Iranian Textbook of

Psychiatryfor Medical Students

Psychiatry DepartmentTehran University of Medical Sciences

Editorial BoardShahin Akhond Zadeh, Ahmad Ali Abhari, Seyed Mohammad Assadi, Homayoun Amini,Seyed Ahmad Jalili, Haratoun Davidian, Firouzeh Raisi, Vandad Shari�, 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 Lot�, 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.DAssociate Editor:Hamed Ekhtiari, M.D

Iranian Textbookof Psychiatry

for Medical Students

Tehran University ofMedical Sciences

Psychiatry Department

Title: Iranian Textbook of PsychiatryAuthors: Scienti!c Board of Psychiatry Department, TUMSEditor in Chief: Mohammad Reza MohammadiAssociate Editor: Hamed EkhtiariCirculation: 1000 CopiesCover Design: Sanaz FalahatiPagination: Leila EdalatTypesetting: Fateme Nemati, Mohammad Ma`danipurPublication: Tehran University of Medical SciencesISBN: 978-964-8941-96-8First Edition: 2010

Scienti!c Board of Psychiatry DepartmentTehran University of Medical Science,Mohammad Reza Mohammadi,Hamed Ekhtiari,Mahdi Ghasemi,Nasir Rostam Beigi &Anahita Basiri Nia.

Authors

Psychiatry Department• , Tehran University of Medical Sciences.Psychiatry and Clinical Psychology Research Center• , TehranUniversity of Medical Sciences.Neurocognitive Laboratory• , Iranian National Center for AddictionStudies.

Sponsored by

© 2010 All rights reserved by Tehran University of Medical Sciences

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و اختياري حامد محمدي، محمدرضا مولفين ايران/ روانپزشكي جامع درسنامه پديدآور: نام و عنوانهمكاران. و تهران پزشكي علوم دانشگاه روانپزشكي گروه علمي هيأت اعضاي از گروهي

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شابك:978-964-8941-96-8فيپا نويسي: فهرست وضعيت

يادداشت:نمايهروانپزشكي موضوع:

تهران درماني بهداشتي خدمات و پزشكي علوم دانشگاه افزوده: شناسهRC454/35د كنگره:1388 بندي رده

ديويي:616/89 بندي رده1898116 ملي: كتابشناسي شماره

Title/ Authors PageNO.

Chapter 1. Introduction to Psychiatry/ Shokrollah Tarighati/ Mohamadreza KazemiChapter 2. History of Psychiatry in Iran and World/ Haratun Davidian/

Mohamadreza Kazemi/ Shahin SadeghiChapter 3. Signs and Symptoms in Psychiatry/Ahmad Ali Abhari/Nima KhoshnoodiChapter 4. Psychiatric Interview/Ahmad Jalili/Misagh SagharianChapter 5. Classi!cation of Psychiatric Disorders/ Majid Sadeghi/ Ali AghiliChapter 6. Psychological Basis of Behavior/ Habibollah Ghasem Zadeh/ Hamed

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

KhoshnoodiChapter 8. Mood Disorders/Ahmad Ali Nourbala / Mohammad MohamadiChapter 9. Psychotic Disorders/Seyed Mohammad Assadi/Mehdi AlooshChapter 10. Anxiety Disorders/Mohammad Sanati/Mahdi GhasemiChapter 11. Somatoform Disorders/Shokrollah Tarighati/Behzad Lot!Chapter 12. Cognitive Disorders/Maryam Noroozian/Ali KouhiChapter 13. Sexual Disorders/Firouzeh Raisi/Arian BehzadiChapter 14. Eating Disorders/Javad Alagheband-Rad/Mahdi GhasemiChapter 15. Sleep Disorders/ Zahra Shahrivar/Adel Erfanian/ Mahdi GhasemiChapter 16. Substance Abuse Disorders and Addiction/Azarakhsh Mokri/ Hamed

EkhtiariChapter 17. Dissociative Disorders/Mahdie Moein/Mahdi GhasemiChapter 18. Personality Disorders/Homayoun Amini/Reza PakdamanChapter 19. Emergencies in Psychiatry/Vandad Shari!/Behzad ElahiChapter 20. Child and Adolescence Psychiatry/Mohammad-Reza Mohammadi/

Javad Alagheband-Rad/ Nasir Rostam BeigiChapter 21. Geriatric Psychiatry/Manouchehr Naraghi/Mehrnaz Afshar PadChapter 22. Mental Health and Preventive Psychiatry/Omran Mohammad

Razaghi/ Taha GholipourChapter 23. Psychiatry and Medicine/Mohammad-Reza mohammadi/ Taha GholipourChapter 24. Spiritual Psychiatry/Mohammad-Reza Mohammadi/Nasir Rostam BeigiChapter 25. Psychological Assessment/Hamed Ekhtiari/Zahra Molla Nassrollah AlamChapter 26. Laboratory Assessment in Psychiatry/ Aliakbar Nejati Safa/Nasir

Rostam BeigiChapter 27. Neuroimaging in Psychiatry/Aliakbar Nejati Safa/Nasir Rostam BeigiChapter 28. Cognitive Behavioral "eory/Hossein Kaviani/Giti ShamsChapter 29. Psycho Analysis Treatment/Mahdi Ghasemi/ Mahdie MoeinChapter 30. Pharmacologic Interventions in Psychiatry/Gholamreza Mirsepasi/

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

Malek/Nasir Rostam BeigiChapter 32. Evidence Based Psychiatry/Mohammad-Reza Mohammadi/Afshin AslaniChapter 33. Drug Index/Padideh Ghaeli/Houshiar Honarmand/Mohammad Mojtahed/Ali

Mojtahed/ Pedram HeidariPersian Alphabetic IndexEnglish Alphabetic Index

913

23375359

85

103131167197213231247255261

283297313323

349357

367381393415

423431447461

499

511523

Table of Contents

Human is the exhaus�ve limbo

Who encompasses both creatures’ and creator’s traces

His face no different from the world

His mind deep in world reali�es

The world will go through fundamental changes in people’shealth demands and specially their mental health in thenext three decades. Non- communicable diseases, such asdepression and heart diseases, will quickly replace human’sold enemies like infec�ous diseases in developing countries,which include four fi�hs of the world popula�on and will bethe top factors causing impotency, disability and prematuredeath.

Based on old conven�ons, determining health condi�onrelied only on the existence or non-existence of illnesses andnot on impotency or disability. In recent years, universi�es,scien�fic associa�ons and the World Health Organiza�onhave defined health as “enjoying a complete physical,mental, spiritual and social health”, whereas in the past thisdefini�on included only the non-existence of illness.

In this defini�on four dimensions; physical, spiritual,mental and social are interconnected to each other and itis difficult to set boundaries and dis�nguish between them.There are specific measurable aspects regarding physical,mental, spiritual, social and even soul health includesindices. Though mental, social and spiritual health is moredifficult to define and measure due to their complexi�esto the extent that some scien�sts and experts either denytheir existence or have forgo�en their role.

According to es�mates, by 2020, 7 out of 10 deaths indeveloping countries will be due to non- communicablediseases. Whereas today the number is 3.5 out of 10 cases.

Injuries resul�ng from damages, inten�onal anduninten�onal traumas are increasing in the world. Differentmental disorders and diseases due to trauma will replacethe current sources of disease including infec�ous diseasesand malnutri�on in the next 13 years. Mental disorders likeanxiety, depression, bipolar disorder and etc will form 11%of all world diseases. Researches suggest mental diseasesaccount for 1% causes of deaths. The disaster of ignoranceregarding mental disorders becomes more obvious whenone considers Harvard University’s, World Bank’s and theWorld Health Organiza�on’s research findings. The resultsof these studies show that the causes of prevalent illnesses

will change from 1990 to 2020 in the following manner:

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

• 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 first 10 causes of the years spent with disability, 5include mental disorders like major depression, alcoholism,bipolar disorder, obsession and compulsion, andschizophrenic disorders. In total 28% of a life�me generallywill pass with disability from mental disorders. Accordingto recent criteria which consider both death and disability,mental disorders will be one of the most important causesof all illnesses reaching 15%, from 11%, the highest risein the causes of illnesses, even higher than the rise ofcardiovascular diseases.

So far we have been able to obtain 51 cases of researchfrom all psychiatric disorders of epidemiological studiesfrom ar�cles, journals, final reports, and most importantlyand accessible, the Iranpsych website of psychological andpsychiatric research center (Tehran University of MedicalSciences). Out of the 51 performed field works in provincial,rural and state areas only two na�onal studies have beenconducted in Iran by Mohammadi and Noorbala, thefindings of which are accessible in local journals like Hakim,Mind and Behavior (Andisheh va Ra�ar), interna�onaljournals and these in the h�p://iranpsych.ac.ir informa�onbase and interna�onal data base.

A�er many years of teaching psychology and psychiatryto medical and psychology students, general prac��oners,psychiatry assistants and sub-specialists assistants in TehranUniversityofMedicalSciences, Ihavecometotheconclusionthat there are limited psychology and psychiatry resources inPersian, and even them are some�mes at odds with Iranianculture and do not meet the needs of Iranian prac��oners’and experts’. Regarding the immediate needs of medicalstudents’, 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 paststudies, experiences and Iran’s researches with the use ofpsychological and psychiatric books, and mul�ple Englishlanguage resources and present them all in the frameworkof the present book. It is taken for granted that this book has

Preface

its weaknesses; we are open to cri�cisms and sugges�on fromstudents, assistants and colleagues. Of course the present bookdoes not meet all our expecta�ons and does not include allthe findings of colleagues’ and psychologists’ and psychiatrics’experiences, as well as na�onal and local research, but it will bea 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 Iranwho have worked hard in this field in recent decades. We thankthelateDr.AbdolhosseinMirsepasi,DrRezayi,DrSaiidShamloo,and other respected professors like Dr. Haratun Davidian, Dr.Shokrollah Tarigha� and other people who have contributed alot to this field. We also thank the dis�nguished professor, Dr.Gholamreza Mirsepasi who was handed the task of collec�onof materials which unfortunately was not achieved due to thedifficultly of the work and the lack of coordina�on even thoughhe made a lot of effort in this regard. The present book includes32 different chapters star�ng from the psychiatric historyto different mental disorders and whatever a medical andpsychological student, a prac��oner, psychologist and expertsin other fields need. The present book is superior to otherbooks of the psychological and psychiatric field, first becauseof data and epidemiologic informa�on about Iranian peopleregarding different mental disorders and the effec�veness ofvarious drugs, and second chapters like psychiatric and fas�ng,psychiatric based on evidence and psychiatry and spiritualitywhich is needed by every Iranian prac��oner and expert.

In the end, our thanks to all the faculty members who wereinvolved in collec�ng and compiling the chapters of this bookand also the medical students who were of great help andwhose names are men�oned together with the respectedprofessors in each chapter. Our special thanks go to Dr. HamedEkh�ari and his coordina�on team and Dr. Anahita Basirnia,who without their help it would have been impossible topublish such a book. We also thank the research deputy andpress office of Tehran University of Medical Sciences and fortheir assistance in the publica�on of this book.

We hope this book will pave the way for the applica�on ofpsychology and psychiatry in Iranian society.

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

Psychiatry is a complex science and as a medicalspecialty, perhaps more than other branches of medicine,overlaps significantly with humanis�c disciplines such asliterature, law, philosophy, religion and arts. And for thisreason, psychiatry as a knowledge pool is ever expandingand rapidly advancing in breadth and depth. Althoughthe underpinning science and core knowledge aspectsof psychiatry are the same world-wide, because of thepathoplas�c influence of cultural, religious, sociologicand ethnic variables that vary across cultures, there is aneed for local and regional understanding of psychiatry.To enhance such a relevant and varied understandingand to share knowledge within and beyond this vastdiscipline, expert clinicians, scien�sts and scholars fromvarious interlinked disciplines need to come togethercollabora�vely.

It is to meet the above-men�oned objec�ves that thePsychiatry department of Tehran University of MedicalSciences (TUMS) and the Vice Chancellor for Researchcame up with the idea to produce the Iranian Textbookof Psychiatry. The primary target audience for this bookconsists of medical students and general prac��onersin Iran, although a much wider readership could alsofind this book a useful reference guide. This produc�onis the result of a 60-member team’s intense work andcommi�ed efforts over many months. Not all of it hasbeen plain sailing though: we were hindered by thelack of systema�cally organized na�onal databanks andother such reports and research publica�ons. We thankGod that, despite all these obstacles, he bestowed uponus the courage to persevere and convic�on to succeed.A special thanks also to Professor MohammadrezaMohammadi, the former Chair of TUMS’s PsychiatryDepartment and head of research center for psychiatryand clinical psychology in TUMS, without whose constantencouragement and guidance, this dream would not havebeen fulfilled.

I acknowledge that this textbook is not without itsdrawbacks and is far from a finely ‘finished’ academicproduc�on. This book wherein we have a�empted tocombine an interna�onal knowledge base with ourown local clinical and research experiences, we aspireto update every four years. So to con�nue on that questfor perfec�on, we would welcome sugges�ons andconstruc�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

Prologue

“The Iranian Textbook of Psychiatry” is wri�en andpublished to be studied during Psychiatry educa�oncourses in medical facul�es of Iran’s universi�es and as acomprehensivesourceforcon�nuedmedicaleduca�onforgeneral prac��oners and other medical fields’ specialists.

The following points and components are consideredin prepara�on of this textbook based on the most recentstructures of medical textbooks, meant for audiences’use.

1. It is tried to provide the contents regarding thePsychiatry instruc�on syllabus in the country. Chapterslike “Psychiatry and Islamic Fas�ng” ,and “Evidence BasedPsychiatry” are also added to the book to help achieve thebook’s aim as to promote Science of Psychiatry based onlocal needs and interna�onal achievements.

2. At the beginning of each chapter, objec�ves areintroduced separately meant for medical students andinterns in an assessable manner; this characteris�c of thebook helps to present the instruc�onal goals separatelyto the students in a comprehensive manner and to testthem in the same way. These objec�ves are consideredin this edi�on of this books based on every chapter’sauthors’ experience and personally believed priori�es.We hope in later edi�ons of this book, these objec�ves besubmi�ed by the na�onal board of Psychiatry accordingto the na�onal medical educa�on priori�es.

3. At the beginning of each chapter a clinical case isintroducedtoacquainttheaudiencewithclinicalobjec�vesand necessi�es of the contents and to raise ques�ons, andthis clinical case is analyzed at the end of the chapter basedon the proposed ques�ons. It is a�empted to plan andorganize this part based on an Iranian general prac��onerneeds and skills, and frequent cases in clinics in Iran.

4. Introduc�on of key words in each chapter anda defini�on for each at the beginning part draws aninstruc�onal and scien�fic image of later pages in theaudience mind.

5. It is sought to collect and prepare the body of eachchapter based on domes�c needs and most recent worldscien�fic findings done by an experienced instructors inthe field in coopera�on with an expert medical booksauthor considering the appointed word-count budgetpre determined for each chapter. In both scien�fic andliterary editorial process, it has been tried to present bodyof the chapters, even wri�en by different authors, to theaudiences in one format.

6. At the end of each chapter, conclusion part, reviewques�ons and Persian and English mul�ple choiceques�ons provide the chance to review and recall thecontents and presented points in the chapter, in addi�onto bolstering the learning process, and the opportunity torefer again to and retrieve studied informa�on.

7. Since presenta�on of all points and contents isbeyond the scope of the book, a “for Further Readings”sec�on is also provided by authors at the end of eachchapter to make it possible for the audience to study thecomplementary points.

8. The Iranian Psychiatric Drug Index at the end of thebook is wri�en based on the audience needs and ismeant to introduce different Psychiatric medicines in thedomes�c market briefly and quickly.

Due to the authors’ inten�on to complete and publishlater edi�ons of the book based on local needs andresearch findings, it is requested from all instructors,researchers and experts to:

1. Modify every chapter of the textbook, send youropinions, sugges�ons and cri�cisms to both the author(authors’ emails are available at the beginning of eachchapter) and to Psychiatric Department Office of TehranUniversity Medical Sciences located in Rouzbeh Hospital,Karegar-e Jonoubi Avenue or to this Textbook’s secretariatwith fax number 55419113-55421959 or in le�er form orto irjp@sina. tums.ac.ir.

2. Send your ar�cles, thesis or regional and na�onalresearch findings related to the proposed contents ineach chapter to the above addresses so that we can addthem to each chapter while we are modifying the bookcontent.

3. Send your sugges�ons to cooperate in the editorialteam and prepare new versions of textbook to the above-men�oned addresses.

It is hoped that the book is going to proceed in its wayand to get a scien�fic na�onal posi�on proper for its name“Iranian Textbook of Psychiatry”.

Editorial Of�ce,Iranian Textbook of Psychiatry

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