minimize stress.  Do not argue with psychotic thinking.  Psycheducation for patients and their families: o Importance of treatment adherence o Early signs of relapse o Avoidance of expression of hostility and constant criticism by family members to patient’s behavior. Medication  Refer to psychiatrist as urgent referral.  If the patient is agitated /aggressive; o Lorazepam: oral ; 1-2 mg , if no response add o Promethazine: inj ;25- 50 mg IM or o Haloperidol: inj; 5-10 mg IM. If still agitated add o Lorazepam: inj; 1mg IM o If still agitated, use Diazepam inj; 5-10mg IV slowly (over at least 5 minutes). o Refer to psychiatrist after stabilizing the patient.

 All acutely psychotic patients should be referred to Referral secondary psychiatric care after initial assessment and stabilization(urgent referral)

32 Schizophrenia- F20

Diagnostic features The following symptoms should present for significant portion of time during one month period.

 Delusions; False, fixed, unshakeable beliefs that are held with complete conviction (can not be dispelled by adequate reasoning) and are inappropriate with the sociocultural background.  Hallucinations; False perceptions without external stimulus( auditory hallucinations are usually more than other types of hallucinations)  Disorganized speech ;( derailment, incoherence, irrelevance).  Grossly disorganized behaviour.  Negative symptoms (affective flattening, poverty of speech content, lack of motivation).  Social/occupational dysfunction  Duration of the disorder is more than 6 months  The disturbance is not due to general medical condition/ substance abuse.

Differential diagnosis  General medical condition :( Temporal lobe epilepsy, delirium, brain tumour…)  Drug abuse/ dependence: chronic intoxication or withdrawal from alcohol or other substances (like stimulants, hallucinogens) can cause psychotic symptoms  Depression with psychotic features; if low or sad mood, pessimism ,delusions of guilt and ill health  Bipolar disorder; (if symptoms of are prominent) Information, advice,  Diagnosis and treatment of schizophrenia at first support and other presentation should made by psychiatrist. measures for patient  Discuss treatment plan with family members. and family  Explain that drugs minimize relapse rate, and inform about side effects.  Minimize stress and exposure to overstimulating environment: o Do not argue with psychotic thinking o avoid confrontation or criticism o during periods when symptoms are more severe, rest and withdrawal from stress may be helpful  encourage patient to function at the highest

33 reasonable level in work and other daily activities  Keep the patient’s physical health under review (personal hygiene, smoking...).  Psychoeducation of the patient and family to identify early signs of relapse, supervise medication adherence and risks of exploitation and abuse of patients

Medication  First presentation of schizophrenia: refer to psychiatrist for further evaluation and .management  Acute relapse: o Haloperidol: oral; start with 1.5mg-3mg in two divided doses and increase gradually to 5-15mg in 2-3 divided doses. or o Chlorpromazine: oral; 25mg tid, then increase gradually to 300mg in 3 divided doses. o During acute relapse follow up should be frequent (everyday if possible) to check for compliance, assess dangerousness, and screen for side effects. o After stabilizing the patient, assess the patient every two weeks for 2 months then monthly assessment is recommended. o If no response after 4-6 weeks refer to secondary care psychiatric services.  Maintenance treatment; o Regular visits every month or as needed. o Regular mental state assessment in each visit o Prescribe the same treatment that stabilized the patient’s condition o Monitor for side- effects of medications (parkinsonian features, akathisia and tardive dyskinesia...)

Referral  First presentation of suspected schizophrenia.  Significant risk to self/others.  Inadequate response to treatment.  Poor adherence to treatment.  Adverse effects of medications (parkinsonian symptoms, tardive dyskinesia, akathisia).  Need for rehabilitation program.

34 Bipolar affective disorder-F31

Diagnostic features  Manic episode: o Distinct period of persistently elevated, expansive, or irritable mood, lasting at least one week. o Inflated self esteem or grandiosity. o Decrease need for sleep (feels rested after only 3 hours of sleep). o Overtalkative, pressured speech. o Distractibility (attention too easily drawn to unimportant details). o Increase in goal directed activity (either socially, at work or school, or sexually) or . o Excessive involvement in pleasurable activities that have high potential for painful consequences (buying sprees, sexual indiscretions, or foolish business investments).

 Depressive episode: (see depression)  Mixed episode: Criteria are met both for manic episode and depressive episode at the same time.

 The disorder cause marked impairment in social, occupational functioning, or necessitate hospitalisation.  Symptoms are not due to direct physiological effects of a substance/ General medical condition.

Differential diagnosis  Substance use disorders (stimulants, alcohol…)  General medical condition (Hyperthroidism, brain tumour…)  Schizophrenia.  Depression Information, advice, support  Assess risk of suicide/harm to others. and other measures for  Stress reduction. patient and family  Close supervision by family is needed.  Educate the patient and family about importance of treatment adherence.  Explain to the family the risk of exploitation/ abuse of patients.  Advise caution regarding impulsive/ dangerous behaviour.  Work with the patient, family to identify early warning signs of manic or depressive episodes.  Avoid alcohol or psychoactive substance intake.  Ensure regular monitoring tests as recommended in medication guidelines.

35 Medication  Manic episode/mixed episode: o Not severely agitated / disorganized: Refer to secondary psychiatric care for further evaluation and management. o Severely agitated /disorganized: Promethazine inj; 50mg IM or Haloperidol inj; 5-10mg IM. If still agitated add Diazepam inj ; 5-10 mg slowly IV. Then refer to psychiatrist after calming the patient.  Depressive episode: Refer to psychiatrist.  Maintenance therapy: . Full mental state examination and risk assessment (on each visit). . Check for treatment adherence. . Don’t stop /change prophylactic medications . Follow medications use guidelines in this manual. . Liaise with secondary care psychiatrist. . Follow up every month.

Referral  Acute manic episodes with or without marked behavioral disorganization  Recent depressive episode in bipolar affective disorder.  Significant risk of suicide/harm to others.  Marked disruptive behavior.

36 Mental and behavioral disorders due psychoactive substance use:

Substance related disorders are divided into two groups: 1. Substance use disorders: a. : b. Substance abuse

2. Substance induced disorders: a. b. Substance withdrawal c. Substance induced delirium d. Substance induced dementia e. Substance induced psychotic disorders f. Substance induced mood disorders g. Substance induced anxiety disorders h. Substance induced sexual dysfunction i. Substance induced sleep disorders

Substance dependence:

A maladaptive pattern of substance use, leading to clinically significant distress or impairment in functioning. It is manifested by the following occurring at any time in the same 12 months period:  Tolerance: a need for markedly increased amounts of the substance to achieve desired effect or markedly diminished effect with continued use of the same amount of the substance.  Withdrawal: Characteristic withdrawal symptoms for each substance due to cessation of or reduction in substance use that was heavy and prolonged.  Substance is often taken in larger amounts or over a longer period than it was intended.  There is a persistent desire or unsuccessful efforts to cut down or control substance use.  A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.  Important social, occupational, or recreational activities are given up or reduced because of substance use.  Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

Substance abuse:

37 A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by the following, occurring in 12 months period:  Recurrent substance use resulting in failure to fulfil a major role obligation at work, school, or home (repeated absences, poor work performance, suspensions, expulsion from school)  Recurrent substance use in situations in which it is physically hazardous (driving or operating dangerous machinery under the effects of the substance).  Recurrent substance related legal problems.  Continued use of the substance despite having persistent or recurrent social or interpersonal problems.

Substance intoxication:

 The development of a reversible substance –specific syndrome due to recent ingestion of the substance.  Clinically significant maladaptive behavioural or psychological changes due to the effects of the substance on the central nervous system (agitation, cognitive impairment, impairment of judgement, impaired social functioning) and develop during and shortly after use of substance.

Substance withdrawal:

 The development of substance- specific syndrome due to the cessation of (or reduction in) substance use that has been heavy or prolonged.  The substance – specific syndrome cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Disorders due to the use of alcohol- F 10

Diagnostic features Alcohol intoxication:.  Recent ingestion of alcohol  Clinically significant maladaptive behavioural or psychological changes (e.g. inappropriate sexual or aggressive behaviour, mood lability, impaired judgement, impaired social or occupational functioning) that developed during, or shortly after, alcohol ingestion.  Slurred speech  Incoordination  Unsteady gait  Nystagmus  Impairment of memory or attention  Coma  Death

Alcohol withdrawal:  Cessation of (reduction in) alcohol use that has been heavy and prolonged

38  The following symptoms may develop within several hours or few days after cessation or reduction of intake; o Autonomic hyperactivity( e.g. sweating, increase pulse rate) o Hand tremor o Insomnia o Nausea or vomiting o Transient visual , tactile, or auditory hallucinations or illusions o Psychomotor agitation o Anxiety o Grand mal seizures(may occur after 6-48 hours from abstinence) o Delirium tremens (DT): appear within few days from withdrawal (2-5 or even 7 days), may last for 2 weeks. It is a medical emergency requiring an inpatient medical care. Characterized by acute confusional state, tremor, agitation, vivid hallucinations and autonomic over activity (sweating, tachycardia and increase in blood pressure)

Physical complication of alcohol use(harmful use):  Hepatic; o Fatty changes. o Alcoholic hepatitis o Cirrhosis  Gastro-intestinal o Gastritis o Peptic ulcer o Chronic pancreatitis  Cancers; liver, stomach, oesophagus  Cardiovascular; o Hypertension o Cardiomyopathy o Arrhythmia o CVA  Neurological; o Dementia o Wernicke-Korsakoff syndrome(see medical emergencies in psychiatric practice) o Peripheral neuropathy o Myopathy o Optic atrophy o Cerebellar degeneration  Others ;erectile problems, gout, foetal alcohol syndrome

39 Differential diagnosis  Other substance use disorder  Mood disorders.  Anxiety disorders  Psychosis Information, advice,  Proper thorough assessment( history “including support and other collateral history” , mental state assessment ,physical measures for patient examination, screening tests and necessary lab and family investigations  Assess for associated physical psychiatric disorders (can not be reliably assessed if the patient is still abusing alcohol)  Risk assessment.  Support to patient and family(counselling)  Motivate the patient to seek further treatment  Psychoeducation and nutritional information  Advise pregnant women or those who plan pregnancy to avoid alcohol completely

Referral  Refer to general hospital as an acute medical emergency in the following conditions;

o Acute severe intoxication /overdose. o Acute severe alcohol withdrawal symptoms(seizures, DT) o Serious medical and surgical complications.

 Refer to secondary psychiatric care(referral to regional psychiatrist) o Alcohol abuse/dependence( for planned detoxification/ rehabilitation) o Risk to self/others o Associated psychiatric disorders o Referral to specialized addiction services will be decided by secondary care psychiatrist

40 Disorders due to the use of Opioids - F 11(Morphine, Heroin, Codeine, Methadone and others):

Diagnostic features Intoxication:.  Recent use of an opioid  Clinically significant maladaptive behavioural or psychological changes that developed during ,or shortly after, opioid use; o Initial euphoria followed by apathy o Dysphoria o Psychomotor retardation/ agitation o Impaired judgement o Impaired social or occupational functioning  Pupillary constriction(or dilatation due to anoxia from severe overdose)  Drowsiness  Slurred speech  Impairment of attention or memory Withdrawal:  It occurs after either of the following: o Cessation of (or reduction in)opioid use that has been heavy and prolonged (several weeks or longer) o Administration of opioid antagonist after a period of opioid use.  Symptoms developing within minutes to several days after cessation: o Dysphoric mood o Nausea or vomiting o Muscle aches o Lacrimation or rhinorrhea o Pupillary dilatation, piloerection, or sweating o Diarrhoea o Yawning o Fever o Insomnia  These symptoms cause significant distress or impairment of social or occupational functioning Differential diagnosis  Other substance use disorder  Mood disorders.

41  Anxiety disorders  Psychosis Information, advice, support and  Proper thorough assessment; history (including other measures for patient and Collateral history), proper mental state family assessment, physical examination (look for injection signs, bruises) and necessary lab investigations if available.  Assess for comorbid physical and psychiatric disorders.  Risk assessment.  Support and counselling for the patient and family.  Motivate the patient to seek further treatment.  Motivate the patient to use safety measures ( sterilized needles, safe sexual practice…).  Symptomatic treatment if necessary. Referral  Refer to general hospital as an acute medical emergency in the following conditions; o Acute severe intoxication / overdose o Acute / serious medical complications (respiratory depression, coma, convulsions...)  Refer to secondary psychiatric care(referral to regional psychiatrist); o Opioid abuse/ dependence for planned detoxification and other treatment measures. o Significant risk to self or others. o Comorbid psychiatric disorders. o Referral to specialized addiction services will be decided by secondary care psychiatrist

Disorders due to the use of Cannabinoids - F 12 (Hashish, Marijuana…):

Diagnostic features Intoxication:.  Recent use of cannabis  Clinically significant maladaptive behavioural or psychological changes occurring during or shortly after use; o Impaired motor coordination o Euphoria o Anxiety o Sense of time slowness o Impaired judgement

42 o Social withdrawal  Symptoms and signs develop within 2 hours of cannabis use; o Conjunctival redness o Increased appetite o Dry mouth o Tachycardia  Withdrawal symptoms are usually limited and brief (restlessness, nausea, irritability)

Differential diagnosis  Mood disorders.  Anxiety disorders  Psychosis  Other substance use disorder

Information, advice, support and  Thorough history taking , mental state other measures for patient and assessment and physical examinations family  Assess for comorbid psychiatric disorders.  Risk assessment.  Support and counselling for the patient and family.  Motivate the patient to seek further treatment

Referral Refer to secondary psychiatric care(referral to regional psychiatrist);  Cannabis abuse/ dependence for further management.  Significant risk to self or others.  Associated psychiatric disorders.  Referral to specialized addiction services will be decided by secondary care psychiatrist

Disorders due to the use of Sedatives or hypnotics - F 13 (Benzodiazepines, Barbiturates…): diazepam, lorazepam, clonazepam, phenobarbital

Diagnostic features Intoxication:.  Recent use of sedative or hypnotic medication.  Clinically significant maladaptive behavioural or psychological changes that develop during or shortly after intake of sedative/ hypnotic medications; o Inappropriate sexual or aggressive behaviour o Mood lability o Impaired judgement o Impaired social, occupational functioning  Slurred speech  Incoordination  Unsteady gate

43  Nystagmus  Impaired attention or memory  Stupor or coma Withdrawal:  Cessation of (or reduction in) sedative, hypnotic use that has been heavy and prolonged.  Signs and symptoms usually occurs within several hours to a few days after cessation; o Autonomic hyperactivity (e.g. sweating, tachycardia...) o Hand tremor o Insomnia o Nausea or vomiting o Transient visual, tactile, or auditory hallucinations or illusions o Psychomotor agitation o Anxiety o Grand mal seizures  Symptoms cause significant distress or impairment of functioning

Differential diagnosis  Other substance use disorder  Mood disorders.  Anxiety disorders  Psychosis

Information, advice, support and  Thorough history taking , mental state assessment other measures for patient and and physical examinations family  Assess for comorbid psychiatric disorders.  Risk assessment  Advise the patient and his family that he must avoid driving and operating dangerous machinery under the effect of drugs.  Advise that these medications should not be taken with other CNS depressants (alcohol…)  Motivate the patient to seek further treatment

Referral Refer to secondary psychiatric care(referral to regional psychiatrist);  Sedative hypnotic abuse / dependence for planned detoxification and other treatment measures.  Significant risk to self or others.  Associated psychiatric disorders  Referral to specialized addiction services will be decided by secondary care psychiatrist

44 Disorders due to the use of Cocaine - F14 Other stimulants (Amphetamine, ephedrine ...) - F 15

Diagnostic features Intoxication:.  Recent use of the cocaine or other stimulant  Clinically significant maladaptive behavioural or psychological changes ,occurring during or shortly after the use of substance; o Euphoria or affective blunting o Changes in sociability o Hypervigilance o Anxiety, tension, or anger o Stereotyped behaviour o Impaired judgement o Impaired social and occupational functioning  Tachycardia or bradycardia  Pupillary dilatation  Elevated or lowered blood pressure  Perspiration or chills  Nausea or vomiting  Evidence of weight loss  Psychomotor retardation or agitation  Muscle weakness, respiratory depression, chest pain, or cardiac arrhythmia  Confusion, seizures, dyskinesia, dystonia , coma and death Withdrawal:  Cessation of (or reduction in) cocaine/ other stimulants use that has been heavy and prolonged.  Signs and symptoms usually occurs within few hours or several days after cessation; o Dysphoria o Vivid unpleasant dreams o Insomnia or hypersomnia o Increased appetite o Psychomotor retardation or agitation  Symptoms cause clinically significant distress or impairment of functioning.

45 Differential diagnosis  Other substance use disorder  Mood disorders  Anxiety disorders  Psychosis

Information, advice, support and  Thorough history taking , mental state other measures for patient and assessment and physical examinations family  Risk assessment  Assess for comorbid psychiatric disorders  Motivate the patient to seek further treatment

Referral  Refer to general hospital as an acute medical emergency in the following conditions; o Acute severe intoxication / overdose  Refer to secondary psychiatric care(referral to regional psychiatrist);

o Stimulant abuse / dependence for planned detoxification and other treatment measures. o Significant risk to self or others o Associated psychiatric disorders

Disorders due to the use of Solvents (Glue, Benzene, Paint thinners) – F18 Common in adolescents.

Diagnostic features Intoxication:.  Recent intentional use or short term, high dose exposure to volatile inhalants  Clinically significant maladaptive behavioural or psychological changes during or shortly after exposure to volatile solvents; o Belligerence o Assaultiveness o Apathy o Impaired judgement o Impaired social, educational and occupational functioning  Dizziness  Nystagmus  Incoordination  Slurred speech  Unsteady gait  Lethargy  Depressed mood

46  Euphoria  Psychomotor retardation  Tremor  Muscle weakness  Blurred vision or diplopia  Stupor or coma

Complications;  Delirium  Dementia(brain atrophy)  Psychosis  CNS complications  Liver damage  Renal damage(tubular acidosis)  Permanent muscle damage(rhabdomyolysis)  CVS diseases

Differential diagnosis  .Other substance use disorder  Mood disorders  Anxiety disorders  Psychosis Information, advice, support and  Thorough history taking , mental state assessment other measures for patient and and physical examinations family  Risk assessment  Assess for comorbid psychiatric disorders  Motivate the patient to seek further treatment  Psychoeducation for patient and family . Referral  Refer to general hospital as an acute medical emergency in the following conditions; o Acute severe intoxication / overdose  Refer to secondary psychiatric care(referral to regional psychiatrist); o Abuse / dependence for planned detoxification and other treatment measures. o Significant risk to self or others o Associated psychiatric disorders

47 Dementia – F00

Diagnostic features  Multiple cognitive deficits manifested by; o Memory impairment (impaired ability to learn new information or to recall previously learned information) o Aphasia (language disturbance) o Apraxia ( impaired ability to carry out motor activities despite intact motor function) o Agnosia (failure to recognize or identify objects despite intact sensory function o Disturbance in executive functioning( i.e. planning, organizing sequencing, abstracting)  The cognitive deficits cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning  The course is characterised by gradual onset and continuing cognitive decline Types of dementia  Dementia of Alzheimer’s type(most common type); o Early onset; if onset is at age below 65 years o Late onset ; if onset is at age after 65 years  Vascular dementia;  Central nervous system conditions that cause dementia; o Parkinson’s disease o Huntington’s disease o Subdural haematoma o Brain tumour  Systemic conditions; o Hypothyroidism o Vitamin B12 or Folic acid deficiency o HIV

48 o Neurosyphilis o Uraemia  Substance induced ;( alcohol, volatile solvents, heavy metals poisoning…)  Dementia due to multiple aetiologies; Reversible dementia Dementia which could be reversed or arrested by treating the cause ;  Hypothyroidism  Hypoglycaemia  Alcohol / drug induced  Vitamin deficiency  Normal pressure hydrocephalus  Subdural haematoma

Differential diagnosis  Depression  Schizophrenia  Substance misuse

Information, advice, support  Thorough history taking (collateral history is and other measures for patient important) Mental state assessment, Mini mental and family state examination (see annexure 1), complete physical and neurological examination.  Be aware that dementia is different from mild cognitive decline in elderly in that it is more pervasive, severe and progressive.  Assess and screen for reversible causes of dementia and investigate accordingly.  Assess and treat associated physical and psychiatric conditions  Multidisciplinary team is needed for the care of patients  Provide counselling services to the patients and their families.  Ensure safe environment at home  Provide some orientation information to the patients (clocks, calendars...)  Assess for basic activities of daily living  Risk assessment (falls, suicide, risk of exploitation, neglect or abuse)  Manage sensory deficits, if present (Glasses, hearing aids)  Refer to old age services if available  Follow up every 3 months Medication  If the patient is agitated/ aggressive. Use Haloperidol: oral; 1.5 -5mg in divided dose or inj; 2.5 mg IM. Referral Refer to specialist medical care; o First presentation (to identify the cause and treat reversible conditions) o Associated medical conditions Refer to secondary psychiatric care; o Associated mental symptoms

49 (depression, psychosis) o Severe behavioural disturbances

Mental Health in women and reproductive psychiatry: Psychiatric disorders more prevalent among women:  Depressive disorders  Anxiety disorders including panic disorder and phobias  Somatization disorder  Conversion and dissociative disorders

Whereas antisocial personality ,violence, substance abuse and suicide are more prevalent in men. Psychiatric disorders in pregnancy: 1. Adjustment disorders :restlessness ,apprehension irritability, depressed mood, difficulty to cope and overwhelming frustration. 2. Anxiety disorders: restlessness, apprehension, poor sleep , excessive worries. 3. Depression :depressed mood ,loss of interest ,pessimistic ideas ,loss of appetite and poor sleep. 4. Aggravations of pre-existing mental illness.

Effects of substance misuse on child health:

1. Alcohol: foetal alcohol syndrome: facial anomalies, growth retardation and mental retardation . 2. Benzodiazepines: oral clefts, floppy infant and apnoeic episodes. 3. Cannabis :intrauterine growth retardation 4. Amphetamine and cocaine: miscarriage, intrauterine growth retardation and possibly intracranial bleeding. 5. opioids: intrauterine growth retardation, microcephaly, and withdrawal symptoms(tremor, sneezing, diarrhoea, poor feeding and possibly seizure , coma and death). Psychiatric disorders in puerperium: 1. Maternity blues: common , usually starts within few days after delivery, short lived mild depressive symptoms. 2. Post partum depression: appears usually within 6 weeks from delivery, depressed mood, loss of interest ,lethargy, insomnia, poor appetite, guilt feeling, excessive worries about the health of a child, intrusive thoughts of harming the baby and suicidal ideas. 3. Post partum psychosis: less common than depression, depressive or manic symptoms, confusion, hallucinations, delusions, and agitation with increase risk of harming the baby or self harm. Treatment;

50 -Anti depressive medications(clomipramine, amitriptyline) - Antipsychotic medications(haloperidol) - Mood stabilizers(carbamazepine)

Psychotropic medications in pregnancy: general rules for use  All medications that are not absolutely essential should be avoided.  In pregnant women with worsened psychiatric disorder it is better to use psychotherapy before routine use of medications.  Establish a clear indication for the drugs(absence of alternative treatment).  Use the lowest effective dose for the shortest time.  Make individual assessment for risks and benefits(involve the patient).  Avoid prescribing in first trimester .  Avoid poly pharmacy.  Discuss with psychiatrist.

Breast feeding:  Drugs or breast feeding should be avoided if the baby is vulnerable ( prematurity, hepatic, renal, cardiac or neurological impairment).  If possible, prescribe the medications as a single daily dose after the baby's longest feed and before it's longest sleep.  Close monitoring of baby's behaviour as well as appropriate blood tests might be necessary.  Sedating medications should be avoided.

51 Mental disorders of childhood and adolescence Mental retardation - F70--- F79

Diagnostic features  Significantly subaverage intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test  Concurrent deficits or impairments in present adaptive functioning(i.e. the person’s effectiveness in meeting the standards expected for his or her age by his or her cultural group) in the following areas; o Communication o Self care o Home living o Social/interpersonal skills o Use of community resources o Self direction o Functional academic skills o Work o Leisure activities o Health o safety  Onset before age 18 years

Mild mental retardation- F 70 (IQ=50- 69) o Usually detected on school age o Delay in speech acquisition, but eventual ability to use everyday speech o Generally able to independently self care o Main problems in academic settings(i.e. reading and writing) o Potentially capable of working o Variable degrees of social and emotional immaturity o Minority of them with clear organic etiology Moderate mental retardation- F 71

52 (IQ=35- 49) o Delay in acquiring speech o Ultimate deficits in use of language and comprehension o Few acquire numeracy and literacy o Occasionally capable of simple supervised work o Majority have identifiable organic aetiology

Severe mental retardation- F 72 (IQ=20- 34) o Poor speech development( limited to few words or phrases) o Poor social skills o Poor self care skills o Marked motor deficits o Neurological deficits(epilepsy, autism ,visual and motor defects) Profound mental retardation- F 73 (IQ=below 20) o Very limited use of language o Limited basic skills o Clear organic etiology o Severe physical and neurological disabilities o Associated problems are common(epilepsy, autism, visual and hearing defects)

Differential diagnosis  Attention deficit /hyperactivity disorder  Sensory deficits(visual ,hearing and speech impairment)  Conduct disorder  Autistic disorder  Learning disorder

Information, advice, support and  Screen for associated physical or mental condition other measures for patient and  Basic counselling and support for the patient and family family Medication  If the patient is agitated/ aggressive use; o Haloperidol: oral; 1.5m od , if no response increase to 1.5mg bid or o Chlorpromazine: oral; 25 mg od, if poor response then increase to 25mg bid

Referral Refer to neurologist or physician: o Associated neurological or physical problems (epilepsy, sensory impairment, involuntary movements, cardiac problems ….) Refer to psychiatrist: o Diagnostic uncertainty o Associated psychiatric symptoms(depression, psychosis) o Uncontrolled behavioural disturbances.

53 Hyperkinetic disorder F-90(Attention –deficit / Hyperactivity disorder)

Diagnostic features  Inattention: o Often fails to give close attention to details or make careless mistakes in schoolwork, work ,or other activities o Difficulties in sustaining attention in tasks or play activities o Often does not seem to listen when spoken to directly o Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace o Difficulties in organizing tasks and activities o Avoids, dislikes tasks that require sustained mental effort(studying) o Repeatedly loses things (toys, school assignments, pencils) o Easily distracted by extraneous stimulus o Often forgetful in daily activities

 Hyperactivity: o Often fidgets with hands or feet or squirms in seat o Often leaves seat in classroom or in other situations in which remaining in seat is expected o Often runs about or climb excessively o Has some difficulties in playing or engaging in leisure activity quietly o Talks excessively  Impulsivity: o Often blurts out answers before questions have been completed o Has difficulty in waiting turn o Often interrupts or intrudes on others  Symptoms present in more than 2 settings(at school, work and at home)

54  Clear impairment of social, academic or occupational functioning

Differential diagnosis  Autistic disorder  Mental retardation  Conduct disorder Information, advice, support and  Psycho education of the patient and family other measures for patient and  Maintain consistency and structure(routines, family family rules)  Promote positive interaction with the child  Ensure adequate sleep  Establish constructive communication with school

Referral  All patients should be referred to secondary care psychiatrists for further assessment and management  Secondary care psychiatrists will decide on referral to specialized child &adolescent mental health services

Conduct disorder- F91

Diagnostic features Repetitive and persistent pattern of behaviour in which the basic rights of others or major age – appropriate societal norms or rules are violated, as manifested by the following;  Aggression to people o Often bullies, threaten, or intimidates others o Often initiates physical fights o Has used weapons that can cause serious physical harm to others(bat, brick, knife, gun) o Physically cruel to people o Physically cruel to animals o Has stolen while confronting a victim(mugging, purse snatching, extortion, armed robbery) o Has forced someone into sexual activity  Destruction of property o Has deliberately engaged in fire setting with the intention of causing serious damage o Has deliberately destroyed other’s property  Deceitfulness or theft o Has broken into someone else’s house,building , or car o Often lies to obtain goods or favours or to avoid obligations o Have stolen items without confronting the victim (shoplifting)  Serious violation of rules

55 o Often stay out at night despite parental prohibitions (beginning before age 13 years) o Has run away from home overnight at least twice or once for a lengthy period o Often truant from school, beginning before age 13 years  The disturbance in behaviour causes clinically significant impairment in social, occupational , or academic functioning

Differential diagnosis  Attention deficit/hyperactivity disorder  Depressive disorder  Learning disability Information, advice,  Psycho education of the patient and family support and other o Promote effective communication between measures for patient and child and parents family o Promote positive joint activities between parents and child o Encourage praise and rewards for specific agreed desired behaviours o Set clear house rules and give short specific commands about desired behaviour o Avoid unnecessary arguments with the child o Monitor the whereabouts of teenagers; get to know his friends( check with parents)  Educate the child on anger management  Work with teachers where appropriate  Treat any coexisting condition Referral  All children suffering from conduct disorder should be referred to psychiatric care for further evaluation and management  Secondary care psychiatrists will decide on referral to specialized child &adolescent mental health services

Childhood emotional disorders - -F 93 Depression is common in adolescents

Presenting complaints  often presents with physical symptoms, frequently related to school work

Diagnostic features  headache and other aches and pains  difficulty in concentration  poor sleep  loss of appetite  withdrawal from family and friends  feeling bad about oneself  becoming moody and irritable  seeing life is pointless  suicidal feelings and ideas  irritability

56  effects of depression - poor school work - poor relationship with family and friends - increased risk of self harming - drugs or alcohol misuse

 assess the situation with parents and adolescent to identify the problem and cause - how has your health been recently-sleep, concentration, emotions - have you been worried about anything recently - have you shared these worries or concerns with anyone else - have you felt like ending your life/ how often? since when? - has anyone hurt you recently? - have you been drinking alcohol or taking drugs?

Information, advice,  listen to adolescent’s account of feelings and concerns support and other  help adolescent make link between his/her feelings and measures for patient and stressful situation he/she is facing family  suggest you could talk to parents and teachers  make practical suggestions  teach adolescent problem solving techniques to cope with stress  advise not to use alcohol or drugs  follow up review

Medication  if none of above works, give antidepressant e.g. amitryptyline 25mg orally at night.

Referral  if symptoms are not resolving, and are interfering with education  if risk of harm to adolescent or others

Specific reading disorder (Dyslexia)-F81:0

Causes  neurobiological  may be aggravated by - large class sizes - poorly trained teachers - language not commonly used at home  mental retardation  depression  conduct disorder  difficulties with hearing or vision  drug misuse

Presenting complaints  learning difficulty that affects ability to read or deal with numbers, irrespective of intelligence  problems with concentration, perception and memory  verbal skills, abstract reasoning, hand-eye coordination

57  social adjustment (low self esteem), poor grades, underachievement  child may have difficulties with - copying, spelling and writing - understanding instructions - numbers and mathematics - reading - behaviour problems

Information, advice,  a dyslexic child is not stupid, dumb or thick support and other  teachers, parents and health worker need to work measures for patient and together to help the child family  teach reading and spelling through phonetics  extra individual help with numeracy and literacy  homework to be given early enough and left on the board for long enough to ensure every child could write it down  parents should assist dyslexic children through assignments  position child in front seat  help child to learn through more than one sense including touch and movement  organise extra time in exams  continued support  dyslexic children can be very intelligent, but get frustrated by their difficulties  crucial to assist as much as possible to enable children to progress educationally  children should be helped to build self confidence - let child identify strengths and weaknesses - discuss objectively and build on strengths - promote positive thinking - praise child for all their achievements, both non- academic and academic - value the child as a person

58 Pervasive developmental disorder ( Disorder)- F 84 Impairment in communication skills and social interactions; restricted, repetitive and stereotypical patterns of behaviour

Causes  genetic factors

Presenting complaints  parents may complain of obvious developmental problems - unresponsive to people or focusing intently on one item for long periods of time - outbursts of crying or screaming

Diagnostic features  abnormal or impaired development before the age of 3 in at least one of the following - selective social attachment or reciprocal social interactions - repetitive or expressive language, as used in social communication - restricted , repetitive and stereotyped pattern of behaviour-functional or symbolic play  social difficulties - avoids eye contact, seem indifferent to others and prefers being alone - difficulties in interacting reciprocally with others:  slower in learning to interpret what others are thinking or feeling  may ignore other people or be insensitive to their needs, thoughts and feelings  difficulties in seeing things from another perspective  difficulties in regulating emotions e.g. crying in class or verbal outbursts that seem inappropriate to those around them  communication difficulties - delayed language development with no effort to do so - use of language in unusual ways-repetition of phrases or words over and over - young children may show little interest in the speech of others - difficulties in understanding body language, facial expressions, movements and gestures rarely match - difficulties in expressing own body language-facial expressions, movements and gestures rarely match what they re saying - difficult to let others know what they need - some may remain mute throughout their lives  behavior difficulties - odd repetitive movements e.g. flapping arms or

59 walking on toes. some suddenly freeze in position - routinised behaviour, resistance to change: a slight change in any routine can be extremely disturbing - unusual persistent , intense pre-occupation or interests e.g. intellectual, art  other difficulties - sensory problems e.g. sensitivity to sounds, textures, taste and smell - mental retardation - seizures

Differential diagnosis  attention deficit hyperactivity disorder  learning disability  epilepsy

Information, advice,  identify patients strengths and potentials and build on the support and other strengths measures for patient  family education and ongoing support and family  help child develop full potential  child’s education placement-special school or mainstream with extra attention and assistance

Advice and support to  behavioral management to reinforce desirable behavior patient and family and reduce undesirable ones  an effective treatment programme will build on the child’s interest, and have a predictable schedule - teach tasks as a series of simple steps - engage attention in highly structured activities - provide regular reinforcement of behaviour - involve parents , teachers and other professionals e.g. social workers - physical activity to develop coordination and body awareness - social interactions - medication-treat co-existing problem e.g. epilepsy

60 Section 3: Psychiatric Emergencies Managing violent patients

What is violence? . Violence is the exercise of physical force so as to cause injury to self, others or damage to property whereas aggression is the threat of violence.

. Act of violence or recent act of violence. Usual presentation: . Recurrent thoughts of harm to others. . Verbal or physical threats to harm others . Symptoms of the associated conditions. . Irritable or angry mood. Warning signs and . Increased arousal, restlessness, agitation, dilated pupils, symptoms: loud & high tone voice. . Suspiciousness, hostility, aggressive gestures. . Command hallucinations, persecutory delusions, or delusions of control. . Preoccupation with violent themes/ fantasies. . Carrying weapons or other potentially harmful objects. High risk groups . Young males . Unemployed/ low socio-economic circumstances. . Living alone with limited social support. . History of previous violence or aggression. . History of recent severe stress, particularly of loss events or threats of loss. . History of mental disorder. . History of alcohol and other substance misuse. . History of criminal act/ imprisonment. . History of childhood abuse and family violence. . Poor insight, disengagement and poor adherence to treatment. . Direct/ free access to weapons.

Conditions . Substance abuse( intoxication or withdrawal) associated with . Any organic condition leading to altered level of violence/aggression consciousness, cognitive impairment or acutely disturbed behaviour (Epilepsy, head injury, cerebral infection, cerebral neoplasm, metabolic disorder, endocrine disorders...) . Schizophrenia . Personality disorders(dissocial ,impulsive, paranoid) . Bipolar affective disorder. . Mental retardation . Delirium . Dementia . Head injuries-personality changes . Depression with psychomotor agitation.

61 Management: . Ensure safety of yourself, patient and others. He/ She Information, advice, must NOT be attended alone and must NOT have direct support and other access to potentially harmful objects. measures for patient . Nursing staff attending to the patient should ideally be and family trained in breakaway techniques and control& restraint. A minimum of three members should be available and immediately accessible if restraint becomes absolutely necessary. . Do not interview a patient who is holding a weapon (call the police). . Never interview the patient alone. Ideally two nurses should be present which is usually not considered by the patient as threatening. Adequate back-up team should be secured. . Maintain an adequately safe personal space. Ensure free exit for yourself and other staff. . Maintain non- judgemental and empathetic attitude. Avoid confronting or challenging the patient. . Ascertain the cause of violence. Assess for the presence of organic or functional disorders . Patient may require sedation before attempting examination or undertaking the necessary investigation. As soon as the situation allows, perform physical and neurological examination. If indicated , establish IV access and draw blood for necessary investigations including complete blood count, urea, creatinine, electrolytes , glucose, toxicology screen and alcohol level(if available) etc. Medication . If other means such as talking down and repeated re- assurances have been unsuccessful in containing and de- escalating the situation and if patient has remained highly aroused, Initiate rapid tranquillisation to achieve sufficient sedation to minimize risks to patient and others, as follows: 1. Avoid oversedation. Always explain the procedure to the patient before intervening. 2. A short acting Benzodiazepine: Lorazepam oral; 1- 2 mg and/or Antipsychotic: Haloperidol oral; 5 mg to be used as first line of treatment. 3. Consider administering Lorazepam 1-2 mg intramuscularly and or Haloperidol 5-10 mg intramuscularly (can be repeated after 30 minutes if the response was inadequate). 4. If Lorazepam is not available then Promethazine 25-50 mg intramuscularly can be used (it can be given in addition to Haloperidol). 5. Medications should never be mixed in the same syringe

62 6. Intravenous Diazepam; 5-10 mg can be used as a second line of treatment. It must be administered slowly.(beware of respiratory depression) Ensure immediate access to antidote (Flumazenil/ resuscitation equipment before considering intravenous route) 7. Avoid intramuscular Diazepam as it is slowly absorbed and painful. Also avoid intamuscular Chlorpromazine as it is associated with acute and severe postural hypotension. 8. Close monitoring of vital signs and level of consciousness. 9. If patient still needs further sedation CONSULT psychiatrist . Physical restraint is to be only applied when there is an immediate and significant threat to self and or others. If applied a team must ensure airway and breathing not compromised .Explain to the patient the aim of procedure. . If organic condition is suspected then arrange for emergency transfer to the local Accident & Emergency Department where patient must undergo thorough physical assessment and receive the necessary intervention.

. Avoid stigmatising and challenging patient’s views. Psycho-education for patient and family . Violence could be a sign of physical and/ or mental illness. . Violence could be an indicator for the severity of the associated condition. Risk of violence could be minimized if ; . There is a good level of social support and understanding by family and friends. . Early recognition of signs of relapse of underlying condition. . Patient adheres to the care plan including medication and regular reviews for the associated condition. . Patient should avoid alcohol/substance misuse.

. Any threat to harm others must be taken seriously. Advice and support . Patient must not have a direct access to potentially harmful for the patient and objects. family . If safety endangered, or patient has carried out major assault, police must be called. . Potential victims should be aware of the danger against them. . Next of kin/nearest relative must accompany the patient when referred to the psychiatrist. Emergency referral to the psychiatrist to be made only after Referral ensuring that the patient is physically stable and after discussion with the nearest psychiatrist

63 Rapid tranquilization of ACUTELY DISTURBED/ violent patients In PHC

Ensure safety of patient, staff, and attendants

Oral treatment  Lorazepam tab1-2mg,repeat after 45-60 minutes  Haloperidol tab 5 mg  If no response to oral treatment or severely agitated patient , use IM treatment

Intramuscular treatment  Lorazepam injection; 1-2 mg IM or  Promethazine injection;25- 50 mg IM or  Haloperidol injection; 5 mg IM, if insufficient effect repeat after 30-60 minutes  Ensure IM Procyclidine is available (to treat acute dystonia , if developed after Haloperidol use) 

Intravenous treatment  Diazepam 5-10 mg IV slowly (over at least 5 minutes)  Repeat after 5-10 minutes if insufficient effect (up to three times)  Have Flumazenil in hand  Refer to psychiatrist after stabilization

64 Intentional self harm / Suicide ICD –10: X60-X84

 Suicide is a major cause of death worldwide.  It is widely under-reported and a large proportion of undetermined deaths are actual suicides.  Most people who kill themselves are psychologically disturbed at the time.  The UN has called for all countries to have a national suicide prevention programme.  Assessment of suicidal risk is essential for any psychiatric patient in PHC.  Suicidal risk means the extent of suicidality i.e. how much a patient is at risk of attempting suicide in future. this should be done at two levels; 1. The cross section analysis ( The present attempt):This is a very essential part of the assessment , it includes assessment of suicidal ideas ( recurrence, persistence, duration) suicidal plans ( concrete, elaborated, precautions against discovery) suicidal intent ( seriousness, not directed to attract attention or manipulate others) suicidal attempt ( planning in advance, using dangerous means, leaving notes)

2. The longitudinal section analysis( The patient’s history): This includes past history of psychiatric disorders ( depression, schizophrenia, personality disorders) , alcohol or drug abuse, medical diseases ( chronic disabling illnesses, terminal illnesses), family history of suicide or psychiatric illnesses, previous attempts at suicide, being single, divorced, widowed, unemployed, living alone, middle aged.  Best predictor for future suicide is previous suicidal attempt.  A detailed history taking and full mental state examination should be performed to exclude any psychiatric disorder especially depressive disorder. .

Usual presentation . Act of self harm or recent act of self harm . Recurrent thoughts of self harm . Verbal threats of self harm . Symptoms of the associated condition

Warning signs and symptoms . Depressed, anxious or angry mood. . Insomnia. . Anhedonia. . Psychomotor agitation. . Feelings of guilt, worthlessness, hopelessness and helplessness. . Psychotic symptoms especially command hallucinations, persecutory delusions, and delusions of guilt. . Recent change of behaviour including social isolation/withdrawal. . Ending contracts (e.g. leaving a job), writing a will. . Hoarding tablets/ seeking means of self harm.

High Risk Groups . Elderly and the young (15-24 years). . Males. . Unemployed/lowered socio-economic circumstances.

65 . Living alone, single /separated/ divorced/ widowed. . History of previous attempt. . History of recent bereavement, loss events. . History of mental disorder/ substance misuse. . History of poor physical health including painful, chronic, debilitating, degenerative, or terminal illnesses. . Family history of suicide. .

Conditions associated with . Alcohol and other substance abuse/ dependence. suicidal risk: . Dementia. Physical illnesses: . Epilepsy (especially temporal lobe epilepsy). . HIV/ AIDS. . Cancer. . Multiple sclerosis. . Huntington’s disease. . Head injury, CVA. . Cardiovascular disease. . Peptic ulcer, liver cirrhosis. . Renal disease.

Functional illnesses: . Depression . Schizophrenia . Bipolar Affective Disorder . Personality Disorders(Borderline, Dissocial ) . Anxiety disorders( especially panic disorder)

Management: If patient has presented shortly following the act of self harm

 Ensure patient’s safety. He/ she must NOT be left alone and must NOT have direct access to potentially harmful objects.  Maintain non-judgemental and empathetic attitude.  Obtain relevant history including an account of the precipitant circumstances and the method used.  Perform physical including neurological examination.  If indicated establish I/v access and draw a blood for the necessary investigations including complete blood count, urea, creatinine, electrolytes, toxicology screen etc.  Arrange for emergency transfer to the local Accident & Emergency Department where patient must undergo thorough physical assessment and receive the necessary intervention.  Avoid prescribing any psychotropic medication in case of overdose.

66  If patient is highly agitated and actively suicidal, a small dose of Haloperidol and or short acting benzodiazepine can be given.  Do not over sedate.  Physical restraint is to be applied if there is immediate and significant threat to self or to others.  Emergency referral to the psychiatrist to be made only after ensuring that patient is physically stable.

Remember: . Patient may have used more than one method of self harm. . Never underestimate the act of deliberate self harm even if it appears to be minor. . In cases of overdose, patient may initially be asymptomatic. . Next of kin/ nearest relative must be informed of the risk. . Patient must be accompanied by the next of kin/ nearest relative when referred to the psychiatrist.

If the patient is assessed to be . Ensure patient’s safety is maintained .He/ she must at significant risk of self harm be under supervision and must NOT have direct and has not yet carried out the access to potentially harmful objects/weapons. act of self harm . Maintain non-judgemental and empathetic attitude. . Assess for the presence of associated organic / functional conditions. . Arrange for emergency referral to the psychiatrist after ensuring physical stability. . If the patient is highly agitated, a small dose of benzodiazepines and or Haloperidol can be given. . Do not prescribe potentially lethal medications(in overdose) unless it is necessary in which case,, prescribed medication is to be dispensed for shorter duration(i.e. weekly supply) and medication administered under supervision of a family member.

Remember . Always assess suicide risk for patients with mental health problems and other high risk groups. . A statement from the patient that he/she intends to self harm is the strongest indicator of risk and must never be dismissed. . Assess for homicidal ideation.

. Next of kin/ nearest relative must be informed of the risk. . Patient must be accompanied by the next of kin/ nearest relative when referred to the

67 psychiatrist.

Psycho- education for patient . Intentional self harm could be a sign of a mental and family: and/or physical illness. . Intentional self harm could be an indicator of the severity of the associated condition. . Avoid stigmatising and criticizing the patient. Risk of suicide could be minimized if: . There is good social support by family and friends. . Family maximizes support following life events and observe closely for suicidal thoughts/or behaviour with early recognition of associated symptoms. . Adherence to the care plan including medication and regular reviews. . Precautionary measures are maintained to supervise access to potentially lethal objects. . Patient avoids alcohol/ substance misuse.

Advice and support to patient . Any threat to self harm must be taken seriously. and family: . Patient who has expressed wish to end his life should not be left alone and must not have direct access to lethal objects.

Referral;  High suicidal risk.  Recent suicidal attempt (refer to psychiatrist after stabilization of general health condition).

Main medical / drug related emergencies in psychiatry:

68 Delirium (acute confusional state) –F05

Diagnostic features  Disturbance of consciousness(reduced clarity of awareness to the environment) with reduced ability to focus ,sustain , or shift attention  Change in cognition; o Memory deficit o Disorientation o Language disturbance o Perceptual disturbance  The disturbance develops over a short period of time(hours to days) and tends to fluctuate during the course of the day  There is evidence from history , physical examination or laboratory findings that disturbance is caused by general medical condition or it is substance induced(substance intoxication, substance withdrawal) Common causes  CNS disorders: o Seizures o Migraine o Head trauma o Tumour o CVA o Sudural , epidural and subarachnoide haemorrhage  Metabolic disorders: o Electrolytes disturbances o Hypo/hyperglycaemia  Infections: pneumonia, UTI, HIV etc.  Nutritional deficiencies(Vitamin B12, B1 ,Niacin)  Burns  Cardiac; MI, arrhythmia, heart failure  Respiratory; Chronic obstructive pulmonary disease  Renal; Renal failure  Hepatic; Hepatitis, hepatic failure  Neoplasm  Toxins  Medications: o Pain medications(Morphine, Meperidine) o Steroids o Antihypertensives o Antineoplastic agents o Anticholinergics o Antibiotics,antiviral  Drugs of abuse Differential diagnosis  Dementia(delirium is acute and associated with impairment of consciousness) , however delirium could be superimposed on dementia  Acute psychosis Information, advice,  Take measures to prevent the patient from harming support and other himself or others

69 measures for patient and  Reassure and support patient and relatives family  Perform necessary investigations and interventions Referral  Delirium is an emergency medical condition  The patient must be referred to A&E department / medical department for further evaluation and treatment(by treating the underlying cause)

Catatonia (organic catatonic disorder)-F06.1

Diagnostic features  Motoric immobility as evidenced by catalepsy(including waxy flexibility) or stupor(see glossary)  Excessive motor activity(that is apparently purposeless and not influenced by external stimuli)  Extreme negativism (apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism  Peculiarities of voluntary movement as evidenced by posturing( voluntary assumption of inappropriate or bizarre postures) stereotyped movements, prominent mannerism, or prominent grimacing  Echolalia or echopraxia (see glossary) Common causes  General medical disorders; o Metabolic disturbances(uraemia, hepatic encephalopathy) o Endocrine disorders (hypoglycaemia, hypo/ hyperthyroidism) o Viral infection(HIV, herpes) o Typhoid fever o Heat stroke  Neurological conditions; o Post encephalitic state o Parkinsonism o Seizures(non convulsive status epilepticus) o General paresis o Thalamic lesion(CVA, tumour)  Drug related; o Antipsychotics o Benzodiazepine withdrawal o Opioids intoxication  Mood disorders: i.e. depressive stupor  Schizophrenia

Differential diagnosis  Elective mutism  Stroke  Malignant hyperthermia  Neuroleptic malignant syndrome

70  Serotonin syndrome Information, advice,  Full history(including collateral history), mental state support and other assessment, physical & neurological examination measures for patient and  Necessary investigations and interventions family Referral  is a medical emergency and the patient should be referred to A&E / medical departments to exclude general medical conditions that may cause catatonia  Refer to psychiatrist if general medical conditions excluded and the patient’s condition is medically stable for further assessment and management

Extrapyramidal side effects of antipsychotic medications:

1- Acute dystonia :

Signs and symptoms  Muscle spasm at any part of the body (e.g. neck, jaw, larynx, tongue): o oculogyric crisis (upward and outward deviation of the eyes) o Head and neck twisted to the side(torticollis) o Tongue protrusion o Trismus(locked jaw)  The patient may be unable to swallow or speak clearly  It can be painful and very frightening

Prevalence and risk  Approximately 10% in conventional (typical) antipsychotic factors use ( Haloperidol, Trifluoperazine, Fluphenazine)  Less in atypical antipsychotics (olanzapine, clozapine)  Rarely in SSRI and other psychotropic medications  More in young males  More in neuroleptic- naïve

Time taken to develop  Usually develops within hours of starting antipsychotic orally  Shortly after taking antipsychotic injections

Treatment  Anticholinergics: (Procyclidine): orally, IM or IV depending on severity of symptoms. Procyclidine injection 5-10 mg IM, IV or Procyclidine tab 5mg tid.  Patient may be unable to swallow( he may need rapid intervention)  Response to IV administration may be noticed after 5 minutes  Response to IM administration may be noticed after

71 20 minutes

Referral  Refer to psychiatrist: o If no response to the above mentioned measures o after stabilizing the condition for further management  Refer to emergency department if laryngeal dystonia(difficulties in breathing or swallowing)

2-Akathisia

Signs and symptoms  Subjective unpleasant feeling of inner restlessness  Strong desire and compulsion to move  Rocking from foot to foot  Constantly pacing up and down  Constantly crossing or uncrossing legs

Prevalence and risk  Approximately 25% (less in atypical antipsychotics) factors Time taken to develop  Acute akathisia develop within hours to weeks of starting antipsychotics or increasing the dose  Tardive akathisia takes longer time to develop Treatment  Reassure the patient and family  If symptoms are severe and distressing ;Propranolol tab 30-80mg/day(if not contraindicated) in divided doses for few days before referral Referral  Refer to psychiatrist after diagnosis for further evaluation and management

3-Neuroleptic malignant syndrome: It is a rare but potentially serious or even fatal adverse effect of antipsychotics

Signs and symptoms  Fever, diaphoresis, rigidity, confusion, fluctuating consciousness  Fluctuating blood pressure, tachycardia  Elevated creatine kinase, leukocytosis, altered liver function test  Mortality rate=5-20% Prevalence and risk  Fewer than 1% of patients taking antipsychotics factors  High potency ,conventional (typical) antipsychotics (Haloperidol, Fluphenazine, Trifluoperazine) recent use or rapid dose increase  Psychosis  Organic brain disease  Alcoholism  Parkinson’s disease

72  Hyperthyroidism  Mental retardation  Agitation  Dehydration Time taken to develop  Few days after recent use or rapid dose increase, rapid dose reduction, abrupt withdrawal of anticholinergics Treatment  Monitor pulse, BP, temperature  Rehydrate the patient  Withdraw antipsychotic medications  Neuroleptic malignant syndrome is a medical emergency; refer to the medical/A&E unit immediately for all suspected cases. Referral  Refer to A& E department for emergency management  After the patient became stable refer to psychiatrist for further evaluation and management

Serotonin syndrome: A rare but potentially fatal syndrome occurring in the context of initiation or dose increase of serotonergic agents such as SSRI, or combination of SSRI and MAO inhibitors, Buspirone, Clomipramine.

Signs and symptoms  Agitation/ restlessness  Sweating  Diarrhoea  Fever  Hyperreflexia  Ataxia  Mental state changes(confusion, hypomania)  Myoclonus  Shivering  Tremor Prevalence and risk  Less than 1% in patients taking Serotonergic drugs factors  Mortality rate is about 1/1000  It is due to increase Serotonin quantity or activity : SSRI, L –tryptophan, Buspirone, Amphetamine, Cocaine

Time taken to develop  Few days Treatment  Close monitoring of vital signs  Stop serotonergic medications  Immediate transfer to A&E department Referral  After stabilization of physical condition , refer to psychiatrist for further assessment and management

Delirium tremens (alcohol withdrawal symptom)

A toxic confusional state that occur when alcohol withdrawal symptoms are severe.

73 Signs and symptoms  Onset 1-7 days after the last drink(peak incidence2-4 days after the last drink)  Clouding of consciousness  Disorientation  Amnesia for recent events  Marked psychomotor agitation  Visual, auditory, and tactile hallucinations  Marked fluctuation in severity hour by hour(usually worse at night)  Tremor  In severe cases; heavy sweating, fear, paranoid delusions, agitation, raised temperature, sudden cardiovascular collapse  Reported mortality of 5-10% (20% if untreated) Prevalence and risk  DTs occurs in approximately 5% of episodes of factors withdrawal  Risk factors; o Severe alcohol dependence o Past experience of DT o Long history of alcohol dependence o Old age o Concomitant acute medical illness o Severe withdrawal symptoms when presenting for treatment

Time taken to develop  Symptoms usually develop from 2-4 days after the last drink, peak after 72-96 hours persist for 10-14 days Treatment:  Most important measure taken is prevention; Preventive measures: o Thorough assessment of alcohol dependent patients o Psychoeducation of patient and family o Refer to psychiatrist for planned detoxification programs Referral  Refer to A&E / Medical department immediately after diagnosis  After the patient is medically clear ,refer to psychiatrist for further evaluation and management of alcohol dependence

Wernicke – Korsakoff syndrome

74 Wernicke encephalopathy is the acute form of this syndrome while Korsakoff psychosis is the chronic form. This syndrome is caused by neuronal degeneration secondary to thiamine deficiency, most commonly seen in heavy alcohol drinkers.

Wernicke encephalopathy

Signs and symptoms  Acute confusional state  Ophthalmoplegia  Nystagmus  Ataxia  If untreated it can develop into Korsakoff syndrome (permanent memory impairment and confabulation)

Risk factors  Thiamine(Vitamin B1) deficiency ,which may occur in; o Heavy alcohol drinkers o Starvation o Poor absorption o Post gastric resection o o Hyperemesis gravidarum Time taken to develop  Wernicke encephalopathy is an acute condition which may develop and progress within days  84% of untreated cases for 2 weeks may develop features of Korsakoff psychosis  Mortality rate is 15% in untreated cases

Treatment  Treat immediately when diagnosis is made or strongly suspected. In addition consider treating all those at high risk(alcohol dependent patients with poor nutrition) prophylactically with parenteral vitamins  Avoid carbohydrates until thiamine replacement is complete  Start thiamine replacement immediately  Parenteral Thiamine IM 200-300mg /day for 3-5days or high potency B complex vitamins(Pabrinex) IM/IV two ampoules three times daily for 3-5 days .  Emergency referral to medical department

Referral  Emergency referral to medical department for evaluation and management  Refer to psychiatrist after the patient is medically stabilized for further management

75 Section 4: Medication guidelines

General principles:

1. Promote insight and understanding to the patient and family about illness and the benefits of treatment 2. Provide information about;  Types of medication prescribed  Methods of administration  Target symptoms for treatment  Importance of adherence to treatment  Onset of effect (most antipsychotics and antidepressants exert their therapeutic effects after 2-3 weeks)  Potential adverse reactions  Important drug interactions  Discontinuation / withdrawal symptoms  Duration of treatment  Follow up recommendations

3. Simplify drug regime(use single dose regime whenever possible) to improve adherence 4. Minimize side effects through the use of medication with the lowest side effects profile , slow escalation of dose and using the lowest therapeutic dose 5. Supervise administration by family/ carers 6. Avoid starting psychotropic medications in; pregnant/lactating women, children and adolescents. 7. Consult psychiatrist and general physician when prescribing medications to elderly patients or patients with general medical conditions.

Medications included in this section are those used or recommended in:  PHC practice  Secondary care practice in psychiatric clinics  Tertiary care in mental hospitals only

Medications prescribed in secondary and tertiary care may be dispensed in PHC, so the physicians should have some basic knowledge about them.

76 Antipsychotic medications

1. Dopamine receptor antagonists (DRA):  High potency :Haloperidol, Trifuoperazine Fluphenazine  Low potency : Chlorpromazine

Medication Dose Adverse effects Follow up guidelines  Haloperidol  Start with 1.5-3  Extrapyramidal side  Start low and go slow o tab; mg /day effects: (more in high  Side effects may appear early 1.5mg,5mg  Increase dose potency) , but therapeutic effects slowly o Acute dystonia appear after2-3 weeks and  Effective dose o Pseudoparkinsonism: usually reach its peak in 4-6 is 5-15mg per (tremor ,rigidity, weeks day in 2-3 bradykinesia, shuffling  Check for medications side divided doses gait, drooling of saliva effects on each visit and expressionless  Monitoring of the following face) parameters recommended  Start with 5mg o Akathisia Blood pressure: baseline, o Injections; IM, if no o Tardive dyskinesia : o 5 mg IM response (involuntary orofacial ,and in every visit during repeat after 30 and chorioform titration of dose minutes movements of the o Body weight: baseline, body)  Use only in then every 3 months for Neuroleptic malignant emergency o one year, then yearly conditions syndrome:(see o ECG: baseline & after medical emergencies  Effective dose dose increase or in psychiatry) 5-15mg per day changing drugs IM in 3 divided  Antichloinergic side o Urea/electrolytes; doses effects: (more in low baseline then yearly potency) o Full blood count: baseline o Dry mouth ,then yearly Blurred vision o o Blood lipids: baseline Constipation o ,every 3 months for one o Urinary year, then yearly retention o Plasma Glucose: baseline, every 4  Antiadrenergic side months for two years, effects: then yearly o Postural o Liver function tests: hypotension baseline, then yearly o Tachycardia o Prolactin : baseline , every o Sexual 6 months for two years, dysfunction then yearly o Examine the patient  Antihistaminic side monthly : effects: for pseudoparkinsonism and o Sedation tardive dyskinesia o Weight gain

77  Cardiac effects: (more in low potency) o Prolongation of QT and PR interval o Blunted T wave o ST depression o Risk of torsade de pointes(fatal arrhythmia)  Other side effects: o Cholestatic jaundice o Hypersensitivity reactions o Skin photosensitivity o Increase serum prolactin o Lowering of epileptic threshold Precautions; oNarrow angle glaucoma oProstatic hypertrophy oEpilepsy o Cardiac diseases o Liver and renal diseases o Pregnancy / lactation o Elderly patients

 Chlorpromazine  Start with  Same as Haloperidol  Same as Haloperidol tab; 25mg per  Less extrapyramidal side 25mg,100mg day effects  Increase the  More anticholinergic, dose slowly antiadrenergic,  Effective dose antihistaminergic and 75-300mg cardiac side effects per day in 2- 3 doses  Fluphenazine  Start with a  Same as Haloperidol  Same as Haloperidol decanoate(depot test dose  Takes longer time to antipsychotic); 12.5 mg IM appear 25mg IM  Therapeutic (secondary and dose is 25mg tertiary care) IM every 2-4 weeks 2. Serotonin- Dopamine antagonists: Risperidone, Olazapine

Medication Dose Adverse effects Follow up guidelines

Risperidone  Initial dose is 1-2  Extrapyramidal side  Same as conventional tab; mg at night effects (dose antipsychotics 1mg, 2mg, 4mg  Increase gradually dependent) but less (tertiary care) to 2-4 mg per day than conventional (single dose or antipsychotics bid)  Weight gain  Nausea, vomiting  Rhinitis  Sedation  Increase serum prolactin(erectile dysfunction, galactorrhoea, amenorrhoea) Olanzapine  Initial dose is 5 mg  Somnolence Same as in conventional at night  Weight gain antisychotics,but with tab;  Increase slowly  Dizziness some differences in; 5mg,10 mg  Effective dose is  Dry mouth  Body weight: baseline, (tertiary care) 5-20 mg  Constipation then every 3 months for  Tremor one year, then yearly  Dose dependent Plasma Glucose: extrapyramidal side baseline, every month effects for 12months, every 4  Elevated blood sugar months for two years,  Elevated blood lipids then yearly  Elevated liver enzymes Blood lipids: baseline ,every 3 months for one year, then yearly Liver function tests: baseline ,then yearly

79 3. Clozapine; Used only in treatment- resistant schizophrenia

Medication Dose Adverse effects Follow up guidelines Clozapine Start with 25 mg  Anticholinergic; dry  Temperature, pulse, tab; daily mouth, constipation ,blood pressure ,lymph 25mg, 100mg Slowly increase the ,blurred vision, retention nodes, should be (Tertiary care) dose by 25 mg of urine checked every visit every 3 days  Antiadrenergic;  Full blood count: Effective dose is hypotension, sexual baseline then weekly for 300-400mg daily dysfunction 18 weeks, then in 3 divided doses  Sedation, nausea, fortnightly for one year, vomiting, weight gain then monthly(if WBC ,hypersalivation, fatigue count below 3000/mm 3  Potentially life or neutrophils count threatening side effects: below 1500/mm 3 (stop o Seizures immediately and refer to emergency medical unit) o Leukopenia o Agranulocytosis  Blood lipids: baseline ,every 3 months for one o Hepatitis year, then yearly o Pancreatitis  Plasma Glucose: o Myocarditis baseline, every month for Diabetes mellitus o 12months, every 4 months o Increase blood lipids for two years then yearly  Liver function tests: baseline, then yearly  Body weight: baseline, then every 3 months for one year, then yearly  ECG: baseline and after dose increase or changing drugs  Blood pressure; baseline and in every visit during titration of dose  Urea/electrolytes;baseline ,then yearly  Prolactin : baseline , every 6 months for two years, then yearly Antidepressant medications

1. Selective serotonin reuptake inhibitors(SSRI): Fluoxetine, Fluvoxamine, paroxetine, Sertraline, Citalopram, Escitalopram 2. Tricyclic and Tetracyclic antidepressants: amitriptyline, imipramine, maprotiline

1. Selective Serotonin reuptake inhibitors: first line antidepressive medications

Medication Dose Adverse effects Follow up guidelines Fluoxetine  Start with 20 mg orally Nausea, vomiting, dyspepsia, Start with low dose cap; in the morning(with abdominal pain, loss of weight , Gradual increase 20mg food to decrease increase weight, diarrhoea of the dose nausea) Anxiety, restlessness, agitation Follow up every 2  Gradual titration Insomnia weeks for 3  Effective dose is 20-60 Headache months , with mg in three divided Sweating assessment of doses Rash suicidal risk Tremor every visit Sexual dysfunction(male and Regular follow up female) every month Hyponatraemia CBC, LFT. Cutaneous bleeding disorders Baseline then every 6 months

Paroxetine  Start with 10-20 mg As for Fluoxetine Same as tab; orally at night More sedative Fluoxetine 20mg  Gradual titration Anticholinergic side effects  Effective dose 20-60mg Extrapyramidal side effects in divided doses Discontiuation syndrome; (dizziness, weakness, nausea, headache, rebound depression, insomnia , anxiety, headache and poor concentration)

Citalopram  Start with 20 mg orally Nausea, vomiting, dyspepsia, Same as tab; in the morning(with abdominal pain, loss of weight , Fluoxetine 20mg food to decrease increase weight, diarrhoea nausea) Anxiety, restlessness, agitation  Gradual titration Insomnia  Effective dose 20- Headache 60mg/day in single Sweating dose Rash Tremor Sexual dysfunction(male and female) Hyponatraemia Cutaneous bleeding disorders

2. Tricyclic and Tetracyclic antidepressants: amitriptyline, imipramine, maprotiline

81 Medication Dose Adverse effects Follow up guidelines Amitriptyline  Start with 25 mg at Sedation  Start with low dose tab; night Anticholinergic; dry mouth,  Gradual increase of 25mg,50 mg  Slowly increase the constipation ,blurred vision, the dose dose retention of urine,drowsiness,  Follow up every  Effective dose is75- confusion month 200mg Antiadrenergic: Avoid prescribing big Postural hypotension, amounts in each tachycardia,sexual dysfunction visit Antihistaminergic: weight gain, Blood pressure; sedation baseline and in Cardiac effects: tachycardia, flat every visit during T wave, ST depression titration of dose prolonged QT interval ECG: baseline and after dose Others: reduction of seizure increase or threshold, jaundice, elevated changing drugs liver enzymes, leukopenia, agranulocytosis Full blood count: baseline then Overdose toxicity; agitation,  yearly delirium, convulsions, Liver function tests: hyperactive tendon reflexes, baseline then bowel and bladder paralysis, yearly dysregulation of BP, temperature and mydriasis it will eventually leads to respiratory depression, arrhythmia and death. It is a medical emergency , needs immediate referral to A&E / medical department

Clomipramine  Start with 25 mg at Same as Amitriptylline Same as tab; night Amitriptylline 25 mg  Slowly increase the dose  Effective dose is 75- 200mg Imipramine  Start with 25 mg at Same as Amitriptylline Same as tab; night Less sedative Amitriptylline 25mg  Slowly increase the dose  Effective dose is 75- 200mg Maprotiline  Start with 25 mg at Same as Amitriptylline Same as tab; night At doses more than 250 mg it Amitriptylline 25mg, 50mg  Slowly increase the may decrease epileptic dose threshold(increase risk of fits)  Effective dose is 100- 200mg

Mood stabilizing medications

82 1.Lithium 2.Carbamazepine 3.Valproate 4.Lamotrigine

1. Lithium

Medication Dose Adverse effects Follow up guidelines

 Narrow therapeutic  Most side effects are Information should be index dose dependent provided to the patient and Lithium  Start slowly, 400mg  GIT distress, nausea, his family about; Carbonate; at night vomiting, dyspepsia,  How and when to take the tab;  Gradual increase diarrhoea dose 400 mg depend on serum  Weight gain  Common side effects, (secondary and monitoring  Tremor  Need for follow up and tertiary care)  Serum Lithium level  Cognitive problems, monitoring, should be measured for drowsiness, impaired  drug interactions dose titration memory, mental slowness,  Signs of toxicity  Treatment of acute sedation mania, serum level  Polyurea / polydypsia should be 0.8-1.2 mmol  Cardiac conduction / L problems; T wave changes, Lithium level; should be  Prophylaxis in exacerbation of arrhythmia checked after: bipolar affective  Subclinical / Clinical  5 days from starting, disorder, serum level hypothyroidism  5 days after each dose should be from 0.4-0.8  Hair loss change mmol/ L  Acne and aggravation  Every 3 moths after  Effective dose is of psoriasis stabilizing the dose usually 800-1200mg  Teratogenic effects /day in divided dose Monitoring; Lithium toxicity:  GFR, urea/electrolytes;  Appears with levels baseline and every 3 months higher than 1.5mmol/ L  Thyroid function test;  More than 2 mmol/ L baseline and every 6 months cause definite life  ECG ; baseline and every threatening toxicity 12 months  Early signs ;  Pregnancy test (when o Coarse tremor relevant) o Anorexia  Body weight ;baseline then o Nausea, vomiting every 6 months o Diarrhoea Discontinuation of lithium o Lethargy therapy should be discussed  Then as the level rises; with psychiatrist , because o Restlessness of the high risk of relapse o Muscle fasciculation o Myoclonic jerks o Chorioathetoid movements o Hypertonia o Ataxia

83 o Dysarthria o Confusion,delirium o Coma o Death  It is a medical emergency the patient must be referred to A&E / Medical department immediately

2. Carbamazepine; Anticonvulsant and mood stabilizer:

Medication Dose Adverse effects Follow up guidelines

Carbamazepine  Start with low dose  Headache, dizziness  Full medical history and tab; 300-600mg /day in ,drowsiness examination 200mg divided dose  Diplopia,  LFT; baseline, then (secondary and  Gradual increase  Nausea every 2 weeks for two tertiary care)  Effective dose in  Ataxia months, then every 3 Bipolar affective  Oedema, hyponatremia months disorder(acute mania)  Dermatological;  Full blood count(FBC); is 800-1200 mg/day erythematous rash, baseline, then every 2 in 3 divided doses exfoliative dermatitis weeks for two months,  Maintenance dose is ( Stevens-Johnson then every 3 months 600 mg/day in 3 syndrome)  ECG; baseline divided dose  A plastic anaemia,  Pregnancy test;( when Agranulocytosis relevant)  Hepatic failure

84 3. Valproate; Anticonvulsant and mood stabilize

Medication Dose Adverse effects Follow up guidelines

Sodium valproate  Start with low Common;  Full medical history tab; divided dose 200mg  GIT irritation and examination 200mg, 500mg tds  Sedation  LFT; baseline, then (secondary and  Increase gradually  Tremor monthly for 6 months, tertiary care)  Effective dose in  Weight gain then every 6 months bipolar affective  Hair loss  Full blood count disorder is 1000-  Ataxia (FBC); baseline, then 1500mg/day in  Dysarthria every 6 months divided dose  Elevation of liver  Body weight ; enzyme baseline then every 6  Teratogenicity; months ( better to avoid in  Pregnancy test; pregnancy as it may ( when relevant) cause neural tube defects) Rare;  Hepatotoxicity  Reversible thrombocytopenia  Pancreatitis  Hyperammonemia  Polycystic ovary  Hyperandrogenism

4. Lamotrigine; anticonvulsant and mood stabilizer

Medication Dose Adverse effects Follow up guidelines

Lamotrigine  Start with low  Dizziness  Start with low dose tab; dose;25mg/day  Ataxia  Slow titration 25 mg  Increase by 25 mg  Headache  Weekly visits during (secondary and every 2 weeks  Blurred vision titration tertiary care)  Effective dose in  Nausea  Look for skin rash bipolar affective  Skin rash  Stop medication if rash disorder is  Stevens-Johnson appears 200mg/day in two syndrome  Slower titration if divided dose  Toxic epidermal combined with necrolysis Valproate  Avoid use in children and adolescents under 16 years

85 Anticholinergic drugs :( Benzhexol, procyclidine, Benzatropine) Used to treat extrapyramidal side effects of antipsychotic medications

Medication Dose Adverse effects Follow up guidelines

Procyclidine  Tab 5mg tid in  Dry mouth  It should not be tab; patients with  Constipation prescribed routinely 5 mg pseudoparkinsonism  Blurred vision with antipsychotics Injection; or acute dystonia  Urinary retention due to high potential 5mg IM,IV  Injection 5mg IM in  Tachycardia for abuse and side patients with acute  Visual hallucinations effects dystonia  Confusion  Prescribe for one  Dilated pupils week and send the patient to secondary  Aggravation of narrow care psychiatrist for angle glaucoma further management  High potential for and follow up abuse

86 Anxiolytics, sedatives and hypnotics (benzodiazepines); Diazepam, Lorazepam, Clonazepam These medications act as:  Anxiolytic  Sedative  Hypnotic  Muscle relaxant  Anticonvulsant

Medication Dose Adverse effects Follow up guidelines

1.Diazepam;  Dose depends on;  Headache Do not prescribe tab; o general  Confusion routinely 2mg, 5mg. medical condition,  Ataxia Use with precaution in injection; o diagnosis  Slurred speech elderly 5mg IM,IV o Age  Blurred vision In PHC practice ,do  GIT disturbances not prescribe for 2.Clonazepam;  In anxiety disorders;  Amnesia more than 2 weeks tab; Diazepam dose usually  Paradoxical  Cases of abuse or 0.5 mg, 2 mg 5-10mg/day (used for aggression (especially dependence should (secondary and short term management) in elderly) be referred to tertiary care)  In alcohol detoxification  Disinhibition psychiatrist for higher dose of Diazepam  High risk of further evaluation 3.Lorazepam; and management tab ; needed abuse/dependence 1mg, 2 mg  Lorazepam tab 1-2 mg  Overdose/toxicity may Injection; used for violent patient. lead to respiratory 1mg,2mg IM  High risk for depression 1. abuse/dependence if prescribed for more than 4 weeks  Start with low dose and increase gradually  Injections used only in emergency cases (agitation, violence, status epilepticus) Diazepam:5mg IV Lorazepam: 1-2 mg IM  Should be tapered gradually.

87 ANNEXURE 1: Other useful materials

Checklists and screening tests for use by professionals in PHC

1- CAGE questionnaire; Used for screening of alcohol abuse/ dependence.

Alcohol dependence is likely if the patient gives two or more positive answers to the following questions  Have you ever felt you should Cut down on your drinking?  Have people Annoyed you by criticising your drinking?  Have you ever felt bad or Guilty about your drinking?  Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?

2- Mini mental state examination: Used for screening of cognitive impairment.

 Orientation:

a. Time: - Which day of the week is it? - What is the date? - What is the month? - What is the season? - What is the year?

(One point for each correct response) 5 points

b. Place: - What is the name of the building? - What floor are we on? - What town are we in? - What region are we in? - What country are we in?

(One point for each correct response) 5 points

88 Maximum 10 points

 Registration/ concentration/ recall - Give the patient a list of 3 objects (e.g. apple, ball, table) to remember (ask the patient to repeat the three objects) one point for each word learned.Then, tell the patient that you will ask about these words again later. 3 points - Spell the word "WORLD” (or any Arabic word made from 5 letters) backwards "DLROW" one point for each letter in a correct place. 5 points - Ask about the three objects given before. One point for each object recalled. 3 points

Maximum 11 points

 Language / drawing - Show a written instruction, ask the patient to read and carry out the instruction. 1 point - Ask the patient to write a complete sentence on a paper 1 point - Ask the patient to copy a drawing, as shown below. 1 point

- Ask the patient to repeat back a sentence 1 point - Show the patient 2 objects (e.g. wrist watch and pen) then ask him to name them. 2 points - Give the patient a three steps command (e.g. take the paper in your right hand; fold the paper with both hands; and put the paper on your lap) one point for each correct response. 3 points

Maximum 9 points

Test scores:

89 - Above 27 is normal - Less than 25 is suggestive of dementia

3- Risk assessment:

1. Risk of deliberate self present past none Remarks harm(DSH) . Ideas/verbal threats of self harm . Serious contemplation/ planning of self-harm . Act of DSH without significant risk to life . Act of DSH with significant risk to life 2.Risk of physical harm to present past none Remarks others(person& property)

. Known access to dangerous weapons . Ideas of violence toward others . Plans of violence toward others . Aggression toward others . Act of violence towards others . Arson/ fire setting behaviour

3. Risk of self neglect; present past none Remarks Exploitation/ abuse by others . Difficulties with activities of daily living . Inability to recognize hazards . Self neglect . Financial exploitation/ Abuse . Physical exploitation/ Abuse . Sexual Exploitation/ Abuse 4. Risk of sexual harm to present past none Remarks others . Sexual fantasies expressed . Inappropriate sexual behaviour . Indecent assault . rape 5.Substance/alcohol misuse present past none Remarks

. Substance/alcohol misuse . Multi-Drug misuse . Intravenous use of illicit substances . History of overdose . Hazardous practice e.g. sharing needles

90 . Serious psychiatric symptoms due to misuse 6. Forensic history present past none Remarks

. Minor offences . Serious crimes . Imprisonment

4- The short term opiate withdrawal scale:

Symptoms None Mild Moderat Severe e Feeling sick Stomach cramps Muscle spasm / twitching Feeling of coldness Heart pounding Muscular tension Aches and pains Yawning Runny eyes Insomnia/ problem sleeping

. Please tick in the box which indicate symptoms over the last 24 hours . Scoring: 0= none , 1= mild, 2= moderate, 3 = severe . Total the score and divide by 10 to get the mean score that indicates the overall severity of withdrawal symptoms

91 ANNEXURE 2:

Medications approved to use in PHC

S.N Therapeutic Item Description Remarks Health Centre Category/Subcategory Level 1. Anxiolytics, sedatives& hypnotics

Diazepam tab A+B a. Benzodiazepines 5 mg

,Diazepam injection Emergency A+B 5 mg, in 2ml drug cabinet ampoule b. Phenothiazines Promethazine A+B HCL tab, 10mg , 25 mg 2. Antipsychotics

Phenothiazines Chlorpromazine A+B a. tab, 25 mg Haloperidol tab b. Butyrophenones 1.5 mg A+B Haloperidol injection 5mg/ml Emergency A+B drug cabinet

3. Antidepressive medications

Tricyclic, tetracyclic and Maprotiline tab, A+B a. related antidepressants 25 mg, 50 mg

Clomipramine tab, A+B 10mg, 25 mg

92 Amitriptyline tab, 25 mg Approved A+B only for treatment of tension headache 4. Drugs for parkinsonian features

a Antimuscarinics Procyclidine Emergency A+B (Anticholinergics) injection, drugs cabinet 10 mg ampoule

Suggested medications for approval in PHC

S.N Therapeutic Item Description Remarks Health Centre Category/Subcategory Level a. Selective serotonin Fluoxetine cap A+B reuptake inhibitors 20mg Paroxetine tab 20 A+B mg Citalopram tab A+B 20mg b. Tricyclic antidepressants Imipramine tab, Use in A+B 25 mg depression with psychomotor retardation Amitriptyline tab Use in A+B depression 25 mg with agitation and insomnia c. Anxiolytics, sedatives& Lorazepam tab A+B hypnotics 1mg Lorazepam injection 1mg

93 ANNEXURE 3: Glossary of psychiatric signs and symptoms

 Affect: The emotional state prevailing in a patient at a particular moment .Affect has outward manifestations that can be classified into;

o Restricted affect: reduced emotional response to external and internal events o Blunted affect: more severe reduction of emotional response to events o Flat affect: loss of emotional response to events o Emotional lability: excessive emotional responsiveness characterized by unstable and rapidly changing emotions o Inappropriate (incongruent affect): emotional tone out of harmony with the idea, speech, and external event associated with.

 Aggression: forceful , goal directed action (verbal or physical);the motor counterpart of rage, anger or hostility  Agitation: motor restlessness  Agoraphobia: morbid fear of open places, crowds, leaving familiar settings. leading to avoidance of these situations  Akathisia: subjective feeling of motor restlessness manifested by compelling need to be in constant movement  Amnesia: partial or total inability to recall past experiences  Anhedonia: loss of interest in , and withdrawal from all pleasurable activities  Apathy: dulled emotional tone associated with detachment or indifference  Apraxia: Inability to perform a voluntary purposeful activity despite normal sensory motor functions  Bereavement: feeling of grief or desolation, especially at the death or loss of a loved one  Thought block: abrupt interruption in train of thinking before a thought or idea is completed, after a brief pause, the person indicates no recall of what was being said or was going to be said  Bradykinesia: slowness of motor activity, with a decrease of normal spontaneous movements  Catalepsy: condition in which the patient maintain the body position into which they are placed(seen in catatonia)  Cataplexy: temporary sudden loss of muscle tone, causing weakness and immobilization, usually precipitated by variety of emotional states and followed by sleep(associated usually with narcolepsy)  Catatonic excitement: excited uncontrolled motor activity

94  Catatonic posturing: voluntary assumption of an inappropriate or bizarre postures  Catatonic rigidity: fixed and sustained motoric position that is resistant to change  Catatonic stupor: normal awareness but poor motor or verbal response  Chorea: characterized by random and involuntary ,quick, jerky ,purposeless movements  Circumstantialilty: tedious elaboration of unnecessary details in speech before reaching goal  Clang association: association of speech directed by the sound of a word rather than meaning(punning or rhyming dominates verbal behaviour)  Clouding of consciousness: disturbance of consciousness in which the person is not fully awake, alert and oriented  Compulsion: pathological need to act on an impulse that, if resisted, produce anxiety; repetitive behaviour in response to an obsession or performed according to certain rules  Concrete thinking: literal thinking characterized by actual things, events and immediate experiences, rather than abstractions  Confabulation: unconscious filling of gaps in memory by imagination of false detailed events  Constructional apraxia: inability to copy a drawing such as a cube, clock or pentagon  Conversion phenomena: the development of symbolic physical symptoms and distortions involving the voluntary muscles, or special sense organs; not under voluntary control and not explained by any physical disorder  Delirium: acute reversible mental disorder characterized by confusion and some impairment of consciousness; generally associated with emotional lability, hallucinations or illusions, and inappropriate, impulsive, irrational and violent behaviour  Delirium tremens: acute and sometimes fatal reaction to withdrawal from alcohol usually occurring 3-4 days after the cessation of heavy drinking; characterized by marked autonomic hyperactivity(tachycardia, fever, hyperhidrosis and dilated pupils) ,usually accompanied with tremor, hallucinations, illusions and delusions  Delusions: false, fixed, unshakeable and firmly held belief despite objective and obvious contradictory proof or evidence. Delusional beliefs are not shared with other members of the same sociocultural background. Types of delusions are: o Delusion of persecution: false belief of being harassed or persecuted o Delusion of grandeur: exaggerated sense of self importance ,power or identity o Delusion of infidelity(jealousy): false belief that spouse or lover is unfaithful o Delusion of control: false belief that the patient’s will, thoughts or feelings are controlled and influenced by external forces o Delusion of poverty: the patient believes that he is bereft or will be deprived of all material possessions o Nihilistic delusion: delusion of non-existence of self or part of self o Delusions of reference:false beliefs that neutral events, behaviours by others have personal significance(usually of negative nature) to the patient o Delusion of guilt :false belief that one has committed a crime or other irresponsible act

95 o Delusion of love(erotomania): false belief that someone is deeply in love with the patient Denial: defence mechanism in which the existence of unpleasant realities is disavowed; refers to keeping out of conscious awareness any aspects of external reality that , if acknowledged ,would produce anxiety Depersonalisation: sensation of unreality concerning one’s self ,parts of one’s self, or one’s environment that occurs under extreme stress or fatigue Derailment: gradual or sudden deviation in train of thought without blocking  Derealization: sensation of changed reality or that one’s surroundings have altered  Detachment: distant interpersonal relationships and lack of emotional involvement  Diminished libido: decreased sexual interest or drive Disinhibition: greater freedom to act in accordance with inner drives or feelings and with less regard for restraints dictated by cultural norms or one’s superego Disorientation: confusion; impairment of awareness of time, place, and person Dissociation: unconscious defence mechanism involves segregation of any group of mental or behavioural processes from the rest of the person psychic activity; may entail the separation of idea from it’s accompanied emotional tone  Dysphoria: feeling of unpleasantness or discomfort ; a mood of general dissatisfaction and restlessness Echolalia: psychopathological repeating of words or phrases of one person by another Elation: mood consisting of feeling of joy, euphoria, intense sense of self satisfaction and optimism Emotion: complex feeling state with psychic, somatic and behavioural components; external manifestation of emotion is affect Encopresis: involuntary passage of feces Enuresis: involuntary voiding of urine during sleep or day time Euphoria: exaggerated feeling of well-being that is inappropriate to real events Flight of ideas: rapid succession of thoughts or speech in which content changes abruptly and speech may be incoherent  Formal thought disorder: disturbance in the form of thinking ; thinking characterized by loosened associations, neologisms, and illogical constructs Free floating (generalized ) anxiety: severe ,pervasive, generalized anxiety that is not attached to any particular idea, object, or event Fugue: that is characterized by period of complete amnesia, during which the person flees from an immediate life situation and begins a different life pattern Galactorrhea: abnormal discharge of milk from the breast; may result from endocrine influences(e.g. increase prolactin) of dopamine receptor antagonists, such as phenothiazines Grandiosity: exaggerated feelings of one’s importance, power, knowledge, or identity  Grief: alteration of mood and affect consisting of sadness appropriate to real loss; normally , it is self –limited Guilt: emotional state associated with self - reproach and the need for punishment Hallucination: false sensory perception occurring in the absence of any relevant external stimulation of the sensory modality involved ; it includes:

o Auditory hallucinations o Visual hallucinations o Olfactory hallucinations o Tactile hallucinations o Gustatory hallucinations o Deep somatic hallucinations

96 Hypersomnia: excessive time spent asleep Hyperventilation: excessive breathing Hypervigilance: excessive attention to , and focus on ,all internal and external stimuli  Hypnosis: artificially induced alteration of consciousness characterized by increase suggestibility Hypochondria: exaggerated concern about health that is based not on real medical pathology Hypomania: mood abnormality with the same qualitative characteristics of mania , but less intense Illusion: perceptual misinterpretation of a real external stimulus  Immediate memory: reproduction, recognition or recall of a perceived material within seconds after presentation  Impaired insight: diminished ability to understand the objective reality of a situation  Impaired judgement: diminished ability to understand a situation correctly or act properly Incoherence: communication that is disconnected, disorganized, or incomprehensible  Insomnia: o Initial: difficulty in falling asleep o Middle: interrupted sleep o Late: early wakefulness Intelligence: capacity for learning and ability to recall, integrate constructively, and apply what one has learned; the capacity to understand and think rationally Long term memory: reproduction, recognition, or recall of experiences or information that is in the distant past  Loosening of association: disorder of logical progression of thoughts, and shifting from one subject to another irrelevantly Malingering: feigning disease to achieve specific goal Mania: mood state characterized by elation, agitation, hyperactivity, , and accelerated thinking and speaking (flight of ideas) Mannerism: ingrained , habitual involuntary movement Melancholia: severe depressive state Mood congruent delusion: delusions with content that is mood appropriate(depressed patients who believe that they are responsible for the destruction of the world) Mood congruent hallucination: hallucination with content that is consistent with depressed or manic mood(depressed patients hear voices telling them that they are bad, or manic patients hear voices telling them that they have inflated worth, power , or knowledge)  Mood incongruent delusion: delusion which has no association with mood (e.g.depressed patient thinks that he is a king)  Mood incongruent hallucination: content of hallucination not consistent with mood(e.g.depressed patient hearing voices that he is a very important person) Mood swings: oscillation of a person’s emotional feeling tone between periods of elation and periods of depression  Negative signs of schizophrenia: flat affect, social isolation, lack of motivation, poverty of speech content and apathy  Negativism: verbal or nonverbal opposition or resistance to outside suggestions and advice Neologism: new word or phrase who is derivation cannot be understood

97 Obsession: persistent and recurrent intrusive idea, thought, or impulse .These ideas are involuntary, considered by the patient as nonsense and can not be eliminated by resistance  Overvalued ideas: false unreasonable belief that is sustained beyond the bounds of reason. It is held with less intensity or duration than a delusion  Panic : acute, intense attack of anxiety , associated with sense of being overwhelmed and sense of impending doom Paranoid delusions: persecutory, grandiose, and delusions of reference Perseveration: pathological repetition of the same response to different stimuli, as in a repetition of the verbal response to different questions Positive signs of schizophrenia: hallucinations, delusions, disorganized speech (formal thought disorder) and disorganized behaviour  Posturing: strange, fixed, and bizarre bodily positions ,held by the patient for extended time(appear in catatonia) Poverty of speech : restriction of the amount of speech used Poverty of speech content: speech is adequate in amount ,but carries a little information Pressured speech: increase in amount of spontaneous speech, rapid ,loud and accelerated speech

 Psychosis: mental disorders in which thoughts, affective response, ability to recognize reality, and ability to communicate and relate to others are impaired. The classic characteristics of psychosis are impaired reality testing, hallucinations, delusions, and illusions Recent memory: recall of events over the past few days Recent past memory: recall of events over the past few months Remote memory: recall of events from the distant past Short term memory: reproduction, recognition, or recall of perceived material within minutes after the initial presentation  Somatic hallucination: hallucination involving the perception of physical experience localized within the body Suicidal ideation: thoughts of taking one’s own life Thought broadcasting: a belief that the one’s own thoughts are being broadcasted and accessible to others  Thought insertion: a belief that one’s own thoughts are being implanted in his mind by an external agency  Thought withdrawal: a belief that one’s own thoughts are being removed from his mind by other people or forces

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