Schizophrenia was coined in 1908 by the Swiss psychiatrist Eugen Bleuler.

The word was derived

from the Greek skhizo (split) and phren (mind).
A variable combination of:
•​ genetic predisposition
•​ biochemical dysfunction
•​ physiological factors
•​ psychosocial stress.
Schizophrenia probably is responsible for lengthier hospitalizations, greater chaos in family life, more
exorbitant costs to individuals and governments, and more fears than any other.
Psychosis - A severe mental condition in which there is disorganization of the personality,
deterioration in social functioning, and loss of contact with, or distortion of, reality. There may be
evidence of hallucinations and delusional thinking. Psychosis can occur with or without the presence
of organic impairment.
4 PHASES PATTERN OF DEVELOPMENT IN SCHIZOPRENIA
Phase I. The Premorbid Phase
•​ indicates social maladjustment, social withdrawal, irritability, and antagonistic thoughts and
behavior
•​ very shy and withdrawn, having poor peer relationships, doing poorly in school, and
demonstrating antisocial behavior.
Phase II. The Prodromal Phase
•​ begins with a change from premorbid functioning and extends until the onset of frank psychotic
symptoms. This phase can be as brief as a few weeks or months, but most studies indicate that
the average length of the prodromal phase is between
•​ 2 and 5 years. Lehman and associates (2006).
Phase III. Schizophrenia
•​ active phase of the disorder, psychotic symptoms are prominent.
•​ diagnostic criteria for schizophrenia:
1. Characteristic symptoms: Two (or more)
a.​ Delusions
b.​ Hallucinations
c.​ Disorganized speech (e.g., frequent derailment or incoherence)
d.​ Grossly disorganized or catatonic behavior
e.​ e. Negative symptoms (i.e., affective flattening, alogia, or avolition
Phase IV. Residual Phase
•​ usually follows an active phase of the illness.
•​ symptoms of the acute stage are either absent or no longer prominent.
•​ Negative symptoms may remain, and flat affect and impairment in role functioning are
common.
Prognosis - A return to full premorbid functioning is not common (APA, 2000). However, several
factors have been associated with a more positive prognosis

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ETIOLOGICAL IMPLICATIONS - The cause of schizophrenia is still uncertain. Most likely no single
factor can be implicated in the etiology; rather, the disease probably results from a combination of
influences including biological, psychological, and environmental factors
1.​ Biological Influences - Genetics - Twin Studies, Adoption Studies
2.​ Biochemical Influences - abnormal brain biochemistry “chemical disturbance”
•​ Dopamine Hypothesis - caused by an excess of dopamine dependent neuronal activity in the
brain.
•​ Other Biochemical Hypotheses- Abnormalities in the neurotransmitters norepinephrine,
serotonin, acetylcholine, and gamma-aminobutyric acid and in the neuro regulators, such as
prostaglandins and endorphins, have been suggested.
3.​ Physiological Influences
•​ Viral Infection - high incidence of schizophrenia after prenatal exposure to influenza
•​ Anatomical Abnormalities - Ventricular enlargement is the most consistent finding; however,
sulci enlargement and cerebellar atrophy are also reported.
4.​ Psychological Influences -family relationship factors as major influences, early theories
implicated poor parent-child relationships and dysfunctional family systems as the cause of
schizophrenia, but they no longer hold any credibility. Researchers now focus their studies in
terms of schizophrenia as a brain disorder.
5.​ Environmental Influences
•​ Sociocultural Factors - lower socioeconomic classes experience symptoms associated with
schizophrenia than do those from the higher socioeconomic groups
•​ Stressful Life Events -There is no scientific evidence to indicate that stress causes
schizophrenia, may contribute to the severity and course of the illness
TYPES OF SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDER
1.​ DELUSIONAL DISORDER - characterized by the presence of delusions that have been experienced
by the individual for at least 1 month (APA, 2013).
Subtypes of delusional disorder include the following:
•​ Erotomanic Type - the individual believes that someone, usually of a higher status, is in love
with him or her. Famous persons are often the subjects of erotomanic delusions.
•​ Grandiose Type - have irrational ideas regarding their own worth, talent, knowledge, or power.
They may believe that they have a special relationship with a famous person, or even assume
the identity of a famous person
•​ Jealous Type - delusions centers on the idea that the person’s sexual partner is unfaithful. The
idea is irrational and without cause, but the individual with the delusion searches for evidence
to justify the belief.
•​ Persecutory Type - individuals believe they are being persecuted or malevolently treated in
some way, cheated or defrauded, followed and spied on, poisoned, or drugged.
•​ Somatic Type - Individuals with somatic delusions believe they have some type of general
medical condition.
2.​ BRIEF PSYCHOTIC DISORDER - sudden onset of psychotic symptoms that may or may not be
preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1
month experiences emotional turmoil or overwhelming perplexity or confusion.
•​ Individuals with preexisting personality disorders (most commonly histrionic, narcissistic,
paranoid, schizotypal, and borderline personality disorders) appear to be susceptible to this
disorder (Sadock & Sadock, 2007). Catatonic features may also be associated with this disorder.
3.​ Schizophreniform Disorder - The essential features of schizophreniform disorder are identical to
those of schizophrenia, with the exception that the duration, including prodromal, active, and
residual phases, is at least 1 month but less than 6 months (APA, 2013)

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4.​ Schizoaffective Disorder - associated with the mood disorders (depression or mania). The client
may appear depressed, with psychomotor retardation and suicidal ideation, or symptoms may
include euphoria, grandiosity, and hyperactivity
Content of Thought
Delusions - false personal beliefs
•​ Delusion of Persecution - feels threatened and believes that others intend harm or persecution
toward him or her
•​ Delusion of Grandeur - exaggerated feeling of importance, power, knowledge, or identity
•​ Delusion of Reference - All events within the environment are referred by the psychotic person
to him- or herself
•​ Somatic Delusion - has a false idea about the functioning of his or her body
•​ Nihilistic Delusion - has a false idea that the self, a part of the self, others, or the world is
nonexistent
•​ Religiosity- excessive demonstration of or obsession with religious ideas and behavior.
•​ Paranoia - have extreme suspiciousness of others and of their actions or perceived intentions
(e.g., “I won’t eat this food. I know it has been poisoned.”).
•​ Magical Thinking - the person believes that his or her thoughts or behaviors have control over
specific situations or people. e.g. “It snowed last night because I wished very, very hard that it
would.”
Form of Thought
•​ Associative Looseness - Thinking is characterized by speech in which ideas shift from one
unrelated subject to another.
•​ Neologisms - psychotic person invents new words that are meaningless
•​ Concrete Thinking - literal interpretations of the environment, represents a regression to an
earlier level of cognitive development.
•​ Clang Associations - often take the form of rhyming. e.g “It is very cold. I am cold and bold. The
gold has been sold.”
•​ Word Salad - is a group of words that are put together randomly, without any logical
connection (e.g., “Most forward action grows life double plays circle uniform.”).
•​ Circumstantiality - the individual delays in reaching the point of a communication because of
unnecessary and tedious details.
•​ Tangentiality - Unrelated topics are introduced, and the focus of the original discussion is lost.
•​ Mutism - is an individual’s inability or refusal to speak
•​ Perseveration - persistently repeats the same word or idea in response to different questions
Perception
•​ Hallucinations -false sensory perceptions not associated with real external stimuli, may
involve any of the five senses.
•​ Auditory
•​ Visual
•​ Tactile
•​ Gustatory
•​ Olfactory
•​ Illusions - misperceptions or misinterpretations of real external stimuli.
Sense of Self - Sense of self describes the uniqueness and individuality a person feels. Because of
extremely weak ego boundaries, the individual with schizophrenia lacks this feeling of
uniqueness and experiences a great deal of confusion regarding his or her identity.

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 •​ Echolalia - repeat words that he or she hears
•​ Echopraxia - purposelessly imitate movements made by others.
•​ Identification and Imitation - Identification which occurs on an unconscious level, and
imitation, which occurs on a conscious level, are ego defense mechanisms used by individuals
with schizophrenia and reflect their confusion regarding self-identity.
•​ Depersonalization - unstable self-identity of an individual with schizophrenia may lead to
feelings of unreality (e.g., feeling that one’s extremities have changed in size; or a sense of
seeing oneself from a distance).
Affect- describes the behavior associated with an individual’s feeling state or emotional tone.
•​ Inappropriate Affect - inappropriate when the individual’s emotional tone is incongruent
with the circumstances (e.g., a young woman who laughs when told of the death of her
mother).
•​ Bland or Flat Affect - described as bland when the emotional tone is very weak. The
individual with flat affect appears to be void of emotional tone
•​ Apathy - often demonstrates an indifference to or disinterest in the environment.
Avolition- the individual with schizophrenia, this may take the form of inadequate interest,
motivation, or ability to choose a logical course of action in a given situation.
•​ Emotional Ambivalence -fear of intimacy
•​ Deteriorated Appearance - Personal grooming and selfcare activities may be neglected.
Interpersonal Functioning and Relationship to the External World - social isolation, emotional
detachment, and lack of regard for social convention.
•​ Impaired Social Interaction - exhibiting behaviors that are not socially and culturally
acceptable.
•​ Social Isolation -exclusion of the external environment
Psychomotor Behavior
•​ Anergia - lack sufficient energy to carry out activities of daily living or to interact with others.
•​ Waxy Flexibility - allows body parts to be placed in bizarre or uncomfortable positions for
long periods.
•​ Posturing - voluntary assumption of inappropriate or bizarre postures.
•​ Pacing and Rocking - Pacing back and forth and body rocking
Associated Features
•​ Anhedonia - inability to experience pleasure. This is a particularly distressing symptom that
compels some clients to attempt suicide
•​ Regression - retreat to an earlier level of development. Regression, a primary defense
mechanism of schizophrenia

PERSONALITY DISORDER
According to WHO abnormal personality can be defined as "deeply ingrained maladaptive
pattern of behavior, continuing throughout the most of adult life, although often becoming
less obvious in middle or old age.

CHARACTERISTIC OF PERSONALITY DISORDER

●​ It is not a mental illness.
●​ It is a maladaptive behavior.

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 ●​ It is long lasting, most of the time lifelong problems.
●​ It causes significant impairment in social oroccupational functioning.
●​ It produces distress to the individual and to others.

●​ Whereas the symptoms of personality disorder are continuous and start from
adolescence or even before.
●​ These patients are odd but not mad.

ETIOLOGY FACTORS:
1. Biological factors.
2. Developmental factors.
3. Social cultural factors.
4. Psychological stressors.

PERSONALITY DISORDERS
Types: The following are the classical types of Personality Disorders.
1. Schizoid Personality Disorder
2. Paranoid Personality Disorder
3. Antisocial Personality Disorder
4.. Histrionic Personality Disorder
5. Obsessive-Compulsive Personality Disorder

CLASSIFICATION
●​ Cluster A: Odd, aloof features - paranoid, schizoid, schizotypal.
●​ Cluster B: Dramatic, impulsive, and erratic features - Borderline, Antisocial,
Narcissistic, histrionic
●​ Cluster C: Anxious and fearful features - Avoidant, Dependent,
Obsessive-compulsive

1. SCHIZOID PERSONALITY DISORDER

●​ Marked preference to do things alone (socially withdrawn).
●​ Constricted emotions.
●​ Humorless
●​ Aloof, distant and cold.
●​ Touchy, sensitive to feeling of rejection
●​ Deficient motivation.
●​ Schizoid
●​ He lacks interest and hobbies.
●​ No apparent desire to pursue relationships.
●​ He prefers jobs that do not involve dealing with people.
●​ He works below his potential.
●​ He may show considerable creativity.
●​ N.B. No relation between Schizoid Personality Disorder and Schizophrenia.

Schizoid Personality Disorder

"SIR SAFE"
●​ Solitary lifestyle
●​ Indifferent to praise or criticism

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 ●​ Relationships of no interest
●​ Sexual experiences not of interest
●​ Activities not enjoyed
●​ Friends lacking
●​ Emotionally cold and detached

2. PARANOID PERSONALITY DISORDER:

●​ Grandiose feelings.
●​ He externalizes blame for his difficulties, e.g., he sees himself as the target of abuse
or persecution.
●​ He feels insecure
●​ He overestimates minor events.
●​ He searches intensively to confirm suspicions in others.
●​ He cannot relax.
●​ He has little or no sense of humor.
●​ He is envious and pathologically jealous.
●​ He is critical to those whom he sees as weaker, needs or defective.
●​ Multiple problems with authority figures.
●​ Anger and hostility are the main affects
●​ He will only rely on himself

Paranoid Personality Disorder

"GET FACT"
●​ Grudges held for long periods
●​ Exploitation expected (without a
●​ sufficient basis)
●​ Trustworthiness of others doubted
●​ Fidelity of sexual partner questioned
●​ Attacks on character are perceived
●​ Confides in others rarely, if at all
●​ Threatening meanings read into

Schizotypal Personality Disorder

"UFO AIDER"
●​ Unusual perceptions
●​ Friendless except for family
●​ Odd beliefs, thinking, and speech
●​ Affect - inappropriate, constricted
●​ Ideas of reference
●​ Doubts others - suspicious
●​ Eccentric - appearance/behavior
●​ Reluctant in social situations, anxious

3. ANTISOCIAL PERSONALITY DISORDER:

●​ It usually has an onset during childhood.
●​ Before the age 18 years, it is known as conduct disorder.
●​ Constant lack of conformity to major societal & religious rules.
●​ Criminal versatility.

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 ●​ Promiscuity.
●​ Poor impulse control.
●​ Avoids responsibility for actions.
●​ Abusive and manipulative of others.
●​ Abuse of substance is a common association.
●​ Requires constant stimulation.
●​ Shallow emotions with lack of care for the feelings of others.
●​ N.B. Likely to abuse relation with doctor to obtain benefits and avoid responsibility.

Antisocial Personality Disorder

"CALLOUS MAN"
●​ Conduct disorder before age 15y;Current age at least 18y
●​ Antisocial acts; commits acts that are grounds for Arrest
●​ Lies frequently
●​ Lacunae - Lacks a superego
●​ Obligations not honored
●​ Unstable - can't plan ahead
●​ Safety of self and others ignored
●​ Money problems - spouse and children are not supported
●​ Aggressive, Assaultive
●​ Not occurring exclusively during schizophrenia or mania

4. HISTRIONIC PERSONALITY DISORDER:

●​ More prevalent in females.
●​ Immature personality, emotionally unstable, and
●​ tends to emotionally overreact.
●​ She craves and works to be constantly the centre of attraction.
●​ Dramatization of situations and emotions
●​ Sexually provocative and seductive.
●​ Highly suggestible and dependent.
●​ Egocentric.
●​ Over dress and over use of accessories and make-up

Histrionic Personality Disorder

"I CRAVE SIN"
●​ Inappropriate behavior - seductive or provocative
●​ Center of attention
●​ Relationships are seen as closer than they really are
●​ Appearance is most important
●​ Vulnerable to others' suggestions
●​ Emotional expression is exaggerated
●​ Shifting emotions, Shallow
●​ Impressionistic manner of speaking (lacks detail)
●​ Novelty is craved

Narcissistic Personality Disorder

"A FAME GAME"
●​ Admiration required in excessive amounts

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 ●​ Fantasizes about unlimited success, brilliance, etc.
●​ Arrogant
●​ Manipulative
●​ Envious of others
●​ Grandiose sense of importance
●​ Associates with special people
●​ Me first attitude
●​ Empathy lacking for others

Avoidant Personality Disorder

"RIDICULE"
●​ Restrained within relationships
●​ Inhibited in interpersonal situations
●​ Disapproval expected at work
●​ Inadequate (view of self)
●​ Criticism is expected in social situations
●​ Unwilling to get involved
●​ Longs for attachment to others
●​ Embarrassment is the feared emotion

Dependent Personality Disorder

"DARN HURT"
●​ Disagreement is difficult to express
●​ Advice - needs excessive input
●​ Responsibility for major areas
●​ delegated to others
●​ Nurturance - seeks excessive degree from others
●​ Helpless when alone
●​ Unrealistically preoccupied with being left to care for self
●​ Relationships are desperately sought (when an estab-lished one ends)
●​ Tasks - has difficulty initiating projects

Obsessive-Compulsive Personality
"LOW MIRTH"
●​ Leisure activity is minimal
●​ Organizational focus
●​ Work and productivity predominate
●​ Miserly spending habits
●​ Inflexible around morals, values, etc.
●​ Rigidity and stubbornness
●​ Task completion impaired (by perfectionism)
●​ Hoards items - cannot discard them

Treatment: The aim of treatment is to improve the social adaptation and vocational
functioning of the patient, as well as to reduce the suffering of his surrounding family
members.
●​ Psychotherapy: - The modality and type is chosen according to the individual
patient.

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 ●​ Techniques vary from cognitive behavioral, brief dynamic and extended deeper
forms.
●​ Group therapy can be extremely helpful in certain types of personality disorders, e.g.
Schizoid Personality Disorder.
●​ Individual psychotherapy is more helpful in certain cases, e.g. a well motivated
Paranoid personality disorder.

MALADAPTIVE COGNITIONS HYPOTHESIZED TO

BE ASSOCIATED WITH EACH PERSONALITY
DISORDER
●​ Avoidant - If people know the real me, they will reject me.
●​ Dependent - I need people to survive and I need constant encouragement and
reassurance
●​ Obsessive Compulsive - I know what's best, people should do better and try harder
●​ Paranoid - Don't trust anyone, Be on guard
●​ Anti-social - I am entitled to break rules
●​ Narcissistic - Since I am Special, I deserve special rules, I am better than others
●​ Histrionic - People are there to serve or admire me
●​ Schizoid - Others are Unrewarding, Relationships are messy and Undesirable.

Personality disorder is different from mental illness. Whereas the symptoms of personality
disorder are continuous and start from adolescence or even before.
●​ It is not a mental illness.
●​ It is a maladaptive behavior.
●​ It is long lasting, most of time lifelong problems.
●​ It produces distress to the individual and to others.

ANXIETY DISORDERS
Fear - fear is an emotional response to a real or perceived threat.
Anxiety- is a subjective feeling of fear and uneasiness to an unknown threat or internal
conflict

●​ Anxiety is the body's natural response to stress that causes increased alertness, fear,
and physical signs.
●​ Anxiety disorders include disorders that share features of excessive fear and anxiety
and related behavioral disturbances.
●​ Individuals with anxiety disorders usually overestimate the danger in the situation
●​ Many of the anxiety disorders develop during childhood and tend to persist if not
treated.

How much is too much?

●​ Anxiety is usually considered a normal reaction to a realistic threat or danger that
dissipates when danger is no longer present.

Anxiety can be considered abnormal or pathological if:

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 ●​ It is excessive or persisting beyond developmentally appropriate period
●​ It is out of proportion to the situation creating it.
●​ It interferes with social, occupational or other important areas of functioning.

ICD -10 CLASSIFICATION

According to ICD -10 anxiety disorders fall under the chapter F40 and F41

F40 Phobic anxiety disorders

●​ Agoraphobia
●​ Social phobia
●​ Specific phobias
F41 Other Anxiety Disorders
●​ Panic disorder
●​ Generalized anxiety disorder (GAD)
●​ Mix anxiety and depressive disorder
●​ Others (mix and unspecified)

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CLASSIFICATION OF ANXIETY DISORDERS
●​ Separation anxiety disorder
●​ Selective mutism
●​ Specific phobias
●​ Social anxiety disorder
●​ Panic disorder
●​ Agoraphobia
●​ Generalized anxiety disorder
●​ Substance/ medication induced anxiety disorder
●​ Anxiety disorder due to another medical condition
●​ Other specified anxiety disorder
●​ Unspecified anxiety disorder

ETIOLOGICAL THEORIES FOR ANXIETY DISORDERS

Biological theories
Genetics:
●​ First degree relatives
●​ Monozygotic twins
●​ Family history
Neuroanatomical:
●​ Increased sympathetic activity
●​ Sympathetic nervous system adapts slowly to the repeated stimuli and response
excessively to moderate stimuli

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Psychoanalytic theory
●​ According to the Freud's psychoanalytic theory anxiety is the result of inability of the
ego defense mechanism to resolve the conflict between ID and superego
●​ Repression helps in dealing the anxiety producing situations without symptom
formation.
●​ If repression is unsuccessful as a defense mechanism, other defense mechanisms
(conversion, displacement, regression) are used. This defense mechanisms may
cause symptoms that produce a picture of neurotic disorder.

Cognitive behavior theory

●​ According to cognitive behavior theory anxiety is the result of faulty cognitions of an
individual.
●​ Response to any anxiety producing situation depends on the cognitive appraisal of
the situation by an individual.
●​ Patients suffering from anxiety disorder tend to overestimate the degree of danger in
a given situation and underestimate their capacity to cope with that situation.

Behavior theory
●​ This theory explains that anxiety is a conditioned or learned response to a specific
environmental stimulus.
●​ e.g. a person not having food allergies, may get sick after eating contaminated food
at a restaurant. Through generalization the person can distress all food prepared by
others.
●​ The individual may also learn to have an internal response of anxiety, intimating the
anxiety response of his parents or significant others (social learning)

Psychosocial factors
●​ Disturb mother child relationship
●​ Object loss theory
●​ Stressful life events
●​ Certain temperament or personality traits
●​ Childhood maltreatment (abuse or neglect)
●​ Overprotective parents
●​ Family environment

Symptoms of anxiety
Physical
●​ Dry mouth
●​ Difficulties swallowing
●​ Palpitations
●​ Restlessness, tremor
●​ Gastrointestinal discomfort
●​ Headache
●​ Choking sensation
●​ Breathlessness
●​ Dilated pupils
●​ Muscle tension

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 ●​ Tightness of chest
●​ Excessive thirst

Psychological symptoms of anxiety

●​ Withdrawal
●​ Irritability
●​ Insomnia
●​ Lack of interest or apathy
●​ Feeling of worthlessness, apprehension, or helplessness
●​ Inability to concentrate
●​ Fear of losing control

TYPES OF ANXIETY DISORDERS

Separation anxiety disorder
-​ Separation anxiety disorder is a childhood onset disorder in which the child is having
unusual fear and anxiety about separation from parents or attachment figures to a
degree that is developmentally inappropriate
-​ The fear or separation cause great distress to the child and may interfere with normal
activities such as going to school or playing with others

Clinical features of separation anxiety disorder

●​ Fear of losing or being separated from attachment figures
●​ Nightmares
●​ Physical symptoms of distress
●​ Refusal to leave the attachment figures
●​ Repeated temper tantrums
●​ Unusual distress at the discussion of separation from attachment figures
●​ Persistent worry of an unexpected event that could lead to separation

Phobic anxiety disorder

-​ Phobia is defined as a persistent (long lasting) fear of specific object, activity or
situation that produces continuous avoidance of the feared object, activity or
situation.
-​ The fear is out of proportion to the situation and cannot be explained
-​ It is beyond voluntary control of the individual and leads to significant distress or
disturbances in personal, occupational and social functioning

Types of Phobic Anxiety Disorders

1.​ Social phobia
2.​ Specific phobia
3.​ Agoraphobia

Social Phobia (social anxiety disorder)

-​ Social phobia is fear of social situations where the person may be examined closely,
embarrass or judged
-​ The person is having negative ideation of being negatively evaluated by others,
embarrass, humiliated, rejected or insulted by others
Clinical Features

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 ●​ Strong persistent fear of an interpersonal situation
●​ Fear of meeting unfamiliar people
●​ Fear or avoidance of situations in which the person can be observed eating or
drinking
●​ Fear of being criticized
●​ Fear of public speaking or public performance

Specific phobias
-​ Specific phobias are characterized by unrealistic and unreasonable fear related to a
specific object or situation
-​ Exposure to phobic stimulus provokes an immediate anxiety response which may
take form of a panic attack
-​ Examples of specific phobias are acrophobia, hematophobia, claustrophobia,
zoophobia etc

Agoraphobia
-​ Agoraphobia can be defined as a fear of being at places or situations where rapid
exit is not possible or it is difficult to obtain help.
-​ The person has a fear of being trapped and helplessness
This may include:
●​ Enclosed spaces ( movie theaters, elevators, stores)
●​ Open spaces ( parking lots, bridges)
●​ Public transport (bus, aeroplane, train)

Panic anxiety disorders

Panic
-​ A sudden uncontrolled fear or anxiety related to a perceived threat or danger usually
accompanied by behavioral cognitive and physiological signs
-​ Panic anxiety disorder is characterized by recurring, unexpected, intense fear that
brings on a panic attack
-​ Panic attacks begin abruptly, and reach a peak within about 10 minutes
-​ This panic attacks are accompanied by somatic symptoms and are usually short lived
(<1 hour)

Clinical features of panic anxiety disorders

Symptoms may include:
●​ Sweating
●​ Shortness of breath
●​ Chest pain
●​ Palpitations
●​ Trembling
●​ Sensation of choking or having heart attack
●​ Fear of dying
●​ Altered reality

Generalized anxiety disorder (GAD)

-​ Generalized anxiety disorder can be defined as a chronic persistent and realistic and
excessive worry or anxiety that interferes with daily activities.

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 -​ People with gad have persistent excessive at realistic worry associated with muscle
tension impaired concentration and insomnia.
-​ GAD is more common among women (widowed, divorce, unemployed, house
makers)

Clinical features of generalized anxiety disorder

●​ Muscle tension
●​ Restlessness and fatigue
●​ Insomnia
●​ Anxiety related to personal safety
●​ Trembling, sweating, palpitations
●​ Difficulty controlling worry
●​ Avoid activity and events that can bring negative outcomes
●​ Poor personal, social and occupational functioning

Medication induced anxiety disorder

-​ Medication induced anxiety disorder, use of certain medications or illegal drugs, or
withdrawal from certain drugs, can trigger some symptoms of anxiety disorder

Antidepressants
-​ Modern antidepressants (SSRI and SNRIs) are typically the first line treatment for
anxiety disorder.
-​ Examples of SSRI are escitalopram ( Lexapro) and fluoxetine (Prozac). SNRI include
duloxetine ( Cymbalta) and venlafaxine ( Effexor)
-​ Bupropion. This is another type of antidepressant commonly used to treat chronic
anxiety
Second line treatment
●​ Benzodiazepines. Benzodiazepines are sedatives that can help relax your muscles
and calm your mind. They work by increasing the effects of certain neurotransmitters.
●​ Examples are alprazolam (Xanax) and clonazepam ( Klonopin)
●​ Buspirone (BuSpar). This anti anxiety drug is used to treat both short term and
chronic anxiety
●​ Beta- blockers. Treat physical symptoms of anxieties such as a raising heart, severe
palpitations, trembling or shaking
●​ Anticonvulsants. Used to prevent seizures and also relieve certain anxiety disorder
symptom

Psychotherapy
Cognitive behavioral therapy (CBT)
-​ Cognitive behavior therapy is focused on turning the negative, orphanic causing
thoughts and behaviors into positive ones.
-​ The client is trained to carefully approach and manage careful or worry some
situations without anxiety

Behavior techniques
●​ Biofeedback
●​ Systematic desensitization (effective in phobias)
●​ Flooding

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Relaxation techniques
●​ Progressive muscle relaxation techniques
●​ Yoga
●​ Meditation
●​ Deep breathing exercise

Nursing diagnosis
1.​ Panic anxiety related to real or perceive threat passively evidence by restlessness
and poor impulse control
2.​ Ineffective coping related to lack of coping resources possibly evidence by ritualistic
behavior or inability to meet basic needs
3.​ Powerlessness related to fear of disapproval from others possibly evidence by
dependence on others and verbal expressions of having no control
4.​ Social isolation related to panic level of anxiety possibly evidence by withdrawn
behavior and insecurity in public
5.​ Deficient knowledge related to unfamiliarity with medications use and potential
adverse effects possibly evidenced by verbalising a deficiency in knowledge on skill
or request information.

NURSING MANAGEMENT FOR ANXIETY DISORDERS CONDITION

To reduce panic anxiety
●​ Stay with the patient and offer reassurance of safety and security
●​ Maintain a calm and non threatening approach
●​ Use simple words and brief messages, speak calmly and clearly to explain hospital
experiences
●​ Keep immediate surrounding low in stimuli
●​ Provide reassurance and comfort measures
●​ Encourage the client's participation in relaxation exercises such as deep breathing,
progressive muscle relaxation, guided imagery and meditation
To improve the coping abilities of client
●​ Talk with the patient about his or her anxious behavior and explore possible reasons
for occurrence
●​ Help the patient to recognize signs and symptoms of increasing anxiety and ways to
interrupt its progression
●​ Teach the client a step by step approach to solve problems i.e. identifying problems,
exploring alternatives, evaluating consequences of each alternative and making a
decision
●​ Encourage the patient to evaluate the success of choosing alternative and help the
patient to choose alternatives, if initial choice is not successful
●​ Give patient a positive feedback as patient learns to express emotions and problems
solving

To improve decision making abilities and problem solving skills

●​ Allow the patient to take as much responsibility as possible for self care practices
●​ Allow the patient to establish on schedule for self care activities
●​ Provide patient with privacy as needed
●​ Provide positive feedback for decisions made

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 ●​ Help the patient to identify areas of life situation that patient can control
●​ Help the patient to verbalize his or her feelings

MOOD DISORDERS
●​ Mood: prevailing internal emotional state
●​ Affect: external display of feelings
●​ Mood disorders are a category of illnesses that describe a serious change in mood

Classification of mood disorders:

Depressive (unipolar)
●​ Major Depressive Disorder
●​ Dysthymic Disorder
Bipolar
●​ Bipolar I
●​ Bipolar II
●​ Cyclothymic disorder

Etiology
Biological Factors
●​ More common in monozygotic twins
●​ Unipolar depressions in a parent
●​ Abnormalities in amine neurotransmitter
●​ Neuroendocrine abnormalities in hypothalamic pituitary adrenal (HPA) axis.
Psychological factors
●​ Major life events

17
 ●​ Interpersonal relations, absent or unsatisfactory significance special bonds have
negative effects on self regards
●​ Rapid hormonal changes
●​ Distorted thinking
●​ Lose hopefulness

Diagnosis
●​ Depressed mood
●​ Anhedonia- inability to feel pressure
●​ Guilt
●​ Sleep disturbances
●​ Appetite
●​ Energy
●​ Concentration
●​ Psychomotor
●​ Suicidality

Differential diagnosis
1.​ Other psychiatric disorders, sleep disturbances, and neurological disorders
2.​ Endocrine disorders: Addison's disease, Cushing's disease, Hyper/hypothyroidism,
Perimenstrual syndromes
3.​ Metabolic Disorders: Hypoglycemia, hypercalcemia, porphyria (hemoglobin
abnormally metabolized
4.​ Hematological Disorders: anemia
5.​ Inflammatory condition: SLE
6.​ Infections: syphilis, lyme disease, HIV encephalopathy
7.​ Medication related: anti hypertensive, steroids
8.​ Substance misuse: alcohol, benzodiazepines, opiates, marijuana, etc.

Management
Hospitalization if there is:
●​ Serious risk of suicide
●​ Serious risk of harm to others
●​ Significant self neglect
●​ Severe depressive symptoms
●​ Severe psychotic symptoms
●​ Lack of breakdown of social supports
●​ Initiation of ECT
●​ Treatment resistant depression
●​ I need to address comorbid conditions

TREATMENT
First line treatment: antidepressant
●​ Effective in 65 to 75% of patients
●​ Patient factor: age, sex, comorbid illness, previous response to antidepressants
●​ Symptomatology: sleep problem (sedative agents), lack of energy/hypersomnia
(adrenergic stimulatory agents), OCD symptoms (clomipramine), risk of suicide
(avoid TCA)

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Tricyclic antidepressants TCA
Action: reuptake inhibition of norepinephrine and serotonin, increasing both in synaptic cleft
●​ Examples:
○​ Imioramine ( Tofranil)
○​ Clomipramide (Anafranil)
○​ Amitriptyline (Tryptizol)
●​ TCA are cheap drugs but have many side effects.

SELECTIVE SEROTONIN REUPTAKE INHIBITORS SSRI

●​ Action: more selective inhibitory effect and reuptake of serotonin
●​ Lesser side effects than TCA
●​ Examples
○​ Fluoxetine (Prozac)
○​ Sertaline (Lustral)
○​ Paroxetine (Seroxat)
○​ Fluvoxamine (Faverin)

Second Line of Treatment

●​ When the first line treatment fail
●​ Unacceptable side effects from first line drugs
●​ Change of antidepressant to different class or the same class with different side
effects

Electroconvulsive therapy
-​ Maybe use when there are severe biological features ( significant weight loss or
reduce appetite) or marked psychomotor retardation

Dysthymic Disorder
●​ Mild, chronic depression for at least 2 years
●​ Common psychiatric comorbidities: major depression (up to 75%), “double
depression” anxiety disorders (up to 50%), personality disorders (20-40%)
somatoform disorders (2.8% - 45.2%), substance abuse (up to 50%)
●​ Difficult to diagnose due to soft mood symptoms, distracting comorbidities and lack of
patient recognition
●​ Treatment include psychotherapy mainly

Bipolar disorders
-​ Known as manic depressive illness
-​ A brain disorder
-​ Causes unusual shifts in mood energy activity levels in the ability to carry out day to
day tasks

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Symptom and Signs
Manic Episode
●​ Feel very “up “high” or elated
●​ A lot of energy
●​ Increase activity levels
●​ Trouble sleeping
●​ Talk really fast about a lot of different things
●​ Be agitated, irritable or touchy
●​ Feel like their thoughts are going very fast
●​ Think they can do a lot of things at once
●​ Do risky things like spend a lot of money or have reckless sex

Depressive Episode
●​ Very sad, down, empty, or hopeless
●​ Decrease activity levels
●​ Trouble sleeping, then may sleep too little or too much
●​ Feel like they can't enjoy anything
●​ Feel worried and empty
●​ Trouble concentrating
●​ Forget things a lot
●​ Eat too much or too little
●​ Feel tired or slow down
●​ Think about that or suicide

20
Lithium

21
 ●​ Level of lithium (0.5 to 1.5 meq/L)
●​ Increase urination (polyuria)
●​ Tremors- fine hand
●​ Hydration
●​ Increase peristalsis
●​ U2- 4 weeks effective
●​ Increase bowel movement
●​ Mouth is dry
○​ Assess function of kidney
○​ Toxicity: nausea and vomiting, diarrhea
Antidepressants
●​ SSRI
○​ Selective serotonin reuptake inhibitor
○​ Safest
○​ Side effects are low
○​ 1 to 4 weeks
○​ Prozac, paxil, zoloft, luvox

●​ TCA
○​ Tricyclic antidepressants
○​ 2-4 weeks
○​ Anticholinergic
○​ Amitriptyline, nortriptyline, doxepin, trimipramine, amoxapine, anafranil,
venlafaxine
●​ MAOI's
○​ Increase all neurotransmitters
○​ 2-6 weeks
○​ Hypertensive crisis
○​ Don't take:
■​ Avocado
■​ Aged cheese
■​ Beer/b6 thiamine
■​ Chocolate
■​ Fermented foods
■​ Soy sauce

Suicide
-​ The intentional act of killing oneself
-​ Suicidal ideation- means thinking about oneself
-​ Passive suicidal ideation- when a person thinks about one thing to die or wishes he
or she were dead but has no plans to cause his or her death
-​ Active suicidal ideation- when a person thinks about and seeks to commit suicide

Precipitating Factors
-​ Social isolation- have difficulty forming and maintaining relationships
Norman Cousins story:
A woman who committed suicide had written in her diary everyday during the week before
her death “nobody called today”, “nobody called today”

22
 -​ Severe life events- divorce, death, sickness, leg problems, interpersonal discord.
-​ Sensitivity to loss- may react tragically to separation or loss of a loved one

Assessing verbal and nonverbal clues

Verbal Clues
●​ Overt statements: “i can't take it anymore”
●​ Covert statement: “it's okay now, soon everything will be fine”
Nonverbal Clues
●​ Behavioral clues: sudden behavioral changes especially when depression is lifting
and when the person has more energy available to carry out the plan
●​ Signs: giving away prized possessions, writing farewell notes, making out a wheel
and putting personal affairs in order
●​ Somatic clues: physiological complaints can mask psychological pain and
internalized stress
●​ Headaches, muscle aches, trouble sleeping, irregular bowel habits, unusual appetite
or weight loss
●​ Emotional clues
●​ Social withdrawal, feeling of hopelessness and helplessness, irritability and
complaints of exhaustion

Suicide precautions
●​ Execute a no suicide contract. The client informs the nurse when he or she has
suicidal ideations
●​ Ask direct questions. Find out if the person specific plan for suicide. Determine what
method
●​ Be alert for cries for suicide
●​ Provide a safe environment and protect client from self
●​ Encourage to vent feelings and thought
●​ Give emotional support
●​ Make the patient realize that the tendency to commit suicide is due to the disturbance
in the brain chemistry and is treatable once they know that an episode of suicidal
thinking will pass, baby likely not act on the impulse
●​ Provide structured scheduled and involved in activities with other to increase self
worth and divert attention
●​ On discharge: help patient create plan for life
●​ Always remember:
○​ That a suicidal person want to die only during the period of suicidal
crisis-during this time the person is ambivalent about living and dying
○​ Suicidal people gives warning
○​ Persons recovering from depression are high risk for 9 to 15 months after
recovery
○​ Suicidal people are extremely unhappy but not always mentally ill

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COGNITIVE DISORDERS

COGNITION
-​ information processing, This definition encompasses the acquisition of sensory
information, the storage, retrieval, and use of that information for making behavioral
decisions." (Rowe & Healy, 2014)

EXAMPLES
●​ Perception
●​ Attention
●​ Memory retrieval
●​ Problem solving
●​ Decision making
●​ Judgment formation
●​ Imagery visualization
●​ Language comprehension
●​ Inductive Reasoning
●​ Concept formation

COGNITIVE DISORDER
-​ Is a disruption or impairment in the higher- level functions of the brain.
-​ Devastating effects on the ability to function in daily life.
-​ Can cause people to forget the names of the family members, to be unable to
perform daily tasks, and to neglect personal hygiene.

PRIMARY CATEGORIES
*DELIRIUM
*DEMENTΙΑ
*AMNESTIC DISORDERS

Delirium
●​ Characterized by disturbance of consciousness and a change in cognition such as
impaired attention span and disturbances in consciousness that develop over a short
period of time.
●​ Classified as mild to severe.
●​ Sundowning

SYMPTOMS
●​ Difficulty with attention
●​ Easily distractible
●​ Disoriented
●​ May have sensory disturbances such as illusions, misinterpretations, or
hallucinations
●​ Can have sleep- wake cycle disturbances
●​ Changes in psychomotor activity
●​ May experience anxiety, fear, irritability, euphoria, or apathy

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TREATMENT
Primary treatment: identify any causal or contributing medical conditions.

NURSING MANAGEMENT
●​ Client's safety is a priority.
●​ Meet their physiologic and psychologic needs.
●​ Behavior, mood, and level of consciousness of these clients can fluctuate rapidly
throughout the day.

DEMENTIA
●​ A mental disorder that involves multiple cognitive deficits, primarily memory
impairment, and at least one of the following disturbances:
●​ Aphasia: deterioration of language function.
●​ Apraxia: inability to execute motor functions despite intact memory abilities.
●​ Agnosia: inability to recognize or name objects despite intact sensory abilities.
●​ Disturbance in executive functioning, which is the ability to think abstractly and to
plan, initiate, sequence, monitor, and stop complex behavior.

* Cognitive deficits must be sufficiently severe to impair social or occupational functioning

and must represent a decline from previous functioning.

* MEMORY IMPAIRMENT: the prominent early sign.

* Recent memory first before remote memory

Aphasia
●​ Usually begins with the inability to name familiar objects or people and then
progresses to speech that becomes vague or empty with excessive use of terms
such as "it" or "thing."

May exhibit:
●​ Echolalia: echoing what is heard
●​ Palilalia: repeating words or sounds over and over

Apraxia: May cause clients to lose the ability to perform routine self-care activities such as
dressing or cooking.

Agnosia: may be frustrating for clients.

Disturbances in executive functioning: evident due to inability to learn new material, solve
problems, or carry out daily activities.

Onset and Clinical Course

Mild: forgetfulness (hallmark of beginning, mild, dementia). It exceeds the normal,
occasional forgetfulness as part of the aging process.
●​ Difficulty finding words, frequently loses objects, and feels anxious about these
losses
●​ Occupational and social settings are less enjoyable, may avoid them

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Moderate: confusion is apparent, along with progressive memory loss.
●​ Can no longer perform complex tasks but remains oriented to person and place.
●​ Still recognizes familiar people.
●​ Toward the end of the stage, the person loses the ability to live independently and
requires assistance because of disorientation to time and loss of information such as
address.

Severe: personality and emotional changes.

●​ May be delusional, wander at night, forget the name of his spouse and children, and
require assistance in ADLs.
●​ Usually live in nursing facilities when they reach this stage.

Most common types of dementia

Alzheimer's disease
●​ Progressive brain disorder that has a gradual onset but causes an increasing decline
of functioning, including loss of speech, loss of motor function, and profound
personality and behavioral changes such as paranoia, delusions, hallucinations,
inattention to hygiene, and belligerence.
●​ Evidenced by: atrophy of cerebral neurons, senile plaque deposits, and enlargement
of the third and fourth ventricles of the brain.

Head Trauma
●​ Dementia can be a direct pathophysiologic consequence.
●​ Degree and type of cognitive impairment and behavioral disturbance depend on the
location and extent of the brain injury.
●​ When it occurs as a single injury, the dementia is usually stable rather than
progressive. Repeated head injury may lead to progressive dementia.

Huntington's Disease
●​ An inherited, dominant gene disease that primarily involves cerebral atrophy,
demyelination, and enlargement of brain ventricles.
●​ Initially, there are choreiform movements that are continuous during waking hours
and involve facial contortions, twisting, and turning, and tongue movements.

Parkinson's disease
●​ Slowly, more progressive condition characterized by tremor, rigidity, bradykinesia,
and postural instability.
●​ Results from loss of neurons of the basal ganglia.
●​ 20%-60% has dementia

Delirium Vs Dementia
Delirium
Onset: Usually sudden
Course: Usually brief with return to usual level of functioning
Age group: any

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Dementia
Onset: Usually gradual
Course: Usually long-term and progressive, occasionally maybe arrested or reversed
Age group: elderly

Nursing Interventions
Promoting patient's safety and protecting from injury.
●​ Offer unobtrusive assistance with or supervision of cooking, bathing, or self-care
activities.
●​ Identify environmental triggers to help clients avoid them.

Promoting adequate sleep, proper nutrition, hygiene and activity.

●​ Prepare desirable foods and foods clients can self- feed; sit with client while eating.
●​ Monitor bowel elimination patterns; interfere with fluids and fiber or prompts.
●​ Remind clients to urinate; provide pads or diapers as needed, checking and changing
them frequently to avoid infection, skin irritation, unpleasant odors.
●​ Encourage mild activity such as walking.

Providing emotional support.

●​ Be kind, respectful, calm and reassuring; pay attention to the client.

Structuring environment and routine.

●​ Encourage clients to follow a regular routine and habits of bathing and dressing
rather than imposing on new ones.
●​ Monitor the amount of environmental stimulation, and adjust when needed.

Promoting interaction and involvement

●​ Plan activities geared towards client's interests and activities
●​ Reminisce with client about the past
●​ If the client is nonverbal, remain alert to nonverbal behavior.
●​ Employ techniques of distraction, time away, going along, or reframing to calm clients
who are agitated, suspicious, or confused.

EATING DISORDERS
-​ Eating disorders are mental illnesses that cause serious
disturbances in a person's everyday diet.
-​ It can manifest as eating extremely small amounts of food or
severely overeating.
-​ The condition may begin as just eating too little or too much but
obsession with eating and food takes over the life of a person
leading to severe changes.

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TYPES OF EATING DISORDERS
●​ Anorexia Nervosa
●​ Bulimia Nervosa
●​ Binge Eating Disorder
●​ Not Otherwise Specified (NOS)

ANOREXIA NERVOSA
-​ Anorexia nervosa happens when one is obsessed with becoming
thin that they reach extreme measures and this leads to extreme
weight loss.

Etiology
●​ A specific cause for eating disorders is unknown. Initially dieting
may be the stimulus that leads to their development. Biologic
vulnerability, developmental Problems and family and social
influences can turn dieting into an eating disorder.
●​ Disturbance in hypothalamus
●​ Many neurochemical changes accompany eating disorders, but it
is difficult to tell whether they cause or result from eating disorders.

Sign and symptoms

●​ Dramatic weight loss
●​ Refusal to eat certain foods or food categories.
●​ Consistent excuses to avoid situations involving food
●​ Excessive and rigid exercise routine
●​ Withdrawal from usual friends/relatives
●​ Involves extreme weight loss at least 15 per cent below the
individual's body weight.

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Diagnostic findings
●​ History collection
●​ Physical examination
●​ Complete blood count
●​ Liver profile
●​ Electrolytes
●​ Blood glucose levels
●​ ECG

Complications
●​ Increased susceptibility to infection
●​ Hypoalbuminemia
●​ Chronic inflammatory bowel disease
●​ Esophageal erosion, ulcers, bleeding, dental caries (due to
frequent vomiting)
●​ Cardiovascular issues
●​ Amenorrhea

Medical management
-​ Medical management focuses on weight restoration, nutritional
rehabilitation and correction of electrolyte imbalances.

Pharmacotherapy
●​ Neuroleptics
●​ Appetite stimulants
●​ Antidepressants

Psychological therapies
●​ Individual psychotherapy
●​ Behavioral therapy
●​ cognitive behavior therapy
●​ Family therapy

Nursing interventions
●​ Maintain strict intake and output chart
●​ Monitor status of skin and oral mucous membranes

29
 ●​ Short term management is focused on ensuring weight gain and
correcting nutritional deficiencies.
●​ Eating must be supervised by the nurse and a balanced diet of at
least 3000 calories should be provided in 24 hours
●​ Monitor electrolyte levels.
●​ Weight should be checked regularly
●​ Control vomiting by making the bathroom inaccessible for at least
2 hours after food.
●​ In extreme cases when a patient refuses to eat and comply with
the treatment, gavage feedings may need to be instituted.
●​ Encourage families to participate in education regarding the
connection between family processes and the patient's disorder.

BULIMIA NERVOSA
-​ Bulimia nervosa is characterized by episodes of binge eating
followed by feelings of guilt, humiliation and self-condemnation.
-​ Clients with bulimia nervosa report dissatisfaction with their bodies,
as well as they believe that they are fat, unattractive and
undesirable.

Etiology
●​ Family history of mood or anxiety disorders (e.g,
obsessive-compulsive disorder) places a person at risk for an
eating disorder.
●​ Altered serotonin levels in brain
●​ Society's emphasis on appearance and thinness
●​ Sexual abuse
●​ Struggle for control or self-identity
●​ Learned maladaptive behavior

Clinical features
●​ Heartburn
●​ Persistent sore throat
●​ Callused or scarring on back of hands and knuckles.
●​ Tooth staining or discoloration
●​ Loss of dental enamel

30
 ●​ Increased dental caries
●​ Normal or slightly overweight appearance.
●​ Epigastric or abdominal pain
●​ Amenorrhea
●​ Fluid and electrolyte imbalance
●​ Poor impulse control
●​ Low tolerance for frustration
●​ Excessive exercise regimen
●​ Withdrawal from friends.

Diagnostic findings
●​ History collection
●​ Physical examination
●​ Psychological evaluation and beck depression inventory
●​ Blood investigations (Electrolytes, blood glucose)
●​ ECG
●​ Medical evaluation to rule out Gastrointestinal disorder.

Medical management
●​ Psychotherapy
●​ SSRI’s
●​ Cognitive behavioral therapy
●​ Most clients with bulimia are treated on an outpatient basis.
Hospital admission is indicated if binging and purging behaviours
are out of control and the client's medical status is compromised.

Complications
●​ Dehydration or electrolyte imbalances
●​ Chronic, irregular bowel movements
●​ Constipation
●​ Increased risk of suicide
●​ Gastric rupture during periods of binge eating
●​ Dental caries and gum infections.

Nursing care
●​ Encourage patient to recognize and verbalize her feelings about
her eating behavior

31
 ●​ Provide assertiveness training
●​ Explain risks of emetic, laxative and diuretic abuse
●​ Set a time limit for each meal.

KEY POINTS

Anorexia nervosa is a life-threatening eating disorder characterized by

body weight less than 85% of normal, an intense fear of being fat and
refusal to eat or binge eating and purging.

Bulimia nervosa is an eating disorder that involves recurrent episodes

of binge eating and compensatory behaviour such as purging, use of
laxatives and diuretics or excessive exercise.

Severely malnourished clients with anorexia nervosa may require

intensive medical treatment to restore homeostasis before psychiatric
treatment can begin.

CHILDHOOD AND ADOLESCENCE DISORDERS

MENTAL RETARDATION
●​ below 70: Significantly below average intelligence
●​ Adaptive functioning deficits: Challenges in communication, self-care, home living,
social skills, community use, self-direction, academics, work, leisure, health, and
safety

Classification of mental retardation

●​ MILD - 50-70: educable
●​ MODERATE - 35-50: trainable
●​ SEVERE - 20-35: dependable
●​ PROFOUND - <20: life support

Chronic condition
●​ Prognosis varies by IQ and severity
●​ More common in males (1.6:1), except severe cases
●​ Causes: genetic disorders (e.g., Down syndrome), environmental factors (such as
neglect or abuse), prenatal issues (like maternal illness, alcohol, drugs, poor
nutrition), postnatal problems (including malnutrition, infections, head injuries)
●​ Treatment: behavioral therapy (e.g., social skills training), communication therapy
(e.g., speech therapy), supported living, job coaching, mainstreaming in schools

32
LEARNING DISORDER

●​ More common in Black children (higher diagnosis rates)

●​ Negative effects: poor school experience (e.g., frustration, low grades), dropouts,
fewer job opportunities, and lower career goals
●​ Causes: genetics (family history) and brain differences (structure and function)
●​ Treatment: educational support targeting processing (e.g., memory exercises),
thinking (e.g., problem-solving), and behavior skills (e.g., focus training)

TIC DISORDER
- are neurological conditions marked by sudden, repetitive, nonrhythmic movements or
vocalizations called tics. These can range from simple motor tics, like eye blinking or
shoulder shrugging, to complex vocal tics involving words or phrases.

TYPES
1.​ Motor tics = Involuntary movements
●​ Cause = Contraction of muscles
●​ (A) Simple Motor tics = head shaking, eye blinking,
●​ sniffing, shoulder shrugging,grimace
●​ (B) Complex motor tics = head banging, lip biting, gesture
2. Vocal tics = Clearing the throat humming
●​ (A) Simple vocal tics = coughing, barking, throat clearing.
●​ (B) Complex vocal tics = Echolalia,coprolalia(abuse language use)

MANAGEMENT
1.​ Drug therapy
●​ Haloperidol 0.5-6mg(antipsychotic drug)
●​ Pimozide 1-10mg
●​ Clonidine 0.05-0.25mg
2.​ Behavioral therapy

33
 3.​ Individual and family counseling therapy

ADHD
ADHD includes two main syndromes:
●​ In attention and hyperactivity-impulsivity
●​ Syndromes can occur separately or together often with overlapping symptoms
●​ Symptoms start before age 7
●​ Symptoms can cause impairment in two or more settings

Inattention: 6+ symptoms must persist for 6+ months

●​ Frequently misses details and makes careless mistakes
●​ Struggles to maintain attention on tasks
●​ Often appears not to listen when spoken to directly
●​ Commonly fails to follow instructions
●​ Regularly does not complete school work, chores, or duties
●​ Has trouble organizing tasks and activities
●​ Avoids or dislikes task needing sustained mental effort
●​ Often loses necessary items
●​ Easily distracted by unrelated stimuli
●​ Forgetful in daily routines

Hyperactivity
●​ Fidgets or squirms in seat
●​ Difficulty staying seated
●​ Excessive running, climbing, or restlessness
●​ Trouble playing quietly
●​ Acts “driven by a motor”
●​ Tox excessively

Impulsivity
●​ Blurted out answers
●​ Impatience, difficulty waiting turn
●​ Interrupts or intrudes on others

Subtypes of ADHD
●​ Predominantly inattentive
●​ Predominantly hyperactive-impulse
●​ Combined
Typical Onset: Between 3 and 4 years old
●​ Persistence: 68% continue to have symptoms into adulthood; inattentive subtype is
more common in adolescents and adults
●​ Gender difference: male to female ratios range from 2:1 to 9:1; combined and
hyperactive types are more frequent in males
●​ Prevalence: affects 3-7% percent of school age children

ADHD: Associated Features

●​ Academic deficits and school related problems

34
 ●​ Peer rejection and low self esteem
●​ Low frustration tolerance and frequent tantrums
●​ Mood swings, bossiness and stubbornness
●​ Increase risk of accidents
●​ Driving difficulties, including speeding and accidents

ADHD: Contributing Factors

●​ Genetics: higher ADHD and psychopathology rates in families
●​ Prenatal factors: low oxygen, drug exposure, maternal smoking
●​ Neurotransmitters: low dopamine; norepinephrine, serotonin, GABA also involved
●​ Brain abnormalities: smaller frontal cortex, basal ganglia, cerebellar vermis
●​ Exposure to toxins: allergens, food additives
●​ Parenting: negative control attempts; overbearing behavior

Treatments
●​ Medications
○​ Ritalin- stimulant
○​ Wellbutrin- to help manage symptoms.
●​ Psycho education and reading materials- (bibliotherapy) can help you understand the
condition better
●​ Building skills: training and things like managing your time, staying organised,
studying effectively, solving problems, and improving social skills can make a big
difference.

Conduct Disorder
-​ Involves a repetitive, persistent pattern of behavior or violating others rights or major
societal norms.
-​ Diagnosis requires at least 3 of the following behaviors in the past 12 months, with at
least one present in the past 6 months:
a.​ Aggression toward people or animals
b.​ Destruction of property
c.​ Deceitfulness or theft
d.​ Serious rule violations

Aggression toward people or animals

●​ Bullying, threats, intimidation
●​ Physical fights
●​ Use of weapons
●​ Physical cruelty to people
●​ Physical cruelty to animals
●​ Mugging, purse snatching, extortion armed robbery

Destruction of property
●​ Deliberate fire setting
●​ Deliberate destruction of others property

Deceitfulness or theft
●​ Breaking and entering

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 ●​ Lying: conning
●​ Stealing; shoplifting; forgery

Serious violations of rules

●​ Breaking curfew prior to age 13
●​ School truancy prior to age 13
●​ Running away from home

Subtypes of Conduct Disorders

●​ Childhood onset: at least one symptom before age 10
●​ Adolescent onset: no symptoms before age 10
●​ Unspecified onset: age of onset unknown

Specifiers
●​ Mild: few conduct problems beyond diagnosis criteria; minor harm caused
●​ Moderate: intermediate number of problems and impact
●​ Severe: many problems behind diagnosis criteria; considerable harm caused

●​ Causes: genetics, low arousal, low serotonin, brain issues

●​ Prevalence: 2 to 9% general population; 33 to 50% of child mental health cases; 87
to 91% of juvenile inmates
●​ Mostly males
●​ Onset: starts as early as preschool
●​ Prognosis: poor; 2/3 develop anti-social personality disorder
●​ Treatment: parent training, community programs (group homes, wilderness, boarding
schools), CBT (social skills, problem, thinking skills)

Autism
-​ Autism spectrum disorder are a group of disorders with common disabilities in three
key areas
-​ Social awareness and interaction
-​ Language and other communication skills
-​ Imaginative play
-​ Autism consists of disorders of development of brain functions
-​ Causes are not yet known for sure

Labels of autism
Autistic savants: distinctive abilities in art music mathematics or memory. 1% in the whole
population
Asperger's syndrome: seven times as many people as classic autism; average to higher iq
Pervasive Developmental Disorder (PDD)
Classic Autism and Kanner Autism
-​ Two-thirds of classic autism: severely to mildly handicapped in cognition and intellect
-​ Classic Autism: four times more common in boys than in girls

Causes of Autism
●​ Unknown Theories

36
 ○​ Postnatal environment: allergies, and exposure of children to drugs, vaccines,
infection, certain foods
○​ Lack of vit D
○​ Refrigerator mother
●​ Valid Theories
○​ Genetic Factors: the most significant cause
○​ Prenatal environment: age in either parent (m40+, f40+, m30); diabetes,
bleeding, and use of psychiatric drugs in the mother during pregnancy

Signs of Autism: Strengths

●​ Reading skills
●​ Exceptional balance
●​ Drawing skills
●​ Computer skills
●​ Exceptional memory
●​ Music skills

Signs of Autism: Weakness

●​ Social interaction
●​ Communication
●​ Bizarre behaviors
●​ Sensory issues
●​ Motor issues
●​ Self-injurious behaviors

When does autism appear ?

●​ Several symptoms appear by 18 months of age:
○​ Poor eye contact, trouble with pretend play and imitation, delayed
communication skills, joint attention
●​ Average age of diagnosis: about three years old
●​ Regression: stop using the language, play or social skills they had already learned;
usually between the first and second birthday

Treatment and Therapies

Disabilities are lifelong and there is no known cure
●​ Biomedical
○​ Medication
○​ Diets - gluten free
●​ Behavioral
○​ Applied behavior analysis
○​ Son-rise program
●​ Communication Therapies
○​ Sign language
○​ Facilitated communication (FC)
●​ Other therapies
○​ Music therapy
○​ Service dogs

37
 ●​ There's no medication to cure autism spectrum disorder, but some some medication
can help manage related symptoms like irritability, anxiety, hyperactivity, and
aggression
●​ ABA- develop new skills, improve communication, reduce challenging behavior, and
enhance social interactions
●​ Son-Rise- a child centered, home-based therapy

Temple Grandin (1947- )

●​ Diagnosed with autism (brain damage) in 1950
●​ Had supportive mentors from primary school onwards
●​ At age 4 began talking and making progress
●​ A nerdy kid when everyone teased; called tape recorder
●​ Bachelor's degree in psychology in 1970
●​ Master's degree in animal science in 1975
●​ Doctoral degree in animal science in 1989
●​ Professor at colorado state university
●​ Best selling author
●​ Widely noted for her work in autism advocacy
●​ Inventor of the hug machine

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