Psychiatric Disorders

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Overview

Psychiatry is one of the major specialties of medicine, and is concerned with the diagnosis and treatment of the psychiatric disorders. This volume on Psychiatry is currently in the initial stages of development. Further development will be a project of the Educational Taskforce of the World Psychiatric Association. For further information, please contact Dan Stein (dan.stein@curie.uct.ac.za).

Mental health status examination

Observe:
Appearance

• Give a written description of the patient's physical state, noting bizarre physical traits or possessions such as special clothes or ornaments with symbolic significance.
• Note possible self-neglect (e.g. lack of cleanliness).

Behavior

• Involuntary movements or tics.
• Distinctive mannerisms.
• Purposeful behavior such as pacing or fiddling.
• Threatening, seductive, or friendly demeanor.
• Congruity between the affect (outer expression of mood) and the topics of discussion.

Mood

• Ask about patient's mood and overall emotional state.
• Infer or observe mood, whether elevated, lowered, euthymic, etc.
• Note the range of the patient's moods from restricted to increased.

Speech

• Observe irregular speech patterns (e.g. slow speaking pace, long pauses before answering or between words)
• Note any increases in amounts of spontaneous speech relative to social norms. This may manifest as:
  • Rapid speech.
  • Lack of sentence completion due to eagerness to move on to a new idea.
  • Simple questions answered at great length, unnecessarily.
  • Refusal to be interrupted
  • Loud and emphatic speech.
  • Speaking regardless of lack of social stimulus or listener. Patient may talk, mutter, or whisper to self out of the context of the conversation with the examiner.
  • Muteness.
• Poverty of speech (laconic speech) may also be observed:
  • Restricted amount of spontaneous speech, with brief, concrete, and unelaborated answers to questions.
  • Rare provision of unprompted information.
  • Monosyllabic replies or ignored questions.
• Use of neologisms (creation of a completely new word or phrase whose derivation cannot be understood). Note examples of neologisms.
  • Example: "I got so angry I picked up a dish and threw it at the geshinker."
• Note instances of:
  • Word approximations (giving existing words a new and unconventional meaning or creating new words using conventional rules of word formation). Often the meaning of a word will be evident even though the usage seems peculiar or bizarre (e.g.: gloves referred to as "handshoes"). Sometimes the word approximations may be based on the use of stock words, so that the patient uses one or several words repeatedly in ways that give them a new meaning (e.g.: a watch may be called a "time vessel," the stomach a "food vessel," a television set a "news vessel"). Note examples of word approximations.
• Disordered speech content: Three types of disordered content are specified: incoherence, flight of ideas and poverty. There are overlapping concepts and in each case, the effect is to make it very difficult to grasp what the patient means. However, the symptoms are defined in terms of specific components so that it should, in most cases, be possible to say whether one, two or all three symptoms are present. If in doubt, rate hierarchically with most severe observations at the top.
• Incoherence of speech: see Incoherence in section on Thought Form
• Clanging: A pattern of speech in which sounds rather than meaningful relationships appear to govern work choice, so that the intelligibility of the speech is impaired and redundant words are introduced. In addition to rhyming relationships, this pattern of speech may also include punning associations, so that a word similar in sound brings in a new thought.
  • Example: "I'm not trying to make noise. I'm trying to make sense. If you can make sense out of nonsense, well, have fun. I'm trying to make sense out of sense. I'm not making sense (cents) anymore. I have to make dollars".
• Poverty of speech content (Alogia, Verbigeration, Negative Formal Thought Disorder): Although replies are average in length, they convey little information. Vague and repetitive language that is either overly abstract or concrete. The interviewer may characterize the speech as "empty philosophizing".
• Misleading answers: Patient's answers are misleading (e.g. answers yes or no to everything or frequent contradicts self) whether consciously or inadvertently.
• Distractible speech: During the course of a discussion or interview, the patient repeatedly stops talking in the middle of a sentence or idea and changes the subject in response to a nearby stimulus, such as an object on a desk or the interviewer's clothing or appearance.
  • Example: "Then I left San Francisco and moved to– Where did you get that tie? It looks like it's left over from the '50s. I like the warm weather in San Diego. Is that a conch shell on your desk? Have you ever gone scuba diving?"
• Stilted speech: Excessively stilted or formal speech. It may seem outdated, pompous, distant, or over-polite. The stilted quality is usually achieved through use of particular word choices (multisyllabic words when monosyllabic alternatives are available and appropriate), extremely polite phrases. ("Excuse me, madam, may I request a conference in your office at your convenience?"), or stiff and formal syntax ("Whereas the attorney comported himself indecorously, the physician behaved as is customary for a born gentleman.").
• Paraphasia:
  • Recognizable mispronunciation of a word because sounds or syllables have slipped out of sequence. Severe forms occur in aphasia, milder forms may occur as "slips of the tongue" in everyday speech. The speaker often recognizes their error and may attempt to correct it.
    • Example: "I slipped on the lice and broke my arm while running to catch the bus."
  • Substitution of an inappropriate word during an effort to say something specific. The speaker may or may not recognize this error and attempt to correct it. It typically occurs in both Broca's and Wernicke's aphasia. This type of paraphrasia may be difficult to distinguish from incoherence, since incoherence may also be due to semantic substitutions that distort or obscure meaning.

Insight

• Does the patient know there is a problem; how does she assess her impairment, disability, and handicap due to the problem?
• How important is it to them?
• Do they want treatment?
• How rational is their understanding of the problem and its treatment?

Physical examination

Pay special attention to:

• Signs and causes of delirium
• Stigmata of drug use and abuse (acute: intoxication vs chronic: needle track marks, stigmata of alcohol and tobacco use)
• Stigmata of self-harm such as scars
• General body habitus: obesity, degree of fitness

Cognitive disorders

Cognitive disorders are organic disorders that may have a treatable basis. This group of disorders includes delirium, dementia and other disorders listed below where they are proved to be secondary to a physical cause (e.g. a mood disorder secondary to changed thyroid function). Disorders which are caused by intoxication or withdrawal may also be consider ed under organic disorders, although we will consider substance use and misuse disorders separately

Dementia Definition: usually permanent disorder of memory ,other cogntive functions and overall level of functioning. Major types of Dementia

Alzheimer's Disease Vascular Dementia Lewy Body Dementia

Psychotic Disorders

The Psychotic Disorders are characterised by alterations in thinking or perception that cause distress or impairment in functioning. These include disorders such as Schizophrenia, Schizoaffective disorder and related disorders. There are clusters of symptoms broadly characterised as positive and negative symptoms. Positive symptoms include delusions, hallucinations or disorganisation of thought, negative symptoms include social withdrawal and loss of enjoyment, motivation or drive.

Mood Disorders

The Mood Disorders include a variety of syndromes characterised by the symptoms of depressed mood, elevated mood and characteristic other physical symptoms. These may be present in a continuous, intermittant or cyclical pattern.

Anxiety Disorders

The Anxiety Disorders include disorders with symptoms of anxiety or excessive worrying, phobias and panic attacks.

Substance misuse and dependence

Substance abuse disorders are those disorders or problems caused by substance use, abuse, intoxication or withdrawal. These may also contribute to other conditions. Substances involved may include legal ones such as tobacco, caffiene and alcohol, or illegal substances such as cannabis, 'Party Pills' or Cocaine.

Personality disorders

Personality disorders are loosly defined clusters of maladaptive coping strategies that cause a person discomfort or repeatedly cause negative interactions with others.

DSM IV groups personality disorders into three clusters.

Cluster A

Cluster B

Cluster C

It is not unusual for any given patient to fulfill criteria for more than one personality disorder; the diagnoses are by no means mutually exclusive.

Psychiatric Treatments

These may be biological, psychological, and/or social. In fact psychiatry is the area in medicine par excellence where it most makes sense --ideologically and practically-- that these three domains be integrated, since psychiatry focuses on examining and remedying disorders which involve the whole person.

Biological: these commonly include medications and electroconvulsive therapy. Many psychiatrists consider that physical aspects of lifestyle such as activity level and diet have an influence on symptomatology, for instance upon the mood disorders. More controversial but receiving increasing recognition are the effects of vitamin and mineral deficiency (for instance zinc deficiency in depression), and glucose intolerance.

Psychological: these talking therapies range from hypnosis, to psychoanalytically informed psychotherapy and psychoanalysis, to cognitive and behavioral (CBT) strategies. Psychoanalytic and CBT techniques are amongst the most researched treatment modalities in all of medicine and find a particular place in the treatment-- often long-term-- of patients with personality disorders; they also allow amelioration of a wide variety of other conditions. One mediating concept is that of attachment, both in childhood and throughout the lifespan.

Social: Housing, family and social support structures, financial difficulty all play a role in the genesis of psychiatric disorders and certainly affect prognosis. The role of the allied treatment team may be crucial. Stress responses, involving increasingly well-understood biological mechanisms, mediate.

Forensic Psychiatry

Forensic psychiatry is a branch of medicine which focuses on the interface of law and mental health. It includes psychiatric consultation in a wide variety of legal matters (including expert testimony), as well as clinical work with perpetrators and victims. Although the media protrays persons who commit horrific acts as being "disturbed" by making vague statements regarding a persons, often unknown, mental health staus. Persons with mental illness are more often the victim than the perpetraitor. More than one-fourth of persons with severe mental illness are victims of violent crime in the course of a year, a rate 11 times higher than that of the general population, according to a study by researchers at Northwestern University.They estimated that nearly 3 million severely mentally ill people are crime victims each year in the United States. This is the first such study to include a large, random sample of community-living, mentally ill persons and to use the same measures of victimization used by the U.S. Bureau of Justice Statistics, said lead author Linda Teplin, Ph.D., Owen L. Coon Professor of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine of Northwestern University, in the August Archives of General Psychiatry.

On To Treatments

External links

• The Merck Manual Section 15 Psychiatric Disorders[2]
• ICD-10 "Blue Book"
• Internet Mental Health

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