ANXIETY DISORDERSYard. Doç. Dr. Berfu AkbaşA diffuse, unpleasant, vague sensation of apprehension, often accompanied by autonomic symptoms; palpitations, perspiration, headache, tightness in the chest, mild stomach discomfort, restlessness, dizziness, diarrhea, tremors, urinary frequency, hesitancy.Normal Anxiety : advantageous response to a threatening situationPathological Anxiety: inappropriate response to a given stimulus.Fear: A response to a known, external, definite threat

Epidemiology: women life-time prevalence: % 30.5 Men : % 17.7 Autonomic Nervous System Neurotransmitters: Norepinephrine, serotonin, GABA Neuroanatomy:Locus cereleus, raphe nuclei, limbic system, temporal

lobes Genetics:

Anxiety Disorders Panic Disorder Specific Phobia Social Phobia Posttraumatic Stress Disorder ( PTSD ) Acute Stress Disorder Generalized Anxiety Disorder

PANIC DISORDER Epidemiology: PD:1.5-5%,PA: 3-5.6% A: 0.6-6% DSM 5 CRITERIA FOR PANIC DISORDER 1- Recurrent unexpected panic attacks 2- Persistent concern about having additional attacks 3- Worry about its consequences ( going crazy..) 4- Significant change in behaviour 5- Panic attacks are not due to a substance or a medical condition or

another mental disorder PANIC ATTACK

4 or more of the following symtoms: * palpitations * sweating * trembling or shaking * shortness of breath * feeling of choking * chest pain * nausea or abdominal discomfort * feeling dizzy, lightheaded, faint * derealization- depersonalization * fear of losing control or going crazy * fear of dying * numbness or tingling sensations * chills or hot flushes

MEDİCAL CONDITIONS THAT CAN MIMIC A PANIC ATTACKAngina pectorisArrithmiasCOPDTemporal lobe epilepsyPulmonary EmbolismAsthmaHyperthyroidismHypoglycemiaPheochromacytomaCOURSE AND PROGNOSISOnset: early adulthood%30-40→long term symptom free%50→mild symptoms%10-20→significant symptoms%40-80→depression develops%20-40→alcohol adn substance dependance TREATMENT:Benzodiazepines ( alprazolam, lorazepam )SSRI’s ( paroxetine, sertraline, citalopram )Cognitive behaviour therapySPECIFIC PHOBIASSPECIFIC PHOBIA

A phobia is defined as an irrational fear that produces conscious avoidance of the fearred subject, activity or situation.

5-10% ( most common anxiety disorder ) Early beginning Animals ( ailurophobia-cats, cynophobia-dogs) Natural enviroment( storms,acrophobia-height) Blood-injection-injury Situational ( elevators, airoplane ) Other ( mysophobia-germs,nasophobia-illness, death) Treatment: Exposure therapy benzodiazepines

SOCIAL PHOBIA3-13%, teenshyperactivation of the amygdala and insula in fMRIA marked fear of social or performance situations in which the person is exposed to unfamiliar people. The individual fears that he will act in a way that will be humiliating or embarrassing.Exposure to the feared social situation provokes anxiety which may take the form of panic attackThe person recognizes that the fear is excessive or unreasonable.The feared social or performance situations are avoidedTreatment:SSRI’s, benzodiazepinesBehavioral and cognitive therapyGENERALIZED ANXIETY DISORDER

Prevalance: ~ % 5More likely to occur in people with «behavioral inhibition»Excessive anxiety and worry about a number of events or activities.Anxiety and worry is associated with at least 3 of the followings: restlessness, being easily fatiqued, difficulty in concentrating, irritability, muscle tenion, sleep disturbance.Treatment:Cognitive and behavioral therapySSRI’s, benzodiazepinesPOSTRAUMATIC STRESS DISORDER

Develops after a person sees, is involved in or hears of an extreme traumatic stressor. The persons response involves intense fear, helplessness or horror.

The event is persistantly reexperienced as images, flashbacks, thoughts, dreams.

Intense psychological distress at exposure to cues that symbolize or resemble the event

Persistance avoidance of the stimuli and numbing of general responsiveness

Sleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle response

1 week-30 yearsACUTE STRESS DISORDERDevelops after a person sees, is involved in or hears of an extreme traumatic stressor. The persons response involves intense fear, helplessness or horrorA subjective sense of numbing, detachment, absence of emotionsDerealization, depersonalization,Dissociative amnesiaThe event is persistantly reexperienced as images, flashbacks, thoughts, dreamsSleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle responsePharmacotherapyBenzodiazepines: GABA A agonistSSRI’sTCI’sMAO inhibitorsB- adrenergic receptor antagonists ( propranololAntihistaminicsBuspirone ( HT1a agonist)Ca channel blockersANXIETY DISORDER DUE TO A GENERAL MEDICAL CONDITIONThyroid disorders ( hyper-hypothyroidism )HypoglycemiaNeurological Disorders ( MS, epilepsy, CVD, Parkinson)AnemiaCardiomyopathies, hypoxia, cardiac arrytmiasSLE, RA, PANALCOHOL – DRUG WITHDRAWALcaffeine

MOOD DISORDERS 1-DEPRESSIVE DISORDERS

-MAJOR DEPRESSIVE DISORDER( MDD )(unipolar depression ) %10-25 women, %5-12 men- Persistant depressive disorder ( dysthymia)- Distruptive mood dysregulation disorder- Premenstrual dysphoric disorder

2- BIPOLAR DISORDERSMajor Depressive Disorder Prevalance %12 Female / Male: 2/1 Monozygotic Twins: %37 Risk Factors: Early life stress Parental neglect / abuse Social factors( isolation, criticism ) Neurobiological approaches to aetiology Monoamine hypothesis:

Serotonin(5-HT):- plasma tryptophan⇩- Blunted 5-HT neuroendocrine responses- brain 5-HT1A receptor binding⇩- brain %-HT reuptake sites⇩

Noradrenaline:- Blunted NA mediated growth hormone release

Dopamine:- HVA levels inCSF⇩

Aminoacid neurotransmitters

Glutamate (é), GABA(ê) brain-derived neurotrophic factor Substance P

Endocrine abnormalitiesHPA axis ( CRF ñ )

DSM 5 CRITERIA for DEPRESSION For at least 2 weeks, at least 5 of the below symptoms should be present: Depressed mood* Decreased interest or pleasure in activities* Change in apetite Sleep changes Pscyhomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Concentration difficulties Thoughts of death Anatomic Changes ñ ventricular – brain ratio Smaller frontal lobe volumes ( prefrontal lobe most affected )

Smaller hippocampal volumeImmune System

- TNF concentrations, interleukin-6 ñ- SPECIFIERS DESCRIBING MOST RECENT EPISODE

Psychotic features Anxious Distress Melancholic features (endogeneous depression) Atypical features (overeating, oversleeping, reactive to pleasurable

stimuli) Catotonic features ( immobility, negativism, mutism) Postpartum onset Seasonal pattern

DYSTHYMIA Depressed mood for at least 2 years + 2 of the following; Apetite changes, sleep changes, low energy, low self-esteem, poor

concentration, feelings of hopelessness. “İll humored”, most cases early onset

DOUBLE DEPRESSION: dysthymia + MDDSubstances/ medications that cause depression

Alcohol Beta-blockers Steroids Opiates Barbiturates Cocaine-amphetamine withdrawal Heavy metal posioning Cholinesterase inhibitors Cimetidine Chemotherapy agents

Medical conditions that can cause depression ENDOCRINE: Hyper/hypothyroidism Severe anemia ( Vit B12 Deficiency) Hyperparathyroidism Hypokalemia / hyponatremia Cushing’s Disease Addison’s Disease Uremia Hypopituitarism Porphyria Wilson’s disease Wernicke-Korsakoff’s Disease INFECTIONS: TBC, EBV, HIV, tertiary syphilis, encephalitis NEURODEGENERATIVE: Alzheimers, MS, Parkinson, Huntington Subdural hematoma, NPHydrocephalus, stroke, cerebral tumors NEOPLASIA: Pancreas Ca, Carcinomatosis, ca of lung, breast

SLE, collogen vascular disorders Vit D deficiency

TREATMENT Pharmacotherapy: Tricyclic antidepressants: İmipramine ( tofranil), clomipramine

( anafranil ), amitriptiline ( laroxyl ), ( side effects: hypotension, arrithmias, seizures )

Serotonin reuptake inhibitors: Fluoxetine ( prozac), citalopram ( cipram), sertraline ( Lustral ), paroxetine ( paxil), essitalopram ( cipralex ) ( side effects: GI disturbance, bleeding? Bruxism? )

ECTBIPOLAR DISORDERS

BIPOLAR 1 DISORDER: %0.4-1.6, equal prevelance among sexes. Onset is earlier than depression 1 parent Bipolar: %25 risk in the sibling Dx: At least 1 manic episode lasting for 1 week Mania: at least 3 of following:

-Grandiosity - psychomotor agitation-Decreased need for sleep - excessive activities-Talking -Flight of ideas-distractibility

Manic Patients are: Excited, talkative, sometimes amusing Cannot be interrupted while speaking, loud Delusions occur in %75 ( grandiose ) %75 assaultive or treatening Unreliable, lying

BIPOLAR II DISORDER Presence of one or more depressive episodes Presence of at least one hypomanic episode Hypomania:at least 4 days 3 of the following ; Grandiosity Decreased need for sleep Talkative Flight of ideas Distractibility Psychomotor agitation Excessive pleasurable activities

TREATMENT Depressive attacks: antidepressants Manic attacks: mood stabilizers+ antipsychotics + benzodiazepines Mood Stabilizers: Lithium Antiepileptics These drugs are used chronically CYCLOTHYMIC DISORDER

-Episodes of hypomania and mild depression for 2 years.

-%1 life time prevalance, 15-25 years onset- F/M=3/2- ınstability in relationships- Changes in mood are irregular, abrupt- Common substance use disorders- Tx: mood stabilizers- Antidepressants switch to mania

• EATING DISORDERS• Statistics on Eating Disorders• Anorexia

• Average age of onset :17yrs• 15 – 19 year old females 0.5%

20 – 24 year old females 0.25% • Bulimia Nervosa• 2% women between 15 and 40• Incidence 15 new cases per 100,000 pa. • Male: female ratio ranges between 1:6 to 1:10• ANOREXIA NERVOSA• A refusal to maintain body weight at or above a minimally normal weight

for age and height (e.g. weight loss leading to a maintenance of body weight less than 85% of that expected, or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

• B. Intense fear of gaining weight or becoming fat, even though underweight.

• C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

• Specify type: • Restricting Type: During the current episode of Anorexia Nervosa, the

person has not regularly engaged in binge-eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics or enemas)

• Binge-Eating/Purging Type: During the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behaviour (i.e. self induced vomiting or the misuse of laxatives, diuretics or enemas).

• Other• Frequent weighing• Talking about new diets and expressing the desire to be thinner• Increasing isolation, disinterest in social activities, work and /or study• Social Withdrawal and intolerance of others• Excessive exercising• Wearing baggy clothes• Deny being ill • BULIMIA NERVOSA• (1) eating, in a discrete period of time (e.g. within any 2 hour period), and

amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

• (2) a sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating)

• B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas or other medications; fasting; or excessive exercise.

• C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for 3 months.

• D. Self-evaluation is unduly influenced by body shape and weight. • E. The disturbance does not occur exclusively during episodes of Anorexia

Nervosa. • Specify type:

• Purging Type: During the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas.

• Non-purging Type: During the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas.

• Behavioural Signs• Repeatedly avoiding meals• Not wanting to eat what everyone else is having• Saying “I’ll eat later” • Eating meals but extremely restless after the meal as their anxiety grows• Visits to the bathroom shortly after a meal (explaining its to have a bath

or wash their hair)• Dramatic fluctuations in weight• Mysterious disappearance of food• Evidence of binge eating: actual observation, verbal report, large amounts

of food missing• Discoveries of food wrappers under chair pillows, mattresses or in

bedroom cupboards• Continual overdrafts, debts and missing money. Inability to account for

how the money was spent• Frequent weighing• Talking about new diets and expressing the desire to be thinner• General dissatisfaction with appearance and figure. Expressing the wish

to change• Evidence of purging (vomiting, laxative/diuretic abuse, emetics, frequent

fasting, excessive exercise)• Impromptu walks (often to buy food)• Night owl behaviour (so they can binge once everyone has gone to bed)• Increasing isolation, disinterest in social activities, work and /or study • General apathy and/or depressive outlook on life• Moodiness, irritability, depression• Low self esteem• Oversensitive to criticism• Shoplifting or stealing of food or money •• Physical and Emotional Signs• Side effects of bingeing• Abdominal swelling and pain• Swelling of the hands, legs and feet• Swelling of the salivary (Parotid) glands around the face and jawline• Tiredness, nausea, breathlessness, dizziness• A pre-disposition to dental decay and gum disease as a result of bingeing

on sugary foods, also because of vomiting • Side effects of vomiting• Hypoglycemia (low blood sugar). This can cause: sweating; irregular

heartbeats; epileptic fits; convulsions; weakness; lethargy; mental

confusion; irrational behaviour; anxiety; panic attack; feelings of hunger; and depression

• Mineral and Chemical Imbalance. Especially potassium and sodium are lost through vomiting, laxative or diuretic abuse. It can cause: muscular weakness; bloated feeling; lethargy; tingling/numbness in fingers and toes; confusion; poor concentration; dehydration; irregular heartbeat; low blood pressure; kidney damage; and further mineral losses.

• Dental Problems. Loss of tooth enamel leading to tooth decay.• Bleeding from the upper intestinal tract• Lack of Protein• Swollen salivary (parotid) glands• COMPULSIVE(BINGE) EATING• Compulsive eating is eating large quantities of food when a person is not

hungry. This may occur in a short period of time (a binge) or it may be continuous snacking throughout the day. People of any size may eat compulsively.

• Compulsive eating is often accompanied by a feeling of being out of control, not knowing why they are eating, and not being able to stop. Compulsive eating is usually a very secretive thing and the person often feels a sense of shame.

DRUG ADDICTION AND ALCOHOLISM Yard. Doç. Dr. N. Berfu Akbaş

Yeditepe Üniversitesi Psikiyatri Anabilim Dalı DEPENDENCE: A maladaptive pattern of substance use, leading to clinically significant

impairment or distress, manifested by TOLERANCE, WITHDRAWAL, PERSISTANT DESIRE, a great time and activity spent, social activities given up, use is continued despite knowledge of harms.

ABUSE: recurrent substance use in a failure to fulfill major role obligations, use in situations physically hazardous, recurrent legal problems, continued use despite social and interpersonal problems

INTOXICATION: the development of a reversible substance-specific syndrome due to recent exposure ( clinicaly significant maladaptive behavioral or psychological changes on central nervous system )

WITHDRAWAL: the development of a reversible substance-specific syndrome due to the cessation of substance

ALCOHOL RELATED DISORDERS%0.05 in blood: thought, judgment, restraint loosened% 0.1 : voluntary motor actions clumsy% 0.3 : confusion and stupor0.5 promil: 0.5gr alcohol in 1lt blood: %0.063 alcoholIntoxication: inappropriate behaviour, mood lability, impaired judgement, slurred speech, incoordination, nystagmus, impaired attention amd memory, comaWithdrawal: autonomic hyperactivity, hand tremor, insomnia, nausea-vomitting, hallusinations, illusions, psychomotor agitation, anxiety, grand mal seizuresDelirium Tremens: Alcohol ıntoxication delirium, mortal %20. ın 1 week after alcohol cessation. Hallusinations, delusions, tachycardia, diaphoresis, fever, hypertension, hyperexcitability or lethargy

Wernicke-Korsakoff Sydrome: alcohol-induced persisting amnestic disorder. Thiamine deficiency.

Wernicke’s Encephalopaty: alcoholic encephalopaty, ataxia, confusion, nystagmus, gaze palsy, anisocoria. Reversible if treated, if not→ Korsakoff’s Sydrome: chronic amnestic sydrome.

Marciafava-Bignami Syndr: demyelination of corpus callosum, optic tracts, cerebellar peduncles.

Medical complications of alcohol use: Liver damage, peptic ulcer, pancreatitis Peripheral neuropathies, myopathy, hepatocerebral degeneration,

cerebellar degeneration, gynecomastia HT, stroke cardiomyopathy, anemia, electrolyte imbalances Ca of mouth, pharynx, liver, breast Idiosyncratic alcohol intoxication : small amounts, agression Pathological jealosy Alcoholic hallusinosis: auditory AMPHETAMINE-RELATED DISORDERS Ice, crystal, speed, XTC, adam, eve...psychostimulants. Metamphetamine, ephedrine, pseudoephedrine, MDMA( ecstasy),

methylphenidat

A single dose ( 5mg): ıncrease the sense of well-being, elation, euphoria, friendliness, improve attention, increase performance, anorexia

Severe hypertension, myocardial infarction, cerebrovascular infarction, ischemic colitis, seizures, coma.

CAFFEINE RELATED DISORDERS A cup of coffee: 100-150mg. Caffeine ( methylxanthine) Low doses: + reinforcer, doses > 300mg: increased anxiety and mild

dysphoria. Global cerebral vasoconstriction Intoxication: restlessness,nervousness, excitement, muscle twitching,

cardiac arrhytmia Withdrawal: fatique, drowsiness, anxiety and depression, nausea and

vomitting CANNABIS-RELATED DISORDERS Hashish ( flower), marijuana ( leaves)

(tetrahidrocannabiol- THC)- Physical dependance is not strong- No respiratory depression Euphoria, sensitivity to external stimuli, slows time, motor skill

impairment may last 12 hrs, red eye, tachycardia, increased appetite, hypotension, long term use; cerebral atrophy, seizures, chromosomal damage, decreased testesterone, amotivational syndrome

COCAINE-RELATED DISORDERS Vasoconstrictive and topical anesthetic effects Dopamine reuptake blockage Produces euphoria→personality changes, impulsive behaviour, weight loss, insomnia,nasal congestion, cerebrovascular(infarcts) cardiological disorders ( arritymia, MI, CMP ) seizures, crash syndrome ( post intoxication depression) formication ( cocaine bugs) Hallucınogens mushrooms( psilocybin), mescaline( cactus),LSD Phencylidine (PCP) “hallucinogen persisting perception disorder”- “flashbacks” Opioid Related Disorders: morphine, heroin, fentanyl, codeine,

hydrocodone receptor *: analgesia, resp. depres., hypothermia, bradycardia, constip.μ receptor: analgesia, diuresis, sedationκ receptor: analgesiaΣ Euphoric high ( rush )→ sedation,

Dry mouth, ichy nose, red face, pinpoint pupils, constipation, smooth muscle contraction, respiratory depression,anaphylactic shock, arrythmia,hyptension, hypothermia...

COGNITIVE AND MENTAL DISORDERS DUE TO A GENERAL MEDICAL CONDITION (DGMC )

Yard. Doç.Dr. N. Berfu AKBAŞ “Clinically significant deficit in cognition and memory that represents a

significant change from a previous level of functioning” DELIRIUM DEMENTIA AMNESTIC DISORDER COGNITIVE DISORDERS DGMC DELIRIUM

Disturbance of consciousness and a change in cognition with sudden onset.Abnormalities of mood, perception, behaviour, tremor, nystagmus, incoordination, urinary incontinanceFluctuates during day, worse at night“It’s a syndrome, not a disease!”Other names: acute confusional state, acute brain syndrome, metabolic encephalopathy, toxic psychosis, acute brain failure

Important to recognize; %90 postcardiotomy %40-50 after hip fracture surgery %30 AIDS %20 after severe burns %15-20 in general medical wards Advanced age ( >65-%30-40) 1 year mortality %50 ( poor prognostic sign) Etiology: CNS disease ( epilepsy, brain trauma, infections, neoplasms, vascular

disorders) Systemic Diseases ( arrhytmias, hypoglycemia, hypoxia, hepatic-uremic

encephalopathies, endocrine dysfunction, fever, sepsis) Post-operative states Drugs and poisons Electrolyte imbalance of any cause Major neurotransmitter: Acetylcholine Neuroanatomical area: Reticular Formation ( attention and arousal ) EEG: diffuse slowing of background activity TX: treat the underlying cause!! Psychotic features: haloperidol Insomnia: benzodiazepines( lorazepam) DEMENTIA Multiple cognitive defects ( impairment in memory, general

intelligence,learning, language,problem solving, orientation, perception, attention, judgement ) without impairment in consciousness.

>65, %5 have severe, %15 mild dementia. Time of death after onset of symptoms: 5-9 years %60- Alzheimer type, after that vascular dementia most common

Psychiatric and Neurological Changes Personality Hallucinations and delusions Mood Cognitive changes( aphasia, apraxia, agnosia, seizures, primitive reflexes

AMNESTIC DISORDERS Retrograde Amnesia: inability to recall previously learned information Anterograde Amnesia: impairment in the ability to learn new information Usually short-term, recent memory impaired İmmediate and remote memory intact. The specific cause determines the course and prognosis Thiamine Deficiency ( Korsakoff’s Syndrome) Hypoglycemia Seizures Head trauma Cerebral Tumors SVA Herpes Simplex Encephalitis Hypoxia ECT Multiple Sclerosis Alcohol Benzodiazepins

• SOMATOFORM DISORDERS• DR. N. BERFU AKBAŞ

• SOMATIZATION DISORDER• CONVERSION DISORDER• HYPOCONDRIASIS• BODY DYSMORPHIC DISORDER• ✪ ✪• FACTITIOUS DISORDERS• MALINGERING• SOMATIZATION DISORDER• Many physical complaints before age 30• 4 pain symptoms – 4 different sites• 2 gastrointestinal symptoms• 1 sexual symptom• 1 pseudoneurological symptom• Previously called hysteria, Briquet’s Syndrome• %1-5 women, %0.2 men• %50 psychiatric comorbidity ( personality disorders, depression,

anxiety )• Psychosocial factors: • To avoid obligations• Express emotions• Symbolize feelings• Parental examples• Patients medical histories are vague, inconsistent, disorganized• Describe their complaints in a dramatic, emotional, exaggerated fashion• Substance abuse• Chronic course – doctor shopping• Tx:• Listen somatic complaints as emotional expressions• Avoid additioonal lab and diagnostic procedures• Increase the patients’ awareness• CONVERSION DISORDER• One or more neurological symptoms that cannot be explained by a known

neurological or medical condition• Psychological factors are associated with the initiation or exacerbation of

the symptoms• The symptom is not intentionally produced• Most common among rural populations, little education• Psychiatric morbidity high• F/M= 5/1• Most common symptoms of conversion• Involuntary movements• Tics• Blepharospasm• Torticollis• Seizures• Abnormal gait• Falling• Paralysis• aphonia

• Anesthesia (extremity)• Blindness• Tunnel vision• Deafness• Vomitting• Pseudocyesis• Globus hystericus• Syncope• Urinary retention• diarrhea• Conversion of anxiety into a physical symptom• Symptoms represent an unconscious psychological conflict• Nonverbal means of controlling or manipulating others• Histrionic, passive-dependent personality types• La belle indifference• Learning theory-identification

• %90-100 of patients recover spontaneously in a few days• Psychotherapy• Never tell the patient that symptoms are imaginary• HYPOCHONDRIASIS• Preoccupations with fear of having a serious disease with

misinterpretation of bodily symptoms• Persists despite appropriate medical evaluation and reassurance• Lasts at least 6 months• F=M, • %3 of medical students• Have low threshold for physical discomfort• BODY DYSMORPHIC DISORDER• Pervasive subjective feeling of ugliness of some aspect of their

appearance despite a normal or nearly normal appearance.• Strong belief that she/he is unattractive or repulsive• Patients more likely to go to dermatologists, internists, plastic surgeons• Displacement of a sexual or emotional conflict onto a nonrelated body

part• Nose/hair/breasts/genitals/skin/body build• Tx: SSRI’s effective• FACTITIOUS DISORDERS• ıntentıonal productıon of physical and psychological signs and symptoms• The motivation for the behaviour is to assume the sick role• External incentives are absent• Munchausen Syndrome (1951)• %3 hospital patients• Childhood abuse or deprivation,rejecting mother• MALINGERING

the patient has obvious gains in producing signs and symptoms