lecture psychiatry

Lecture №1 Object and task of psychiatry and narcology, their place among other medical disciplines. History of development and modern state of psychiatry and narcology. Psychonosology and diseases. Principles of therapy, prophylaxis and rehabilitation of psychic disorders Lecturer Savka Svitlana Dmytrivna

Psychiatry
(from the Greek words "psyche" - the soul, "iatreia" - treatment) is a branch of medicine concerned with the study, diagnosis, treatment and prevention of mental disorders.

Tasks psychiatry
to study the aetiology and pathogenesis of mental disorders;
to carry out their classification;
to investigate the epidemiology of mental disturbances;
to study the symptoms and signs, as well as syndromes and the clinical course of different mental disorders;
to develop find practice effective methods of their diagnosing;
to work out and use efficient treatment methods;
to develop a network of mental health services for the population;
to develop a system for the prevention of mental disorders.

History of development of psychiatry
the first period (pre-scientific), characterised by primitive religious understanding of the mentally ill people's abnormal behaviour;
the secend period of ancient antique medicine, a more progressive period, when the first attempts at organising mental health treatment were made;
the third period, corresponding to the Middle Ages, was in general a period or regress, when psychiatry returned to its prescientific period (theological scholastics);

the fourth period, from the beginning of the XVIII to the beginning of XIX century was the stage of formation of psychiatry part of the medical science;
the fifth period was the epoch of E. Krepellin's nosological psychiatry. The creation of a nosological classification of mental disorders was the main outcome of this stage;
the sixth period, modern stage of development of psychiatry, formed in the XX century can be called the period of social psychiatry; it is characterised by wide development community, social forms of mental health services; somatological aspects of mental disorders got more attention.

FRAME OF PSYCHIATRY.
General psychopathology - studies the basic laws of an etiopathogenesis, clinic, diagnostics, therapy and prophylaxis of alienations.
Private psychiatry - studies separate mental diseases.
Age psychiatry.
Organizational psychiatry.
Judicial psychiatry - solves questions of a sanity and capacity for acting.
Psychopharmacotherapy - studying of action on mentality of medicinal substances.
Social psychiatry.

Addictology - studies influence of the psychotropic substances on a condition of the person.
Trans-cultural psychiatry - is engaged in comparison of a mental pathology in the different countries, cultures.
Orthopsychiatry - surveys alienations from the point of view of different disciplines.
Biological psychiatry.
Sexology.
Suicidology.
Military psychiatry - studies posttraumatic stressful frustration, psychopathology a wartime.
Ecological psychiatry - studies influence of ecological factors on mentality.

CONTRA-INDICATION FOR HOSPITALIZATION IN PSYCHIATRIC CLINIC:
Mentally healthy man.
Persons in a state of simple and, even, heavy degree of alcoholic intoxication.
Persons in the state of intoxication.
Persons with the affects reactions and antisocial forms conducts, which do not suffer by the psychical diseases.
Persons with psychopath’s character traits.
Persons in which found out the neurotic reactions.
Persons with a mental backwardness (after the exception of examination).
Persons with total dementia.
Mentally ill with acute somatic pathology which requires surgical intervention.

The criteria of mental health
awareness and feeling of continuity, constancy and identity of one's physical and mental self;
feeling of constancy and identity of experience in similar circumstances;
insight (good judgement) concerning oneself, one's own mental production and its results;
accordance (adequacy) of mental reactions to intensity and frequency of environmental influences,, social circumstances and situations;
capacity to self-regulation of one's behaviour in accordance with social norms, rules and laws;
capacity to plan one's life activities and to realise these plans;
capacity to change one's behaviour depending on the changes of life situations and circumstances.

Levels of mental health :
Ideal or standard health.
Average statistical health.
Constitutional health.
Accentuation — a variant of mental health (norm), characterized by increased, emphasized character features and certain personality disharmony, which decreases the level of adjustment.
Pre-illness — appearance of first episodic mild symptoms of disorder, which cause slight dysfunction and social maladjustment.

Basic classification categories:
1 . Menial retardation: impairment of intellectual functioning present continuously from early life.
2 . Personality disorders: dispositions to behave in certain abnormal ways present continuously from early adult life.
3. Adjustment disorders: disorders that are less severe than mental disorders and occur in relation to stressful events or changed circumstances.
4. Mental disorders: abnormalities of behaviour or psychological experience with a recognisable onset after a period of normal functioning.
5. Other disorders: conditions that do not fit into the first four groups, for example abnormalities of sexual preference and drug dependence.

Classification m ental disorders (ICD-10)
F00-09Organic, including symptomatic, mental disorders
F10-19 Mental and behavioural disorders due to psychoactive substance use
F20-29 Schizophrenia, schizotypal and delusional disorders
F30-39 Mood (affective) disorders
F40-48Neurotic,stress-related and somatoform disorders
F50-59 Behavioural syndromes associated with physiological disturbances and physical factors
F60-69 Disorders of adult personality and behaviour
F70-79 Mental retardation
F80-89 Disorders of psychological development
F90-98 Behavioural and emotional disorders with onset usually occurring in childhood and adolescence

Classification of mental disorders on the basis of aetiology and pathogenesis
1) endogenous disorders (schizophrenia, bipolar affective disorder and genuine epilepsy) caused by internal mechanisms, the nature of which isn't yet quite clear; these are disorders with hereditary predisposition.
2) exogenous disorders, caused by external reasons: infection, intoxication, head injury, etc.;
3) psychogenous disorders are caused by psychological trauma (posttraumatic stress syndrome) and other psychological factors (adjustment disorders, behavioural disorders, neuroses, etc.).

The methods of investigation
clinical interview and collection of anamnesis data;
physical examination;
observation;
psychological investigation;
additional investigations:
a) neurophysiological investigations
b) X-ray investigations
c) laboratory tests

Psychotropic drugs
Antipsychotics
Antidepressants
Mood stabilizers
Anxiolytics
Hypnotics
Cognitive enhancers
Stimulants

ANTIPSYCHOTICS (Neuroleptics, Major Tranquillisers)
Antipsychotics are used principally in the treatment of psychoses. They diminish the agitation, delusions, hallucinations and thought disorder of these illnesses. The drugs have less effect on the symptoms of apathy and withdrawal. Treatment response is most dramatic during the first six weeks thereafter it tapers off.

TYPICAL ANTIPSYCHOTICS
SHORT ACTING INJECTIBLES
GENERIC NAME BRAND NAME
chlorpromazine Largactil
haloperidol Serenace
trifluoperazine Stelazine
LONG ACTING INJECTIBLES
flupenthixol decanoate Fluanxol
fluphenazine decanoate Modecate
haloperidol decanoate Haldo
zuclopenthixol decanoate Clopixol Depot

ATYPICAL ANTIPSYCHOTICS
GENERIC NAME BRAND NAME(S)
amisulpride Solian
aripiprazole Abilify
clozapine Clozaril, Clopine
olanzapine Zyprexa, Zydis (wafers)
quetiapine Seroquel
risperidone Risperdal

ANTIPSYCHOTICS – GENERAL PRECAUTIONS
All antipsychotics are central nervous system depressants and metabolised in the liver therefore care should be taken when:
• prescribing them for persons with respiratory or cardiac problems;
• using with other central nervous system depressants including alcohol;
• driving a car or as reaction times can be slowed.
• prescribing for persons with liver problems;
• prescribing with other drugs metabolised in the liver.
Lower doses are usually required in the elderly.
They should be used with caution in children and adolescents.
These drugs should not be prescribed for persons with known hypersensitivity to the drugs.

ANTICHOLINERGICS (Side Effect Drugs, Antiparkinsonians)
These drugs are used principally for the treatment of Parkinson’s Disease. In this context,they are used to treat drug-induced parkinsonism and other movement disorders caused by the administration of antipsychotic medications. They may be taken orally or given by injection as the situation warrants.

ANTI-DEPRESSANTS
These drugs are used to treat major depressive disorder. All anti-depressants can treat depression, however, not all depression sufferers will respond to treatment. The medicines have an immediate action in the body but the desired improvement in mood and depressive symptoms may take some weeks.

Classification anti-depressants
1. TRICYCLICS
2. MONOAMINE OXIDASE INHIBITORS
3. REVERSIBLE INHIBITOR OF MONOAMINE OXIDASE
4. SELECTIVE SEROTONIN REUPTAKE INHIBITORS
5. SELECTIVE SEROTONIN NORADRENALINE REUPTAKE INHIBITOR
6. NORADRENERGIC AND SPECIFIC SEROTONIN ANTAGONIST
7. HETEROCYCLIC
8. SELECTIVE NORADRENALINE REUPTAKE INHIBITORS

1.TRICYCLICS antidepressants
amitriptyline Tryptanol, Endep
clomipramine Anafranil, Placil, ETC
dothiepin Prothiaden, Dothep
doxepin Sinequan, Deptran
imipramine Tofranil, Melipramine
nortriptyline Allegron
trimipramine Surmontil

2. MONOAMINE OXIDASE INHIBITORS
These were used in patients resistant to tricyclic treatment and in phobic anxiety disorders, but are now rarely prescribed.
phenelzine Nardil
tranylcypromine Parnale

3. REVERSIBLE INHIBITOR OF MONOAMINE OXIDASE A
Reversible inhibition of the MAO enzyme limits the problem of food and drug interactions. This class of drug is a safer alternative to MAOIs and no major dietary precautions are needed. RIMAs have fewer interactions, fewer cardiovascular effects and greater safety in overdose.
moclobemide Aurorix, Arima

4. SELECTIVE SEROTONIN REUPTAKE INHIBITORS
This class of antidepressant is well tolerated, and relatively safe in overdose.
citalopram Cipramil, Celepram, Talohexal,etc
Escitalopram Lexapro
fluoxetine Prozac-20, Lovan, Erocap, Zactin, etc
fluvoxamine Luvox, Faverin, Movox
paroxetine Aropax, Paxtine, Oxtine, etc
sertraline Zoloft,Xydem

5. SELECTIVE SEROTONIN NORADRENALINE REUPTAKE INHIBITOR
At low doses venlafaxine acts like an SSRI.and at higher doses it is a bit more like a tricylic without some of the adverse effects.
venlafaxine Efexor, Efexor XR
6 . NORADRENERGIC AND SPECIFIC SEROTONIN ANTAGONIST
mirtazapine Avanza, Remeron, etc

7. HETEROCYCLIC
mianserin Tolvon, Lumin
8. SELECTIVE NORADRENALINE REUPTAKE INHIBITORS
reboxetine Edronax

MOOD STABILISERS
This group of drugs effectively treat a current episode of mania or depression. They also help prevent future episodes of mania and depression when taken consistently.
lithium carbonate Lithicarb, Quilonum SR
carbamazepine Tegretol, Teril
sodium valproate Epilim, Valpro
lamotrigine Lamictil

ANXIOLYTICS (Antianxiety Drugs)
These compounds are effective in relieving the symptoms of anxiety. The main compounds in this category are the benzodiazepines.
SIDE EFFECTS
Drowsiness
Impairment of concentration and reaction times
Impairment of some memory functions
Muscle incoordination – especially in the elderly which can lead to falls
Muscle weakness
Blurred vision

BENZODIAZEPINES
alprazolam Xanax, Kalma
bromazepam Lexotan
clobazam Frisium
clonazepam Rivotril, Paxam
diazepam Antenex, Ducene, Valium
lorazepam Ativan
oxazepam Alepam, Murelax, Serepax

BUSPIRONE
Buspirone is a non-benzodiazepine anxiolytic. Symptom relief is delayed (unlike the benzodiazepines, which are immediately relieve symptoms). It is generally well tolerated. It does not impair alertness, attention, memory, reaction time or driving.
Its use does not lead to abuse, tolerance or withdrawal neither does it influence the effects of alcohol or sedative-hypnotics.

SEDATIVE – HYPNOTIC AGENTS
These agents are used to help in the short–term management of insomnia. Generally the medications are prescribed for 2-4 weeks to help re-establish normal sleeping patterns. Occasionally, they are prescribed for a longer period of time. The main agents used are benzodiazepines. Other non-benzodiazepine agents have also been used. The disadvantages of the hypnotics are similar to anxiolytics. Tolerance and physical dependence can develop rapidly hence their indication for short-term intervention in sleep disturbance.

BENZODIAZEPINES
flunitrazepam Hypnodorm
nitrazepam Mogadon, Alodorm
temazepam Euhypnos, Normison, Temaze, Temtab
triazolam Halcion
NON-BENZODIAZEPINES
zopiclone Imovane
zolpidem Stillnox

PSYCHOSTIMULANTS
These medicines are used to treat attention deficit disorder, usually in children. They may also be used in narcolepsy.
Atomoxetine Strattera
Dexamphetamine
Methylphenidate Ritalin, Attenta

Electroconvulsive therapy (ECT)
Electroconvulsive therapy , also known as electroshock, is a well-established, albeit controversial, psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Today, ECT is most often used as a treatment for severe major depression which has not responded to other treatment, and is also used in the treatment of mania (often in bipolar disorder), catatonia and schizophrenia.

Psychotherapy
Psychoanalytic
Cognitive behavioral
Psychodynamic
Existential
Humanistic
Transpersonal
Hypnotherapy
Gestalt Therapy

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