Premature ejaculation (PE) occurs when a man experiences orgasm and expels semen soon after sexual activity and with minimal penile stimulation. It has also been called early ejaculation, rapid ejaculation, rapid climax, premature climax and (historically) ejaculatio praecox. There is no uniform cut-off defining “premature”, but a consensus of experts at the International Society for Sexual Medicine endorsed a definition of around one minute after penetration. The International Classification of Diseases (ICD-10) applies a cut-off of 15 seconds from the beginning of sexual intercourse.

Causes of Premature Ejaculation

Psychological factors

• sexual inexperience
• issues with body image
• the novelty of a relationship
• overexcitement or too much stimulation
• relationship stress
• anxiety
• feelings of guilt or inadequacy
• depression
• issues related to control and intimacy
• strict sexual teaching and upbringing
• traumatic experiences of sex
• conditioning, for example, when a teenager learns to ejaculate quickly to avoid being found masturbating

Medical Causes

• diabetes
• multiple sclerosis
• prostate disease
• thyroid problems
• illicit drug use
• excessive alcohol consumption

Biological causes

• Abnormal hormone levels
• Abnormal levels of brain chemicals called neurotransmitters
• Inflammation and infection of the prostate or urethra
• Inherited traits

Other factors that can play a role include:

• Erectile dysfunction – Men who are anxious about obtaining or maintaining an erection during sexual intercourse might form a pattern of rushing to ejaculate, which can be difficult to change.
• Anxiety – Many men with premature ejaculation also have problems with anxiety — either specifically about sexual performance or related to other issues.
• Relationship problems –  If you have had satisfying sexual relationships with other partners in which premature ejaculation happened infrequently or not at all, it’s possible that interpersonal issues between you and your current partner are contributing to the problem.
• The nucleus para giganto cellulitis – of the brain has been identified as having involvement in ejaculatory control. Scientists have long suspected a genetic link to certain forms of premature ejaculation. However, studies have been inconclusive in isolated the gene responsible for Lifelong PE. Other researchers have noted that men who have premature ejaculation have a faster neurological response in the pelvic muscles

Symptoms of Premature Ejaculation

Primary 

• Ejaculation always, or nearly always, happens before sexual penetration has been achieved, or within about a minute of penetration.
• There is an inability to delay ejaculation every time, or nearly every time, penetration occurs.
• Negative personal consequences arise, such as distress and frustration, or avoidance of sexual intimacy.
• Psychological symptoms are secondary to the physical ejaculatory events. The man, his partner, or both may experience them.

Secondary 

• Decreased confidence in the relationship
• Interpersonal difficulty
• Mental distress
• Anxiety
• Embarrassment
• Depression

Diagnosis of Premature Ejaculation

Premature ejaculation as a medical problem under evidence-based criteria generated by the International Society for Sexual Medicine in 2014 as being not the result of a nonsexual mental illness, a problem in a given relationship, or caused by medication, by the person ejaculating around a minute after penetration and before the person wants to ejaculate, occurring for a duration longer than 6 months and happening almost every time, and causing significant distress for person. These factors are identified by talking with the person, not through any diagnostic test.

The 2007 ICD-10 defined PE as ejaculating without control, and within around 15 seconds

• Blood test (CBC, ESR, Hb)
• Urine analysis to detect the UTI infection
• Sex hormon tests- 

Treatment of Premature Ejaculation

It can sometimes help to

• masturbate an hour or two before having sex
• use a thick condom to help decrease sensation
• take a deep breath to briefly shut down the ejaculatory reflex (an automatic reflex of the body during which ejaculation occurs)
• have sex with your partner on top (to allow them to pull away when you are close to ejaculating)
• take breaks during sex and think about something boring

Couples therapy

If you’re in a long-term relationship, you may benefit from having couples therapy. During these sessions, the therapist will:

• encourage couples to explore any relationship issues they have, and give them advice about resolving them
• show the couple techniques that can help you “unlearn” the habit of premature ejaculation (the two most popular techniques are the “squeeze” and “stop-go” techniques)

In the squeeze technique, your partner masturbates you, but stops before the point of ejaculation and squeezes the head of your penis for between 10 to 20 seconds. They then let go and wait for another 30 seconds before resuming masturbation. This process is carried out several times before ejaculation is allowed to occur. The stop-go technique is similar, but your partner doesn’t squeeze your penis. Once you feel more confident about delaying ejaculation, you and your partner can begin to have sex, stopping and starting as required.

These techniques may sound simple, but they require lots of practice.

Antidepressants (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are designed to treat depression, but they also delay ejaculation. SSRIs used for this purpose include:

• paroxetine
• sertraline
• fluoxetine

Dapoxetine

An SSRI specifically designed to treat premature ejaculation, known as dapoxetine (Priligy), has now been licensed in the UK.

It acts much faster than the SSRIs mentioned above and can be used “on demand”. You’ll usually be advised to take it between one and three hours before sex, but not more than once a day. Your response to the treatment will then be reviewed after four weeks (or after six doses), and again every six months.

‘Long love’ condoms

German scientists have come up with a slightly different approach that won’t cause vaginal irritation. It’s called the ‘long love condom’ and it contains a local anesthetic (benzocaine or lidocaine) inside it. Long love condoms are now being sold in many countries, under a variety of brand names.

Tramadol

This is a pain reliever that can delay ejaculation. It may be prescribed if antidepressants don’t help. This medicine is addictive, so it may not be an option for you.

Anesthetic creams or sprays

You put these on the head of your penis to make it less sensitive. Leave it on for about 30 minutes. It must be washed off before sex so you don’t lose your erection or cause loss of sensation for your partner.

Switching medication

There are a number of medications that can be used if it’s thought SSRIs are responsible for causing delayed ejaculation. These include:

• amantadine – originally designed to treat viral infections
• buproprion – usually prescribed to help people quit smoking
• yohimbine – originally designed to treat erectile dysfunction

This help block some of the chemical effects of SSRIs that may contribute towards delayed ejaculation.

Alcohol and drugs

Alcohol misuse and drug use can be separate underlying causes of delayed ejaculation, so addressing these problems may help.

Pseudoephedrine

Pseudoephedrine tablets may be tried, but these will need to be prescribed “off-label”. This means the medicine shows promise in treating delayed ejaculation but it hasn’t been licensed for this particular use (pseudoephedrine is normally used as a decongestant).

Cognitive behavior treatment (stop-start technique)

In 2006, we attended a conference on sexual medicine in Vienna. One of the speakers, Dr. Mehmet Sungur, claimed good results for the cognitive behavior (CBT) method of treatment for PE. The CBT method focuses on addressing the kind of thinking that has proved unhelpful.For example, a man may believe that ‘real men’ must thrust endlessly to give a woman pleasure. Such thinking is not only damaging to the man but wrong. Most women want penetration but also derive great pleasure from love play – often preferring fondling and oral sex to intercourse.

Counseling

There are sex therapists and other specialists to deal with ejaculation and other sexual problems. You may benefit from seeing one of these professionals.

Exercises

• Electrostimulation – of the perineal floor muscle
• Strengthen your muscles – Weak pelvic floor muscles sometimes contribute to PE.  Kegel exercises may help strengthen them. Find the right muscles to tighten by stopping your urine in midstream. Hold them tight for 3 seconds and then release them for 3 seconds. Do this 10 times, at least 3 times a day.
• Kegel exercises – which aim to strengthen the pelvic floor muscles, can help men with lifelong PE.
• Physio-kinesiotherapy – to achieve muscle contraction
• Electrostimulation – of the perineal floor
• Biofeedback –which helped them understand how to control the muscle contractions in the perineal floor

After 12 weeks of treatment, over 80 percent of the participants gained a degree of control over their ejaculation reflex. They increased the time between penetration and ejaculation by at least 60 seconds.

References

Substance abuse is when you take drugs that are not legal. It’s also when you use alcohol, prescription medicine, and other legal substances too much or in the wrong way. So substance abuse, also known as drug abuse, is a patterned use of a drug in which the user consumes the substance in amounts or with methods which are harmful to themselves or others, and is a form of the substance-related disorder. Widely differing definitions of drug abuse are used in public health, medical and criminal justice contexts. In some cases, criminal or anti-social behavior occurs when the person is under the influence of a drug, and long-term personality changes in individuals may occur as well. In addition to possible physical, social, and psychological harm, use of some drugs may also lead to criminal penalties,

Types of Substance Abuse

Symptoms of Substance Abuse

Each substance affects people differently, but there are some signs of addiction that are fairly universal

• The onset of withdrawal symptoms after the person suddenly stops using the substance
• Feeling as though he or she must consume the substance to deal with the stresses of daily life
• Increased tolerance levels requiring the person to consume more of the substance to achieve the same effect
• Uncharacteristic or irrational behavior such as angry or violent outbursts
• Dramatic changes in appearance like weight loss, hair loss, or skin problems
• Loss of interesting previously enjoyable activities
• Loss of important relationships
• Lying to cover up consumption patterns
• Impaired performance at work, home, or school
• Incessantly borrowing money or stealing money
• Legal, medical, or personal problems associated with consumption of the substance

Or

Effects of Substance Abuse

Substance abuse can wreak havoc on a person’s life. Depending on the longevity and severity of the addiction itself, the effects that could result can be life-changing. The effects listed below are among those that may occur if a person continues to abuse substances without seeking professional help:

• Development of certain types of cancers
• Job loss
• Financial difficulties
• Interaction with the legal system
• Development or worsening of mental health concerns
• Malnutrition
• Hindered immune system
• Heart failure
• Damage to vital organs
• Poor lung functioning
• Exposure to viruses, including HIV and hepatitis
• Stroke
• Seizures
• Coma
• Overdose
• Self-harm
• Suicidal ideation
• The demise of meaningful relationships
• Loss of child custody
• Irreversible cognitive damage
• Memory loss

Co-Occurring Disorders of Substance Abuse

Some individuals who are grappling with mental health concerns turn to the abuse of drugs and/or alcohol as a means of coping with their turmoil. Additionally, there are those who only begin to suffer from mental health disorders once they start abusing substances. In either case, it is possible for a person to seek treatment for an substance abuse and be diagnosed with a mental illness at the same time. The following mental health conditions are among those that people can suffer from at the same time as a substance abuse problem:

• Borderline personality disorder
• Bipolar disorder
• Depressive disorders
• Posttraumatic stress disorder (PTSD)
• Attention-deficit/hyperactivity disorder (ADHD)
• Antisocial personality disorder
• Anxiety disorders

Effects of Withdrawal and Overdose

Effects of withdrawal: The longer than an individual abuses drugs and/or alcohol, the more likely that person will be to develop a tolerance to his or her substance(s) of choice. When this occurs, it can signify that that individual has become chemically dependent on that substance(s) and will thusly experience withdrawal symptoms in the event he or she ceases his or her substance abuse. The process of withdrawing from a substance can be extremely uncomfortable and, unfortunately, trigger a person to seek out his or her substance of choice once more. The following are signs and effects of withdrawal, which also suggest that a person is in need of treatment for his or her addiction:

• Cravings
• Seizures
• Bone pain
• Muscle pain
• Suicidal ideation
• Nausea, Vomiting
• Anxious feelings
• Paranoia
• Depression

Effects of Overdose of Substance Abuse

For many substances of abuse, there is an ever-present risk of overdose when drugs and/or alcohol are used on an ongoing basis. Depending on the substance that is being abused, the telltale warning signs of overdose can vary. If any of the following occur, it should heed as a warning that emergency medical attention is needed in order to prevent a grave outcome

• Seizures
• Losing consciousness
• Dizziness
• Disorientation
• Labored breathing
• Stroke
• Chest pains
• Heart failure
• Psychosis
• Confusion
• Skin tone changes

Diagnosis of Substance Abuse

If a healthcare provider suspects that you are misusing alcohol or medications, he or she will first confirm that you are dependent on a harmful substance by:

• asking you questions
• reviewing your prescriptions for commonly abused drugs or medicines
• examining your body
• ordering blood and urine tests

The CAGE questionnaire is often used by healthcare providers to establish whether you have a drinking problem. It has four questions:

• “Have you ever felt you should cut down on your drinking?”
• “Have you ever felt annoyed by criticism about your drinking?”
• “Have you ever felt guilty or bad about drinking?”
• “Have you ever felt the need for a drink (an “eye-opener”) in the morning to steady your nerves?”

Treatment of Substance Abuse

When you drink alcohol with some medications, the alcohol can make the effect of the medication dangerously strong. For example, taking alcohol with pills for sleeping, pain, anxiety, or depression can produce harmful effects. In particular, you should avoid alcohol if you take:

• Benzodiazepines (sedatives)
• Sleeping pills
• Pain medications
• Anti-seizure or anti-psychotic medications
• Antihistamines
• Anti-depressants

Non-Drug Therapies of Substance Abuse

Substance and Medication Abuse

The following are among the effective treatments that are part of a team approach:

• Talk therapy (psychotherapy) with a trained supportive counselor
• Group therapy with a trained therapist
• Keeping a diary to record your patterns of use of the problem substance
• Residential care in a rehabilitation facility
• 12-step programs and other long-term programs (such as Alcoholics Anonymous)
• Programs to help you stop smoking

Tobacco Abuse (Cigarette, Cigar or Pipe Smoking)

If you are addicted to smoking, you have probably tried to quit many times. But another serious try is always worth it, even if you are among the very old. Quitting at any age slows the decline in lung function.

Let your healthcare provider know that you want to stop smoking. Together, you will take the following steps

• Choose a date that suits you
• Obtain any needed medications
• Arrange a follow-up visit
• Educate yourself about smoking and the benefits of quitting
• Get involved in a support group or buddy system to help keep you motivated

Self-help for substance abuse and co-occurring disorders

In addition to getting professional treatment, there are plenty of self-help steps you can take to address your substance abuse and mental health issues. Remember: Getting sober is only the beginning. As well as continuing mental health treatment, your sustained recovery depends on learning healthier coping strategies and making better decisions when dealing with life’s challenges.

Recovery tip 1

• Learn how to manage stress – Drug and alcohol abuse often stems from misguided attempts to manage stress. Stress is an inevitable part of life, so it’s important to have healthy coping skills so you can deal with stress without turning to alcohol or drugs. Stress management skills go a long way towards preventing relapse and keeping your symptoms at bay.
• Cope with unpleasant feelings – Many people turn to alcohol or drugs to cover up painful memories and emotions such as loneliness, depression, or anxiety. You may feel like doing drugs is the only way to handle unpleasant feelings, but Help guide’s free Emotional Intelligence Toolkit can teach you how to cope with difficult emotions without falling back on your addiction.
• Know your triggers and have an action plan – When you’re coping with a mental disorder as well as a substance abuse problem, it’s especially important to know signs that your illness is flaring up. Common causes include stressful events, big life changes, or unhealthy sleeping or eating patterns. At these times, having a plan in place is essential to preventing a drink or drug relapse. Who will you talk to? What do you need to do to avoid slipping?

Recovery tip 2

• Make a face-to-face connection with friends and family a priority – a Positive emotional connection to those around you is the quickest way to calm your nervous system. Try to meet up regularly with people who care about you. If you don’t have anyone you feel close to, it’s never too late to meet new people and develop meaningful friendships.
• Get therapy or stay involved in a support group – Your chances of staying sober improve if you are participating in a social support group like Alcoholics Anonymous or Narcotics Anonymous or if you are getting therapy.
• Follow doctor’s orders – Once you are sober and you feel better, you might think you no longer need medication or treatment. But arbitrarily stopping medication or treatment is a common reason for relapse in people with co-occurring disorders. Always talk with your doctor before making any changes to your medication or treatment routine.

Make healthy lifestyle changes

• Exercise regularly – Exercise is a natural way to bust stress, relieve anxiety, and improve your mood and outlook. To achieve the maximum benefit, aim for at least 30 minutes of aerobic exercise on most days.
• Practice relaxation techniques – When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, and deep breathing can reduce symptoms of stress, anxiety, and depression, and increase feelings of relaxation and emotional well-being.
• Adopt healthy eating habits – Start the day right with breakfast, and continue with frequent small meals throughout the day. Going too long without eating leads to low blood sugar, which can make you feel more stressed or anxious. Getting enough healthy fats in your diet can help to boost your mood.
• Get enough sleep – A lack of sleep can exacerbate stress, anxiety, and depression, so try to get 7 to 9 hours of quality sleep a night.

Recovery tip 4

To stay alcohol- or drug-free for the long term, you’ll need to build a new, meaningful life where substance abuse no longer has a place.

• Develop new activities and interests – Find new hobbies, volunteer activities, or work that gives you a sense of meaning and purpose. When you’re doing things you find fulfilling, you’ll feel better about yourself and substance use will hold less appeal.
• Avoid the things that trigger your urge to use – If certain people, places, or activities trigger a craving for drugs or alcohol, try to avoid them. This may mean making major changes to your social life, such as finding new things to do with your old buddies—or even giving up those friends and making new connections.

Group support for substance abuse and co-occurring disorders

• As with other addictions, groups are very helpful, not only in maintaining sobriety but also as a safe place to get support and discuss challenges. Sometimes treatment programs for co-occurring disorders provide groups that continue to meet on an aftercare basis. Your doctor or treatment provider may also be able to refer you to a group for people with co-occurring disorders.
• Just make sure your group is accepting of the idea of co-occurring disorders and psychiatric medication. Some people in these groups, although well-meaning, may mistake taking psychiatric medication as another form of addiction. You want a place to feel safe, not pressured.

Helping a loved one with a substance abuse and mental health problem

• Helping a loved one with both a substance abuse and a mental health problem can be a roller coaster. Resistance to treatment is common and the road to recovery can be long.

The best way to help someone is to accept what you can and cannot do. You cannot force someone to remain sober, nor can you make someone take their medication or keep appointments. What you can do is make positive choices for yourself, encourage your loved one to get help, and offer your support while making sure you don’t lose yourself in the process.

• Seek support – Dealing with a loved one’s mental illness and substance abuse can be painful and isolating. Make sure you’re getting the emotional support you need to cope. Talk to someone you trust about what you’re going through. It can also help to get your own therapy or join a support group.
• Set boundaries – Be realistic about the amount of care you’re able to provide without feeling overwhelmed and resentful. Set limits on disruptive behaviors and stick to them. Letting the co-occurring disorders take over your life isn’t healthy for you or your loved one.
• Educate yourself – Learn all you can about your loved one’s mental health problem, as well as substance abuse treatment and recovery. The more you understand what your loved one is going through, the better able you’ll be to support recovery.

References

Post traumatic stress disorder (PTSD) is a mental disorder that can develop after a person is exposed to a traumatic event, such as sexual assault, warfare, traffic collisions, or other threats on a person’s life. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in how a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress but instead may express their memories through play. A person with PTSD is at a higher risk for suicide and intentional self-harm.

Types of Post Traumatic Stress Disorder

Are there different types of PTSD

• Delayed-onset PTSD – if your symptoms emerge more than six months after experiencing trauma, this might be described as ‘delayed PTSD’ or ‘delayed-onset PTSD’.
• Complex PTSD – if you experienced trauma at an early age or it lasted for a long time, you might be given a diagnosis of ‘complex PTSD’.
• Birth trauma – PTSD that develops after a traumatic experience of childbirth is also known as ‘birth trauma’.

Causes of Post Traumatic Stress Disorder

• Genetic – Anxiety disorders tend to run in families. People who have first-degree relatives who struggle with anxiety disorders are at a greater risk for developing the disorder themselves. While not a definitive cause for PTSD, it does make a person more vulnerable to developing the disorder after a traumatic event.
• Brain Structures – It’s believed that certain areas of the brain that regulate emotions and fear are different than those who do not develop PTSD after a traumatic event.
• Environmental  – Those who have a history of trauma and stress are more likely to develop PTSD than those who do not have a similar history. Also, children who grow up in families where addiction is present are at greater risk for developing a post-traumatic stress disorder.
• Psychological – People who struggle with certain types of mental illness, notably anxiety and depression, are at a higher risk of developing a post-traumatic stress disorder.

Others causes are following

Types with Symptoms

There are four main types of symptoms.

 Re-experiencing the traumatic event

• Intrusive, upsetting memories of the event
• Flashbacks (acting or feeling like the event is happening again)
• Nightmares (either of the event or of other frightening things)
• Feelings of intense distress when reminded of the trauma
• Intense physical reactions to reminders of the event (e.g. pounding heart, rapid breathing, nausea, muscle tension, sweating)

Avoidance and numbing

• Avoiding activities, places, thoughts, or feelings that remind you of the trauma
• Inability to remember important aspects of the trauma
• Loss of interest in activities and life in general
• Feeling detached from others and emotionally numb
• Sense of a limited future (you don’t expect to live a normal life span, get married, have a career)

Hyperarousal

• Sleep problems
• Irritability or angry outbursts
• Hypervigilance (on constant “red alert”)
• Feeling jumpy and easily startled
• Aggressive, self-destructive, or reckless behavior

Negative thought & mood changes

• Guilt, shame, or self-blame
• Feeling alienated and alone
• Feelings of mistrust and betrayal
• Difficulty concentrating or remembering things
• depress

Symptoms over all of 

You might notice

• intrusive memories of the event that you have no control over
• flashbacks
• Fear of being separated from the parent
• Sleep problems and nightmares
• distress when you come across things that remind you of the event
• physical symptoms like sweating or heart palpitations
• feeling watchful or ‘on guard‘
• New phobias and anxieties that seem unrelated to the trauma (such as a fear of monsters)
• Somber, compulsive play in which themes or aspects of the trauma are repeated
• trouble sleeping
• Losing previously-acquired skills (such as toilet training)
• Acting out the trauma through play, stories, or drawings
• Aches and pains with no apparent cause
• angry or emotional outbursts
• blaming yourself for the events
• Irritability and aggression
• feeling like there is nothing to look forward to.

Diagnosis of Post Traumatic Stress Disorder

PTSD can be particularly difficult to diagnose because numerous factors can lead to over-reporting (e.g., disability) and under-reporting (e.g., avoidance) symptoms, dysfunction, and distress.

Screening and assessment

A number of screening instruments are used for screening adults for PTSD, such as the PTSD Checklist for DSM-5 (PCL-5) and the Primary Care PTSD Screen for DSM-5(PC-PTSD-5).

There are also several screening and assessment instruments for use with children and adolescents. These include the Child PTSD Symptom Scale (CPSS), Child Trauma Screening Questionnaire, and UCLA Posttraumatic Stress Disorder Reaction Index for DSM-IV.

Diagnostic and statistical manual

PTSD was classified as an anxiety disorder in the DSM-IV but has since been reclassified as a “trauma- and stressor-related disorder” in the DSM-5. The DSM-5 diagnostic criteria for PTSD include four symptom clusters: re-experiencing, avoidance, negative alterations in cognition/mood, and alterations in arousal and reactivity.

International classification of diseases

The International Classification of Diseases and Related Health Problems 10 (ICD-10) classifies PTSD under “Reaction to severe stress, and adjustment disorders.”The ICD-10 criteria for PTSD include re-experiencing, avoidance, and either increased reactivity or inability to recall certain details related to the event.

Differential diagnosis of Post Traumatic Stress Disorder

A diagnosis of PTSD requires that the person has been exposed to an extreme stressor such as one that is life-threatening. Any stressor can result in a diagnosis of adjustment disorder and it is an appropriate diagnosis for a stressor and a symptom pattern that does not meet the criteria for PTSD, for example a partner being fired, or a spouse leaving. If any of the symptom pattern is present before the stressor, another diagnosis is required, such as brief psychotic disorder or major depressive disorder. Other differential diagnoses are schizophrenia or other disorders with psychotic features such as Psychotic disorders due to a general medical condition.

The symptom pattern for acute stress disorder must occur and be resolved within four weeks of the trauma. If it lasts longer, and the symptom pattern fits that characteristic of PTSD, the diagnosis may be changed.

Treatment of Post Traumatic Stress Disorder

• Trauma-focused cognitive-behavioral therapy –  involves gradually “exposing” yourself to feelings and situations that remind you of the trauma, and replacing distorted and irrational thoughts about the trauma with a more balanced picture.
• Family therapy  – can help your loved ones understand what you’re going through and help the family work through relationship problems.
• EMDR (Eye Movement Desensitization and Reprocessing) – incorporates elements of cognitive-behavioral therapy with eye movements or other forms of rhythmic, left-right stimulation, such as hand taps or sounds. These techniques work by “unfreezing” the brain’s information processing system, which is interrupted in times of extreme stress.CBT can help you change these ‘extreme’ ways of thinking, which can also help you to feel better and to behave differently.
• Psychotherapy – All the effective psychotherapies for PTSD focus on the traumatic experience – or experiences – rather than your past life. You cannot change or forget what has happened. You can learn to think differently about it, about the world, and about your life.
• EMDR (Eye Movement Desensitisation & Reprocessing) – This is a technique which uses eye movements to help the brain to process flashbacks and to make sense of the traumatic experience.  It may sound odd, but it has been shown to work.
• Group therapy – This involves meeting with a group of other people who have been through the same, or a similar traumatic event. It can be easier to talk about what happened if you are with other people who have been through a similar experience.
• Medication – SSRI antidepressant tablets may help to reduce the strength of PTSD symptoms and relieve any depression that is also present. They will need to be prescribed by a doctor.
• Antidepressants – Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) may have some benefit for PTSD symptoms. Tricyclic antidepressants are equally effective but are less well tolerated. Evidence provides support for a small or modest improvement with sertraline, fluoxetine, paroxetine, and venlafaxine. Thus, these four medications are considered to be first-line medications for PTSD.
• Anti-anxiety medications – These drugs can relieve severe anxiety and related problems. Some anti-anxiety medications have the potential for abuse, so they are generally used only for a short time.
• Prazosin  – If symptoms include insomnia with recurrent nightmares, a drug called prazosin (Minipress) may help. Although not specifically FDA approved for PTSD treatment, prazosin may reduce or suppress nightmares in many people with PTSD.
• Benzodiazepines – Benzodiazepines are not recommended for the treatment of PTSD due to a lack of evidence of benefit and risk of worsening PTSD symptoms. Some authors believe that the use of benzodiazepines is contraindicated for acute stress, as this group of drugs promotes dissociation and ulterior revivals. Nevertheless, some use benzodiazepines with caution for short-term anxiety and insomnia. While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD and may actually increase the risk of developing PTSD 2–5 times.
• Glucocorticoids – Glucocorticoids may be useful for short-term therapy to protect against neurodegeneration caused by the extended stress response that characterizes PTSD, but long-term use may actually promote neurodegeneration.
• Cannabinoids – Evidence as of 2017 is insufficient to determine if medical cannabis useful for PTSD. Despite the uncertain evidence, use of cannabis or derived products is widespread among U.S. veterans with PTSD. The cannabinoid nabilone is sometimes used off-label for nightmares in PTSD. Although some short-term benefit was shown, adverse effects are common and it has not been adequately studied to determine efficacy. Additionally, there are other treatments with stronger efficacy and less risks (e.g., psychotherapy, serotonergic antidepressants, adrenergic inhibitors). The use of medical marijuana for PTSD is controversial, with only a handful of states permitting its use for that purpose.
• Exercise, sport and physical activity – Physical activity can influence people’s psychological and physical health. The U.S. National Center for PTSD recommends moderate exercise as a way to distract from disturbing emotions, build self-esteem and increase feelings of being in control again. They recommend a discussion with a doctor before starting an exercise program.
• Play therapy for children – Play is thought to help children link their inner thoughts with their outer world, connecting real experiences with abstract thought. Repetitive play can also be one way a child relives traumatic events, and that can be a symptom of trauma in a child or young person. Although it is commonly used, there have not been enough studies comparing outcomes in groups of children receiving and not receiving play therapy, so the effects of play therapy are not yet understood.
• Military programs  – Many veterans of the wars in Iraq and Afghanistan have faced significant physical, emotional, and relational disruptions. In response, the United States Marine Corps has instituted programs to assist them in re-adjusting to civilian life, especially in their relationships with spouses and loved ones, to help them communicate better and understand what the other has gone through. Walter Reed Army Institute of Research (WRAIR) developed the Battlemind program to assist service members to avoid or ameliorate PTSD and related problems. Wounded Warrior Project partnered with the US Department of Veterans Affairs to create Warrior Care Network, a national health system of PTSD treatment centers
• Cognitive Processing Therapy (CPT)  – where you learn skills to understand how trauma changed your thoughts and feelings. Changing how you think about the trauma can change how you feel.
• Prolonged Exposure (PE) – where you talk about your trauma repeatedly until memories are no longer upsetting. This will help you get more control over your thoughts and feelings about the trauma. You also go to places or do things that are safe, but that you have been staying away from because they remind you of the trauma.
• Eye Movement Desensitization and Reprocessing (EMDR)  – which involves focusing on sounds or hand movements while you talk about the trauma. This helps your brain work through traumatic memories.
• Body-focused therapies – These don’t help PTSD directly, but can help to control your distress and hyperarousal, the feeling of being ‘on guard’ all the time. These include physiotherapy and osteopathy, but also complementary therapies such as massage, acupuncture, reflexology, yoga, meditation and tai chi. They can help you to develop ways of relaxing and managing stress.
• The way of best works – At present, there is evidence that EMDR, Cognitive Behavioural Therapy, behavior therapy, and antidepressants are all effective. There is not enough information for us to show that one of these treatments is better than another. There is not yet any evidence that other forms of psychotherapy or counseling are helpful for PTSD.
• Getting better – Try to start doing the normal things of life that have nothing to do with your past experiences of trauma. This could include finding friends, getting a job, doing regular exercise, learning relaxation techniques, developing a hobby or having pets. This helps you slowly to trust the world around you.

Lack of trust in other people – and the world in general – is central to complex PTSD. Treatment often needs to be longer to allow you to develop a secure relationship with a therapist –  to experience that it is possible to trust someone in this world without being hurt or abused. The work will often happen in 3 stages:

• Stabilization – learn how to understand and control your distress and emotional cutting-off, or ‘dissociation’. This can involve ‘grounding’ techniques to help you to stay in the present – concentrating on ordinary physical feelings to remind you that you are living in the present, not the abusive and traumatic past.start to ‘disconnect’ your physical symptoms of fear and anxiety from the memories and emotions that produce them, making them less frightening. Start to be able to tolerate day-to-day life without experiencing anxiety or flashbacks.
• Trauma-focussed Therapy – EMDR or Cognitive Behavioural Therapy can help you to remember your traumatic experiences with less distress and more control. Other psychotherapies, including psychodynamic psychotherapy, can also be helpful. Care needs to be taken in complex PTSD because these treatments can make the situation worse if not used properly.
• Reintegration – You begin to develop a new life for yourself. You become able to use your skills or learn new ones and to make satisfying relationships in the real world. Medication can be used if you feel too distressed or unsafe, or if psychotherapy is not possible. It can include both antidepressants and antipsychotic medication – but not usually tranquillisers or sleeping tablets.
• Exercise, sport and physical activity – Physical activity can influence people’s psychological and physical health. The U.S. National Center for PTSD recommends moderate exercise as a way to distract from disturbing emotions, build self-esteem and increase feelings of being in control again. They recommend a discussion with a doctor before starting an exercise program.
• Play therapy for children – Play is thought to help children link their inner thoughts with their outer world, connecting real experiences with abstract thought. Repetitive play can also be one way a child relives traumatic events, and that can be a symptom of trauma in a child or young person. Although it is commonly used, there have not been enough studies comparing outcomes in groups of children receiving and not receiving play therapy, so the effects of play therapy are not yet understood.

For friends, relatives & colleagues

Do …….

• watch out for any changes in behaviour – poor performance at work, lateness, taking sick leave, minor accidents
• watch for anger, irritability, depression, lack of interest, lack of concentration
• take time to allow a trauma survivor to tell their story
• ask general questions
• let them talk, don’t interrupt the flow or come back with your own experiences.

Don’t …….

• tell a survivor you know how they feel – you don’t
• tell a survivor they’re lucky to be alive – it doesn’t feel like that to them
• minimise their experience – “it’s not that bad, surely …
• suggest that they just need to “pull themselves together.

Risk Factors and Resilience Factors for PTSD

Some factors that increase risk for PTSD include:

• Living through dangerous events and traumas
• Getting hurt
• Seeing another person hurt, or seeing a dead body
• Childhood trauma
• Feeling horror, helplessness, or extreme fear
• Having little or no social support after the event
• Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home
• Having a history of mental illness or substance abuse
• Seeking out support from other people, such as friends and family
• Finding a support group after a traumatic event
• Learning to feel good about one’s own actions in the face of danger
• Having a positive coping strategy, or a way of getting through the bad event and learning from it
• Being able to act and respond effectively despite feeling fear

Researchers are studying the importance of these and other risk and resilience factors, including genetics and neurobiology.

As well as many of the symptoms of PTSD described above, you may find that you:

• feel shame and guilt
• have a sense of numbness, a lack of feelings in your body
• can’t enjoy anything
• control your emotions by using street drugs, alcohol, or by harming yourself
• cut yourself off from what is going on around you (dissociation)
• have physical symptoms caused by your distress
• find that you can’t put your emotions into words
• want to kill yourself
• take risks and do things on the ‘spur of the moment’.

It is worse if

• it happens at an early age – the earlier the age, the worse the trauma
• it is caused by a parent or other care giver
• the trauma is severe
• the trauma goes on for a long time
• you are isolated
• you are still in touch with the abuser and/or threats to your safety.

Support to prevent furthers PTSD

If stress and other problems caused by a traumatic event affect your life, see your doctor or mental health professional. You can also take these actions as you continue with treatment for post-traumatic stress disorder:

• Follow your treatment plan – Although it may take a while to feel benefits from therapy or medications, treatment can be effective, and most people do recover. Remind yourself that it takes time. Following your treatment plan and routinely communicating with your mental health professional will help move you forward.
• Learn about PTSD – This knowledge can help you understand what you’re feeling, and then you can develop coping strategies to help you respond effectively.
• Take care of yourself – Get enough rest, eat a healthy diet, exercise and take time to relax. Try to reduce or avoid caffeine and nicotine, which can worsen anxiety.
• Don’t self-medicate – Turning to alcohol or drugs to numb your feelings isn’t healthy, even though it may be a tempting way to cope. It can lead to more problems down the road, interfere with effective treatments and prevent real healing.
• Break the cycle – When you feel anxious, take a brisk walk or jump into a hobby to re-focus.
• Stay connected – Spend time with supportive and caring people — family, friends, faith leaders or others. You don’t have to talk about what happened if you don’t want to. Just sharing time with loved ones can offer healing and comfort.
• Consider a support group – Ask your mental health professional for help finding a support group, or contact veterans’ organizations or your community’s social services system. Or look for local support groups in an online directory.

Remember that you can’t change someone. However, you can

• Learn about PTSD – This can help you understand what your loved one is going through.
• Recognize that avoidance and withdrawal are part of the disorder –  If your loved one resists your help, allow space and let your loved one know that you’re available when he or she is ready to accept your help.
• Offer to attend medical appointments – If your loved one is willing, attending appointments can help you understand and assist with treatment.
• Be willing to listen – Let your loved one know you’re willing to listen, but you understand if he or she doesn’t want to talk. Try not to force your loved one to talk about the trauma until he or she is ready.
• Encourage participation  – Plan opportunities for activities with family and friends. Celebrate good events.
• Make your own health a priority –  Take care of yourself by eating healthy, being physically active and getting enough rest. Take time alone or with friends, doing activities that help you recharge.
• Seek help if you need it – If you have difficulty coping, talk with your doctor. He or she may refer you to a therapist who can help you work through your stress.
• Stay safe –  Plan a safe place for yourself and your children if your loved one becomes violent or abusive.

References

How you prepare for Cognitive Behavioral Therapy

You might decide on your own that you want to try cognitive behavioral therapy. Or a doctor or someone else may suggest therapy to you. Here’s how to get started:

• Find a therapist – You can get a referral from a doctor, health insurance plan, friend or other trusted source. Many employers offer counseling services or referrals through employee assistance programs (EAPs). Or you can find a therapist on your own — for instance, through a local or state psychological association or by searching the Internet.
• Understand the costs – If you have health insurance, find out what coverage it offers for psychotherapy. Some health plans cover only a certain number of therapy sessions a year. Also, talk to your therapist about fees and payment options.
• Review your concerns – Before your first appointment, think about what issues you’d like to work on. While you can also sort this out with your therapist, having some sense in advance may provide a starting point.

Steps in CBT

The basic steps in a cognitive-behavioral assessment include

Step 1: Identity critical behaviors step 2: Determine whether critical behaviors are excesses or deficits

Step 3: Evaluate critical behaviors for frequency, duration, or intensity (obtain a baseline)

Step 4: If excess, attempt to decrease the frequency, duration, or intensity of behaviors; if deficits, attempt to increase behaviors

CBT typically includes these steps

• Identify troubling situations or conditions in your life – These may include such issues as a medical condition, divorce, grief, anger, or symptoms of mental illness. You and your therapist may spend some time deciding what problems and goals you want to focus on.
• Become aware of your thoughts, emotions, and beliefs about these problems – Once you’ve identified the problems to work on, your therapist will encourage you to share your thoughts about them. This may include observing what you tell yourself about an experience (self-talk), your interpretation of the meaning of a situation, and your beliefs about yourself, other people and events. Your therapist may suggest that you keep a journal of your thoughts.
• Identify negative or inaccurate thinking – To help you recognize patterns of thinking and behavior that may be contributing to your problem, your therapist may ask you to pay attention to your physical, emotional and behavioral responses in different situations.
• Reshape negative or inaccurate thinking – Your therapist will likely encourage you to ask yourself whether your view of a situation is based on fact or on an inaccurate perception of what’s going on. This step can be difficult. You may have long-standing ways of thinking about your life and yourself. With practice, helpful thinking and behavior patterns will become a habit and won’t take as much effort.

Length of therapy

CBT is generally considered short-term therapy — about 10 to 20 sessions. You and your therapist can discuss how many sessions may be right for you. Factors to consider include:

• Type of disorder or situation
• The severity of your symptoms
• How long you’ve had your symptoms or have been dealing with your situation
• How quickly you make progress
• How much stress you’re experiencing
• How much support you receive from family members and other people

CBT combines cognitive therapy and behavior therapy

CBT focuses on changing unhelpful or unhealthy thoughts and behaviors. It is a combination of two therapies: ‘cognitive therapy’ and ‘behavior therapy’. The basis of both these techniques is that healthy thoughts lead to healthy feelings and behaviors.

• Cognitive therapy – The aim of cognitive therapy is to change the way the person thinks about the issue that’s causing concern. Negative thoughts cause self-destructive feelings and behaviors. For example, someone who thinks they are unworthy of love or respect may feel withdrawn in social situations and behave shyly. Cognitive therapy challenges those thoughts and provides the person with healthier strategies. Many techniques are available. One technique involves asking the person to come up with evidence to ‘prove’ that they are unlovable. This may include prompting the person to acknowledge the family and friends who love and respect them. This evidence helps the person to realize that their belief is false. This is called ‘cognitive restructuring’. The person learns to identify and challenge negative thoughts, and replace them with more realistic and positive thoughts.
• Behavior therapy – The aim of behavior therapy is to teach the person techniques or skills to alter their behavior. For example, a person who behaves shyly at a party may have negative thoughts and feelings about themselves. They may also lack social skills. Behavior therapy teaches the person more helpful behaviors. For example, they may be taught conversational skills that they practice in therapy and in social situations. Negative thoughts and feelings reduce as the person discovers they can enjoy themselves in social situations.

Treatment with CBT

The details of treatment will vary according to the person’s problem. However, CBT typically includes the following:

• Assessment – this may include filling out questionnaires to help you describe your particular problem and pinpoint distressing symptoms. You will be asked to complete forms from time to time so that you and your therapist can plot your progress and identify problems or symptoms that need extra attention
• Personal education – your therapist provides written materials (such as brochures or books) to help you learn more about your particular problem. The saying ‘knowledge is power’ is a cornerstone of CBT. A good understanding of your particular psychological problem will help you to dismiss unfounded fears, which will help to ease your anxiety and other negative feelings
• Goal setting – your therapist helps you to draw up a list of goals you wish to achieve from therapy (for example, you may want to overcome your shyness in social settings). You and your therapist work out practical strategies to help fulfill these goals
• The practice of strategies – you practice your new strategies with the therapist. For example, you may role-play difficult social situations or realistic self-talk (how you talk to yourself in your head) to replace unhealthy or negative self-talk
• Homework – you will be expected to actively participate in your own therapy – for example, the therapist may ask you to keep a diary – and you are encouraged to use the practical strategies during the course of your daily life and report the results to the therapist.
• Graded Exposure – Exposure is a cognitive behavioral therapy exercise designed to reduce anxiety and fear through repeated contact with what is feared. This has been to shown to be among the most effective treatments for any psychological problem. The underlying theory has to do with avoidance of things that we fear resulting in increased fear and anxiety. By systematically approaching what you might normally avoid, a significant and lasting reduction in anxiety takes place.
• Successive Approximation – Successive approximation is a cognitive behavioral therapy exercise that helps people tackle difficult or overwhelming goals. By systematically breaking large tasks into smaller steps, or by performing a task similar to the goal, but less difficult, people are able to gain mastery over the skills needed to achieve the larger goal.
• Mindfulness Meditation – Mindfulness meditation is a cognitive behavioral therapy exercise that helps people disengage from harmful ruminating or obsessing by learning to connect to the present moment. Mindfulness comes from Buddhist meditation and is the subject of a significant amount of new research on the effective treatment of psychological problems.
• Skills Training – Skills Training is a cognitive behavioral therapy exercise to help remedy skills deficits, and works through modeling, direct instruction, and role-plays. The most common subjects of skills training are social skills training, assertiveness training, and communication training.
• Problem Solving – Problem Solving is a cognitive behavioral therapy exercise to help people take an active role in finding solutions to problems. Chronic mood problems or repeated disappointment can result in people taking a passive role when difficult situations arise. By teaching people effective problem-solving strategies, they are able to regain control and make the best of difficult situations.
• Relaxation Breathing Training – Relaxation training is a cognitive behavioral therapy exercise designed to help people reduce physiological symptoms of anxiety, such as shortness of breath, rapid heart rate, dizziness, etc. By reducing the body’s anxious arousal, people are able to think more clearly, thus increasing feelings of comfort and further decreasing anxiety symptoms.

Origins of Cognitive Behavior Therapy

The idea for developing this form of psychotherapy took root when Aaron Beck began to notice that his patients with depression often verbalized thoughts that were lacking in validity and noted characteristic “cognitive distortions” in their thinking. His empirical observations led him to start viewing depression not so much as a mood disorder but as a cognitive disorder. Based on his clinical observations and empirical findings, Beck outlined a new cognitive theory of depression. He published Cognitive Therapy for Depression (Beck, Rush, Shaw, and Emery, 1979) after having published a study that evaluated and demonstrated the efficacy of cognitive therapy. The combination of a detailed treatment protocol manual with outcome research was an innovation in psychotherapy practice that had only previously been attempted by behavior therapists in treating discrete behavioral problems. By accomplishing the same feat with a more complex set of clinical interventions that included cognitive, emotional, and behavioral components, Beck pioneered a model for what psychologists many years later defined as an “empirically validated psychological treatment.”

Other clinicians and researchers became interested and began developing CBT treatment protocols and evaluating their efficacy. Specific treatment protocols were developed for some psychiatric disorders. As behavioral strategies were incorporated, the term cognitive therapy changed to cognitive behavior therapy. Today CBT is the most extensively researched of all psychotherapies with several evidence-based treatment protocols.

Cognitive Model

CBT is based on a straightforward, common-sense model of the relationships among cognition, emotion, and behavior.[rx][rx][rx][rx]

Three aspects of cognition are emphasized:

• Automatic thoughts
• Cognitive distortions
• Underlying beliefs or schemas

Automatic Thoughts

An individual’s immediate, unpremeditated interpretations of events are referred to as automatic thoughts. Automatic thoughts shape both the individual’s emotions and their actions in response to events. For example, a friend may cross you in the hallway and not say hello to you. If you were to have an automatic thought of “he hates me,” or “I have done something to anger him,” it is likely to impact your mood and cause you to feel upset and also to behave in an avoidant manner when you see him next. On the other hand, if you had the automatic thought, “he is in a hurry,” you would not be too concerned, and you would not be avoidant when you were to see him next.

CBT is based on the observation that dysfunctional automatic thoughts that are exaggerated, distorted, mistaken, or unrealistic in other ways, play a significant role in psychopathology.

Cognitive Distortions

Errors in logic are quite prevalent in patients with psychological disorders. They lead individuals to erroneous conclusions. Below are some cognitive distortions that are commonly seen in individuals with psychopathology:

• Dichotomous thinking – Things are seen regarding two mutually exclusive categories with no shades of gray in between
• Overgeneralization – Taking isolated cases and using them to make wide generalizations
• Selective abstraction – Focusing exclusively on certain, usually negative or upsetting, aspects of something while ignoring the rest
• Disqualifying the positive – Positive experiences that conflict with the individual’s negative views are discounted
• Mind reading – Assuming the thoughts and intentions of others
• Fortune telling – Predicting how things will turn out before they happen
• Minimization – Positive characteristics or experiences are treated as real but insignificant
• Catastrophizing – Focusing on the worst possible outcome, however unlikely, or thinking that a situation is unbearable or impossible when it is just uncomfortable
• Emotional reasoning – Making decisions and arguments based on how you feel rather than objective reality
• “Should” statements – Concentrating on what you think “should” or “ought to be” rather than the actual situation you are faced with or having rigid rules which you always apply no matter the circumstances
• Personalization, blame, or attribution – Assuming you are completely or directly responsible for a negative outcome. When applied to others consistently, the blame is the distortion

Underlying Beliefs

Underlying beliefs shape the perception and interpretation of events. Belief systems or schemas take shape as we go through life experiences. They are defined as templates or rules for information processing that underlie the most superficial layer of automatic thoughts. Beliefs are understood at two levels in CBT:

Core Beliefs

• The central ideas about self and the world
• The most fundamental level of belief
• They are global, rigid, and overgeneralized

Examples of dysfunctional core beliefs

• “I am unlovable.”
• “I am inadequate.”
• “The world is a hostile and dangerous place.”

Intermediate Beliefs

• Consist of assumptions, attitudes, and rules
• Influenced in their development by the core beliefs

Examples of dysfunctional intermediate beliefs

• “To be accepted, I should always please others.”
• “I should be excellent at everything I do to be considered adequate.”
• “It is best to have as little as possible to do with people.”

Schizophrenia is a mental disorder characterized by abnormal social behavior and failure to understand reality. Common symptoms include false beliefs, unclear or confused thinking, hearing voices that others do not, reduced social engagement and emotional expression, and a lack of motivation. People with schizophrenia often have additional mental health problems such as anxiety, depressive, or substance-use disorders. Symptoms typically come on gradually, begin in young adulthood, and last a long time.

Subtypes of Schizophrenia

With the publication of DSM-5, the APA removed all sub-classifications of schizophrenia. The five sub-classifications included in DSM-IV-TR were

• Paranoid type – Delusions or auditory hallucinations are present, but thought disorder, disorganized behavior, or affective flattening are not. Delusions are persecutory and/or grandiose, but in addition to these, other themes such as jealousy, religiosity, or somatization may also be present.
• Disorganized type – Named hebephrenic schizophrenia in the ICD. Where thought disorder and flat affect are present together.
• Catatonic type – The subject may be almost immobile or exhibit agitated, purposeless movement. Symptoms can include catatonic stupor and waxy flexibility.
• Undifferentiated type – Psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met.
• Residual type – Where positive symptoms are present at a low intensity only.

The ICD-10 defines additional subtypes

• Post-schizophrenic depression – A depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present.
• Simple schizophrenia – Insidious and progressive development of prominent negative symptoms with no history of psychotic episodes.
• Other schizophrenia – include cenesthopathic schizophrenia and schizophreniform disorder NOS.

Causes of Schizophrenia

While the causes of schizophrenia are not fully known, it seems to result from a complex interaction between genetic and environmental factors.

• Genetic causes – While schizophrenia runs in families, about 60% of schizophrenics have no family members with the disorder. Furthermore, individuals who are genetically predisposed to schizophrenia don’t always develop the disease, which shows that biology is not destiny.
• Environment – Exposure to viruses or malnutrition before birth, particularly in the first and second trimesters has been shown to increase the risk of schizophrenia. Inflammation or autoimmune diseases can also lead to increased immune system
• Brain chemistry – Problems with certain brain chemicals, including neurotransmitters called dopamine and glutamate, may contribute to schizophrenia. Neurotransmitters allow brain cells to communicate with each other. Networks of neurons are likely involved as well.
• Substance use – Some studies have suggested that taking mind-altering drugs during teen years and young adulthood can increase the risk of schizophrenia. A growing body of evidence indicates that smoking marijuana increases the risk of psychotic incidents and the risk of ongoing psychotic experiences. The younger and more frequent the use, the greater the risk. Another study has found that smoking marijuana led to earlier onset of schizophrenia and often preceded the manifestation of the illness.

Environmental Causes

Studies suggest that inherited genes make a person vulnerable to schizophrenia and then environmental factors act on this vulnerability to trigger the disorder.

More and more research is pointing to stress, either during pregnancy or at a later stage of development, as a major environmental factor. Stress-inducing factors could include:

• Prenatal exposure to a viral infection
• Low oxygen levels during birth (from prolonged labor or premature birth
• Exposure to a virus during infancy
• Early parental loss or separation
• Physical or sexual abuse in childhood

Abnormal brain structure

In addition to abnormal brain chemistry, abnormalities in brain structure may also play a role in schizophrenia. However, it is highly unlikely that schizophrenia is the result of any one problem in any one region of the brain

Behaviors that are early warning signs of schizophrenia include

• Hearing or seeing something that isn’t there
• A constant feeling of being watched
• The peculiar or nonsensical way of speaking or writing
• Strange body positioning
• Feeling indifferent to very important situations
• Deterioration of academic or work performance
• A change in personal hygiene and appearance
• A change in personality
• Increasing withdrawal from social situations
• Irrational, angry or fearful response to loved ones
• Inability to sleep or concentrate
• Inappropriate or bizarre behavior
• Extreme preoccupation with religion or the occult

Anyone who experiences several of these symptoms for more than two weeks should seek help immediately.

Symptoms of Schizophrenia

Positive major symptoms are disturbances that are “added” to the person’s personality.

• Delusions – the patient displays false beliefs, which can take many forms, such as delusions of persecution, or delusions of grandeur. They may feel others are attempting to control them remotely. Or, they may think they have extraordinary powers and abilities.
• Hallucinations – hearing voices is much more common than seeing, feeling, tasting, or smelling things which are not there, however, people with schizophrenia may experience a wide range of hallucinations.
• Thought disorder – the person may jump from one subject to another for no logical reason. The speaker may be hard to follow or erratic.
• Disordered thinking and speech –moving from one topic to another, in a nonsensical fashion. Individuals may also make up their own words or sounds, rhyme in a way that doesn’t make sense or repeats words and ideas.
• Disorganized behavior –this can range from having problems with routine behaviors like hygiene or choosing appropriate clothing for the weather, to unprovoked outbursts, too impulsive and uninhibited actions. A person may also have movements that seem anxious, agitated, tense or constant without any apparent reason.

The symptoms are classified into four categories

• Positive symptoms – also known as psychotic symptoms. For example, delusions and hallucinations.
• Negative symptoms – these refer to elements that are taken away from the individual. For example, the absence of facial expressions or lack of motivation.
• Cognitive symptoms – these affect the person’s thought processes. They may be positive or negative symptoms, for example, poor concentration is a negative symptom.
• Emotional symptoms – these are usually negative symptoms, such as blunted emotions.

Other symptoms may include

• Lack of motivation (avolition) – the patient loses their drive. Everyday actions, such as washing and cooking, are neglected.
• Poor expression of emotions – responses to happy or sad occasions may be lacking, or inappropriate.
• Social withdrawal – when a patient with schizophrenia withdraws socially, it is often because they believe somebody is going to harm them.
• Unawareness of illness – as the hallucinations and delusions seem so real for patients, many of them may not believe they are ill. They may refuse to take medication for fear of side effects, or for fear that the medication may be poison, for example.
• Cognitive difficulties – the patient’s ability to concentrate, recall things, plan ahead, and to organize their life are affected. Communication becomes more difficult.

Negative symptoms are capabilities that are “lost” from the person’s personality.

• Social withdrawal
• Extreme apathy (lack of interest or enthusiasm)
• Lack of drive or initiative
• Emotional flatness

Diagnosis of Schizophrenia

Determining a diagnosis of schizophrenia may include

• Physical exam – This may be done to help rule out other problems that could be causing symptoms and to check for any related complications.
• Tests and screenings – These may include tests that help rule out conditions with similar symptoms, and screening for alcohol and drugs. The doctor may also request imaging studies, such as an MRI or CT scan.
• Psychiatric evaluation – A doctor or mental health professional checks mental status by observing appearance and demeanor and asking about thoughts, moods, delusions, hallucinations, substance use, and potential for violence or suicide. This also includes a discussion of family and personal history.
• Diagnostic criteria for schizophrenia – A doctor or mental health professional may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Treatment of Schizophrenia

The most common schizophrenia medications are

• Risperidone (Risperdal) – less sedating than other atypical antipsychotics. Weight gain and diabetes are possible side effects, but are less likely to happen, compared with Clozapine or Olanzapine.
• Olanzapine (Zyprexa) – may also improve negative symptoms. However, the risks of serious weight gain and the development of diabetes are significant.
• Quetiapine (Seroquel) – the risk of weight gain and diabetes, however, the risk is lower than Clozapine or Olanzapine.
• Ziprasidone – the risk of weight gain and diabetes is lower than other atypical antipsychotics. However, it might contribute to cardiac arrhythmia.
• Clozapine (Clozaril) – effective for patients who have been resistant to treatment. It is known to lower suicidal behaviors in patients with schizophrenia. The risk of weight gain and diabetes is significant.
• Haloperidol – an antipsychotic used to treat schizophrenia. It has a long-lasting effect (weeks).
• Schizophrenia requires long-term treatment. Most people with schizophrenia need to continue treatment even when they’re feeling better to prevent new episodes and stay symptom-free. Treatment can change over time, though, so your doctor may be able to lower the dosage or change medication as your symptoms improve.
• Therapy  – can help you improve coping and life skills, manage stress, address relationship issues, and improve communication. Group therapy can also connect you to others who are in a similar situation and gain valuable insight into how they’ve overcome challenges.

The 7 keys to self-help

Seek social support – Not only are friends and family vital to helping you get the right treatment and keeping your symptoms under control, regularly connecting with others face-to-face is the most effective way to calm your nervous system and relieve stress. Stay involved with others by continuing your work or education-or if that’s not possible, consider volunteering, joining a schizophrenia support group, or taking a class or joining a club to spend time with people who have common interests. As well as keeping you socially connected, it can help you feel good about yourself.

• Manage stress – High levels of stress are believed to trigger schizophrenic episodes by increasing the body’s production of the hormone cortisol. As well as staying socially connected, there are plenty of steps you can take to reduce your stress levels, including relaxation techniques such as meditation, yoga, or deep breathing.
• Get regular exercise – As well as all the emotional and physical benefits, exercise may help reduce symptoms of schizophrenia, improve your focus and energy, and help you feel calmer. Aim for 30 minutes of activity on most days or if it’s easier three 10-minute sessions. Try rhythmic exercise that engages both your arms and legs, such as walking, running, swimming or dancing.
• Get plenty of sleep – When you’re on medication, you most likely need even more sleep than the standard 8 hours. Many people with schizophrenia have trouble with sleep, but getting regular exercise and avoiding caffeine can help.

• Avoid alcohol, drugs, and nicotine – Substance abuse complicates schizophrenia treatment and worsens symptoms. Even smoking cigarettes can interfere with the effectiveness of some schizophrenia medications. If you have a substance abuse problem, seek help.
• Eat regular, nutritious meals  – to avoid symptoms exacerbated by changes in blood sugar levels. Omega-3 fatty acids from fatty fish, fish oil, walnuts, and flaxseeds can help improve focus, banish fatigue, and balance your moods.
• Family psycho-education and support – In addition to educating family members about the symptoms, course, and treatment of schizophrenia, this form of treatment consists of providing the family with supportive therapy, problem-solving skills, and access to ongoing community supports, including care providers during times of crises. When this intervention is consistently provided for at least several months, it has been found to decrease the relapse rate for the person with schizophrenia and improve social and emotional outcomes. Also, the burden that family members experience as a result of having a loved one with schizophrenia is less, family members tend to be more knowledgeable about the disorder and feel more supported by the professionals involved, and family relationships are improved.
• Assertive community treatment (ACT) – This intervention consists of members of the person’s treatment team meeting with that individual on a daily basis, in community settings (for example, home, work, or other places the person with schizophrenia frequents) rather than in an office or hospital setting. The treatment team is made up of a variety of professionals. For example, a psychiatrist, nurse, case manager, employment counselor, and substance-abuse counselor often make up an ACT team. Over the long term, ACT tends to be successful in reducing how often people with schizophrenia are psychiatrically hospitalized or become homeless.
• Substance abuse treatment – Providing medical and psychosocial interventions that address substance abuse should be an integral part of treatment as about 50% of individuals with schizophrenia suffer from some kind of substance abuse or dependence.
• Social skills training – Also called illness management and recovery programming, social-skills training involves teaching clients ways to handle social situations appropriately. It may be conducted as part of individual or group psychotherapy and often involves the person scripting (thinking through or role-playing) situations that occur in social settings in order to prepare for those situations when they actually occur. This treatment type has been found to help people with schizophrenia resist using drugs of abuse, as well as improve their relationships with health care professionals and with people at work.
• Supported employment – This intervention provides supports like a job coach (someone who periodically or consistently counsels the client in the workplace), as well as instruction on constructing a résumé, interviewing for jobs, and education and support for employers to hire individuals with chronic mental illness. Supported employment has been found to help schizophrenia sufferers secure and maintain employment, earn more money, and increase the number of hours they are able to work.
• Cognitive behavioral therapy (CBT) – CBT is a reality-based intervention that focuses on helping a client understand and change patterns that tend to interfere with his or her ability to interact with others and otherwise function. Except for people who are actively psychotic, CBT has been found to help individuals with schizophrenia decrease symptoms and improve their ability to function socially. This intervention can be done either individually or in group therapy.
• Group therapy – Group therapy is usually supportive and expressive, in that participants are encouraged in their efforts to care for themselves and otherwise engage in healthy, appropriate behaviors in the community.
• Weight management – Educating people with schizophrenia about weight gain and related health problems that can be a side effect of some antipsychotic and other psychiatric medications have been found to be helpful in resulting in a modest weight loss. That is also true when schizophrenia sufferers are provided with behavioral interventions to help with weight loss.

References

51-year-old male with a history of HTN, DM and chronic alcohol abuse presenting with lower extremity swelling. He notes one month of progressive, bilateral lower extremity swelling, in the past two weeks associated with increasing pain and redness and is now no longer able to ambulate due to pain. He denies fevers/chills, chest pain or shortness of breath. He also denies orthopnea and paroxysmal nocturnal dyspnea. He states that he has not had these symptoms prior to one month ago. On review of systems, he denies nausea/vomiting, abdominal pain, and changes in bowel or urinary habits. He has a history of GI bleeding (unknown treatment) but denies hematemesis, hematochezia or melena. He has previously experienced alcohol withdrawal, which manifested as tremors, but no hallucinations or seizures

Types of Edema

• Peripheral edema –This usually affects the legs, feet, and ankles, but it can also happen in the arms. It could be a sign of problems with your circulatory system, lymph nodes, or kidneys.
• Pedal edema –This happens when fluid gathers in your feet and lower legs. It’s more common if you’re older or pregnant. It can make it harder to move around in part because you may not have as much feeling in your feet
• Lymphedema –This swelling in the arms and legs is most often caused by damage to your lymph nodes, tissues that help filter germs and waste from your body. The damage may be the result of cancer treatments like surgery and radiation. Cancer itself can also block lymph nodes and lead to fluid buildup.
• Pulmonary edema – When fluid collects in the air sacs in your lungs, you have pulmonary edema. That makes it hard for you to breathe, and it’s worse when you lie down. You may have a fast heartbeat, feel suffocated, and cough up a foamy spittle, sometimes with blood.
• Cerebral edema –This is a very serious condition in which fluid builds up in the brain. It can happen if you hit your head hard if a blood vessel gets blocked or bursts or you have a tumor or an allergic reaction.
• Macular edema – This happens when fluid builds up in a part of your eye called the macula, which is in the center of the retina, the light-sensitive tissue at the back of the eye. It happens when damaged blood vessels in the retina leak fluid into the area.

Physical Exam

Labs/Studies

• CBC: 7.4/13.1/39/180
• Creatinine: 0.84
• Albumin: 4.3
• BNP: 28

Imaging

Venous Lower Extremity Ultrasound

1. No DVT.
2. Pulsatile flow in bilateral EIV (external iliac veins) suggestive of elevated right heart pressure.

Assessment/Plan

51M with HTN, DM, EtOH abuse presenting with lower extremity edema. Chronic bilateral lower extremity edema likely secondary to chronic venous insufficiency perhaps related to OSA given ultrasound findings of pulsatile flow in EIV’s. Doubt systemic cause: no evidence of heart failure on exam and normal BNP, no stigmata of cirrhosis and normal albumin, normal creatinine. Also, no evidence of DVT on ultrasound though bilateral DVT unlikely. Bilateral cellulitis also unlikely as the patient is afebrile without leukocytosis, however the patient was started on antibiotics including ceftriaxone and TMP/SMX given erythema, warmth and tenderness to palpation. The patient received benzodiazepines which eased withdrawal symptoms and he was admitted for continued treatment.

Mechanisms of Lower Extremity Edema

Differential Diagnosis of Lower Extremity Edema

Evaluation

History

• Duration: acute (<72h) vs. chronic
• Pain: DVT, CRPS, less severe in venous insufficiency
• Systemic Disease
  • Cardiac: orthopnea, PND
  • Renal: proteinuria
  • Hepatic: jaundice, ascites
• Malignancy: lymphedema
• Improvement with elevation/recumbency: venous insufficiency
• OSA: snoring, daytime somnolence
• Medications: B-blocker, CCB, hormones, NSAID’s

Physical Exam

• Distribution: unilateral, bilateral, generalized
• Quality: pitting, non-pitting
• TTP: DVT, cellulitis
• Varicose veins: venous insufficiency
• Kaposi-Stemmer: inability to pinch dorsum of foot at base of 2nd toe (lymphedema)
• Systemic Disease
  • Cardiac: JVD, crackles
  • Hepatic: ascites, scleral icterus, spider angiomas
• Brawny, medial maleolar involvement: venous insufficiency

Key Features Distinguishing Cellulitis

• Typically unilateral and acute
• Often with systemic symptoms (fever, leukocytosis)
• Risk Factors: immunosuppression, previous episodes, DM, PVD

Treatment of Edema

Medications. Many medicines can cause edema, including:

• NSAIDs (such as ibuprofen and naproxen)
• Calcium channel blockers
• Corticosteroids (like prednisone and methylprednisolone)
• Pioglitazone and rosiglitazone
• Pramipexole

References

Electrolyte Abnormalities

Epileptic seizure also known as an epileptic fit is a brief episode of signs or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. The outward effect can vary from uncontrolled jerking movement (tonic-clonic seizure) to as subtle as a momentary loss of awareness (absence seizure). Diseases of the brain characterized by an enduring predisposition to generate epileptic seizures are collectively called epilepsy

Differences between seizure & Epilepsy

Seizure

Pathologic neuronal activation leading to abnormal function

Epilepsy

Recurrent unprovoked seizures

Types

Cause

• Primary: Unprovoked
• Secondary: Provoked, caused by trauma, illness, intoxication, metabolic disturbances, etc.

Effect on mentation

• Generalized: involvement of both hemispheres with associated loss of consciousness (tonic-clonic, absence, atonic, myoclonic)
• Focal: Involving single hemisphere with the preserved level of consciousness.

Status epilepticus

• Witnessed convulsions lasting >5min
• Recurrent seizure without recovery from a postictal period

Furthers classification of seizures

• Tonic-clonic (or grand mal) seizures – These are the most noticeable. When you have this type, your body stiffens, jerks, and shakes, and you lose consciousness. Sometimes you lose control of your bladder or bowels. They usually last 1 to 3 minutes. That can lead to breathing problems or make you bite your tongue or cheek
• Clonic seizures – Your muscles have spasms, which often make your face, neck, and arm muscles jerk rhythmically. They may last several minutes.
• Tonic seizures – The muscles in your arms, legs, or trunk tense up. These usually last less than 20 seconds and often happen when you’re asleep. But if you’re standing up at the time, you can lose your balance and fall. These are more common in people who have a type of epilepsy known as Lennox-Gastaut syndrome, though people with other types can have them, too.
• Atonic seizures  – Your muscles suddenly go limp, and your head may lean forward. If you’re holding something, you might drop it, and if you’re standing, you might fall. These usually last less than 15 seconds, but some people have several in a row. Because of the risk of falling, people who tend to have atonic seizures may need to wear something like a helmet to protect their heads.
• Myoclonic seizures – Your muscles suddenly jerk as if you’ve been shocked. They may start in the same part of the brain as an atonic seizure, and some people have both myoclonic and atonic seizures.
• Absence (or petit mal) seizures – You seem disconnected from others around you and don’t respond to them. You may stare blankly into space, and your eyes might roll back in your head. They usually last only a few seconds, and you may not remember having one. They’re most common in children under 14.

Focal Seizures can ber break these into three groups

Causes 

Different causes of seizures are common in certain age groups.

• Stroke
• Cancer
• Brain tumors
• Head injuries
• Electrolyte imbalance
• Very low blood sugar
• Repetitive sounds or flashing lights, as in video games
• Some medications, like antipsychotics and some asthma drugs
• Withdrawal from some medications, like Xanax, narcotics, or alcohol
• Use of narcotics, such as cocaine and heroin
• Brain infections, like meningitis
• Seizures in babies are most commonly caused by hypoxic ischemic encephalopathy, central nervous system (CNS) infections, trauma, congenital CNS abnormalities, and metabolic disorders.
• The most frequent cause of seizures in children is febrile seizures, which happen in 2–5% of children between the ages of six months and five years.
• During childhood, well-defined epilepsy syndromes are generally seen.
• In adolescence and young adulthood, non-compliance with the medication regimen and sleep deprivation are potential triggers.
• Pregnancy and labor and childbirth, and the post-partum, or post-natal period (after birth) can be at-risk times, especially if there are certain complications like pre-eclampsia.
• During adulthood, the likely causes are alcohol-related, strokes, trauma, CNS infections, and brain tumors.
• In older adults, cerebrovascular disease is a very common cause. Other causes are CNS tumors, head trauma, and other degenerative diseases that are common in the older age group, such as dementia.

Symptoms

For generalized onset seizures

• Motor symptoms may include sustained rhythmical jerking movements (clonic), muscles becoming weak or limp (atonic), muscles becoming tense or rigid (tonic), brief muscle twitching (myoclonus), or epileptic spasms (body flexes and extends repeatedly).
• Non-motor symptoms are usually called absence seizures. These can be typical or atypical absence seizures (staring spells). Absence seizures can also have brief twitches (myoclonus) that can affect a specific part of the body or just the eyelids.

For focal onset seizures

• Motor symptoms –  may also include jerking (clonic), muscles becoming limp or weak (atonic), tense or rigid muscles (tonic), brief muscle twitching (myoclonus), or epileptic spasms. There may also be automatisms or repeated automatic movements, like clapping or rubbing of hands, lip-smacking or chewing, or running.
• Non-motor symptoms – Examples of symptoms that don’t affect movement could be changes in sensation, emotions, thinking or cognition, autonomic functions (such as gastrointestinal sensations, waves of heat or cold, goosebumps, heart racing, etc.), or lack of movement (called behavior arrest).

For unknown onset seizures

• Motor seizures  – are described as either tonic-clonic or epileptic spasms.
• Non-motor seizures –  usually include a behavior arrest. This means that movement stops – the person may just stare and not make any other movements.

Diagnosis

Physical Exam

Treatment

Medications for Treatment of Seizures

References

Electrocardiography (ECG or EKG) is the process of recording the electrical activity of the heart over a period of time using electrodes placed on the skin. These electrodes detect the tiny electrical changes on the skin that arise from the heart muscle’s electrophysiologic pattern of depolarizing and repolarizing during each heartbeat. It is a very commonly performed cardiology test.

In a conventional 12-lead ECG, ten electrodes are placed on the patient’s limbs and on the surface of the chest. The overall magnitude of the heart’s electrical potential is then measured from twelve different angles (“leads”) and is recorded over a period of time (usually ten seconds). In this way, the overall magnitude and direction of the heart’s electrical depolarization are captured at each moment throughout the cardiac cycle. The graph of voltage versus time produced by this noninvasive medical procedure is an electrocardiogram.

Medical Uses

The overall goal of performing electrocardiography is to obtain information about the structure and function of the heart. Medical uses for this information are varied and generally relate to having a need for knowledge of the structure and/or function. Some indications for performing electrocardiography include:

• Suspected myocardial infarction (heart attack) or new chest pain
• Suspected pulmonary embolism or new shortness of breath
• A third heart sound, fourth heart sound, a cardiac murmur or other findings to suggest structural heart disease
• Perceived cardiac dysrhythmias either by pulse or palpitations
• Monitoring of known cardiac dysrhythmias
• Chest pain
• Atypical chest pain
• Epigastric pain
• Back, neck, jaw or arm pain without chest pain
• Palpitations
• Syncope or near syncope
• Pulmonary edema
• Exertional dyspnea
• Weakness
• Diaphoresis unexplained by ambient temperature
• Feel of anxiety or impending doom
• Suspected diabetic ketoacidosis
• Fainting or collapse
• Seizures
• Monitoring the effects of a heart medication (e.g. drug-induced QT prolongation)
• Assessing the severity of electrolyte abnormalities, such as hyperkalemia
• Hypertrophic cardiomyopathy screening in adolescents as part of a sports physical out of concern for sudden cardiac death (varies by country)
• Perioperative monitoring in which any form of anesthesia is involved (e.g. monitored anesthesia care, general anesthesia); typically both intraoperative and postoperative
• As a part of a pre-operative assessment sometime before a surgical procedure (especially for those with known cardiovascular disease or who are undergoing invasive or cardiac, vascular or pulmonary procedures, or who will receive general anesthesia)
• Cardiac stress testing
• Computed tomography angiography (CTA) and Magnetic resonance angiography (MRA) of the heart (ECG is used to “gate” the scanning so that the anatomical position of the heart is steady)
• Biotelemetry of patients for any of the above reasons and such monitoring can include internal and external defibrillators and pacemakers

Diagnosis

Numerous diagnoses and findings can be made based upon electrocardiography, and many are discussed above. Overall, the diagnoses are made based on the patterns. For example, an “irregularly irregular” QRS complex without P waves is the hallmark of atrial fibrillation; however, other findings can be present as well, such as a bundle branch block that alters the shape of the QRS complexes. ECGs can be interpreted in isolation but should be applied – like all diagnostic tests – in the context of the patient. For example, an observation of peaked T waves is not sufficient to diagnose hyperkalemia; such a diagnosis should be verified by measuring the blood potassium level. Conversely, a discovery of hyperkalemia should be followed by an ECG for manifestations such as peaked T waves, widened QRS complexes, and loss of P waves. The following is an organized list of possible ECG-based diagnoses.

Rhythm disturbances/arrhythmias:

• Atrial fibrillation & atrial flutter without rapid ventricular response
• Premature atrial contraction (PACs) & Premature ventricular contraction (PVCs)
• Sinus arrhythmia
• Sinus bradycardia & sinus tachycardia
• Sinus pause & sinoatrial arrest
• Sick sinus syndrome: bradycardia-tachycardia syndrome
• Supraventricular tachycardia
  • Atrial fibrillation (afib) with a rapid ventricular response
  • Atrial flutter with a rapid ventricular response
  • AV nodal reentrant tachycardia
  • Atrioventricular reentrant tachycardia
  • Junctional ectopic tachycardia
  • Atrial tachycardia
    • Ectopic atrial tachycardia (unicentric)
    • Multifocal atrial tachycardia
    • Paroxysmal atrial tachycardia
  • Sinoatrial nodal reentrant tachycardia
• Torsades de pointes (polymorphic ventricular tachycardia)
• Wide complex tachycardia
  • Ventricular flutter
  • Ventricular fibrillation
  • Ventricular tachycardia (monomorphic ventricular tachycardia)
• Pre-excitation syndrome
  • Lown–Ganong–Levine syndrome
  • Wolff–Parkinson–White syndrome
• J wave/Osborn wave

Heart block and conduction problems

• Aberration
• Sinoatrial block: first, second, and third-degree

AV node

• • First-degree AV block
  • Second-degree AV block (Mobitz I & II; Mobitz I aka Wenckebach)
  • Third-degree AV block/complete AV block

Right bundle

• • Incomplete right bundle branch block
  • Complete right bundle branch block (RBBB)

Left bundle

• • Complete left bundle branch block (LBBB)
  • Incomplete left bundle branch block
  • Left anterior fascicular block (LAFB)
  • Left posterior fascicular block (LPFB)
  • Bifascicular block (LAFB plus LPFB)
  • Trifascicular block (LAFP plus FPFB plus RBBB)
• QT syndromes
  • Brugada syndrome
  • Short QT syndrome
  • Long QT syndromes, genetic and drug-induced
• Right and left atrial abnormality

Electrolytes disturbances & intoxication

• Digitalis intoxication
• Calcium: hypocalcemia and hypercalcemia
• Potassium: hypokalemia and hyperkalemia

Ischemia and infarction:

• Wellens’ syndrome (LAD occlusion)
• de Winter T waves (LAD occlusion) 
• ST elevation and ST depression
• High Frequency QRS changes
• Myocardial infarction (heart attack)
  • Non-Q wave myocardial infarction
  • NSTEMI
  • STEMI
  • Sgarbossa’s criteria for ischemia with an LBBB

Structural

• Acute pericarditis
• Right and left ventricular hypertrophy
• Right ventricular strain/S1Q3T3 (can be seen in pulmonary embolism)

Grid and Leads

The ECG grid

Axis

Atrial Enlargement

Normal:

First portion of deflection is RA, second is LA

Right Atrial Enlargement:

P-wave amplitude > 2.5mm in inferior leads

Normal duration P-wave

Left Atrial Enlargement:

P-wave duration increased (terminal negative portion >0.04s)

Amplitude of terminal negative component >1mm below isoelectric line in V1

Ventricular Hypertrophy

Right Ventricular Hypertrophy:

Right axis deviation

Abnormal R-wave progression

• Increased R-wave amplitude in leads overlying the right ventricle (V1)
• Increased S-wave amplitude in leads overlying the left ventricle (V6)

Criteria

• V1: R>S
• V6: S>R

Left Ventricular Hypertrophy:

Left axis deviation

Increased R-wave amplitude in leads overlying the LV (I, aVL, V5, V6)

Increased S-wave amplitude in leads overlying the RV (V1)

Criteria:

• Precordial Leads
  • R-wave in V5/V6 + S-wave in V1/V2 > 35mm
  • R-wave in V5 > 26mm
  • R-wave in V6 > 20mm
• Limb Leads
  • R-wave in aVL > 11mm
  • R-wave in aVF > 20mm
• Combined
  • R-wave in aVL + S-wave in V3 > 20mm (F), 28mm (M)

Secondary Repolarization Abnormalities

• Downsloping ST-segment depression
• Asymmetric T-wave inversion

Bundle Branch Blocks

Left Bundle Branch Block

• QRS duration > 0.12s (3 boxes)
• Broad or notched R-wave with prolonged upstroke in I, aVL, V5, V6
• Associated ST-segment depression and T-wave inversion
• Reciprocal changes in V1, V2 (deep S-wave)
• Possible LAD

Right Bundle Branch Block

• QRS duration > 0.12s (3 boxes)
• RSR’ in V1, V2
• Reciprocal changes in I, aVL, V5, V6 (deep S-wave)

Hemiblocks

Other Blocks

• Non-specific intraventricular conduction delay: QRS >0.10s without BBB
• Incomplete BBB: LBBB/RBBB pattern with non-prolonged QRS
• Bifascicular block: RBBB + LAFB/LPFB (by axis deviation)

Ischemia and Infarction

1. Hyperacute T-waves
2. T-wave inversion: Symmetric, compared to TWI associated with repolarization abnormalities
3. ST-elevation: Unlike J-point elevation, ST-segment merges with T-wave
4. Q-waves
   1. Duration > 0.04s
   2. Amplitude > 1/3 R-wave
   3. Normal in aVR

Coronary Artery Territories

ECG Guide: Part II

STEMI

• ST-segment elevation ≥ 1mm in two contiguous leads
• : ≥ 2mm V2-V3
• : ≥ 1.5mm V2-V3

Posterior STEMI

• ST-segment depression V1-V3  Posterior ECG
• ST-segment elevation ≥ 0.5mm in V7-V9

Sgarbossa Criteria

• Evaluation for STEMI in LBBB or paced rhythm
• Normal: ST-segment discordant with QRS
  •  QRS associated with ST-segment depression
  •  QRS associated with (commensurate) ST-segment elevation
• Score ≥ 3 98% specific for MI

Elevation

• Concordant ST-segment elevation ≥ 1mm in any lead (5 points)

Depression

• Concordant ST-segment depression ≥ 1mm in V1-V3 (3 points)

Discordant Elevation

• Discordant ST-segment elevation ≥ 5mm in any lead (2 points)

Modified Sgarbossa Criteria

• ST:S ratio ≥ 0.25 in any lead
• Presence of any criterion is positive

Other Causes of ST-segment Elevation

Benign Early Repolarization

• Concave ST-segment elevation
• Notch at J-point
• Asymmetric T-waves (steeper descent)

Pericarditis

• Diffuse ST-segment elevation (except aVR)
• PR-segment depression
• Ratio: ST-elevation to T-wave amplitude ≥ 0.25 in V6 suggests pericarditis

LVH Strain

• ST-segment elevation in V1-V3 in the setting of LVH

LV Aneurysm

• Q-waves with ST-segment elevation in precordial leads

Ischemia and Prior Infarcts

Wellens: Type A

• Suggestive of proximal LAD lesion

Wellens: Type B

Q-waves

• ≥ 40ms duration
• Depth ≥ 25% of R-wave height

---

Syncope

ARVD

• Epsilon wave

Brugada Syndrome: Type 1

• Type 1: Coved ST-segment elevation

Brugada Syndrome: Type 2

• Type 2: Saddle-back ST-segment elevation

HCM

• Deep, narrow Q-waves

Wolff-Parkinson-White

• Shortened PR-interval
• Delta-wave

Other

Atrial Abnormalities

1. Normal
2. RAA: P-wave amplitude > 2.5mm in inferior leads
3. LAA: P-wave duration increased (terminal negative portion >0.04s), amplitude of terminal negative component >1mm below isoelectric line in V1

Left Bundle Branch Block

• QRS duration > 0.12s (3 boxes)
• Broad or notched R-wave with prolonged upstroke in I, aVL, V5, V6
• Associated ST-segment depression and T-wave inversion
• Reciprocal changes in V1, V2 (deep S-wave)
• Possible LAD

Right Bundle Branch Block

• QRS duration > 0.12s (3 boxes)
• RSR’ in V1, V2
• Reciprocal changes in I, aVL, V5, V6 (deep S-wave)

Axes

All ECG tracings are available for free, licensed (along with all content on this site) under Creative Commons Attribution-ShareAlike 4.0 International Public License.

The format of this article is atypical for the structure and concept of the website – but it’s always been about learning. Here is a simplified guide to ECG interpretation with a focus on the aspects I find more challenging to understand or recall.

Grid and Leads

The ECG grid

Axis

Atrial Enlargement

Normal:

First portion of deflection is RA, second is LA

Right Atrial Enlargement:

P-wave amplitude > 2.5mm in inferior leads

Normal duration P-wave

Left Atrial Enlargement:

P-wave duration increased (terminal negative portion >0.04s)

Amplitude of terminal negative component >1mm below isoelectric line in V1

Ventricular Hypertrophy

Right Ventricular Hypertrophy:

Right axis deviation

Abnormal R-wave progression

• Increased R-wave amplitude in leads overlying the right ventricle (V1)
• Increased S-wave amplitude in leads overlying the left ventricle (V6)

Criteria

• V1: R>S
• V6: S>R

Left Ventricular Hypertrophy:

Left axis deviation

Increased R-wave amplitude in leads overlying the LV (I, aVL, V5, V6)

Increased S-wave amplitude in leads overlying the RV (V1)

Criteria:

• Precordial Leads
  • R-wave in V5/V6 + S-wave in V1/V2 > 35mm
  • R-wave in V5 > 26mm
  • R-wave in V6 > 20mm
• Limb Leads
  • R-wave in aVL > 11mm
  • R-wave in aVF > 20mm
• Combined
  • R-wave in aVL + S-wave in V3 > 20mm (F), 28mm (M)

Secondary Repolarization Abnormalities

• Downsloping ST-segment depression
• Asymmetric T-wave inversion

Bundle Branch Blocks

Left Bundle Branch Block

• QRS duration > 0.12s (3 boxes)
• Broad or notched R-wave with prolonged upstroke in I, aVL, V5, V6
• Associated ST-segment depression and T-wave inversion
• Reciprocal changes in V1, V2 (deep S-wave)
• Possible LAD

Right Bundle Branch Block

• QRS duration > 0.12s (3 boxes)
• RSR’ in V1, V2
• Reciprocal changes in I, aVL, V5, V6 (deep S-wave)

Hemiblocks

Other Blocks

• Non-specific intraventricular conduction delay: QRS >0.10s without BBB
• Incomplete BBB: LBBB/RBBB pattern with non-prolonged QRS
• Bifascicular block: RBBB + LAFB/LPFB (by axis deviation)

Ischemia and Infarction

1. Hyperacute T-waves
2. T-wave inversion: Symmetric, compared to TWI associated with repolarization abnormalities
3. ST-elevation: Unlike J-point elevation, ST-segment merges with T-wave
4. Q-waves
   1. Duration > 0.04s
   2. Amplitude > 1/3 R-wave
   3. Normal in aVR

Coronary Artery Territories

DISTRIBUTION	CORONARY ARTERY	LEADS	RECIPROCAL CHANGES
1. Inferior	RCA, PDA	II, III, aVF	Anterior, Lateral
2. Lateral	LCx	I, aVL, V5, V6	Inferior
3. Anterior	LAD	V1-V6	Inferior
4. Posterior	RCA	Posterior	Anterior (esp. V1)

References

Show More

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1614214/
• https://www.ncbi.nlm.nih.gov/books/NBK354/
• https://www.ncbi.nlm.nih.gov/books/NBK2214/
• https://www.ncbi.nlm.nih.gov/pubmed/15528292
• https://www.ncbi.nlm.nih.gov/pubmed/10147730