Overview of psychiatric disorders.

1. IDENTIFICATION OF
PSYCHIATRIC DISORDERS IN
PRIMARY CARE SETTINGS
DR. SUJIT KUMAR KAR
ASSOCIATE PROFESSOR IN PSYCHIATRY
KING GEORGE’S MEDICAL UNIVERSITY, LUCKNOW, U.P

2. OVERVIEW OF PSYCHIATRIC DISORDERS
What are the psychiatric disorders?
• Mood disorders (depression, bipolar affective disorders)
• Schizophrenia and related psychotic disorders
• Anxiety disorders (generalized anxiety disorder, phobia, panic disorder)
• Stress related disorders
• Substance use disorders
• Psychosexual disorders (Premature ejaculation, erectile dysfunction)
• Dementia
• Sleep disorders
• Personality disorder
• Childhood psychiatric disorders
• Eating disorders

3. OVERVIEW OF PSYCHIATRIC DISORDERS
• Psychosis Versus neurosis
• Severe mental disorder versus common mental
disorder
• Organic versus functional disorders

4. ETIOLOGY
• Why does an individual develop psychiatric disorder?
• Biological factors
• Psychological factors
• Socio-cultural factors

5. WHAT IS THE RELEVANCE OF IDENTIFICATION OF
PSYCHIATRIC DISORDERS IN PRIMARY CARE SETTINGS?
• Early diagnosis and treatment
• Timely referral
• Early presentation commonly occurs in the primary care setting
• Reducing health care expenses

6. WHAT ARE THE SYMPTOMS OF PSYCHIATRIC
DISORDER?
• Mood symptoms (depression, anxiety, fear)
• Cognitive symptoms (delusion, obsession, attention & concentration,
executive function, memory, intelligence, social cognition)
• Behvioural symptoms (aggression, hostility, suicidal behaviour, disinhibited
behaviour, disorganized behaviour, withdrawn behaviour, impulsive
behaviour)
• Perceptual symptoms (hallucination, illusion)
• Somatic symptoms (pain, numbness)

7. Case Vignette 1
• A 15 yr old boy reading in 10th standard presented with episodes of severe
headache followed by abnormal body movements and unresponsiveness.
• Episodes last 20-30mins, sometimes even a hour or long & present for
approximately 1 year.
• Associated with withdrawn behavior*, school refusal, poor scholastic
performance, occasional irritability*, fearfulness*, apprehension*,
hopelessness, crying spells, sadness of mood*.
* These symptoms were present for more than 2 years

8. Case Vignette 1
• Neuro-imaging, EEG, Routine hemogram, Thyroid function test, ECG – WNL
• Treated with antiepileptics (Valproate, Carbamazepine, Clobazam, Levetiracetam-
alone as well as in combination)
• Treated with antipsychotics (Trifluoperazine, Risperidone+ THP, Quetiapine-
alone & in combination), Antidepressants (Sertraline 50mg/day, Imipramine
25mg/d, Dothepin25mg/d, Amitryptyline), Benzodiazepines (Clonazepam,
Lorazepam), Anti-migraine drugs (flunarizine, propranolol) Analgesics, PPIs,
Multivitamins.
• Also visited several traditional healers and physicians of alternative medicine

9. Case Vignette 1
• Reviewing the diagnosis –
• For more than 2 years, he had recurrent thoughts of-
• Door is not locked properly, thieves will enter the house
• The cooking gas is left open, gas will leak
• Also h/o repeated thoughts of contamination followed by compulsive washing behavior
• Always preoccupied by these thoughts
• In school- Unable to concentrate on studies
• Always stays at home, to keep a watch on these things with an apprehension, something
wrong may happen at home
• Symptoms worsened since last one year

10. Case Vignette 1
• Diagnosis – OCD with Moderate Depressive Episode With Mixed
Dissociative Disorder
• Treated with Fluoxetine alone (increased upto 60mg/day, Clobazam
10mg/d in divided doses), all other medications were stopped.
• In 2 months, depressive symptoms, dissociative symptoms, headache
resolved completely. OCD symptoms improved significantly.

11. • OCD in pediatric population
• Varied presentation
(eg.Withdrawn behavior to
marked irritability)
• PANDAS (Pediatric
Autoimmune Neuropsychiatic
Disorders Associated with
Streptococcal infections)
• US FDA approved medications
• Role of CBT

12. • Dissociation
• A stress response
• Varied clinical presentations
• True seizure Vs Pseudo-seizures
• Relevance of pharmacological management

13. Case Vignette 2
• A 24 year old young male was complaining of weakness, lethargy,
reduced sleep, reduced appetite, inability to concentrate on studies,
disturbed sleep & withdrawn behavior for 6 months.
• Since last 2 months, he reported about sadness of mood,
hopelessness, feeling of guilt, suicidal thoughts (twice attempted
suicide during that time).
• He lost 10 kg weight in last 6 months.

14. • In the initial period, he was treated with Syrup. Cyproheptidine,
Multivitamins & Benzodiazepine (Clonazepam) for sleep.
• Sleep improved.
• Due to two suicidal attempts and worsening of symptoms, he was
referred for psychiatric consultation
Case Vignette 2

15. • History reviewed
• He expressed his worries related to semen loss by nocturnal emission and masturbation
• Extreme guilt feeling was present
• He attributes all his symptoms to semen loss
• He was prescribe Escitalopram 10mg/day and Psychosocial intervention has
been done. Sexual myths were addressed.
• His symptoms resolved in 2 weeks.
• Diagnosis: Dhat Syndrome with Severe Depressive Episode
Case Vignette 2

16. • Dhat Syndrome
• Culture bound syndrome
• Psychosomatic features
• Common in late adolescence to
young adults

17. • Depression
• Normal emotional response Vs Depression
as a pathological entity
• FDA black box warnings
• Association with physical illnesses

18. Case vignette 3
• A 60 year old female complaining of disturbance in sleep for past 4 years. She had
difficulty in falling a sleep as well as frequent interruptions in sleep throughout
the night.
• She also report about terrifying dreams in the night.
• Over past six months, she had increase in irritability, difficulty in concentration
and decrease interest in work.
• She used to take over-counter sleeping pills for past two years, but since past six
months she continued to have sleep difficulties despite taking 2 to 3 tablets of
sleeping pills.

19. KEY ISSUES IN CASE 3

21. Scholastic difficulties…
Look for
Intellectual disability
ADHD
Learning disorder
Several other
psychiatric disorders and
medical conditions cause
decline in scholastic
performance

22. SYMPTOMS THAT MIMIC
PHYSICAL ILLNESSES
• Panic attack
• Hyperventilation
• Dissociative stupor/amnesia/seizure/
sensory or motor disorder/Possession
• Anorexia nervosa
• Somatoform disorder

26. Thank You