Psychiatry

It is the branch of medicine which deals with the diagnosis, treatment and prevention of disorders
of the mind. It is also known as psychological medicine.

Classification of psychiatric disorders

Psychiatric disorders can be classified under the following classes.
1. Neurotic disorders
2. Psychotic disorders
3. Psychosomatic disorders
4. Personality disorders
5. Psychosexual disorders
6. Organic disorder
7. Drug dependence and alcoholism
8. Disorders of childhood
9. Mental retardation
1. Neurotic disorders
It is a group of mental disorders in which the patient remains in contact with reality. His
judgment and perception remains intact. However some known and unknown conflicts alter his
mood, feelings, wishes, preoccupations or acts.
i. Anxiety neurosis
ii. Depressive neurosis
iii. Phobic neurosis
iv. Hysterical neurosis
v. Obsessive compulsive neurosis
vi. Hypochondrial neurosis

2. Psychoti c disorders
It is a group of mental disorders in which there is marked disorganization of personality and
thinking. The patient loses his contact with reality and is withdrawn from his surroundings and
lives in his own world (Autism). His judgment can be defective too. The boundaries between self
and the outside world become slurred.
Psychosis may be of two types;
A): Organic psychotic disorders
B): Functional psychotic disorders
A): Organic psychotic disorders
They include
i. Acute (Delirium)
ii. Chronic (Dementia)
B): Functional psychotic disorders
This includes
a) Schizophrenia
b) Manic depressive psychosis
a): Schizophrenia includes
 Simple schizophrenia
 Paranoid schizophrenia
 Hebephrenic schizophrenia
 Catatonic schizophrenia
b): Manic depressive psychosis include
 Mania and hypomania
 Psychotic depression
 Melancholia
 Puerperal anxiety and depression
3. Psychosomatic disorders
Those disorders in which emotional factor play an important role in the causation of the
illness are known as psychosomatic disorders.
Psychosomatic disorders include
i. Asthma
ii. Hypertension
iii. Peptic ulcer
iv. Ulcerative colitis
v. Skin eruption
vi. Rheumatoid arthritis
vii. Sexual disorders
4. Personality disorders
Personality disorders are characterized by a set of inflexible, maladaptive personality traits
that keep a person from functioning properly in the society.
Personality disorders include
i. Paranoid personality disorder
ii. Schizoid personality disorder
iii. Schizotypal personality disorder
iv. Antisocial personality disorder
v. Borderline personality disorder
vi. Hysterical personality disorder
vii. Narcissistic personality disorder
viii. Avoidant personality disorder
ix. Dependant personality disorder
x. Obsessive compulsive personality disorder
5. Psychosexual disorders
Psychosexual disorders may be
b) Sexual dysfunctional disorders
c) Sexual deviation disorders
a): Sexual dysfunctional disorders
They include
 Impotence
 Frigidity
 Vaginism
b): Sexual deviation disorders
They include
 Homosexuality
 Lesbianism
 Exhibitionism
 Transvertion
  Voyeurism
6. Organic disorders
Disorders caused by a detectable physiological or structural change in an organ are known as
organic disorders.
Organic disorders include
a) Organic psychosis
b) Degenerative disorders
a): Organic psychosis
They include
 Infection
 Brain trauma
 Hyperpyrexia
 Carbon monoxide poisoning
 Vitamin deficiencies
 Diabetes
 Myxedema
 Hyperthyroidism b
b): Degenerative disorders
They include
 Senile dementia
 Presenile dementia
 Arteriosclerotic dementia
7. Drug dependence and alcoholism
Drug dependence is a state, psychic and sometimes also physical, characterized by the
compulsion to take the dru g on continuous or periodic basis in order to enjoy its psychic effects
and also to avoid the discomfort of its absence.
This includes dependence of
 Morphine
 Heroin
 Opium
  Cocaine
 Barbiturates
 Bhang
 Hashish
 Marijuana
 Diazepam
And alcohol.
8. Disorders of childhood
They include
 Neurotic disorders
 Psychotic disorders
 Behavior disorders
 Developmental disorders
 Problems due to cerebral dysfunction
9. Mental retardation
Impairment in intelligence from early life and inadequate mental development through out
the growth period is known as mental retardation.

TREATMENT METHODS IN PSYCHIATRY

In the management of psychiatric patients, one or more of the following methods are used
concurrently or successively.
A. Physical therapies
B. Drug therapy
C. Psychotherapy and case work
D. Other therapies
A. Physical therapies
 Physical therapies include
1. Convulsive therapy
2. Insulin therapy
3. Abreaction therapy

1. Convulsive therapy:

In this therapy generalized convulsions are produced in the patient with the help of chemicals
or electricity. In electro convulsive therapy (ECT) 90 or 120 volts of 50 cycle alternating current
is passed for 0.3-0.7 seconds through the electrodes which are applied bitemporally.

Indications of ECT:

ECT is indicated in case of

 Severe depression
 Psychomotor retardation
 Suicidal risk
 In elderly patients where medications are contraindicated
 Poor response to all the drugs
 Destructive and assaultive behavior

Contraindications of ECT:

The only absolute contraindication of ECT is a recent myocardial infarction. There are a few
relative contraindications i.e. conditions in the patient where ECT should be avoided in
preference to the other treatment but may be given when they fail to improve the patient.
i. Systemic diseases involving the heart, kidneys, lungs and other viscera
ii. First trimester of pregnancy
iii. Diseases of bones like osteomalacia, fractures etc.
Complications of ECT:

Complications include
1. Immediate complications
2. Delayed complications

1. Immediate complications:
Immediate complications after ECT include
 Body ache
 Headache
 Drowsiness
 Painful masticatory movements
 Abrasions on the lips
 Tongue bite
 Dislocation of joints like temporomandibular joint
 Fractures of bones like spine of the vertebra
 Confusion
 Excitement
 Dyspnea
 Apnea
 Cardiac irregularities including cardiac arrest
2. Delayed complications:
 Delayed complications of ECT include
 Amnesia of recent events
 Confusional psychosis
2. Insulin therapy:

In this therapy injections of plain insulin are given to the patient to produce
hypoglycemia of varying depth with the intention of achieving remission of symptoms.
3. Abreaction therapy:

In this therapy an abreaction i.e. heightened psychological and physiological reaction is

produced with the intention of helping the patient to discharge his pent out tension of the
unconscious mind. The patient relieves his psychologically traumatic and painful experiences in
the therapeutic situations, releases the associated emotional disturbances and conflicts and thus
drives benefits from the treatment in the form or symptom remission and correction of the basic
psychopathology.

Indications of abreaction therapy:

Indications include
i. Hysteria
ii. Anxiety
iii. Phobia
iv. Obsessive compulsive neurosis
v. Reactive and neurotic depression
vi. Alcoholism
vii. Drug addiction
viii. Sexual deviation
ix. Personality and character disorder

B. Drug therapy

Dugs used in drug therapy are:

1) Sedatives and hypnotics

2) Anxiolytic drugs
3) Central nervous system stimulant drugs
4) Antidepressant drugs
 5) Antipsychotic drugs
6) Antimanic drugs
7) Hallucinogenic drugs

1. Sedatives and hypnotics:

1) Aconitum ferox----- Mitha zahar

2) Amomum subulatum______Bari elaychi
3) Apoltaxis auriculata___________Kut
4) Aquilaria agallocha __________Agar
5) Artemisia absinthium___________Afsantin
6) Berberis aristata ____________Dar hald
7) Bombax malabaricum_________Senbhal
8) Calophyllum inophyllum_________Sultan champa
9) Camphora offcinarum_____________Kafoor
10) Cannabis sativa________________Bhang
11) Cedrus deodara______________Deodar
12) Cocculus indicus_____________Kakmari
13) Curcuma longa________________Haldi
14) Datura alba_____________ Safed dhatura
15) Datura fastuosa______________Kala dhatura
16) Datura metel ________________Tukhm-e-dhatura
17) Ellettaria cardamomum___________Elayechi khurd
18) Ferronia elephantum____________Kavitha
19) Foeniculum vulgare______________Saonf bari
20) Glycyrrhiza glabra_________________Mulethi
21) Hyoscymus niger_______________Ajwain khurasani
22) Lactuca scariola__________Kahu
23) Meconopsis aculeate__________Kanta
24) Melia azadirach________________Bakayin
25) Myrica sypida__________Kaiphal
26) Myristica fragrans___________Jaiphal
27) Myristica malabarica____________Ramphal
28) Nauclea cadamba____________Kadam
29) Nelumbium speciosum______________Kanwal
30) Nicotiana tabacum_____________Tambaku
31) Nymphaea lotus______Nelofar
32) Papaver somniferum___________Afiyun, Post khashkhash
33) Pistacia terebinthus_____________Pista villayeti
34) Santulum album_____________Sandal
35) Saraca indica_____________Ashok
36) Semecarpus anacardium______Bhilanwa
37) Shorea robusta_____Sal
38) Typha angustipholia_____________Pater
39) Valeriana wallichii______________Asarun
40) Withanai somnifera__________Asgand
41) Zingiber officinale_____________Adrak
42) ______________________Burg-e-koi
43) ______________________Muqul
44) _____________________Shelam
45) _________________________Shokran

2. Central nervous system stimulant drugs

1) Acidum arseniosum____Sammulfar
2) Aconitum ferox----- Mitha zahar
3) Aconitum heterophyllum_______________Vaj turki
4) Aleutites moluccana_______________Maghz akhrot
5) Atropa belladona______________Yabruj
6) Benincasa cerifera___________Maghz petha
7) Cannabis indica____Charas
8) Cannabis sativa________________Bhang
9) Canscora decussata___________Shankhaholi
10) Centipeda orbicularis_____________Nakchikni
11) Coffee arabica_____________Kafi
12) Corylus avellana________________Mughz findaq
13) Crocus sativus______________Zafran
14) Dalbergia sissoo__________________Shisham
15) Datura alba_____________ Safed dhatura
16) Datura fastuosa______________Kala dhatura
17) Delphinium danudatum_____________Jadwar
18) Emblica officinalalis_____________Murraba amla
19) Flacourtia cataphracta_____________Zarnab
20) Gymnema sylvestres________________Gurmar
21) Herpestis monniera___________Barhmi buti
22) Hyoscymus niger_______________Ajwain khurasani
23) Nardostachys jatamansi________Balchar
24) Nicotiana tabacum_____________Tambaku
25) Rauwolfia serpentina___________Asrol
26) Sida cordifolia______________Kheranti
27) Solanum nigrum_______________Mako
28) Strychnos ignatii_____________Vilaiti papita
29) Strychnos nux-vomica____________Kuchla
30) Withanai somnifera__________Asgand

3. Anticonvulsants

1) Allium cepa_____________Piyaz
2) Anacyclus pyrethrum___________Aqarqara
3) Barringtonia racemosa___________Samunderphal
4) Brassica nigra______ Safed rai
5) Butea monosperma__________Palas
6) Canscora decussta _____________Sankhavli
 7) Castoreum__________Jundbedaster
8) Centipeda orbicularis_____________Nakchikni
9) Colchicum luteum__________Suranjan talkh
10) Delphinium danudatum_____________Jadwar
11) Datura metel ________________Tukhm-e-dhatura
12) Ferula galbaniflua ____________Jawashir
13) Gossypium herbaccum___________Doda kapas
14) Hemisesmus indica________________Anantamul
15) Hyoscymus niger_______________Ajwain khurasani
16) Ipomoea hederacea____________Burg neel
17) Lavandula steochas_______________Ustukhuddus
18) Moringa oleifera_______________Sohanjna
19) Nardostachys jatamansi________Balchar
20) Paeonia emodi_________Ood salib
21) Sarpindus trifoliatus_Ritha
22) Saussurea lappa_________Qust
23) Sodii biboras______________Suhaga
24) Solanum xanthocarpum______________Khatai khurd
25) Trichosanthes anguina_________Chichinda
26) Valeriana hardwickii_______________Asarun
27) Punica granatum____________Gul anar
28) Semecarpus anacardium_______________Bhilwan sokhta
29) Quercus infectoria_____________Mazu
30) Tamarix articulate___________Main khurd
31) Tamarix gallica__________Main kalan
32) Terminalia chebula________________Halia zard

Indications of drug therapy:

Indications of drug therapy include;

 i. Alleviation of symptoms of psychiatric illnesses particularly of short duration
ii. Additional treatment in patients who are refractory or only particularly responding to
other forms of treatment
iii. Maintenance of improvement and social rehabilitation of the patients
iv. Prophylactic use in certain illnesses like mania

Contraindications of drug therapy:

No significant and serious side effects are observed during the use of these drugs and therefore
they are considered quite safe even for prolong use.

Certain precautions are recommended.

i. Avoid concurrent or successive use of tricyclic compounds and the MAO inhibitors
ii. Drug holidays for the schizophrenic patients ob high doses of phenothiazines to avoid
dermatological and ocular complications
iii. Avoid so far as possible all psychotropic drugs during the first trimester of pregnancy to
prevent fetal abnormalities
iv. Regular medical check ups and if necessary, routine laboratory investigations like
haemogram, urine analysis and liver function tests in patients who are on prolonged drug
therapy.

C. Psychotherapy
In this method of treatment, certain psychological processes are used to relieve the
patient’s symptoms, to correct the psychopathology and to modify his personality patterns.
Types of psychotherapy:

Psychotherapy is classified as;

1. According to the depth of probing in the unconscious mind

2. Number of patients treated in any one therapeutic session
3. Radical formulation used in psychotherapy e.g. psychoanalysis
1. According to the depth of probing in the unconscious mind

This includes
 Superficial or short term (Supportive psychotherapy)
 Deep or log term (Analytical psychotherapy)
 Educative (counseling) e.g. group discussion for
 Epileptics and their relatives
 Relatives of psychotic patients
 Parents of mentally defective children
 Parents of children with behavior problems
 Patients suffering from sexual complaints

2. Number of patients treated in any one therapeutic session

This includes;
 Individual psychotherapy
 Group psychotherapy
 Family therapy

Individual psychotherapy:

One therapist treats one patient in every session.

Group psychotherapy:

One therapist treats group of 10-12 patients in every session.

Family therapy:

The patient and his family is taken as a unit as the entire family is treated.
Phases in psychotherapy:

There are three phases in psychotherapy.

1) Ventilation
2) Interpretation
3) Re-education

1. Ventilation

The patient releases his emotional tension by talking about his life situations, his
conflicts, frustration, unhappiness etc

2. Interpretation

The patient understands the like between his symptoms and the repressed intrapsychic
conflicts.
`
3. Re-education

The patient learns the ways of solving his conflicts in a socially acceptable way and thus
prevents accumulation of tension in the unconscious mind.
These three phases do not follow in succession. They always occur concurrently.

Indications of psychotherapy:

These include,
 Psychotherapy is the treatment of first choice for neurotic illnesses like anxiety neurosis,
hysteria, phobia and obsessive compulsive neurosis.
 It is useful in psychosomatic illnesses.
 It is necessary for patients suffering from schizophrenia, depression, mania etc.
  It is necessary for patients suffering from schizophrenia, depression, mania and other
psychotic states after remission of acute symptoms to correct the psychopathology.
 It is also recommended in
 Alcoholism
 Drug addiction
 Sexual deviation
 Personality and character disorders

Contraindications of psychotherapy:

There is no unanimity of opinion regarding the contraindications of psychotherapy.

Taking into consideration the practical difficulties one encounters in psychotherapy, the
treatment should be withheld in psychotic patients with severe behavior disturbances like
excitement, assaultive and destructive behavior etc. In this group of patients psychotherapy
should be recommended after the patient had recovered from the acute and disturbing symptoms
to correct the psychopathology.
 Anxiety Disorders

Anxiety disorders are mental health conditions in which patients feel excessive anxiety,
fear or distress during situations in which most other people would not experience these
symptoms. People with these disorders may feel chronic, intense and irrational anxiety on a
regular or even daily basis. As a result, anxiety disorders seriously diminish quality of life,
hampering a person’s ability to work, travel or form and maintain interpersonal relationships.

Normally, anxiety is part of the body’s alarm system, alerting a person to danger or
providing an extra energy to help accomplish a task. However, some people experience anxiety
for no particular reason, or that is out of proportion with the actual threat that may be present.
Some of these individuals may have an anxiety disorder. Others may experience anxiety in
conjunction with another mental disorder, such as depression, or as a side effect of prescribed
medications.

Depression is often associated with anxiety disorders. Symptoms of depression include

feelings of sadness, hopelessness and low energy.

Despite the fact that many anxiety disorders are highly treatable, just one-third of those
who experience symptoms actually visit a physician. Patients who have previously undergone t
reatment for an anxiety disorder but did not find it effective should not be discouraged. Most
cases of anxiety disorder that do not respond to one form of treatment will respond to another. In
addition, new approaches are emerging all the time. Patients should tell their physician about
their previous treatment regimen (including types of medications or psychotherapy) and whether
or not it was effective.

Types and differences of anxiety disorders

There are five major categories of anxiety disorders. All share the quality of excessive and
irrational fear. The fear may be of a specific object or situation (e.g., spiders or public speaking),
or it may be generalized fear that the patient feels without being able to identify a specific source
of that fear. Although each anxiety disorder has its own distinct features, in all cases the patient’s
fear dramatically reduces productivity and/or significantly diminishes quality of life. The
categories include:

a. Generalized anxiety disorder

b. Obsessive-compulsive disorder

c. Panic disorder

d. Phobias

e. Post-traumatic stress disorder (PTSD)

a. Generalized anxiety disorder

It is diagnosed when a person worries excessively about all types of life issues, including
health, family, money and work, for six months or longer. Patients with this disorder may find
themselves unable to relax, even when there are no signs of trouble in their lives.

b. Obsessive-compulsive disorder

It is diagnosed when a person is helpless to control intrusive and unwanted thoughts

(obsessions) and/or to stop performing ritual actions (compulsions), such as counting, hand
washing or repetitively checking locks.

c. Panic disorder

It is diagnosed when a person regularly experiences panic attacks – sudden episodes of fear
and anxiety that usually last for between 10 and 30 minutes and cause symptoms such as racing
heartbeat, heavy sweating and shortness of breath. In some cases, panic disorder may be
accompanied by agoraphobia, a condition in which patients fear being caught in a place or
situation in which escape might be difficult, or being trapped in circumstances in which medical
help might not be available during a panic attack. In other cases, panic disorder actually causes
agoraphobia.

d. Phobias
 It is diagnosed when a person has extreme and irrational fears of something that in actuality
poses little or no threat. Social phobia (also known as social anxiety disorder) involves a fear of
being judged by others, whereas people with specific phobias suffer from intense fear of certain
objects (such as fear of snakes) or situations (such as fear of heights). Agoraphobia is a phobia
closely related to panic disorder (see above). People with phobias avoid objects or situations that
they view as threatening.

e. Post-traumatic stress disorder (PTSD)

It is diagnosed when a patient who has experienced a traumatic event such as war, rape,
child abuse or a natural disaster begins to have nightmares, flashbacks, depression or other
symptoms for more than a month. Stress disorders that occur within a month of the traumatic a

Other anxiety disorders are related to physiological changes that are induced by
substances (e.g., recreational drugs, alcohol, and caffeine) or a medical condition (such as
thyroid abnormalities). Some patients may have intense anxiety that does not fit the criteria for
any of the recognized anxiety disorders. In such cases, a diagnosis known as “anxiety disorder
not otherwise specified” may be made.

Risk factors and causes of anxiety disorders

The exact cause of most anxiety disorder is unknown. However, a combination of

psychological, biological and environmental factors may be responsible. Heredity is also
believed to play a role in many anxiety disorders. The combination of heredity and the anxiety
experienced may vary.

Research is ongoing into how the brain creates feelings of anxiety and fear. Scientists
believe that an almond-shaped structure called the amygdala serves as a central location that
coordinates messages between the parts of the brain that process incoming sensory signals and
the parts that interpret those signals. The amygdala signals the body when a threat is present,
triggering anxiety or fear.
 Another brain structure called the hippocampus also helps process threatening signals and
changes information into memories. Research shows that people who have experienced severe
stress (such as child abuse or combat experience) appear to have a smaller hippocampus.

Most anxiety disorders begin in childhood, adolescence or early adulthood. In many

cases, anxiety disorders affect women more often than men. However, in other disorders – such
as social anxiety disorder – the percentages are nearly equal.

Signs and symptoms of anxiety disorders

Symptoms related to anxiety disorder may differ slightly depending on the nature of the
disorder affecting a patient. For example, patients with panic disorder may experience panic
attacks that include rapid heartbeat, heavy sweating and shortness of breath. Meanwhile, patients
with obsessive-compulsive disorder may find themselves unable to stop thinking certain thoughts
or to stop performing rituals repetitively, to the point that the rituals become time-consuming.

Patients diagnosed with one form of anxiety disorder often are also diagnosed with a
second anxiety disorder. In addition, many patients with anxiety disorders also are diagnosed
with other mental health disorders, such as depression, eating disorders or substance abuse.

Some of the symptoms associated with major anxiety disorders are as follows:

Condition Symptoms

Panic disorder Recurrent episodes of panic attacks which feature rapid or pounding
heartbeat or palpitations, heavy sweating and shortness of breath

Phobias Extreme and irrational fears of something that in actuality poses little
or no threat.

Obsessive- Recurrent and persistent thoughts or impulses – examples include

compulsive excessive handwashing or checking repeatedly to make sure the
disorder stove is off
 Post-traumatic Flashbacks or nightmares, emotional numbness, headaches,
stress disorder dizziness, chest pain

Acute stress Anxiety, dissociation and other symptoms within a month of

disorder exposure to trauma

Generalized anxiety Excessive anxiety and worry, irritability, restlessness, fatigue,

disorder trembling

Diagnosis methods for anxiety disorders

In some cases, patients may be unaware that they have an anxiety disorder and will visit
a physician because of physical symptoms that they experience. For example, a patient with
panic disorder may visit a physician believing that symptoms such as chest discomfort, heart
palpitations and shortness of breath indicate a heart problem rather than an anxiety disorder.

In such cases, a physician will have to rule out the possibility of an underlying medical
illness such as heart disease before suspecting that an anxiety disorder may be causing physical
symptoms. Blood tests such as a complete blood count or tests such as an echocardiogram (an
image of the heart produced by ultrasound) may be used to rule out certain heart conditions.

In other cases, patients may not experience acute physical symptoms, but may instead
report feelings of unease or anxiety. These patients may find that anxiety is interfering with their
lives and that they require medical treatment to help alleviate the problem.

In most cases, a physician will perform a complete medical examination and compile a
thorough medical history. Once other conditions have been ruled out, the physician may
diagnose an anxiety disorder if certain criteria are present.

All anxiety disorders have their own, specific criteria as defined by the American Psychiatric
Association (APA). For example, panic disorder is diagnosed when the patient has recurrent,
unexpected panic attacks, and when for a month or more after at least one attack, the patient has
one or more of the following:

 Ongoing concern about future attacks

 Concerns about the significance of future attacks and their potential consequences
 Change in behavior to reduce the likelihood of future attacks

In addition, to diagnose a panic disorder, symptoms should not be caused by a general

medical condition or the use of substances, and cannot better be explained by another anxiety
disorder or other mental illness.

A patient who appears to have an anxiety disorder may be referred to a mental health
professional such as a psychiatrist to confirm diagnosis and treat the disorder. Experts in mental
health care can establish a diagnosis for one or more anxiety disorders or another mental illness
such as depression.

Treatment options for anxiety disorders

Patients diagnosed with anxiety disorder have a number of effective treatment options.
In many cases, a combination of psychotherapy and medications may be the best treatment. In
other cases, one form may be more beneficial than another. For example, certain phobias respond
only to psychotherapy. Medications include

 Antidepressant medications

 Anti-anxiety medications

 Beta-blocker medications

Many antidepressant medications are approved by the U.S. Food and Drug
Administration for the treatment of anxiety disorders. These drugs are usually effective, even in
patients who are not depressed. However, they sometimes take several weeks to become
effective, so patients should not become discouraged if they do not see immediate improvement.
 Patients should be aware that a physician may need to adjust the dosage or change
medications to achieve the best results with minimal side effects. In addition, the U.S. Food and
Drug Administration (FDA) has advised that antidepressants may increase the risk of suicidal
thinking in some patients and all people being treated with them should be monitored closely for
unusual changes in behavior. However, in most cases, the benefits of such medications outweigh
the potential risks.

Anti-anxiety medications may also be prescribed. They are generally used only for short
periods of time, because some patients may develop a tolerance to some of these drugs. This
means that over time, it takes increasing dosage levels to achieve the same effect from the drug,
which may lead to drug dependency. However, patients with panic disorder may take the drug
for as long as six months to a year.

Patients should not stop using antidepressant or anti-anxiety medications unless under
close supervision of a physician, because this may cause withdrawal symptoms.

Beta-blocker medications – which are typically used to treat heart conditions – are
effective in treating some anxiety disorders, particularly social phobia. Patients who experience
severe and disabling anxiety and are aware that they soon will be in an anxiety-provoking
situation – such as giving a speech – may be prescribed beta blockers to reduce symptoms such
as a pounding heart or trembling hands.

Psychotherapy is particularly effective for anxiety disorders such as social phobia and
panic disorder. It is likely to take the form of behavioral therapy and cognitive therapy, or a
combination of the two (cognitive-behavioral therapy). In behavioral therapy, the patient learns
to change specific actions and to use different techniques to stop harmful behavior. The patient
may learn relaxation techniques such as deep breathing and may be gradually exposed to
situations that are frightening and in which the patient can test new coping skills.

Cognitive therapy involves learning new skills to react differently to situations that
typically trigger anxiety. Patients also learn more about negative thought patterns that increase
anxiety and ways to redirect such thinking.
 Psychotherapy for those with anxiety disorders is likely to last around 12 weeks. It may
be conducted one-on-one or in a group setting. Patients also may be treated for other
psychological or physical conditions while they receive treatment for an anxiety disorder.

Prevention methods for anxiety disorders

Although anxiety disorder cannot be prevented, they can be more effectively managed
by taking steps that can reduce symptoms. Relaxation techniques such as meditation, muscle
relaxation, breathing techniques and guided imagery may help people with anxiety disorders feel
more relaxed.

Taking time to engage in leisure and recreational activities may help restore balance to
patients’ lives, leaving them less vulnerable to anxiety, stress and panic. Eating a healthy diet,
exercising and avoiding certain substances – such as some types of medications, caffeine,
amphetamines and marijuana – can reduce the likelihood of symptoms related to anxiety
disorders.

Support groups can also help patients relieve their anxiety. These are sessions in which
people with anxiety disorders share their own experiences and offer encouragement and
understanding to one another.
Phobias

Phobias are persistent, irrational fears of objects or situations that persist even though the
fear has no base in current reality.

People who have certain phobias go to great lengths to avoid the places or actions which
cause their feelings of fear and anxiety. For example, people who fear the ocean or speaking in
front of large audiences may be able to simply sidestep these fears by avoiding the situations that
cause problems.

Phobias are considered to be mental disorders when they become so uncontrollable that
they interfere with day-to-day life (including job duties and social interactions).

Phobias differ from simple fear or anxiety. For example, a student may have anxiety
about making a presentation in a school assembly. If the student has not prepared, anxiety about
failure or embarrassment is expected. A well-prepared student who still experiences an
unreasonable amount of anxiety may have a phobia about public speaking. In many cases, a
person with a phobia recognizes that the fear is unreasonable, but they remain afraid.

Phobias commonly begin in adolescence or early adulthood, although they may also
begin in childhood. Children with phobias may not recognize that their fear is unreasonable and
express the fear through crying, tantrums or clinging to adults.

Many people who have phobias leave them untreated. Instead, they avoid the anxiety-
producing situations, are unaware of their problem or are too embarrassed by it to seek help.
However, untreated phobias can be associated with significant mental health problems, including
depression and substance abuse. In their worst form, phobias can result in patients attempting
suicide.

Types of phobias

There are three major types of phobias. They include:

1. Specific phobias
 2. Social phobia

3. Agoraphobia

1. Specific phobias

Specific phobias are also known as simple phobias, they are diagnosed in people who
have phobias associated with specific objects or situations that do not possess intrinsic danger.
People who have this fear know that it is irrational, but feel powerless to control it. When faced
with one of these objects or situations, the person becomes nervous or panicky. This is known as
anticipatory anxiety. Patients may experience full-blown panic attacks - sudden episodes of
extreme fear and anxiety that usually last between 10 and 15 minutes and cause symptoms such
as racing heartbeat, heavy perspiration and shortness of breath- in some of these situations.
Specific phobia is divided into several subtypes:

a. Situational type
b. Natural environment type
c. Blood-injection-injury type
d. Animal type
e. Other type

a. Situational type

It includes fear of enclosed spaces (claustrophobia), flying, crossing bridges and public
transportation.

b. Natural environment type

It includes fear of thunderstorms, water and heights (acrophobia).

c. Blood-injection-injury type

It is the fear initiated by seeing blood or an injury or receiving an injection. It can cause a
vasovagal response, in which reduced heart rate and blood pressure cause a person to faint.
d. Animal type

It is the fear of certain animals or insects (e.g., cats, spiders). Commonly begins in
childhood.

e. Other type

It is the fear from other stimuli, including fear of choking, vomiting or loud sounds.

2. Social phobia

Social phobia is also known as social anxiety disorder; social phobia is diagnosed in
people who have extreme anxiety in certain social and public situations. Unlike shyness,
people with social phobia are often at ease with people most of the time, but experience
extreme discomfort in certain situations. As a result, they avoid these social situations.
Patients may worry for days or weeks in advance of a dreaded social situation.

People with social phobia exaggerate the impact of mistakes and feel that all eyes are on
them, watching to see them sweat, blush or otherwise show fear, and that others are ready to
pass judgment when they fail. Fear of speaking in public, dating or talking to people in
authority is hallmarks of this condition. Patients may also fear using public restrooms or
eating in front of others, or talking on the phone or writing while others watch. They tend to
believe that showing anxiety is a sign of weakness, and believe that other people are more
confident or competent than they really are.

Patients may find it difficult to make and maintain friends, and may avoid school, work
or other day-to-day situations. When they are in situations that provoke anxiety, they may
experience symptoms such as blushing, profuse sweating, trembling, muscle tension, nausea
and difficulty talking.

Feelings of inferiority and low self-esteem appear to be at the root of social phobia. Some
research indicates that social phobia has a genetic component, as the disorder is more
common in people who have first-degree relatives diagnosed with the phobia. The type of
 social phobia that a patient suffers from may depend on gender. For example, fear of
blushing is more prevalent among women than men. In other cases, fears may be based on
experience. Fear of eating in front of others is more likely in someone who has had a past
embarrassing episode while eating in public.

Social phobia is often associated symptom seen with other anxiety disorders and depression.
Many patients self-medicate by using drugs and alcohol, sometimes leading to substance
abuse problems.

3. Agoraphobia

Agoraphobia is diagnosed in people who fear being caught in a situation from which
escape might be difficult or embarrassing, or who fear being trapped in circumstances in which
medical help might not be available during an emergency (e.g., having a panic attack in a public
place). These people may seldom or never leave their home due to their fears.

Agoraphobia is closely linked with panic disorder, a type of anxiety disorder in which a
person regularly experiences panic attacks. In many cases, panic disorder is actually the cause of
agoraphobia. In other cases, people have agoraphobia without a history of panic disorder. These
people fear panic-related symptoms, but may not have had panic attacks or been diagnosed with
panic disorder.

Risk factors and causes of phobias

It is not well understood what causes specific phobias, although genetics appear to play a
role and scientists are working to identify which genes may affect anxiety and fearfulness. In
addition, environmental factors may play a role. For instance, children may learn certain phobias
from observing the reactions of their parents and others to certain stimuli – seeing parent recoil
from a snake is likely to give the child a fear of snakes.

Researchers also believe that biochemical factors may influence development of phobias.
A neurotransmitter called serotonin helps regulate mood and emotions, and it is believed that an
imbalance of this biochemical may help cause phobias.
 The structure of the brain may also be partly responsible for phobias. The amygdala,
which is located deep inside the brain, appears to be responsible for controlling the fear response.
People with an overactive amygdala may have heightened anxiety.

Certain phobias tend to occur more in one gender than another, and at different ages.
Both social phobia and specific phobias, for instance, tend to begin in childhood or adolescence.
Specific phobias are most likely to begin in childhood, around age 7, whereas the incidence of
social phobia peaks in the middle teens.

Women and men are equally likely to have social phobia. However, women are far more
likely than men to develop specific phobias.

Signs and symptoms of phobias

People who have phobias may experience a number of symptoms, including the following that
are common to all types of phobias:

 Persistent, irrational fear of an object, activity or situation

 Anxiety from mere anticipation of an encounter with a feared stimulus
 Physical symptoms such as sweating, rapid heartbeat, breathing difficulties and intense
anxiety (e.g., panic attack)
 Impaired ability to engage in normal tasks due to fear
 Inability to control fear despite knowledge that it is irrational or out of proportion with
the stimulus causing the fear
 Strong desire to avoid the source of fear, including taking unusual measures to keep away
from such objects, people or situations

Symptoms associated with specific phobias include

Condition Symptoms

Agoraphobia  Fear of being caught without a means to escape

 Agitation, short temper
  Feeling disconnected from others
 Confused thoughts
 Staying home to avoid feared situations

Specific phobia  Fear of clearly defined objects or situations

 Fear of losing control

Social phobia  Fear of social or performance situations

 Fear of embarrassment or being judged
 Blushing
 Poor social skills

Diagnosis of phobias

People who experience symptoms associated with phobias – such as anxiety and
persistent, irrational fears – may not be aware of the source of their problem. However, if these
feelings interfere with their daily lives or become debilitating, they should see a physician.

Before diagnosing a phobia, a physician may perform a complete physical examination

and compile a thorough medical history if the physician feels these steps are warranted. Patients
will be asked to describe their symptoms and to explain what triggers them and how often they
occur. The physician will also want to rule out other medical conditions that could be causing
symptoms, such as a heart problem, overactive thyroid gland or substance abuse problems.

In attempting to diagnose a phobia, a physician may ask questions of patients, such as:

 Do they feel intense fear in situations where they are unable to escape or unable to find
help?
 Does the thought of being exposed to certain objects or situations cause fear?
  Do they fear social or performance situations (such as public speaking) where they may
be judged?
 Do they avoid certain situations that seem to provoke anxiety?

All anxiety disorders have their own criteria as defined by the American Psychiatric Association
(APA) in the Diagnostic and Statistical Manual IV-TR (DSM-IV). Some criteria apply to all
phobias. For instance, a phobia is not diagnosed when there is another illness (medical or
emotional) causing the symptoms but is when the patient either avoids certain situations or
objects (to the point where the phobia interferes with normal living), or endures them with great
anxiety.

In addition, the patient will generally recognize that their reaction to a stimulus is unreasonable
or excessive.

Specific criteria for the three major phobias include the following:

Condition Criteria

Agoraphobia  Anxiety associated with being in places or situations where escape

may be difficult or embarrassing or in which help may not be
available if needed, resulting in reduction or elimination of leaving
the home

Specific  Persistent, excessive or unreasonable fear when exposed to or in

phobia anticipation of encountering a specific object or situation

 Exposure to the stimulus provokes immediate anxiety response

 In patients under age 18, duration of symptoms is at least six

 months

Social phobia  Marked, persistent fear of social or performance situations in which

a person is exposed to strangers or scrutiny by others

 Exposure to the stimulus provokes immediate anxiety response

 In patients under age 18, duration of symptoms is at least six

months

A patient who appears to have a phobia may be referred to a psychiatrist or other mental
health care professional who can help make a specific diagnosis and treat the condition. Patients
may be asked to fill out questionnaires or self-assessments that can help pinpoint a diagnosis. In
many cases, phobias are symptoms of other anxiety disorders or mental illnesses such as
depression, substance abuse or eating disorders

Treatment and prevention of phobias

Most people with phobias do not get better on their own and require treatment.
Psychotherapy is an effective way of treating most phobias. It is likely to focus on reducing
anxieties and fears and managing reactions to fear-inducing stimuli. Cognitive behavior therapy
is a common treatment for phobias.

Cognitive therapy involves learning new skills to react differently to situations that
typically trigger anxiety. Patients also learn about negative thought patterns that increase anxiety
and ways to redirect such thinking.

In the behavioral portion of therapy, the patient learns to change specific actions and to
use different techniques to stop harmful behavior. The patient may learn relaxation techniques
such as deep breathing and may be gradually exposed to situations that are frightening and in
which the patient can test new coping skills. This is known as exposure therapy. For example, a
person with fear of flying may first visit an airport. On a later visit, they will sit on an airplane
that does not leave. Eventually, the patient will take a flight.

In addition, medications may be prescribed to help reduce the anxiety that patients feel.
Antidepressant medications are usually effective in treating anxiety disorders, even in patients
who are not depressed. These drugs sometimes take several weeks to become effective, so
patients should not become discouraged if they do not see immediate improvement.

Anti-anxiety medications may also be prescribed. They are generally used only for short
periods of time to stabilize an acute situation because patients may develop a physical and
psychological dependence on them. Patients should not stop using anti-anxiety medications
unless under close supervision of a physician because this may cause withdrawal symptoms.

The use of both antidepressant and anti-anxiety medications should be closely monitored.
Patients should be aware that a physician may need to adjust the dosage or change medications to
achieve the best results with minimal side effects. In addition, the U.S. Food and Drug
Administration (FDA) has advised that antidepressants may increase the risk of suicidal thinking
in some patients, especially children and adolescents, and all people being treated with them
should be monitored closely for unusual changes in behavior.

Beta-blocker medications – which are typically used to treat heart conditions – are also
effective in treating some of the symptoms associated with phobias, particularly social phobia.
These medications work by blocking the stimulating effect of the hormone adrenaline. Patients
who know in advance that they soon will be in an anxiety-provoking situation – such as giving a
speech – may use beta blockers to reduce symptoms such as a pounding heart or trembling
hands.

Mood Disorders

A mood disorder is a mental health disorder with an abnormal mood as its primary
feature. “Mood” refers to the sustained feelings and emotions through which a person interprets
life. Most mood disorders are defined and diagnosed by the occurrence of one or more mood
episodes, or periods of abnormal happiness or sadness. Such episodes do not constitute a mood
disorder in themselves.

Episodes of abnormal happiness often indicate the presence of mania, which may be
accompanied by elevated feelings and self-esteem and abnormal and sometimes reckless
behavior. Episodes of abnormal sadness indicate a depressive disorder (e.g., major depression,
dysthymia, seasonal affective disorder) and involve lengthy periods of time where a patient is
sad, fatigued and has little interest in usual activities.

Mood disorders affect people of all ages, races and genders. Children with mood
disorders often display similar symptoms as adults, but they may not meet the full criteria for
diagnosis. Once believed to be rare in children, mood disorders, particularly depression, are now
known to be common even under the age of 12 years. Mood disorders seem to be occurring
earlier in life today than in previous years.

Suicide is a serious risk involved in mood disorders, especially among children and
adolescents. According to the National Alliance on Mental Illness (NAMI), about two-thirds of
all children and adolescents who commit suicide have a mood disorder.

Many mood disorders are associated with anxiety disorders and other mental illnesses.
This often results in misdiagnosis or under diagnosis, particularly among children with attention
deficit hyperactivity disorder (ADHD).

According to the National Institute of Mental Health (NIMH), in any given year, about
9.5 percent of American adults, or about 18.8 million people, have a mood disorder. Mood
disorders can occur in any race or social class. They generally affect women more often than
men.

Types and differences of mood disorder

There are many different types of mood disorders, most of which involve some episodes
of depression. To meet established criteria for a depressive mood disorder, episodes must not be
related to a general health condition or the use of a substance. There are three main groups of
mood disorders.

They include

1. Depressive mood disorders

2. Bipolar disorder

3. Other mood disorders

1. Depressive mood disorders

Depressive mood disorders include:

a. Major depression

b. Dysthymia

c. Seasonal affective disorder (SAD).

d. Postpartum depression (PPD).

e. Depressive disorder, not otherwise specified (NOS)

a. Major depression

One or more major depressive episodes occur in a patient with no history of any type of
manic episodes.

b. Dysthymia

Dysthymia is the depression that is not severe enough to fulfill the criteria for a major
depressive episode and lasts for at least two years. The patient must not have a history of manic
episodes.

c. Seasonal affective disorder (SAD)

 Seasonal affective disorder (SAD) Occurs when people become depressed during a
particular season (most often the winter).

d. Postpartum depression (PPD)

Postpartum depression is the type of depression that follows childbirth. Historically, PPD
has been diagnosed solely in women, but researchers now believe that men may be affected by
the condition as well.

e. Depressive disorder, not otherwise specified (NOS)

A patient with depressive symptoms that do not meet the criteria for any specific
depressive disorder may receive this diagnosis.

2. Bipolar disorders

Bipolar disorder is a mood disorder that includes at least one episode of abnormally high
mood, which cannot be attributed to a general medical condition or the use of a substance.

Types of bipolar disorder include:

a. Bipolar I disorder

b. Bipolar II disorder

c. Cyclothymia

d. Bipolar disorder, NOS

a. Bipolar I disorder

There is occurrence of at least one manic or mixed episode (includes both manic and
depressive elements at the same time), with or without episodes of major depression.

b. Bipolar II disorder
 There is occurrence of at least one episode of major depression and one episode of
hypomania (a milder form of mania). The patient must have never experienced a manic or mixed
episode. This disorder may develop into bipolar I disorder if a manic episode occurs.

c. Cyclothymia

Repeated mood swings with hypomania and lows in mood that do not meet the criteria
for major depressive episodes. This disorder is chronic and lasts for at least two years. It may
develop into bipolar I disorder if a manic episode occurs or into bipolar II disorder if a major
depressive episode occurs.

d. Bipolar disorder, NOS

There are symptoms of bipolar disorder that do not meet the criteria for any other bipolar
diagnosis. These may be more common in early onset bipolar disorder.

3. Other mood disorders

Other mood disorders include:

a. Mood disorder due to a general medical condition

b. Substance-induced mood disorder

c. Mood disorder, NOS

a. Mood disorder due to a general medical condition

Abnormal highs or lows in mood caused by a physical illness. Conditions that can lead to
a mood disorder include endocrine disorders (e.g., thyroid disorders), neurological conditions
(e.g., Alzheimer’s disease, epilepsy, and stroke), brain tumors and viral infections.

b. Substance-induced mood disorder

Abnormal highs or lows in mood caused by the use of a substance, such as alcohol,
illegal drugs or prescription medications (e.g., anti-anxiety drugs, corticosteroids).
c. Mood disorder, NOS

Any alteration in mood that does not meet the criteria for the diagnosis of any other mood
disorder

Risk factors and causes of mood disorders

The cause of mood disorders cannot be narrowed down to a single factor. However, it
appears that brain chemistry plays a major role. Brain chemicals called neurotransmitters convey
messages between the nerves. Abnormalities in the regulation of these neurotransmitters,
particularly nor epinephrine, serotonin and dopamine, are believed to cause alterations in mood.

Mood disorders also appear to be linked to genetics, and researchers are making great
strides in identifying the genetic links involved. Individuals who have relatives with a history of
a mood disorder are at a higher risk of developing either the same or a different mood disorder.
This is especially true for first-degree relatives (e.g., parents, children, siblings). Some
researchers believe that some people inherit a tendency to develop mood disorders, which may
then be triggered by environmental factors (e.g., stressful life events, disturbances in seasonal or
circadian rhythm).

Gender is another major risk factor for mood disorders, particularly depressive disorders.
According to the National Institute of Mental Health (NIMH), women have nearly twice as much
risk of developing major depression as men. Many mental health professionals believe that
hormones involved in pregnancy and miscarriage and hormone changes during the menstrual
cycle, postpartum period, premenopause and menopause may lead to a major depressive episode.

Signs and symptoms of mood disorders

Mood disorders are characterized by mood swings or episodes of abnormal highs or lows
of mood. Major depressive episodes are the most common mood episodes. Nearly all patients
with a mood disorder will have one at some point during their lifetime.

The symptoms of major depressive episodes include:

 a. Altered mood

b. Anhedonia

c. Significant change in appetite or weight

d. Changes in sleep patterns

e. Changes in physical or verbal activity

f. Diminished self-worth

g. Impaired concentration

h. Death thoughts

i. Fatigue and loss of energy

a. Altered mood

Patients may experience sadness, anxiety, anger, irritability or apathy (lack of emotion).
They may be pessimistic (feel that everything in life will turn out badly) or discouraged and may
experience crying spells or excessive emotional sensitivity.

b. Anhedonia

Patients may experience a reduction or loss of interest in activities they once found
pleasurable, such as food, sex, work, friends, hobbies and entertainment.

c. Significant change in appetite or weight

Patients may experience reduced or increased appetite or significant weight loss or gain.

d. Changes in sleep patterns

 Patients may sleep too much (hypersomnia) or not enough (insomnia). Often, patients
will wake up early in the morning and cannot go back to sleep.

e. Changes in physical or verbal activity

Patients may be agitated and anxious, may wring their hands, or may pace or not be able
to sit still. Conversely, patients may have sluggish movements or speech. They may pause before
answering questions or starting actions. Patients may speak quietly or not be able to be heard.
They may not speak except in response to a direct question or may become completely mute (not
talking at all).

f. Diminished self-worth

Patients may have feelings of worthlessness, self-reproach or excessive or inappropriate

guilt.

g. Impaired concentration

Patients may have a diminished ability to think or concentrate.

h. Death thoughts

Patients may have recurrent thoughts of death and death wishes. They may think about
committing suicide (suicidal ideation) or have suicidal actions. Patients may even attempt or
complete suicide.

i. Fatigue and loss of energy

Patient may have increased fatigue and there is complaint of loss of energy.

Symptoms of manic episodes include:

 Euphoria and elevated, “high” feelings or irritability. Patients remain in a good mood,
even when events occur that would normally dampen the mood.
  Uncharacteristically elevated self-esteem, feelings of grandiosity or unrealistic
confidence. Patients often feel very good about themselves or feel like they can take on
the world.
 Decreased need for sleep. Patients may wake up feeling rested after only a few hours of
sleep.
 Rapid talking, talking more than usual or feeling a need to keep talking. Patients may be
excessively talkative. They may be loud or talk too fast.
 “Flight of ideas,” feeling as though thoughts are racing, distraction or agitation. Patients
may be easily distracted or restless. They may have rapidly shifting thoughts that may be
revealed in conversation as constantly changing subjects.
 Increased goal-directed activity. Productivity may be increased.
 Intrusive or aggressive behavior. Patients may seem nosy or aggressive, sometimes with
destructive outbursts.
 Denial that anything is wrong. Because patients feel good and are often more productive,
they may deny that there is a problem.
 Seeking pleasure without regard to consequences, reckless behavior or poor judgment.
Patients may engage in spending sprees, sexual promiscuity, substance abuse or other
behavior when they would normally exercise better judgment.

In children and adolescents, manic episodes are more likely to be characterized by irritability
and destructive outbursts than by elation or euphoria.

Sometimes, symptoms of depression may occur during a manic episode, resulting in a mixed
episode. These may be more frequent in early onset bipolar disorder.

Hypomanic episodes are similar to manic episodes, but are less severe or have a shorter
duration. They may not cause actual impairment. In fact, hypomania often results in increased
productivity.

In severe cases, these mood episodes can involve psychotic symptoms, such as hallucinations
or delusions. Such psychotic features tend to be mood congruent. For example, during manic
episodes, patients may believe they are invulnerable to physical harm and, during major
depressive episodes, patients may believe they are guilty of a great crime or sin. Obsessions and
compulsions may also occur.

Diagnosis methods for mood disorders

The evaluation of a patient with a suspected mood disorder begins with a physical
examination by a physician. Medical conditions and side effects of medications must be ruled
out as potential causes of symptoms.

A physical examination is followed by a mental health evaluation by a physician or a

mental health professional. This evaluation includes a complete history of symptoms, including
when they started, how long they have lasted and how severe they are. It is also noted whether
the patient has experienced these symptoms before and, if so, whether and how they were
treated. The physician or mental health professional will also ask about alcohol and drug use,
whether the patient has thought about death or suicide and whether other family members have
had a mood disorder. If there is a history of a mood disorder in any family members, their
treatment and its effectiveness will be discussed.

Despite being serious and common disorders, mood disorders are highly under diagnosed
for many reasons. Some people believe there is a stigma attached to seeking help for any
potential mental health condition. Mood disorders may be overlooked in pregnancy and medical
conditions with similar symptoms. Diagnosis in adolescents may be difficult because many
adults may expect moodiness in teens. Children may be difficult to diagnose because of
confusion with attention deficit hyperactivity disorder (ADHD), which may also exist alongside
mood disorders. ADHD and mood disorders must be identified separately because they require
different treatment.

Mood disorders are not diagnosed if certain other mental illnesses, particularly ongoing
substance abuse or psychotic disorders (e.g., schizophrenia, schizoaffective disorder), are
present.

When major depressive episodes occur in patients with no history of manic, hypomanic
or mixed episodes, major depression may be diagnosed. The diagnosis of an episode of major
depression requires that symptoms must be severe enough to cause distress or impairment in
function and last for two weeks or longer. The patient must experience at least five key
symptoms. One of these five symptoms must be altered mood or loss of interest in pleasurable
activities (Anhedonia).

The other key symptoms include:

 Substantial change in appetite or weight

 Too little or too much sleep
 Observable agitation or sluggishness in activity
 Fatigue
 Reduced feelings of self-worth
 Problems with concentration
 Thoughts about death or suicide

If a manic or mixed episode ever occurs, bipolar I disorder is diagnosed. The diagnosis of a
manic episode requires symptoms that are severe enough to impair function in occupational
performance or social relationships. If the mood is elevated, three or more key symptoms must
be present. If the mood is irritable, four or more symptoms must occur. All symptoms must last
for one week or longer.

The key symptoms of mania include:

 Uncharacteristically elevated self-esteem or feelings of grandiosity

 Decreased need for sleep
 Talking more than usual or feeling a need to keep talking
 “Flight of ideas” or feeling as though thoughts are racing
 Distractibility
 Increased goal-directed activity
 Seeking pleasure without regard to consequences, reckless behavior or poor judgment
(e.g., spending sprees, sexual promiscuity, substance abuse)

Mixed episodes fulfill the symptom-based criteria for both manic and depressive episodes,
but must last a minimum of only one week. During these episodes, the patient often cycles
rapidly between manic and depressive symptoms.
 When hypomanic episodes occur in patients with a history of at least one major depressive
episode but no history of manic or mixed episodes, bipolar II disorder is diagnosed. The criteria
for a diagnosis of a hypomanic episode are the same as for a manic episode, except that they
symptoms need only occur for a minimum of four days and a change in function, not necessarily
impairment, must be present. The symptoms must be observable to others, not necessarily the
patient.

If depression that lasts for two or more years and does not meet the criteria for a major
depressive episode occurs in a patient with no history of manic, mixed or hypomanic episode,
dysthymia is diagnosed. When rapid mood swings and hypomania occur along with a similar
low-grade, chronic depression, cyclothymia is diagnosed.

For postpartum depression (PPD), the symptoms of depression must begin within four weeks
of childbirth. For seasonal affective disorder (SAD), the symptoms must begin during the same
season each year (frequently, the onset of winter) and must not be attributable to another cause.
For example, a worker who is unemployed each winter may be stressed by unemployment, not
seasonal affective disorder.

Treatment and prevention of mood disorders

Although there are no known cures for mood disorders, they are treatable. There is no
known way to prevent a mood disorder itself, but individual episodes may be prevented with the
use of medications and therapy. Hospitalization may be necessary during severe episodes.

Medications are often the first line of treatment for mood disorders. They are used to
rapidly establish control of dangerous or disabling symptoms, alleviate the symptoms and
prevent further episodes. If thyroid dysfunction is present, it needs to be treated with thyroid
medications for the treatment of a mood disorder to be effective.

The primary medications for the depressive mood disorders are antidepressants. These
are not habit-forming, but need to be carefully monitored to ensure that the correct dosage is
given. Antidepressants typically take several weeks to be effective and are generally taken for at
least four to nine months, or even indefinitely, to prevent recurrence. It is important to never stop
taking an antidepressant without consulting a physician because some types must be reduced
gradually to allow the body time to adjust. Patients should be aware that a physician may need
to adjust the dosage or change medications to achieve the best results with minimal side effects.

In addition, the U.S. Food and Drug Administration (FDA) has advised that
antidepressants may increase the risk of suicidal thinking in some patients and all people being
treated with them should be monitored closely for unusual changes in behavior.

Mood stabilizing drugs are the primary medications for bipolar disorders. Different types
of mood stabilizers may be more effective in different patients and a second mood stabilizer may
be added if a single medication is not effective. Lithium is the most common mood stabilizer and
generally the first medication used. Anticonvulsant mood stabilizing drugs may be used for
difficult-to-treat bipolar disorder or if there is a concern about lithium side effects. Lifelong
maintenance with mood stabilizers is generally required to prevent new episodes and reduce the
likelihood that subsequent episodes will be more severe.

Patients should be aware that not all medications are appropriate for every individual.
Certain medical conditions (e.g., pregnancy) may preclude the use of some medications.

Psychotherapy is effective for many patients with major depression, especially when
combined with medications. Psychotherapy encourages patients to take medication properly,
assists patients and families in establishing and maintaining appropriate behavioral boundaries,
provides counseling and support and addresses substance abuse when appropriate.

Some therapies commonly used to treat mood disorders include:

 Cognitive behavior therapy (CBT)

 Psycho education.
 Family therapy
 Interpersonal and social rhythm therapy
 Group therapy
 Psychodynamic therapy

 Cognitive behavior therapy (CBT).

 Patients learn to change and control inappropriate thought patterns and behaviors that
contribute to or result from their disorder.

 Psycho education.

Psycho education teaches patients about their mood disorder, its treatment and how to
recognize early signs of new episodes so that early intervention can take place. This is often
helpful for family members of patients with a mood disorder, as well.

 Family therapy.

It reduces the levels of distress within the family that may contribute to or result from the
symptoms of a mood disorder.

 Interpersonal and social rhythm therapy.

It improves the interpersonal relationships of bipolar patients and regularizes their daily
routines and sleep schedules to give them more control of their lives and their condition.

 Group therapy.

Group therapy focuses on acceptance of the mental health condition and the need for long-
term medication. This may include families.

 Psychodynamic therapy.

It focuses on resolving the conflict in a patient’s feelings, such as the desire for praise
coupled with feelings of worthlessness. This therapy is often reserved until symptoms are
significantly improved.

Light therapy is often useful in mood disorders with seasonal onset (e.g., seasonal affective
disorder [SAD]). This involves the use of a box that emits bright, white light. The box is set at
eye level and the patient looks into the light for a prescribed amount of time each day. Some
patients find it more useful to participate in this therapy at a particular time of day that varies
from patient to patient.

When a mood disorder is life threatening or severe in patients who cannot take medications
or medications do not provide sufficient relief, electroconvulsive therapy (ECT) may help
significantly. ECT is useful, particularly for individuals whose depression is severe or life
threatening or who cannot take antidepressant medication. ECT has been much improved in
recent years with modern techniques, and problems such as long-lasting memory loss have been
greatly reduced. ECT is administered using brief anesthesia and muscle relaxants. Electrodes are
precisely placed to deliver electrical impulses to the brain. Several sessions are typically needed,
usually at a rate of three sessions per week, to achieve the full therapeutic effect.

Depression

Definition:

Depression is characterized by
 Low mood
 Lack of interest and enjoyment
 Pessimistic thinking
  Reduced energy
And that is persistent for at least 2 weeks.

Classification of depression

Depression is classified on the basis of

1. Severity
2. Cause
3. With or without biological features
4. With or without hallucinations or delusions
5. With or without mania
6. Secondary to illness or drugs

1. Severity

Upon the basis of severity depression can be classified into the following types.
a. Mild depression
b. Moderate depression
c. Severe depression

2. Cause

On the basis of cause depression can be classified into

a. Primary depression
b. Secondary depression

a. Primary depression

Depression is called as primary when no identifiable cause can be found.

b. Secondary depression
 It is the type in which the symptoms of depression are produced due to some other
psychiatric disorder.

3. With or without biological features

Depression is associated with or without biological features such as

a. Sleep
b. Psychomotor retardation
c. Sexual desire
d. Appetite etc

4. With or without hallucinations or delusions

Depression is associated with or without hallucinations or delusions.

a. Hallucinations are the false believes.
b. Delusions are the false perceptions.

5. With or without mania

It is also known as manic depression. It is a functional psychosis characterized by

alternating cycles of manic psychosis and depressive psychosis. A history of other family
member of having suffered from the same illness is very common since the disease is transmitted
through autosomal genes in a dominant fashion.

6. Secondary to illness or drugs

Any illness either mild or severe can cause significant depression such as
a. Rheumatoid arthritis
 b. Malignancy of any organ
c. Chronic heart disease
d. Endocrine disorder
These disorders are particularly associated and more likely to develop depression.

Drug induced depression occurs with the use of

a. Morphine
b. Alcohol
c. Sedatives
And many other drugs

Old classification

Previously depression was classified into following two types.

1. Reactive depression
2. Endogenous depression

1. Reactive depression

It may also be known as neurotic depression. It may occur as a reaction to some outside
(exogenous) adverse life situation usually
a. Loss of a person by death
b. Divorce
c. Financial reversal
d. Loss of job
e. Marital problems
f. Sexual disharmony etc

2. Endogenous depression
 It is also known as psychotic depression. This type of depression occurs relatively
independently of the patient’s life situations or events. The depression may occur at any time
from childhood to adult life.

Etiology

Depression can be due to the following causes.

1. Genetics
2. Families
3. Physic
4. Sex
5. Stressful events
6. Childhood abuse
7. The belief
8. Endocrine problems

1. Genetics

Depression is more common in monozygotic than in dizygotic twins.

2. Families

Depression runs in families.

3. Physic

Depression is more common in obese people.

4. Sex
 Females are more prone to develop depression. For females there are some vulnerability
factors such as,
a. Loss of mother in early life
b. After delivery of a new baby, after some days weeping spells come and signs and
symptoms of depression appear.

5. Stressful events

Any stressful event can induce depression such as

a. Divorce
b. Prolong physical illness
c. Loss of job
d. Loss of parents
e. Loss of wife
f. Loss of husband
g. Loss of children
h. Loss of beauty
i. Failure
j. Threatening etc

6. Childhood abuse

Experience of being abused in childhood can induce depression. It is of four types.

a. Physical depression
b. Emotional depression
c. Sexual depression
d. Child neglected depression

7. The belief
 The belief that patient has no control over stress and pain. These kinds of beliefs are more
likely to develop depression.

8. Endocrine problems

Endocrine problems such as

a. Reduced serotonin neurotransmission
b. Reduced non-adrenergic function
They are associated with high incidence of depression.

Clinical features

The illness produces changes in soma as well as psyche. All the systems of the body are
affected to a greater or lesser degree. The various symptoms can be grouped into

1. Physical symptoms
2. Psychological symptoms

1. Physical symptoms

Common physical symptoms are

a. Loss of appetite
b. Loss of weight
c. Dryness of mouth
d. Abdominal discomfort
e. Constipation
f. Urinary frequency
g. Sexual disturbances like diminished sexual rive and interest
 h. Menstrual changes like amenorrhea
i. Cardiovascular disturbances like chest pain, palpitation and breathlessness
j. Headache and heaviness of head
k. Giddiness
l. Blurred vision
m. Insomnia
n. Dermatological disturbances like
o. Pruritis
p. Rash
q. Neurodermatitis
r. Excessive or diminished perspiration

2. Psychological symptoms

In addition to mood varying from mild depression to black despair the manifestations are
a. Insomnia of a type characterized by early awakening after 2 or 3 hours sleep
b. Diurnal variations of mood in which the depression often lifts considerably towards
evening
c. Slowness of thought and inability to make decisions
d. Ideas of guilt and self-blame
e. In addition to these there is loss of cheerfulness and diminished interest in daily activities
f. Lack of confidence
g. Unexplained fears (phobias) and anxiety
h. Helplessness
i. Suicidal tendencies
j. Such patients often find meeting people a painful deal and prefer to suffer alone. Such a
patient may sit immobile on the edge of a chair obviously in depth of misery, weeping
silently, wringing his hands and answering questions in slow monosyllables
k. Many severely depressed patients are afraid that they are going mad, many frightened as
well as ashamed at their own suicidal thoughts.
Diagnosis

To be diagnosed with depression, a patient must have five or more of the above mentioned
symptoms for at least a two week time period with impairment of daily living.

Complications

Complications of depression include

a. Suicide and attempted suicide
b. Malnutrition and dehydration
c. Retention of urine
d. Abuse of drugs and alcohol in an attempt to fight of depression
e. Self mutilation e.g. picking the skin, pulling hairs etc
f. Deterioration of co-existing physical disease e.g. diabetes mellitus

Differential diagnosis

Depression should be differentiated from

a. Bipolar disorder (sometimes depression and sometimes mania)
b. Schizophrenia
c. Dementia
d. Myxoedema
e. Parkinsonism
f. Addison’s disease

Treatment

Treatment includes
1. Hospitalization
2. Electroconvulsive therapy (ECT)
3. Drugs
4. Psychotherapy

1. Hospitalization

Patient should be hospitalized in case of

a. Severe attack of depression
b. Suicidal and homicidal tendencies
c. Failure to eat or drink
d. Social circumstances

2. Electroconvulsive therapy (ECT)

Many psychiatrists prescribe and regard it as the treatment of choice in depression. Only
endogenous or psychotic depression responds best to ECT. In fact, reactive or neurotic
depression gets worse. About 6-8 convulsions spread over a period of 2-3 weeks give excellent
results.
Some factors associated with good response to ECT in depression are
a. Absence of precipitating factors
b. Diurnal variations of mood
c. Family history of depression
d. Early morning awakening
e. Self-blame and guilt feelings
f. Mental retardation
g. Suicidal risk
h. In elderly where medications are contraindicated
i. Poor response to all drugs

3. Drugs
 Drug treatment is indicated in
a. Mild to moderate degree of depression
b. Patients where ECT is contraindicated

Drugs used are

a. Sedatives
b. Stimulants
c. Neuroleptics
d. Tranquilizers

a. Sedatives

Sedatives should be given if the patient is agitated.

b. Stimulants

Stimulants are useful to lift up the mood.

c. Neuroleptics

Neuroleptics are used if the agitation or anxiety symptoms are marked.

d. Tranquilizers

Tranquilizers can be used in case of severe attack of depression.

4. Psychotherapy

Psychotherapy is useful in all types of depression. For successful outcome

a. First explain the side-effects of the drugs and reassure the patient
 b. Supportive psychotherapy to identify and solve the problems in patient’s life
c. Resolve the underlying conflicts
d. Marital therapy is used to solve the marital problems
e. Cognitive therapy to modify the way of thinking

Prognosis

a. 1/3 of the patients get better

b. 1/3 of the patients stay the same
c. 1/3 of the patients get worse

Mania

Mania is a psychiatric symptom characterized by excess of physical activity or emotions,

such as extreme exhilaration or anger. Patients may also exhibit rapid thoughts and speech
patterns, poor judgment and impulsive behavior, which all lead to impaired functioning. The
extremity of action or emotion is often out of proportion to circumstances or events in the
patient’s life.

Mania most often occurs as part of bipolar disorder, which is characterized by extreme
swings in mood, from highs (mania) to lows (depression). Manic episodes in bipolar disorder
may last from a day up to several months. Some patients who have bipolar disorder may also
experience episodes when their manic and depressive feelings coincide. This is known as a
mixed state.

During a manic phase, patients may become much more talkative than usual and their
speech patterns may reveal that their mind is racing from thought to thought. They may also
engage in reckless behavior, such as excessive gambling, risky sexual activity or impulsive
spending sprees.
 Although mania is usually associated with bipolar disorder, in rare cases it may appear
largely without depression. In some cases, a patient may experience manic symptoms that are
less intense than those traditionally associated with mania. This is known as hypomania and
episodes last less than a week.

Mania is considered a potentially dangerous symptom because people undergoing a

manic episode often experience dramatic shifts in their personality and may engage in
uncharacteristically reckless behavior. However, mania is more likely to go unidentified in
patients than depression, because the feelings of elation that accompany mania are often viewed
as positive by patients who have them.

Even when patients see a physician, mania can be difficult to diagnose. People who
experience mania often deny that anything is wrong with them. As a result, physicians may have
to rely on the testimony of friends and family to help diagnose mania. Because mania is
considered to be a psychiatric emergency, patients may be treated in a hospital while undergoing
episodes.

Potential causes of mania

Many factors have the potential to trigger manic episodes. Although mania is most
commonly associated with bipolar disorder, it can also occur as a result of medication use or
other illnesses.
Certain types of drugs may cause mania as a side effect of their use. Amphetamines,
antidepressants (and withdrawal from antidepressants) and corticosteroids all may cause episodes
of mania. Specific medications that have been associated with mania include bromocriptine
(used to treat various conditions, including amenorrhea, infertility and Parkinson’s disease),
levodopa (used to treat Parkinson’s disease) and methylphenidate (used to treat attention deficit
hyperactivity disorder [ADHD]). Cocaine and other stimulant use may also cause mania-like
symptoms.

Certain diseases can also trigger manic episodes, including infections such as acquired
immune deficiency syndrome (AIDS), encephalitis (inflammation of the brain), influenza and the
late stages of syphilis (a sexually transmitted disease). High levels of thyroid hormone and the
connective tissue disease systemic lupus erythematosus also are associated with mania.

In addition, several neurological disorders are known to be potential triggers of mania. These
include:

 Brain tumors
 Head injuries
 Huntington’s disease (progressive wasting of nerve cells in the brain)
 Multiple sclerosis (autoimmune disease that affects the central nervous system [CNS])
 Stroke
 Sydenham’s disease (movement disorder associated with rheumatic fever)
 Temporal lobe epilepsy (marked by seizures that cause abnormal electrical activity in the
temporal lobe)

Other symptoms related to mania

Manic episodes typically first manifest in a patient’s 20s, although they may begin as
early as adolescence and as late as age 50 or older. Episodes usually begin suddenly, and may
escalate rapidly over the course of a few days. Some episodes last from a few weeks to several
months.

Mania is associated with many emotions that manifest as related symptoms, including
euphoria and increased self-esteem. Patients in the early stages of a manic episode may feel
exuberant, energetic and extremely productive.

However, not all the symptoms associated with mania are positive. Patients who are
manic often have racing thoughts and are extremely talkative and speak rapidly. They act
differently than they normally do. For example, they may begin to collect various items or to
stop grooming themselves. They may easily become irritable, hostile or impatient, and may
intrude in the lives of others. Mania also makes it difficult to stay focused on one activity, and
patients often flit from one task to another.
 Feelings of grandiosity are also commonly associated with mania. Patients may falsely
believe that they are extremely wealthy and powerful and have an inflated sense of self-esteem.
Some believe that they are geniuses, and this can escalate to the delusional belief that they are
God.

During severe manic episodes, patients may have hallucinations and begin to believe that
they are either being helped or hindered by others. Patients often sleep less, exhibit poor
judgment and become excessively and impulsively involved in high stakes, reckless behavior
such as road rage, risky sex, substance abuse or impulsive spending.

When behavior becomes so extreme that there is no clear link between mood and
behavior, it is known as delirious mania. Patients with this condition are at risk of dying of
physical exhaustion if they are not immediately hospitalized and treated. Patients who are manic
are frequently unaware that their feelings are not normal.

Relief options for mania

A physician or mental health professional is likely to diagnose mania if the patient

experiences a period of abnormally elevated or irritable mood that lasts at least one week. Mania
may also be diagnosed if the changes in mood last for a shorter period of time but require
hospitalization.

During the mood disturbance, three or more of the following symptoms must be present (or
four symptoms, if the mood is only irritable):

 Heightened self-esteem or feelings of grandiosity

 Reduced need for sleep
 More talkative than usual
 Sense that thoughts are racing
 Easily distracted
 Increase in goal-seeking activity
 Impulsive or risky behavior
 These symptoms also cannot be better accounted for by another condition, or caused by the
effects of a substance.

Patients who engage in extremely risky behavior may need to be hospitalized during manic
episodes to prevent them from harming themselves or others. This is particularly true for patients
who reach the stage of delirious mania.

Mood stabilizing drugs such as lithium are the primary medications for treating both mania
and bipolar disorder. According to the National Mental Health Association (NMHA), lithium is
effective in controlling mania in 60 percent of patients with bipolar disorder. It is also effective
in preventing new episodes of both mania and depression and appears effective in reducing
suicide among patients with bipolar disorder.

Although lithium is very effective in treating euphoric mania, it may not be beneficial in
treating mixed episodes in which mania and depression occur simultaneously. Some patients
may experience undesirable side effects, such as hand tremors, excessive thirst, and excessive
urination and memory problems. These patients may find relief from manic symptoms through
the anticonvulsant drug valproic acid. This drug has fewer side effects than lithium, although
some patients may experience nausea, drowsiness, dizziness, weight gain or tremors. Valproic
acid should be monitored closely in patients who have a liver disorder, because it can cause
serious liver damage.

Finally, some patients have found relief from manic symptoms by using
certain antipsychotic medications. Side effects of these medications may include sedation,
stiffness of arms and legs, weight gain and abnormal movements.

Some patients may have to be monitored when they take medications for mania. Patients
often feel a sense of “dullness” after taking medications and miss the “high” of their manic
phases. As a result, they may be tempted to stop taking their medications.
Schizophrenia

Schizophrenia is a type of psychotic disorder (severe mental condition that causes the
patient to lose touch with reality). People may develop schizophrenia alone, or it may occur in
combination with other psychiatric or medical conditions.
This is only one of a number of illnesses that include psychotic symptoms. Losing touch
with reality or having abnormal thoughts does not mean that someone has schizophrenia, and
schizophrenia is not the same thing as a split personality, as some people believe because of the
origin of the word "schizophrenia."

Schizophrenia can be diagnosed at any age, but 75 percent of people with the disorder
first develop symptoms between the ages of 16 and 25 years. Schizophrenia rarely occurs before
puberty, although cases in children as young as 5 years old have been reported. The illness is
difficult to recognize in children and adolescents because hallucinations, the hallmark of
schizophrenia, can be caused by a number of other unrelated conditions, and because its slow
onset can lead to an assumption that it is a behavior problem.

The illness affects men and women equally, although it often appears at an earlier age in
males than females. Onset in males typically occurs between the late teens and early 20s. In
females, onset usually occurs between the 20s or early 30s.

Schizophrenia may be related to development of a child's brain during pregnancy. One

theory is that changes before birth lead to faulty connections within the brain. These poor
connections are dormant until puberty, when the brain undergoes dramatic changes, which can
lead to the psychotic symptoms associated with the condition. There is, however, no direct
scientific evidence that leads scientists and doctors to believe that there is a single cause for this
illness.

The structure of the brain appears different in some patients as compared to the general
population. Some of these differences include the following:

 The fluid-filled cavities at the center of the brain (ventricles) are larger.
 The volume of gray matter (which consists of the neurons, brain cells) is lower.
  Some areas of the brain have abnormal metabolic activity.

It is important to note that not all patients with schizophrenia have these differences. Nor do
all patients with these differences have schizophrenia.

Myths and misperceptions about schizophrenia

Patients are often stigmatized by lack of public understanding about schizophrenia. The
disease is often confused with split personalities (dissociative identity disorder, DID), but they
are different disorders. DID, which is rare, is characterized by the presence of two or more
alternate personalities in one body, each having their own memories, behavior and relationships.
Patients with schizophrenia may have strange and unpredictable behavior, but they do not have
more than one personality.

Nor should schizophrenia be confused with two similarly named conditions:

 Schizoid personality disorder (marked by withdrawn, solitary and emotionally detached

behavior)

 Schizotypal personality disorder (marked by widespread social deficits and eccentric

behaviors).

Another misperception about schizophrenia is that patients are violent. However, most
people with schizophrenia are not prone to violence and often prefer to be left alone. Studies
have demonstrated that if patients do not have a criminal record or substance abuse problem
prior to developing schizophrenia, they are unlikely to commit crimes after becoming ill. Patients
with paranoid schizophrenia are more likely to commit an act of violence, which is usually
directed at a someone close to them or someone about whom they have delusions.

People with schizophrenia do abuse alcohol and drugs more frequently than the general
population. However, most scientists do not believe that substance abuse causes schizophrenia.
Also, some people who abuse drugs exhibit symptoms similar to those of schizophrenia, and
patients are sometimes mistakenly thought to be under the influence of drugs. Drugs can also
make the symptoms of schizophrenia worse, both directly because of the effect of the drug on the
brain and secondarily because people who are using illegal drugs frequently do not take their
medication as they should.

Nicotine is the most common form of substance abuse among patients with schizophrenia.
Research has shown that people with schizophrenia are addicted to nicotine at three times the
rate of the general population (75 to 90 percent versus 25 to 30 percent), according to National
Institute of Mental Health (NIMH).

Types and differences of schizophrenia

There are five recognized types of schizophrenia:

a. Paranoid schizophrenia

b. Disorganized schizophrenia

c. Catatonic schizophrenia

d. Undifferentiated schizophrenia

e. Residual schizophrenia

a. Paranoid schizophrenia

It is characterized by delusions (fixed false beliefs held by a person despite evidence to the
contrary) in addition to other symptoms of schizophrenia, such as abnormal ways of thinking,
and/or hallucinations. Typically, the onset of the disorder is later than with other types of
schizophrenia, with some studies reporting an average age of 35 years. The complex of
symptoms makes this paranoid schizophrenia -- if the only symptom is delusions, it is a
delusional disorder, not paranoid schizophrenia.

b. Disorganized schizophrenia

It is characterized by disorganized behavior and speech. Expressions of emotion are often flat
or inappropriate. Patients with this type of schizophrenia often deteriorate rapidly, talk gibberish
and neglect personal hygiene and appearance. Frequently everything about their lives become
disorganized.

c. Catatonic schizophrenia

It is characterized by abnormal physical movements. Although some patients may exhibit

motor (motion) activity that is speeded up, most patients exhibit slow motor activity, sometimes
to the point of stupor. This type of schizophrenia may also be marked by negativism or peculiar
behavior such as posturing (maintaining an unusual or awkward posture for a long period of
time).

d. Undifferentiated schizophrenia

Patients who have been diagnosed with schizophrenia, but do not meet the characteristics of
the paranoid, disorganized or catatonic types.

e. Residual schizophrenia

Patients who were previously diagnosed with schizophrenia but are no longer experiencing
positive symptoms, such as catatonic behavior, delusions, hallucinations or disorganized speech
or behavior. However, patients still experience some symptoms of mental illness, such as flat
expressions of emotion, reduced speech output or lack of volition (capability of conscious
choice, decision and intention).

There are also two conditions related to schizophrenia:

a. Schizophreniform disorder

b. Schizoaffective disorder

a. Schizophreniform disorder

This condition has similar symptoms except that they last from one to six months, compared
to at least six months for schizophrenia, and it does not necessarily involve a decline in
functioning. However, for many people the diagnosis of schizophreniform disorder represents a
prodrome (beginning) stage of schizophrenia.

b. Schizoaffective disorder

Patients with this condition exhibit signs of schizophrenia as well as mood disorders such
as depression or mania. Because the diagnosis is not clearly schizophrenia, but also does not
have all the symptoms needed to diagnose a depression, anxiety disorder or bipolar disorder, it
falls into this category.

Risk factors and potential causes of schizophrenia

The exact cause of schizophrenia is not known. Mental health experts believe that the
condition results from a combination of genetic and environmental factors.

Schizophrenia tends to run in families

Although it occurs in about 1 percent of the general population, it occurs in 10 percent of

people who have a first-degree relative (parent, brother or sister) with schizophrenia. People with
a second-degree relative (aunt, uncle, grandparent or cousin) also develop schizophrenia at
higher rates than the general population. People who have a twin with the disorder face the
highest risk, with a 40 to 65 percent chance of developing schizophrenia, according to the
National Institute of Mental Health (NIMH).

Genes have also been linked to an increased risk of schizophrenia

Genes are located on 23 pairs of chromosomes (rod-shaped structures found in the

nucleus of a cell that contain hereditary material). People inherit two copies of each gene, one
from each parent. However, scientists believe that each gene may play a small role in the
development of the disorder and is not responsible for causing the disease by itself. Also,
scientists are not able to predict who will develop the disorder simply by studying genes.

Recent research studies have also found an increased risk of schizophrenia, autism and
certain other disorders in children born to a mother or father of advanced age. This risk is
attributed to the declining genetic quality of aging eggs and sperm.
 Environment has also been identified as playing a role. Possible environmental factors
associated with the development of schizophrenia include:

 Exposure to viruses or malnutrition in the womb.

 Complications during birth, such as mild brain damage.
 Toxoplasmosis, an infection with a common parasite carried by cats.
 Psychosocial factors, such as stressful environmental conditions (e.g., malnutrition).

People with schizophrenia have an imbalance of the brain chemicals serotonin and dopamine.
These chemicals are neurotransmitters, which allow nerve cells in the brain to send messages to
each other. Everything we experience is the result of brain chemistry sending us messages. In
schizophrenia, the input from other people and the environment does not result in the same
messages that everyone else receives. An imbalance of brain chemicals can lead to hallucinations
and paranoia, which respond to medication that corrects the imbalances.

Signs and symptoms of schizophrenia

Signs and symptoms of schizophrenia differ greatly among patients, but may be divided
into three broad categories:

1. Positive symptoms

2. Negative symptoms

3. Cognitive symptoms

1. Positive symptoms

Positive symptoms involve an excess or distortion of normal function. They usually involve a
loss of contact with reality. They can be severe at times and hardly noticeable at other times.
They include:

a. Hallucinations

b. Delusions
 c. Thought disorder

d. Movement disorder

a. Hallucinations

Hallucinations are perception by the senses of something that is not actually there. They can
involve any of the five major senses -- vision, hearing, smell, touch or taste -- although auditory
(hearing) hallucinations are the most common. Many people with the disorder hear voices that
may comment on their behavior, order them to do things, warn them of impending danger or talk
to each other (usually about the patient).

b. Delusions

Delusions are fixed false beliefs of the person despite evidence to the contrary.Common
types of delusions include:

 Persecution

These are the most common. Patients believe they are being tormented, followed, tricked,
spied on or ridiculed.

 Referential

These are also common. Patients believe that references in books, song lyrics,
newspapers or other areas are directed at them.

 Grandeur

Patients believe they are persons of high status, such as a deity or a movie star.

 Guilt

Patients believe they have committed a grave sin or mistake.

  Ill health

Patients believe they have a bad disease.

 Jealousy

Patients believe their spouses or partners have been unfaithful.

 Passivity

Patients believe they are being controlled or manipulated by outside influences, such as
radio waves.

 Poverty

Patients believe they are facing destitution, even though they have a job or money in the
bank.

 Thought control

Patients believe ideas are being put into their minds by others.

c. Thought disorder

Patients often have unusual thought processes. They may have difficulty organizing
thoughts or connecting them logically. Speech may be disorganized (sometimes called loose
associations), or people may connect thoughts by rhymes or puns rather than logic. Thoughts
also may be tangential, that is, the person may take the conversation in a totally different
direction and have difficulty staying on any one topic.

d. Movement disorder

Patients with schizophrenia may be clumsy and uncoordinated. They may have
involuntary movements or unusual mannerisms. These may occur as side effects of some
antipsychotic medications, but as symptoms they occur even before someone takes any
medication.

2. Negative symptoms

Negative symptoms involve a loss of normal emotional and behavioral functioning. Many of
these symptoms are also symptoms of other medical disorders or may occur in healthy
individuals. They include:

a. Flattened affect

b. Anhedonia

c. Avolition

d. Alogia

a. Flattened affect

There is reduced range of emotion. This may include immobile facial expressions or
monotonous voice.

b. Anhedonia

Lack of pleasure in everyday activities is known as anhedonia.

c. Avolition

Loss of ability to initiate and sustain planned activity is called as avolition.

d. Alogia

Inability to sustain conversation, even when forced to speak is called alogia.

3. Cognitive symptoms

Cognitive symptoms are often subtle and may be detected only when neuropsychological
tests (specifically designed tasks used to measure a psychological function known to be linked to
a particular brain structure or pathway) are conducted. Cognitive symptoms can greatly create
big problems in a person's ability to lead a normal life. They include:

a. Poor functioning

b. Poor attention

c. Problems with memory

a. Poor functioning

The ability to retain and interpret information and make decisions based on that
information.

b. Poor attention

There is inability to sustain attention.

c. Problems with memory

The ability to retain recently learned information and access it.

Patients with schizophrenia often neglect basic hygiene and need assistance with
activities of daily living. Some patients' ability to function in personal and job settings
deteriorates over time. Other patients exhibit symptoms that come and go. Staying on medication
and involved in treatment can help minimize symptoms.

Diagnosis methods for schizophrenia

The diagnosis of schizophrenia usually begins with a physical examination conducted by

a physician, who will also review the patient's medical history, including any family history of
mental illness.
 A physician may try to rule out other mental or physical illnesses that may be causing
symptoms. Blood or urine tests may be conducted to determine whether medications, substance
abuse or illness is contributing to symptoms. Some infections, cancers, nervous system disorders,
thyroid disorders, immune system disorders, seizures and head trauma can produce psychotic
symptoms. At times, imaging studies such as MRI may be ordered to rule out other conditions
that can affect the brain.

A patient will be referred to a psychiatrist who can conduct a psychiatric evaluation,

which should include a detailed description of signs and symptoms, a mental status examination
and overview of social, family and psychiatric history. Patients with schizophrenia usually begin
experiencing symptoms in late adolescence or early adulthood.

In general, a patient must be experiencing psychotic or "loss of reality" symptoms

associated with schizophrenia for at least six months to be diagnosed with the disorder. The
symptoms must be accompanied by a decreased ability to function in work, school, home and/or
social settings.

Schizophrenia can sometimes be difficult to diagnose because many of its symptoms are
also symptoms of other mental disorders, such as depression or bipolar disorder. Also, a person
with schizophrenia may not be able to recognize the symptoms because they are not thinking
straight. In some cases, patients are referred to medical professionals by family members or
friends. With early diagnosis and treatment, however, the disorder can be managed more
effectively, and some measure of recovery can occur

Treatment options for schizophrenia

The cause of schizophrenia is largely unknown, and there is no known way to prevent or
cure the disorder. The focus of treatment is often to control symptoms with minimal side effects
from medication, and achieve the best recovery possible.

Patients are usually treated at home. However, they can be treated in a hospital if they
experience acute symptoms, such as severe delusions or hallucinations, serious suicidal thoughts,
an inability to care for themselves or if they are violent or threatening others as a result of their
illness.
 The most common treatment for schizophrenia is antipsychotic medication. Patients with
schizophrenia sometimes stop taking medications because they feel better, forget to take them or
dislike the side effects, or take them sporadically because they think regular use is not important.
Following the physician's directions for medications and communicating any problems to the
physician is the most important thing to make sure there is adequate treatment.

In addition to medication, patients with schizophrenia may need psychosocial

rehabilitation (therapy that involves addressing both social and psychological behavior).
Research has shown that patients treated with rehabilitation and medications are best able to
manage their illness.

Psychosocial treatment may include therapy to address substance abuse (common in

people with schizophrenia), social and vocational training to help people work and live in the
community, occupational therapy to increase independence with activities of daily living such as
grooming and meal preparation and job skills, and illness management techniques to help
patients understand their condition, identify signs of relapse and develop a plan in case relapse
occurs.

It is very important that the therapy the person gets is appropriate for that individual's
needs. Some people are more disabled than others and need more basic therapy and vocational
training. Others are well controlled on their medication and not only do not benefit from basic
training and therapy, but can become very frustrated if they are "required" to participate and stop
all of their treatments. Treatment should always be individualized to the needs of the person.

Cognitive behavior therapy may be helpful for patients whose symptoms continue even
with medication. Cognitive therapists teach patients how to monitor the reality of their thoughts
and perceptions, how to ignore auditory hallucinations and how to cope with apathy that can be
immobilizing.

Self-help groups can provide comfort and support among members who share their
experiences. Networking in groups can also generate social action when members unite and
advocate for more research or treatment programs.
 Schizophrenic people have a higher risk of suicide than the population at large. Threats of
suicide or any activity that you think might be a suicide attempt or planning for suicide should be
taken very seriously and evaluated by a professional.

People with schizophrenia often resist treatment because they believe that their
hallucinations and delusions are real and that they do not need psychiatric help. Although laws
differ from state to state, civil rights laws to protect patients with schizophrenia from being
involuntarily committed into a mental health facility have become strict. If patients pose a danger
to themselves or others and refuse to seek treatment, family members may have to call the police
to transport the patient to the hospital. Once at the hospital, the patient will be evaluated by a
mental health professional.

Patients with schizophrenia often need assistance from family members, friends and
others to ensure that they continue to receive treatment and take their medications. Schizophrenia
is a chronic disease. If patients stop taking medications, psychotic symptoms can reappear and
may impair their ability to care for basic needs, such as food, clothing and shelter. Family and
friends can also help patients set realistic goals for coping with their illness. It is important to
show support and encouragement because patients who feel pressured or criticized often regress,
making symptoms worse.

In very rare cases, electroconvulsive therapy (ECT) may be recommended by a

psychiatrist to treat certain symptoms of schizophrenia. ECT is particularly useful for people
with schizophrenia who have bad catatonic symptoms or hallucinations that do not respond to
any medications and are life threatening. Most frequently, ECT is used for other psychiatric
disorders.

Dementia

Dementia is a decline in mental function that may interfere with the ability to perform
daily activities.
 Dementia is not a disease. Instead it describes a collection of symptoms (most commonly
memory loss, behavioral changes and problems with language) that generally occur together and
can be caused by certain conditions.

Classification of dementia

Dementia is classified in many different ways. Some physicians and scientists classify
dementia as being either

a. Cortical dementia

b. Subcortical dementia

a. Cortical dementia

Cortical dementia occurs as a result of impairment or damage to the cerebral cortex. This
is the outer layer of the brain and is associated with memory and language, along with many
other aspects of consciousness. Cortical dementias (e.g., Alzheimer's disease, Creutzfeldt-Jakob
disease) often result in loss of memory and language skills.

b. Subcortical dementia

Subcortical dementia results from impairment or damage to parts of the brain underneath
the cerebral cortex. Because the cortex can be undamaged, people with subcortical dementia
(such as those with Huntington’s disease) rarely experience memory loss and problems with
language. Instead, people with subcortical dementia can experience behavior and personality
changes, resulting in socially inappropriate and unusual actions.

Some forms of dementia are progressive, which means that they get worse over time.
Alzheimer's disease, Lewy body dementia and frontotemporal dementia are all forms of
progressive dementia. Most progressive forms of dementia are poorly understood by physicians
and scientists and can be difficult or impossible to treat. Other forms of dementia, especially
those caused by factors such as medical reactions, alcohol abuse and malnutrition, are usually
temporary and reversible.

Types and differences of dementia

The most common types of dementia include

a. Alzheimer's disease

b. Vascular dementia

c. Lewy body dementia

d. Frontotemporal dementia

e. Corticobasal degeneration

f. Huntington’s disease

g. Creutzfeldt-Jakob disease (CJD)

h. Niemann Pick disease

a. Alzheimer's disease

The most common type of dementia is Alzheimer's disease. Alzheimer's disease is a

progressive, degenerative neurological disorder that occurs when neurons in the brain die or
break their connections with other neurons. This is believed to occur because of abnormal lesions
in the brains of people with Alzheimer's disease called beta-amyloid plaques and neurofibrillary
tangles. These plaques and tangles disrupt brain function and are known to increase in quantity
as Alzheimer's disease progresses.

b. Vascular dementia

Another common form of dementia is vascular dementia, which accounts for up to 20

percent of all dementias according to National Institute of neurological disorders and Stroke
(NINDS). Vascular dementia is caused by lack of blood flow to the brain, usually following a
stroke. It is the second most common type of dementia in older people. Unlike Alzheimer's
disease, vascular dementia often develops suddenly after a cerebrovascular event and may or
may not get worse over time. Some patients may recover certain aspects of cognitive function
after a period of time.
 There are different types of vascular dementias. Multi-infarct dementia (MID), for
example, is caused by multiple small strokes in the brain. People with MID can experience only
isolated symptoms of dementia such as memory loss or language impairments, depending on the
area of the brain damaged by the strokes. A rare type of vascular dementia, Binswanger’s
disease, is caused by damage to the small blood vessels in the brain. People with Binswanger’s
disease often experience other symptoms such as urinary incontinence, clumsiness and problems
walking.

c. Lewy body dementia.

This progressive dementia is similar to Alzheimer's disease in that its symptoms seem to be
caused by the build up of pieces of protein (Lewy bodies) within the neurons of the brain. People
with Lewy body dementia also experience pronounced lapses in concentration or alertness,
visual hallucinations and Parkinson’s disease-like motor function problems. People with Lewy
body dementia often have clinical signs of Parkinson’s disease and Alzheimer's disease.
However, the true relationship between Lewy body dementia, Alzheimer's disease and
Parkinson’s disease is not yet fully understood.

d. Frontotemporal dementia

Also called frontal lobe dementia, frontotemporal dementia results from damage to the
frontal and/or temporal lobes of the brain. People with frontotemporal dementia develop changes
in a protein known as tau. Frontotemporal dementia is a type of dementia that results in mood
and personality changes, which means that some people with frontotemporal dementia may
exhibit inappropriate behavior (e.g. stealing, cursing) and have problems in social situations.

e. Corticobasal degeneration

This progressive dementia is more common in people over age 60 and is the result of
nerve cell loss throughout the brain. People with corticobasal degeneration experience symptoms
that are similar to Parkinson’s disease along with the conventional symptoms of dementia,
including, most notably, apraxia (the inability to make purposeful movements).
f. Huntington’s disease

This type of dementia is hereditary and is caused by a genetic abnormality. Children whose
parents have Huntington’s disease have a 50 percent chance of developing the disorder,
according to NINDS. Unlike many forms of dementia, the symptoms of Huntington’s disease,
which include personality changes, psychosis and abnormal muscle movements, begin to
develop in the patient’s 30s or 40s. After diagnosis, people with Huntington’s disease live for
about an average of approximately 15 years.

g. Creutzfeldt-Jakob disease (CJD)

Although CJD has received a large amount of media coverage over the last few years, the
disease is still very rare. CJD is a type of progressive dementia caused by a prion, which is an
infectious protein. Individual can be infected with the prion by consuming the brain or spinal
tissue of an animal that has been infected. In animals, a variant of CJD is calledh mad cow
disease. In can also be hereditary. People with CJD may experience personality changes,
hallucinations, blindness and problems with coordination.

h. Niemann Pick disease

Dementia may occur as a symptom of this group of genetic disorders. Patients with the disease
cannot metabolize cholesterol and other types of fats normally, and these fats accumulate in the
brain. The disease may begin during childhood, adolescence or early adulthood.

Risk factors and causes of dementia

One of the biggest risk factors for most types of dementia is age. Although some forms of
dementia may affect those under 50 – some even occur in children – the risk of dementia
occurrence increases rapidly as people age. For example, the number of people with Alzheimer's
disease doubles every five years after the age of 65, according to the National Institute of
Neurological Disorders and Stroke (NINDS). However, it is important to note that dementia is
not part of the normal aging process. Some people have a long lifespan and experience only a
very slight mental decline.

Another important risk factor for many forms of dementia is genetics and family history.
Some forms of dementia can be traced to genetic abnormalities. This is the case with
Huntington’s disease, which is passed from parent to child through a gene mutation.
Additionally, people who have a sibling or parent with Alzheimer's disease are more likely to
develop the disease themselves. This risk is even greater if more than one member of the family
has been diagnosed with Alzheimer's disease. The specific relationship between genetics and
dementia is still being studied.

Some causes of dementia include:

a. Stroke

b. Brain injury

c. Malnutrition or metabolic disorders

d. Infections

e. Medication reactions

f. Drug and alcohol use

g. Poisoning

h. Brain tumor or lesion

a. Stroke

A stroke is a life-threatening event in which part of the brain is deprived of adequate oxygen
(hypoxia). Also known as a cerebrovascular accident (CVA) or a “brain attack,” a stroke occurs
when a blood vessel in the brain bursts or becomes clogged by a blood clot or other mass. This
prevents oxygen and nutrients from traveling to nerve cells in the affected area of the brain.
These nerve cells can die within minutes, and the area of the body they control can cease to
function. In many cases, this damage is permanent, especially if the patient is not treated
immediately. Stroke is the most common cause of vascular dementia.

b. Brain injury

Dementia may occur following a traumatic head injury, depending on which part of the brain
is affected. Repeated concussions (such as those sustained while boxing) increase the risk for
dementia pugilistica, a form of dementia that can also result in Parkinson-like symptoms.

c. Malnutrition or metabolic disorders

Malnutrition is defined as the deficiency in one or more vital nutrients. Many people are
malnourished without realizing it, especially if they do not eat a balanced diet. Deficiency in any
of the B vitamins may result in dementia. Some people are unable to absorb or metabolize
certain vitamins or minerals, which may lead to dementia. In some cases, treatment for
malnutrition or metabolic disorders may reverse the dementia.

d. Infections

Some infections, especially those that cause high fever, can cause many of the symptoms of
dementia. These are often resolved once the infection has been treated. Infections that directly
affect the brain, such as human immunodeficiency virus (HIV) and meningitis, can result in more
severe and possibly permanent brain damage and dementia. An untreated infection with the
sexually transmitted disease syphilis can lead to tertiary syphilis, which can include symptoms of
dementia.

e. Medication reactions

Some medications can cause memory loss and other symptoms of dementia as a side
effect. These may include medications used to treat depression, seizures or Parkinson’s disease.
Additionally, some medications interact with other substances to produce symptoms similar to
dementia. People who experience symptoms of dementia should inform their physician of all
medications they are taking. They should also consult with their physician about any vitamin
supplements, topical treatments or over-the-counter products they are taking.
f. Drug and alcohol use

Abusing most illegal drugs may lead to symptoms of dementia, which can normally be
resolved once the substances are removed from the body. Severe alcohol abuse, especially heavy
drinking followed by sudden withdrawal, can lead to a permanent form of dementia called
Wernicke-Korsakoff disorder.

g. Poisoning

Some substances such as lead and mercury can cause dementia if people are exposed to
unsafe levels. Mercury poisoning is generally associated with broken thermometers or working
in a thermometer factory. Lead poisoning is more common and can occur after exposure to lead-
based paint used in older homes, breathing contaminated air or eating contaminated food.

i. Brain tumor or lesion

Tumors or brain lesions, which can cause pressure to build up in the brain, can disrupt the
function of neurons. This can lead to symptoms of dementia. In certain cases, removal of the
tumor or lesion can restore cognitive function, although sometimes the damage may be
permanent.

Signs and symptoms of dementia

The most commonly recognized symptom of dementia is memory loss. People with
dementia, especially a cortical dementia such as Alzheimer’s disease, often have problems
transferring short-term memory into long-term memories. This may include forgetting the name
of someone who has just been introduced or asking the same question repeatedly without ever
remembering what the answer was or even asking the question in the first place. People with
dementia may also find themselves misplacing items or putting them in strange places (e.g. the
phone in the freezer, keys in the oven). In most cases memory loss gets worse over time and is
one of the most debilitating symptoms of dementia.
Other symptoms of dementia may include:

a. Aphasia

b. Poor judgment

c. Mood and personality changes

d. Lethargy and depression

a. Aphasia

Aphasia is a loss of the ability to use and understand language. People with dementia may
forget words and have difficulty communicating with others (expressive aphasia). They may also
have problems understanding spoken or written words (receptive aphasia). It is often described
as being similar to traveling to a foreign country and being surrounded by people speaking an
unknown language.

b. Poor judgment

People with dementia may exercise poor judgment when it comes to making decisions. For
example, they may not wear a coat when it is obviously cold outside.

c. Mood and personality changes

People with dementia, particularly subcortical dementia (e.g. Huntington’s disease), may find
that they experience sudden changes of mood or personality. This can be especially hard for
caregivers to cope with.

d. Lethargy and depression

Many people with dementia experience some form of depression, often because of
chemical imbalances in the brain. The frustration associated with dementia can also cause
depression and lethargy and patients may stop attempting to communicate or perform certain
tasks.
Diagnosis methods for dementia

People who are concerned about a decline in cognitive function, including memory loss
or unusual changes in mood or behavior should consult their physician as soon as possible.
Diagnosis will usually begin with a medical history and a physical examination. People are
encouraged to keep a log of their symptoms to report to their physician. A physician may also
ask family members or close friends about the nature of the patient’s symptoms. During the
medical history, the physician may ask questions related to the patient’s dietary habits and use of
alcohol in order to establish potential causes of dementia that can be reversible. During the
physical examination, the physician will likely assess neurological function by testing the
patient’s reflexes, balance and coordination.

A physician may conduct a mental status examination to assess the patient’s stage of
dementia. During the exam, the physician may ask the patient a variety of questions aimed at
testing the patient’s awareness of surroundings, problem solving skills and memory skills.
Examples of items on the test may include:

 Situational questions such as “What year is it?” or “What is the address of this office?”
 Remembering and recalling a short list of items (e.g. a ball, a pencil, a dog)
 Counting backwards or spelling a word backwards
 Naming familiar objects in the room as the physician points to them
 Following simple instructions or writing a simple sentence

This test can also be used after diagnosis to evaluate the progression of dementia in the patient.

Additionally, blood and urine tests may be performed to test for conditions that cause
dementia. These may include tests for vitamin deficiencies, poisoning or infections. A sample of
spinal fluid may also be taken using a spinal tap to test for infections of the brain or spine.

Imaging tests, such as magnetic resonance imaging (MRI) tests and computed axial
tomography (CAT) scans may be used to identify signs of brain abnormalities that may be the
result of injury, stroke or a tumor. This enables physicians to identify the underlying cause of the
dementia or to take steps towards preventing potential causes of dementia (e.g. strokes).
However, imaging tests have limitations and are unable to identify many of the brain
abnormalities that are the hallmark of progressive dementias such as the plaques and tangles of
Alzheimer's disease and the Lewy bodies of Lewy body dementia.

Treatment options for dementia

Treatment for dementia often relies on treating the underlying cause. If dementia is
caused by medication interactions or drug or alcohol abuse, it may be possible to reverse the
dementia by no longer taking the medication or substance. In some cases, dementia caused by a
brain tumor or lesion may be treated and resolved by removing the tumor or lesion. However the
damage the tumor or lesion caused to brain tissues and function can be permanent.

In the case of progressive dementias or dementias that are caused by brain injury, there is
rarely a cure. However, there are treatment options available that can minimize or stabilize
patients’ symptoms and in some cases delay the necessity of nursing home care.

There are certain medications that a physician may prescribe to try to reduce the
symptoms of dementia. Some of these medications are designed to maintain the levels of a
neurotransmitter in the brain called acetylcholine, which is important for brain function. Other
medications work to regulate the function of the neurotransmitter glutamate, which is important
for learning and memory.

Behavioral or psychiatric symptoms due to dementia may first be treated with non-drug
methods. This usually includes identifying the trigger for the symptoms and attempting to
resolve it. Many times this involves making adjustments to the environment that the patient lives
in – for example, simplifying the environment or increasing the time between stimulating events
(e.g. bath-time, getting dressed).

In addition to non-drug methods, a physician may recommend certain medications to control

behavioral or psychiatric symptoms. It is important that these medications be used according to
physician instructions. People with dementia are more likely to experience severe side effects
from these medications than other people. Medications that may be prescribed for patients with
behavioral or psychiatric symptoms include:
  Antidepressants to treat depression and low moods
 Anti-anxiety medications to treat anxiety or verbally disruptive behavior
 Anti-psychotic medication to treat hallucinations, delusions or aggression
 Sedatives to treat sleep problems

Some companies market herbal supplements as alternative treatment methods for dementia.
However, in most cases, these treatments have not been thoroughly tested. In addition, unlike
prescribed medication, they have not been approved and are not regulated by the Food and Drug
Administration (FDA). It is important to discuss the use of alternative treatment methods with a
physician before they are started. Some alternative remedies could interact with prescribed
medication or lead to more serious health complaints.

Prevention methods for dementia

Many types of dementia are poorly understood by scientists and have few prevention
methods. Vascular dementia is often caused by a stroke, therefore taking action to help protect
the body against stroke may be an effective prevention method for this type of dementia. This
can be achieved by eating a healthy diet, quitting smoking and controlling high blood pressure.
Some studies have shown that controlling systolic blood pressure (the top number of a blood
pressure reading) in people older than age 60 can help reduce the risk of dementia by up to 50
percent, according to the National Institute of Neurological Disorders and Stroke (NINDS).

Other potential prevention methods for dementia may include:

a. Reducing cholesterol

b. Lowering homocysteine levels

a. Reducing cholesterol levels

Some studies have linked high cholesterol levels with an increased risk of Alzheimer's
disease.
b. Lowering homocysteine

Related to high cholesterol levels, high homocysteine (an amino acid used to produce
proteins) has also been linked to an increased risk of both Alzheimer's disease and vascular
dementia.

Scientific studies have also indicated that remaining physically and mentally active
throughout life helps to keep the brain healthy, especially in later life. It is not known whether
physical and mental activity directly reduces the risk of dementia, but scientists agree that it
seems reasonable that keeping the body healthy will also keep the mind healthy.

Lifestyle considerations for dementia

Dementia can be frustrating and overwhelming for both the patient and the patient’s
friends and family.

Dementia may affect many aspects of the patient’s life. If the disease progresses, the
patient may not be able to drive or live independently. Daily activities can become more difficult
and many people with dementia experience some form of depression. People with severe or
degenerative dementias usually require constant supervision and care as the disease progresses to
its latter stages. People with dementia may also need to live in a simplified environment, which
may involve removing obstacles in the home that may cause harm, or moving the patient to a
long-term care facility.

Individual or group therapy may be a valuable outlet for both the patient and the patient’s
caregiver to discuss feelings of frustration or depression. It is important that the caregiver have
scheduled time off from the often intense supervision of the person with dementia.

Personality Disorders

Personality disorders are conditions in which a person has a lasting pattern of inner
experience and behavior that is significantly different from the expectations of the individual’s
culture. In addition, the disorder is pervasive and inflexible, begins in adolescence or early
adulthood and remains stable over time, leading to some form of distress or impairment.

A person’s personality is made up of lasting patterns of perceiving, relating to and

thinking about oneself and the surrounding environment. It is formed by a combination of
heredity and early life experiences and involves distinctive traits, behavior styles, attitudes,
thoughts and feelings.

A person with a healthy personality is able to form relationships with family, friends and
co-workers and to cope with everyday stresses that arise. However, those with personality
disorders have traits that cause them to think and behave in ways that are socially distressing.
They struggle to get along with other people and to have successful careers, tend to be inflexible,
and are unable to respond to life’s changes and demands. Despite these difficulties, people with
personality disorders usually believe their thoughts and behaviors are correct and are unable to
recognize the mental health disorder.

A person’s ethnic, cultural and social backgrounds also play a role in determining
whether a personality disorder exists. For example, the habits, customs, religious and political
values that appear inappropriate in one culture may be entirely appropriate in another.

The onset of personality disorders usually takes place no later than early adulthood.
However, in many cases the disorder is not diagnosed until years later. In addition, personality
disorders are rarely diagnosed in childhood and adolescence, because symptoms that appear
similar to those of a personality disorder are frequently examples of temporary conditions that
pass when the child enters adulthood.

Personality disorders often continue through adulthood, but in many cases they become
less prominent as a person reaches middle age. In other cases, a personality disorder may become
more prominent as patient ages. There is no cure for these disorders, but treatments can be
effective in helping patients to live more fulfilling lives.

Types and differences of personality disorders

 There are 10 major types of personality disorders. Each is categorized in one of three
different “clusters” based on its characteristic symptoms. The American Psychiatric
Association (APA) cautions that these categories have significant limitations, and that
individuals often have a combination of the different personality disorders.

1. Cluster A disorders

Cluster A disorders are characterized by odd or eccentric behavior. They often become less
prominent with age and include:

a. Paranoid personality disorder

b. Schizoid personality disorder

c. Schizotypal personality disorder

a. Paranoid personality disorder

Patients with this disorder frequently view the actions of others as intentionally
threatening or demeaning, and suspect others of lying or trying to exploit them. People with
paranoid personality disorder tend to be distrustful, unforgiving, emotionally detached, jealous
and prone to outbursts.

b. Schizoid personality disorder

Schizoid personality disorder is marked by introverted, withdrawn, solitary and

emotionally detached behaviors. People with this disorder are often self-absorbed and tend to
disregard others’ opinions. They fear intimacy with others, including members of their own
family.

c. Schizotypal personality disorder

Schizotypal personality disorder is characterized by a pattern of peculiarities, such as odd

or eccentric ways of speaking and dressing. People with this disorder may have trouble forming
relationships and may have extreme anxiety in social situations. They may have trouble
conversing appropriately with others and may talk to themselves. They may also display magical
thinking, believing they can influence people and events with their thoughts.

2. Cluster B disorders

Cluster B disorders are marked by dramatic, emotional or erratic behavior. They often
become less prominent with age and include:

a. Antisocial personality disorder

b. Borderline personality disorder (BPD)

c. Histrionic personality disorder

d. Narcissistic personality disorder

a. Antisocial personality disorder

Patients typically act out conflicts while ignoring rules of acceptable social conduct. They
tend to be impulsive, irresponsible, belligerent and callous, and may have violent, aggressive
relationships. They often lack respect for others, persistently steal or lie, and feel no remorse
about the effects of their behavior on others. People with antisocial personality disorder tend to
be at high risk for substance abuse problems.

b. Borderline personality disorder (BPD)

Borderline personality disorder (BPD) is characterized by instability in several areas of a

person’s life, including relationships, behavior, mood and self-image. Patients have difficulty
controlling emotions and impulses. They may also have a great fear of abandonment that leads to
an excessive dependency on others, while at the same time their behavior tends to push people
away.

c. Histrionic personality disorder

Histrionic personality disorder is characterized by an excessive need for others’ approval

and constant, sudden shifts in emotions. Patients are fixated on their physical appearance and
may use provocative clothing and behavior to gain attention. In many cases, these behaviors
result in little more than a false sense of intimacy with others.

d. Narcissistic personality disorder

Narcissistic personality disorder is marked by an inflated sense of self-importance,

intense focus on achievements and talents and fantasies of success. Despite feelings of
grandiosity, patients often fear failure and may complain of multiple physical symptoms. People
with narcissistic personality disorder seek constant attention and engage in attention-getting
behavior, but tend to exploit others.

3. Cluster C disorders

Cluster C disorders are distinguished by anxious, fearful behavior. These disorders often
become more prominent with age and include:
 a. Avoidant personality disorder (APD)

b. Dependent personality disorder

c. Obsessive-compulsive personality disorder

a. Avoidant personality disorder (APD)

Avoidant personality disorder (APD) is marked by a patient’s hypersensitivity to

rejection or criticism and fear of becoming involved with others. Symptoms associated with this
condition include excessive social discomfort, timidity and avoidance of social and work
activities that involve interpersonal contact. Patients are usually upset by an inability to form
close relationships outside the family circle.

b. Dependent personality disorder

Patients often exhibit a pattern of dependent and submissive behavior and rely on others
to make major decisions. They lack self-confidence, are easily hurt by criticism and disapproval,
and seek constant reassurance and advice. They will frequently tolerate poor treatment from
other people in order to maintain relationships.

c. Obsessive-compulsive personality disorder

Obsessive-compulsive personality disorder is marked by levels of perfectionism and

aspiration that are so high that they may struggle to make decisions or complete tasks. Patients
with this disorder are never satisfied with their achievements and tend to take on increasing
levels of responsibility. Although conscientious and dependable people, they are usually
inflexible, which makes it difficult to share responsibility with others or to adapt to changed
circumstances. They may feel isolated or helpless when their feelings are not under strict control
or when events are unpredictable. This condition should not be confused with obsessive-
compulsive disorder (OCD), which is an anxiety disorder that shares some of the same
symptoms but is considered more disabling.

Patients who have some symptoms of various personality disorders but not enough
symptoms of any one disorder to warrant a specific diagnosis may be diagnosed with a
personality disorder not otherwise specified. This designation also includes passive aggressive
behavior – a personality trait that no longer is officially recognized as a disorder by the APA.

Potential causes of personality disorders

The exact cause of personality disorders is not known. Many mental health experts
believe that early childhood trauma such as physical, sexual or emotional abuse may lead to the
eventual development of some personality disorders. For example, patients with borderline
personality disorder (BPD) report high rates of childhood sexual abuse. Other stressors that can
trigger these conditions include combat, natural disasters, kidnapping, torture and invasive
medical procedures.

In addition, studies have shown that some people may be genetically predisposed to
developing personality disorders. For example, patients with a family history of schizophrenia
are at higher risk of developing schizotypal, schizoid and paranoid personality disorders.
Obsessive-compulsive personality disorder and antisocial personality disorder also appear to
have a genetic component.

Other potential risk factors for developing personality disorders include an unstable
family life and a childhood head injury.

Avoidant, borderline, dependent and paranoid personality disorders are more likely to
occur in women, whereas antisocial personality disorder and obsessive-compulsive disorder are
more likely in men.

Signs and symptoms of personality disorders

The signs and symptoms associated with personality disorders differ depending on the
nature of the disorder. Personality disorders also raise the risk of several related behaviors and
conditions. Patients may become socially disconnected and find themselves both lacking the
desire for close relationships and having an inability to forge such relationships. They are also at
greater risk for developing depression, anxiety and eating disorder.

Other behaviors and conditions associated with personality disorders include:

 a. Crime

b. Homicide and other violence

c. Self-destructive behavior

d. Substance abuse

e. Suicide

a. Crime

People with antisocial personality disorder are at increased risk of committing crimes that
lead to incarceration.

b. Homicide and other violence

People with paranoid and antisocial personality disorders are more likely to engage in
aggressive behavior.

c. Self-destructive behavior

People with borderline personality disorder often engage in destabilizing behaviors such
as gambling or risky sex. People with dependent personality disorder are so desperate to remain
in relationships that they may place themselves at risk of physical, emotional and sexual abuse.

d. Substance abuse

The risk is highest among people with personality disorders in cluster B.

e. Suicide

The risk is highest among people with personality disorders in cluster B, especially if
they also suffer from major depression and alcoholism.

Diagnosis methods for personality disorders

In most cases, patients with personality disorders do not recognize that they need
treatment. It is more likely that patients will be diagnosed with a personality disorder while
seeking treatment for a related mental health condition, such as substance abuse or depression. In
some cases, patients will seek this help on their own whereas in others, family or friends may ask
them to seek help.

There are no specific tests that are used to diagnose personality disorders. A physician
will instead ask questions about the patient’s well-being and perform a complete physical
examination that includes a medical history.

Questions that a physician may ask patients include:

i. Are they experiencing any relationship difficulties?

ii. Are they having any problems in the workplace?

iii. What types of behaviors are contributing to such difficulties?

In addition, a physician may request to talk to relatives and friends about a patient’s behavior
to get perspectives separate from that of the patient. If a primary care physician suspects the
presence of a personality disorder, the patient may be referred to a psychiatrist, psychologist or
other mental health professional.

The criteria for diagnosing a personality disorder depend on the disorder that is present.
However, there are some criteria that are common to all personality disorders. A personality
disorder is diagnosed when there is an enduring pattern of personal experience and behavior that
sharply differs from the expectations within an individual’s culture. This pattern must appear in
two or more of the following areas:
 i. Cognition (ways of perceiving and interpreting the self, other people and events)

ii. Affectivity (the range, intensity, and appropriateness of emotional response)

iii. Interpersonal functioning

iv. Impulse control

In addition, the enduring pattern of the patient’s experience and behavior must be inflexible
and widely spread across a range of personal and social situations, and must lead to significant
distress or impairment in social, occupational or other areas of functioning.

The behavior pattern must be stable and must date back to at least adolescence or early
adulthood. Other mental illnesses must also be ruled out prior to diagnosis. In addition, the
enduring pattern cannot be due to the direct physiological effect of a substance or a general
medical condition.

The following are examples of criteria for individual disorders established by the American
Psychiatric Association (APA). Unless otherwise noted, these criteria must be present by early
adulthood and in several contexts:

1. Cluster A disorders

a. Criteria for Paranoid personality disorder

Distrust and suspicion of others such that motives are interpreted as sinister. Symptoms may
include:

 Suspects others are exploiting or harming the patient despite lacking supporting evidence

 Unjustified doubts about others’ loyalty and trustworthiness

 Reluctant to confide in others due to unwarranted fear of how information may be used

 Reads negative meanings into others’ remarks

 Persists in bearing grudges

  Perceives attacks on character

 Suspects spouse’s infidelity

b. Criteria for Schizoid personality disorder

There is pattern of detachment from social relationships and restricted expression of

emotions in interpersonal settings. Symptoms may include:

 Neither desires nor enjoys close relationships, even with family

 Almost always chooses solitary activities

 Has little desire for sexual experiences with another person

 Takes pleasure in few activities

 Lacks close friends

 Indifferent to others’ praise or criticism

 Emotionally cold

c. Criteria for Schizotypal personality disorder

There is pattern of acute discomfort with close relationships, distorted thinking and
perceiving or eccentric behavior. Symptoms may include:

 Personalizing external events

 Odd beliefs or magical thinking that influences behavior

 Unusual perceived experiences, including bodily illusions

 Odd thinking and speech

 Suspiciousness or paranoid ideas

  Inappropriate, odd, stiff behavior

 Lack of close friends

 Excessive and lasting social anxiety

2. Cluster B disorders

a. Criteria for Antisocial personality disorder

Disregard for and violation of the rights of others that has occurred since age 15. Individual
must currently be at least 18 years of age. Symptoms may include:

 Failure to conform to social norms and laws

 Deceitfulness including repeated lying, use of aliases or conning others for personal
profit or pleasure

 Impulsiveness or failure to plan ahead

 Irritability and aggressiveness

 Reckless disregard for safety

 Consistent irresponsibility

 Lack of remorse
b. Criteria for Borderline personality disorder

There is pattern of instability in interpersonal relationships and self-image. Symptoms may

include:

 Frantic efforts to avoid real or imagined abandonment

 Pattern of unstable and intense interpersonal relationships

 Unstable self-image with impulsive behavior in at least two areas that are potentially self-
damaging (spending, sex, binge eating)

 Recurrent suicidal thoughts or behavior and/or self-injury (e.g., cutting)

 Unstable moods

 Feelings of emptiness, loneliness

 Inappropriate, intense anger

 Stress-related paranoid ideas

c. Criteria for Histrionic personality disorder

There are excessive emotions and attention-seeking behavior. Symptoms may include:

 Discomfort in situations in which the patient is not the center of attention

 Interactions characterized by inappropriate sexually seductive or provocative behavior

 Rapidly shifting and shallow expression of emotions

 Draws attention to self with physical appearance

 Emotionally intense speech

 Tendency to be dramatic and theatrical

  Easily influenced by others/circumstances

 Considers relationships to be more intimate than they are

d. Criteria for Narcissistic personality disorder

There is pattern of inflated concept of identity, need for admiration and lack of empathy.
Symptoms may include:

 Grandiose sense of self-importance

 Preoccupation with fantasies of unlimited success, power, brilliance, beauty or ideal love

 Belief that patient is “special” and can only be understood by high-status people

 Need for excessive admiration

 Sense of entitlement

 Takes advantage of others

 Lacks empathy

 Envious of others, or believes others are jealous of patient

 Arrogance and haughty behaviors

3. Cluster C disorders

a. Criteria for Avoidant personality disorder (APD)

There is patterned social inhibition, feelings of inadequacy and hypersensitivity to

criticism. Symptoms may include:

 Avoiding work/school activities that involve significant interpersonal contact

 Unwillingness to get involved with people unless certain of being liked

  Restraint in intimate relationships because of the fear of being shamed or ridiculed

 Preoccupation with being criticized/rejected in social situations

 Inhibited in new relationships by fear of inadequacy

 Views self as socially inept or inferior

 Reluctant to take personal risks for fear of embarrassment

b. Criteria for Dependent personality disorder

Excessive need to be taken care of that leads to submissive, clinging behavior and fears of
separation. Symptoms may include:

 Difficulty making everyday decisions without excessive advice and reassurance from
others

 Need for others to assume responsibility for most major areas of the patient’s life

 Difficulty expressing disagreement with others for fear of loss of support or approval

 Difficulty initiating things by oneself

 Goes to great lengths to get support

 Feels helpless when alone

 Seeks a relationship quickly when another relationships ends

 Preoccupied with fears of being left alone

c. Criteria for Obsessive-compulsive personality disorder

There is preoccupation with orderliness, perfectionism and mental and interpersonal control.
Symptoms may include:
  Preoccupation with details, rules, lists, order, organization or schedules to the extent that
the major point of the activity is lost

 Perfectionism that interferes with finishing tasks

 Devoted to work and productivity to the exclusion of leisure activities and friendships

 Over conscientious and inflexible about morality and ethics

 Unable to discard worn-out objects

 Reluctant to delegate tasks

 Adopts miserly spending patterns

 Rigid and stubborn

In teenagers, many of the signs and symptoms of personality disorders are merely part of a
phase of life that will disappear with maturity. Therefore, special caution should be taken when
the diagnosis of one of these disorders is being considered for a teenage patient.

Treatment options for personality disorders

Treatment of personality disorders can be very difficult, as patients often have difficulty
trusting and confiding in a therapist. In addition, they may react angrily to perceived criticism
and may be at risk for suddenly discontinuing treatment. Nonetheless, treatments can have a
significant impact in improving a patient’s quality of life, particularly in patients who are highly
motivated and willing to commit to therapy over the long term.

Psychotherapy is the major form of treatment for individuals with personality disorders
and may take the form of individual therapy, group therapy or family therapy. It is aimed at
trying to reduce the behavior patterns associated with personality disorders that may interfere
with day-to-day living. Patients are encouraged to focus on the unconscious conflicts that may be
contributing to symptoms. They also are encouraged to examine the impact of their behavior on
others and to use cognitive behavior therapy (CBT) to become more flexible in thinking and
behavior patterns.

Through all of these techniques, patients can learn to overcome difficulties such as an
inability to make important life decisions or to form relationships.

Medications such as

 Antidepressants

 Anticonvulsants

 Antipsychotic

 Anti-anxiety medications

 Mood stabilizers

may also be used to treat personality disorders.

Mental Retardation

Mental retardation is a significantly below average intelligence combined with difficulty

adapting and functioning in daily life. All patients with mental retardation require some degree
of support. To be diagnosed with mental retardation, the condition must occur before adulthood
(generally recognized as an age of 18 years).

Most cases of mental retardation are mild, and many people with mental retardation can
live full, healthy lives. However, other physical problems may be present depending on the cause
of the mental retardation. According to the Centers for Disease Control and Prevention (CDC),
mental retardation is the number one long-term condition that causes major activity limitations in
America.
 The severity of mental retardation is most frequently measured by the patient’s intelligence
quotient (IQ). The average IQ is 100 and “normal” intelligence ranges from an IQ of 90 to 110.
People with an IQ of about 70 to 89 are considered below average, but not mentally retarded.
The severity of mental retardation is divided into five categories:

 Mild retardation. IQ ranging from between 50 and 55 to about 70.

 Moderate retardation. IQ ranging from between 35 and 40 to between 50 and 55.
 Severe retardation. IQ ranging from between 20 and 25 to between 35 and 40.
 Profound retardation. IQ below 20 or 25.
 Unspecified. IQ cannot be tested, but is assumed to be low.

There is some overlap in IQ between each of these categories. When a patient’s IQ falls in
this overlap, his or her level of functioning is used to determine severity. For example, a patient
with an IQ of 52 and a higher level of functioning would be considered to have mild retardation.
However, a patient with an IQ of 53 and a lower level of functioning would be considered to
have moderate retardation.

In some cases, the severity of mental retardation is determined by how much and what kind
of support is required. However, this can be vague and some physicians and scientists do not find
it as useful as categorizing severity by IQ ranges.

Patients with mental retardation face numerous difficulties, including problems with
communication, self-care skills, social situations and school activities. They tend to develop
these and other skills more slowly than average.

Childhood issues for mental retardation

Screening for developmental delays, including mental retardation, begins at birth.

However, mental retardation is not usually diagnosed until much later, often when parents notice
that a child is lagging behind peers or siblings. In general, the more severe the retardation, the
earlier it is noticed. Mild cases may not be detected until the child begins school. The earlier
mental retardation is identified, the better. If treatment and learning assistance begins early,
levels of functioning can be increased and cognitive disabilities can be reduced.
 All children with mental retardation require an ever-changing educational and training
program that is individualized especially for their abilities and needs. These programs are
guaranteed by the federal government through the Individuals with Disabilities Education Act
(IDEA). This law regulates early intervention and special education services (provided by local
schools) for all children with disabilities.

Young children with mental retardation may need assistance developing certain basic
skills (e.g., motor skills, speech and language skills). These children are eligible for early
intervention services, which may be available at little or no charge to parents. These services
include an Individualized Family Services Plan (IFSP). This plan evaluates the unique needs and
goals for each child and devises methods to address them.

Early intervention services frequently focus on adaptive skills. These are the skills that
allow an individual to live, work and play in his or her community. They include communication
skills, self-care skills (e.g., dressing, bathing, toilet training), health and safety lessons, home
skills (e.g., making the bed, cleaning the bedroom, setting the table) and social skills (e.g.,
manners, rules of conversation, group structure and playing games).

Once children with mental retardation reach school-age, an Individualized Education

Plan (IEP) replaces the IFSP. Like the IFSP, the IEP evaluates and addresses the unique needs
and goals of a child. However, the plan is now more geared toward academics and school.
Children with mental retardation require a special setting, including individual attention and
support. However, many children with mild mental retardation may attend regular classes with
other children their age, although they still require personal assistance from a teacher or aide,
both in and out of the classroom. The education of children with mental retardation focuses on
lifelong vocational pursuits. A particular interest or talent may be honed, with special vocational
training or exposure to the job setting. For example, a child with an interest in cars may be
educated with a strong focus towards machines and mechanics.

Children with mental retardation often can participate in many activities (e.g., sports,
dance, music, art) with other children their age who do not have developmental disabilities. Their
abilities to participate in these activities depend on their overall physical condition, including any
condition that may have caused their mental retardation.
 It is important that children with mental retardation are treated kindly and fairly. They
may realize that they are behind other children their age in development and academics. In some
cases, they may be bullied. Some of these children suffer from frustration or anxiety and some
may act out in order to gain attention. Children with mental retardation need encouragement and
support to prevent or overcome these potential obstacles.

Severe and profound mental retardation can lead to other problems. Children with such
retardation may never learn adequate self-care or communication skills. There is some
controversy as to whether these children are better suited to residential settings that include
special education and extensive services or to community group homes and other smaller, more
normal environments.

There are a number of steps parents, caretakers and teachers of children with mental
retardation can take to help the child. It is important to encourage independence, including
teaching adaptive skills whenever possible. The presentation of tasks and information needs to be
concrete and clear. Breaking tasks and new information into smaller steps and facts and giving
immediate feedback tends to help these children learn. Appropriate chores, with special attention
to the child’s age, attention span and abilities, can make the child feel productive and
independent. Socialization (e.g., scouts, recreational center activities, sports) can help build
social skills and allow the child to have fun with other children of similar age. The child’s
strengths and interests can be emphasized both in the classroom and at home.

Adolescent issues for mental retardation

As a child with mental retardation enters adolescence, his or her education may focus
more on skills for independent living, such as work skills, using public transportation, social
adaptation and managing money. The emphasis on individual strengths and interests and related
vocations becomes even stronger at this point, making specialized vocational training a major
goal.

Adolescents with mental retardation may become depressed. Depending on the severity
of retardation, they may lack communication skills to express their feelings. This may result in
other problems, such as eating or sleeping disorders. It is important to be attentive to these and
similar problems and address them quickly.
 Adolescents with mild retardation can usually look forward to living at least semi-
independently once they reach adulthood. Those with more severe forms may require more direct
care from a family member or other caretaker throughout their lives.

Risk factors and causes of mental retardation

Hundreds of specific causes of mental retardation have been identified. Many of these are
multiple congenital anomaly/mental retardation syndromes. These include any condition
characterized by mental retardation as well as multiple birth defects. However, in nearly a
quarter of all cases, the cause of mental retardation is not known.

Any brain injury or developmental problem in the brain may result in mental retardation.
Such problems may occur before, during or after birth. Prenatal causes of mental retardation
include genetic disorders (e.g., Down syndrome, Fragile X syndrome, phenylketonuria),
infections in the mother or fetus during pregnancy (e.g., rubella, cytomegalovirus, chickenpox)
and exposure to various teratogens during pregnancy. A teratogen is any chemical, substance or
other harmful agent that may cause birth defects to a developing fetus. These include certain
medications, alcohol, recreational drugs, smoking, and radiation. Prenatal conditions, especially
chromosomal disorders or other genetic conditions, are by far the most common cause of mental
retardation. Asphyxia (lack of oxygen to the brain) and other problems during delivery may also
cause mental retardation. However, problems during delivery only rarely result in mental
retardation.

Although the development of mental retardation in infancy or childhood is rare, it can

occur due to several potential causes. Serious infections in infancy (e.g., meningitis, whooping
cough, measles) and serious head injuries (e.g., shaken baby syndrome, head trauma) are
important postnatal causes. Lead or mercury poisoning, suffocation, stroke and extreme
malnutrition can also cause mental retardation. Infants who are born premature or with a low
birthweight may also have an increased risk. There also seems to be an association between the
age of the mother during the pregnancy and the risk of mental retardation in the child.

Conditions associated with mental retardation

 Most causes of mental retardation are present at birth (congenital). Some of these are major
causes. Others are quite rare or only occasionally lead to mental retardation. Some of the major
congenital conditions associated with mental retardation include:

a. Down syndrome

b. Fragile X syndrome

c. Fetal alcohol syndrome

d. Cerebral palsy

e. Phenylketonuria

a. Down syndrome

It is a common genetic disorder that is among the most common causes of mental retardation.
It is also characterized by slow growth and abnormal facial features. Heart defects are also
common. Down syndrome is more common in children born to older mothers.

b. Fragile X syndrome

It is a common genetic disorder that is a major cause of mental retardation in boys. It affects
boys more frequently and more severely than girls. Other characteristics include shyness and
social anxiety, learning disabilities, and autistic features (e.g., poor eye contact, odd movements).

c. Fetal alcohol syndrome

It is a collection of birth defects and other problems caused by maternal alcohol consumption
during pregnancy. Characterized by a low birthweight, abnormal facial features, behavioral
problems and delayed development, including mental retardation.

d. Cerebral palsy
 It is a condition that causes brain damage and affects muscle control. The degree of
impairment varies greatly among patients. Mental retardation and other neurological disorders
(e.g., seizures) also occur in over half of all patients with the condition.

e. Phenylketonuria

It is a metabolic abnormality in which protein is not properly processed and builds up in

the bloodstream. It leads to mental retardation if left untreated, but early treatment with a special
diet can be used to prevent brain damage.

Other conditions that often result in mental retardation, but are usually rare include:

a. Miller-Dieker syndrome

b. Rubinstein-Taybi syndrome

c. Johanson-Blizzard syndrome

d. Williams syndrome

e. Prader-Willie syndrome

f. Hunter syndrome

g. Noonan syndrome

h. Thrombocytopenia absent radius (TAR) syndrome

i. Dubowitz syndrome

j. Ohdo blepharophimosis syndrome

k. Smith-Lemli-Opitz syndrome

l. Shprintzen syndrome

a. Miller-Dieker syndrome
 It is a disorder characterized by an abnormally smooth brain surface (lissencephaly). This
tends to result in severe mental retardation and other developmental problems, seizures and
abnormal facial features.

b. Rubinstein-Taybi syndrome

It is a genetic condition associated with moderate to severe mental retardation. Other

characteristics include short stature, abnormal facial features, and broad thumbs and first (“big”)
toes.

c. Johanson-Blizzard syndrome

It is a rare genetic disorder that typically causes moderate mental retardation. However, some
patients may have mild retardation or normal intelligence. Other characteristics include an
abnormal nose that is small or “beak shaped,” tooth abnormalities, low birthweight and problems
with digestion, the pancreas and the thyroid.

d. Williams syndrome

It is a rare genetic condition associated with mild to moderate mental retardation and learning
disorders. It is characterized by abnormal facial features that may be described as “elfin-like,”
low muscle tone (hypotonia), loose joints, poor growth during infancy and early childhood, and
heart and blood problems.

e. Prader-Willie syndrome

It is a rare genetic disorder characterized by obesity due to constant, insatiable hunger. It is

also associated with mental retardation and decreased muscle tone.

f. Hunter syndrome

It is a rare metabolic disorder that only affects boys. It causes certain enzymes to build up
and damage body tissues. It is characterized by abnormal facial features, mental retardation,
hyperactivity, stiff joints, enlarged organs (e.g., liver, spleen) and hearing loss.
g. Noonan syndrome

It is a genetic disorder that causes abnormal development. It is associated with abnormal

facial features, mental retardation, short stature, delayed puberty and congenital heart disease.

h. Thrombocytopenia absent radius (TAR) syndrome

It is a rare genetic disorder caused by low platelet levels (thrombocytopenia). It is

characterized by potentially severe bleeding, which is worst during infancy. It often causes
mental retardation, possibly due to bleeding in the brain. Other characteristics include
underdevelopment or absence of the bones in the forearms, congenital heart disease and kidney
defects.

i. Dubowitz syndrome

It is a very rare genetic disorder with a wide range of signs and symptoms that may vary
widely in severity between patients. Common signs and symptoms include mental retardation
(usually mild), short stature, abnormal facial features, small head size and eczema.

j. Ohdo blepharophimosis syndrome

It is a condition characterized by an inability to open the eye fully (blepharophimosis) and

drooping eyelids. It is also associated with developmental delays, including mental retardation,
tooth abnormalities, deafness, and congenital heart disease.

k. Smith-Lemli-Opitz syndrome

It is a condition that occurs primarily in Caucasians. It is characterized by abnormal facial

features, a small head size, mental retardation or learning disabilities, behavior problems, low
muscle tone, and defects in the heart, lungs, kidneys, digestive tract and/or genitalia.
l. Shprintzen syndrome

It is also called velocardiofacial syndrome, this genetic condition is characterized by

abnormalities in the back of the mouth and top of the throat, which cause speech problems. It is
also associated with developmental delays, including mental retardation, congenital heart disease
and abnormal facial features.

Other conditions that may occasionally result in mental retardation include:

a. Adams-Oliver syndrome

b. Oculoauriculovertebral dysplasia

c. Weaver syndrome

d. Asymmetric crying facies syndrome

e. Beckwith-Wiedemann syndrome

f. Chondroectodermal dysplasia

g. Pallister-Hall syndrome

a. Adams-Oliver syndrome

It is a rare condition that affects the scalp and cranium. It is associated with limb
abnormalities and, occasionally, mental retardation.

b. Oculoauriculovertebral dysplasia

It is a rare genetic disorder with widely varying signs and symptoms that may occur in
some patients but not in others. Some abnormalities in the cheeks, jaw, mouth, ears, eyes, and/or
spinal column are usually present. They may occur on both or only one side of the body. Mild
mental retardation may also be present.

c. Weaver syndrome
 It is another condition characterized by rapid growth. It is associated with increased
muscle tone (hypertonia), exaggerated reflexes (spasticity), foot deformities, and developmental
delays, which may include mental retardation.

d. Asymmetric crying facies syndrome

It is a condition caused by an underdeveloped facial muscle that causes the right and left
side of the face to be misbalanced and look unmatched (asymmetry), particularly when smiling
or crying. It is often associated with congenital heart disease.

e. Beckwith-Wiedemann syndrome

It is a rare disorder that causes rapid growth. It is characterized by large body size, a large
tongue, enlarged organs and kidney problems.

f. Chondroectodermal dysplasia

It is also called Ellis-van Creveld syndrome, this rare form of dwarfism is most common
among the Pennsylvania Amish. It is characterized by short forearms and lower legs, extra
fingers and toes (polydactyly), abnormal nails and teeth and heart defects.

g. Pallister-Hall syndrome

It is a wide-ranging disorder than may be very mild and nearly unnoticeable or severe and
life-threatening. When mild, it is associated with extra fingers or toes and bifid epiglottis (split in
the tissue that blocks food from entering the windpipe). When severe, it is characterized by a
split in the windpipe, resulting in death shortly after birth. More moderate forms may lie
anywhere between these two extremes.

Signs and symptoms of mental retardation

 Children with mental retardation tend to have trouble learning and adapting to their
environment. At very young ages, including infancy, they may seem to be in their own world
(e.g., not interacting with the world around them). For example, they may not respond to their
own reflections. They develop many skills and reach many developmental milestones at a later
age than other children. For example, they often sit up, crawl, or walk at an older age, or develop
social skills (e.g., understanding social rules and the consequences of their actions), self-care
skills (e.g., dressing and eating without assistance) and speech and language skills later.

Children with mental retardation may have trouble learning in school (e.g., difficulty
solving problems or thinking logically). In general, the more severe the mental retardation, the
sooner these delays are apparent. Mild mental retardation may not be noticed until the child
reaches school-age. In most cases, children with mental retardation have a greater delay in
language skills than in other areas of development.

Some behavioral problems may occur in children with mental retardation. These include
eating disorders, such as pica (desire to eat non-food items) and rumination (bringing up already
swallowed food to re-chew), and self-stimulating movements (e.g., head-banging). These
problems are less common in mild retardation and more common in more severe forms.

Diagnosis methods for mental retardation

In some cases, prenatal tests (e.g., blood tests, ultrasound) may indicate whether a child
may have a condition (e.g., a birth defect) that can cause mental retardation. For instance,
ultrasound is among the most common prenatal tests. A fetal ultrasound can indicate whether a
fetus may have Down syndrome.

Amniocentesis may also be performed to evaluate the likelihood of mental retardation. In

amniocentesis, a needle is inserted into the uterus through the mother’s abdomen and a sample of
amniotic fluid is extracted for testing. Chorionic villus sampling (CVS), which involves
removing a sample of the placenta, may also be useful. Karyotypes (tests that allow a physician
to evaluate the patient’s genetic structure) can be performed using both amniocentesis and CVS.

Diagnosing mental retardation after birth relies on an evaluation of how well the patient
thinks and functions. A certified psychologist is typically required for an accurate diagnosis. This
psychologist must be able to give, score and interpret standardized intelligence tests for the
individual child and must be able to observe the child for how well he or she functions in daily
life.

Several different standardized intelligence tests are available, with different tests
appropriate for different ages. The Wechsler Intelligence Scales are the most commonly used
intelligence tests for children older than 3 years. The Wechsler Scales include separate tests for
children older and younger than 6 years, although a functional age is more important than a
chronological age in this division.

This means that a child of 7 years who functions on a level closer to children of 5 years
would be given the test directed towards the younger children. The Stanford-Binet Intelligence
Scale may be used instead of the Wechsler Scales for school-aged children. Both of these scales
focus on verbal skills. The Wechsler Scales also evaluates general performance skills, while the
Stanford-Binet Scale evaluates thinking, memory and reasoning skills. The scores of different
intelligence tests do not typically correlate with each other. In general, the tests for school-aged
or older children are much more accurate than those for younger children.

While observing the child, the psychologist will be looking for self-care skills (e.g., toilet
training, eating, and dressing), communication skills and social skills. These skills may also be
evaluated using a test called the Vineland Adaptive Behavior Scale. If the child is under the age
of about 3-1/2 years, the Bayley Scales of Infant Development may be used.

Children who may have mental retardation also require a thorough examination,
including a physical examination and an evaluation of their medical history. The medical history
evaluation typically includes a thorough developmental history, including the progress of the
pregnancy and delivery of the child. The child will also require periodic re-evaluations to
monitor the condition. This allows any changes that may affect treatment to be noted.

Children with mental retardation are frequently tested for underlying conditions (e.g.,
Down syndrome, Fragile X syndrome) that may have caused their retardation. However, this is
not always necessary or beneficial. Many causes of mental retardation are unknown, so many of
these tests cause further financial and other burdens to the child’s family without providing any
information. Physicians take many factors into consideration when deciding whether or not to
perform these additional tests. These factors include the severity of the child’s mental
retardation, whether or not the child appears to be at risk for a condition or a diagnosis seems
likely, and parental concerns.

Testing is also more important if the child’s parents intend to have more children. If the
mental retardation has a genetic cause, subsequent children may be at an increased risk of mental
retardation as well.

Various tests may also be employed in an attempt to determine the cause of the mental
retardation. This may include neuroimaging, blood tests and electroencephalograms (EEG).
Karyotyping may be needed for children who may have a genetic disorder related to their
chromosomes. If a condition that increases a child’s risk for mental retardation was noted during
newborn screening tests, tests may be performed to ensure that it is still under control.

Treatment options for mental retardation

All children with mental retardation require a comprehensive evaluation to examine their
own unique strengths, weaknesses and needs. This may require several different specialists, but
typically includes a developmental pediatrician (a physician who specializes in child
development).

Most cases of mental retardation are mild. These children can usually function at a near-
normal level and, as adults, may be able to live independently. However, more severe cases
require more constant support, often throughout life.

Children with mental retardation may require therapy and special training to learn many life-
skills. This therapy may frequently be started before the child reaches school-age. It may include
speech therapy (to improve communication skills), physical therapy (to improve motor skills)
and special tutelage in other skills (e.g., social skills, work skills). Most children with mental
retardation also require special schooling with an emphasis on individual attention and
assistance.

A child’s pediatrician can help parents find local resources, such as early intervention
agencies, support services and current literature and media. Local schools are another excellent
source of information.
 With comprehensive management, many children with mental retardation are able to
vastly improve their levels of functioning. Sometimes, children with mild retardation no longer
meet the criteria for retardation once they enter adulthood. Even children with more severe forms
of mental retardation can greatly improve their ability to function. With time and training, their
retardation may become less severe.

Prevention methods for mental retardation

In many cases, mental retardation cannot be prevented. However, there are many steps
both parents and children can take to help prevent mental retardation or reduce the child’s risk of
developing it.

Many prevention methods begin before and during pregnancy. Genetic counseling can
help evaluate a couple’s risk of having a child with a condition linked to mental retardation (e.g.,
Down syndrome). It is important for women to get any medical conditions under control and to
get any needed vaccinations (e.g., rubella) several months before becoming pregnant. Certain
blood tests can help evaluate a couple’s risk factors. For instance, blood tests can identify the
likelihood of having a baby with Fragile X syndrome, a major cause of retardation.

While pregnant, a woman can reduce the risk of having a child with mental retardation by
eating right, including plenty of calories and folic acid, and avoiding teratogens (harmful
substances, such as alcohol or recreational drugs).

After a child is born, there are ways to help prevent the development of mental retardation.
Newborn screening tests check for conditions that can cause mental retardation (e.g.,
phenylketonuria). If these conditions are treated early, mental retardation can often be prevented.

Another important step in the prevention of mental retardation is to prevent head injuries.
Steps that can help prevent head injuries include:

a. Never shake an infant

b. Be careful to not drop an infant

c. Use car safety measures

d. Vaccinate children
 e. Protect children from falls

f. Encourage children to wear helmets

a. Never shake an infant

This may result in shaken baby syndrome, with can lead to mental retardation and infant
death.

b. Be careful to not drop an infant

Never leave an infant unattended on a changing table or other surface they could fall from.
Any blow to the head could result in brain damage.

c. Use car safety measures

Always use car seats, booster seats, or other child restraints, as appropriate for the child’s
age, when in an automobile.

d. Vaccinate children

Vaccinate children against common and serious infections, as directed by a pediatrician.

Many infections can lead to mental retardation. However, there are now highly effective
vaccinations for many of these.

e. Protect children from falls

Children should be encouraged to use guard rails when using stairs and should not stand
close to the edges of balconies, cliffs and other high places.

f. Encourage children to wear helmets

 All children should wear appropriate helmets when biking or skating. Certain sports (e.g.,
football, hockey) should only be played with appropriate helmets, as well.

Sexual Disorders

Sexual disorders are conditions that prevent people from having rich and fulfilling sexual
relationships. These disorders involve problems related to sexual functioning, desire or
performance. A person with one of these conditions may have physical or emotional difficulty
enjoying sexual activity, or may have sexual feelings that most people do not consider to be
conventional.

In some cases, sexual disorders begin very early in a person’s life, whereas other people
may develop these conditions later in life after enjoying many years of healthy sexual activity.
These disorders appear in a variety of forms.

Some sexual disorders occur suddenly, whereas others develop slowly over time. Patients
may experience a partial inability to perform part of a sex act, or may be completely disinterested
in any type of sexual activity. The disorder itself may be related to a physical problem, a
psychological condition or a combination of both.

Types of sexual disorders

Sexual disorders can be divided into three categories

1. Sexual dysfunctions

2. Paraphilias

3. Gender identity disorders

1. Sexual dysfunctions

Sexual dysfunctions are persistent or recurrent problems that occur during the various stages
of sexual response.
These stages are described as

 Appetitive (desires and fantasies about sexual activities)

 Excitement (feelings of pleasure and physiological change)

 Orgasm (release of sexual tension at the height of sexual excitement)

 Resolution (general relaxation and a sense of well-being)0

Sexual dysfunctions include:

a. Low sexual desire disorders

b. Sexual arousal disorders

c. Orgasmic disorders

d. Sexual pain disorders

e. Secondary and other sexual dysfunctions

a. Low sexual desire disorders

Patients may have an extremely low desire for sex. Low sexual desire disorder occurs
when patients are not generally interested in sex, but may perform adequately after sexual
activity has begun. Sexual aversion disorder is marked by a feeling of disgust toward the notion
of sexual activity.

b. Sexual arousal disorders

Patients are interested in sex, but not enough to complete a sex act. In female sexual
arousal disorder, a woman may not achieve adequate levels of lubrication to permit vaginal sex.
In male erectile disorder, the penis may not achieve an erection sufficient to begin or complete
sex.

c. Orgasmic disorders

Patients are partially or completely unable to experience sexual climax. This may occur
despite adequate sexual interest and arousal. Female orgasmic disorder occurs when a woman
experiences either a delayed or nonexistent climax, whereas male orgasmic disorder involves the
same criteria for males. In addition, males may experience premature ejaculation, which involves
repeated climaxes before, during or shortly after penetration.

d. Sexual pain disorders

These disorders involve pain during the sex act. In dyspareunia, either a woman or man
feels genital pain at some point during intercourse, particularly during insertion. Vaginismus is a
severe spasm of the vagina that prevents penetration.

e. Secondary and other sexual dysfunctions

Sexual dysfunction due to a general medical condition (involving anatomical or other

physical problems) and substance-induced sexual dysfunction (caused by intoxication or
withdrawal from alcohol or drugs) may feature symptoms listed in the disorders above. Sexual
dysfunction not otherwise specified is used when the sexual disturbances do not meet criteria for
any specific sexual dysfunction. A lack of sexual interest may be caused by another mental
disorder, such as somatotization disorder, depression or schizophrenia.

2. Paraphilias

Paraphilias are a class of sexual disorder that involves behaviors most people find distasteful,
unusual or abnormal, and that are associated with clinically significant distress or disability. The
word paraphilia means “abnormal or unnatural attraction.” Patients with paraphilias have sexual
desires that relate to objects or animals (other than humans), humiliation or suffering of oneself
or one’s partner, or nonconsenting partners. Desires or fantasies usually are not usually
sufficient to diagnose a paraphilia; more commonly, the patient must actually act on these desires
before a diagnosis is made. Paraphilias usually begin in adolescence and affect males almost
exclusively. Many types of paraphilias – such as pedophilia, exhibitionism and voyeurism –
involve acts that are against the law in many societies.
 Four types of paraphilias occur more commonly than the rest. These disorders may be
identified through crimes perpetrated against another person.

They include the following (in descending order of frequency):

a. Pedophilia

b. Exhibitionism

c. Voyeurism

d. Frotteurism

a. Pedophilia

Pedophilia urges involving sexual activities with children.

b. Exhibitionism

Exhibitionism involves a compelling urge to display one’s genitals to people who do not
expect it.

c. Voyeurism

Voyeurism is sexual urges related to watching an unsuspecting person disrobe or engage

in sexual activity.

d. Frotteurism

It is compelling urge to rub one’s genitals against a person who has not consented to such
an action.

Other paraphilias occur much less commonly than those listed above. These include:

a. Fetishism

b. Sexual masochism
 c. Sexual sadism

d. Transvestic fetishism.

e. Paraphilia not otherwise specified

a. Fetishism

Sexual urges related to the use of inanimate objects.

b. Sexual masochism

Sexual masochism is sexual satisfaction from being bound, humiliated or injured.

c. Sexual sadism

Sexual sadism is sexual satisfaction from inflicting suffering or humiliation on someone

else.

d. Transvestic fetishism

Transvestic fetishism is sexual urges on the part of a heterosexual man that are related to
the act of cross-dressing.

e. Paraphilia not otherwise specified

There are many paraphilias that are either so rare or unstudied that they have not received
official classifications to date. These include sexual urges involving specific parts of the human
anatomy (partialism), corpses (necrophilia), animals (zoophilia), feces (coprophilia), urine
(urophilia), enemas (klismaphilia) or making obscene phone calls (telephone scatalogia). .

3. Gender identity disorders

 Involve feelings of strong identification with the gender opposite to that of the person. There
is some controversy in the psychological community whether gender identity issues should still
be regarded as sexual disorders.

Gender identity disorders involve feelings of strong identification with the opposite gender.
These disorders are not related to sexual preference. Patients feel uncomfortable with their own
gender roles and some patients detest their genitals. In many cases, these patients begin wearing
clothing associated with the opposite sex. Some patients request hormone therapy that helps
them develop sexual characteristics of the opposite gender (e.g., breasts), whereas others undergo
sex-change operations. Intersex conditions (such as hermaphroditism, in which a person has
genitalia and secondary sexual characteristics of both genders) and people with ambiguous
sexual assignment may be classified in the category general identity disorder not otherwise
specified.

Whether gender identity disorders will remain categorized as sexual disorders is uncertain.
There is significant controversy over whether transgendered or intersexed persons should be
considered to have a mental health disorder. The concept that heterosexuality is the only normal
form of sexual expression has been and will continue to be questioned by both professionals and
lay-persons. However, at this time a person who requests hormonal treatment or a sex-change
operation requires evaluation by a mental health professional and a diagnosis of a gender identity
disorder.

Finally, sexual problems that do not meet the criteria for the other categories may be
classified as sexual disorder not otherwise specified.

Potential causes of sexual disorders

A variety of factors can contribute to the development of sexual disorders. Psychological

factors that can cause sexual disorders include mental illnesses such as depression, past episodes
of sexual abuse or other sexual trauma, and fears or guilt related to sexual issues.
 There are many physical factors that can contribute to a person’s sexual problems. They
include:

 Birth defects.
 Blood-supply problems.
 Conditions and diseases. Examples include diabetic neuropathy (nerve damage resulting
from high levels of blood sugar), multiple sclerosis (autoimmune disorder that affects the
central nervous system), tumors (abnormal growth of tissue) and tertiary syphilis (a late-
phase form of the sexually transmitted disease). Research also indicates that conditions
such as high blood pressure may be linked to sexual dysfunction in some cases.
 Drugs. These may include alcohol, nicotine, narcotics, stimulants, antihypertensives (high
blood pressure medications), antihistamines (allergy medications) and psychotherapeutic
medications.
 Endocrine disorders. These may include problems with the thyroid, pituitary or adrenal
glands.
 Enlarged prostate gland.
 Failure of various organ systems. These may include problems with the heart and lungs.
 Hormonal deficiencies. Including low leves of testosterone, estrogen or androgens.
 Injuries to the back.
 Nerve damage. Examples include spinal cord injuries.

People who abuse drugs and alcohol are at higher risk for developing sexual dysfunctions, as
are people who have diabetes and degenerative neurological disorders, persistent psychological
problems or difficulty with relationships. Age may also be a factor as people in their late-20s and
30s are especially likely to experience these problems and incidence levels rise again in seniors.

Signs and symptoms of sexual disorders

Symptoms associated with sexual disorders that may be experienced by either gender include:
  Lack of interest in or desire for sex
 Difficulty becoming aroused
 Pain during intercourse

Symptoms that may affect women include:

 Difficulty relaxing vaginal muscles enough for intercourse

 Lack of adequate vaginal lubrication prior to and during intercourse
 Inability to have an orgasm
 Burning pain on the vulva or in the vagina during sexual contact

Symptoms that may affect men include:

 Difficulty or inability to attain or maintain an erection

 Delay or absence of ejaculation even after adequate stimulation
 Inability to control the timing of an ejaculation

Some types of sexual disorders may lead to infertility. Patients may also experience
depression or may find that relationships with significant others deteriorate due to the disorder.

Diagnosis and treatment of sexual disorders

Patients who complain of symptoms related to a sexual disorder will undergo a complete
physical examination. The physician will also compile a thorough medical history of the patient.
A psychiatric evaluation that focuses on any fears, anxieties or preferences may also be
necessary. Psychological testing may also be performed.

Treatment options vary depending on the nature of the sexual disorder that is suspected.
In some cases, a physical problem can be treated through surgery or another medical procedure.
Patients whose sexual disorder is the result of illness or disability may find relief through
physical therapy or mechanical aids that can be used during sex.

Medications may also be helpful in some instances. Sildenafil became the first oral
medication for erectile dysfunction and has been widely touted as a treatment for men who have
difficulty maintaining an erection. Since then, other medications have been approved, providing
more options for oral therapy. Among oral medications, lubricating gels, hormone creams and
hormone replacement therapy have all been used to help treat inadequate vaginal lubrication.

Psychotherapy may also be beneficial for some patients, especially if the source of their
symptoms is believed to be psychological in nature. Behavior therapy techniques can help
patients who have problems becoming aroused or achieving orgasm. Individual counseling
sessions can help patients address feelings of guilt or shame associated with sex, or other
psychological problems, such as poor body image.

Couples can attend joint counseling sessions to improve communication problems that
may be at the root of sexual disorders.

Treatment approaches for paraphilias include behavior therapy techniques and

medication therapy. In some cases, a class of drugs called antiandrogens that drastically lowers
the sex drive in males and reduces the frequency of paraphiliac urges may be prescribed.
Serotonergic antidepressants may be prescribed for treatment of paraphilias with sexual
impulsivity. Patients taking these medications should also receive treatment that includes a
specialized sex offender program, group therapy, a 12-step "sexual addiction/compulsion"
recovery program or a therapist familiar with paraphilias.

Prevention methods for sexual disorders

Prevention of sexual disorders can begin relatively early in a person’s life. Parents who
openly communicate with their children about sexual issues and body image may prevent them
from developing feelings of anxiety and guilt that can later lead to sexual disorders. Open
communication is also a key to preventing sexual disorders from developing in adults. Sexual
partners are urged to openly and honestly communicate their feelings and desires to one another.

People who do not abuse drugs and alcohol lower their risk of developing sexual
disorders. Avoiding certain medications can also reduce or eliminate symptoms related to sexual
disorders. Patients should consult their physician about which drugs to avoid, and which
alternative medicines may be available. Patients should not stop taking drugs without first
consulting their physician.

Finally, victims of rape, sexual abuse or other sexual trauma are urged to seek psychiatric
counseling to help address and treat the psychological consequences of surviving violent acts.

Alcoholism

Alcoholism is a chronic disorder characterized by the excessive and compulsive use of

alcohol. Alcohol is a drug, a substance that affects the function (and often the judgment) of the
person using it. Although alcohol is not illegal, it can still have negative effects when it is
misused, and can lead to addiction. Alcoholism usually includes the following components:

a. Craving

b. Loss of control

c. Physical dependence

d. Toleranc

a. Craving

It is a strong urge to drink.

b. Loss of control

The inability to limit intake or to stop drinking once started.

c. Physical dependence
 After heavy drinking, symptoms of withdrawal are experienced, such as nausea,
sweating, shakiness and anxiety.

d. Tolerance

Tolerance is the need for increasingly greater amounts of alcohol to achieve the same
level of intoxication.

Alcoholism is different from alcohol abuse. Alcohol abuse is defined as drinking that results
in one or more of the following consequences in a 12-month period:

 Inability to fulfill major work, school or home responsibilities

 Drinking in dangerous situations, such as while driving a car or operating machinery
 Legal problems that result from drinking, such as being arrested for driving under the
influence of alcohol
 Ongoing relationship problems that worsen due to drinking

Unlike people with alcoholism, individuals who abuse alcohol do not crave alcohol or
experience physical withdrawal symptoms if they do not drink. However, people who abuse
alcohol can eventually develop alcoholism.

Although they do not meet the criteria for alcoholism or alcohol abuse, some people may be
problem drinkers.

The following may indicate a problem with drinking alcohol:

 Feeling the need to cut down on drinking

 Becoming annoyed at criticism about drinking
 Feeling bad or guilty about drinking
 Having a drink in the morning to steady nerves or get rid of a hangover
 Alcoholism depresses the central nervous system by acting as a sedative.

Excessive alcohol use can result in harm to the brain and nervous system and cause fatigue,
short-term memory loss and weakness and paralysis of the eye muscles. It can also cause the
following health problems:
 a. Liver disease
b. Gastrointestinal problems
c. Cardiovascular problems
d. Diabetes complications.
e. Sexual and menstrual dysfunction.
f. Birth defects
g. Neurological problems
h. Increased risk of cancer

a. Liver disease

Heavy drinking can cause alcoholic hepatitis (inflammation of the liver). This can lead to
cirrhosis (irreversible and progressive destruction of liver tissue).

b. Gastrointestinal problems

Alcohol can cause inflammation of the stomach lining (gastritis). It can also damage the
pancreas (pancreatitis).

c. Cardiovascular problems

Heavy drinking can lead to high blood pressure (hypertension) and damage the heart
(cardiomyopathy).

d. Diabetes complications

Alcohol prevents the release of glucose (blood sugar) from the liver and can cause it to
fall too low (hypoglycemia). This is dangerous for people with diabetes.

e. Sexual and menstrual dysfunction

Alcohol can cause erectile dysfunction in men and can interfere with menstruation in
women.
f. Birth defects

Drinking while pregnant can cause fetal alcohol syndrome. This condition results in a
small head, heart defects, shortening of the eyelids and may lead to developmental disabilities in
the child. Research also indicates that alcohol consumption during pregnancy may lead to
behavioral problems in children.

g. Neurological problems

Heavy drinking can affect the nervous system and cause numbness of the hands and feet,
disordered thinking and dementia.

h. Increased risk of cancer

Chronic drinking can increase the risk of developing cancers of the esophagus, larynx,
liver and colon.

Alcoholism can also result in the following:

 Domestic abuse
 Divorce and impaired relationships (e.g., with friends, family members)
 Difficulty performing at work or school
 Financial problems
 Motor vehicle accidents
 Alcohol-related arrests
 Accidental injuries that occur while or after drinking
 Higher incidence of suicide and murder

Alcohol alters the balance of some chemicals in the brain, such as gamma-aminobutyric acid
(GABA, a major inhibitory neurotransmitter) and glutamate (neurotransmitter involved in
learning and memory). It also increases the amount of dopamine (neurotransmitter essential to
thought, motivation, short-term memory and some emotions) in the brain.
 Alcoholism tends to develop gradually over time as heavy drinking increases or reduces
brain chemicals, which causes a person to crave alcohol to elevate their mood or to avoid
negative feelings.

Some other factors that may lead to excessive drinking and alcoholism include:

a. Genetics

b. Emotions and psychological factors

c. Social and cultural factors

a. Genetics

People with an inherited imbalance of brain chemicals may be more likely to develop
alcoholism.

b. Emotions and psychological factors

People who experience high levels of stress, anxiety and/or poor self-esteem may be
more apt to drink to cope with the turmoil. People with mental health disorders, such as
depression, bipolar disorder and schizophrenia, are also more likely to develop alcoholism. In
addition, associating with heavy drinkers may increase the likelihood of drinking or the amount
of alcohol consumed.

c. Social and cultural factors

Alcohol is often portrayed in glamorous ways on television and in advertisements. This

may contribute to social acceptance of heavy drinking.

Over time, heavy drinking habits can result in a dependence on alcohol. In general, men
who consume more than 14 drinks a week and women who consume more than seven drinks a
week have a greater risk of developing alcoholism. Other risk factors include:

a. Age

b. Gender
 c. Family history

a. Age

People who begin drinking early in life (age 14 or younger) are more likely to develop
alcoholism.

b. Gender

Men are more likely to develop alcoholism than women.

c. Family history

People with a parent who abused alcohol are more likely to develop alcoholism.

Recent research reveals that teenage girls who mature earlier than their peers and have
older boyfriends are more likely to become problem drinkers. Additionally, research indicates
that there is a relationship between frequent consumption of alcohol and unhealthy eating habits.

Signs and symptoms of alcoholism

There are many signs and symptoms associated with alcoholism. These may include:

a. Compulsion

b. Blackouts

c. Tolerance

d. Physical withdrawal symptoms

e. Social problems

f. Anhedonia

g. Unusual drinking habits

h. Irritability
a. Compulsion

There is feeling of strong need to drink.

b. Blackouts

Periods of time after drinking that cannot be remembered.

c. Tolerance

Tolerance is requiring increasingly larger amounts of alcohol to experience the same

effect.

d. Physical withdrawal symptoms

These may include nausea as well as shaking, sweating, confusion and hallucinations
(delirium tremens) while not drinking. Delirium tremens (also known as “the DTs”) is the most
serious symptom of acute alcohol withdrawal.

e. Social problems

There are many Legal, relationship, financial problems.

f. Anhedonia

Loss of interest in once pleasurable activities.

g. Unusual drinking habits

These may include drinking alone or in secret, gulping drinks or making a ritual of
having drinks before, during and after dinner.

h. Irritability

Feeling irritable when drinking patterns are disrupted.

Research also suggests that people with alcoholism may have difficulty interpreting the emotions
of others.

Many people who abuse alcohol experience many of the same symptoms as those who
have alcoholism. However, a main difference is that people who abuse alcohol do not experience
compulsion to drink or physical withdrawal symptoms when they do not drink.

Although it tends to take years for adults to develop alcoholism, young teenagers can become
addicted to alcohol more quickly. Some signs and symptoms of problems with alcohol in
teenagers include:

 Loss of interest in activities or hobbies

 Bloodshot eyes, slurred speech, scent of alcohol on breath or memory loss
 Difficulties in relationships or changes in friendships
 Declining school attendance, performance or other problems at school
 Mood swings and defensive behavior

Many people with alcoholism also experience denial (the refusal to recognize truth or
reality). This results in failure to recognize a problem with alcohol, even though signs and
symptoms are present. Many people with alcoholism seek help only at the insistence of friends,
family members, coworkers or others.

People are encouraged to consult a physician about alcohol use if they:

 Feel that drinking is a problem

 Feel guilty about drinking
 Cannot control drinking
 Drink shortly after waking up
 Need increasing amounts of alcohol before feeling its effects

Diagnosis of alcoholism

Alcoholism may be determined by a physician during a physical examination that

includes a medical history and list of medications. It is sometimes difficult to diagnose because
many people with alcoholism also experience denial (the refusal to recognize truth or reality).
This may cause people to hide aspects of drinking or to fail to recognize that physical symptoms
(such as digestive problems) may be related to drinking.

Patients suspected of having alcoholism may be asked to fill out a questionnaire, such as
the CAGE questionnaire. The questionnaires include questions aimed at identifying drinking
patterns and emotions that indicate alcoholism.

For example, the CAGE questionnaire includes four questions. An affirmative answer to two
or more questions indicates a high likelihood of alcoholism. The questions are:

 Have you felt you should Cut down on your drinking?

 Have people Annoyed you by criticizing your drinking?
 Have you felt bad or Guilty about your drinking?
 Have you ever had to drink first thing in the morning to steady your nerves or get rid of a
hangover (Eye-opener)?

Blood alcohol tests are not usually performed because they only identify levels of alcohol
ingested at a particular point in time, not long-term use. However, patients may be given other
tests, such as liver function tests and other blood tests. People with alcoholism may have
elevated liver function tests (which indicates liver damage) and anemia (low red blood cell
count).

Patients suspected of having alcoholism may be referred to a substance abuse counselor or

other health professional that specializes in treating addiction.

Treatment options for alcoholism

Because people with alcoholism often experience denial (the refusal to recognize truth or
reality), they often begin treatment only at the insistence of friends, family members, coworkers
or others. Sometimes, patients seek treatment after an intervention (an orchestrated attempt by
family and friends to encourage a person to seek help for addiction).
 Treatment techniques vary according to the severity of the alcohol problem and other
factors. Treatment for people who abuse alcohol may involve cutting back on drinking. For those
who are dependent upon alcohol, treatment must involve refraining from drinking (abstinence).
Patients may be treated in an outpatient program or a residential inpatient program.

Components of alcoholism treatment programs may include:

a. Detoxification

b. Medical assessment and treatment

c. Medical assessment and treatment

d. Psychological treatment

a. Detoxification

Patients withdraw from alcohol, a process which usually lasts four to seven days.
Medications to minimize symptoms experienced with withdrawal (such as seizures) are usually
administered.

b. Medical assessment and treatment

Patients are treated for medical conditions that may be present with alcoholism, such as
high blood pressure, increased blood sugar and liver and heart disease.

c. Psychological treatment

Patients with mental health disorders that contribute to alcoholism, such as depression,
may receive treatment for the underlying disorder. Others receive support through group and
individual counseling.

d. Medications
 Some patients are treated with special drugs, designed remove the compulsion to drink,
block the intoxicating effects of alcohol or help to prevent relapses in people who have stopped
drinking alcohol.

Because relapse (using alcohol after a period of abstinence) is common, people with
alcoholism often receive ongoing treatment. This may involve individual or group counseling or
participation in a self-help group. One of the most popular self-help groups is Alcoholics
Anonymous (worldwide fellowship of people with alcoholism whose primary goal is to advocate
recovery and sobriety through a 12-step process). Members meet on a regular basis and share
personal stories of their recovery in an attempt to provide support and foster sobriety.

Because family support is important to recovery, many programs offer marital counseling
or couples therapy, family therapy or other services as part of treatment. Programs may also help
patients find other types of services needed for recovery, such as legal assistance, job training,
childcare and parenting classes.

Other therapies for patients with alcoholism may include:

a. Acupuncture

b. Motivational enhancement therapy

c. Cognitive behavior therapy

d. Couples therapy

e. Aversion therapy

a. Acupuncture

There is insertion of thin needles under the skin. This may reduce cravings for alcohol.
Acupuncture is performed by an acupuncturist.

b. Motivational enhancement therapy

Therapy aimed at helping the patient acknowledge the alcohol problem and change
behavior through stages.
c. Cognitive behavior therapy

Psychotherapy that relies on the recognition of distorted thinking and replacing such
thinking with more realistic ideas.

d. Couples therapy

Therapy attended by both the patient with alcoholism and their significant other.
Involving a partner may increase the chance of successful treatment.

e. Aversion therapy

It involves taking a medication that causes an adverse response, such as nausea and
vomiting, when alcohol is ingested.

Prevention methods for alcoholism

The best way to prevent alcoholism is to abstain from drinking alcohol. For those who
drink, recognizing a family history of alcoholism is an important first step in preventing
alcoholism. Also, recognizing signs and symptoms of problem drinking (such as binge drinking
and drinking shortly after waking up) is important. Problem drinkers who change drinking habits
may prevent the development of alcoholism in the future.

Early intervention is particularly important with teenagers because they can become addicted
to alcohol more quickly than adults. Parents can curb alcohol use in teenagers by:

 Talking to children about alcohol, including the legal and medical consequences of
drinking.
 Setting a good example with alcohol by drinking responsibly.
 Spending time with children, but also understanding their need for independence.
 Establishing boundaries with children and letting them know what behaviors are accepted
and not accepted.

Obsessive Compulsive Disorder

 Obsessive-compulsive disorder (OCD) is an anxiety disorder in which
patients experience recurrent, persistent thoughts they cannot control (obsessions) and/or an
uncontrollable need to perform certain actions over and over (compulsions). Patients usually
understand that their thoughts and behaviors are irrational, excessive and interfere with their
ability to work and live their lives normally, but cannot free themselves from them.

There are many people with a compulsive nature, such as those determined to complete
tasks early and to the best of their ability or to master a new sport or activity. Though such
people may be labeled “compulsive,” this type of behavior does not qualify as a mental disorder
and may in fact be a key factor in building self-esteem and contributing to success.

People with OCD take these feelings and actions a step further, repeatedly engaging in
thoughts and/or behaviors until the process becomes disruptive to their lives. For example,
people who have obsessive thoughts about accidentally burning down their house may feel they
must repeatedly return home to make sure they have not left the stove on or the iron plugged in.
These people may feel a sense of relief when they have completed the behavior they feel
compelled to engage in, but it usually does not last long before the next obsessive thought arises.
As the discomfort returns, the patient may feel compelled to repeat the obsessive-compulsive
cycle again. Over time, these behaviors may take over a person’s life to an increasing degree and
prevent the patient from living a normal life.

OCD is usually diagnosed by a physician. The typical patient is someone who has
obsessions and/or compulsions for more than an hour each day, and the symptoms cause distress
to the patient and are disruptive to their lives. OCD can affect people of all age groups, and tends
to affect men and women equally. About one-third of adults with this condition first experienced
symptoms during childhood. When the condition is diagnosed earlier in life, it tends to appear
more frequently in boys than in girls.

Potential causes of OCD

 The exact cause of obsessive-compulsive disorder (OCD) is unknown. However, a
combination of psychological, biological and environmental factors may be responsible.
Heredity is believed to play a strong role in the development of the disorder.

Growing evidence indicates that chemical imbalances may be common in the

development of OCD. Various studies have indicated that low levels of the chemical serotonin (a
neurotransmitter that helps nerve cells communicate) may contribute to OCD. Many patients
with OCD who take medications that boost serotonin levels show improvement in symptoms. In
addition, people who have brain injuries sometimes develop OCD, which further suggests that
physical damage in the brain can cause the disorder.

OCD also appears to increase metabolism in the basal ganglia (a region of specialized
nerve cells that is mainly involved in body movement) and frontal lobes (the upper brain area,
which is mainly involved in emotions and personality) of the brain. This may cause repetitive
movements, rigid thinking and lack of spontaneity. Finally, people with OCD have been shown
to have higher levels of the hormone vasopressin (which raises blood pressure and reduces
excretion of urine).

People with close family members (e.g., parents) with a history of OCD have a higher
risk for developing the condition themselves. Researchers have identified a previously unknown
gene variant that makes a person twice as likely to develop OCD. A gene variant, or allele, is an
alternate form of a gene that often affects appearance. For instance, different alleles are
responsible for variations in eye color. The allele is part of the human serotonin transporter gene
(hSERT) that is affected by selective serotonin reuptake inhibitors (SSRIs), commonly
prescribed medications for OCD, other anxiety disorders and depression. A recent study found
that patients with OCD were twice as likely to have the hSERT genetic variant. In a subsequent,
related study, researchers found that the newly-discovered gene variant was twice as likely to be
passed down from a parent to a child with OCD. Those who are shown to have this variant are
likely to respond well to medication.

Signs and symptoms of OCD

 Obsessive-compulsive disorder (OCD) is characterized by two major symptoms:
obsessions and compulsions. Some patients experience one component more strongly than the
other.

Obsessions are recurrent persistent and unpleasant thoughts or impulses that a person
cannot control. These thoughts may appear once in a while or may be almost constant, crowding
the mind and preventing a person from concentrating on other tasks. Typical obsessions include
fear of dirt or contamination; excessive concern with order, symmetry and exactness; constant
thoughts of specific sounds, images, words or numbers; fear of harming a loved one; and fear of
thoughts considered evil or sinful.

Compulsions are repetitive behaviors that a person engages in and cannot control. A
patient engages in compulsions as a means of relieving obsessive thoughts, even though this
action may seem irrational to the person and others. For example, people who are obsessed with
a fear of germs may wash their hands compulsively to combat this fear. In other cases, the
compulsive act is not as clearly associated with the obsessive thought. Many people also develop
rules to follow that help control anxiety in the midst of obsessive thoughts, such as touching
objects a specific number of times or counting to a certain number. In some cases, performing
the compulsion does indeed relieve the anxiety, but only temporarily.

Typical compulsions include excessive washing of hands, repeatedly checking doors to

make sure they are locked or checking to make sure appliances are turned off, keeping items
arranged in a certain order and hoarding items such as coupons.

People with OCD also may have other mental illnesses, including eating disorders, other anxiety
disorders and/or depression. Children with OCD may also have learning disorders (e.g., dyslexia)
or behavior disorders.

Diagnosis methods for OCD

Patients may be embarrassed about acknowledging suspected obsessive-compulsive

disorder (OCD). However, people who have deeply ingrained rituals that disrupt their lives are
encouraged to consider seeking psychiatric treatment. The longer these patterns continue, the
more difficult they are to treat successfully.
 Before diagnosing OCD, a physician should perform a complete physical examination
and compile a thorough medical history. The physician should ask about the nature of a patient’s
obsessions and compulsions. Consultation with family and friends may help reveal behavior
patterns that will lead to a more accurate diagnosis.

The physician may ask the patient the following questions:

 Does the patient have repeated unwanted thoughts that seem senseless?
 Does the patient do things repeatedly in a way that seems excessive?

There is no specific laboratory test to diagnose OCD. It is usually diagnosed in patients who
have obsessive thoughts and/or who perform compulsive actions, and who recognize that these
feelings and actions are unreasonable. In order for the diagnosis to apply, the obsessive-
compulsive thoughts should appear for more than an hour each day and cause marked distress
and interruption of a patient’s lifestyle.

If a physician suspects that OCD is present, the patient may be referred to a psychiatrist or
other mental health professional. Referral is best for patients who do not want medication
therapy, who have other psychiatric disorders along with their OCD, or whose symptoms present
a risk to themselves or others.

Treatment options for OCD

Although there is no guaranteed cure for obsessive-compulsive disorder (OCD), certain

treatments can help control or eliminate some symptoms. A combination of psychotherapy and
medications is the approach most likely to result in improvement or remission of symptoms.
Psychotherapy may take place in an individual or group setting. Cognitive behavior therapy can
help patients learn to use different thought patterns and routines that will steer them away from
obsessive thoughts and/or compulsive behaviors.

In addition, patients may be asked to participate in a form of exposure therapy known as

exposure and response prevention. In this therapy, the patient is gradually exposed to the
situation that triggers obsessive thoughts and is taught new coping skills that do not include
obsessive-compulsive behavior. For example, patients with a fear of germs may be asked to dirty
their hands and then to refrain from washing them for a specific period of time. This pattern is
repeated over a long period of time until symptoms gradually decrease in frequency and
intensity. The therapist assists the patient in managing any anxiety that is produced during this
process. The treatment is sometimes difficult, but it can be a highly effective therapy for patients
with OCD, particularly children and adolescents.

Some patients may also benefit from using certain types of medication. Antidepressants
such as selective serotonin reuptake inhibitors (SSRIs) or tricyclics are most often prescribed,
although some newer antipsychotic medications or monoamine oxidase inhibitors (MAOIs) may
also be recommended. Patients should be aware that a physician will almost certainly need to
adjust the dosage and/or change medications to achieve the best results with minimal side
effects. In addition, the U.S. Food and Drug Administration (FDA) has advised that
antidepressants may increase the risk of suicidal thinking in some patients, particularly children
and adolescents, and all people being treated with them should be monitored closely for unusual
changes in behavior or dangerous new thought patterns. However, the benefits of such
medications typically outweigh the potential risks.

 Other medications that may be used to treat OCD include:

a. Antipsychotics
b. Mood stabilizers
c. Anticonvulsants
d. Anti-anxiety medications

a. Antipsychotics

Medications used control hallucinations and delusions due to psychosis. Some of the
newer antipsychotics also have an indication for treatment of anxiety. Some obsessive thoughts
are closely associated with psychotic phenomena.

b. Mood stabilizers
 Medications of various drug classes used to treat fluctuations of mood. For some
individuals a mood stabilizer helps to stop the cycle of obsessive thoughts and compulsive
behaviors.

c. Anticonvulsants

Medications used to prevent seizures. Some anticonvulsants have been shown to be

effective mood stabilizers.

d. Anti-anxiety medications

Medications used to treat anxiety, tension and agitation. The benzodiazepines, one of the
classes of medications used for anxiety, should only be prescribed for a relatively short period of
time, usually while other medications are being started to help with a more immediate control of
anxious mood

Dysthymia

Dysthymia – meaning “bad state of mind” or “ill humor” in Greek – is a mood disorder
in which a chronically depressed mood is present on the majority of days for at least two years.
Patients often regard the low mood they live with as normal, and many individuals may not
realize that anything is wrong at all. Although dysthymia causes significant distress or some
impairment in function of school or work performance, socially or otherwise, it is not as severe
as the impairment caused by major depression.
 The onset of dysthymia is usually gradual. The median age of onset is 31 years, though it
may begin much earlier or later. Most patients cannot pinpoint precisely when they first became
depressed. In children and adolescents, the altered mood may be irritable instead of depressed,
and must last at least one year instead of two.

There is a close relationship between dysthymia and major depression. For instance,
many patients with dysthymia will eventually develop major depression, and patients with major
depression may eventually develop dysthymia. If an episode of major depression occurs during
dysthymia, both dysthymia and major depression may be diagnosed, resulting in what is referred
to as double depression. Dysthymia may also be associated with other mental health disorders
(e.g., anxiety disorders, substance abuse). Dysthymia in children may be associated with
attention deficit hyperactivity disorder and other medical or psychological conditions.

Risk factors and causes of dysthymia

The cause of dysthymia is not completely understood. It is believed that changes in brain
structures and chemistry may cause alterations in mood. Too many or too few neurotransmitters
(chemicals that convey messages between nerves), particularly serotonin, are believed to play a
key role.

There are many risk factors for dysthymia. These include:

a. Gender
b. Family history
c. Long-standing life stresses

d. Marital status and quality

a. Gender
 Women have about twice the risk of developing dysthymia as men. Although the reason for
this is unknown, it may be due to factors such as differences in hormones in certain life stages,
such as after pregnancy and menopause. It should be noted that the disparity between the genders
also may be related to women being more willing to report symptoms of depression than men.

b. Family history

Individuals who have relatives with a history of any form of depression, especially dysthymia
or major depression, are at a higher risk of developing dysthymia. This is especially true for first-
degree relatives (e.g., parents, children, siblings).

c. Long-standing life stresses

Individuals who experience constant sources of major stress, such as from discrimination,
poverty, constant abuse or chronic illness, have an increased risk of dysthymia.

d. Marital status and quality

In general, unmarried people have a greater risk of developing dysthymia. However,

unhappily married people may also have a higher risk of developing the disorder. Whether these
are actual risk factors for developing dysthymia, or if they are due to the fact that people with
chronic depression may be less likely to marry and when they do marry are more likely to have
unhappy marriages, is unclear. Individuals who feel rejected or depreciated by a loved one or are
isolated are also at an increased risk.

Signs and symptoms of dysthymia

The symptoms of dysthymia may vary greatly from one patient to another. They may result
in decreased activity, effectiveness or productivity. Most are similar to the symptoms of major
depression, but not as severe. Because patients with dysthymia may consider their symptoms
normal, symptoms may be noticed by others before they are recognized by the patient. Signs and
symptoms of dysthymia include:

a. Altered mood
 b. Lack of interests and/or social withdrawal

c. Self-worth

d. Fatigue and low energy

e. Concentration

f. Significant change in appetite or weight

g. Changes in sleep patterns

a. Altered mood

The patient will usually experience feelings of sadness, hopelessness, discouragement or

apathy (lack of emotion). The patient may be pessimistic (feel that everything in life will turn out
badly) or discouraged and may experience crying spells or excessive emotional sensitivity.
Excessive anger, irritability or crankiness may also be noticeable, particularly in children.

b. Lack of interests and/or social withdrawal

Patients may have little or no interest in activities they used to find pleasurable, such as food,
sex, work, friends, hobbies and entertainment (anhedonia). They may be also socially withdrawn
or shy.

c. Self-worth. Poor self-esteem is common in dysthymia

The patient may have feelings of worthlessness, self-reproach, inadequacy or excessive or

inappropriate guilt.

d. Fatigue and low energy

The patient feels excessive fatigue and low energy.

e. Concentration

The patient may be indecisive, have diminished ability to think, pay attention to tasks
or concentrate, or have memory problems.
f. Significant change in appetite or weight

Patients with dysthymia may experience reduced or increased appetite or significant weight
loss or gain over a relatively short period of time.

g. Changes in sleep patterns

The patient may sleep too much (hypersomnia) or be unable to sleep enough (insomnia).

Diagnosis methods for dysthymia

Before dysthymia is diagnosed, a physical examination needs to be performed by a

physician to rule out other medical conditions. Many long-term medications (e.g.,
corticosteroids) or chronic medical conditions (e.g., hypothyroidism, anemia) can cause
symptoms similar to those of dysthymia.

The diagnosis of dysthymia begins with a mental health evaluation performed either by a
physician or after a referral to a non-physician mental health professional. This evaluation
includes a complete history of symptoms, including when they started, how long they have lasted
and how severe they are. It is also noted whether the patient has experienced these symptoms
before and, if so, whether and how they were treated. The physician or other mental health
professional will also inquire about alcohol and drug use and whether other family members
have had a depressive illness, such as dysthymia or major depression. If there is a history of a
depression in any family members, the treatment method and effectiveness will need to be
reported.

The American Psychiatric Association identifies particular criteria for the diagnosis of
dysthymia in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV). These
criteria include:

a. Quality and duration of mood

 b. Symptoms

c. Consistency

d. Impairment

a. Quality and duration of mood

Adults must have a depressed mood for most of the day on the majority of days for at least
two years. Children or adolescents must have a depressed or irritable mood for most of the day
on the majority of days for at least one year.

b. Symptoms

Two different, overlapping sets of symptoms may be used by different physicians or non-
physician mental health professionals. In general, patients must display two or more of the
following symptoms during the time that they have an altered mood:

 Substantial change in appetite (overeating or reduced appetite)

 Too much or too little sleep (hypersomnia or insomnia)
 Reduced energy or fatigue
 Reduced self-image or confidence (poor self-esteem)
 Indecisiveness or problems with concentration
 Hopelessness, despair or pessimism

c. Consistency

Symptoms must not be absent for more than two consecutive months in a two-year period in
adults or a one-year period in children.

d. Impairment
 The symptoms must be severe enough to cause significant distress (as per the DSM-
IV) or impairment in function of work or school performance, socially or otherwise.

The diagnosis of dysthymia is only made if the patient has not been diagnosed with other
particular mood disorders (e.g., major depression, bipolar disorder). However, there are certain
circumstances where both dysthymia and major depression may be diagnosed (double
depression). For instance, many patients with dysthymia will eventually develop major
depression, and patients with major depression may eventually develop dysthymia. To be
diagnosed with either of these conditions, the symptoms must be unrelated to a physical medical
condition or use of any prescribed medications or recreational substances.

The diagnosis of dysthymia may be described as early or late onset depending on whether
it began before or after the age of 20 years. The age of onset may affect treatment options.
Patients with early onset dysthymia are more likely to eventually develop a major depressive
episode in the future.

Treatment and prevention of dysthymia

There is only about a 10 percent chance per year that the symptoms of dysthymia will go
away without treatment. The symptoms of dysthymia can often be completely eliminated, though
treatment may have to be maintained indefinitely to prevent them from returning. In many cases,
dysthymia responds equally to psychotherapy and medication.

Psychotherapy teaches coping skills and more effective ways to deal with problems in
life. It also targets symptoms and addresses any substance use. One form known as cognitive
behavior therapy (CBT) is often used. During CBT, the therapist engages the patient with
conversation to gain insight into and to change negative patterns of thought or behavior that are
associated with dysthymia. Sometimes, the patient will be given “homework” assignments
between sessions. CBT teaches patients to gain more satisfaction and rewards from their own
actions and resolve problems.

Medications for dysthymia typically offer relatively quick relief of symptoms. The
primary medications for this disorder are antidepressants. Patients should be aware that a
physician may need to adjust the dosage or change medications to achieve the best results with
minimal side effects. In addition, the U.S. Food and Drug Administration (FDA) has advised that
antidepressants may increase the risk of suicidal thinking in some patients, particularly children
and adolescents, and all people being treated with them should be monitored closely for unusual
changes in behavior. However, the benefits of such medications typically outweigh the risks.

Over-the-counter herbal and dietary supplements may be used by some people for
dysthymia. Among the most commonly used of these is the herb St. John’s wort. Although used
in Europe for the treatment of many forms of mild to moderate depression, including dysthymia,
scientific studies demonstrating their effectiveness are lacking. The National Institute of Mental
Health (NIMH) is currently conducting studies on the effectiveness and safety of this herb in the
treatment of dysthymia and other forms of depression. It is important for patients to speak with a
physician before taking any herbal or dietary supplement because many supplements may cause
serious drug interactions.

Amnestic Disorder

Amnestic disorders are the disorders related to Memory and memory loss. It derives its
name from Amnesia which means partial memory loss. “Amnestic Disorders is characterized by
cognitive impairment involving an inability to form new memories and an inability to recall old memories.”

Memory is the ability to retain and recall new information. Memory can be subdivided
into short-term memory, which involves holding onto information for a minute or less, and long-
term memory, which involves holding onto information for over a minute. Long-term memory
can be further subdivided into recent memory, which involves new learning, and remote
memory, which involves old information. In general, amnestic disorders more frequently involve
deficits in new learning or recent memory.

In order to retain information, an individual must be able to pay close enough attention to
the information that is presented; this is referred to as registration. The process whereby
memories are established is referred to as encoding or storage. Retaining information in the long-
term memory requires passage of time during which memory is consolidated. When an
individual's memory is tested, retrieval is the process whereby the individual recalls the
information from memory. Working memory is the ability to manipulate information from short-
term memory in order to perform some function. Amnestic disorders may affect any or all of
these necessary steps.

The time period affecting memory is also described. Anterograde amnesia is more
common. Anterograde amnesia begins at a certain point in time and continues to interfere with
the establishment of memory from that point forward in time. Retrograde amnesia refers to a loss
of memory for information that was learned prior to the onset of amnesia. Retrograde amnesia
often occurs in conjunction with head injury, and may result in erasure of memory of events or
information from some time period (ranging from seconds to months) prior to the head injury.
Over the course of recovery and rehabilitation from a head injury, memory may be restored or
the period of amnesia may eventually shorten.

Types

Amnestic disorders have been broadly classified into transient amnesias and persistent memory
disorders. Transient amnesias include transient global amnesia, transient epileptic amnesia,
posttraumatic amnesia and alcoholic blackouts, while persistent memory disorders include
Korsakoff syndrome and amnestic syndromes that follow herpes encephalitis, severe hypoxia,
vascular disorders or head injury.

Transient global amnesia (TGA)

TGA is a syndrome of severe, forgetful confusion characterized by memory loss and total
disorientation except for self-identity, followed by gradual resolution within 24 hours. The
memory loss includes a profound impairment of long-term episodic memory, while working
memory is spared. TGA presumably results from transient dysfunction of the temporal lobes or
diencephalons. Commonly, the presumed cause is transient ischemia. TGA may arise during
coughing, exercise, sexual intercourse, driving, medical procedures or after severe emotional
stress; and other known precipitants include seizures, migraine, and medications like sildenafil.
Posttraumatic amnesia

TBI is the common cause of amnestic syndromes seen in clinical practice. Duration of the
coma after TBI is the best predictor of the severity of posttraumatic memory and cognitive
deficits, and duration of post-traumatic amnesia is correlated with posttraumatic intellectual
disorders.

Alcoholic blackouts

Alcoholic blackouts are among the most frequently reported symptoms in the progression
of alcoholism, and are defined as the temporary, complete inability to form long-term memory as
a result of a high blood alcohol level. The risk of blackouts is associated with increased alcohol
consumption, age of drinking onset, the number of alcoholic relatives, and the individual's
capacity to control drinking behavior.

Korsakoff syndrome

Many cases of the Korsakoff syndrome are diagnosed following an acute Wernicke
encephalopathy, but the disorder can also have an insidious onset and such cases are more likely
to come to the attention of the psychiatrists. Patients with the syndrome have difficulty learning
new information and usually have a retrograde amnesia that extends 3-20 years prior to the onset
of the amnesia. Typically, patients remain amnestic for 1-3 months after onset and then begin to
recover over a 1- to 10- month period. A personality change, usually emotional indifference or
apathy, frequently accompanies the amnesia.

Causes
There are numerous causes of Amnestic Disorders which ranges from trauma to other mental
disorder. A number of brain disorders can result in amnestic disorders, including following:

 Various types of dementia (such as Alzheimer's disease ),

 Traumatic brain injury (such as concussion),
 Stroke
  Accidents that involve oxygen deprivation to the brain or interruption of blood flow to
the brain (such as ruptured aneurysms )
 Encephalitis
 Tumors in the thalamus and/or hypothalamus
 Wernicke-Korsakoff syndrome (a sequelae of thiamine deficiency usually due to severe
alcoholism),
 Seizures
 Cerebrovascular disease (disease affecting the blood vessels in the brain)
 Alcoholism

Psychological disorders can also cause a type of amnesia called "psychogenic amnesia.

Symptoms
The main symptom of amnestic disorder is the ability to remember things and recall them at
the right time. Symptoms of amnestic disorders may include following:

1. Difficulty in recalling remote events or information

2. Difficulty in learning and then recalling new information.
3. The patient in some cases is fully aware of the memory impairment, and frustrated by it;
4. In some other cases, the patient may seem completely oblivious to the memory
impairment or may even attempt to fill in the deficit in memory with confabulation.
5. Depending on the underlying condition responsible for the amnesia, a number of other
symptoms may be present as well.

Diagnosis

Diagnosis of amnestic disorders begins by establishing an individual's level of orientation

to person, place, and time. Does he or she know who he or she is? Where he or she is? The
day/date/time? An individual's ability to recall common current events (who is the president?)
may reveal information about the memory deficit. A family member or close friend may be an
invaluable part of the examination, in order to provide some background information on the
onset and progression of the memory loss, as well as information regarding the individual's
original level of functioning.

A variety of memory tests can be utilized to assess an individual's ability to attend to

information, utilize short-term memory, and store and retrieve information from long-term
memory. Both verbal and visual memory should be tested. Verbal memory can be tested by
working with an individual to memorize word lists, then testing recall after a certain amount of
time has elapsed. Similarly, visual memory can be tested by asking an individual to locate
several objects that were hidden in a room in the individual's presence.

Depending on what types of conditions are being considered, other tests may include
blood tests, neuroimaging (CT, MRI, or PET scans of the brain), cerebrospinal fluid testing, and
EEG testing.

Treatment
Since the causes of Amnestic Disorder are the other varied brain conditions and injuries,
in some cases, treatment of the underlying disorder may help improve the accompanying
amnesia.

There are no treatments that have been proved effective in most cases of amnestic disorder,
as of 2002. Many patients recover slowly over time, and sometimes recover memories that were
formed before the onset of the amnestic disorder.

 There are some other treatment options available for mild cases of amnesia such as
rehabilitation which may involve teaching memory techniques and encouraging the use
of memory tools, such as association techniques, lists, notes, calendars, timers, etc.
 Memory exercises may be helpful.
  Recent treatments for Alzheimer's disease and other dementias have involved
medications that interfere with the metabolism of the brain chemical (neurotransmitter)
called acetylcholine, thus increasing the available quantity of acetylcholine.

Prognosis

The prognosis is very dependent on the underlying condition that has caused the memory
deficit, and on whether that condition has a tendency to progress or stabilize. Alzheimer's
disease, for example, is relentlessly progressive, and therefore the memory deficits that
accompany this condition can be expected to worsen considerably over time. Individuals who
have memory deficits due to a brain tumor may have their symptoms improve after surgery to
remove the tumor. Individuals with transient global amnesia can be expected to fully recover
from their memory impairment within hours or days of its onset. In the case of some traumatic
brain injuries, the amnesia may improve with time (as brain swelling decreases, for example),
but there may always remain some degree of amnesia for the events just prior to the moment of
the injury.