Iranian Textbook of Psychiatry by M. A.

Iranian Textbook of

Psychiatry for Medical Students Psychiatry Department Tehran University of Medical Sciences

Tehran University of Medical Sciences Psychiatry Department

Iranian Textbook of Psychiatry for Medical Students Editorial Board Shahin Akhond Zadeh, Ahmad Ali Abhari, Seyed Mohammad Assadi, Homayoun Amini, Seyed Ahmad Jalili, Haratoun Davidian, Firouzeh Raisi, Vandad Sharifi, Zahra Shahrivar, Giti Shams, Majid Sadeghi, Mohammad Sanati, Shokrollah Tarighati, Zahra Molla Nassrollah Alam, Javad Alagheband-Rad, Habibollah Ghasem Zadeh, Padideh Ghaeli, Hossein Kaviani, Omran Mohammad Razzaghi, Mohammad Reza Mohammadi, Mahdie Moein, Azarakhsh Mokri, Gholamreza Mirsepasi, Aliakbar Nejati Safa,Maryam Noroozian, Manouchehr Naraghi, Ahmad Ali Nourbala.

Main Contributors Mohammadreza Mohammadi, Hamed Ekhtiari, Mahdi Ghasemi, Nasir Rostam Beigi, Anahita Basiri Nia, Mohammad Reza Kazemi, Nima Khoshnoodi, Misagh Sagharian, Ali Aghili, Mohammad Mohammadi, Mehdi Aloosh, Behzad Lotfi, Ali Kouhi, Arian Behzadi, Somayeh Mahintorabi, Adel Erfanian, Hanie Edalati, Reza Pakdaman, Behzad Elahi, Mehrnaz Afshar Pad, Taha Gholipour, Ayoub Malek, Afshin Aslani, Ali Mojtahed, Mohammad Mojtahed, Houshyar Honarmand, Ali Heidari.

Editor in Chief: Mohammad Reza Mohammadi, M.D

Associate Editor: Hamed Ekhtiari, M.D

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Authors Scientific Board of Psychiatry Department Tehran University of Medical Science, Mohammad Reza Mohammadi, Hamed Ekhtiari, Mahdi Ghasemi, Nasir Rostam Beigi & Anahita Basiri Nia.

Sponsored by • Psychiatry Department, Tehran University of Medical Sciences. • Psychiatry and Clinical Psychology Research Center, Tehran University of Medical Sciences. • Neurocognitive Laboratory, Iranian National Center for Addiction Studies.

Title: Iranian Textbook of Psychiatry Authors: Scientific Board of Psychiatry Department, TUMS Editor in Chief: Mohammad Reza Mohammadi Associate Editor: Hamed Ekhtiari Circulation: 1000 Copies Cover Design: Sanaz Falahati Pagination: Leila Edalat Typesetting: Fateme Nemati, Mohammad Ma`danipur Publication: Tehran University of Medical Sciences ISBN: 978-964-8941-96-8 First Edition: 2010

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Table of Contents Title/ Authors Chapter 1. Introduction to Psychiatry/ Shokrollah Tarighati/ Mohamadreza Kazemi Chapter 2. History of Psychiatry in Iran and World/ Haratun Davidian/

Page NO.

9 13

Mohamadreza Kazemi/ Shahin Sadeghi

Chapter 3. Signs and Symptoms in Psychiatry/Ahmad Ali Abhari/Nima Khoshnoodi Chapter 4. Psychiatric Interview/Ahmad Jalili/Misagh Sagharian Chapter 5. Classification of Psychiatric Disorders/ Majid Sadeghi/ Ali Aghili Chapter 6. Psychological Basis of Behavior/ Habibollah Ghasem Zadeh/ Hamed

23 37 53 59

Ekhtiari

Chapter 7. Principles of Psycho Pharmacology/Shahin Akhond Zadeh/Nima

Khoshnoodi

Chapter 8. Mood Disorders/Ahmad Ali Nourbala / Mohammad Mohamadi Chapter 9. Psychotic Disorders/Seyed Mohammad Assadi/Mehdi Aloosh Chapter 10. Anxiety Disorders/Mohammad Sanati/Mahdi Ghasemi Chapter 11. Somatoform Disorders/Shokrollah Tarighati/Behzad Lotfi Chapter 12. Cognitive Disorders/Maryam Noroozian/Ali Kouhi Chapter 13. Sexual Disorders/Firouzeh Raisi/Arian Behzadi Chapter 14. Eating Disorders/Javad Alagheband-Rad/Mahdi Ghasemi Chapter 15. Sleep Disorders/ Zahra Shahrivar/Adel Erfanian/ Mahdi Ghasemi Chapter 16. Substance Abuse Disorders and Addiction/Azarakhsh Mokri/ Hamed

103 131 167 197 213 231 247 255 261

Ekhtiari

Chapter 17. Dissociative Disorders/Mahdie Moein/Mahdi Ghasemi Chapter 18. Personality Disorders/Homayoun Amini/Reza Pakdaman Chapter 19. Emergencies in Psychiatry/Vandad Sharifi/Behzad Elahi Chapter 20. Child and Adolescence Psychiatry/Mohammad-Reza Mohammadi/

283 297 313 323

Javad Alagheband-Rad/ Nasir Rostam Beigi

Chapter 21. Geriatric Psychiatry/Manouchehr Naraghi/Mehrnaz Afshar Pad Chapter 22. Mental Health and Preventive Psychiatry/Omran Mohammad

349 357

Razaghi/ Taha Gholipour

Chapter 23. Psychiatry and Medicine/Mohammad-Reza mohammadi/ Taha Gholipour Chapter 24. Spiritual Psychiatry/Mohammad-Reza Mohammadi/Nasir Rostam Beigi Chapter 25. Psychological Assessment/Hamed Ekhtiari/Zahra Molla Nassrollah Alam Chapter 26. Laboratory Assessment in Psychiatry/ Aliakbar Nejati Safa/Nasir

367 381 393 415

Rostam Beigi

Chapter 27. Neuroimaging in Psychiatry/Aliakbar Nejati Safa/Nasir Rostam Beigi Chapter 28. Cognitive Behavioral Theory/Hossein Kaviani/Giti Shams Chapter 29. Psycho Analysis Treatment/Mahdi Ghasemi/ Mahdie Moein Chapter 30. Pharmacologic Interventions in Psychiatry/Gholamreza Mirsepasi/

423 431 447 461

Mahdi Ghasemi

Chapter 31. Islamic Fasting and Psychiatry/Mohammad-Reza Mohammadi/Ayoub

499

Malek/Nasir Rostam Beigi

Chapter 32. Evidence Based Psychiatry/Mohammad-Reza Mohammadi/Afshin Aslani Chapter 33. Drug Index/Padideh Ghaeli/Houshiar Honarmand/Mohammad Mojtahed/Ali Mojtahed/ Pedram Heidari

Persian Alphabetic Index English Alphabetic Index

511 523

Preface Human is the exhaus•ve limbo

will change from 1990 to 2020 in the following manner:

Who encompasses both creatures’ and creator’s traces

• Major depression disorders from the 4th highest cause to the 2nd cause

His face no di•erent from the world His mind deep in world reali•es The world will go through fundamental changes in people’s health demands and specially their mental health in the next three decades. Non- communicable diseases, such as depression and heart diseases, will quickly replace human’s old enemies like infec•ous diseases in developing countries, which include four ••hs of the world popula•on and will be the top factors causing impotency, disability and premature death. Based on old conven•ons, determining health condi•on relied only on the existence or non-existence of illnesses and not on impotency or disability. In recent years, universi•es, scien••c associa•ons and the World Health Organiza•on have de•ned health as “enjoying a complete physical, mental, spiritual and social health”, whereas in the past this de•ni•on included only the non-existence of illness. In this de•ni•on four dimensions; physical, spiritual, mental and social are interconnected to each other and it is di•cult to set boundaries and dis•nguish between them. There are speci•c measurable aspects regarding physical, mental, spiritual, social and even soul health includes indices. Though mental, social and spiritual health is more di•cult to de•ne and measure due to their complexi•es to the extent that some scien•sts and experts either deny their existence or have forgo•en their role. According to es•mates, by 2020, 7 out of 10 deaths in developing countries will be due to non- communicable diseases. Whereas today the number is 3.5 out of 10 cases. Injuries resul•ng from damages, inten•onal and uninten•onal traumas are increasing in the world. Di•erent mental disorders and diseases due to trauma will replace the current sources of disease including infec•ous diseases and malnutri•on in the next 13 years. Mental disorders like anxiety, depression, bipolar disorder and etc will form 11% of all world diseases. Researches suggest mental diseases account for 1% causes of deaths. The disaster of ignorance regarding mental disorders becomes more obvious when one considers Harvard University’s, World Bank’s and the World Health Organiza•on’s research •ndings. The results of these studies show that the causes of prevalent illnesses

•

Suicide from the 17th cause to the 4th

•

Violence from the 19th cause to the 12th

•

Car accidents from the 9th cause to the 3rd

•

War from the 16th cause to the 8th

Of the •rst 10 causes of the years spent with disability, 5 include mental disorders like major depression, alcoholism, bipolar disorder, obsession and compulsion, and schizophrenic disorders. In total 28% of a life•me generally will pass with disability from mental disorders. According to recent criteria which consider both death and disability, mental disorders will be one of the most important causes of all illnesses reaching 15%, from 11%, the highest rise in the causes of illnesses, even higher than the rise of cardiovascular diseases. So far we have been able to obtain 51 cases of research from all psychiatric disorders of epidemiological studies from ar•cles, journals, •nal reports, and most importantly and accessible, the Iranpsych website of psychological and psychiatric research center (Tehran University of Medical Sciences). Out of the 51 performed •eld works in provincial, rural and state areas only two na•onal studies have been conducted in Iran by Mohammadi and Noorbala, the •ndings of which are accessible in local journals like Hakim, Mind and Behavior (Andisheh va Ra•ar), interna•onal journals and these in the h•p://iranpsych.ac.ir informa•on base and interna•onal data base. A•er many years of teaching psychology and psychiatry to medical and psychology students, general prac••oners, psychiatry assistants and sub-specialists assistants in Tehran University of Medical Sciences, I have come to the conclusion that there are limited psychology and psychiatry resources in Persian, and even them are some•mes at odds with Iranian culture and do not meet the needs of Iranian prac••oners’ and experts’. Regarding the immediate needs of medical students’, general prac••oners’, psychiatrist assistantes’, and Iran’s and Islam’s cultural issues like fas•ng, psychology, etc it was decided to prepare, modify and complete past studies, experiences and Iran’s researches with the use of psychological and psychiatric books, and mul•ple English language resources and present them all in the framework of the present book. It is taken for granted that this book has

its weaknesses; we are open to cri•cisms and sugges•on from students, assistants and colleagues. Of course the present book does not meet all our expecta•ons and does not include all the •ndings of colleagues’ and psychologists’ and psychiatrics’ experiences, as well as na•onal and local research, but it will be a step, however small, towards wri•ng a text book for students, general prac••oners and psychiatric assistants. It is incumbent upon us to thank all psychiatry pioneers in Iran who have worked hard in this •eld in recent decades. We thank the late Dr. Abdolhossein Mirsepasi, Dr Rezayi, Dr Saiid Shamloo, and other respected professors like Dr. Haratun Davidian, Dr. Shokrollah Tarigha• and other people who have contributed a lot to this •eld. We also thank the dis•nguished professor, Dr. Gholamreza Mirsepasi who was handed the task of collec•on of materials which unfortunately was not achieved due to the di•cultly of the work and the lack of coordina•on even though he made a lot of e•ort in this regard. The present book includes 32 di•erent chapters star•ng from the psychiatric history to di•erent mental disorders and whatever a medical and psychological student, a prac••oner, psychologist and experts in other •elds need. The present book is superior to other books of the psychological and psychiatric •eld, •rst because of data and epidemiologic informa•on about Iranian people regarding di•erent mental disorders and the e•ec•veness of various drugs, and second chapters like psychiatric and fas•ng, psychiatric based on evidence and psychiatry and spirituality which is needed by every Iranian prac••oner and expert. In the end, our thanks to all the faculty members who were involved in collec•ng and compiling the chapters of this book and also the medical students who were of great help and whose names are men•oned together with the respected professors in each chapter. Our special thanks go to Dr. Hamed Ekh•ari and his coordina•on team and Dr. Anahita Basirnia, who without their help it would have been impossible to publish such a book. We also thank the research deputy and press o•ce of Tehran University of Medical Sciences and for their assistance in the publica•on of this book. We hope this book will pave the way for the applica•on of psychology and psychiatry in Iranian society.

Mohammad Reza Mohammadi, M.D. Editor in Chief, Professor of Child and Adolescent Psychiatry Psychiatry and Psychology Research Centre, Tehran University of Medical Sciences mohammadimr@tums.ac.ir

Prologue Psychiatry is a complex science and as a medical specialty, perhaps more than other branches of medicine, overlaps signi•cantly with humanis•c disciplines such as literature, law, philosophy, religion and arts. And for this reason, psychiatry as a knowledge pool is ever expanding and rapidly advancing in breadth and depth. Although the underpinning science and core knowledge aspects of psychiatry are the same world-wide, because of the pathoplas•c in•uence of cultural, religious, sociologic and ethnic variables that vary across cultures, there is a need for local and regional understanding of psychiatry. To enhance such a relevant and varied understanding and to share knowledge within and beyond this vast discipline, expert clinicians, scien•sts and scholars from various interlinked disciplines need to come together collabora•vely. It is to meet the above-men•oned objec•ves that the Psychiatry department of Tehran University of Medical Sciences (TUMS) and the Vice Chancellor for Research came up with the idea to produce the Iranian Textbook of Psychiatry. The primary target audience for this book consists of medical students and general prac••oners in Iran, although a much wider readership could also •nd this book a useful reference guide. This produc•on is the result of a 60-member team’s intense work and commi•ed e•orts over many months. Not all of it has been plain sailing though: we were hindered by the lack of systema•cally organized na•onal databanks and other such reports and research publica•ons. We thank God that, despite all these obstacles, he bestowed upon us the courage to persevere and convic•on to succeed. A special thanks also to Professor Mohammadreza Mohammadi, the former Chair of TUMS’s Psychiatry Department and head of research center for psychiatry and clinical psychology in TUMS, without whose constant encouragement and guidance, this dream would not have been ful•lled. I acknowledge that this textbook is not without its drawbacks and is far from a •nely ‘•nished’ academic produc•on. This book wherein we have a•empted to combine an interna•onal knowledge base with our own local clinical and research experiences, we aspire to update every four years. So to con•nue on that quest for perfec•on, we would welcome sugges•ons and construc•ve cri•cisms.

Hamed Ekhtiari, M.D. Associate Editor, Director of Neurocognitive Laboratory, Iranian National Center for Addiction Studies, Tehran University of Medical Sciences. H_Ekhtiari@razi.tums.ac.ir

How to Read This Book “The Iranian Textbook of Psychiatry” is wri•en and published to be studied during Psychiatry educa•on courses in medical facul•es of Iran’s universi•es and as a comprehensivesourceforcon•nuedmedicaleduca•onfor general prac••oners and other medical •elds’ specialists. The following points and components are considered in prepara•on of this textbook based on the most recent structures of medical textbooks, meant for audiences’ use. 1. It is tried to provide the contents regarding the Psychiatry instruc•on syllabus in the country. Chapters like “Psychiatry and Islamic Fas•ng” ,and “Evidence Based Psychiatry” are also added to the book to help achieve the book’s aim as to promote Science of Psychiatry based on local needs and interna•onal achievements. 2. At the beginning of each chapter, objec•ves are introduced separately meant for medical students and interns in an assessable manner; this characteris•c of the book helps to present the instruc•onal goals separately to the students in a comprehensive manner and to test them in the same way. These objec•ves are considered in this edi•on of this books based on every chapter’s authors’ experience and personally believed priori•es. We hope in later edi•ons of this book, these objec•ves be submi•ed by the na•onal board of Psychiatry according to the na•onal medical educa•on priori•es. 3. At the beginning of each chapter a clinical case is introducedtoacquainttheaudiencewithclinicalobjec•ves and necessi•es of the contents and to raise ques•ons, and this clinical case is analyzed at the end of the chapter based on the proposed ques•ons. It is a•empted to plan and organize this part based on an Iranian general prac••oner needs and skills, and frequent cases in clinics in Iran. 4. Introduc•on of key words in each chapter and a de•ni•on for each at the beginning part draws an instruc•onal and scien••c image of later pages in the audience mind. 5. It is sought to collect and prepare the body of each chapter based on domes•c needs and most recent world scien••c •ndings done by an experienced instructors in the •eld in coopera•on with an expert medical books author considering the appointed word-count budget pre determined for each chapter. In both scien••c and literary editorial process, it has been tried to present body of the chapters, even wri•en by di•erent authors, to the audiences in one format.

6. At the end of each chapter, conclusion part, review ques•ons and Persian and English mul•ple choice ques•ons provide the chance to review and recall the contents and presented points in the chapter, in addi•on to bolstering the learning process, and the opportunity to refer again to and retrieve studied informa•on. 7. Since presenta•on of all points and contents is beyond the scope of the book, a “for Further Readings” sec•on is also provided by authors at the end of each chapter to make it possible for the audience to study the complementary points. 8. The Iranian Psychiatric Drug Index at the end of the book is wri•en based on the audience needs and is meant to introduce di•erent Psychiatric medicines in the domes•c market brie•y and quickly. Due to the authors’ inten•on to complete and publish later edi•ons of the book based on local needs and research •ndings, it is requested from all instructors, researchers and experts to: 1. Modify every chapter of the textbook, send your opinions, sugges•ons and cri•cisms to both the author (authors’ emails are available at the beginning of each chapter) and to Psychiatric Department O•ce of Tehran University Medical Sciences located in Rouzbeh Hospital, Karegar-e Jonoubi Avenue or to this Textbook’s secretariat with fax number 55419113-55421959 or in le•er form or to irjp@sina. tums.ac.ir. 2. Send your ar•cles, thesis or regional and na•onal research •ndings related to the proposed contents in each chapter to the above addresses so that we can add them to each chapter while we are modifying the book content. 3. Send your sugges•ons to cooperate in the editorial team and prepare new versions of textbook to the abovemen•oned addresses. It is hoped that the book is going to proceed in its way and to get a scien••c na•onal posi•on proper for its name “Iranian Textbook of Psychiatry”.

Editorial Office, Iranian Textbook of Psychiatry