Sultanate of Oman

Ministry of Health
Directorate General of Primary Health Care

Guideline for Management

of Mental Disorders
in Primary Health Care Third Edition
 Sultanate of Oman
Ministry of Health
Directorate General of Primary Health Care

Guideline for Management

of Mental Disorders
in Primary Health Care Third Edition
 Preface

Mental health problems are among the most common reasons that
clients consult doctors, and most of these consulta ons take place in
primary care, in the accident and emergency department, in the
outpa ent clinics or in the general hospital wards. Hence, all health
care providers should be equipped with basic mental health skills in
order to provide high quality care to these pa ents. This guideline is
aimed to be part of a systema c and comprehensive program to
integrate mental health into Oman's primary health care system. It will
give all clinicians guidance on prac cal management of mental
disorders in an easily accessible format.

It is important that primary health care providers are empowered with

the necessary knowledge, skills, competence and a tude to recognize
as well as manage mental health problems in both the community and
primary health care facili es.

1
Expert work groups of psychiatrists have developed the manual, and in
addi on, a panel of mental health experts as well as consultants have
reviewed it. It contains updated methods with clear algorithms of case
iden fica on, management and referral pathway health care facili es
in Oman predominantly related to the primary and secondary health
ins tu ons. It is a concise summary of mental health disorders that are
prevalent at the primary care level and does not replace the exis ng
textbooks.

This manual should be readily available to all primary health care

professionals and used as a general guidance to evaluate and manage
pa ents presented with mental health problems at the primary health
care level.
We hope that the implementa on of this guideline will be beneficial to
all and will help raise awareness amongst health care providers and
pa ents alike to the importance of mental health care.

Dr. Said Hareb Al Lamki

Director General of Primary Health Care.

2
Contributors:
Chief Editor:
SSN. Muzna S. Al Balushi, Mental Health Sec on, Department of
Non-Communicable Diseases.
Task Force Team:
Dr. Amira Al Raidan, Head of Mental Health Sec on, Department of
Non-Communicable Diseases.
Dr. Azza Al Hinai, Psychiatrist, Barka Polyclinic.
Dr. Rahma Al Naamani, Consultant Psychiatrist, Al Massara Hospital.
Dr. Mandhar Al Maqbali, Psychiatrist, Sohar Polyclinic.
Dr. Zakia Al Dafai, Senior specialist, Samail Hospital.
Dr. Ahmed Komsan, Psychiatrist, Ibra Health center.
Dr. Tamer El Zaafrani, Psychiatrist, Ibri Hospital.

Reviewers:
We also acknowledge the expert review and comments on this guideline by:
Dr. Shadha S. Al Raisi, Director of Non-Communicable Diseases Department.
Dr. Ghaniya Al Ghafri, Consultant Child and Adolescent Psychiatry, Head of
Psychiatry Department, Ibri Hospital.
Dr. Muna Al Shekaili, Consultant Child and Adolescent Psychiatry, Head of
Child and Adolescent Department, Al Massara Hospital.
Dr. Asila Al Zaabi, Consultant psychiatrist, Head of Addic on Psychiatry
Department, Al Massara Hospital.
Dr. Saleha Al Jadidi, Consultant Psychiatry and Geriatric, Head of Geriatric
Services, Al Massara Hospital.
Also, we graciously acknowledge:
Mrs. Anju Jessy Kurian, Medical coordinator, Office of Undersecretary for
Health Affairs for her help with edi ng and proofreading of the guideline.

3
 Content

Table of contents Page

Preface 1
Contributors and Reviewers 3
List of Abbrevia ons 5
Introduc on 7
Sec on1. How to Use The Guideline 11
Core competencies for health care providers working in primary health
care 12
Iden fying and processing clients' need 15

Sec on2. Types of Mental Health Problems 23

ICD-10 Classifica on of Mental And Behavioral Disorders 24

Sec on 3. Management of Common Mental Disorders at PHC

Ins tu ons 27
Mood Disorders 30
Psycho c Disorders 38
Anxiety Disorders 41
Substance-Related And Addic ve Disorders 53
Women Mental Disorders 68
Childhood Psychiatric Disorder 83
Psychiatric Emergencies 106
Neuro-Cogni ve Disorders 119
Soma c Symptom Disorders 126
Ea ng Disorders 129
Sleep Disorders 136

Annexes 140
References 141

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 List of abbrevia ons

Alcohol Withdrawal Delirium AWD

Alcohol, Smoking And Substance Involvement Screening Test ASSIST
At night HS
A en on Deficit Hyperkine c Disorder ADHD
Child Protec on Commi ee CPC
Cogni ve Behavioral Therapy CBT
Delirium Tremens DTs
Diagnos c And Sta s cal Manual Of Mental Disorders Fi h Edi on DSM-5
Electroconvulsive Treatment ECT
Emergency Department ED
Family And Community Medicine FAMCO
Food And Drug Administra on FDA
Gastrointes nal GI
General Physician GP
Generalized Anxiety Disorder GAD
Intelligence Quo ent IQ
Interna onal Classifica on Of Diseases ICD
Interpersonal Psychotherapy IPT
Mental Health Emergency Crisis MHEC
Mental Health Gap Ac on Programme Interven on Guide
mhGAP-IG
(mhGAP-IG)
Mental State Examina on MSE
Mini Mental State Examina on MMSE
Ministry Of Health MOH

5
Modified Checklist For Au sm In Toddlers M-CHAT
Mood Disorder Ques onnaire MDQ
Obsessive-Compulsive Disorder OCD
Once a day OD
Post-Trauma c Stress Disorder PTSD
Primary Health Care PHC
Quick Inventory Of Depressive Symptomatology QIDS
Random Blood Sugar RBS
Regional Hospital Task Force for Child Abuse RHTFCA
Selec ve Mu sm SM
Selec ve Serotonin Reuptake Inhibitors SSRIs
Severity of Violence Against Women Scales SVAWS
Sexually Transmi ed Diseases STDs
Strengths And Difficul es Ques onnaire SDQ
Three mes a day TID
Tricyclic An depressants TCAs
Twice a day BID
World Health Organiza on WHO

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 Introduc on

Mental illness is a health problem that significantly influences how a person

feels, thinks, behaves and interacts with others. It is diagnosed according to a
standardized criteria.
The term mental disorder is also used to refer to this type of health problem.
Importance of Mental Health

1. It is a component of health (physical, psychological, and social) as defined by

the World Health Organiza on (WHO).
2. There is a lack of public awareness regarding the signs and symptoms of
mental illness, methods of inves ga on, and treatment.
3. Medical reasons for its importance:
Ÿ The prevalence of mental disorders is high.
Ÿ There are a limited number of health workers who can manage mental
health problems.
The Problem
Mental disorders are a leading direct cause of disease burden worldwide.¹ The
primary area of concern is the limited access to mental health care services in
Primary Health Care (PHC) se ngs in Oman by a large propor on of affected
individuals and their families.
PHC centers o en lack essen al psychotropic medica ons as well as assessment
and treatment measures. For this reason, the WHO strongly recommends the
integra on of mental health care into general PHC services as the most viable way
of ensuring that people have access to the mental health care they need.² Essen al
mental health services to be delivered within PHC include early iden fica on,
treatment of common mental disorders, management of stable psychiatric
pa ents, referral to other levels when appropriate, a en on to the mental health
needs of people with physical health problems, and mental health promo on and
preven on.²

7
The Situa on in Oman
The latest annual report of the Ministry of Health (MOH) covered mental health
and total visits to psychiatric clinics at MOH ins tu ons. The total number of visits
in 2018 showed an increase of 3.8% as compared to 2017. The age group of 20–44
represented most of the visits (53.194 visits), and the female popula on showed
fewer visits among all age groups when compared to the male popula on. The
North Al-Ba nah region had the highest number of visits (29,345), followed by the
Muscat region (21,034). The main reasons for the visits to the psychiatric clinics at
MOH ins tu ons were mental and behavioral disorders due to drug or substance
uses, followed by delusional disorders, stress-related disorders, mental
retarda on, and emo onal disorders during childhood plus adolescence.
According to the WHO Assessment Instrument for Mental Health Systems (WHO-
AIMS), there are 26 outpa ent mental health facili es in Oman, and the number of
human resources working in the mental health sector, including those in private
prac ce, is 14.2 per 100,000 people. The bulk of the mental health services are
located in major urban areas as the density of psychiatrists in and around the
largest city of Muscat, is 2.42 mes greater than the density of psychiatrists in the
en re country. ³
Early assessment and interven on can posi vely change the natural progression
of mental disorders into chronic and disabling condi ons. This is par cularly
important, given that the burden of mental disorders worsens the outcomes of
co-occurring condi ons, such as cancer, heart disease, and diabetes. ⁴,⁵
Scope

This guideline is intended to serve as a reference for all health care providers who
work in primary and secondary health care ins tu ons to deal with psychiatric
cases, provide early detec on, as well as explain methods of treatment. Although
the number of psychiatrists is compara vely low in Oman, there are significant
numbers of psychologists, mental health nurses and other workers who if
supported with proper training and are regulated as a profession will play a crucial
role in integra ng mental health into primary care.

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Aims and Objec ves of the Guideline

The World Health Assembly has approved a strategic plan for the development of
mental health services around the world for the period 2013-2020. In turn, the
Ministry of Health (MOH) aims to achieve a vision to provide comprehensive
primary health care through:
Ÿ Providing psychological and mental health services in primary health care
se ngs.
Ÿ Reducing admissions to specialized psychiatric hospitals, which will also
have a posi ve impact on reducing the s gma related to mental illness.
Ÿ Increasing early detec on and improving treatment results.
Ÿ Reducing the burden that results from mental disorders.

Policy and Procedure

This guideline is designed for use by non-specialized health care providers working
at first and second level healthcare facili es. These providers include primary care
doctors, nurses and other members of the healthcare workforce. It is intended to
help provide an integrated approach to the iden fica on and assessment of
common mental health disorders, par cularly in a primary health care se ng.
Also, specialists have an essen al and substan al role in training, support and
supervision, and this guideline indicates where access to specialists is required for
consulta on or referral.
Training in the use of this guideline is best done as part of a systems approach
involving health planners, managers and policymakers so that the interven ons
proposed are supported by necessary resources e.g. availability of essen al
medicines.
Training on the guideline also needs to be incorporated in an ongoing manner with
mechanisms in place to ensure adequate support, supervision and refresher
training for the healthcare providers.

9
How to Use the Guideline?

WHO recommends contextualiza on of the generic version of the Mental Health

Gap Ac on Programme Interven on Guide (mhGAP-IG) to be implemented in
each country/local context to produce a fully adapted guideline that meets the
needs of the exis ng health system in which it is to be used.
Consequently, this guideline is adapted from WHO's mhGAP Interven on Guide,
as it is extracts essen al informa on from the mhGAP-IG starts with [General
Principles of Care] which help in good clinical prac ces for the interac ons of
healthcare providers with people seeking mental health care. All users of this
manual should familiarize themselves with these principles and should follow
them as far as possible. Moreover, it includes addi onal elements and modules
specific to common mental disorders in Oman.
There are eleven modules in this guideline. Each module is in a different color to
allow easy differen a on. Each of the modules consists of five sec ons:
Ÿ Brief descrip on (Defini on)
Ÿ Signs and symptoms
Ÿ Screening and assessment
Ÿ Management
Ÿ Flowchart
Along with the guideline. It is important that the non-specialist healthcare
providers are trained and then supervised and supported in using the mhGAP-IG in
assessing and managing people with mental, neurological and substance use
disorder to accelerate the reduc on of the mental health treatment gap.

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 Section 1
How

?
to Use
The
Guideline

11
Core Competencies for Health Care Providers Working in Primary Health Care
Mental health clinical prac ce is crucial for safe and effec ve mental health service
integra on in primary care.
Therefore, health care providers have to be competent in communica on skills,
empathy, competent in assessing physical and mental health, addressing
confiden ality, involving family members in care. mhGAP Interven on Guide
(mhGAP-IG 2016) version 2.0,⁶ highlighted two important core competencies for
good clinical prac ce as following:

A. General 1- Use effec ve communica on skills

Principles 2- Promote respect and dignity

1- Assess physical health

B.Essen als of 2- Conduct mental, neurological and substance
Mental Health use(MNS) assessment
Clinical Prac ce 3- Manage mental condi ons

Figure 1. Core competencies of clinical prac ce 6

All users of the guideline should familiarize themselves with core

competencies and should follow them as far as possible.

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1- Tips of Effec ve Communica on Skills
Meet the person in a private space, if possible.
Be welcoming and conduct introduc ons in a culturally
appropriate manner.
Maintain eye contact and use body language and facial
expressions that facilitate trust.
Create an open Explain that informa on discussed during the visit will be
communica on kept confiden al.
environment If caregivers are present, suggest to speak with the person
alone (except for young children) and obtain consent to
share clinical informa on.
When interviewing a young woman, consider having
another female staff member or caregiver present.
Include the person (and with their consent, their caregivers
Involve the and family) in all aspects of assessment and management as
person much as possible. This includes children, adolescents and
older adults.
Ac vely listen. Be empathic and sensi ve.
Allow the person to speak without interrup on.
If the history is unclear, be pa ent and ask for clarifica on.
Start by For children, use language that they can understand. For
listening example, ask about their interests (toys, friends, school,
etc.).
For adolescents, convey that you understand their feelings
and situa on.
Be friendly, Always be respec ul.
respec ul and Don’t judge people by their behaviours and appearance.
non-judgmental
at all mes Stay calm and pa ent.

Use simple language. Be clear and concise.

Use good verbal Use open-ended ques ons, summarizing and clarifying
communica on statements.
skills
Summarize and repeat key points.

Respond with Show extra sensi vity with difficult topics.

sensi vity when Remind the person that what they tell you will remain
people disclose confiden al.
difficult Acknowledge that it may have been difficult for the person
experiences
(e.g. sexual to disclose the informa on.
assault, violence
or self-harm)

Figure 2. Tips of Effec ve Communica on Skills⁶

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2- Tips on How to Promote Respect and Dignity for the client

DOs DON'Ts

Treat people with mental health Do not discriminate against

condi ons with respect and people with mental health
dignity. condi ons.
Protect the confiden ality of Do not ignore the priori es or
people with mental health wishes of people with mental
condi ons. health condi ons.
Ensure privacy in the clinical Do not make decisions for, on
se ng. behalf of, or instead of the
Always provide access to person with mental health
informa on and explain the condi ons.
proposed treatment risks and Do not use overly technical
benefits in wri ng, if possible. language in explaining
Make sure the person provides proposed treatment.
consent to treatment.
Promote autonomy and
independent living in the
community.
Provide persons with mental
health condi ons with access to
supported decision making
op ons.
Figure 3. Promote Respect and Dignity 6

14
 Iden fying and Processing Clients' Needs

Conduct A Mental Health Screening and Clinical Assessment

Screening for Mental Disorder: Mental health screening is one of the easiest and
quickest ways to indicate whether a client is experiencing symptoms of a mental
health condi on like depression or anxiety. Physician/nurse can do the screening
of mental disorder using common scales. Screening tools don't diagnose mental
disorders. However, they are powerful tools which help in understanding the
client's mental health to decide if they should see a mental health professional and
to figure out what needs to improve.

Various interna onal/local assessment and screening tools are available and are
covered in this manual. These tools can be implemented in PHC ins tu ons to
detect common mental disorders.
Mental health screening and clinical assessment tools include:
Ÿ Observa on (the doctor
BASIC HEAD -TO-TOE ASSESSMENT
or counselor watches, 1
General
General health status 2
listens, and makes Mobility and self-care
Vital signs and weight Observe posture
notes). Nutri onal status. Assess gait and balance
Ÿ Ra ng scales. Evaluate mobility
3
Ac vi es of daily living.
Ÿ Physical Assessment Head face and neck
Evaluate cogni on level of consciousness
(using Head-to-Toe (LOC)
Approach). (Figure 4) Orienta on
Mood
Ÿ Interviews with the Language and memory Sensory func on
Test vision Inspect and examine ears
client and the client's Test hearing
Cranial nerves
family (including Inspect lymph nodes Inspect neck veins.
4
collateral history from Chest
rela ves). (Figure 5) Inspect and palpate breast
Inspect and
Ÿ Basic laboratory tests auscultate lungs
5 Auscultate heart.
should be obtained as Abdomen
Inspect, auscultate, palpate four quadrants
early as possible. These Palpate and percuss liver, stomach, bladder
Bowel elimina on
include complete blood Urinary elimina on.
7
Figure 4. Basic Head-to-Toe Assessment
count, random blood
glucose, urea and electrolytes, liver func on test, renal func ons and drug

15
 screen (if available). Further tests should be conducted depending on the
indica ons such as Thyroid Func on Test, ECG, EEG, Sexually Transmi ed
Diseases (STD) Screen (including tes ng for HIV) and radiological
examina ons.

Presen ng Complaint
Main symptom or reason that the person is seeking care.
Ask when, why, and how it started.
It is impotant at this stage to gather as much informa on
as possible about the person's symptoms and their
situa on.

Past Mental History

Ask about similar problems in the past, any psychiatric
hospitaliza ons or medica ons prescribed for mental
health condi ons, and any past suicide a empts.
Explore tobacco, alcohol and substance use.

General Health History

Ask about physicaI health problems and medica ons.
Obtain a list of current medica ons.
Ask about allergies to medica ons.

Family History of Mental Health Condi ons

Explore possible family history of mental health
condi ons and ask if anyone had similar symptoms or
has received treatment for a mental health condi on.

Psycho Social History

Ask about current stressors, coping methods and social
support.
Ask about current socio occupa onal func oning (how
the person is func oning at home, work and in
rela onships).
Obtain basic informa on including where the person
lives, level of educa on, work/ employment history,
marital status and number/ages of children , income,
and household structure /living condi ons.
Figure 5. Tips of assessment for mental health condi ons (History taking)⁶

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 Ÿ Mental State Examina on (MSE): An essen al tool that assists physicians in
differen a ng between a variety of condi ons, as well as neurologic and
psychiatric disorders. The general physician (GP) assesses the client's
appearance, a tude, ac vity, mood and emo ons, speech/language,
thought process/ content, cogni on (thoughts, memory, etc.), as well as
insight and judgement.⁸ The MSE helps doctors and mental health
counselors to know how the client is func oning and how he or she is
moving toward their goals. (Table.1)

General Appearance and Behaviour:

Apparent age, dress, grooming.

Movement, gait and posture.
Facial expression and eye to eye contact.
Psychomotor ac vity (agitated i.e.disturb/restless or retarded).
Overt social behaviour and a tude toward examiner (coopera ve, friendly,
evasive, hos le or aggressive).

Speech:

Rate: Normal, rapid, pressure of speech, slow.

Tone and volume: Normal, monotonous, loud or whispered.
Quality: Spontaneous, hesitant, slurred, stu ering (stammering).
Abnormal features: Neologism (inven on of new strange words),
echolalia (parrot like repe on of words or statements).

Mood and Affect:

Mood: Pervasive and sustained emo on that colours the pa ent's percep on
of the world (depressed/anxious/elated etc.).
Affect: The outward expression of pa ent's inner experience
(blunted/flat/inappropriate).
Quality: Depressed, anxious, euphoric.
Quan ty: Restricted, blunted, flat.
Appropriateness: Congruent i.e agreement, incongruent.
Stability: Emo onal lability (mood swings).
Depressive Ideas: worthlessness, hopelessness, low self-esteem and guilt.
Suicidal risk: Suicidal ideas, plans and previous a empts.

17
Perception:

Awareness of the significance and meaning of sensory s mulus.

Hallucina ons: percep on without external s mulus (auditory, visual,
olfactory, tac le and gustatory).
Illusions: mispercep on of external s mulus (faulty percep on of external
s mulus) it can occur in normal people.
Depersonalisa on and derealisa on: Extreme feeling as if one's self or
external world is unreal.
Thought:

Thought disorders are divided into:

Disorders of form:
Produc vity: Overabundance of ideas, paucity of ideas, flight of ideas,
retarda on(slowness) of thinking.
Con nuity: loose associa ons, illogical thinking, tangen al thinking,
persevera on, thought block, circumstan ality, derailment.
Language impairment: Incoherent or incomprehensible speech (word
salad), clang associa ons, neologisms.
Disorders of content:
Preoccupa ons: Obsessions, phobias, suicidal or homicidal ideas,
hypochondriacal ideas (about illness).
Thought disturbances: Delusions (false unshakeable, fixed beliefs which
cannot be dispelled by logical reasoning and not corresponding with
sociocultural background) e.g. persecutory delusions, grandiose delusions,
delusions of reference, delusions of guilt, hypochondriacal delusions.

Cogni ve Func ons:

Consciousness and awareness: Clarity of awareness to the environment

(drowsiness, stupor, coma).
A en on and concentra on: The ability to focus on the task on hand. Serial
sevens (subtract 7 out of 100 serially several mes).Enumerate days of the
week backwards.

18
 Orienta on:
Time: Year, season, month, day, date.
Place: Country, region, city, hospital, ward.
Person: A endants, interviewer.
Memory:
Immediate reten on and recall: Ability to repeat names of 3 objects
a er the examiner dictates them, then a er a few minutes of
interrup on by a distrac ng ques on, the pa ent asked to repeat the
figures.
Recent memory: Past few days' events (what did the pa ent have for
breakfast, lunch or dinner).
Recent past memory: Past few weeks or months events.
Remote memory: Childhood data, important events.
Intelligence: General knowledge.
Abstract thinking: Proverb test (understand the aim and abstract meaning
of a given proverb).
Visio-spa al abili es: Draw shapes and copy designs.
Insight and Judgement:

Insight: Does the pa ent no ce a change? Does he recognize that this

change is abnormal? Does he acknowledge that his problem is psychiatric?
Does he realize the need for some form of treatment?
Intact: If yes for all above ques ons. Par al if yes for some of above
ques ons.
Impaired if no for above ques ons.
Judgement: Pa ent's predic ons of what he would do in imaginary
situa ons (what he would do if he found an addressed le er in the street).
Table1. Mental State Examina on (MSE)

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Management of Mental Condi ons

Once the assessment is conducted, follow the management algorithm in each

chapter to manage the common mental health condi ons (mhGAP-IG 2016). Key
steps in management are found in the box below.

1- Develop a treatment plan

in collabora on with the
person and their caregiver.

2- Always offer
psychosocial interven ons
for the person and their
caregiver.
3- Treat the mental disorder
using pharmacological
interven ons when
indicated.

4- Refer to specialists or
hospital when indicated
and available.

5- Ensure that appropriate

plan for follow-up is in
place.

6- Work together with

caregiver and families in
suppor ng the person
with the mental disorder.
7- Foster strong links with
employment, educa on,
social services (including
housing) and other relevant
sectors.
8- Modify treatment plans
for special popula ons
(children, mothers,
old age).
Figure 6. Management of mental health Condi ons 6

20
The following table illustrates the management steps for mental health
condi ons.⁶

1- Develop a treatment Ÿ Discuss and determine treatment goals that

plan in collabora on respect the willingness and preferences for
with the person and care.
their caregiver. Ÿ Involve the caregiver or family a er obtaining
the person's agreement.
Ÿ Encourage self-monitoring of symptoms and
explain when to seek care urgently.
Ÿ Psychoeduca on: Provide informa on about
2- Always offer
psychosocial the mental problems to the person, including
interven ons for the treatments for the condi on, dura on,
person and their poten al side-effects of any prescribed
caregivers. medica on.
Ÿ Psychotherapy: therapeu c interac on or
treatment contracted between a trained
professional and a pa ent who suffers from
psychological problems. It can be effec vely
delivered by trained and supervised non-
specialized workers and through guided self-
help (e.g. with use of e-mental health
programs or self-help books).
Ÿ Example of psychotherapy:
Ÿ Cogni ve Behavioral Therapy (CBT):
focuses on modifying dysfunc onal
emo ons, behaviors, and thoughts by
changing nega ve or irra onal beliefs with
healthier, more realis c ones.
Ÿ Interpersonal Therapy (IPT): focuses on
improving the quality of a client's
interpersonal rela onships and social
func oning to help reduce their distress.
3- Treat the mental Ÿ Follow the guidelines on pharmacological
disorder using management in each chapter.
pharmacological Ÿ Use pharmacological interven ons when
interven ons when available and when indicated in the
indicated. management algorithm and table provided.

21
 4- Refer to specialists Ÿ Stay alert for situa ons that may require
or hospital when referral to a specialist/hospital, for example,
indicated and non-response to treatment, serious side
available. effects with pharmacological interven ons,
comorbid physical and/or mental health
condi ons, risk of self-harm/ suicide.
5- Ensure that Ÿ Arrange a follow-up visit a er the ini al
appropriate plan for assessment.
follow-up is in place. Ÿ A er every visit, schedule a follow-up
appointment and encourage a endance.
6- Work together with Ÿ When appropriate, and with the consent of
caregiver and families the person concerned, involve the caregiver
in suppor ng the or family member in the person's care.
person with the
mental disorder.
7- Foster strong links Ÿ To ensure comprehensive care and based on
with employment, the ini al assessment, link the person to
educa on, social
services (including employment, educa on, social services
housing) and other (including housing) and other relevant
relevant sectors. sectors.
8- Modify treatment Ÿ Special popula ons, including women (non-
plans for special pregnant and pregnant), children, and the
popula ons (children, elderly, require addi onal considera on.
mothers, old age).

Table2. Management steps for mental health Condi ons

22
 Section 2
Paranoia
psychopsis
Panic attacks
schizophrenia depression
Dissociaticve disorders
drugs-recreational
premenstrual dysphoric drugs & alcohol
disorder (PMDD) Self- esteem Self-
harm
Body dysmorphic
Postnatal depression& Perinatal disorder (BDD)
mental health phobias
Tardive
dyskinesia
schizophrenia disorder Eating
problems
Post - traumatic stress Borderline personality
Stress
disorder (PTSD) disorder (BPD) Sleep
Hearing voices Anxiety & panic attacks problems
Obsessive – compulsive disorder (OCD)
Bipolar disorder Suicidal feelings Anger
Personality Hypomania
disorders and mania
Loneliness
Seasonal affective
disorder (SAD)

Types of
Mental
Health
Problems

23
 ICD-10 Classification of
Mental and Behavioral Disorders

In primary health care and clinical mental health se ngs, two diagnos c manuals
are currently in use:
Ÿ The first is the Diagnos c and Sta s cal Manual of Mental Disorders Fi h
Edi on (DSM-5), published by the American Psychiatric Associa on.
Ÿ The second is the Interna onal Classifica on of Diseases: Classifica on and
Mental and Behavioral Disorders 10th Revision (ICD-10), published by the
World Health Organiza on (WHO).
According to the ICD-10, mental and behavioral disorders are divided into ten
categories, as cited from WHO (2010).⁹

F 00-F 09

Organic, Including Symptoma c, Mental Disorders:

Demen a: Demen a in Alzheimer's disease, vascular demen a, demen a
in pick's disease, demen a in Creutzfeldt-Jackob disease (prion disease that
leads to rapidly progressive demen a), demen a in Hun ngton's disease,
demen a in Parkinson's disease, demen a in HIV disease, demen a in
other specified diseases, unspecified demen a.
Organic amnesic syndrome, not induced by alcohol and other psychoac ve
substances.
Delirium.
Other mental disorders due to brain damage, dysfunc on, and physical
disease.
Personality and behavioral disorders due to brain disease, damage or
dysfunc on.
Unspecified organic or symptoma c mental disorders.

F 10-F 09
Mental and Behavioral Disorders Due to Psychoac ve Substance Use:
Alcohol, opioids, cannabinoids, seda ves and hypno cs, cocaine, other
s mulants, hallucinogens, tobacco and solvents.

24
F 20-F 29
Schizophrenia, Schizotypal and Delusional Disorders:
Schizophrenia, schizoaffec ve disorder and non-organic related disorders
such as acute and transient psycho c disorders and persistent delusional
disorders.

F 30-F 39
Mood (Affec ve) Disorders:
Manic episodes, depressive episodes, bipolar affec ve disorders, recurrent
depressive disorders and persistent mood (affec ve) disorders.

F 40-F 48
Neuro c, Stress-related and Somatoform Disorders:
Phobic anxiety disorders: agoraphobia with or without panic disorder,
social phobia, specific phobia.
Other anxiety disorder: panic disorder, generalized anxiety disorder,
mixed anxiety and depressive disorder.
Obsessive-compulsive disorder.
Reac on to severe stress and adjustment disorders
Dissocia ve (conversion) disorders.
Somatoform disorders.

F 50-F 59
Behavioral Syndromes Associated with Physiological Disturbances and
Physical Factors:
Ea ng disorders, non-organic sleep disorders, sexual dysfunc on (not
caused by an organic disorder or disease), puerperal mental and behavioral
disorders and abuse of non-dependence producing substances (e.g.
an depressants, laxa ves, analgesics etc).
F 60-F 69
Disorders of Adult Personality and Behavior:
Specific personality disorders: paranoid, schizoid, dissocial, emo onally
unstable (impulsive and borderline), histrionic (Cluster B" or "drama c"
personality disorder), anxious, dependent.

25
 Habit and impulse disorders: pathological gambling, pathological fire
se ng(pyromania), pathological stealing (kleptomania), tricho llomania
(hair-pulling disorder).
Gender iden ty disorders.
Disorders of sexual preference.
Psychological and behavioral disorders associated with sexual
development and orienta on.

F 70-F 79
Mental Retarda on:
Mild mental retarda on.
Moderate mental retarda on.
Severe mental retarda on.
Profound mental retarda on.
F 80-F 89

Disorders of Psychological Development:

Specific developmental disorders of speech, and language, Specific
developmental disorders scholas c skills and Specific developmental
disorders of motor func ons.
Pervasive developmental disorders: childhood au sm, atypical au sm, etc.

F 90-F 99

Behavioral and Emo onal Disorders with Onset Usually Occurring in

Childhood and Adolescence:
Hyperkine c disorders.
Conduct disorders.
Mixed disorders of conduct and emo ons.
Emo onal disorders with onset specific to childhood.
Disorders of social func oning with onset specific to childhood and
adolescence.
Tic disorders (repe ve involuntary movements and sounds).
(WHO, 2010)
Table 3. ICD-10 for Mental and Behavioral Disorders.

26
 Section 3

Management of
Common Mental
Disorders at
PHC Institutions

27
 Management of Common Mental
Disorders at PHC Institutions

It is important to know the high prevalence of common mental disorders and their
suscep bility to treatment so the GPs along with other health care providers will
con nue to manage them in their prac ce. The following informa on package has
been developed as a flexible and prac cal tool to assist GPs to assess and manage
the following mental disorders of pa ents a ending the PHC ins tu ons.

Types of disorders Common Examples

Depression
Mood Disorders
Bipolar Disorder
Acute transient psychosis
Psycho c Disorders
Schizophrenia
General Anxiety Disorder (GAD)
Anxiety Disorders
Phobias
Obsessive Compulsive Disorder (OCD)
Panic a ack
Alcohol abuse
Substance-Related and
Opioids abuse
Addic ve Disorders
Benzodiazepine abuse
Peri-natal depression
Women Mental Disorders
Post-partum psychosis
Violence Against Women
Au sm spectrum disorders
Childhood Disorders
A en on deficit hyperac vity disorder
(ADHD)
Mental retarda on
Selec ve mu sm
School Refusal
Child Abuse

28
 Aggressive/ agitated behaviors
Psychiatric Emergencies
Suicidal idea on or thoughts
Extrapyramidal symptoms (EPS)
Mental problems during pandemic
Neuro-Cogni ve Disorder Common Types of Demen a (Alzheimer)
Sleep-Wake Disorders Insomnia
Soma c Symptom Disorder Soma za on
Anorexia Nervosa
Ea ng Disorder
Bulimia Nervosa
Table 4. Common mental disorders in primary care ins tu ons.

29
 Mood Disorders: Depression F32

Definition:
Defined as a group of symptoms that are characterized by a persistent low mood or
a marked loss of interest or pleasure (known as anhedonia) in all or nearly all daily
ac vi es for at least 2 weeks. Depression can be mild, moderate, severe and
severe with psycho c features, depending on the severity of the symptoms. ¹⁰

Mood Disorders Depressive Disorder

Mania Severe
with Hyop- Normal Dys- Mild Moderate Severe Depression
Mania Ela on with
Psychosis Mania Mood Thymia Depression Depression Depression
Psychosis

Cyclothymia

Recurrent Depressive Disorder

Bipolar Affec ve Disorder

Figure 7. Mood Disorders 11

Signs and Symptoms

Depressed mood most of the day, for Agita on or slowing of movement
nearly every day for at least 2 weeks or speech (monotonous low
Diminished interest or pleasure in speech)
most ac vi es Fa gue or loss of energy
Headache or redness most of the Guilty feeling or worthlessness
me Poor concentra on
Irritability Suicidal thoughts, (plans, or acts)
Anxiety, insomnia worries about Dura on should be at least for 2
social problems. weeks
Insomnia or hypersomnia
Table 5. Signs & Symptoms of depression

30
Screening, Assessment and Differential Diagnosis.

General Physician (GP) should do the following:

Ÿ Perform physical assessment (using Head-to-Toe Approach)(See Figure 4)
Ÿ Conduct a mental health screening and clinical assessment:
History taking (See Figure 5)
Observa on
Basic laboratory tests
Mental State Examina on (MSE) (See Table 1)
Ÿ Assess the risk of suicide (See the chapter of suicide).
There are several standardized assessment tools for depression that can help you
develop a treatment plan, and assess symptom severity or treatment progress
such as Hamilton Depression Scale (HAM-D), the Beck Depression Inventory (BDI),
and the Hospital Anxiety and Depression Scale (HADS). The Pa ent Health
Ques onnaire (PHQ-9) is one of the validated instruments that GP's can use to
assess the pa ent's clinical state.¹² (Annex 1)
Differen al Diagnosis
Depressive symptoms may be caused by several medical and psychiatric
condi ons, the major differen al diagnoses for depressive symptoms are:
Ÿ General medical condi ons like: hormone imbalance, neurological
problems, hypothyroidism, cancer and anemia.
Ÿ A side effect of medica ons e.g. an hypertensive medica on.
Ÿ Substance related disorder (alcohol, opioids).
Ÿ Soma za on disorder.
Ÿ Bipolar affec ve disorder (depressive episode).

31
Management Guidelines

Non-Pharmacological Treatment (Refer to essen als of mental health clinical prac ce in

mhGAP-IG book 2016) ⁶
Ÿ Provide psycho-educa on by informing the pa ent that depression is
a treatable condi on and that is common in the community.
Ÿ Address the current psychosocial stressors.
Ÿ Reduce pa ents stress and strengthen their social support.
Ÿ Advise to stop alcohol or any other drug abuse.
Ÿ Structured physical ac vity program.
Pharmacological Treatment of Depression
Fluoxe ne 20 mg oral OD, if no response a er 6 weeks then increase the
dose to 40 mg.
Citalopram 20 mg oral OD, if no response a er 6 weeks then increase to 40
mg.
Paroxe ne 20 mg oral OD, if no response a er 6 weeks then increase the
dose to 40 mg.
If SSRIs not available, give amitriptyline from 75 mg to 200 mg start with 25
mg as HS.
Follow up every 2 weeks for 8 weeks then every month.
For elderly/geriatric doses:
Fluoxe ne 20 mg oral OD, if no response a er 6 weeks refer to geriatric
specialized unit or geriatric psychiatrist.
Citalopram 10 mg oral OD, if no response a er 6 weeks then refer to
geriatric specialized unit or geriatric psychiatrist.
Paroxe ne 10 mg oral OD, if no response a er 6 weeks then refer to geriatric
specialized unit or geriatric psychiatrist.
If SSRIs not available, refer directly to geriatric specialized unit or geriatric
psychiatrist.
Note: (Maximum geriatric doses for fluoxe ne 40 mg, for citalopram 20 mg
and paroxe ne 30 mg)
For elderly: DO not prescribe amitriptyline or other TCAs, due to increased
risk of cardiac side effects in this popula on.
Must do basic laboratory tests including CBC, LFT, RFT, TFT and ECG (other
tests as clinically indicated) must be done before star ng an depressants in
elderly.
Table 6. Pharmacological treatment of depression

32
 Clinical Management Flowchart for Suspected Depression

Pa ent with depressive symptoms

Take detailed history

Mental State Examina on MSE
Physical assessment (using Head-to-Toe Approach)
Rou ne lab inves ga ons
Use screening tool Pa ent Health Ques onnaire (PHQ-9)

Ac ve suicidal idea on with No suicidal ideas

clear plan (emergency) Social occupa onal func on
PHQ9 score above 15 (severe not affected
depression) PHQ9 score (5-9) mild
depression

Func on impaired
No ac ve suicidal plans
PHQ9 score (10-14)
moderate depression

Inform rela ve about risk Can be managed by family

Referral for admission at physician at local health
nearest hospital with in- center
pa ent admission for mental Consider an depressant
illness
Call on-call doctor at hospital Assess
before sending the pa ent improvement (4-6)
weeks
Refer to regional psychiatrist Repeat PHQ9
Need early appointment
within a week
No improvement
Consider psycho-educa on
un l appointment
Can be started on Improved
an depressant by family Con nue
physician un l appointment treatment (6-12
months)
Refer to regional psychiatrist
as rou ne case

33
 Mood Disorders:
Bipolar Affec ve Disorder F31

Defini on:

Bipolar disorder is characterized by Figure.8 Bipolar Severity ¹³

episodes in which the person's mood Severe Mania

and ac vity levels are significantly Moderate Mania
Hypomania
disturbed. This disturbance consists on
Normal mood
some occasions of an eleva on of mood
Mild Depression
and increased energy and ac vity Moderate Depression
(mania), and others of a lowering of Severe Depression
mood and decreased energy and ac vity Grohol,j. (2011). Bipolar Severity [Photograph]. Retrieved
form h p://psychcentral.com/disirders/bipolar/
(depression).
Mixed episodes: When symptoms of depression and mania or hypomania, occur at
the same me or quickly one a er the other. Characteris cally, recovery is
complete between episodes. People who experience only manic episodes are also
classified as having bipolar disorder.
Signs and Symptoms

Manic episode Depression episode

Excessive happiness or euphoria Constantly feeling depressed or sad
Increase in energy level and Worthless for most of the day,
ac vity nearly every day for at least 2 weeks
Agitated and irritable mood (that Not interested or finding pleasure in
lasts at least one week) all or almost all ac vi es
Less need for sleep (feels rested Loss of appe te and weight or
a er only 3 hours of sleep) some mes increase in appe te and
Easily distracted weight
Non-stop talking Insomnia or hypersomnia
Increased self-confidence or Agitated and tensed
grandiosity Fa gue or loss of energy
Focused on ge ng things done, Being withdrawn or avoiding people
but does not accomplish much Being physically less ac ve than
Involved in risky ac vi es even usual
though bad things may happen Poor concentra on
Suicidal thoughts, plans or acts
Table 7. Differences between clinical depressive and manic episodes⁶

34
 To diagnose bipolar mood, there must have been at least one
hypomanic, manic, or mixed affec ve episode in the past.

Screening, Assessment and Differential Diagnosis

General physicians (GP) should do the following:

Ÿ Perform physical assessment (using Head-to-Toe Approach). (See Figure 4)
Ÿ Conduct a mental health screening and clinical assessment:
History taking. (See Figure 5)
Observa on.
Basic laboratory tests.
Mental State Examina on (MSE). (See Table 1)
Ÿ Assess the risk of suicide. (See the chapter of suicide)
Ÿ Administra on of a screening tool can be very helpful in iden fying pa ents
likely to have bipolar disorder. Mood Disorder Ques onnaire (MDQ) tool
can easily be u lized in PHC se ngs. (Annex 2)
The MDQ is designed for screening purpose only and not to be used
as a diagnos c method.
The MDQ includes 13 ques ons associated with the symptoms of
bipolar disorder plus items assessing clustering of symptoms and
func onal impairment.
Ÿ Depressive symptomatology in bipolar pa ents may be assessed and
evaluated using (PHQ-9) tool or Quick Inventory of Depressive
Symptomatology (QIDS) tool.¹⁴ (Annex 3)
Differen al Diagnosis:
Other mental disorders: depression or schizophrenia or anxiety
disorders.
Personality disorders.
Substance use disorders (s mulants, alcohol…).
General medical condi on (Hyperthyroidism, brain tumor…).
Infec ons.
A en on-Deficit/Hyperac vity Disorder (ADHD).

35
Management Guidelines

Non-Pharmacological Treatment
Psycho-educa on.
Stress reduc on.
Close supervision by the family is needed.
Educate the pa ent and family about the importance of treatment
adherence.
Avoid alcohol or psychoac ve substance intake.
Refer to essen als of mental health clinical prac ce in mhGAP-IG book 2016) ⁶

Pharmacological Treatment
Manic episode
Severe agita on and aggression (Dangerous to self and/or others):
Promethazine 25 mg/ml IM STAT with Haloperidol 5-10 mg/ml IM
injec on. If the agita on con nues, add Diazepam 5-10 mg/2ml IV
by slow injec on.
Managing agita on in elderly
Use verbal de-escala on techniques (see Agita on behaviors and
restlessness chapter)
If no improvement or response to above use Promethazine 12.5 mg
IM STAT.
Promethazine 12.5 mg/ml IM STAT together with Haloperidol 1mg IM
injec on.
Do not use diazepam or other benzodiazepine to manage agita on in
elderly.
Maintenance Therapy:
Full mental state examina on and risk assessment (for each visit).
Check for treatment adherence.
Liaise with the secondary care psychiatrist.
Follow up every month.
Referral
Refer pa ents with manic episodes with aggressive symptoms to a mental
hospital with an available admission service.
Refer pa ents with manic episodes and no aggressive symptoms to a
regional psychiatrist.

36
 Depressive episode: refer to a regional psychiatrist if there is no high risk of
suicide.
Significant risk of suicide/harm to others: refer to a mental hospital with an
available admission service.

Management Flowchart for Bipolar Affec ve Disorder

Bipolar Affec ve Disorder (BAD)

Pa ent presented with depressive Pa ent presented with

symptoms usually with previous manic/hypomanic symptoms e.g.:
manic or hypomanic symptoms
Excessive happiness or euphoria
Energe c
Assess with Pa ent Health Reduced need to sleep
Ques onnaire (PHQ-9) screening tool Over talka ve
Grandiosity
If score 14 or less If score 15 or more
No ac ve suicidal Ac ve suicidal Assess for bipolar disorder
ideas plan or ideas plans with mood disorder
a empts ques onnaire (MDQ) tool

Refer to Urgent case No aggressive With aggressive

regional Refer to nearest psychiatrist symptoms symptoms
psychiatrists with admission service
Referral need available Refer to regional
to include the Call the ins tu on before psychiatrist
following referring the pa ent
notes: Referral need to include the
The pa ent is following notes: Emergency case
diagnosed The pa ent is diagnosed Stabilize the pa ent
with BAD with BAD (Go to Agita on Behavior and
Medica on Medica on used Restlessness Chapter page 110)
used before previously

MDQ Scoring Refer to nearest psychiatrist with

In order to screen posi ve for admission service available
possible bipolar disorder, all three Call the ins tu on before referring
parts of the following criteria must the pa ent
be met: Referral need to include the
[Yes] to 7 or more of the 13 items following notes:
in Ques on.1 The pa ent is diagnosed with BAD
[Yes] to Ques on.2 Medica on used previously
[Moderate problem] or [Serious Depend on severity of symptoms
problem] to Ques on.3 (might need pa ent escor ng)

37
 Psycho c Disorders:
Schizophrenia F20

Defini on:

Ÿ It is a serious mental illness that interferes with person’s percep on and

thoughts. People with psycho c disorders lose contact with reality and
experience a range of extreme symptoms called “Psychosis” and these
symptoms usually include:
Hallucina ons are false percep ons- hearing or seeing things that are
not real, such as voices.
Delusions are false beliefs, or believing things that are not true.
Ÿ If the pa ent presents with psychosis for less than one month. It is called
acute and transient psychosis.
Ÿ If psychosis con nues for more than one month but less than 6 months, it is
called a Schizophreniform disorder.
Ÿ If psychosis con nues for more than 6 months, then it is called
Schizophrenia.
However, these symptoms can occur in people with other health problems,
including bipolar disorder, demen a, substance abuse disorders or brain
tumors. The most common and well known psycho c disorder is
Schizophrenia.
Signs and Symptoms
The following symptoms should present for significant por on of me during
one-month period:
Delusions: False and fixed beliefs that the person strongly believes to be
true. For example, people trying to harm the person, TV programs refer to
the pa ent.
Hallucina ons: False percep ons, involve sensing things such as visions,
sounds, or smells that seem real but are not. These things are created by
the mind. (Auditory hallucina ons are observed usually more than other
types of hallucina ons).

38
 Disorganized speech: Words or sentences are difficult to be connected
which makes speech not understandable.
Grossly disorganized or abnormal motor behavior (including catatonia).
Nega ve symptoms (affec ve fla ening, poverty of speech content, lack of
mo va on).
Social/occupa onal dysfunc on.

Screening and assessment

Mental State Examina on (MSE). (See Table 1)

Assess the risk of harm to self or others.
Detailed physical assessment (using Head-to-Toe Approach).(See Figure 4)
Assess for an acute manic episode: Have several symptoms occurred for at
least one week. (Table 7. Differences between clinical depressive and manic episodes)
Assess for psychosis: hallucina on, delusion and disorganized speech or
behavior e.g. [irrelevant speech, laughing to self, signs of self-neglect,
appearing unkempt].
Co-morbid substance use.
Lab inves ga ons.

Management Guidelines

1. Assess risk to self or others.

2. Assess the nutri onal status of the pa ent.
3. Do all rou ne blood inves ga ons- CBC, Electrolytes, LFT, RFT, and TSH.
4. If organicity is suspected, brain imaging needs to be done. For example, if
there are visual hallucina ons or if there is a neurological deficit.
5. Refer the pa ent to a psychiatrist to start an psycho c medica on.

39
 Clinical Management Flowchart for Suspected Schizophrenia

Pa ent presented with psychosis feature

(with hearing voices and believes that
people want to harm him)

Ini ate assessment by GP:

History taken including (medical, previous
psychiatric history)
Mental State Examina on (MSE)
Physical assessment (using Head-to-Toe
Approach)
Assess risk of harm to self or others
Assess for psychosis: hallucina on,
delusion and disorganized speech or
behavior
Co-morbid substance use
Lab inves ga ons

Sugges ve of schizophrenia with Sugges ve of schizophrenia with

no risk to self or others risk to self or others

Physical assessment Emergency case:

Lab inves ga ons Refer to psychiatric
hospital with admission
service available

No neurological problems Sugges ve of neurological

or No visual hallucina on problems or having visual
hallucina on

Refer to regional Need medical review

psychiatrsit Need CT/ MRI to rule
out organic cause

40
 Anxiety Disorders

Definition:
Feeling anxious is a normal reac on to perceived stressful situa ons. For example,
we feel anxious before exams and become worried when our health is at risk.
When the symptoms of anxiety are overwhelming and affec ng daily
func ons/lifestyle or the feared object is irra onal, anxiety is considered
pathological and thus requires treatment.
Anxiety disorders are common among pa ents visi ng primary health care
centers. The most common anxiety disorders are Phobias, Generalized Anxiety
Disorder and Panic Disorders. Thus, recogni on of these disorders by a general
prac oner is very important. Early diagnosis and treatment can help the pa ent
get rid of the symptoms and avoids invasive and expensive medical interven ons.
In general, anxiety has two types of symptoms- emo onal and physical symptoms.
Ÿ Emo onal symptoms: excessive worrying thoughts, fearful an cipa on and
irritability.
Ÿ Physical symptoms: may appear as palpita on, shortness of breath, poor
concentra on and muscle tension.
It is very important to understand that these biological and emo onal symptoms
of anxiety are overlapping and may interact in a vicious cycle. Therefore,
palpita on for example may cause worrying thoughts and in turn worrying
thoughts cause more palpita on.
Obsessive-Compulsive Disorder (OCD) is regarded as a separate en ty in the new
diagnos c scheme. However, it will be discussed in this chapter for convenience
purposes. OCD is easily recognized when the symptoms are of classical themes.
For example, recurrent washing to relieve the obsession of contamina on can be
easily diagnosed by non-psychiatrists. However, more complicated themes of OCD
may be missed and the pa ent suffers for many years before referral to a specialist.
In this chapter, we will discuss briefly the following diagnoses:
1- Generalized Anxiety Disorder. (F41.1)
2- Phobias (mainly social phobia). (F40.9)
3- Panic Disorder. (F41.0)
4- Obsessive-Compulsive Disorder. (F42.9)

41
 Anxiety Disorders: Generalized Anxiety Disorder (F41.1)

Definition
As the name implies, Generalized Anxiety Disorder (GAD) refers to persistent
symptoms of anxiety that are not restricted to a par cular situa on or object.
Therefore, the pa ent feels “always at edge” and his/her anxiety is “free-floa ng”.
For example, the pa ent is worried about his/her future, health, work and finance.
He/she is unable to relax and expects the worst to happen. GAD is more common in
females and persons with a family history of anxiety disorders.

Signs and Symptoms

The clinical features of GAD include emo onal and biological symptoms.
Emo onal Symptoms Biological Symptoms
Persistent worrying thoughts Insomnia
Apprehension i.e. anxiety or fear Poor concentra on
that something bad or unpleasant
will happen
Irritability Muscle tension
Inability to relax Fa gue
Table 8. Examples of emo onal & biological symptoms of (GAD)

Understanding the differences between [normal anxiety] and GAD is very

important. The key differences are:
In GAD, the worrying thoughts are persistent (at least for 6 months according
to DSM-5).
In GAD, the symptoms are more distressing.
GAD is associated with func onal impairment.
Moreover, some medical disorders such as hyperthyroidism may produce
symptoms similar to those observed in GAD. Therefore, tac ul clinical assessment
is required to work out any medical e ology of the pa ent's symptoms. For
example, the presence of palpita on, heat intolerance, increased appe te and
significant weight loss in addi on to anxiety symptoms are more sugges ve of
thyroid problems.

42
 Screening, Assessment and Differential Diagnosis

Inves ga ons:
Clinical assessment-history and physical examina on- will guide the clinician for
the necessary inves ga ons. Rou ne blood work up such as full blood count, renal
func on test and liver func on test may be done as a baseline.
The clinician may consider using scales to rate the severity of the symptoms and
provides a reference for future monitoring. A scale such as the 7-item generalized
anxiety disorder scale can be used for this purpose. (Annex 4)

Management Guidelines

Treatment of all psychiatric disorders is composed of 3 parts: biological,

psychological and social. This approach is called the bio-psychosocial approach.
The summary of the bio-psychosocial approach in the treatment of generalized
anxiety disorder is outlined in Table 9.
The psychological treatment should be started first unless the symptoms are
distressing or causing significant func onal impairment.

Non-Pharmacological Cogni ve Behavioral Therapy (CBT)

Treatment Relaxa on training.
YouTube videos/ phone applica ons can be
very helpful for self-help and psycho-
educa on.
Pharmacological First line: SSRIs: e.g. Fluoxe ne
Treatment/ Biological For elderly: ini ate SSRIs: e.g. Fluoxe ne
[geriatric doses were described in depression chapter-
“Table 6 in Page 32”] OR refer directly to Geriatric
specialized unit.
If treatment ini ated with no response a er 6
weeks refer Geriatric specialized unit.
In some cases anxioly c medica ons can be
used.
Involving the social worker to explore further
Social
and to deal with the stressors.
Table 9. Bio-Psychosocial treatment of Generalized Anxiety Disorder (GAD)

43
Important points for treatment of anxiety disorder:
Ÿ Start low and go slow: Fluoxe ne 20 mg (a lower dose) once daily for
2 weeks and tapered up according to the clinical response.
Ÿ Selec ve Serotonin Reuptake Inhibitors (SSRIs) should be taken a er food to
avoid gastrointes nal (GI) side effects such as abdominal pain and nausea.
Ÿ SSRIs must not be stopped abruptly.

Refer the pa ent to the psychiatry clinic in the following condi ons:
Pregnancy and lacta on.
If the pa ent did not respond to the recommended dose of the first
an depressant.
Medical co-morbidi es that can be linked to anxiety include:
Heart disease.
Diabetes.
Thyroid problems, such as hyperthyroidism.
Respiratory disorders, such as asthma.
Drug misuse or withdrawal.

44
 Clinical Management Flowchart for Suspected Anxiety

Pa ent presented with fear, excessive worry, palpita on, difficult breathing

Scores represent: History taken:

0-5 mild Physical assessment (using Head-to-
6-10 moderate Toe Approach)
11-15 moderately severe Mental State Examina on
anxiety Rou ne lab inves ga ons
15-21 severe anxiety Co-morbid medical or mental illness
Assess with using 7-item generalized
anxiety disorder scale

GAD-7 score less GAD-7 score 6-10 GAD-7 score >10 (moderately
than 5 (mild anxiety) (moderate anxiety) severe anxiety-severe anxiety)

Provide reassurance Provide reassurance Provide reassurance.

Consider Consider Consider
psychoeduca on psychoeduca on psychoeduca on
about the rela onship about the rela onship about the rela onship
between fear & between fear & between fear &
physical symptoms physical symptoms physical symptoms
Can be managed by Educa on about Educa on about
family physician availability of availability of
Involve social worker medica on for medica on for
to explore further managing mental managing mental
problems problems
Can be managed by First line medica ons
family physician can be started by
Involve social worker family physician

Assess improvement (4-6 weeks) Assess improvement (4-6 weeks)

Repeat screening using GAD-7 to Repeat screening using GAD-7 to
assess improvement. assess improvement

No family physician available No improvement Improved

Refer to regional psychiatrist Con nue treatment

Include score result in referral (6-12 months)

45
 Anxiety Disorders: Phobia F40.9

Defini on
All of us may experience some form of anxiety when speaking to a crowd or when
we see a scorpion. However, these are not phobia unless the fear is persistent and
out of propor on to the danger posed by the object or situa on.
Phobia is an extreme or irra onal fear or aversion to a specific object or situa on.
The pa ent avoids the phobic object or situa on or endures it with intense fear.
Common examples of phobic s muli are spiders, elevators, taking blood and
airplanes.

Signs and Symptoms

Social phobia is intense fear in social situa ons where the person feels that he is
closely observed by others or maybe cri cized by them. Tremor, palpita on,
swea ng and change in the vocal tone are frequent features. Common phobic
situa ons for social phobia are public speaking, praying at mosques
and ea ng at restaurants. The person may avoid these situa ons or
endures them with intense fear.
Social phobia may also present with an intense fear of failing in
situa ons where one needs to perform and is clinically referred to as
Performance Anxiety. Examples include students avoiding exams
because of an intense fear of failing and a husband with sexual dysfunc ons due to
distrac ng thoughts of not performing well.

Management Guidelines

The main treatment for specific phobia is behavioral therapy that relies on re-
exposing the pa ent to the phobic s mulus. This therapy requires special training
and thus referral to a psychologist is recommended. Medica ons are generally not
helpful in the treatment of specific phobias.
However, the treatment of social phobia consists of Cogni ve Behavioral Therapy
(CBT) and psycho-pharmacological interven on. The table below summarizes the
bio-psychosocial approach for the treatment of social phobia.

46
Again, medica ons should be started low and tapered up slowly according to the
clinical response. For example, SSRIs medica ons [Fluoxe ne 20 mg, Citalopram
20 mg] can be prescribed as once daily (OD) for 2 weeks and should be increased
according to the symptoms. Propranolol 10 mg may be given one hour before the
feared situa ons in case of performance anxiety.
Bio-Psychosocial Treatment of Social Phobia

First line: SSRIs medica on e.g. Fluoxe ne,

Pharmacological
Citalopram can be prescribed as OD for 2
Treatment/ Biological
weeks. [Geriatric doses were described specifically in
depression chapter- “Table 6 in Page 32”].
Beta-blockers e.g. Propranolol may help in
controlling the physical symptoms such as
tremor and palpita on.
Ÿ Use beta-blockers cau ously for elderly
as it may cause bradycardia and do not
ini ate it without close monitoring.
Preferably to refer to geriatric specialized
unit for assessment and possible
ini a on.
Non-Pharmacological Cogni ve Behavioral Therapy (CBT).
treatment Websites and YouTube videos/ phone
/Psychological applica ons are very helpful for self-help.
Involving the social worker to explore further
Social
and deal with the stressors.
Table 10. Bio-Psychosocial treatment of social phobia

47
 Anxiety Disorders: Panic Disorder F41.0

Defini on
Panic a acks are sudden and unexpected episodes of shortness of breath,
palpita on, tremor and swea ng. The pa ent may interpret these symptoms as
signs of heart a ack, leading to an escala on in his anxiety.

Signs and Symptoms

Symptoms of panic a acks are grouped into:

1- Physical symptoms such as palpita on, dizziness and
shortness of breath.
2- Psychological symptoms such as fear of death, fear of losing
control or going crazy.

Screening and Assessment

Before diagnosing the pa ent with panic disorder, medical causes for panic a acks
must be ruled out. Thus, GPs must refer cases of panic a acks presented for the
first me to the general medicine clinic for medical workup. Table.11 lists examples
of medical disorders that may present with panic a acks.
Anemia
Cardiovascular Disease Angina
Arrhythmias
Asthma
Pulmonary Diseases
Pulmonary Embolism
Hypoglycemia
Endocrine Diseases
Hyperthyroidism
Substance-related disorders Caffeinated drinks (e.g. Coffee)
Table 11. Examples of medical condi ons that may present with panic a acks

Panic a acks start suddenly, peaks in 10 minutes and then subside gradually.
Presence of a recent stressor (e.g. death of a beloved rela ve) and an cipatory
anxiety usually favors psychiatric explana on for the panic a acks.

48
Management Guidelines

An depressant treatment and Cogni ve Behavioral Therapy (CBT) was shown to

be useful in the treatment of panic disorders. Although a short course of
Benzodiazepine such as Clonazepam 0.25 mg twice daily (BID) may help in
controlling the panic a acks in some pa ents, it is not recommended by some
guidelines [such as NICE guidelines]. The bio-psychosocial approach in the
treatment of a panic disorder is outlined in Table 12.

Non-Pharmacological Cogni ve Behavioral Therapy (CBT).

treatment Websites and YouTube videos/ phone
/Psychological applica ons are very helpful for self-help.
Pharmacological First line: SSRIs medica on e.g. Fluoxe ne 20
Treatment/ Biological mg, Citalopram 20 mg, cab be prescribed as
OD for 2 weeks then re-assessed. [Geriatric
doses were described specifically in depression
chapter- “Table 6 in Page 32”].

Social Involving the social worker to explore further

and deal with the stressors.
Table 12. Biopsychosocial treatment of panic disorder

49
 Anxiety Disorders: Obsessive
Compulsive Disorder (OCD) F42.9

Defini on
Obsessive-Compulsive Disorder (OCD) is possibly the most distressing illness
among all psychiatric disorders. It is a ached with a high degree of s gma
especially when obsessions stem from religious convic ons. Therefore, pa ents
with OCD usually present late to the psychiatric u lity.
OCD is excessive thoughts (obsessions) that lead to repe ve behaviors
(compulsion).

Signs and Symptoms

Obsessions usually present in the form of thoughts, images or impulses that are
recurrent, intrusive and regarded as irra onal by the pa ents. As pa ents a empt
to resist these obsessions, anxiety builds up. Table 13 illustrates common
obsessions with their corresponding compulsions.
Obsessional thoughts Recurrent thoughts of contamina on.
Obsessional Impulse Urges to perform acts such as injuring a child.
Obsessional Image Recurrent scenes imagined vividly (e.g. sexual
scenes between rela ves).
Table 13. Examples of common obsessions seen in psychiatry

Some mes, there will be an obvious connec on between the obsession and the
compulsion (e.g. contamina on and washing). In other cases, the connec on may
be more personal, depending on the individual's beliefs. Table 14 illustrates of
common obsessions with their corresponding compulsions.
Obsession Compulsion
Common themes

Fear of contamina on Repe ve washing and cleaning

Safety (e.g. door lock,
Repe ve checking, coun ng
safety of children)
Repe ve ordering, organizing and
Symmetry symptoms
arranging things
Religious obsession Repe ve praying
Table 14. Common obsession and compulsion pairings

50
Screening and Assessment

Following clinical assessment can be done:

Ÿ Physical examina on.
Ÿ Take a full history use screening ques ons for example:
Ÿ Do you have frequent unwanted thoughts that seem uncontrollable?
Ÿ Do you try to get rid of these thoughts and, if so, what do you do?
Ÿ Do you keep things extremely clean or wash your hands frequently?
Ÿ Do you keep checking things over and over again?
Ÿ Do you have rituals or repe ve behaviors that take a lot of me in a day?
Ÿ Do these problems trouble you?
Ÿ Does this behavior make sense to you?
Ÿ Co-morbid medical or mental illness
Ÿ Current regular medica ons
Ÿ Lab inves ga ons.

Management Guidelines

The table below summarizes general treatment for OCD.

SSRIs an depressant medica ons are usually

Pharmacological
considered the first line psycho-pharmacological
Treatment/ Biological
treatment.
Clomipramine (Anafranil).
Other medica ons: (Risperidone, MAO
Inhibitors).
Geriatric doses (elderly) were described
specifically in depression chapter (Table 6 Page 32).
For elderly: DO NOT INTAITE Clomipramine
(Anafranil), (Risperidone, MAO Inhibitors),
instead refer to geriatric specialized unit for
assessments.
Non-Pharmacological Cogni ve Behavioral Therapy (CBT) (e.g.
Treatment exposure and response preven on EX/RP) is the
/Psychological treatment of choice and effec ve type of CBT).

51
 Social Dealing with the precipita ng and maintaining
factors of the illness.
Table 15. Treatment of pa ents with Obsessive-Compulsive Disorder (OCD)

Clinical Management Flowchart for Suspected OCD Case

Pa ent presented with: Examples of common repeated

Repeated thoughts/images/ thoughts/images/ behaviors:
behaviors about different things Fear of germs, dirt (washing
Feels anxious, worry, distress hands frequently)
Unable to control the unwanted Feeling unsafe(locking/
thoughts & behavior unlocking doors)
Repe ve behavior to reduce Imaging having harmed self
worry & anxiety or others (checking)

Take detailed history

Assess the effect of symptoms on daily func on
[academic, social, marital, occupa onal]
Rou ne lab inves ga on
Physical assessment (using Head-to-Toe Approach)
Mental State Examina on (MSE)
Assess risk of self-harm or others
Co-morbid medical or mental illness
Medica ons & drug allergies

Reassure the pa ent

Psycho-educa on about the illness
Educa on about availability of
medica on & that is treatable
mental problem
Start an depressant (SSRI) as Can be managed by family
first line treatment physician if available

Assess improvement (4-6) weeks

No family physician available No improvement Improved

Refer to regional psychiatrist Con nue treatment

(6-12 months)

52
 Substance Related Disorders

Drug abuse is a public health problem that demands close a en on by all

members of the community. It causes significant social, medical and psychological
impacts on the individual and the na on. It affects the young popula on who are
the building blocks of growth and development in every country. Therefore,
spreading awareness and early treatment are very important steps in dealing with
substance abuse.
In this chapter, only alcohol, opioids and benzodiazepines will be discussed
because they are among the most common substances abused. Please note that
the dis nc on between [abuse] and [dependence] is no longer necessary in the
new diagnos c scheme. The diagnosis “Substance Use Disorder” had replaced
both terms.
Drugs can have many names in the street so-called (street slang) and recognizing
these names is important for the diagnosis and treatment. Table 16 shows the
street names for common drugs abused in the community.

Street Name of The Drug Drug

Vex Morphine (Injec on)
Red (in Arabic: Ahmar)
Tramadol
Strawberry ( in Arabic: Farawla)
Klonobin , Reev , Abu Zamba Clonazepam/ Rivotril
Joint, Baskuta, Brown (in Arabic: Bunni) Hashish
MSD Amitriptyline
Welcome Procylidine
Dormicum Midazolam
JK Carbamazepine
Phenargan, PN Promethazine
White (in Arabic: Abyadh) Captagon
Table 16. Street names of common drugs abused in the community

53
Screening and Assessment

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) tool
was originally developed by the World Health Organiza on (WHO). The ASSIST is a
brief, structured ques onnaire that assesses substance use and substance related
problems.
The ASSIST is a short (5-15 minute) screener that includes eight ques ons
assessing the frequency of substance use, consequences of use and failure to stop
or reduce use as well as manage substance use and related problems in primary
and general medical care se ngs. (Annex 5)
Also, General Physicians (GP) should do the following:
Ÿ Perform physical assessment (using Head-to-Toe Approach). (See Figure 4)
Ÿ Conduct a mental health screening and clinical assessment:
Ÿ History taking. (See Figure 5)
Ÿ Observa on.
Ÿ Basic laboratory tests.
Ÿ Mental State Examina on (MSE). (See Table 1)
Ÿ Assess the risk of suicide. (See the chapter of suicide)

Management Guidelines

Ÿ Provide psycho-educa on (using a non-judgmental way) and emphasize

that the level/pa ern of substance use such as (drugs, alcohol) is causing
harm to health.
Ÿ Ask the pa ent the reasons for their substance use, including as a response
to other issues such as mental health problems or specific stressors, and the
perceived benefits they have from substance use, even if only in the short
term. ⁶
Ÿ Conduct mo va onal interviewing for pa ents who are either recovered
(those who stopped abusing), relapsed (those who stopped for a while, but
returned to abuse), or ac ve abuser status (those who s ll abusing), for the
pa ent to be ready for detoxifica on and rehabilita on services. ⁶
Ÿ Advice stopping the substance completely or consuming it at a non-harmful
level, if one insists. Verbalize your inten on to support the pa ent to do this.
Ask them if they are ready to make this change.
Ÿ Explore strategies for reducing or stopping use and strategies for reducing
harm shown in (Table 17).

54
 Ÿ Address food, housing, and employment needs.
Ÿ Follow up.
Ÿ Consider the proper management if the person is an adolescent or
a woman of child-bearing age, pregnant, or breas eeding. ⁶

Strategies for Reducing and Strategies for Reducing

Stopping Use Harm
If the person is interested in If the person injects drugs:
reducing their substance use, Inform the person about the risks
discuss the following steps with of intravenous drug use, which
them: include: being at higher risk of
Iden fy triggers for use and ways infec ons such as HIV/AIDS,
to avoid them. Hepa s B and C, skin infec ons
For Example: pubs where people that can cause sep caemia,
are drinking or areas where the endocardi s, spinal abscesses,
person used to obtain drugs, etc. meningi s, and even death.
Iden fy emo onal cues for use Considering that the person may
and ways to cope with them (i.e. not stop injec ng drugs right
rela onship problems, difficul es away, provide informa on on less
at work, etc.). risky injec on techniques.
Encourage the person not to keep Emphasize the importance of
substances at home. using sterile needles and syringes
each me they inject and to never
share injec ng equipment with
others.
Encourage and offer, at minimum,
annual tes ng for blood-borne
viral illnesses, including HIV/AIDS
and Hepa s B and C.
Encourage Hepa s B vaccina on.
Educate on the importance of
using condoms.
Ensure availability of treatment
for people with HIV/AIDS and
hepa s.

Table 17. Strategies for reducing or stopping use and strategies for reducing harm.⁶

55
 Alcohol Related Disorder F10

Defini on:
It is defined as alcohol seeking and harmful consump on behavior. Excessive
drinking of alcohol is associated with medical, psychological and social impacts.
Many hospital admissions are due to the harmful use of alcohol. Drinking alcohol in
any amount is strongly discouraged in Muslim communi es. The role of health
care providers is to iden fy people with [drinking problems] and guide them to the
appropriate facility.

Signs and Symptoms of alcohol withdrawal

Withdrawal symptoms are unpleasant physical and mental symptoms that occur
when stopping or reducing the intake of alcohol or other drugs.
The characteris cs of the withdrawal symptoms vary depending on what
substance or alcohol is being used. Common withdrawal symptoms include:
Ÿ Anxiety and agita on
Ÿ Tremor
Ÿ Tachycardia
Ÿ Seizure
Ÿ Insomnia
In pa ents with severe dependency on alcohol, the withdrawal state might be
more complicated and results in life-threatening condi ons such as Delirium
Tremens (DT) and Wernicke's encephalopathy. Always think [DT] in any pa ent
with a background of alcoholism presen ng with:
Ÿ Confusion
Ÿ Coarse tremor
Ÿ Visual hallucina on

This scenario may occur in a person arriving in a country where alcohol is not
readily available or during hospital admission. Delirium Tremens (DT) is a medical
emergency, thus pa ents must be evaluated and treated by the medical team.
Wernicke's encephalopathy is another life-threatening condi on associated with
alcohol withdrawal. It is characterized by:

56
 Ÿ Confusion
Ÿ Ataxia (loss of muscle control and balance)
Ÿ Nystagmus (repe ve movement of the eyes)

Wernicke's encephalopathy results from nutri onal deple on of thiamine due to

chronic alcoholism.
Intravenous or intramuscular thiamine HCL (Vit.B1) should be administrated
before dextrose solu on. Giving dextrose before thiamine may cause neuronal
deple on of thiamine and precipitates Korsakoff's syndrome (results from
thiamine deficiency)

Confusion Confusion

Delirium
Wernicke's
Tremens
Hallucina on Tremor Ataxia Nystagmus

Screening and Assessment

One of the most widely used screening tools to iden fy people with a drinking
problem is [CAGE] ques onnaire showing in Table 18. A total score of 2 or higher
indicates a problem with alcohol drinking.
Ques on Yes No
C Have you ever felt you should Cut on your drinking? 1 0
Have you ever been Annoyed by people cri cizing
A 1 0
your drinking?
G Have you ever felt Guilty about your drinking? 1 0
Have you ever used alcohol as the first thing in the
E 1 0
morning ( Eye-opener )
Table 18. CAGE ques onnaire

Nevertheless, the clinical assessment of the drinking pa ern remains the most
useful tool. Assessment should include evalua on for alcohol tolerance,
withdrawal symptoms and degree of craving. It should also include informa on
about using alcohol in hazardous situa ons (e.g. driving).

57
Medical and psychiatric consequences of alcohol drinking should be obtained as
well as previous a empts to cut down or stop alcohol drinking. Physical
examina on should be done in all pa ents with alcohol drinking problems.

Management Guidelines
1.Alcohol Withdrawal Management protocol
Ÿ Provide a quiet and non-s mula ng environment as possible; well-lit during
the day and lit enough at night to prevent falls if the person wakes up at night.
Ÿ Ensure adequate fluid intake and that electrolyte requirement are met,
such as potassium and magnesium.
Ÿ Address dehydra on: maintain adequate hydra on including I.V. hydra on,
if needed, and encourage oral fluid intake. Be sure to give thiamine before
glucose to avoid precipita ng Wernicke's encephalopathy.
Ÿ Assess alcohol withdrawal fits.
Ÿ Check Random Blood Sugar (RBS).

2.Preven ng and trea ng Wernicke's encephalopathy

Ÿ Chronic heavy users of alcohol are at risk for Wernicke's encephalopathy, a
thiamine deficiency syndrome.
Ÿ To prevent this syndrome, all persons with a history of chronic alcohol use
should be given thiamine 100 mg OD per day. Give thiamine before
administering glucose to avoid precipita ng Wernicke's encephalopathy.

Clinical Tips
General principles to apply during the management of any withdrawal:
Ÿ Maintain hydra on.
Ÿ Manage specific withdrawal symptoms as they emerge, i.e. treat nausea
with an -eme cs, pain with simple analgesics, and insomnia with light
seda ves.
Ÿ Allow the person to leave the treatment facility if they wish to do so.
Ÿ Con nue treatment and support a er detoxifica on.
Ÿ Depressive symptoms may occur in the post-intoxica on period, during or
a er withdrawal, and/or the person may have pre-exis ng depression. Be
alert to the risk of suicide.
Ÿ Offer all persons con nued treatment, psychological support, and
monitoring a er successful detoxifica on, regardless of the se ng in which
detoxifica on was delivered.

58
 Clinical Management Flowchart for Alcohol Related Disorder

Pa ent presented with alcohol use

History taken:
Severity of alcohol dependence,
Past history of complicated withdrawal (withdrawal Seizure or Delirium
Tremens)
Co-morbid substance use
Co-morbid medical or mental illness,
Current regular medica ons
Screening tool (CAGE) if scoring >2 points further inves ga on is required
Physical Examina on

Assessing the stability of the vital signs

Vital signs not stable Vital signs stable (Not Vital signs stable (willing
complicated withdrawal willing to stop alcohol to stop alcohol use)
(Alcohol withdrawal use) Thiamine 100 mg OD for
seizure, Delirium Tremens Thiamine 100 mg OD 5 days can be started
or Wernicke's for 5 days can be
encephalopathy) started
Consider (Medical (Rou ne case):
emergency) necessitate Consider psychosocial E-Referral to specialized
Emergency High Medical support addic on unit at
Care Restate concern about [AlMassara Hospital or
pa ent's health regional addic on unit if
Refer as emergency to Brief counseling about available] with
nearest emergency care risk of con nuing to detoxifica on and
with Intensive Care/ High drink alcohol rehabilita on services
Dependency Unit se ng Encourage reflec on by OR self-referral is
asking (what are the possible
barriers to cu ng down
A er medical stabiliza on: alcohol?
Refer to specialized Offer support and the
addic on unit at Al Massara willingness to help when
Hospital or regional pa ent is ready to stop
addic on unit [if available] alcohol use
for psychiatric assessment
and alcohol rehabilita on
The referral needs to include these
notes: co-morbidi es and any
medica ons that the pa ent may be on

59
 Opioids Related Disorders: F11

Defini on:
It is defined in the DSM-5 as a problema c pa ern of opioid use leading to clinically
significant impairment or distress.
Opioids such as morphine and heroin are among the most common substances
abused in Oman. Some pa ents abuse opioids such as tramadol and pethidine
a er ini al prescrip on by doctors for pain management. Such pa ents may seek
the drug from different hospitals or even obtain them from the street.
Along with its medical and social consequences, abusing morphine and heroin
may spread infec ons such as HIV and hepa s viruses through shared needles.
Also, the tolerance to morphine and heroin develops rapidly, thus the person may
rely on stealing or other criminal acts to provide money for the increasing
demands of the drug.

Signs and Symptoms

The withdrawal symptoms of opioids can occur a er a few hours following the last
use and include:
Ÿ A strong craving for the substance
Ÿ Irritability
Ÿ Excessive yawning
Ÿ Body ache/ severe joint pain
Ÿ Nausea and vomi ng
Ÿ Insomnia
Ÿ Dilated pupils
The pa ent may use increasingly higher doses to obtain the same degree of
euphoria (a feeling of intense happiness and excitement). A er a period of
abs nence due to incarcera on for example, this tolerance to the drug may be
lost. Therefore, returning to the same last dose can result in a fatal overdose.

Screening and assessment

While iden fying pa ent with substance use problems and before referring for
appropriate addic on treatment, general physicians (GP) need to take a careful

60
medical history, including substance abuse history, as well as perform a medical
evalua on, assess co-morbid medical and mental illness, and use (ASSIST) tool to
screen for substances abuse. (Annex 5)

Management Guidelines

The opioid withdrawal symptoms are usually not life-threatening and the
treatment should be symptoma c.
Here are some general advice on managing pa ents with opioids use disorder:
Ÿ Avoid being judgmental.
Ÿ Do not use threatening language.
Ÿ Offer a referral to a psychiatrist and explain to the pa ent the detoxifica on
and rehabilita on services available.
Ÿ Explain harm reduc on techniques: if a drug is to be used, needles and
other tools must not be shared.
Ÿ Explain to the pa ent that a er release from prison or discharge from
hospital to not return on the same last dose.
Ÿ Offer the pa ent con nuous follow-up and psychological support.

How to iden fy an opioid Signs of opioid overdose:

overdose? Ÿ Unconsciousness
An overdose occurs when a Ÿ Pinpoint pupil (Small pupils)
person takes too many opioids, Ÿ Slow or shallow breathing (less than 1
unresponsive and not breath every 5 seconds), or no breathing
Ÿ Snoring sound
breathing or struggling to
Ÿ Blue, grey, or pale skin color
breathe (i.e., respiratory
Ÿ Sweaty skin
depression).

61
 Steps to Respond to an Opioid Overdose
1
Shake person's shoulder and shout name.

2
Call for emergency medical assistance immediately if
the person not responsive, not breathing, and has no
pulse.

3
Inject Naloxone into upper arm or upper leg. Start
with 0.04 mg and trate up every 2-3 minutes as
needed for ven la on to 0.5 mg, 2 mg, 5 mg, up to a
maximum of 10 mg.

4
Perform rescue breathing and/or chest compressions
technique “cardiopulmonary resuscita on (CPR)” if
you are trained.

5
If not responding in 3-5 minutes, perform step 3 and
4 again (give a second dose of naloxone and perform
CPR)

6
If responding, stay and observe un l alert, then shi
the person to appropriate emergency se ng.

If s ll no response, repeat step 3 and 4 again,

con nue the steps un l the pa ent is shi ed to
appropriate emergency se ng or become alert.
Table 19. Steps to Respond to an Opioid Overdose

62
 Responding to an Opioid Overdose with Naloxone Flow Chart

Assess for responsiveness and breathing

Signs of opioid overdose: decreased
level of consciousness, constricted pupils
and slow or no breathing

Responsive Not Responsive

Stay and observe Begin C.A.B of cardiopulmonary resuscita on

un l alert (CPR)
Restore blood circula on with chest
Compression
Clear the Airway
Give rescue Breaths

Responsive Unresponsive or Adequate pulse rate but

no pulse inadequate respiratory rate

Shi to appropriate Begin CPR Rescue Breathing: one

emergency se ng breath every 5 seconds
using Ambubag

If no response a er 2
minutes of rescue breaths

Administer naloxone 0.4 mg

IM con nue rescue breaths

If adequate response If no response a er 2

achieved, closely observe minutes of rescue breaths
pa ent for ≥ 90 minutes
Administer the 2nd dose of naloxone
0.4 mg IM and if no response
observed give the 3rd dose of
naloxone 0.4 mg IM
Con nue rescue breathing un l the
pa ent is shi ed to appropriate
emergency se ng

63
 Clinical Management Flowchart for Opioid Abuse

Pa ent presented with opioids use and

complains of withdrawal symptoms

Withdrawal symptoms of opioids History taken and assess poten al

include: dependence:
Strong craving for the substance Physical examina on: observe
Irritability signs of withdrawal or
Excessive yawning intoxica on
Body ache/ severe joints pain Co-morbid medical or mental
Nausea and vomi ng, diarrhea illness
Insomnia Current regular medica ons
Dilated pupils Use (ASSIST) tool to screen for
substance abuse
Lab inves ga ons

Start symptoma c treatment

It is managed as out-pa ent

Diclofenac sodium (Olfen) as Pain killer

An histamine for insomnia
Metoclopramide for nausea
Lopermaide for diarrhea

Not willing to stop opioids use Willing to stop opioids use

Consider psychosocial support (Rou ne case):

Restate concern about pa ent's E-Referral to specialized
health. addic on unit at (Al Massara
Brief counseling about risk of Hospital or regional addic on
con nuing opioids use unit if available with
Encourage reflec on by asking detoxifica on and rehabilita on
(what are the barriers to cu ng services OR self-referral is
down opioids?) possible)
Offer support and the willingness
to help when pa ent is ready to The referral needs to include
stop opioids use these notes: co-morbidi es and
any medica ons that the
pa ent may be on

64
 Benzodiazepines Related Disorder: F13

Defini on:
Benzodiazepine use disorder is the use of benzodiazepines without a prescrip on,
o en for recrea onal purposes which pose risks of dependence, withdrawal and
other long-term effects.
Benzodiazepines have many clinical indica ons such as seizure disorders and
insomnia. However, the long term use may result in dependence and tapering
down of the drug becomes challenging. Intermediate and short-ac ng
benzodiazepines such as (Alprazolam), Lexotanil (Bromazepam) and Clonazepam
are more likely to be abused than long-ac ng Benzodiazepine (e.g. Diazepam).

Signs and Symptoms

The withdrawal features of benzodiazepines include:

Ÿ Anxiety, irritability and restlessness
Ÿ Insomnia
Ÿ Swea ng
Ÿ Tremor
Ÿ Alerted body percep on
Ÿ Seizure

Screening and Assessment

Also, General Physicians (GP) should do the following:

Ÿ Physical examina on.
Ÿ Use (ASSIST) tool to screen for benzodiazepine and other substances
abuse. (Annex 5)
Ÿ Take a full history to assess poten al dependence:
Ÿ Benzodiazepine use diary for two weeks.
Ÿ History of regular daily benzodiazepine use for more than three months.
Ÿ Descrip on of typical withdrawal when benzodiazepine not taken
Ÿ Co-morbid medical or mental illness
Ÿ Current regular medica ons
Ÿ Lab inves ga ons

65
Management Guidelines

Ÿ Benzodiazepine withdrawal can be managed by switching to a long-ac ng

benzodiazepine and gradually decreasing the dose, tapered over 8-12
weeks, and in conjunc on with psychosocial support. More rapid tapering is
possible only if the person is in an in-pa ent se ng in a hospital or
detoxifica on facility.
Ÿ If severe, uncontrolled benzodiazepine withdrawal develops or occurs due
to a sudden or unplanned cessa on, consult a specialized doctor
immediately to start a high-dose benzodiazepine seda on regime and to
hospitalize the person. Be cau ous with unsupervised dispensing of
benzodiazepines to unknown pa ents.
Ÿ Provide psycho-educa on (using non-judgmental techniques). These may
include:
Ÿ Provide personalized feedback to the pa ent about the risks
associated with their pa ern of benzodiazepine use and the specific
harms they may be experiencing or causing to others.
Ÿ Ask the pa ent the reasons for their substance and benzodiazepine
use, including as a response to other issues such as mental health
problems or specific stressors, and the perceived benefits they have
from substance and benzodiazepine use.
Ÿ Advise stopping the substance completely or consuming it at a non-
harmful level, if one exists. Verbalize your inten on to support the
person to do this. Ask them if they are ready to make this change.
Ÿ Provide informa on on the next steps as needed (further review,
detoxifica on, psycho-social support), and by providing the pa ent
and family with take-home materials if available.
Ÿ Explore strategies for reducing or stopping use and strategies for reducing
harm shown in (Table 17).
Ÿ Consult specialized doctor to start a high-dose benzodiazepine seda on
regime and to hospitalize the person. Be cau ous with unsupervised
dispensing of benzodiazepines to unknown pa ents.

66
 Clinical Management Flowchart for Benzodiazepines Use Disorder

Pa ent presented with benzodiazepine problems e.g. (using

seda ves or sleeping pills), and withdrawal symptoms

Withdrawal features of History taken and assess poten al dependence

benzodiazepines include: Benzodiazepine use diary for two weeks
Anxiety, irritability and History of regular daily benzodiazepine use
restlessness for more than three months
Insomnia Descrip on of typical withdrawal when
Swea ng benzodiazepine not taken
Tremor Past history of complicated withdrawal
Alerted body percep on (withdrawal Seizure or Delirium Tremens)
Seizure Co-morbid medical or mental illness
Current regular medica ons
Inves ga on is required
Physical Examina on
Use (ASSIST) tool to screen for benzodiazepine
and other substances abuse

Assessing the stability of the vital signs

Vital signs not stable, Vital signs stable Vital signs stable [willing to
dizziness, tremors, [Not willing to stop stop benzodiazepine abuse]
withdrawal seizure benzodiazepine abuse]

Refer to nearest Consider psychosocial [Rou ne case]:

medical unit for support E-Referral to
management of Restate concern about specialized addic on
withdrawal pa ent's health unit at Al Massara
Brief counseling about Hospital or regional
A er medical risk of con nuing addic on unit if
stabiliza on: benzodiazepine abuse available with
Refer to specialized Encourage reflec on by detoxifica on and
addic on unit at Al asking [what are the rehabilita on services
Massara Hospital or barriers to cu ng down OR self-referral is
regional addic on unit benzodiazepine?] possible
if available with Offer support and the
detoxifica on and willingness to help when
rehabilita on services pa ent is ready to stop
OR self-referral is
possible The referral needs to include these notes:
co-morbidi es and any medica ons that
the pa ent may be on

67
 Women Mental Disorders
Intimate Partner Violence (IPV)

Defini on

It is behavior by a current or previous in mate partner that causes physical, sexual

or psychological harm, including acts of physical aggression, sexual coercion,
psychological abuse and controlling behavior. ¹⁵
In mate Partner Violence (IPV) against women specifically are more likely than
men, as women experience more forms of violence and abuse as well as sustain
more serious physical and mental health sequelae.
There are five types of IPV:
1.Physical violence: use of any physical force to cause harm, injury, disability or
death by use of a weapon, one's body or restraint.
2.Emo onal or psychological violence: such as insults, beli ling, constant
humilia on, in mida on (e.g. destroying things), threats of harm, threats to
take away children.
3.The threat of physical or sexual violence: words, gestures or weapon to
communicate the intent to cause death, disability or physical harm.
4.Sexual violence: use of physical force to compel the partner to engage in a
sexual act against her will.
5.Stalking: following an ex-partner.

Signs and Symptoms

It is divided into emo onal sequelae and physical sequelae which make the doctor
suspect partner violence.
Physical health Physical: death, fractures, contusions, lacera ons,
sequelae dental injuries, concussion
Func onal: GI symptoms, musculo-skeletal
symptoms and pains, Quality of Life decreased
Reproduc on: miscarriages, infer lity, unintended
pregnancy, shorter gesta on, fetal death

68
 Mental health Post-Trauma c Stress Disorder (PTSD)
sequelae Depression, anxiety
Sexual problems
Sleep and ea ng disorders
Suicide and self-harm
Chronic pains and soma za on
Risky behaviors
Table 20. Sequelae of Violence

IPV also can be detected by its effect on children leading to psychological and
behavioral effects on children. E.g. reduced school performance will more likely
lead them to be vic ms or abusers as adults.
Signs of possible in mate partner violence
Ÿ Unexplained injuries (or unlikely explana ons).
Ÿ Unexplained fears (especially from partner no ced in interviewing the vic m).
Ÿ Social withdrawal from friends and family.
Ÿ Restricted access to family finances.
Ÿ Delay in seeking help for medical problems.
Ÿ Missed appointment.
Ÿ Frequent u liza on of medical care.

Screening and Assessment

There is insufficient evidence to jus fy universal screening in a healthcare se ng

but when cases are suspected, its best to talk with the pa ent and start
psychological first aid.

Two screening ques ons can be helpful in suspected cases:

Ÿ Do you feel safe at home? The Severity of Violence Against
Ÿ Have you been harmed by your Women Scales (SVAWS)
spouse? Is a 46-item instrument designed to measure
the severity of violence consists of three
Also the Severity of Violence Against
subscales that differ in level of severity (i.e.,
Women Scales (SVAWS) tool can be
threats of violence, acts of violence, and
used if the woman has been detected by sexual aggression). These scales can be
a health worker as a vic m of In mate further divided into nine dimensions to
Partner Violence (IPV) or if assumed that determine the level of violence (mild,
she'd been exposed to (IPV). (Annex 6) moderate, and severe).¹⁶

69
Management Guidelines

Ÿ In all cases, the vic m presents with emo onal, physical or behavioral
problems a er exposure to an extreme stressor (e.g. physical or sexual
violence) provide Suppor ve Psychological First Aid (LIVES).
Ÿ Reassure the vic m that her reac on is understandable.
Ÿ Do not pressure her to talk about the LIVES¹⁷
Listen empathically and non-
event. judgmentally.
Ÿ Address her social needs: Inquire about their needs and
Ÿ Ask the vic m about her needs and concern (do not assume her
concern but ask her).
concerns. Validate: how you believe and
Ÿ Help her to address basic needs, understand the vic m.
Enhance safety: discuss how to
access services and connect with protect against further harm.
family and other social supports. Support: help connect to
services and social support.
Ÿ Protect her from (further) harm, if needed.
Ÿ Encourage her to return to previous, normal ac vi es, e.g. at work, at
home, and socially, if it is feasible and culturally appropriate.
Ÿ Assist with referrals to appropriate services; locally in each social affairs
sec on for family issues or report to police /court.
Ÿ Like anxiety, depression, hyperarousal, irritability, sleep disturbances there
is no evidence for use of any medica on immediately a er trauma to
prevent the development of Post-Trauma c Stress Disorder (PTSD).
Ÿ Benzodiazepine should not be prescribed rou nely and reserved for severe
anxiety for a short me.
Ÿ Follow- up visits possibly a er 2 weeks and then a er 1 month.
Ÿ If post-trauma c stress disorder (PTSD) is suspected, refer the pa ent to
psychiatric service for further assessment and management.
Ÿ A er a poten ally trauma c event, the pa ent may have PTSD if the
symptoms involve considerable difficulty with daily func oning for at least 1
month and include recurring frightening dreams, flashbacks or intrusive
memories of the events accompanied by intense fear or horror; deliberate
avoidance of reminders of the event; excessive concern and alertness to
danger or reac ng strongly to loud noises or unexpected movements.

70
Notes:
Prac cally to get the support service available:
A.Get the number of social affairs responsible for family issues.
B.Encourage women to contact court but not force her.
Other interven ons/
Severity Psychological Medica ons
Referrals
Mild Psychological Not rou nely
First Aid. prescribed.
Seda ves if
needed for short
term.
Moderate Psychological Not rou nely Refer to psychiatrist
First Aid. needed. if symptoms persist
Psychological Medica on for a er a month of
treatment of associated trauma.
associated psychiatric illness. Refer to psychiatrist
psychiatric of chronic abuse.
illness. Refer to social
support or police if
woman accepted.
Severe Psychological Severe abuse does Refer to psychiatrist
First Aid. not necessary if symptoms persist
Psychological mean severe a er a month of
treatment of mental illness. trauma.
associated Management Refer to psychiatrist
psychiatric depends on of chronic abuse.
illness. psychological Refer to social
symptoms, support or police if
severity and woman accepted.
chronicity.
Treatment for
associated
psychiatric illness.
Table21. Management on in mate partner violence against women.

71
Clinical Management Flowchart for Suspected In mate Partner Violence

In mate Partner Violence (IPV) abuse suspected

Response is “women-centered care”

(act in response to her concerns and
wishes)

Affirm the abuse is real Pa ent interviewed alone

No excuses for violence Don't confront spouse
Don't call police without
permission

Offer psychological first aids (LIVES)

Listen empathically and non-judgmentally
Inquire about their needs and concern
(children, money)
Validate: how you believe and understand
the vic m
Enhance safety: discuss how to protect
against further harm
Support: help connect to services and social
support

Refer to regional psychiatrist if her

life func on impaired or developed
psychiatric symptoms

Note:
Domes c violence is common don't ignore it

72
 Postpartum psychiatric disorders F53

For many women, the months a er delivery are a me of vulnerability to

psychiatric disorders which is significantly increased in the 6 months postpartum
compared to other mes in a women's life. Postpartum psychiatric disorders are
classified as:
1) Postpartum blues
2) Postpartum depression
3) Postpartum psychosis

Incidence Onset Symptoms(DSM-5)

Postpartum blues 50 - 85% Within 1 week Fluctua ng, labile mood;
(maternity blues) postpartum anxiety; tearfaulness
Perinatal depression 10 -15% Insidious, during Depressed mood;
pregnancy or prominent anxiety
within first 3 symptoms
months postpartum
Postpartum 0.1 - 0.2% Drama c, within Mania and/or mixed
psychosis (affec ve 2 weeks affec ve state; agita on,
puerperal psychosis) postpartum mixed mood,
bewilderment, delusions,
disorganised behaviour
Figure 9. Classifica on of postpartum according to American Psychiatric Associa on ¹⁸

Postpartum blues:
It is a transitory state beginning within the first 2-4 days a er delivery and las ng
no more than two weeks.
Women may benefit from support and reassurance that symptoms are common
and will end soon. She should be monitored that symptoms do not persist or
evolve into postpartum depression.

73
 Perinatal Depression

Perinatal disorders do not cons tute a special group in ICD-10.

Defini on

The care of pregnant women and postpartum must include depression detec on
and management. Depression can be more common than other illness
screened during pregnancy to ensure the safety and well-being of
women and her fetus. Untreated perinatal depression places the
mother and infant at risk and is associated with significant long-term
effects on child development and behavior. Perinatal depression is
associated with poor nutri on, pre-eclampsia [a combina on of hypertension and
proteinuria in pregnancy] and poor weight gains and distress.

Signs and Symptoms

Signs and symptoms of postpartum depression are clinically indis nguishable

from major depressions that occur in women at other mes. It includes:
Ÿ Depressed mood, tearfulness.
Ÿ Anhedonia [loss of interest used to be enjoyable and loss of interest in life
generally].
Ÿ Insomnia [either ini a on of sleep or maintaining sleep].
Ÿ Fa gue.
Ÿ Appe te disturbance [increased or decreased].
Ÿ Poor concentra on.
Ÿ Suicidal thoughts and recurrent thoughts of death.
Ÿ Intense sadness, anxiety or despair.
Ÿ Inability to func on which affects her care for self and baby.
Ÿ Anxiety is a prominent feature in perinatal depression, including worries or
obsessions about the infant's health and well-being or ambivalent or
nega ve emo ons toward her child.
Ÿ Ideas may become intrusive and unpleasant fears or thoughts of harm for
the infant [different than wan ng to harm the baby].
Ÿ Mother with depression can feel worthlessness or incompetence as a mother.

74
 Ÿ She may feel no love or bond with her baby.
Ÿ Feeling entrapped or imprisoned.
Ÿ Escape fantasies and then feeling guilty or ashamed from her thoughts.

Screening and Assessment

The Edinburgh Postnatal Depression Scale is a 10-item, self-rated ques onnaire.

It has been developed to detect mothers suffering from perinatal
depression. (Annex7)
The cut-off point is 12.5 and is listed as likely to be suffering from
depressive illness. Alterna vely, two [focused ques ons] could be
used to detect depression (high sensi vity but low specificity) in
the primary and secondary se ng. They are:
Ÿ Over the past 2 weeks have you been bothered by feeling down, depressed
or hopeless?
Ÿ Over the past 2 weeks have you felt li le interest or pleasure in doing
things?

Management Guidelines
Ÿ Severity of depression depends on prominent neuro-vegeta ve symptoms
(level of energy, sleep and appe te) and marked impairment of func on.
Ÿ Ini al evalua on includes proper physical examina on and inves ga ons to
rule out medical condi ons caused for her presenta on (e.g. anemia,
infec ons, sleep depriva on and thyroid problems). ⁶
Ÿ Mild to moderate depression can be treated with psychotherapy⁶ including:
Ÿ Psychological support: hospital and community nurses, health visitors,
counsellors (groups and individual sessions, anxiety management…)
Ÿ Social support: social workers, motherhood classes and occupa onal
therapy.
Ÿ Involvement of fathers (Interpersonal therapy).
Ÿ Pharmacological interven on:
Ÿ Can be started in pregnancy or postpartum if non-pharmacological
approach failed or as a conjunc ve therapy with psychotherapy or when
proper psychotherapy is not available in a clinical se ng.
Ÿ For more severe condi ons, pharmacological treatment is needed.

75
 Ÿ In case of severe symptoms of suicidal or infan cide idea ons, refer the
pa ent to a psychiatrist urgently (preferably to an ins tu on with in-pa ent
services). The pa ent may require hospitaliza on and Electroconvulsive
Treatment (ECT) for cases of high suicidal risk.
Ÿ Follow up visits:
Ÿ A er two weeks, and then a er 4 weeks and possibly 8 weeks if a more
stable and good response is required.
Ÿ Medica on can be given 8 months to one year then gradually the dosage
can be reduced or stopped.
Ÿ If enrolled in psychotherapy sessions: once a week or once every two
weeks for a course of 8-16 sessions.

Treatment with an -depressants

There have been inconsistent findings regarding associa ons between an -

depressants and complica ons of pregnancy and effect in fetus or child for
postpartum and lacta ng mothers. It is reasonably certain that commonly used
an -depressants are not major teratogens. Untreated depression and anxiety
carry its risks for fetus and distress the life of women and her family.

Fluoxe ne [SSRI an depressant] dose of 20- 60 mg/day.

Citalopram [dose of 20- 40 mg/day].
Paroxe ne can be used during lacta on for cases of postpartum
depression but to avoid during pregnancy.
Amitriptyline [TCA an depressant] dose of 25 – 100 mg at bed me can
be used [keep in mind fetal exposure to TCA is high so should not use
as first line].

76
 Severity Other
of Psychotherapy Pharmacotherapy interven ons/
symptoms Referrals
Mild Suppor ve SSRI: If the pa ent is
counselling. Fluoxe ne not responding
Cogni ve Behavioral Citalopram refer her to a
Therapy (CBT). specialist.
Interpersonal
therapy (IPT)
(involve father).
Social support
(involve social
worker &
psychologist if
available).
Social support SSRI If the pa ent is not
Moderate
(involve social TCA: responding refer
worker & Amitriptyline her to a specialist.
psychologist if
available).
Cogni ve Behavioral
Therapy (CBT).
Interpersonal
therapy.

Severe Should integrate SSRI Refer to

both psychosocial TCA psychiatrist
and An psycho c [if May need
pharmacological psycho c hospitaliza on.
interven ons. features].
Table 22. Management guideline for postpartum psychiatric disorders

77
 Clinical Management Flowchart for Suspected
Postpartum Depression Disorders

Woman presents with symptoms of mood

disturbance in postpartum period

Screen using (EPDS) tool

Score less than 12 Score more than 12

Depression not likely Assess for presence of depression

Refer to depression flowchart (Page 33)
Assess woman's intent to harm self or
infant

Reassurance Mild to moderate Severe depression

Consider family support depression
Offer educa onal materials
on postpartum depression SSRI (consider an - With suicidal or
depressant medica ons) infan cide ideas

Emergency case:
Refer to mental hospital with
admission service available
If no response, refer to Ensure the mother is not le
regional psychiatrist alone with the baby

78
 Postpartum Psychosis F53

ICD 10 code F53 under 'mental and behavioral disorders associated with the
puerperium, not elsewhere classified'.

Defini on
Postpartum psychosis is the most severe form of postpartum mental illnesses with
drama c onset shortly a er childbirth, the majority (around 90% of them) in the
first few days or the first two weeks postpartum. Highest risks are women known to
have bipolar affec ve disorder or previous episodes of puerperium psychosis.

Signs and Symptoms

Postpartum Psychosis is a wide variety of psycho c phenomena. Women can

present with:
Ÿ Mood symptoms both ela on and depression or mixed state.
Ÿ Prominent symptoms are a disturbance of consciousness marked by
confusion and perplexity (disconcer on).
Ÿ Symptoms such as restlessness, insomnia, irritability,
disorganized behavior can also be part of the picture.
Ÿ May have delusional beliefs that relate to the infant (e.g.
the baby is defec ve or dying, the infant is sultan or god).
Ÿ May have hallucina ons like hearing voices order her to harm herself or the
infant.
NOTE: The clinical picture o en changes rapidly with wide fluctua ons in the
intensity of symptoms and severe swings of mood.

Infan cide and suicide Risk

Infan cide is a term generally used to refer to the killing of the
newborn. It is high among women with untreated puerperium
psychosis. A high propor on of maternal suicide occurs in women
with an acute onset of psychosis in the early postpartum period.

79
Early symptoms of postpartum psychosis:
Ÿ Restlessness, agita on or perplexity
Ÿ Feeling energe c or ac ve
Ÿ Irritability
Ÿ Insomnia

Screening and Diagnosis

No screening test can help provide a clinical diagnosis.

A wide range of diagnosis can present with psycho c features in the puerperium
and include acute confusional state due to a variety of medical or mental causes.
Differen al diagnosis:
Ÿ Post-eclampsia
Ÿ Infec ons
Ÿ Hypoglycemia
Ÿ Electrolytes disturbance
Ÿ Psycho c illness [schizophrenia, schizoaffec ve, psycho c depression,
mania disorders]

Management Guidelines

Most women with postpartum psychosis need to refer to psychiatry facility for
assessment.
Home treatment usually is not suitable because of severity, inherent risks and
rapidly changing clinical picture. With the severity of the illness, and the chao c
presenta on breas eeding o en becomes impossible.
Breas eeding while being on medica on depends on the symptoms the mother
experience, level of disturbance, previous medica ons used with a response, baby
systemic illness and prematurity.
If pa ents are known to have a psycho c illness [Bipolar Affec ve Disorder or
Schizophrenia] they need to be under follow up with the psychiatrist to manage
their medica ons.

Medica ons for Treatment of Postpartum Psychosis

Medica on for an acute psycho c episode is not different to that given outside the
perinatal period. Postpartum psychosis should be treated as an affec ve psychosis
and a mood stabilizer is indicated.

80
 May start Olanzapine dose 2.5 mg to 10 mg at bed me (HS).
Haloperidol 1.5 mg to 15 mg (at bed me if small dose or divided dose if
higher doses to BID or TID) prescribed by a psychiatrist.
Lithium for mood stability (should be prescribed by a psychiatrist to
monitor the dose, stop lacta on because of risk of toxicity to infant).
Consider Benzodiazepine for agita on (if breast-feeding, give short-
ac ng divided doses; Lorazepam 1mg BID, Bromazepam 0.75 mg BID)
Fluphenazine (Modecate) 25 mg/ml lnjec on prescribed by
psychiatrist.

Also, Electroconvulsive Therapy (ECT) is well tolerated and rapidly effec ve for
severe postpartum depression and psychosis.

Management Guideline

Other
Severity of Psychotherapy Pharmacotherapy
interven ons/
symptoms
Referrals
Mild May Start Refer to regional
Olanzapine psychiatrist.
2.5 - 10 mg HS
Moderate Refer to regional
psychiatrist.

Severe Refer to mental

hospital with
admission service.
Table 23. Management guideline for postpartum psychosis

81
 Clinical Management Flowchart for
Suspected Postpartum (Puerperal) psychosis

Mother came with acute change of mood

Pa ent is confused Pa ent has psycho c features

Inves gate for medical No aggressive behaviors Present with

causes for confusion No risk to harm self, aggressive behavior
infant or others Risk to harm self,
infant or others

If normal inves ga on
No medical cause found

Refer to regional Emergency case:

psychiatrist for Refer to mental hospital
management with admission service

82
 Childhood Psychiatric Disorders

Defini on

Mental disorders among children are described as serious changes in the way
children typically learn, behave, or handle their emo ons, which cause distress
and problems ge ng through the day. The common childhood psychiatric
disorders are:
Ÿ Mental Retarda on
Ÿ Childhood Au sm
Ÿ Hyperkine c Disorders
Ÿ Child Abuse
Ÿ School Refusal
Ÿ Selec ve Mu sm

Psychiatric Assessment of a Child or Adolescent

General Physician (GP) should do the following:

Ÿ Physical assessment (using Head-to-Toe Approach). (See Figure 4)
Ÿ Conduct a mental health screening and clinical assessment:
History taking. (See Figure 5)
Basic laboratory tests.
Mental State Examina on (MSE). (See Table 1)
Screening tools for some childhood psychiatric disorders:
Strengths and Difficul es Ques onnaire (SDQ). (Annex 8)
School screening report. (Annex 9)
SNAP-IV Teacher and Parent Ra ng Scale. (Annex 10)
Ÿ WHO-(mhGAP) psychiatric assessment for a child and adolescent.⁶ (Table 24)

83
1. Assess for For toddlers and young children:
developmental Difficul es with age-appropriate milestones
disorders across all developmental areas.
Are there any For older children and adolescents:
difficul es with the Difficul es with school (learning, reading, and
following wri ng), communica ng with others, self-
developmental care, and everyday ac vi es.
domains: motor,
Adolescents should be offered the
cogni ve, social,
communica on, and opportunity to be seen without caregiver.
adap ve? Clarify confiden ality and indicate when
parents or other adults will be given
informa on.

1.1 Consider Are there signs/symptoms sugges ng any of

developmental the following:
delay/disorder Nutri onal deficiency, including iodine
deficiency, anaemia, malnutri on.
Acute or chronic infec ous illness, including
ear infec on and HIV/AIDS.
Assess the child for visual and/or hearing
impairment:
For vision, see if the child fails to:
Look at your eyes.
Follow a moving object with the head and
eyes.
Grab an object.
Recognize familiar people.
For hearing, see if the child fails to:
Turn head to see someone behind them when
they speak.
Show reac on to loud noise.
Make a lot of different sounds [tata, dada], if
an infant.

84
2. Assess for problems Is the child/adolescent:
with ina en on or Overac ve.
hyperac vity Unable to stay s ll for long.
Easily distracted, has difficulty comple ng
tasks.
Moving restlessly .
Assess if symptoms are persistent, severe, and
causing difficulty with daily func oning. Are ALL
of the following present?
Symptoms present in mul ple se ngs
Las ng >6 months.
Inappropriate for the child/adolescent's
developmental level.
Considerable difficulty with daily func oning
in personal, family, social, educa onal,
occupa onal or other areas.
3. Assess for conduct Does the child/adolescent show repeat
disorders aggressive, disobedient, or defiant behavior,
for example:
Arguing with adults.
Defying or refusing to comply with their
requests or rules.
Extreme irritability/anger.
Frequent and severe temper tantrums.
Difficulty ge ng along with others.
Provoca ve behavior.
Excessive levels of figh ng or bullying.
Cruelty to animals or people.
Severe destruc veness to property,
fire-se ng .
Stealing, repeated lying, truancy from school,
running away from home.
3.1 Are symptoms Present in different se ngs (e.g. at home, at
persistent, severe, school and in other social se ngs).
and inappropriate for Present for >6 months.
the child/adolescent's More severe than ordinary childish mischief
developmental level? or adolescent rebelliousness.
Considerable difficulty with daily func oning
in personal, family, social, educa onal,
occupa onal or other areas.

85
4. Assess for Ask if the child/adolescent:
emo onal disorders Ÿ Feels irritable, easily annoyed, down or sad.
Ÿ Has lost interest in or enjoyment of
ac vi es.
Ÿ Has many worries.
Ÿ Has many fears or is easily scared.
Ÿ Complains of headaches, stomach-aches or
sickness.
Ÿ Is o en unhappy or tearful.
Ÿ Avoids/strongly dislikes certain situa ons
(e.g. separa on from caregivers, mee ng
new people, closed spaces).
4.1 Is there Consider emo onal disorders.
considerable difficulty
with daily func oning
in personal, family,
social, educa onal,
occupa onal or other
areas?
4.2 Are there any Thyroid diseases.
signs/symptoms Infec ous illness, including HIV/AIDS.
sugges ng physical Anaemia.
condi ons that can Obesity.
resemble or Malnutri on.
exacerbate emo onal Asthma.
disorders? Medica on side-effects (e.g. from
cor costeroids or inhaled asthma
medica ons).
4.3Does the Con nue assessment.
adolescent have
problems with mood
(feeling irritable,
down or sad) OR has
lost interest in or
enjoyment of
ac vi es?

86
4.4 Has the Disturbed sleep or sleeping too much.
adolescent had Significant change in appe te or weight
several of the (decrease or increase).
following addi onal Beliefs of worthlessness or excessive guilt.
symptoms most days Fa gue or loss of energy.
for the last 2 weeks? Reduced concentra on.
Indecisiveness.
Observable agita on or physical restlessness.
Talking or moving more slowly than usual.
Hopelessness.
Suicidal thoughts or acts.
4.5 Does the Consider depression.
adolescent have Consider problems with emo ons.
considerable difficulty
with daily func oning
in personal, family,
social, educa onal,
occupa onal or other
areas?

5. Assess for Pay special a en on to:

concurrent mental Risk of self-harm/suicide.
condi ons Signs and symptoms of disorders due to
substance use.
For children with developmental
delay/disorders, assess fort epilepsy .
! IF THERE IS IMMINENT RISK OF SUICIDE,
ASSESS AND MANAGE BEFORE
CONTINUING. Go to » Suicide chapter in the
manual.

87
 6. Assess the home Assess for:
environment Clinical features or any element in the clinical
Are the emo onal, history that suggest maltreatment or
behavioral or exposure to violence.
developmental Any recent or ongoing severe stressors (e.g.
problems a reac on illness or death of a family member, difficult
to or aggravated by a living and financial circumstances, being
distressing or bullied or harmed).
frightening situa on? Ask the child/adolescent directly about these
when developmentally appropriate and safe.
Offer adolescents the opportunity to be seen
on their own.
» Refer to child protec on services if necessary.
» Explore and manage stressors.
» Ensure child/adolescent's safety as a first
priority.
» Reassure the child/adolescent that all
children/adolescents need to be protected from
abuse.
» Provide informa on about where to seek help
for any ongoing abuse.
» Arrange addi onal support including referral to
specialist.
» Contact legal and community resources, as
appropriate and as mandated.
» Consider addi onal psychosocial interven ons
» Ensure appropriate follow-up.
7. Assess the school Is the child/adolescent:
environment Being bullied, picked on or made fun of?
Not able to par cipate and learn?
Not wan ng/refusing to a end school?
Ask the child/adolescent directly about these
exposures when developmentally appropriate
and safe to do so.

A er consent, liaise with teacher/staff

» Try to facilitate return to school and reasons
for absence.
Table 24. Psychiatric assessment for child and adolescent as prescribed by WHO mhGAP⁶

88
 Common Child and adolescent
Mental and Behavioral Disorders

Mental retarda on F70-F7:

F70 Mild mental retarda on
F71 Moderate mental retarda on
F72 Severe mental retarda on
F73 Profound mental retarda on
F78 Other mental retarda on
F79 Unspecified mental retarda on

Defini on
Mental retarda on is a condi on of arrested or incomplete development of the
mind, which is especially characterized by impairment of skills manifested during
the developmental period, which contribute to the overall level of intelligence, i.e.
cogni ve, language, motor, and social abili es.

Signs and Symptoms:

Ÿ Delay or poor speech development.

Ÿ Ul mate deficits in comprehension.
Ÿ Academic difficul es e. g. reading, wri ng and calcula on.
Ÿ Poor self-care skills.
Ÿ Variable degrees of social and emo onal immaturity.
Ÿ Motor deficits.
Ÿ Neurological deficits e.g. epilepsy.

Screening and Assessment

Deficits in intellectual func oning may be confirmed by:

1.Clinical and psychiatric assessment for the child and adolescent. (Table 24)
2.Standardized intelligence tes ng (IQ test) done by a trained regional
psychologist.

89
Management Guidelines

Ÿ Psychosocial support for the pa ent and family.

Ÿ Basic counseling of the family.
Ÿ Special educa onal programs.
Ÿ Rehabilita ve therapy depends on the case e.g. speech therapy,
occupa onal therapy and Physical therapy.

Referral
Ÿ Refer to a pediatrician as co-occurring neuro-developmental, medical and
physical condi ons frequently occur in conjunc on with intellectual
disability.
Ÿ Refer the child to a psychiatrist or regional psychiatrist when the presence
of following is diagnosed:
Behavioral disturbances.
Mental disorders.
Ÿ Refer to a counselor or a therapist for behavioral therapy.

90
 Childhood Au sm F84.0

(Au sm Spectrum Disorder in DSM-5)

Defini on (ICD-10):

A pervasive developmental disorder defined by the presence of abnormal and/or

impaired development that is manifested before the age of 3 years, and by the
characteris c type of abnormal func oning in the following three areas:
Ÿ Social interac on.
Ÿ Communica on.
Ÿ Restricted/repe ve behavior.

Signs and Symptoms

Ÿ Delayed language development.

Ÿ Loss of previously acquired speech, babbling or social skills.
Ÿ Avoidance of eye contact.
Ÿ Persistent preference for solitude (to be isolated) e.g. doesn't play with
other people or share interest and enjoyment.
Ÿ Difficulty understanding other people's feelings.
Ÿ Persistent repe on of words or phrases (echolalia).
Ÿ Resistance to minor changes in rou ne or surroundings.
Ÿ Restricted interests.
Ÿ Repe ve behaviors (flapping, rocking, spinning, etc.)
Ÿ Unusual and intense reac ons to sounds, smells, tastes, textures, lights
and/or colors.

Screening and Diagnosis

The Modified Checklist for Au sm in Toddlers, revised (M-CHAT-R)

is a screening tool use for children from 18 months to 30 months
old and according to the score of M-Chat follow the referral
pathway. The Guidelines for the na onal screening program for
Au sm Spectrum Disorder (ASD) first edi on 2018 describes the screening tool
(M-CHAT-R) and (M-CHAT-R with Follow-up) and the scoring system with clear
algorithms of case management and referral pathway. (Annex 11)

91
 Management Flowchart for Early screening of
Au sm Spectrum Disorder in Children
Early screening of Au sm Spectrum Disorder in children
Complete (M-CHAT/R) ques onnaire
Immunization Parent - Caregiver
Clinic
Review the ques onnaire and calculate
the overall result EPI-Nurse

Score 0-2 Score 3-7 Score 8-20

Low risk Medium risk High risk

If child is younger than 24

months, screen again a er Physician in Health ins tu on:
second birthday Open visit for the child
No further ac on required Refer the case (urgently) to
unless surveillance
indicates risk for ADS

Pediatrician in
Polyclinic/Wilayate Hospital

Specialized Centers Fax#:

Administer the Follow-up SQUH:(24144389)
(M-CHART-R/F) Royal Hospital:(24211419)
Al-Masarra Hospital: (24873800)
Document result In
(Score is 0-1) child health record
Child has screened Nega ve Refer child to ENT
No further ac on required Doctor for hearing
unless assessment
surveillance indicates risk at
future well-child visits Refer child to receive rehabilita on
care support in socialdevelopment
center (Form A)
(Score is ≥ 2 ) Diagnos c
Child has screened Posi ve Assessment

Refer child to receive rehabilita on

care in social development center (Form B)

The Guidelines for The Na onal Screening Program for Au sm Spectrum Disorder (ASD) and Other Developmental
Disorders.¹⁹

92
 Hyperkine c disorder F90 /Disturbance of
Ac vity and A en on F90.0

(A en on deficit hyperkine c disorder in DSM-5)

Defini on in (ICD-10):

Hyperkine c disorder is a psychiatric neuro-developmental condi on emerging in

early childhood that features an enduring pa ern of severe, developmentally
inappropriate symptoms namely ina en on, hyperac vity, and impulsivity across
different se ngs (e.g., home and school) that significantly impair academic, social
as well as work performance.

Signs and Symptoms

Ÿ Fails to give close a en on to details, or makes careless errors in

schoolwork, or other ac vi es.
Ÿ Fails to sustain a en on in tasks or play ac vi es.
Ÿ Appears to not listen to what is being said to him or her.
Ÿ Fails to follow through on instruc ons or to finish schoolwork or du es in
the (not because of opposi onal behavior or failure to understand
instruc ons).
Ÿ Difficulty in organizing tasks and ac vi es.
Ÿ Avoids or strongly dislikes tasks that require sustained mental effort.
Ÿ O en loses things such as school assignments, pencils, books, toys or tools.
Ÿ Easily distracted.
Ÿ Forge ul in the course of daily ac vi es.
Hyperac vity
Ÿ Fidgets with hands or feet or squirms on seat.
Ÿ Leaves seat in classroom or in other situa ons in which
remaining seated is expected.
Ÿ Runs about or climbs excessively in situa ons in which
it is inappropriate (in adolescents or adults, only feelings of restlessness
may be present).
Ÿ Is o en unduly noisy in playing or has difficulty in engaging quietly in leisure
ac vi es.

93
 Ÿ O en exhibits a persistent pa ern of excessive motor ac vity that is not
substan ally modified by social context or demands.
Ÿ Talks excessively without appropriate response to social constraints.

Impulsivity
Ÿ Blurts out answers before ques ons have been completed.
Ÿ O en fails to wait in lines or await turns in games or group situa ons.
Ÿ O en interrupts or intrudes on others (for example, bu s into others'
conversa ons or games).
Note:
Ÿ The criteria should be for at least 6 months and met for more than a single
situa on. The symptoms should be present both at home and school, or
both school and another se ng where children are observed, such as a
clinic.
Ÿ The characteris c behavior problems should be of early-onset (before age
6 years). According to DSM-5 (before age of 12 years old).
Ÿ The symptoms cause clinically significant distress or impairment in social,
academic or occupa onal func oning.

Screening and Assessment

Ÿ Physical assessment (using Head-to-Toe Approach). (See Figure 4)

Ÿ Conduct a mental health screening and clinical assessment:
History taking. (See Figure 5)
Basic laboratory tests.
Mental State Examina on (MSE). (See Table 1)
Ÿ Screening tools can be used:
Strengths and Difficul es Ques onnaire (SDQ). (Annex 8)
School screening report. (Annex 9)
SNAP-IV Teacher and Parent Ra ng Scale. (Annex 10)
Ÿ WHO-(mhGAP) psychiatric assessment for a child and adolescent. (Table 24)

Management Guidelines

Ÿ Refer to regional psychiatrist or child psychiatrist for further assessment

and management.

94
 Clinical Management Flowchart of Suspected/ADHD Child

Pa ent presented with symptoms

include:
Poor a en on,
Impulsive behaviors: [crossing
roads without checking ,jumping
from heights]
Restlessness

Take detailed history and

assessment the current
symptoms, effects on daily
life and academic Screen current symptoms using
achievements following tools:
Strengths and Difficul es
Ques onnaire (SDQ) one to be filled
by parents and one by teacher
School screening report by teacher

Refer the child to psychologist

for IQ test
A ach the result of above
ques onnaires

95
 Child Abuse T74

Defini on:
Child abuse or maltreatment is defined as “all forms of physical and/or emo onal
ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other
exploita on, resul ng in actual or poten al harm to the child's health, survival,
development or dignity in the context of a rela onship of responsibility, trust or
power''.
Types of child abuse are:
Ÿ Physical abuse.
Ÿ Sexual abuse.
Ÿ Emo onal abuse.
Ÿ Neglect.

Physical abuse is characterized by physical injury (e.g., bruises,

fractures and internal injuries), resul ng from hi ng, punching,
pinching, kicking, bi ng, burning, shaking, or otherwise harming a
child.
Sexual abuse is defined as those acts where the abuser uses a child
for sexual gra fica on which may involve forcing or en cing a child
to take part in sexual ac vi es. Sexual abuse can both happen by an
adult or another child.
Emo onal abuse is defined as the failure of a caregiver to provide an
appropriate and suppor ve environment and includes acts that
harm the emo onal health and development of a child. Such acts
include restric ng a child's movements, denigra on, ridicule,
threats and in mida on, discrimina on, rejec on and other
nonphysical forms of hos le treatment.
Neglect is caregiver's failure to meet the basic nutri onal, medical,
educa onal, and emo onal needs of a child. Neglect is legally
reportable. Nutri onal neglect is likely the most common form of
neglect that is recognized, typically in the form of failure to thrive.

96
Signs and Symptoms

Signs and symptoms of child abuse differ according to the type of abuse and
differ from pa ent to pa ent. They can present with the following symptoms:
Ÿ Feel guilty, ashamed and confused, afraid to express about abuse
especially if it is a close family member.
Ÿ Withdrawal from normal ac vity.
Ÿ Behavioral changes such as aggression, anger, decrease school
performance.
Ÿ Becoming unconfident, anxious or depressed.
Ÿ Self-harm behaviors.
Some symptoms related to the type of abuse for example:
Physical abuse:
Ÿ Unexplained injuries.
Ÿ History not matching the given explana on.
Sexual abuse:
Ÿ Sexual behaviors inappropriate to child age.
Ÿ Sexually transmi ed infec ons.
Ÿ Pregnancy.
Ÿ Blood in child underwear.
Emo onal abuse
Ÿ Loss of confidence or self-esteem.
Ÿ Social withdrawal.
Ÿ Sadness.
Ÿ Desperately seeking a en on.
Ÿ Decrease in school performance.
Neglect:
Ÿ Failure to thrive.
Ÿ Poor hygiene.
Ÿ Taking food or money without permission.
Ÿ Poor school performance.
Ÿ Lack of necessary follow-ups for appointments.

97
Also, consider the following parent's behaviors:
Ÿ Li le concern about the child.
Ÿ Unable to recognize physical or emo onal distress in the child.
Ÿ Blames the child for the problem.
Ÿ Using harsh physical and verbal discipline.
Ÿ Does not explains child injuries appropriately.

Screening and Assessment

If there is a suspected/child abuse case, the trea ng physician should do the

following:
Ÿ Take history and perform general examina on.
Ÿ Look for signs of abuse (physical, sexual, emo onal and neglect).
Ÿ No fy the case using the child maltreatment no fica on form.
Ÿ Assess the severity of the case. At any level/category of severity, referral to
Regional Hospital Task Force for Child Abuse (RHTFCA) and the Child
Protec on Commi ees (CPC) should be considered if the child safety
cannot be assured or a life-threatening insult is an cipated.

Management Guidelines

Notes to be considered: ²⁰
Ÿ Management of cases of Child abuse is an integral part of the child health
services provided at all levels of the health care system in all governorates of
the Sultanate.
Ÿ This service provided to all children from birth ll 18 years of age.
Ÿ All physicians should be aware of risk factors and common symptoms and
signs of the different types of child abuse.
Ÿ Any suspected/abuse case to be reported on the assigned no fica on form
by the trea ng physician at any level of health care system (primary,
secondary or ter ary).
Ÿ The no fica on form should be kept confiden al and not to be used for any
legal purposes.
Ÿ Medical examina on of sexually abused girls to show their virginity or not
should be done by the forensic medicine only even in the event of receiving
correspondences from the courts or the public prosecutor.

98
 Ÿ Medical management of vic ms of child abuse should be carried out at all
levels of health care depending on the severity of the case.
Ÿ Trea ng physician at Primary Health Care should coordinate with the focal
point of Regional Hospital Task Force for Child Abuse and Child Protec on
Commi ees whenever needed to ensure child safety and provide a
comprehensive care.
Ÿ Regional Hospital Task Force for Child Abuse (RHTFCA) and the Child
Protec on Commi ees (CPC) are responsible for developing a strategic
approach to child protec on within the overall children's services at the
Regional Hospital and overall Wilayat/ Governorate and formula ng an
interven on plan for suspected and confirmed cases of child abuse.

Management of Suspected/Abused Cases according to the (Clinical

Guidelines on Child Abuse and Neglect First Edi on 2016) ²⁰
Non-Emergency cases: This includes cases of mild-moderate neglect, physical,
emo onal abuse and non-emergency sexual abuse. Examples: use of discipline at
schools or by a caregiver, cases of neglect leading to metabolic syndrome
(hypoglycemia, obesity and failure to thrive) or accidents, etc.
The child has suffered a substan al amount of injury and might need to be sent to a
higher level of care but does not require admission and can be managed in an out-
pa ent basis by a pediatrician, psychologist or a family physician.
Emergency cases: This includes cases of severe neglect, physical (shaken baby
Syndrome), emo onal abuse and emergency sexual abuse.
Child is suffering from severe injury or a life threatening event and needs to be
immediately sent to a hospital for specialized care/admission/protec on
measures.
For penetra ng sexual abuse: Prophylac c treatment must be started within 72
hours of the assault.
Ÿ Prophylac c an bio cs for the treatment of gonorrhea, Chlamydia,
trichomonas and bacterial vaginosis to be given. Recommended Regimens
(Ce riaxone 250 mg IM in a single dose + Azithromycin 1 g orally in a single
dose + Metronidazole 2 g orally in a single dose).
Ÿ Emergency contracep ve pills: two tablets given immediately and two
tablets are given 12 hours later for an adolescent girl.

99
 Ÿ Post-exposure hepa s B vaccina on (without HBIG) if the hepa s status
of the assailant is unknown and the survivor has not been previously
vaccinated. If the assailant is known to be HBsAg-posi ve, unvaccinated
survivors should receive both hepa s B vaccine and HBIG.
Ÿ Recommenda ons for HIV Prophylaxis is individualized according to risk,
consult an expert.
Note:
Ÿ At any level/category of severity, referral to RHTFCA and informing CPC
should be considered if the child safety cannot be assured or a life
threatening insult is an cipated
Ÿ All no fied cases should be reported to the CPC by the women and child
health sec on in the governorate.

100
 Clinical Management Flowchart for Suspected/Child Abuse Cases

Suspected/Child Abuse
Trea ng Physician
Take history & perform general examina on
Look for signs of abuse:
Physical
Sexual
Emo onal
Neglect
Provide medical management
No fy the case
Assess severity of the case & urgency to refer to RHTFCA

Non-Emergency Emergency
Child has suffered substan al amount Child is suffering form severe
of injury Might need to be sent to a injury or a life threatening
higher level of care but does not event and needs to be
require admission & can be managed immediately sent to a hospital
in an out-pa ent basis for specialized
Includes: mild-moderate neglect, care/admission/protec on
physical, emo onal abuse and non- measures
emergency sexual abuse Includes: severe neglect,
Examples: use of discipline at schools physical [shaken baby
or by caregiver, cases of neglect Syndrome), emo onal abuse
leading to metabolic syndrome and emergency sexual abuse
[hypoglycemia, obesity and failure to
thrive] or accidents, etc 1- Provide emergency care
2- Inform immediately RHTFCA
1- Send referral to RHTFCA pediatric focal point & transfer to Hospital
clinic by ambulance for admission
2- Follow up appointment if needed 3- Call child protec on line (#1100)

RHTFCA
Inform CPC.
Set appointment for clinic & monitor ll
safety of the child ensured CPC
Discuss the case in the regular mee ng of the Inves gate no fied cases
RHTFCA to formulate a management plan. Provide social services
Send a report to CPC of all no fied & and protec on measures
discussed cases whenever needed
NOTE: If the child safety can not be assured or a life threatening insult is an cipated, refer
to RHTFCA and inform CPC at any level/ category of severity.
The Clinical Guidelines on Child Abuse and Neglect, First Edi on 2016.²⁰

101
 School Refusal F93.0

Defini on

School refusal is a child-mo vated refusal to a end school on a regular basis or has
problems staying in school. It is a clinical feature or symptom that can be
associated with several other diagnoses, for example, generalized anxiety
disorder, specific phobia, major depression, post-trauma c stress disorder.

Signs and Symptoms

Ÿ Problem with school a endance: excessive school absences or par al day

a endance (frequently leaving class, may spend me in guidance, nurse,
etc., leaving school early or entering school late.
Ÿ Waking up with soma c symptoms: a headache, stomachache, sore throat,
nausea, diarrhea, vomi ng or rapid heart beat.
Ÿ Common behaviors: Lying, crying spells, temper tantrums.
Ÿ These problems quickly fade if the child is allowed to stay home.

Screening and Assessment

Ÿ Physical assessment (using Head-to-Toe Approach). (See Figure 4)

Ÿ Conduct a mental health screening and clinical assessment:
History taking. (See Figure 5)
Basic laboratory tests.
Mental State Examina on (MSE). (See Table 1)
Ÿ Screening tools can be used:
Strengths and Difficul es Ques onnaire (SDQ). (Annex 8)
School screening report. (Annex 9)
SNAP-IV Teacher and Parent Ra ng Scale. (Annex 10)
Ÿ WHO-(mhGAP) psychiatric assessment for a child and adolescent. (Table 24)

102
Management Guidelines

Ÿ Complete Strengths and Difficul es Ques onnaire (SDQ).

Ÿ Refer to a regional psychiatrist for further assessment and diagnosis.
Ÿ A ach the screening tool and report's result with the referral.

Clinical Management Flowchart for School Refusal

Child presented with frequent refusal and

extreme reluctance to a end school

Take detailed history about

Think: can be variety of fears the condi on and its effects
(separa on, social anxiety, test on daily life and academic
anxiety) achievements
Feel: worry, tension, increased Ask about bullying or abuse
heart rate, shaking, swea ng at school or change of
Do: frequent absence, tardiness, school or teacher recently
tears, tantrums, soma c
complaints, visits to school nurse
Child abuse not suspected

Screen current symptoms

using following tools:
Strengths and Difficul es
Ques onnaire (SDQ) one to
be filled by parents and one
by teacher
School screening report by
Child abuse suspected teacher

Follow child abuse

management guideline

Refer the child to regional

psychiatrists for further
assessment and diagnosis
A ach the result of above
ques onnaires

103
 Selec ve Mu sm F94.0

Defini on
Selec ve Mu sm (SM) is a childhood anxiety disorder in which a child who is
normally capable of speech cannot speak in specific situa ons or to specific
people. Selec ve Mu sm usually co-exists with shyness or social anxiety. Children
with Selec ve Mu sm stay silent even when the consequences of their silence
include shame, or punishment.

Signs and Symptoms

Ÿ Failure to speak in specific social situa ons (in which there is an expecta on
for speaking, e.g., at school) despite speaking in other situa ons.
Ÿ The disturbance interferes with educa onal or occupa onal achievement
or with social communica on (The dura on of the disturbance is at least
1 month).
Ÿ Shyness.
Ÿ Difficulty maintaining eye contact.
Ÿ Blank expression and reluctance to smile.
Ÿ S ff and awkward movements.
Ÿ Difficulty expressing feelings, even to family members.
Ÿ A tendency to worry more than most people of the same age.
Ÿ A desire for rou ne and dislike of changes.
Ÿ Sensi vity to noise and crowd.
Ÿ Moodiness.
Ÿ Sleep problems.

Screening and Assessment

Ÿ Physical assessment (using Head-to-Toe Approach). (See Figure 4)

Ÿ Conduct a mental health screening and clinical assessment:
History taking. (See Figure 5)
Basic laboratory tests.
Mental State Examina on (MSE). (See Table 1)

104
 Ÿ Screening tools can be used:
Strengths and Difficul es Ques onnaire (SDQ). (Annex 8)
School screening report. (Annex 9)
SNAP-IV Teacher and Parent Ra ng Scale. (Annex 10)
Ÿ WHO-(mhGAP) psychiatric assessment for a child and adolescent. (Table 24)

Management Guidelines

Ÿ Complete the strengths and difficul es ques onnaire (SDQ).

Ÿ Consult regional psychiatrist/ may refer to psychologist.
Ÿ Psychotherapy indicated e.g. Cogni ve Behavioral Therapy (CBT)
Ÿ Medica ons: Anxioly cs in few cases.

Clinical Management Flowchart for Suspected Selec ve Mu sm

Child presented with inability to speak in

certain situa ons [school] despite ability
to speak in other se ngs [home]

Take detailed history include:

Child's developmental and family history,
behavioral characteris cs, medical history
View a video or voice record of the child
speaking well in another situa on. [if possible]
Physical examina on including hearing,
developmental and psychological assessment

Screen current symptoms using following

tools:
Strengths and Difficul es Ques onnaire
(SDQ) one to be field by parents and one
by teacher
School screening report by teacher

Refer the child to nearest psychologist or

consult regional psychiatrist for further
interven ons
A ach the result of above ques onnaires

105
 Psychiatric Emergencies

Defini on

A psychiatric emergency is a condi on wherein the pa ent has disturbances of

thought, affect and psychomotor ac vity leading to a threat to his existence
(suicide), or threat to the people in the environment [homicide].
This condi on needs immediate interven on: to safeguard the life of the pa ent,
bring down the anxiety of the family members and enhance emo onal security to
others in the environment.

Psychiatric emergencies include the following condi ons:

Ÿ Suicidal a empt or homicidal tendencies [considered to be one of the
commonest emergencies].
Ÿ Aggressive Behavior, violence, and excitement. [Agitated behavior].
Ÿ Panic a acks.
Ÿ Drug or alcohol overdose.
Ÿ Alcohol Withdrawal Delirium (AWD) is the most serious form of alcohol
withdrawal. It causes sudden and severe problems in the brain and nervous
system. Also known as delirium tremens (DTs).
In this chapter, we will discuss briefly the following condi ons:
1. Suicidal a empt.
2. Agita on and Restlessness.
3. Extrapyramidal side effects [ EPS].
4. Mental Health Emergency crisis [MHEC].

106
 Suicidal A empt T14.91

Defini on
A suicidal a empt is defined as self-harm in inten on to kill self. While para-suicide
refers to an act of self-harm without the realis c expecta on of death
(Unsuccessful suicide). It is some mes difficult to dis nguish between the two and
para-suicide can lead to death some mes.

Screening and Assessment

The following are considered as risk factors for suicide which need to be
considered when assessing the suicidal risk:

Demographic Male, widowed, divorced, increase with age.

Being diagnosed with mental illness,
Illnesses
presence medical comorbidi es.
Social Absence of social support, family history of suicide.
Presence of previous suicidal a empt, impulsivity
Behavioral problems
and aggression.
Trauma Presence of trauma, sexual/physical abuse.
Table 25. Risk factors for suicide.

Suicide Risk Assessment

Assess if the person Is there evidence of self-injury and/or signs/
has a empted a symptoms requiring urgent medical treatment?
medically serious act Signs of poisoning or intoxica on
of self-harm Bleeding from self-inflicted wound
Loss of consciousness
Extreme lethargy
Assess for imminent Has the person had ANY of the following?
risk of self- Current thoughts or plan of self-harm/suicide
harm/suicide Pa ent had wri en suicidal note
History of thoughts or plan of self-harm in the
past month or act of self-harm in the past year
in a person who is now extremely agitated,
violent, distressed or lacks communica on

107
 Assess for any of the Does the person have concurrent MNS
priority mental condi ons?
condi ons Depression
Disorders due to substance use
Child & adolescent mental and behavioral
disorders
Psychoses
Epilepsy
Assess for chronic pain Does the person have chronic pain?
Assess for severity of Does the person have emo onal symptoms
emo onal symptoms severe enough to warrant clinical management?
Difficulty carrying out usual work, school,
domes c or social ac vi es
Repeated self-medica on for emo onal
distress, or unexplained physical symptoms
Marked distress or repeated help-seeking
Table 26. Suicide risk assessment as prescribed in WHO mhGAP interven on Guide⁶

Screening

The modified SAD PERSONS Scale is a very easily administered screening tool to
assess suicidal risk.²¹ (Annex 12). A simple reference table for the suicidal risk level:

High Risk Presence of specific suicide plan

Access to lethal method
Poor social support
Previous suicidal a empt
Low Risk No access to lethal method
No clear plan
Having good social support
Table 27. Suicide risk level

Management Guidelines

Ÿ Pa ent with a high suicidal risk should be hospitalized immediately.

Ÿ The family should be informed of the decision and the risk to proceed with
hospitaliza on.

108
 Ÿ The pa ent should not be le alone while he or she is transferred to a more
secure environment.
Ÿ If the pa ent is presented a er a emp ng a suicide, then this pa ent needs
to be stabilized medically and then be referred for admission in a mental
hospital.

Clinical Management Flowchart for Suicidal Ideas and Thoughts

Pa ent presented with suicidal ideas and thoughts

Figure 10. SAD PERSONS score²¹

Meaning Ini ate assessment by GP:

S Sex:Male 1 History taken
A Age:<19 or >45 1 Physical examina on
D Depression or hopelessness 1 Screening for suicidal risk
Points Assigned

P Previous a empts or psychiatric care 1 using (SAD PERSONS scale)

E Excessive alcohol or drug use 1 Mental State Examina on
R Ra onal thinking loss 1
S Separated/divorced/widowed 1
(MSE)
O Organized or serious a empt 1 Assess risk of harm to self or
N No social support 1 others
S Stated future intent 1 Co-morbid substance use
Score > 6:high suicide risk, need psychiatry directed hospitaliza on

High suicidal risk with clear Low suicidal risk with no clear
plan and intent plan or intent

Emergency case: Not urgent:

Maintain suicide precau ons: pa ent Can be managed as outpa ent.
safety by one to one observa on Refer to regional psychiatrist for
un l referral and admission are further assessment and
arranged management

Disclose the suicidal risk to

pa ent's family

Admission indicated for further

management of any mental problems

109
 Agita on Behavior and Restlessness

Defini on

Restlessness is also known as terminal agita on. Agita on can be described as

“excessive verbal and/or motor behavior” in addi on to feelings of anxiety.
Agita on is an acute behavioral emergency. It is best to intervene as early as
possible before symptoms progress. Agitated pa ents can be categorized into the
following:
Ÿ Mild: Agitated but co-opera ve.
Ÿ Moderate: Disrup ve without danger.
Ÿ Severe: Dangerous to self and/or others. Capable of causing property
damage.
Signs and Symptoms

Ÿ Involuntary behaviors such as hand-wringing and pacing.

Ÿ Excessive talking.
Ÿ Tension, excitement, or hos lity.
Ÿ Poor impulse control.
Ÿ Poten al to harm self, others, or property.
Restlessness and agita on can be a presenta on of different mental and medical
condi ons. The best treatment is the treatment of the cause.

Management Guidelines
Ÿ Ensure that the safety and dignity of pa ents and the safety of staff in the
se ng are priori es when an cipa ng or managing violence and
aggressive pa ent.
Ÿ Use de-escala on techniques (including verbal and non-verbal
communica on skills) showing in (Table 28).
Ÿ Breakaway techniques can be applied in such situa ons. However, only
those who have been trained in these techniques should use them.(Annex 13)
Ÿ Staff should remove themselves from the situa on and, if there is an
immediate risk to life, contact the police.

110
 De-escala on Techniques
1. Do not be alone with the pa ent.
2. Talk slowly with caring tone of voice with clear language.
3. Remain calm and be confident.
4. Use nonthreatening body language (avoid poin ng.)
5. Avoid being nervous.
6. Avoid shou ng or sudden movement.
7. Keep a distance between you and the pa ent.
8. Reduce distrac ons.
9. Do not challenge psycho c thinking.
10.Don't argue with the pa ent or threaten.
11.Avoid intensive ques oning to the pa ent.
12.Paraphrase the pa ent concerns.
13.Remove any sharp objects from the interview place and anything that
can be harmful if used to a ack.
14.Ask the pa ent how you can help, offer medica on to feel be er.
Table 28. De-escala on Techniques

Medica ons doses that are used as rapid tranquilizers (Calming medica ons)
A combina on of Haloperidol 5 mg /ml IM STAT and Promethazine 25 mg/ml
IM STAT can be repeated a er 30-60 minutes if needed.
A combina on of Haloperidol 5 mg /ml IM STAT and Diazepam 5 mg/ml IM
STAT can be repeated a er 30- 60 minutes if needed.
IM Midazolam 5 mg/ml, 3 ml injec on can be repeated a er 45- 60 minutes
if needed.
Elderly medica ons doses that are used as rapid tranquilizers:
A combina on of Haloperidol 1m IM STAT and Promethazine 12.5 mg IM
STAT can be repeated a er 1-2 hours (max dose of haloperidol 3 mg /24hrs
and max dose of Promethazine 25 mg/24 hrs).
DO NOT USE Diazepam OR Midazolam for elderly.

111
 Clinical Management Flowchart for Agitated Behavior
Pa ent presented with agitated behavior /violent Behavioral Cues for
aggression
Verbal Cues:
Try De-escala on techniques techniques What is being said
Do not be alone with the pa ent How it is being said
Talk slowly with caring tone of voice with clear (volume, speed,
language silence)
Remain calm and be confident Physical behavioral
Use nonthreatening body language (avoid poin ng) cues
Avoid being nervous Pacing back and forth
Avoid shou ng or sudden movement Fidge ng: hyperac ve
Keep a distance between you and the pa ent or nervous?
Reduce distrac ons Name calling
Do not challenge psycho c thinking Cursing
Don't arguing with the pa ent or threatening Posture
Avoid intensive ques oning to the pa ent
Paraphrase the pa ent concerns
Remove any sharp or harmful objects from the
interview place
Ask the pa ent how you can help, offer medica on De-escala on failed
to feel be er move to step.1

Step.1
Offer oral medica on to
calm the pa ent, if no Step.2
response, go to step.2 Offer IM medica on to
help the pa ent calm if Step.3
If agreed no response, go to Maintain your safety
step.3 never be alone with
A combina on of Haloperidol the pa ent
5 mg oral & promethazine If agreed Call police if needed
25 mg oral
Or a combina on of Haloperidol A combina on of Haloperidol 5 mg/ml IM
5 mg oral & Diazepam 5 mg oral STAT & promethazine 25 mg/ml IM STAT
[repeated a er 30-60 minutes]
Consider elderly medica ons Or a combina on of Haloperidol 5 mg /ml
doses: IM STAT and Diazepam 5 mg/ml IM STAT
A combina on of Haloperidol 1m [repeated a er 30-60 minute]
IM STAT and Promethazine 12.5 mg Or Midazolam 5 mg/ml, 3 ml injec on
IM STAT can be repeated a er 1-2 [repeated a er 45-60 minutes] if needed
hours [max dose of haloperidol 3 Medica on should never be mixed in the
mg /24hrs and max dose of same syringe
Promethazine 25 mg/24hrs]
DO NOT USE Diazepam OR Refer to psychiatrist
Midazolam a er stabiliza on

112
 Extrapyramidal Symptoms (EPS)

Defini on:
Extrapyramidal symptoms (EPS) term, also known as extrapyramidal side effects
(EPSE), refers to the neurological adverse effects of an psycho c medica ons. It is
common a er haloperidol and risperidone which are commonly used medica ons
in primary care ins tu ons. Some pa ents are more at risk to develop EPS, for
example, geriatric, pediatric and mentally disabled pa ents.

Signs and Symptoms

Symptoms may be no ced a er taking one dose of an psycho c medicine or a er

long-term use. These are the most common EPS and how they can present. (Figure 11)

Acute dystonia Muscle spasms of the face, tongue, neck,

and back
Facial grimacing
Abnormal or involuntary upward eye
movement
Laryngeal spasms that can impaired
respira on
Akinesia Decreased movements
(parkinsonian- Stooped posture
like) Tremor at rest
Rigidity inflexibility of the muscles
Pill-rolling movements of the hand
Akathisia Increased movements
Restlessness
Rocking mo ons while si ng
Constantly crossing and uncrossing legs
Pacing the floor
Tardive Jaw clenching
dyskinesia Rapid eye blinking
Rolling tongue, s cking out tongue
Lips smacking
Drooping of the mouth or eyes
Rapid body movement in the arms, legs
and trunk
Figure 11. Extrapyramidal Side Effects (EPSE)²²

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 Important note:
There is one rare extra pyramidal side effect of an psycho cs which is
Neurolep c Malignant Syndrome (NMS), the only serious and life threatening
condi on. It presents with vital instability (fluctua on in BP, tachypnea,
tachycardia, excessive saliva on, excessive swea ng, flushing, skin pallor,
incon nence, fever rigidity, altered mental status (drowsiness, agita on,
confusion, coma) and lab inves ga ons are showing high crea ne kinase (CK)
and leukocytosis. Thus it is considered a medical emergency. GP should be aware
of the ini al steps and its management.

Management Guidelines

Management of Extrapyramidal Side Effects (EPS)

Acute dystonia Akinesia Akathisia Tardive
(parkinso dyskinesia
nian-like)
Acute means early Occurs Occurs 5 - 60 days
Tardive means
Dura on

Occurs 1 - 5 days a er 1 - 4 weeks a er drug late Occurs

drug ini a on a er drug ini a on months to
ini a on years a er
drug ini a on
Most common Refer to Can be managed Refer to
Give oral procyclidine regional by star ng regional
5 mg if the pa ent can psychiatrist propranolol 10 mg psychiatrist
take orally BID
If not able to take Refer to regional
orally give 10 mg psychiatrist for
Management

procyclidine as IM possible dose

injec on For elderly doses:
For elderly doses: Propranolol 10 mg
Give oral procyclidine OD can be used
2.5 mg if the pa ent cau on in elderly.
can take orally. If not If no
able to take orally give improvement,
2.5 mg procyclidine IM refer to geriatric
injec on specialized unit or
geriatric
psychiatrist
Table 29. Management of Common Extrapyramidal Side Effect (EPS)

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If neurolep c malignant syndrome (NMS) is highly suspected, consider
suppor ve management:
Connect pa ent to monitor.
Insert 2 large burrs cannula.
Start IV fluid rehydra on the pa ent.
Start medica ons to reduce fever.
If pa ent is agitated, consider benzodiazepine.
Shi the pa ent to nearest medical unit with ICU se ng.

Clinical Management Flowchart for

Suspected Extrapyramidal Symptoms (EPS)

Pa ent is on an -psycho c medica ons presented with:

Facial grimacing
Up-rolling of the eyes
Muscle spasm of the face and neck

Take detailed history about

diagnosis, medica on being
used, when it is started and
recent change in doses
Inves ga on is required
Physical Examina on (vital signs)

Most likely diagnosis acute dystonia

Give pa ent oral procyclidine 5 mg if the

pa ent can take orally
If not able to take orally give 10 mg
procyclidine as IM injec on
For elderly doses: Give pa ent oral
procyclidine 2.5 mg if the pa ent can take
orally If not able to take orally give 2.5 mg
procyclidine IM injec on

Refer to regional psychiatrist as

rou ne case
Involve psychiatrist especially for
dose adjustment or long term
therapy with procycliidine is
required

115
 Mental health Emergency crisis (MHEC)

Definition
Mental illnesses are medical condi ons that disrupt a person's thinking, feeling,
mood, daily func oning and ability to relate to others.
A mental health crisis is any situa on in which a person's behavior puts them at
risk of hur ng themselves or others and/or prevents them from being able to care
for themselves or func on effec vely in the community.
Many things can lead to a mental health crisis. For example, health emergencies
(epidemic/pandemic disease outbreak resul ng in lockdown status), economic
crisis (there are sudden changes related to financial status, which could lead to
losing a job, nega ve impact on social and occupa onal status), losing a beloved
family member and/or a friend, na onal disasters (storms, floods), war …etc.
Such unpredictable event or an unforeseeable consequence of some event,
affects people well-being, psychologically and financially.
Regardless of the diagnosis, symptoms can be similar and can overlap, especially in
mes of crisis.

Warning Signs/symptoms of a Mental Health Emergency Crisis (MHEC):

Warning Signs and Symptoms

Social Si ng and doing nothing for long periods and losing friends.
withdrawal Unusual self-centeredness and self-absorp on.
Dropping out of previously enjoyed ac vi es.
Declining academic, work or athle c performance.
Irregular Hos lity from one who is usually pleasant and friendly.
expression Indifference to situa ons, even highly important ones.
of feelings Inability to express joy.
Laughter at inappropriate mes or for no apparent reason.

116
 Mood Deep sadness unrelated to recent events or circumstances.
Disturbance Depression las ng longer than two weeks.
Loss of interest in ac vi es once enjoyed.
Expressions of hopelessness.
Excessive fa gue, or an inability to fall asleep.
Pessimism; perceiving the world as grey or lifeless.
Thinking or talking about suicide.
Changes in Hyperac vity, inac vity, or alterna ng between the two.
Behavior Lack of personal hygiene.
No ceable and rapid weight loss or gain.
Involvement in automobile accidents.
Drug and alcohol abuse.
Forge ulness and loss of personal possessions.
Moving out of home to live on the street.
Not sleeping for several nights in a row bizarre behavior,
e.g. skipping, staring, strange posturing, and grimacing.
Unusual sensi vity to noises, light, clothing.
Thought Inability to concentrate.
Disturbances Inability to cope with minor problems.
Irra onal statements.
Use of peculiar words or language structure.
Excessive fears or suspiciousness, paranoia.
Table 30. Warning signs & symptoms of Mental Health Emergency Crisis (MHEC)

Any emergency crises can lead to increase stress and emergence of mental
health condi ons/illnesses mainly:
Anxiety disorder / Depression disorder
Bipolar disorder/ Post-trauma c stress disorder (PTSD)
Obsessive convulsion disorder (OCD)
Panic disorder/ Phobia disorder
Increase suicide rate
Burn-out syndrome

Therefore, the Mental Health Emergency crisis (MHEC), seeks to minimize the
damage a crisis causes, before, during and a er a crisis.

117
 Techniques that May Help De-escalate a Crisis

Pa ent presented with fear symptoms /or sadness during a crisis

Take detailed history

Assess exact concerns of pa ent
Assess impairment on daily
func ons (sleep, appe te,
academic, social, occupa onal)

Func on is not impaired Func on impaired

Apply the following: Make referral to regional

1. Feeling anxious and stressed during psychiatrist for assessment
Mental Health Emergency Crises (MHEC),
is normal and is expected Make sure to men on in
2. Sense of losing control over once life is referral the concerned
expected as well and effect on func ons
3. Use healthy coping strategies to reduce
anxiety and stress
Un l appointment is
4. Stay informed … not overloaded
arranged, provide pa ent
(Trusted source of informa on from MOH)
with psycho-educa on
5. Take care of your own health:
skills
Live in a healthy environment
Follow recommended precau onary
measures
Follow healthy life-style
6. Manage your own stress: Note:
Accept it has to happen and to cope Health care providers need
with it to be aware of:
Keep social contact with family and Their own mental health
friends condi on.
Take care of your loved ones Use same coping
7. Keep yourself busy: Drawing, reading, strategies.
movies & play games Ask for help by
8. Prac ce medita on and relaxa on a psychiatrist help if
techniques needed.
9. Ask for help when stressed:
Contact your friends and family
Take psychiatrist consulta ons if needed
Do exercise

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 Neuro-Cogni ve Disorder

Defini on
It was formerly called Organic Mental Syndromes. It involves problems in memory,
orienta on, level of consciousness, and other cogni ve func ons. Pa ents with
cogni ve disorders may show psychiatric symptoms (e.g. depression, anxiety,
paranoia, hallucina ons, and delusions).
The major cogni ve disorders are demen a, delirium and amnes c disorder. In
this chapter, we will briefly discuss demen a.

Defini on of Demen a:
Demen a presents with deteriora on in mental abili es which
interfere with the ac vity of daily living: dressing, bathing, ea ng, and
orienta on. Consciousness is not affected. Some mes the impairment
affects emo onal control, social behavior and judgment.
There are different types of demen a. The most common one is the one discussed
below which is demen a of Alzheimer's disease. The second most common type of
demen a that is explained briefly below is vascular demen a.

Demen a in Alzheimer's disease F00

It is usually gradual in onset and develops slowly but steadily over a period of years.
This period can be as short as 2-3 years or longer. There is no sudden neurological
deficit before the onset of memory impairment. Lab inves ga ons are done to
exclude reversible causes of demen a.

Vascular Demen a F01

Vascular demen a, on the other hand, shows sudden onset and presence of
neurological deficit. There might be a history of transient ischemic a acks before
the onset of memory impairment. Lab inves ga ons are nega ve for reversible
causes of demen a.

119
Screening, Assessment and Diagnosis of Demen a in Alzheimer Disease

Demen a is a clinical diagnosis. In order to diagnose demen a properly the

following should be done:
Demen a History Taking:
Ÿ Presen ng Complaint
Ÿ Confusion/ memory Loss.
Ÿ History of Presen ng Complaint
Ÿ Onset: acute/chronic/acute-on-chronic.
Ÿ Progression: slowly progressive (Alzheimer's), step-like (Vascular).
Ÿ Triggers: Infec on, Stress.
Ÿ Associated symptoms:
Ÿ Depression.
Ÿ Psychiatric symptoms: hallucina ons/Delusions.
Ÿ Behavioral change: agita on, aggression, wandering, disinhibi on,
calling out.
Ÿ Sleeping pa ern: awake at night (Alzheimer's), early morning.
waking (depression), fluctua ng consciousness (delirium).
Ÿ Cogni ve disturbances: aphasia, difficulty planning/organizing.
Ÿ Past Medical History
Ÿ Ask about: Parkinson's, vascular disease/ diabetes, head injury,
infec on.
Ÿ Psychiatric history.
Ÿ Drug History (all medica ons the pa ent is taking).
Ÿ Family History
Ÿ Related condi ons e.g. demen a, vascular disease, depression.
Ÿ Social History
Ÿ Living situa on, careers, home support.
Ÿ Who performs their daily tasks (if the pa ent does them, how well?).
Ÿ Washing.
Ÿ Dressing.
Ÿ Cooking.
Ÿ Cleaning.
Ÿ Shopping.

120
 Ÿ Work/ drive.
Ÿ Smoking , alcohol , other cardiovascular risk factors.
Ÿ RISK:
Ÿ To self: wandering, leaving gas on, abuse, neglect by self or others.
Ÿ To others: aggression, risky behavior.
Table 31. Demen a history taking ²³

WHO-(mhGAP) psychiatric assessment for demen a can be used shown in (Table 32):
Assess for signs of Ask the person, and someone who knows
demen a them well, about problems with memory,
orienta on and language
(e.g. forge ng what happened the previous day
or not knowing where he or she is).
Conduct a general neurological assessment,
u lizing culturally adapted tools if available.
See Essen al Care & Prac ce (ECP).
Ask when the problems began and if they
have been ge ng worse over me.
Does the person have difficul es in
performing key roles/ac vi es?
(e.g. with daily ac vi es such as shopping,
paying bills, cooking, etc.).
Assess for other Have the symptoms been present and slowly
explana ons for the progressing for at least 6 months?
symptoms? Does the person have depression?

Evaluate for other Does the person have ANY of the following?
physical condi ons Under age 60 prior to symptom onset.
Onset of symptoms associated with head
injury, stroke, or altered or loss of
consciousness.
Clinical history of goiter, slow pulse, dry skin
(hypothyroidism).
History of sexually transmi ed infec on
(STI), including HIV/AID.

121
 Assess for behavioral Does the person have ANY of the following
or psychological symptoms?
symptom Behavioral symptoms:
Wandering.
Night- me disturbance.
Agita on.
Aggression.
Psychological symptoms:
Hallucina ons.
Delusions.
Anxiety.
Uncontrollable emo onal outbursts.
Assess for concurrent A person may have more than one mental
mental condi ons condi on at the same me.
Assess for concurrent mental condi ons).
Pay special a en on to:
Risk of self-harm/suicide and.
Signs and symptoms of disorders due to
substance use.
! IF THERE IS IMMINENT RISK OF SUICIDE,
ASSESS AND MANAGE BEFORE CONTINUING.
Go to »Suicide Chapter .
Evaluate for other Determine:
physical condi ons Who are the main caregivers?
Who else provides care and what care do
they provide?
What is difficult to manage?
Is the caregiver having difficulty coping or
experiencing strain?

» Explore psychosocial interven ons ...

for respite care, ac va on of community
support network, family/individual therapy.
Table 32. Assessment for demen a (WHO mhGAP)⁶

Ÿ A Mini-Mental State Examina on (MMSE) is a set of ques ons that

doctors and other healthcare professionals commonly use:
Ÿ To check for cogni ve impairment (problems with thinking,
communica on, understanding and memory).
Ÿ It is also some mes used as part of the process for determining if
someone has demen a. (Annex 14)

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 Ÿ Inves ga on for suspected demen a:
CBC.
Biochemistry (electrolytes profile, glucose, LFT, RFT).
Thyroid Func on Tests.
Vitamin B12 and folate levels.
Order urine test if delirium is suspected.
ECG.
CT or MRI if early onset or rapidly deteriora on or neurological deficit.
Syphilis serology and HIV only done if there are risk factors.
As summery for diagnosis of Alzheimer type demen a:
Presence of demen a as described above.
Absence of clinical evidence, or findings from special inves ga ons, to
suggest that the mental state may be due to other systemic or brain
disease which can induce a demen a (e.g. hypothyroidism, vitamin B12
deficiency, or subdural hematoma).
Absence of a sudden neurological deficit.

Management Guidelines

Refer all demen a pa ents to specialized unit for proper assessment and
management DO NOT MANAGE AT LOCAL HEALTH CENTER BEFORE
ASSESSMENT BY GERIATRIC PSYCHIATRIST AND/OR GERIATRIC UNIT.
Management in demen a is symptoma c. There is no cure for demen a,
(however, there are available medica ons: Cholinesterase inhibitors,
prescribed by specialized geriatric and geriatric unit which may improve
cogni on and delay deteriora on) ensuring a good quality of life and
delaying the progression in memory decline is important.

Non- Caregiver
Ÿ Caregiver education
educa on aboutabout theand
the illness illness and
burden of
Non-
Pharmacological burden of care.
care.
Pharmacological
Management Doingdaily
Ÿ Doing daily
rouroutine for the
ne for the patient
pa ent with with simple
simple
Management
acactivity.
vity.

123
 Pharmacological Cholinesterase inhibitors, prescribed by specialized
anagement geriatric and geriatric unit which may improve
cogni on and delay deteriora on).
AVOID use of an psycho cs in demen a pa ents
as it may cause sudden death or CVA as stated by
the Food and Drug Administra on (FDA black box
warnings).²⁴
Refer to specialized geriatric unit for assessment
and for possible cau on use.
Table 33. Management guidelines for suspected demen a.

Tips for managing common problems/ behavior problems in pa ents with

demen a
Although changes in behavior can be difficult to deal with, it can help to work out if
there are any triggers. Table 34 describes the ps of managing common demen a
behaviors.

Aggression Target the cause for aggression.

Pain and environmental stressors can be triggers.
Use of short term medica ons only if necessary.
Atypical an psycho c.
Wandering Medica on are not of great help in such a problem.
Target the cause for the behavior.
Pain and environmental stressors can be triggers.
Presence of depression or psycho c symptoms can be the
cause for wondering.
Aromatherapy could help.
Making sure that the pa ent is safe and cannot go out alone.
Psychosis AVOID use of an psycho cs in demen a pa ents as it may
cause sudden death or CVA (FDA black box warnings).²⁰
Refer to specialized geriatric unit for assessment and for
possible cau on use.
Table 34. Tips for managing common demen a behaviors

124
 Clinical Management Flowchart for Suspected Demen a

Pa ent presented with memory

concern [cogni ve impairment]

Ini ate assessment by General Physician

(GP):
History taken (self-report/collateral
history)
Physical examina on
Mini Mental State Examina on (MMSE)
Assess behavioral and psychological
symptoms like (aggression, agita on,
hallucina on, anxiety, depression)
Co-morbid medical or mental illness

Refer to nearest medical unit

[to rule out any neurological
deficit, reversible causes for
cogni ve impairment]

No reversible causes found

No neurological deficit
Refer to geriatric psychiatrist or geriatric
unit at Al Massara Hospital [currently, the
only center available for geriatric and
demen a]

125
 Somatoform Disorder F45

Defini on
Somatoform disorders are mental illness characterized by a history of complaints
about physical symptoms, affec ng many different areas of the body, for which
medical a en on has been sought but no physical cause is found. The symptoms
are severe enough to interfere with the pa ent's ability to func on in social or
occupa onal ac vi es.

Signs and Symptoms

Ÿ Pain related to different sites or func ons:

Ÿ Head
Ÿ Abdomen
Ÿ Back
Ÿ Limbs
Ÿ Chest
Ÿ During menstrua on
Ÿ During urina on or intercourse.
Ÿ GIT symptoms [nausea, bloa ng, vomi ng, diarrhea]
Ÿ Sexual symptoms [erec le dysfunc on, ejaculatory problems, irregular
menses]

Screening and Assessment

To determine a diagnosis, General Physicians (GP) should do the following:

Ÿ Perform physical assessment (using Head-to-Toe Approach). (See Figure 4)
Ÿ Conduct a mental health screening and clinical assessment:
Ÿ History taking. (See Figure 5)
Ÿ Observa on.
Ÿ Mental State Examina on (MSE). (See Table 1)
Ÿ Ask the pa ent about alcohol, drug or other substance use.
Ÿ Over-evalua on and unnecessary tes ng should be avoided.

126
General Physicians (GP) may also refer the pa ent to a mental health professional,
who may:
Conduct a psychological evalua on to talk about the symptoms, fears or concerns,
stressful situa ons, rela onship problems, situa ons that the pa ent may be
avoiding, and family history.

Differen al Diagnosis

Ÿ Depressive disorder
Ÿ Generalized Anxiety Disorder
Ÿ Drug abuse
Ÿ Other somatoform disorder (conversion disorder or hypochondriasis).

Management Guidelines

Ÿ Avoid unnecessary inves ga on.

Ÿ Regular short visit by same doctor (GP or FAMCO doctor).
Ÿ Reassure the pa ent with psychoeduca on.
Ÿ Treat underlying causes especially psychiatric.

Medica on:
Ÿ If there is depression and anxiety, start with SSRIs medica on for example
fluoxe ne 20 mg OD for 4-6 weeks and anxioly c for short period if
indicated, then gradually stopped. [Geriatric doses were described specifically in
depression chapter- “Table 6 in Page 32”].
Ÿ Refer the pa ent to a psychiatrist if there is poor response to treatment.

127
Clinical Management Flowchart for Suspected Soma za on Disorder

Pa ents presen ng with mul ple soma c symptoms

Perform physical examina on and

assessment:
History taking
Observa on
Mental State Examina on MSE

Psychosocial support, psychoeduca on

for the pa ent and family
Avoid medica on
Avoid unnecessary inves ga on from
the start
Follow up by single doctor only

If there is depression and anxiety,

start with SSRIs for 4-6-weeks -and
anxioly c for short period if
indicated, then gradually stopped

No

Refer to regional psychiatrist

128
 Ea ng Disorder: Anorexia Nervosa F50.0

Defini on
1. Restric on of energy intake rela ve to requirements leading to significantly
low body weight in the context of age, sex, developmental trajectory, and
physical health.
2. Intense fear of gaining weight or becoming fat, even though underweight.
Disturbances in the way in which one's body weight or shape is experienced, or
denial of the seriousness of the current low body weight.
It is two types which are:
Ÿ Restric ng type (F50.01): during the last 3 months, the individual has not
engaged in recurrent episodes of being ea ng or purging
behavior [i.e. self-induced vomi ng or the misuse of laxa ves,
diure cs or enemas] presenta on of weight loss is through
fas ng, die ng and/or excessive exercise.
Ÿ Binge-ea ng/purging type (F50.02): during the last 3 months, the individual
has engaged in recurrent episodes of binge ea ng or purging behavior.

The severity can be divided according to the Body mass index (BMI) to:
Ÿ Mild: BMI >17 kg/m2
Ÿ Moderate: BMI 16 – 16.99 kg/m2
Ÿ Severe: BMI 15 – 15.99 kg/m2
Ÿ Extreme: <15 kg/m2

Signs and Symptoms

Ÿ Psychological symptoms: Disturbed body image [body-image as

overweight although low body weight, low concentra on, poor decision-
making, irritability, depressed mood, low self-esteem, loss of appe te,
reduced energy level, poor sleep, social withdrawal, obsessive about food].
Ÿ Cardiovascular System (CVS): Heart rate and BP drop, heart failure,
irregular heart rate, death (low potassium due to repeated vomi ng or
excess water intake).

129
 Ÿ Gastrointes nal (GI): Swollen paro d salivary gland (repeated vomi ng),
Intes nal obstruc on, infec on and perfora on.
Ÿ Central Nervous System (CNS): Numbness of extremi es, Fain ng,
Dizziness, seizures, Muscle camps, peripheral neuropathy.
Ÿ Endocrine: Irregular menses, amenorrhea, osteoporosis, DM type2, high
cholesterol (starva on).
Others:
Ÿ Amenorrhea
Ÿ Anemia
Ÿ Kidney failure
Ÿ Dry skin
Ÿ Hair loss and bri le hair

Screening, Assessment and Diagnosis

The SCOFF Ques onnaire (The SCOFF Ques onnaire)²⁵

is screening tool that can S . Do you make yourself Sick because you feel
uncomfortably full?
be used by General C . Do you worry you have lost Control over how
Physicians (GP) to iden fy much you eat?
people who may be at risk O . Have you recently lost more than One stone
(6.35 kg) in a three-month period?
or have an ea ng disorder
F . Do you believe yourself to be Fat when others
as shown in (Figure 12). say you are too thin?
F . Would you say Food dominates your life?
Figure 12. SCOFF ques onnaire

Moreover, GPs can screen the pa ent through:

Ÿ Asking ques ons focused on the par cular person.
Ÿ Proper history taking.
Ÿ Assessment of quan es and frequency of ea ng.
Ÿ Reasons for avoiding food (self-image).
Ÿ History of binging (overea ng episodes).
Ÿ Behaviors to lose weight like purging, excessive exercise and use of laxa ves
or diure cs.
Ÿ Body Mass Index (BMI).
Ÿ Menstrual changes.

130
 Ÿ History of cons pa on or muscle cramps.
Ÿ Lab inves ga ons.

Management Guidelines

Ÿ The cri cal first step in the treatment of anorexia nervosa is re-nutri on
(carefully monitored feeding, o en with the assistance of a medical team)
and weight restora on back to the healthy weight range.
Ÿ Psychotherapy is the main therapy, even if medica ons are
used; it should be combined with psychotherapy.
Ÿ Psychotherapy can be delivered by trained healthcare workers.
Ÿ Cogni ve Behavioral Therapy (CBT): to address distorted views and
a tudes about weight, shape and appearance and prac ce behavioral
modifica on.
Ÿ Insight-oriented individual psychotherapy: this will allow the person to have
a deep understanding of the meanings of food, their body and other factors
that can be a life-long struggle.
Ÿ Interpersonal psychotherapy: focus on improving rela onships and
communica ons, and resolving iden fied problems has been found to
reduce ea ng disorder symptoms.
Ÿ Family-based psychotherapy: family therapy appears to be helpful for
younger pa ents who have recently developed an ea ng disorder.
Ÿ Group therapy where they can find support, and openly discuss their
feelings and concerns with others who share common experiences and
problems.

Medica ons for treatment of Anorexia Nervosa

Medica ons should not be used alone. (It should be combined with psychotherapy
program for ea ng disorders).
Ÿ Fluoxe ne (SSRI) to stabilize recovery and treat comorbid depression.
Ÿ Low dose of Olanzapine (atypical an psycho cs) to treat comorbid
anxiety, increase appe te, reduce obsessive ra ng-related rumina ons and
treatment for resis ve cases.

131
 Severity Psychological Medica ons Other interven ons
/ Referrals
Mild Cogni ve Fluoxe ne Treat any medical
Behavioral (20 – 40 mg OD) complica ons
Therapy (CBT Olanzapine Referral to
Family therapy (2.5 – 10 mg HS psychiatrist or
Interpersonal psychotherapist
psychotherapy
Moderate Treat any medical
complica ons
Referral to
psychiatrist or
psychotherapist
Severe Treat any medical
complica ons.
Referral to
a psychiatrist
Table 35. Management guideline for anorexia nervosa

Clinical Management Flowchart for Suspected Anorexia Nervosa

Use screening ea ng tool

The SCOFF Ques onnaire

Measure BMI

Assessment of medical
complica ons of anorexia
nervosa

Referral to medical
teams if any medical
emergencies

Referral to psychiatrist for

psychotherapy

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 Bulimia Nervosa F50.2

Defini on
Bulimia Nervosa refers to recurrent episodes of binge ea ng. An episode of binge
ea ng is characterized by both of the following:
Ÿ Ea ng in a discrete period of me (e.g. within any 2-hour period), an
amount of food that is larger than what most individuals would eat in a
similar period of me under similar circumstances.
Ÿ A sense of lack of control over ea ng during the episode (e.g. a feeling of
that one cannot stop ea ng or control what or how much one is ea ng).
It is also defined as recurrent inappropriate compensatory behaviors to prevent
weight gain, such as self-induced vomi ng; misuse of laxa ves, diure cs, or other
medica ons; fas ng; or excessive exercises.
Ÿ The binge ea ng and inappropriate compensatory behaviors both occur, on
average, at least once a week for 3 months.
Ÿ Self –evalua on is extremely influenced by body shape and weight.
Severity categories
Ÿ Mild: An average of 1 -3 episodes of inappropriate compensatory behavior
per week.
Ÿ Moderate: An average of 4–7 episodes per week.
Ÿ Severe: An average of 8–13 episodes per week.
Ÿ Extreme: An average of 14 or more episodes per week.
Types
There are two subtypes:
1. The purging type includes those individuals who self-induce vomi ng or use
laxa ves, diure cs, or enemas.
2. The non-purging type refers to those who compensate through excessive
exercising or dietary fas ng.

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Signs and Symptoms

Common signs that a person may have bulimia are when the person:
Ÿ Have frequent weight changes. E.g. the person may gain and lose large
amounts of weight in short periods.
Ÿ Have irregular menstrual cycles.
Ÿ Seems preoccupied with exercise.
Ÿ O en talks about die ng, weight, and body shape.
Ÿ Seems to be overusing laxa ves and diure cs.
Ÿ Have low levels of potassium or other blood electrolyte imbalances.
Ÿ Looks sick or has symptoms such as:
Ÿ Dental caries or erosion of tooth enamel.
Ÿ Sore gums or mouth sores.
Ÿ Dry skin.
Ÿ Loose skin.
Ÿ Thin or dull hair.
Ÿ Swollen salivary glands.
Ÿ Bloa ng or fullness.
Ÿ Lack of energy.
Ÿ Teeth marks on the backs of the hands or calluses on the knuckles from
self-induced vomi ng.
Ÿ Feels depressed, anxious, or guilty.
Ÿ Frequent relapses.

Screening, Assessment and Diagnosis

Ÿ There is no specific screen ques onnaire for Bulimia Nervosa.

Ÿ The useful ques ons in history taking is about diet, binging, ea ng behavior,
guilt feeling about ea ng, behaviors to reduce weight like induced-
vomi ng, excessive exercising.
Ÿ Take BMI and blood inves ga ons to rule out complica ons like anemia
(CBC), electrolytes imbalance (RFT), glucose (RBS), osteopenia (X-ray).
Ÿ Assess pa ent's mental status by asking about depressive and anxiety
symptoms:
Ÿ Conduct Mental State Examina on (MSE). (See Table 1)

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Management Guidelines

Ÿ Do not offer medica ons as the single treatment.

Ÿ Provide psychotherapy and advice by trained healthcare workers.
Ÿ Focused Family Therapy: 18 - 20 sessions over 6 months to support the
family to help the person recover, encourage healthy die ng and stop
compensatory behavior.
Ÿ Ea ng disorder focused Cogni ve Behavioral Therapy (CBT): typically, 18
sessions over 6 months aimed to teach the person to monitor their
thoughts, feelings and behaviors, encouraging the person to gradually
establish regular ea ng habits.
Ÿ Long-term interpersonal psychotherapy.
Ÿ Technology as self-help therapy (such as internet preven on programs,
internet-based CBT).

Medica ons

Ÿ Fluoxe ne dose of 20 - 60 mg once a day for at least one year and

combina on with psychotherapy.
Ÿ TCA's are not recommended as ini al treatment because of the risk of
toxicity and the risk of adverse effects.

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 Sleep Disorders

Sleep disorders are among the most common clinical presenta ons. Sleep
problems can markedly impair the pa ent's quality of life.
Nonorganic Insomnia F51.0 / A.1 Insomnia
Sleep requirements vary from person to person. Insomnia is considered clinically
significant when a pa ent perceives the loss of sleep as a problem

Defini on

Insomnia is a condi on that occurs when a person is unable to get long enough of
refreshing enough sleep at night. It occurs at least 3 days/week for one month.
Sleep problems cause distress and excessive concern to the pa ents as his/her
social or occupa onal func oning gets affected.

Signs and Symptoms

Ÿ A decrease in sleep efficiency or decreased sleep hours [compared to his

lifelong normal night sleep me]. The quality of sleep is more important
than the total number of hours slept.
Ÿ Ini al insomnia: sleep-onset insomnia is difficulty falling asleep, with an
increase of sleep latency which is the me between going to bed and
failing a sleep [frequently related to anxiety].
Ÿ Middle insomnia: sleep-maintenance insomnia, interrupted sleep is
difficulty in maintaining sleep, fragmented unres ul sleep and frequent
waking during the night. This may be associated with pain syndromes,
medical illness or depression.
Ÿ Terminal insomnia: early morning awakening insomnia is when the
pa ent wakes up earlier than needed. This is frequently associated with
major depression.
Ÿ Delayed sleep phase syndrome, is when the pa ent is unable to fall
asleep un l very early morning. The sleep me gets progressively delayed
with me.
Ÿ Altera on of the sleep-wake cycle is associated with work-shi s or jet lag
(results of air travel across mul ple me zones).

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Screening, Assessment and Diagnosis

Ÿ History taken: Ask about other sleep-related problems to rule

out comorbidi es:
Ÿ Sleepwalking [somnambulism].
Ÿ Nightmares in which the pa ent wakes up from sleep caused
by vivid and distressing recall of dreams. Upon awakening
from the dream, the person rapidly re-orients to me and
place.
Ÿ Night terrors are recurrent episodes of abrupt awakening from sleep in
which the pa ent starts being panicky, fearful, starts screaming and
experiences autonomic arousal. Usually, the pa ent cannot recall details
of the event and can be unresponsive during the episode.
Ÿ Perform physical assessment (using Head-to-Toe Approach). (See Figure 4)
Ÿ Conduct a mental health screening and clinical assessment:
Ÿ Basic laboratory tests.
Ÿ Mental State Examina on (MSE). (see Table 1)
Ÿ Can use and keep a sleep-diary [for two weeks to include daily ac vi es, the
pa ern of sleep, meal- me, consump on of caffeine, exercise and day- me
nap].

Management Guidelines

Treatment goals are outlined to:

Ÿ Improve sleep quality.
Ÿ Improve related day me impairment.
Ÿ The component of sleep management
Ÿ Sleep hygiene educa on
Ÿ By limi ng the day- me naps to 30 minutes.
Ÿ Avoiding s mulants such as caffeine close to bed me.
Ÿ Regular exercise to promote good sleep.
Ÿ Avoiding fa y or heavy meals before sleep.
Ÿ Reduce exposure to natural light.
Ÿ Establishing regular relaxing rou ne like warm showers or reading a
book.
Ÿ Avoiding emo onally upse ng conversa ons or ac vi es before
sleep if possible.

137
 Ÿ Making sure that sleep environment is pleasant like ma ress and
pillow are comfortable, the temperature is suitable, avoid light
screens of TV and phones before sleep.
Ÿ Cogni ve Behavioral Therapy (CBT): It guides pa ent change ac ons or
thoughts that affect their ability to sleep well. It helps to develop habits
that promote a healthy pa ern of sleep.
Ÿ Relaxa on therapy: Deep breathing, massage and listening to music.
Ÿ Sleep-restric on therapy: A behavioral treatment aims to limit the me
spent in bed to no more than the actual me spent sleeping and to
increase sleep efficiency by prolonging sleep me.
Ÿ Medica ons (Pharmacological Management):
Ÿ Benzodiazepines: Diazepam (2.5-10 mg/Day) and Bromazepam doses
(0.75-1.5 mg/day).
Ÿ Seda ve or sleep aid: Promethazine doses (25 mg – 50 mg), Hydroxyzine
doses (10 mg-30 mg).
Ÿ For elderly: Refer to specialized geriatric unit for further assessment.
(DO NOT use Benzodiazepines: Bromazepam OR Diazepam OR Amitriptyline for
elderly).

Ÿ To prescribe seda ve medica on, the GP needs to ensure the following:

Ÿ Start with a low effec ve dose.
Ÿ Encourage pa ent to use it when truly necessary and not daily.
Ÿ Avoid using for more than 2 weeks.
Ÿ In case of comorbid depression, the following an depressant is known to
be more seda ve:
Ÿ Amitriptyline start with 12.5 mg for (one week) then 25 mg un l next
appointment a er 2 weeks. Do Not use amitriptyline for elderly.
Ÿ Need ECG before star ng the dose.
Ÿ For elderly: DO NOT use Benzodiazepines (The elderly medica ons should
be considered).
Ÿ For resis ve cases, and those that show no improvement refer to a regional
psychiatrist.
Table 36. Pharmacological management for sleep disorder.

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 Clinical Management Flowchart for Suspected Sleep Disorder

Pa ent complains with sleep problems

Medical history and examina on

Physical examina on
Lab inves ga on
Substance use (medica on, alcohol, caffeine,
nico ne, illegal drugs)
Psychiatric/psychological history
Sleep–wake pa ern, including day me sleep (sleep
ques onnaires)
History of the sleep disorder, including triggering
factors

Non organic cause found Evidence of mental Organic cause indicates

No clear evidence of problems found physical medical problem or
mental problems disease
[anxiety/depression]
found

Sleep hygiene Consult family Need to treat organic

Seda ve an histamine physician if available cause
Might need referral to
medicine unit

Not improved No family physician available

Refer to psychiatrist

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 Annexes

Annex 1 Pa ent Health Ques onnaire (PHQ-9)

Annex 2 Mood Disorder Ques onnaire ( MDQ)
Annex 3 Quick Inventory of Depressive Symptomatology (QIDS)
Annex 4 7-item Generalized anxiety disorder scale
Alcohol, Smoking and Substance Involvement Screening Test
Annex 5
(ASSIST)
Annex 6 Severity of Violence Against Women Scales (SVAWS)
Annex 7 Edinburgh Postnatal Depression Scale
Annex 8 Strengths and Difficul es Ques onnaire (SDQ)
Annex 9 School screening report
Annex 10 SNAP-IV Teacher and Parent Ra ng Scale
The Modified Checklist for Au sm in Toddlers, revised (M-
Annex 11
CHAT-R)
Annex 12 SAD PERSONS scale
Annex 13 Breakaway Techniques
Mini-Mental State Examina on (MMSE) a screening test for
Annex 14
cogni ve impairment

The above list of tools can be found at the following link:

https://app.box.com/s/gqgi7phj2vskn10rdgn4ewlf92m45lww

WHO’s mhGAP-IG 2.0 App (e-mhGAP) 2017, available in both iOS and Android at
the link:
https://www.who.int/mental_health/mhgap/e_mhgap/en/

140
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