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Date posted: May 2, 2012

Dr Mansoor Ali 

CLASSIFICATION IN PSYCHIATRY 

A. ORGANIC PSYCHIATRIC DISORDERS
Delirium
Dementia
Amnesic disorder
Organic hallucinosis
Organic mood disorders
Organic anxiety disorders
Organic personality disorders

B. FUNCTIONAL PSYCHIATRIC DISORDERS
Psychotic disorders
Scizhhophrenia
Affective disorders
Others eg. Paranoid disorders
Neurotic disorders
Anxiety disorder
Phobic disorder
Obsessive compulsive disorder
Hysteria
Hypochondrias is
Neurotic depression
Other neurotic & stress related disorders
Personality disorders
Eg. Histerionic personality disorder
Psychosexual disorders
Gender identity disorder
Paraphilias
Psychosexual dysfunctions

C. DRUG & ALCOHOL USE DISORDERS
Abuse
Dependence
Intoxication
Withdrawal

D. PSYCHOSOMATIC DISORDERS
Bronchial asthma
Hyperventilation
Peptic ulceration

E. SLEEP DISORDERS
Dyssomnias
Parasomnias

F. CHILD PSYCHIATRIC DISORDERS
Autism
Developmental disorders
MR
Attention deficit disorder
Conduct disorder
Tic disorder
Enuresis & encopresis
Speech disorder

Other disorders

Psychosis
It is a condition characterized by an impairment of insight and reality with a marked effect on the personality and functioning of the individual.
40%in total
Features
Biological factors are more important than environmental factors in aetiology
Total disintegration of personality
There are gross disturbance of thinking, emotion & behavior
There is loss of insight and judgment
Therapeutic response is not remarkable
Organic, functional and symptomatic

Organic Psychosis
Result from organic damage of the brain tissue from primary brain disease or the brain may be secondarily involved from various diseases involving liver, kidney, endocrine gland etc.

Aetiology
Head injury, meningitis, encheohalitis,CVA ,Icsol, neurosyphilis, epilepsy
Cerebral malaria, drugs, anoxic state
Endocrine disease, renal disease, hepatic diseases
Senile artriosclerosis, presenile degeneration, avitaminosis
Clinical Features
Amnesia for recent events, while recalling of remote events till the advanced stage
Disorientation of time, person place & self
Loss of judgment
Dementia
Confabulation or story making
Circumstantialities or discussion beyond the present topic
Lack of attention
Loss of emotional control, easily provoked by anger or laughter
Instinctual anomalies
Hypochondrias is
Deterioration of personal care, social bandage & custom
Disorders of concisions of varying degree
Change in personality

Investigations
1.Routinely hepatic, cerebral, renal & endocrine disturbances
2. Psychologically
Bender gestalt test – Asked to copy 8
Verbal and non verbal intelligence test
Memory test by counting the digits

Treatment
Treat the underline cause
Fluid,electrolyte & acid base balance
Massive vitamin therapy
Antipsychotic drugs
ECT & rehabilitation

Organic functional
Having an organic disease
No organic disease
Disorientation of time place & person Not
Impaired consciousness Not
Visual hallucinations Auditory
Disturbed conceptual thinking Not so
Confabulation Not
Deteriorated personal & social habits Not so
Psychological tests +ve Negative
EEG show abnormality Usually normal

Functional psychosis
Scizophrenia
Dementia precox
A form of mental illness characterized by an abnormal emotional reaction associated with deterioration in personality

Aetiology
No definite
Genetic – 40% if both parents,   50% in monozygotic twins
Intra uterine brain damage
Increased dopamine activity
Dysfunction of limbic system of dominant hemisphere

Predisposing factors
Hereditary
In narrow typed physique ( athletes & displastic types)
In schizoid personality – are unsocial shy & oversensitive
Parent child relationship – broken homes etc.
Low socioeconomic classes
Extrinsic factors – physical illness, pregnancy, child birth, psychic upset etc.
Endocrine & metabolic disturbances
Influence of surroundings- poor housing condition, overcrowding etc.

Clinical features
15-35 age Females more
Withdrawal
Thought disorder – flight of ideas, poverty of ideas, meaningless talk
Emotional abnormalities – emotional flattering & incongruity rapid change of emotions
Change in behavior and motor function – awkward, abrupt, violent, repeat things said to him
Disorders of perception –  hallucination than illusion – auditory hallucination

Types of schizophrenia
1. SIMPLE
Gradual loss of interest in the surroundings
Withdraw himself from reality, fantasy

2. HEBEPHRENIC
Hallucinations & delusions prominent
Meaningless giggles & self satisfied smile

3. CATATONIC
In adults
Out burst of excitement, depression, stupor
Disturbance of behavior & motor phenomena
Homicidal & suicidal tendencies

4.PARANOID
Females
Late stage
Delusion of persecution
Hypochondriacally delusions
Well preserved personality

5.OTHERS
Schizoaffective – associated symptoms of mania & depression
Pseudo neurotic – features of neurotic illness like hysteria, phobic syndrome etc.
Periodic catatonia – a correlation between onset & metabolic disturbances
Late praphrenia – Females & widows
Delusion of persecution & hallucinations
Oneiroid schizophrenia – acute onset, clouding of consciousness, disorientation
Dream like state & perceptual disturbances.

Prognosis
15-20 % Complete recovery

Factors to be considered
Onset –a/c good prognosis
Type-Paranoid and Catatonic-good prognosis
Precipitating factor-bad
Age-early-bad
Personality-well adjusted and stable- good
Duration shorter good
Family history positive – bad
Personal relation ship – warm good
Home relation ship warm – good
Mood- disturbed – bad
Treatment prompt – good

Treatment
Drugs
Psychological treatment
Reassurance
Moral support
Good patient relation ship
Environmental and social background

Paranoid psychosis
Defined as
Gross impairment of reality thinking
Marked impairment in personality with impairment in social, interpersonal and occupational functioning
Marked impairment in judgment and behavior
Having delusions & hallucinations
Non organic – Schizophrenia & mood disorders
Organic _ paranoid disorders

Paranoid scizophrenia
Is characterized by
Delusions of persecution
Delusions of reference
Delusions of grandeur
Delusions of jealousy
Schneidors first rank symptoms.
Well systematized delusions
Apprehensive , evasive and guarded.
Onset insidious, progressive course, no recovery, remission and relapses.

Differential diagnosis
Paranoid disorder
Paranoid personality disorder.

Paranoid disorder (delusion disorder)
Persistent delusion of persecution, grandeur, jealousy, etc
Absence of significant or persistent hallucination.
Personality disorder only in areas of delusion.
No underlying cause.
Absence of schizophrenic and mood disorders.
Depending on the content of delusions.
1.Acute Paranoid disorder.
Having an acute onset and good prognosis,6 months duration.
Common etiology in abrupt change in environment.
2. Paranoia
A disorder with an insidious onset, stable and chronic course, characterized by well-systematized delusions.
Eccentrics, suspiciousness, reduced social interaction.
Disturbed in delusional areas, normal in other areas.
Well systematized delusions; no other thought disorder.
Hallucinations are uncommon; insight absent.
Contact with reality disturbed in delusional areas.
3. Shared paranoid disorder.
Transfer of delusions from one person to another who is usually depend on the first person and in highly suggestible. both having knit emotional bond, on separation they give up delusions.
4.Paranoid personality disorder.
Restrained social interaction, no deterioration of personality no thought disorder, or hallucination. Insight present. Contact with reality present.

Differential diagnosis.
Paranoid schizophrenia
mania
depression
personality disorder and
organic delusional disorder

Treatment
Drugs
Supportive psychotherapy.

Maniac depressive psychosis
An affective disorder
If the affect remain depressed or sad the resulting illness – MDP depression
If the affect remain happy or elated the resulting illness – MDP depression
Thus mania and depression are the two phases of MDP
Cyclic : When depression and mania alternate with symptom free interval
Circular : When one phase of depression directly leads to mania or vice versa

Etiology
A dominant inheritance
Having cycloid temperament – rapid change of mood without any cause
Jewish ,Females
Physical illness like arteriosclerosis ,head injury, neurosyphilis & hypothyroidism
May lead to depression
Drugs as reserpine
Deficiency of dopamines & amines as seratonine and residual sodium increase by 50%
MDP MANIA

Symptomatology
Elation
Well dressed, cheerful, entertaining and highly interfering
Having euphoria & excitement
Speech : Over talkative, coherent, rate of talk is high. Flight of ideas, grandious or persecutory delusions in talk
Disorders of perception _ illusion
Get up early, and engage in various unwanted activities which are left uncompleted
Unreasonably interfering with affairs of other people
Turn violent, aggressive, destructive and uncontrollable
Drug addiction and intoxication
Apparent impairment of memory, lack of insight & judgment

Diagnosis
From clinical features
Elation ,increased psychomotor activity
Presence of talk, flight of ideas & grandiose delusions
D/D
Schizophrenia
GPI
Phenobarbitone poisoning
Alcoholic excitement & delirium

Course
Self limiting course
Recurrence may occur

Treatment
Drugs
ECT

MDP depression
Symptoms are subjected to diurnal variations, being aggravation in the morning hours.

Features
Sad mood
Gloomy face, wrinkled forhead, drooping of eyelids, sagging angle of mouth
Speech is slow, low voice, delusion of guilt for imagined crimes & blames
Hopelessness and worthlessness’s uicidal ideas
Nihilistic and hypochondriacally delusions, depressive mutism
Auditory hallucinations, retarded motor activity, tend to stoop while walking
Self centered and left undisturbed
Ignore routine work due to feeling of general weakness
Depressive stupor later, pseudo dementia ( apparent impaired memory)

Somatic symptoms
Headache, chest pain , generalized ache
Giddiness, amenorrhoea, impotence
Anorexia, constipation, insomnia

Diagnosis
From clinical features
Depressed mood, retarded psychomotor activity
Pessimistic attitude, wirthleness, quilt
Suicidal tendencies, hypochondriasis
Masked depression – only somatic symptoms
D/D
Schizophrenia
Secondarydepression( due to atherosclerosis,gpi,hypothyroidism,vit-b12 deficiency )

Course
Risk of suicide is high

Treatment
Drugs
ECT

Psychoneurosis  

1.ANXIETY NEUROSIS
Commonest form of psychoneurosis characterized by lack of concentration, loss of interest and unforeseen fears due to the failure of adaptation to environmental stress.

AETIOLOGY
Genetic – family history
Learning theory – thought to be a fear response which by conditioning is attached to another impulse
Psychodynamic theory – stresses like familial ,personal or sexual
Emotional instability
Constitutional,enviromental or hereditary factors
Sexual background

CLINICAL FEATURES
Anxiety symptoms always dominate
Fear of body and mind, think that he may die or commit suicide
Insomnia, sleep disturbed by night terrors – an autonomic imbalance
GIT : Nausea, vomiting, hiccough, diarrhea, dysphagia, dry mouth

NERVOUS :
Twitching, terror. blurring of vision, giddiness, tinnitus
GENITOURINARY : Seminal emission, frequency of mictiuriation
CVS : Palpitation, low BP, precordial pain
Effort syndrome ( Dacosta syndrome) if the above seen in soldiers
RESP : Constriction chest, dyspnoea, hyperventilation syndrome, pain chest
OTHERS : Head ache, insomnia, fear of open place

PROGNOSIS : Good

TRETMENT
Psychotherapy
Drugs
Good food & poly vitamins
Change of place may be effective
Treat the cause

HYSTERIA
A condition of unconscious want of relief from intolerable stress characterized by clear cut physical signs and mental symptoms in absence of any pathological change in the body.

AETIOLOGY
Family history
Characteristic hysteric type personality
Mental stress
Constitutional factors

CLINICAL FEATURES
Aged.
Female more
a) Conversion hysteria (where patient present with same physical symptoms with or without sign)
b) Dissociative hysteria where different types or altered states of awareness are present due to dissociation between different mental activities
Neurological : Motor weakness with flaccidity
Limping gate, mute
Stock & glove type cutaneous sensibility
Hysterical blindness( 2 different type of field defect)
GIT : Vomiting with out prior nausea
Globus hystericus
Pseudocysis
Chronic abdominal pain
RESP : Hysterical hyperventilation
Hysterical aphonia
CVS : Palpitation & pericardial pain
OCCULAR : Blepharospasm
SKIN : Dermatitis artifact ( dermographism)artificial eruptions made by the patient
MENSTRUAL : Amenorrhoea or oligomenorrhoea
DISOCIATIVE HYSTERIA : Delirium or may talk nonsense

TREATMENT
Psychological
Drugs
Psychotherapy

OBSESSIVE COMPULSIVE NEUROSIS
These are thoughts and feelings which cannot be get rid of by voluntary effort because of their persistent recurrence in the mind against the will and the patient has insight of this abnormality.

AETIOLOGY
Constitutional factors
Hereditary influences
Physical factors-head injury,enchephalitis etc.
Psychological factors – conflict between moral standards & more primitive urges eg.sex
Rigid routine made by the parents

Clinical features
# . Anxious pre occupation with same obsessive facts
A) Obsess ional ideas
On religious or philosophical problem Eg. Existence of god
Patient have repetitive brooding on thought (obsess ional rumination)
Having obsess ional doubt – examine scrupulously every aspect of his action
B) Obsess ional impulse
Sexual – fear of pregnancy in females /impregnating women in males
Aggressive – connected with causing harm or injury to others
C) Obsess ional phobias
Repetitive irritable fears of closed or open spaces, sharp instruments etc.
Ultimately every sort of social binding at home
#. Morbid compulsion or compulsive acts
Checking doors and windows repeatedly before going to bed
Constantly washing hands on account of fear of contamination, washing clothes several times – Ritualistic behavior
Compulsive acts are so designed to allay anxiety
May compelled to touch or steal something

Prognosis
Poor if no affective disorder and sloe onset
When obsession as a part of depression – good

Treatment
Psychotherapy has no use
Reassurance,modelling
Behavior therapy
Keeping the patient engaged at work
Drugs

PSYCHOSOMATIC DISORDERS
These are disorders where the emotional and physical factors might have a cause and effect relationship in the aetiopathogenesis.
Are often precipitated by emotional upset or stressful period
CVS – Essential hypertension,IHD
RESP – asthma,vasomotor rhinitis
GIT – peptic ulcer,ulcerative colitis
Endocrine – Thyrotoxicosis,DM,DI
Loco motor – rheumatoid arthritis
Skin- urticaria,eczema
Reproductive–PMt,menopausal syndrome,amernorrhoea,dysmenorrhoea

TREATMENT
Assertion the factors responsible for precipitation
Each case should be judged by its independent merits
Advice to modify their attitude- tension & anxiety avoided
Discuss the problem of child freely with parents

PERSONALITY DISORDERS
Personality is a deeply ingrained behavior pattern which include modes of perception, relating to and thinking about oneself and the surrounding environment.
Having 3 clusters
Cluster A – Odd & eccentric
Cluster B – Dramatic, emotional & erratic
Cluster C – Anxious & fear full

PARANOID PERSONALITY DISORDER
Having
Persistent unwanted suspiciousness and mistrust of people
Restricted ability to have proper emotional response
Unusually critical of others, but sensitive to be criticized
Tense.garded,secretive hyper vigilant behavior
Marked difficulty in confiding others, developing intimacy and trusting others
Underlying defense mechanism is projection
D/D : Paranoid schizophrenia,paranoid disorders

TREATMENT
Individual psychotherapy
Supportive psychotherapy

SCZHOID PERSONALITY DISORDER
Having
Sustained social withdrawal
Marked indifference to social and interpersonal relationship, avoiding close friends
Constricted emotional response
Indifferent to praise and criticism
Excessive day dreaming and fantasy in life – a prominent feature
Cold and aloof with introverted temperament

TREATMENT
Psychotherapy
Psychoanalysis

SCHIZOTYPAL PERSONALITY DISORDER
Lies between schizoid and schizophrenia
Marked persistent disturbance in speech & thought
Behavior and general appearance
Social & interpersonal relationship
2. Having Social withdrawal
Odd speech pattern
Magical thinking / odd ideas – sixth sense
Perceptual abnormalities
Mannerism and mutterism of self
3.Transient psychotic episodes
4.Odd and eccentric

TREATMENT
Psychoanalysis
Psychotherapy
Drug therapy

ANTISOCIAL PERSONALITY DISORDERS
Having
Significant and persistent antisocial and irresponsible behavior begins in early child hood as conduct disorder
Antisocial acts which are unlawful
Poor work, financial and social record
Repeated lying, lack sincerity, impulsive behavior ,disregard foe safety of self
Lack of feeling for others, lack of guilty and remorse

TREATMENT
Psychoanalysis
Psychotherapy
Drug therapy

HISTERIONIC PERSONALITY DISORDERS
Having
Excessive and overly dramatic emotionality
Tantrums and anger outburst are common
Attention seeking attitude with constant need for praise and approval
Seek instant satisfaction and approval
Marked egocentricity, emotionally shallow
Exhibitionism like dressing flamboyantly, mannerism of speech and motor behavior
Look charming, beautiful and seductive
Un gratifying and stormy interpersonal relation ship

TREATMENT
Psychoanalysis
Psychotherapy (individual)

NARCISTIC PERSONALITY DISORDERS
Having
Ideas of grandiosity – self importance
Preoccupation with fantasies
Attention seeking dramatic behavior
Lack empathy, exploitative behavior
Underlying sense of inferiority
Depressed by minor events

TREATMENT
Individual psychotherapy

BORDERLINE PERSONALITY DISORDERS
Having
Significant and persistent disturbance of identity of self
Unstable and intense interpersonal relationship pattern
Impulsivity
unstable emotional response with rapid shift
Chronic feeling of emptiness or boredom with inability to stay alone
Deliberate self harm in the form of self mutilation
- include ambulatory and pseudoneurotic schizophrenia
Splitting is the defense mechanism

TREATMENT
Psychoanalytic psychotherapy
Supportive psychotherapy
Antidepressants

AOIDANT PERSONALITY DISORDER
Significant and persistent social withdrawal
Fear of criticism
Shyness and timidity
Hypersensitivity to rejection
Low self esteem
They don’t enter in to the interpersonal relationship

TREATMENT
Psychotherapy
Behavior therapy

DEPENDANT PERSONALITY DISORDER
Significant and persistent pattern of submissive & dependant behavior
Poor self esteem & lack of self confidence
Self doubt and inability to take decisions

TREATMENT
Individual and group therapy
Behavior therapy in the form of assertions

OBSESSIVE COMPULSIVE PERSONALITY DISORDER
Significant and persistent drive for perfectionism which is inflexible
Emotional constriction
Orderliness,stubbornness,preoccupation with rules
Moralistic attitude and judgment
Indecisiveness with postponement of decision making
Major depressive episodes are frequent
Reaction formation as defense mechanism

TREATMENT
Psychoanalysis
Group therapy

PASSIVE AGGRESSIVE PERSONALITY DISORDER
Significant and persistent passive resistant to demands for social and occupational performance
Stubboness,unjustified protest ,forgetfulness

TREATMENT
Supportive psychotherapy
Behavior therapy
Group & drug therapy

SADISTIC PERSONALITY DISORDER
Persistent significant pattern of cruel, demeaning and aggressive behavior directed towards others, in social and occupational relations ( Not only to sexual partner)

MASOCHIST PERSONALITY DISORDER
Persistent and significant pattern of self defeating behavior
A self defeating personality disorder

TREATMENT
Similar to passive aggressive personality disorder

DRUG DISORDERS
Acute intoxication
Withdrawal symptom
Dependence
Abuse

1.Acute intoxication
A transient condition following administration of a drug resulting in psycho physiological disturbances. High blood levels of drug. In idiosyncratic cases even low dose may lead to intoxication.

2.Withdrawal symptom
A cluster of symptom specific to that drug used, which develop on total or partial withdrawal of drug after repeated high doses. A short lasting syndrome with usual duration of few hours or days.

3.Drug dependence
When there is physical and psychic dependence which arouse by using drug on a periodic or continues basis.

Characterized by
Tolerance – need for the higher dose to achieve the same  result
Withdrawal syndrome
Persistent and strong desire to take the drug
Spending most of the time in a day around the drug
Impairment of social interpersonal and occupational relationship
Drug with intention of revealing or preventing withdrawal symptom when faced to leave the drug.
Either a psychic- tendency to increase the drug
Or physical – absence of physical symptom
Drug abuse
Having
Continued drug use despite awareness of harmful medical or social effect of the drug being used
A pattern of physically hazardous use of the drug

MAJOR DEPENDENCE PRODUCING DRUGS ARE
Alcohol,Opiods, Canabinoids
Coccane,Hallucinogens –LSD
Nicotine,Sedatives & hypnotics

REASON FOR DEPENDENCE
Surface theory of paten – to take the substance it will go a cope with neurotransmitter resulting in withdrawal symptom.
When neurotransmitters are blocked for along time, receptors become very sensitive, interaction very severe, enervation suspensibility.
Induction of enzyme

ALCOHOL

ACUTE INTOXICATION`
After a brief period of excitation, generalized CNS depression
With increasing intoxication there is increased reaction time, lowered thinking distractibility and poor motor control. Later dysarthria,ataxia and incordination,progressive loss of self control with frank disinherited behavior.
Pathological intoxication – when small dose produce intoxication

WITHDRAWAL SYNDROME
Common –hang over ,mild tremor,nausea,vomiting,weakness,iritabilty,insomnia and anxiety.
In severe cases

1.Delirium tremens
Is the most severe alcohol withdrawal syndrome ,2-4 days after complete abstinance,recovery with in 3-7 days.

Having  

Clouding of consciousness with disorientation in time and place
Poor attention span and distractibility
Visual hallucination and illusions
Marked autonomic disturbance with tachycardia,fever, sweating ,Ht,& pupilary dilatation.
Psychomotor agitation and ataxia
Insonia,dehydration with electrolyte imbalance .

2. Alcohol seizures ( Rum fit )
Generalized tonic clonic seizures occurs in 10% alcohol dependance,after 12-48 hours after a heavy bout of drinking. Seizures 2 –6 at a time, more common than single seizures- may status epileptics.

3. Alcohol hallucinosis
 Having hallucination during abstinences following regular alcohol intake, persist even after the withdrawal symptoms are over and occur in clear consciousness-recovery with in one month.

NEUROPSYCHIATRIC COMPLICATION OF ALCOHOL ABUSE
A) Wernicke’s encephalopathy
An acute reaction to severe thiamine deficiency ,onset occur after a period of persistent vomiting.
Ocular signs – Cornus nystagmus,opthlmoplegia with bilateral extensor rectos paralysis
Pupillary regularizes, retinal he and papilledema
Higher mental functions : disorentation,recent memory disturbances, poor attention span and distractibility.
Neuronaldegeneration,haemerrhage in thalamus,hypothalamus,mammilary bodies and midbrain.

B) Korkoff’s psychosis
Often follows Wernicke’s present as an amnesic syndrome,charescterised by gross memory disturbances with confabulation, impaired insight .
Most consistent change in the bilateral dorsomedial nuclei of thalamus and mammillary bodies.
The cause is severe untreated thiamine deficiency secondary to chronic alcohol abuse.

OTHERS
Marchifa –bignamitidis
Alcoholic dementia
Cerebellar degeneration
Peripheral neuropathy

TREATMENT
Rule out any physical or psychiatric disorder
Assessment of motivation, social support personality characteristics
Current and post social, interpersonal & occupational functioning
1) Detoxification
This is the treatment of alcohol withdrawal syndrome
Best way is stop suddenly
7-14 days uncomplicated withdrawal symptom
Aim of detoxification is symptomatic treatment of withdrawal symptoms.
Drugs
Vitamin B
Hospitalization if – signs of impeding delirium
Psychiatric symptoms or diseases
Physical illness
Inability to stop alcohol in the settings of home
2) Treatment of alcohol dependence
Behavior therapy,psychotherapy,group therapy and drugs

CHILD PSYCHIATRY

CLASSIFICATION
1 .Mental retardation
2 .Specific developmental disorders
3. Autism and other childhood psychosis
4. Attention deficit disorder
5.Conduct disorder Tic disorder
6.Enuresis & encopresis
7.Speech disorder
8.Habit disorder

MENTAL RETARDATION
1-2 % Of the population

Defined as
1. Significantly sub average general intellectual functioning (std deviation below mean IQ below 70)
2. significant deficit or impairment in adaptive functioning
3. which manifest during the developmental period ( before 18 years)
MR person vary in their,psychological,physical and social characteristics as normal population.
IQ =MA/CA X100
Mild MR 50-70
Moderate 35-50
Severe 20-35
Profound below 20

1. Mild MR
85-90 %
They can progress up to 6th standard and achieve vocational and social self suffering with little support. Only under stressful condition . supervised care is needed. -referred as educable

2.Moderate MR
10% -“trainable”
They drop out school after 2nd standard. Trained to support by performing semiskilled or unskilled work under supervision. A mild stress may de-stabilize them.

3. Severe MR.
Recognized in early life with poor motor development and absent or markedly delayed speech and other communication skills.
Can perform simple talks under close supervision. -dependent-

4. Profound MR.
1-2%
Associated physical disorders
Markedly delayed mile stones
Need naming care and support under planned environment.

Aetiology.
1. Genetic. 5%
1.Chromosomal- Down Syndrome
Turner’s Syndrome
Klinfelter’s Syndrome.
2. Inborn errors of metabolism
Phenylketonuria       -Goucher’s disease
Glycogen storage diseaes
Lesch –Nyhan Syndrome.
3. Single –gene disorders
Tuberous sclerosis
Neurofibromatosis
D.myotonia
4. Cranial anomalies
-Microcephaly.

2.Perinatal cause:
1.Infection- Rubella, Syphilis, Toxoplasmosis.
2.Prematurity
3.Birth trauma
4. Hypoxia
5. IUGR
6. Kernicterus
7. Placental abnormalities
8. Drugs during 1st trimester

3. Acquired physical disorders in childhood
Encepahlopathies
Cretinism, trauma
Lead poisoning
Cerebral palsy

4.Sociocultural causes
Deprivation of socio-cultural stimulation
5.Psychiatric disorders
Infantile autism
Childhood onset schizophrenia

DIAGNOSIS
History, General & neurological examinations
Mental status examinations
Investigations
Routine,Urine,EEG
Blood levels,
Chromosomal studies
CT scan
Thyroid function test
Liver function test
Psychological tests
Seguin form board test
Stanferd-binet test
Weschler intellegence scale for children
Bhala’s battery of perfomance test
For adaptive behavioir
Vinoland social maturity scale
Derner develop.screening
Gessell’s develop.scale

D/D
1) .Deaf and dumb
2) Deprived children with inadequate social stimulation
3) Isolated speech defect
4) Psychiatric disorders
1) Systemic disorders
2) Epilepsy

MANAGEMENT
A) PRIMARY PREVENTION
Improving socioeconomic status
Education of lay public
Medical measures for good prenatal medical care to prevent infection, trauma & malnutrition
Facilitating research activities to study MR
Genetic counseling in at risk

B) SECONDARY PREVENTION
Early detection & treatment of preventable disorders
Early detection of handicap in sensory, motor or behavoiur areas with early remedial measures.
Early treatment of correctable disorders
Early recognition of presence of MR

C) TERTIORY PREVENTION
Treatment of psychological & behavioral problems
Behaviour modification
Rehabilitation
Parental counseling
Institutionalization

SLEEP DISORDERS

A.DYSSOMNIAS
Insomnia
Hypersomnia
Disorders of sleep wake schedule

B. PARASOMNIAS
Stage 4 disorder
Other disorders

DYSSOMNIAS
Characterized by disturbance in the amount, quality or timing of sleep

1. INSOMNIA –DIMS
Difficulty in Initiating and Maintaining Sleep
Means – Difficulty in initiating sleep
- Difficulty in maintaining sleep,include frequent awakening at night & early morning awakening
- Non restorative sleep – feeling of not having rested

COMMON CAUSE
a) Medical illness
Any painful or uncomfortable illness
Old age, heart & respiratory disease, rheumatic complaint
Delerium,brain stem lesion
PMS- periodic movement in sleep

a) Alcohol and drug abuse
b) Psychiatric disorders
Mania,depression,anxiety disorder,stressful life situations
Restless leg syndrome
During waking an extremely uncomfortable feeling in the leg muscles.

TREATMENT
1. A thorough medical & psychiatric assessment
2. Treat underline physical or psychiatric disorder
3. Relaxation technique,psychotherapy,regular exercise

HYPERSOMINA
DOES- disorders of excessive somnolence
Having…
Excessive day time sleepiness
Sleep attacks during day time
Sleep drunkenness ( need much more time to awaken)

AETIOLOGY
A )Medical illness
Narcolepsy – excessive daytime sleepiness
Sleep apnea- repeated episodes of apnea during sleep
Klein Levin syndrome
Menstrual associated somnolence
Sleep deprivation
Head injury,hypothyroidism,cerebral tumors
Hypothalamic lesion
PMS
Trypnosomniasis

B) Alcohol and drug abuse
Stimulant withdrawal
Alcohol intoxication
CNS depressants

C)Psychiatric disorders
Neurotic depression
Atypical depression

D) Idiopathic  

PARASOMINAS
Having – stage 4 disorders
Sleep walking
Sleep terror
Night terror
Enuresis
Bruxism
Talking
Arousal is difficult and on waking complete amnesia of events – other disorders
Night mares- fearful dream occur most commonly in the last 1/3 of night sleep. Awake frightened and remember the events
Night terror – in early night 4 NREM
Complete amnesia
( In both case observer find the patient is frightened)

KLEINE LEVIN SYNDROME
Always
hypersomnia
hyperphagia
hyper sexuality
apathy, social withdrawal
delusions & hallucinations
mainly in males
having EEG abnormalities

TREATMENT
Thorough physical and psychiatric assessment
Treat the underline cause
Withdrawal of current medication

NACROLEPSY
A disorder characterized by excessive day time sleepiness, often disturbed nighttime sleep and disturbance in REM sleep.
Decreased REM latency – decreased latent period before the first REM period occurs.
Normal REM latency 90-100 minutes ,in this REM sleep occur within 10 mts of onset of sleep.

CLINICAL FEATURES
15-25 YEARS
1.Sleep attacks
Unable to resist a sleep attack or nap from which awaken  refreshed
Occur during day time
A gap of 2-3 hours between two attacks

2. Catalepsy
Loss of muscle tone in various parts of the body
Precipitated by sudden emotions
Clear consciousness with normal memory

3. Hypnogogic hallucinations
Dream like vivid perception with fearfulness occurs at the onset of sleep
Hypnopomic- when these occurs on awakening

4. Sleep paralysis
At onset of sleep or awakening in morning
Conscious but unable to move the body
Last for 30 seconds to few minutes

TREATMENT
Forced at nap at regular times in the day
Stimulant medication
Anti depressants

NORMAL SLEEP  

REM or active sleep
NREM or quit sleep
Onset of sleep in characterized by disappearance of alpha activity

NREM
4 stages
First and lightest sleep no alpha waves, low voltage activity
Sleep spindles-regular spindle shaped waves  K. complex- intermittently high voltage spike
High voltage delta waves
Predominant delta activity

REM
Alpha wave sleep,light sleep
Charecterised by return of alpha waves,other changes similar to 1st NREM sleep
Rapid eye movements,muscular atony
Penile erection,
Autonomic hyperactivity ( PR,RR,BP )
Movement of small muscle groups,arousal difficult
Occur 90 minutes of onset, can start as early as 7 minutes.
TIME periods
In 8 hour sleep 6-61/2 hour NREM,1-1/2 hour REM
0ut of 6-61/3 NREM only 70-80 mts – stage 4
maximum stage 4 in the one third of night.
REM max. at last one third of night
Occur regularly at every 90-100 minutes
1st REM last in less than 10 minutes
4-5 REM per night.

MANCHUHAUSEN SYNDROME ( Factitious disorder)
Hospital addiction,polysurgical condition, used for those patients who repeatedly simulate or fake disease for the sole purpose of obtaining medical attention. No other recognizable motive.
Pseudologia fantastica – patient distort their clinical histories, lab investigation reports and other aspect of their life.
They have a detailed superficial knowledge of medical terms and procedures
The patient is often manipulative, convicing liars and creating problems in IP and move out LAMA ( left against medical advice)
Early childhood is characterized by deprivation and neglect.
Probably they are masochist’s dependency from father figure- the physician
Attempt to maneuver over father figure and see the surgical procedure as partial suicide.

PHYSICIAN should…
Avoid the feeling of anger, hostility and ridicule which are aroused by discovery of factious illness.
Patient should not be confronted or labeled as liars, but psychiatric consultation
Avoid unnecessary surgical procedures.

PROGNOSIS
Poor
Treatment often unsuccessful

DHAT SYNDROME
A culture bound syndrome prevalent in Indian sub continent
Dhat urine passage
multiple somatic syndrome
anxiety or depression
asthenia
sexual dysfunction
Dhat is a white discharge passed in the urine and believed to be semen by the patient and think that loss of semen will lead to weakness and sexual dysfunction. Frequent masturbatory anxiety and over concern with nocturnal emission are associated.

TREATMENT
Counseling- removing the misconception regarding the semen loss
Sex education
Symptomatic treatment of depression, hypochondriasis & sexual dysfunction.

References
Nirja Ahuja A short text book of psychiatry
Krishna das Text book of medicine
Das P C : Text book of medicines
Kaplan : A comprehensive study on psychiatry
Mehta : Practice of medicine

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